There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissue including the infrapatellar fat pad. In this study, stem cells isolated from the infrapatellar fat pad were characterised to ascertain their origin, and allowed to undergo adipogenic differentiation to confirm multilineage differentiation potential.

The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated and expanded in monolayer culture. Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained poorly for LNGFR and STRO1 (markers for freshly isolated bone marrow derived stem cells), and sparsely for 3G5 (pericyte marker). Staining for CD34 (haematopoetic marker) and CD56 (neural and myogenic lineage marker) was negative. {BR}For adipogenic differentiation, cells were cultured in adipogenic inducing medium consisting of basic medium with 10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine. By day 16, many cells had lipid vacuoles occupying most of the cytoplasm. On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining confirmed the adipogenic nature of the observed vacuoles and showed failure of staining in control cells.

Our results show that the human infrapatellar fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.

AIM: To create a set of reference data of commonly used scoring systems in the normal population, and to compare these results with published postoperative scores for commonly performed knee operations.

METHODS: This was a questionnaire-based study and a total of 657 questionnaires were sent out, of which 407 replies were received. A further 159 were excluded due to ongoing knee problems or previous knee surgery. Six scoring systems were addressed: Lysholm and Oxford Knee Scores, Tegner and UCLA activity scales and Visual Analogue Scales (VAS) for both pain and function. Data was collected into groups based on age (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89 years). The reference data obtained was then compared to published postoperative scores for knee arthroplasty and ACL reconstruction, to assess whether these patients did indeed return to “normal”.

RESULTS: The mean scores for sequential age groups (described above) were as follows: Oxford Knee Score – 13, 14, 14, 14, 17, 15, 19; Lysholm Knee Score – 95, 92, 92, 90, 88, 90, 79; Tegener Activity Scale – 5, 5, 5, 4, 4, 3, 3; UCLA Activity Scale – 9, 7, 7, 7, 6, 6, 5; VAS pain – 2, 9, 9, 9, 14, 12, 20; VAS function 97, 94, 92, 90, 86, 86, 83. Symptom based scoring systems (Oxford Knee Score, Lysholm) were independent of age. Activity scores (Tegner, UCLA) showed a statistically significant decrease with age. There was no significant difference detected between scores in different sexes in the same age group. Compared to published scores in an age-matched population following TKR, the data obtained showed that patients do not return to normal scores following arthroplasty. Following ACL reconstructive surgery, activity scores were higher than compared to the data obtained from our population.

CONCLUSIONS: Data generated from this study can be used as reference data and can play an important role in interpreting post-intervention scores following knee surgery.

There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissue including the infrapatellar fat pad. In this study, stem cells isolated from the infrapatellar fat pad were characterised to ascertain their origin, and allowed to undergo adipogenic differentiation to confirm multilineage differentiation potential.

The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated and expanded in monolayer culture. Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained poorly for LNGFR and STRO1 (markers for freshly isolated bone marrow derived stem cells), and sparsely for 3G5 (pericyte marker). Staining for CD34 (haematopoetic marker) and CD56 (neural and myogenic lineage marker) was negative.

For adipogenic differentiation, cells were cultured in adipogenic inducing medium consisting of basic medium with 10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine. By day 16, many cells had lipid vacuoles occupying most of the cytoplasm. On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining confirmed the adipogenic nature of the observed vacuoles and showed failure of staining in control cells.

Our results show that the human infrapatellar fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.

Aim: Rehospitalisation following surgery is widely regarded as an important outcome measure. In this study we identified causes of readmission following surgery, in proximal hip fracture patients.

Method: A total of 267 patients underwent surgery for proximal hip fractures in one year (2001–2002) at our institution. Notes of these patients were reviewed to look for readmissions within three months.

Results: A total of 43 (16.1%) patients died during initial hospital admission episode. Of the remaining 224 patients, 46 (20.5%) patients had an emergency unplanned readmission back to the hospital, within 3 months of discharge. 9 admissions (19.5% of readmissions, 4.01% of discharged patients) were due to operative site complications. 8 patients (17.3% of readmissions, 3.5% of discharged patients) were referred back for suspected thromboembolic events. 29 admissions (63.04% of readmissions, 12.9% of discharged patients) were due to other medical problems. Of these 18 medical problems could be attributed to preceding hip fracture. 15 patients died during this 2nd admission episode. 10 of these patients could have their ‘cause of death’ attributable to previous hip fracture, though this was not mentioned in their death certificates. A total of 8 patients had died in community in the 3 months following discharge giving a total mortality of 24.7% (66/267 patients) within 3 months.

Conclusions: Hip fracture is underreported as a cause of prolonged morbidity and mortality. A high percentage of these patients were readmitted adding to resource crunch. An understanding of the causes of readmission would help to decrease this workload.

Aim: To determine effect of single post-operative injection of Sodium Hyaluronate (Viscoseal) on the pain and joint function, following arthroscopic knee surgery.

Method: Study design: A randomized, prospective, controlled, double blinded trial after ethical approval. Study procedure: Consenting patients (age group 18–60 years) undergoing arthroscopic knee surgery were randomized to either study group or control group, after the completion of their operation. Control group had 10 mls of 0.5% Bupivacaine injected in the joint after the procedure, while study group had 10 mls of Viscoseal (Sodium Hyaluronate preparation devoid of animal protein) injected in the joint. Patients were given questionnaires to assess their pain and function at various times (Preoperatively; 2 hour following surgery; Day 1, Day 7, 3 week and 6 week following surgery). Primary efficacy parameters used were Pain visual analogue scores at rest, on movement and on weight bearing. Secondary efficacy parameters used included WOMAC questionnaire, SF-12 general health questionnaire and use of rescue medication. Patients were evaluated clinically at 6 weeks by a blinded physiotherapist.

Results: 48 patients (Average age-41 years, 20 female, 28 male) undergoing knee arthroscopy were randomized (24 patients each). The hyaluronate group exhibited markedly lesser degrees of immediate post-operative pain and swelling; reduced need for analgesics, and a significantly larger drop in WOMAC scores than the bupivacaine group (p< 0.05). SF-12 scores and delayed pain VAS score improved by a comparable amount. In particular, those undergoing partial meniscectomy exhibited greater benefits with hyaluronate. No complications were recorded in either of the groups.

Conclusion: Sodium hyaluronate (Viscoseal) injections could be safely used following arthroscopic knee surgery, to facilitate patient’s recovery.

Introduction Surgical treatment of metatarsalgia remains controversial, with many different techniques described. Recently the Weil osteotomy is gaining in popularity because of its relatively simple technique and excellent union rates, however, it is well known that the procedure does lead to stiffness in the metatarsophalangeal (MTP) joint with a reduction in plantarflexion. The aim of this study was to evaluate the outcome of the Weil osteotomy from a radiological and patient-based perspective.

Method This was a retrospective review of 42 patients (110 Weil osteotomies), with mean follow up of 24.8 months (range 6–48). Clinical examination and X-ray assessment were performed at follow-up, along with completion of patient questionnaires, American Orthopaedic Foot and Ankle Society (AOFAS) Score and Lesser Metatarsal Scores (LMTS). Additional parameters including arc of motion of each metatarsal, metatarsal shortening, non-union, redislocation and requirement for further surgery were also recorded.

Results Results showed that the average arc of motion for the second metatarsal was 61.1 degrees, the third metatarsal 59.6 degrees, and the fourth metatarsal 69.8 degrees. In all cases there was a significant reduction in plantarflexion at the MTP joint, with the average combined plantar flexion of less than 5 degrees. The average shortening was 7.2 mm, and there were no cases of redislocation or non-union. Analysis of the scoring systems showed that with AOFAS there were 88% excellent/ good results and with LMTS there were 83% excellent/ good results. No patients had residual metatarsalgia and plantar callosities disappeared in almost all patients, with 91% of patients reporting excellent/good satisfaction.

Conclusion Formal scoring systems and patient satisfaction scores showed that dorsiflexion contractures post-operatively were not of concern to the patients. The study suggests that the Weil osteotomy remains a safe, reliable and predictable operation with excellent results, and may be of value in the treatment of resistant metatarsalgia.

A 78 year old lady attended casualty with complaints of low back pain and calf pain following a fall. Radiographs of lumbar spine did not reveal any bony injury. Clinically deep vein thrombosis (DVT) of the calf could not be excluded. Hence, venogram was performed that confirmed the diagnosis of below knee DVT. Patient was then discharged. Patient attended casualty 2 months later with complaints of sudden increase in back pain and difficulty in mictuirition. Radiographs of lumbar spine revealed a collapse of L1 vertebra. Routine blood tests were all normal except for raised International Normalised Ratio (INR), 3.5. Patient developed parapaeresis within three days. Coagulation status was controlled but no obvious primary source could be identified. After discussion with Neurosurgeons, urgent Computerised Tomography (CT) guided biopsy was arranged which was performed one week after presentation. Histopathological examination of the specimens revealed only fibrous tissue and blood. At 3 weeks after presentation patient started recovering rapidly though there was some amount of residual power loss in the lower limbs. Patient did not regain bladder control. A repeat CT guided biopsy at 6 weeks, again revealed only fibrous tissue.

This case is presented to discuss the rarer etiologies that can present as a metastatic spinal cord compression.

Aim: To study the management and survival outcome of patients with metastatic long bone deposits referred to a general orthopaedic unit at a district general hospital.

Methods and materials: 43 patients with pathological or impending long bone fractures were identified between 1998 and 2001. Details of primary tumor, bony metastatic involvement and management were recorded. Additional data was collected regarding prophylactic versus therapeutic treatment, oncological input, time to death and Mirel’s score, where relevant.

Results: The most common areas of long bone metastases were found to be proximal femur 29/43 (67%) and humeral shaft 11/43 (26%). Proximal femoral lesions included subcapital, intertrochanteric and subtrochanteric lesions. Operative stabilisation was carried out in 27/43 (63%), and involved intramedullary fixation (10/27; 37%), extramedullary fixation (15/27; 56%), and arthroplasty (2/27; 7%). Of the initial 43 patients, 14 (33%) presented with impending fractures, with Mirel’s scores ranging from 7 to 11 (average 9).

The duration of pre-existing pain in the in the fracture group varied from 3 days to 6 months (average 55 days). None of these patients received oncological input during this time period. Of these 15 patients, 12 subsequently required surgery.

Patient survival times in the operated group averaged 3 months (2 days to 9 months) – with the exception of one patient who survived for 36 months. This compared equally with survival times for the unoperated group.

Only 2/43 patients received preoperative oncology input. In the postoperative group (27 patients), 16 (59%) received radiotherapy. Of the remaining 11 patients, 9 (33%) did not receive radiotherapy due to significant postoperative complications and died within 8 weeks.

Discussion: The main aims of surgery in patients with metastatic bony disease are pain relief, and preservation of stability and function. In view of the low life expectancy, preoperative oncology input is important in determining patient longevity and in deciding if surgery is beneficial. All patients should be considered for postoperative radiotherapy once the wound has healed. This multi disciplinary approach can be difficult to achieve in the setting of a district general hospital where oncology services are limited.

Contracture of the iliotibial band leading to flexion and abduction deformity at the hip is common in residual paralysis after polio. Ober’s test has been used to detect this, but it is unreliable and cannot determine the degree of contracture.

We describe a new test which quantifies this contracture and can be used for comparative purposes.