Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates-Functional Results before and during the SARS-COVID-19 Pandemics.

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life-being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer's three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck-shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant-Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant-Murley score (p = 0.0048; Student's t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.

Narrative Review of the Mechanism of Hip Prosthesis Dislocation and Methods to Reduce the Risk of Dislocation.

Total hip arthroplasty (THA) is one of the most effective surgical procedures. It improves quality of life, increases range of motion, and reduces pain in patients with hip joint degeneration. THA allows patients to return to everyday social and professional activities. Therefore, today it is the best approach to treatment of several chronic conditions affecting the hip joint, including advanced degenerative diseases, avascular necrosis, and some traumatic events. The aim of this study was to present the mechanism of hip prosthesis dislocation, associated risk factors, and the factors reducing the risk of dislocation, as well as its consequences and methods of risk minimization. Hip dislocation is a common complication following THA. It is responsible for up to 2% to 3% failures of primary replacements, increasing even to 10% in extreme cases of patients highly predisposed to this condition. In most cases, technical errors during implant placement are responsible for the incidence. The measures taken to prevent complications include activities aimed at correct implant insertion and the selection of the most appropriate type of implant for the patient, depending on individual needs. We summarized the current knowledge of implant dislocation to help surgeons understand the changes in biomechanics of the hip after its replacement and the impact of each particular element that participates in it. This knowledge can enable a surgeon choose the most favorable surgical method and the most appropriate implant to reduce the risk of implant dislocation.

Literature Analysis Regarding the Combination of Substances: Glucosamine + Chondroitin in the Treatment of Osteoarthritis.

An essential component of joint quality is cartilage. Therefore, the protection of this is a prerequisite for maintaining the condition of each joint. The assessment of the presence of articular cartilage is shown by X-ray of both joints in the standing position. Cartilage protection is possible for 1, 2 and 3 degree of cartilage damage according to the Kellgren and Lawrence scale.The challenge for the physician is to identify the cause of OA in accordance with the principles of Evidence Based Orthopedics/Traumatology, and not merely treat symptomatically, which is usually ineffective.In order to objectively present treatment methods, indications and the period of their implementation, it is biologically reasonable to refer to the needs of cartilage tissue resulting from the analysis of the causes of its damage and indications for justified methods of its protection.Biomechanical and biological elements are important in the process of implementing articular cartilage protection.The biomechanical elements are: limb axis disorders, differences in length, distortions at the level of the support quadrilateral, pelvic triangle and shoulder triangle, as well as balance disorders resulting from disturbances in the segmental proportion of the Fi number according to Leonardo da Vinci.There are many biological elements of the discussed disorder and they concern: the state of articular cartilage structure, matrix structure, matrix biophysical elements, molecular sponge mechanism, chondrocytes, cartilage nutrition and the severity of osteoarthritis (OA).The improvement of the conditions of the biological elements of damaged articular cartilage is considered fundamental and concerns the positive impact on numerous cartilage matrix proteins by chondroprotection. This element of treatment consists in the use of chondroitin sulphate and glucosamine as a drug, administered together in the appropriate dose and for a long time depending on the degree of degradation of the articular cartilage, usually from several to several months. The combination of chondroitin sulfate with glucosamine causes the activation of a much larger number of matrix proteins than each of the preparations separately.The pharmacokinetics of chondroitin sulfate and glucosamine are positive and favor their chondroprotective effect.The pharmacoproteomics of chondroitin sulfate and glucosamine administered together result from the activation of as many joint cartilage matrix proteins as possible. The development of proteomic techniques creates completely new therapeutic possibilities and is used to study the action of individual molecules.A clinically significant fact is that both chondroitin and glucosamine are natural, endogenous components of bone tissue and articular cartilage, so the use of both drugs is biologically compatible and results in numerous elements of cartilage protection.

Evolution of the Hyaluronic Acid in Viscosupplementation - from Linear Particles to Hybrid Complexes.

The discovery of unique properties of the hyaluronic acid and learning about the role of this aid in pathophysiology of extracellular matrices resulted in using this substance in pharmacological support in cases of tissue dysfunction due to numerous disease units. Therefore, the products containing this substance are now widely used in medicine including dermatology and aesthetic medicine, ophthalmology, facial-mandibular surgery and orthopedics, being among the most effective products used in the treatment of numerous cases of function impairment and deformation of tissues and organs. There are applied in both post-traumatic and post-inflammatory conditions as well as in symptoms due to chronic conditions. Their therapeutic effects result from joint surface moisturizing, reduction of the coefficient of friction (COF) and good bio-tolerance and biocompatibility confirmed by a low percentage of side effects and biocompatibility. The introduction of hyaluronic acid hybrid complexes with high and low molecular mass (H/L-HA) has increased the clinical usefulness of hyaluronic acid products thanks to their increased viscoelasticity, increased anti-inflammatory and chondroprotective properties and thermodynamic stabilization of the product guaranteeing its half-life. Thanks to the above mentioned pro-perties it becomes more effective in the non-surgical treatment of osteoarthritis.

Advances in Imaging of Hip Osteoarthritis.

Osteoarthritis is the most common musculoskeletal disease worldwide, generating enormous social and medical costs. In recent years, research shedding new light on the etiology and pathogenesis of osteoarthritis has been closely related to innovations in diagnostic imaging. Precise visualization of all joint structures affected by osteoarthritis is critical for early detection and assessment of the prognosis and response to treatment. The purpose of this paper is to present recent advances in the imaging of hip osteoarthritis.

Evaluation and Comparison of the Effectiveness of Rehabilitation Procedures in the Area of ​Pain in the Lumbosacral Spine Performed in Sanatoria and Outpatient Conditions.

BACKGROUND: Low back pain is among the most frequent conditions of nowadays and due to its high prevalence, it is defined as a social and civilization-related disease.Today, increasingly young patients present with this condition affecting about 80% of the population. In Poland, 70% of the population complain of back pain and the prevalence rate increases with age. The treatment includes application of various procedures, both in outpatient conditions and in sanatoria. The aim of the study was to compare the effects of sanatorium treatment with those of outpatient treatment. MATERIAL AND METHODS: 240 patients with low back pain participated in the study. The sample was divided into two groups: 120 pa-tients undergoing treated in outpatient conditions and next, 120 patients undergoing sanatorium treatment. The research was based on survey in a form of a questionnaire, selected mobility tests and assessment of pain using thermal imaging camera and an algometer. RESULTS: The patients undergoing rehabilitation procedures in a sanatorium obtain improvement in terms of pain sensation (5.39 points in VAS scale) as compared with the patients undergoing rehabilitation in outpatient conditions (4.13 points in VAS scale) ; their results also indicate improvement in low back mobility (the obtained values, however, turned out statistically insignificant). Better results can be obtained by combining conventional rehabilitation with the approaches applied in sanatorium treatment, as confirmed by the assessment of each group of patients. CONCLUSIONS: 1. Rehabilitation of patients with lumbar spine pain conditions conducted in spa conditions is a more effective treat-ment method than in an outpatient clinic and should be used universally. 2. Research is indicated to determine the effect of rest in a sanatorium (the ambience) involving low back pain relief.

Anemia - the Neglected Problem in Patients with Orthopedic Conditions.

Anemia and the necessity of blood product transfusion in perioperative procedures is an important and frequently discussed clinical issue. Presently, a constantly growing interest in this problem is observed among clinicians who search the ways to reduce the number of blood or blood product transfusions in patients after surgical procedures, both during the preoperative period and during and after the surgery. Generally, the decision whether to start transfusion or not should follow the analysis of pros and cons, considering the beneficial effect of transfusion and the risk of undesirable effects. The most effective approach in prophylaxis and treatment of anemia among patients on the orthopedic service should combine surgical anesthetic and pharmacological procedures during the preoperative, perioperative and postoperative periods. The aim of the paper is presenting the latest knowledge of the practical determinants concerning anemia pharmacological treatment, especially considering the principles, value and therapeutic effectiveness of iron supplementation, both at orthopedic injury clinics and outpatient clinics.

Evaluation of the Health-related Behaviour of Pregnant Women from Warsaw, Poland.

BACKGROUND: Pregnancy is a period of time when women tend to suffer from the weakening of their psychophysical fitness. This research evaluated several selected elements of the lifestyle of pregnant women compared to those of non-pregnant women. METHODS: Overall, 482 women attended to the Childbirth School in Gynecological-Obstetric Hospital "Inflancka" in Warsaw, Poland, in the years 2011-2013; Group 1 contained 214 pregnant, and Group 2 contained 268 non-pregnant completed a survey inquiry. The research tool applied was Juczynski's "Inventory of Health Behaviour" (Inwentarz Zachowan Zdrowotnych). In this tool, the author evaluates health behaviors through four separate categories: dietary habits, prophylactic behaviors, mental attitude, and health behaviors. The differences between the data were defined through the Student's t-test for independent groups, with a minimal level of significance set at P ≤ 0.05. RESULTS: Pregnant women take care of following a healthy lifestyle. The general health behaviour index figure was significantly higher in Group 1 as compared with the Group 2 (P<0.001). A higher level (P<0.001) of healthy behaviour was typical of physically-active individuals, regardless of their Group (1 & 2). CONCLUSION: Pregnancy might cause women to increase their interest in matters of their own health and adopt a healthier lifestyle. Physical activity can influence other health-related practices.

Practical Aspects of Hyaluronic Acid Application in Biolevox HA Preparations - Report on Research.

HA preparations in intraarticular injections have been applied in medicine since 1986 and became widely used in Poland at the beginning of the 90s of the twentieth century. Since then, numerous cases of successful application of intra-articular injections (the so called viscosupplementation) have been described in Polish and foreign literature. Changes in the molecular mass of hyaluronic acid and the related specific spatial structure result in different metabolic and immunological properties. Presently, in clinical practice, it is indicated to use the preparations produced by selected manufacturers who offer different forms of HA, containing different percentage of active substance (1 to 2.5%) and different molecular mass, making the desired number (1-5) of intra-articular injec-tions possible, depending on the type and intensity of a specific disease unit. Numerous studies have been con-ducted to confirm the effectiveness of treatment using hyaluronic acid. In Poland a research program was implemented to assess the practical application of 2 ml of Biolevox HA preparation in 2.2% concentration. During the study 15,000 patients were subjected to analysis. The physicians participating in the study injected the hyaluronic acid, in that case, Biolevox HA, to the knee joint, in patients with osteoarthritis, chondromalacia, knee joint injuries and other conditions.

Genetic and Epigenetic Interactions in the Etiopathogenesis of Osteoarthritis. Selected Molecular Factors in OA Etiopathogenesis.

Osteoarthritis (OA) is a widespread disease characterized by a multifaceted etiopathogenesis and complicated pathophysiology. OA is connected with systematic degeneration of subchondral bone tissue, articular cartilage, synovial membrane and stenosis of the joint space, which substantially contributes to premature reduction of functional mobility. The results of many epidemiological studies carried out in various populations around the world including genome-wide association studies and analysis of epigenetic modifications (such as miRNA expression, DNA methylation and histone modifications) have indicated a multifaceted nature of the disease. The aim of this paper is to present the state of the art for gene-expression level changes of relevance for the pathogenesis of osteoarthritis, including the contribution of epigenetic regulations.The source of search data for this paper was the PubMed database. The following keywords were used as search terms: osteoarthritis, GWAS, epigenetics and miRNA.The reports presented in this paper provide a starting point for further considerations regarding the development of personalized biological therapy. Several hypothetical strategies for the targeted OA treatment development exist nowadays. However, it is important to emphasize that in-depth understanding of the genetic-epigenetic interaction in OA pathogenesis is crucial. Based on the analysis of the aforementioned available study results, the following conclusions can be made: Both environmental factors and genetic-epigenetic interactions contribute to the complex pathogenesis of OA; OA risk genes have been identified; Differences in gene expression in OA may be helpful in assessing progression of the disease; The epigenetic goals of OA therapy have been indicated.

The analysis and assessment of the effect of selected endo- and exogenous substances on prevention and treatment of selected conditions and injuries within the musculoskeletal system.

The aim of the presented report, prepared based on the results of the newest studies available in the reference sources, is the analysis and assessment of the important endo- and exogenous substances, whose role and significance in prevention and complex treatment of civilization-related diseases (including the pathological conditions and injuries of the musculoskeletal system) can be essential and significantly contribute to the improvement of the efficacy of the accepted treatment approach. Three substances, namely a-lipoic acid, y-linolenic acid and a-linoleic acid were subject to a detailed analysis and assessment.

Preventive Chair Massage with Algometry to Maintain Psychosomatic Balance in White-Collar Workers.

People working at computers often suffer from overload-related muscle pain, and physical and mental discomfort. The aim of the study was to evaluate the effectiveness of chair massage, conducted in the workplace among white-collar workers, in relieving symptoms of musculoskeletal strain related to prolonged sitting posture. The study was conducted in 124 white-collar workers, 55 women and 69 men, aged 33.7 ± 7.6 years. Subjects were randomly assigned to three groups: chair massage program, relaxing music sessions, and a control group, each of four-week duration. Each group was evaluated before and after the program completion. Pain perception was assessed algometrically as a threshold for compression pain of neck muscles, measured in kg/cm2. The relaxation level was assessed from the heart rate variability. We found that the chair massage increased both the pain threshold in all tested muscles (p < 0.001) and the relaxation level from 31.9% to 41.6% (p < 0.05). In the group with music sessions, muscle pain threshold remained unchanged, except for the trapezoid muscle where it decreased (p < 0.05), while the relaxation level increased from 26.0% to 33.3% (p < 0.05). In both massage and relaxing music groups, there was a significant decrease in muscle tension (p < 0.01). Changes in the control group were inappreciable. We conclude that the chair massage performed in the workplace is an effective method for prevention of musculoskeletal overstrain related to prolonged sitting posture. The program seems worth implementing in various occupational environments.

Biopsychosocial Rehabilitation Programme for Patients with Chronic Back Pain. Pilot Study.

BACKGROUND: In the search for effective and comprehensive therapies of back pain, an increasing emphasis in being placed on the biopsychosocial model and multidimensional support programmes for patients as well the use of modern technologies in this area of medicine. This study aimed to assess a programme of customised ad hoc physiotherapeutic consultations for patients with back pain who had been on the waiting list for rehabilitation treatment for a long time. MATERIAL AND METHOD: The study group comprised 68 patients of the Rehabilitation Centre Non-Public Health Care Institution who had been waiting for rehabilitation treatment for at least three months. The patients, diagnosed with chronic back pain and aged 40-80 years, were randomly assigned into two groups. The experimental group took part in a programme of three consultations, provided on average once a month. The patients from both groups were assessed after the three-month programme, immediately before the commencement of the prescribed rehabilitation treatment. We evaluated the pain threshold at trigger points of selected muscles using the algometric method (kg/cm 2 ), subjective assessment of pain (VAS), functional limitations (Rolland Morris Disability Questionnaire) and quality of life (36-Item Short Form Health Survey, SF-36). The statistical analysis of the results used non-parametric methods: significance of differences between the groups was evaluated with the Mann-Whitney U test and correlations between the variables were assessed separately for each group using Spearman's rank order correlation. The significance threshold was accepted at α=0.05. RESULTS: The algometric evaluation of all the muscles revealed significantly lower sensitivity to pain, demonstrated by a higher pain threshold (p<0.0001), in the experimental group. Moreover, this group also included a much smaller percentage of patients with a high level of functional limitations according to the Rolland Morris Disability Questionnaire. The quality of life evaluation revealed that the control group scored poorer in the mental domain (p=0.02). CONCLUSIONS: The ad hoc intervention programme for patients referred for rehabilitation due to chronic back pain showed demonstrable beneficial effects with regard to their psychophysical health. Similar programmes should be more readily offered to patients at health care centres and implemented into clinical practice.

Analysis of Therapeutic Effectiveness of Selected Types of Collagen in Prevention and Treatment of Degenerative Joint Disease.

Loss of collagen is a natural development accompanying aging of the body. It may be additionally accelerated by various conditions, including osteoarthritis (OA). Within the last two decades numerous and diverse studies have been conducted worldwide with the aim of identifying substances containing collagen, producing therapeutic preparations of expected effectiveness in the prevention and therapy of OA that would be safe to use and developing methods of delivering the final product into the body. The authors reviewed and analysed the latest available literature by selecting papers presenting the findings of studies conducted in line with the principles of Evidence-Based Medicine (EBM). The studies have been ordered from in vitro trials (studies on animals in the laboratory setting, use of tissue engineering methods to assess the effect of cartilage transplants, use of different collagen types for development of scaffolds etc.) to in vivo clinical trials. It appears that the findings of the latest multidimensional studies presented below, which confirm the therapeutic effectiveness of new-generation injectable medical collagen preparations, will help these medical products gain their well-deserved position in the comprehensive treatment of osteoarthritis both with respect to their analgesic properties as well as their ability to enable functional recovery and stimulate regeneration of tissues at the molecular level.

Neuropathy - Damage to Peripheral Nerves in Diseases and Injuries of the Musculoskeletal System.

The musculoskeletal diseases and injuries affect not only the musculoskeletal system itself, but also the closely related structures, such as blood vessels and nerves (both within the central and the peripheral nervous system). If these relationships are neglected or the directed neuroprotective and neuro-regeneration therapy is delayed, the final effect of the treatment is compromised. The aim if this paper is describing the important medical and social problem of peripheral neuropathies from the point of view of epidemiology, etiopathogenesis, imaging diagnostics and complex medical procedures using modern approaches and techniques, based on the available literature.

Comparison of Biocompatibility of Cemented vs. Cementless Hip Joint Endoprostheses Based on Postoperative Evaluation of Proinflammatory Cytokine Levels.

BACKGROUND The yearly increase in the number of procedures involving implantation of hip joint endoprostheses forces prosthetics manufacturers to search for biologically neutral implants. The goal of this study was to assess the concentration of Interleukin-6 (IL-6) and its correlation with C-reactive protein (CRP), depending on the type of hip joint endoprosthesis (cemented or cementless endoprosthesis) in order to determine implant biotolerance during the early postoperative period. MATERIAL AND METHODS The sample comprised 200 patients [mean age=64 (31-81) years] with coxarthrosis. All patients underwent hip joint arthroplasty using a cemented or cementless endoprosthesis. Blood samples were collected 3 times: before the procedure, on the first day after the procedure, and after 6 weeks. IL-6 and CRP levels were assayed using immunoenzymatic methods. The results were subjected to statistical analysis using the Shapiro-Wilk test. RESULTS On the 1st day after the procedure, CRP and IL-6 concentration increased rapidly after implantation of both cemented and cementless endoprostheses. At 6 weeks postoperatively, the CRP value remained at a similar level in patients after cemented arthroplasty and was almost 2-fold lower in patients who underwent cementless arthroplasty. The IL-6 value returned to the baseline level in patients after cementless arthroplasty and showed an ongoing increasing tendency in patients after cemented arthroplasty. CONCLUSIONS 1. The measurement of C-reactive protein and Interleukin-6 is a high-sensitivity test, assessing implant biotolerance. 2. The implantation of a cemented endoprosthesis induces a higher increase in the level of proinflammatory cytokines as compared with a cementless endoprosthesis. 3. For a complete assessment of both early and later body responses to implantation and the related surgical procedure, further studies using available approaches and tools are recommended.

A Water Rehabilitation Program in Patients with Hip Osteoarthritis Before and After Total Hip Replacement.

BACKGROUND Pain associated with coxarthrosis, typically occurring in middle-aged and elderly patients, very commonly causes considerable limitation of motor fitness and dependence on pharmacotherapy. This article provides an assessment of a rehabilitation program with tailored water exercises in patients with osteoarthritis before and after total hip replacement. MATERIAL AND METHODS A total of 192 patients (the mean age 61.03±10.89) suffering from hip osteoarthritis (OA) were evaluated before and after total hip replacement (THR). The clinical study covered measurements of hip active ranges of motion (HAROM) and the forces generated by pelvis stabilizer muscles. Pain intensity was assessed according to analogue-visual scale of pain (VAS) and according to the Modified Laitinen Questionnaire. The patients were divided into 6 groups (4 treatment and 2 control). We compared 2 rehabilitation programs using kinesitherapy and low-frequency magnetic field. One of them also had specially designed exercises in the water. Statistical analysis was carried out at the significance level α=0.05. This was a cross-sectional study. RESULTS A positive effect of water exercises on a number of parameters was found in patients with OA both before and after total hip replacement surgery. We noted a significant reduction of pain (p<0.001), increased ranges of motion and muscle strength, and reduced use of medicines (NASAIDs) (p<0.001). A correlation was found between the degree of degenerative deforming lesions and the effects of the treatment process (p<0.01). CONCLUSIONS 1. The rehabilitation program including water exercises most significantly reduced pain in patients with OA before and after total hip replacement surgery. 2. Inclusion of water exercises in a rehabilitation program can reduce the use of medicines in patient with OA and after THR.

Relationships between personality traits, resting serum hormones and visuomotor ability in male judokas.

INTRODUCTION: The purpose of this research was to study the relationships between selected personality features, the speed and accuracy of visumotor ability and hormonal status in the blood of male judokas. MATERIALS AND METHOD: Forty-five male judokas whose body mass ranged from 66-100 kg were included in the study. Each one was examined once during a single annual competitive season lasting from March-October. The protocol of the study comprised five procedures carried out in the following order: (a) capillary blood sampling in the morning (07:30), (b) second capillary blood sampling directly prior to the personality examination, (c) examination of the personality traits, (d) testing of visuo-motor ability with the use of an electronic cross-shape electronic device, (e) third capillary blood sampling after the entire study. The entire study started and ended in the morning. For each subject, the three serum samples were pooled and the levels of cortisol (C) and testosterone (T) were determined in the serum specimen. RESULTS: There were significant correlations among the scores in selected personality traits, anxiety (A), neuroticism (N), extraversion (E), perseveration (P), emotional reactivity (ER) and achievement motivation (AM). The C level did not correlate with any variables, however, it did positively correlate with E and visuo-motor ability. There were inverse relationships between E and A, N, P and ER. CONCLUSIONS: The study confirmed relationships in the androgenic status in circulation, personality traits and psycho-motor abilities.

Chondroitin - application in the treatment of degenerative joint disease.

Chondroitin is an organic compound, belonging to the group of glycosaminoglycans. In the treatment of degenerative joint disease, aka osteoarthritis, chondroitin sulphate is applied as a medicine or a dietary supplement. The biological importance of chondroitin sulphate has been already largely determined. The newest data on glycobiology research suggest that proteoglycans, as well as their complex polysaccharide macroparticles not only are the structural elements, but also they participate in multiple metabolic processes at a molecular level as well as in the physiological processes, regulating this type of mechanisms. The preparations applied in the treatment of degenerative joint disease, containing chondroitin sulphate, are attributed numerous therapeutic and chondroprotective properties including stabilizing synthesis processes and cartilage degradation through stimulation and inhibition of chondrocyte apoptosis (production of the elements of the intracellular substance and osteocyte stimulation), an increased proteoglycan and hyaluronic acid biosynthesis, inhibition of the activity of proteolytic enzymes and hyaluronidase, reduction of inflammatory mediators (prostaglandins and leukotrienes) and a decreased collagen II degradation. Based on the results of the multidirectional research available in the newest source literature, the analysis of the therapeutic efficacy and safety of chondroitin application in the treatment of degenerative joint disease was conducted.