DIP Joint Research Articles

Distal phalangeal bone erosions observed by HR-pQCT in patients with psoriatic onycholysis.

PsA prevalence among skin psoriasis is ∼30%. Nail psoriasis, especially onycholysis, is present in >70% of PsA and the risk of developing PsA is more than doubled in patients with nail involvement. We hypothesized that onycholysis may be associated with early bone erosions of the DIP joint without harbouring PsA symptoms. We compared tendon thickness, assessed by US, and bone erosions, assessed by high-resolution peripheral quantitative CT, of the DIP joint in patients with psoriatic onycholysis without PsA (ONY) with those in patients with cutaneous psoriasis only (PSO). We used patients with PsA as reference (PsA group), and healthy age-matched controls (CTRL). Differences between groups were assessed by analysis of variance tests followed by post hoc analysis using the Scheffe method. Mean (s.e.m.) age of the 87 participants (61% males) was 45.2 (1.3) years. The mean extensor tendon thickness was significantly larger in ONY than in PSO patients. In the PsA group, 68% of patients exhibited erosions of three different shapes: V-, Omega- and U-shape. Association with erosions was greater in the ONY group than in the PSO group (frequency: 57 vs 14%; P < 0.001; mean number of erosions: 1.10 (0.35) vs 0.03 (0.03); P < 0.001). Onycholysis was associated with significant enthesopathy and bone erosions in our cohort. These data support the pathogenic role of enthesopathy in PsA. Onycholysis may be considered as a surrogate marker of severity in psoriasis. ClinicalTrails.gov, https://clinicaltrials.gov, NCT02813720.

Posttraumatic Arthritis of Dip Joint with Deformity and its Management- A CaseReport

Posttraumatic Distal interphalangeal joint arthritis is a rare occurrence which is managed with arthrodesis by dorsal approach. When it occurs with deformity and soft tissue contracture, it will be difficult for a surgeon to do arthrodesis without damaging the skin. Our patient was 24 years old male with posttraumatic arthritis of 4th DIP joint with deformity and skin contracture. The patient was operated with wedge osteotomy and arthrodesis by volar approach. The patient had good functional outcome with no complications. Hence by reviewing this case we conclude that planning and individualised approach is necessary especially when managing a case like this

AB0582 DIAGNOSING SYSTEMIC SCLEROSIS WITH PHOTOACOUSTIC AND HIGH-FREQUENCY ULTRASOUND IMAGING

Background:Vasculopathy is already evident in early systemic sclerosis (SSc); Raynaud’s phenomenon and typical nailfoldcapillaroscopic findings are part of the criteria of very early diagnosis of SSc (VEDOSs) (1). As not all early SSc patients have alterations in their nailfoldcapillaries, there is need for other diagnostic tools. Photoacoustics(PA) and high-frequency ultrasound (HFUS) might be able to fulfill this need (2). The former can measure the oxygen saturation of hemoglobin by using short pulsed laser light while the latter can provide high-resolution images that allow measuring skin thickening distal from DIP joint, which could be used to determine skin involvement early.Objectives:We hypothesize that photoacoustics and high-frequency ultrasound can distinguish (early) SSc patients from individuals with primary Raynaud’s phenomenon (PR) by measuring the oxygenation (by PA) of the fingertip and skin thickening (by HFUS).Methods:In our cross-sectional study, we compared measurements of the third finger in (early)SSc patients with individuals with PR and healthy volunteers. Smoking and beta-blockage were exclusion criteria. The level of oxygenation (by PA) and skin thickness (by HFUS) were compared between groups. Nailfoldcapillaroscopy was performed on all subjects and analyzed for the pattern.Results:Thirty-one adult subjects participated in this study: twelve patients with SSc, 5 patients with early SSc, 5 volunteers with PR and 9 healthy controls.We found a significant difference in median (IQR) oxygen saturation between earlySSc patients 75.9% (IQR 75.1%-86.6%) and subjects with PR 94.1% (IQR 93.1%-94.5%) (p=0.0002) using the Wilcoxon rank-sum test (figure 1).Figure 1.Boxplot of saturation (%) per group.Measurements of skin thickening also showed a significant difference in early SSc patients compared to subjects with PR, respectively 0.5mm (IQR 0.4mm-0.5mm) vs. 0.3mm (IQR 0.3mm-0.3mm), P=0.0002 (figure 2).Figure 2.Boxplot of skin thickness (mm) per group.Conclusion:Our results demonstrate that photoacoustic and high-frequency ultrasound can distinguish between (early)SSc and PR in both oxygenation saturation and skin thickening. In a larger prognostic study we want to determine the value of photoacoustic and high frequency ultrasound in diagnosing earlySSc.

Long-term Stack splint immobilization for closed tendinous Mallet Finger.

Closed tendinous mallet finger can be treated non-operatively by extension splinting of the distal interphalangeal joint (DIPJ) for 6 to 8 weeks. However, method of conservative treatment in detail differs among various reports, especially in type of orthosis, duration of full-time immobilization and additional night orthotic wear after full-time immobilization. In our institution, full-time Stack splint is applied with distal interphalangeal joint (DIPJ) in extension for 12 weeks and night orthosis is worn for 4 weeks. The purpose of this study was to evaluate clinical and functional outcomes of tendinous mallet finger using our treatment protocol. Between March 2007 and December 2017, patients with tendinous mallet finger who were managed conservatively according to our treatment protocol were retrospectively reviewed. A total of 100 patients (101 cases) were enrolled, including 77 males and 23 females. Extension lag was measured before, soon after treatment, and at the final follow-up. Flexion angle of DIP joint was measured at the final follow-up. Patients were clinically evaluated based on the Crawford classification scale and Abouna & Brown criteria. The mean age of patients was 40 years and the mean follow-up was 48 months. The mean extension lag was 28.3 degrees initially and 2.6 degrees at the final follow-up. (p-value < 0.001) Flexion angle at the final follow-up was 68.3 degrees. Based on the Crawford classification scale, 56 % of patients had excellent results, and 25 % of patients had good results. According to Abouna & Brown criteria, 78 % of patients had success results and 7.5 % of patients had improved results. Wearing orthosis for up to 16 weeks (12 weeks full time and 4 weeks night orthosis) in the treatment of tendinous mallet finger injuries can achieve satisfying result.

Disease features associated with a low disease impact in patients with psoriatic arthritis: results of a cross-sectional multicenter study

BackgroundPatient-reported outcomes measures, such as those provided by the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, have been found to be a reliable indicator of change during treatment, predictive of long-term outcomes, and the impact of psoriatic arthritis (PsA) on patients’ lives. The objective of the study was to describe the demographic and clinical characteristics of PsA patients with a low disease impact and to analyze predictive factors for that state.MethodsPost hoc analysis of a cross-sectional multicenter study that included 223 consecutive patients. PsAID questionnaire was used to estimate disease impact. Patients with a PsAID < 4 were considered in low disease impact. Minimal disease activity (MDA) response and the Health Assessment Questionnaire (HAQ) were also assessed. The degree of agreement between the different outcomes was addressed by Cohen’s kappa index.ResultsOne hundred and twenty-two (54.7%) patients reached a PsAID < 4. Among them, 52.0% and 68.0% presented articular or skin remission, respectively. Almost 75% of patients were in MDA state and 85.2% presented a low disability state according to the HAQ. A moderate concordance between HAQ ≤ 0.5 and PsAID < 4 (k = 0.53), fair between MDA and PsAID < 4 (k = 0.36), and moderate between DAPSA remission and PsAID < 4 (k = 0.46) was observed. Multivariate logistic regression analysis showed that patients with distal interphalangeal joint (DIP) disease (OR 0.40, 95%CI, 0.20–0.79, p = 0.009), family history of PsA (OR 0.25, 95%CI, 0.09–0.72, p = 0.010), and higher C-reactive protein (OR 0.92, 95%CI, 0.85–0.99, p = 0.036) were significantly less likely to reach a PsAID < 4.ConclusionsThere is certain discrepancy between disease activity measures and a low impact of disease in PsA. Clinical features (DIP joint involvement), biologic activity, and genetic factors (familial history) seem to be associated with lower odds of reaching a low disease impact.

GENDER ORIENTED VARIATIONS IN THE FINGER FLEXION CASCADE IN NORMAL INDIVIDUALS

Background: A normal Finger Flexion Cascade (FFC) is formed by the fingers of the hand when the hand in a relaxed position. Usually, the fingers of the hand assume a flexed position; gender may influence the normative values of the resting hand due to differences in the anatomical structure of hand and frequency of usage of joints of hand in their respective occupation and habitual activities of daily living. Hence the study aims to find the difference in the FFC between men and women in power grip and nonpower grip occupational activities.Methods: A cross-sectional study was conducted in a mixed population of five hundred active individuals aged between 25 and 40 years belonging to various occupations of industrial work and individuals working with software companies. Individuals who fulfilled the inclusion criteria participated in the study. After completing a questionnaire based on occupation, the subjects were grouped into power grip users and nonpower grip users. The range of motion of the joints of all the fingers, namely, metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of both dominant hand and nondominant hand was measured using universal finger goniometer, and the composite finger flexion was recorded using a geometric ruler. The results were analyzed, and Un-paired T-test was used to compare the FFC between the power grip and the nonpower grip group.Results: The FFC variations in both the hands of male and female subjects in power grip users (PGU) and nonpower grip users(NPGU) were recorded. In the dominant hand, it was found that the DIP joint of 5th digit in female subjects had a greater ROM values than male subjects, but greater ROM values in MCP joints of the hand in males were found. The comparison between the range of values of both groups revealed that the values in the PGU group were more than the NPGU group with a statistical significance of p&lt;0.001.Conclusion: The finger flexion cascade was found to be more closed in female subjects than males in both the dominant and nondominant hands of in the power grip users than in the nonpower grip users.

Replantation of the total skin-only avulsions of fingers

Skin-only avulsion is a particular type of avulsion surgery. In this type of injury, tendons, bones, and joints maintain their integrity. In this report, we aimed to report the promising results of replantation in seven fingers with total skin-only avulsions. From 2007 to 2015, 6 patients with a mean age of 34.6 (20–52) who underwent replantation surgery for total skin-only avulsion injuries distal to metacarpophalangeal (MP) joint were evaluated according to the injury type, etiology, level of repair, and the repaired structures. Seven fingers of 6 patients were evaluated. The mean repaired artery and vein number were 1.5 (1–2) and 3.8 (3–5), respectively. The mean percentage of partial necrosis in the three fingers and an amputated finger was 25.70%. Three fingers survived completely, whereas three developed partial necrosis which were managed by debridement and full thickness skin grafting. Mean static and dynamic two-point discriminations were 6 mm and 3.83 mm, respectively. The mean ROM degree of PIP/IP joints and DIP joints was 74.1 (60–85) and 56.6 (40–70) degrees, respectively. The mean follow-up was 28.3 months (24–36). Skin-only avulsions are a particular type of avulsion injury and very challenging to treat. In order to avoid from the partial necrosis due to the vascular deprivation of perforating branches of the proper digital artery, we recommend repairing both arteries in this type of avulsion. Skin-only replantation results can be successful when several technical details are observed. Level of evidence: Level V, therapeutic study.

Degenerative and inflammatory hand joint changes in osteoarthritis according to magnetic resonance imaging

Erosive osteoarthritis (EOA) of the hand is an osteoarthritis (OA) phenotype that is characterized by central and marginal erosions of the articular surfaces in the distal and proximal interphalangeal (DIP and PIP) joints and in some cases by a fairly aggressive course with obvious pain syndrome and a high level of functional impairment. Diagnostic criteria and management tactics for EOA patients are still under investigation. Objective: to evaluate the nature of the changes detected by hand joint magnetic resonance imaging (MRI) in patients with EOA and non-erosive OA (NEOA) of the hand. Subjects and methods . Examinations were made in 61 females meeting the American College of Rheumatology (ACR) diagnostic criteria for hand OA; the patients' mean age was 66.34+5.79 years; the median age at disease onset was 50 [45; 56] years; the duration of pain was 15 [11; 20] years. All the patients underwent MRI of the second-fifth DIP, PIP, and metacarpophalangeal (MCP) joints of the right hand. The patients also filled out the AUSCAN questionnaire. EOA and NEOA were detected in 30 and 31 patients, respectively. Results and discussion . The patients with EOA and those with NEOA were matched for gender, age, and disease duration. The DIP joints in patients with EOA were found to have significantly more frequently and a greater number of large osteophytes (OPs), (53 and 16%, respectively), joint space narrowing (JSN) (73 and 35%), degenerative collateral ligament changes (DCLCs) (93 and 55%), subluxations (47 and 13%), and bone marrow edema (BME) (57 and 19%) than in those with NEOA. Synovitides and subchondral cysts occurred with approximately the same frequency in EOA and NEOA. The PIP joints in patients with EOA significantly more frequently showed BME (37%) and DCLCs (97%) than in those with NEOA. Subluxations in the PIP joint of the right hand were encountered exclusively in patients with EOA. Their incidence was 17%. Degenerative symptoms (small, less often moderate sizes of OPs, JSN, and DCLCs) were identified with approximately the same frequency in both groups (p>0.05). The PIP joints in patients with EOA were significantly more often found to have BME (53 and 26%, respectively; (p 0.05). Large OPs in the PIP joint were found relatively rarely. Subluxations in the PIP joints were undetected in both groups. Conclusion. The symptoms of active inflammation are predominant and degenerative changes are more pronounced in patients with EOA unlike those with NEOA. Articular surface defects in the PIP joints in patients with hand OA differ from erosions in those with rheumatoid arthritis. These CDs in EOA are much more common than those in NEOA; however, the nature of their occurrence is unclear; therefore, the patients in whom they have been found need dynamic monitoring.

Quantifying Soft Tissue Artefacts and Imaging Variability in Motion Capture of the Fingers

This study assessed the accuracy of marker-based kinematic analysis of the fingers, considering soft tissue artefacts (STA) and marker imaging uncertainty. We collected CT images of the hand from healthy volunteers with fingers in full extension, mid- and full-flexion, including motion capture markers. Bones and markers were segmented and meshed. The bone meshes for each volunteer’s scans were aligned using the proximal phalanx to study the proximal interphalangeal joint (PIP), and using the middle phalanx to study the distal interphalangeal joint (DIP). The angle changes between positions were extracted. The HAWK protocol was used to calculate PIP and DIP joint flexion angles in each position based on the marker centroids. Finally the marker locations were ‘corrected’ relative to the underlying bones, and the flexion angles recalculated. Static and dynamic marker imaging uncertainty was evaluated using a wand. A strong positive correlation was observed between marker- and CT-based joint angle changes with 0.980 and 0.892 regression slopes for PIP and DIP, respectively, and Root Mean Squared Errors below 4°. Notably for the PIP joint, correlation was worsened by STA correction. The 95% imaging uncertainty interval was < ± 1° for joints, and < ± 0.25 mm for segment lengths. In summary, the HAWK marker set’s accuracy was characterised for finger joint flexion angle changes in a small group of healthy individuals and static poses, and was found to benefit from skin movements during flexion.

Experimental study of the mechanical behavior of unfilled rough jointed specimens under uniaxial compression

The mechanical behavior of unfilled rough jointed specimens under compression are significant when evaluating the stability and safety of a natural rock mass with discontinuities, and the compression condition can reflect landslide conditions better than the direct shear condition due to the preexisting rough joint. Therefore, a series of uniaxial tests was conducted to analyze the mechanical behavior of specimens containing joints with different dip angles (α) and joint roughness coefficients (JRC). The peak strength and elastic modulus remain nearly constant with increasing JRC when α = 0°, 30°, and 90°, whereas these parameters first increase and then enter a stable phase when α = 45° and 60°. The failure modes are defined as four typical failure models. The failure models are independent of JRC when α = 0° (model T1), 30° (model M), and 90° (model T2), and the failure model shifts from S to M with increasing JRC when α = 45° and 60°. Crack initiation is more likely at the joint than in the intact part, and more active AE events were observed in the intact parts than those along the joint. Stress resolution and Barton’s model were used to explain the variation of the failure model with α and JRC, and the failure model corresponded well with the stress state and shear strength.

Open Reduction and Internal Fixation for Dorsal Fracture-dislocation of the Proximal Interphalangeal Joint.

The purpose of this study was to investigate and compare the clinical and radiological results of ORIF with inter-fragment screw or buttress plate fixation of acute PIP joint fracture dorsal dislocation. Between January 2007 to December 2016, nineteen patients-14 men and 5 women with an average age of 40.9 (19 to 64) years-were included in this study; 9 patients underwent small sized interfragmentary screw fixation and 10 patients underwent small buttress plating. The average follow-up period was 45.1 (13 to 78) months. Clinical assessment included measurement of range of motion (ROM) of the proximal and distal interphalangeal joint (PIP, DIP), grip and pinch strength, and pain with use of the Visual Analog Scale (VAS). At the postoperative X-ray, articular step off, gap, and degree of dorsal subluxation was measured, and maintenance of the reduction, fracture union, and the presence of degenerative changes were assessed. All patients achieved solid unions without instability. The overall average range of motion of PIP joint were from 9° to 85° (10-83° in the screw group, 8-87° in the plate group without significant difference). However, the screw group (average: 53°) presented more flexion in the distal interphalangeal joint than the plate group (average: 34°). Plate fixation can cause limited DIP flexion. Six of the ten patients from the plate group, underwent implant removal and two of these patients required PIP joint arthrolysis due to the PIP flexion contracture of more than 30°. Three of the nine patients in screw group underwent implant removal and two of the three patients required PIP joint arthrolysis. Mini plate and screw fixation of acute PIP joint fracture dorsal dislocation can achieve comparable favorable clinical and radiographic outcomes through stable fixation and early range of motion exercise. Screw fixation, if possible, is probably preferable to plate fixation because of better DIP joint ROM and lower incidence of hardware removal. If there is a need for plate fixation the use of a short plate is recommended to avoid joint stiffness.

Fluctuation Characteristic Test of Oblique Stress Waves in Infilled Jointed Rock and Study of the Analytic Method

The propagation of stress waves in filled jointed rocks involves two important influencing factors: transmission‐reflection phenomena and energy attenuation. In this paper, the split Hopkinson pressure bar (SHPB) test is used to shock the filled rock with joint angles of 0, 30, and 45° and the thickness of 4 mm and 10 mm, respectively, in three different velocities. The wave curves of the incident wave, reflected wave, and transmission are obtained. The effects of the filling angle and joint thickness on wave propagation are analyzed. Based on the propagation characteristics of stress waves in joints, the stress expression of oblique incident stress waves propagating in filling joints is derived, and the energy coefficient of transmission and reflection is calculated. The results show that the propagation of stress wave in filling joints is related to the impact rate. The larger the impact rate is, the larger the maximum voltage amplitude of the three waves is. And the increasing amplitude of the incident and reflected waves is larger than the transmitted wave; the greater the impact velocity is, the smaller the stress‐strain curve gap of the three dip joints is, and the fracture strength of the specimen decreases with the increase of the joint dip angle. The larger the joint dip angle is, the smaller the deformation of the rock‐like specimen is. The change of the transmission coefficient is related to the joint angle, and the larger joint angle weakens the influence of the joint width on the transmission of the transmitted wave; under each impact velocity, the theoretical and experimental stress peaks are approximately the same, and the transmission coefficient maintains a good consistency with the oblique incident angle.

Evaluation of three scoring methods for Fluorescence Optical Imaging in erosive hand osteoarthritis and rheumatoid arthritis

Fluorescence Optical Imaging (FOI) demonstrates indocyanine green (ICG)-enhanced microcirculation in wrist and finger joints, as a sign of inflammation. We wanted to assess the reliability of three FOI scoring methods from Berlin, Stockholm, and Copenhagen, to assess the validity of FOI with MRI as reference and to compare enhancement in hand joints in erosive hand osteoarthritis (OA) vs. rheumatoid arthritis (RA). Five readers scored all finger and wrist joints of 26 patients with erosive hand OA and RA on semi-quantitative 0-3 scales using three different FOI scoring methods. To evaluate inter-reader reliability, we calculated the intraclass correlation coefficients (ICC) for sum scores and prevalence and bias adjusted kappa values for ordinal scales (Pabak-OS) on joint level. Enhancement in joint groups in erosive hand OA vs. RA was compared using Mann-Whitney test. Sensitivities and specificities of FOI was calculated with MRI as reference for hand OA patients only. We found moderate to good inter-reader reliability for all FOI scoring methods (Pabak-OS: 0.50-0.78, ICC: 0.43-0.85) and different patterns of enhancement in erosive hand OA vs. RA with significantly more FOI enhancement in DIP joints in erosive hand OA across all methods. With MRI as reference the different FOI scoring methods reached similar sensitivities (63-65%) and specificities (76-91%). FOI enhancement can be measured reliably in erosive hand OA and RA using three different scoring methods. More DIP enhancement in erosive hand OA patients and good agreement with MRI support the diagnostic performance of FOI.

Hemi-hamate osteochondral autograft for acute dorsal proximal interphalangeal fracture-dislocations.

Our aim was to investigate the clinical and radiological results of a hemi-hamate autograft arthroplasty method in patients with acute trauma who had a fragmented fracture of the proximal palmar joint surface of the middle phalanx and dorsal PIP subluxation. A total of 13 fingers from 13 patients who met the criteria were included in the study (11 men and 2 women) and prospectively reviewed. The mean age of the patients was 39.5years. The mean interval between the injury and surgery was 6.3days. The active movement of the DIP, PIP, MP and wrist joints was started on postoperative day. Follow-ups were performed at 6weeks, 3, 6 and 12months postoperatively. Range of motion for the DIP, PIP and MP joints, DASH and VAS scores, grip strength, two-point discrimination, finger pulp and palmar curve distance were evaluated. All PIP joints were stable against coronal and sagittal stress at the 1st postoperative year and there was no limitation in wrist movements. Two-point discrimination was < 5mm in all fingers. Union was achieved in all grafts except one. The mean active total PIP range of motion was 82.3°, DIP range of motion was 61.1°, MP joint motion was 87°. The mean DASH score was 7.6, and the mean VAS score was 1.5. The mean grip strength was 33.7kg, which was 93% of the healthy side. The mean finger pulp and palmar curve distance was 8.6mm. We believe that HHA is an appropriate alternative in cases of acute dorsal PIP fracture-dislocations with an intact middle phalanx dorsal cortex that is not suitable for primary fixation, with the advantages of obtaining stable joint and satisfactory functional results.

Open reduction and compression with double Kirschner wires for the treatment of old bony mallet finger

BackgroundThe management of old bony mallet fingers is complicated. The aim of the study is to present a new method of open reduction and compression with double Kirschner wires (K-wires) in treating old bony mallet fingers.MethodsThis was a retrospective analysis of patients with old closed bony mallet fingers treated between June 2013 and December 2016. Complications were observed. The range of motion (ROM) of the DIP joints was measured using a protractor. At the last follow-up, anteroposterior and lateral X-ray of the affected finger was performed, the flatness of the articular surface was scored, and the results were graded using Crawford’s criteria.ResultsSeventeen patients were followed up for 8 (6–19) months. The width of the avulsion fracture block accounted for 25–62% of the articular surface of the distal phalanx. Twelve (70.6%) patients had anterior dislocation of the interphalangeal joint. All patients reported healing at the fracture sites. Healing time was 7.6 ± 2.1(5–13) weeks. All patients had incision healing of I/Class A. Lateral X-ray showed 13 and four patients had excellent and good articular surface flatness, respectively. At the last follow-up, no traumatic arthritis was present. Only one patient developed mild pain after surgery (VAS score of 3). Postoperative ROM was 76.5 ± 10.6° (P = 0.0625 vs. healthy side). At the last follow-up, the angle of loss of dorsiflexion was 0–10° (P < 0.0001 vs. baseline). The flexion angle was 50–90° (P = 0.0625 vs. healthy side).ConclusionsOpen reduction and compression with double K-wires is feasible in treating old bony mallet finger.

Radiologic hand and wrist changes in systemic sclerosis: Associations with the disease duration, skin score and capillaroscopy

Objectives Patients with systemic sclerosis (SSc) have some musculoskeletal manifestations. The radiologic manifestations can be articular or non-articular. There is inconsistency in the correlation between clinical manifestations and radiologic changes; there are few reports on the correlation between them and capillaroscopy. Material and Methods We evaluated 81 patients with SSc, using a cross- sectional single center study, referred to scleroderma clinic affiliated to Shiraz University of Medical Sciences, Iran. Skin score and capillaroscopy were performed and an expert radiologist did the radiologic evaluation of the posterior-anterior views of both hands and wrists. For data analysis, SPSS version 19 was used.Results The participants consisted of 73 women and eight men aged 42±2.6 years old. There were 60.5% limited scleroderma (lcSSc) and 39.5% diffuse scleroderma (dcSSc) patients. After 5 years, 91% of them had some radiologic changes mostly asymptomatic.The most common radiologic changes were non-articular (70.1%), including acro-osteolysis, subcutaneous and peri-articular calcinosis and avascular necrosis. Flexion deformities and DIP joint space narrowing were more seen in patients with dcSSc. Resorption of the distal ulna and avascular necrosis was observed more in lcSSc. There was a correlation between radiologic changes and duration, but not with the skin score. The most common capillaroscopic pattern in patients with radiologic change was late scleroderma pattern.Conclusions Radiologic changes which were mostly asymptomatic were common in patients with SSc. The changes were different in patients with dcSSc and lcSSc and there were associations with duration and capillaroscopic patterns, but not with the skin score.

E-POSTERS – EARLY ONSET MUSCLE DISEASE – CASE REPORTS: EP.120ADSSL1 distal myopathy presenting with a more rapid progressive course in patient with trisomy 21

We report a 22 year old female of mixed European and Mexican background with novel compound heterozygous ADSSL1 gene mutations (p.Gly326Asp, pat and c.1202+1G>A, mat) identified by exome sequencing with a more progressive clinical course due to her other diagnosis of trisomy 21 (T21). Her development was appropriate for T21, but she never learned to run, jump or use stairs independently. At age 8 yr, her motor skills started to regress with emergence of weakness. She used a walker by 10 yr and lost ambulation at 12 yr. Currently, she cannot weight-bear (strength 1/5 in most leg muscles; quadriceps at 1-2/5), but has more preserved upper extremity use (strength 3 to 3-/5 range). She has hip, knee contractures, end-grade elbow contractures, and coexistence of finger flexor contractures with laxity in PIP and DIP joints. Her cognitive delays are typical for T21. She developed progressive scoliosis that required T4-L4 spinal fusion at 12 yr of age. There is no cardiomyopathy and her LVSF is 36%. Nocturnal hypoventilation started at age 13 yr with use of BiPAP during sleep since 16 yr of age. Unlike previously reported cases, she had a normal CK and her muscle biopsy at 14 yr did not show rimmed vacuoles or nemaline rods but rather severe myopathic changes: fibrosis and adipose infiltration, variation in fiber size with small, atrophic fibers intermixed with hypertrophic fibers, rounded and splitting fibers, increased central nuclei and occasional degenerating/regenerating fibers. To date, ADSSL1 gene mutations, encoding an enzyme converting inosine monophosphate (IMP) to adenosine monophosphate (AMP), have been reported only in 9 Korean patients from 6 families with 8 of the 9 patients having the same compound heterozygous mutations, suggesting a founder-effect. Identification of another patient with novel mutations suggests that this form of myopathy is panethnic and likely underdiagnosed among patients presenting with signs of generalized and distal myopathy.

Experimental study on deformation and failure characteristics of discontinuous prefabricated fractured tuff

Abstract To study more fully the characteristic law of deformation and failure of tuff jointed rock mass of prefabricated parallel discontinuous joint test specimens, the uniaxial compression test was used. The stress–strain curve, peak intensity, deformation parameters, energy characteristics, etc., of the rock test specimens were systematically studied under different combinations of joint dip angle and joint spacing. The research found that: (1) during the failure process of tuff, the peak intensity and elastic modulus followed a U-shaped change pattern and the minimum value was reached when α = 60°; (2) the fracture modes of test specimens with different joint dip angles were different. When α = 30° and 45°, failure characteristics were mixed modes of tensile or tensile shear failure. When α = 60°, failure characteristics were shear. At α = 75°, the failure characteristic was tensile shear failure. (3) The absorbed and dissipated energy of the rock increased nonlinearly at each stage of deformation. (4) We quantified rock energy damage through a correlation between dissipated energy and absorbed energy of the rock in the process of energy evolution, and obtained an evolution of the relationship between the dissipated energy ratio, crack dip angle and crack spacing. Based on different fracture distribution methods and according to the strain equivalence principle, the constitutive equation of the pre-peak rock damage was obtained.

Intra- and inter-observer reliability of the AFCP classification for sagittal plane deformities of the second toe

BackgroundThe French Association of Foot Surgery (AFCP) recently proposed a morphological classification of lesser toe deformities, describing the position of each joint (metatarsophalangeal or MTP, proximal interphalangeal or PIP and distal interphalangeal or DIP) in relation to their anatomic position in the sagittal plane. A study was designed to test its reliability for assessment of sagittal plane deformities of the second toe. MethodsIn this retrospective study 55 toes (55 feet, 50 patients) were evaluated. Eleven foot and ankle surgeons assessed independently standardized photographs of each case acquired in a blinded fashion. Assessment was repeated three times, each 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss’ Kappa coefficient) were calculated for each joint. ResultsIntra- and inter-observer reliability were moderate for the MTP joint (ICC range, 0.54–0.61) (Kappa range, 0.53–0.61) and substantial for the PIP (ICC range, 0.60–0.71) (Kappa range, 0.68–0.75) and DIP joints (ICC range, 0.69–0.78) (Kappa range, 0.74–0.78). Mean assessment time±standard deviation was 35±10s per case. ConclusionsThe AFCP classification proved itself reliable in the assessment of sagittal plane defomities of the second toe among eleven foot and ankle surgeons. It is based only on a visual description of the deformity, and does not provide informations on either the clinical reducibility of the deformity and the radiographic joint status. Level of evidenceLevel IV, retrospective cohort study

Study on the Control of Underground Rivers by Reverse Faults in Tunnel Site and Selection of Tunnel Elevation

Along with the need for western economic development, the number of long tunnel projects which go through mountains is constantly on the rise. In the process of construction, various disaster-causing structures are frequently exposed, which leads to many geological disasters. The traditional idea is that the reverse fault is not easily developed for an underground river, which means that the tunnel elevation design is not considered adequately. When some tunnels cross the bottom of the river, the fractures near the fault between the underground river and the excavation space may be activated and then evolve into channels, causing serious water inrush accidents during construction and operation processes. Taking the Qiyueshan Tunnel site as an example, on the premise of the anatomy of the control mechanism of the reverse fault on the development of the underground river, based on the multiperiod typical structural traces of the tunnel and surface outcrop, it was found that stratifications, dip joints, transverse joints, and tension joints of good aperture grade are important control factors. The cut block easily loses its stability and provides space for karst development, while intermittent uplifting of regional structures provides hydrodynamic conditions for the development of the underground river, causing the hydraulic gradient to be inconsistent in the overall underground river. Finally, the rainwater dynamic monitoring and tracer connectivity are data that can be fully utilized to demonstrate that a reverse fracture can control the development of the underground river. The authors further considered the effect of the vertical zoning of the fault structure and the excavation disturbance, and, drawing on the experience of the relative location of the same site in the same field, put forward the suggestion that the construction of the follow-up tunnel in the study area should be slightly higher than the elevation of the underground river. The research results can provide useful reference for similar engineering problems in the future.