Arthroscopic assisted percutaneous fixation in ankle pilon fracture: A case report.

INTRODUCTION: Results of operative fixation for ankle fractures had been suboptimal, with cases of posttraumatic osteoarthritis occurring following the surgeries. Intra-articular injuries have been suggested as the cause of this problem. This case report aims to present an ankle pilon fracture Ruedi Allgower type II case treated with percutaneous fixation and arthroscopy evaluation. PRESENTATION OF CASE: Female, 17 years old, complained of pain and swelling at the right ankle. The physical examination revealed swelling, deformity, tenderness, and limited range of motion at the right ankle. The radiological examination showed a Ruedi Allgower type II pilon fracture with right ankle dislocation. The patient underwent closed reduction, arthroscopy to evaluate her right ankle and percutaneous internal fixation. The post-surgery evaluation showed a stable ankle. DISCUSSION: Patients undergoing ankle fracture surgery may benefit from ankle arthroscopy because it may increase visualization of articular reductions, assess and repair cartilage and ligament damage, remove loose bodies, decrease soft tissue exposure, preservative vascularity, and evaluate syndesmosis. Moreover, rapid arthroscopic evaluation has a low complication rate. The ability of arthroscopy to improve syndesmotic instability diagnosis suggests that arthroscopy may play a significant role in managing ankle fractures. CONCLUSION: Arthroscopy-assisted internal fixation provides more benefits and information as a single case report, and more studies are warranted; regarding patients' intra-articular injuries, preventing future complications, such as posttraumatic osteoarthritis.

The effectiveness ORIF for neglected periprosthetic femoral fractures after hemiarthroplasty: A case report.

INTRODUCTION AND IMPORTANCE: Periprosthetic fractures are a growing concern due to the increasing frequency of primary joint replacement surgery, with total hip arthroplasty being the most common. The incidence of periprosthetic fractures after revision surgery ranges from 4 to 11 %, with up to 30 % reported after knee revision surgery. This case report aims to describe the treatment of an 81-year-old woman suffering from neglected periprosthetic femoral fracture post hemiarthroplasty. CASE PRESENTATION: An 81-year-old woman with a history of hemiarthroplasty surgery and hypertension was admitted to the ER with pain in her right thigh. She had a middle shaft femoral fracture and was scheduled for open reduction and internal fixation. Despite being fully conscious and having an average pulse rate and blood pressure, she had cardiomegaly and congestive pulmonum. Unfortunately, this patient did not receive appropriate medical treatment after it occurred for 1 month. After surgery, we evaluated the implant, and the implant stabilized the fracture. After 1-3 months after surgery, the LEFS (The Lower Extremity Functional Scale) score was found that the score increase significantly after surgery. CLINICAL DISCUSSION: The Vancouver classification system manages periprosthetic fractures by assessing location, stability, and bone quality. Type A fractures involve the trochanter, while type B fractures are diaphyseal and can extend distally. ORIF is used for subtype B1 fractures, but newer techniques offer shorter operating times and fewer complications. CONCLUSION: From this study, we can conclude that even though neglected cases procedure with ORIF promises a good outcome based on clinical evaluation.

The Banff Patellar Instability Instrument: validity and reliability of an Indonesian version.

BACKGROUND: The Banff Patellar Instability Instrument (BPII) is a valuable scoring tool for assessing patellofemoral instability in patients suffering from patellofemoral pain syndrome (PFPS). The BPII 2.0 is a shortened version of the BPII. However, there is no Indonesian edition of BPII 2.0 that has been validated. This study aimed to determine the validity and reliability of the Indonesian version of the BPII 2.0. MATERIALS AND METHODS: This was a cross-sectional study that used a forward-backward translation protocol to create an Indonesian version of the BPII 2.0. Thirty patients with PFPS were given the questionnaires. The questionnaire's validity was evaluated by analyzing the correlation between score of each subscale and the overall score to the Indonesian version of the Kujala score using Pearson correlation coefficient, while the reliability was evaluated by measuring the internal consistency (Cronbach α) and test-retest reliability (intraclass correlation coefficient). RESULTS: The Indonesian version of BPII 2.0 and the Indonesian version of Kujala score had a strong Pearson correlation coefficient for construct validity. For all subscales, Cronbach α was 0.90-0.98, indicating adequate internal consistency. The test-retest reliability was high, with intraclass correlation coefficient ranging from 0.89 to 0.98 for all subscales. There was no difference in the Indonesian version of BPII 2.0 response between the first and second administration of the questionnaire which was taken 7 days afterward. CONCLUSION: The Indonesian version of BPII 2.0 was determined to be valid and reliable and is therefore an objective instrument to evaluate patellofemoral instability in patients with PFPS in the Indonesian population.

Patellofemoral functional outcome of gracilis sparing compared to gracilis sacrificing ACL reconstruction.

Introduction: The hamstring is the most popular autograft used for anterior cruciate ligament reconstruction (ACLR). Despite its excellent outcome, donor site morbidity is also irritating. Patellofemoral problems are reported to be one of the side effects after hamstring autograft harvesting, suggested to be due to both gracilis & semitendinosus sacrificing. Some experts propose retaining gracilis to decrease patellofemoral problems. The all-inside technique is an advantageous ACLR technique that can preserve the gracilis muscle while reducing muscle strength loss of affected limbs and the risk of knee joint instability under rotational load. This study aims to compare the patellofemoral functional outcome of both gracilis sparing and sacrificing using a validated Kujala score three months after ACLR. Methods: There was total of 20 subjects who underwent ACLR between December 2021 and May 2022 and met the inclusion criteria. They were then grouped into gracilis sparing group (n = 10) and gracilis sacrificing group (n = 10). Follow up assessment (Kujala Score) was conducted during phase II of the rehabilitation program. The assessed variables were surgery technique, time of surgery-to-evaluation, and Kujala Score. Result: There were no significant differences in Kujala Score between gracilis sparing and gracilis sacrificing groups (p = 0.809). There was a strong positive correlation between the time of surgery-to-evaluation and Kujala Score in each group (p = 0.942 and p = 0.910, respectively). Conclusion: There are no differences in patellofemoral functional outcomes between patients who undergo gracilis sparing and gracilis sacrificing ACLR with good scores of Kujala, which means both gracilis sparing and sacrificing show no harm to the patellofemoral after the ACLR.

Implant surface modifications as a prevention method for periprosthetic joint infection caused by Staphylococcus aureus: a systematic review and meta-analysis.

Background: Periprosthetic joint infection is the most common infection due to joint replacement. It has been reported that, over a 5-year time span, 3.7 % of cases occurred annually. This statistic has increased to 6.86 % over 16 years. Thus, an effective method is required to reduce these complications. Several strategies such as coating methods with various materials, such as antibiotics, silver, and iodine, have been reported. However, the best preventive strategy is still undetermined. Therefore, this systematic review aims to evaluate the outcome of coating methods on joint arthroplasty as a treatment or preventive management for infection complications. Methods: Eligible articles were systematically searched from multiple electronic databases (PubMed, Cochrane library, and ScienceDirect) up to 2 June 2022. Based on the criterion inclusion, eight articles were selected for this study. The Newcastle-Ottawa scale (NOS) was used to assess the quality of the study, and the meta-analysis test was conducted with Review Manager 5.4. Results: The quality of the articles in this study is in the range of moderate to good. It was found that the application of modified antibiotic coatings significantly reduced the occurrence of periprosthetic joint infection (PJI) ( p 0.03), and silver coating could not significantly ( p 0.47) prevent the occurrence of PJI. However, according to the whole aspect of coating modification, the use of antibiotics, silver, and iodine can minimize the occurrence of PJI ( p   < 0.0001 ). Conclusion: Coating methods using antibiotics are an effective method that could significantly prevent the occurrence of PJI. On the other hand, coating with non-antibiotic materials such as silver could not significantly prevent the incidence of PJI.

Patellar height measurement in Indonesian normal adult population.

Background: Patellar height is the distance formed by the patella and the length of the patellar tendon. Patellar height measurement can predispose to various abnormalities in the knee joint. Patellar height can be measured using several sizes, such as the Insall-Salvati ratio (IS), Modified Insall-Salvati ratio (MIS), Caton-Deschamps index (CD), and the Blackburne-Peel (BP) index. In Indonesia, no data on the value of patellar height is available. This study aims to determine the patellar height value in Indonesians and compare if there are differences with the standard values commonly used by other countries. Matherials and methods: This study is descriptive with 136 research subjects aged 20-40. Data were taken from December 2021 to February 2022. The results of patellar X-ray were measured using the Insall-Salvati, Modified Insall-Salvati, Caton-Deschamps, and Blackburne-Peel methods. Results: In the measurement of patellar height, the longest measurement was found in the MIS measurement, while the shortest patellar height was measured using the BP method. The normal value of the IS method is 0.78-1.26, the MIS method is > 1.98, the CD method is 0.79-1.23, and the BP method is 0.70-1.10 for patellar height in Indonesia. This study also shows no significant difference in the value of patellar height between male and female sex using the IS measurement method. Conclusion: There is a difference in the standard value of patellar height, which is commonly used by other countries with the standard value of patellar height in Indonesia, but it is not significant.

Plating technique outcome evaluation in calcaneal fracture based on American orthopaedics foot and ankle score and Böhler-Gissane angle: A case series.

INTRODUCTION: Intraarticular Calcaneal fracture treatment nowadays is still up for debate. Surgical plating treatment is favorable because of the rapid healing process and better anatomical reduction despite the invasive intervention. Hence, clinical evaluation is needed to assess the quality-of-life index from foot and ankle by the American orthopaedics Foot and Ankle Society (AOFAS) score postoperatively. Then, the outcome evaluation of reduction in calcaneal plating of intraarticular calcaneal fracture with Böhler angle and Gissane angle to see if the calcaneal plating technique is a recommended treatment for the calcaneal fracture. METHODS: We treated six patients from December 2020-July 2021 with a calcaneal fracture that underwent surgical plating, mainly by one surgeon. A calcaneal fracture is classified according to sanders classification. In this study, four patients are above the age of 40, and two are under 25. Pre-operative Böhler angle ranged from 8 to 65°, and Gissane angle ranged from 134 to 158°. OUTCOMES: Surgical plating was performed on all six patients. From clinical evaluation using the AOFAS score, we got satisfactory results on all patients who underwent calcaneal plating surgery. Three patients achieved excellent range outcomes with 95% and 99% of AOFAS Scores, and three patients reported AOFAS score good range outcomes with the lowest score of 88%. From the radiological outcome, most of the patient's Böhler and Gissane angles achieved normal value after surgical plating. CONCLUSION: The calcaneal plating technique gives better anatomical reduction depending on Bohler and Gissane angle. These results promise that anatomical reduction can improve clinical outcomes based on the AOFAS score. Thus, the plating method can be used effectively to treat an intraarticular calcaneal fracture.

Prosthetic joint infection of the hip and knee due to Mycobacterium species: A systematic review.

BACKGROUND: Mycobacterium species (Mycobacterium sp) is an emerging cause of hip and knee prosthetic joint infection (PJI), and different species of this organism may be responsible for the same. AIM: To evaluate the profile of hip and knee Mycobacterium PJI cases as published in the past 30 years. METHODS: A literature search was performed in PubMed using the MeSH terms "Prosthesis joint infection" AND "Mycobacterium" for studies with publication dates from January 1, 1990, to May 30, 2021. To avoid missing any study, another search was performed with the terms "Arthroplasty infection" AND "Mycobacterium" in the same period as the previous search. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart was used to evaluate the included studies for further review. In total, 51 studies were included for further evaluation of the cases, type of pathogen, and treatment of PJI caused by Mycobacterium sp. RESULTS: Seventeen identified Mycobacterium sp were reportedly responsible for hip/knee PJI in 115 hip/knee PJI cases, whereas in two cases there was no mention of any specific Mycobacterium sp. Mycobacterium tuberculosis (M. tuberculosis) was detected in 50/115 (43.3%) of the cases. Nontuberculous mycobacteria (NTM) included M. fortuitum (26/115, 22.6%), M. abscessus (10/115, 8.6%), M. chelonae (8/115, 6.9%), and M. bovis (8/115, 6.9%). Majority of the cases (82/114, 71.9%) had an onset of infection > 3 mo after the index surgery, while in 24.6% (28/114) the disease had an onset in ≤ 3 mo. Incidental intraoperative PJI diagnosis was made in 4 cases (3.5%). Overall, prosthesis removal was needed in 77.8% (84/108) of the cases to treat the infection. Overall infection rate was controlled in 88/102 (86.3%) patients with Mycobacterium PJI. Persistent infection occurred in 10/108 (9.8%) patients, while 4/108 (3.9%) patients died due to the infection. CONCLUSION: At least 17 Mycobacterium sp can be responsible for hip/knee PJI. Although M. tuberculosis is the most common causal pathogen, NTM should be considered as an emerging cause of hip/knee PJI.

Superconstructs in reconstruction surgery of Charcot foot Brodsky 1: A case report.

INTRODUCTION: Charcot neuropathic osteoarthropathy (CN) is a chronic, progressive condition of joints, soft tissues, and bones. CN causes considerable high mortality and morbidity. A common issue is early diagnosis and appropriate treatment. Thus, the operative treatment is indicated when patients have progressive deformities, infection and ulceration. The superconstructs method for Charcot foot (CF) is considered giving better clinical outcome than other methods. PRESENTATION OF CASE: A 61-year-old male admitted to an outpatient clinic with chief complaint of swelling and pain on a left foot with history of diabetes mellitus type 2. From the physical examination, left foot revealed a swelling with rocker bottom deformity and limited range of motion. The radiological examination showed sclerotic appearance of bone deformity metatarsal joint of midfoot of toe. The patients were diagnosed with left Charcot foot Brodsky Type 1, Eichenholtz grade III with diabetes mellitus type 2. DISCUSSION: We made superconstructs rather than standard fixation which is frequently inadequate due to changes accompanying the Charcot process. Thus, we performed an adequate reduction of deformity, reduce soft tissue tension, fixation extension beyond a zone of injury, then use of strongest fixation devices that are applied to maximize mechanical function. CONCLUSION: This study showed that superconstructs provide satisfactory clinical and outcomes. This method is useful for achieving construct and stable fixation especially for Charcot foot.

Unusual combination of posterior cruciate ligament tibial avulsion fracture and Segond fracture: A case report.

INTRODUCTION AND IMPORTANCE: Posterior cruciate ligament (PCL) avulsion fracture is an uncommon entity, but it poses significant morbidity to patient's knee and activities. A combination of PCL avulsion fracture with Segond fracture is rare and has not been described much before in known literature. In this case report, we present a rare case of a combination of these two injuries. CASE PRESENTATION: A 16-year-old cyclist who sustained left knee injury after a high-velocity fall while cycling. He fell with his anteromedial side of his left knee hitting the ground in flexion. After the fall, he felt excruciating pain and unable to bear weight. Examination revealed severe joint effusion, tenderness on posterior and lateral side of the left knee, no vascular injury and neurological deficit present. Radiographic examination revealed PCL avulsion fracture and Segond fracture. Five days after the injury, the avulsed PCL fragment and the lateral tibial plateau fragment were reduced and fixed with 3.5 mm cortical screw and washers. On the follow up, the patient stated that there is no pain on weightbearing position and after evaluated with Knee injury and Osteoarthritis Outcome Score (KOOS), the result is 90%. CLINICAL DISCUSSION: Although the combination of PCL avulsion fracture and Segond fracture is rare, this pattern of injury could happen and could be considered when evaluating knee injuries. CONCLUSION: Both fractures need to be addressed and managed adequately to restore knee stability and prevent early joint degeneration.

Double posterior lateral plating arthrodesis for charcot ankle: A case series.

INTRODUCTION: Ankle arthrodesis is one of the managements for a significantly unstable Charcot ankle. Some of the methods of internal fixation for ankle arthrodesis include the use of intramedullary nails, screws, and plates. Ankle arthrodesis using intramedullary nails has become more popular. However, studies evaluating the use of plate fixation, particularly double posterior lateral plating, are limited. We report the clinical and radiological outcomes of double posterior lateral plating ankle arthrodesis in three diabetic Charcot ankle patients. PRESENTATION OF CASE: Three patients, aged 73, 67, and 65 years old, complained of ankle pain and with a history of type 2 diabetes mellitus. The physical examination revealed swelling and erythema without a sign of active infection. The radiological examination showed ankle deformity, and the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scores were 5, 10, and 0, respectively. All patients were diagnosed with a diabetic Charcot ankle and underwent ankle arthrodesis using double posterior lateral plating. Four months and six months follow up revealed talus union, improved ankle deformity, and improved AOFAS Ankle-Hindfoot scores to 70, 76, and 73, respectively. DISCUSSION: Various methods of ankle arthrodesis are retrograde intramedullary nails, screws, and plates. In this report, we opt for plate fixation because it allows for stable internal fixation, adequate compression, high angular stability, and a lower irreversible deformation in osteoporotic bone. CONCLUSION: Double posterior lateral plating ankle arthrodesis provided satisfactory clinical and radiological outcomes. This method can be an alternative for patients with Charcot ankle requiring ankle arthrodesis.

Knee Injury and Osteoarthritis Outcome Score: Validity and Reliability of an Indonesian Version.

Background: The Knee injury and Osteoarthritis Outcome Score (KOOS) is a useful diagnostic tool to assess knee ligament injury and osteoarthritis, but no validated Indonesian version of the KOOS was available. Methods: We used the forward-backward translation protocol to develop the Indonesian version of the KOOS. The translated questionnaire was administered twice to 51 subjects diagnosed with a knee ligament injury and osteoarthritis. Validity of the questionnaire was assessed by analyzing the correlation between the score of each subscale and the overall score of the 36-Item Short Form Health Survey (SF-36) using the Pearson correlation coefficient. Reliability was measured by evaluating internal consistency (Cronbach α) and test-retest reliability (intraclass correlation coefficient). Results: For construct validity, moderate Pearson correlation coefficients were found between the KOOS subscales and the SF-36. Cronbach α was 0.84 to 0.97 for all subscales, indicating adequate internal consistency. The test-retest reliability was excellent, with intraclass correlation coefficients ranging from 0.91 to 0.99 for all subscales. No significant differences were found in the KOOS subscale responses between the first administration of the questionnaire and the second administration within 21 days. Conclusion: The Indonesian version of the KOOS was determined to be valid and reliable and is therefore an objective instrument for evaluating knee ligament injury and knee osteoarthritis in the Indonesian population.

The direct anterior approach in total hip arthroplasty: Publication trends of Asian countries on PubMed.

BACKGROUND: Total hip replacement (THR) is one of the most successful surgical treatment for advanced hip osteoarthritis. Some surgical approaches for THR have been established, one of it is Direct Anterior Approach (DAA), which is a relatively new and less commonly used, especially in Asian countries. This review aims to consolidate information from PubMed on the direct anterior approach (DAA) for total hip replacement (THR) in Asian countries. PURPOSE: To collect and consolidate information from PubMed on the total hip replacement (THR) using the direct anterior approach (DAA) in Asian countries. METHODS: A search on the PubMed was done for DAA for THR. There were 461 search results about the DAA for THR publications obtained in total, and 51 articles meet the criteria were analyzed for details. The details include top countries publishing the topics, number of publications per year, top 5 journal publishing the DAA for THR topics, top 5 first authors publishing the articles on this topic, and top 5 author on all position published this topic. RESULTS: The Journal of Arthroplasty was the leading publisher on this topic, with 10 articles published. Author Yasuhiro Homma, Tomonori Baba, and Kazuhiro Oinuma published the most number with 9 articles as one of the authors. Japan is the leading country for the publication on this topic with 34 published journals in total. CONCLUSION: The number of published articles in Asian country per year is still inconsistent, with one year without any publication on this topic. Searching the data on the DAA for THR in PubMed bestow useful information about good sources of publication on this topic.

Validity and Reliability of the Indonesian Version of the Kujala Score for Patients With Patellofemoral Pain Syndrome.

BACKGROUND: The Kujala score is a useful diagnostic tool to evaluate patellofemoral pain syndrome (PFPS). However, no validated Indonesian version of the Kujala score has been available. PURPOSE: To develop and validate an Indonesian version of the Kujala score. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: This was a cross-sectional study to develop an Indonesian version of the Kujala score by using a forward-backward translation protocol. The resulting questionnaire was given to 51 patients diagnosed with PFPS. The validity of the questionnaire was evaluated by correlating the final score with the Indonesian version of the 36-Item Short Form Health Survey (SF-36). Reliability was measured by evaluating the internal consistency (Cronbach alpha) and test-retest reliability (intraclass correlation coefficient [ICC]). RESULTS: The Indonesian version of the Kujala score had a positive correlation with the physical components of the SF-36. The internal consistency was fairly high (α = .74), and the test-retest reliability was excellent (ICC, 0.996). CONCLUSION: The Indonesian version of the Kujala score was proven to be a valid and reliable tool to diagnose PFPS. Future epidemiological studies could implement this score to find the prevalence of PFPS in Indonesia. Further, ensuing studies could explore the application of this scoring system in posttreatment and postoperative settings.

Union of Brodsky type 1/Eichenholtz stage III Charcot neuroarthropathy after forefoot arthrodesis.

INTRODUCTION: One of the surgical intervention options for Charcot neuroarthropathy (CN) is arthrodesis. The arthrodesis procedure for the foot and ankle joint have been widely used in previous studies. This study aimed to evaluate the functional and radiological outcomes after arthrodesis procedure for the CN patient with Brodsky type 1/Eichenholtz stage III. PRESENTATION OF CASE: A 49-years-old diabetic woman presented with alteration of her right foot's shape and a cracking sensation while walking in the last six months. Rocker-bottom deformity and a decreased sensation on the right foot were found, and the initial American Orthopaedic Foot & Ankle Society (AOFAS) score was 45. Subsequently, forefoot arthrodesis of the right foot was performed. DISCUSSION: Several studies state that arthrodesis procedure is often used for CN management in order to achieve a plantigrade and stable foot. This study presents an improvement of the foot arch, AOFAS score, and union of the talus six months after surgery. CONCLUSION: The arthrodesis procedure by using screws and Kirschner wire (K-wire) fixation is an effective method in CN management if the patient is compliant. This study showed a good result, anatomically restored the foot arch, and excellent radiological union, but different tools to analyze foot functional status and longer follow up period are needed for a better analysis.

Influence of anthropometric features on peroneus longus graft diameter in Anterior Cruciate Ligament reconstruction: A cohort study.

BACKGROUND: Anterior Cruciate Ligament (ACL) is the most common ligament injury during sports activities that was treated with ACL reconstruction. Nowadays, peroneus longus is used in ACL reconstruction. However, it is difficult to predict the peroneus longus graft diameter for ACL reconstruction. Thus, preoperative measurements are very important to predict peroneus longus autograft for ACL reconstruction. METHODS: A cohort retrospective study was conducted using consecutive sampling method from February 2016 until October 2017 in our center. We recorded patients' characteristics include gender, age, body weight, height, and Body Mass Index (BMI) preoperatively. We measured peroneus longus graft diameter intraoperatively, and analysed data using Spearman correlation. RESULTS: Thirty-nine patients met inclusion criteria. There were 28 males and 11 females in the peroneus group. From the patients' mean characteristics, age was 25.10 ±â€¯9.16, body weight 71.23 ±â€¯14.17, height 169.13 ±â€¯8.81, and BMI 20.96 ±â€¯3.44. Intraoperative peroneus longus diameter measurement was 8.56 ±â€¯0.82. Spearman correlation showed significant correlation between intraoperative peroneus longus diameter with patient's height, body weight, and BMI with p < 0.05. CONCLUSION: Patients' characteristics including gender, height, weight, and BMI in preoperative measurements can predict peoneus longus graft diameter intraoperatively.

Primary single stage Total Hip Arthroplasty in a patient 40 years post traumatic Hip dysplasia, a case report.

INTRODUCTION: Hip dysplasia refers to an abnormal development of size, shape, or organization of the femoral head, acetabulum, or both. Managing acetabular dysplasia is very challenging in arthroplasty especially in traumatic hip dysplasia case. Mostly, hip dysplasia cases need a special implant, procedure and techniques. CASE PRESENTATION: We performed primary Total Hip Arthroplasty (THA) + partial tenotomy of hamstring, iliotibial band, hip abductor in a 73 year old male. His main complaint was that he was unable to sit due to an increasingly intense pain since 3 months ago and he has been unable to walk properly since 40 years ago when he had a major traffic accident and received inadequate treatment. The procedure had been successfully done using a well press-fit cementless acetabular cup and a cementless narrow stem application 1 cm on leg length discrepancy (LLD). CONCLUSION: Preoperative planning, surgical techniques and a post-surgery rehabilitation are the key to a successful management in this case.