Radiographic changes after resection of the distal ulna in rheumatoid arthritis

Progressive ulnar translocation of the carpus and problems with the ulnar stump have been reported after resection of the distal ulna in rheumatoid arthritis (RA). However this has only occasionally been quantitatively assessed. In this study 24 wrists in 21 patients with RA were followed up for an average of 100 months after resection of the distal ulna. An additional 24 wrists in 14 non-operated RA patients were followed up for 92 months. In a retrospective radiographic analysis we demonstrate similar increases in ulnar translocation and ulnar-carpal distances in both groups.

[The mid-term results of proximal row carpectomy in the treatment of degenerative wrist joint derangements]

OBJECTIVES

We evaluated the mid-term results of proximal row carpectomy (PRC) in patients who underwent treatment for wrist joint derangements.

METHODS

Nine patients (4 men, 5 women; mean age 38 years; range 23 to 66 years) underwent PRC to relive pain in the wrist joint and to improve motion and grip strength. Indications for surgery were acute transscaphoid-perilunate fracture dislocation in one patient, formerly unreduced perilunate fracture dislocation in one patient, Kienbock's disease in four patients, and scaphoid nonunion associated with scapholunate advanced collapse (SLAC) in three patients. The duration of the symptoms ranged from eight months to 10 years. The results were assessed with the use of pre- and postoperative clinical and radiographic studies, and measurements of active and passive motion, grip strength, and pulp and key pinch strengths. The mean follow-up was 35.4 months (range 13.5 to 72 months).

RESULTS

Postoperatively, pain relief was achieved in all the patients and no complications were encountered in the early period. One patient with acute transscaphoid-perilunate fracture dislocation developed radiocapitate joint degeneration three years after surgery and underwent total wrist arthrodesis. Compared to the uninvolved side, wrist functions were found adequate with painless motion, except for passive radial deviation which exhibited a significant decrease (p<0.05). Age, sex, and the duration of symptoms did not influence postoperative results.

CONCLUSION

In selected patients with wrist joint derangement, PRC enables painless and adequate motion and grip strength for daily activities. However, radial styloidectomy seems to be necessary to prevent restriction in radial deviation.

Radiography and visual pathology of the osteoarthritic scaphotrapezio-trapezoidal joint, and its relationship to trapeziometacarpal osteoarthritis

PURPOSE

To determine and quantify the relationship of osteoarthritis (OA) in the trapeziometacarpal, scaphotrapezial, and scaphotrapezoidal joints; to ascertain the dependability of radiographic assessment of trapeziometacarpal, scaphotrapezial, and scaphotrapezoidal OA; to determine the articular topography of the scaphotrapezio-trapezoidal (STT) joint (composed of the scaphotrapezial and scaphotrapezoidal articulations) using stereophotogrammetry; and to characterize the articular wear patterns of STT OA.

METHODS

Sixty-nine fresh-frozen human cadaveric hands were staged radiographically and by gross visual examination for the presence of OA in the trapeziometacarpal and STT joints. Twenty randomly selected joints also were evaluated to determine the topography of the STT joint using stereophotogrammetry.

RESULTS

Concomitant severe osteoarthritic degeneration was found in the trapeziometacarpal and STT joint in 60% of our specimens. A correlation was found in the severity of OA in the trapeziometacarpal and STT joints. Radiographic and gross visual evaluation of STT OA concurred in 39% of our specimens.

CONCLUSIONS

The prevalence of concomitant trapeziometacarpal and STT OA, and the uncertainty of radiographic evaluation of STT OA, indicate the need to visualize the STT joint intraoperatively to determine the true degree of degenerative changes present.

New radiographic bone erosions in the wrists of patients with rheumatoid arthritis are detectable with magnetic resonance imaging a median of two years earlier

OBJECTIVE

In a 5-year followup study, we investigated the temporal relationship between development of wrist joint erosions as visualized by magnetic resonance imaging (MRI) versus conventional radiography (CR), in patients with rheumatoid arthritis. We also evaluated the risk of erosive progression on CR associated with the presence of MRI erosions.

METHODS

In 10 patients with rheumatoid arthritis, MRI and CR of the dominant wrist were performed annually for 5 years. In each image set, each wrist bone (metacarpal bases, carpal bones, radius, and ulna) was assessed for the absence or presence of bone erosions.

RESULTS

Nine bones showed radiographic erosions at baseline. Twenty-seven new radiographic erosions developed during the 5-year followup period. Of these 27 new erosions, 21 were detected 1-5 years earlier by MRI than by CR, 3 were simultaneously detected by both methods, 2 were detected 1-2 years later by MRI than by CR, and 1 erosion (radiographically detected at 5-year followup) was not visualized with MRI. MRI detection of new radiographic erosions preceded CR detection by a median of 2 years. In bones with MRI erosions at baseline, the relative risk of radiographic erosions at 5-year followup was 4.5 (95% confidence interval [95% CI] 2.6-7.6), compared with bones without baseline MRI erosions. If bones with baseline radiographic erosions were excluded from the analysis, the relative risk was 4.1 (95% CI 2.2-7.5).

CONCLUSION

Most new radiographic bone erosions (78%) were visualized at least 1 year earlier by MRI than by CR. This illustrates that the information on joint destruction provided by CR is considerably delayed compared with that provided by MRI. A significantly increased risk of progression of radiographic erosion in bones with baseline MRI erosions was observed, demonstrating a prognostic value of MRI with respect to long-term radiographic outcome.

Bone edema scored on magnetic resonance imaging scans of the dominant carpus at presentation predicts radiographic joint damage of the hands and feet six years later in patients with rheumatoid arthritis

OBJECTIVE

Magnetic resonance imaging (MRI) is capable of revealing synovitis and tendinitis in early rheumatoid arthritis (RA), as well as bone edema and erosion. These features are visible before radiographic joint damage occurs. We sought to examine whether MRI of one body region (the wrist) can be used to predict whole-body radiography scores reflecting joint damage at 6 years.

METHODS

We conducted a 6-year prospective study of a cohort of patients who fulfilled the criteria for RA at presentation, using clinical parameters, radiographs, and MRI scans of the dominant wrist. Of the 42 patients enrolled at baseline, full MRI, radiographic, and clinical data were available for 31 at 6-year followup. MRI scans were scored by 2 radiologists, using a validated scoring system. Radiographs of the hands and feet were graded using the modified Sharp scoring method. MRI and radiography scores obtained at baseline and 6 years were compared, and baseline MRI scores were examined for their ability to predict radiographic outcome at 6 years.

RESULTS

At 6 years, the total Sharp score correlated significantly with the total MRI score and the MRI erosion score (r = 0.81, P < 0.0001 and r = 0.79, P < 0.0001, respectively). The 6-year Sharp score also correlated with the baseline total MRI and MRI erosion scores (r = 0.56, P < 0.0001 and r = 0.33, P = 0.03, respectively). MRI synovitis and bone edema scores remained constant for the group as a whole over 6 years, but bone erosion scores progressed (P = 0.0001), consistent with radiographic deterioration. Erosions on 6-year MRI scans were frequently preceded by MRI bone edema at baseline (odds ratio 6.5, 95% confidence interval 2.78-18.1). Regression models indicated that the baseline MRI bone edema score was predictive of the 6-year total Sharp score (P = 0.01), as was the C-reactive protein (CRP) level (P = 0.0002). Neither shared epitope status nor swollen or tender joint counts predicted radiographic outcome in this cohort. A model incorporating baseline MRI scores for erosion, bone edema, synovitis, and tendinitis plus the CRP level and the erythrocyte sedimentation rate explained 59% of the variance in the 6-year total Sharp score (R(2) = 0.59, adjusted R(2) = 0.44).

CONCLUSION

MRI scans performed at the first presentation of RA can be used to help predict future radiographic damage, allowing disease-modifying therapy to be targeted to patients with aggressive disease.

A case of pseudarthrosis of the capitate

Pseudarthrosis of the capitate bone is extremely rare. In this case, the injury and pseudarthrosis was so old, the bone with a nutrient vessel was grafted, and bone union and excellent results are obtained.

[Direct MR arthrography of the wrist in comparison with arthroscopy: a prospective study on 125 patients]

OBJECTIVE

In literature the diagnostic value of MRI for detecting lesions of the carpal ligaments and the TFCC is judged controversially. The aim of the following study is to determine the diagnostic accuracy of direct MR arthrography for depicting and staging of intraarticular lesions of the wrist.

MATERIAL AND METHODS

One day before undergoing arthroscopy, 125 patients suffering from wrist pain were examined with direct MR arthrography in a prospective and blinded study. A mixture of contrast medium (iodine-containing contrast medium and gadopentetate in relation 200 : 1) was injected into both radiocarpal and midcarpal joints. The following sequences were acquired on a 1.5T scanner: coronal T1-weighted SE, coronal fat-saturated T1-weighted SE, coronal T1-/T2*-DESS-3D, and sagittal T2*-weighted MEDIC. MRI results were compared with arthroscopic findings using statistical analysis (SEN = sensitivity, SPE = specificity, PPV = positive predictive value, NPV = negative predictive value, ACC = accuracy).

RESULTS

In comparison to arthroscopy as the accepted diagnostic gold standard, the following results were found for MR arthrography. Detection of TFCC lesions: SEN 97.1 %, SPE 96.4 %, PPV 97.1 %, NPV 96.4 %, ACC 96.8 %. Detection of complete tears of the scapholunate ligament: SEN 91.7 %, SPE 100 %, PPV 100 %, NPV 99.1%, ACC 99.2%. Detection of partial tears: SEN 62.5 %, SPE 100 %, PPV 100 %, NPV 94.8 %, ACC 95.2 %. Detection of cartilage defects: SEN 84.2 %, SPE 96.2 %, PPV 80 %, NPV 97.1 %, ACC 94.4 %. In total, only three lesions of the lunotriquetral ligament were present.

CONCLUSION

Direct MR arthrographic imaging is well suited for detecting intraarticular lesions of the wrist. The presented diagnostic results of MR arthrography are superior to the results of unenhanced MRI reported in the literature. Direct MR arthrography as a reliable diagnostic tool is strongly recommended if lesions of the scapholunate ligament and the triangular fibrocartilage complex are suspected. In contrast, an attitude of caution must be adopted in diagnosing lesions of the articular cartilage of the wrist.

OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Exercise 3: an international multicenter reliability study using the RA-MRI Score

We examined inter-reader agreement of the revised OMERACT 5 Rheumatoid Arthritis MRI Score (RAMRIS v3). Magnetic resonance (MR) images of 10 sets of metacarpophalangeal (MCP) joints 2-5 and 8 sets of rheumatoid arthritis (RA) wrists [1.5 T, coronal and axial T1 and T2 spin-echo, +/- fat saturation (FS), +/- intravenous gadolinium (Gd)] were scored for (1) synovitis using a global score (0-3) and a direct measurement of synovial thickness (mm) and (2) three bone lesions: erosions, defects and edema, (score 0-10 by the volume of the lesion as a proportion of the "assessed bone volume" by 10% increments). Six readers from 5 multinational centers performed all scoring. Three statistical methods were used to analyze the data: (1) single-measure fixed effects intraclass correlations (sICC) and average-measure fixed effects ICC (avICC), (2) percentage exact and close agreement, and (3) the smallest detectable difference (SDD). The sICC were moderate to good (between 0.60 and 0.91) for half of the joint sites for the 2 synovitis scoring methods, and for bone erosions and bone edema. After adjusting for 6 readers, the avICC was very good to excellent (0.80-0.98) for two-thirds of the joint sites by lesion, excluding bone defects that performed relatively poorly, primarily because few readers scored these lesions. The aggregated scores with the best reliability were those with a wide range of scores, high ICC, low SDD, and low percentage SDD (< 33%). The metacarpophalangeal (MCP) bone erosion (sICC 0.58, avICC 0.89, %SDD +/- 27), wrist bone erosion scores (0.72, 0.94, +/- 31%), the wrist synovitis global (0.74, 0.94, +/- 32%), and synovial maximal thickness (0.6, 0.94, +/- 32%) met these conditions. MCP joint synovitis global (0.76, 0.95, +/-35%), MCP joint bone edema (0.63, 0.91, +/- 34%), and wrist bone edema (0.78, 0.95, +/- 38%) performed marginally less well. Bone defects performed poorly (MCP joint 0.18, 0.46, +/- 56%; wrist 0.06, 0.24, +/- 55%). The revised OMERACT 5 RAMRIS has acceptable inter-reader reliability for measures of disease activity (synovitis global and bone edema scores) and damage (bone erosion score). Whether the score is sensitive to change will be determined by its performance in longitudinal and intervention studies.

Surface landmarks to locate the thenar branch of the median nerve: an anatomical study

The thenar branch of the median nerve can be injured during carpal tunnel release. The purpose of this study was to identify surface landmarks to consistently predict the location of the thenar branch of the median nerve. Surface landmarks were marked and incised in 28 cadaveric hands. The incisions were made along the longitudinal line of the third web space and the horizontal cardinal line from the hamate hook to the ulnar border of the thumb. The origin of the thenar branch was determined in relation to these longitudinal and horizontal vectors. The origin of the thenar nerve branch was consistently observed in the radial proximal quadrant formed by the aforementioned longitudinal and horizontal vectors. The thenar branch origin was observed to be an average of 8.6 +/- 1.9 mm radial to the longitudinal axis along the third web space. The origin of the thenar branch was observed to be an average of 6.3 +/- 2.0 mm proximal to the horizontal axis between the hamate hook and the ulnar border of the thumb. The thenar branch was observed precisely at the intersection of the longitudinal vector from the second web space to the scaphoid tubercle and the horizontal vector from the hamate hook to the radial edge of the proximal metacarpophalangeal crease in all 28 cadaveric hands. On the basis of these 28 cadaveric dissections, the location of the thenar branch of the median nerve can be predicted by the intersection of the longitudinal vector from the second web space to the scaphoid tubercle and the horizontal vector from the hamate hook to the radial aspect of the metacarpophalangeal crease.

Radiographic changes after resection of the distal ulna in patients with rheumatoid arthritis

Radiographic changes in the wrist after resection of the distal ulna in 61 rheumatoid patients (63 wrists) were evaluated more than five years after operation. The wrists were classified on preoperative radiographs into stable or unstable forms as defined by Simmen and Huber. Of 63 wrists, 52 were classified as stable and the remaining 11 were classified as unstable. At follow up, 50 of 52 wrists (96%) that were stable before operation had remained stable. Five of the 11 wrists that were unstable before operation had bony ankylosis or partial radiocarpal ankylosis, and in the remaining six cases there was carpal collapse. Resection of the distal ulna yields good results in stable wrists but operation is not indicated for unstable ones.

[Pisiforme-hamate coalition: a case report]

The authors report a symptomatic case of pisiforme hamate coalition in a young woman. The resection of the synchondrosis allowed the complete resolution of the pain. The pisiforme hamate fusion is an exceptional deformity and it is confirmed by the revue of the Literature.

Aneurysmal bone cyst in the hamate

Aneurysmal bone cysts (ABCs) show a predilection for the metaphysis of the long bones and the vertebrae and seldom involve the carpal bones. We present a case of an ABC in the left hamate of an 18-year-old man. Curettage and bone grafting were performed, and, because destruction of the cortex was extensive, the hamate was excised. At 3-year follow-up, the wrist was stable.

[Clinical impact of MRI in acute wrist injuries. Indication and therapeutic consequences]

PURPOSE

This prospective study was aimed at evaluating the clinical impact of magnetic resonance imaging (MRI) vs conventional radiographs in the early diagnosis of acute wrist fractures. The influence of MRI on the period of being unable to work was demonstrated.

MATERIALS AND METHODS

MRI was performed within a mean of 6.6 days after initial radiographs in 54 patients (56 wrists) with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. MRI findings were read without knowledge of the initial radiographs.

RESULTS

In 31 of 56 wrists MRI findings resulted in a change of diagnosis. There was a false positive diagnosis on plain radiographs in nearly one-half ( n=25) of the cases,whereas only six cases had false negative results. In 28 cases MRI allowed the detection of additional injuries of soft tissues. In 35 of 56 cases radiological follow-up was no longer necessary. In 22 of 54 patients the period of immobilization could be shortened or treatment discontinued ( n=18). The period of being unable to work was shortened in 16 of 54 patients, while in 7 of 54 patients this time span had to be prolonged for therapeutic reasons. In 31 of 54 patients MRI-based therapeutic consequences had no influence on the period of being unable to work.

CONCLUSION

Our results show a high clinical impact of MRI in the detection of acute wrist fractures. Early MRI is able to reduce economic costs due to efficient therapeutic treatment and shortened periods of being unable to work. We recommend MRI immediately on the day of trauma in the presence of clinical suspicion and equivocal plain radiographs

Mechanical wearing down of flexor tendons in rheumatoid arthritis as a result of extreme volar-flexed intercalated segment instability

We report the case of a 72-year-old patient with rheumatoid arthritis complicated by spontaneous ruptures of the flexor digitorum superficialis and profundus tendons of the left index finger. Extreme volar-flexed intercalated segment instability resulted in protrusion of the head of the capitate bone into the carpal tunnel and rupture of both tendons caused by wear. Reconstruction of the flexor digitorum profundus tendon, interposition of a tendon graft, and radiolunate arthrodesis restored function.

Congenital absence of the 5th digital ray and its proximal segmental structures

Limb reduction anomalies involving digits or parts of limbs are not uncommon. Most cases take the form of terminal transverse absence defects involving hypoplasia or aplasia of all structures distal to a particular level on a limb with relative preservation of the more proximal tissues. Longitudinal absence defects are a more rare form of limb reduction anomalies. Structures within one or more digital rays are typically involved. More proximal segmental tissues may also be affected with the most serious cases resulting in absence of the radius or ulna. We report a case of isolated, longitudinal absence of the 5th finger and its corresponding proximal segmental structures in a newborn infant. The embryology of limb development and possible etiologies for skeletal absence defects are summarized.

The relationship between basal joint arthritis and carpal tunnel syndrome: an MRI pilot study

PURPOSE

This investigation explored 2 questions. First, does basal joint arthritis lead to morphologic alterations that significantly narrow the carpal tunnel? Second, does trapezial excision alter the morphology of the carpal tunnel and decompress the median nerve?

METHOD

Four patients with basal joint arthritis alone were treated with ligament reconstruction and tendon interposition (LRTI) arthroplasty. Three patients with basal joint arthritis and carpal tunnel syndrome were treated with LRTI and carpal tunnel release. Preoperative and postoperative magnetic resonance imaging (MRI) scans were obtained to assess differences in carpal tunnel volume and morphology between the groups before and after surgery.

RESULTS

The difference in preoperative carpal tunnel volume between groups was not significantly different. Carpal tunnel volume increased by 7% with LRTI and by 24% after LRTI and carpal tunnel release. The anteroposterior diameter of the carpal canal increased in both groups to allow a volar migration of the median nerve.

CONCLUSION

LRTI increases the anteroposterior diameter and volume of the carpal tunnel. A larger comparative study would be necessary to determine whether LRTI is sufficient to decompress the carpal tunnel.

Osteoblastoma of the carpal scaphoid frequency and treatment

A rare case of osteoblastoma of the carpal scaphoid is presented. Review of the literature revealed two more cases that have been previously reported. The authors present the diagnostic difficulties and the treatment which was applied: proximal row carpectomy and tendon transfers for wrist stabilization. Treatment options, according to the literature, also include scaphoidectomy and tumor curettage with bone grafting.

[Total carpometacarpal dislocations. Two case reports]

We report two cases of carpometacarpal dislocation of the four long fingers. They were diagnosed in emergency and treated by open reduction and stabilization by intramedullary pinning. They were followed for an average of 30 months. The results were rated good, and the two patients had an excellent grip strength, no deformity, no instability, no disabling or limited prehension. Dislocation or fracture-dislocation of the carpometacarpal joints are uncommon injuries. The diagnosis can be easily missed. The authors recommend closed or open reduction and fixation by pins and immobilisation in a plaster cast. The results was good in the two cases without complications.

[Isolated dislocation of the carpal scaphoid. A case report with review of the literature]

Isolated dislocation of the carpal scaphoid is an extremely rare injury, which is usually accompanied by significant ligamento-capsular lesions. A review of the literature found only 21 reported cases. The aim of this report is to present a single case of isolated radio-palmar dislocation of the scaphoid treated conservatively, which provided a good functional result at 10 years follow up.

The distribution of solitary enchondromata at the hand

The location of 327 solitary enchondromata of the hand reported in the English and German medical literature and 30 solitary enchondromata treated at our hospital was studied. Four were located in the carpus, 70 in the metacarpals and 283 in the phalanges. There were highly significant preferences for involvement of the proximal phalanges and the little finger ray. The proximal phalanx of the little finger was the most commonly involved bone.

Risk analysis for a radio-carpal joint replacement

Risk analysis is required by the medical device directives to provide evidence that manufacturers have eliminated or reduced risks as far as possible so that a medical device does not compromise the safety of patients or health workers. This paper presents a risk analysis for the Swanson wrist implant, which is made from an implantable-grade silicone elastomer and used to replace the radiocarpal joint in the rheumatoid wrist. The main hazards identified were that the implant fractures and that silicone synovitis occurs in patients. The results of this risk analysis will be used to aid the design of a new wrist implant.

Renal cell carcinoma with metastases to the triquetrum: case report

Metastatic tumors of the hand are rare, with fewer than 200 cases reported in the literature. Renal cell carcinoma is among the most common tumors to metastasize, but we are not aware of reports of this tumor metastasizing to the carpal bones. We describe a case of renal cell carcinoma that metastasized to the triquetrum to draw attention to the potential for such lesions developing within the hand and wrist.

Patterns of gadopentetate-enhanced MR imaging of radiocarpal joints of healthy subjects

OBJECTIVE

The aim of our study was to evaluate prospectively the grades and patterns of gadopentetate-enhanced MR imaging in the radiocarpal joints of healthy subjects after IV contrast administration.

SUBJECTS AND METHODS

The study included 18 healthy subjects (nine men, nine women; age range, 24-34 years; mean age, 30.8 years). We obtained coronal T1-weighted spin-echo images with fat suppression before and after IV administration of gadopentetate dimeglumine and additional axial T1-weighted spin-echo images after contrast administration. Patterns of signal-intensity enhancement in and around the radiocarpal joints were evaluated qualitatively and quantitatively.

RESULTS

In eight (44.4%) of 18 healthy subjects, enhancement of the radiocarpal joints was seen and exclusively located in the region of the prestyloid recess. Enhancement patterns were bandlike in three (16.7%) of 18 healthy subjects, homogeneous in another three (16.7%) of 18, and nodular in two (11.1%) of 18.

CONCLUSION

After IV administration of gadopentetate, signal-intensity enhancement in the radiocarpal joint is frequently seen in healthy subjects and is not predictive of inflammatory joint disease. If contrast enhancement is present, three distinct patterns are usually revealed, all invariably located in the region of the prestyloid recess.

[Traumatic dislocation of the pisiform bone: a case report and review of the literature]

Traumatic dislocation of the pisiform bone is uncommon. The authors report a case treated by primary excision with a good result. The literature is reviewed and treatment choices are discussed.