BORS Fellows 2009 blog

Saturday 21st February 2009

The BORS-US Travelling Fellows [3 orthopaedic registrars – Ines Reichert (SpR South-East Thames / Hon Lecturer Imperial College London), Wasim Khan (Stanmore), Jim Huntley (Edinburgh); 2 engineers – Tom Joyce (Newcastle), Nicholas Dunne (Belfast); 1 cell biologist – Sarah Snelling (Oxford)] meet the President of BORS, Brigitte Scammell (Nottingham), in the environs of the Virgin Atlantic check-in desk, South Terminal, Gatwick Airport.

Most of us have to unpack and repack for some weight restriction or other. Happily no one seems more than mildly eccentric.

 

Our first stop is Las Vegas where we will be attending the 55th Annual Meeting of the Orthopaedic Research Society (ORS) and the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). We are staying at the Orleans Hotel & Casino. Virgin Atlantic neglect to wish Sarah a happy birthday over the tannoy!

A long flight and a long day. After registering for the Orthopaedic Research Society, we have a monosyllabic, all-you-can-eat buffet, at Flamingos. ( Left to right – Wasim, Tom, Ines, Sarah, Nicholas (Jim the other side of the camera)).

 

Sunday 22nd February 2009

The ORS Annual Meeting starts at 8.00 am, with 5 parallel sessions. There are poster presentations in the afternoon, with several of us participating. We take a taxi into town – they don’t seem to mind coffee in the car, nor a ‘fluffy’ (steamed milk with shredded marshmallow) for Sarah. There are some great presentations and everyone broadly conforms to type, rushing off to their own areas of interest.

 

In the evening we show Miss Scammell the delights of Flamingos (picture 2). We wonder if our President knows just how grateful we are for her organisation, time and effort spent in getting us here (Left to right – Miss Scammell, Sarah, Wasim, Ines, Nicholas, Tom (Jim Camera shy)..

 

Monday 23rd February and Tuesday 24th February 2009

Attending the ORS Annual Meeting. Great science – a highlight is the extended workshop session “Orthopaedic complications in animal models of aging”.

On Monday evening, the ‘dugout’ sports bar provides the backdrop to chatter. We meet up with a number of previous colleagues from both the USA and Europe.

Tuesday evening we enjoy the Fellows’ dinner at Canaletto’s Restaurant in the Venetian Palace, overlooking St Mark’s Square; guests include Dr and Mrs Amadio (Mayo Clinic, Rochester), Dr HI Roach (Southampton), Professor Marsh (Stanmore), and one of the inaugural BORS Travelling Fellows, Mark Gaston.

 

Wednesday 25th February 2009

Today sees the start of the Annual Meeting of the American Academy of Orthopaedic Surgeons

(AAOS), again in Las Vegas, but initially there is a combined half-day with ORS. The key combined symposia are “Current controversies in bearing surface science” and “Hyaline cartilage biological joint repair, restoration and resurfacing”. These seminars contained something for everyone in the party and were very much inter-disciplinary. Then it was off to the AAOS, with its posters, exhibitions and special presentations. Nicholas corrects a keynote speaker labouring with misunderstandings concerning antibiotic–loaded cements.

 

American Academy of Orthopaedic Surgeons Annual Meeting

The Fellows were ecstatic to learn that their Fellowship would include the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting from 25 to 27 February, providing a further three days in the vibrant city of Las Vegas. Following on from the Orthopaedic Research Society (ORS) Meeting, the AAOS Meeting provided yet another excellent opportunity to experience the excitement of new ideas and discoveries.

The Annual Meeting had something on offer for all Fellows. The ORS/AAOS combined symposium sessions included ‘Current Controversies in Bearing Surface Science’ and ‘Hyaline Cartilage Biological Joint Repair, Restoration and Resurfacing’, and represented the research interests of the Fellows particularly well. These sessions were very well attended by surgeons and scientists alike. The Fellows made the most of the very best in orthopaedic education, research and technology that were on offer at the Meeting. The 33 symposia, 675 podium presentations, 567 poster presentations, 196 instructional courses, 89 scientific exhibits and 500 technical exhibits were of exceptional scientific, educational and clinical standard, and it was encouraging to see a strong British representation.

Miss Reichert particularly enjoyed the instructional course 'Statistics for Orthopods’, and Dr Dunne made the most of the technical exhibits showcasing an excellent fusion of surgery and engineering.

The last night was spent soaking in the stimulating vibe of The Strip and visiting the World-famous Bellagio Fountains. Miss Scammell was kind enough to take time out of her busy schedule and join the Fellows for an end-of-meeting Dinner for some fine French cuisine at Mon Ami Gabi in the delightful surrounds of the Paris Resort. The following morning the Fellows headed off to San Francisco.

   

2nd Stop – University California – San Francisco

We arrived 4.30pm at our hotel, which was located on Clay Street. After we dropped our bags, we went for an excellent pizza in the Italian Quarter of San Francisco (S/F). Following the meal, we all went on a sightseeing expedition of the Fisherman’s Wharf and Fort Mason, allowing us to get sight of the Golden Gate Bridge and Alcatraz. Our first impressions of San Francisco are that it’s an amazing place with so much to offer the tourist. We eventually managed to get back to our hotel using the excellent map reading skills of Wasim (Khan). Following a short recess at the hotel, we then went out to sample the night-life of S/F; Saturday nights are extremely busy in S/F, a fact we had not fully appreciated. We eventually managed to find another (Italian) restaurant, which satisfied everyone’s requirements. Similar to previous evening meals, the discussion always seemed go back to how would our research be received by the Institutions that we were visited, etc. We also found as the week progressed that there were many potential opportunities for cross-over between the different disciplines and even within the same subject area. For example, Drs Dunne and Joyce discussed the at length potential collaborative projects….Following dinner; it was back to the hotel for some well deserved sleep.
Sunday morning, Drs Dunne and Snelling went for a long run (12 miles) around the streets of S/F and the bay. Although it was a wet, miserable morning both agreed it was good to get some fresh air after being subjected to hotel gyms for the previous seven days. Breakfast followed and then off to the Museum of Modern Art (http://www.sfmoma.org/) for some culture and deep discussion about art and its relevance. The museum has in its collection important works by Jackson Pollock, Richard Diebenkorn, Paul Klee, Marcel Duchamp and Ansel Adams, among others. After the museum, we went for a quick meal and then back to the hotel to practice our presentations.

Monday morning (6.30am) we were greeted by Dr Ted Miclau before being taken to the UCSF Parnassas campus. There we met Dr Hubert Kim and Dr Tamara Alliston, the moderator for the research presentations that day. Dr Joyce (In vitro wear tests of orthopaedic biopolymers with a visco-supplement added to the lubricant), Mr Huntley (Bone-cartilage transfer - death at the mosaicplasty graft edge) and Dr Snelling (Differential allelic expression of FRZB in OA) presented their research, which was combined with some very interesting talks by Dr Kim (A case for disease modifying articular injury drugs) and Dr Alliston (Cartilage matrix material properties) of the UC-SF faculty. Following Dr Kim’s presentation, Dr Khan discussed at length the validity of using the rabbit as a model for investigating cartilage repair as oppose to other larger model. Dr Dunne and Dr Joyce also offered opinions and comments to Dr Alliston on the various methods she was using to determine the mechanical properties of cartilage.

After being introduced to the two-headed pig, endearingly known as ‘Ditto’, tours of the Tissue Laboratory (supervised by Dr Alliston) and the Morphogenesis Laboratory followed (supervised by Dr Rich Schneider) followed. Dr Alliston’s research focuses on the role of two structurally unrelated growth and differentiation factors, transforming growth factors-alpha and -beta, in epithelial and mesenchymal cell proliferation and differentiation. Dr Schneider’s research focuses on the extent to which the neural crest, a mesenchymal stem cell population, serves as a source of spatiotemporal patterning information during craniofacial morphogenesis. All Fellows found the tours of laboratories were insightful; Mr Huntley was particularly impressed with the dermestid beetle used to remove the skin from decaying animal skeletons. Moreover, Miss Reichert was interested to learn that Dr Andrew Jhen at UCSF used fluoroscopic microspheres successfully in duck bills. She was aware of fluoroscopic microspheres as a possible alternative to radioactive microspheres, but so far had not been able to ascertain if fluoroscopic microspheres can be used for 'hard' tissues.

   
Following an excellent lunch at a Vietnamese restaurant, the Fellows dodged the heavy rain and took the bus to Dr Kim’s Laboratory, which is based in the Veterans’ Administration-Medical Center (VA-MC). The research conducted by Dr Kim and his group is heavily focused on the molecular and cellular mechanisms responsible for secondary injury cascades that are set in motion after mechanical trauma. During the VA-MC visit, we met with Dr Kim’s research students (Tiffany and Andrew) and postdoctoral Fellows (Alfred), who showed the research projects they were working on. All the Fellows were in agreement that they work being conducted at VA-MC was excellent and they were very impressed with the research texture and environment.
Following from the VA-MC, we met with Dr Alliston, Dr Kim and Dr Schneider for an excellent dinner at a restaurant near the UCSF Parnassas campus.
   
Tuesday morning (9.30am), Dr Miclau collected the Fellows and brought us to the newly opened UCSF/San Francisco General Hospital Orthopaedic Trauma Institute (OTI). The OTI recently celebrated the official opening, the Institute is a first-of-its kind, fully integrated research, training and patient care facility. Dr Miclau gave a guided tour of the 14,000-square-foot, newly renovated space that included state-of-the-art labs, the latest medical equipment, and enough room for 70 physicians, rehabilitation specialists, scientists, clinical researchers and support staff. All the Fellows were taken aback by the vision and strategic mindset of the PIs that resulted in the successful completion of the OTI and the humility that Dr Miclau demonstrated when speaking of the successful venture.

Following the OTI tour, Dr Ralph Marcucio moderated the research presentations of Dr Dunne, Miss Reichert and Dr Khan and members of the OTI faculty. Dr Celine Colnot, who was sponsored as Young Investigator by the AAOS to take part in the AAOS Fracture Repair Symposium 2007, gave a very informative lecture on the cross-over between developmental biology and fracture repair. The presentation by Dr Lu explored the effect of hypoxia on fracture repair. Both presentations tied in well with the Fellows papers on characterisation of stem cells under hypoxic conditions (Dr Khan), haemodynamic changes during fracture healing in the presence of reamed and unreamed nailing (Miss Reichert) and the replication of marine sponges in the development of bone substitutes (Dr Dunne).

Lunch followed the research presentations at Dr Miclau’s favorite Mexican restaurant, where the food was excellent and the conversation topical, if not tropical. After dinner, Dr Marcucio took the Fellows to the site of the new research facilities at Mission Bay.

We then visited the very impressive biomechanics and bioengineering laboratory, which is supervised by Dr Jeffery Lotz. Dr Jenny Buckley showed examples of current research, which included strain gauged surgical instruments and in vitro testing of spinal fusion devices. We were also shown testing equipment which combined motion analysis and tensile testing of prostheses. As with many of the other laboratories tours, it was encouraging to see the positive synergistic outcomes of orthopaedic surgeons and engineers working together to overcome current challenges related to musculo-skeletal diseases.

After all the research tours had been completed, Dr Miclau took the Fellows to the Twin Peaks area; allowing them to get bird’s eye view of the city. It was an excellent vantage point to see the expanse of the city in one shot. Or it would have been if the rain had not been so heavy to obscure the view.

That evening, Dr Miclau and Dr Marcucio took the Fellows for a beer and a burger in the Latin Quarter. As beers were drunk and burgers eaten, the conversation went from the virtues of the BORS-US Fellowship program to similarities and differences in the UK and US research and development structure in academia and hospitals. Following dinner the Fellows and the UCSF faculty parted and it was agreed by all that the time spent at UCSF was fantastic, and we all hope to keep in touch with those we meet there, and return their hospitality whenever they find time to visit the UK.
   

Thursday 5th March

We met Dr Amadio at 06:30 and had a brief tour of the Mayo facility as far as the 14th Floor (orthopaedics), before splitting the tour party for the early morning clinical conferences: Shoulder & Elbow (Wasim, Nick, Ines, Tom) and Bone Tumours (Jim, Sarah). The shoulder and elbow meeting – chaired by Dr Morrey – involved the discussion of two patients in particular. Biomechanical considerations of a patient with an unstable elbow used an ad-hoc free-body-diagram for clarification. This patient was treated with a customised radial head replacement which was constructed at the Mayo Clinic. The results of a 'just completed study' on arthroscopic elbow debridement helped to plan surgery of another patient who suffering an inflammatory reaction years after a silicone implant.
The tumour conference involved presentation of several cases including a patient with sacral chordoma, and the approach to give the best attempt at sparing the sacral nerve roots.
We noted that - in terms of questioning - the residents were given a far stiffer time than their UK counterparts.

A.M. We gave presentations of our work to the department after Dr. Kai-Nan An had kindly introduced us. Apart from Sarah, everyone gave a different talk to that presented in San Francisco. Certainly Sarah’s talk, “Differential allelic Expression of FRZB in OA” bore the repetition well, allowing some of us to progress further before being lost in the world of cellular signaling.

It was a great pleasure for Ines Reichert to present her bone blood flow data at the Mayo as both of her supervisors, Dr Ian McCarthy and Professor Sean Hughes, had been Fellows at the Mayo Clinic. Indeed, the indicator fractionation technique using radiolabelled microspheres was established at the Mayo Research Laboratories under the lead of Patrick Kelly. The Mayo Clinic remains one of the few centres at the forefront of bone circulation research - Dr J Bronk was in the audience and contributed to the discussion.

P.M. At noon, we were treated to an excellent lunch at Chester’s, before 3 hours of laboratory tours and discussions with the laboratory supervisors: Cartilage and Connective Tissue (James Fitzsimmons), Tissue Engineering and Biomaterials Laboratory (Dr. Michael Yaszemski), Osteoblast Biology and Transcriptional Relation (Dr. Jennifer Westendorf), Biomaterials Characterization & Quantitative Histomorphometry

Core Laboratory (Dr. Theresa Hefferan), Biomechanics Laboratory (Kristin Zhao), Motion Analysis Laboratory (Diana Hansen). We were greatly impressed by all of the laboratories, and several firm links were established on overlapping research interests. The tour through the laboratories was very well organised and the use of discussion of posters in addition to lab equipment helped to get an overview of the research work at the Mayo. We experienced a remarkable willingness to give us insight into current work,as well as pride and palpable enthusiasm for research - an inspiring place!

Jim Huntley and Nicholas Dunne were particularly taken with the periosteal graft/scaffold/neo-cartilage research which Jim Fitzsimmons from Shawn O’Driscoll’s group, and there is certainly the basis for future collaborative ventures here. Dr Dunne

impressed everyone with histhoughts concerning the application of novel K-wire technology.

Dr Theresa Hefferan heads a state of the art bone histomorphometry laboratory which was very much appreciated by Ines Reichert who had some experience in the difficult art in the preparation of bone sections from her own work. Dr Hefferan offered immediately help and assistance for any future project!

In the evening we were hosted to a dinner at Prescott’s Restaurant, by Dr Amadio. Dr Reichert continued to the discuss - with Dr An especially - the importance of basic bone physiology and biomechanics. Subjects as the effect of injury on bone blood flow and imaging and measurement of such in patients were explored and they agreed to stay in touch!

 

Friday 6th March
A later start this morning with the 07:00 Paediatric Orthopedic Conference, at which Jim Huntley was in his element. Thereafter after a brief break, we were given two tours of the hospital facilities – this was absolutely outstanding - from multiple perspectives: historical – the talk concerning the HS Plummer Building and the insights into the importance of Plummer for the development of this institution was inspiring. Procedural – the attention to detail for the patients perspective in terms of clinic design was outstanding. This was inspiring, though by contrast it paints my own (JSH) UK experiences of outpatient organisation in a dilatory light.

After an enormous lunch at the Oak Room – during which Mr Dunne was uncharacteristically quiet - , we were treated to a great sequence of lectures, which provoked a strom of questions and discussion: “Incorporating electrically conductive polymers into Biomaterials” (Dr. Brett Runge), “Over expression of Lef1-short Increases Bone Mass in Mice” (Dr. Frank Secreto), “In Vivo Bone Regeneration” (Dr. Theresa Hefferan), “Ultrasonographic assessment of idiopathic carpal tunnel syndrome” (Dr. Margaretha van Doesburg), “Lubricin decreases adhesion after flexor tendon repair” (Dr. Chunfeng Zhao). This afternoon showed us the breadth and depth of Mayo musculoskeletal research. A lot of discussion after very stimulating talks.

We have been so very well looked after here – The Mayo clinic stay has been an inspiration, but with great hospitality too.

 
Saturday 7th March - Flights: Rochester-Chicago-Philadelphia
   

On Saturday 7 March, the weekend of the Philadelphia Flower Exhibition, the Fellows arrived in Philadelphia and settled into their hotel. They were greeted by their host, Javad Parvizi from the Thomas Jefferson Institute, the following morning and taken for breakfast. They were then invited to a Parvizi family day out at the Philadelphia Museum of Art that was also displaying an Exhibition by Paul Cézanne and holding festivities for the Persian New Year. The Rocky statue and the views of the city from the top of the steps leading up to the Museum were spectacular. Following the Cézanne Exhibition, the Fellows were treated to lunch at a beautiful restaurant overlooking Schuylkill river.

On 9 March the Fellows had an opportunity to attend theatre lists at the Thomas Jefferson Institute. It was great to be able to see William Hozack perform two, obviously uncemented, total hip replacements, and talk to orthopaedic residents who had travelled from across the US to do their clinical fellowships at the prestigious institution.

This was followed by a working lunch where the Fellows got to meet Maurizio Pacifici and other scientists and clinicians at the Institute. James Huntley was able to get some useful tips on how to set-up and run a large clinical database.

Presentations by the Fellows were followed by presentations by members of the faculty with corresponding research themes. Thomas Joyce’s presentation on the analysis of ex-vivo resurfacing hip prostheses, and Nicholas Dunne’s presentation on the antibacterial and mechanical properties of cement impregnated with chitosan were particularly well-received. Noreen Hickok from the faculty who presented her work on antibiotic impregnated smart-implants took the opportunity to establish collaborative links with Thomas Joyce and Nicholas Dunne for more detailed analyses of her implants. Sarah Snelling spoke about the role of FRZB gene in osteoarthritis and Motomi Enomoto-Iwamoto from the faculty spoke about the role of the Wnt pathway in osteoarthritis. Wasim Khan spoke about the role of hypoxia in stem cells, and Vickram Srinivas

from the faculty, a World leader in hypoxia research,presented his important and impressive work on the Hypoxia Inducible Factor-2 (HIF2) pathway in chondrogenesis. Ines Reichert spoke about the inter-relationship of blood flow in the cortex and the periosteum or 'acute reversal of blood flow' following intramedullary reaming. Her talk, despite being at the end of a very long day, was enthusiastically received by scientists and clinicians alike because of the content encompassing the interests of both disciplines.

That evening the Fellows were invited by Javad Parvizi to the Philadelphia Orthopaedic Society Lecture at which Roger Mann spoke about his experience with total ankle replacements. The Fellows were then taken for dinner by Javad Parvizi.

 

 

Tuesday 10th March - University of Pennsylvania

The program at UPenn, organized by Lou Soslowsky, began with a trip to the Mutter Museum (http://www.collphyphil.org/mutter.asp). We were exceptionally privileged to receive a guided tour from the Museum's Director, who provided a unique insight into the history and future aims of the museum as well as the exhibits. Exhibits of particular note included the ossified skeleton of Harry Eastlack, an FOP sufferer; the 'soap woman' whose saponified body and radiographs provide clues to her life and her death; and over 2000 objects that have been extracted from people's throats! The museum also houses an extensive ossuary and Joseph Hyrtl's collection of skulls giving information on the age, sex, occupation and cause of death of the owner was particularly thought provoking. An exhibition on the causes and consequences of lead poisoning was also fascinating, with the sources of 'plumbism' be as current as confectionary available for sale today.

After this relaxed, yet educational morning we were taken to the 'Greek Lady Restaurant' for another excellent lunch. Rob Mauck collected us and then acted as our tour guide. We were taken to the old Vet school laboratories complete with a new CT machine - with a resolution of 18 micron, to Dr Reicherts’ enthusiasm that would be sufficient to image a single Haversian canal! In contrast, outside, there was a giant scale for weighing the farm animals that used to be treated at the school). The fellows also visited the McKay laboratories and the Bioengineering labs. We were all impressed with the well-equipped and organized laboratories, with the access of the bioengineering groups to molecular and cell biology equipment being particularly noteworthy for Drs Dunne and Joyce. The UPenn campus itself was also conducive to a friendly, yet academic atmosphere.


After our tour we were all eager to see in more detail the research being pursued within UPenn and felt honoured to be the cause of a well-attended poster session in the 'Biomedical Research Building' which gave good views over Philadelphia. The poster session was diverse yet complementary to the fellows current and developing research interests. Posters included some fascinating work on tendon healing and rotator cuff injury and repair, and on intervertebral disc degeneration. The thorough analysis of the molecular mechanisms underlying FOP led by Prof Eileen Shore were read eagerly, especially following our meeting with Harry Eastlacks’ skeleton at the Mutter Museum. Research from Rob Maucks’ laboratory on soft tissue engineering captured Dr Snelling and Dr Khan due to their interest in their analysis of mesenchymal versus

left to right Rob Mauck, Dr Joyce, Dr Huntley, Dr Snelling, Dr Dunne, Dr Khan.

chondrogenic cells and Dr Dunne and Dr Huntley pursuing questions on meniscus tissue engineering. The BORS-US fellows all agreed that the poster session was a great way to encourage interaction and stimulate discussion between themselves and researchers of all career stages at UPenn.
   
After the poster session the fellows were given the opportunity to present their research including a presentation by Dr Reichert presented a paper on the use of a novel MRI sequence to image cortical bone and periosteum in patients (Magn Res Imaging 23 (2005) 611-18), that had been awarded the Lodwick Award for excellence in Musculoskeletal Radiology by Massachusetts General Hospital and Harvard University, Boston in 2006. Each presentation was met with enthusiastic and in depth questioning, reflecting the breadth of research and knowledge at UPenn. Following the presentations the fellows were treated to a buffet dinner and had another opportunity to look at the excellent posters on display. Dinner conversation was stimulated by the presentations the fellows had given with Dr Snelling having discussion with Prof. Shore about the roles of pleiotropy of BMP signalling in musculoskeletal disorders and with Prof. Mauck about a mutual interest in a number of genes showing altered expression during chondrogenesis. Once again the fellows were taking many notes and email address with numerous potential collaborations

borne through their day at UPenn. On the walk back to the hotel conversation between Dr Dunne and Dr Reichert centred around the exact definition of a burst fracture, sparked by Dr Dunne's earlier presentation on the development of bone substitutes for spinal repair. On arrival back at the hotel the weary fellows returned to their rooms to reflect on another intellectually stimulating day, to pack and finish preparing talks for their upcoming trip to New York
   
On 11 March the Fellows had an opportunity to listen to the research themes and visit the laboratories of Maurizio Pacifici, Markarand Risbud and Terry Freeman. One of the highlights of the Fellowship has to be the one-hour tutorial on embryonic chondrogenesis by Maurizio Pacifici, showing his mastery of teaching as well as research. That evening the Fellows boarded a train for New York, their final destination
   
Final Stop – Hospital for Special Surgery (New York)  

The Fellows took the train from Philadelphia to New York and, on arriving in NewYork, took a cab to the Hospital for Special Surgery (HSS). Dr Adele Boskey from the hospital had organised rather luxurious shared accommodation at the Belaire apartments. Therefore, ensuring that all Fellows had a relaxing and much deserved sleep, ensuring they were ready for the busy day ahead.

The next morning we were met by Dr Adele Boskey (Program Director of the Musculoskeletal Integrity Program), who had put together a very full and exciting program for the Fellows. Dr Boskey conducted part of her post doctoral research at Imperial College London and she was winner of the Kappa Delta Young Investigator Award for discovering the role of phospholipids in mineralisation (1979) and later was elected the first female president of the Orthopaedic Research Society (ORS) an honour that is indicative of her standing within the US research community. During our breakfast meeting, we were joined by Dr Steven Goldring (Chief Scientific Officer) and Dr Mary Goldring (Faculty member of the Tissue Engineering, Regeneration, and Repair Program) who both gave informative overviews of the research structure at the HSS, in particular in areas of cartilage and OA research. Dr Jo Hannafin (Attending Orthopaedic Surgeon and Director of Orthopaedic Research at HSS and a Professor in the Department of Orthopaedic Surgery at Weill Cornell Medical College) also formed part of the morning discussions sharing her thoughts and insights into the challenges of balancing high quality scientific research and a stable family environment. The presentation by Dr Hannafin was excellent and thought provoking, highlighting many insights on how to achieve the end goal of being the best at what you do without sacrificing family life and your extracurricular interest.
Following the breakfast meeting, the Fellows and faculty members of HSS presented some of their research to Orthopaedic Surgeons and HSS Research Scientists. The focus of the morning presentations was ‘Genetics of Musculoskeletal Tissues’. Dr Cathleen Raggio (Assistant Attending Orthopaedic Surgeon) from the Musculoskeletal Integrity Research group presented her work on osteogenic imperfecta and other skeletal dysplasias. Subsequently, Dr Snelling (The role of BMP5 in osteoarthritis), Mr Huntley (Bone-cartilage transfer - death at the mosaicplasty graft edge) and Mr Khan (Cell surface characterisation of synovial fat derived stem cells and the effects of fgf-2 expansion of chondrogenisis) presented their research findings providing the platform for some very stimulating and though provoking discussions.

After the first round of presentations, the Fellows had the opportunity to tour the research laboratories of the No. 1 Orthopaedic Hospital in the US. Miss Reichert, who has an interest in the fluid space in bone, was privileged to receive one to one tuition on Fourier transform infrared imaging (FTIR) a technique used to analyse the mineral / matrix ratio, carbonate content, mineral crystallinity, collagen maturity of bone. FTIR is a very powerful tool, which can be used to assess the heterogeneity of tissue bone and its variation in composition as a function of different bone diseases, for example osteoporosis. The identification of the 'bisphosphonates fracture' at the HSS, a characteristic sub-trochanteric fracture in osteoporotic patients on prolonged alendronate treatment, has led to a particular interest in this field. Dr Dunne and Dr Joyce had the privileged opportunity of visiting the Biomaterials and Biomechanics Test Facilities. Both were very impressed and almost envious of the extensive inventory of explanted prostheses that had been gathered over the years.

During lunch the Fellows had the opportunity to meet with Dr Ivashkiv, the Associate Chief Scientific Officer at the HSS. His primary interests are in clinical care of patients with arthritis and inflammatory diseases combined with basic research in inflammation and gene regulation. Dr Ivashkiv also serves as head of the Rheumatoid Arthritis Registry.

Following lunch, presentations concentrating on Biomaterials and Biomechanics were given. Dr Tim Wright presented an overview of the research being conducted at the HSS, which included optimal design and assessment of orthopaedic devices. Additionally, Dr Wright also presented exciting research being conducted at the HSS relating to pre-clinical experimental evaluation of novel hydrogel based biomaterials for use in total joint replacements. Thereafter, Dr Dunne (Real time monitoring of PMMA bone cement: A novel understanding) and Dr Joyce (Analysis of ex vivo resurfacing hip prostheses and comparison with clinical data) presented their research papers. All the papers were very well received and an active discussion followed on the difficulties in taking a research concept through to commercial realisation.

The next research session focussed on issues relating to ‘Bone Healing’. The first paper on bone healing and remodelling was presented by Professor Marjolein van der Meulen, an Affiliated Investigator of the Musculoskeletal Integrity Program. Professor van der Meulen is based at Cornell University in Ithaca and travels on a regular basis to the HSS to conduct research using FTIR microscopy to evaluate the mineral structure in osteoporosis and to understand the role of microstructure in nanomechanical behaviour of bone tissue (NIH funded projects). Then Dr Philip Kuckuk-Mayer from the Bone Cell Biology and Imaging Laboratory at HSS presented his research paper investigating the the molecular mechanisms which control bone biology in normal and damaged bone. Dr Kuckuk-Mayer paper allowed for a seamless link to the paper presented by Miss Reichert (Does 'bone injury' evoke a systemic haemodynamic response?).

At the end of the Bone Healing session, the Fellows and HSS faculty attended an excellent and entertaining dinner at the invitation of Dr Mathias Bostrom, a specialist in hip and knee surgery. The event took place in the historic surroundings of the Union Club, which was founded in 1836 and is the second oldest city club in the United States. The Union Club, located on East 69th Street and Park Avenue, occupies a National Historic Landmark building opened in 1933 and was designed by Delano & Aldrich.

The following day, the Fellows attended a lecture by Professor Karen Lyons from the Department of Orthopaedic Surgery at University of California. The lecture was part of the Distinguished Research Lecture Series that is held on selected Fridays at the HSS. The title of the presentation was BMP and TGF beta Signalling Pathways in the Growth Plate. The Fellows also had another opportunity to visit research and development laboratories of interest. Miss Reichert met up with Dr Kuckuk-Mayer, as it emerged a fellow country man of hers. They share an interest in vascularity and angiogenesis of fracture healing and exchanged information about research aims and methodology, Miss Reichert provided details about techniques to measure bone blood flow and was in turn fascinated by Dr Mayer-Kuckuk's expertise in molecular imaging techniques just recently applied to VEGF. Some of the other Fellows had the opportunity to meet with Dr Torzilli, the Program Director of the Tissue Engineering, Regeneration and Repair Program. During the meeting Dr Torzilli shared his knowledge and expertise relating to cell and tissue biology, function and biomechanics in healthy and diseased articular cartilage. The attending Fellows thoroughly enjoyed their insightful discussions with Dr Torzilli as he is widely regarded as one of the leading researchers in the field of articular cartilage repair.

Following two excellent days of topical research papers, laboratory tours and informal discussions, the Fellows felt they had been very honoured to spend time at the No. 1 Orthopaedic Hospital in the US. Moreover, they were very appreciative of the hospitality and goodwill demonstrated by HSS faculty and they promised to stay in touch.
The final day was spent exploring the Big Apple and buying presents before making the trip back to the UK, to friends, family and a return to our day jobs!

On Reflection.........
The three weeks that we spent in the US will always be a very unique experience for the BORS-US Fellows, we have made many new acquaintances across the US and have been privileged to meet with world leading orthopaedic researchers and see their research laboratories. We are grateful to BORS for their continued support for the trip; and to Dr Ted Miclau (University California, San Francisco), Dr Peter Di Amadio (Mayo Clinic, Rochester), Dr Javad Parvizi (Thomas Jefferson Institute, Philadelphia), Dr Lou Soslowsky (University of Pennsylvania), Dr Adele Boskey (Hospital for Special Surgery), Professor Hamish Simpson (University of Edinburgh) and Miss Brigitte Scammell (University of Nottingham) for their efforts they went to in the ensuring the success of the BORS-US travelling fellowship and their excellent work in bringing together such a fantastic programme of events. We must also thank all the staff involved at each of the host institutions for making us all feel so welcome. They were selfless in giving their time and ensuring we had the best possible experience and exposure to their research expertise.