Search

Introduction: Metatarsal stress fractures typically occur in the second and third metatarsus metaphysis, with only rare cases in the fourth and first. The main factors influencing its onset are repetitive stress from prolonged training, biomechanical factors and bone weakness. There is only a paucity of literature documenting first metatarsal stress fractures; the authors present a rare bilateral first metatarsal stress fracture. Case Report: A Caucasian 52-years-old amateur female runner with no other risk factors or medical condition was admitted in our institute with complaints of severe bilateral forefoot pain for 2 weeks arisen after a 20 km run of an amateur race. The patient presented bilateral hallux valgus (HVA) and advanced osteoarthritis of the first metatarsal-phalangeal joint, which is not usually considered a biomechanical risk factor for metatarsal stress fractures. Radiographs of both feet showed linear sclerosis, perpendicular to the diaphysis of the first metatarsal, approximatively in the half of the bone. Signs of osteoarthritis of the first metatarsal-phalangeal were also detected bilaterally. The patient was treated with rest, bilateral post-operative rocker sole shoes that she has worn for 6 weeks, cryotherapy, analgesics as needed and pulsed electromagnetic fields for 8 h per day for 40 days with a complete resolution of symptoms and the previous radiological findings. Conclusion: The authors believed that the bilateral HVA condition could be considered an indirect sign of overuse, and it may be investigated and eventually treated as a responsible for this pathologic condition. Keywords: Stress fracture, first metatarsal, pulsed electromagnetic fields.

Anterior cruciate ligament (ACL) rupture in skeletally immature athletes is becoming an injury with increasing incidence. Choices of treatment are still debated, including conservative management vs. various surgical techniques. The lack of long-term reports has been highlighted in the literature. Aim: To evaluate long-term results of ACL reconstructions performed in skeletally immature patients using the Over the Top technique with lateral extra-articular tenodesis. Retrospective study. All surgeries performed by same surgeon. A total of 42 patients included. All patients had pre-operative radiological studies. Subjects: 30 males and 12 females. Average age: 12.5 years (range 11–14 years). Average follow-up: 96.1 months. Clinical evaluation: Pedi-IKDC, Tegner-Lysholm, KT-1000 and plain radiographs. Standardized rehabilitation protocol. No instability or leg length discrepancy was recorded. Average pre-operative Tegner-Lysholm and Pedi-IKDC scores were 55 and 40, respectively, with a score of 94.8 (p

Background Pediatric supracondylar humeral fractures (PSHF) are most common elbow fractures among children and adolescents. While there is substantial agreement on treating type 1 and type 3 fractures (conservatively and surgically, respectively), the debate on optimal treatment of Gartland type 2 fractures is still open. We wanted to review our cases, analyzing outcomes and seeking for parameters that could help surgeons treating these injuries. Methods We retrospectively reviewed 41 patients treated with reduction and casting (group A) and matched to 38 patients treated with closed reduction and percutaneous pining (CRPP, group B) for Gartland type 2 fractures between 2009 and 2013. At a mean follow-up of more than 6 years patients were analyzed by an accurate clinical exam and evaluation scales. Radiographic parameters at time of cast or pins removal were studied too. Results There were no statistically significant differences in clinical exam and evaluation scales between groups. Two patients in group A developed a cubitus varus deformity and one patient in group B had a superficial pin-tract infection. Baumann angle (BA) was out of normal range in two cases of conservative group and anterior humeral line (AHL) bisected capitellum in 42.1% of patients in group A and 73.2% in group B (p Conclusion It is reasonable to expect satisfactory outcomes both after conservative and surgical treatment of type 2 fractures, if cornerstones of both treatments are applied. Parameters that should be focused are probably two: complications (2 cases of cubitus varus in group A versus one superificial pin-tract infections in group B) and the better trend in surgical group in regards to loss of flexion and hyperextension of the affected elbow, likely related to the other notable datum, that is the percentage of cases in which AHL bisects capitellum. We think that, in absence of vascolonervous lesions and important swelling, BA and AHL are the most important parameters that can help us choosing the optimal treatment, as clarified in the algorithm we developed. Level of evidence Level III – retrospective comparative study.

CASE Lipofibromatous hamartoma (LFH) is a rare benign tumor of the peripheral nerves, which often affects upper extremity. There is no consensus regarding management of these lesions. We report a case of median nerve LFH in the volar forearm of a 24-year-old man with carpal tunnel syndrome symptoms. Clinically, the mass appeared tender to palpation, ill-defined and soft, located on the volar aspect of the left forearm. Open epineurotomy and neurolysis of the median nerve were performed with full recovery at 1 year. CONCLUSION Surgical approach may be resolutive in patients with large masses refractory to conservative treatment.

Introduction Unstable intra articular fractures of distal radius are frequently being managed with open reduction and internal fixation. Volar locking plate based on polyetheretherketon (PEEK) polymer has developed lately as an alternative to conventional metallic devices. The advantage of this kind of plates include the lack of metal allergies, radiolucency, low artefacts on MRI or imaging scans and the high resistance associated to loading forces. The aim of this study was to evaluate the clinical and radiological results using a new Carbon-PEEK volar locking plate compared with titanium volar locking plates for the treatment of distal radius fractures. Methods and Material Thirty patients were included in this study. They all underwent traumatic intra-articular distal radius fractures and were surgically treated with volar locking plates. The patients were randomly divided in two groups: In Group A (15 patients) the fracture was stabilized with a CarboFix volar locking plate whereas in group B (15 patients) with an Acu-Lock Volar Distal Radius Plate. Range of motion (ROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score and X-rays were evaluated. The mean follow up was 12 months. Results Analysis of Wrist ROM revealed that there was no statistical significant difference (p > 0.05) in regards to extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm and between Group A and Group B. The mean score on the DASH was 15.3 in Group A and 13.2 in Group B (p > 0.05). Patients were able to return to their normal activities of daily living at an average of 4 weeks post-op in both Groups. Overall, the mean VAS score was 3.6 There were no statistically significant differences (p > 0.05) on X-Rays examination between two Groups in regards to alignment and fracture healing. Conclusions Volar locking plates represent the most common procedure for the treatment of displaced distal radius fractures. In our series Carbon-peek volar locking plates seems to be analogue to titanium volar locking plates in terms of radiographic parameters and functional outcome.

Biological arthroplasties are the most used surgical techniques, for the treatment of trapeziometacarpal osteoarthritis; all of them provide the reconstruction of trapeziometacarpal joint by a tendon graft. The aim of the study is to compare two surgical techniques: interposition arthroplasty and suspension arthroplasty at 12-month follow-up in order to evaluate the clinical and radiographic results. Sixty-seven patients surgically treated for basal thumb osteoarthritis were divided into two groups: 36 patients, (8 M; 27 F) (39 hands), treated with interposition arthroplasty are included in group A and 31 patients, (6 M; 25 F) (34 hands), treated with suspension are included in group B. Both groups were radiographically evaluated with X-ray and MRI at 12 months and clinically evaluated with DASH score, VAS, Grind test, hand grip tests, Kapandji test and ROM before surgery and at final follow-up. At final follow-up about Kapandji test, in group A, 31 hands (79.4%) presented Kapandji score of 10 and eight hands (20.6%), a Kapandji score of 8. In group B, six hands (17.6%) reported a Kapandji score of 8 and 28 patients (82.4%), a Kapandji score of 10 (p

Background. Healing of tibia fractures occurs over a wide time range of months, with a number of risk factors contributing to prolonged healing. In this prospective, multicentre, observational study, we investigated the capability of FRACTING (tibia FRACTure prediction healING days) score, calculated soon after tibia fracture treatment, to predict healing time.Methods. The study included 363 patients. Information on patient health, fracture morphology, and surgical treatment adopted were combined to calculate the FRACTING score. Fractures were considered healed when the patient was able to fully weight-bear without pain.Results. 319 fractures (88%) healed within 12 months from treatment. Forty-four fractures healed after 12 months or underwent a second surgery. FRACTING score positively correlated with days to healing:r=0.63(p<0.0001). Average score value was 7.3 ± 2.5; ROC analysis showed strong reliability of the score in separating patients healing before versus after 6 months: AUC = 0.823.Conclusions. This study shows that the FRACTING score can be employed both to predict months needed for fracture healing and to identify immediately after treatment patients at risk of prolonged healing. In patients with high score values, new pharmacological and nonpharmacological treatments to enhance osteogenesis could be tested selectively, which may finally result in reduced disability time and health cost savings.

We report a case of post-traumatic trigger finger due to a partial longitudinal tear of the flexor digitorum superficialis. The suspect came from the clinical history and the young age of the patient. It was successfully treated with tendon flap suture and pulley A1 release.

Introduction The aim of our study is to compare the clinical and radiological outcomes of the treatment of distal fibular fracture with the traditional stainless steel or the new radiolucent CFR-PEEK plates. The hypothesis is that there are no differences in clinical and radiological outcomes at the final follow-up between the two fixation devices. Methods All consecutive patients aged from 18 or over, who had undergone operative treatment for malleolar fracture between 2013 and 2014, have been included in the study. 87 were available for the study. The patients were assigned to group A (47 patients, radiolucent plate group) and group B (41 patients, stainless steal plate group). At 6, 12 and 24 months all patients were prospectively reviewed with radiographic and clinical evaluations (OMAS scale, AOFAS, VAS, ROM). Results The groups were homogenous with regard to age, gender, BMI, dominance and disease duration. The mean follow-up was 23 +/− 2 months. The mean waiting time to operation was 2.94 days (SD 2.74) (range 0.2–6.8). Statistical analysis showed no difference (p > 0.05) about the VAS, OMAS, AOFAS and ROM evaluation at 6, 12 and 24 month follow-up between two groups. Radiographic evaluation showed no difference between two groups at all the follow-up with similar results obtained with the two fixation devices. Discussion Our results showed a substantial equivalence of the two fixation devices at 6, 12 and 24 month of clinical and radiographic follow-up. Fixation of the lateral malleolus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. These results are comparable to those achieved with conventional plates.

A B S T R A C T The radiolucent plate has many advantageous properties in the treatment of complex ankle fractures, particularly trimalleolar fractures. Surgeons may sometimes have difficulty observing the posterior malleolus after synthesis of lateral malleolus with a traditional plate because common materials of conventional plates are not radiolucent. In this study, the authors highlight the importance of the radiolucent property in the treatment of ankle fractures and describe their preliminary experience with a carbon fibre-reinforced polyetheretherketone distal fibula plate, with good results at 4 months’ followup and no signs of tissue inflammatory reaction.

Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Salvage treatment with hip arthroplasty may be considered. The aim of this study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Twenty-one patients were treated in our hospital with hip arthroplasty for failed treatment of intertrochanteric hip fracture. There were sixteen women and five men with a mean age of 75.8 years (range 61–85 years). Fourteen patients had failure of a previous nail fixation procedure, five had failure of a plate fixation, one of hip screws fixation and one of Ender nail fixation. In 19 out of 21 patients we performed a total hip arthroplasty—14 cases used modular implants with long-stems and five cases used a standard straight stem. In 2 of 21 cases we used a bipolar hemiarthroplasty. A statistically significant improvement was found comparing pre and postoperative conditions (p

Morton's neuroma (MN) is a frequent cause of metatarsalgia. The aim of our study was to evaluate the efficacy of neuroma alcohol-sclerosing therapy (NAST) under US guide in MN after a 10-month follow-up. Forty intermetatarsal neuromas underwent alcohol-sclerosing therapy after sonographic evaluation of their dimensions and echotexture. After subcutaneous anesthesia, a sclerosing solution composed of anesthetic (carbocaine-adrenaline 70%) and ethylic alcohol (30%) was injected inside the mass under US guidance. The procedure was repeated at intervals of 15 days until the resolution of the symptoms. A total or partial symptomatic relief was obtained in 36 cases (90%). No procedure-related complications were observed. Transitory plantar pain, due to the flogistic reaction induced by the sclerosing solution, occurred in 6 cases (15%). The 10-month follow-up revealed a 20-30% mass volume reduction and an adiposus-like change in echotexture. In the 4 cases (10%) of therapeutic failure, the preliminary sonography demonstrated a hypoechoic echotexture with a strong US beam attenuation corresponding to a highly fibrous neuroma after surgical resection. The NAST is a feasible and cost-efficient procedure with high rates of therapeutic success.

The purpose of this study was to describe four exceptional cases of Salter–Harris type III and IV fractures of the proximal phalanx of the hallux in young high-level gymnasts. All gymnasts underwent the same mechanism of injury of hyperadduction, which indicates a role of the abductor hallucis muscle in the genesis and displacement of these fractures. An open reduction and internal fixation was performed to achieve an anatomical reduction and avoid chronic disability. At 1-year follow-up, all patients had an excellent American Orthopaedic Foot and Ankle Society (AOFAS) score (100 points), and there was no shortening or angulation of the first ray and no evidence of degenerative joint disease on X-ray. Moreover, all the gymnasts had returned to pre-injury levels of sporting activity. To our knowledge, there are no previous studies that address these types of injuries and how they are handled in gymnasts.

The aim of this study was to compare two intramedullary devices used in the treatment of intertrochanteric fractures.During the period 2006-2007 46 TGN and 51 PFNA were used for the treatment of intertrochanteric fractures in our hospital. Clinical and radiological follow-up were available. Surgical time, blood loss and complications have been considered.The mean operative time for the TGN group was significantly higher than in the PFNA group (62 min and 45 min, respectively) with a p = 0.04. The mean blood loss was significantly higher in the TGN group (285 ml; SD 145) in relation to the PFNA group (226 ml; SD 136) with p = 0.03. Also, rate of complications was higher in the TGN group (p = 0.01). Clinical outcomes were good for both groups. Intra-operative and post-operative complications in the TGN group were associated with a longer operative time and a higher blood loss, probably due to the reaming needed in TGN that can increase blood loss and risk of comminution or fracture propagation. Moreover, all but one of the procedure-related complications were observed in very elderly patients.Based on our results in the intertrochanteric fracture, use of PFNA should be recommended in cases of elderly and osteoporotic patients, while TGN should be used in more severely displaced fractures in patients with a slightly better bone mineral density.

The aim of this study was to compare shoulder manipulation and arthroscopic arthrolysis with glenohumeral steroid injections in patients affected by idiopathic adhesive shoulder capsulitis.In this prospective study we randomly assigned patients to enter group A (23 patients, shoulder manipulation and arthroscopic arthrolysis) and group B (21 patients, glenohumeral steroid injections). Patients were followed-up at three, six and 12 weeks, and at six and 12 months with the Constant and Murley, ASES, UCLA and SST evaluation scales. Moreover, passive forward flexion, abduction, and internal and external rotations were recorded.Range of motion showed satisfactory results in both groups at final follow-up: in group A the mean ABD increased from 60° to 154°, ER from 20° to 40°, and FF from 75° to 174°; in group B, ABD raised from 76° to 145°, ER from 20° to 35°, and FF from 115° to 164°. All the evaluation scales performed increased significantly at final follow-up in both groups. However, while patients of group A had already reached significant improvement at the six-week follow-up (p0.03), in group B this happened only at the 12 week follow-up (p0.03).Both types of treatment were effective in improving final range of motion; however, while patients of group A accomplished their goal by the six-week follow-up, in group B the same result was obtained at the 12-week follow-up.

We analysed the possibility that some blood values could be considered as a prognostic index of shoulder adhesive capsulitis. Fifty-six conservatively treated patients were clinically evaluated and prospectively followed at the moment of their freezing phase. At the beginning of the disease (time 0) and after 4 months (time 1), we registered some blood parameters values and their Constant Score (CS). Differences emerged for the white blood cell count (P = 0.037) that decreased and for the CS (P < 0.00001) that increased. At time 0, no significant correlation emerged between the studied parameters and the CS. At time 1, significant inverse correlations with the CS were found for glycaemia (P = 0.007), triglycerides (P = 0.05), ESR (P = 0.017) and CRP (P = 0.013). At time 1, patients with a better shoulder function were those with a low value of glycaemia, triglycerides, ESR and CRP.

Summary Background We clinically and radiologically assessed mid- to long-term follow-up of a group of patients treated with a modified Watson-Jones technique for chronic ankle instability. Methods Fourteen athletes were retrospectively evaluated with physical examination, and Tegner, Good and AOFAS scales; moreover, a 2-view stress, side-to-side X-ray, was performed. Results All patients were followed-up at a mean of 10.8 years. No one reported further ankle sprains. Mean Good scale value decreased from 3.7 to 1.6, while the Tegner scale decreased from 6.8 to 5.1; the mean AOFAS score was 92.2. Mean sagittal-plane ROM was 62.3° (4.9° S/S difference), while mean coronal-plane ROM was 25.5° (3.8° S/S difference). Mean X-ray talar tilt angle was 4.5° (0.1° S/S difference), while mean anterior drawer test angle was 5.4mm (0.5mm S/S difference). Conclusions The modified Watson-Jones procedure seems to be a reliable technique in providing satisfactory mid- to long-term clinical and radiological results.

We evaluated patients at very long term with rupture of the long head biceps tendon (LHBT) in whom the tendon stump had been sutured to the coracoid tip (Gilcreest technique). Our aim was to determine the natural history of shoulders deprived of the LHBT and to assess the validity of the surgical technique. Between 1969 and 1981, 30 patients with rupture of the LHBT and no evidence of cuff tear underwent the Gilcreest operation. The mean age of the patients was 32 years (range, 20–49). Six of them were professional gymnasts. The 28 patients that could be traced were evaluated a mean of 31 years after operation. The mean Constant score (CS) was 74 in the entire group, and 86 in 22. The latter patients complained occasionally of mild shoulder pain. The remaining six patients had a mean CS of 56 (range, 40–81). Of the six, four (aged 66–71 years) had clinical and MR evidence of rotator cuff tear. The other two had undergone arthroscopic cuff repair (CS, 75–81). After operation, all professional gymnasts had returned to sport activity and all the other patients had resumed their jobs. After 30 years, the majority of the patients who had undergone the Gilcreest operation had good functional and cosmetic outcomes. Only a few patients had a cuff tear. The role of the LHBT as depressor of the humeral head is probably less important than generally believed.

Classical ballet is an art form requiring extraordinary physical activity, characterised by rigorous training. These can lead to many overuse injuries arising from repetitive minor trauma. The purpose of this paper is to report our experience in the diagnosis and treatment of stress fractures at the base of the second and third metatarsal bones in young ballet dancers. We considered 150 trainee ballet dancers from the Ballet Schools of "Teatro Alla Scala" of Milan from 2005 to 2007. Nineteen of them presented with stress fractures of the base of the metatarsal bones. We treated 18 dancers with external shockwave therapy (ESWT) and one with pulsed electromagnetic fields (EMF) and low-intensity ultrasound (US); all patients were recommended rest. In all cases good results were obtained. The best approach to metatarsal stress fractures is to diagnose them early through clinical examination and then through X-ray and MRI. ESWT gave good results, with a relatively short time of rest from the patients’ activities and a return to dancing without pain.

The objective of this study is to report the clinical and radiological long-term follow-up evaluation of young patients arthroscopically treated for anterior tibial eminence fracture. Ten patients (mean age: 13.5 years) were treated between 1992 and 2006. At follow-up they were clinically and radiologically evaluated. Moreover, they underwent assessment with the International Knee Documentation Committee (IKDC) forms, Lysholm and Tegner knee scales and measurement with the KT-1000 arthrometer. At a mean follow-up of 85.8 months, all of the patients reported a subjective good-excellent outcome. Objectively, the Lachman test was negative in seven patients and positive in three patients; six patients (60%) registered a slight (+) to mild (++) pivot-glide test. The mean value of KT-1000 arthrometer measurements was 3 mm; all knee scales showed satisfactory results. Radiological exam always showed good healing of the fracture. Fractures of the tibial spine often lead to anterior and rotational knee laxity. However, despite this instrumental finding, patients usually do not report any type of restriction in their functional or sports activities.

Deltoid detachment is one of the complications in open rotator cuff repair. Although it is often described, the actual prevalence, time at which it occurs and the predisposing causes are still unknown. We prospectively studied 112 patients with massive rotator cuff tears with a mean age of 67. The surgical approach was performed with a lateral para-acromial incision. Clinical assessment was performed with Constant's method. Of the 112 patients, 9 (8%) had deltoid detachment. It occurred about 3 months after surgery. Of the nine patients, two underwent revision surgery for the deltoid trans-bone reattachment. At the follow-up, the patients with deltoid detachment had a mean increase of only 5.5 points in the Constant score compared to that of 16.9 obtained by the control group. Deltoid reattachment, performed on the two patients, provided a mean increase of 7 points only with respect to the post-operative control at the 4th month. Considering the unsatisfactory functional result consequent to deltoid detachment and the slight improvement obtained with the reattachment, we recommend the following: use suture thread thicker than #2, do not use a simple stitch and avoid extending acromioplasty to the lateral margin of the acromion.

Trapeziometacarpal distraction arthroplasty is a surgical technique for the treatment of trapeziometacarpal arthrosis. It consists of distracting the first metacarpal and then anchoring it in suspension to the second metacarpal by means of a tendon graft. Both a reduction of the subluxation of the base of the first metacarpal and an opening or distraction of the trapeziometacarpal joint, with a clear decrease in the forces of attrition on its joint surfaces, are thereby obtained. Compared with the traditional techniques of arthroplasty, this technique avoids trapeziectomy; it is therefore less destructive and is quicker and easier to carry out. It appears to be equally effective regarding pain, correcting the deformity, and recovering grip strength.

The menisci plays a key role in the knee joint. Meniscal tears are the most common knee injuries. It is none that complete or partial meniscectomy predispose the knee to degenerative joint disease. However, artrhoscopic meniscectomy remains the most frequently perform orthopaedic procedure. Therefore it would be seem logical to try to preserve meniscal tissue by repair, reconstruction or replacements. None of these procedures has been completely successfull and can be considered suitable for all patients, as meniscal tears require specific and patient-related treatments depending on the size and type of lesion. Recent advances in cell biology, biomaterial science and bioengineering have now the potential to drive meniscus regeneration into a series of clinically relevant strategies.

The objective of the work is to compare and improve the accuracy of existing methods for the computation of rigid body parameters from positions, velocities and accelerations of a set of non colinear anatomical landmarks. Instead of the common Euler angles, Cardan angles or Bryant angles, the results are expressed in terms of the screw axis parameters (i.e. axis versor and rotation angle). In clinical analysis the physical meaning of this axis is surely better understood than the named angles. The paper summarizes also the main steps of noteworthy algorithms for the extraction of finite and infinitesimal screw motion parameters from noisy measurements of markers positions, velocities and accelerations. The sensitivity to data errors of the methods reviewed has been investigated by means of numerical tests. A commercial human motion analysis was also used for the field testing.

We reviewed 42 patients (mean age 37.7+/-14.2 years) with closed fracture dislocations of Lisfranc's joint treated with percutaneous screw fixation. Mean follow-up was 58.4+/-17.3 months. The aim was to compare dislocations in which a perfect anatomical reduction had been reached with dislocations in which reduction was only near anatomical. The mean American Orthopaedic Foot and Ankle Society score for all patients was 81.0+/-13.5. There were no significant differences in outcome scores between patients with perfect anatomical reduction and patients with near anatomical reduction. However, patients with combined fracture dislocations obtained statistically better scores than patients with pure dislocations.

A 49-year-old woman had a haemangiopericytoma in the distal third of the arm, which is an extremely rare location. There was no recurrence of the tumor 5 years after wide margin surgical excision.

We assigned 67 patients with central lumbar stenosis alternately to either multiple laminotomy or total laminectomy. The protocol, however, allowed multiple laminotomy to be changed to total laminectomy if it was thought that the former procedure might not give adequate neural decompression. There were therefore three treatment groups: group I consisting of 26 patients submitted to multiple laminotomy; group II, 9 patients scheduled for laminotomy but submitted to laminectomy; and group III, 32 patients scheduled for, and submitted to, laminectomy. The mean follow-up was 3.7 years. Bilateral laminotomy at two or three levels required a longer mean operating time than total laminectomy at an equal number of levels. The mean blood loss at surgery and the clinical results did not differ in the three groups. The mean subjective improvement score for low back pain was higher in group I but there was also a higher incidence of neural complications in this group. No patient in group I had postoperative vertebral instability, whereas this occurred in three patients in groups II and III, who had lumbar scoliosis or degenerative spondylolisthesis preoperatively. Multiple laminotomy is recommended for all patients with developmental stenosis and for those with mild to moderate degenerative stenosis or degenerative spondylolisthesis. Total laminectomy is to be preferred for patients with severe degenerative stenosis or marked degenerative spondylolisthesis.

Depression of the ankle reflex is the most common neurological change in patients with impairment of conduction of the 51 nerve root. Unilateral absence of the ankle jerk is easily recognised, but it may be difficult to detect a slight reduction of response. This may be important, not only for diagnosis, but also for prognostic and therapeutic purposes, since the decrease in the reflex is very often directly related to the degree of nerve root dysfunction. The ankle jerk may be examined with the patient in various positions : supine with hip and knee flexed; sitting ; kneeling on a chair; or lying prone with the knee flexed. It is our experience that the activity of the ankle reflex may be conditioned by posture, but we could find no mention of this in the literature. Methods. We tested the ankle reflex in each of the four postures listed above in 118 men and 92 women, aged 21 to 74 years. All had a unilateral 51 root syndrome, either isolated or associated with an L5 root syndrome. Patients with bilateral absence of the ankle jerk were excluded from the study. Results. The ankle reflex on the symptomatic side in all four postures was normal in 58 patients and absent in 77. In the remaining 65 patients, reflex activity differed according to the posture in which the test was carried out (Table I). In 35 patients the reflex was normal, slightly depressed or markedly depressed when tested in the supine, sitting or kneeling positions and, respectively, slightly depressed, markedly depressed or absent in the prone position. In 13 patients it was uncertain whether the reflex was normal or depressed in the first three positions, while it was clearly decreased in the prone position. In eight cases the reflex was normal in both supine and kneeling positions and decreased in both the sitting and prone postures. Nine patients had a normal or uncertain reflex in the supine, kneeling and prone positions, but definite depression in the sitting position. Of the 65 patients showing modifications in reflex with change of posture, 48 had one or more CT scans

Background The all-inside graft-link technique for anterior cruciate ligament reconstruction is performed with two cortical suspension devices with adjustable loops on both femur and tibia. This technique requires meticulous graft preparation. The aim of this study was to biomechanically test three different graft configurations resulting from differences in initial graft length. Materials and methods Thirty bovine digital extensor tendons were arranged in three different ways: “half-quadrupled”, “tripled” and “quadrupled”. The final graft length was 65–75 mm. The specimens were fixed vertical to the loading axis of a tensile testing machine. After a static pre-conditioning of 50 N for 5 min, a load to failure test was performed and data regarding the ultimate failure load (UFL), the stiffness and mode of failure were recorded. Results The evaluation of UFL showed a significant differences between group means as determined by one-way analysis of variance (F = 21.92, p = 0.002). Post hoc comparisons showed a significantly better UFL of “tripled” (p = 0.007) and “quadrupled” preparations (p = 0.014) compared to the “half-quadrupled” configuration, with no significant differences between “tripled” and “quadrupled” grafts (p = 0.061). No significant differences were found when evaluating the stiffness between the groups. Failure occurred by tendon slippage across the suture in all specimens. Conclusion The “quadrupled” tendon achieved the best UFL, with even the “tripled” configuration having sufficient biomechanical characteristics to withstand the loads experienced during early rehabilitation. For this reason, with a total semitendinosus length of less than 260 mm it could be better to “triple” instead of “half-quadruple” it to achieve better performance of the graft.

Acromioclavicular joint cyst (AJC) is a rare condition, usually occurring in the presence of a wide communication between glenohumeral and acromioclavicular joints in patients with a massive rotator cuff tear. In the presence of AJC, accurate evaluation of the status of the rotator cuff should always be made. Removal of the cyst only must be avoided because the condition tends to recur if the cuff tear is not repaired. When the tear is so large that it cannot be repaired, excision of the cyst should be associated with a resection of the lateral end of the clavicle.