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 adipose tissue that are currently used differ substantially from cells that are processed and prepared under defined laboratory protocols. The term ‘stem cells’ should be reserved for laboratory-purified, culture-expanded cells. The number of cells in uncultured preparations that meet these defined criteria is estimated to be approximately one in 10 000 to 20 000 (0.005% to 0.01%) in native bone marrow and 1 in 2000 in adipose tissue. It is clear that more refined definitions of stem cells are required, as the lumping together of widely diverse progenitor cell types under the umbrella term ‘mesenchymal stem cells’ has created confusion among scientists, clinicians, regulators, and our patients. Validated methods need to be developed to measure and characterize the ‘critical quality attributes’ and biological activity of a specific cell formulation. It is certain that ‘one size does not fit all’ – different cell formulations, dosing schedules, and culturing parameters will likely be required based on the tissue being treated and the desired biological target. As an alternative to the use of exogenous cells, in the future we may be able to stimulate the intrinsic vascular stem cell niche that is known to exist in many tissues. The tremendous potential of cell therapy will only be realized with further basic, translational, and clinical research.

Cite this article: Bone Joint J 2019;101-B:361–364.

1. A study of 2,200 patients receiving electro-convulsive therapy showed that fifty-three sustained fractures or dislocations—an incidence of 2·4 per cent. Of the fifty-three injuries, twenty-one occurred in the spine, fifteen in the neck of femur, fifteen in the upper end of humerus, one in the coracoid process; one dislocated jaw required anaesthesia for its reduction (other cases of transient dislocation of the jaw are excluded). 2. The incidence, site, and type of spinal fractures are recorded, and the relation of the fracture to the first convulsion is noted. No late changes were found in the spines of patients examined two years or more after treatment. A neutral position of the spine during the convulsion is believed to diminish the risk of fracture. 3. Fracture of the neck of the femur is a serious injury in these patients. In one case the injury was bilateral. 4. The fifteen cases of fracture-dislocation of the upper humerus are analysed. They included two cases of posterior dislocation of the humeral head; the possible mechanism of this is explained and a method of prevention suggested. 5. Fifty-three patients with chronic epilepsy with psychosis were examined. Four cases of fractured spine were discovered. The site of fracture was different from that of fractures caused by convulsive therapy and a reason for this is suggested. The type and mechanism of the fracture are similar in the two groups

Traumatic uraemia is of particular significance to orthopaedic surgeons in so far as this complication is responsible for high mortality in cases of severe injury, crushing injury, traumatic shock, gun-shot wounds, incompatible blood transfusions, and the misuse of tourniquets. In this contribution the association between muscle injury and renal failure is reviewed. The syndrome of the "crush kidney," which at first was thought to be the result of deposition of myohaemoglobin in the renal tubules, is almost certainly due to the association of many factors, all of which lead to alteration of the renal circulation and renal ischaemia. Certainly the combination of ischaemia of the kidney with deposition of pigment and haemolysis of blood causes a high mortality in animals, and it is believed that this may account for the serious prognosis in human cases where there is both shock and haemolysis. Disturbance of water balance, allergic phenomena, and chemical nephrotoxic action are also discussed. The pathology is considered together with significant changes in the blood chemistry. A plea is made for early recognition of this clinical syndrome with its characteristic features. Important aspects of treatment are discussed. The dangers of excessive intravenous infusion are emphasised. Closer investigation and further research promise to throw light on the more accurate localisation of function in the nephron, to add to our knowledge of traumatic arterial spasm, and to explain many orthopaedic problems which hitherto appeared insoluble

Subtalar dislocation is a significant injury characterised by late complications, including subtalar arthritis. We describe a rare case of irreducible posterior subtalar dislocation due to incarceration of a fracture of the anterior process of the calcaneum in the subtalar joint, and discuss appropriate management

We present the case of a young male patient with inferior dislocation of the hip and postulate a possible mechanism for this extremely rare injury

We performed a retrospective study of the factors affecting the outcome of Weber type-C ankle fractures in 43 patients reviewed at two to nine years after injury. We determined the functional result in relation to the use of a diastasis screw, the accuracy of reduction, the presence of tibiotalar dislocation, and of injury to the medial side of the ankle by medial malleolar fracture or deltoid ligament rupture. We assessed the use of a diastasis screw as appropriate or inappropriate on the basis of an anatomical study performed by Boden et al (1989). The diastasis screw was used unnecessarily in 19 of the 31 patients so treated, but this did not appear to affect the final functional result. The worse functional results were in ankles dislocated at the initial injury, and in those with medial malleolar fractures as opposed to those with deltoid ligament ruptures. The best results were after accurate reduction of the fibula and the syndesmosis, and greater increase in the width of the syndesmosis was associated with a worse result. Our results suggest that an increase of more than 1.5 mm in syndesmosis width is unacceptable. We recommend that when the deltoid ligament is ruptured, a diastasis screw should be used if the fibular fracture is more than 3.5 cm above the top of the syndesmosis. When a medial malleolar fracture has been rigidly repaired a diastasis screw is required if the fibular fracture is more than 15 cm above the syndesmosis

From a series of 190 consecutive fractures of the shaft of the femur treated by closed Kuntscher nailing, 32 of the more severely comminuted have been studied to determine whether treatment by closed nailing was justified. Radiological criteria were used to divide them into 19 who were moderately comminuted and 13 grossly so. Twenty-four patients were less than 21 years of age and 19 patients had 40 significant associated injuries. Fifteen fractures were nailed on the day of injury, and complications were few. Nineteen patients had a supplementary cast-brace and all those who had been employed returned to work. Twelve patients had shortening of up to two centimetres and two had three centimetres; four had mild rotational deformities; seven had mild restriction of knee flexion; and two had delayed union. There were no infections. The advantages of this technique include a negligible risk of infection and rapid stabilisation of even grossly comminuted fractures, thus facilitating management of other injuries. The 44 per cent incidence of shortening is counterbalanced by early mobilisation and rapid return of knee function. It is concluded that when proper equipment and expertise are available then closed nailing is the treatment of choice for severely comminuted fractures of the femoral shaft

1. Fifty-nine patients with various inter-carpal dislocations have been reviewed. 2. In this series trans-scapho-perilunar fracture-dislocation was the commonest injury. Early cases can be reduced by closed manipulation but in late cases operative reduction is usually advisable. When the injury is more than three months old, arthrodesis of the wrist joint is indicated. 3. When trans-scapho-perilunar fracture-dislocation was complicated by avascular necrosis of the proximal scaphoid fragment, the results in a small series treated by early excision were approximately equal to those treated by continued immobilisation. The results of grafting the scaphoid were poor. 4. Dislocations of the lunate seen within ten days of injury could usually be reduced with good results; no such case developed Kienböck's disease within the period of review. In late cases excision gave satisfactory results. 5. Forward dislocation of the lunate with half the scaphoid gave good results when manual reduction succeeded, but the results of excision of fragments were less satisfactory. 6. There was one case of forward dislocation of the lunate together with the distal half of the scaphoid. 7. Subluxation of the scaphoid is disclose in antero-posterior radiographs by a typical gap between it and the lunate bone. The subluxation may become recurrent and present a characteristic syndrome. 8. Other rare dislocations of the carpal bones are described

Objectives

Mesenchymal stem cells (MSCs) are of growing interest in terms of bone regeneration. Most preclinical trials utilize bone-marrow-derived mesenchymal stem cells (bMSCs), although this is not without isolation and expansion difficulties. The aim of this study was: to compare the characteristics of bMSCs and adipose-derived mesenchymal stem cells (AdMSCs) from juvenile, adult, and ovarectomized (OVX) rats; and to assess the effect of human parathyroid hormone (hPTH) 1-34 on their osteogenic potential and migration to stromal cell-derived factor-1 (SDF-1).

Aims

The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.

We present the prevalence of multiple fractures in the elderly in a single catchment population of 780 000 treated over a 12-month period and describe the mechanisms of injury, common patterns of occurrence, management, and the associated mortality rate. A total of 2335 patients, aged ≥ 65 years of age, were prospectively assessed and of these 119 patients (5.1%) presented with multiple fractures. Distal radial (odds ratio (OR) 5.1, p <  0.0001), proximal humeral (OR 2.2, p < 0.0001) and pelvic (OR 4.9, p < 0.0001) fractures were associated with an increased risk of sustaining associated fractures. Only 4.5% of patients sustained multiple fractures after a simple fall, but due to the frequency of falls in the elderly this mechanism resulted in 80.7% of all multiple fractures. Most patients required admission (> 80%), of whom 42% did not need an operation but more than half needed an increased level of care before discharge (54%). The standardised mortality rate at one year was significantly greater after sustaining multiple fractures that included fractures of the pelvis, proximal humerus or proximal femur (p < 0.001). This mortality risk increased further if patients were < 80 years of age, indicating that the existence of multiple fractures after low-energy trauma is a marker of mortality

1. Eighty consecutive open fractures of the tibial shaft were treated by primary internal fixation and wound closure. Wound healing was complicated by deep infection in eight patients (10 per cent) and by skin loss of varying degree in ten (l2·5 per cent). 2. Careful selection of patients on the basis of associated soft-tissue injuries is urged. A simple method of grading open fractures by the appearance of the wound and adjacent skin and the effectiveness of wound closure is suggested. If internal fixation is indicated on mechanical grounds, the nature of the soft-tissue injury should be the deciding factor in the choice of the method of treatment. In the less severe (Grade 1) fractures internal fixation and wound closure may be safely employed. In the severe (Grade 3) injuries, primary wound closure with or without internal fixation should be avoided. Moderately severe (Grade 2) fractures should be carefully assessed and treated by internal fixation and wound closure only if primary wound healing is confidently expected. 3. Wound healing by first intention requires, in addition to adequate debridement of the deep layers of the wound, careful approximation of healthy wound edges without excessive tension. An adequate knowledge of skin-plastic procedures is essential to achieve this. 4. A combination of systemic penicillin and streptomycin in adequate doses is a safe and effective prophylactic antibiotic for use in the treatment of open fractures

1. Injuries to the atlas and axis may occur at any age. They are usually not fatal. 2. In children spontaneous rotatory dislocation is the commonest type of lesion. In adults fracture of the odontoid process is more likely. 3. The spinal cord is often undamaged. In some cases complicated by cord damage the neurological disturbance is caused by an associated injury to the lower cervical spine. 4. Spinal cord damage may be immediate or delayed. 5. In cases of incomplete cord lesion there may be recovery of function after reduction of the displacement or without such reduction. 6. Diagnosis rests on the history and physical signs, and radiographic findings. Radiographs of this area require careful interpretation, and special radiographic techniques may he necessary. A normal radiograph does not necessarily exclude the possibility of atlanto-axial injury. 7. Though many patients would survive without treatment the initial discomfort and danger of complications demand that adequate protection be provided. In relatively minor injuries and in old people protection by a plaster collar may be sufficient. In some cases it is justifiable to undertake manipulation and apply a plaster. Cases with severe displacement require traction, preferably by skull calipers. Recurrent displacement, instability, and cord signs demand operative reduction and fusion. Satisfactory fusion of the atlas and axis alone is feasible, and good function is preserved. More extensive fusion of the cervical spine is seldom necessary

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation

We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions. The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee