Unlike the English National Joint Registry (NJR) for arthroplasty, no surgeon driven national database currently exists for ligament surgery in England. Therefore information on outcome and adverse events following anterior cruciate ligament (ACL) surgery is limited to case series. This restricts the ability to make formal recommendations upon surgical care. Prospectively collected data, which is routinely collected on every NHS patient admitted to hospital in England, was analysed to determine national rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE) rate, 30-day wound infection and readmission rates following primary ACL reconstruction between March 2008 and February 2010 (13,941 operations, annual incidence 13.5 per 100,000 English population). 90-day DVT and PTE rates were 0.30% (42) and 0.18% (25) respectively. There were no in-hospital deaths. 0.75% (104) of the consecutive patient cohort had a wound complication recorded. 0.25% (35) underwent a further procedure to wash out the infected knee joint and 1.36% (190) were readmitted to an orthopaedic ward within 30 days. This is the first national comprehensive study of the incidence of significant complications following ACL surgery in England. This should allow meaningful interpretation of future baseline data supporting the development of a national ligament registry.

Arthroscopy of the knee is one of the most commonly performed orthopaedic procedures worldwide. Large-volume outcome data have not previously been available for English NHS patients. Prospectively collected admissions data, routinely collected on every English NHS patient, were analysed to determine the rates of complications within 30 days (including re-operation and re-admission), 90-day symptomatic venous thromboembolism and all-cause mortality. There were 301,701 operations performed between 2005 and 2010--an annual incidence of 9.9 per 10,000 English population. Of these, 16,552 (6%) underwent ligament reconstruction and 106,793 (35%) underwent meniscal surgery. The 30-day re-admission rate was 0.64% (1662) and 30-day wound complication rate was 0.26% (677). The overall 30-day re-operation rate was 0.40% (1033) and the 90-day pulmonary embolism rate was 0.08% (230), of which six patients died. 90-day mortality was 0.02% (47). Age < 40 years, male gender and ligament reconstruction were significantly associated with an increased rate of 30-day re-admission and unplanned re-operation. In addition, a significant increase in 30-day admission rates were seen with Charlson comorbidity scores of 1 (p = 0.037) and ≥ 2 (p < 0.001) compared with scores of 0, and medium volume units compared with high volume units (p < 0.001). Complications following arthroscopy of the knee are rare. It is a safe procedure, which in the majority of cases is performed as day case surgery. These data can be used for quality benchmarking, in terms of consent, consultant re-validation and individual unit performance.

Satisfactory osseous tissue integration of the soft tissue graft with bone is the mainstay of healing following surgical reconstruction of the anterior cruciate ligament (ACL). However, tissue remodelling is slow and significantly impacts on quality of life by delaying return to work and sport and accelerating the onset of degenerative diseases such as osteoarthritis. Delivery of multipotent human mesenchymal stem cells (hMSCs) at surgery could enhance osseous tissue integration. We aim to use hMSCs derived from haemarthrosis fluid (HF) (the intra-articular bleed accrued post-trauma) which is aspirated and discarded as clinical waste. With the aim of improving our bioprocessing methodologies for clinical translation we have investigated the effect of low oxygen tension on the derivation and osteogenic potential of this novel HF-hMSC population. Mononuclear cells were isolated from HF aspirated samples and divided for derivation and culture under normal or low oxygen tension. HF-hMSCs were derived from 100 % of cultures under low oxygen tension compared to 71 % for normal oxygen tension; this was coupled with increased CFU-Fs. We investigated the osteogenic potential and cellular health of HF-hMSC populations following ex vivo expansion. HF-hMSC populations showed enhanced matrix mineralisation and cellular health when differentiated under low oxygen tension. This positive effect of low oxygen on osteogenesis and cellular health was reduced with prolonged culture. These data demonstrate that derivation and culture of HF-hMSC populations under low oxygen tension will enable the translation of a cellular therapy for the treatment of broad patient numbers with optimal osteogenic potency and cellular vitality.

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A 15-year-old boy presented with a locked knee after a football injury. Sudden valgus impact to the planted right leg caused a patellar osteochondral fracture diagnosed by magnetic resonance imaging. The 2.5-cm fragment had avulsed off the medial facet without damage to the medial retinaculum or the medial patellofemoral ligament. The fracture was stabilised with headless compression screws. It had healed at 8 weeks, with the patient being able to bear full weight, and with a full range of active knee movement. At 4 months, he had returned to playing football for his school team. Normally, such a fracture occurs due to sheering force on the patella against the femur during the relocation phase of an acute patellar dislocation. In this case, the patella may have subluxed and then reduced spontaneously, without causing a true dislocation or damage to the medial soft tissue restraints. The energy dissipated at contact with the femur would however be sufficient to sheer the fragment off the patella. We believe this is the first report of successful repair of an osteochondral patellar fracture sustained by this mechanism.

A fit and well 36-year-old male presented to his general practitioner with a 10-day history of pain and swelling in his right leg following a football injury. He had sustained blunt trauma to the lateral aspect of his right thigh and described it as a "dead leg". A clinical diagnosis of deep vein thrombosis (DVT) was made and the patient was advised to attend the DVT outpatient clinic. In line with hospital protocol, he was commenced on low molecular weight heparin (LMWH enoxaparin) as an outpatient pending urgent ultrasound scan. Following his second dose of enoxaparin, he developed worsening pain in his thigh and was admitted for urgent ultrasound scan which showed a large haematoma (15/5 cm) in the thigh (figure 1). A diagnosis of acute compartment syndrome was made and the patient was taken to theatre for an emergency right thigh fasciotomy and decompression of the haematoma.