Rehabilitation following arthroscopic meniscectomy

Meniscal injuries are reported to be the most common injury sustained by athletes, with sports injuries being responsible for over 30% of the total number of lesions. Treatment of meniscal lesions has evolved considerably over the past 20 years and partial meniscectomies, or menisci repairs, are now the treatment of choice for the majority of lesions. Following arthroscopic meniscectomy, patients are routinely able to walk without support within 1 to 3 days, return to work after 1 to 2 weeks, resume athletic training by 2 to 4 weeks and return to competition in 3 to 4 weeks. Physiotherapy has been widely prescribed following arthroscopic meniscectomy and exercise protocols have been described in the literature. However, few studies have actually ascertained whether or not physiotherapy accelerates recovery. From these studies, there is little doubt that some form of rehabilitation, e.g. pain control or exercises, may be effective in accelerating the recovery of muscle strength to preoperative values. Therefore, whether or not physiotherapy is required following arthroscopic meniscectomy may depend on the presence or absence of preoperative strength deficits, and thus, on whether it is the dominant or nondominant leg that is injured. In patients with no preoperative deficits, and a normal post-surgery evolution, full recovery may be expected within 6 weeks if pain and swelling are brought under control. Physiotherapy intervention may not, perhaps, be justified for these patients, except in professional athletes where a faster return to preoperative values may be desired.     

The load applied to the foot in a patellar ligament-bearing cast

The purpose of this study was to determine whether a patellar ligament-bearing cast reduces the load applied to a foot in a cast. In a study of ten people who had no history of gait abnormalities, disease involving the motor system, or deformities of the lower extremities, we compared the load applied to the plantar aspect of a foot in a cast (as detected with F-Scan computer-monitored pedobarographic sensors) with the total load that an extremity in a cast receives relative to the ground (as detected with force-plates). Six trials were completed three times by each person. The trials consisted of walking (1) while wearing regular shoes; (2) with a patellar ligament-bearing cast on one leg; (3) with a patellar ligament-bearing cast and an overlying soft knee brace, locked in full extension, on the leg; (4) with only a below-the-knee cast on the leg; (5) with a below-the-knee cast and an overlying knee brace, locked in full extension, on the leg; and (6) with only a knee brace, locked in full extension, on the leg. The loads at peak heel-strike for all three trials were averaged and normalized to body weight. The load on the plantar aspect of the foot, as compared with the total load, was reduced a mean of 11 percent when the patellar ligament-bearing cast was worn alone, and it was reduced a mean of 26 percent when the patellar ligament-bearing cast was used with an overlying knee brace locked in full extension. This difference was significant (p = 0.007). With the numbers available, we could not detect a significant difference between the reduction in load when a patellar ligament-bearing cast was worn alone compared with that when a below-the-knee cast was worn alone or between the reduction when a below-the-knee cast was worn alone compared with that when a below-the-knee cast was used with a knee brace (p = 0.3). In conclusion, we could not demonstrate a significant reduction in the load on the foot when a patellar ligament-bearing cast was used in a traditional fashion; however, a significant (p = 0.007) reduction in load was found when a knee brace locked in full extension was worn in addition to the patellar ligament-bearing cast.     

Non-comparative evaluation of a new hydrofiber dressing in the treatment of vascular ulcers

OBJECTIVE: To evaluate the performance of the hydrofiber dressing in the treatment of leg ulcers. METHODS: Multicenter, open, non-comparative study of 23 patients with the mean age of 69.6 years. The mean duration of actual ulcer was 2.6 years. RESULTS: Twelve (55%) patients had marketed improvement in overall change in the condition on the wound and 5 (23%) patients had mild improvement. The majority of dressing changes were pain-free (63%). The dressing changes, application and removal, were easy 171 (99%) and 149 (87%). The mean dressing wear time was 2.4 days. The mean ulcer area at the start of the study was 2.730 mm2 and the final dressing change was 1.963 mm2. The median percentage reduction was 36%. CONCLUSION: The use of the non-occlusive hydrofiber dressing is suitable for the treatment of exudating leg ulcers.     

The effects of functional knee braces on speed in collegiate basketball players

Knee braces are worn by many athletes following injury. The purpose of this study was to determine whether two functional knee braces (noncustom design) significantly affected straight line and successive turning trial running times in noninjured collegiate basketball players. Twenty-five coed basketball players completed 2 days of running trials. Subjects ran three full lengths of a basketball court and 10 lengths between the baseline and the foul line first without wearing a brace, then wearing either a DonJoy GoldPoint brace or an Omni OS-5 brace, and finally wearing the other brace. The results indicated no significant difference (p < .05) in straight line or successive turning running times when the two braces were compared with the nonbraced condition and when the two braces were compared with each other. The results implied that speed was not significantly affected by a functional knee brace in noninjured collegiate basketball players.     

Acute repair of injury to the anterior cruciate ligament. A long-term followup

We reviewed 30 patients at an average of 7.4 years after acute repair of the anterior cruciate ligament augmented with a loop of iliotibial tract. A noncontact twisting had been the mechanism of injury in 18 of these patients, with 28 having been injured in sports. At followup, 25 patients had not experienced symptoms of instability and 23 were able to return to unrestricted athletic activity; only 5 had been unable or unwilling to return to sporting activity at all. There had been no swelling in 23 patients; however, 17 suffered from pain on exertion. The average Lysholm score was 93.2. Joint laxity was assessed and anteroposterior tibial translation quantified with a KT-1000 arthrometer. Eighteen patients had a normal or 1+ Lachman test and 27 had an absent or 1+ pivot shift. When compared with the results of a similar study performed on this group of patients at 2 years after surgery, there had been little subjective change in knee function. However, objectively there had been significant deterioration of the anteroposterior stability of the knees at 7 years, suggesting failure of the integrity of the repaired ligament with time. An associated medial collateral ligament injury had a significant adverse effect both on the integrity of the anterior cruciate ligament repair and the incidence of postoperative stiffness.     

Cast brace treatment of plateau and bicondylar fractures of the proximal tibia

Twenty-nine patients with 30 intraarticular proximal tibial fractures were treated with early application of a cast brace. All fractures united, knee motion was excellent or good in all but one patient. The fracture fragments did not lose position after cast brace application. Varus or valgus deformities could be corrected and maintained. Ninety per cent had no pain at follow-up. Hospital stay was as short as two days and generally under two weeks.     

Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial

BACKGROUND: Groin pain is common among athletes. A major cause of long-standing problems is adductor-related groin pain. The purpose of this randomised clinical trial was to compare an active training programme (AT) with a physiotherapy treatment without active training (PT) in the treatment of adductor-related groin pain in athletes. METHODS: 68 athletes with long-standing (median 40 weeks) adductor-related groin pain--after examination according to a standardised protocol--were randomly assigned to AT or PT. The treatment period was 8-12 weeks. 4 months after the end of treatment a standardised examination was done. The examining physician was unaware of the treatment allocation. The ultimate outcome measure was full return to sports at the same level without groin pain. Analyses were by intention to treat. FINDINGS: 23 patients in the AT group and four in the PT group returned to sports without groin pain (odds ratio, multiple-logistic-regression analysis, 12.7 [95% CI 3.4-47.2]). The subjective global assessments of the effect of the treatments showed a significant (p=0.006) linear trend towards a better effect in the AT group. A per-protocol analysis did not show appreciably different results. INTERPRETATION: AT with a programme aimed at improving strength and coordination of the muscles acting on the pelvis, in particular the adductor muscles, is very effective in the treatment of athletes with long-standing adductor-related groin pain. The potential preventive value of a short programme based upon the principles of AT should be assessed in future, randomised, clinical trials.     

Bupivacaine infiltration into the neurovascular bundle of the prostatic nerve does not improve postoperative pain or recovery following transvesical prostatectomy

PURPOSE: We assessed the effect of intraoperative bupivacaine infiltration into the neurovascular bundle of the prostatic nerve on postoperative pain and patient outcome. MATERIALS AND METHODS: The study included 40 American Society of Anesthesiologists physical status I to III patients undergoing transvesical prostatectomy. Following surgical resection of the prostate the neurovascular bundle of the prostatic nerve was infiltrated with either 10 ml. bupivacaine 0.5% or saline. Postoperative pain intensity was assessed using a patient generated 100 mm. visual analog scale and a patient controlled analgesia device. Additional analgesic requirements, time to ambulation, length of hospitalization and return to normal activity were also recorded. RESULTS: There were no differences in visual analog scale for pain, patient controlled analgesia demands or actual morphine delivered. Similarly, saline versus bupivacaine infiltration did not influence ambulation time (21.3 +/- 2.7 versus 25.0 +/- 11.8 hours, respectively), length of hospitalization (7.06 +/- 0.8 versus 7.11 +/- 0.6 days, respectively), return to normal activity (14.4 +/- 8.8 versus 14.2 +/- 8.2 days, respectively) or patient satisfaction. On postoperative days 1 and 2 more patients in the saline treatment group requested additional oral analgesia compared to the bupivacaine treatment group. However, no statistical difference was demonstrated. CONCLUSIONS: Following transvesical prostatectomy, prostatic nerve blockade has no beneficial effects on postoperative pain or patient outcome.     

The effect of Gynostemma pentaphyllum mak (GP) on carcinogenesis of the golden hamster cheek pouch induced by DMBA]

AIM: of this study is to compare two similar groups presenting inguinal herniae, one group having laparoscopic herniography and the other having a Bassini or Fruchaud repair. METHOD: Since September 1994, in our department, patients presenting with symptoms of unilateral or bilateral inguinal herniae to our practice were offered the transperitoneal or preperitoneal approach as an alternative of open surgical repair. We considered the first 50 patients operated by laparoscopic technic (35 M and 15 F), age between 22-72 years (group A), and similar group operated by Bassini or Fruchaud technic (group B). All the patients had general anesthesia and perioperative antibiotics. In the group A we used Prolene, Mercilene or Plastex mesh. The following parameters were assessed: 1) operative time from incision to closure: 2) amount and type of analgesia required postoperatively; 3) morbidity related to the procedure; 4) interval before returning to full activity; 5) early recurrence rate; 6) hospital cost. RESULTS: The mean operative time for unilateral herniae in group A was 70 +/- 10 minutes versus 40 +/- 12 minutes in group B. Group A required to return to work was significantly shorter for the patients in group A (7 +/- 3 days) compared with group B patients (25 +/- 10 days). Although no recurrent herniae have yet been found in patients from either group; follow-up was only 2-18 months in the two groups. The cost of hospital care of group A patients exceeded that of group B by approximately 1.7 more. IN CONCLUSION: was consider that although is more expensive, the laparoscopic procedure in treatment of inguinal herniae, has more benefits for the patients.     

Shin splints and forefoot contact running: a case report

Many athletes develop shin splints after athletic activity. The purpose of this case report is to describe the treatment of a patient with posteromedial tibial pain (shin splints) who habitually ran with a forefoot contact running style. The 20-year-old male patient, who played volleyball and basketball about 7 hours a week, complained of pain in the middle one-third of the posteromedial tibia after an acute but prolonged episode of running. Routine observational analysis and in-shoe pressure analysis of the patient's running style showed that he habitually ran on his toes with an absence of heelstrike (forefoot contact running). After instructing the patient on heel-toe running, he no longer complained of posteromedial tibial bone pain. Several possible reasons are proposed for the reduction of leg pain following cessation of forefoot contact running. This case report proposes forefoot contact running as a possible contributor to posteromedial shin splints and that a change in running style may be the optimal treatment for some patients.     

The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child

The purpose of this study was to evaluate the outcome of transphyseal ligament reconstruction in skeletally immature children with midsubstance anterior cruciate ligament (ACL) disruption. Five consecutive patients (mean age, 12.9 years; range, 8 to 14 years) with radiographically documented "wide" open growth plates and a minimum of 5 cm of expected remaining growth, underwent intra-articular reconstruction of the ACL. Operative treatment included three ACL reconstructions using hamstring tendons and two with quadriceps patellar tendon. All involved a centrally placed 6-mm or smaller tibial drill hole through an open physis and graft placement in an over-the-top position on the femur. At an average follow-up of 7.4 years (range, 4.5 to 9.9 years), no patient had a positive anterior drawer, Lachman, or pivot shift test. On KT-1000 arthrometer testing, all patients had 3 mm or less of increased anterior-posterior displacement (mean +/- SD = 1.0 +/- 1.6 mm). Magnetic resonance imaging showed that four tibial physes had fused in a symmetric fashion and one was still open. Orthoroentgenograms showed that no patient had a significant leg length discrepancy (-0.8 mm +/- 3.4 mm). The mean increase in height postoperatively was 17.7 cm (range, 7.6 to 31.0 cm). Overall, using the International Knee Documentation Committee (IKDC) evaluation form, there were four patients with grade A and one with grade C. The one patient with a poor IKDC grade had sustained a subsequent patellar dislocation with osteochondral fracture. In conclusion, ACL reconstruction using small drill holes placed through open tibial physes does not seem to adversely affect outcome or future growth.     

Complete neurological recovery following prolonged cardiac arrest. Description of a clinical case

The therapy of fibular ligament ruptures is still a controversial subject. Reports on healing processes following operative or conservative treatment have been verified hitherto by means of clinical examinations and stress tests. The MRT, as a highly sensitive non-invasive method, allows exact documentation of the ligament structures in the ankle joints. This technique was used in a randomized clinical trial over a 6-month period. The 29 patients (ages 17-51 years) had recent ligament rupture [admission criteria: clinical signs of trauma, talar tilt in anteroposterior stress radiographs (15 kp) > or = 10 degrees, talar shift > or = 10 mm] were examined with regard to ligament healing during functional therapy with AIRCAST pneumatic leg braces. Within the first week an MRT was done for verification of ligament injury. Treatment was conservative and functional: lower leg cast for 2 weeks and subsequent mobilization with protection provided by an AIRCAST brace. Follow-up examination was 3 months after injury, taking the form of clinical examination, a-p-radiographs with stress tests, and MRT. In all patients both clinical and radiological examination confirmed that ligament structures had healed, as was also verified by MRT.     

Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance

This article characterizes chondral injuries and reviews the results of microfracture treatment in high-level competitive and recreational athletes. Thirty-eight high-level and 140 recreational athletes completed functional questionnaires preoperatively and yearly postoperatively, recording symptoms, function, and activity level. Second-look arthroscopy tapes were available in 26 high-level and 54 recreational athletes. The mean follow-up for the high-level athletes was 3.7 +/- 1.4 years. Chondral defects averaged 223 +/- 180 mm2. Lesion size and follow-up were not significantly different in the recreational group. Functional questionnaire responses demonstrated significant improvements from the time of microfracture to final follow-up. Improvement in function and symptoms was similar for the competitive and recreational athletes.     

Treatment of myositis ossificans traumatica in athletes

Myositis ossificans traumatica, although it is one of a number of heterotopic bone formation entities, is a specific lesion with a clearly recognized etiology and natural evolutionary pattern. Early conservative treatment with rest, elevation, and immobilization minimizes additional trauma and decreases the likelihood of incapacitating bone formation. Subsequently, active range of motion exercises progressing to resistive exercises usually effect a satisfactory recovery and return to full athletic participation. With this treatment regimen, few athletes will be left with significant functional impairment. However, surgery does have a definite role in the treatment of this condition and is indicated in those athletes who develop a large mass of mature lamellar bone which is painful and is associated with muscle weakness and a significant loss of joint motion. Four patients are presented in which surgery resulted in satisfactory recovery and return to full participation in football.     

Some biomechanical aspects of the foot and ankle in athletes with and without shin splints

Thirteen adult male athletes (long-distance runners and orienteerers without foot problems) and 35 male athletes with shin splints were compared with respect to: 1) the position of the lower leg and the heel while standing, 2) the passive range of mobility in the subtalar joint, and 3) the angular displacement between the calcaneus and the midline of the lower leg (Achilles tendon angle) while running with bare feet on a treadmill. In standing, the two groups differed statistically significantly in the Achilles tendon angle, which values were greater in the shin splint group. With respect to passive mobility, the athletes with shin splints had significantly greater (P less than 0.05-0.01) angular displacement values in inversion, eversion, and in their sum than the control group. While running, the Achilles tendon angle of the shin splint group was significantly greater (P less than 0.01) at the heel strike. Further, the shin splints group had a significantly greater (P less than 0.01) angular displacement between the heel strike and the maximal everted position. The results suggest structural and functional differences in the feet and ankles between healthy athletes and those with shin splints.     

Demonstration of dermatophyte dissemination from the infected soles using the foot-press method

The toxicity and outcome after high-dose ara-C/daunorubicin (HDara-C/DNR) consolidation therapy in de novo AML was compared in 11 patients who received an idarubicin-containing induction therapy (IDA; from June 1995 to March 1997) and 16 patients pretreated with daunorubicin (DNR; from July 1990 to May 1995) for induction. The DNR group consisted of two cohorts, one (n = 6) of patients who had received, as had the IDA group, two induction and one intermediate-dose ara-C consolidation courses, and another (n = 10) of patients who had been pretreated with one induction and one consolidation course prior to HDara-C/DNR. There was no difference in the relative dose between the three cohorts. Following HDara-C/DNR, the IDA-pretreated patients experienced a more prolonged myelosuppression during consolidation therapy compared with the DNR group. Duration of neutropenia (< 500 neutrophils/microl) following HDara-C/DNR was 31.2 +/- 16 days (mean +/- SEM) in the IDA group compared with 18.7 +/- 5 days in the DNR group (p < .001 Mann-Whitney U-test). The duration 'of thrombocytopenia (platelets < 25000/microl) was 34.8 +/- 20 days in the IDA group vs. 18.5 +/- 6 days in the DNR group (p < .005). The more prolonged myelosupression was associated with a longer duration of fever (18.9 +/- 24 vs. 6.9 +/- 5.2 days). A greater incidence, length (11 +/- 8 vs. 1.2 +/- 2 days), and severity of diarrhea were observed in the IDA-pretreated group. Three of 11 IDA patients experienced WHO grade III-IV diarrhea. In the IDA group two patients developed severe enterocolitis with Candida septicemia, and one of these patients died. One patient in the IDA group died during prolonged aplasia. In the DNR group 6/16 patients experienced grade I-II diarrhea. Two patients in each group died during consolidation therapy. The CR rate was 87% in the IDA group and 79% in the DNR group. Relapse-free survival after HDara-C is 50% at a median follow-up of 60 months in the DNR group and 45% after a median follow-up of 17 months in the IDA group. Whether the advantage of the superior response rate in the IDA-treated patients may be lost during HDara-C consolidation treatment due to increased toxicity remains to be proven in larger trials.     

Is laparoscopic resection of colorectal polyps beneficial?

BACKGROUND: We set out to compare the results of laparoscopic and open resections of colorectal polyps. METHODS: Forty-five consecutive patients who underwent operation by a single surgeon for endoscopically irretrievable colonic polyps between April 1992 and March 1996 were classified into the following two groups: group I, laparoscopic procedures for colonic polyps (n = 23); and group II, open procedures for colonic polyps (n = 22). RESULTS: No significant differences were seen between the groups relative to age [71.7 +/- 10.7 versus 70.6 +/- 13.7 years], gender [male:female = 10:13 versus 13:9], history of previous abdominal operation (eight of 23 [34.8%] versus 10 of 22 [45.5%]), type of pathology (villous: seven of 23 [30.4%] versus four of 22 [18.1%], tubulovillous: nine of 23 [39.1%] versus six of 22 [27.2%], tubular: three of 23 [13.0%] versus seven of 22 [31.8%]), size of polyps (2.6 +/- 1.7 cm versus 2.7 +/- 1.5 cm), or type of procedures (right hemicolectomy: 15 of 23 [65.2%] versus 11 of 22 [50%], sigmoid colectomy: five of 23 [21.7%] versus six of 22 [27.3%], left hemicolectomy: two of 23 [8.7%] versus two of 22 [9.1%]). There was no mortality and no difference in the incidence of postoperative complications (four of 23 [17.4%] versus seven of 22 [31.8%]), blood loss (167 cc versus 243 cc), number of retrieved lymph nodes (7.1 +/- 5 versus 6.6 +/- 4), incidence of carcinoma in polyps (two of 23 [13.0%] versus four of 22 [18.2%]), or medical cost ($22,840 versus $18,420), respectively, between the two groups. There were statistically significant differences in length of ileus (3.5 +/- 1.0 days versus 5.5 +/- 1.8 days), postoperative pain (2.3 +/- 1.4 versus 3.7 +/- 1.9 on postoperative day 1 [patient pain rating scale 1-10]), length of hospital stay (6. 5 +/- 2.0 days versus 9.4 +/- 2.7 days), and return to normal activity (5.2 +/- 4.2 weeks versus 9.3 +/- 12.1 weeks) in group I compared to group II, respectively. However, patients in group II had a longer mean specimen length (18.5 +/- 6.4 cm versus 29.1 +/- 22.7 cm) and a shorter mean operative time (177.6 +/- 52.7 min versus 143 +/- 51.4 min) than patients in group I. CONCLUSIONS: Laparoscopic colectomy for colonic polyps has definite advantages over traditional open surgery, including less postoperative pain, earlier return of bowel function, and earlier return to normal activity. Conversely, its disadvantages include longer operative time and a shorter specimen.     

Doxycycline is a cost-effective therapy for hospitalized patients with community-acquired pneumonia

BACKGROUND: Doxycycline has a high degree of activity against many common respiratory pathogens and has been used in the outpatient management of lower respiratory tract infections, including pneumonia. OBJECTIVE: To evaluate the efficacy of intravenous doxycycline as empirical treatment in hospitalized patients with mild to moderately severe community-acquired pneumonia. PATIENTS AND METHODS: We conducted a randomized prospective trial to compare the efficacy of intravenous doxycycline with other routinely used antibiotic regimens in 87 patients admitted with the diagnosis of community-acquired pneumonia. Forty-three patients were randomized to receive 100 mg of doxycycline intravenously every 12 hours while 44 patients received other antibiotic(s) (control group). The 2 patient groups were comparable in their clinical and laboratory profiles. RESULTS: The mean+/-SD interval between starting an antibiotic and the clinical response was 2.21+/-2.61 days in the doxycycline group compared with 3.84+/-6.39 days in the control group (P = .001). The mean+/-SD length of hospitalization was 4.14+/-3.08 days in the doxycycline group compared with 6.14+/-6.65 days in the control group (P = .04). The median cost of hospitalization was $5126 in the doxycycline group compared with $6528 in the control group (P = .04). The median cost of antibiotic therapy in the doxycycline-treated patients ($33) was significantly lower than in the control group ($170.90) (P<.001). Doxycycline was as efficacious as the other regimens chosen for the treatment of community-acquired pneumonia. CONCLUSION: Doxycycline is an effective and inexpensive therapy for the empirical treatment of hospitalized patients with mild to moderately severe community-acquired pneumonia.     

Tendon transfer for equinovarus deformed foot caused by cerebrovascular disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.     

A prospective assessment of gastroesophageal reflux before and after treatment of achalasia patients: pneumatic dilation versus transthoracic limited myotomy

OBJECTIVES: We conducted this study to determine whether reflux should be a major consideration in the choice of treatment for achalasia patients. Achalasia patients undergoing either pneumatic dilation or transthoracic limited esophagomyotomy were monitored for reflux before and after treatment, for comparison. METHODS: Twenty-four hour ambulatory esophageal pH tests and esophageal manometry were performed on 32 consecutive, untreated achalasia patients. Studied (before and after treatment) were 17 patients who underwent pneumatic dilation and 15 patients who received transthoracic limited myotomy without fundoplication. All follow-up studies were completed within 12 months of treatment. RESULTS: The ages of the two groups were not significantly different (p > 0.05, 45 +/- 9 yr myotomy vs. 44 +/- 13 yr dilation). The resting lower esophageal sphincter pressure was not significantly different (p > 0.05 before treatment) between groups but was reduced significantly (p < 0.05 after treatment) in both groups (30 +/- 9 mm Hg before vs. 9 +/- 4 mm Hg after myotomy, and 27 +/- 10 mm Hg before vs. 11 +/- 4 mm Hg after pneumatic dilation. The total time the pH was < 4.0 was not significantly different, p > 0.05, in either group before treatment (myotomy, 3.7 +/- 4.4%; dilation, 2.9 +/- 4.9%) or after treatment (myotomy, 8.6 +/- 9.2%; dilation, 10.2 +/- 15.9%). Twelve of 32 patients (38%), had a percent total time < 4.0 that exceeded 6% after treatment, eight of whom were asymptomatic. CONCLUSIONS: These results indicate that the amount of reflux after treatment by both pneumatic dilation and transthoracic esophagomyotomy is similar. The absence of reflux symptoms in treated achalasia patients does not exclude the possibility of significant acid reflux.