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In humans, mutations in the PIEZO2 gene, which encodes for a mechanosensitive ion channel, were found to result in skeletal abnormalities including scoliosis and hip dysplasia. Here, we show in mice that loss of Piezo2 expression in the proprioceptive system recapitulates several human skeletal abnormalities. While loss of Piezo2 in chondrogenic or osteogenic lineages does not lead to human-like skeletal abnormalities, its loss in proprioceptive neurons leads to spine malalignment and hip dysplasia. To validate the non-autonomous role of proprioception in hip joint morphogenesis, we studied this process in mice mutant for proprioceptive system regulators Runx3 or Egr3 . Loss of Runx3 in the peripheral nervous system, but not in skeletal lineages, leads to similar joint abnormalities, as does Egr3 loss of function. These findings expand the range of known regulatory roles of the proprioception system on the skeleton and provide a central component of the underlying molecular mechanism, namely Piezo2 . Mutations in human PIEZO2 , encoding for a mechanosensitive ion channel, lead to skeletal abnormalities including scoliosis and hip dysplasia. Here, the authors show that deletion of Piezo2 in proprioceptive neurons, but not in skeletal lineages, recapitulated the human phenotype in mice.

Purpose Injury or loss of the meniscus generally leads to degenerative osteoarthritic changes in the knee joint. However, few surgical options exist for meniscal replacement. The goal of this study was to examine the ability of a non-degradable, anatomically shaped artificial meniscal implant, composed of Kevlar ® -reinforced polycarbonate-urethane (PCU), to prevent progressive cartilage degeneration following complete meniscectomy. Methods The artificial meniscus was implanted in the knees of mature female sheep following total medial meniscectomy, and the animals were killed at 3- and 6-months post-surgery. Macroscopic analysis and semi-quantitative histological analysis were performed on the cartilage of the operated knee and unoperated contralateral control joint. Results The PCU implants remained well secured throughout the experimental period and showed no signs of wear or changes in structural or material properties. Histological analysis showed relatively mild cartilage degeneration that was dominated by loss of proteoglycan content and cartilage structure. However, the total osteoarthritis score did not significantly differ between the control and operated knees, and there were no differences in the severity of degenerative changes between 3 and 6 months post-surgery. Conclusion Current findings provide preliminary evidence for the ability of an artificial PCU meniscal implant to delay or prevent osteoarthritic changes in knee joint following complete medial meniscectomy.

Background Diabetic foot ulcers are frequently related to elevated pressure under a bony prominence. Conservative treatment includes offloading with orthopaedic shoes and custom made orthotics or plaster casts. While casting in plaster is usually effective in achieving primary closure of foot ulcers, recurrence rates are high. Minimally invasive surgical offloading that includes correction of foot deformities has good short and long term results. The surgery alleviates the pressure under the bony prominence, thus enabling prompt ulcer healing, negating the patient’s dependence on expensive shoes and orthotics, with a lower chance of recurrence. The purpose of this protocol is to compare offloading surgery (percutaneous flexor tenotomy, mini-invasive floating metatarsal osteotomy or Keller arthroplasty) to non-surgical treatment for patients with diabetic foot ulcers in a semi-crossover designed RCT. Methods One hundred patients with diabetic neuropathy related foot ulcers (tip of toe ulcers, ulcers under metatarsal heads and ulcers under the hallux interphalangeal joint) will be randomized (2:3) to a surgical offloading procedure or best available non-surgical treatment. Group 1 (surgery) will have surgery within 1 week. Group 2 (controls) will be prescribed an offloading cast applied for up to 12 weeks (based on clinical considerations). Following successful offloading treatment (ulcer closure with complete epithelization) patients will be prescribed orthopaedic shoes and custom made orthotics. If offloading by cast for at least 6 weeks fails, or the ulcer recurs, patients will be offered surgical offloading. Follow-up will take place till 2 years following randomization. Outcome criteria will be time to healing of the primary ulcer (complete epithelization), time to healing of surgical wound, recurrence of ulcer, time to recurrence and complications. Discussion The high recurrence rate of foot ulcers and their dire consequences justify attempts to find better solutions than the non-surgical options available at present. To promote surgery, RCT level evidence of efficacy is necessary. Trial registration Israel MOH_2017–08-10_000719. NIH: NCT03414216 .

Background This prospective study aimed to assess the reliability and validity of the Hebrew version of the forgotten joint score-12 in patients undergoing total knee arthroplasty, because it is going to be used in the Hebrew-speaking populations in Israel. Methods The English version of forgotten joint score-12 was translated into Hebrew version by using the standard procedures and in collaboration with its authors. The consecutive patients who had undergone total knee arthroplasty in a single hospital were asked to fill out the Hebrew version of forgotten joint score-12, Oxford knee score, Short Form 12, and visual analog scale. A random subgroup of 60 patients were then asked to fill out a second Hebrew version of forgotten joint score-12 at a minimum of 2-week interval. The reliability was assessed in terms of internal consistency, test-retest reliability and split-half reliability. The validity was measured in terms of the outcomes as mentioned above. Results A total of 102 patients participated in the study. The Hebrew version of forgotten joint score-12 showed high reliability. The internal consistency was excellent (Cronbachs’ α = 0.943) and test-retest reliability was high (Intraclass correlation = 0.97). The forgotten joint scores were correlated with the Oxford knee score, Short Form 12, and visual analog scale ( r  = 0.86, r  = 0.72, and r =-0.8, respectively), indicating a high validity. Conclusions The Hebrew version of forgotten joint score-12 has excellent reliability, excellent test-retest reliability and good validity. It can be safely used for assessing outcomes of TKA.

Background The aim of this study was to gain a deeper understanding of the gender differences in knee osteoarthritis (OA) by evaluating the differences in gait spatio-temporal parameters and the differences in pain, quality of life and function between males and females suffering from knee OA. Methods 49 males and 85 females suffering from bilateral medial compartment knee OA participated in this study. Each patient underwent a computerized gait test and completed the WOMAC questionnaire and the SF-36 health survey. Independent t-tests were performed to examine the differences between males and females in age, BMI, spatio-temporal parameters, the WOMAC questionnaire and the SF-36 health survey. Results Males and females had different gait patterns. Although males and females walked at the same walking speed, cadence and step length, they presented significant differences in the gait cycle phases. Males walked with a smaller stance and double limb support, and with a larger swing and single limb support compared to females. In addition, males walked with a greater toe out angle compared to females. While significant differences were not found in the WOMAC subscales, females consistently reported higher levels of pain and disability. Conclusion The spatio-temporal differences between genders may suggest underlying differences in the gait strategies adopted by males and females in order to reduce pain and cope with the loads acting on their affected joints, two key aspects of knee OA. These gender effects should therefore be taken into consideration when evaluating patients with knee OA. Trial Registration The study is registered in the NIH clinical trial registration, protocol No. NCT00599729.

IntroductionThe meniscotibial ligament (MTL) limits extrusion of the medial meniscus (MM). While meniscal extrusion may be detrimental to knee joint biomechanics, the role of the MTL in meniscal extrusion is debatable. We sought to perform a systematic review and meta-analysis to evaluate the role of the MTL and surgical techniques for MTL repair.Materials and methodsFollowing Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines we searched PubMed, Cochrane Library, and Embase for: ((“Meniscotibial”) OR (“Coronary”) OR (“Ramp”)) AND (“Extrusion”). After screening and applying eligibility criteria, data were extracted for MTL pathology types (“traumatic” ruptures or “induced” injuries) and meniscal extrusion. A meta-analysis evaluated the mean difference of extrusion between “intact” MTLs (native or repaired) and “injured” MTLs (induced or traumatic). We further performed a subgroup analysis between traumatic and induced MTL lesions.ResultsThis systematic review included six studies, which all evaluated MM extrusion. There were 74 knees with induced MTL injuries and 19 knees with traumatic MTL ruptures. Study designs were heterogenic and utilized three types of MTL repair procedures. The meta-analysis included 18 human knees and revealed that sectioning the MTL created a 2.92 mm [− 0.18 to 6.03] MM extrusion, while MTL repair decreased MM extrusion by − 2.11 mm [− 3.03 to − 1.21].ConclusionsMTL injury may result in approximately 3 mm of MM extrusion, while repair of the MTL can decrease extrusion by 2 mm. Several novel surgical techniques exist to repair the MTL. However, studies reporting clinical outcomes of these various procedures are scarce.

Purpose To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. Methods Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients’ satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. Results The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. Conclusions Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Purpose To evaluate the intra/inter-rater and diagnostic reliability of the sagittal plane adjusted patellar instability ratios (PIRs) compared to tibial tubercle-trochlear groove (TT–TG) distance alone while employing a matched case–control analysis for age and sex to minimize a potential confounding effect. Methods A retrospective case–control study was performed of all knee MRI studies of patients diagnosed with patellar instability, between 2005 and 2020 at a regional tertiary medical centre. Using a 1:1 case–control matching of sex and age at the time of the diagnosis, one control subject was assigned to each case of patellar instability. Measurements of TT–TG distance, sagittal patellar length (PL), sagittal patellar tendon length (PTL), TT–TG/PL ratio, and TT–TG/PTL ratio were conducted. Two orthopaedic surgery residents and a senior musculoskeletal radiologist were assigned to assess the intra- and inter-rater reliability. Inter-class coefficients were calculated (ICC). The receiver operating characteristic (ROC) curve and area under curve (AUC) for each parameter were compared to evaluate for diagnostic reliability. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated and a multivariable logistic regression model was performed to control for possible confounders. Results The study included 324 individuals (162 case–control matched pairs). In terms of intra- and inter-rater reliability, TT–TG/PL and TT–TG/PTL ratios showed an excellent correlation within and between readers (TT–TG/PL; intra-rater ICC 0.94 and inter-rater ICC 0.92, TT-TG/PTL; intra-rater ICC 0.91 and inter-rater ICC 0.88). The ROC curve showed a slightly greater AUC of the TT-TG/PL ratio compared to TT-TG distance alone (0.75 vs 0.73, p  < 0.001). When applying the pathologic cutoff of TT–TG ≥ 20 mm and TT–TG/PL ≥ 0.5; the calculated odds ratios for the above cutoff were as follows; TT–TG distance alone had an OR of 14 (95% CI 1.8–106.5, p  = 0.011) and OR for TT–TG/PL ratio was 23 (95% CI 3.1–170.3, p  = 0.002). In the multivariable analysis, while controlling for height and weight, only the association between TT–TG/PL ratio and patellar dislocation remained statistically significant with an adjusted OR of 2.7 (CI 1.3–5.4, p  = 0.006), compared to TTTG distance alone (OR = 1.9, n.s.). Conclusions Patellar instability ratios are significantly more reliable compared to TT–TG distance alone for the evaluation of patellar instability. Patellar instability ratios present superior diagnostic reliability, sensitivity and specificity, and intra\\inter rater reliability. Thus, patellar instability ratios could function as a valuable diagnostic tool for the evaluation of patellar instability. Level of evidence III.

Background Excessive shoe heel abrasion is of concern to patients, parents and shoe manufacturers, but little scientific information is available. The purpose of this study was to describe the phenomenon in a group of infantry recruits performing similar physical activity, and search for biomechanical factors that might be related. Methods Seventy-six subjects (median age 19) enrolled. Pre-training parameters measured included height, weight, tibial length, foot arch height and foot progression angle. Digital plantar pressure maps were taken to calculate arch indexes. Shoe heel abrasion was assessed manually after 14 weeks of training with different-sized clock transparencies and a calliper. Results Outsole abrasion was posterolateral, averaging 12 degrees on each shoe. The average heel volume that was eroded was almost 5 cm 3 . The angle of maximum wear was related to right foot progression angle ( r = 0.27, p = 0.02). Recruits with lateral ankle sprains had higher angles of maximal abrasion (17° versus 10°, p = 0.26) and recruits with lateral heel abrasion had more lateral ankle sprains (14% versus 3%, p = 0.12). Conclusion While shoe heel wear affects many people, very little has been done to measure it. In this study in healthy subjects, we found the main abrasion to be posterolateral. This seems to be related to foot progression angle. It was not related to hindfoot valgus/varus or other factors related to subtalar joint motion. These findings do not warrant modification of subtalar joint motion in order to limit shoe heel abrasion.

IntroductionPatient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research.Materials and methodsWe reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle–Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies.ResultsOverall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001).ConclusionsPROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.