[The interesting case: schwannoma of the nervus pudendus after triple pelvic osteotomy according to toennis]. / Der interessante Fall: Schwannom des Nervus pudendus nach Triple-Osteotomie nach Tönnis.

Schwannomas (neurilemmomas) are benign neural sheath tumours which commonly arise from cranial nerves and cutaneous nerves of the head and neck. The most common site is the acoustic neuroma of the 8th cranial nerve. Pelvic schwannomas are rare and often present with non-specific symptoms leading to misdiagnosis and prolonged morbidity. Most cases of pelvic schwannoma have been reported in the gynaecological and urological literature due to their presentation as a pelvic mass or from urinary tract compression. We present a schwannoma of the nervus pudendus with clinical, radiological, MRI scan and intraoperative findings together with a description of the technique of surgical resection.

[Long-term results of the cementless Hofer-Imhof threaded titanium cup]. / Langzeitergebnisse der zementfreien Hofer-Imhof-Titan-Schraubpfanne.

AIM: This retrospective monocentre study investigates long-term results of the cementless parabolic-shaped HI threaded cup. MATERIAL AND METHODS: 678 threaded cups made of titanium were implanted into 641 patients from November 1991 to May 1995. Mean age was 67 years, 65 % female, 35 % male. From December 2005 until October 2006, 165 patients (168 hips) underwent complete clinical and radiological follow-up, data of the remaining group were taken from the files. Using the Kaplan-Meier method, survival rates of the threaded cup were calculated. RESULTS: For all patients the average survival time of the cup was 14.2 years, the corresponding survival probability was 93 % (+/- 3.7 %) after 14.5 years. For the patients with complete follow-up, average survival time of the cup was 14.0 years, the corresponding survival probability was 93 % (+/- 5.2 %) after 14.5 years. CONCLUSION: Our results are comparable to those of threaded cups with a conical design (Zweymüller), the HI threaded cup can thus be recommended for primary implantation.

[Septic arthritis caused by erysipelotrix rhusiopathiae: case report and review of the literature]. / Kniegelenksinfekt mit Erysipelotrix rhusiopathiae: Fallbericht und Ubersicht der internationalen Fachliteratur.

A 68-year-old man presented at our department with a suspected bacterial arthritis of the left knee. All diagnostic measures confirmed this diagnosis and the detected germ was Erysipelothrix rhusiopathiae. After arthroscopic debridement of the left knee, intravenous and oral antibiotic treatment for a total of 6 weeks, the patient was treated by total knee arthroplasty 6 months after the first presentation. The postoperative follow-up was without any pathological findings. There are only 4 other case reports in the international literature of Erysipelotrix rhusiopathiae linked to septic arthritis in humans. This case report of an infected knee further illustrates the pathogenicity of Erysipelothrix rhusiopathiae in humans.

[The interesting case: Nora's lesion of the big toe]. / Der interessante Fall: Nora-Läsion der Grosszehe.

"Bizarre parosteal osteochondromatous proliferations" are extremely rare manifestations first described by Nora and only a few more than 100 cases have been described in the international literature. In spite of clinically resembling an osteochondroma, a subungual exostosis or a parosteal osteosarcoma, the lesion is characterised by distinct radiological and histological findings. The lesion is defined as a reactive heterotopic ossification and is mostly found in the hands and feet of adults in the third decade of life. A high rate of local recurrence of up to 50% has been described, but since it is defined as a benign lesion no metastases can be found. We report the instructive case of a BPOP ("Nora's lesion") in the area of the proximal phalanx of the big toe in which, after performing a biopsy, a resection of the lesion under preservation of the big toe was performed. At the last follow-up examination (4 years postoperatively) the patient showed no sign of recurrence of the lesion. The clinical, radiological and MRI appearance of the lesion are described together with the distinct clinical findings.

[Total hip replacement in high total hip dislocation by performing a Z-shaped shortening osteotomy]. / Die endoprothetische Versorgung der Koxarthrose bei kongenitaler Hüftgelenksluxation: Implantation einer Hüfttotalendoprothese kombiniert mit Z-förmiger Verkürzungsosteotomie des Femurs.

AIM: Total hip arthroplasty for severe chronic proximal femoral migration, most commonly seen in congenital dislocation of the hip, has been associated with high rates of complications. Placement of the acetabular component in the true acetabulum has yielded the most durable results, but leads to significant limb lengthening. In this paper six cases of a total hip arthroplasty combined with a Z-shaped osteotomy of the proximal femur are described. METHOD: All patients presented with a complete congenital dislocation of the hip. In all procedures the acetabular component was placed in the true acetabulum and the proximal femur was shortened according to a preoperative drawing in a Z-shaped manner. RESULTS: The clinical and radiological results of the patient collective are presented in this study, the mean follow-up period was 60 months. At the last follow-up no nerve palsy, osteotomy pseudarthrosis or dislocation were detected objectively. CONCLUSION: The performed procedure seems to be a viable technique in the treatment of coxarthritis in high total hip dislocation.

Lymphoscintigraphy using (99m)Tc filtered sulfur colloid in chylothorax: a case report.

OBJECTIVE: A 66-y-old man was diagnosed with esophageal carcinoma and underwent a right thoracotomy and esophagectomy. Postoperatively, a recurring right pleural effusion developed. Because an attempt at lymphangiography failed, lymphoscintigraphy was suggested. Because of the inability to obtain radiolabeled albumin, dextran, or nanocolloid, we used filtered sulfur colloid. (0.1 um). The study confirmed the diagnosis of chylothorax.

Sestamibi/iodine subtraction single photon emission computed tomography in reoperative secondary hyperparathyroidism.

BACKGROUND: Sestamibi/iodine subtraction single photon emission computed tomography (SPECT) has been used successfully for the preoperative localization of adenomatous and hyperplastic parathyroid tissue in primary hyperparathyroidism, but the clinical usefulness of this technique in secondary hyperparathyroidism remains uncertain. The purpose of this study was to evaluate parathyroid localization that uses sestamibi/iodine subtraction SPECT in patients with secondary hyperparathyroidism before reoperative parathyroid surgery. METHODS: Fourteen consecutive patients with chronic renal failure and secondary hyperparathyroidism who had previously undergone total parathyroidectomy combined with parathyroid autotransplantation in a sternocleidomastoid muscle were studied. Before reoperation, each patient received 400 microCi of sodium iodide I 123 orally and 20 to 25 mCi of technetium Tc 99m ((99m)Tc)-sestamibi intravenously, followed by sestamibi/iodine subtraction SPECT of the neck and chest. At surgery, the location, weight, and histopathologic results of all identified parathyroid tissue were recorded. RESULTS: At surgery, 1 hyperplastic parathyroid gland was resected from each of 13 patients; including 1 undescended gland, 6 parathyroid autotransplants, and 5 mediastinal glands. The mean weight of the resected parathyroid glands was 1707 mg (range, 85-5300 mg). Sestamibi/iodine subtraction SPECT correctly identified and localized all 13 parathyroid glands (100% sensitivity) and was negative in the 1 patient whose surgery was unsuccessful. CONCLUSIONS: The (99m)Tc-sestamibi/(123)I subtraction SPECT is able to correctly localize hyperplastic parathyroid tissue in patients with secondary hyperparathyroidism who have previously undergone parathyroid surgery and is a clinically useful study before reoperation.

Scintigraphic detection of post-pneumonectomy bronchopleural fistulae.

A total of 20 ventilation studies [16 with xenon-133 and four with technetium-99m diethylenetriamine pentaacetic acid (DTPA)] were performed in 11 patients with suspected post-pneumonectomy bronchopleural fistulae. The findings on the ventilation scan were correlated with bronchoscopy, taken as the gold standard for purposes of comparison. The sensitivity and specificity for 133Xe scans were 83% and 100% respectively, while the sensitivity for 99mTc-DTPA aerosol studies was poor at 0%. Special techniques for optimal visualization of the fistulae are enumerated.

Parathyroid detection in secondary hyperparathyroidism with 123I/99mTc-sestamibi subtraction single photon emission computed tomography.

123I/99mTc-sestamibi subtraction single photon emission computed tomography (SPECT) has been proposed to detect hyperplastic parathyroid tissue, but the clinical usefulness of this technique in secondary hyperparathyroidism is uncertain. The purpose of this study was to evaluate preoperative parathyroid localization using 123I/99mTc-sestamibi subtraction SPECT in patients with renal failure and secondary hyperparathyroidism. Nineteen patients with chronic renal failure and secondary hyperparathyroidism underwent 123I/99mTc-sestamibi subtraction SPECT imaging preoperatively. None of these patients had undergone previous neck surgery. The location, weight, and histopathological results of all identified parathyroid glands were recorded. Surgery was considered successful in all patients, with resection of a total of 74 hyperplastic parathyroid glands. 123I/99mTc-sestamibi subtraction SPECT correctly identified 57 of these parathyroid glands (77% sensitivity). The mean weight among the true positive glands (n = 57) was 1031 mg (range, 45-7900 mg), and that among the false negative glands (n = 17) was 465 mg (range, 20-1800 mg). This difference between the mean weights was statistically significant (P = 0.018). There was a positive correlation between parathyroid weight and detectability with 123I/99mTc-sestamibi subtraction SPECT (Spearman correlation = 0.28; P = 0.0167). 123I/99mTc-sestamibi subtraction SPECT is able to correctly localize hyperplastic parathyroid glands in patients with renal failure and secondary hyperparathyroidism, but there is a fairly weak relationship between preoperative detection rate and anatomical parathyroid gland size.

Comparison of double-phase 99mTc-sestamibi with 123I-99mTc-sestamibi subtraction SPECT in hyperparathyroidism.

OBJECTIVE: Our purpose was to compare double-phase 99mTc-sestamibi single-photon emission computed tomography (SPECT) and simultaneous 123I-99mTc-sestamibi subtraction SPECT for preoperative localization of hyperfunctioning parathyroid tissue in patients with primary hyperparathyroidism. SUBJECTS AND METHODS: Fifteen patients with primary hyperparathyroidism underwent preoperative double-phase 99mTc-sestamibi SPECT and simultaneous 123I-99mTc-sestamibi subtraction SPECT imaging. At surgery, the location, weight, and histopathologic evaluation of all identified parathyroid glands were recorded. RESULTS: At surgery, 17 parathyroid adenomas and 37 normal parathyroid glands were identified. The sensitivity, specificity, and diagnostic accuracy for the detection of parathyroid adenomas were 88%, 97%, and 94%, respectively, for simultaneous 123I-99mTc-sestamibi subtraction SPECT and 53%, 86%, and 76%, respectively, for double-phase 99mTc-sestamibi SPECT. The differences in sensitivity and diagnostic accuracy were statistically significant (p = .031 and p = .016, respectively). CONCLUSION: Compared with double-phase 99mTc-sestamibi SPECT, simultaneous 123I-99mTc-sestamibi subtraction SPECT is a superior imaging study for the preoperative localization of hyperfunctioning parathyroid tissue.

Preliminary experience with double-phase SPECT using Tc-99m sestamibi in patients with hyperparathyroidism.

BACKGROUND: There is a continual search for a better imaging modality for parathyroid pathology. In recent years, Tc-99m sestamibi has been proposed as an alternative to T1-201 for parathyroid scintigraphy. The purpose of this study is to assess the usefulness of a double-phase Tc-99m sestamibi SPECT technique for parathyroid imaging. METHODS: Sixty-one consecutive patients with hyperparathyroidism were studied. Sixteen had previously undergone unsuccessful surgery for hyperparathyroidism. SPECT imaging of the neck and chest was performed at 15 minutes and again at 2 hours after 20-25 mCi of Tc-99m sestamibi was given intravenously. A positive scan was defined as a region of increased focal uptake that persisted on the delayed images. RESULTS: When compared with surgical findings, double-phase sestamibi SPECT correctly identified 55% (26/ 47) of the parathyroid adenomas in the previously unoperated group, and 91% (10/11) of the parathyroid adenomas in the reoperative group. Double-phase sestamibi SPECT was negative in 92% (109/118) of the normal parathyroid glands in the previously unoperated group, and in 88% (15/17) in the reoperative group. CONCLUSIONS: These preliminary data suggest that double-phase Tc-99m sestamibi SPECT is a promising procedure for the preoperative detection and localization of hyperfunctioning parathyroid tissue, especially in patients with recurrent or persistent postoperative hyperparathyroidism.

Myocardial viability studies using fluorine-18-FDG SPECT: a comparison with fluorine-18-FDG PET.

UNLABELLED: Multidetector SPECT systems equipped with a high-energy, or 511-keV collimator, have been proposed to offer a less expensive alternative to PET in myocardial viability studies with [18F]FDG. The objectives of this investigation included: (a) measuring the physical imaging characteristics of SPECT systems equipped with either a high-energy general-purpose collimator (HE), or the dedicated 511-keV collimator (UH), when imaging 511-keV photons, and comparing them with conventional FDG PET; and (b) directly and quantitatively comparing the diagnostic accuracy of SPECT, with either an UH or HE collimator, to that of PET in myocardial viability studies using 18F-FDG. METHODS: Physical imaging characteristics of SPECT and PET were measured and compared. Both SPECT and PET studies were performed in two groups of 18 patients each, with Group I using HE SPECT and Group II using UH SPECT. Myocardial perfusion studies were also performed using 82Rb PET at rest and during dipyridamole stress to identify areas of persistent hypoperfusion. For each myocardial region with a persistent perfusion defect, a perfusion-metabolism match or mismatch pattern was established independently, based on the results of 18F-FDG SPECT as well as PET. RESULTS: PET is superior to SPECT in all physical imaging characteristics, particularly in sensitivity and contrast resolution. PET had a sensitivity 40-80 times higher than that of SPECT, and its contrast resolution was 40-100% better than SPECT. Between FDG-SPECT using an HE collimator and that using a 511-keV collimator, the latter showed marked reduction in septal penetration (from 56% to 38%), improvement in spatial resolution (from 17 mm to 11 mm FWHM) as well as contrast resolution (from 34% to 45%), while suffering reduced system sensitivity (from 75 to 34 cpm/microCi). Patient studies demonstrated that although FDG-SPECT, using a HE or UH collimator, provided concordant viability information as FDG PET in a large majority of myocardial segments with persistent perfusion defects (88% and 90%, respectively), there is an excellent statistical agreement (kappa = 0.736) between SPECT with UH collimator and PET, while the agreement between SPECT using HE collimator and PET are moderate (kappa = 0.413). CONCLUSION: Despite its markedly inferior physical imaging characteristics compared with PET, SPECT with the dedicated 511-keV collimator offers a low-cost, practical alternative to PET in studying myocardial viability using [18F]FDG. SPECT systems with a high-energy, general-purpose collimator, on the other hand, are inadequate in such studies.

Regional body FDG-PET in postoperative recurrent hyperparathyroidism.

PURPOSE: The use of preoperative imaging studies in patients with persistent or recurrent hyperparathyroidism after initial operation is generally accepted to improve the success rate and minimize the morbidity from reoperative surgery. The purpose of this study was to define the performance of FDG-PET for the localization of hyperfunctioning parathyroid tissue prior to reoperation. METHOD: Twenty patients with biochemical evidence of recurrent or persistent hyperparathyroidism following previous neck surgery were investigated. Regional body PET imaging of the neck and upper chest (axial field of view 27.5 cm) was acquired 45 min after 5-10 mCi FDG was given intravenously. RESULTS: Subsequent surgery revealed solitary parathyroid adenomas in 14 patients, seven hyperplastic glands in 2 patients, and parathyroid carcinoma in 1 patients. FDG-PET correctly identified 79% (11/14) of the parathyroid adenomas, 29% (2/7) of the hyperplastic glands, and the parathyroid carcinoma. FDG-PET was negative in 79% (30/38) of the surgically identified normal parathyroid glands. Eight false-positive findings led to a positive predictive value of 64%. CONCLUSION: These preliminary data suggest that regional body FDG-PET is a promising procedure in the evaluation of patients with persistent or recurrent postoperative hyperparathyroidism.

Recurrent postoperative parathyroid carcinoma: FDG-PET and sestamibi-SPECT findings.

Parathyroid carcinoma is a rare cause for primary hyperparathyroidism. A 65-yr-old man presented with postoperative, recurrent hyperparathyroidism after resection of parathyroid carcinoma. Misleading findings were demonstrated by both double-phase 99mTc-sestamibi scintigraphy and MRI. The location and extent of the parathyroid carcinoma were correctly detected by PET using 18F-fluorodeoxyglucose. FDG-PET provided accurate information before reoperation and proved to be valuable for preoperative surgical planning.

Comparison of FDG-PET and sestamibi-SPECT in primary hyperparathyroidism.

UNLABELLED: Preoperative localization of hyperfunctioning parathyroid tissue in patients with primary hyperparathyroidism has been a longstanding diagnostic challenge. This study directly compared FDG-PET and sestamibi-SPECT for preoperative detection of abnormal parathyroid tissue. METHODS: Twenty-one consecutive patients with primary hyperparathyroidism were studied prospectively before surgical neck exploration. SPECT of the neck and chest was performed at 15 min and 2 hr after intravenous 99mTc-sestamibi. Regional body PET was performed 45 min after intravenous FDG. RESULTS: Surgery revealed 19 solitary parathyroid adenomas, 2 parathyroid adenomas in one patient; and 3 hyperplastic parathyroid glands in one patient, and 51 normal parathyroid glands. The diagnostic sensitivities for detection of parathyroid adenomas of 43% (9 of 21) for dual-phase sestamibi-SPECT and 86% (18 of 21) for FDG-PET were significantly different (p < 0.001). The difference in diagnostic specificities of 78% (40 of 51) for FDG-PET and 90% (46 of 51) for dual-phase sestamibi-SPECT approached statistical significance (p = 0.063). CONCLUSION: This study demonstrates that FDG-PET is more sensitive than sestamibi-SPECT in the preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism.

Parathyroid localization with technetium-99m-sestamibi: a prospective evaluation.

BACKGROUND: The purpose of this study was to prospectively evaluate parathyroid localization using technetium-99m-sestamibi (MIBI). STUDY DESIGN: Technetium-99m-sestamibi scintigraphy was performed in 124 patients with hyperparathyroidism and the results were correlated with serum calcium and parathyroid hormone (PTH) levels, weight, location, and pathology of parathyroid tissue, and associated thyroid abnormalities. RESULTS: Hyperparathyroidism was primary in 118 patients, secondary in four patients, and tertiary in two patients. The parathyroid pathology was a solitary adenoma in 95 patients (77 percent), double adenoma in five (4 percent), hyperplasia in 14 (11 percent), carcinoma in one (1 percent), and unconfirmed in nine (7 percent) who underwent noncurative parathyroidectomy. Associated thyroid disease was present in 29 (23 percent) patients. Fourteen patients (11 percent) had undergone previous parathyroid exploration. The mean calcium level was 11.4 +/- 0.8 mg/dL (range, 8.3 to 13.7 mg/dL) and the mean adjusted PTH level was 395 +/- 702 (range, 70 to 4,331). The sensitivity and positive predictive value of MIBI scintigraphy were 81 and 89 percent, respectively, in patients with a solitary adenoma and 37 and 100 percent, respectively, in patients with multiglandular disease. The mean adjusted PTH level was higher in patients with true-positive scans compared with false-negative scans (440 +/- 628 compared with 243 +/- 499, p > 0.05). The mean adenoma weight was 1,877 +/- 3,212 mg in patients with a true-positive scan compared with 485 +/- 296 mg with a false-negative scan (p > 0.05). CONCLUSIONS: The sensitivity and positive predictive value of MIBI scintigraphy is comparable to or better than the results reported for other localization procedures. Its lack of sensitivity for detection of multiglandular disease precludes its use in lieu of routine bilateral neck exploration in the management of patients with hyperparathyroidism.

The incidence of scintigraphically viable and nonviable tissue by rubidium-82 and fluorine-18-fluorodeoxyglucose positron emission tomographic imaging in patients with prior infarction and left ventricular dysfunction.

BACKGROUND: Although reversible perfusion defects, perfusion-metabolism mismatch and match patterns are important for differentiating viable from nonviable myocardium, the frequency of these scintigraphic patterns has not been reported. The study objective was to establish the incidence of these scintigraphic patterns to estimate the clinical need for metabolic positron emission tomography for evaluating tissue viability in patients with prior myocardial infarction (MI). METHODS AND RESULTS: 82Rb perfusion images were interpreted to identify reversible or irreversible defects, followed by determination of their 18F-fluorodeoxyglucose (18F-FDG) uptake pattern. In 155 patients with prior MI, analysis of 613 abnormal segments showed reversible perfusion defects in 13%. The 87% irreversible defects, 18% showed perfusion-metabolism mismatch, whereas 69% showed the match pattern. Reversible perfusion defects and perfusion-metabolism mismatches were noted in 20% (31/155) and 29% (45/155) of patients, respectively, whereas the match pattern was noted in 51% (79/155) of patients. CONCLUSION: Irreversible perfusion defects were common in our patients with prior MI, and distinction between viable and nonviable tissue was not possible by perfusion imaging alone. The identification of hibernating myocardium was possible only with the additional 18F-FDG imaging in about one third of patients. This indicates a significant clinical demand for 18F-FDG imaging that identifies patients who will benefit from revascularization.

Malignant pheochromocytoma of the anterior mediastinum: PET findings with [18F]FDG and 82Rb.

A case of a malignant pheochromocytoma arising from the anterior mediastinum is presented. We report the use of positron emission tomography with 82Rb and [18F]fluorodeoxyglucose to successfully image this neoplasm.