Orthopaedic surgeons and their patients continue to seek better functional outcomes after total knee replacement, but TKA designs claim characteristic kinematic performance that is rarely assessed in patients.

The objectives of this investigation is to determine the in vivo kinematics in knees with Cruciate Retaining TKA using Patient Specific Technology during activities of daily living and to compare the findings with previous studies of kinematics of other CR TKA designs.

Four knees were operated by Triathlon CR TKA using Patient Specific Technology and a fluoroscopic measurement technique has been used to provide detailed three-dimensional kinematic assessment of knee arthroplasty function during three motor tasks. 3D fluoroscopic analysis was performed at 4-month follow-up.

The range of flexion was 90°(range 5°–95°) during chair-rising, 80°(range 0°–80°) during step up and 100° (range 0°–100°) during leg extension. The corresponding average external rotation of the femur on the tibial base-plate was 7.6° (range +4.3°; +11.9°), 9.5° (+4.0°; 13.5°) and 11.6° (+4.5°; +16.1°). The mean antero-posterior translations between femoral and tibial components during the three motor tasks were +4.7 (−3.7; +1.0), +6.4 (−3.8; +2.6) and +8,4 (−4.9; +3.5) mm on the medial compartment, and −2.5 (−7.1; −9.6), −3.6 (−6.1; −9.7), −2.6 (−7.7; −10.3) mm on the lateral compartment, respectively, with the medial condyle moving progressively anterior with flexion, and the medial condyle moving progressively posterior with flexion.

We compared Triathlon CR PSI TKA results from this study with Genesis II CR TKA, with Duracon CR TKA, with Triathlon CR TKA and with the healthy knee kinematics. The results of this study showed no screw home mechanism. The internal rotation of the tibia with knee flexion is close to normal, better than Genesis II, Duracon and Triathlon CR TKA operated with standard surgery.

The medial condyle is characterized by the same pattern of the other implants, with a paradoxical anterior translation of 5 mm.

The lateral condyle shows a posterior rollback better than Triathlon CR operated with standard surgery.

For the first time is demonstrated that the surgical technique can modify the tibio-femoral kinematics.

Introduction: In situ subtalar arthrodesis cannot restore anatomical shape of the hindfoot in severe flat foot deformities. Purpose of this paper is to evaluate the result of 250 feet consecutively operated by subtalar arthrodesis with distraction and insertion of a mini structural bone block (SAMBB).

Material and Methods: 178 patients (250 feet), mean age 55+/−11 years affected by acquired adult flat foot with subtalar arthritis were evaluated clinically and radiographically and selected to receive SAMBB.

Arthrodesis was performed through a 2.5 cm incision, with partial cartilage removal and insertion of a structural corticocancellous block (2 × 1cm), harvested from the proximal ipsilateral tibia, vertically positioned into the sinus tarsi. Associate procedures were Achilles tendon lengthening (124), SERI procedure (61), hind-foot deformity correction (32). Postoperatively plaster-cast without weight-bearing for 4 weeks followed by walking boot was advised. All patients were reviewed at a minimum follow-up of 5 years.

Results: Before surgery the mean AOFAS score was 42+/−15, while it was 90+/−8 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+/−8° preoperatively and 6°+/−5° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 160°+/−11° preoperatively and 174°+/−8 at follow-up. No complications were found. No or minimal arthritis progression was observed in the ipsilateral foot joints at follow up.

Conclusions: SAMBB resulted in an adequate correction of the deformity, with restoration of the anatomical shape of the hind foot and correction of the relationship with the midtarsal joint with no need of hardware. Consequent reduced arthritis progression and excellent clinical result were obtained.

The aim of this study is to present guidelines for treatment of acquired adult flat foot (AAFF) and review the results of a series of patients consecutively treated. 180 patients (215 feet), mean age 54? 12 years affected by AAFF were evaluated clinically, radiographically and by MRI to chose the adequate surgical strategy. Tibialis posterior dysfunctions grade 1 were treated by tenolysis and tendon repair (48 cases), grade 2 by removal of degenerated tissue and tendon augmentation (41 cases), grade 3 by flexor digitorum longus tendon transfer (23 cases); in these cases subtalar pronation without arthritis was corrected by addictional procedures consisting of either calcaneal osteotomy (66 cases), subtalar athroereisis (25 cases) or Evans procedure (21 cases) in case of severe midfoot abduction. Subtalar arthrodesis (82 cases) or triple arthrodesis (21 cases) were performed in case of subtalar arthritis isolated or associated with midtarsal arthritis respectively. Postoperatively plastercast without weight-bearing for 4 weeks followed by walking boot for 4 weeks was advised. All patients were followed up to 5 years. Before surgery the mean AOFAS score was 48+\−11, while it was 89+\−10 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+\−5° preoperatively and 8°+\−4° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 165°+\−12° preoperatively and 175°+\6 at follow-up. Surgical strategy in AAFF should include adequate treatment of tibialis posterior disfunction and osteotomies for correction of the skeletal deformities if joints are arthritis free; arthrodesis should be considered in case of severe joint degeneration

INTRODUCTION: Diaphyseal aseptic nonunions are challenging complications in forearm fractures, as length imbalance of radius and ulna impairs severely its function. The aim of this study is to report the results of a series of patients operated on by an original technique.

MATERIAL AND METHODS: 60 patients aged 17–72 years (mean 35) were treated between 1980 and 2000. Ten patients presented radius nonunion, 37 ulna non-union, and 13 nonunion of both bones. Nonunions occurred after conservative treatment in 8 cases, after one surgical procedure of plating or nailing in 47 cases and after 2 or more surgical procedures in 5 cases. Surgical treatment occurred at mean 36 months after the fracture and consisted of freshening the bone and applying a plate and an opposite cortical bone allograft; in 17 cases omologous intercalary bone graft was applied to restore length, axial and rotational alignment. Postoperative treatment consisted of functional bracing associated with intensive rehabilitation of the elbow and wrist beyond clinical and radiographic union. Average follow up was 15±7 years.

RESULTS:. One implant failed due to infection, requiring additional surgery. Mean elbow ROM was 122°±18. Compared with the contralateral arm, mean loss of wrist ROM was 20°±17. Mean loss of forearm rotation was 25°±15. Average healing time was 14±4 weeks X-ray analysis showed bone healing and good osteointegration of the graft in all cases.

DISCUSSION AND CONCLUSION: Combining a plate and an opposite massive cortical bone graft resulted to be a very effective technique for surgical treatment of forearm nonunions.

INTRODUCTION: Displaced comminuted intra-articular calcaneal fractures (DCCF) need anatomic reduction to avoid painful subtalar joint, deformities, tendon or nerve impingment. Open reduction and internal fixation has been extensively reported, but all series reported considerable rate of skin complications, infections and need of additional plastic procedure. The aim of this study is to review a series of DCCF operated by minimally invasive technique.

MATERIAL AND METHODS: 66 DCCF type Sanders II-III were selected in 63 patients aged 18–57 years. X-ray and CT scan were performed. Surgery consisted of percutaneous traction-reduction of the calcaneal body by bone forceps and fixation by K-wires under image intensifier. Then, a lateral 3 cm skin incision was performed to reduce subtalar joint and to fix it by 1 or 2 screws. In case of involvement of the calcano-cuboid joint, the incision was distally extended and a 4-hole plate was applied. K-wires were removed 5 weeks after surgery and weight bearing was permitted 12–16 weeks after surgery. Patients were evaluated clinically by AOFAS score and radiographically at 4 years follow-up (3–7).

RESULTS: No skin complications or infections were encountered in the series. All fractures healed. Mean postoperative Bohler angle was 29±5°. AOFAS score was 89±11. 31 cases were excellent, 22 good, 9 fair and 4 poor. 25 cases presented radiographic signs of subtalar joint arthritis, painful only in 4.

DISCUSSION AND CONCLUSION: Minimally invasive surgical treatment resulted adequate for treating DCCF, in fact if soft tissues are preserved by surgical trauma, dangerous complications like infections and skin problems can be avoided.

Introduction: Neck hyperextension (NH) is defined as a progressive increase of lordosis associated with a limitation in flexion of the cervical spine, which ultimately results in an inability to approximate the chin to the sternum. NH may occur in relation to several myopathies. It is characterized by a general weakness and contractures of the axial muscles which produces a progressive increase of lordosis associated with a limitation in flexion of the cervical spine, that forces the patient to assume awkward compensatory postures to maintain balance and level vision. This study reports on operative complications, the degree of correction, the achievement of a solid arthrodesis, the maintenance of the correction and the clinical assessment of 7 patients.

Material and methods: Seven patients affected by various myophaties and NH were included. The mean age was 16.5 years (10–28 years). All underwent surgery, in which the paravertebral muscles were detached from the spinous processes and then transversally sectioned in order to bilaterally expose the laminas of vertebrae C2 to C7. The space between C1–C2 appeared mobile, while the spinous processes from C2 to C7 were close together and thus allowed only a very limited motion in between them. Ligamenti interspinosus and nuchae were detached and the facet joints from C2 to C7 were enlarged by capsulotomy. With a spreader rongeur, the interspinous spaces at each level were gently opened. Cortical cancellous autologue graft were shaped into wedges. After careful opening of each interspinous space, the bone wedges were driven between the spinous processes to maintain the achieved correction. The average follow-up time was 10.4 years (2.4–16.5 years).

Results: No major surgical complications occurred. At follow-up, the average angle between C2–C7 in neutral position had decreased (p = 0.016) from 50.7 (40–70) to 21.4 (2–50). The range of motion in the C1–C2 joint remained unaffected, while it decreased in C2–C7 (p = 0.016) from 33.5 (15–64) to 1.8 (0–8). In all cases, a solid arthrodesis was achieved.

Discussion and conclusion: The follow-up showed significant clinical improvement of posture in all patients. Our study has shown surgical treatment of NH to be an effective method within the whole series of seven patients, achieving both good immediate and good long-term results.