Lunate Bone Research Articles

Effects of Laptop use on Wrist in Students and Teachers of Different Universities during Covid-19

The wrist is an ellipsoidal type (condyloid) of articulation synovial is permitting movements at two axes. The anatomical name of the joint is the radio-carpal joint [1-5].It presents a sinuous opposing. The concave proximal articular surface is formed by the lower end of the radius and the articular disc of the inferior radio-ulnar joint. The reciprocally convex distal articular surface is formed by the scaphoid, lunate and triquetral bones from lateral to the medial side. The joint capsule surrounds the wrist and is attached to the distal ends of the radius and ulna and proximal rows of carpals excluding the pisiform. Strong ligaments strengthen and stabilize the joint from the sides, and on the ventral and dorsal surfaces. Repeated episodes of mechanical stress can cause the event of repetitive motion injuries or overuse injuries, which when including poor posture and biomechanics put much strain on the joints. They usually develop slowly over an extended period of your time. Wrists are one of the foremost common sites of repetitive motion injury. Therefore this research was designed to study the effect of laptop usage among physiotherapists(students and teachers). This study may give awareness to the individual to avoid or minimize the overuse of laptops and therefore the complications by breaking bad habits, practicing recommended/approved posture while using the laptop, and modulating the planning of the keyboards. Due to covid 19 era, the use of laptops and computer has significantly increased among students and teachers of different universities for teaching purposes. Therefore the study was designed to study the impact of laptop use on the wrist in students and Teachers duringcovid 19.Objective: To find the impact of laptop use on the wrist in Physiotherapist during covid 19

Shelf Osteotomy for Madelung's Deformity in Adults: A Novel Technique.

Background Madelung's deformity (MD) comprises increased volar and ulnar tilt of the distal radius joint facet, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and a consequent distal ulnar prominence, along with wrist pain and loss of motion. Classic surgical techniques are problematic for adults, as they are specific for children and adolescents whose distal radial physis is still open. Description of Technique It is suggested a new treatment method for MD in skeletally mature patients: a distal radius osteotomy and joint realignment are performed through a volar approach to increase the support area of the lunate bone. The rotation and lengthening of the distal epiphysis of the radius generate support and cover to the lunate bone, with improvement of both radiocarpal and distal radioulnar joints. Patients and Methods We describe the technique in details and report the treatment of a 25-year-old female patient. Results Early clinical and radiographic outcomes are encouraging for the treatment of symptomatic patients. Conclusion There is a plethora on the literature about conflicting opinions on the best treatment options and surgical techniques are quite variable, although usually with good results. Besides, the technique here described is indicated during a specific stage of disease presentation, consisting of young adults without any wrist-degenerative changes. Having said that, it is possible to claim that MD treatment with shelf osteotomy is a concept change. Our main goal is to reconstruct the diseased segment and improve wrist stability.

Carpal Kinematics in Madelung Deformity

Various skeletal and soft tissue abnormalities have been identified in Madelung deformity and have been hypothesized to play a causal role in its progressive symptomatology; however, our pathological understanding of these changes remains limited. In this study, we biomechanically assessed the Madelung deformity wrist, using 4-dimensional computed tomography imaging. Nine Madelung deformity wrists (5 patients; age, 24 ± 5 y) and 18 healthy wrists (9 volunteers; age, 28 ± 3 y) underwent 4-dimensional imaging during flexion-extension motion and radioulnar deviation. Carpal kinematics and radiocarpal joint parameters were quantified and compared. In Madelung deformity wrists, significantly decreased rotation was seen in the lunate (-4.6°) and the triquetrum (-4.8°) during flexion-extension motion. During radioulnar deviation, significant decreases were visible in lunate bone translation (-0.7 mm), triquetrum bone translation (-0.6 mm), and triquetrum bone rotation (-1.9°). Patients had significantly decreased articulating surface areas of the scaphoid (1.4 ± 0.2 cm2 versus 1.6 ± 0.2 cm2) and lunate (1.2 ± 0.4 cm2 versus 1.5 ± 0.3 cm2) fossa, and significantly increased radioscaphoid (1.3 ± 0.1 mm versus 1.2 ± 0.1 mm) and radiolunate (1.6 ± 0.2 mm versus 1.3 ± 0.3 mm) joint space thicknesses. There is a decreased mobility of the lunate and triquetrum bones in Madelung deformity. Four-dimensional imaging could be used in future studies that investigate the effect of surgical ligament release on carpal kinematics and subsequent wrist mobility.

A case report of lunate excision with scapho-capitate arthrodesis in Kienbock’s disease

Case study of a 22-year female presented to our clinic with complaints of dorsal wrist pain, swelling and stiffness with decreased motion at left wrist joint with a duration of 2 months without any significant traumatic history. On evaluation dorsal wrist pain and point tenderness over lunate bone was present. Radiographs and Advanced imaging MRI was suggestive of Kienbock’s disease. This was treated with Lunate excision and scapho-capitate arthrodesis along with bone grafting. Advanced stages of Kienbock’s are usually managed by Wrist fusion or proximal row carpectomy. We are reporting our result of scapho-capitate arthrodesis which was performed to stop progression of carpal collapse and carpal-ulnar translation and thereby preserve functional motion and provide pain relief.

Lunate Bone Morphology and Wrist Arthrosis: a Radiographic Study of the Type 2 Lunate

It is well known that there are two lunate types. The type II variation of the lunate is of clinical importance since significant cartilage erosion at the proximal pole of the hamate bone is evident in more than half of the type II lunates, but is not seen in the type I lunates. The aim of this study is to determine the incidence of lunate types, using posteroanterior hand X-rays and to establish a connection with radiocarpal, midcarpal, or thumb carpometacarpal joint osteoarthritis. We retrospectively analyzed 1000 X-rays of subjects who were admitted to the Clinical Centre of Vojvodina complaining for trauma of the hand. In each of the analyzed X-ray, the lunate was classified as type I or type II according to the method of Viegas et al. and analyzed for degenerative changes on 9 different locations. The study group consisted of 753 subjects with type I lunate and 247 subjects with type II lunate. Osteoarthritis was found on 305 wrist X-rays. There was no statistically significant difference between wrist osteoarthritis and lunate type. The present study revealed a 24.7% incidence of type II lunate, which is lower than reported in previous literature. Furthermore, there was no correlation between lunate type and radiocarpal, midcarpal, or thumb carpometacarpal joint osteoarthritis.

Radial shortening osteotomy vs partial capitate shortening osteotomy in Kienböck’s disease: Medium-term radiological and clinical results

This study aimed to compare medium-term results for partial capitate shortening (PCS) and radial shortening (RS) osteotomies on lunate bone revascularization and disease progression in patients with stage II or IIIA Kienböck’s disease. Patients who underwent surgery for Kienböck’s disease between March 2010 and July 2020 were retrospectively evaluated. Clinical evaluation included assessment of pain, joint range of motion, strength, DASH, visual analog scale (VAS) for pain, Modified Mayo Wrist Score (MMWS), satisfaction and time to return to work, with comparison as appropriate to the contralateral side. Preoperative and postoperative plain radiographs and magnetic resonance imaging (MRI) were used for radiological evaluation. Lichtman staging and signal changes in the lunate were evaluated using MRI. Group 1 (PCS) included 14 patients and Group 2 (RS) 14. Mean follow-up was 57.8 months (range 24–102) in Group 1 and 49.4 months (range 36–73) in Group 2. Clinical evaluation included pain on VAS, DASH score, MMWS, range of motion, and grip, palmar and key pinch strength. Regarding lunate bone vascularization, increased signal on final follow-up MRI was observed in 10 of the 14 patients in Group 1 and 7 of the 14 patients in Group 2. There was a positive correlation between revascularization and final follow-up MMWS (p = 0.006). The present study thus showed that functional scores were improved by revascularization in Kienböck’s disease. Both osteotomies had clinically and radiologically satisfactory results. However, we believe that PCS osteotomy is preferable, as it leads to higher revascularization rates without increasing ulnolunate load.

Hydroxyapatite deposition disease of the wrist with intraosseous migration to the lunate bone

Hydroxyapatite deposition disease (HADD) is a mostly uniarticular, self-limiting condition caused by deposition of hydroxyapatite (HA) crystals in tendons or in the peritendinous soft tissues. Commonly, the glenohumeral joint is affected. More rarely, the HA depot can be cause of a carpal tunnel syndrome due to an acute inflammatory reaction and space-occupying soft tissue oedema. We report a case of acute HA depot located at the volar site of the right wrist with affection of the deep flexor tendons and intraosseous migration into the lunate bone in a 50-year-old female. There are two main goals of this case report: First, to remind the diagnosis of HADD as a cause of wrist pain and also of carpal tunnel syndrome, as this entity being often misdiagnosed clinically, and second, to report a rare case of intraosseous migration of HA crystals into the lunate bone.

Effect of gadolinium perfusion magnetic resonance imaging on surgeons’ management preferences in kienböck’s disease. A survey study

In literature, the use of gadolinium perfusion magnetic resonance imaging (GP-MRI) is recommended in Kienböck's disease to evaluate the lunate bone’s perfusion. This survey study sought to assess how GP-MRI findings affect the management preferences of hand surgeons. A questionnaire consisting of 11 scenarios differing in ulnar variance, GP-MRI findings and management preferences was developed. The scenarios were designed based on the last published clinical guidelines. The questionnaire was sent to the members of a national hand surgery society consisting of 160 hand surgeons. Sixty-six surgeons completed the questionnaire. The surgeons’ preferences changed significantly by ulnar variance in stages II and IIIA, and by GP-MRI in stages I and II. No need for other diagnostic tools was found in any of the scenarios. Management preferences of the study participants related to alterations in ulnar variance and treatment choices in all stages were in accordance with previously published clinical and survey studies. This study showed that GP-MRI findings significantly changed the management preferences of hand surgeons in early stages of Kienböck's disease. There was no significant tendency among the participants to use further assessment tools beyond direct radiography, MRI, and GP-MRI. Given the study results and the literature, we emphasize the limited and well-defined indications of GP-MRI in Kienböck’s disease.

Comparison of Biomechanical Results about the Effect of Three Surgery Methods in Decompression of Lunate Bone.

Objective Kienbock's disease is an unusual disorder caused by osteonecrosis and the collapse of lunate bone which leads to pain and a chronic decrease in wrist function. The treatments in this disease aim to relieve pain and maintain wrist function and movement. Various surgical procedures have been recommended for the subjects with Kienbock's disease; however, the main question posed here is which of the selected procedures are more successful in relief of the pressure applied on lunate. Methods and Materials Computed tomography (CT) scan images of a normal subject were used to create a three-dimensional model of the wrist joint. The effects of several surgical procedures, including radial shortening, capitate shortening, and a combination of both radial and capitate shortening, on the joint contact force of the wrist bones were investigated. Results The pressure applied to the lunate bone in articulation with radius, scaphoid, capitate, hamate, and triquetrum varied between 19.7 and 45.4 MPa. The Von Mises stress, maximum principal stress, and minimum principal stress decreased in the model with a combination of radius and capitate shortening. Conclusion It can be concluded from the results of this study that the combinations of radius and capitate shortening seem to be an effective procedure to decrease joint pressure, if the combined surgery could not be done, shortening of radius or capitate would be recommended. Level of Evidence This is a Level III study.

Efficiency of concentrated bone marrow aspirate combination with temporary fixation of the scaphoid-trapezius-trapezoidal joint in Kienbeck’s disease

Method of concentrated bone marrow aspirate (BMAC) injection into aseptic bone necrosis of different localizations are described in the literature, however, without demonstrating structural and functional results for Kienbeck’s disease. Objective. To establish functional and radiological changes at injection of concentrated bone marrow aspirate into lunate bone in combination with scaphoid-trapezoid-trapezius joint temporary fixation in patients with idiopathic lunate bone necrosis. Methods. The procedure was performed in 11 patients. Age 18–46 years (28,9 ± 9,5) 6 women, 5 males. Kienbeck's disease stage II — 4 patients, IIIa — in 2, IIIb in 5 patients. Bone marrow aspirate concentration from the ili­ac bone was obtained using Arthrex-Angel technique, injection of 2–3 ml of the concentrate with intraosseous needle under X-ray control into the focus of aseptic necrosis of the lunate bone, STT-fixation of the wrist joint in the position of rotational correction of the scaphoid. Immobilization followed for 2 months, than remo­val of the K-wires and rehabilitation. X-ray, CT control and DASH testing before the procedure and in a year. Results. Five patients (45 %) had a distinct positive clinical and radiological dynamics, definite positive changes on CT (pathological fracture consolidation, lunate bone remodeling), as well as DASH scale improvement, maintenance of wrist joint radiometric parameters and an increase in strength and range of motions in the wrist. Four patients had no significant dynamics, and in two patients there was a distinct decline in function, advance lunate bone destruction, and an increased wrist joint instability. Conclusions. The technique requires advance revision of the conditions under which it demonstrates its effectiveness. Today it can be recommended in addition to other surgical procedures (shortening of the radius, STT arthrodesis), which have more predicted effectiveness.

Kienböck's Diseases Treatment. A Novel Technique via Distal Capitate Shortening Accompanied by 3rd Metacarpal Base Fusion in Neutral Variance Ulna

Background: Since there is not a definite cause for Kienbock's diseases despite appropriate knowledge of lunate bone blood supply, so there is a great debate about the ideal treatment protocol for treatment of Kienbock's diseases. Objective: The aim of this study is to assess outcome of combining distal capitate shortening and fusion to the base of the third metacarpal bone for treatment of Kienbock's disease (Lichtman stage II or stage IIIA) with neutral ulna variance. Methods: Twenty patients with 20 consecutive Kienbock's disease, their age mean was 26.1(SD 5.6) y. Patients were evaluated radiologically and clinically including pre- and post-operatively for pain, (ROM) and grip strength. Functional evaluation was carried out using (MMWS). Results: The final post-operative (MMWS) showed increasing from 17 (SD 2.5) to 88.5 (SD7.3). Conclusion: The technique of distal capitate shortening with capito-metacarpal fusion yielded satisfactory results especially for treatment of stage II, than in stage IIIA.

Dorsally displaced distal radius fractures: introduction of Pacetti's line as radiological measurement to predict dorsal fracture displacement.

Background and aim of the work:In the best of our knowledge there is not yet in the literature a measurement able to assess post reduction stability of distal radius fractures. Aim: to study the relationship between our newly introduced Pacetti’s line, anatomical reduction of DRFs and post-reduction stability of fractures.Methods:Retrospective observational study. Patients/Participants: 230 patients (122men, 108women) who sustained a dorsally displaced distal radius fracture. Close reduction procedures attempted; below elbow cast applied. Follow-up: Pacetti’s line used on true AP and lateral view xrays after reduction and casting (T0) and at 7-14 days (T1-T2). Main Outcome Measurements: Assessment and prediction of early displacement of DRFs.19Results:The Pacetti’s line intersected the lunate bone in 162 cases (70.4%) after anatomical reduction, of which 20.4% (N=33) lost anatomical reduction. Cramer’s V test: significant relationship between transition of Pacetti’s line through the semilunar bone and stability of anatomical reduction at T0 follow-up (p<0.001, Cramer’s value=0.83). The Pacetti’s line intersected the lunate bone in 119 cases (51.7%) at 7-14 days follow-up. None of patients lost anatomical reduction. Cramer’s V test: significant relationship between transition of Pacetti’s line through the semilunar bone and stability anatomical reduction at T1 and T2 follow-up (p<0.001, Cramer’s value=0.73).Conclusions:We strongly recommend the use of the Pacetti’s line as it seems to provide reliable prediction of further fracture displacement and consequently of definitive management. The Pacetti’s line seems to represent a very useful tool providing simple, feasible, efficient and reliable information on DRFs characteristics and natural course.

Scapholunate Ligament Reconstruction With a Novel Technique for Passing Split Extensor Carpi Radialis Brevis Tendon Graft Through Bone Tunnels.

We report 2 patients with acute scapholunate dissociation with static instability and wide scapholunate gapping. They underwent scapholunate reconstruction using a split extensor carpi radialis brevis (ECRB) tendon graft via a dorsal approach. This technique is adapted from the modified Brunelli tenodesis, utilizing a portion of the ECRB instead of a flexor carpi radialis tendon graft to reconstruct the scapholunate interosseous ligaments and dorsoradiotriquetral ligaments. The novel aspects of this technique include the use of a trifold plastic sheet of biaxially oriented polypropylene to facilitate the smooth passage of the 2 mm size ECRB tendon graft through the 2 mm bone tunnel. This enables us to avoid drilling larger holes in carpal bones with a relatively poor vascular supply and allows this technique to be utilized in patients with more delicately sized scaphoid and lunate bones. A 2 mm drill bit was used to create the scaphoid and lunate tunnels, which is smaller than that in the published literature. This trifold biaxially oriented polypropylene plastic sheath can be adapted to the use of many other techniques that require passing a tendon graft through a bone tunnel.

Isoelastic resurfacing prosthesis for distal radius fractures: Outcomes in 24 cases with at least 2 years’ follow-up

BackgroundUnicompartmental resurfacing prostheses have been reported to be useful for treating comminuted fractures involving the distal radial joint surface in elderly patients with osteoporosis. However, the data on this method remain scarce and further evaluations are needed. The objective of this study was to evaluate the clinical and radiological outcomes after unicompartmental resurfacing prosthesis implantation in patients with distal radius fractures and at least 2 years’ follow-up. HypothesisOutcomes with Prosthelast® are as good in the mid-term as in the short term. Materials and methodsWe studied 24 patients with type C fractures in the AO classification. The Prosthelast® prosthesis was implanted in each. Mean age was 78 years (60 to 91). There were 22 females. Three of the fractures were open. The patients were evaluated clinically using a visual analogue scale (VAS) for pain, ranges of motion at the wrist, and grip strength. In addition, functional scores were determined, and radiographs obtained. ResultsMean follow-up was 55.2 months (24–97). Mean tourniquet time was 61.9minutes (37–126). Mean motion ranges were 39° in flexion, 49° in extension, 74° in pronation, and 68° in supination. The mean VAS pain score was 2.1 (0–7). The mean Quick DASH was 39.8 (9.09–77), the mean PRWE was 42.7 (5–95), and mean grip strength was 38 (25–150). Painful motion limitation of the elbow was noted in a patient treated with total elbow prosthesis. Complex regional pain syndrome developed in 6 patients, and 5 patients required revision surgery. Asymptomatic perforation of the radial head occurred in 8 patients. No cases of peri-prosthetic osteolysis or osteoarthritis were noted. The prosthesis impinged on the lunate bone in 2 patients and on the scaphoid bone in one patient. Mean ulnar variance was +0.17mm (−1 to 7.5). Bone remodelling about the prosthesis was noted in all the patients, but 2. DiscussionOur data obtained after a mean follow-up of 55 months indicate that resurfacing prostheses have a role to play in the treatment of comminuted articular fractures in patients with osteoporosis. A long-term study is needed to further evaluate these results. Level of evidenceIV; therapeutic.

Osteocondroma solitario en el hueso pisiforme con artrosis piso-piramidal. A propósito de un caso

Osteochondroma is the most common bone tumour, which appears most commonly in the long bones. However, cases have been described in the scaphoid, capitate, lunate, trapezium, and trapezoid bones, which can be a cause of pain in the hand and wrist. Osteochondromas can occur concomitantly with other traumatic or degenerative processes or generate complications in adjacent structures. Below we present an osteochondroma in the pisiform bone associated with pisotriquetral osteoarthritis.

Experimental shortening of the radius in the treatment of Kienböck's disease

AimThe aim of the research was to determine the smallest amount of loading on the lunate bone obtained by gradually shortening the radius in different ulnar variants as the potential treatment of Kienböck's disease. MethodsThe research was conducted on anatomic preparations of 20 upper extremities using only the distal part of the forearm and hand, placing them in exactly defined positions. A Fuji Prescale film was inserted in the open radiocarpal joint to measure pressure after compressing axially by changing the length of forearm in four stages by the gradual shortening of the radius. ResultsThe greatest reduction of average pressure on the lunatum achieved by shortening the radius depended on ulnar variant. In ulnar variant 0, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (24% reduction). For ulnar variant −1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 2 mm (37% reduction). For ulnar variants −2, −3 and +1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (5%, 75% and 9% respectively). ConclusionsThe pressure distribution in the distal radiocarpal joint is vital for healing, and shortening of the radius relieves the pressure on the lunate bone. The exact type of surgery and the amount of radial osteotomy depends on preoperative ulnar variant.

Mid-Term Results of the Use of a Suture Anchor Fixation for Chronic Reducible Scapholunate Dissociation.

Background: Scapholunate dissociation (SLD) is a common and sometimes disabling ligamentous injury of the wrist. The aim of the treatment is to restore carpal alignment and to prevent joint degeneration. In the current study, we reported mid-term results of our technique using suture anchor fixation within the SL interface. Methods: Nine male patients with an average age of 35 years underwent scapholunate suture anchor fixation (SLAF) for chronic and symptomatic dynamic or reducible static SLD from 2011 to 2016 with a mean follow-up of 36 months. After dorsal wrist exposure, a 2.8 mm suture anchor was inserted in the dorsoproximal lateral articular surface of the lunate bone. The two ends of the sutures were passed through the two divergent canals in the scaphoid. The sutures were tied over the tuberosity after reducing the SL alignment. Two K-wires supported SL and scaphocapitate (SC) alignment for 8 weeks. Radiographic parameters, wrist range of motion and grip strength were measured. Quick-DASH and Modified Mayo Wrist Score (MMWS) were used to assess the functional outcome. Results: The grip strength and passive motion reached to 75% and 88% of the other side, respectively. The SL gap was 5.4 mm, 2.6 mm and 3.4 mm before surgery, after pin removal, and on the follow-up stress radiographs, respectively. The SL angle was 82, 52 and 65 degrees at any time point, respectively. Average Quick-DASH score was improved from 60 to 25. According to MMWS score, one patient was excellent, one was good, five were fair, and two were poor. Conclusions: SLAF is a simple technique with minimal soft tissue manipulation that enables correction and maintaining of the carpal alignment with favorable mid-term results.

Osteonecrosis of the Upper Extremity: MRI-Based Zonal Patterns and Differential Diagnosis.

Regarding the upper extremity, osteonecrosis can relate to the humeral head and to any carpal bone, most commonly the lunate (Kienböck's disease), scaphoid (Preiser's disease and nonunion), and capitate bone (osteonecrosis of the capitate head). In children and adolescents, osteochondrosis is an important differential diagnosis at the epiphyses. Appropriate imaging of osteonecrosis depends on knowledge about blood supply, biomechanical load, and bone repair mechanisms. Contrast-enhanced MRI (ceMRI) enables the differentiation of up to three mostly band-shaped zones: necrotic tissue (proximal), hypervascular repair tissue (intermediate), and viable bone (distal). To distinguish between necrotic and repair zones, intravenous gadolinium is recommended in MRI. Osteosclerosis and insufficiency fractures in early and intermediate stages as well as osteoarthritis in advanced stages are best depicted using high-resolution CT (HRCT). The combination of HRCT and ceMRI allows for exact classification of osteonecrosis regarding morphology and viability.

Quantitative three-dimensional assessment of Madelung deformity.

In the diagnostic work-up of Madelung deformity conventional radiographic imaging is often used, assessing the three-dimensional deformity in a two-dimensional manner. A three-dimensional approach could expand our understanding of Madelung deformity’s complex wrist anatomy, while removing inter- and intra-rater differences. We measured previous two-dimensional-based and newly developed three-dimensional-based parameters in 18 patients with Madelung deformity (28 wrists) and 35 healthy participants (56 wrists). Madelung deformity wrists have increased levels of ulnar tilt, lunate subsidence, lunate fossa angle, and palmar carpal displacement. The lunate fossa is more concave and irregular, and angles between scaphoid, lunate, and triquetral bones are decreased. These findings validate the underlying principles of current two-dimensional criteria and reveal previously unknown anatomical abnormalities by utilizing novel three-dimensional parameters to quantify the radiocarpal joint.

Lunate bone osteonecrosis in hemodialysis patient with rheumatoid arthritis: case report

Kienbock's disease is the osteonecrosis of lunate bone. Patients usually present with unilateral localized dorsal wrist swelling and pain that increase with movement. Direct radiographic and other imaging methods are used for diagnosis. Cautious evaluation of the radiological findings is substantial, because the management of the disease depends on radiological stage. Here, we present a 46-year-old woman with rheumatoid arthritis who admitted to the outpatient clinic of our hospital, because of pain, swelling and limitation of movement in the left wrist. We want to draw attention Kienbock's disease in patient with rheumatoid arthritis.