Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up.

BACKGROUND: Subtalar arthroereisis (SA) is an increasingly applied minimally invasive approach for flexible flat foot (FFF) not responsive to conservative treatment. This study aimed at evaluating the long-term clinical and radiographic outcomes of SA in pediatric patients with symptomatic FFF. METHODS: Thirty-seven patients (11.9 ± 1.6yy) underwent SA (74 feet), with outcomes assessed after a mean 10-year follow-up. Pain, quality of life, foot functionality, and alignment were evaluated using validated tools and radiographic parameters, calculated on weightbearing x-rays pre- and post-operatively. RESULTS: Clinical outcomes reached excellent postoperative results (FFI: 9.1, AOFAS: 94.5) with a low 0.9 NRS pain (p < 0.01) and a 92 % satisfaction. All radiographic parameters improved significantly towards normal values: CP 17.5 ± 3.9, MA 4.3 ± 5.8, TCA 42.8 ± 6.2, TNCA 21.1 ± 8.5, TNU% 26.6 ± 8.4 (all p < 0.01). CONCLUSIONS: SA with a metallic endosinotarsal device provided significant long-term clinical and radiographic improvements, with low complication rates and high patient satisfaction, supporting its efficacy as a treatment option for pediatric symptomatic FFF. LEVEL OF EVIDENCE: IV.

Walking with a Posterior Cruciate Ligament Injury: A Musculoskeletal Model Study.

The understanding of the changes induced in the knee's kinematics by a Posterior Cruciate Ligament (PCL) injury is still rather incomplete. This computational study aimed to analyze how the internal loads are redistributed among the remaining ligaments when the PCL is lesioned at different degrees and to understand if there is a possibility to compensate for a PCL lesion by changing the hamstring's contraction in the second half of the swing phase. A musculoskeletal model of the knee joint was used for simulating a progressive PCL injury by gradually reducing the ligament stiffness. Then, in the model with a PCL residual stiffness at 15%, further dynamic simulations of walking were performed by progressively reducing the hamstring's force. In each condition, the ligaments tension, contact force and knee kinematics were analyzed. In the simulated PCL-injured knee, the Medial Collateral Ligament (MCL) became the main passive stabilizer of the tibial posterior translation, with synergistic recruitment of the Lateral Collateral Ligament. This resulted in an enhancement of the tibial-femoral contact force with respect to the intact knee. The reduction in the hamstring's force limited the tibial posterior sliding and, consequently, the tension of the ligaments compensating for PCL injury decreased, as did the tibiofemoral contact force. This study does not pretend to represent any specific population, since our musculoskeletal model represents a single subject. However, the implemented model could allow the non-invasive estimation of load redistribution in cases of PCL injury. Understanding the changes in the knee joint biomechanics could help clinicians to restore patients' joint stability and prevent joint degeneration.

Does the Foot and Ankle Alignment Impact the Patellofemoral Pain Syndrome? A Systematic Review and Meta-Analysis.

BACKGROUND: A convincing association between the foot and ankle alignment (FAA) and patellofemoral pain syndrome (PFPS) remains debatable in the literature. Therefore, all studies investigating the role of FAA in patients with PFPS were systematically reviewed. METHODS: A systematic literature search was performed on the databases PubMed, Embase, Cochrane Library, and Web of Science. Inclusion criteria were all studies investigating static and/or dynamic FAA factors and PFPS. Studies with less than 20 patients or with patellofemoral osteoarthritis were excluded. The quality assessment was based on Cochrane study criteria, and the maximum score was set at eight. RESULTS: Of 2246 articles, only 13 case-control studies were eligible. Considering static FAA factors, two studies found an association with rearfoot eversion and one with rearfoot inversion. While examining dynamic FAA characteristics, one study found an association with rearfoot eversion range of motion and three with gait kinematics. No further associations were reported. The quality assessment mean score was 5.5 (SD = 0.97) corresponding to moderate quality. CONCLUSIONS: In contrast to our expectations, a limited number of studies were founded supporting an association between FAA and PFPS. At present, the quality of the literature is still poor and conflicting, thus the need for further studies to determine any association between FAA and PFPS.

Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis.

Background: Nonunion is one of the most challenging problems in the field of orthopedics. The aim of this study was to perform a systematic review of the literature to evaluate the effectiveness of extracorporeal shockwave therapy (ESWT) in the treatment of nonunion in long bones. Methods: We conducted a search of three databases (PubMed, Scopus, and Web of Science) and found 646 total publications, of which 23 met our inclusion criteria. Results: Out of 1200 total long bone nonunions, 876 (73%) healed after being treated with ESWT. Hypertrophic cases achieved 3-fold higher healing rates when compared to oligotrophic or atrophic cases (p = 0.003). Metatarsal bones were the most receptive to ESWT, achieving a healing rate of 90%, followed by tibiae (75.54%), femurs (66.9%) and humeri (63.9%). Short periods between injury and treatment lead to higher healing rates (p < 0.02). Conversely, 6 months of follow-up after the treatment appears to be too brief to evaluate the full healing potential of the treatment; several studies showed that healing rates continued to increase at follow-ups beyond 6 months after the last ESWT treatment (p < 0.01). Conclusions: ESWT is a promising approach for treating nonunions. At present, a wide range of treatment protocols are used, and more research is needed to determine which protocols are the most effective.

Percussion test: description and diagnostic accuracy of a new manual test for bone marrow edema of the knee.

BACKGROUND: Prompt diagnosis of bone marrow lesion (BML) is difficult but critical for correct treatment. Magnetic resonance imaging is the gold standard, although expensive and time consuming. Simple and reliable clinical test for BML detection is lacking. Aim of the study is to describe a new manual clinical test called Percussion Test (PT) and to statistically determine its diagnostic accuracy in BML, compared to MRI imaging. METHODS: After evaluation of the inclusion and exclusion criteria, 218 consecutive patients with unilateral knee pain and age comprised between 18 and 80 years old were enrolled in our observational prospective study. Informed consent was obtained for each patient. After medical history collection, PT was performed by a single operator as described. MRI was performed in the affected knee to detect the presence of BML. Coherence in PT and MRI assessment was evaluated in each quadrant of the knee via contingency tables, as sensitivity, specificity, NPV, PPV and diagnostic accuracy were calculated. RESULTS: No correlation with a positive PT was demonstrated for the covariables gender (p = 0.156), age (p = 0.272) and BMI (p = 0.639). PT showed a sensitivity ranging from 60.6 (40.6-80.6) to 79.5 (63.0-96.0) and a specificity ranging from 85.7 (80.0-91.5) to 96.0 (93.1-98.9) depending on knee quadrant. Diagnostic accuracy ranged from 81.6 (75.9-86.6) to 89.4 (84.6-93.2), and p-value was < 0.00001 in a chi-squared analysis for all quadrants. CONCLUSIONS: PT showed sensitivity and specificity values that are comparable with other clinical tests routinely adopted in clinical practice. In the absence of other reliable clinical test, PT has the potential to become a useful bedside tool in the diagnosis and management of BMLs.

Open versus arthroscopic ankle arthrodesis in high-risk patients: a comparative study.

PURPOSE: Arthroscopic ankle arthrodesis is known to offer high fusion rates, improvements in pain and functional outcomes, low risks of complications, and reinterventions. The aim of this study is to compare open vs. arthroscopic ankle arthrodesis in patients at high risk of complications. METHODS: A single-centre retrospective comparative analysis of ankle fusions was conducted. Patient records were screened for demographics, type of arthrodesis, follow-up length, pre-operative diagnosis, risk factors for non-union, operative time, radiographic union, time to union, complications, and reinterventions. The American Orthopedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Italian version of the Foot Function Index (FFI), and a visual analog scale (VAS) for pain scores collected pre-operatively and in the last follow-up were used to assess clinical outcomes. RESULTS: There were 23 open and 21 arthroscopic ankle fusions. Union rate was higher (90.5% vs. 65.2%, p < 0.05) and complication rate was lower (14.3% vs. 47.8%, p < 0.05) in the arthroscopic group. In addition, patients who underwent arthroscopic arthrodesis reported better pain control, with higher improvements in VAS for pain scores. There was no significant difference in length of operative time, time to fusion, AOFAS, and FFI scores improvements between the two groups. CONCLUSIONS: Arthroscopic ankle arthrodesis resulted in higher union rates, fewer complications, and lower reoperation rates in patients at high risk of complications.

Detailed Methodology to Establish a Synovium/Cartilage-on-a-Chip Model to Investigate the Process of Monocyte Extravasation.

Microfluidics allows for recapitulating organotypic environments in miniaturized cell culture platforms. This ability paves the way to the investigation of complex biological processes in a relevant milieu. Here we describe the protocols to generate an organotypic model including a vascularized compartment mimicking the synovial membrane and designed for the study of monocyte extravasation during osteoarthritis.

Remote Management of Patients after Total Joint Arthroplasty via a Web-Based Registry during the COVID-19 Pandemic.

BACKGROUND: In 2020, due to the outbreak of the COVID-19 (Coronavirus Disease 2019) pandemic, patients who underwent total joint arthroplasty were not able to undergo the proper postoperative surgical and rehabilitative care. This study aims to evaluate the potential of a web-cloud-based database on patients' follow-up in extraordinary situations, when a traditional in-person follow-up cannot be warranted. METHODS: Patients who underwent joint arthroplasty at our Institute between 21 February and 16 March 2020 were included in the study group and were matched to a similar population undergoing joint arthroplasty in February/March 2019. All patients routinely complete questionnaires before and after treatment, including patient-reported outcome measures such as the Visual Analogues Scale (VAS), Knee/Hip Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS/HOOS-PS) and Short-Form Health Survey (SF-12) for the monitoring of clinical improvements. RESULTS: 56 (study group) and 144 (control group) patients were included in the study. Both groups demonstrated significant improvements at 3 months. HOOS-PS improvement was significantly reduced in the 2020 group compared to 2019 (21.7 vs. 33.9, p < 0.001). This reduction was related to intense physical activities. Similarly, the functional score improvement related to these activities was reduced for patients undergoing knee replacement (8 vs. 10, p < 0.05). CONCLUSIONS: The web-based Institute Registry emerged as a meaningful and sensitive tool during an extraordinary situation such as the COVID-19 pandemic to monitor patients' progression after total joint arthroplasties. Thanks to this tool, it was possible to observe that the prevention of usual postoperative care due to pandemic-related restrictions did not alter the benefits observed after joint replacement surgeries, even if this condition reduced the postoperative improvements in the most burdensome physical activities. A broader use of this kind of tool would improve and potentially reduce the burden and costs of postoperative patients' monitoring in standard and extraordinary conditions. In addition, the systematic remote collection of data would allow for the identification of relevant differences in clinical outcomes in specific conditions or following the modification of treatment and rehabilitation protocols.

Recapitulating monocyte extravasation to the synovium in an organotypic microfluidic model of the articular joint.

The synovium of osteoarthritis (OA) patients can be characterized by an abnormal accumulation of macrophages originating from extravasated monocytes. Since targeting monocyte extravasation may represent a promising therapeutic strategy, our aim was to develop an organotypic microfluidic model recapitulating this process. Synovium and cartilage were modeled by hydrogel-embedded OA synovial fibroblasts and articular chondrocytes separated by a synovial fluid channel. The synovium compartment included a perfusable endothelialized channel dedicated to monocyte injection. Monocyte extravasation in response to chemokines and OA synovial fluid was quantified. The efficacy of chemokine receptor antagonists, RS-504393 (CCR2 antagonist) and Cenicriviroc (CCR2/CCR5 antagonist) in inhibiting extravasation was tested pre-incubating monocytes with the antagonists before injection. After designing and fabricating the chip, culture conditions were optimized to achieve an organotypic model including synovial fibroblasts, articular chondrocytes, and a continuous endothelial monolayer expressing intercellular adhesion molecule-1 and vascular cell adhesion molecule-1. A significantly higher number of monocytes extravasated in response to the chemokine mix (p< 0.01) and OA synovial fluid (p< 0.01), compared to a control condition. In both cases, endothelium pre-activation enhanced monocyte extravasation. The simultaneous blocking of CCR2 and CCR5 proved to be more effective (p< 0.001) in inhibiting monocyte extravasation in response to OA synovial fluid than blocking of CCR2 only (p< 0.01). The study of extravasation in the model provided direct evidence that OA synovial fluid induces monocytes to cross the endothelium and invade the synovial compartment. The model can be exploited either to test molecules antagonizing this process or to investigate the effect of extravasated monocytes on synovium and cartilage cells.

Long-term follow-up of Bologna-Oxford (BOX) total ankle arthroplasty.

PURPOSE: The purpose of this retrospective study was to evaluate the long-term results with a minimum of ten years follow-up of primary Bologna-Oxford (BOX) TAA. METHODS: Between December 2004 and December 2009, 80 patients (82 ankles) underwent a primary BOX TAA performed by a single senior surgeon, expert in foot and ankle surgery. Pain and functional outcomes were analysed using Visual Analogue Scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) scoring system, Foot Functional Index Disability and Pain (FFI-Disability, FFI-Pain) score for comparative analysis. RESULTS: A total of 52 patients (54 implants) in a cohort of 80 (82 implants) were examined at a minimum ten years follow-up. Twenty implants out of 54 underwent implant failure (37 %) and 34 patients were enrolled in the present study. The mean VAS for pain decreased significantly from 8.5 ± 1.2 to 2.9 ± 2.2 (p<0.01) and the mean AFOAS score changed from 28.6 ± 11.8 pre-operatively to 72.7 ± 16.9 (p<0.01) at last follow-up. Ninety-seven percent was satisfied with a mean FFI-Disability score that improved from 77.6 ± 19.3 to 26.7 ± 25.4 (p<0.01) and FFI-Pain score that decreased from 76.2 ± 14.2 to 31.4 ± 25.6 (p<0.01). We calculated post-operative alignment using alpha, beta and gamma angles with no difference at long-term follow-up. The survival rate of the implant was 66% at ten years of follow-up. CONCLUSIONS: Our data suggest that BOX TAA is an implant with a good patient satisfaction rate at long-term follow-up; therefore, it is a valid option to increase the quality of life in subjects with end-stage osteoarthritis; however, long-term survivorship is unsatisfactory when compared to modern knee and hip implant.

Quality of Life in Young Adults after Flatfoot Surgery: A Case-Control Study.

The true impact of surgery for flatfoot deformities on patient's quality of life and health status remains poorly defined. The aim of this study is to evaluate the quality of life and the return to daily tasks and sports or physical activities in young adults after surgical correction of flatfoot deformity. Patients treated for bilateral symptomatic flat foot deformity were retrospectively studied. The healthy control group comprised a matched reference population with no history of foot surgery or trauma that was voluntary recruited from the hospital community. All subjects were asked to fill out questionnaires centered on the assessment of the health-related quality of life (Short-form 36; SF-36) and physical activity (International Physical Activity Questionnaire; IPAQ). Most study group SF-36 subscales were lower when compared to the control group. Among the study group, post-operatively, 36.6% of patients managed to resume low levels of sports activity, 40% were sufficiently active and were able to perform moderate sports activity (an activity that requires moderate physical effort and which forces the patient to breathe with a frequency only moderately higher than normal), while 23.3% of them were active or very active and were able to perform intense physical activity. Most IPAQ scores were statistically different from the control group. The present study suggests that patients treated with medializing calcaneal osteotomy and navicular-cuneiform arthrodesis for symptomatic flafoot had lower levels of quality of life and physical activity when compared to healthy subjects. After surgery, patients showed a significant improvement in the clinical scores.

HemiCAP® implantation after failed previous surgery for osteochondral lesions of the talus.

BACKGROUND: The aim of this study is to enhance data about the effectiveness of HemiCAP® implantation after failed previous surgery for osteochondral defects (OCDs). METHODS: 12 consecutive patients were retrospectively included in this study. The American Orthopedic Foot and Ankle Society Score (AOFAS), the Visual Analogue Scale (VAS) score for pain, the sub-scales Pain and Disability of the Foot Function Index (FFI-P and FFI-D) Score, and the patients' satisfaction were evaluated. RESULTS: AOFAS increased from poor to fair (p < 0.001), VAS score decreased from moderate to mild pain (p = 0.001), the final FFI-P and FFI-D were 37.50 ± 18.54 and 33.44 ± 16.24, respectively (p < 0.001). Five patients were not satisfied, three were moderately satisfied and four were highly satisfied. One implant repositioning, one ankle fusion (implant failing) and an additional surgery (double arthrodesis) were performed during the follow-up. Neither intra- nor postoperative complications were registered. CONCLUSION: Despite the clinical improvement, pain was still present at the final follow-up. Metal resurfacing might not be considered a definitely valid alternative for treatment of OCDs after failed previous surgery. LEVEL OF EVIDENCE: Level III, retrospective study.

Transtendinous approach calcaneoplasty versus endoscopic calcaneoplasty for Haglund's disease.

PURPOSE: In this study, we performed a comparison between open calcaneoplasty through transtendinous approach and endoscopic calcaneoplasty for Haglund's disease. METHODS: A retrospective review was performed of patients who had undergone either a calcaneoplasty with transtendinous approach or endoscopic for Haglund's disease from three centres. Inclusion criteria were patients with Haglund's disease confirmed radiographically, neutral alignment of the hindfoot and at least one year of follow-up. Patients were excluded in case of ipsilateral ankle osteoarthritis or other neighbouring joints, previous foot surgery, hindfoot malalignment and marked calcific insertional Achilles tendinosis. A chart review was performed to collect demographic data, including age, sex and body mass index (BMI). Functional outcome analysis included the Foot Function Index, AOFAS score and VAS for pain pre-operatively and post-operatively at the last follow-up. This patient-reported outcome scores were used in the native language of each patient (Italian). RESULTS: Clinical and functional outcomes were collected from 54 patients (28 heels treated by open technique and 26 heels treated by endoscopic technique). In the open group, the AOFAS score improved from a pre-operative value of 65.67 ± 10.09 points to a value of 91.78 ± 9.67 points at the last follow-up (P < 0.05). In the endoscopic group, the AOFAS score improved from a pre-operative value of 66.69 ± 7.19 points to a value of 93.69 points ± 10.04 at the last follow-up (P < 0.05). The VAS and the FFI (Disability and Pain) scores were also improved significantly in both groups at the final follow-up evaluation (P < 0.001). Comparing the final follow-up post-operative clinical scores between the two groups, there was no difference in the AOFAS, VAS or the FFI scores between the two groups. No major complications were recorded, except for one Achilles tendon tear after open calcaneoplasty. The satisfaction rate was similar for both techniques. CONCLUSIONS: Both techniques provided good clinical outcomes with a low rate of complications.

Pulsed electromagnetic fields improve the healing process of Achilles tendinopathy: a pilot study in a rat model.

AIMS: In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy. METHODS: A total of 68 Sprague Dawley rats received a single injection of type I collagenase in Achilles tendons to induce the tendinopathy and then were daily exposed to PEMFs (1.5 mT and 75 Hz) for up to 14 days - starting 1, 7, or 15 days after the injection - to identify the best treatment option with respect to the phase of the disease. Then, 7 and 14 days of PEMF exposure were compared to identify the most effective protocol. RESULTS: The daily exposure to PEMFs generally provided an improvement in the fibre organization, a decrease in cell density, vascularity, and fat deposition, and a restoration of the physiological cell morphology compared to untreated tendons. These improvements were more evident when the tendons were exposed to PEMFs during the mid-acute phase of the pathology (7 days after induction) rather than during the early (1 day after induction) or the late acute phase (15 days after induction). Moreover, the exposure to PEMFs for 14 days during the mid-acute phase was more effective than for 7 days. CONCLUSION: PEMFs exerted a positive role in the tendon healing process, thus representing a promising conservative treatment for tendinopathy, although further investigations regarding the clinical evaluation are needed.Cite this article: Bone Joint Res 2020;9(9):613-622.

Translation, cross-cultural adaptation, and validation of the Italian language Forgotten Joint Score-12 (FJS-12) as an outcome measure for total knee arthroplasty in an Italian population.

BACKGROUND: With ever-increasing numbers of patients undergoing elective total knee arthroplasty (TKA) and as TKA is performed in increasingly younger patients, patient demands and expectations have also increased. With improved patient outcomes, new PROMs with heightened discriminatory power in well-performing patients are needed. The present study aimed to translate and validate the Italian version of the Forgotten Joint Score (FJS-12) as a tool for evaluating pre-operative through longitudinal post-operative outcomes in an Italian population. METHODS: In this prospective study, patients with unilateral osteoarthritis, undergoing TKA surgery between May 2015 and December 2017 were recruited to participate in the study. The FJS-12 and WOMAC were collected pre-operatively and at six and 12 months post-operatively. According to the COSMIN checklist, reliability, internal consistency, validity, responsiveness, effect size, and ceiling effects and floor effects were evaluated. RESULTS: One hundred twenty patients completed the study, 66 of which participated in the evaluation of test-retest reliability. Good test-retest reliability was found (ICC = 0.90). The FJS-12 also showed excellent internal consistency (Cronbach α = 0.81). Construct validity with the WOMAC, as a measure of the Pearson correlation coefficient, was moderate (r = 0.45 pre-operatively; r = 0.46 at 6 months and r = 0.42 at 12 months post-operatively). From six to 12 months, the change was slightly greater for the WOMAC than for the FJS-12 patients (effect size d = 0.94; d = 0.75, respectively). At 12-months follow-up, the ceiling effects reflecting the maximum score were 12% for the FJS-12 and 6% for the WOMAC; however, scores within 10% of the maximum score were comprised 30% of the FJS-12 scores and 59% for the WOMAC. CONCLUSION: The Italian FJS-12 demonstrated strong measurement properties in terms of reliability, internal consistency, and construct validity in TKA patients. Furthermore, a more detailed look at ceiling effects shows a superior discriminatory capacity when compared to the WOMAC at 12-months follow-up, particularly in better-performing patients. TRIAL REGISTRATION: clinicaltrials.gov NCT03805490. Registered 18 January 2019 (retrospectively registered).

High prevalence of burnout syndrome in orthopedic nurses in Italy.

BACKGROUND: Recent studies reported particularly high levels of burnout in nurses working in Orthopedic and Trauma departments. OBJECTIVE: The objectives of the present study were to evaluate the estimated prevalence of burnout and psychiatric morbidity in a population of nurses that work in Italian orthopedic and traumatology departments and to reveal eventual correlations between socio-demographic factors, stress factors, and satisfaction at work. METHODS: Nurses, employed in orthopedics and traumatology departments, were asked to complete an anonymous questionnaire including: a section on demographic data, the Maslach Burnout Inventory, the Short-Form 12, a section on personal and social life, work conditions, and feelings about the work. RESULTS: A high emotional exhaustion (EE) value was present in 35 nurses (66%), a high depersonalization (DP) value in 44 nurses (83%), and a low personal accomplishment (PA) value in 47 nurses (88%). High levels of burnout (EE and DP) were strongly correlated to nurses' perception of health-related quality of life (in the Mental Component Summary-12). CONCLUSION: The average subscales of burnout were remarkably high among Italian orthopedic nurses, suggesting the need of further studies for obtaining a more exact prevalence of this phenomenon.

Novel treatment for hallux rigidus using a temporary metal interpositional device.

BACKGROUND: The aim of this prospective study is to evaluate the results of a consecutive series of patients suffering from grade II-III hallux rigidus who underwent a mobility preserving surgical technique consisting of resection arthroplasty with implantation of a temporary metal spacer. METHODS: Thirty consecutive patients, 18 female and 12 male with a diagnosis of a grade II-III hallux rigidus, not responding to conservative treatment, underwent a minimal resection arthroplasty followed by the implantation of a temporary metal interpositional device by the same surgeon. All spacers were removed after 6 months through a minimal incision under regional anaesthesia. Patients were clinically and radiographically evaluated at 3, 6, 12 months, and 5 years after spacer removal. RESULTS: The clinical AOFAS scores improved already at first follow-up and continued to improve over time with a statistically significant change until the first year. At 3, 6, and 12 months follow-ups, the number of patients with severely limited ROM (i.e. under 30°, that means grade II-III according to Coughlin and Shaurnas classification) significantly decreased. There were only two minor complications, so defined as both of which resolved spontaneously and did not affect the procedure's effectiveness. CONCLUSIONS: We observed good to excellent results with the use of this mobility preserving surgical technique for the treatment of symptomatic grades II and III hallux rigidus. The never before published procedure is easy to perform and inexpensive. LEVEL OF EVIDENCE: Level IV.

Thumbs up: Imagined hand movements counteract the adverse effects of post-surgical hand immobilization. Clinical, behavioral, and fMRI longitudinal observations.

Motor imagery (M.I.) training has been widely used to enhance motor behavior. To characterize the neural foundations of its rehabilitative effects in a pathological population we studied twenty-two patients with rhizarthrosis, a chronic degenerative articular disease in which thumb-to-fingers opposition becomes difficult due to increasing pain while the brain is typically intact. Before and after surgery, patients underwent behavioral tests to measure pain and motor performance and fMRI measurements of brain motor activity. After surgery, the affected hand was immobilized, and patients were enrolled in a M.I. training. The sample was split in those who had a high compliance with the program of scheduled exercises (T+, average compliance: 84%) and those with low compliance (T-, average compliance: 20%; cut-off point: 55%). We found that more intense M.I. training counteracts the adverse effects of immobilization reducing pain and expediting motor recovery. fMRI data from the post-surgery session showed that T+ patients had decreased brain activation in the premotor cortex and the supplementary motor area (SMA); meanwhile, for the same movements, the T- patients exhibited a reversed pattern. Furthermore, in the post-surgery fMRI session, pain intensity was correlated with activity in the ipsilateral precentral gyrus and, notably, in the insular cortex, a node of the pain matrix. These findings indicate that the motor simulations of M.I. have a facilitative effect on recovery by cortical plasticity mechanisms and optimization of motor control, thereby establishing the rationale for incorporating the systematic use of M.I. into standard rehabilitation for the management of post-immobilization syndromes characteristic of hand surgery.

Strength Reduction in Unilateral Shoulder Pain: Is the Healthy Side Really Healthy in Rotator Cuff Disease?

OBJECTIVE: The primary aim was to ascertain whether unilateral shoulder pain is implicated in strength reduction both on the ipsilateral and contralateral side. Secondarily, we aimed to determine whether strength was affected by sonographic tendon abnormalities. DESIGN: A total of 122 subjects were evaluated. Sixty-six female subjects with unilateral shoulder pain in the dominant arm were recruited. Abduction strength was measured in both the dominant and nondominant arm. High-resolution ultrasonography was also conducted on both shoulders. A match-paired control group (n = 66) composed of healthy volunteers underwent the same strength and sonography tests. Subjects with any radiographic anomaly were excluded from the control group. A mixed analysis of variance was performed to test the effect of unilateral shoulder pain on abduction strength. The effect of tendinopathy on shoulder strength was investigated using a mixed 2 × 2 analysis of variance. RESULTS: Analysis of variance showed that patients with dominant shoulder pain had lower shoulder strength (11.65 ± 4.05 kg) when compared with controls (14.37 ± 4.00 kg; F = 10.454, P = 0.002). No statistically significant effects were found when comparing subjects with and without tendinopathy among the study group. CONCLUSIONS: In patients with unilateral shoulder pain, abduction strength was found to be lower both on the ipsilateral and contralateral side. The presence of tendinopathy did not affect the reduction in strength. Future research is needed to substantiate these findings.

Bone marrow lesions of the knee: longitudinal correlation between lesion size changes and pain before and after conservative treatment by extracorporeal shockwave therapy.

BACKGROUND: Bone marrow lesions (BMLs) of the knee have become a common finding on magnetic resonance imaging (MRI), leading to a growing interest in BML, not only for its potential role in the progression of several musculoskeletal conditions, but also for its clinical impact and treatment implications. At present, there is limited and conflicting evidence regarding whether or not pain may be correlated to BML size or not. AIM: To verify the longitudinal correlation between BML size and knee pain. DESIGN: Longitudinal. SETTING: Italian Orthopedic Institute. POPULATION: The study sample was composed of 72 patients, 27 males and 45 females, with a mean age of 55.9±10.22 years and a mean BMI of 26.1±3.7 kg/m2. All patients presented with BMLs and acute knee pain. METHODS: All 72 patients underwent a knee MRI before and 6 months after a course of high energy ESWT, in order to perform a quantitative measurement of the BML areas. KOOS (Knee Injury and Osteoarthritis Outcome Score) Pain subscale scores were obtained at the same time point. A regression analysis was performed to verify the correlation between knee BML size and KOOS pain subscale score before treatment and the correlation between the reduction of BML size and the improvement of KOOS pain score 6 months after treatment. RESULTS: A statistically significant correlation between the KOOS Pain subscale and the BML size (beta=-0.362 [CI95%: -0.019/-0.05], P=0.002) was demonstrated. The clinical score and BML area significantly improved after treatment (P<0.001). The clinical improvement was correlated to the BML size reduction (beta=0.254 [CI95%: 0.001/0.017], P=0.031). CONCLUSIONS: This study confirmed a significant correlation between the BML size and the intensity of knee pain. Furthermore, the before and after study using ESWT to treat symptomatic BMLs, revealed a correlation between size reduction of BML and KOOS pain subscale score improvement, demonstrating the utility of BML reduction as a therapeutic goal. Finally, ESWT was validated as a safe and potentially effective treatment of subchondral bone marrow lesions. CLINICAL REHABILITATION IMPACT: Our results confirm that severity of pain is correlated with BML size, and furthermore, demonstrate that increases and decreases in the amount of pain reflect growth or reduction in BML size, respectively. This information may be useful for rehabilitation and decrease the reliance on MRIs for checking the progress of bone lesions. Absence or marked reduction of pain should allow for the resumption of weight-bearing and more strenuous exercises for an adequate musculoskeletal recovery.