Patient Outcomes of Virtual Foot and Ankle Telephone Clinics During COVID-19 Pandemic: 1 Year Experience.

COVID-19 pandemic has instigated to find alternative methods of assessing and treating patients with foot and ankle disorders. We have implemented virtual telephone clinic consultations along with the face-to-face consultations. It has reduced overcrowding in the busy outpatient waiting area and thus limiting close patient contact. The aim of this study is to audit the patient satisfaction outcomes, assess the feasibility and to find out the potential financial implications of introducing telephone clinic consultations for foot and ankle disorders. A total of 426 patients who had telephone consultations for foot and ankle disorders for a period of 1 year were included. Patients were given individual time slots for the consultations. The patient satisfaction outcomes were assessed using a structured questionnaire. The outcomes following the telephone consultation was audited. The financial cost was calculated for the study period. Following the telephone consultation 35% of the patients were discharged and 36% were given further face to face appointments. 97.5% were very satisfied or satisfied with the methodology and outcomes of the telephone consultation. Ninety-five percent of the patients commented that they would recommend telephone consultations for foot and ankle to their friends and family. The financial savings calculated during the study period was about £25,000 ($30,000). Virtual telephone clinic consultations are safe, efficient and cost effective with good patient satisfaction outcomes. It is an alternative or can be conducted adjunct to face to face consultations with adequate planning, training, good communication skills and proper documentation.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases.

BACKGROUND: Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success. METHODS: A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores. RESULTS: The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively. CONCLUSIONS: Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

Three-Year Follow-Up Results of Combined Short Scarf Osteotomy With Akin Procedure for Hallux Valgus.

The short scarf osteotomy has been developed as a less-invasive method of preserving the soft tissue envelope, at the same time maintaining the strength, correction, and utility of a classic long scarf osteotomy. We carried out a review of 166 short scarf osteotomies performed combined with the Akin procedure with a mean follow-up of 34.6 (range 28 to 38) months. These radiographic parameters were evaluated preoperatively, at 6 weeks, and at 3 years. The functional evaluation was based on the American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal scale score. At follow-up, the mean American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal scale score improved from a preoperative average of 54.6 to a postoperative average of 92.8 (p < .001). The radiographic evaluation gave the following results: the preoperative hallux valgus angle of 27.92° improved to an average of 11.85° (p < .001); the preoperative inter metatarsal angle of 14.03° improved to an average of 9.64° (p < .001). There were no fractures during the procedure. There were no incidences of infection or recurrence of deformity. Three patients have to undergo metatarsophalangeal joint fusion because of progression of osteoarthritis of the joint. No avascular necrosis of the metatarsal head was seen. The short scarf osteotomy along with Akin procedure is minimally invasive compared to the standard scarf osteotomy. It is a simple technique with good mechanical strength, signifying excellent patient satisfaction while reconstructing normal anatomy and restoring radiological measurements with fewer complications.

The role of edmonton frailty scale and asa grade in the assessment of morbidity and mortality after fracture neck of femur in elderly.

Frailty is a complex syndrome which affects the energy, physical ability, cognition and general health. Hip fractures are associated with causes and consequences of frailty such as osteoporosis, frequent falls, low body mass index, multiple medications and cognitive impairment. The aim of our study is to assess the value of ASA grade and Edmonton frailty score in the outcome of treatment of fracture neck of femurs in elderly patients. 192 patients admitted with fracture neck of femur were included in the study. The mean age was 79.23 years .120 patients had ASA grade 3, 56 patients had ASA grade 2 and 16 patients had ASA grade 1.The frailty index was calculated using Edmonton scoring index. Ninety four patients (49%) had low frailty score and 88 patients (51%) had a high frailty score of more than 10.All patients were followed up 4 weeks and one year after the surgery. In conclusion the patients with frailty scores and ASA grade have got more chance of developing wound infection. They also have got higher incidence of mortality and morbidity following fracture neck of femur.

The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip.

The assessment of a patient with chronic hip pain can be challenging. The differential diagnosis of intra-articular pathology causing hip pain can be diverse. These includes conditions such as osteoarthritis, fracture, and avascular necrosis, synovitis, loose bodies, labral tears, articular pathology and, femoro-acetabular impingement. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip. A retrospective analysis of 113 patients who had MRI arthrogram and who underwent hip arthroscopy was included in the study. The MRI arthrogram was performed using gadolinium injection and reported by a single radiologist. The findings were then compared to that found on arthroscopy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and 95% confidence interval were calculated for each pathology. Labral tear-sensitivity 84% (74.3-90.5), specificity 64% (40.7-82.8), PPV 91% (82.1-95.8), NPV 48% (29.5-67.5), accuracy 80%. Delamination -sensitivity 7% (0.8-22.1), specificity 98% (91.6-99.7), PPV 50% (6.8-93.2), NPV 74% (65.1-82.2) and accuracy 39%. Chondral changes-sensitivity 25% (13.3-38.9), specificity 83% (71.3-91.1), PPV 52% (30.6-73.2), NPV 59% (48.0-69.2) and accuracy 58%. Femoro-acetabular impingement (CAM deformity)-sensitivity 34% (19.6-51.4), specificity 83% (72.2-90.4), PPV 50% (29.9-70.1), NPV 71% (60.6-80.5) and accuracy 66%. Synovitis-sensitivity 11% (2.3-28.2), specificity 99% (93.6-100), PPV 75% (19.4-99.4), NPV 77% (68.1-84.6) and accuracy 77%. Our study conclusions are MRI arthrogram is a useful investigation tool in detecting labral tears, it is also helpful in the diagnosis of femoro-acetabular impingement. However, when it comes to the diagnosis of chondral changes, defects and cartilage delamination, the sensitivity and accuracy are low.

An evaluation of the effectiveness of medial patellofemoral ligament reconstruction using an anatomical tunnel site.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability has gained popularity, and anatomical and biomechanical studies have recently altered our operative techniques. The aim of this study was to report the clinical outcome of this new anatomical MPFL reconstructive technique and investigate whether correlating factors could be identified. METHODS: Between 2009 and 2012, a total of 31 consecutive patients underwent MPFL reconstruction using an autologous gracilis graft and anatomical tunnel placement. Pre- and post-operative data were collected as a part of routine clinical practice. The preoperative assessment included a rotational profile CT scan of the lower extremity according to the Lyon protocol with TT-TG distance measurement. Outcomes were evaluated with the Kujala and Norwich patella instability (NPI) scores preoperatively and at follow-up (1.5-5.1 years). RESULTS: A significant improvement in both the Kujala (p < 0.001) and NPI (p = 0.012) scores was recorded. A medium and large negative correlations were found between TT-TG distance and Kujala score improvement (ρ = -0.48, p = 0.020) and NPI score improvement (ρ = -0.83, p = 0.042), respectively. Multiple regression analysis identified TT-TG distance, Beighton score and BMI as factors explaining the variance of Kujala score improvement. CONCLUSION: Anatomical MPFL reconstruction with the gracilis autograft for patellar instability resulted in good outcome. This underlines the importance of anatomical tunnel placement in MPFL reconstruction. With a precise preoperative work-up, factors can be identified that may guide selecting the optimal operative strategy and improve counselling of the patient. LEVEL OF EVIDENCE: Case series, Level IV.

Clinical outcomes and complications of titanium versus stainless steel elastic nail in management of paediatric femoral fractures-a systematic review.

Femoral shaft fractures in children account for approximately 1.6% of all fractures. These fractures can be treated both operatively and non-operatively. Surgical fixation is more common in the age group above 6 years. Elastic intramedullary nails have become the most popular surgical modality of treatment over the last few decades. However, there is continuous debate about which type of elastic nails (titanium and stainless steel) provides better clinical outcomes with less complication. The main purpose of this study was to systematically search for and critically appraise articles comparing clinical outcomes and complications of titanium elastic nail system (TENS) and stainless steel elastic nail system (SSENS) in management of femoral fractures in the paediatric age group. A comprehensive search of MEDLINE, EMBASE, and Cochrane library databases was performed using specific search terms and limits. Applying strict eligibility criteria, the identified studies were screened. Five studies were identified and reviewed. All of the identified studies were non-randomised comparative studies apart from one randomised controlled study. Studies provide contradictory evidence with regard to time to fracture union and time to full weight bearing. Only one study commented on time to nail removal and found that it is shorter in the TENS group. Two studies showed significantly higher rate of malunion in the TENS group, whereas the rest showed no difference. There was no difference in the rates of delayed union or infection between the two groups and no consistent difference in the rates of skin irritation. Three studies compared Flynn's outcome score and found no difference apart from one study which found better scores in the SSENS group. There is no consistent evidence to indicate the advantage of one type of elastic nails over the other in management of paediatric femoral shaft fractures; however, the overall trend is in favour of SSENS especially being cheaper than TENS. Critical appraisal of the studies identified significant methodological deficiencies, and further prospective randomised trials are recommended for more potent evidence.

Primary Bacterial Gluteal Pyomyositis: A Rare Disease in Temperate Climates Presenting as Suspected Septic Arthritis of the Hip.

BACKGROUND: In nations with temperate climates, primary polymyositis is a rare, life-threatening bacterial infection that can mimic various clinical diseases depending on the area involved, leading to delayed diagnosis and management. CASE REPORT: We describe a young postpartum woman who presented to the emergency department with hip pain that was initially suspected to be caused by septic arthritis. However, hip arthrocentesis was negative, and a magnetic resonance imaging scan revealed extensive pyomyositis of the gluteal muscles. She underwent surgical debridement and was given parenteral antibiotics with good clinical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We emphasize that cases of pyomyositis in temperate countries are often diagnosed late and therefore delay life- and potentially limb-saving treatment. For patients who present with hip and thigh pain and clinical features of sepsis, pyomyositis should be considered in the differential diagnosis and an early magnetic resonance imaging scan should be performed to confirm the diagnosis and reduce the high morbidity and mortality associated with this emerging disease.

The value of delayed MRI scans in the assessment of acute wrist injuries.

The aim of this study was to better quantify the role of delayed MRI scans in acute wrist injuries, and to assess the prevalence and distribution of multiple occult injuries of the wrist. A retrospective study was made of all patients who had been referred to the orthopaedic trauma clinic for a possible scaphoid fracture and with normal radiographs over a two year period. There were 110 patients. Patients were initially treated conservatively with a scaphoid cast or a futura splint for two weeks. This was then removed and the wrist examined and further radiographs taken. The patients with normal radiographs who had positive clinical findings for a scaphoid fracture at two weeks or persisting pain at six weeks had an MRI scan. MRI was performed with and without fat saturation sequences. A total of 110 wrists were analysed. Twenty-eight (25.4%) were reported as normal; 24 patients (21.8%) had occult bone fractures. Three (2.7%) had scaphoid fractures diagnosed by MRI scans. There were nine (8.1%) distal radius, two trapezium and five hook of hamate fractures. Bone bruising was seen in 12 (10.9%). Carpal degeneration was seen in ten and a TFC tear was noted in five (4.5%). Other findings were a ganglion in 14 (12.7%) and three (2.7%) had Kienbock's disease. The MRI scan is a useful tool in obtaining a definite diagnosis in acute wrist injuries. Among other findings, an occult scaphoid fracture was diagnosed on MRI in 2.7% of cases in this study. To conclude, in the majority of patients with persisting symptoms after two weeks following a wrist trauma, the cause of symptoms was pathology in other tissues in the wrist including soft tissues, other carpal bones and distal forearm.

The use of the three-point index in the management of extra-articular distal radius fractures.

Conservative management has been the mainstay of treatment for simple extra-articular distal radius fractures. Several factors, such as quality of definitive casting, have been implicated in the risk of fracture re-displacement during follow-up. Objective assessments of the quality of casting using various indices have been documented in literature, although overall evidence remains scant, and only one study in the literature discusses the use of the three-point index (3-PI) in adults. Currently, no independent study assessing the 3-PI in adults has been documented. This retrospective study aimed to assess the 3-PI in terms of (1) predicting fracture re-displacement and (2) evaluating its practicality in everyday clinical use. We had 54 patients (47 female, 7 female), out of which 35 patients had a 3-PI greater than the suggested cutoff value of 0.8; of these, 22 went on to re-displace. The remaining 19 patients had a 3-PI below the cutoff and 14 went on to re-displace. No statistical significance was found for the 3-PI as a predictor for fracture re-displacement, although inter-observer reliability was high; its impact on clinic times (in calculating the 3-PI) remained low.

The outcomes of constrained total hip arthroplasty for recurrent dislocation of hip hemiarthroplasty.

INTRODUCTION: The incidence of hemiarthroplasty dislocation for fracture neck of femurs ranges between 1 and 15% and the one-year mortality is 49- 70%. Revision of hemiarthroplasty to total hip replacement using a constrained liner has shown to improve the morbidity and mortality rates. The aim of the study was to assess whether conversion of dislocated hemiarthroplasty to total hip replacement improve functional and one year mortality. METHODS: A retrospective analysis of the number of patients who had recurrent dislocations of hemiarthroplasty for fracture neck of femurs were carried out. The data were obtained from NHFD (National Hip Fracture Database) and internal hospital computer systems (Medway, Theatre notes and PACS) between Dec 2008 and Dec 2020. Patient demographics including age, sex, Abbreviated Mental Test Score (AMTS), functional assessment, mortality at one and two years were documented. The risk factors which led to dislocations such as Parkinsons disease, Cerebrovascular accidents, Musculo-neuropathies and Alzheimer`s disease was also noted. RESULTS: A total of 3994 patients were admitted during the study period of which 1735 (43.4%) patients had hemiarthroplasty. Fifty-six (3.23%) patients had dislocation of hemiarthroplasty. The mean age was 81.4 years (range - 61 to 95). There were 40 (71.4%) females and 16 males (28.6%). The average AMTS score was 5.3. All 56 patients had closed manipulative reduction under anaesthesia within in 12 h of admission. Thirty-one patients (55.4%) went on to have recurrent dislocations of which 18 patients (58.4%) had total hip replacement using captive cup, 6 patients (19.4%) had open reduction,3 patients (9.7%) had excision arthroplasty procedure and four patients (12.5%) had no intervention, Eighteen patients who had total hip replacement with constrained captive for followed up to a minimum of two years (range2- 12 years). There were no intraoperative complications, dislocation or periprosthetic fractures in the follow up period. There was no mortality at the end of two years of follow up in this group, two-year mortality for the patients with alternative management for dislocated hemiarthroplasty was 76.67. CONCLUSION: Treatment of recurrent hemiarthroplasty dislocation by revising to a total hip replacement with a constrained liner gives good functional and mortality outcomes.

The Role of Endoscopy in Investigating the Causes of Persistent Anaemia in Post-operative Fractured Neck of Femur Patients.

Introduction Post-operative anaemia in hip fracture patients has been associated with increased risk of blood transfusion, poorer functional outcomes, increased morbidity and mortality. Patients with persisting drop in haemoglobin after fractured neck of femur with no obvious source of blood loss are often referred for endoscopy to find the cause of anaemia. The reported incidence of perioperative acute upper gastrointestinal bleeding varies from 1 to 15%. Objective The aim of our study is to find out the usefulness of endoscopy in finding gastrointestinal causes leading to the occult loss of blood causing irreversible anaemia in post-operative neck of femur fractures. Material and methods The orthogeriatric unit conducted a study using retrospective data on neck of femur fracture patients from January 2015 to December 2020. Out of 1863 cases, 918 (49.3%) developed post-operative anaemia. Forty-five patients (5%) with refractory anaemia underwent endoscopy referral. Patient demographics, fracture patterns, pre-existing anaemia, and co-morbidities (anaemia, heart disease, chronic kidney disease, oral anticoagulant usage) were recorded. The recorded information also included the type of procedure undergone by each patient. Intra-operative tranexamic acid injections were administered to all patients. Results Male patients accounted for 24% (11) and females for 76% (34). The average age was 82.3 years (range: 73-94). In terms of fracture type, 60% (27) were intracapsular and 40% (18) were extracapsular. Iron deficiency anaemia was present in 24% (11), oral anticoagulants in 20% (9), and systemic malignancy in 12% (6) of patients. The mean post-operative hemoglobin level during endoscopy referral was 7.3 g/dL. Endoscopy revealed normal findings in 60% (27), esophagitis/gastritis in 20% (8), and hiatus hernia in 16% (7) of patients. No patients were diagnosed with active gastrointestinal bleeding or malignancy as the cause of post-operative hemoglobin drop. Conclusion The study did not show evidence of any gastrointestinal bleeding in patients with resistant and refractory post-operative anaemia following fractured neck of femur surgery using endoscopy procedure. The value of such difficult, expensive and time-consuming procedure may be reviewed further.

The Role of Frailty Scores to Predict the Outcomes in Non Operative Treatment of Valgus Impacted Neck of Femur Fractures.

OBJECTIVES: The management of valgus-impacted neck of femur fracture is controversial between operative and conservative treatments. This study aimed to investigate the usefulness of the Clinical frailty Score for predicting the prognosis of patients who underwent non-operative treatment for the valgus-impacted neck of femur fracture (NOF). METHODS: A single-centred retrospective review of patients admitted with valgus impacted NOF. Data were collected from patients' records, including demographics, Clinical Frailty Score (CFS), Nottingham Hip Fracture Score (NHFS) and Abbreviated Mental Test Score (AMTS). Patients were followed up to 24 months postoperatively. RESULTS: Fifty-eight patients who were treated non-operatively with a mean follow-up of 2.6 years met our inclusion criteria. Twenty-nine patients failed the non-operative treatment and required replacement surgeries, while 29 had successful outcomes (50%). There were no differences between the two groups' mean age and gender distributions (P 0.527 and 0.139, respectively). The successful group had significantly higher CFS (P 0.013), worse AMTS and higher mortality risk based on the NHFS (P 0.006 and P < 0.001, respectively). CONCLUSION: This study demonstrates that CFS, AMTS and NHFS can be used as predictors when considering non-operative treatment for the valgus-impacted neck of femur fracture. Patients who are frail, demented and high risk based on the NHFS have higher success rates with non-operative treatment.

Safety of total hip replacement following an intra-articular steroid hip injection--an audit.

The aim of this study was to determine the deep infection rates in patients who underwent a total hip replacement after having had a prior diagnostic steroid injection into the same hip. We identified and reviewed the case notes, relevant radiographs and microbiology reports of all patients who underwent a total hip replacement after a diagnostic steroid hip injection in our unit from 1 January 2007 to 31 April 2009. There were 40 patients. (10 males and 30 females) Their mean age was 68.4 (52-82) years. The mean time interval from the injection to the joint replacement was 6.2 (2-23) months. The mean follow-up was 23.2 (11-37) months. None of the patients in the study group developed a deep infection during this followup period. Diagnostic intra articular steroid and local anaesthetic injection prior to total hip replacement appears to be safe.

The crucial factors influencing the development and outcomes of postoperative delirium in proximal femur fractures.

Objective: The aim of this study is to find the incidence, risks, and reasons for prolonged length of hospital stay, short, long-term mortality, and the factors contributing to mortality of postoperative delirium in proximal femoral fractures. Methods: The data for the study was obtained from National Hip Fracture Database (NHFD) and internal hospital computer systems (Medway, ICE, Clinic letters) between January 2018 and December 2019. One hundred seventy-five patients were found have developed postoperative delirium. The outcomes measured were postoperative anemia, lower respiratory tract infection, urinary tract infection, acute kidney injury, urinary retention, cardiac event and stroke, alcohol or drug withdrawal, length of hospital stay, and 30 day and 1 year mortality. Results: The patients who developed delirium were 68 (38.9%) with American Society of Anesthesiologists (ASA) grade 4 and 94 (22.3%) without delirium (p < 0.05). The average length of stay after developing postoperative delirium was 19.69 days compared to 17.4 days for patients without delirium. The mortality at 30 days and 1 year was 10.9% and 37% in patients who had postoperative delirium compared to 2.1% and 2.8% to those without delirium, respectively. Conclusion: Postoperative delirium is three times more common in hip fractures. Early detection and timely management are crucial in the improvement of functional outcomes and mortality.

Incisional metastatic breast carcinoma deposit in a total knee replacement presenting as peri-prosthetic joint infection-a case report.

Cutaneous metastasis from the primary breast carcinoma occurs when the disease is wide spread and can present as skin infection especially in a previous well-healed scar. If the secondary deposit is over a total knee incisional site it can mimic peri-prosthetic joint infection. We report a rare and unusual case of a woman who presented with clinical signs and symptoms of a peri-prosthetic total knee replacement which on biopsy turned out to be cutaneous metastasis from a previously treated breast cancer. Chronic granulation tissue in a total joint incisional scar may present as peri-prosthetic joint infection. A good history taking and clinical examination with specimens from the skin lesions send for both microbiology and histopathology is recommended to arrive at an early and accurate diagnosis.

Achilles tendinopathy and plantar fasciopathy: Are we ignoring calcaneal bone morphology? - A radiological assessment of calcaneal parameters.

BACKGROUND: A radiological study was conducted to determine whether calcaneal morphological differences contribute to the pathophysiology of Achilles tendinopathy and plantar fasciopathy. This study is aimed to support our new hypothesis to explain the pathophysiology leading to recalcitrant disease and also to identify the role of calcaneal osteotomy for treating these conditions. MATERIALS AND METHODS: Calcaneal width and height distance deviation from centre of ankle joint rotation was measured on standardised lateral weight bearing Ankle radiographs. A comparison was made between control group and study group to identify the differences in measured parameters. RESULTS: Significant difference (P = 0.05) was observed in calcaneal width distance in study group with Achilles tendinopathy. In Plantar fasciopathy the vertical distance was reduced suggesting flattening of arch in study group. However, the difference was not statistically significant. CONCLUSION: The study identifies the importance of evaluating calcaneal morphology for patients with recalcitrant Achilles tendinopathy and plantar fasciopathy. A new hypothesis is proposed to explain the high stresses produced in entire Achilles -calcaneus -plantar fascia unit which leads to chronic inflammatory response and intra substance degeneration.

Autologous Conditioned Plasma and Hyaluronic Acid Injection for Isolated Grade 4 Osteochondral Lesions of the Knee in Young Active Adults.

OBJECTIVES: To compare the short-term benefits and results of autologous conditioned plasma (ACP) and hyaluronic acid (HA) injection in osteochondral defects in the knee of young adults. The effectiveness of intra-articular platelet-rich plasma (PRP) injections has been evaluated in osteoarthritis. However, few studies investigated its efficacy in knee osteochondral defects. METHODS:  This is a retrospective analysis of prospectively collected data. A matched cohort of 30 patients in each group was studied. Group 1 received three HA injections at weekly intervals, and group 2 received three ACP injections at two weekly intervals. We measured Kujala, Lysholm, Oxford, and visual analog scale (VAS) scores at baseline, six, 12, and 36 months to assess function and pain. RESULTS:  Most lesions were in the medial femoral condyles in both groups, followed by lateral femoral condyle and patellofemoral regions. In group 1 (HA), the mean pre-injection scores for Kujala, Lysholm, and Oxford improved significantly at six and 12 months. The scores decreased at 36 months, however, they remained significantly better than the baselines (P < 0.05). The pre-injection VAS scores continued to improve significantly from 6.06±0.785 to 3.40±0.912 at 36 weeks. In group 2 (ACP), VAS and the outcome scores showed a consistent and statistically significant improvement from pre-injection to 36 months.  Conclusions: Our study confirms the short-term clinical benefits of using ACP for symptomatic osteochondral defects of the knee. Further high-quality comparative studies with longer follow-ups are needed to ascertain whether ACP is beneficial in the long term.

Functional outcomes after fibula locking nail for fragility fractures of the ankle.

The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of complications. It also helps to restore function and results in patient satisfaction.

Acute Pyogenic Osteomyelitis of the Pubic Bone in a Patient with Systemic Lupus Erythematosus Mimicking Fracture of the Pubic Bone and Periprosthetic Joint Infection of the Hip.

INTRODUCTION: Pubic bone osteomyelitis is atypical, and the diagnosis is often overlooked. It may present as osteitis pubis, fracture, or noninfectious inflammation of the pubic symphysis. Case Report. We report a case of a 65-year-old lady who has systemic lupus erythematosus with acute pyogenic osteomyelitis of the pubic bone who presented initially with a suspicious healing pubic rami fracture and periprosthetic infection of the hip joint. CONCLUSION: Acute osteomyelitis of the pubic bone has often an infrequent and delayed presentation. Clinical awareness, early diagnosis, and appropriate treatment including surgical debridement and long-term antibiotics can prevent ongoing morbidities such as chronic osteomyelitis, pain, and deformities of pelvic bone and joints.