Chapel Allerton Hospital

Elbow injuries resulting from acute trauma or repetitive overuse are a common source of pain and functional limitation in both athletes and the general population. This review presents a radiologic approach to the evaluation and management of these conditions. It describes the roles of key imaging modalities and provides practical guidance for assessing traumatic injuries such as fractures, ligamentous disruptions, and tendon avulsions. Common overuse conditions, such as medial epicondylitis, lateral epicondylitis, and nerve compression syndromes, are reviewed with attention to characteristic imaging features and diagnostic challenges. The article also explores the role of image-guided interventions, particularly ultrasound-guided injections, in both diagnosis and treatment. By consolidating imaging strategies and emphasizing the strengths of each modality, this review will help radiologists and clinicians achieve an accurate diagnosis and manage elbow injuries effectively, ultimately promoting better outcomes and a timely return to activity.

To evaluate the validity of the 3-item visual analog scale (3VAS) and 4-item VAS (4VAS) and determine the minimal clinically important difference (MCID) and minimal detectable change (MDC) for each measure using data from 3 phase III randomized clinical trials of guselkumab in psoriatic arthritis (PsA). Pooled data (1405 participants) from the DISCOVER-1, DISCOVER-2, and COSMOS studies were used. 3VAS/4VAS MCID and MDC were estimated using established formulas. Receiver-operating characteristic curve analysis was used to identify 3VAS/4VAS thresholds for low, moderate, and high disease activity. Criterion validity was assessed by correlating 3VAS/4VAS with other PsA measures. Mixed models evaluated the association between changes from baseline in 3VAS/4VAS at week 8 of guselkumab treatment with the total PsA-modified Sharp-van der Heijde (SvdH) score through week 100. 3VAS/4VAS showed moderate-to-strong correlation with all outcome measures assessed, with coefficients ranging from 0.56/0.62 for Health Assessment Questionnaire-Disability Index to 0.92/0.94 for patient global assessment. MCID was 0.9 for both 3VAS (range 0.7-1.3 depending on method used) and 4VAS (0.6-1.3); MDC was 3.1 and 3.0, respectively. 3VAS cutoffs for low, moderate, and high disease activity were 2.1, 3.3, and 4.8, respectively, and 2.1, 3.4, and 5.0 for 4VAS. Change in 4VAS at week 8 of guselkumab treatment significantly associated with change in SvdH score through week 100 (P = 0.04). These analyses support the validity of 3VAS/4VAS as multidimensional measures of PsA disease activity. 4VAS may be preferred owing to its greater face validity and separate measurements of the 2 cardinal aspects of PsA (joint/skin disease) and pain.

Recent advances in sequencing technologies have increasingly enabled the identification of genetic causes for human monogenic diseases. However, systematic understanding remains limited due to the rarity, genetic heterogeneity, and complex genotype–phenotype relationships of these diseases. Primary ciliopathies are a diverse group of rare disorders caused by variants in genes associated with the cilium, a cellular organelle involved in signaling during development and cell homeostasis. These genetic variants result in a wide spectrum of clinical phenotypes involving the brain, eye, kidney, and skeleton. It remains unclear to what extent this phenotypic diversity can be attributed to the disease-causing genes and their specific roles in ciliary function. Here, we systematically compared human primary ciliopathies with each other and with mouse phenotypes by propagating known disease genes through a network of protein interactions. Network propagation improved the clustering of primary ciliopathies with shared clinical phenotypes and facilitated the identification of mouse phenotypes closely related to primary ciliopathies, due to shared groups of proteins in the interaction network. By leveraging this phenotype-specific approach, we prioritized candidate genes for specific ciliopathies and identified likely pathogenic variants in CEP43, a previously unrecognized ciliopathy gene, in three previously unsolved cases. This study demonstrates that network propagation enhances the genetic and phenotypic understanding of primary ciliopathies, aiding in the prioritization of candidate genes and providing a framework for unraveling shared underlying mechanisms for other rare genetic diseases.

Isolated anterior wall acetabulum fracture (AWF) represents a rare injury. There is a paucity of information available about this fracture and no classification has been proposed so far. The aim of this study was to analyse the various possible fracture patterns, related treatment approaches and to develop a new classification system. Common search engines were systematically searched, according to the PRISMA guidelines. Data relating to the studies that reported surgical approaches and results about isolated AW fractures were included. Data quality was also assessed. We topographically subdivided the fractures, according to the percentage of the anterior wall involved, location of the fracture, and the degree of comminution. The mean follow-up was 38.8 months (6-240). 17 papers were eligible for this study. The ilio-inguinal (ILI) approach was the most used one (58.2 %). Different reconstruction techniques were deployed. Anatomical reduction was obtained in 46.6 % of the cases. 3 patients required hip prosthesis within 18 months. Based on the evidence gathered the anterior wall was divided into 3 segments (proximal, (P) middle (M) and distal (D)1/3 segment. Based on the area of involvement in each zone was also divided into Type I < 25 %; Type II 25-50 % and Type III >50 %. Comminution (C) was also assigned if present in any of the 3 zones. Isolated anterior wall acetabulum fracture is an uncommon injury. The IIL approach was the most used for fixation. A new classification system was developed to guide surgical approach and fixation techniques.

Biomorphic hydroxyapatite scaffolds derived from rattan wood (GreenBone) show significant promise in bone tissue engineering due to their inherent structural similarity to natural bone. Laser-drilled GreenBone scaffolds were studied for enhanced porosity, nutrient diffusion, cellular infiltration, and vascularisation. Patient-derived bone marrow mesenchymal stromal/stem cells (BMMSCs) and culture-expanded mesenchymal stem cells (cMSCs) demonstrated high cell viability (>90%), considerable adhesion, and extensive cytoskeletal organisation. Trilineage differentiation confirmed the multipotency of BMMSCs, with osteogenic, adipogenic, and chondrogenic markers being successfully expressed. BMMSCs and cMSCs exhibited enhanced differentiation and gene expression profiles. At week 4, key osteogenic and angiogenic genes such as BMP2, VEGFC, RUNX2, and COL1A1 showed elevated expression, indicating improved bone formation and vascularisation activity. Markers associated with extracellular matrix (ECM) remodelling, including MMP9 and TIMP1, were also upregulated, suggesting active tissue remodelling. ELISA analysis for VEGF further demonstrated increased VEGF secretion, highlighting the scaffold's angiogenic potential. The improved cellular response and vascular signalling emphasise the translational relevance of laser-modified GreenBone scaffolds for bone tissue engineering, particularly for critical-sized defect repair requiring rapid vascularised bone regeneration.

Patients with symptoms of pain and restricted function related to knee osteoarthritis are typically offered a knee replacement. However, a proportion remain dissatisfied with their outcomes, and the failure risk is disproportionately higher in the young. Knee joint distraction may be an intervention to postpone the time to knee replacement in this patient population. The primary objective of the Knee Arthroplasty versus Joint Distraction Study for Osteoarthritis (KARDS) was to evaluate the effectiveness of knee joint distraction compared to knee replacement based on patient-reported pain 12 months post surgery using the Knee Injury and Osteoarthritis Outcomes Score pain score as the primary outcome. KARDS was an open-label, two-arm individually randomised controlled non-inferiority trial with an embedded 12-month internal pilot phase and process evaluation to evaluate recruitment feasibility. A hybrid expertise design was used to account for surgeon expertise and potential lack of individual equipoise. The trial was closed to recruitment early following cessation of elective orthopaedic surgery secondary to COVID-19 pandemic. Descriptive statistics are reported. United Kingdom National Health Service Trusts. Adult patients aged < 65 years with symptoms severe enough to warrant knee replacement, in the opinion of the treating clinician. Participants were randomised to receive either knee joint distraction (static distraction of 5mm, using external fixator for 6 weeks) or knee replacement. Twenty-four participants were randomised from a single centre between March 2021 and October 2022 with minimum 3-month safety follow-up post surgery. Eleven participants were randomised to knee joint distraction and 13 to knee replacement. Seventeen patients were male (71%), median age 60 (47-65) years. One patient withdrew due to being medically unfit for surgery and two received a different treatment than which they were randomised (one crossover from each arm). The median Knee Injury and Osteoarthritis Outcomes Score pain score in the knee joint distraction group improved from 38.9 (22-50) at baseline to 55.6 (0-100) at 12 months, corresponding scores in the knee replacement improved from 30.6 (6-36) to 75.0 (50-100). Adverse events were more common with knee joint distraction, pin site infection being the commonest complications (n = 4, 58%). As part of process evaluation, we conducted semistructured qualitative interviews with staff in secondary care and with study participants. Data were analysed using thematic content analysis. One overarching theme emerged: 'An unexpected journey', which encapsulates staff and participants' experiences. Reduced research capacity and the suspension of elective surgery following the COVID-19 pandemic caused significant recruitment barriers. Despite early termination, KARDS demonstrated that patients were willing to be recruited to a trial investigating a novel treatment for knee osteoarthritis and the trial was feasible and implementable. The limited results indicated that the technique is safe with no safety concerns. Clinical and cost-effectiveness of knee joint distraction remains uncertain. The embedded KARDS process evaluation has provided helpful insights. Reduced research capacity at sites and suspension of elective surgery services within the United Kingdom following COVID-19 caused significant recruitment barriers to KARDS. All the recruited patients in both arms of the study were White. As a commissioned piece of research with delivery significantly impacted by the National Health Service environment post-COVID and the impact on National Health Service surgical services, the research question remains highly relevant. Any future research in this field can be helped by the pilot data published here along with the lessons learnt. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/122/06.

<h2>ABSTRACT</h2><h3>Objectives</h3> To perform a systematic literature review (SLR) to inform the EULAR Task Force "Points to Consider for the definitions of Difficult-to-Manage (D2M) and Treatment-Refractory (TR) psoriatic arthritis (PsA)". <h3>Methods</h3> The SLR addressed 3 separate questions concerning the following: (1) prevalence, (2) outcomes, and (3) predictors of D2M/TR PsA. A search was conducted in MEDLINE (Ovid), Cochrane Database of Systematic Reviews, CENTRAL, EMBASE, and Epistemonikos from inception to March 3, 2024, as well as EULAR/ACR abstracts for 2023/24 and 2022/23, respectively. This systematic review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered on PROSPERO. Data are summarised descriptively. Meta-analysis was not possible due to significant heterogeneity and/or lack of high-quality evidence. Risk of bias (RoB) was assessed using the Newcastle-Ottawa Scale. <h3>Results</h3> Overall, 70, 4, and 25 articles/abstracts were included for questions 1, 2, and 3, respectively. For question 1, 30/70 records had low/moderate RoB, with the prevalence of D2T PsA ranging from 5% to 80% depending on both the timepoint at which prevalence was measured and the definition of D2M/TR PsA applied, which varied significantly between studies. For question 2, all records had a high RoB; therefore, no conclusions could be drawn. For question 3, all records had a moderate RoB, and 84 categories of potential predictors were identified, with large differences in strength and direction of association between studies. <h3>Conclusions</h3> Despite significant heterogeneity in the published literature regarding the scope, definition, long-term outcomes, and predictors of D2M/TR PsA, certain patterns emerged that helped shape the final EULAR Task Force recommendations.

Musculoskeletal adverse events due to immune checkpoint inhibitors are common and can present clinically as inflammatory arthritis, polymyalgia rheumatica, or arthralgia. The pathoanatomy of musculoskeletal adverse events related to immune checkpoint inhibitors remains undefined, with a paucity of available imaging data. We aimed to investigate the whole-body imaging phenotype of arthralgia and inflammatory arthritis following exposure to immune checkpoint inhibitors, to fully characterise the pattern of inflammation in these patients and subsequently inform clinical management. In this prospective imaging study, patients aged 18 years or older with new musculoskeletal symptoms that started during or up to 6 months after receiving an immune checkpoint inhibitor and healthy controls aged 18 years or older, with no personal history of rheumatological autoimmune disease, no active cancer, and no self-reported joint pains in the 4 weeks before their MRI scan date, were recruited at the Leeds Rheumatology department of Chapel Allerton Hospital, Leeds, UK, and underwent gadolinium contrast-enhanced whole-body MRI. Joint, tendon, bursal, entheseal, and whole spinal imaging lesions were graded by two independent masked assessors and consensus reported. Inflammatory whole-body MRI patterns were analysed and patients were followed up for 6 months. People with lived experience of inflammatory arthritis and musculoskeletal toxicity related to immune checkpoint inhibitors highlighted the importance of knowing and understanding imaging findings to help inform risk versus benefit decisions about immunosuppressive treatments. Between Oct 20, 2021, and May 22, 2024, 60 patients (35 [58%] with arthralgia and 25 [42%] with inflammatory arthritis) and 20 healthy controls were recruited. The mean age of patients was 65 years (SD 11) and that of healthy controls was 62 years (7); 34 (57%) patients were men and 26 (43%) were women, and 12 (60%) healthy controls were men and eight (40%) were women. All patients and healthy controls were White. Median total joint synovitis, joint erosions, enthesitis, and tenosynovitis scores were significantly higher in patients with arthralgia or inflammatory arthritis induced by immune checkpoint inhibitors compared with healthy controls, without significant differences between the inflammatory arthritis and arthralgia subgroups. Acromioclavicular (46 [77%] of 60), glenohumeral (45 [75%] of 60), wrist (43 [73%] of 59), and metacarpophalangeal (35 [59%] of 59) joints were the most frequently affected by synovitis in all patients. There were three distinct global inflammatory patterns: peripheral inflammatory arthritis in 22 (37%) of 60 patients; polymyalgia rheumatica in seven (12%), and an overlapping phenotype of polymyalgia rheumatica and peripheral inflammatory arthritis in 12 (20%). Axial inflammation was only identified in one patient. Four of the five patients requiring disease-modifying antirheumatic drug therapy were in the peripheral inflammatory arthritis group, which also had the highest initial and ongoing glucocorticoid requirement. MRI inflammation and erosions are as prevalent in patients with arthralgia exposed to an immune checkpoint inhibitor as in those with inflammatory arthritis. This finding suggests that the overall burden of musculoskeletal toxicity associated with immune checkpoint inhibitors is currently under-recognised. Patients who develop inflammatory arthritis or arthralgia after exposure to immune checkpoint inhibitors have three main imaging patterns: polymyalgia rheumatica, peripheral inflammatory arthritis, and an overlap of polymyalgia rheumatica and inflammatory arthritis. Patients with peripheral inflammatory arthritis were most likely to require disease-modifying antirheumatic drugs. The National Institute for Health and Care Research (NIHR) Leeds Biomedical Research Centre.