[Morbid obesity in total knee arthroplasty: a critical case review]. / Morbide Adipositas in der Knieendoprothetik: Eine kritische Einzelfallbetrachtung.

HISTORY AND ADMISSION FINDINGS: In a 66-year-old obese woman (WHO stage III, BMI 51 kg/m2) pronounced osteoarthritis of the right knee was diagnosed. Because of progressive chronic pain of the right knee joint her walking distance was limited to a few meters. Conservative therapy was exhausted. INVESTIGATIONS: Clinical examination showed a restricted and painful range of motion of the right knee and distinctive obeseness on the trunk and the extremities including a lipedema/lymphedema. TREATMENT AND COURSE: After a complicated course of treatment lasting for 220 days the total knee replacement ended in an arthrodesis combined with a gastrocnemius muscle flap. CONCLUSION: With respect to this case the high complication-rates in obese patients should be taken into account: Total knee replacement can even lead to loss of the limb in the worst case. In addition to extended preoperative examination this indication should be critically scrutinized.

[Arthropathia ochronotica: a rare cause of early joint degeneration]. / Arthropathia ochronotica: eine seltene ursache frühzeitiger gelenkdegeneration.

HISTORY AND ADMISSION FINDINGS: A 70-year-old deaf-mute women suffered from progressive chronic pain of the right hip joint caused by destructive osteoarthritis of the hip. INVESTIGATIONS: In addition to painfully restricted range of motion of the right hip joint the clinical examination showed a bluish-black pigmentation of the ear-cartilage and the sclera. TREATMENT AND COURSE: A total endoprosthetic replacement of the right hip joint was performed. During surgery, blackening of the hip joint capsule and cartilage was found. Histological, the diagnosis of an ochronosis was confirmed. Discoloration after exposure of urine to air supported the diagnosis. Based on extensive internal medical examination relevant cardiac changes were excluded. CONCLUSION: Ochronosis (arthropathia ochronotica) is a rare entity which can be identified by a visual diagnosis. Early diagnosis can provide crucial information for the prognosis. Additionally, an interdisciplinary treatment concept should be established because of the early onset of degenerative changes at the skeletal system and pathological changes at internal organs. With suspicion on an ochronosis extended internal examinations are recommended in order to avoid complications.

Intraosseous foreign body granuloma in rotator cuff repair with bioabsorbable suture anchor.

Biodegradable implants lead to problems such as cyst formation, soft-tissue inflammation, loose implant fragments or local osteolysis. This report represents the first published case of an intraosseous foreign body granuloma in the humeral head after arthroscopic rotator cuff tear fixation with a poly-L: -lactide (PLLA) suture anchor. A 48-year-old female patient presented with pain in her right shoulder. A refixation of her right supraspinatus tendon with a biodegradable suture anchor was performed 11 months ago at an external hospital. Laboratory tests showed normal values for C-reactive protein, leukocytes and the erythrocyte sedimentation rate. No signs of infection or instability were noted. The visual analogue scale (VAS) was 8, the simple shoulder test (SST) was 4 and the American shoulder and elbow surgeons score (ASES) was 44. Plain radiographs showed high lucency in the area of the tuberculum majus. MRI showed an intra- and extraosseous mass surrounded by fluid in this area. Surgical care involved arthroscopic debridement and removal of the suture anchor. Histological examination revealed a foreign body granuloma. At the 18-month follow-up the patient was nearly pain-free. The VAS was 2, SST was 10 and ASES was 88. Foreign body granulomas are a well known but rarely described complication that arises after the use of biodegradable suture anchors in shoulder surgery. Every patient presenting with shoulder pain after usage of a biodegradable fixation material should be evaluated closely. Orthopaedic surgeons should be aware of the possibility of delayed foreign body reactions, especially after using PLLA anchors.