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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. Keywords: Rheumatoid arthritis, neuropathic osteoarthropathy, foot deformities, arthrodesis, Charcot foot.

The diagnostic accuracy of infection scintigraphy with99mTc-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 of99mTc-Fab' fragments is highly sensitive and specific for diagnostic imaging of infection in patients with septically-loosened TKA.

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.

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.

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.

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 three-phase 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.

Ziel der vorliegenden Studie war die Bewertung der diagnostischen Treffsicherheit nuklearmedizinischer Untersuchungstechniken bei Patienten mit schmerzhafter Knieprothese. Zwischen 2003 und 2007 wurden 87 Patienten mit schmerzhafter Knieprothese sowohl mit der 99mTc-Dreiphasenskelettszintigraphie (99mTc-Dreiphasen-DPD; n=120) als auch mit 99mTc-anti-Granulozyten-Antikorpern (Behring-Werke 250/183; n=20) untersucht. Ausgewertet wurden 87 Patienten mit 94 Knieprothesen mit Verdacht auf septische Prothesenlockerung. Sensitivitat, Spezifitat, positiver und negativer pradiktiver Wert sowie die diagnostische Genauigkeit mit der 99mTc-Dreiphasen-DPD zur Unterscheidung zwischen septischer und aseptischer Knieprothesenlockerung betrugen 100, 85, 55, 100, 73 und bei BW 250/183 91, 66, 76, 85, 80%. Ein signifikanter Zugewinn an diagnostischer Genauigkeit mit entsprechend 94, 88, 89, 95 und 89% (p

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.

Chopart's joint is fundamental to foot function. Until today, intra-articular force and peak pressure has not been investigated under dynamic conditions.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.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.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.

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.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.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).Knowledge of the physiological centre of rotation of the hip may be useful in navigation of the cup in total hip arthroplasty.

Are autologous blood transfusions sufficient or do we need the transfusion of unwashed or washed wound drainage blood in total hip arthroplasty?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.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.We do not recommend the transfusion of wound drainage.

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.

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.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.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.For the correct determination of cup orientation pelvic tilt in relation to the frontal plane has to be accounted for.

Presentation of the value of postsurgical computed tomography (CT) to diagnose loosening of uncemented femoral stems.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.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.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.

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.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.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.Our early results are promising, but we have to wait for the long-term results, which are part of a current study.

Die Schultergelenksinstabilitat ist als eine klinische Diagnose anzusehen. Die zentrale Bedeutung der klinischen Untersuchung muss insbesondere bei den zunehmenden Moglichkeiten einer modernen bildgebenden Diagnostik immer wieder betont werden. Ein Vergleich der klinischen Untersuchung mit bildgebenden Verfahren zeigt eine hohere Sensitivitat und Spezifitat der klinischen Untersuchung der Schultergelenksinstabilitat gegenuber der MRT auf (Liu et al. 1999).

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.