A giant extrasynovial osteochondroma in the infrapatellar fat pad: end stage Hoffa’s disease

The infrapatellar fat pad of Hoffa is commonly injured but rarely discussed in the orthopaedic literature. Hoffa’s disease is the extension of various traumatic events due to impingement and inflammation of the infrapatellar fat pad and known as a vague reason for anterior knee pain. Inflammation is foreground during acute phase of the disease while impingement due to fibrosis and scar tissue of infrapatellar fat pad plays a major role in the chronic phase. The osteochondroma of the infrapatellar fat pad secondary to the Hoffa’s disease can be more problematic. Although, the fibrocartilaginous transformation and osteochondral metaplasia of infrapatellar fat pad was pointed out frequently in the literature, the published papers seem far from clarifying the relation between chronic impingement and formation of osteochondroma. We present a case of a giant ossifying chondroma in the infrapatellar fat pad that resulted from chronic Hoffa’s disease. Complete open resection was performed successfully after arthroscopic examination. The infrapatellar fat pad contains the entire progenitor cells for the development of an osteochondroma and chronic impingement may have promoter affect on this issue, thus, an osteochondroma may occur at the end-stage Hoffa’s disease.     

New Technologies for the Surgical Curriculum

The aim of a surgical residency program is to produce competent professionals displaying the cognitive, technical, and personal skills required to meet the needs of society. Current changes to the delivery of healthcare necessitate the development of new models of training. These can be supported with the development of new technologies to train and assess surgical practitioners. This article describes recent developments within Imperial College London with regard to eye tracking, noninvasive brain imaging, and an innovative mentoring scheme for the new surgical curriculum. The concept of eye tracking is described, together with surgical application for this technique in terms of dexterity analysis during minimally invasive procedures. We have also begun to understand spatial localization within the brain cortex during surgical knot-tying tasks. The aim is to develop a map of the cortex with regard to surgical novices and experienced surgeons and then to develop the hypothesis that a translational process of cortical plasticity occurs during training. Finally, the article is intended to describe a training scheme that goes beyond dexterity, and moves toward the development of a successful surgeon through surgical mentoring. It is hoped that some of these tools will enhance the training of future surgeons in order to continue to provide a high-quality service to our patients.     

A Perspective on the Surgical Management of Congestive Heart Failure

Surgical treatment of patients with congestive heart failure (CHF) has steadily advanced from rescue procedures such as aneurysmectomy, rupture repair, ventricular assist devices (VADs), and transplantation to procedures that can prevent or delay the progression of cardiac dysfunction and failure. The latter include operations such as coronary artery bypass grafting (CABG) and mitral valve repair for patients with ischemic cardiomyopathy (ICMP) and mitral annular dilatation, ventricular restoration and remodeling, and cardiac resynchronization therapy. As the number of heart transplants reported worldwide continues to decline over the past decade (by over 30%), newer surgical therapies have emerged. A need arises for clinical registries such as the NIH-sponsored LVAD registry and registries for biventricular pacing and AICD implantation, for total artificial heart implants, and for mitral valve repair in patients with ICMP. Prospective trials comparing sole ventricular restoration therapy (SVR) to SVR with concomitant CABG/MVR, coronary sinus versus epicardial LV pacing for ventricular resynchronization therapy, trials comparing LVAD as destination therapy to AICD implants, mitral valve repair versus chordal-sparing valve replacement for ischemic and valvular cardiomyopathy, and off-pump versus on-pump CABG for patients with ICMP are urgently needed. Future research should also be directed toward drugs targeting “B-cell mediated” humeral vascular rejection—the Achilles heel of cardiac transplantation, xenotransplantation, permanently implantable VADs, gene therapy, and myocardial cell regeneration therapy.