Aims. We performed a meta-analysis investigating the association between preoperative psychological distress and postoperative pain and
Most patients (95%) with fibular hemimelia have
an absent anterior cruciate ligament (ACL). The purpose of this study
was to assess the long-term outcome of such patients with respect
to pain and knee
We investigated the extent to which improved
balance relative to pain relief correlates with the success of total knee
replacement (TKR). A total of 81 patients were recruited to the
study: 16 men (19.8%) and 65 women (80.2%). Of these, 62 patients
(10 men, 52 women) with a mean age of 73 (57 to 83) underwent static
and dynamic assessment of balance pre-operatively and one year post-operatively.
The parameters of balance were quantified using commercially available
and validated equipment. Motor
There is controversial whether synovectomy must be done in primary total knee arthroplasty (TKA). The objectivity of the study was to compare the effect of synovectomy on inflammation and clinical outcomes after surgical treatment of knee osteoarthritis. A total of 240 patients who underwent primary unilateral TKR were randomly divided into a group without (Group A) and with synovectomy (Group B). All operations were performed by the same surgeon and follow-up was for 4 year. Clinical outcomes (including American Knee Society score (AKS), SF-36, and HSS scores) serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the affected knee skin, swelling, ROM, patients VAS satisfaction score and VAS pain score were sequentially evaluated until 4 years after surgery.Purpose
Methods
The aim of this study was to determine the association
between the Oxford knee score (OKS) and direct assessment of outcome,
and to examine how this relationship varied at different time-points
following total knee replacement (TKR). Prospective data consisting
of the OKS, numerical rating scales for ‘worst pain’ and ‘perceived
mean daily pain’, timed functional assessments (chair rising, stairs
and walking ability), goniometry and lower limb power were recorded
for 183 patients pre-operatively and at six, 26 and 52 weeks post-operatively.
The OKS was influenced primarily by the patient’s level of pain
rather than objective functional assessments. The relationship between report
of outcome and direct assessment changed over time: R2 =
35% pre-operatively, 44% at six weeks, 57% at 26 weeks and 62% at
52 weeks. The relationship between assessment of performance and report
of performance improved as the patient’s report of pain diminished,
suggesting that patients’ reporting of functional outcome after
TKR is influenced more by their pain level than their ability to
accomplish tasks.
Up to 20 percent of patients remain dissatisfied after primary total knee arthroplasty (TKA) surgery. Understanding the reasons for dissatisfaction post TKA may allow for better patient selection and optimized treatment for those who remain dissatisfied. The association between
Aims. The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence. Methods. Radiological (absolute radiological measurements aided by computer software) and clinical (clinical interpretation of radiographs) definitions of malunion were compared within the Ankle Injury Management (AIM) trial cohort, including people aged ≥ 60 years with an unstable ankle fracture. Linear regressions were used to explore the relationship between radiological malunion (RM) at six months and changes in
During aging, tendons demonstrate substantial disruptions in homeostasis, leading to impairments in structure-function. Impaired tendon
Aims. Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative
Abstract. Introduction. The extent to which hip arthroscopy (HA) treatments influence sexual
Matrix-bound vesicles (MBVs) are embedded within osteoid and
Aims. The primary aim of our study was to assess the influence of age on hip-specific outcome following total hip arthroplasty (THA). Secondary aims were to assess health-related quality of life (HRQoL) and level of activity according to age. Methods. A prospective cohort study was conducted. All patients were fitted with an Exeter stem with a 32 mm head on highly cross-linked polyethylene (X3RimFit) cemented acetabulum. Patients were recruited into three age groups: < 65 years, 65 to 74 years, and ≥ 75 years, and assessed preoperatively and at three, 12, 24, and 60 months postoperatively. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), and Hip disability and Osteoarthritis Outcome Score (HOOS), were used to assess hip-specific outcome. EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and 36-Item Short Form Survey (SF-36) scores were used to assess HRQoL. The Lower Extremity Activity Scale (LEAS) and Timed Up and Go (TUG) were used to assess level of activity. Results. There were no significant (p > 0.05) differences in the WOMAC scores, HSS, HOOS, or EQ-5D-5L at any postoperative timepoint between the age groups. Patients aged ≥ 75 years had significantly lower physical
Aims. Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint
Aims. Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent
Risk factors for poor outcomes after total knee replacement (TKR) have been identified, but the underlying causes are not fully understood. The aim of this research was to establish the relationship between measurable gait parameters and patients' subjective
Young adult hip pathology commonly affects patients of reproductive age. The extent to which hip arthroscopy (HA) treatments influence sexual
To investigate temporal changes in synovial lymphatic system (SLS) drainage
Nerve transfer is an emerging treatment to restore upper limb
Aims. Perthes’ disease (PD) is a childhood hip disorder that can affect the quality of life in adulthood due to femoral head deformity and osteoarthritis. There is very little data on how PD patients
The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow
Aims. The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA). Methods. A randomized controlled trial was undertaken (May 2019 to December 2021), and patients were allocated to either mTKA or rTKA. A total of 100 patients were randomized, 50 to each group, of whom 43 rTKA and 38 mTKA patients were available for review at 12 months following surgery. There were no statistically significant preoperative differences between the groups. The minimal clinically important difference in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was defined as 7.5 points. Results. There were no clinically or statistically significant differences between the knee-specific measures (WOMAC, Oxford Knee Score (OKS), Forgotten Joint Score (FJS)) or HRQoL measures (EuroQol five-dimension questionnaire (EQ-5D) and EuroQol visual analogue scale (EQ-VAS)) at 12 months between the groups. However, the rTKA group had significantly (p = 0.029) greater improvements in the WOMAC pain component (mean difference 9.7, 95% confidence interval (CI) 1.0 to 18.4) over the postoperative period (two, six, and 12 months), which was clinically meaningful. This was not observed for
Aims. To determine the trajectories of patient reported pain and functional disability over five years following total hip arthroplasty (THA) or total knee arthroplasty (TKA). Methods. A prospective, longitudinal cohort sub-study within the National Joint Registry (NJR) was undertaken. In all, 20,089 patients who underwent primary THA and 22,489 who underwent primary TKA between 2009 and 2010 were sent Oxford Hip Score (OHS) and Oxford Knee Score (OKS) questionnaires at six months, and one, three, and five years postoperatively. OHS and OKS were disaggregated into pain and
Despite total knee arthroplasty demonstrating high levels of success, 20% of patients report dissatisfaction with their result. Wellness Stasis Socks are embedded with a proprietary pattern of neuro-receptor activation points that have been proven to activate a precise neuro-response, as according to the pattern theory of haptic perception, which stimulates improvements in pain and
Smartphone-based apps that measure step-count and patient reported outcomes (PROMs) are being increasingly used to quantify recovery in total hip arthroplasty (THA). However, optimum patient-specific activity level before and during THA early-recovery is not well characterised. This study investigated 1) correlations between step-count and PROMs and 2) how patient demographics impact step-count preoperatively and during early postoperative recovery. Smartphone step-count and PROM data from 554 THA patients was retrospectively reviewed. Mean age was 64±10yr, BMI was 29±13kg/m2, 56% were female. Mean daily step count was calculated over three time-windows: 60 days prior to surgery (preop), 5–6 weeks postop (6wk), and 11–12 weeks postop (12wk). Linear correlations between step-count and HOOS12
Purpose of study and background. Spinal muscle area (SMA) is often employed to assess muscle functionality and is important for understanding the risk individuals may have of developing back pain or the risk of postural instability and falls.. However, handgrip strength (HGS) has also been utilized as a measure of general muscle capacity. This study aimed to examine the relationship between SMA and HGS to assess whether the latter could be used as an accurate indicator of the former. Methods. 150 participants (75 males and 75 females, aged 47–70 years) were selected from the UK Biobank dataset. Handgrip strength values were extracted and averaged over left and right values. Abdominal MRI images were examined and cross-sectional area of the erector spinae and multifidus determined at the L3/4 level and summed to provide a total muscle area. Results. HGS and SMA (mean±sd) were 39.6 ± 7.4 kg and 4664 ± 868 mm. 2. for males and 24.7 ± 5.9 kg, and 3822 ± 579 mm. 2. for females. Pearson correlation between HGS and SMA was r = 0.41 for males (p = <0.001), r = 0.40 for females (p = <0.001), and r = 0.61 for the combined groups (p<0.001). Conclusion. Significant correlations were found between HGS and SMA for individual sexes and combined groups. However, although HGS may be a useful measure for predicting modifications in group responses in spinal muscle
Aims. This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung
Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l. Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. The extent of cardiovascular injury, measured by global longitudinal strain (GLS), in patients with elevated blood cobalt levels has not previously been examined. Sixteen patients with prospectively collected blood cobalt ion levels above 13µg/l were identified and matched with eight patients awaiting hip arthroplasty with no history of cobalt implants. Patients underwent echocardiogram assessment including GLS. Patients with MoM hip arthroplasties had a mean blood cobalt level of 29µg/l compared to 0.01µg/l in the control group. There was no difference or correlation in EF, left ventricular (LV) end systolic dimension, LV end diastolic dimension, fractional shortening, ventricular wall thickness or E/e’ ratio. However, GLS was significantly reduced in patients with MoM hip arthroplasties compared to those without (−15.2% v −18%, (MoM v control) p= 0.0125). Pearson correlation demonstrated that GLS is significantly correlated with blood cobalt level (r= 0.8742, p=0.0009). For the first time, this study has demonstrated reduced cardiac
Aims. The Patient-Reported Outcomes Measurement Information System (PROMIS) has demonstrated faster administration, lower burden of data capture and reduced floor and ceiling effects compared to traditional Patient Reported Outcomes Measurements (PROMs). We investigated the suitability of PROMIS Mobility score in assessing physical
Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l (13ppb, 221nmol/l). Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Global longitudinal strain (GLS) is an echocardiography measurement known to be more sensitive than ejection fraction at diagnosing early cardiomyopathies. The extent of cardiovascular injury, as measured by GLS, in patients with elevated blood cobalt levels has not previously been examined. Sixteen patients with documented blood cobalt ion levels above 13µg/l were identified from a regional arthroplasty database. They were matched with eight patients awaiting hip arthroplasty with no history of cobalt implants. All patients underwent electrocardiogram and echocardiogram assessment for signs of cardiomyopathy including GLS. Patients with MoM hip arthroplasties had a mean blood cobalt level of 29µg/l (495nmol/l) compared to 0.01µg/l (0.2nmol/l) in the control group. There was no difference or correlation in ejection fraction (EF), left ventricular (LV) end systolic dimension, LV end diastolic dimension, fractional shortening, ventricular wall thickness or E/e’ ratio. However, GLS was significantly reduced in patients with MoM hip arthroplasties compared to those without (−15.2% v −18%, (MoM v control) p= 0.0125). Pearson correlation demonstrated that GLS is significantly correlated with blood cobalt level (r= 0.8742, p=0.0009). For the first time, this study has demonstrated reduced cardiac
Aims. The primary aim of this study was to compare the hip-specific functional outcome of robotic assisted total hip arthroplasty (rTHA) with manual total hip arthroplasty (mTHA) in patients with osteoarthritis (OA). Secondary aims were to compare general health improvement, patient satisfaction, and radiological component position and restoration of leg length between rTHA and mTHA. Methods. A total of 40 patients undergoing rTHA were propensity score matched to 80 patients undergoing mTHA for OA. Patients were matched for age, sex, and preoperative
Aims. Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired
Aims. Elevated blood cobalt levels secondary to metal-on-metal (MoM) hip arthroplasties are a suggested risk factor for developing cardiovascular complications including cardiomyopathy. Clinical studies assessing patients with MoM hips using left ventricular ejection fraction (LVEF) have found conflicting evidence of cobalt-induced cardiomyopathy. Global longitudinal strain (GLS) is an echocardiography measurement known to be more sensitive than LVEF when diagnosing early cardiomyopathies. The extent of cardiovascular injury, as measured by GLS, in patients with elevated blood cobalt levels has not previously been examined. Methods. A total of 16 patients with documented blood cobalt ion levels above 13 µg/l (13 ppb, 221 nmol/l) were identified from a regional arthroplasty database. They were matched with eight patients awaiting hip arthroplasty. All patients underwent echocardiography, including GLS, investigating potential signs of cardiomyopathy. Results. Patients with MoM hip arthroplasties had a mean blood cobalt level of 29 µg/l (495 nmol/l) compared to 0.01 µg/l (0.2 nmol/l) in the control group. GLS readings were available for seven of the MoM cohort, and were significantly lower when compared with controls (-15.5% vs -18% (MoM vs control); p = 0.025)). Pearson correlation demonstrated that GLS significantly correlated with blood cobalt level (r = 0.8521; p < 0.001). However, there were no differences or correlations for other echocardiography measurements, including LVEF (64.3% vs 63.7% (MoM vs control); p = 0.845). Conclusion. This study supports the hypothesis that patients with elevated blood cobalt levels above 13 µg/l in the presence of a MoM hip implant may have impaired cardiac
Abstract. Objectives. Exploring the association of objective lower limb
Aims. It is unclear whether acute plate fixation facilitates earlier return of normal shoulder
Aims. To establish the survivorship,
Although the Western Ontario and McMaster Universities
(WOMAC) osteoarthritis index was originally developed for the assessment
of non-operative treatment, it is commonly used to evaluate patients
undergoing either total hip (THR) or total knee replacement (TKR).
We assessed the importance of the 17 WOMAC
Abstract. Introduction. Articular cartilage degradation is a defining feature of osteoarthritis. Synovium is a reactive tissue with synovial villae, neoangiogenesis and intimal hyperplasia common to many joint pathologies. The consequences of cartilage debris in osteoarthritis impacting the synovial intima is not well understood. We analysed the immunohistology of synovium from 16 patients with osteoarthritis and 17 patients undergoing knee surgery for non-arthritic pathologies. This data was integrated with imaging and functional scores to correlate synovitis in osteoarthritis. Methodology. Formalin-fixed paraffin embedded synovial biopsy sections were cut in serial sequence and processed for routine staining (H&E or CD3, CD68, CD20, Vimentin, vWF and PCNA IHC) using standardised Dako monoclonal mouse anti-human antibodies. Digital images scanned at x20 were evaluated for fragments of cartilage and aggregates of inflammatory cells. Clinical data (gender, BMI, KL grade, WOMAC & SF-12 scores) was aligned with histopathological data. Results. Cartilage fragments were seen in the synovial intimal layer from end-stage osteoarthritis especially those with BMI<30kg/m2. Macrophages, T-cells and B-cells were identified surrounding cartilage inclusions. Inflammatory aggregates of T-cells, B-cells and macrophages were located peri-cartilage in the intima and peri-vascular in the sub-intimal layer of the synovium. Worse synovitis and
Aim: As the shoulder and elbow joints share a common objective – spatial positioning of the hand – can the Modified Constant Score of shoulder
Introduction. Despite the rising popularity of 1st carpometacarpal joint (CMCJ) arthrodesis as one of the surgical options for basilar thumb arthritis, the available literature on this is poor. This study aims to investigate post-operative pinch and grip strength following 1st CMCJ arthrodesis, at a minimum of 1 year follow-up. Complication rates, range of motion and patient reported scores were also evaluated. Methods. A retrospective cohort (2012–2020) was used, which included patients who had arthrodesis performed by the Hands surgeons at Counties Manukau DHB. In a 15 minute visit, we took the measurements using our standard dynamometer and pinch gauge, and collected three questionnaires [QuickDASH, PRWHE, PEM]. For analysis, we compared our results to the preoperative measures, contralateral hand, and to a previous study on a similar cohort looking at thumb strength following trapeziectomy. Results. 42 arthrodesis were performed, and 24 were available for follow-up. The average follow-up time was 77 months and the average age was 51 years old. Overall, we found a statistically significant improvement in thumb strength following surgery. Mean preoperative grip strength was 21.4kg and 32.5kg postoperatively (= +11kg). Preoperative pinch strength was 5.5kg and 7kg postoperatively (= +1.5kg). These results were significantly higher compared to the trapeziectomy cohort. We also found an improvement in 1st CMCJ ROM post-operatively. 7 complications were reported (29.1%). 4 were metalware-related and 3 were non-union. QuickDASH score significantly improved from a median of 42.95 to 12.5 while PRWHE from 67.5 to 14.5. Overall patient satisfaction was 87.4%. Conclusion. 1st CMCJ arthrodesis leads to an improvement in thumb
Osteoarthritis (OA), one of the most common motor system disorders, is a degenerative disease involving progressive joint destruction caused by a variety of factors. At present, OA has become the fourth most common cause of disability in the world. However, the pathogenesis of OA is complex and has not yet been clarified. Long non-coding RNA (lncRNA) refers to a group of RNAs more than 200 nucleotides in length with limited protein-coding potential, which have a wide range of biological
Aims. Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of
Introduction. Robotic-assisted total knee arthroplasty (TKA) has demonstrated significant benefits, including improved accuracy of component positioning compared to conventional jig-based TKA. However, previous studies have often failed to associate these findings with clinically significant improvements in patient-reported outcome measures (PROMs). Inertial measurement units (IMUs) provide a more nuanced assessment of a patient's functional recovery after TKA. This study aims to compare outcomes of patients undergoing robotic-assisted and conventional TKA in the early postoperative period using conventional PROMS and wearable sensors. Method. 100 patients with symptomatic end-stage knee osteoarthritis undergoing primary TKA were included in this study (44 robotic-assisted TKA and 56 conventional TKA). Functional outcomes were assessed using ankle-worn IMUs and PROMs. IMU- based outcomes included impact load, impact asymmetry, maximum knee flexion angle, and bone stimulus. PROMs, including Oxford Knee Score (OKS), EuroQol-Five Dimension (EQ-5D-5L), EuroQol Visual Analogue Scale (EQ-VAS), and Forgotten Joint Score (FJS-12) were evaluated at preoperative baseline, weeks 2 to 6 postoperatively, and at 3-month postoperative follow-up. Results. By postoperative week 6, when compared to conventional TKA, robotic-assisted TKA was associated with significant improvements in maximum knee flexion angle (118o ± 6.6 vs. 113o ± 5.4; p=0.04), symmetrical loading of limbs (82.3% vs.22.4%; p<0.01), cumulative impact load (146.6% vs 37%; p<0.01), and bone stimulus (25.1% vs 13.6%; p<0.01). Whilst there were no significant differences in PROMs (OKS, EQ-5D-5L, EQ-VAS, and FJS-12) at any time point between the two groups, when comparing OKS subscales, significantly more robotic-assisted TKA patients achieved an ‘excellent’ outcome at 6 weeks compared to conventional (47% vs 41%, p= 0.013). Conclusions. IMU-based metrics detected an earlier return to
Abstract. Objectives. Although hip replacement and resurfacing procedures both aim to restore mobility, improve joint
Aims. To explore the clinical efficacy of using two different types of articulating spacers in two-stage revision for chronic knee periprosthetic joint infection (kPJI). Methods. A retrospective cohort study of 50 chronic kPJI patients treated with two types of articulating spacers between January 2014 and March 2022 was conducted. The clinical outcomes and functional status of the different articulating spacers were compared. Overall, 17 patients were treated with prosthetic spacers (prosthetic group (PG)), and 33 patients were treated with cement spacers (cement group (CG)). The CG had a longer mean follow-up period (46.67 months (SD 26.61)) than the PG (24.82 months (SD 16.46); p = 0.001). Results. Infection was eradicated in 45 patients overall (90%). The PG had a better knee range of motion (ROM) and Knee Society Score (KSS) after the first-stage revision (p = 0.004; p = 0.002), while both groups had similar ROMs and KSSs at the last follow-up (p = 0.136; p = 0.895). The KSS in the CG was significantly better at the last follow-up (p = 0.013), while a larger percentage (10 in 17, 58.82%) of patients in the PG chose to retain the spacer (p = 0.008). Conclusion. Prosthetic spacers and cement spacers are both effective at treating chronic kPJI because they encourage infection control, and the former improved knee
Background: The overall goal in the treatment of RA is to minimize the loss of
Abstract. Objectives. Exploring the relationship of gait
Aims. Osteosarcoma is the most common primary bone malignancy among children and adolescents. We investigated whether benzamil, an amiloride analogue and sodium-calcium exchange blocker, may exhibit therapeutic potential for osteosarcoma in vitro. Methods. MG63 and U2OS cells were treated with benzamil for 24 hours. Cell viability was evaluated with the MTS/PMS assay, colony formation assay, and flow cytometry (forward/side scatter). Chromosome condensation, the terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay, cleavage of poly-ADP ribose polymerase (PARP) and caspase-7, and FITC annexin V/PI double staining were monitored as indicators of apoptosis. Intracellular calcium was detected by flow cytometry with Fluo-4 AM. The phosphorylation and activation of focal adhesion kinase (FAK) and signal transducer and activator of transcription 3 (STAT3) were measured by western blot. The expression levels of X-linked inhibitor of apoptosis protein (XIAP), B-cell lymphoma 2 (Bcl-2), B-cell lymphoma-extra large (Bcl-xL), SOD1, and SOD2 were also assessed by western blot. Mitochondrial status was assessed with tetramethylrhodamine, ethyl ester (TMRE), and intracellular adenosine triphosphate (ATP) was measured with BioTracker ATP-Red Live Cell Dye. Total cellular integrin levels were evaluated by western blot, and the expression of cell surface integrins was assessed using fluorescent-labelled antibodies and flow cytometry. Results. Benzamil suppressed growth of osteosarcoma cells by inducing apoptosis. Benzamil reduced the expression of cell surface integrins α5, αV, and β1 in MG63 cells, while it only reduced the expression of αV in U2OS cells. Benzamil suppressed the phosphorylation and activation of FAK and STAT3. In addition, mitochondrial
Combined Partial Knee Arthroplasty (CPKA) is a promising alternative to Total Knee Arthroplasty (TKA) for the treatment of multi-compartment arthrosis. Through the simultaneous or staged implantation of multiple Partial Knee Arthroplasties (PKAs), CPKA aims to restore near-normal
Aims. The aims were to assess whether preoperative joint-specific
The knee joint has also a periarticular adipose tissue, which is known as Hoffa's fat pad (IPFP). IPFP has a dual