Thomas Böni

Unsuspected osteomyelitis is frequent in persistent diabetic foot ulcer and better diagnosed by MRI than by 18F-FDG PET or 99mTc-MOAB

Aim.  Prevalence, optimal diagnostic approach and consequences of clinically unsuspected osteomyelitis in diabetic foot ulcers are unclear. Early diagnosis of this infection may be crucial to ensure correct management.

Variability of Human Foramen Magnum Size

The foramen magnum is an important landmark of the skull base and is of particular interest for anthropology, anatomy, forensic medicine, and other medical fields. Despite its importance, few osteometric studies of the foramen magnum have been published so far. A total of 110 transverse and 111 sagittal diameters from Central European male and female dry specimens dating from the Pleistocene to modern times were measured, and related to sex, age, stature, ethnicity, and a possible secular trend. Only a moderate positive correlation between the transverse and the sagittal diameter of the foramen magnum was found. Surprisingly, neither sexual dimorphism, individual age‐dependency, nor a secular trend was found for either diameter. Furthermore, the relationship between the individual stature and foramen magnum diameters was weak: thus foramen magnum size cannot be used as reliable indicator for stature estimation. Further consideration of possible factors influencing the variability of human foramen magnum size shall be explored in larger and geographically more diverse samples, thus serving forensic, clinical, anatomical, and anthropological interests in this body part. Anat Rec, 2009.

Mammalian target of rapamycin (mTOR) inhibitors slow skin carcinogenesis, but impair wound healing.

Summary Background  Recent studies suggest that patients on mammalian target of rapamycin (mTOR) inhibitors experience a reduction in cutaneous carcinogenesis by an estimated 50% or more compared with calcineurin inhibitors. While randomized trials are running, organ transplant recipients are frequently switched from calcineurin inhibitors to mTOR inhibitors when cutaneous carcinogenesis increases.

Recurrence of acute Charcot neuropathic osteoarthropathy after conservative treatment.

Background: Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive-destructive process affecting the feet of patients with sensory neuropathy. Data on CN recurrence are underrepresented in the literature. The aim of the present study was to evaluate the rate of CN recurrence after its treatment and to find predisposing factors. Methods: Fifty-two patients (age 59 ± 11 years, 16 female) with acute CN with 57 affected feet were enrolled. Comorbidities, localization, and stage of disease at first diagnosis as well as ulcerations, need for surgery, noncompliance, and subsequent treatment (orthopedic footwear or orthotic treatment) during the course of therapy were recorded. During follow-up, the incidence of recurrence of CN was observed. Mean follow-up was 47 ± 40 months. Results: Diabetes was the most common reason for sensory neuropathy (79%). Recurrence of CN was seen in 13 feet (23%) with an interval of 27 ± 31 months (range, 3-102 months) after the end of initial immobilization. Patients with recurrence were immobilized for a shorter period of time and had a more advanced stage of CN at time of first diagnosis. Predictors of recurrence were noncompliance (odds ratio 19.7; confidence interval, 4.1-94.4; P < .001) and obesity (odds ratio 6.4; confidence interval, 1.6-25.9; P = .06). Conclusions: Recurrence of osteoarthropathic activity is a possible complication after conservative treatment of CN. Obesity and noncompliance are strong predictors for the recurrence of CN. Level of Evidence: Level III, retrospective comparative study.

Shedding New Light on the 18th Dynasty Mummies of the Royal Architect Kha and His Spouse Merit

The mummies of Kha and his wife Merit were found intact in an undisturbed tomb in western Thebes near the ancient workers’ village of Deir el-Medina. Previous MDCT (this abbreviation needs spelling out) investigations showed that the bodies of Kha and Merit did not undergo classical royal 18th Dynasty artificial mummification, which included removal of the internal organs. It was, therefore, concluded that the retention of the viscera in the body, combined with an absence of canopic jars in the burial chamber, meant the couple underwent a short and shoddy funerary procedure, despite their relative wealth at death. Nevertheless, all internal organs - brain, ocular bulbs/ocular nerves, thoracic and abdominal organs - showed a very good state of preservation, which contradicts the previous interpretation above. In order to better understand the type of mummification used to embalm these bodies, both wrapped mummies were reinvestigated using new generation X-ray imaging and chemical microanalyses Here we provide evidence that both individuals underwent a relatively high quality of mummification, fundamentally contradicting previous understanding. Elucidated “recipes”, whose components had anti-bacterial and anti-insecticidal properties, were used to treat their bodies. The time and effort undoubtedly employed to embalm both Kha and Merit and the use of imported costly resins, notably Pistacia, do not support the previously held view that the two individuals were poorly mummified. Despite a lack of evisceration, the approach clearly allowed their in situ preservation as well as affording a fairly successful mummification.

SSEP analysis in surgery of idiopathic scoliosis: the influence of spine deformity and surgical approach.

Abstract. The study was conducted to assess the possible impact of spine deformity in patients with idiopathic scoliosis (IS) on tibial nerve somatosensory evoked potentials (t-SSEPs) and the influence of spine correction upon postoperative SSEP recordings. In 61 consecutive patients undergoing 64 spinal instrumentations, 129 pre- and postoperative SSEPs were analyzed. The degree of spine deformity was assessed by the pre-operative Cobb angle of the major scoliotic curve. In a control group, reference values of t-SSEP latencies were established with respect to body height. In a cohort study, IS patients were compared with healthy controls with respect to t-SSEP latency, amplitude, configuration and interside difference. The results of the analysis showed that preoperative-body-height-corrected t-SSEP latencies were prolonged in 61% of patients, with a pathological interside difference in 23.4% of them. The impairment of t-SSEPs was not related to the extent of spine deformity as assessed by the Cobb angle. Even without occurrence of postoperative neurological deficits, postoperative t-SSEPs showed significantly increased latencies without changes in t-SSEP configuration. The prolongation of t-SSEP latencies was related to the surgical procedure (combined ventro-dorsal approach), but not to the extent of spine correction, level of instrumentation, or number of fused segments. The analysis of preoperative t-SSEPs was of no predictive value for intra- or postoperative neurological complications. t-SSEPs are significantly affected in IS patients, although these patients show no obvious clinical neurological deficits. The extent of t-SSEP impairment is not related to the severity of scoliosis. Even in clinically uneventful surgery, the postoperative t-SSEPs can be deteriorated depending on the surgical approach. This indicates a subclinical impact of spine surgery upon spinal cord function.

Management of the diabetic foot

Die Pravention und korrekte Behandlung eines Fusulkus bei Patienten mit Diabetes mellitus haben eine wichtige soziookonomische Bedeutung. Eine Einteilung in eine Risikostufe hilft, fruhzeitig geeignete Masnahmen zu ergreifen. Die Zuordnung in eine Risikostufe erfolgt mit gezielter Anamnese und korrekter klinischen Untersuchung. Ein Fusproblem bei Diabetes mellitus bedarf einer fruhzeitigen interdisziplinaren Zusammenarbeit. Fusdeformitaten und eine periphere Polyneuropathie sind Risikofaktoren, welche eine geeignete Schuhanpassung notwendig machen. Eine periphere arterielle Verschlusskrankheit sollte fruhzeitig diagnostiziert und mit Hilfe weiterer angiologischer Abklarungen die geeignete Therapieform (Dilatation, Bypassoperation) gewahlt werden. Ein weiterer wichtiger Faktor stellt die Behandlung kardiovaskularer Risikofaktoren dar. Insbesondere eine gute Einstellung des Diabetes mellitus hilft, ein Fortschreiten der Hauptrisikofaktoren (PAVK, periphere Polyneuropathie) zu verhindern. Bei einem Ulkus mus...

Queen Nefertari, the Royal Spouse of Pharaoh Ramses II: A Multidisciplinary Investigation of the Mummified Remains Found in Her Tomb (QV66)

Queen Nefertari, the favourite Royal Consort of Pharaoh Ramses II (Ancient Egypt, New Kingdom, 19th Dynasty c. 1250 BC) is famous for her beautifully decorated tomb in the Valley of the Queens. Her burial was plundered in ancient times yet still many objects were found broken in the debris when the tomb was excavated. Amongst the found objects was a pair of mummified legs. They came to the Egyptian Museum in Turin and are henceforth regarded as the remains of this famous Queen, although they were never scientifically investigated. The following multidisciplinary investigation is the first ever performed on those remains. The results (radiocarbon dating, anthropology, paleopathology, genetics, chemistry and Egyptology) all strongly speak in favour of an identification of the remains as Nefertari’s, although different explanations—albeit less likely—are considered and discussed. The legs probably belong to a lady, a fully adult individual, of about 40 years of age. The materials used for embalming are consistent with Ramesside mummification traditions and indeed all objects within the tomb robustly support the burial as of Queen Nefertari.

Fight-or-flight Response in the ancient Egyptian novel "Sinuhe" (c. 1800 BCE).

Highlights: • Description of the fight-or-flight response in ancient times. • Comparison between contemporary and ancient understanding of the response. • Expansion of database of recorded cases of fight-or-flight response before Darwins and Cannons descriptions.

Nonsurgical Treatment of Osteomyelitis of the Hallux Sesamoids: A Case Series and Literature Review

ABSTRACT The aim of the present study was to determine the effectiveness of nonsurgical treatment for osteomyelitis of the hallucal sesamoids. Osteomyelitis of the hallucal sesamoids in young and healthy patients is rare and might originate from hematogenous spread or after a puncture wound. In diabetic patients with peripheral neuropathy, it often results from direct contiguous seeding from adjacent ulceration. The superiority of surgical versus nonsurgical therapy is still debated. In our institution, all patients presenting with osteomyelitis of the hallucal sesamoids are first treated nonsurgically but eventually usually require a surgical procedure. We reviewed 18 patients with a clinical and radiologic diagnosis of osteomyelitis of the hallucal sesamoids treated in our institution during a 13‐year period (from January 2000 to December 2012). The inclusion criteria were a signal alteration on magnetic resonance imaging or bone lesions on computed tomography or conventional radiographs, combined with a deep ulcer with a positive probe‐to‐bone test. Nonsurgical therapy consisted of frequent wound treatment, immobilization, offloading in a cast or other orthotic device, and oral antibiotics. Of the 18 patients, 11 had diabetes, 16 had peripheral neuropathy, 11 had peripheral arterial disease, and 5 had immunosuppression. After a period of nonsurgical therapy ranging from 4 weeks to 9 months, 15 of 18 patients required surgical excision, internal resection, or amputation. In this patient population, we no longer consider nonsurgical therapy a viable option. Patients should be advised, before starting nonsurgical treatment, that the therapy will be long and demanding and very often results in a surgical procedure.