Joint fusions in palaeopathology: diagnosis and epidemiology

Paja László
Joint fusions in palaeopathology: diagnosis and epidemiology.
[Thesis] (Unpublished)

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Abstract in foreign language

Biological anthropology (humanbiology) is the science that focuses on the human being, man of the present and past may also be a challenging object. Human biology examines the biological characteristics of past populations. Its goal is to reconstruct the past societies on the basis of their biological characteristics, its analytical results let us to get more information about the life of ancient populations. Palaeopathology is a discipline of the biological anthropology; it focuses on the analyses of human remains. The examination of pathological skeletal alterations may help us to reconstruct special conditions like state of health, special environmental effects on a population or characteristics of the way of living in the past. The discipline can reveal such pathological conditions that were present in an archaeological period, it is able to analyse the prevalence and manifestation of a disease. Pathological processes may leave proliferative or lytic traces in the bones, fusions of the joints or their neighbouring area may also appear. These ankyloses may lead to partial or complete loss of capacity of movement in any joint; numerous aetiological factor may be responsible for the development of them. As the prevalence of ankyloses is quite low, we can usually meet them through case reports in the palaeopathological literature. Synthetic publications based on systematic analyses generally focus on only special diseases. Present study focuses on the analysis of the joint fusions’ nosological and epidemiological characteristics. Our primary aim following the data collection is to describe and analyze those potential macromorphological, radiological and histological signs or alterations, which may support our diagnostic effort and may provide one or more useful diagnostic criteria to recognize a disease in a more precise way. Ankyloses are relatively rarely observable alterations in osteoarchaeological series, thus we analyzed skeletal remains of numerous cemetery. Our examination material incorporated 29 series originating from the Great Hungarian Plain, the skeletal remains represent several archaeological periods. The oldest specimens are dated back the Sarmatian period (1st-5th c. AD), while the most present series are dated to the early modern times (18th c. AD). Summarizing the data, we can say that skeletal remains of 10.976 individuals have been included the examined material; our series are very diverse in their completeness and state of preservation. During the analysis basic anthropological data (sex, age at death, age categories) were available for us from previously carried out anthropological studies. Macromorphological examinations were made in the majority of the cases, but medical imaging techniques (X-ray, computed tomography) and histological methods were also utilized in certain cases. Results of previously carried out molecular biological analyses were available for us in some instances, these results helped to confirm our diagnosis. During our analyses single or multiple ankyloses were found in the skeletal remains of 346 individuals, they are associated with numerous nosological categories. Concerning the number of ankyloses, developmental diseases were found in the biggest number among our findings, the alterations were seen in all age categories. Their recognition was fairly easy, and the most typical predilectional areas are the spine and the thorax. The manifestation and distribution of the synostosis vertebralis and sacralization cases broadly correspond to the characteristics found in the literature. Fusions involving the sternal segments and functional ankyloses of the ribs are also seen, the recognition of the aetiology is not difficult in these cases, similarly to the developmental defects of the previous group. The distribution of the cases corresponds to the data seen in medical and palaeopathological references. Joint fusions associated with degenerative processes developed in the spine and the limbs. Concerning the axial localization, both the vertebral bodies and the posterior elements are involved. Common features of these fusions that irregular ankylosis line and fusion area characterized with irregular bony structure are recognizable. The cervical spine is involved the most; in the majority of cases signs of other degenerative processes (e.g. traces of spondylosis deformans and/or osteoarthritis) are also visible in the bony elements. An increasing tendency with ageing is recognizable, ankyloses of degenerative origin developed in more males than females. Ankyloses associated with traumatic events are easily recognizable in those cases, when dislocation or shortening of a bone (e.g. in compression fractures) directly refer to the aetiology. Traumatic alterations may develop both in the segments of the vertebral column and in long bones; strong male predominance is seen in this group. In the majority of cases, alterations associated with some infection are also present, ankyloses can be interpreted as the sign of the healing. Particular phenomenon appears in four distal tibiofibular ankyloses; the joints themselves are not involved in the bony fusions, but a bony bridge hinders the movement of the joint. In the cases of vertebral compression fractures slight or moderate vertebral collapse is recognizable, but kyphosis is not found. Ankyloses developed mainly between the bodies, but zygapophyseal joints are also involved in some cases. Joint fusions are found in association with healing process following both non-specific and specific infections. Concerning non-specific infections, the spine and the extremities are also involved, characteristic periosteal reactions and cloacal openings (drainages of the pus) refer to the presence of some non-specific infection. In extravertebral localization, distal areas of the limbs are more involved, bony fusions localized to ankles and hands are recognizable. Identification of tuberculosis and leprosy was possible among the specific infection cases. In cases of vertebral fusions associated with TB, the thoracic and upper lumbar spine is affected the most, pathognomic Pott’s disease is recognizable here. The collapse of the vertebral bodies result in wedge shape bodies, multiple ankyloses may appear. Concerning the affected elements, all vertebral parts are involved in most of the cases. In the second localization kyphosis is not present, but other lesions, like new periosteal bone formations, cold abscess and extensive paravertebral bony mass are suggestive of TB. Concerning the sex distribution, much more females than males are involved in TB-associated ankyloses. Analyses of CT scans and 3D reconstructions together with analysis of written sources from the preantibiotic age helped to clarify the aetiology of two rare knee ankyloses, the probable underlying disease is tuberculous infection in these cases. The ossification of the anterior longitudinal ligament (OALL) is pathognomic sign in the cases of diffuse idiopathic skeletal hyperostosis. The alteration is recognizable only in males in our series; individuals belonging to Maturus and Senium age categories were affected. Other typical diagnostic criteria, the preserved intervertebral spaces and intact zygapophyseal joint gaps were also seen in the individuals diagnosed with DISH. An association between the OALL and ossification of other ligaments (e.g. ligamentum flavum, supraspinous ligament) is found, the development of enthesopathies presents similar association. Our results suggest that the utilized diagnostic criteria used for the separation of DISH and early-DISH cases may lead to too thin boundary between the categories, thus the classification will become too strict. In our opinion, some individuals diagnosed as early –DISH – on the basis of extravertebral manifestation - case should be moved to DISH category. In those cases, where characteristic ankyloses were found in the spine and/or in the sacroiliac joint(s), we were able to diagnose the representative disease of the so-called seronegative spondylarthropathies. Except one case, when almost the entire spine is fixed, our ankylosing spondylitis cases present lumbar spine involvement. Sacroiiliac fusions are not associated with ligament ossification, but sacroiliitis is seen as a typical concomitant alteration. Only males are affected in the disease, all of them are belonging to the Maturus or Senium age categories. Concerning the utility of the diagnostic tools, distinct conclusions can be drawn. Classical macromorphological examinations are unavoidable and useful techniques in most of the cases. By systematic and thoroughgoing analyses the underlying disease can be found with certainty. We did not find diagnostically useful traces during the histological analyses. As the development of the true bony ankyloses may take a long time, mature bone tissue of normal structure can develop in different diseases either. The use of radiological techniques helped us to gain more information on the development of a disease, on the other hand, a more precise diagnosis is obtainable by these techniques. While the conventional X-ray images give us overlapping 2D picture, CT is able to reveal the fused bones’ interior structure from multiple directions. Thus computed tomography proved to be a more useful technique from diagnostical point of view. We have to note those precise 3D reconstructions (e.g. with the help of TIVMI software) that enable us to evaluate the alterations; furthermore the comparison to descriptions found in the literature will also be possible with the help of these reconstructions. Concerning the experienced morphological, epidemiological or methodological traits and statements, present study may provide some helpful or supportive information for those researches that focus on the biological reconstruction of past populations.

Item Type: Thesis (PhD)
Creators: Paja László
Hungarian title label: Csont-ízületi fúziók a paleopathológiában: diagnózis és epidemiológia
Divisions: Doctoral School of Environmental Sciences
Discipline label: Natural Sciences > Biology
Defence date label: 2013. May 08.
Item ID: 1691
Identification Number: 2849833
Date Deposited: 2013. Jan. 17. 10:11
Last Modified: 2019. Dec. 07. 14:47
Depository no.: B 5498
Defence/Citable status: Defended.

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