Case Report of an Unusual Differential Diagnosis of a Red and Atraumatic Swollen Foot Charcot Arthropathy in Rheumatoid Arthritis.

Introduction: Neuropathic osteoarthropathy of the foot and ankle (Charcot foot) is a disease that can lead to progressive malpositioning and deformation up to complete collapse of the foot. In most cases, diabetic polyneuropathy is the underlying disease, but polyneuropathy of any cause can lead to neuropathic osteoarthropathy. Pathogenesis is still not completely understood. Due to the non-specific clinical presentation, the symptoms of Charcot arthropathy are generally easily misdiagnosed and proper therapy is delayed, especially in patients with an underlying disease other than diabetes mellitus. To date, published literature on patients with rheumatoid arthritis who develop neuropathic osteoarthropathy of the foot is scarce. Case Report: We present a rare case of a 61-year-old patient with Charcot foot and rheumatoid arthritis. The patient presented with an extreme foot deformity after a failed conservative treatment. The surgical procedures, complications, and outcome are described. The pitfalls in this special patient group are highlighted. Conclusion: If necessary, a variety of surgical options are available to maintain ambulation and prevent infection from open ulcers and amputation. For surgical management of patients with rheumatoid arthritis, the overall statics of the lower extremity and the influence of antirheumatic drugs must be considered.

Intact versus fragmented 99mTc-monoclonal antibody imaging of infection in patients with septically loosened total knee arthroplasty.

OBJECTIVE: This prospective study compared the diagnostic accuracy of imaging using an intact murine antigranulocyte antibody 99mTc-besilesomab, and a murine antibody Fab fragment 99mTc-sulesomab, in patients with suspected septically loosened total knee arthroplasty. METHODS: Images from 20 patients who underwent threephase bone scintigraphy followed by imaging using 99mTc-besilesomab (n=10) or 99mTc-sulesomab (n=10) were evaluated and compared. Final diagnosis was determined by microbiological evaluation of aspirated synovial fluid, intraoperative samples through the clinical course, or by long-term follow-up. RESULTS: Prosthesis infection was shown in 18 patients. At 4 and 24 h after intravenous injection, absolute uptake of 99mTc-besilesomab was significantly higher than 99mTc-sulesomab in infected knee joints. Infected-to-healthy knee activity ratios were similar at 4 and 24 h for 99mTc-besilesomab and 99mTc-sulesomab. CONCLUSIONS: Both 99mTc-besilesomab and 99mTc-sulesomab had similar diagnostic accuracy for the detection of septic arthroplasty. If repeated use of immunoscintigraphy is needed for follow-up, 99mTc-sulesomab should be preferred over 99mTc-besilesomab since it is known to be well tolerated and without side effects or incompatibility reactions.

(99m)Tc-Fab' fragments (sulesomab) for imaging septically loosened total knee arthroplasty.

The diagnostic accuracy of infection scintigraphy with (99m)Tc-labelled monoclonal antibody Fab' fragments (sulesomab) was studied in patients with suspected total knee arthroplasty (TKA) infection. Images from 26 patients were evaluated by two independent readers and compared with a quantitative interpretation of time-activity courses. Microbiological examinations and joint aspiration results were used as reference standards. Histologically, aseptic TKA loosening occurred in two patients and severe, moderate or mild septic loosening in four, nine and 11 patients, respectively. Diagnostic accuracy for severe infection was 100% for both readers, whereas for moderate infection accuracy decreased by 12% and 12% for readers one and two, respectively. For mild infection a further decrease of approximately 61% and 52% occurred for readers one and two, respectively. Quantitative evaluation gave significantly better results over visual interpretation with a diagnostic accuracy of 100% for severe infection and decreased by only 10% and 15% in patients with moderate and mild infection, respectively. Quantitative evaluation of (99m)Tc-Fab' fragments is highly sensitive and specific for diagnostic imaging of infection in patients with septically-loosened TKA.

[Nuclear medical imaging in case of painful knee arthroplasty]. / Nuklearmedizinische Diagnostik bei schmerzhafter Knieprothese.

RATIONALE: The aim of the present study was to calculate the overall diagnostic accuracy of nuclear medical imaging in patients with painful knee arthroplasty. MATERIAL AND METHODS: This retrospective study of all patients (n=87) where a (99m)Tc-triple phase bone scintigraphy (TPBS; n=120) and (99m)Tc-anti-granulocyte scintigraphy (BW 250/183; n=20) for a painful knee arthroplasty was performed between 2003 and 2007. RESULTS: A total of 87 patients with 94 knee arthroplasties were examined to detect septic and aseptic loosening and to differentiate between them. The sensitivity, specificity, the positive and negative predictive value and accuracy of TPBS for the detection of septic knee arthroplasty loosening was 100%, 85%, 55%, 100%, 73% and for BW 250/183 was 91%, 66%, 76%, 85%, 80% for sepsis, respectively. A significant increase in diagnostic accuracy with 94%, 88%, 89%, 95% und 89% (p <0.001) could be achieved when both methods were used in combination. CONCLUSION: Both methods alone have high negative predictive values, but the combination of both is complementary and significantly increases the diagnostic accuracy and positive predictive value for final diagnosis of knee arthroplasty loosening.

Secretion of angiogenic proteins by human multipotent mesenchymal stromal cells and their clinical potential in the treatment of avascular osteonecrosis.

Osteonecrosis is a frequent complication after treatment for childhood leukemia and other steroid-based therapies. The success rate of core decompression surgery is limited. Therefore, we evaluated relevant biological characteristics of human multipotent mesenchymal stromal cells (MSCs) in vitro. MSCs cultured under low-oxygen tensions showed decreased proliferation and differentiation into bone. However, these MSCs secreted significant amounts of vascular endothelial-derived factor in the presence of interferon-gamma. These in vitro results with potential effects on neovascularization and bone regeneration as well as findings in animal models prompted us to treat five patients with steroid-induced osteonecrosis of the femur by core decompression surgery and instillation of expanded autologous MSCs. Within 3 weeks of culture, sufficient numbers of MSCs were generated using animal protein-free culture conditions. No chromosomal aberrations were detected by matrix-based comparative genomic hybridization. Application of MSCs during core decompression was feasible and safe. Median follow-up is 16 months and the patients in this pilot study reported clinical improvement. Formation of mineralized bone in the osteonecrotic cavity was proven by computed tomography. Taken together, MSCs display biological properties that may add to the efficiency of surgical treatment in osteonecrosis and should be evaluated in larger patient cohorts.

Chopart's joint load during gait. In vitro study of 10 cadaver specimen in a dynamic model.

BACKGROUND: Chopart's joint is fundamental to foot function. Until today, intra-articular force and peak pressure has not been investigated under dynamic conditions. METHODS: The study used a cadaver model to measure intra-articular force and peak pressure with electronic sensors. Force was applied to extrinsic tendons via cables attached to computer-regulated hydraulic cylinders. A ground reaction force of 350 N was simulated in a tilting angle- and force-controlled translation stage. RESULTS: We observed a characteristic rising curve with a peak during push-off for intra-articular force and peak pressure. The increase of intra-articular force at the talonavicular and calcaneocuboid joint from a low level at heel-on varies up to a maximum of 174 N/149 N and a peak pressure of 3877 kPa/3396 kPa, respectively, at push-off. We observed highest loading at the dorsal aspect of the talonavicular joint and the plantar aspect of calcaneocuboid joint. CONCLUSION: The highest loading on Chopart's joint is attained during push-off. We observe higher force and peak pressure on the medial column of the foot compared to the lateral column. The higher load of the dorsal aspect of talonavicular joint and plantar aspect of calcaneocuboid joint confirms the theory of a previous described locking mechanism for forceful push-off.

[Foreign blood saving measures in orthopedic surgery]. / Fremdblutsparende Massnahmen bei orthopädischen Eingriffen.

Major transfusion-free orthopaedic surgery can be performed successfully. This requires advanced planning, good routines and close collaborative team efforts. Since most blood saving techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative and postoperative blood saving approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, intraoperative autotransfusion, individualized assessment of anemia tolerance, meticulous surgical techniques and the use of pharmacologic agents for limiting blood loss. For various reasons, we do not recommend the transfusion of wound drainage. This article describes the various methods for bloodless medical care.

K-wire transfixation or distraction following the Keller-Brandes arthroplasty in Hallux rigidus and Hallux valgus?

A total of 118 feet with Hallux valgus and Hallux rigidus treated by the Keller-Brandes method were re-examined clinically and radiologically after 9.1 years (range: 1.7-24.3). Correction of the Hallux valgus angle was obtained from an average of 40 degrees to 23 degrees in the Hallux valgus group. Improvement in the postoperative range of motion was observed when the aftertreatment consisted of Kirschner-wire distraction instead of an axial Kirschner-wire transfixation. The patients who underwent Keller-Brandes surgery for Hallux valgus had less pain when the aftertreatment was carried out using an axial Kirschner wire, while those operated on for Hallux rigidus had less pain when the aftertreatment consisted of distraction. The percentage of satisfied or very satisfied patients with the cosmetic results of the Keller-Brandes arthroplasty was more than 66.7%. Patients with Hallux valgus and postoperative aftertreatment with Kirschner wire transfixation were the most satisfied patients, while patients with Hallux rigidus were very satisfied with the postoperative distraction. Our good results are comparable to those in other studies and confirm the success of the Keller-Brandes resection arthroplasty in Hallux valgus with osteoarthritis of the first metatarsophalangeal joint in older patients whose demand for movement is less, and in Hallux rigidus in less active older patients.

[Prediction of the location of the centre of rotation of the hip joint external landmarks]. / Die Bestimmbarkeit des Hüftrotationszentrums anhand palpabler Landmarken des Beckens.

AIM: The object of this study was to develop a new method to predict the location of the centre of rotation of the hip joint reasonably accurately. METHOD: We collected the coordinates of palpable bony landmarks in 50 patients, 25 males and 25 females, using CT scans to predict the physiological location of the centre of the hip joint centre. RESULTS: The centre of the hip was located, on average, at 12% (+/- 2.9) of the inter-ASIS (anterior superior iliac spine) distance medial, 33% (+/- 3.9) distal and 19% (+/- 2.7) posterior to the anterior superior iliac spine (ASIS). CONCLUSION: Knowledge of the physiological centre of rotation of the hip may be useful in navigation of the cup in total hip arthroplasty.

[Postoperative autologous transfusion from blood drainage after total hip joint arthroplasty--how much value is really there?]. / Postoperative Rücktransfusion von Drainageblut in der Hüft-Endoprothetik--Wie gross ist der Nutzen wirklich?

AIM: Are autologous blood transfusions sufficient or do we need the transfusion of unwashed or washed wound drainage blood in total hip arthroplasty? METHOD: 253 patients undergoing total hip arthroplasty were retrospectively randomized to autologous blood transfusion or transfusion of unwashed wound drainage. We compared the haemoglobin and haematocrit levels as well as the rate of complications. RESULTS: Postoperative blood salvage and reinfusion after total hip joint arthroplasty didn't show any advantages. In 10 % we saw complications after transfusion of unwashed wound drainage. CONCLUSION: We do not recommend the transfusion of wound drainage.

[Pigmented villonodular synovitis]. / Seltene Schleimhauterkrankung zerstört die Gelenke. Frühzeitige Diagnose erspart Gelenkersatz.

Pigmented villonodular synovitis (PVNS) is a rare, strongly proliferative disease of the lining of thejoint, synovial bursa and tendon (synovial) sheath. If left untreated, it leads to severe destruction of the joint resulting in an early need for endoprosthetic replacement. The clinical signs are unspecific. Using the diagnostic gold standard MRI, the complete extent of PVNS can usually be determined non-invasively. Once histological confirmation has been obtained, radical tumor resection, synovectomy, possibly curettage, and postoperative irradiation must be applied.

[Quantification and visualization of the influence of pelvic tilt upon measurement of acetabular inclination and anteversion]. / Quantifizierung und Visualisierung des Einflusses der Beckenkippung auf die Messung von Pfanneninklination und -anteversion.

AIM: The indication of acetabular inclination and anteversion not only depends on definition but also on a correctly aligned patient. Determination of anteversion and inclination according to Sven-Johannsson and Visser were simulated with 3D calculations. The influence of pelvic tilt in relation to the frontal plane was evaluated and visualized. METHOD: With 3D calculations of planar X-ray photographs for artificial hip cups the normal vector of the acetabular cup was used to calculate anteversion and inclination. RESULTS: The main axis of the projected acetabular rim is equally suited to determine the cup orientation as the normal vector of the cup plane. Pelvic tilt of about 10 degrees causes measuring errors of about 8 degrees when measured with conventionally used techniques. CONCLUSION: For the correct determination of cup orientation pelvic tilt in relation to the frontal plane has to be accounted for.

[Postsurgical computed tomography of uncemented hip arthroplasty]. / Postoperative Computertomographie zementfreier Hüftprothesenschäfte.

PURPOSE: Presentation of the value of postsurgical computed tomography (CT) to diagnose loosening of uncemented femoral stems. MATERIALS AND METHODS: Incremental CT and spiral CT were performed on six femora with implanted uncemented stems after the entire femora were embedded in polymethylmethacrylate. The femora were subsequently sectioned (thickness 1 mm, separation 8 mm) and the medial and lateral contact areas of the prosthetic stem compared with the CT data. RESULTS: The CT showed a contact of femoral stem and cortical bone between 0.4 mm (3.4 %) and 4.8 mm (47.1 %) and the section specimens between 0.9 mm (8.7 %) and 3.4 mm (36.7 %). No correlation was found between the results (r = 0.61), since the individual differences were up to 24 % in almost all sections. CONCLUSIONS: Neither single-slice nor two-slice CT is capable of demonstrating the direct bone-endoprosthesis contact. Multidetector row CT (MDCT) is conceivably more accurate to measure the cortical contact of the femoral stem.

[Clinical and radiological results of individual hip stems of the type Adaptiva(R) without cement]. / Klinische und radiologische Ergebnisse der zementfreien individuellen Hüftendoprothese vom Typ Adaptiva(R).

AIM: Long-term anchorage of foreign material in vital bone has proven to be the main problem in hip arthroplasty. Bone cement, a material for filling and fitting, allows an excellent solution for older people. Many failures have been blamed on the use of polymethylmethacrylate in younger patients. In our opinion, modelling a stem to the individual anatomic needs of younger patients and to implant it without cement but with a stable press-fit is a good way to transmit stress harmoniously from the prosthesis to the bone and to obtain a long-lasting function. This individual hip stem is now available in the third generation under the name Adaptiva(R). We would like to present our first results. METHOD: Between October 1993 and September 1995 150 individual hip prosthesis of the Adaptiva(R) type have been implanted. In the average the patients were 53,2 years old. The average time of follow-up was 19.9 (12 to 44) months. RESULTS: The Merle d'Aubigné score showed excellent absolute and relative results for pain, mobility and ability to walk. No aseptic loosening of the stem occurred. CONCLUSION: Our early results are promising, but we have to wait for the long-term results, which are part of a current study.

[Proteus syndrome: a case report]. / Proteus-Syndrom: Ein Fallbericht.

The Proteus-syndrome is a recently described congenital hamartomatosis consisting of numerous clinical features of great variety. Mainly affected are the musculo-skeletal system, primarily by hemihypertrophy, macrodactyly and exostoses, and the skin and the subcutaneous tissue, primarily by pigmented naevi and subcutaneous tumors. The differential diagnosis includes other malformation syndromes, e. g. Klippel-Trenaunay-Weber syndrome and other hamartomatosis. Surgical intervention and treatment is difficult because of a frequency of complications and recurrences. This article describes clinical manifestations of Proteus syndrome, differential diagnosis and therapeutic strategies.

The Wagner revision stem in alloarthroplasty of the hip.

Forty-one Wagner revision stems were implanted at the Orthopedic Department of the University of Tübingen between July 1990 and January 1993. We report the results of 37 patients at an average follow-up of 27 months (13-48 months) postoperatively. The main indication was stem loosening with considerable loss of bone. In addition, we used the implant 4 times in primary arthroplasty. At follow-up examination 33 patients (89%) were satisfied with the postoperative outcome. According to the Merle D'Aubigné score (12-point scale), 32 patients showed a poor functional result of less than 6 points preoperatively. Postoperatively, the results of 36 patients could be classified as very good to good. To categorise the radiological destruction of the implant bed, we used the femoral shaft defect classification of the DGOT (Deutsche Gesellschaft für Orthopädie und Traumatologie) in conjunction with the classification of Pak and Paproski [5, 11]. Twenty patients presented with trochanteric and calcar defects, and 11 patients with a combination of a calcar and shaft defect. We found a circular shaft defect in 2 patients. In 7 cases we assessed the bone remodelling postoperatively as very good, with strong newly formed bone structures, and in 25 cases as good, with remodelling of the old stem bed and bony structuring of the osteolyses. A secondary sinking in of the Wagner stem was seen in 7 cases. Only one stem had to be revised because of pain symptoms and loosening; in all other cases a secondary stabilisation of the revision-stem took place. With the Wagner revision stem, there is the possibility of achieving mechanical stability even in situations with massive bone loss. The evacuation of bone cement and granulation tissues is facilitated by the transfemoral approach, bony remodelling is accelerated, and bone grafting is often not necessary. As our short-term results show, the concept is a promising one. Nevertheless, we will be very careful in following these patients in the long term, as we have noticed stem sinkage in a small percentage of cases.