Arthordesis of small joints of the foot is a commonly performed procedure in orthopaedics. A variety of fixation devices have been used for this purpose. Nickel-Titanium Memory compression staples for arthrodesis have been used in our institute since June 2003. We report the results of the procedure over a period of 7years involving 252 feet in 232 consecutive patients who underwent arthrodesis or an osteotomy fixation using compression staples. The patients were evaluated to determine the period of immobilization in cast and the time to radiographic joint fusion.

The emphasis of this study was to validate the safety of the implant for fusion of small joints of the foot, as well as to determine whether there is a demonstrable trend in time to fusion and period of immobilization required.

The average time to fusion was 7.2 weeks, the average period of immobilisation was 6.5 weeks. Successful union was achieved in 98% cases. We report the follow up results, finer technical aspects of the procedure and pitfalls to avoid whilst performing the fusions.

Background

Controversy persists regarding preference between Herbert and Acutrak screw for internal fixation of scaphoid non-union. Acutrak screw has been shown to have better biomechanical compression properties than Herbert screw in the laboratory setting. The aim of this study was to assess the clinical, radiological and functional outcome of patients treated with the two different screw systems.

Introduction

It is well established that non-union of the scaphoid requires operative intervention to achieve stable union, restore scaphoid anatomy and prevent further degenerative change. Acutrak screw has been shown to have better biomechanical compression properties than the Herbert screw in the laboratory setting. The aims of the study were to assess the rate of union, the functional outcome and post- operative complications of patients with the two different screw systems.

Arthrodesis of small joints of the feet has been used for a variety of conditions. Described initially for treatment of congenital or paralytic foot deformities, arthrodesis has now been widely accepted as treatment for a range of foot disorders from inflammatory and post traumatic arthritis to acquired flat foot. A variety of fixation devices have been used to achieve compression at the Arthrodesis site.

The aim of our study is to evaluate the use of Memory compression staples in small joint fusions of the feet. The staples are made of a nickel-titanium alloy which exhibits a phenomenon called “Marmen” effect. When kept at ice-cold temperature (0–5°C), the alloy becomes plastically deformed, but, regains its original shape at body temperature. The emphasis of this study is to validate the safety of the implant for fusion of small joints of feet, as well as to determine whether the higher cost of the implant is justified by a demonstrable trend in time to fusion and period of immobilization required.

Between June 2003 and June 2008, a total of 148 feet (276 joints) had Arthrodesis using memory compression staples.

Data was collected retrospectively and clinical and radiological outcomes were assessed.

The average period of immobilization in cast was 6.8 weeks (range, 6–12). The average time to fusion was 8 weeks (range, 6–16).

The use of memory staples provides an accurate, reproducible and predictable method of achieving arthrodesis in small joints of the feet. The time to fusion is less, thereby reducing the recovery time after surgery.

Introduction: A successful total knee replacement (TKR) relies upon effective soft tissue management. Historically, soft tissue balancing has been difficult to assess and quantify intraoperatively. Computer navigation permits us to accurately assess kinematics during surgery. In a previous study we performed a series of varus and valgus stress measurements in extension to devise an algorithm for soft tissue management. In this study we evaluate the effectiveness of this algorithm.

Methods: This prospective study used the Orthopilot® CT-free navigation system during TKR for 57 patients with end-stage arthritis. We collected intraoperative kinematic data for 42 varus knees. Pre- and post-operatively, a varus and valgus stress was applied at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. The following medial releases were performed based upon the kinematics and the algorithm below:

No release–MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°.

Results: Pre-operatively, the mean MFT angle was −9.6°varus (−3° to −22°) with varus stress and −0.8°varus (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.5° varus (0° to −5°) with varus stress, and 2.1° valgus (4° to −1°) with valgus stress.

Using regressional analysis, there was a strong linear correlation between both varus (r=0.871, p< 0.0001) and valgus (r=0.894, p< 0.0001) stresses and the MFT angle.

Post-operatively, the mean MFT angle was maintained within a narrow range (0° to −5° with varus stress, 4° to −1° with valgus stress), with no outliers. There were no extension deficits.

Conclusions: Using computer navigation a quantifiable soft tissue management system was introduced. We evaluated this algorithm, and obtained reproducible results within a narrow range and no outliers. This algorithm may provide an effective soft tissue management plan in TKR.

Introduction: Computer navigation systems allow real time evaluation of knee behaviour intraoperatively. Measurements made by navigation reflect soft tissue balance throughout surgery. We studied three different populations of patients undergoing total knee replacement (TKR) with a CT-free navigation system where the goal was to achieve normal alignment. We compared the initial pathological kinematics in each group with the resultant kinematics after correction.

Method: The Orthopilot® was used during TKR for three groups of patients A (n=71), B(n=60) and C(n=43) all with endstage osteoarthritis. Patients in groups A and B had TKR performed by surgeon 1, and group C by surgeon 2.

Results: Pre-operatively, the mean mechanical femoral axis and the mean mechanical femoro-tibial (MFT) angle were calculated. The mean mechanical femoral axis for group A was −0.5° varus (−6° to 9°), group B was −0.68° varus(−6° to 6°), and for group C was 2.67° valgus (−12° to 10°). P< 0.0001, using Kruskal-Wallis test. Pre-operatively, the mean MFT angle for group A was −3.75° varus(−15° to 17°), group B was −2.98° varus(−17° to 13°), and for group C was 0.16° valgus(−17° to 25°). P=0.003 using Kruskal-Wallis test. These results show that the initial preoperative kinematics are different for the three different populations.

Post-operatively we measured the mean MFT angle in groups A, B and C. In group A, the mean MFT angle was −0.38° varus (−4° to 2°), group B was −0.41° varus(−5° to 2°), and group C was −0.02° varus(−3° to 5°). P=0.7 using the Kruskal-Wallis test. These results show that the post-operative kinematics are similar between the three different populations.

Discussion: Populations A and B preoperatively exhibited a mean varus MFT angle (−0.5° and −0.68° respectively), compared with a mean valgus MFT angle for group C(2.67°), which were statistically significantly different. Although different surgeons operated on the 3 groups (surgeon 1 operated on groups A and B, and surgeon 2 operated on group C), post-operative kinematics were within a narrow range (−0.02° to −0.41°) and not statistically different (p=0.7).

Conclusion: The Orthopilot® results showed that these populations had different initial pathological kinematics. Despite this, and using different operators we obtained similar post-op results within a narrow range. Computer navigation produces reliable, reproducible results independent of population or operator variables.

Patients with DDH are known to be at risk of early degenerative changes to their hips. To date, no consensus exists as to the most appropriate management of this group, with many surgical options being associated with specific complications such as dislocation and early wear. In addition, modern resurfacing methods are considered by many to be contra-indicated in patients with DDH due to the technical difficulty of the procedure.

This prospective study analyses a single surgeon series of known DDH hips that underwent metal on metal resurfacing from November 1999 to July 2004 inclusive.

There were 31 resurfacings carried out on 28 patients (11 males, 17 females). The mean age of the study group at the time of surgery was 43.9+/−9.1 years. No patient was lost to follow up. Pre-operatively, 23 hips were classified as Crowe I (n=9), II (n=5), III (n=5) and IV (n=4). Patients were followed up to a mean of 46.4+/−18.1 months. The mean Harris Hip scores were 54.9+/−9.3 pre-operatively and 98.1+/−4.9 post-operatively (p< 0.001, Student’s t-test). Using the UCLA activity profile, the mean scores were 3.2+/−1.0 pre-operatively and 6.4+/−1.8 post-operatively (p< 0.001, Student’s t-test).

Although the management of young patients with early degenerative changes secondary to DDH remains controversial, the results of this study suggest that not only is resurfacing technically possible even in advanced cases, it also offers excellent functional outcomes and should be considered in appropriate cases.

Introduction: Accurate soft tissue balancing is an essential part of total knee replacement (TKR), but has been difficult to quantify using traditional instrumentation methods. Computer navigation systems allow us to accurately assess intra-operative kinematics, which are affected by soft tissue management. The aims of this study were to evaluate the role of varus and valgus stress measurements and subsequently devise an algorithm for soft tissue management during TKR.

Methods: We used the Orthopilot® CT-free navigation system during TKR for patients with primary end-stage arthritis. This was a prospective study with 71 patients collecting intra-operative kinematic data. 57 knees were varus, 13 valgus, and 1 well aligned.

Pre- and post-operatively, the surgeon applied a varus and valgus stress at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. We compared the kinematics of each varus knee. Based upon the kinematics and the surgeon’s experience the following medial releases were performed as usual and divided into three categories:

No release (limited medial approach).

Results: Pre-operatively, the mean MFT angle was −9.6° (−3° to −22°) with varus stress and −0.8° (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.7° (−1° to −7°) with varus stress, and 1.1° (4° to −3°) with valgus stress. Using regressional analysis, there was a strong linear correlation between both varus (r=0.742, p< 0.0001) and valgus (r=0.771, p< 0.0001) stresses and the MFT angle.

With the following medial releases, these kinematics were found:

No release – MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°.

The results show that post-operatively, the mean MFT angle is maintained within a narrow range (−1° to −7° with varus stress, 4° to −3° with valgus stress). 5/57(9%) patients had a mean MFT angle of 6.4°(0° to 7°) with valgus stress, and were considered to have been over-corrected. There were no extension deficits.

Conclusions: Navigation allows us to quantify soft tissue balancing based upon the initial kinematics with varus and valgus stress testing. From these measurements, an algorithm was developed, which showed that an appropriate release was made in 52/57 (91%) patients, but this may require some adjustment to reduce the number of outlying results.

Introduction: Computer navigated total knee replacement does not require the use of intramedullary alignment rods, and is thus less invasive than traditional methods.

One previous study has suggested that the computer-assisted technique may reduce blood loss in comparison to traditional methods. This study (Kalairajah et al, 2005) used blood volume loss from drainage bottles as a primary outcome measure (n=60). Hidden (internal) blood losses were not accounted for.

Our study uses a more accurate method of assessing blood loss, and the sample size is larger (n=136; 68 standard TKR versus 68 computer assisted TKR).

Methods: 136 TKR patients were included, of which 68 had standard TKR and 68 computer assisted. Patients were matched such that in each group half had BMI in the range 20–30, and half had BMI between 30–40. Patients were also matched for gender. All patients had Tranexamic acid at the start of the procedure.

Total body blood volume was calculated using the formula of Nadler, Hidalgo & Bloch (1962). This was then used, together with haematocrit and volume re-infused or transfused, to calculate true blood loss, as described by Sehat, Evans, and Newman (2004). This method is considered to be more reliable than measuring drain output, as it takes account of “hidden” losses. The navigated and non-navigated groups were compared using Student’s t-test.

Results: The average blood loss was 583ml in the standard TKR group, and 442ml in the computer assisted TKR group. This difference was statistically significant (p=0.003).

Conclusions: A previous study found reduced blood loss when performing total knee replacement using computer navigation, compared with traditional methods. Our study confirmed this finding, using a larger sample size, and a more reliable method of assessing blood loss.

Our study found that overall blood loss was less for both groups, when compared to the findings of Kalairajah Y et al. We suspect that this difference was due to our departmental policy that all patients receive tranexamic acid at the start of joint replacement procedure.

The accuracy of measurement in computer-assisted total knee arthroplasty is dependent on the quality of data acquisition at the start of the procedure; errors in landmark identification could lead to misalignment and therefore poorer longterm outcomes.

Some navigation systems require the surgeon to explicitly identify the femoral epicondyles in order to calculate the trans-epicondylar axis, whereas other systems are able to interpolate the epicondylar location based on a number of points acquired from the distal femoral surface. Significant inter-observer variability in landmark identification has been previously reported in dry bone studies. The purpose of this study was to test the accuracy of identification of the epicondyles during a simulated total knee replacement on a fresh cadaveric specimen.

An unfixed fresh cadaveric left lower limb was used to perform a navigated total knee replacement using the Orthopilot® (B|Braun-Aesculap, Tuttlingen, Germany) image-free navigation system.

Sixteen surgeons attending an advanced navigation training course were invited to take part. A single consultant surgeon performed initial dissection and pin placement, up to the point of landmark acquisition. Each subject was then asked to use a pointer tool to identify the medial and lateral epicondyles, as they would in an operative situation. Data were recorded by the Orthopilot® system, and exported as a 3D array for further analysis.

Initial visualisation with a 3D scatter plot showed that points were evenly distributed within a circular pattern around each epicondyle. The length of a vector between each point on each epicondyle was calculated in turn. The maximum distances between points were 15.6mm for the medial epicondyle, and 19.9mm for the lateral epicondyle.

We then calculated the length and angulation of the trans-epicondylar axis (TEA) for each observer, equivalent to the vector between each pair of points (medial and lateral epicondyle). An average TEA was calculated, and the range and standard deviation of angulation were determined. In the x axis the range was 16.3° (–8.3° to 7.9°, SD 5.1°), in the y axis the range was 18.7° (–8.7° to 10°, SD 5.2°) and in the z axis the range was 20.5° (–10.1° to 10.4°, SD 6.5°). Range of recorded TEA length was 64.5 to 74.9mm (mean 70.6mm, SD 3.3mm).

We conclude that in this simulated operative scenario, surgeons exhibited considerable variability when locating the epicondyles. Range of angulation of the TEA exceeded 16° (SD > 5.1°) in all 3 planes. We cannot recommend the use of a trans-epicondylar axis determined from 2 single points, as a reliable landmark in navigated total knee replacement.

Computer navigated total knee replacement is less invasive than traditional methods, as it avoids the use of intramedullary alignment rods. A previous study (Kalairajah et al, 2005) has shown that computer-assisted techniques may reduce blood loss in comparison to traditional methods. Our study uses a more accurate method of assessing blood loss, and the sample size is larger.

136 TKR patients were selected from a prospectively collected database of all those undergoing arthroplasty at our institution; 68 had standard TKR and 68 had a computer assisted TKR. In each group, half had BMI in the range 20–30, and half had BMI between 30–40. There were an equal number of males and females in each group. All patients received a standardised anaesthetic, and had tranexamic acid at the start of the procedure.

Total body blood volume was calculated from patient height, weight and sex, using the model described by Nadler, Hidalgo & Bloch (1962). This was then used, together with pre- and post-op haematocrit and volume re-infused or transfused, to calculate true blood loss, as described by Sehat, Evans, and Newman (2004). This method is considered to be more reliable than measuring drain output, as it takes account of “hidden” (internal) losses.

The average blood loss was 603ml in the standard TKR group, and 448ml in the computer assisted TKR group. Student’s t-test showed that this difference was statistically significant (p = 0.007). Regression analysis showed no significant difference between obese and non-obese patients, nor a difference between sexes. Blood loss in both groups was lower than in a previous study, which we attribute to our department’s routine use of tranexamic acid.

We conclude that computer-assisted total knee replacement leads to significant reduction in blood loss when compared with traditional techniques. This confirms previous reports.

Computer technology allows real time evaluation of knee behaviour throughout flexion. These measurements reflect tibial rotation about the femoral condyles, patellar tracking and soft tissue balance throughout surgery. An understanding of intraoperative kinematics allows accurate adjustment of TKR positioning. We studied computer navigation with the femoral component aligned to Whiteside’s line.

We used CT free navigation during TKR for 71 end-stage osteoarthritic patients. Patients demographics: 29 right–42 left; 44 female −27 male; age 70.4 years (+/− 8.4); mean BMI 30.8 (+/− 4.7; 23.2–48.6); Oxford score: 43 +/− 7.7 (28–58). Preoperatively, 57/71 knees were varus knees, 1 well-aligned and 13 valgus; 75% were cruciate retaining and 25% were posterior stabilised knees.

During surgery the frontal femorotibial or Hip-Knee-Ankle (HKA) angle was measured from maximum extension through 30°,60° and 90° of flexion. Measurements of the femoro tibial angles (HKA) in 0°, 30°, 60° and 90° of knee flexion before and after TKR were collected. No patella was replaced. We compared the kinematics of each knee. Femoral component rotation was 2.06° external rotation +/−1.32° (−1°; 5°) referenced from the dorsal condylar axis. Analysis divided the 71 patients into three groups:

When the femoral component was placed between 1° internal rotation and 0° of external rotation (7 patients) HKA tended to flex into valgus.

Performing Total Knee Replacement (TKR) surgery using computer assisted navigation systems results in more reproducibly accurate component alignment. Navigation allows real time evaluation of passive knee behaviour throughout flexion. These kinematic measurements reflect tibial rotation about the femoral condyles, patellar tracking and soft tissue balance throughout surgery. In this study, we aim to study dynamic knee function in navigated and standard instrumentation TKR patients performing a range of everyday activities using gait analysis.

A prospective randomised controlled trial evaluated the functional outcome using gait analysis with 20 patients in each of three groups – Standard, Navigated and Control. The same implant (Scorpio) and navigation system (Strykervision) was used for each patient. The control group were subjects with no history of knee pathology or gait abnormality. Using an 8-camera Vicon motion analysis system set at 120Hz (real-time motion), we assessed the following functional activies: walking, rising from/sitting in chair, ascending/descending stairs. One functional outcome measure we have analysed so far is the maximum flexion angle.

The maximum flexion angle was recorded for each activity in standard, navigated and control groups respectively. ANOVA was performed, with significance set at p< 0.05. Maximum flexion angle during gait was 65.6°, 72.6° (p=0.009) and 73.5° (p=0.74), chair rising/sitting was 82.5°, 92.8° (p=0.01), and 93.5° (p=0.64), stairs ascent/descent was 81.8°, 99° (p< 0.0001), and 113.4° (p< 0.0001).

In terms of dynamic functional outcome, we found that the average maximum flexion angle for the navigated group was greater than for the standard group; moreover, this was similar to the maximum flexion angle for the control group when performing a variety of normal daily activities.

Introduction: Carpal tunnel decompression is the most commonly performed procedure in hand surgery. This study was done to assess the effectiveness and acceptability by patients of open carpal tunnel release under local anaesthetic and compare our results with previous published work from our department following alterations to our operative techniques.

Methods: 92 carpal tunnel releases were performed on 80 patients over a four year period, 2001 to 2004. 55 were females and 25 were males. A patient satisfaction survey was done by a postal questionnaire which addressed opinion regarding preference for LA over GA, pain due to LA infiltration, effectiveness of LA, patient comfort during surgery, outcome of surgery and overall satisfaction with the procedure. In this cohort of patients we did not use a tourniquet which caused severe pain in 29% of cases in the previous study. We also administered LA with adrenaline using a dental syringe to reduce pain which was previously reported as severe in 20% of cases.

Results: 62 patients replied to the questionnaire, a response rate of 77.5%. Preference for LA over GA was 90% as compared to 70% in the previous study. Pain due to tourniquet use was previously reported as severe in 29% of cases but this did not apply in this subset of patients. Pain due to infiltration of LA with a dental syringe was severe in 9% of cases compared to 20% with a 25G needle. Effectiveness of LA, outcome of surgery and overall satisfaction with the procedure remained unchanged.

Conclusion: Carpal tunnel decompression is a quick, convenient, inexpensive and safe method of treatment. We have demonstrated that injecting LA with adrenaline using a dental syringe obviates the need for tourniquet and improves patients’ acceptability and tolerance of this procedure.

Background: Aseptic loosening remains the most common cause of failure of total hip arthroplasty. Its pathogenesis is based upon the generation of wear debris particles which trigger synovial macrophage activation.

Statins, inhibitors of 3-hydroxy-3 methylglutaryl coenzyme A (HMG-Co-A) reductase, have revolutionised the treatment of hypercholesterolaemia. More recently statins have been shown to have potent anti inflammatory effects. We investigated the effects of cerivastatin in attenuating the activation of human macrophages by polymethylmethacrylate (PMMA) particles.

Methods: Polymethylmethacrylate-particle-stimulated human macrophages were cultured in vitro with cerivastatin at 75 and 150... mols/litre. TNF-α (tumour necrosis factor alpha) and MCP-1 (monocyte chemotactic protein) expression were determined using ELISA. An ERK1/2 inhibitor, UO126 was utilised to identify the mitogen activated protein kinase (MAP-Kinase) pathway involved and western blotting was used to demonstrate the effect of Cerivastatin on this pathway.

Results PMMA-stimulated TNF-α and MCP-1 expression was consistently attenuated by cerivastatin therapy.

PMMA activation was attenuated by the ERK1/2 inhibitor, UO126.

Western blotting confirmed ERK downregulation by cerivastatin, establishing a mechanism for its anti-inflammatory effects.

Conclusion: We have demonstrated the beneficial effects of statins in suppressing particle mediated activation of macrophages and the potential to prevent or treat periprosthetic osteolysis.

Background: Periprosthetic osteolysis precipitates aseptic component loosening, increases periprosthetic fracture risk and through massive bone loss, complicates revision surgery.

Its pathogenesis is based upon the generation of wear debris particles which trigger synovial macrophage activation. Statins, inhibitors of 3-hydroxy-3 methylglutaryl coenzyme A (HMG-Co-A) reductase, have revolutionised the treatment of hypercholesterolaemia and cardiovascular disease. The antiinflammatory properties of HMG-CoA reductase inhihitors or the statin family are well recognised. We investigated the effects of ceriv-astatin in attenuating the activation of human macrophages by polymethylmethacrylate (PMMA) particles.

Methods: Polymethylmethacrylate-particle-stimulated human macrophages were cultured in vitro with cerivastatin at 75 and 150micromols/litre. TNF- alpha (tumour necrosis factor alpha) and MCP-1 (monocyte chemotactic protein) expression were determined using ELISA. UO126, a Raf/MEK/ERK intracellular transduction pathway inhibitor, was utilised to identify the mitogen activated protein kinase (MAP- Kinase) pathway involved and western blotting was used to demonstrate the effect of cerivastatin on this pathway.

Results Human monocyte/macrophage cultures were activated by PMMA particles evidenced by TNF- alpha and MCP-1 expression(p< 0.05). This activation was consistently attenuated by cerivastatin therapy. Similarily, PMMA activation was attenuated by the Raf/MEK/ERK inhibitor, UO126.

Western blotting confirmed Raf/MEK/ERK down-regulation by cerivastatin, establishing a mechanism for its anti-inflammatory effects.

Conclusion We have demonstrated in vitro, that statins can abrogate particle induced inflammatory responses in a dose dependent manner and this is mediated intra-cellularily through its effect on the Raf/MEK/ERK transduction pathway. We propose that by attenuating this inflammatory response, the associated subsequent osteoclast activation and osteolysis is attenuated. Statins therefore may have role in promoting implant longevity

Aims: Pharmacological modulation of skeletal muscle reperfusion injury after trauma associated ischaemia may improve limb salvage rates and prevent the associated systemic sequelae. Resuscitation with hypertonic saline restores the circulating volume and has favourable effects on tissue perfusion and blood pressure. The purpose of our study was to evaluate the effects of hypertonic saline on skeletal muscle ischaemia reperfusion (I/R) injury and the associated endorgan injury.

Methods: Adult male Sprague Dawley rats (n=24) were randomised into three groups: control group, I/R group treated with normal saline and I/R group treated with hypertonic saline. Bilateral hind-limb ischaemia was induced by rubber band application proximal to the level of the greater trochanters for 2.5 hours. Treatment groups received either normal saline or hypertonic saline prior to tourniquet release. Following twelve hours reperfusion, the tibialis anterior muscle was dissected and muscle function assessed electrophysiologically by electrical field stimulation. The animals were then sacrificed and skeletal muscle harvested for evaluation. Lung tissue was also harvested for measurement of wet-to-dry ratio, myeloperoxidase content and histological analysis.

Results: Hypertonic saline significantly attenuated skeletal muscle reperfusion injury as shown by reduced twitch and tetanic contractions of the skeletal muscle (Table). There was also a significant reduction in lung injury as demonstrated by differences in wet-to-dry ratio, myeloperoxidase content and histological analysis.

Conclusion: Resuscitation with hypertonic saline may have a protective role in attenuating skeletal muscle ischaemia reperfusion injury and its associated systemic sequelae.

Aims: Circulating endothelial precursor cells (CEPs) are thought to play a role in angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model. Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, deþned by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bonemarrow precursors deþned byLy-6A/E and c-Kit expression were harvested following the traumatic insult from the murine model and quantiþed on ßow cytometry. Human and murine progenitor populations were cultured on þbronectin and examined for markers of endothelial cell lineage (Ulexeuropaeus- agglutinin-1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis. Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300% (p=0.008) and returning to normal levels by day 10. Murine bone marrow precursors were mobilisd within 24 hrs peaking at 48hrs (900% p=0.035). On culture, morphologically characteristic endotheliallike cells binding UEA-1 and incorporating LDL were identiþed. Serum VEGF levels increased signiþcantly within 24 hrs of the insult, (p=0.018) preceeding the peak in CEP mobilisation. Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEPs from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing.

Background: Circulating endothelial precursor cells (CEPS) are thought to play a role in postnatal angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model.

Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, defined by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bone marrow precursors defined by Ly-6A/E and c-Kit expression were harvested following traumatic insult from the murine model and quantified on flow cytometry. Human and murine progenitor populations were cultured on fibronectin and examined for markers of endothelial cell linage (Ulexeuropaeus- agglutinin- 1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis.

Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300%.

Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEP from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing.