Stem cells are defined by their potential for self-renewal and the ability to differentiate into numerous cell types, including cartilage and bone cells. Although basic laboratory studies demonstrate that cell therapies have strong potential for improvement in tissue healing and regeneration, there is little evidence in the scientific literature for many of the available cell formulations that are currently offered to patients. Numerous commercial entities and ‘regenerative medicine centres’ have aggressively marketed unproven cell therapies for a wide range of medical conditions, leading to sometimes indiscriminate use of these treatments, which has added to the confusion and unpredictable outcomes. The significant variability and heterogeneity in cell formulations between different individuals makes it difficult to draw conclusions about efficacy. The ‘minimally manipulated’ preparations derived from bone marrow and
Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears. Cite this article:
We modelled a 'clean' surgical wound lightly contaminated with airborne bacteria, using agar, ovine muscle and ovine
Shoulder injury related to vaccine administration (SIRVA) is a prolonged episode of shoulder dysfunction that commences within 24 to 48 hours of a vaccination. Symptoms include a combination of shoulder pain, stiffness, and weakness. There has been a recent rapid increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programmes associated with COVID-19 and influenza. The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process. It has been hypothesized that this is associated with a vaccine injection site that is “too high” and predisposes to the development of SIRVA. Nerve conduction studies are routinely normal, but further imaging can reveal deep-deltoid collections, rotator cuff tendinopathy and tears, or subacromial subdeltoid bursitis. However, all of these are common findings within a general asymptomatic population. Medicolegal claims in the UK, based on an incorrect injection site, are unlikely to meet the legal threshold to determine liability. Cite this article:
Total hip replacement in patients with Gaucher’s disease with symptomatic osteonecrosis of the femoral head is controversial because of the high early failure rates. We describe four patients who had an uncemented total hip replacement following enzyme replacement therapy for a median of two years and one month (1 to 9.8 years) prior to surgery, and who remained on treatment. At operation, the bone had a normal appearance and consistency. Histopathological examination showed that, compared with previous biopsies of untreated Gaucher’s disease, the Gaucher cell infiltrate had decreased progressively with therapy, being replaced by normal
The influence of metabolic syndrome (MetS) on the outcome after hip and knee arthroplasty is debated. We aimed to investigate the change in patient-reported outcome measure (PROM) scores after hip and knee arthroplasty, comparing patients with and without MetS. From 1 May 2017 to 30 November 2019, a prospective cohort of 2,586 patients undergoing elective unilateral hip and knee arthroplasty was established in Denmark. Data from national registries and a local database were used to determine the presence of MetS. Patients’ scores on Oxford Hip Score (OHS) or Oxford Knee Score (OKS), EuroQol five-dimension five-level questionnaire (EQ-5D-5L), University of California, Los Angeles (UCLA) Activity Scale, and Forgotten Joint Score (FJS) at baseline, three, 12, and 24 months after surgery were collected. Primary outcome was the difference between groups from baseline to 12 months in OHS and OKS. Secondary outcomes were scores of OHS and OKS at three and 24 months and EQ-5D-5L, UCLA Activity Scale, and FJS at three, 12, and 24 months after surgery. Generalized linear mixed model was applied, adjusting for age, sex, Charlson Comorbidity Index, and smoking to present marginal mean and associated 95% CIs.Aims
Methods
Although periacetabular osteotomies are widely used for the treatment of symptomatic dysplastic hips, long-term surgical outcomes and patient-reported outcome measures (PROMs) are still unclear. Accordingly, we assessed hip survival and PROMs at 20 years after transpositional osteotomy of the acetabulum (TOA). A total of 172 hips in 159 patients who underwent TOA were followed up at a mean of 21.02 years (16.6 to 24.6) postoperatively. Kaplan-Meier analysis was used to assess survivorship with an endpoint of total hip arthroplasty (THA). PROMs included the visual analogue scale (VAS) Satisfaction, VAS Pain, Oxford Hip Score (OHS), and Forgotten Joint Score-12 (FJS-12). Thresholds for favourable outcomes for OHS (≥ 42) and FJS-12 (≥ 51) were obtained using the receiver operating characteristic curve with VAS Satisfaction ≥ 50 and VAS Pain < 20 as anchors.Aims
Methods
Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature. A systematic search was conducted in MEDLINE, EMBASE, and Google Scholar databases according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies involving sarcopenic patients who underwent defined orthopaedic surgery and recorded postoperative outcomes were included. The quality of the criteria by which a diagnosis of sarcopenia was made was evaluated. The quality of the publication was assessed using Newcastle-Ottawa Scale.Aims
Methods
A boy aged eleven with a solitary chondroma of the right tibia, and angiomata of the skeletal muscle, subcutaneous tissues, and periarticular tissues of the same limb, is considered to be a case of Maffucci's syndrome (dyschondroplasia with angiomata), although there was not the severe deformity encountered in the previously reported cases. There was a secondary atrophy and
1. Two cases are reported in which there was diffuse fibro-fatty overgrowth or tumour formation involving the
We report a case of systemic intraosseous lipomatosis involving the proximal femur, both ends of the tibia, and the tarsal and metatarsal bones. The lesions progressed during a five-year follow-up with a pathological fracture of the tibial plateau. CT scans were characteristic and helpful in diagnosis but MR imaging added little information. Intraosseous lipomatosis is a hamartomatous malformation due to hyperplasia of
The cavities left after resection of bone bridges for partial closure of growth plates in children have commonly been filled with free fat grafts. Such cavities have been seen to elongate and thus enlarge during growth after the operation, but the fate of the grafts has been unknown. Similar cavities, made in the tibiae of growing pigs were filled with autogenous fat and studied by radiography for periods of up to 9 1/2 months. These cavities elongated in a manner similar to those in the clinical cases, and histological section showed them to be filled with living
The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and Arksey and O’Malley frameworks were followed. A three-step search strategy identified relevant published primary and secondary studies, as well as grey literature. The identified studies were screened with criteria for inclusion comprising clinical studies evaluating the use of biologic therapies in professional and Olympic athletes, systematic reviews, consensus statements, and conference proceedings. Data were extracted using a standardized tool to form a descriptive analysis and a thematic summary.Aims
Methods
The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article:
Previous research has demonstrated increased early complication rates following total hip arthroplasty (THA) in obese patients, as defined by body mass index (BMI). Subcutaneous fat depth (FD) has been shown to be an independent risk factor for wound infection in cervical and lumbar spine surgery, as well as after abdominal laparotomy. The aim of this study was to investigate whether increased peritrochanteric FD was associated with an increased risk of complications in the first year following THA. We analyzed prospectively collected data on a consecutive series of 1,220 primary THAs from June 2013 until May 2018. The vertical soft tissue depth from the most prominent part of the greater trochanter to the skin was measured intraoperatively using a sterile ruler and recorded to the nearest millimetre. BMI was calculated at the patient’s preoperative assessment. All surgical complications occuring within the initial 12 months of follow-up were identified.Aims
Methods
The hypothesis of this study was that thigh circumference, distinct from body mass index (BMI), may be associated with the positioning of components when undertaking total hip arthroplasty (THA) using the direct anterior approach (DAA), and that an increased circumference might increase the technical difficulty. We performed a retrospective review of prospectively collected data involving 155 consecutive THAs among 148 patients undertaken using the DAA at an academic medical centre by a single fellowship-trained surgeon. Preoperatively, thigh circumference was measured at 10 cm, 20 cm, and 30 cm distal to the anterior superior iliac spine, in quartiles. Two blinded reviewers assessed the inclination and anteversion of the acetabular component, radiological leg-length discrepancy, and femoral offset. The radiological outcomes were considered as continuous and binary outcome variables based on Lewinnek’s ‘safe zone’.Aims
Patients and Methods
The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels. A total of 226 patients with high-grade non-metastatic osteosarcoma in the limbs were investigated. Median age at diagnosis was 15 years (4 to 67) with the ratio of male to female patients being 1.5:1. The most common site of the tumour was the femur (n = 103) followed by tibia (n = 66). The vascular proximity was categorized based on the preoperative MRI after neoadjuvant chemotherapy into four types: type 1 > 5 mm; type 2 ≤ 5 mm, > 0 mm; type 3 attached; type 4 surrounded.Aims
Patients and Methods
Mesenchymal stem cells (MSCs) have several properties that may support their use as an early treatment option for osteoarthritis (OA). This study investigated the role of multiple injections of allogeneic bone marrow-derived stem cells (BMSCs) to alleviate the progression of osteoarthritic changes in the various structures of the mature rabbit knee in an anterior cruciate ligament (ACL)-deficient OA model. Two months after bilateral section of the ACL of Japanese white rabbits aged nine months or more, either phosphate buffered saline (PBS) or 1 x 106 MSCs were injected into the knee joint in single or three consecutive doses. After two months, the articular cartilage and meniscus were assessed macroscopically, histologically, and immunohistochemically using collagen I and II.Aim
Materials and Methods
Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI. A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Aims
Materials and Methods
The aim of this study was to assess the influence of obesity on the clinical outcomes and survivorship ten years postoperatively in patients who underwent a fixed-bearing unicompartmental knee arthroplasty (UKA). We prospectively followed 184 patients who underwent UKA between 2003 and 2007 for a minimum of ten years. A total of 142 patients with preoperative body mass index (BMI) of < 30 kg/m2 were in the control group (32 male, 110 female) and 42 patients with BMI of ≥ 30 kg/m2 were in the obese group (five male, 37 female). Pre- and postoperative range of movement (ROM), Knee Society Score (KSS), Oxford Knee Score (OKS), 36-Item Short-Form Health Survey (SF-36), and survivorship were analyzed.Aims
Patients and Methods
This study investigated the influence of body mass index (BMI)
on patients’ function and quality of life ten years after total
knee arthroplasty (TKA). A total of 126 patients who underwent unilateral TKA in 2006
were prospectively included in this retrospective study. They were
categorized into two groups based on BMI: < 30 kg/m2 (control)
and ≥ 30 kg/m2 (obese). Functional outcome was assessed
using the Knee Society Function Score (KSFS), Knee Society Knee
Score (KSKS), and Oxford Knee Score (OKS). Quality of life was assessed
using the Physical (PCS) and Mental Component Scores (MCS) of the 36-Item
Short-Form Health Survey.Aims
Patients and Methods
There is increasing evidence that flexible flatfoot (FF) can
lead to symptoms and impairment in health-related quality of life.
As such we undertook an observational study investigating the aetiology
of this condition, to help inform management. The hypothesis was
that as well as increased body mass index (BMI) and increased flexibility of
the lower limb, an absent anterior subtalar articulation would be
associated with a flatter foot posture. A total of 84 children aged between eight and 15 years old were
prospectively recruited. The BMI for each child was calculated,
flexibility was assessed using the lower limb assessment scale (LLAS)
and foot posture was quantified using the arch height index (AHI).
Each child underwent a sagittal T1-weighted MRI scan of at least
one foot. Aims
Patients and Methods
The success of anterior cruciate ligament reconstruction (ACLR)
depends on osseointegration at the graft-tunnel interface and intra-articular
ligamentization. Our aim was to conduct a systematic review of clinical
and preclinical studies that evaluated biological augmentation of
graft healing in ACLR. In all, 1879 studies were identified across three databases.
Following assessment against strict criteria, 112 studies were included
(20 clinical studies; 92 animal studies). Aims
Materials and Methods
This study investigates and defines the topographic
anatomy of the medial femoral circumflex artery (MFCA) terminal
branches supplying the femoral head (FH). Gross dissection of 14
fresh–frozen cadaveric hips was undertaken to determine the extra
and intracapsular course of the MFCA’s terminal branches. A constant
branch arising from the transverse MFCA (inferior retinacular artery;
IRA) penetrates the capsule at the level of the anteroinferior neck,
then courses obliquely within the fibrous prolongation of the capsule
wall (inferior retinacula of Weitbrecht), elevated from the neck,
to the posteroinferior femoral head–neck junction. This vessel has
a mean of five (three to nine) terminal branches, of which the majority
penetrate posteriorly. Branches from the ascending MFCA entered
the femoral capsular attachment posteriorly, running deep to the
synovium, through the neck, and terminating in two branches. The
deep MFCA penetrates the posterosuperior femoral capsular. Once
intracapsular, it divides into a mean of six (four to nine) terminal
branches running deep to the synovium, within the superior retinacula
of Weitbrecht of which 80% are posterior. Our study defines the
exact anatomical location of the vessels, arising from the MFCA
and supplying the FH. The IRA is in an elevated position from the
femoral neck and may be protected from injury during fracture of
the femoral neck. We present vascular ‘danger zones’ that may help
avoid iatrogenic vascular injury during surgical interventions about
the hip. Cite this article:
The aim of this study was to determine whether
obesity affects pain, surgical and functional outcomes following lumbar
spinal fusion for low back pain (LBP). A systematic literature review and meta-analysis was made of
those studies that compared the outcome of lumbar spinal fusion
for LBP in obese and non-obese patients. A total of 17 studies were
included in the meta-analysis. There was no difference in the pain
and functional outcomes. Lumbar spinal fusion in the obese patient resulted
in a statistically significantly greater intra-operative blood loss
(weighted mean difference: 54.04 ml; 95% confidence interval (CI)
15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio:
1.91; 95% CI 1.68 to 2.18; n = 43858; p <
0.001) and longer duration
of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p <
0.001). Obese
patients have greater intra-operative blood loss, more complications
and longer duration of surgery but pain and functional outcome are
similar to non-obese patients. Based on these results, obesity is
not a contraindication to lumbar spinal fusion. Cite this article:
The ability of mesenchymal stem cells (MSCs)
to differentiate Despite their increasing application in clinical trials, the
origin and role of MSCs in the development, repair and regeneration
of organs have remained unclear. Until recently, MSCs could only
be isolated in a process that requires culture in a laboratory;
these cells were being used for tissue engineering without understanding
their native location and function. MSCs isolated in this indirect
way have been used in clinical trials and remain the reference standard
cellular substrate for musculoskeletal engineering. The therapeutic
use of autologous MSCs is currently limited by the need for In this annotation we provide an update on the recent developments
in the understanding of the identity of MSCs within tissues and
outline how this may affect their use in orthopaedic surgery in
the future. Cite this article:
Periprosthetic joint infection (PJI) is a devastating
complication for patients and results in greatly increased costs
of care for both healthcare providers and patients. More than 15
500 revision hip and knee procedures were recorded in England, Wales
and Northern Ireland in 2013, with infection accounting for 13%
of revision hip and 23% of revision knee procedures. We report our experience of using antibiotic eluting absorbable
calcium sulphate beads in 15 patients (eight men and seven women
with a mean age of 64.8 years; 41 to 83) as part of a treatment
protocol for PJI in revision arthroplasty. The mean follow-up was 16 months (12 to 22). We report the outcomes
and complications, highlighting the risk of hypercalcaemia which
occurred in three patients. We recommend that serum levels of calcium be routinely sought
following the implantation of absorbable calcium sulphate beads
in orthopaedic surgery. Cite this article:
Patellofemoral complications are common after
total knee replacement (TKR). Leaving the patellar unsurfaced after
TKR may lead to complications such as anterior knee pain, and re-operation
to surface it. Complications after patellar resurfacing include
patellar fracture, aseptic loosening, patellar instability, polyethylene
wear, patellar clunk and osteonecrosis. Historically, patellar complications
account for one of the larger proportions of causes of failure in
TKR, however, with contemporary implant designs, complication rates
have decreased. Most remaining failures relate to patellofemoral
tracking. Understanding the causes of patellofemoral maltracking
is essential to prevent these complications as well as manage them
when they occur. Cite this article:
We have developed a novel method of calculating the radiological magnification of the hip using two separate radio-opaque markers. We recruited 74 patients undergoing radiological assessment following total hip replacement. Both the new double marker and a conventional single marker were used by the radiographer at the time of x-ray. The predicted magnification according to each marker was calculated, as was the true radiological magnification of the components. The correlation between true and predicted magnification was good using the double marker (r = 0.90, n = 74, p <
0.001), but only moderate for the single marker (r = 0.50, n = 63, p <
0.001). The median error was significantly less for the double marker than for the single (1.1% The double marker method appears to be superior to the single marker method when used in the clinical environment.
Hypovitaminosis D has been identified as a common
risk factor for fragility fractures and poor fracture healing. Epidemiological
data on vitamin D deficiency have been gathered in various populations,
but the association between vertebral fragility fractures and hypovitaminosis
D, especially in males, remains unclear. The purpose of this study
was to evaluate serum levels of 25-hydroxyvitamin D (25-OH D) in
patients presenting with vertebral fragility fractures and to determine
whether patients with a vertebral fracture were at greater risk
of hypovitaminosis D than a control population. Furthermore, we
studied the seasonal variations in the serum vitamin D levels of
tested patients in order to clarify the relationship between other
known risk factors for osteoporosis and vitamin D levels. We measured
the serum 25-OH D levels of 246 patients admitted with vertebral
fractures (105 men, 141 female, mean age 69 years, Cite this article:
Obesity is a risk factor for complications following
many orthopaedic procedures. The purpose of this study was to investigate
whether obesity was an independent risk factor increasing the rate
of complications following periacetabular osteotomy (PAO) and to
determine whether radiographic correction after PAO was affected
by obesity. We retrospectively collected demographic, clinical and radiographic
data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were
followed for a mean of 48 months (12 to 60) after PAO. A total of
65 patients (23.2%) were obese (body mass index (BMI) >
30 kg/m2).
Univariate and multivariate analysis demonstrated that BMI was an independent
risk factor associated with the severity of the complications. The
average probability of a patient developing a major complication
was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese
patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient
The odds of a patient developing a major complication were 11 times
higher (95% CI 4.71 to 17.60, p <
0.0001) for an obese compared
with a non-obese patient. Following PAO surgery, there was no difference in radiographic
correction between obese and non-obese patients. PAO procedures
in obese patients correct the deformity effectively but are associated
with an increased rate of complications. Cite this article:
Given the growing prevalence of obesity around
the world and its association with osteoarthritis of the knee, orthopaedic
surgeons need to be familiar with the management of the obese patient
with degenerative knee pain. The precise mechanism by which obesity
leads to osteoarthritis remains unknown, but is likely to be due
to a combination of mechanical, humoral and genetic factors. Weight loss has clear medical benefits for the obese patient
and seems to be a logical way of relieving joint pain associated
with degenerative arthritis. There are a variety of ways in which
this may be done including diet and exercise, and treatment with
drugs and bariatric surgery. Whether substantial weight loss can
delay or even reverse the symptoms associated with osteoarthritis
remains to be seen. Surgery for osteoarthritis in the obese patient can be technically
more challenging and carries a risk of additional complications.
Substantial weight loss before undertaking total knee replacement
is advisable. More prospective studies that evaluate the effect
of significant weight loss on the evolution of symptomatic osteoarthritis
of the knee are needed so that orthopaedic surgeons can treat this
patient group appropriately.
A child with traumatic laceration of the tendo Achillis developed secondary infection after primary repair. This resulted in the loss of 5 cm of the distal part of the tendon and overlying soft tissue. The patient was treated with a free skin flap to cover the wound and to control the infection leaving reconstruction for a second-stage procedure. However, when he was assessed two years after the skin-flap, delayed reconstruction proved to be unnecessary since he had regained normal ankle function spontaneously and could demonstrate equal function in both tendons.
Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell. Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%). At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis. Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.
Articular cartilage repair remains a challenge to surgeons and basic scientists. The field of tissue engineering allows the simultaneous use of material scaffolds, cells and signalling molecules to attempt to modulate the regenerative tissue. This review summarises the research that has been undertaken to date using this approach, with a particular emphasis on those techniques that have been introduced into clinical practice, via in vitro and preclinical studies.
We performed a series of 16 anatomical dissections
on Caucasian cadaver material to determine the surgical anatomy
of the medial femoral circumflex artery (MFCA) and its anastomoses.
These confirmed that the femoral head receives its blood supply
primarily from the MFCA via a group of posterior superior nutrient
arteries and the posterior inferior nutrient artery. In terms of
anastomoses that may also contribute to the blood supply, the anastomosis
with the inferior gluteal artery, via the piriformis branch, is
the most important. These dissections provide a base of knowledge
for further radiological studies on the vascularity of the normal
femoral head and its vascularity after dislocation of the hip.
We analysed the incidence of slipped capital
femoral epiphysis (SCFE) in South Australia, investigating possible associations
between an increased incidence of SCFE, the local indigenous population
and the Australian obesity epidemic during the last 20 years. Data
including race, age and gender were collected to obtain a profile
of the South Australian SCFE patient, and were then compared with
epidemiological data for South Australian adolescents. We concluded
that the incidence of both obesity and SCFE is increasing. We also
noted that the median weight of SCFE patients has increased and
the mean age at diagnosis has decreased. Despite weight profiles
comparable with those of the general population, we noted that an
indigenous child was three times more likely to develop SCFE than
a non-indigenous child. As far as we know there is no published
literature on the predisposition of Aboriginal Australians to SCFE.
Limb salvage involving wide resection and reconstruction is now well established for managing musculoskeletal sarcomas. However, involvement of major nerves and vessels with a large volume of muscle and skin may result in a useless limb, contributing to depression and a low quality of life. We have been studying alternative treatments for musculoskeletal sarcoma since 1990, and have recently established a regime using photodynamic surgery with cells labelled with acridine orange, photodynamic therapy with cells treated similarly and radiodynamic treatment using the effect of X-rays on such cells. These techniques have been used after marginal or intralesional resection of tumours since 1999 and have enabled maintenance of excellent limb function in patients with sarcomas.
Failure of bone repair is a challenging problem in the management of fractures. There is a limited supply of autologous bone grafts for treating nonunions, with associated morbidity after harvesting. There is need for a better source of cells for repair. Mesenchymal stem cells (MSCs) hold promise for healing of bone because of their capacity to differentiate into osteoblasts and their availability from a wide variety of sources. Our review aims to evaluate the available clinical evidence and recent progress in strategies which attempt to use autologous and heterologous MSCs in clinical practice, including genetically-modified MSCs and those grown on scaffolds. We have compared various procedures for isolating and expanding a sufficient number of MSCs for use in a clinical setting. There are now a number of clinical studies which have shown that implantation of MSCs is an effective, safe and durable method for aiding the repair and regeneration of bone.
The scarcity of mesenchymal stem cells (MSCs) in iliac crest bone marrow aspirate (ICBMA), and the expense and time in culturing cells, has led to the search for alternative harvest sites. The reamer-irrigation-aspirator (RIA) provides continuous irrigation and suction during reaming of long bones. The aspirated contents pass via a filter, trapping bony fragments, before moving into a ‘waste’ bag from which MSCs have been previously isolated. We examined the liquid and solid phases, performed a novel digestion of the solid phase, and made a comparative assessment in terms of number, phenotype and differentiation capacity with matched ICBMA. The solid fraction from the filtrate was digested for 60 minutes at 37°C with collagenase. Enumeration was performed via the colony-forming unit fibroblast (CFU-F) assay. Passage (P2) cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages, and their phenotypes assessed using flow cytometry (CD33, CD34, CD45, CD73, CD90, and CD105). MSCs from the RIA phases were able to differentiate at least as well as those from ICBMA, and all fractions had phenotypes consistent with other established sources. The median number of colonies for the three groups was: ICBMA = 8.5 (2 to 86), RIA-liquid = 19.5 (4 to 90), RIA-solid = 109 (67 to 200) per 200 μl. The mean total yield of cells for the three groups was: ICBMA = 920 (0 to 4275), RIA-liquid = 114 983 (16 500 to 477 750), RIA-solid = 12 785 (7210 to 28 475). The RIA filtrate contains large numbers of MSCs that could potentially be extracted without enzymatic digestion and used for bone repair without prior cell expansion.
Advances in hip arthroscopy have renewed interest in the ligamentum teres. Considered by many to be a developmental vestige, it is now recognised as a significant potential source of pain and mechanical symptoms arising from the hip joint. Despite improvements in imaging, arthroscopy remains the optimum method of diagnosing lesions of the ligamentum teres. Several biological or mechanical roles have been proposed for the ligament. Unless these are disproved, the use of surgical procedures that sacrifice the ligamentum teres, as in surgical dislocation of the hip, should be carefully considered. This paper provides an update on the development, structure and function of the ligamentum teres, and discusses associated clinical implications.
We have investigated whether cells derived from haemarthrosis caused by injury to the anterior cruciate ligament could differentiate into the osteoblast lineage Our results suggest that the haemarthrosis induced by injury to the anterior cruciate ligament contains osteoprogenitor cells and is a potential alternative source for cell-based treatment in such injury.
Bone marrow mesenchymal stromal cells were aspirated from immature male green fluorescent protein transgenic rats and cultured in a monolayer. Four weeks after the creation of the osteochondral defect, the rats were divided into three groups of 18: the control group, treated with an intra-articular injection of phosphate-buffered saline only; the drilling group, treated with an intra-articular injection of phosphate-buffered saline with a bone marrow-stimulating procedure; and the bone marrow mesenchymal stromal cells group, treated with an intra-articular injection of bone marrow mesenchymal stromal cells plus a bone marrow-stimulating procedure. The rats were then killed at 4, 8 and 12 weeks after treatment and examined. The histological scores were significantly better in the bone marrow mesenchymal stromal cells group than in the control and drilling groups at all time points (p <
0.05). The fluorescence of the green fluorescent protein-positive cells could be observed in specimens four weeks after treatment.
Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.