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Introduction: This study aimed to describe the evolution of bone regeneration in children with hip osteonecrosis associated with sickle cell disease, treated with bone marrow-derived mesenchymal stem cell implants at the Professor Edgar Santos University Hospital Complex. Materials and methods: A non-randomized clinical trial was conducted with 48 patients of both sexes, aged between 11 and 18 years, diagnosed with femoral head osteonecrosis secondary to sickle cell disease. Patient selection was based on strict criteria, including confirmed diagnosis of sickle cell anemia and a stage of osteonecrosis compatible with the proposed treatment. Bone regeneration assessment was performed through radiographic examinations and magnetic resonance imaging, following the Ficat & Arlet criteria and the Salter-Thompson classification. Results: Statistical analysis revealed a significant association between the patients' age and positive treatment outcomes, suggesting that autologous bone marrow cell implantation is a safe and effective approach in the early stages of osteonecrosis. The majority of patients (87.5%) reported complete pain relief, while 10.42% experienced significant symptom improvement. Only one patient (2.08%) did not observe improvement. The results indicate that cell therapy can regenerate or slow the progression of bone necrosis, reducing the need for more invasive surgical procedures. Conclusion: The study demonstrates the potential of bone marrow-derived mesenchymal stem cell implantation in treating hip osteonecrosis in children with sickle cell disease, emphasizing the importance of long-term monitoring of bone structure stability.

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INTRODUCTION: Anterior external fixation is a well-established technique for treating pelvic ring injuries, but many complications are associated with it. The subcutaneous anterior internal fixator (INFIX) technique is associated with reduced complication rates and is less uncomfortable for patients. OBJECTIVE: This study evaluated functional outcomes among patients with pelvic ring injuries treated using the INFIX method. PATIENTS AND METHODS: In this retrospective case series, patients treated using the INFIX technique were reviewed for functional outcomes, using the Iowa Pelvic Score (IPS). Thirty-four patients, of mean age 39.2 years, were evaluated after a mean follow-up of 1.2 years. RESULTS: Twenty-three of the 34 patients experienced reduction classified as excellent, and eleven as good, with no instances of moderate or poor reduction. One patient developed implant exposure and infection during follow-up. Twenty-six ultimately experienced an excellent or good functional result. The average final IPS was 79.4 (range: 48-100). CONCLUSION: Our results reinforce prior evidence that the INFIX method is safe for fixating pelvic ring lesions. Most of our patients also experienced excellent or good functional recovery, suggesting that this technique is a viable option for treating certain pelvic ring injuries.

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OBJECTIVE: To compare bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies. METHODS: 48 patients diagnosed with gluteal tendinopathy at a university hospital were selected by a randomized clinical trial and divided into two groups: (G1) bone marrow aspirate concentrate and (G2) corticosteroid injections. RESULTS: 40 of the 48 selected patients were monitored for six months and both groups showed better scores. Visual analog scale (VAS) scores and Lequesne index were statistically significant higher in patients submitted to BMAC treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference. CONCLUSION: BMAC constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy. Level of Evidence II, Randomized Clinical Trial.

OBJETIVO: Estudo comparativo entre tratamento com corticóide e aspirado de medula óssea concentrado (BMAC) para o tratamento de tendinopatias glúteas. MÉTODOS: O ensaio clínico randomizado selecionou pacientes diagnosticados com tendinopatia glútea e os dividiu em dois grupos: (G1) aspirado de medula óssea concentrada e (G2) injeção de corticosteróide. RESULTADOS: Foram selecionados 48 pacientes, dos quais 40 foram monitorados por 6 meses, com melhora nos escores nos dois grupos. Os pacientes que foram submetidos ao tratamento com BMAC tiveram uma melhora estatisticamente significativa nos escores de EVA e nos escores de Lequesne em comparação ao tratamento padrão. Houve uma melhora na avaliação da qualidade de vida em ambos os grupos, sem diferença estatisticamente significativa. CONCLUSÃO: O aspirado de medula óssea concentrada surge como uma alternativa ao tratamento padrão da tendinopatia glútea, provando ser uma técnica segura e com resultados promissores quando combinada à terapia comportamental de equipe multidisciplinar. Nível de Evidência II, O ensaio clínico randomizado.

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ABSTRACT Objective: To compare bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies. Methods: 48 patients diagnosed with gluteal tendinopathy at a university hospital were selected by a randomized clinical trial and divided into two groups: (G1) bone marrow aspirate concentrate and (G2) corticosteroid injections. Results: 40 of the 48 selected patients were monitored for six months and both groups showed better scores. Visual analog scale (VAS) scores and Lequesne index were statistically significant higher in patients submitted to BMAC treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference. Conclusion: BMAC constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy. Level of Evidence II, Randomized Clinical Trial.

RESUMO Objetivo: Estudo comparativo entre tratamento com corticóide e aspirado de medula óssea concentrado (BMAC) para o tratamento de tendinopatias glúteas. Métodos: O ensaio clínico randomizado selecionou pacientes diagnosticados com tendinopatia glútea e os dividiu em dois grupos: (G1) aspirado de medula óssea concentrada e (G2) injeção de corticosteróide. Resultados: Foram selecionados 48 pacientes, dos quais 40 foram monitorados por 6 meses, com melhora nos escores nos dois grupos. Os pacientes que foram submetidos ao tratamento com BMAC tiveram uma melhora estatisticamente significativa nos escores de EVA e nos escores de Lequesne em comparação ao tratamento padrão. Houve uma melhora na avaliação da qualidade de vida em ambos os grupos, sem diferença estatisticamente significativa. Conclusão: O aspirado de medula óssea concentrada surge como uma alternativa ao tratamento padrão da tendinopatia glútea, provando ser uma técnica segura e com resultados promissores quando combinada à terapia comportamental de equipe multidisciplinar. Nível de Evidência II, O ensaio clínico randomizado.

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The potential use of bone marrow mesenchymal stromal cells (BM-MSCs) for the treatment of osteonecrosis in sickle cell disease (SCD) patients is increasing. However, convenient BM-MSC quantification and functional property assays are critical factors for cell-based therapies yet to be optimized. This study was designed to quantify the MSC population in bone marrow (BM) samples from SCD patients with osteonecrosis (SCD group) and patients with osteoarticular complications not related to SCD (NS group), using flow cytometry for CD271+CD45-/low cell phenotype and CFU-F assay. We also compared expanded BM-MSC osteogenic differentiation, migration, and cytokine secretion potential between these groups. The mean total cell number, CFU-F count, and CD271+CD45-/low cells in BM mononuclear concentrate were significantly higher in SCD than in NS patients. A significant correlation between CD271+CD45-/low cell number and CFU-F counts was found in SCD (r = 0.7483; p = 0.0070) and NS (r = 0.7167; p = 0.0370) BM concentrates. An age-related quantitative reduction of CFU-F counts and CD271+CD45-/low cell number was noted. Furthermore, no significant differences in the morphology, replicative capacity, expression of surface markers, multidifferentiation potential, and secretion of cytokines were found in expanded BM-MSCs from SCD and NS groups after in vitro culturing. Collectively, this work provides important data for the suitable measurement and expansion of BM-MSC in support to advanced cell-based therapies for SCD patients with osteonecrosis.

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INTRODUCTION Adult gluteal tendinopathy is part of a group of pathologies of Greater Trochanteric Pain Syndrome (GTPS). This disorder is characterized by pain, functional limitation and loss of local strength. The diagnosis is made from clinical examination associated with complementary exams (Ultrasound or Magnetic Resonance). OBJECTIVE Comparative study between standard treatment and bone marrow aspirate concentrate (BMAC) for the treatment of gluteal tendinopathies. The randomized clinical trial selected patients diagnosed with gluteal tendinopathy at a university hospital and divided them into two groups: (G1) bone marrow aspirate concentrate and (G2) Corticosteroids injection. RESULTS 48 patients were selected, of which 40 were monitored for 06 months, with an improvement in scores in both groups. Patients who were submitted to the BMAC treatment had a statistically significant improvement in VAS scores and Lequesne scores compared to standard treatment. There was an improvement in the assessment of the quality of life in both groups with no statistically significant difference. CONCLUSION BMAC arises as an alternative to the standard treatment of gluteal tendinopathy, proving to be a safe technique and with promising results when combined with multidisciplinary team behavioral therapy.

INTRODUÇÃO A tendinopatia glútea adulta faz parte de um grupo de patologias da Síndrome Dolorosa Trocantérica (SDT). Esse distúrbio é caracterizado por dor, limitação funcional e perda de força local. O diagnóstico é feito a partir de exames clínicos associados a exames complementares (ultrassonografia ou ressonância magnética). OBJETIVO Estudo comparativo entre tratamento com corticóide e aspirado de medula óssea concentrado (BMAC) para o tratamento de tendinopatias glúteas. MATERIAL E MÉTODOS O ensaio clínico randomizado selecionou pacientes diagnosticados com tendinopatia glútea e os dividiu em dois grupos: (G1) aspirado de medula óssea concentrada e (G2) injeção de corticosteróide . RESULTADOS Foram selecionados 48 pacientes, dos quais 40 foram monitorados por 06 meses, com melhora nos escores nos dois grupos. Os pacientes que foram submetidos ao tratamento com BMAC tiveram uma melhora estatisticamente significativa nos escores de EVA e nos escores de Lequesne em comparação ao tratamento padrão. Houve uma melhora na avaliação da a qualidade de vida em ambos os grupos, sem diferença estatisticamente significativa. CONCLUSÃO O aspirado de medula óssea concentrada surge como uma alternativa ao tratamento padrão da tendinopatia glútea, provando ser uma técnica segura e com resultados promissores quando combinada à terapia comportamental de equipe multidisciplinar.  Ensaio Clínico Randomizado.

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Recent evidence suggests that abnormalities involving CD4+T lymphocytes are associated with the pathophysiology of osteonecrosis (ON); however, few studies have addressed the CD4+T cells in ON related to sickle cell disease (SCD/ON). In addition, T cells producing multiple cytokines simultaneously are often present in the inflammatory milieu and may be implicated in the immune response observed in SCD/ON. In the present study, we aimed to characterize the functional status of CD4+T cells in SCD by simultaneously determining the frequency of IFN-γ +, IL-4+, and IL-17+ CD4+T in cell cultures under exogenous stimuli. Peripheral blood mononuclear cells (PB-MNCs) from 9 steady-state SCD patients, 15 SCD/ON patients, and 19 healthy controls had functional status of CD4+T cells analyzed. Bone marrow mononuclear cells (BM-MNCs) from 24 SCD/ON patients (SCD BM) and 18 patients with ON not related to SCD (non-SCD BM) were also analyzed. We found that PB-MNC of SCD patients with or without ON presented significantly reduced TCD4+, TCD8+, and TCD4+ naïve cell frequencies and increased frequency of circulating CD4+T cells able to simultaneously produce IFN-γ +/IL4+ and IL-17+/IL4+ compared to healthy controls. Conversely, the polyclonal stimulation of BM-MNC induced an increased frequency of CD4+IFN-γ + and CD4+IL-17+ in SCD BM compared to non-SCD BM. The increased proportion of CD4+ T cells able to produce a broad spectrum of proinflammatory cytokines after a strong stimulus indicates that the immune system in SCD/ON patients presents an expressive pool of partially differentiated cells ready to take on effector function. It is possible that this increased subpopulation may extend to inflammatory sites of target organs and may contribute to the maintenance of inflammation and the pathophysiology of osteonecrosis in sickle cell disease.

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ABSTRACT Objectives: To determine the prevalence of high patella in adult patients with knee pain, and to correlate patellar height with symptoms of patellar instability, episode of patellofemoral dislocation and anterior pain in the knee; and also verify the concordance correlation between the Insall-Salvati and Caton-Deschamps indices. Method: Cross-sectional study analyzing the medical records of patients with knee pain, using lateral view knee radiographs with 30º degrees of flexion and computed tomography. The values of the Insall-Salvati index and the Caton-Deschamps index were used to determine the patellar height. Results: A total of 756 records were analyzed, resulting in 140 knees studied, 39% men and 61% women. Both indices produced statistically significant associations for the occurrence of high patella and signs of instability and episodes of dislocation, but there was no significant association for anterior knee pain. The Kappa index obtained when analyzing the concordance correlation between the Insall-Salvati index and Caton-Deschamps index points to a regular association between them. Conclusion: Patients with high patella present a higher prevalence of instability. Having a high patella has no significant relationship with the presence of anterior knee pain. The Insall-Salvati and Caton-Deschamps indices demonstrate a regular agreement on the presentation of patellar heights results.

RESUMO Objetivos: Determinar a prevalência de patela alta em pacientes adultos portadores de dor no joelho, correlacionar a altura patelar com sintomas de instabilidade patelar e dor anterior no joelho. Verificar índice de concordância entre os índices de Insall-Salvati e Caton-Deschamps. Métodos: Estudo de corte transversal, com análise de prontuários de pacientes portadores de dor no joelho e radiografias em perfil do joelho a 30º graus de flexão e tomografia computadorizada. Usadas as medidas do Índice de Insall-Salvati e Índice de Caton-Deschamps para determinar a altura patelar. Resultados: Foram analisados 756 prontuários, 140 joelhos, 39% de homens e 61% de mulheres. Para ambos os índices obtivemos associações estatisticamente significantes para a ocorrência de patela alta e sinais de instabilidade patelar, entretanto não houve associação significativa para a dor anterior no joelho. O índice Kappa obtido para analisar a relação de concordância entre o Índice de Insall-Salvati e Caton-Deschamps aponta para uma associação regular entre eles. Conclusão: Pacientes portadores de patela alta apresentam maior prevalência de instabilidade na população estudada. Ter patela alta não apresenta relação significativa com a presença de dor anterior do joelho. Os Índices de Insall-Salvati e Caton-Deschamps apresentam concordância regular na apresentação dos resultados das alturas patelares.

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ABSTRACT Fournier's gangrene is a rare, high-mortality infection that affects the subcutaneous tissue with rapidly progressive necrosis. The objective is to report a case of Fournier's gangrene involving the region of the shoulder girdle after closed fracture of the clavicle, and to discuss this unusual evolution. The patient underwent a series of surgical procedures and was followed up on an outpatient basis for 12 months, at which point she was discharged. Fournier's gangrene is an aggressive lesion and requires early diagnosis (clinical-laboratory correlation) with the appropriate adequate surgical approach and clinical stabilization.

RESUMO A gangrena de Fournier é uma infecção rara e com alta mortalidade que acomete o tecido subcutâneo, com necrose rapidamente progressiva. O objetivo é relatar um caso de gangrena de Fournier que envolveu a região da cintura escapular após fratura fechada da clavícula e discutir essa incomum evolução. A paciente foi submetida a procedimentos cirúrgicos seriados e acompanhada ambulatorialmente por 12 meses, quando obteve alta. A gangrena de Fournier é uma lesão agressiva e necessita de diagnóstico precoce (correlação clínico-laboratorial) com adequada abordagem cirúrgica e estabilização clínica.

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OBJECTIVES: To determine the prevalence of high patella in adult patients with knee pain, and to correlate patellar height with symptoms of patellar instability, episode of patellofemoral dislocation and anterior pain in the knee; and also verify the concordance correlation between the Insall-Salvati and Caton-Deschamps indices. METHOD: Cross-sectional study analyzing the medical records of patients with knee pain, using lateral view knee radiographs with 30° degrees of flexion and computed tomography. The values of the Insall-Salvati index and the Caton-Deschamps index were used to determine the patellar height. RESULTS: A total of 756 records were analyzed, resulting in 140 knees studied, 39% men and 61% women. Both indices produced statistically significant associations for the occurrence of high patella and signs of instability and episodes of dislocation, but there was no significant association for anterior knee pain. The Kappa index obtained when analyzing the concordance correlation between the Insall-Salvati index and Caton-Deschamps index points to a regular association between them. CONCLUSION: Patients with high patella present a higher prevalence of instability. Having a high patella has no significant relationship with the presence of anterior knee pain. The Insall-Salvati and Caton-Deschamps indices demonstrate a regular agreement on the presentation of patellar heights results.

OBJETIVOS: Determinar a prevalência de patela alta em pacientes adultos portadores de dor no joelho, correlacionar a altura patelar com sintomas de instabilidade patelar e dor anterior no joelho. Verificar índice de concordância entre os índices de Insall-Salvati e Caton-Deschamps. MÉTODOS: Estudo de corte transversal, com análise de prontuários de pacientes portadores de dor no joelho e radiografias em perfil do joelho a 30° graus de flexão e tomografia computadorizada. Usadas as medidas do Índice de Insall-Salvati e Índice de Caton-Deschamps para determinar a altura patelar. RESULTADOS: Foram analisados 756 prontuários, 140 joelhos, 39% de homens e 61% de mulheres. Para ambos os índices obtivemos associações estatisticamente significantes para a ocorrência de patela alta e sinais de instabilidade patelar, entretanto não houve associação significativa para a dor anterior no joelho. O índice Kappa obtido para analisar a relação de concordância entre o Índice de Insall-Salvati e Caton-Deschamps aponta para uma associação regular entre eles. CONCLUSÃO: Pacientes portadores de patela alta apresentam maior prevalência de instabilidade na população estudada. Ter patela alta não apresenta relação significativa com a presença de dor anterior do joelho. Os Índices de Insall-Salvati e Caton-Deschamps apresentam concordância regular na apresentação dos resultados das alturas patelares.

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Fournier's gangrene is a rare, high-mortality infection that affects the subcutaneous tissue with rapidly progressive necrosis. The objective is to report a case of Fournier's gangrene involving the region of the shoulder girdle after closed fracture of the clavicle, and to discuss this unusual evolution. The patient underwent a series of surgical procedures and was followed up on an outpatient basis for 12 months, at which point she was discharged. Fournier's gangrene is an aggressive lesion and requires early diagnosis (clinical-laboratory correlation) with the appropriate adequate surgical approach and clinical stabilization.

A gangrena de Fournier é uma infecção rara e com alta mortalidade que acomete o tecido subcutâneo, com necrose rapidamente progressiva. O objetivo é relatar um caso de gangrena de Fournier que envolveu a região da cintura escapular após fratura fechada da clavícula e discutir essa incomum evolução. A paciente foi submetida a procedimentos cirúrgicos seriados e acompanhada ambulatorialmente por 12 meses, quando obteve alta. A gangrena de Fournier é uma lesão agressiva e necessita de diagnóstico precoce (correlação clínico-laboratorial) com adequada abordagem cirúrgica e estabilização clínica.

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There is an error in the original publication for the photos of the Guest Editors were not included.

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BACKGROUND: The purpose of our study was to evaluate safety, feasibility and clinical results of bone marrow mononuclear cell (BMC) implantation for early-stage osteonecrosis of the knee (OK) secondary to sickle cell disease. METHODS: Thirty-three SCD patients (45 knees) with OK treated with BMC implantation in the osteonecrotic lesion were clinically and functionally evaluated through the American Knee Society Clinical Score (KSS), Knee Functional Score (KFS) and Numeric Rating Scale (NRS) pain score. MRI and radiographic examinations of the knee were assessed during a period of five years after intervention. RESULTS: No complications or serious adverse event were associated with BMC implantation. From preoperative assessment to the latest follow-up, there was a significant (p < 0.001) improvement of clinical KSS (64.3 ± 9.7, range: 45-80 and 2.2 ± 4.1, range: 84-100, respectively), KFS (44.5 ± 8.0, range: 30-55 and 91.6 ± 5.8, range: 80-100, respectively) and reduction of NRS pain score (6.7 ± 1.2, range: 4-9 and 3.4 ± 1.0, range: 2-5, respectively). In total, 87% of patients (29/33) consistently experienced improvements in joint function and activity level as compared to preoperative score. No patient had additional surgery following BMC implantation. Radiographic assessment showed joint preservation and no progression to subchondral collapse at most recent follow-up. CONCLUSIONS: The technique of BMC implantation is a promising, relatively simple and safe procedure for OK in SCD patients. Larger and long-term controlled trials are needed to support its clinical effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov NCT02448121 . Retrospectively registered 19 May 2015.

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PURPOSE: The aim of this study was to describe the clinical features of osteonecrosis (ON) in sickle cell disease (SCD) patients in Bahia, a Northeast state with the highest prevalence of the disease in Brazil. METHODS: Between 2006 and 2017, 283 cases of osteonecrosis in SCD patients were enrolled to analyse the age at diagnosis, genotype, gender, pain, distribution of the lesions and disease staging. MRI and radiograph were obtained at the participation. RESULTS: Of the 283 SCD cases, 120 (42.4%) were haemoglobin SS genotype while 163 (57.6%) were SC genotype. Two hundred and forty-six cases were bilateral and 37 were unilateral, with an average age at diagnosis of 33.7 (range 10-67) years. The most frequent identified ON site not only was the hip (74.6%), but also affected shoulder, knee and ankle. Most cases presented at early stage I (172, 60.8%) disease. No significant differences on the features of osteonecrosis were identified between haemoglobin SS and haemoglobin SC cases. CONCLUSIONS: Given the relatively high prevalence of bilateral osteonecrosis at early stages, painful symptoms and rather late age at diagnosis, SCD patients should have radiological examination of their joints more often in order to prevent severe functional disability and increase patient's life quality.

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INTRODUCTION: Subtotal calcanectomy is a therapeutic option for the treatment of chronic ulcer associated with calcaneal osteomyelitis. Closure of the surgical wound can be difficult due to the lack of local cutaneous coverage. We present the first case of subtotal calcanectomy in which the ankle was positioned in plantar flexion allowing the primary closure of the surgical wound without the need for flap. CASE REPORT: We present a case of 62-year-old female patient with a foot ulcer associated with osteomyelitis. After an initial assessment, a subtotal calcanectomy with primary wound closure was performed. After healing of the surgical wound, the patient started rehabilitation with recovery of dorsiflexion and independent gait without support after 12 weeks. CONCLUSION: The result shows that subtotal calcanectomy with the ankle in plantar flexion allows primary closure of the operative wound, without causing difficulty for rehabilitation.

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Chronic pain in Sickle Cell Disease (SCD) is probably related to maladaptive plasticity of brain areas involved in nociceptive processing. Transcranial Direct Current Stimulation (tDCS) and Peripheral Electrical Stimulation (PES) can modulate cortical excitability and help to control chronic pain. Studies have shown that combined use of tDCS and PES has additive effects. However, to date, no study investigated additive effects of these neuromodulatory techniques on chronic pain in patients with SCD. This protocol describes a study aiming to assess whether combined use of tDCS and PES more effectively alleviate pain in patients with SCD compared to single use of each technique. The study consists of a one-session double blind, block-randomized clinical trial (NCT02813629) in which 128 participants with SCD and femoral osteonecrosis will be enrolled. Stepwise procedures will occur on two independent days. On day 1, participants will be screened for eligibility criteria. On day 2, data collection will occur in four stages: sample characterization, baseline assessment, intervention, and post-intervention assessment. These procedures will last ~5 h. Participants will be divided into two groups according to homozygous for S allele (HbSS) (n = 64) and heterozygous for S and C alleles (HbSC) (n = 64) genotypes. Participants in each group will be randomly assigned, equally, to one of the following interventions: (1) active tDCS + active PES; (2) active tDCS + sham PES; (3) sham tDCS + active PES; and (4) sham tDCS + sham PES. Active tDCS intervention will consist of 20 min 2 mA anodic stimulation over the primary motor cortex contralateral to the most painful hip. Active PES intervention will consist of 30 min sensory electrical stimulation at 100 Hz over the most painful hip. The main study outcome will be pain intensity, measured by a Visual Analogue Scale. In addition, electroencephalographic power density, cortical maps of the gluteus maximus muscle elicited by Transcranial Magnetic Stimulation (TMS), serum levels of Brain-derived Neurotrophic Factor (BDNF), and Tumor Necrosis Factor (TNF) will be assessed as secondary outcomes. Data will be analyzed using ANOVA of repeated measures, controlling for confounding variables.

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Recurrent chronic leg ulcers are among the most severe vasculopathic complications of sickle cell disease (SCD). Their treatment remains a challenge. Stem cell therapy with bone marrow mononuclear cells (BMMC) is a promising new therapeutic option for other forms of chronic ulcers. This prospective pilot study was performed to evaluate safety and feasibility of BMMC implantation in patients with SCD and chronic leg ulcers (SCLU). Ulcer closure, recurrence and local pain were evaluated. BMMC were successfully administered to 23 SCLU patients and no serious adverse events occurred. During the 6-month follow-up period, 91·3% of patients had improved ulcer pain compared with baseline and 29·2% of the treated ulcers achieved total healing. The frequency of progenitor stem cells (CD34CD45low and fibroblast colony-forming units) in BMMC was found to be significantly reduced in SCLU patients and compared to SCD patients without ulcers (P < 0·004 and P < 0·01, respectively). No relationship was observed between treatment outcome and the number of implanted BM progenitor stem cells. In conclusion, BMMC implantation is a feasible and safe procedure, showing favourable outcomes for the treatment of SCLU, and encouraging further controlled clinical trials.

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BACKGROUND: Little is known about the rate of, and factors affecting, progression of talar osteonecrosis related to sickle cell disease. Adult patients with sickle cell disease who presented with hip osteonecrosis were evaluated for talar osteonecrosis with radiographs and magnetic resonance imaging (MRI). Forty-five of them (75 tali) were diagnosed with talar osteonecrosis, and this group was evaluated for factors influencing the progression of the disease. METHODS: Forty-five patients with sickle cell disease and osteonecrosis of the talus were identified with radiographs and MRI between 1985 and 1995. Seven of these patients were homozygous for hemoglobin S (S/S genotype), 26 had hemoglobin S/hemoglobin C, and 12 had hemoglobin S/beta-thalassemia. The talar osteonecrosis was graded with radiographs and MRI. The patients were followed with clinical examination and radiographs every 6 months until talar collapse and every year after the collapse. RESULTS: The osteonecrosis was unilateral in 15 patients and bilateral in 30 at the time of the initial examination. Forty-five ankles were asymptomatic and 30 were symptomatic at the initial evaluation. MRI performed at the time of the most recent follow-up, and compared with MRI performed at diagnosis, did not show partial or total regression of the osteonecrosis in any of the patients, even those with asymptomatic stage-I osteonecrosis. At the time of the most recent follow-up (mean, 20 years; range, 15 to 25 years), pain and collapse had developed in all except 12 ankles. The stage of the osteonecrosis at the initial visit, pain, the genotype of the sickle cell disease, and the extent and location of the lesion in the talus were risk factors for progression of the disease. CONCLUSIONS: In the majority of the patients with sickle cell disease, osteonecrosis of the talus should be expected to show relevant clinical and radiographic evidence of progression over a long period. LEVEL OF EVIDENCE: Prospective Level II. See Instructions for Authors for a complete description of levels of evidence.

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To evaluate the efficacy of viscosupplementation in patients with osteoarthritis of the ankle. A systematic review to evaluate the evidence in the literature on the use of viscosupplementation for osteoarthritis of the ankle. For this review, we considered blind randomized prospective studies involving the use of viscosupplementation for osteoarthritis of the ankle. A total of 1,961 articles were identified in various databases. After examining each of the articles, five articles were included in this review. Treatment with intraarticular hyaluronic acid is a safe treatment modality that significantly improves functional scores of patients, with no evidence of superiority in relation to other conservative treatments. Further clinical trials with larger numbers of patients are needed so that we can recommend its use and address unanswered questions . Systematic Review of Randomized Clinical Trials.