MCP Joints Research Articles

Cross Intrinsic Transfer for Ulnar Drift in the Rheumatoid Hand Under Wide Awake Local Anesthesia No Tourniquet - Surgical Technique

This article introduces a surgical technique for cross-intrinsic transfers (CIT) to correct ulnar drift in rheumatoid hands performed under wide-awake local anesthesia no tourniquet (WALANT). This approach allows real-time adjustment of tendon transfer tension and active patient participation in hand movements and deformity correction during the procedure. It can be combined with other surgeries such as prosthetic replacement arthroplasties of the MCP joints. The technique was applied to six patients, resulting in a significant reduction of ulnar deviation from an average of 70° preoperatively to 8° postoperatively. All patients reported high satisfaction with good outcomes.

Subtle Radiographic Progression at Six Months Can Be Detected Using Automated Quantitative Software in Rheumatoid Arthritis While Receiving Tocilizumab.

We investigated whether our in-house software equipped with partial image phase-only correlation (PIPOC) can detect subtle radiographic joint space narrowing (JSN) progression at six months and predict JSN progression in rheumatoid arthritis (RA) patients receiving Tocilizumab. The study included 39 RA patients who were treated with Tocilizumab. Radiological progression of the metacarpophalangeal and the proximal interphalangeal joints was evaluated according to the Genant-modified Sharp score (GSS) at 0, 6, and 12 months. Automatic measurements were performed with the software. We validated the software in terms of accuracy in detecting the JSN progression. The success rate of the software for joint space width (JSW) measurement was 96.8% (449/464). The 0-12-month JSW change by the software was significantly greater in joints with the 0-6-month PIPOC (+) group than the 0-6-month PIPOC (-) group (p < 0.001). The 0-12-month JSW change by the software was 0-12-month GSS (+) than with 0-12-month GSS (-) (p = 0.02). Here, "(+)" indicates the JSN progression during the follow-up period. Meanwhile, "(-)" indicates no JSN progression during the follow-up period. Linear regression tests showed significant correlations between the 0-6-month and the 0-12-month PIPOC in the left 2nd and 3rd MCP joints (R2 = 0.554 and 0.420, respectively). Our in-house software equipped with PIPOC could predict subsequent JSN progression with only short-term observations.

Evaluating high-resolution computed tomography derived 3-D joint space metrics of the metacarpophalangeal joints between rheumatoid arthritis and age- and sex-matched control participants.

Rheumatoid arthritis (RA) is commonly characterized by joint space narrowing. High-resolution peripheral quantitative computed tomography (HR-pQCT) provides unparalleled in vivo visualization and quantification of joint space in extremity joints commonly affected by RA, such as the 2nd and 3rd metacarpophalangeal joints. However, age, sex, and obesity can also influence joint space narrowing. Thus, this study aimed to determine whether HR-pQCT joint space metrics could distinguish between RA patients and controls, and determine the effects of age, sex and body mass index (BMI) on these joint space metrics. HR-pQCT joint space metrics (volume, width, standard deviation of width, maximum/minimum width, and asymmetry) were acquired from RA patients and age-and sex-matched healthy control participants 2nd and 3rd MCP joints. Joint health and functionality were assessed with ultrasound (i.e., effusion and inflammation), hand function tests, and questionnaires. HR-pQCT-derived 3D joint space metrics were not significantly different between RA and control groups (p > 0.05), despite significant differences in inflammation and joint function (p < 0.05). Joint space volume, mean joint space width (JSW), maximum JSW, minimum JSW were larger in males than females (p < 0.05), while maximum JSW decreased with age. No significant association between joint space metrics and BMI were found. HR-pQCT did not detect group level differences between RA and age-and sex-matched controls. Further research is necessary to determine whether this is due to a true lack of group level differences due to well-controlled RA, or the inability of HR-pQCT to detect a difference.

Pressure pain mapping of equine distal joints: feasibility and reliability.

Osteoarthritis is a prevalent degenerative joint disease initiating chronic pain and lameness in horses. While several objective gait analysis systems have been developed and validated to quantify lameness severity in horses, methods to evaluate whether peripheral sensitization contributes to the pain experienced are missing. To evaluate whether periarticular pressure pain mapping could be proposed as an auxiliary assessment tool in horses. Specific aims were to evaluate the feasibility and intra- and inter-rater reliability of pressure pain thresholds (PPT) determination at sites overlying the distal thoracic limb joints of clinically healthy horses. Prospective, randomized validation study. For feasibility assessment, PPT were measured with a hand-held digital algometer at six periarticular landmarks (2 sites per joint, 3 joints) bilaterally on the distal thoracic limb of 40 healthy horses (20 warmblood and 20 Freiberger). The joints tested were the metacarpophalangeal, on the latero-palmar and dorsal aspects (L-MCP and D-MCP), the proximal interphalangeal, on the dorsal and palmar aspect (D-PIP and P-PIP) and the distal interphalangeal, on the dorsal and lateral aspect (D-DIP and L-DIP). A feasibility score, ranging from 0 to 5, was attributed to each testing session. For intra- and inter-rater reliability assessment, L-MCP and D-MCP were selected to be tested again at 2 weeks intervals in 20 out of the 40 horses. Data were analyzed using a mixed-effect linear model to test differences in threshold per site and limb. Intra- and inter-rater correlation was calculated. Bland-Altman plots were performed to evaluate the variability of the measures. The procedure was considered feasible (score <2) in 95% of horses (95% CI 88%-100%). Overall, median [interquartile range (IQR)] PPT was 9.4 (7.5-11.3) N. No significant side differences were found. P-PIP and D-DIP recorded significantly lower PPT (p < 0.001 and p = 0.002, respectively) than L-MCP. Median (IQR) were 9.9 (7.3-12.4) N, 8.4 (6.1-10.5) N and 9.0 (7.4-10.6) N for L-MCP, P-PIP and D-DIP, respectively. The intra-rater agreement was 0.68 (95% CI 0.35-0.86) for L-MCP, and 0.50 (95% CI 0.08-0.76) for D-MCP. Inter-rater agreement was 0.85 (95% CI 0.66-0.94) for L-MCP and 0.81 (0.57, 0.92) for D-MCP. Evaluation of feasibility was performed only for distal thoracic limbs joints; no data are provided for hind limbs or proximal joints. Only warmblood and Freiberger horses were included. Intra- and inter-rater reliability assessments were performed exclusively on data collected at the MCP joint. Pressure pain mapping of distal thoracic limb joints was feasible in horses. Local sensitivity differed among sites and no side differences were noticed. Data collected from the MCP joint suggest highly variable, subject dependent intra-rater reliability, ranging from poor to good, and good to excellent inter-rater reliability. Further studies evaluating pathologic vs. healthy joints are needed before recommendations can be made about clinical usability and diagnostic validity.

E046 Lytic lesions; metastatic disease or gout?

Abstract Background/Aims Uric acid crystal deposition in the spine is uncommonly diagnosed, although the frequency of axial involvement is thought to be as high as 14-35%. Studies have shown that spinal gout is more common in men aged 35-75 years, with a history of chronic polyarticular tophaceous gout which is not optimally controlled being a key risk factor. Recent studies have shown that spinal gout is under and misdiagnosed due to its non-specific presentation of back pain or absence of symptoms. Our case report exemplifies this diagnostic challenge. Methods In this report we describe a case of a 79-year-old male with a history of polyarticular tophaceous gout, chronic kidney disease and previous renal carcinoma treated with curative radiotherapy. He presented with a 4-week history of progressive exertional dyspnoea and orthopnoea. He was commenced on intravenous diuretics which lead to an acute kidney injury, with his eGFR dropping to 14mL/min. His preadmission allopurinol and colchicine were held and clinically he developed a flare of gout affecting his right wrist and right second and third MCP joints. A CT scan of his abdomen and pelvis, carried out to investigate potential bowel obstruction, showed no evidence of obstruction but it did reveal multiple lytic lesions in the spine with potential extension into the spinal canal at T9 and L5. He did not have any back pain and his neurological examination was normal. Results A working diagnosis of spinal metastasis with potential cord compression was made and the patient was commenced on high dose steroids. He subsequently underwent an MRI whole spine which showed marrow abnormalities and destructive soft tissues changes affecting various facet joints in the thoracic and lumbar spine. The primary differential remained metastases but due to the unusual distribution of the marrow changes in which the vertebral bodies were completely spared, the initial CT images were reviewed on spectral scanning which demonstrated uric acid deposition in the affected facet joints. The diagnosis was confirmed as gout in the spine when a PET-CT scan revealed no potential primary source of malignancy. The gout flare in his hand settled with the steroids prescribed to treat the potential cord compression and he continued to deny suffering from back pain. Conclusion A literature search demonstrates that reports of spinal gout being described as lytic lesions on CT are rare. Spinal gout should be considered as a differential in a patient with facet joint lytic lesions on imaging, without involvement of the vertebral body and where no primary malignancy is found. Our case demonstrates how dual energy CT scanning can prevent the need for invasive biopsy in cases of diagnostic uncertainty in patients with a history of poorly controlled chronic tophaceous gout. Disclosure S.K. Stewart: None. D.J. Coulter: None. C. Masih: None.

CLINICAL FEATURES OF DIGITAL FLEXOR TENDON SHEATH: AN ANATOMIC STUDY

Objectives: To study clinical features of digital flexor sheath. Methods: An observational anatomic study on 26 cadaver hands which were dissected and studied to conclude several anatomic features of the digital flexor sheath contributing to the management of the flexor sheath injuries in clinical practice. Results: The average length of A1, A2, A4 pulleys in the long fingers were 7.11mm, 16.12mm, and 5.94mm, respectively. The average width and thickness of A2, A4 pulleys in the long fingers were 6.25mm x 3.68mm and 4.98mm x 2.90mm, respectively. The distances from the MCP joint to the proximal border of A2, A4 pulleys on the same digitorium were 6.35mm and 7.96mm, respectively. Conclusion: A2 has the longest length and biggest cast thickness and width.

How Does Ultrasound Global OMERACT-EULAR Synovitis Score (GLOESS) for Rheumatoid Arthritis (RA) Activity Assessment Perform in Real-Life?

This study aimed to assess the effectiveness of the Global OMERACT-EULAR Synovitis Score (GLOESS) of bilateral second to fifth metacarpophalangeal joints (MCP 2-5) in evaluating rheumatoid arthritis (RA) activity in a real-life setting. This cross-sectional study included consecutive RA patients without hyperalgesia. Clinical data were extracted from electronic medical records. Evaluations were conducted on bilateral MCP 2-5 by two independent experts in musculoskeletal ultrasound (MSUS). Correlation between clinical and ultrasonographic parameters was analyzed, aiming to define a cutoff value for detecting disease activity. Sixty-nine patients were included. The mean DAS28-ESR was 4.3 (±1.4), and the median GLOESS was 7 (13). The correlation between GLOESS and DAS28 was moderate (r = .62; P < .05). A total GLOESS score of ≤3 and all joints with both GS and PD ≤1 showed good sensitivity and specificity for detecting disease activity (remission/low vs moderate/high, P = 0). In a real-life scenario, GLOESS for MCP 2-5 emerges as a valuable measure of RA activity. The optimal cutoff distinguishing remission/low from moderate/high disease activity was determined to be GLOESS ≤3, with all MCP joints exhibiting both GS and PD scores of ≤1.

Dupuytren's Disease: A Novel Minimally Invasive Pull-Through Technique.

Background Dupuytren's disease decreases quality of life significantly and often requires surgical treatment, nevertheless there is no actual gold standard. The aim of this study was to introduce the use of minimally invasive pull-through technique. Methods From 2016 to 2020, 52 patients suffering from Dupuytren's contracture were treated with the minimally invasive pull-through technique. We evaluated the improvement in range of motion, pain, disability, and quality of life in the long term. Total extension deficit, quick disabilities of the arm, shoulder, and hand (QuickDASH), and EuroQol five dimensions-five levels index were systematically scored before each surgical intervention and reevaluated after 24 months. Results Fourteen patients (26.9%) had already received a previous intervention (percutaneous needle aponeurotomy or collagenase Clostridium histolyticum ). The mean preoperative total active extension deficit was 84.0 ± 23.3 degrees (55-130 degrees). Mean follow-up was 36 months. There were no cases of tendon rupture or neurovascular injury. Total active extension deficit at the final follow-up was 3.4 ± 2.3 degrees (0-12 degrees). The mean active range of motion of the MCP and PIP joints were, respectively, 90.5 ± 3.3 degrees (85-96 degrees) and 82.7 ± 2.5 degrees (80-87 degrees). At 24 months after cord excision, a mean 10.7 points improvement in the QuickDASH questionnaire was registered ( p < 0.001). Pull-through technique was equally effective both on patients with a primary or a recurrent disease. Eight patients (15.4%) had a recurrence of disease in the metacarpophalangeal joint or proximal interphalangeal joint. Conclusion The pull-through technique is a simple, accessible, and effective technique for the treatment of Dupuytren's contracture. The use of palmar mini-incisions combined with minimal dissection has a low risk of iatrogenic injury to the neurovascular bundles and tendons, and has a low risk of recurrence rate. This study reflects level of evidence IV.

Anatomically-Inspired Robotic Finger with SMA Tendon Actuation for Enhanced Biomimetic Functionality.

This research introduces an advanced robotic finger designed for future generalist robots, closely mimicking the natural structure of the human finger. The incorporation of rarely discussed anatomical structures, including tendon sheath, ligaments, and palmar plates, combined with the usage of anatomically proven 3D models of the finger, give rise to the highly accurate replication of human-like soft mechanical fingers. Benefiting from the accurate anatomy of muscle insertions with the utilization of Shape Memory Alloy (SMA) wires' muscle-like actuation properties, the bonding in-between the flexor tendons and extensor tendons allows for the realization of the central and lateral band of the finger anatomy. Evaluated using the computer vision method, the proposed robotic finger demonstrates a range of motion (ROM) equivalent to 113%, 87% and 88% of the human dynamic ROM for the DIP, PIP and MCP joints, respectively. The proposed finger possesses a soft nature when relaxed and becomes firm when activated, pioneering a new approach in biomimetic robot design and offering a unique contribution to the future of generalist humanoid robots.

Outcome of Transfer Flexor Carpi Ulnaris And Plmaris Longus Tendons for Hand Deformity in Persistance Radial Nerve Palsy

Objective; the aim of our study is to evaluate the functional outcome of transfer flexor carpi ulnaris and palmaris longus for patients with persistence radial nerve palsy by minimal tendon transfer technique.&#x0D; Methods; The study included 10 patients 8 male and two female, mean age 25 years, range from 20 to 30 years. They underwent transfer of flexor carpi ulnaris (FCU) and palmaris longus (PL) tendon for patient with persistence radial nerve palsy, the duration of outcome of tendon transfer after radial nerve injury evaluated after one year. Clinical evaluation include wrist joint range of movement by Geniometry and compared with the contralateral normal side.&#x0D; Results; The average ranges of wrist movements were as the follows: the mean wrist flexion was 52⁰(range 46⁰–56⁰), the mean wrist extension was 34⁰(range 30–38), radial deviation 18⁰(range 16⁰–20⁰) and ulnar deviation 21⁰ (range 18–23). The mean extension of the fingers in wrist extension was 7⁰(range 5⁰–10⁰) and in wrist neutral position was 12⁰(range 9⁰–16⁰). The mean abduction of the thumb was 38⁰(range 35⁰–44⁰). In comparison to the measure of joints in the contralateral normal hand, the final extension of the wrist was less, but extension of the fingers and MCP joints was similar to that of the normal hand. All of the patients in our study were able to extend their fingers with the wrist in the neutral position. Thumb abduction and extension was sufficient to deal with daily activities and, even, heavy jobs in most of the patients. Postoperative follow up of the patients was ranged (12–24) months. After 45 days, 8o% of the patients were able to do the normal non heavy daily work. In 20% of cases recovery was not progressing satisfactorily at 5 weeks. These were referred to physiotherapy for a planned exercise program, which the two patients improved their movements.&#x0D; Conclusion; The purpose of this study was to evaluate function of the hand after transfer of the FCU to EDC and PL to EPL, with persistence high nerve injuries. The FCU &amp; PL tendons transfer has some advantages over the other techniques, short duration of operation time, no morbidity, improve range of motion of hand and less surgical scares. It is a viable option to restore hand function and strength following radial nerve injuries.

Accessory and Sesamoid Bones in the Body: A study on their Size and Presence

Aim: Accessory and sesamoid bones are hidden anatomical structures that fulfil a wide variety of functions in the human body. Therefore, studying the nature, formation and dimensions of these structures is of great importance for the medical literature. In our study, we aimed to measure the presence and area (size) of these ossicles.&#x0D; Material and Method: Our study was performed retrospectively on the images of individuals who applied to Ordu University and whose radiological images were obtained. The presence of accessory and sesamoid ossicles (present/absent) and their sizes (measured using the PACS system) were evaluated on radiographs and Computed Tomography (CT) images. The results of the ossicles were divided into gender, age, and bilateral groups. Statistical analyzes were performed with the SPSS program. &#x0D; Results: The most common and largest accessory ossicles in the foot were os peroneum (18.2%), os naviculare accessoria (17.4%), os trigonum (12.1%) and os intermetatarsarum (7.8%). Sesamoid ossicles at the level of the first metatarsophalangeal (mtp) joint of the foot and the first metacarpopgalangeal (mcp) joint of the hand were found to be 100% common. The second most common sesamoid bone in the hand and foot was at the fifth mtp (22.22%) and mcp (68.53%) joints. In the hand, the most common accessory ossicles were os triangulare (6.08%), os radiale externum (2.60%) and os centrale (1.73%). Accessory ossicles (fabella: 19%, cyamella: 17.5%) were found in 25.5% of the knee.&#x0D; Conclusion: Accessory and sesamoid ossicles are most commonly found in the hand, foot, and knee. The presence and size of these ossicles can be both beneficial and harmful. Sesamoids provide mechanical benefit, whereas accessory ossicles can be mistaken for fractures and may lead to unnecessary medical conditions. Knowing the dimensions of these ossicles allows them to be clinically differentiated from avulsion fractures.

Development of a master–slave 3D printed robotic surgical finger with haptic feedback

Robotic surgery started nearly 30 years ago. It has achieved telepresence and the performance of repetitive, precise, and accurate tasks. The “master–slave” robotic system allows control of manipulators by surgeon at distant site. Robotic surgical fingers were developed to allow surgeons to move them with accuracy through sensors fixed on surgeon’s hand. Also, haptic sensors were developed to allow transmission of sensation from robotic finger to surgeon’s finger. A complete system of a, 3D printed by a stereolithography (SLA) 3D printer, robotic surgical finger with haptic feedback system is proposed. The developed system includes a master glove that controls the motion of a 3DOF robotic slave finger while getting haptic feedback of force/pressure exerted on it. The precise control of the slave robotic finger was achieved by applying a Proportional Integral and Derivative (PID), fast and robust, control algorithm using an Arduino based hardware and software module. The individual joint angles, metacarpophalangeal joint (MCP) and proximal interphalangeal joint (PIP), and wrist were measured using rotatory and inertial sensors respectively. The degree of movement for MCP, PIP, and Wrist joints were measured to be 0–86°, 0–71°, and 0–89° respectively. Motion to the robotic finger is mimicked by a glove motion requiring minimal learning curve for the device. The collected data for the slave motion is in good agreement with the master-glove motion data. The vibro-tactile haptic feedback system was developed to distinguish between three different materials to mimic human flesh, tumor, and bone. The master–slave system using robotic surgical finger with good simultaneous movement to surgeon’s finger and good haptic sensation will provide the surgeon with the opportunity to perform finger dissection in laparoscopic and robotic surgery, as it used to be in open surgery. 3D bio printing will make this process even cheaper with the added advantage of making surgical tools locally according to the need of the surgery. An ongoing work is to develop silicone based 8 mm robotic surgical finger with multiple type haptic feedback.

Alternative Surgical Treatment Method for 5th Metacarpal Neck Fractures: Comparison of Clinical Outcomes of Intramedullary and Transverse K-Wire Fixations with Additional Antirotational K-Wire.

The purpose of this study was to assess the clinical outcomes and complications associated with intramedullary and transverse K-wire fixations of 5th metacarpal neck fractures. Patients who were operated for 5th metacarpal neck fractures between 2019 and 2022 were evaluated retrospectively. Regarding the surgical treatment methods, patients were assessed by dividing them into two groups. The first group comprised patients who underwent treatment with an intramedullary K-wire. The second group comprises patients who underwent transverse K-wire fixation. The average quick DASH score of all patients was 5.6±4.7 in the intramedullary K-wire fixation group and 5.9±5.1 in the transverse K-wire fixation group. An average 5th finger metacarpophalangeal joint extension limitation was 6.2±5.7° in the intramedullary fixation group and 6.1±5.8° in the transverse K-wire group. The mean radiological union time was 4.9±0.7 weeks in the intramedullary fixation group and 5.1±0.7 weeks in the transverse K-wire group. No statistically significant difference was found between the quick DASH scores and degrees of the MCP joint extension limitation ( p=0.785). Intramedullary fixation and transverse K-wire fixations are effective surgical treatment methods for metacarpal neck fractures. It has been reported that the intramedullary fixation method in metacarpal bone fractures is more effective than the fixation methods with cross and transverse K-wire. But our results revealed no difference in clinical outcomes between the two surgical fixation methods. We observed no statistically significant difference between the two fixation techniques with regard to union, clinical outcomes, or complications. intramedullary fixation; metacarpal neck fracture; transverse K-wire fixation.

Subtotal palmar fasciectomy with skin Z-plasty results in Dupuytren’s disease : Minimum one year follow-up

Backround Dupuytren's disease is a condition that leads to progressive contractures in the hand, significantly impacting the quality of life. These rigid deformities impair hand functions and have adverse effects on daily life. Various surgical treatment options are available. In this study, our goal is to report the results of patients for whom we performed subtotal palmar fasciectomy and skin Z-plasty. Method A retrospective analysis was conducted on 16 patients who underwent subtotal palmar fasciotomy. The range of motion before and after the operation, along with patient-reported outcome scores using the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QDASH), were compared. Additionally, the time return to work time and any complications were documented. Results The mean preoperative MCP joint flexion contracture degree was 42.8 (range: 30-70 degrees), while the postoperative mean was 2 (range: 0-30 degrees). Similarly, the mean preoperative PIP joint flexion contracture degree was 41 (range: 20-90 degrees), and the postoperative mean was 8 (range: 0-30 degrees). The mean preoperative QDASH score decreased from 44 (range: 32.5-50) to 9.6 postoperatively (range: 7.5-12.5). The average return-to-work time was 42 days. Conclusion Subtotal palmar fasciotomy stands as a surgical alternative with high patient satisfaction in treating Dupuytren's disease. The application of Z-plasty during closure helps to reduce postoperative wound problems by alleviating tension.

An examination of the operative and post-operative management of trapeziometacarpal osteoarthritis in Ireland

BACKGROUND: The trapeziometacarpal or first carpometacarpal (CMC) joint is the second most common joint affected in osteoarthritis (OA) of the hand. Surgical intervention may be required when conservative measures fail to alleviate symptoms. OBJECTIVE: To investigate operative and post-operative management of trapeziometacarpal osteoarthritis in Ireland. METHODS: An on-line Qualtrics survey was used to determine practice patterns of hand surgeons and therapists including surgical technique, patterns of referral to therapy, treatment protocol and perceived pain impact. RESULTS: Twenty surgeon’s responses were received. Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI) was the most common procedure for all stages of arthritis for sedentary and manual patients. Sixty seven percent (n = 18) stated they perform an additional procedure if stage IV arthritis is present. Eighty percent (n = 16) stated they would perform an additional procedure for MCP joint hyperextension. There were 28 therapist responses. Almost all respondents indicated that patients are initially casted post-surgery with 88% (n = 24) indicating they remain casted for 1-2 weeks. A rigid long thumb spica and neoprene splint are most commonly used. The commencement of exercises differed between respondents and surgical procedures. All participants stated that pain is an issue in the rehabilitation of these patients. CONCLUSIONS: There was consistency in the surgical procedure choice. The stage of arthritis and functional level of the patient was not found to be an important factor for choosing this procedure. There is some consensus for post-operative casting and splinting but more variability in terms of exercise prescription. Pain is a factor to consider post-operatively.

E56 A 16-year diagnosis delay of a patient with Pigmented Villonodular Synovitis

Abstract Introduction Pigmented villonodular synovitis (PVNS), a subtype of tenosynovial giant cell tumours, is a rare non-cancerous proliferative synovial disorder usually affecting the knee in adults(1). The incidence rate is 1.8 patients per million people of the general population, with few reports amongst the paediatric population, hence it is frequently misdiagnosed(2). It has a slow onset of symptoms and has been noted to take ∼18 months to make a definitive diagnosis(3). Objective To describe a case of pigmented villonodular synovitis in a seventeen-year-old African female. Methods A retrospective chart review was done to ascertain the clinical presentation and management of the patient. Case description We present a case of a 17-year-old African female who presented with bilateral knee pain and swelling from 10 months of age. She had been on follow-up at a peripheral facility for 14 years, where she was being managed with methotrexate 12.5 mg weekly and folic acid 5 mg OD for Juvenile Idiopathic Arthritis with no marked improvement in her symptoms. In view of her poor response to therapy, the mother stopped her treatment 3 months prior to presentation in our facility. She initially had intermittent bilateral swelling of the small joints of the hand that were tender which eventually evolved to involve both knee joints. The pain was worse in the morning and was associated with the inability to ambulate and occasional night awakening. The systemic inquiry was otherwise unremarkable. She had an unremarkable birth history, and normal developmental milestones. She was however shorter than her peers and had not attained menarche. The patient had been admitted 8–10 times per year during the span of her illness for similar complaints and had undergone multiple knee joint fluid aspirations to relieve the swelling and several laboratory tests and radiological studies were done. On assessment, she was noted to be of fair general condition with gross asymmetric swelling of both knees and a surgical scar over the right knee with no limitation in the range of movement. There was minimal effusion of bilateral elbows and ankles, and the MCP, ICP and wrist joints weren’t affected. The patient had thoracic scoliosis, a grade 3/6 systolic murmur on the left lower sternal border, no radiation, and hepatomegaly 4 cm below the costal margin. She was prepubertal on sexual maturation rating. There was no central nervous system, abdominal, or respiratory abnormalities. A series of lab investigations to exclude the possibility of juvenile idiopathic arthritis were conducted. This panel included a complete blood count, which showed hypochromic, microcytic anaemia, c-reactive protein was raised at 61 mg/l but normal biochemistry and unremarkable autoantibody profile. Imaging done included a bilateral knee X-Ray followed by a bilateral knee MRI which showed large volume bilateral knee joint effusions associated with synovial-based masses causing extrinsic periarticular bony erosions and intra-articular synovial proliferation forming a villonodular appearance. The patient was referred to orthopaedic surgery and bilateral arthrotomy, drainage and synovectomy of both knees were done. She continues to be followed up in our paediatric rheumatology and orthopaedic clinic with good mobility and no other co-morbidities. She is currently undergoing work up for a delayed puberty. Conclusion Pigmented villonodular synovitis is a rare disease in the paediatric population. In the absence of awareness of its existence and expertise on how to diagnose it, patients may be misdiagnosed and mismanaged over a long duration of time as seen in the presented case.

Biological Reconstruction for Metacarpal Osteofibrous Dysplasia Treatment: A Case Report

Background: Osteofibrous dysplasia is a rare benign bone tumor characterized by abnormal differentiation of fibrous tissue in bone and commonly involves the maxilla, mandible, and tibia and affects children less than 10 years old. Osteofibrous dysplasia affecting the metacarpal is a very rare case. This study presents a case report to present biological reconstruction in the management of metacarpal osteofibrous dysplasia. &#x0D; Case presentation: A 48-year-old female presented with swelling and pain in her right hand over 1 year. On examination, palpable mass with immobile and hard consistency on the first metacarpal and distal neurovascular within normal limit. Radiographic examination (X-ray and MRI) supports osteofibrous dysplasia. We performed complete resection of the first metacarpal and used a fibular graft to maintain length, followed by arthroplasty of the first metacarpophalangeal joint and arthrodesis of the first carpometacarpal joint. Pathological results showed a Chinese letter appearance with osteoblastic rimming that confirmed osteofibrous dysplasia. After 6 months of follow-up, there is no recurrence, and the functional outcome is excellent (MSTS score 93,33%).&#x0D; Conclusion: Osteofibrous dysplasia on the metacarpal and affected adult is a very rare case. Treatment with complete resection of the metacarpal, using a fibular graft to maintain bone length, and arthroplasty MCP joint will give good results (MSTS score 93,33%). Follow-up for recurrence is necessary.

Buttered Knuckles of the Martial Arts World – A Comprehensive Review on Boxer’s Knuckle

Introduction:&#x0D; Boxer's knuckle is a common injury that occurs due to repetitive trauma to the hand, often seen in those who engage in boxing or other similar combat sports. It is a painful condition that can cause swelling, tenderness, and limited movement in the affected area. In some cases, boxer's knuckle can be severe enough to require medical attention and even surgery. This injury can have a significant impact on an athlete's training and overall performance, and it is important to take preventative measures to avoid its occurrence. Understanding the causes, symptoms, and treatment options for boxer's knuckle is essential for any athlete who regularly engages in combat sports or any activity that involves repeated hand trauma.&#x0D; Objective of the study:The objective of this review study is to analyze and summarize the literature related to boxer's knuckle, including its epidemiology, pathophysiology, clinical features, diagnosis, and management. The study aims to provide a comprehensive understanding of the condition, its causes, risk factors, and treatments, and to identify the gaps and limitations in the existing literature. Furthermore, this review intends to provide evidence-based recommendations and guidelines for the prevention, assessment, and treatment of boxer's knuckle in athletes and other individuals who are at risk of developing the condition. Ultimately, the study seeks to contribute to the development of a more precise and effective approach to managing this common hand injury.&#x0D; Material and methods:&#x0D; Review of PubMed articles using the following keywords: “mcp joint rupture boxing”, “boxer's knuckle”, “metacarpophalangeal joint boxing”, “extensor hood injuries”. Additionally, related articles proposed by the PubMed website were checked. Single citations that were not in the PubMed database but, in the opinion of the authors, contained valuable knowledge worthy of inclusion in the article were also reviewed.

Abstract #1407325: Acromegalic Arthropathy Masquerading as Rheumatoid Arthritis- A Diagnostic Challenge

Acromegaly is a disorder related to the excessive production of growth hormone after puberty. The estimated incidence of acromegaly is approximately 3/10,00,000 persons per year. Although figures in the literature vary, the diagnosis of acromegaly is often delayed by 7-10 years from the onset of symptoms. Increased provider recognition allows for early diagnosis and treatment, which may prevent long-term complications of acromegaly. This case highlights the importance of increased provider awareness of the condition, and its clinical features. A 50-year-old female presented to primary care with several years of progressive joint pain in the hands with associated swelling and morning stiffness. On examination, she had synovitis in her PIP and MCP joints. Ultrasound of her hands revealed diffuse synovial fluid complexes and tenosynovitis. She was referred to Rheumatology and was diagnosed with seronegative rheumatoid arthritis. She was trialed on MTX, HCQ, and SSZ, followed by several biologics (Adalimumab, Etanercept, Abatacept) without clinical improvement. This prompted re-evaluation of her diagnosis. The rheumatologist recognized clinical features suggestive of acromegaly- mild frontal bossing, enlarged hands and dactylitis. A serum IGF1 level was elevated, which was confirmed on repeat testing upon establishing care with Endocrinology. MRI brain revealed a 7 mm pituitary microadenoma. The patient has been referred to neurosurgery and is awaiting surgical intervention. The clinical manifestations of acromegaly include frontal bone bossing, jaw prognathism, acral overgrowth, osteoarthritis, diabetes mellitus, hypertension, respiratory and cardiac failure. With untreated, prolonged disease, concentric myocardial hypertrophy develops, and diastolic heart failure occurs, which are not reversible. Skeletal disorders cause significant functional disability and compromised quality of life in patients with acromegaly. 70% of such patients have large-joint and axial arthropathy that includes thickened articular cartilage, periarticular calcifications, osteophyte overgrowth, and synovitis. About 40% of cases are initially diagnosed by an internist, and the rest are diagnosed when patients are seen by ophthalmologists for visual disturbances, by dental surgeons for bite disorders, by gynecologists for menstrual dysfunction and infertility, by rheumatologists for osteoarthritis, or by sleep-disorder specialists for obstructive sleep apnea. In conclusion, high suspicion of the diagnosis, along with early diagnosis, is critical in possibly preventing the morbidity associated with acromegaly and improving long-term outcomes.

E028 Seronegative arthritis in the context of CHIP: is this a new entity that needs further investigation?

Abstract Background/Aims We describe a seronegative, non-erosive arthritis in the context of clonal haematopoiesis of indeterminant potential (CHIP), the premalignant stage of most myeloid malignancies and myelodysplastic syndromes (MDS). The use of targeted next-generation sequencing (NGS) has helped the clinician to identify the high risk individuals who are at an increased risk of haematological malignancies. Patients presenting with persistent neutropenia and inflammatory arthritis in addition to bone marrow examination, these genomic sequencing should be considered to identify clonal cytopenia and the risk for progression to myeloid malignancies. Methods A 70-year-old man referred to rheumatology clinic with pain and swelling in the small joints of the hands along with shoulder, hip and knee pains. There were few psoriatic patches but no typical features of psoriatic arthropathy. Clinically he had evidence of synovitis in the MCP joints, high inflammatory markers (CRP 157) and a low neutrophil count. Bone marrow examination at time of initial review was reported as completely normal as there was no evidence of MDS and the neutropenia was attributed to his underlying autoimmune condition. His X-rays showed no evidence of erosions and USS scan confirmed synovitis in the MCP joints. He was RF and anti-CCP negative and the diagnosis of suspected seronegative RA was considered. He was initially treated with steroids and hydroxychloroquine but the symptoms relapsed while tapering dose of steroids. A year later, adalimumab was introduced to manage the inflammatory arthritis. He did not show much response to it and golimumab was started, to which he responded very well. He was maintaining excellent clinical remission for 3 years however the neutropenia worsened. He was referred back to haematology for further investigations. Results The neutrophil counts had been fluctuating between 0.3 and 0.9 while receiving golimumab. Slight improvement in the count was noted after taking a 6-month break from biologics. However, this improvement was very transient. A repeat BM biopsy including myeloid next-generation genomic sequencing which diagnosed a high-risk CHIP/clinical cytopenia of unknown significance (CCUS) (mutation profile: IDH 1 R132 (12%VAF), IDH2 R140 (36% VAF), SRSF2 P95 (47% VAF) with no morphological evidence of MDS. Since this is a premalignant condition and there is a significant risk of developing AML, a decision was taken to stop golimumab and start rituximab. The neutrophil count has increased from 0.36 to 1.89 after starting the rituximab and the inflammatory arthritis remains in remission. Conclusion This case highlights low threshold of suspicion of CHIP in patients presenting with features of inflammatory arthritis and neutropenia and/or other cytopenias. Thus, detailed bone marrow sampling including targeted myeloid NGS panels should be undertaken to exclude CHIP or CCUS. This will potentially help us to guide treatment. Disclosure S. Mohamed: None. T. McKerrell: None. D. Makkuni: None.