Musculoskeletal Research Research Articles

Acknowledging tissue donation: Human cadaveric specimens in musculoskeletal research.

Human cadaveric specimens are an important resource for research, particularly in biomechanical studies, but their use also raises ethical questions and cannot simply be taken for granted. It was asked how much information authors publishing musculoskeletal research actually give about such specimens and about how they were acquired. The aim was to formulate recommendations on how this reporting might be improved. Relevant articles published between 2009 and 2012 in four North American or European journals were scanned for information regarding the characteristics of the human specimens used, their institutional source and the ethical or legal context of their acquisition. While the majority of articles report biological characteristics of specimens (sex, age at death, preservation method), only 40% of articles refer to body donation, only 23% report the institution that provided specimens, and only 17% refer to some kind of formalized approval of their research. There were regional and journal-to-journal differences. No standard for reporting studies involving human specimens could be detected. It is suggested that such a standard be developed by researchers and editors. Information on the source of specimens and on the ethical or legal basis should be regularly reported to acknowledge this unique research resource and to preserve the good relationship between researchers and the communities, that provide the required specimens by body donation and upon which researchers depend.

Development of mRuby2-Transfected C3H10T1/2 Fibroblasts for Musculoskeletal Tissue Engineering.

Mouse C3H10T1/2 fibroblasts are multipotent, mesenchymal stem cell (MSC)-like progenitor cells that are widely used in musculoskeletal research. In this study, we have established a clonal population of C3H10T1/2 cells stably-transfected with mRuby2, an orange-red fluorescence reporter gene. Flow cytometry analysis and fluorescence imaging confirmed successful transfection of these cells. Cell counting studies showed that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells proliferated at similar rates. Adipogenic differentiation experiments demonstrated that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells stained positive for Oil Red O and showed increased expression of adipogenic genes including adiponectin and lipoprotein lipase. Chondrogenic differentiation experiments demonstrated that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells stained positive for Alcian Blue and showed increased expression of chondrogenic genes including aggrecan. Osteogenic differentiation experiments demonstrated that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells stained positive for alkaline phosphatase (ALP) as well as Alizarin Red and showed increased expression of osteogenic genes including alp, ocn and osf-1. When seeded on calcium phosphate-based ceramic scaffolds, mRuby2-transfected C3H10T1/2 cells maintained even fluorescence labeling and osteogenic differentiation. In summary, mRuby2-transfected C3H10T1/2 cells exhibit mRuby2 fluorescence and showed little-to-no difference in terms of cell proliferation and differentiation as untransfected C3H10T1/2 cells. These cells will be available from American Type Culture Collection (ATCC; CRL-3268™) and may be a valuable tool for preclinical studies.

Internal Derangements of Joints-Past, Present, and Future.

The past 50 years have transformed imaging of the joints. Whereas musculoskeletal imaging consisted predominantly of conventional radiography when Investigative Radiology was founded as a journal, the arrival of new imaging modalities, and above all, the introduction of magnetic resonance imaging, resulted in a paradigm shift: In addition to visualizing osseous structures, now the detailed depiction of soft tissue structures became part of routine clinical imaging and had a major impact on understanding pathophysiology and patient treatment. This article analyzes the patterns of innovation that were essential for the transformation of musculoskeletal radiology. Furthermore, state-of- the-art joint imaging is described through 9 key concepts, including both cutting-edge clinical applications as well as topics at the forefront of musculoskeletal research. Eventually, emerging trends are outlined that will likely shape musculoskeletal radiology in the next decades.

Setting the research agenda for improving health care in musculoskeletal disorders.

Despite a substantial contribution to the global burden of disease, musculoskeletal conditions are under-represented in clinical research, and that which is performed is often wasteful and lacking clinical relevance. Even clinically relevant musculoskeletal research might not lead to timely or adequate changes in clinical practice and associated improvements in patient outcomes. The formulation of clinical recommendations alone is usually insufficient to bring about changes in practice patterns. Research exploring how to improve the translation of evidence-based recommendations into practice, as well as the identification and removal of barriers to practice change, is necessary in order for the promise of musculoskeletal research to be realized in improved health outcomes. These goals can be achieved by improvements in the coordination of research activities, the resourcing and allocation of funding, and the involvement of clinicians and patients.

A Practice-Focused Overview of Methods to Assess Obesity Before Arthroplasty.

Musculoskeletal CareVolume 13, Issue 4 p. 258-263 Short Report A Practice-Focused Overview of Methods to Assess Obesity Before Arthroplasty Ladan Sahafi BSci, MEngSci, Corresponding Author Ladan Sahafi BSci, MEngSci Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia Department of Orthopaedics, Flinders Medical Centre, Flinders Drive, Adelaide, Australia International Musculoskeletal Research Institute, Daw Park, Adelaide, Australia Correspondence Ladan Sahafi, Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia. Email: [email protected]Search for more papers by this authorDonald Bramwell BSc (Hons) (ExpThPhys), BSc (Elec Eng), GradDip SciComms, Donald Bramwell BSc (Hons) (ExpThPhys), BSc (Elec Eng), GradDip SciComms International Musculoskeletal Research Institute, Daw Park, Adelaide, AustraliaSearch for more papers by this authorMelanie Harris PhD, MEd, Melanie Harris PhD, MEd Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, AustraliaSearch for more papers by this authorJegan Krishnan MBBS, PhD, FRACS, Jegan Krishnan MBBS, PhD, FRACS Department of Orthopaedics, Flinders Medical Centre, Flinders Drive, Adelaide, AustraliaSearch for more papers by this authorMalcolm Battersby PhD, FRANZCP, FAChAM, MBBS, Malcolm Battersby PhD, FRANZCP, FAChAM, MBBS Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, AustraliaSearch for more papers by this author Ladan Sahafi BSci, MEngSci, Corresponding Author Ladan Sahafi BSci, MEngSci Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia Department of Orthopaedics, Flinders Medical Centre, Flinders Drive, Adelaide, Australia International Musculoskeletal Research Institute, Daw Park, Adelaide, Australia Correspondence Ladan Sahafi, Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia. Email: [email protected]Search for more papers by this authorDonald Bramwell BSc (Hons) (ExpThPhys), BSc (Elec Eng), GradDip SciComms, Donald Bramwell BSc (Hons) (ExpThPhys), BSc (Elec Eng), GradDip SciComms International Musculoskeletal Research Institute, Daw Park, Adelaide, AustraliaSearch for more papers by this authorMelanie Harris PhD, MEd, Melanie Harris PhD, MEd Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, AustraliaSearch for more papers by this authorJegan Krishnan MBBS, PhD, FRACS, Jegan Krishnan MBBS, PhD, FRACS Department of Orthopaedics, Flinders Medical Centre, Flinders Drive, Adelaide, AustraliaSearch for more papers by this authorMalcolm Battersby PhD, FRANZCP, FAChAM, MBBS, Malcolm Battersby PhD, FRANZCP, FAChAM, MBBS Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, AustraliaSearch for more papers by this author First published: 15 June 2015 https://doi.org/10.1002/msc.1109Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Volume13, Issue4December 2015Pages 258-263 RelatedInformation

Foreword: Calcified Tissue International and Musculoskeletal Research Special Issue: Bone Material Properties and Skeletal Fragility.

Skeletal fragility, and to a large extent the risk of fracture, is dependent on three general properties of a bone: the amount of bone (mass), the way the mass is distributed (architecture/geometry), and the material properties (characteristics of the mineral, collagen, non-collagenous proteins, skeletal hydration, and interaction among these constituents) of the tissue that compose the bone (Figure 1). Of these three broad characteristics, bone mass has received the greatest attention as a predictor of fracture in large part because it is the easiest to measure in a clinical setting. DEXA measurements of bone mineral density (BMD) have become the standard measure of skeletal health, and alone is used as the definition for pathology: one is diagnosed with osteoporosis if the BMD is greater than 2.5 standard deviations below the young adult mean for a Caucasian woman, regardless of other compensatory characteristics of the bone that may offset the lower BMD. Even so, most scientists who study bone understand the importance of architecture, both the connectivity of the trabecular lattice, as well as the importance of cortical width, thickness, and porosity to bone's rigidity. Architectural features are not completely independent of bone mass (eg loss of bone will affect trabecular connectivity), but can be (section modulus can increase even as bone mass declines). Thus, BMD does not provide a complete picture of fracture risk. Moreover, architectural features are more difficult to measure in a clinical setting and only recently have they been utilized, in combination with BMD, to try to assess fracture risk. One example of this is the recent use of the trabecular bone score (TBS), which integrates trabecular texture analysis with BMD values.

Targeted intervention for patellofemoral pain (TIPPS): identifying potential clinical subgroups

Background: Patellofemoral pain (PFP) is a specific musculoskeletal disorder that causes significant pain and dysfunction around the knee cap and knee joint, which can lead to long term limitation in societal participation and physical activity. There is a consensus that conservative intervention should be the first treatment option so PFP is a condition that is commonly referred for physiotherapy. Unfortunately, however, current multi modal approaches to intervention in PFP are failing in the long term. Purpose: Given the poor outcome of current treatment regimens, identification of patellofemoral subgroups is an international priority. Large individual variation in outcome results is consistently reported in response to conservative management, therefore understanding whether subgroups have different outcomes has become imperative. However it is unknown whether subgrouping is possible in PFP. The main purpose of this study was to describe the distribution of PFP patients into different subgroups using six routine clinical assessment test criteria. Methods: Design: Cross-sectional with single point assessment prior to commencement of physiotherapy. Participants with PFP underwent clinical assessment of muscle strength (quadriceps and hip abductor), muscle length (quadriceps, hamstrings, gastrocnemius), patellar mobility and foot posture. The presence of subgroups was explored using two classification techniques: Hierarchical Clustering and Latent Profile Analysis. Results: One hundred and twenty seven of 130 recruited participants had complete assessment data: 66% were female, mean (SD) age was 26 (5.7) years, BMI 25.5 (5.8), and Modified Functional Index Questionnaire (MFIQ) was 34 (17). A three subgroup solution appeared optimal from a modelling and clinical perspective. The three suggested clinical subgroups were characterised as: Strong subgroup (n = 44), weak and tight subgroup (n = 58), pronated feet subgroup (n = 25). An ANOVA and post hoc tests confirmed significant differences between subgroups. Strong subgroup: quadriceps strength 1.5 Nm/kg (0.51), hip abductor strength 1.5 Nm/kg (0.51), lowest patellar mobility of the three groups 9.6 mm (3.43). Weak and tight subgroup: hip abductor strength 0.7 Nm/kg (0.27), shortest quadriceps length 118° (17.9). Pronated feet subgroup: highest FPI 7 (3.0), highest patellar mobility 17.6 mm (4.75). Conclusion(s): This study is the largest conducted to date on subgrouping of PFP. The results lend support to the idea that clinical subgroups exist within the patellofemoral population, with three potential subgroups emerging. The key clinical tests for identifying the three subgroups are strength measurement of the quadriceps and hip abductors, and foot posture index. Patellar mobility and quadriceps flexibility contributed to subgroup profiles, so also appear important to consider when identifying PFP subgroups. Implications: These results fit well with other findings in musculoskeletal research where subgrouping has been successful in informing targeted intervention in low back pain patients and is being increasingly adopted as a strategy for managing patients with shoulder problems. Our next step is explore variation in outcome across the identified PFP subgroups and whether subgroup targeted intervention improves overall patient outcomes.

286. Pilot Study of Multispectral Imaging to Measure Skin Oxygenation in Healthy Controls and Patients with Systemic Sclerosis and Primary Raynaud’s Phenomenon

Ian Poxon, Jack Wilkinson, Tonia Moore, Joanne Manning, Mark Dickinson, Ariane Herrick and Andrea Murray Photon Science Institute, University of Manchester, Manchester, Research and Development, Directorate of Rheumatology, Salford Royal Hospital NHS Foundation Trust, Salford and Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK

040. Combining Lifestyle and Metabolic Predictors of Incident Inflammatory Polyarthritis in the Epic-2-Noar Study

Jamie C. Sergeant, Suzanne M. M. Verstappen, Catharine Morgan, Robert N. Luben, Amit Bhaniani, Serena Anuj, RA-MAP consortium, Alex J. MacGregor, Nick Wareham, Deborah P. M. Symmons, Kay-Tee Khaw and Ian N. Bruce Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge and Norwich Medical School, University of East Anglia, Norwich, UK

A computational approach to detect and segment cytoplasm in muscle fiber images.

We developed a computational approach to detect and segment cytoplasm in microscopic images of skeletal muscle fibers. The computational approach provides computer-aided analysis of cytoplasm objects in muscle fiber images to facilitate biomedical research. Cytoplasm in muscle fibers plays an important role in maintaining the functioning and health of muscular tissues. Therefore, cytoplasm is often used as a marker in broad applications of musculoskeletal research, including our search on treatment of muscular disorders such as Duchenne muscular dystrophy, a disease that has no available treatment. However, it is often challenging to analyze cytoplasm and quantify it given the large number of images typically generated in experiments and the large number of muscle fibers contained in each image. Manual analysis is not only time consuming but also prone to human errors. In this work we developed a computational approach to detect and segment the longitudinal sections of cytoplasm based on a modified graph cuts technique and iterative splitting method to extract cytoplasm objects from the background. First, cytoplasm objects are extracted from the background using the modified graph cuts technique which is designed to optimize an energy function. Second, an iterative splitting method is designed to separate the touching or adjacent cytoplasm objects from the results of graph cuts. We tested the computational approach on real data from in vitro experiments and found that it can achieve satisfactory performance in terms of precision and recall rates.

O30. Raising Teenagers’ Awareness of Musculoskeletal Health Through Lifelab: A Collaboration Between School Students, Teachers and Clinical Academic Researchers.

Background: Musculoskeletal (MSK) disease is the major cause of years lived with disability in the UK. The UK is behind other comparable countries in confronting consequences of long-term diseases. One potentially effective approach is by educating people to become more health literate. Early life interventions relating to exercise and good MSK health practices may be an effective addition to traditional approaches. LifeLab is a science-based approach to improving teenagers’ health-related attitudes and behaviour. The LifeLab approach was developed at the University of Southampton and combines educationalists, scientists, clinical researchers and school children and has been effective in improving young peoples’ understanding of the nature of diseases and reasoning about health issues. However, no specific MSK health education components have previously been included in LifeLab. Methods: In 2014 the first MSK LifeLab workshop was designed with educationalists and researchers in biomechanics, occupational therapy, podiatry, and physiotherapy from the MSK Research Cluster at Southampton for year 8 (age 12-13) school students. The workshops aimed to promote young peoples’ health literacy in musculoskeletal health and integrated experiential learning using 3D motion analysis, real-time ultrasound scanning of muscles contracting; radiographs of normal and osteoarthritis foot joints; anatomy models and hand and hip joint implants. The workshops covered a) the impact of osteoarthritis joint disease on daily life b) capturing and illustrating joint movement using state of the art 3D motion analysis technology and c) an in-depth look at muscles using ultrasound imaging. Learning objectives included students being able to: 1. Identify key components of active healthy living for bones, muscles and joints 2. Observe patterns in how healthy joints can move and contrast patterns with injured joint movement 3. Discover what role muscles play in healthy joints 4. Compare healthy joint structures with arthritic joint structures Results: 58 students from 3 state secondary schools, attended a university widening participation outreach day within which the MSK LifeLab workshop was run. On the same day the students also attended workshops in Humanities and Oceanography. When asked which workshop of the outreach day was their favourite 43 % of the students identified the MSK workshops. Feedback on why the workshops were enjoyable included; “I enjoyed biomechanics because I like looking at how things work and move”; “Ostioarphritus. I'm into sports & find the body interesting”; “The bones because you got to find out about the body”. The interactive nature of the workshop with teenagers having hands on learning was also well received “My favourite was bones because they made it fun”; “The bones experiments because the technology involved was awesome.” Conclusions: Using interactive MSK workshops as part of LifeLab presents an exciting health literacy approach to encourage young people to start to engage in understanding their MSK health. Acknowledgements: These are not included in the abstract but will appear if we get a paper accepted. LifeLab, has been developed as a joint initiative, involving, in addition to the University of Southampton and the University Hospital Southampton NHS Foundation Trust; the MRC Lifecourse Epidemiology Unit, the University of Southampton (UoS) Faculty of Medicine and Southampton Education School, the Mathematics and Science Learning Centre (MSLC), the NIHR Southampton Biomedical Research Centre and the Garfield Weston Foundation. KWT is supported by the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre Some facilities and personnel in the MSK Research Cluster are funded by Arthritis Research UK.

How can we assess the burden of muscle, bone and joint conditions in rural Botswana: context and methods for the MuBoJo focused ethnography

BackgroundMusculoskeletal diseases are the most common causes of long-term pain and disability worldwide and a growing international public health concern. However, the everyday burden and impact of musculoskeletal conditions are not well understood, especially among people living in low- and middle-income countries in Africa. Since 2011, World Spine Care, a nongovernmental organisation, has collaborated with the Botswana Ministry of Health to open spine care centres and to conduct research. The broad aim of the Muscle, Bone and Joint (MuBoJo) research project is to examine the sociocultural, organisational and clinical characteristics for the burden of living with and caring for people living with musculoskeletal conditions in rural Botswana. In this paper, we describe the community context, theoretical framework, and research methods to address the project aim with a qualitative study.Methods/DesignThis focused ethnography is based on eight months (November 2011, April 2013, October 2013-March 2014) of fieldwork in Botswana. The project was theoretically informed by the concepts of explanatory models of illness, social suffering, and biographical disruption. Data collection included fieldnotes, non-participant and participant observations, and informal and in-depth interviews with villagers and healthcare providers. Villager interviews were typically conducted in Setswana with an interpreter. Audio recordings were transcribed verbatim in the language spoken with Setswana contextually translated into English. Computer software supported qualitative data management. Analysis is ongoing using constant comparison and a template organising style to facilitate pattern-finding and reveal insights for the burden and care of musculoskeletal conditions.DiscussionFindings from the MuBoJo Project will document the context of musculoskeletal burden, illness beliefs, self-care behaviours, and healthcare options in a Botswana rural village. These data will inform ongoing efforts to establish spine care clinics for underserved populations in low-middle income countries and sustain these healthcare services through local providers and volunteer health professionals. This study also will generate new knowledge about the burden and impact of muscle, bone and joint disorders for cross-cultural comparisons and patient-centred interventions.ConclusionsOur systematic and transparent methodology to conduct musculoskeletal research in more than one language and in a cross-cultural setting may be useful for investigators and NGO healthcare personnel.Electronic supplementary materialThe online version of this article (doi:10.1186/s12998-015-0056-9) contains supplementary material, which is available to authorized users.

Combined musculoskeletal pain in the upper and lower body: associations with occupational mechanical and psychosocial exposures.

Pain in more than one site is common in working populations. We aimed to characterise combined pain (pain in the upper and lower body) and to evaluate whether the prevalence of combined pain is positively related to combined occupational mechanical exposures to the upper and lower body and to high psychosocial job strain. This cross-sectional study was based on questionnaire data from the Musculoskeletal Research Database at the Danish Ramazzini Centre. The study included 14,081 men and 20,173 women. Occupational exposures were assessed by job exposure matrices. We analysed the prevalence of pain limited to the upper body, pain limited to the lower body, and combined pain in relation to occupational exposures using Poisson regression. During the last year, 23.2 % of the men and 33.9 % of the women reported combined pain, which was characterised by somatisation, illness worrying, and low SF-36 scores. For men, the adjusted prevalence ratio for combined pain was 1.51 [95 % confidence interval (95 % CI) 1.40-1.64] in relation to exposures limited to the upper body and 2.24 (95 % CI 2.11-2.39) in relation to combined exposures. For women, the corresponding adjusted prevalence ratios were 1.56 (95 % CI 1.50-1.63) and 1.55 (95 % CI 1.50-1.61). High job strain was related to pain among men, only. Combined pain may in part be explained by local effects of occupational mechanical exposures acting at more than one site.

Yrjö Tapio Konttinen 1952–2014

Yrjö Tapio Konttinen 1952–2014

Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders?

BackgroundMusculoskeletal rehabilitative care and research have traditionally been guided by a structural pathology paradigm and directed their resources towards the structural, functional, and biological abnormalities located locally within the musculoskeletal system to understand and treat Musculoskeletal Disorders (MSD). However the structural pathology model does not adequately explain many of the clinical and experimental findings in subjects with chronic MSD and, more importantly, treatment guided by this paradigm fails to effectively treat many of these conditions.DiscussionIncreasing evidence reveals structural and functional changes within the Central Nervous System (CNS) of people with chronic MSD that appear to play a prominent role in the pathophysiology of these disorders. These neuroplastic changes are reflective of adaptive neurophysiological processes occurring as the result of altered afferent stimuli including nociceptive and neuropathic transmission to spinal, subcortical and cortical areas with MSD that are initially beneficial but may persist in a chronic state, may be part and parcel in the pathophysiology of the condition and the development and maintenance of chronic signs and symptoms. Neuroplastic changes within different areas of the CNS may help to explain the transition from acute to chronic conditions, sensory-motor findings, perceptual disturbances, why some individuals continue to experience pain when no structural cause can be discerned, and why some fail to respond to conservative interventions in subjects with chronic MSD. We argue that a change in paradigm is necessary that integrates CNS changes associated with chronic MSD and that these findings are highly relevant for the design and implementation of rehabilitative interventions for this population.SummaryRecent findings suggest that a change in model and approach is required in the rehabilitation of chronic MSD that integrate the findings of neuroplastic changes across the CNS and are targeted by rehabilitative interventions. Effects of current interventions may be mediated through peripheral and central changes but may not specifically address all underlying neuroplastic changes in the CNS potentially associated with chronic MSD. Novel approaches to address these neuroplastic changes show promise and require further investigation to improve efficacy of currents approaches.

Gendered innovations in orthopaedic science: civil liberties, Darwin, and the evolution of science.

If an international colleague were to ask, I might sum up the history of American civil liberties like this: Slaves, women, and children are people, too. Strike that. Slaves, women, and children are persons, too. Nowadays, courts prefer persons over people. And hold on—a recent lawsuit [12] suggests chimps are persons too, as sentient beings who possess rights. How does this relate to orthopaedic science, or better yet, science in general? As it turns out, how we define people/persons is more legal than physical or metaphysical, in that it is determined by societal norms and collective thought. Our definitions float through the sea of humanity reflecting how we promote and improve musculoskeletal research and healthcare, and the greater body of science. Sadly, society dictates science. Charles Darwin, who struggled with the duality of the natural world before him and the spiritual upbringing so central to his core, also loved language and a pithy saying. On approaching science, he said one “… ought to have no wishes, no affections,—a mere heart of stone” [7]. Darwin viewed himself and his quest for knowledge, as “… turned into a sort of machine for observing facts and grinding out conclusions” [8]. Darwin viewed words as windows to both history and origin. This seminal way of thinking is blended with evolutionary doctrine and surmised from keen observations both of insects and the behavior of his (ch)impish children [13]. One of his more famous lines in the Origin of Species [6] upended the scientific world: “Man is descended from a hairy, tailed quadruped, probably arboreal in its habits.” This was well displayed in a cartoon of the times (Fig. 1). Fig. 1 A caricature of Charles Darwin as an ape published in The Hornet, a satirical magazine, in 1871. Darwin chose his words carefully, and sometimes playfully. The editors of this Journal have highlighted the importance of conscious and conscientious word choices when engaged in scientific reporting [15, 16]. In the spirit of careful word play and usage, I will share some etymologies that highlight the importance of the words we choose.

The 50 Most-cited Articles in Orthopaedic Surgery From Mainland China.

Citation analysis has been widely used to evaluate the impact of articles in medical and surgical specialties. Although China is the most populous country in the world, and although more than 50,000 orthopaedic surgeons practice there, to our knowledge no formal citation analysis of Chinese orthopaedic articles has been performed. We identified the 50 most-cited orthopaedic articles from mainland China and evaluated these articles in terms of their language of publication, source journals, and topics. Science Citation Index Expanded was searched in July 31, 2014 for citations of articles published in 70 selected journals since the inception of the database. The 50 most-cited orthopaedic articles originating in mainland China were identified. Basic information, including title, authors, year of publication, article type, journal in which the work was published, city, institution, number of citations, decade published, and topic or subspecialty of the research were recorded. The number of citations for the top 50 papers ranged from 181 to 31 (mean, 52). These articles were published between 1981 and 2010. The decade of 2000 to 2009 was the most prolific, with 36 of the top 50 articles published during this time. All articles were written in English and they were published in a total of 16 journals. The journal Spine published the largest number of articles (12), followed by Clinical Orthopaedics and Related Research (®) (seven). The journal Lancet had the highest impact factor (39.207 for 2013) among any of the journals that published articles we identified. The top 50 articles originated mainly from Beijing (16) and Shanghai (12), with basic research being the focus of the majority (27 of 50; 54%); the remaining were clinical studies. Bone was the most-investigated topic in basic research; the spine was the most-common topic among the identified clinical studies. The 50 most-cited articles that we identified should be considered influential, although a large gap remains between mainland China and the global orthopaedic community in terms of citations per article. Nevertheless, insofar as the most-recent decade of our survey generated the most articles in this top-50 list, we would characterize mainland China's effect on musculoskeletal research as increasing, and as funding increases to programs in mainland China, we anticipate this trend will continue in the future.

Varicose veins in the lower extremities in relation to occupational mechanical exposures: a longitudinal study

ObjectivesTo evaluate if occupational mechanical exposures are associated with an increased risk of surgery for varicose veins (VV) in the lower extremities.MethodsWe conducted a longitudinal study of persons from the...

How Do We Classify Rheumatoid Arthritis in Established Disease — Can We Apply the 2010 American College of Rheumatology/European League Against Rheumatism Classification Criteria?

The creation of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis (RA; Figure 1)1 sought to address some of the criticisms of the previous ACR criteria set published in 1987 (Figure 2)2 — namely that they were insensitive, particularly early in the disease course, and that this led to the exclusion of many patients with early disease from clinical trials and research studies3. As a result, there was an absence of evidence regarding the efficacy of new treatments in this group of patients, who may have had the potential to benefit the most4,5. Thus, 1 aim of the 2010 criteria was to identify those patients with early RA with the key purpose of rapid disease-modifying antirheumatic drug (DMARD) initiation. However, the ability to classify patients as having RA is important at all phases of the disease, early and late. A case definition is required as an entry criterion not only to clinical trials, but also a consensus for inclusion in longterm observational studies and the whole spectrum of research in RA. Numerous studies have tested the validity of the new criteria since their publication against various standards6, but they have generally been applied in patients with relatively short duration of symptoms, ranging from < 3 months to < 2 years. Thus, the question remains, can we extend these classification criteria to patients with established disease? Figure 1. 2010 ACR/EULAR Classification criteria for RA1. ACR: American College of Rheumatology; EULAR: European League Against Rheumatism; RF: rheumatoid factor; ACPA: anticitrullinated protein antibodies; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; RA: rheumatoid arthritis. From Aletaha, et al. Ann Rheum Dis 2010;69:1580–8; with permission. Figure 2. 1987 ACR Classification criteria for RA2. ACR: American … Address correspondence to Professor D.P.M. Symmons, Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, UK. E-mail: deborah.symmons{at}manchester.ac.uk

The orthopaedic research scene and strategies to improve it.

Trauma and orthopaedics is the largest of the surgical specialties and yet attracts a disproportionately small fraction of available national and international funding for health research. With the burden of musculoskeletal disease increasing, high-quality research is required to improve the evidence base for orthopaedic practice. Using the current research landscape in the United Kingdom as an example, but also addressing the international perspective, we highlight the issues surrounding poor levels of research funding in trauma and orthopaedics and indicate avenues for improving the impact and success of surgical musculoskeletal research.