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The radiograph shows findings consistent with neuropathic arthropathy, which can occur in the setting of chronic diabetes mellitus. The main problem with these patients after total knee arthroplasty is persistant instability that occurs secondary to ligamentous laxity. Therefore, a constrained prosthesis of some type (semi-contrained condylar prosthesis or hinge prosthesis) is indicated in the surgical treatment of these patients. Parvizi et al reviewed 40 neuropathic joints treated with total knee arthroplasty. They reported that ligamentous instability necessitated the use of long stem components in 27 knees and rotating hinge prostheses in five knees. They concluded that careful ligamentous balancing, and appropriate selection of constrained prostheses particularly are important in these patients. Kim et al describe the results of total knee arthroplasty undertaken for severe, neurosyphilitic Charcot arthropathy in nineteen knees. A cemented condylar constrained knee prosthesis was implanted in all but two knees. The authors reported a 16% aseptic loosening rate, which required salvage by arthrodesis. They concluded that although Charcot arthropathy is not an absolute contraindication to total knee replacement, there is a high incidence of serious complications. Morgan et al present a Level 5 review on the different types of arthroplasty and their levels of constraint. Illustration A shows a clinical photograph of a high post semi-constrained total knee prosthesis, which is another type of contrained prosthesis besides a hinge, which may also be acceptable. Incorrect Answers: 2-A cruciate retaining knee arthroplasty requires intact ligaments and is not indicated in the treatment of neuropathic arthropathy. 3-An arthrodesis is generally not necessary as the initial treatment option. 4-A posterior stabilized knee arthroplasty does not provide varus/valgus stability, and requires intact ligaments. It is not indicated in the treatment of neuropathic arthropathy. 5-This patient has tricompartmental arthritis, which is not treated with a unicompartmental knee arthroplasty.
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