Chronic Gastro-Duodenal Ulcerative Disease and the Death of Father Stephan Schätzl from Viechtwang (Austria).

Stephan Schätzl was the parish priest of Viechtwang, Upper Austria. He lived in the aftermath of the Peace of Augsburg in a period of schism between Roman Catholics and Lutherans. His portrait, depicted only 6 days before his demise in 1590, shows that he had extreme ante mortem cachexia. Documentary sources detailed his life and ill-health and it is proposed that he had chronic gastro-duodenal ulcerative disease which ultimately led his to death.

Subchondral bone in osteoarthritis: association between MRI texture analysis and histomorphometry.

OBJECTIVE: Magnetic resonance imaging (MRI) texture analysis is a method of analyzing subchondral bone alterations in osteoarthritis (OA). The objective of this study was to evaluate the association between MR texture analysis and ground-truth subchondral bone histomorphometry at the tibial plateau. DESIGN: The local research ethics committee approved the study. All subjects provided written, informed consent. This was a cross-sectional study carried out at our institution between February and August 2014. Ten participants aged 57-84 with knee OA scheduled for total knee arthroplasty (TKA) underwent pre-operative MRI of the symptomatic knee at 3T using a high spatial-resolution coronal T1 weighted sequence. Tibial plateau explants obtained at the time of TKA underwent histological preparation to allow calculation of bone volume fraction (BV.TV), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp) and trabecular number (Tb.N). Texture analysis was performed on the tibial subchondral bone of MRI images matched to the histological sections. Regression models were created to assess the association of texture analysis features with BV.TV, Tb.Th, Tb.Sp and Tb.N. RESULTS: MRI texture features were significantly associated with BV.TV (R2 = 0.76), Tb.Th (R2 = 0.47), Tb.Sp (R2 = 0.75) and Tb.N (R2 = 0.60, all P < 0.001). Simple gray-value histogram based texture features demonstrated the highest standardized regression coefficients for each model. CONCLUSION: MRI texture analysis features were significantly associated with ground-truth subchondral bone histomorphometry at the tibial plateau.

The Norwich Patellar Instability Score: Validity, internal consistency and responsiveness for people conservatively-managed following first-time patellar dislocation.

BACKGROUND: This paper assessed the validity, internal consistency, responsiveness and floor-ceiling effects of the Norwich Patellar Instability (NPI) Score for a cohort of conservatively managed people following first-time patellar dislocation (FTPD). METHODS: Fifty patients were recruited, providing 130 completed datasets over 12 months. The NPI Score, Lysholm Knee Score, Tegner Level of Activity Score and isometric knee extension strength were assessed at baseline, six weeks, six and 12 months post-injury. RESULTS: There was high convergent validity with a statistically significant correlation between the NPI Score and the Lysholm Knee Score (p<0.001), Tegner Level of Activity Score (p<0.001) and isometric knee extension strength (p<0.002). Principal component analysis revealed that the NPI Score demonstrated good concurrent validity with four components account for 70.4% of the variability. Whilst the NPI Score demonstrated a flooring-effect for 13 of the 19 items, no ceiling effect was reported. There was high internal consistency with a Cronbach Alpha value of 0.93 (95% CI: 0.91 to 0.93). The NPI Score was responsive to change over the 12 months period with an effect size of 1.04 from baseline to 12 months post-injury. CONCLUSIONS: The NPI Score is a valid tool to assess patellar instability symptoms in people conservatively managed following FTPD. LEVEL OF EVIDENCE: Level II.

Detecting new microRNAs in human osteoarthritic chondrocytes identifies miR-3085 as a human, chondrocyte-selective, microRNA.

OBJECTIVE: To use deep sequencing to identify novel microRNAs (miRNAs) in human osteoarthritic cartilage which have a functional role in chondrocyte phenotype or function. DESIGN: A small RNA library was prepared from human osteoarthritic primary chondrocytes using in-house adaptors and analysed by Illumina sequencing. Novel candidate miRNAs were validated by northern blot and qRT-PCR. Expression was measured in cartilage models. Targets of novel candidates were identified by microarray and computational analysis, validated using 3'-UTR-luciferase reporter plasmids. Protein levels were assessed by western blot and functional analysis by cell adhesion. RESULTS: We identified 990 known miRNAs and 1621 potential novel miRNAs in human osteoarthritic chondrocytes, 60 of the latter were expressed in all samples assayed. MicroRNA-140-3p was the most highly expressed microRNA in osteoarthritic cartilage. Sixteen novel candidate miRNAs were analysed further, of which six remained after northern blot analysis. Three novel miRNAs were regulated across models of chondrogenesis, chondrocyte differentiation or cartilage injury. One sequence (novel #11), annotated in rodents as microRNA-3085-3p, was preferentially expressed in cartilage, dependent on chondrocyte differentiation and, in man, is located in an intron of the cartilage-expressed gene CRTAC-1. This microRNA was shown to target the ITGA5 gene directly (which encodes integrin alpha5) and inhibited adhesion to fibronectin (dependent on alpha5beta1 integrin). CONCLUSION: Deep sequencing has uncovered many potential microRNA candidates expressed in human cartilage. At least three of these show potential functional interest in cartilage homeostasis and osteoarthritis (OA). Particularly, novel #11 (microRNA-3085-3p) which has been identified for the first time in man.

The surgical treatment of anterior knee pain due to infrapatellar fat pad pathology: A systematic review.

BACKGROUND: Anterior knee pain (AKP) encompasses a range of pathologies. As a result, there are a number of therapeutic options used to treat AKP. The non-operative treatments have been analysed in a number of randomised controlled trials and systematic reviews. There is however a scarcity of such publications covering the surgical management of AKP. There are no systematic reviews that have investigated surgical interventions for AKP due to pathology of the infrapatellar fat pad (IFP). The aims of this study were to review the literature systematically, to establish which surgical procedures have been used to treat IFP disease and to determine their efficacy. METHODS: The review was conducted in accordance with the PRISMA reporting guidelines. A search of the literature was performed on 1st January 2014 using multiple databases including CENTRAL, MEDLINE, EMBASE, PubMed, and Google Scholar. The quality of the studies was assessed using Oxford Evidence-Based Medicine Levels of Evidence guidelines and the GRADE approach. RESULTS: Twenty-four eligible studies were found and included. The critical appraisal identified that the current evidence-base has low methodology quality. The clinical findings indicated that there is a positive trend towards the surgical management of IFP disease for AKP symptoms. Excision of IFP tumours and resection of the IFP in Hoffa's disease can lead to improvements in symptoms and function. CONCLUSIONS: Truly robust evidence to support the surgical management of IFP pathology requires randomised controlled trials; however the expenses involved to design such trials means that they are unlikely to be undertaken for this uncommon disorder. Consequently well-designed and well-reported case series need to be undertaken to improve our current understanding that includes recording quantitative measures such as range of knee motion, VAS Pain scores and a validated scoring system.

Rehabilitation following first-time patellar dislocation: a randomised controlled trial of purported vastus medialis obliquus muscle versus general quadriceps strengthening exercises.

BACKGROUND: We aimed to define whether distal vastus medialis (VM) muscle strengthening improves functional outcomes compared to general quadriceps muscle strengthening following first-time patellar dislocation (FTPD). METHODS: Fifty patients post-FTPD were randomised to either a general quadriceps exercise or rehabilitation programme (n=25) or a specific-VM exercise and rehabilitation regime (n=25). The primary outcome was the Lysholm knee score, and secondary outcomes included the Tegner Level of Activity score, the Norwich Patellar Instability (NPI) score, and isometric knee extension strength at various knee flexion ranges of motion. Outcomes were assessed at baseline, six weeks, six months and 12months. RESULTS: There were statistically significant differences in functional outcome and activity levels with the Lysholm knee score and Tegner Level of Activity score at 12months in the general quadriceps exercise group compared to the VM group (p=0.05; 95% confidence interval (CI): -14.0 to 0.0/p=0.04; 95% CI: -3.0 to 0.0). This did not reach a clinically important difference. There was no statistically significant difference between the groups for the NPI score and isometric strength at any follow-up interval. The trial experienced substantial participant attrition (52% at 12months). CONCLUSIONS: Whilst there was a statistical difference in the Lysholm knee score and Tegner Level of Activity score between general quadriceps and VM exercise groups at 12months, this may not have necessarily been clinically important. This trial highlights that participant recruitment and retention are challenges which should be considered when designing future trials in this population. LEVEL OF EVIDENCE: Therapeutic study, Level I.

Trochlear boss height measurement: a comparison of radiographs and MRI.

BACKGROUND: A key anatomical consideration and determinant of surgical approach in trochlear dysplasia is the trochlear boss height (TBH), traditionally defined by measurements on plain X-rays (XR). Magnetic resonance (MR) imaging is increasingly used for pre-operative planning and follow-up. However, it is unclear whether measurement of TBH on XR is applicable to MR. The aim of this study was to establish the reliability of TBH measurement on MR compared to XR. METHODS: This study used lateral knee radiographs and MR scans of 14 knees of patients with trochlear dysplasia, six knees of non-dysplastic patients with anterior knee pain (AKP), and five knees of non-dysplastic controls with no AKP. Correlation between XR and MR measurements was assessed using Pearson correlation coefficients. Agreement between methods and observers was assessed using Bland-Altman plots with 95% limits of agreement. Intra- and inter-observer reliability was assessed using intraclass correlation coefficients (ICC). RESULTS: Bland-Altman charts showed a total width of 95% limits of agreement of 4.78 mm for XR and MR subchondral bone (SB) TBH measurements, and 6.73 mm for XR and MR cartilage TBH measurements. Inter-observer ICCs were 0.86 for XR, 0.62 for MR SB, and 0.53 for MR cartilage. The widths of the Bland-Altman 95% limits of agreement between observers were 4.79 mm (XR), 5.04 mm (MR SB) and 4.74 mm (MR cartilage). CONCLUSION: Measurement of TBH on MR is not directly interchangeable with XR. Adjustments need to be made to treatment thresholds based on XR measurement if MR is used instead.

Does knee joint proprioception alter following medial patellofemoral ligament reconstruction?

BACKGROUND: This study firstly aimed to determine whether proprioception deficits, as measured by joint position sense (JPS), occur in people following recurrent patellar dislocations. Secondly, to determine whether JPS changes following medial patellofemoral ligament reconstruction (MPFL) reconstruction for patellar instability. METHODS: Thirty people following recurrent patellar dislocation were recruited. Pre-operative JPS was assessed using the passive angle reproduction test. Through this, an assessor moved a participant's limb to a target position. This was returned to neutral, before finally moving the limb again, whilst requiring the participant to indicate when they thought the target angle was reached. The actual angular error (AAE) was calculated as the difference between the perceived angle and target angle. Clinical outcomes included the Kujala Patellofemoral Disorder Score, the International Knee Documentation Committee (IKDC) form, pain, knee motion, extensor muscle strength and frequency of patellar dislocation. Outcomes were assessed pre-operative, 6 weeks, 3 and 12 months. RESULTS: Mean AAE was 2.2° (inner range) to 3.9° (mid-range); this was not clinically significant. There was no statistically significant difference between the baseline-and-6 week, 6 week-and-3 month or baseline-and-12 month AAE measures (p=0.38 to 1.00). There was a statistically significant improvement in functional outcomes as measured by the Kujala score, IKDC form, reduced pain and increased extension strength from baseline to 12 months (p<0.01). CONCLUSIONS: Following recurrent patellar dislocation, patients exhibit minimal deficits in JPS. Whilst MPFL reconstruction significantly improved clinical and functional outcomes for this population, this operation did not significantly alter JPS during the first post-operative year.

Serial magnetic resonance imaging of metal-on-metal total hip replacements. Follow-up of a cohort of 28 mm Ultima TPS THRs.

Metal artefact reduction (MAR) MRI is now widely considered to be the standard for imaging metal-on-metal (MoM) hip implants. The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended cross-sectional imaging for all patients with symptomatic MoM bearings. This paper describes the natural history of MoM disease in a 28 mm MoM total hip replacement (THR) using MAR MRI. Inclusion criteria were patients with MoM THRs who had not been revised and had at least two serial MAR MRI scans. All examinations were reported by an experienced observer and classified as A (normal), B (infection) or C1-C3 (mild, moderate, severe MoM-related abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed on 80 patients (two to four scans per THR); 63 initial MRIs (61%) were normal. On subsequent MRIs, six initially normal scans (9.5%) showed progression to a disease state; 15 (15%) of 103 THRs with sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision have normal MRI scans. Late progression (from normal to abnormal, or from mild to more severe MoM disease) is not common and takes place over several years.

The intra- and inter-rater reliability of X-ray radiological measurements for patellar instability.

AIM: Patellar instability is a complex, multi-factorial disorder. Radiological assessment is regarded as an important part of the management of this population. The purpose of this study was to determine the intra- and inter-rater reliability of common radiological measurements used to evaluate patellar instability. METHODS AND MATERIALS: One hundred and fifty X-rays from 51 individuals were reviewed by five reviewers, two orthopaedic trainees, a radiological trainee, a consultant radiologist and an orthopaedic physiotherapist. Radiological measurements assessed included patellar shape, sulcus angle, congruence angle, lateral patellofemoral angle, lateral patellar displacement (LPD), lateral displacement measurement (LDM), boss height, and patellar height ratios. All assessors were provided with a summary document outlining the method of assessing each measurement. No further formal teaching was provided. Bland-Altman analyses were adopted to assess intra- and inter-rater reliability. RESULTS: The results indicated generally low measurement error on intra-rater reliability assessment, particularly for LPD, LDM and boss height measurements. Whilst the inter-rater reliability between assessors indicated a low mean difference for assessments of patellar height measurements, patellar angle, lateral patellar dislocation and lateral displacement, wide 95% limits of agreement for all measurements indicated poor precision. CONCLUSION: Many of the standard measurements used to assess the patellofemoral joint on plain radiographs have poor precision. Intra-rater reliability may be related to experience but it seems likely that to achieve good inter-rater reliability, specific training may be required to calibrate observers. More formal training in the technique of radiological measurement for those who were inexperienced might have improved the inter-rater reliability.

Current concepts in osteolysis.

The most frequent cause of failure after total hip replacement in all reported arthroplasty registries is peri-prosthetic osteolysis. Osteolysis is an active biological process initiated in response to wear debris. The eventual response to this process is the activation of macrophages and loss of bone. Activation of macrophages initiates a complex biological cascade resulting in the final common pathway of an increase in osteolytic activity. The biological initiators, mechanisms for and regulation of this process are beginning to be understood. This article explores current concepts in the causes of, and underlying biological mechanism resulting in peri-prosthetic osteolysis, reviewing the current basic science and clinical literature surrounding the topic.

MRI of asymptomatic patients with metal-on-metal and polyethylene-on-metal total hip arthroplasties.

AIMS: To define and compare magnetic resonance imaging (MRI) findings of asymptomatic patients with metal-on-metal (MOM) and polyethylene-on-metal (POM) total hip replacements (THRs). MATERIALS AND METHODS: Twenty-two THRs in 20 asymptomatic patients (seven men, 13 women, mean age 68 years, range 47-86 years) with normal hip radiographs were included in the study. These comprised 10 POM and 12 MOM bearings. Each patient underwent MRI with metal artefact reduction sequences (MARS) at a mean time of 46 months (POM) and 70 months (MOM) after surgery. Two musculoskeletal radiologists independently read each MRI examination for fluid collections, soft-tissue masses, muscle atrophy, and bone marrow signal changes. RESULTS: A pre-MRI hip radiograph showed no significant differences from the postoperative radiograph regarding acetabular inclination, femoral stem angle, and stem mantle grade. There were eight periprosthetic collections (one POM, seven MOM). The majority of THRs had normal gluteal muscles. The ipsilateral piriformis and obturator internus muscles were more frequently abnormal in the MOM group. Overall, there were no significant differences in the number of abnormalities between the two types of bearings. CONCLUSION: A range of MRI abnormalities are present in normal asymptomatic THRs but the increased frequency of these associated with MOM THR suggest that some of these changes might represent subclinical disease.

A review of how to conduct a surgical survey using a questionnaire.

Health surveys using questionnaires facilitate the acquisition of information on the knowledge, behaviour, attitudes, perceptions and clinical history of a selected population. Their internal and external validities are threatened by poor design and low response rates. Numerous studies have investigated survey design and administration but care should be taken when generalising findings in different clinical and cultural settings. The current evidence-base suggests that no single mode of survey administration, such as postal, electronic or telephone, is superior to another. Whilst there is no evidence of an ideal response rate relationship to survey validity, response rates can be enhanced by including monetary incentives, providing a time cue, and repeat contact with non-responders. Unlike other modes of experimental data collection, few guidelines currently exist for survey and questionnaire design and response rate should not be considered a direct measure of a survey's quality.