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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.
Fragment size is associated with post-operative complications following elective arthroscopy of the tibiotarsal joint of horses.
The Canadian veterinary journal = La revue veterinaire canadienne    January 4, 2022   Volume 63, Issue 1 74-80 
Merchán A, Koenig J, Côté N, Cribb N, Monteith G.The objective of this retrospective study was to determine the occurrence of joint-related complications after elective arthroscopy of the tibiotarsal joint (TTJ) in 329 horses, and the association with specific clinical parameters. Data were collected from medical records of horses undergoing elective tibiotarsal joint arthroscopy for fragment removal. Exact conditional univariate regression was used to determine significant risk factors for joint-related post-operative complications. Of 485 joints, 2 (0.4%) developed surgical site infection, 4 (0.8%) developed septic arthritis, 1 (0.2%) deve...
Hospitalisation and Disease Severity Alter the Resting Pattern of Horses.
Journal of equine veterinary science    December 4, 2021   Volume 110 103832 doi: 10.1016/j.jevs.2021.103832
Oliveira T, Santos A, Silva J, Trindade P, Yamada A, Jaramillo F, Silva L, Baccarin R.In humans, hospitalisation, disease type, and environmental factors evidently affect the quality of sleep, further influencing patient recovery. The objective of the present study was to report the resting and lying behaviour of hospitalised horses, and whether lying behaviours differ depending on the physiological severity of joint damage. We hypothesised that the resting and lying behaviour can change during the hospitalisation and physiological severity of joint damage affect the time of rest in horses. A descriptive observational study was performed to evaluate the effect of hospitalisatio...
In vivo joint synovial fluid disposition of a novel sustained-release formulation of diclofenac and hyaluronic acid in horses.
Journal of veterinary pharmacology and therapeutics    December 3, 2021   Volume 45, Issue 2 167-176 doi: 10.1111/jvp.13033
Rhodin M, Haubro Andersen P, Holm Forsström K, Ekstrand C.Intra-articular administration of sustained-release anti-inflammatory drugs is indicated in horses suffering from joint inflammation, but no such drugs are labelled for veterinary use. To obtain initial data on synovial disposition and safety of a new sustained-release formulation of diclofenac (SYN321) in the joints of horses, an experimental interventional study of elimination and side effects of intra-articular administration of SYN321 was conducted. Nine clinically sound horses were included in the study, and SYN321 was administered by the intra-articular route. Dose ranges and sampling in...
Equine Peripheral Gene Expression Changes in Response to Dose-Dependent Lipopolysaccharide-Induced Synovitis.
Journal of equine veterinary science    November 27, 2021   Volume 109 103828 doi: 10.1016/j.jevs.2021.103828
Page AE, Wood C, Partridge E, Horohov DW, Adam E.The use of lipopolysaccharide to induce a localized source of inflammation (acute synovitis) and allow for monitoring of changes in systemic mRNA expression has been recently reported. Here, the goal was to maintain a significant systemic mRNA response while limiting the severity of lameness such that this model can be used to examine the effects of various anti-inflammatory treatment modalities on mRNA expression. Three mixed breeds, four-year-old geldings were utilized for this study. One milliliter of phosphate-buffered saline containing 1,000 ng or less of lipopolysaccharide from E. coli O...
Effects of Production Method and Repeated Freeze Thaw Cycles on Cytokine Concentrations and Microbial Contamination in Equine Autologous Conditioned Serum.
Frontiers in veterinary science    November 25, 2021   Volume 8 759828 doi: 10.3389/fvets.2021.759828
Hale J, Hughes K, Hall S, Labens R.Autologous conditioned serum (ACS) is a common intra-articular treatment for osteoarthritis in horses. The objective of this study was to investigate the influence of ACS preparation method on product contamination and concentrations of relevant cytokines and the influence of multiple freeze/thaw cycles. Blood was obtained from 10 healthy Thoroughbred horses and processed in parallel using a commercial and a non-commercial method to obtain ACS. Fluorescent microsphere immunoassay (FMIA) analysis was performed to quantify Interleukin 1 receptor antagonist (IL-1Ra), Interleukin-10 (IL-10), Inter...
Surgical removal of intra-articular loose bodies from the cervical articular process joints in 5 horses.
Veterinary surgery : VS    November 17, 2021   Volume 51, Issue 1 173-181 doi: 10.1111/vsu.13744
Tucker R, Parker RA, Meredith LE, Hughes TK, Foote AK.To describe the surgical removal of intra-articular loose bodies (LBs) from the cervical articular process joints (APJs) in five horses and to describe the outcome of the surgery. Methods: Short case series. Methods: Five client-owned horses with naturally occurring LBs within the cervical APJs. Methods: Medical records were reviewed of horses that were diagnosed with LBs of the cervical APJs on computed tomography (CT), where the LBs were subsequently removed surgically. Details of case selection and surgical technique were reviewed along with postoperative complications and clinical outcome....
Role of Innate Immunity in Initiation and Progression of Osteoarthritis, with Emphasis on Horses.
Animals : an open access journal from MDPI    November 13, 2021   Volume 11, Issue 11 3247 doi: 10.3390/ani11113247
Estrada McDermott J, Pezzanite L, Goodrich L, Santangelo K, Chow L, Dow S, Wheat W.Osteoarthritis (OA) is a common condition with diverse etiologies, affecting horses, humans, and companion animals. Importantly, OA is not a single disease, but rather a disease process initiated by different events, including acute trauma, irregular or repetitive overload of articular structures, and spontaneous development with aging. Our understanding of the pathogenesis of OA is still evolving, and OA is increasingly considered a multifactorial disease in which the innate immune system plays a key role in regulating and perpetuating low-grade inflammation, resulting in sustained cartilage ...
An Evaluation of Current Preventative Measures Used in Equine Practice to Maintain Distal Forelimb Functionality: A Mini Review.
Frontiers in veterinary science    November 2, 2021   Volume 8 758970 doi: 10.3389/fvets.2021.758970
Clarke EJ, Gillen A, Turlo A, Peffers MJ.Horses are used in a variety of equestrian disciplines predisposing them to musculoskeletal injury or disease including osteoarthritis and tendinopathy. As a result, a number of preventative measures are used within equine medicine and husbandry, ranging from therapeutic shoeing to the use of nutraceuticals. Despite their popularity and routine use evidence base and clinical outcomes are variable, bringing into question the efficacy of these prophylactic measures. In recent years a small number of studies have been performed examining the effect of specific strategies in order to quantify the ...
The Frequency of Communication Between the Synovial Compartments of the Equine Temporomandibular Joint: A Contrast-Enhanced Computed Tomographic Assessment.
Frontiers in veterinary science    October 25, 2021   Volume 8 753983 doi: 10.3389/fvets.2021.753983
Pimentel KL, Carmalt JL. There is conflicting evidence regarding communication between the two compartments of the equine temporomandibular joint (TMJ). Understanding the inter-relationship between TMJ compartments is critical for diagnostic and clinical management purposes. To determine the frequency of communication between the discotemporal joint (DTJ) and the discomandibular joint (DMJ) of the equine TMJ in horses free of overt disease. A randomized, blinded, controlled cadaveric study. Equine cadaver heads ( = 20), with no reported history of potential TMJ disease, were collected and stored frozen until use. ...
A threshold volume of 10 ml is suggested for detecting articular cartilage defects in equine carpal joints using CT arthrography: Ex vivo pilot study. McQuillan S, Kearney C, Hoey S, Connolly S, Rowan C.Computed tomographic arthrography (CTA) has been described as a method for detecting articular cartilage defects in equine carpal joints; however, published studies on the effects of contrast volume for lesion detection are currently lacking. The purpose of this prospective, experimental, pilot study was to determine a threshold volume of iodinated contrast for CTA of the antebrachiocarpal (ABC) and middle carpal (MC) joints for detection of articular cartilage surface defects. Articular cartilage defects were iatrogenically created in the surfaces of the ABC and MC joints of 20 equine cadaver...
Kinesiotaping in Horses [translation]
Tierarztliche Praxis. Ausgabe G, Grosstiere/Nutztiere    October 19, 2021   Volume 49, Issue 5 363 doi: 10.1055/a-1619-9378
Translation: The 2nd edition of this specialized book by Renate Ettl includes basic knowledge about the use of kinesiological tapes, ranging from their foundations to specific applications in horses. The reader is vividly introduced to the material and adhesive properties of the tapes, the various application techniques, and their correct application. The book is mainly aimed at manual therapists and veterinarians, but interested horse owners can also gain insight into the "world of colorful strips" with this work. Part 1 of the book provides foundational knowledge necessary for the correct...
Treatment of shoulder joint luxation with glenoid ostectomy in a miniature donkey.
Journal of the American Veterinary Medical Association    October 15, 2021   Volume 259, Issue 9 1043-1046 doi: 10.2460/javma.259.9.1043
Skelton JA, Hawkins JF, Rochat MC.A 13-year-old 128-kg miniature donkey gelding was evaluated for right forelimb lameness of 7 weeks' duration. Muscular atrophy of the infraspinatus and supraspinatus muscles over the right scapula with a palpable bony prominence over the point of the shoulder was evident. At the walk, the cranial phase of the stride was reduced with adduction of the distal aspect of the limb, dragging of the toe, and lameness (grade, 4/5). Lateral and craniocaudal radiographs of the right shoulder joint revealed lateral luxation of the humerus in relation to the scapula with bony proliferation and remodeling o...
Kinematic Analysis During Straight Line Free Swimming in Horses: Part 1 – Forelimbs.
Frontiers in veterinary science    October 14, 2021   Volume 8 752375 doi: 10.3389/fvets.2021.752375
Santosuosso E, Leguillette R, Vinardell T, Filho S, Massie S, McCrae P, Johnson S, Rolian C, David F.Background: Swimming is used for rehabilitation and conditioning purposes in equine sports medicine despite the lack of understanding of equine swimming kinematics. The aim of this study was to assess forelimb joints kinematics (elbow, carpus, and fetlock) in swimming horses. The specific objectives were 1- to calculate and compare joint angles in swimming vs. passive mobilizations (PM), 2- to determine joint angular velocities during a swimming stride cycle. Methods: Eleven elite endurance horses swam in a 100-m straight pool. Underwater (swimming) and overground (PM) videos were recorded fro...
Responses to an intra-articular lipopolysaccharide challenge following dietary supplementation of Saccharomyces cerevisiae fermentation product in young horses.
Journal of animal science    October 8, 2021   Volume 99, Issue 10 skab272 doi: 10.1093/jas/skab272
Martinez RE, Leatherwood JL, Arnold CE, Glass KG, Walter KW, Valigura HC, Norton SA, White-Springer SH.Dietary intervention may be a valuable strategy to optimize the intra-articular environment in young horses to prolong their performance career. To test the hypothesis that dietary supplementation of a Saccharomyces cerevisiae fermentation product would reduce markers of joint inflammation and increase markers of cartilage metabolism following a single inflammatory insult, Quarter Horse yearlings (mean ± SD; 9 ± 1.0 mo) were balanced by age, sex, body weight (BW), and farm of origin and randomly assigned to the following treatment groups: 1.25% BW/d (dry matter basis) custom-formulated conce...
Sustained Intra-Articular Release and Biocompatibility of Tacrolimus (FK506) Loaded Monospheres Composed of [PDLA-PEG1000]-b-[PLLA] Multi-Block Copolymers in Healthy Horse Joints.
Pharmaceutics    September 10, 2021   Volume 13, Issue 9 doi: 10.3390/pharmaceutics13091438
Cokelaere SM, Groen WMGAC, Plomp SGM, de Grauw JC, van Midwoud PM, Weinans HH, van de Lest CHA, Tryfonidou MA, van Weeren PR, Korthagen NM.There is an increasing interest in controlled release systems for local therapy in the treatment of human and equine joint diseases, aiming for optimal intra-articular concentrations with no systemic side effects. In this study, the intra-articular tolerability and suitability for local and sustained release of tacrolimus (FK506) from monospheres composed of [PDLA-PEG1000]-b-PLLA multiblock copolymers were investigated. Unloaded and tacrolimus-loaded (18.4 mg tacrolimus/joint) monospheres were injected into the joints of six healthy horses, with saline and hyaluronic acid (HA) in the contralat...
Arthroscopic evaluation of the synovial membrane and its relationship with histological changes and biomarkers in equine joint disease.
Research in veterinary science    September 8, 2021   Volume 140 212-220 doi: 10.1016/j.rvsc.2021.09.003
Agreste FR, Moreira JJ, Fülber J, Bogossian PM, Chaible LM, Silva LCLC, Michelacci YM, Baccarin RYA.The synovial membrane (SM) presents itself with distinctive characteristics during arthroscopic procedures in cases of osteoarthritis (OA) as well as osteochondritis dissecans (OCD) in horses. Most of the arthroscopic findings of the SM are limited to a description of a nonspecific inflammation state. In the present study, the macroscopic and histological aspects of the SM in OA and OCD horses were compared to those of healthy horses. The expression of interleukin (IL) in SM was also investigated. Besides, the concentrations of ILs and keratan sulfate (KS) in the synovial fluid (SF), and the m...
Cartilage Degeneration of the Metacarpal Condyle and Enthesopaties of The Collateral Ligaments of Equine Metacarpophalangeal Joint.
Journal of equine veterinary science    August 28, 2021   Volume 106 103754 doi: 10.1016/j.jevs.2021.103754
De Bastiani G, La Côrte FD, Azevedo MDS, Jacobsen TK, Kommers GD.Articular degeneration can be characterized by fibrillation and eburnation of the articular layers of the metacarpophalangeal (MP) joint. Structural changes within the articular joint predispose the development of osteophytes, enthesophytes and, in many cases is associated with changes the collateral ligaments of the MP joint. The aim of the present study was to investigate the relationship between degenerative processes of the articular cartilage and the enthesopathies of collateral ligaments (superficial or deep portion) of the equine MP joint, using radiographic, ultrasonographic and anatom...
Effect of intravenous tiludronate disodium administration on the radiographic progression of osteoarthritis of the fetlock joint in Standardbred racehorses.
Journal of the American Veterinary Medical Association    August 28, 2021   Volume 259, Issue 6 651-661 doi: 10.2460/javma.259.6.651
Bertuglia A, Basano I, Pagliara E, Bottegaro NB, Spinella G, Bullone M.To compare the effects of tiludronate disodium and 3 other medical treatments on clinical and radiographic findings and biomarkers of disease progression in horses with osteoarthritis of the fetlock joint. 100 Standardbred racehorses with spontaneous traumatic injury of the fetlock joint. Horses were retrospectively grouped by whether they received tiludronate IV or triamcinolone acetonide and hyaluronan, polysulfated glycosaminoglycan, or interleukin-1 receptor antagonist protein intra-articularly. Data were collected on clinical, radiographic, and ultrasonographic findings and results for se...
Comparison of ultrasonography and radiography with arthroscopy for diagnosis of dorsoproximal osteochondral fragmentation of the proximal phalanx in 56 Thoroughbred racehorses.
Equine veterinary journal    August 22, 2021   doi: 10.1111/evj.13497
Plevin S, McLellan J.Osteochondral fragmentation of the proximal phalanx (DPP1 fragment) is a common finding in the racehorse. Whilst radiographic assessment has been reported to lack diagnostic sensitivity, ultrasonographic examination has been documented to be extremely sensitive for identification of bone fragments in the metacarpophalangeal joint. Objective: To determine the sensitivity and specificity of ultrasonography as an imaging modality for diagnosis of DPP1 fragmentation and to compare it with radiography in the Thoroughbred racehorse. Methods: Retrospective cohort study. Methods: Medical records (radi...
Systematic Comparison of Biomaterials-Based Strategies for Osteochondral and Chondral Repair in Large Animal Models.
Advanced healthcare materials    August 18, 2021   Volume 10, Issue 20 e2100878 doi: 10.1002/adhm.202100878
González Vázquez AG, Blokpoel Ferreras LA, Bennett KE, Casey SM, Brama PA, O'Brien FJ.Joint repair remains a major challenge in orthopaedics. Recent progress in biomaterial design has led to the fabrication of a plethora of promising devices. Pre-clinical testing of any joint repair strategy typically requires the use of large animal models (e.g., sheep, goat, pig or horse). Despite the key role of such models in clinical translation, there is still a lack of consensus regarding optimal experimental design, making it difficult to draw conclusions on their efficacy. In this context, the authors performed a systematic literature review and a risk of bias assessment on large anima...
What can artificial intelligence and machine learning tell us? A review of applications to equine biomechanical research.
Journal of the mechanical behavior of biomedical materials    August 12, 2021   Volume 123 104728 doi: 10.1016/j.jmbbm.2021.104728
Mouloodi S, Rahmanpanah H, Gohari S, Burvill C, Tse KM, Davies HMS.Artificial intelligence (AI) and machine learning (ML) are fascinating interdisciplinary scientific domains where machines are provided with an approximation of human intelligence. The conjecture is that machines are able to learn from existing examples, and employ this accumulated knowledge to fulfil challenging tasks such as regression analysis, pattern classification, and prediction. The horse biomechanical models have been identified as an alternative tool to investigate the effects of mechanical loading and induced deformations on the tissues and structures in humans. Many reported invest...
A study of the shoulder and elbow joints of the donkey (Equus asinus) by gross anatomical dissection, radiography, computed tomography, and intra-articular injection.
Morphologie : bulletin de l\'Association des anatomistes    August 11, 2021   Volume 106, Issue 354 177-187 doi: 10.1016/j.morpho.2021.07.002
Alsafy MAM, Elbakary RMA, Bassuoni NF.Joint diseases often represent the major part of equine clinician's caseloads. The current study aimed to document the normal anatomy of the donkey shoulder and elbow joints using computed tomography, cadaver sections, and radiography. Seven adult donkeys were used in this study. The current study proved there were no pouches of the donkey shoulder joint. Communication between the joint capsule and bicipital bursa was observed only in two limbs of four used in the present work. The joint was without pericapsular ligaments. The glenohumeral ligament was identified by the thickening of the artic...
Targeting Soluble Epoxide Hydrolase and Cyclooxygenases Enhance Joint Pain Control, Stimulate Collagen Synthesis, and Protect Chondrocytes From Cytokine-Induced Apoptosis.
Frontiers in veterinary science    August 5, 2021   Volume 8 685824 doi: 10.3389/fvets.2021.685824
Tucker L, Trumble TN, Groschen D, Dobbs E, Baldo CF, Wendt-Hornickle E, Guedes AGP.Objective: To determine the symptomatic and disease-modifying capabilities of sEH and COX inhibitors during joint inflammation. Methods: Using a blinded, randomized, crossover experimental design, 6 adult healthy horses were injected with lipopolysaccharide (LPS; 3 μg) from E. coli in a radiocarpal joint and concurrently received the non-selective cyclooxygenase (COX) inhibitor phenylbutazone (2 mg/kg), the sEH inhibitor t-TUCB (1 mg/kg) or both (2 mg/kg phenylbutazone and 0.1, 0.3, and 1 mg/kg t-TUCB) intravenously. There were at least 30 days washout between treatments. Joint pain (assessed...
Repeated intra-articular administration of equine allogeneic peripheral blood-derived mesenchymal stem cells does not induce a cellular and humoral immune response in horses.
Veterinary immunology and immunopathology    August 2, 2021   Volume 239 110306 doi: 10.1016/j.vetimm.2021.110306
Van Hecke L, Magri C, Duchateau L, Beerts C, Geburek F, Suls M, Da Dalt L, Patruno M, Saunders J, Broeckx SY, Depuydt E, Spaas JH.The use of mesenchymal stem cells (MSCs) for the treatment of equine joint disease is widely investigated because of their regenerative and immunomodulatory potential. Allogeneic MSCs provide a promising alternative to autologous MSCs, since the former are immediately available and enable a thorough donor screening. However, questions have been raised concerning the immunogenic potential of allogeneic MSCs, especially after repeated administration. Methods: Current retrospective study assessed the cellular and humoral immunogenicity of ten jumping and dressage horses with naturally occurring d...
Effects of an articular cartilage lubrication with a viscosupplement in vitro and in vivo following osteochondral fractures in horses.
American journal of veterinary research    July 24, 2021   Volume 82, Issue 8 611-618 doi: 10.2460/ajvr.82.8.611
Temple-Wong MM, Raleigh AR, Frisbie DD, Sah RL, McIlwraith CW.To assess whether the combination of hyaluronan, sodium chondroitin sulfate, and -acetyl-d-glucosamine (HCSG) lubricates articular cartilage in vitro and modulates joint lubrication in vivo. Methods: 16 healthy adult horses. Methods: The effects of HCSG injections on SF lubricant properties and joint health, immediately after injury and 2 weeks later, were analyzed by use an equine osteochondral fracture model of post-traumatic osteoarthritis (OA). Middle carpal joints of adult horses were randomly assigned to 1 of 4 surgical treatment groups as follows: normal nonsurgical group (n = 8), norma...
Corrigendum: Standing MRI lesions of the distal interphalangeal joint and podotrochlear apparatus occurs with a high frequency in Warmblood horses. The research paper involves a study targeting lesions in the foot joints of Warmblood horses, which was found to be common. However, the authors acknowledge that the initial paper contained […]
Synovial Concentration of Trimethoprim-Sulphadiazine Following Regional Limb Perfusion in Standing Horses.
Animals : an open access journal from MDPI    July 13, 2021   Volume 11, Issue 7 2085 doi: 10.3390/ani11072085
Gustafsson K, Tatz AJ, Dahan R, Abu Ahmad W, Britzi M, Sutton GA, Kelmer G.The aim of this study was to investigate the safety and pharmacokinetics of trimethoprim-sulphadiazine administered via intravenous regional limb perfusion (IVRLP) into the cephalic vein. According to the hypothesis, the drug could be administered without adverse effects and the synovial concentrations would remain above the minimum inhibitory concentration (MIC) for trimethoprim-sulphadiazine (0.5 and 9.5 µg/mL) for 24 h. Ten ( = 10) horses underwent cephalic vein IVRLP with an Esmarch tourniquet applied for 30 min. Four grams (4 g) of trimethoprim-sulphadiazine (TMP-SDZ) were diluted at 0.9...
Comparison of equine synovial sepsis rate following intrasynovial injection in ambulatory versus hospital settings.
Equine veterinary journal    July 8, 2021   Volume 54, Issue 3 523-530 doi: 10.1111/evj.13485
Krause DM, Pezzanite LM, Griffenhagen GM, Hendrickson DA.Frequency of synovial sepsis in horses following intrasynovial injection has been reported, but not compared with respect to the environment in which the injection was performed. Objective: To describe occurrence of synovial sepsis following intrasynovial injections performed in ambulatory vs hospital settings. Methods: Retrospective cohort study. Methods: Records from the Colorado State University were evaluated (2014-2018) and horses receiving intrasynovial injections were identified. Patients presenting for septic synovial structures were excluded. Patient signalment, primary supervising se...
Current joint therapy usage in equine practice: Changes in the last 10 years.
Equine veterinary journal    June 18, 2021   doi: 10.1111/evj.13489
Zanotto GM, Frisbie DD.Osteoarthritis is a common clinical condition in the performance horse. In the last 10 years, there has been substantial growth in understanding of the disease and in the development of novel therapies. Objective: To document changes in clinical use of joint therapies over the past 10 years. We also aimed to understand how newly developed therapies have been added to routine clinical practice. Methods: Survey of veterinary professionals. Methods: We administered an electronic survey to members of the American Association of the Equine Practitioners. Questions from a similar survey in 2009 we...
Development and Validation of a Three-Dimensional Printed Training Model to Teach Ultrasound-Guided Injections of the Cervical Articular Process Joints in Horses.
Journal of veterinary medical education    June 11, 2021   Volume 49, Issue 4 442-453 doi: 10.3138/jvme-2020-0137
Beaulieu A, Nykamp S, Phillips J, Arroyo LG, Koenig J, Zur Linden A.Intra-articular injections are routinely performed to alleviate pain and inflammation associated with osteoarthritis in horses. Intra-articular injections require accurate needle placement to optimize clinical outcomes and minimize complications. This study's objectives were to develop and validate a three-dimensional (3D) printed model of an equine cervical articular process joint to teach ultrasound-guided injections. Five identical models of an equine cervical articular process joint were 3D printed and embedded in 10% ballistic gelatin. Experts' and novices' ability to successfully insert ...
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