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Objective: To present an objective method to evaluate gait improvements after a tap test in idiopathic normal pressure hydrocephalus (INPH)., Design: Retrospective analysis of gait data., Setting: Public tertiary care center, day hospital. The gait analysis was performed before and 2 to 4 hours after the tap test., Participants: Participants included patients with INPH (n=60) and age- and sex-matched controls (n=50; used to obtain reference intervals). From an initial referred sample of 79 patients (N=79), we excluded those unable to walk without walking aids (n=9) and those with incomplete (pre-/posttap test) gait data (n=10). Thirteen out of 60 patients were shunted and then reappraised after 6 months., Interventions: Not applicable., Main Outcome Measures: Mahalanobis distance from controls, before and after the tap test. Eleven gait parameters were combined in a single quantitative score. Walking velocity was also evaluated because it is frequently used in tap test assessment., Results: Patients were classified into 2 groups: tap test responders (n=22, 9 of them were shunted) and not suitable for shunt (n=38, 4 of them were shunted). In the tap test responders group, 9 out of 9 patients improved after shunt. In the not suitable for shunt group, 3 out of 4 patients did not improve. Gait velocity increased after the tap test in 53% of responders and in 37% of patients not suitable for shunt., Conclusions: The new method is applicable to clinical practice and allows for selecting tap test responders in an objective way, quantifying the improvements. Our results suggest that gait velocity alone is not sufficient to reliably assess tap test effects., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To provide a systematic review of apps for smartphones validated for body position measurement relevant to physical medicine and rehabilitation. TYPE: Systematic search and review., Literature Survey: A literature search was conducted on relevant articles indexed by PubMed before April 15, 2014. We selected only research papers published in English. Papers dealing with apps not relevant to physical medicine and rehabilitation or unavailable on the market were excluded., Methodology: Two independent reviewers screened the articles (full text).We analyzed the following information for all apps: target population, object of the measure, body segment evaluated, modality of use, operating platform system, and validation results., Synthesis: The literature search produced 27 papers, 17 of which met the inclusion criteria for our review. The included papers featured 12 apps validated for angle measurement: 7 were validated exclusively for upper and lower limb joint angles, 4 for spine measurements, ie, cervical or lumbar range of motion and curvature, Cobb angle on radiographs, and the scoliotic distortions of the torso, and 1 for both upper limb and spine measurement. The 12 apps used the inbuilt smartphone magnetometer, accelerometer, or camera to produce angle measurements. Most of the studies assessed the smartphone-apps' reliability (calculating the intraclass correlation coefficients) and validity (showing the limits of agreement)., Conclusion: This review highlights the validated goniometer apps that physiatrists and other health care practitioners can use with confidence in research and clinical practice. We found 12 apps corresponding to these criteria, but there is a need for validation studies on available or new apps focused on goniometric measurement in dynamic conditions, eg, during gait or when performing therapeutic exercises., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

The aim of the study described here was to quantitatively assess thermal and mechanical effects of therapeutic ultrasound (US) by sonicating a joint-mimicking phantom, made of muscle-equivalent material, using clinical US equipment. The phantom contains two bone disks simulating a deep joint (treated at 1 MHz) and a superficial joint (3 MHz). Thermal probes were inserted in fixed positions. To test the mechanical (cavitational) effects, we used a latex balloon filled with oxygen-loaded nanobubbles; the dimensions of the oxygen-loaded nanobubbles were determined before and after sonication. Significant increases in temperature (up to 17°C) with fixed field using continuous waves were detected both in front of and behind the bones, depending on the US mode (continuous wave vs. pulsed wave) and on the treatment modality (fixed vs. massage). We found no significant differences in mechanical effects. Although limited by the in vitro design (no blood perfusion, no metabolic compensation), the results can be used to guide operators in their choice of the best US treatment modality for a specific joint., (Copyright © 2014 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Purpose: Mobile bearing (MB) knee prostheses were designed to improve the performances of the total knee arthroplasties (TKA). The clinical superiority of MB prosthesis compared to its fixed bearing counterpart has remained elusive. This study prospectively evaluates the cumulative survivorship, clinical, radiographic results, and complications of a large series of MB TKAs in relation to patient age, sex, severity of arthritis, and patellar resurfacing., Methods: This study evaluates the 5- to 10-year cumulative survival rate of the NexGen(®) LPS MB. Between 2000 and 2005, we performed a consecutive series of 332 MB, posterior-stabilized TKA in 249 patients (mean age 71.2 years, SD 6.9). The implants were clinically evaluated with the Hospital Special Surgery Knee Score (HSS-KS) and radiographically with the Knee Society Roentgenographic Evaluation System (KS-RES). The mean follow-up was 76.3 months (minimum 5 years)., Results: The HSS-KS improved from 55 pre-operatively to 86 at the end of follow-up. According to the KS-RES, the implants were anatomically aligned and progressive radiolucent lines appeared in four knees (1.2 %). The patella was selectively resurfaced in 162 of 332 knees. Patients with the patella resurfaced had better clinical results compared to those not resurfaced, but there was no difference in terms of survival. The cumulative survival rate was 98.4 % at 10 years (Kaplan-Meier's analysis)., Conclusions: This MB implant provided reliable and durable clinical results with a survivorship of over 98 % at 10 years, in unselected patients regardless of age, sex, severity of disease, and patellar treatment.

Purpose: Incontinentia pigmenti (IP), or Bloch-Sulzberger syndrome, is a rare X-linked dominant genetic disorder with multisystem involvement. To our knowledge, there are no previous reports about rehabilitation in IP adult with intact cognitive development. We report a 20-year-old lady with IP managed and followed into adulthood., Method: Patient management and rehabilitation programs from birth to the last follow-up., Results: There was normal cognitive development despite magnetic resonance imaging (MRI) evidence of white matter, corpus callosum and brainstem hypoplasia. Extensor spasticity was present on both lower limbs for which she underwent rehabilitation from the age of one. Botulinum toxin injections were performed and when she was 15 years old she underwent functional surgery., Conclusion: The absence of mental retardation in our patient enabled us to carry out an active rehabilitation program and provide her with maximum independence in locomotion and in activities of daily living. IMPLICATIONS FOR REHABILIATION: Incontinentia pigmenti (Bloch-Sulzberger syndrome). Incontinentia pigmenti is a rare X-linked dominant genetic disorder with multisystemic involvement. Skin lesions, neurological impairments, motormental retardation, skeletal congenital defects and ophthalmologic involvement are IP most frequent manifestations. Due to the complex multisystem involvement resulting in severe long-term disability, patients with IP require a multidisciplinary team approach for rehabilitation. In IP patients, rehabilitation interventions should always take into consideration the individual phenotype expression, child's physical development and personal needs.

The goal of this study was to analyze the clinical and radiographic results and the survival rate of a series of rotating-hinge implants used for revision total knee arthroplasties in mild and severe instability. Between December 1991 and June 2004, fifty-three revision total knee arthroplasties were performed using the Endo-Modell (Waldemar LINK GmbH and Co, Hamburg, Germany) rotating-hinge prosthesis; 7 (13.2%) patients underwent partial revision of a previous Endo-Modell. All patients were evaluated preoperatively, 3 and 6 months postoperatively, and annually thereafter using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation System (KS-RES). Mean follow-up was 155.2±40.1 months (range, 78-240 months), with 32 patients examined at the final follow-up. All HSS knee scores increased from preoperatively to last follow-up. No statistically significance differences were found in the HSS knee scores between septic and aseptic revisions and between total or partial revisions. Progressive radiolucent lines were detected in 8 (25%) patients. Implant failure occurred in 11 (20.7%) patients; the cumulative survival of the implants was 80.4% at 150 months for the final 32 patients. The authors recommend use of this implant for revision total knee arthroplasty, especially in patients with severe instability and bone loss., (Copyright 2013, SLACK Incorporated.)

Background: The superiority of mobile-bearing total knee arthroplasty implants over fixed-bearing implants, or vice versa, is still debated., Methods: A series of patients with similar clinical and radiographic characteristics were treated consecutively with 100 fixed-bearing followed by 100 rotating-platform implants. Patients underwent prospective clinical and radiographic evaluation., Results: The mean duration of follow-up was 116 months (range, sixty-one to 144 months). Clinical, radiographic, and implant survival outcomes were compared. No significant differences between the mobile-bearing and fixed-bearing groups were found with respect to the clinical outcome or cumulative implant survival at the time of the latest follow-up. Three of the fixed-bearing implants and one of the rotating-platform implants had required revision surgery., Conclusions: No differences between mobile-bearing and fixed-bearing designs were demonstrated at a mean of 116 months of follow-up.

Rotating hinge knee prostheses have been developed as an advancement of the fixed hinge models. Some authors suggest that this type of prosthesis is associated with a greater risk of aseptic loosening because of the increased stresses to the bone-prosthesis interface; therefore, they are scarcely used as primary implants. The current authors evaluated of a series of 98 rotating hinge knee arthroplasties Endo-Modell (Waldemar LINK GmbH and Co, Hamburg, Germany) implanted for knee osteoarthritis. The Hospital for Special Surgery Knee Score and the Knee Society Score were used for the clinical and radiographic evaluation. Log-rank or Wilcoxon tests were used to test the statistical significances, and the Kaplan-Maier method was used to calculate the implant survival probability. After a medium follow-up of approximately 174 months, the clinical scores showed a statistically significant improvement from the pre- to postoperative period. The complication rate was high, and the cumulative implants survival rate was 88.7% at 1 year, 85.9% at 5 years, 79.8% at 10 years, and 75.8% at 15 years. The Endo-Modell rotating hinge implants demonstrated no significant risk of aseptic loosening, and the hinge was not a primary cause of failure. However, the overall failure rate was higher than that of unhinged implants; therefore, this prosthesis is recommended for cases of instability and revision rather than primary knee arthroplasty., (Copyright 2013, SLACK Incorporated.)

The purpose of this cadaveric study was to evaluate the primary stability of a membrane 
(resorbable polyglactin-910/poly-p-dioxanone) for autologous chondrocyte implantation (ACI) inserted by press-fit into defects in the femoral head and acetabulum. The stability of the membrane was evaluated after implantation in a cartilage defect on both sides of the joint in 12 hips in six cadavers. The hip was manually put through a full range of motion for 50 cycles after each lesion had been created and filled, starting with the acetabulum.
The implanted membranes showed stability in 83.3% of the acetabular defects and in 33.3% of the femoral defects after the 50 cycles. After an additional 50 cycles the acetabular membrane showed stability in a total of eight (67%) out of 12 acetabular lesions.
The results indicate that this membrane tissue is potentially stable in cartilage defects of the acetabulum, which may have clinical applications in autologous chondrocyte implantation.

The aim is to perform the assessment of a modular cementless acetabular cup with a tapered internal design for all bearing couplings. In 190 unselected consecutive patients, 207 total hip arthroplasties were implanted. The implants were clinically and radiographically evaluated. Follow-up was 49.7 ± 8.1 months. The average Harris hip score improved from 55.5 ± 5.7 to 94.7 ± 3.4 (P < 0.05). All cups were well-positioned and stable. The Kaplan-Maier cumulative survivorship was 98.5 ± 0.8%. No significant differences have been noted in dividing patients according to the different liner materials (P < 0.005). The study, whose rationale is the novelty of this kind of implant, suggests the efficacy of the Delta-PF acetabular cup.

Rotating-hinge knee implants are used for revision total knee arthroplasty in patients with severe ligament instability and bone loss. This study evaluated the outcomes of a series of rotating-hinge knees. Thirty-one NexGen Rotating Hinge Knees (Zimmer, Warsaw, Indiana) were implanted in 29 patients (2 bilateral), with an average age of 72.8 years. Indications for surgery were aseptic loosening (n=23), septic loosenings (n=4), tibiofemoral instability (n=3), and wear (n=1). The Hospital for Special Surgery Knee Score and the Knee Society Roentgenographic Evaluation System were used. Statistical and cumulative survival rate analyses were performed. Average follow-up was 60.3 months (range, 32-100 months). The Hospital for Special Surgery Knee Score results indicated statistically significant improvement; the total score increased from 65.5 preoperatively to 88.4 postoperatively. Average range of motion increased from 90.9° preoperatively to 114.4° postoperatively. Radiographs showed no periprosthetic bone fractures or implant ruptures. Radiolucent lines were found in 20 of 26 patients and were progressive in 2 (both revised). Complications occurred in 10 patients. The rigidity of the hinge may be associated with a risk of aseptic loosening due to the increased stress transfer to the bone from the prosthesis through the locked hinge. Rotating-hinge knee implants provided acceptable mid-term outcomes for revision knee surgery with ligamentous instability. They are not at higher risk for early loosening unless short tibial stems are used. The high percentage of failures is more related to the complex surgery and to the status of the patients than to the hinged mechanism., (Copyright 2012, SLACK Incorporated.)

Congenital permanent dislocation of the patella is a rare disorder of the knee joint in which the patella is permanently displaced, even in extension and is fixed on the lateral aspect of the femoral condyle. The dislocation is irreducible without surgical techniques. This rare condition is usually detected within the first decade of life, because of inability of active extension in the knee and impaired ability during walking. This report presents an unusual case of a 51-year-old man with bilateral congenital permanent dislocation of the patella. The pathology had never been treated because there were few symptoms. The patient presented with right knee pain caused by a fall on the knee during his work. The right knee was painful on the lateral side and the clinical signs were positive for pathology of the lateral meniscus, confirmed by MRI. The clinical and the imaging findings suggested a lesion of the lateral meniscus as the probable cause of the pain. Therefore we performed a knee arthroscopy, whose intra-operative findings confirmed the MRI findings. During the surgery we performed just a selective arthroscopic meniscectomy, without correcting patella dislocation, because the condition was unusually asymptomatic before the trauma.

Dislocation is a common and important complication of total hip arthroplasty (THA). Larger femoral heads may reduce the risk of dislocation and improve the range of movement. The aim of this study was to compare the relative risk (RR) of dislocation during the first year after THA between implants with 28 mm and 36 mm femoral heads. 198 consecutive hips with 28 mm femoral head (Group-28) and 259 hips with 36 mm femoral head (Group-36) were studied. The patients were assessed preoperatively and periodically using the Harris hip score (HHS) and radiographic analysis. The relative risk (RR) of dislocation was calculated. The average HHS significantly improved from a preoperative baseline to the last follow-up at 82.1 months (28 mm) and 44.3 months (36 mm). No statistically significant differences were revealed between the two groups for HHS results and complications (p>0.05), but the difference in RR of dislocation within the first year between the two groups was 7.85 (95% CI: 1.34-46.03), p=0.046.Although dislocation is multifactorial in etiology, the two groups were homogenous for all principal contributing factors except the diameter of the femoral head. Therefore, the use of 36-mm heads can reduce the risk of dislocation following THA by a factor of 8 compared to conventional 28 mm heads.

Infections in orthopaedic surgery are a serious issue. Antibiotic-loaded bone cement was developed for the treatment of infected joint arthroplasties and for prophylaxes in total joint replacement in selected cases. Despite the widespread use of the antibiotic-loaded bone cement in orthopedics, many issues are still unclear or controversial: bacterial adhesion and antibiotic resistance, modification of mechanical properties which follows the addition of the antibiotic, factors influencing the release of the antibiotic from the cement and the role of the surface, the method for mixing the cement and the antibiotic, the choice and the effectiveness of the antibiotic, the combination of two or more antibiotics, and the toxicity. This review discusses all these topics, focusing on properties, merits, and defects of the antibiotic loaded cement. The final objective is to provide the orthopaedic surgeons clear and concise information for the correct choice of cement in their clinical practice.

Subcoracoid impingement syndrome represents a rare cause of shoulder pain. To date, there are a few papers in literature that have addressed specifically the subcoracoid impingement. We reviewed 13 consecutive patients suffering from this syndrome who underwent an arthroscopic treatment. There were 4 men and 9 women with a mean age of 45 years (range, 23-58 years). The diagnosis of subcoracoid impingement was carried out on the basis of clinical examination and magnetic resonance imaging finding. Arthroscopic surgery consisted of a coracoplasty alone in 2 patients, coracoplasty and acromioplasty in 2 patients, coracoplasty and subscapularis tendon repair in 4 patients, and in the last 5 patients no coracoplasty was done and surgery consisted in treating a minor shoulder instability. Patients were reviewed at a mean follow-up of 2.4 ± 0.7 years. We evaluated the difference between preoperative and final postoperative range of motion, VAS, UCLA, SST and Constant score using a Student's t test. At follow-up, we observed a significant improvement in range of motion and shoulder scores; moreover, clinical findings of subcoracoid impingement were negative in all patients. Different pathological shoulder conditions can be responsible for a subcoracoid impingement that can be primary or secondary to factors different from mechanic attrition against the coracoid because of its morphology. In case of primary impingement, coracoplasty is a good treatment to relieve clinical symptoms. In patients suffering from an associated minor shoulder instability with MGHL capsulolabral lesion, surgical treatment of this lesion without coracoplasty led to the improvement in symptoms.

Irreducibility of the knee following complete dislocation is a rare event determined by the interposition of various capsulo-ligamentous structures in the joint space. Such cases often require urgent surgical treatment. We report the case of a healthy 70-year-old man with a sprain of the left knee that occurred after a sports trauma. The patient showed knee dislocation with multiple ligamentous injuries and articular block due to interposition of a portion of the vastus medialis muscle. After arthroscopic evaluation, we performed surgical treatment to free the muscle, regularize the medial meniscus and suture the posterior and medial capsule and ligaments; the cruciate ligaments were not treated. The most interesting aspect of the articular damage in this case was a wide detachment of the vastus medialis muscle with intra-articular dislocation. The decision to treat only the posterior lesions and allow the healing of the front ones by rehabilitation treatment was supported by full functional recovery and return to sports activity.

The goal of this paper is to outline the pragmatic use of the Clinical Governance and the urge to introduce it in daily practice. The present and future of modern medicine should be based on these principles. The reengineering of the Italian health care system has been mentioned as an example that took place in the early 90s.

Severe injuries at foot and ankle level with loss of soft tissues and bone are often treated by means of amputation. The transfer of composite free flaps from various donor sites may provide anatomical reconstruction of the foot and ankle and function. Ten patients who sustained severe combined tissue injuries of the foot requiring reconstruction with composite free flaps were studied with a mean follow-up of 3.4 years. A thorough clinical examination was performed, and gait analysis was carried out with kinetic and kinematic parameters. Bone integration and healing was observed with satisfactory foot morphology. All the patients returned to normal activities, although biomechanical gait analysis showed some functional disorders mainly in joint angular kinematics. Our results showed that microvascular flaps afford successful combined tissue reconstruction of the foot., (Copyright © 2011 Wiley-Liss, Inc.)

This paper discusses a sciatic nerve palsy developed after a right total hip revision with a Burch-Schneider metal cage. A sciatalgic nerve pain appeared after surgery, while the palsy developed in about fifteen days. An electromyography showed the delay of the nerve impulse gluteal level. During the surgical exploration of the hip, a compression of the nerve on the metal cage was observed. The nerve was isolated, released from the fibrotic tissue and from the impingement, and was protected with a muscular flap. The recover from the pain was immediate, while the palsy recovered one month later.

Background: Mass gatherings require attention toward planning and execution of dedicated medical care., Objectives: The aims were to describe the organization and provision of medical care in the Torino 2006 Winter Olympic Games in light of the epidemiology of illnesses and injuries among athletes during this event., Methods: The organization integrated 18 medical centers operating at Olympic venues, three polyclinics inside the Olympic Villages, and 13 pre-existing Olympic Hospitals. The design was a retrospective study, with review of medical records at Olympic medical facilities. All the athletes who attended any medical center or polyclinic were eligible. The main outcomes included type of injuries and illnesses affecting athletes, incidence of injuries and illnesses by provenance and discipline, and rate of hospital admissions., Results: A total of 330 athletes received medical care and 676 medical encounter forms were documented, with an overall medical utilization rate of 12.66%. Skeleton, snowboard, bobsleigh, and alpine and freestyle skiing had the highest medical attendance rate relative to other disciplines (p < 0.001). The majority of injuries and illnesses were of a minor nature. A total of 23 visits required hospital admissions (3.40%)., Conclusion: The described model of medical coverage for such events seemed to be practical and efficient for the athletes, without depleting services to the general population. The risk of severe injury and illness seemed to be low. These data could be useful for planning medical services in future mass gatherings., (Copyright © 2010 Elsevier Inc. All rights reserved.)

The take-off phase (approximately 6m) of the jumps of all athletes participating in the individual HS-106m hill ski jumping competition at the Torino Olympics was filmed with two high-speed cameras. The high altitude of the Pragelato ski jumping venue (1600m) and slight tail wind in the final jumping round were expected to affect the results of this competition. The most significant correlation with the length of the jump was found in the in-run velocity (r=0.628, p<0.001, n=50). This was a surprise in Olympic level ski jumping, and suggests that good jumpers simply had smaller friction between their skis and the in-run tracks and/or the aerodynamic quality of their in-run position was better. Angular velocity of the hip joint of the best jumpers was also correlated with jumping distance (r=0.651, p<0.05, n=10). The best jumpers in this competition exhibited very different take-off techniques, but still they jumped approximately the same distance. This certainly improves the interests in ski jumping among athletes and spectators. The comparison between the take-off techniques of the best jumpers showed that even though the more marked upper body movement creates higher air resistance, it does not necessarily result in shorter jumping distance if the exposure time to high air resistance is not too long. A comparison between the first and second round jumps of the same jumpers showed that the final results in this competition were at least partly affected by the wind conditions.

Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient's work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist's choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and "core" stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilitation protocol for each patient.

A total of 27 competition days, more than 3000 athletes, over 10,000 components of the Olympic family, 3,500 workers, 2,500 volunteers, an overall business of more than 2 billion Euros. These, in a nutshell, are just a few of the data concerning the XX Olympic and the IX Paralympic Winter Games, Torino, Italy, 2006. Such a huge event, obviously required a meticulously organized medical service to cope with the healthcare of the athletes, official workers and the Olympic family, distributed over a geographic area of approximately 80 km in diameter. An ENT service was organized within the medical service, which was divided between 3 Polyclinics, in which 12 ENT Specialists were on duty. The present report gives an account of the final data concerning the service involved, together with a description of the approach used in the actual organization, with a view to providing useful information for colleagues who will be called upon, for a similar service, in future Olympic Winter Games. The ENT healthcare offered was confirmed to be proportional to the requirements, both from a qualitative and quantitative point of view. All the ENT specialists involved, reported having gained an immense store of human experience from having lived the Olympic atmosphere as a volunteer exerting one's own profession. The facilities available in the Polyclinics, which were at a considerable distance from the Hospital, were found to be more than adequate with respect to the pathological conditions and service requested, particularly in 17% of the cases which would otherwise have been sent to a Hospital Outpatient Unit at least 80 km away.

The success of anatomic repair of Bankart lesion diminishes in the presence of a capsule stretching and/or attenuation is reported in a variable percentage of patients with a chronic gleno-humeral instability. We introduce a new arthroscopic stitch, the MIBA stitch, designed with a twofold aim: to improve tissue grip to reduce the risk of soft tissue tear, particularly cutting through capsular-labral tissue, to and address capsule-labral detachment and capsular attenuation using a double loaded suture anchor. This stitch is a combination of horizontal mattress stitch passing through the capsular-labral complex in a "south-to-north" direction and an overlapping single vertical suture passing through the capsule and labrum in a "east-to-west" direction. The mattress stitch is tied before the vertical stitch in order to reinforce the simple vertical stitch, improving grip and contact force between capsular-labral tissue and glenoid bone.

Different clinical tests have been suggested in the literature as significant indicators of anterior shoulder instability. Sometimes patients with recurrent anterior shoulder instability may show some muscular guarding thus making the evaluation of specific clinical tests very difficult. These patients may also report a medical history with posterior shoulder pain that can be also elicited during some clinical manoeuvres. From September 2005 to September 2006 we prospectively studied patients who underwent an arthroscopic anterior capsuloplasty. Shoulder clinical examination was performed including anterior shoulder instability tests (drawer, apprehension and relocation tests). Furthermore the exam was focused on the presence of scapular dyskinesia and posterior shoulder pain. The patients were also evaluated with ASES, Rowe, SST (Simple Shoulder Test), Constant and UCLA (University of California at Los Angeles) scoring system preoperatively and at the latest follow-up time. In the period of this study we observed 16 patients treated for anterior gleno-humeral arthroscopic stabilisation, who preoperatively complained also of a posterior scapular pain. The pain was referred at the level of lower trapezium and upper rhomboids tendon insertion on the medial border of the scapula. It was also reproducible upon local palpation by the examiner. Four of these patients also referred pain in the region of the insertion of the infraspinatus and teres minor. After arthroscopic stabilisation the shoulder was immobilised in a sling with the arm in the neutral rotation for a period of 4 weeks. A single physician supervised shoulder rehabilitation. After a mean time of 6.8 months of follow-up, all the shoulder scores were significantly improved and, moreover, at the same time the patients referred the disappearance of the posterior pain. Posterior scapular shoulder pain seems to be another complaint and sign that can be found in patients affected by anterior shoulder instability. It can also be related to eccentric work of posterior stabilising muscles of scapula during the altered biomechanics observed in case of anterior shoulder instability. This pain responds positively to surgical intervention showing that re-centring the humeral head probably also re-establishes the periscapular muscle-firing pattern with a mechanism mediated by the proprioceptive system.

Purpose: The purpose of this article is to report the characteristic conditions in which a posterior humeral avulsion of the glenohumeral ligament (PHAGL) lesion occurs, defining also the different possibility of association with other intra-articular shoulder pathologies., Methods: We identified in our database 16 consecutive patients with a PHAGL lesion who underwent surgical treatment. Six of these patients had previous failed anterior shoulder stabilization, and 1 patient failed thermal shrinkage for a multidirectional instability and were not included in this study. The 9 remaining patients were enrolled in this study. All 9 patients developed a PHAGL lesion after a sports-related trauma. Clinical symptoms reported by the patients and clinical examination data were variable depending also on associated intra-articular shoulder pathology. The diagnosis of a PHAGL lesion was not made in any of the cases preoperatively. All 9 patients underwent arthroscopic repair of the PHAGL lesion. During the surgical procedure, any additional intra-articular shoulder lesion was treated. Patients were evaluated preoperatively and postoperatively for pain and range of motion using standardized shoulder scales including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) rating score, and Constant score., Results: Arthroscopic evaluation revealed that PHAGL was seen as an isolated lesion in only 3 patients. At a mean follow-up of 34.2 months, all patients were pain free and reported a complete resumption of sports and daily living activities. Two patients had a limitation of internal rotation to the T11 level. The UCLA score improved from 16.3 to 34.7, the Constant score improved from 52.3 to 80.2, and the SST score improved from 7.9 to 4.2., Conclusions: The PHAGL lesion is challenging to diagnose clinically. It can be the cause of posterior instability or a component of the spectrum of shoulder instability and associated with anterior labral or capsular pathology. Because physical examination can be misleading, a gadolinium-magnetic resonance arthrogram and comprehensive arthroscopic evaluation visualizing from the anterior and posterior portals can confirm the diagnosis. We repaired the PHAGL lesions arthroscopically along with all associated shoulder abnormalities resulting in a good outcome., Level of Evidence: Level IV, therapeutic cases series.

Aim: Aims of the study were: to determine the differences in the mechanical, hormonal and lactate responses to a high-intensity isokinetic exercise in two groups of endurance-trained athletes (EA, n = 11) and sedentary subjects (SED, n = 11); to evaluate the relationships between the hormonal and lactate responses; to evaluate the effects of the training status on the pituitary responsiveness to the exercise., Methods: EA and SED completed, for each leg, 4 sets of 20 maximal concentric contractions of the knee extensor muscle groups at 180 degrees s-1 angular velocity. Blood and saliva for hormonal and lactate determinations were sampled before, immediately after the test and during the subsequent recovery of 2 hours., Results: The exercise was completed by all subjects and elicited significant mechanical and biochemical responses both in EA and in SED subjects. No differences were found between the two groups both in the mechanical performances and in the increases of lactate and hormones of the pituitary-adrenal axis or in the comparison of the slopes of adrenocorticotropic hormone (ACTH), cortisol, and dehydroepiandrosterone recovery after the peak. The correlation analyses showed significant positive relationships between lactate peak values and percentages of change for ACTH (r2 = 0.16, P < 0.05), salivary cortisol (r2 = 0.42, P < 0.01), and serum cortisol (r2 = 0.56, P < 0.001)., Conclusions: The adrenocortical activation was found, in this particular setting, at least partly dependent on the muscular lactate production, while no effect of the training status on the pituitary responsiveness to exercise was evident, as it was indirectly confirmed by no abnormalities in the rates of hormonal recovery after the exercise session.

We present a software tool for the simulation of an X-ray imaging systems. It consists of three virtual objects: the X-ray source, the human body and the detector. The X-ray source is modeled as a radiological tube for which the user can modify the tube potential, the anode material, the tube load, the filtration and some geometric parameters, such as source-skin distance, orientation and field size. The virtual body consists of a 3D voxel matrix in which CT numbers for each point of the body are stored, obtained from tomographic slices. The interactions of X-rays passing through the body are evaluated using pencil beam technique. The image is obtained computing the dose absorbed by the detector and converting it into optical density by the use of a proper response function. The dose absorbed in each point of the body is also computed and can be visualized both in 2D and 3D representations. The influence of each parameter on the beam spectrum, on the image quality and on the dose to the patient can be observed interactively.

The purpose of this paper is to describe a case of heterotopic ossification of the ulnar collateral ligament in a 29-year-old top level weightlifter. Plain radiography of the elbow determined the extent and location of heterotopic ossification. Ultrasound and MR imaging completed the instrumental set-up. This symptomatic case had the resolution of pain after 2 months of a supervised rehabilitation program. At one year follow-up the athlete is asymptomatic referring occasional minor pain only in the periods of vigorous training.

Wilms' tumor (WT) is caused by abnormal development of embryonal kidney cells. WT cells are frequently affected by deletions or functional inactivation of maternal alleles at chromosome 11p15, which indicates that the loss of maternally expressed genes in this region plays an important role in WT pathogenesis. Maternally expressed genes indeed exist within an imprinted region at 11p15.5. Among these, BWR1C is highly expressed in fetal but not in adult kidney, which suggests that it may fulfil an important role in kidney development. Here, we demonstrate that the lack of BWR1C expression is common in WT. Its homology with the proapoptotic gene TDAG51 suggests that the loss of BWR1C expression may be relevant in WT development. In addition, the analysis of the expression of other 11p15 imprinted genes and kidney-developmentally regulated genes indicates that IGF2 overexpression, inappropriate coexpression of RET and GDNF and, in some cases, down-regulation of CDKN1C may also play an important role in the pathogenesis of WT. Our results add new elements to the understanding of the biological basis of WT, which may have implications for WT diagnosis and therapy.

Tumour levels of O6-alkylguanine-DNA-alkyltransferase (O6 AT) and glutathione content (GSH) were correlated with 1, 3-Bis (2-chloroethyl)-1-nitrosourea (BCNU) sensitivity in two human ovarian cancer xenografts (HOC8 and HOC18) and in two human glioblastoma xenografts (HG12 and HG15). HOC8 and HOC18, which were not responsive to BCNU treatment, showed O6 AT levels 14 and 23-fold higher than HG12 that was moderately sensitive to the same BCNU treatment. HG15, which was more sensitive to BCNU than HG12, showed significantly lower O6 AT levels. GSH levels were similar in all tumor xenografts. These data further stress the importance of O6 AT level as a relevant parameter for nitrosourea response in human tumours.

Stenosis of the nerve root canal caused by isolated resorption of a lumbar disc is a frequently observed pathology, but one about which the orthopaedist still knows relatively little. Henry Crock was the first to reveal its principal pathogenetic factor, disc resorption, and to accurately describe the syndrome and its surgical treatment. A total of 22 patients operated according to Henry Crock's indications and followed-up after 2 years were reviewed. In 20 cases decompression alone was performed, while in 2 cases anterior fusion and MOSS instrumentation were associated. Of the 22 patients submitted to decompression 17 revealed complete regression of pain. Three cases failed: 1 patient had previously been treated with chymopapain, while 3 are awaiting anterior fusion to treat persistent lumbar pain. Follow-up is not sufficient for the two patients submitted to anterior fusion.

The MOC-25 tumour arose spontaneously in a female nude mouse and was established as a continuous line intraperitoneally in nude mice, where it reproduces the topological features of its origin, growing preferentially in the uterus, ovaries and liver. Karyotype analysis showed that MOC-25 cells are hyperdiploid. Tumorigenicity and malignant behaviour were studied by transplanting tumour cells into different sites in nude mice. The comparison of tumour take after i.p. and s.c. injections of scaled concentrations of MOC-25 cell suspension showed preferential growth in the peritoneum. Regardless of the route of implantation (s.c., i.v., i.p.), this tumour rapidly and preferentially disseminated to the liver, uterus, ovaries, spleen and bone marrow. No significant differences in tumour growth and metastatic behaviour were observed when MOC-25 was injected in ovariectomized nude mice or in male nude mice. Morphology studies using light and electron microscopy, immunophenotyping and molecular analysis indicated a B-lymphoid origin of the MOC-25 tumour.

Human ovarian carcinomas (HOC) were established s.c. and i.p. in nude mice and the biological characteristics were investigated for 4 xenografts. HOC8 and HOC18, derived respectively from a primary tumor of the ovary and a pleural effusion (from 2 different patients) were established s.c. in nude mice. HOC10 and HOC22, derived from the ascites of 2 patients, were directly established as ascites after i.p. injection in nude mice. The s.c. and i.p. growth behavior of the 4 HOC lines was investigated. HOC18, HOC8 and HOC22 cells produced progressively growing tumor after s.c. injection but HOC10 ascites would not grow s.c. The cell suspension derived from HOC18 only produced carcinomatosis upon i.p. injection, while HOC8 cells produced both ascites and carcinomatosis. The 2 ascites HOC10 and HOC22 produced ascites in nude mice, but only HOC22 formed i.p. carcinomatosis. Histopathological characteristics of the patients' primary tumors persisted in nude mice, regardless of the site of tumor implantation. DNA histograms of the xenografts closely matched the patients' tumors and remained stable at different passages. Cisplatin, adriamycin and cyclophosphamide given i.v. were tested against HOC8 and HOC18 growing s.c. and HOC22 and HOC10 growing i.p. HOC8 showed a significant response to DDP and almost no sensitivity to ADR and CTX. HOC18 showed only moderate growth delay with all 3 drugs. Mice bearing HOC10 and HOC22 ascites had a prolonged survival time after DDP and ADR treatment.