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Topic:Joint Health

Joint health in horses involves the study of anatomical structures such as cartilage, synovial fluid, ligaments, and bones that contribute to the function and mobility of equine joints. Research in this area focuses on understanding the physiology of equine joints, the mechanisms of joint disorders, and the effects of wear and tear over time. Common joint issues in horses include osteoarthritis, synovitis, and joint effusion, which can impact performance and quality of life. Diagnostic techniques often involve imaging, synovial fluid analysis, and clinical evaluation to assess joint condition. This page compiles peer-reviewed research studies and scholarly articles that explore the anatomy, pathology, diagnostics, and therapeutic approaches related to joint health in horses.
Correlation of dickkopf-1 concentrations in plasma and synovial fluid to the severity of radiographic signs of equine osteoarthritis.
Veterinary and comparative orthopaedics and traumatology : V.C.O.T    August 1, 2017   Volume 30, Issue 5 311-317 doi: 10.3415/VCOT-16-11-0157
Mills JS, Kinsley MA, Peters DF, Weber PSD, Shearer TR, Pease AP.The purpose of this study was to determine whether there was a correlation between circulating and intra-synovial Dkk-1 and radiographic signs of equine osteoarthritis. Methods: Circulating and intra-synovial Dkk-1 levels were measured in clinical cases using a commercially available human Dkk-1 ELISA. Radiographs were performed of the joints from which fluid was collected and these were assessed and scored by a boarded radiologist for joint narrowing, subchondral bone sclerosis, subchondral bone lysis, and periarticular modelling. Comparisons were made between radiographic scores and the conc...
Surgical Management of Osteochondrosis in Foals.
The Veterinary clinics of North America. Equine practice    July 9, 2017   Volume 33, Issue 2 379-396 doi: 10.1016/j.cveq.2017.03.010
Ortved KF.Osteochondrosis is common in young, athletic horses. Some lesions respond to conservative therapy. Surgical management is the mainstay of treatment. Arthroscopic debridement is useful in the femoropatellar joint, tarsocrural joint, fetlock joint, and shoulder joint. Debridement is associated with good outcomes, except in the shoulder joint. Osteochondrosis lesions in the elbow may be difficult to access arthroscopically, thereby transosseous debridement. Surgical management of subchondral cystic lesions of the medial femoral condyle consists of debridement, debridement with grafting, transcond...
Antigenicity of mesenchymal stem cells in an inflamed joint environment.
American journal of veterinary research    June 27, 2017   Volume 78, Issue 7 867-875 doi: 10.2460/ajvr.78.7.867
Hill JA, Cassano JM, Goodale MB, Fortier LA.OBJECTIVE To determine whether major histocompatability complex (MHC) class II expression in equine mesenchymal stem cells (MSCs) changes with exposure to a proinflammatory environment reflective of an inflamed joint. SAMPLE Cryopreserved bone marrow-derived MSCs from 12 horses and cartilage and synovium samples from 1 horse euthanized for reasons other than lameness. PROCEDURES In part 1 of a 3-part study, the suitability of a quantitative reverse transcriptase PCR (qRT-PCR) assay for measurement of MHC class II expression in MSCs following stimulation with interferon (IFN)-γ was assessed. I...
Changes in concentrations of haemostatic and inflammatory biomarkers in synovial fluid after intra-articular injection of lipopolysaccharide in horses.
BMC veterinary research    June 19, 2017   Volume 13, Issue 1 182 doi: 10.1186/s12917-017-1089-1
Andreassen SM, Vinther AML, Nielsen SS, Andersen PH, Tnibar A, Kristensen AT, Jacobsen S.Septic arthritis is a common and potentially devastating disease characterized by severe intra-articular (IA) inflammation and fibrin deposition. Research into equine joint pathologies has focused on inflammation, but recent research in humans suggests that both haemostatic and inflammatory pathways are activated in the joint compartment in arthritic conditions. The aim of this study was to characterize the IA haemostatic and inflammatory responses in horses with experimental lipopolysaccharide (LPS)-induced joint inflammation. Inflammation was induced by IA injection of LPS into one antebrach...
Corrigendum to “Multimodality scoring of chondral injuries in the equine fetlock joint ex vivo” [Osteoarthritis Cartilage 25 (5) (2017 May) 790-798].
Osteoarthritis and cartilage    May 27, 2017   Volume 25, Issue 8 1377-1378 doi: 10.1016/j.joca.2017.05.010
Sarin JK, Brommer H, Argüelles D, Puhakka PH, Inkinen SI, Afara IO, Saarakkala S, Töyräs J.No abstract available
The association between oral examination findings and computed tomographic appearance of the equine temporomandibular joint.
Equine veterinary journal    May 25, 2017   Volume 49, Issue 6 780-783 doi: 10.1111/evj.12693
Carmalt JL, Simhofer H, Bienert-Zeit A, Rawlinson JE, Waldner CL.The temporomandibular joint (TMJ) forms the junction between the maxilla and mandible. Movement of the jaw and resulting masticatory forces have been extensively studied in the horse; however, less is known about the inter-relationship between this joint and oral and dental pathology. Objective: To determine the association between specific oral and dental pathologies and anatomical variations of the TMJ imaged with computed tomography (CT) in horses with asymptomatic TMJs. Methods: Retrospective cross-sectional study. Methods: Horses (n = 201) from three practices with a complete oral exami...
Metacarpophalangeal joint injury patterns on magnetic resonance imaging: A comparison in racing Standardbreds and Thoroughbreds. Olive J, Serraud N, Vila T, Germain JP.The metacarpal condyle has received extensive attention as a predominant site of overload arthropathy in racehorses. However, detailed descriptions of MRI lesion patterns for the metacarpophalangeal joint and comparisons between types of racing horses are currently lacking. Aims of this retrospective, cross-sectional study were to describe and compare standing low-field magnetic resonance findings in the metacarpophalangeal joints for groups of Standardbreds and Thoroughbreds using systematic semiquantitative scores. Data archives at the Clinique Vétérinaire Equine de Chantilly and Imavet we...
Effects of tourniquet number and exsanguination on amikacin concentrations in the radiocarpal and distal interphalangeal joints after low volume intravenous regional limb perfusion in horses.
Veterinary surgery : VS    April 29, 2017   Volume 46, Issue 5 675-682 doi: 10.1111/vsu.12662
Schoonover MJ, Moser DK, Young JM, Payton ME, Holbrook TC.To determine the influence of a dual tourniquet technique and limb exsanguination on amikacin concentrations in the synovial fluid of the radiocarpal joint (RCJ) and distal interphalangeal joint (DIPJ) after low volume, cephalic intravenous regional limb perfusion (IVRLP). Methods: Randomized cross-over design. Methods: Six healthy adult horses. Methods: One gram of amikacin in 6 mL of 0.9% NaCl was infused via cephalic IVRLP in 6 standing, sedated horses using 4 techniques: proximal pneumatic tourniquet (P), proximal pneumatic tourniquet with exsanguination (PE), proximal pneumatic and distal...
Biomechanical and histologic evaluation of the effects of underwater treadmill exercise on horses with experimentally induced osteoarthritis of the middle carpal joint.
American journal of veterinary research    April 26, 2017   Volume 78, Issue 5 558-569 doi: 10.2460/ajvr.78.5.558
King MR, Haussler KK, Kawcak CE, McIlwraith CW, Reiser RF, Frisbie DD, Werpy NM.OBJECTIVE To evaluate the effects of exercise in an underwater treadmill (UWT) on forelimb biomechanics and articular histologic outcomes in horses with experimentally induced osteoarthritis of the middle carpal joint. ANIMALS 16 horses. PROCEDURES An osteochondral fragment was induced arthroscopically (day 0) in 1 middle carpal joint of each horse. Beginning on day 15, horses were assigned to exercise in a UWT or in the UWT without water (simulating controlled hand walking) at the same speed, frequency, and duration. Thoracic and pelvic limb ground reaction forces, thoracic limb kinematics, a...
Effects of hyaluronan alone or in combination with chondroitin sulfate and N-acetyl-d-glucosamine on lipopolysaccharide challenge-exposed equine fibroblast-like synovial cells.
American journal of veterinary research    April 26, 2017   Volume 78, Issue 5 579-588 doi: 10.2460/ajvr.78.5.579
Kilborne AH, Hussein H, Bertone AL.OBJECTIVE To investigate effects of hyaluronic acid (HA) or HA combined with chondroitin sulfate (CS) and N-acetyl-d-glucosamine (NAG) by use of a lipopolysaccharide (LPS) in vitro method. SAMPLE Monolayer cultures of synovial cells from 4 adult horses. PROCEDURES Synovial cell cultures were untreated or treated with HA alone or HA-CS-NAG for 24 hours, subsequently unchallenged or challenge-exposed with 2 LPS concentrations (20 and 50 ng/mL) for 2 hours, and retreated with HA or HA-CS-NAG for another 24 hours. Cellular morphology of cultures was evaluated at 0, 24 (before LPS), 26 (after LPS),...
FOXO1, PXK, PYCARD and SAMD9L are differentially expressed by fibroblast-like cells in equine synovial membrane compared to joint capsule.
BMC veterinary research    April 14, 2017   Volume 13, Issue 1 106 doi: 10.1186/s12917-017-1003-x
Thomsen LN, Thomsen PD, Downing A, Talbot R, Berg LC.The synovial membrane lines the luminal side of the joint capsule in synovial joints. It maintains joint homeostasis and plays a crucial role in equine joint pathology. When trauma or inflammation is induced in a joint, the synovial membrane influences progression of joint damage. Equine synovial membrane research is hampered by a lack of markers of fibroblast-like synoviocytes (FLS) to distinguish FLS from other fibroblast-like cells in musculoskeletal connective tissues. The aim of this study is to identify potential FLS markers of the equine synovial membrane using microarray to compare bet...
Science-in-brief: Clinical highlights from 50th Congress of the South African Equine Veterinary Association 2017.
Equine veterinary journal    April 8, 2017   Volume 49, Issue 3 266-268 doi: 10.1111/evj.12678
Miller SM, Spargo KE.No abstract available
The effect of ambient temperature on infrared thermographic images of joints in the distal forelimbs of healthy racehorses.
Journal of thermal biology    April 2, 2017   Volume 66 63-67 doi: 10.1016/j.jtherbio.2017.03.018
Soroko M, Howell K, Dudek K.The aim of the study was to describe the dependence on ambient temperature of distal joint temperature at the forelimbs of racehorses. The study also investigated the influence of differing ambient temperatures on the temperature difference between joints: this was measured ipsilaterally (i.e. between the carpal and fetlock joints along each forelimb) and contralaterally (i.e. between the same joints of the left and right forelimbs). Sixty-four healthy racehorses were monitored over 10 months. At each session, three thermographic images were taken of the dorsal, lateral and medial aspects of t...
How exercise influences equine joint homeostasis.
Veterinary journal (London, England : 1997)    March 28, 2017   Volume 222 60-67 doi: 10.1016/j.tvjl.2017.03.004
Te Moller NCR, van Weeren PR.The maintenance of joint homeostasis is integral to joint health. Knowledge of the influence of exercise on joint homeostasis is not only relevant for determining sustainable levels of equine athletic training, but also for the study of early development of osteoarthritis or cartilage repair in animal models. This review provides an overview of findings derived from in vivo studies and postmortem analyses investigating exercise effects on various joint tissue components in the horse, supplemented where appropriate with data from small animal models. The concept of joint homeostasis and possibl...
Treatment of subchondral lucencies in the medial proximal radius with a bone screw in 8 horses.
Veterinary surgery : VS    March 22, 2017   Volume 46, Issue 4 478-485 doi: 10.1111/vsu.12643
Roquet I, Lane Easter J, Coomer RPC, Ezquerra LJ, Marsh CA, Trostle SS, Santschi EM.To describe the results of screw placement through subchondral lucencies (SCL) of the proximal radius in 8 horses. Methods: Retrospective clinical study. Methods: Horses with cubital SCL causing lameness (n=8). Methods: Medical record review and clinical follow-up. Results: Eight horses with SCL in the proximal radius causing lameness were treated with a screw placed across the lucency. The horses range in age from 1 to 20 years. In 4 of 8 horses, the lameness had been intermittently severe (apparent at the walk). Lameness was isolated to the cubital joint by intra-articular anesthesia in 5 ho...
Correlation of Articular Cartilage Thickness Measurements Made with Magnetic Resonance Imaging, Magnetic Resonance Arthrography, and Computed Tomographic Arthrography with Gross Articular Cartilage Thickness in the Equine Metacarpophalangeal Joint. Osteoarthritis of the metacarpophalangeal joint is common cause of lameness in equine athletes, and is hallmarked by articular cartilage damage. An accurate, noninvasive method for measuring cartilage thickness would be beneficial to screen for cartilage injury and allow for prompt initiation of interventional therapy. The objective of this methods comparison study was to compare computed tomographic arthrography (CTA), magnetic resonance imaging (MRI), and magnetic resonance arthrography (MRA) measurements of articular cartilage thickness with gross measurements in the metacarpophalangeal joi...
Pharmacokinetics of betamethasone in plasma, urine, and synovial fluid following intra-articular administration to exercised thoroughbred horses.
Drug testing and analysis    March 7, 2017   Volume 9, Issue 9 1385-1391 doi: 10.1002/dta.2170
Knych HK, Stanley SD, Harrison LM, Mckemie DS.The use of corticosteroids, such as betamethasone, in performance horses is tightly regulated. The objective of the current study was to describe the plasma pharmacokinetics of betamethasone as well as time-related urine and synovial fluid concentrations following intra-articular administration to horses. Twelve racing-fit adult Thoroughbred horses received a single intra-articular administration (9 mg) of a betamethasone sodium phosphate and betamethasone acetate injectable suspension into the right antebrachiocarpal joint. Blood, urine, and synovial fluid samples were collected prior to and...
Serum snoRNAs as biomarkers for joint ageing and post traumatic osteoarthritis.
Scientific reports    March 2, 2017   Volume 7 43558 doi: 10.1038/srep43558
Steinbusch MM, Fang Y, Milner PI, Clegg PD, Young DA, Welting TJ, Peffers MJ.The development of effective treatments for the age-related disease osteoarthritis and the ability to predict disease progression has been hampered by the lack of biomarkers able to demonstrate the course of the disease. Profiling the expression patterns of small nucleolar RNAs (snoRNAs) in joint ageing and OA may provide diagnostic biomarkers and therapeutic targets. This study determined expression patterns of snoRNAs in joint ageing and OA and examined them as potential biomarkers. Using SnoRNASeq and real-time quantitative PCR (qRT-PCR) we demonstrate snoRNA expression levels in murine age...
Cartilage oligomeric matrix protein neoepitope in the synovial fluid of horses with acute lameness: A new biomarker for the early stages of osteoarthritis.
Equine veterinary journal    February 28, 2017   Volume 49, Issue 5 662-667 doi: 10.1111/evj.12666
Skiöldebrand E, Ekman S, Mattsson Hultén L, Svala E, Björkman K, Lindahl A, Lundqvist A, Önnerfjord P, Sihlbom C, Rüetschi U.Clinical tools to diagnose the early changes of osteoarthritis (OA) that occur in the articular cartilage are lacking. Objective: We sought to identify and quantify a novel cartilage oligomeric matrix protein (COMP) neoepitope in the synovial fluid from the joints of healthy horses and those with different stages of OA. Methods: In vitro quantitative proteomics and assay development with application in synovial fluids samples obtained from biobanks of well-characterised horses. Methods: Articular cartilage explants were incubated with or without interleukin-1β for 25 days. Media were analysed...
Repeated intra-articular injection of allogeneic mesenchymal stem cells causes an adverse response compared to autologous cells in the equine model.
Stem cell research & therapy    February 28, 2017   Volume 8, Issue 1 42 doi: 10.1186/s13287-017-0503-8
Joswig AJ, Mitchell A, Cummings KJ, Levine GJ, Gregory CA, Smith R, Watts AE.Intra-articular injection of mesenchymal stem cells (MSCs) is efficacious in osteoarthritis therapy. A direct comparison of the response of the synovial joint to intra-articular injection of autologous versus allogeneic MSCs has not been performed. The objective of this study was to assess the clinical response to repeated intra-articular injection of allogeneic versus autologous MSCs prepared in a way to minimize xeno-contaminants in a large animal model. Intra-articular injections of bone marrow-derived, culture-expanded MSCs to a forelimb metacarpophalangeal joint were performed at week 0 ...
Ultrasound-guided approach to the cervical articular process joints in horses: a validation of the technique in cadavers.
Veterinary and comparative orthopaedics and traumatology : V.C.O.T    January 17, 2017   Volume 30, Issue 3 165-171 doi: 10.3415/VCOT-16-09-0139
Purefoy Johnson J, Stack JD, Rowan C, Handel I, O'Leary JM.To compare accuracy of the ultrasound-guided craniodorsal (CrD) approach with the dorsal (D) approach to the cervical articular process joints, and to evaluate the effect of the transducer, needle gauge, and operator experience. Methods: Cervical articular process joints from 14 cadaveric neck specimens were injected using either a D or CrD approach, a linear (13 MHx) or microconvex transducer (10 MHz), and an 18 or 20 gauge needle, by an experienced or inexperienced operator. Injectate consisted of an iodinated contrast material solution. Time taken for injection, number of redirects, and ret...
Comparison of four methods for generating decellularized equine synovial extracellular matrix.
American journal of veterinary research    December 3, 2016   Volume 77, Issue 12 1332-1339 doi: 10.2460/ajvr.77.12.1332
Reisbig NA, Hussein HA, Pinnell E, Bertone AL.OBJECTIVE To evaluate 4 methods for generating decellularized equine synovial extracellular matrix. SAMPLE Villous synovium harvested from the femoropatellar and medial femorotibial joints of 4 healthy adult horses 25,000 base pair) DNA fragments. Incubation in Triton and incubation in NaCl resulted in low DNA content and short (< 200 base pair) DNA fragments, but destroyed the synovial villous architecture. Incubation in PAA twice resulted in low DNA content and short DNA fragments while retaining the synovial villous architecture. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that...
Correction: Effects of Moderate Amounts of Barley in Late Pregnancy on Growth, Glucose Metabolism and Osteoarticular Status of Pre-Weaning Horses.
PloS one    December 2, 2016   Volume 11, Issue 12 e0167604 doi: 10.1371/journal.pone.0167604
Peugnet P, Robles M, Mendoza L, Wimel L, Dubois C, Dahirel M, Guillaume D, Camous S, Berthelot V, Toquet MP, Richard E, Sandersen C, Chaffaux S....[This corrects the article DOI: 10.1371/journal.pone.0122596.].
Pro-inflammatory cytokines and structural biomarkers are effective to categorize osteoarthritis phenotype and progression in Standardbred racehorses over five years of racing career.
BMC veterinary research    November 8, 2016   Volume 12, Issue 1 246 doi: 10.1186/s12917-016-0873-7
Bertuglia A, Pagliara E, Grego E, Ricci A, Brkljaca-Bottegaro N.Joint impact injuries initiate a progressive articular damage finally leading to post-traumatic osteoarthritis (PTOA). Racehorses represent an ideal, naturally available, animal model of the disease. Standardbred racehorses developing traumatic osteoarthritis of the fetlock joint during the first year of their career were enrolled in our study. Age-matched controls were contemporarily included. Biomarker levels of equine osteoarthritis were measured in serum and synovial fluid (SF) at baseline, and repeated yearly over the next 4 years of training (from T1 to T4). The effect of time and disea...
Two-Year Evaluation of Osteochondral Repair with a Novel Biphasic Graft Saturated in Bone Marrow in an Equine Model.
Cartilage    November 4, 2016   Volume 8, Issue 4 406-416 doi: 10.1177/1947603516675913
McCarrel TM, Pownder SL, Gilbert S, Koff MF, Castiglione E, Saska RA, Bradica G, Fortier LA.Objective To evaluate a biphasic cartilage repair device (CRD) for feasibility of arthroscopic implantation, safety, biocompatibility, and efficacy for long-term repair of large osteochondral defects. Methods The CRD was press-fit into defects (10 mm diameter, 10 mm deep) created in the femoral trochlea of 12 horses. In the contralateral limb, 10 mm diameter full-thickness chondral defects were treated with microfracture (MFX). Radiographs were obtained pre- and postoperatively, and at 4, 12, and 24 months. Repeat arthroscopy was performed at 4 and 12 months. Gross assessment, histology, mecha...
Degradation, intra-articular retention and biocompatibility of monospheres composed of [PDLLA-PEG-PDLLA]-b-PLLA multi-block copolymers.
Acta biomaterialia    November 2, 2016   Volume 48 401-414 doi: 10.1016/j.actbio.2016.11.003
Sandker MJ, Duque LF, Redout EM, Chan A, Que I, Löwik CWGM, Klijnstra EC, Kops N, Steendam R, van Weeren R, Hennink WE, Weinans H.In this study, we investigated the use of microspheres with a narrow particle size distribution ('monospheres') composed of biodegradable poly(DL-lactide)-PEG-poly(DL-lactide)-b-poly(L-lactide) multiblock copolymers that are potentially suitable for local sustained drug release in articular joints. Monospheres with sizes of 5, 15 and 30μm and a narrow particle size distribution were prepared by a micro-sieve membrane emulsification process. During in vitro degradation, less crystallinity, higher swelling and accelerated mass loss during was observed with increasing the PEG content of the poly...
Acute phase protein haptoglobin as inflammatory marker in serum and synovial fluid in an equine model of arthritis.
Veterinary immunology and immunopathology    October 17, 2016   Volume 182 74-78 doi: 10.1016/j.vetimm.2016.10.005
Barrachina L, Remacha AR, Soler L, García N, Romero A, Vázquez FJ, Vitoria A, Álava MÁ, Lamprave F, Rodellar C.Acute phase proteins are useful inflammatory markers in horses. Haptoglobin (Hp) serum level is increased in horses undergoing different inflammatory processes, including arthritis. However, Hp concentration has not been assessed in inflammatory synovial fluid (SF). The aim of the present study was to investigate the Hp response in serum and SF in horses undergoing experimentally induced arthritis. For this purpose, serum and SF samples were collected from 12 animals before amphotericin B-induced arthritis was created (T0, healthy) and 15days after the lesion induction (T1, joint inflammation)...
The preventive effects of two nutraceuticals on experimentally induced acute synovitis.
Equine veterinary journal    October 13, 2016   Volume 49, Issue 4 532-538 doi: 10.1111/evj.12629
van de Water E, Oosterlinck M, Dumoulin M, Korthagen NM, van Weeren PR, van den Broek J, Everts H, Pille F, van Doorn DA.Nutraceuticals are often used in the management of equine osteoarthritis, but scientific evidence of their efficacy is lacking. Objective: To study the preventive effects of two new nutraceuticals after the experimental induction of synovitis in comparison with positive and negative control treatments. Methods: Blinded, controlled, randomised experiment. Methods: Twenty-four healthy Standardbred horses were randomly allocated to supplement AT (multi-ingredient, 28 days), supplement HP (collagen hydrolysate, 60 days), meloxicam (4 days) or placebo (60 days). Synovitis was induced in the right i...
Influence of oral glucosamine supplementation in young horses challenged with intra-articular lipopolysaccharide.
Journal of animal science    October 4, 2016   Volume 94, Issue 8 3294-3302 doi: 10.2527/jas.2016-0343
Leatherwood JL, Gehl KL, Coverdale JA, Arnold CE, Dabareiner RA, Walter KN, Lamprecht ED.Fourteen yearling Quarter horses (351 to 470 kg) were utilized in a randomized complete block design to evaluate potential of glucosamine hydrochloride (HCl) to mitigate intra-articular inflammation following a single inflammatory insult. Horses were blocked by BW, age, and sex, and randomly assigned to treatments for a 98-d experiment. Treatments consisted of a control diet (CON; = 7) fed 1% BW per d (as-fed) of concentrate only or a treatment diet ( = 7) of concentrate top dressed with 30 mg/kg BW glucosamine HCl (99.6% purity; GLU30) offered at 12 h intervals. Horses were maintained in indi...
Arthroscopy of the Dorsal and Plantar Pouches of the Tarsocrural Joint for the Treatment of Osteochondritis Dissecans in the Horse: Clinical Features and Follow-Up.
Veterinary surgery : VS    September 29, 2016   Volume 45, Issue 8 1049-1055 doi: 10.1111/vsu.12560
James O, Payne R, Bathe A, Greet T, Wylie C.To describe the clinical details and pathology within the dorsal and plantar pouches of the tarsocrural joint of a population of horses that underwent arthroscopic surgery for tarsocrural osteochondritis dissecans (OCD). Methods: Retrospective cohort study. Methods: Horses referred for arthroscopic treatment of tarsocrural OCD between 2005 and 2013 (102 horses; 144 joints). Methods: Case records of all horses that had tarsocrural arthroscopy for OCD at Rossdales Equine Hospital, Newmarket, United Kingdom were included. Cases from 3 ECVS Diplomates were included, 1 of whom routinely examined 70...
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