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Bone marrow lesions (BMLs) around the knee are a common magnetic resonance imaging (MRI) finding. However, despite the growing interest on BMLs in multiple pathological conditions, they remain controversial not only for the still unknown role in the etiopathological processes, but also in terms of clinical impact and treatment. The differential diagnosis includes a wide range of conditions: traumatic contusion and fractures, cyst formation and erosions, hematopoietic and infiltrated marrow, developmental chondroses, disuse and overuse, transient bone marrow oedema syndrome and, lastly, subchondral insufficiency fractures and true osteonecrosis. Regardless the heterogeneous spectrum of these pathologies, a key factor for patient management is the distinction between reversible and irreversible conditions. To this regard, MRI plays a major role, leading to the correct diagnosis based on recognizable typical patterns that have to be considered together with coexistent abnormalities, age, and clinical history. Several treatment options have been proposed, from conservative to surgical approaches. In this manuscript the main lesion patterns and their management have been analysed to provide the most updated evidence for the differential diagnosis and the most effective treatment. Level of evidence IV.

BackgroundDistal third femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved. This study aims to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing, non-locking retrograde intramedullary nailing and anatomical locking plate to surgically treat distal third femoral shaft fractures in young adults. Our hypothesis was that there is no significant statistical difference among the surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).MethodsRetrospective study: 90 patients divided into three groups (group 1 LRN, group 2 NLRN, group 3 plating). Average age was respectively 42.67 (± 18.32), 44.27 (± 15.11) and 42.84 (± 18.32) years. Sex ratio F:M was respectively 2.75, 2.33 and 2.00. AO Classification, KOOS, NUSS and RUSH score, VAS, DEXA scans and plain radiographs were used. Evaluation endpoint: 12 months after surgery.ResultsThere were no statistical differences in terms of surgery time, transfusions, and wound healing. Results were similar with regard to average time of bone healing, RUSH scores, VAS, KOOS, regression between RUSH and VAS, average correlation clinical–radiographic results and patients outcomes.ConclusionsOur results showed no statistical difference in the use of LNR, NLNR and plating for treatment of distal third femur shaft fractures in terms of radiographic, bone densitometry and clinical outcomes. Good subjective and objective results are provided by all three techniques. The choice among the studied techniques must be based on surgeons’ experience, indications and subjective patients’ aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with a bigger cohort is needed for definitive validation.

ObjectiveTo evaluate the long-term evolution of matrix-induced autologous chondrocyte implantation (MACI) with magnetic resonance (MR) arthrography and verify the correlation between radiological and clinical findings.Materials and methodsTwenty-six patients (20 m/6f) were diagnosed with knee chondral injuries and treated with MACI implantation. Each patient received MR arthrography and clinical examination at mid-term (range 22–36 months) and long term (range 96–194 months) after surgery. MR arthrography was performed with dedicated coil and a 1.5-Tesla MR unit. The modified MOCART scale was used to evaluate the status of chondral implants. Implant coating, integration to the border zone, and the surface and structure of the repaired tissue were evaluated. Presence of bone marrow oedema was evaluated. The Cincinnati Knee Rating System (CKRS) was used for clinical assessment.ResultsAt long term, 4/26 patients had complete alignment; 5/26 had a complete integration of the margins; in 4/26 cases, the implant surface was undamaged; in 14/26 cases, the reparative tissue was homogeneous. In 9/26 cases, the implant showed isointense signal compared to articular cartilage, while the presence of subchondral bone oedema was documented in 19/26 cases. The average radiological score decreased from 59.2 (mid-term) to 38.6 (long term). The average clinical score decreased from 8.9 to 8.3.ConclusionsDecrease in clinical results was not significant (0.6 points p = .06), but mMOCART scores decreased significantly (p = .00003). Although imaging studies showed deterioration of the grafts, the patients did not have significant clinical deterioration (231/250).

Quadriceps tendon tears are uncommon lesions and their diagnosis can be missed in up to 50% of cases. We report a case of a 83-year-old man with polio who has a chronic quadriceps tendon tear in a healthy limb. A modified Codivilla technique augmented with an ipsilateral semitendinosus tendon was performed. Partial weight bearing was allowed immediately after surgery, and at 3 months the patient was able to walk with full weight bearing on the involved limb. The 5-year follow-up MRI showed good quadriceps tendon healing with the full integration of the tendon graft. Tendon repair with autograft augmentation represents a potential and effective solution in elderly patients with a chronic quadriceps tendon tear.

Psoriatic arthritis (PsA) is a complex, multiform and chronic inflammatory disease characterised by the association of arthritis and psoriasis combined with other related conditions and comorbidities. Treatment of PsA has rapidly evolved by the introduction of new biological drugs and small molecules which allow to achieve disease remission or low disease activity in most of the patients. However, unmet treatment needs still persist for those patients with persistent disease activity or symptoms, impaired function, reduced quality of life or comorbidities. In this context, non-pharmacological approaches, including diet modifications, an adequate sleep quality and physical activity could provide additional benefits. In recent years, diet modifications, improvement of sleep quality and physical activity became an area of interest for researchers and some studies showed how a holistic non-pharmacological approach may ameliorate the quality of life of patients with PsA.The aim of this manuscript was to review the current evidence on the intriguing link and potential effects of diet, sleep and exercise in PsA patients. In particular, we reviewed the literature focusing on the possible benefits of a holistic approach to PsA patients considering lifestyle modifications.

Background: Acute posterior cruciate ligament (PCL) injuries are uncommon and often challenging to treat. While conservative treatment is frequently proposed in the acute phase, conventional rigid bracing may lead to complications such as joint stiffness and quadriceps atrophy. Dynamic braces applying posterior to anterior force during flexion have been proposed as a more functional alternative. Purpose: To evaluate the biomechanical efficacy of a dynamic PCL brace in reducing posterior tibial translation during the acute post-traumatic phase using standardized stress radiographs. Methods: The study was conducted on 11 patients with acute PCL injuries (four isolated, seven multiligamentous) treated within 15 days from trauma. Posterior tibial translation was measured with X-rays at 90° of flexion under four conditions: static (resting), stress (150 N), brace unloaded, and brace loaded (50 N posterior force). Three blinded orthopedic surgeons performed all measurements independently. Results: The dynamic brace significantly reduced posterior tibial translation across all conditions. Translation under stress was reduced from a mean of 7.1 mm to 2.68 mm with the loaded brace (p < 0.001). Conclusions: The study demonstrates that dynamic bracing provides effective biomechanical control of posterior tibial translation in the acute PCL injury. These findings support the potential role of dynamic bracing in conservative treatment protocols.

BackgroundThe Kujala, Fulkerson, Larsen and Lysholm questionnaires have been demonstrated to be reliable and sensitive in assessing patients with patellofemoral pathology. The purpose of this study is to translate and cross-culturally adapt into Italian the English versions of the Kujala, Fulkerson, Larsen and Lysholm questionnaires, and undertake reliability and validity evaluations of the Italian versions of these scores in patients with patellofemoral pathology.Materials and methodsThe cross-cultural adaptation process was carried out following the simplified Guillemin criteria. The questionnaires were administered to 63 patients with either patellar instability or painful patella syndrome. To assess the validity of the questionnaires, they were compared with the Oxford knee score. The questionnaires were administered to a subsample of 33 patients 5 days later to assess test–retest reliability.ResultsThe interclass coefficient correlation was 0.96 for the Kujala score, 0.92 for the Larsen score, 0.96 for the Lysholm score, 0.94 for the Fulkerson score (P < 0.01), and 0.83 for the Oxford score. Pearson’s correlation was0.96 between the Kujala and Oxford scores, 0.90 between the Larsen and Oxford scores, 0.94 between the Lysholm and Oxford score, and 0.93 between the Fulkerson and Oxford scores. Responsiveness, calculated by standardized response mean, was 1.2, and effect size was 1.4.ConclusionsThe Italian versions of the Kujala, Larsen, Lysholm and Fulkerson scoring systems were shown to be equivalent to their English versions and demonstrated good validity, reliability and responsiveness to surgical treatment of patellofemoral pathology. To the best of the authors’ knowledge, this is the first attempt to adapt four of the most common patellofemoral-specific scoring scales to the Italian language.Level of evidenceLevel II.

BackgroundRevision ACL reconstruction is a complex topic with many controversies and not-easy-to-make decisions. The authors’ aim is to provide some feasible advice that can be applied in daily clinical practice with the goal of facilitating the decision-making process and improving the outcomes of patients subjected to revision ACL reconstruction.MethodsA national survey with seven questions about the most controversial topics in revision ACL reconstruction was emailed to members of two societies: SIOT and SIAGASCOT. The participants’ answers were collected, the most recent literature was analyzed, and a consensus was created by the authors, according to their long-term surgical experience.ConclusionsThe decision-making process in revision ACL reconstruction starts with a standardized imaging protocol (weight-bearing radiographs, CT scan, and MRI). One-stage surgery is indicated in almost all cases (exceptions are severe tunnel enlargement and infection), while the choice of graft depends on the previously used graft and the dimensions of the tunnels, with better clinical outcomes obtained for autografts. Additional procedures such as lateral extra-articular tenodesis in high-grade pivot-shift knees, biplanar HTO in the case of severe coronal malalignment, and meniscal suture improve the clinical outcome and should be considered case by case.Level of evidenceV (Expert opinion).

The aims of this study were as follows: (1) To evaluate the entheseal fibrocartilage (EF) during Achilles tendon insertion in patients with Psoriatic Arthritis (PsA) by using power Doppler ultrasound (PDUS), (2) to assess the intra and inter-reader reliability of the evaluation of EF thickness, (3) to compare the EF thickness of PsA patients, athletes and healthy controls (HCs), and (4) to evaluate the correlations between EF abnormalities, disease activity and functional indices in PsA. Methods: Consecutive PsA patients attending our unit were asked to participate. HCs and agonist athletes were enrolled as a control group. A bilateral PDUS evaluation of Achilles tendons was performed in order to evaluate the EF in all patients and controls. Results: In total, 30 PsA patients, 40 athletes and 20 HCs were enrolled. The median (IQR) EF thickness among the PsA patients, athletes and HCs was 0.035 cm (0.028–0.04) cm, 0.036 (0.025–0.043) cm and 0.030 (0.020–0.038) cm, respectively (p = 0.05 between PsA patients and HCs). The intra-reader reliability was excellent [ICC (95% CI) of 0.91 (0.88–0.95)] and the inter-reader reliability was good (0.80 (0.71–0.86). The assessment of EF was feasible, with a mean time of 2 min. No correlations were found with disease activity indices in PsA patients. Conclusion: The assessment of EF is a feasible and reproducible test and may be explored as a potential imaging biomarker.

Patellofemoral joint cartilage lesions are associated with a variety of clinical situations including blunt trauma, lateral patella dislocations, or as a secondary development in the setting of abnormal joint loading. There is a need for more clarity on how to best address these lesions. Most specifically, when is it necessary to surgically treat these lesions of the patella and trochlea and which technique to use? This review will focus on the spectrum of patellofemoral disease/injury and their treatment strategies, with special emphasis on cartilage damage and early osteoarthritis. Chapter sections will review the most common scenarios of cartilage damage in the patellofemoral joint, with an attempt to summarize current treatment, their outcomes, remaining challenges and unanswered questions. Level of evidence V.