Primary Malignant Osseous Neoplasms in the Hand.

BACKGROUND: Primary malignant osseous neoplasms of the hand are rare malignancies. Comprehensive demographic and survival data regarding primary malignant osseous neoplasms of the hand are lacking in the literature. PATIENTS AND METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified all patients with primary malignant osseous neoplasms of the hand diagnosed between 1983 and 2015. Demographic data were searched for primary osseous neoplasms in the hand and higher incidence of histological subtype. RESULTS: A total of 197 patients were analyzed: 103 patients were diagnosed with histologically low-grade tumor, and 31 were diagnosed with high-grade tumor. Five-year cancer-specific and overall survival rates for the entire cohort were 91.4% and 81.9%, respectively. Histological high tumor grade and regional stage from SEER historic stage data were associated with unfavorable cancer-specific survival. CONCLUSION: Special caution is required if patients have histologically high-grade tumor or tumor extending beyond the periosteum into surrounding joints, as these features worsen cancer-specific mortality.

TNF inhibitor treating osseous sarcoidosis and dactylitis: case and literature review.

A 49-year-old African American male with multiorgan sarcoidosis presented with recurrent episodes of dactylitis and arthritis. Imaging had shown sarcoid osseous involvement of both hands. This would improve temporarily with high-dose corticosteroids but once tapered, he would experience recurrent flares. Despite several different oral immunosuppressant regimens, significant improvement was only observed after the initiation of adalimumab. Not only was adalimumab successful in symptomatic relief, in addition, patient continues to be in remission with no recurrent episodes of dactylitis. Prednisone was successfully tapered from 40 to 3 mg daily. This improvement with TNF inhibitors has been reported with other manifestations of sarcoidosis including pulmonary and ocular involvements. Osseous sarcoidosis is a very rare presentation, and little information regarding treatment with TNF inhibitors is available. TNF inhibitors should be considered as the next-step therapy in resistant cases of osseous sarcoidosis and dactylitis not responding to corticosteroids and traditional immunosuppressant therapy.

Bone and joint infections of the hand.

BACKGROUND: Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. OBJECTIVES: To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. SOURCES: We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. CONTENT: Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. IMPLICATIONS: Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.

Osteoarthritis in the Middle-Aged and Elderly in China: Prevalence and Influencing Factors.

Background: Osteoarthritis is a common joint disease, with the acceleration of the aging process in China, it has troubled the middle-aged and elderly. There have been some epidemiological studies of osteoarthritis conducted in one single site, and most of them were on knee osteoarthritis. The results varied greatly between different surveys. There was still a lack of large-scale and multicenter epidemiological studies of osteoarthritis. This paper aimed to estimate the overall prevalence of lumbar osteoarthritis, cervical osteoarthritis, hand osteoarthritis, knee osteoarthritis, and hip osteoarthritis in the middle-aged and elderly in China by summarizing the existing publications. Methods: We comprehensively searched publications on 1 January 2019 in PubMed, Web of Science, Embase, Cochrane Library, CBM, CNNI, VIP, and Wan Fang. Epidemiological publications on osteoarthritis in the middle-aged and elderly Chinese published from 2000 to 2018 were summarized and analyzed by means of systematic review and meta-analysis. Data of prevalence of osteoarthritis in five joints were extracted from the included publications. The Hoy 2012 tool was used to assess the risk of bias of included studies. Results: After performing a systematic search in eight databases and manually searching, 3058 articles were obtained, and 21 articles were included in the meta-analysis. Lumbar osteoarthritis was the most prevalent with a prevalence of 25.03% (95% CI: 0.1444-0.3562). The prevalence of knee osteoarthritis followed, which was 21.51% (95% CI: 0.1873-0.2429). The prevalence of cervical osteoarthritis was 20.46% (95% CI: 0.1244-0.2849). The prevalence of hand osteoarthritis was 8.99% (95% CI: 0.0435-0.1364). The prevalence of hip osteoarthritis was not pooled due to its lack of data. Higher prevalence of knee, hand, lumbar, and cervical osteoarthritis was seen in the female group and southern regions. The prevalence of knee and hand osteoarthritis increased with age. The prevalence of lumbar and cervical osteoarthritis increased with age. There was also a trend that the prevalence increased with age before 70 years old and slightly decreased in the oldest ages. Conclusions: The lumbar joint was the joint most prevalently affected by osteoarthritis, followed by the prevalence of knee, cervical, hand, and hip joint osteoarthritis. Women, the southern population, and the older population are more susceptible to osteoarthritis. The paucity of epidemiology data of osteoarthritis in China appeals for more population-based surveys being conducted in the future. Based on the relatively high prevalence of osteoarthritis obtained from this review, self-management and community-based management should be considered, which can provide experience from the management of hypertensions and diabetes.

Osseous Metastatic Disease to the Hands and Feet.

Osseous metastases to the hands and feet (acrometastases) are exceedingly rare. Historically, the most common primary cancer observed has been lung carcinoma, treated either nonoperatively or with amputation. The aim of this study was to describe the clinical characteristics associated with acrometastases. This was a retrospective review of 28 patients with histologically proven osseous metastatic disease to the hands and feet. Variables recorded included primary cancer histology, age at diagnosis of primary and acrometastases, location of acrometastases, burden of disease, treatment, and age at death. Kaplan-Meier curves were used to estimate survival, and log-rank tests were used for comparison. The median age at acrometastases diagnosis was 61.5 years, and the most common associated primary cancer was lung carcinoma (n=9). Sixteen patients had acrometastases to the foot, and 12 had acrometastases to the hand. In the foot, most acrometastases were located in the tarsal bones (n=11), followed by the metatarsals (n=4) and the phalanges (n=3). In the hand, most were in the metacarpals and the phalanges (n=6 each), and 2 were in the carpals. The most common treatment was resection or curettage only (n=7). The median duration of survival after acrometastases diagnosis was 9.7 months. Despite advances in cancer treatment and shifting patterns of metastatic disease, there has been little change in the distribution of primary malignancies responsible for acrometastases, with lung carcinoma remaining the most common. Ablative procedures are rarely required, with limb-salvage interventions predominating. [Orthopedics. 2019; 42(2):e197-e201.].

Prevalencia de síntomas músculo-esqueléticos de la mano en estudiantes de odontología / Prevalence of Musculoskeletal Symptoms of the Hand Among Dental Students

Resumen Introducción: Los síntomas músculo-esqueléticos de las extremidades superiores son comunes entre los trabajadores dentales debido a la exposición a factores de riesgo, como movimientos repetitivos, esfuerzos intensos de manos, y malas posturas de muñecas. A medida que los estudiantes de odontología aprenden nuevas habilidades y procedimientos durante la escuela, experimentan un aumento gradual a estos factores de riesgo. El propósito de este estudio fue determinar la prevalencia de los síntomas musculo-esqueléticos (SME) de mano y muñeca entre los estudiantes de odontología de la Universidad de Iowa. Métodos: A 35 estudiantes de primer año y 39 estudiantes de cuarto año (N = 74) se les pidió que llenaran dos cuestionarios. Resultados: La prevalencia de los SME moderados/severos de la mano dominante como entumecimiento, hormigueo y dolor entre los estudiantes de primer año fue de 0, 6 y 20%, respectivamente, comparado con el 18,15 y 36% de los estudiantes de cuarto año. Conclusiones: Los SME de la mano dominante fueron más comunes entre los estudiantes de odontología de cuarto año, en comparación con los de primer año.

Abstract Introduction: Musculoskeletal symptoms of the upper extremities are common among dental workers due to exposure to risk factors including repetition, forceful exertions of the hand, and awkward wrist postures. As dental students learn new skills and procedures during dental school, they experience a gradually increasing exposure to these risk factors. The purpose of this study was to determine the prevalence of hand and wrist musculoskeletal symptoms (MSS) among dental students of the University of Iowa. Methods: Thirty-five first year students and thirty-nine fourth year students (N=74) were asked to complete two questionnaires. Results: The prevalence of moderate/severe MSS of the dominant hand such as numbness, tingling and soreness among first year students was 0, 6 and 20% respectively compared to 18, 15 and 36% of the fourth year students. Conclusions: In this relatively small sample, MSS of the dominant hand were more common among fourth year dental students when compared to first year students.

Third-Ray and Capitate Resection with Limited Midcarpal Fusion for Recurrent Giant Cell Tumor: A Case Report.

CASE: We describe a 23-year-old man who had multiple recurrences of a giant cell tumor (GCT) of the third metacarpal. Initial treatments consisted of curettage without the use of an adjuvant and bone-grafting. At the time of the latest recurrence, the lesion had extended into the capitate and the trapezoid. Treatment included third-ray resection and limited midcarpal fusion. No local recurrence was identified at more than 1 year after surgery. CONCLUSION: GCTs of the hand should be aggressively treated, but care should be taken to preserve function whenever possible.

Structural joint damage and hand bone loss in patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by pain, swelling and progressive destruction of the joints leading to loss of function and invalidity. The bone destruction in RA is characterised by two distinct features: structural joint damage and hand bone loss, and their prevention is an important treatment goal. Inhibitors of tumour necrosis factor alpha (TNF-inhibitors) have markedly improved the treatment options in RA patients who fail treatment with conventional synthetic Disease Modifying Anti Rheumatic Drugs (sDMARDS), but their effectiveness with regards to structural joint damage and hand bone loss, predictors thereof and the association with disease activity during treatment have mainly been investigated in randomized controlled trials (RCTs) with limited generalizability due to strict in- and exclusion criteria.
 The main aim of the PhD thesis was to assess and predict structural joint damage and hand bone loss in patients with early and established RA treated with sDMARDs and TNF-inhibitors. This was investigated in two cohorts: A) The "DANBIO X-ray study": an observational, nationwide, longitudinal cohort study of established RA patients treated in clinical practice who initiated TNF-inhibitor treatment after failure of sDMARDs and B) The "OPERA study": a randomized controlled trial of sDMARD-naïve patients with early RA treated with methotrexate (MTX) and intraarticular glucocorticoid injections in combination with adalimumab or placebo-adalimumab. Structural joint damage progression was assessed with the Sharp/van der Heijde radiographic method and hand bone loss was assessed with Digital X-ray Radiogrammetry. 
From the studies presented in the PhD thesis the following was concluded:
 Structural joint damage progression and hand bone loss were significantly lower during two years of TNF-inhibitor treatment compared to the previous two years of sDMARD-treatment in the DANBIO X-ray Study. The majority of patients had no progression of structural joint damage during two years of TNF-inhibitor treatment, while hand bone loss remained increased compared to reference values from the general population in the majority of patients. Adalimumab had no impact on hand bone loss in the OPERA study.
 Existing structural joint damage, older age, IgM-rheumatoid factor positivity and concomitant treatment with prednisolone were independent predictors of progression in structural joint damage in the DANBIO X-ray cohort, while high hand bone loss in the first 6 months of treatment and placebo treatment were independently associated with increase in structural joint damage scores in the OPERA study. A high hand bone mass and disease activity were independent predictors of increased hand bone loss in the DANBIO X-ray study, while older age and high functional disability predicted hand bone loss in the OPERA study. High disease activity during treatment was associated with structural joint damage progression during TNF-inhibitor treatment in the DANBIO X-ray study and with hand bone loss in the DANBIO X-ray and OPERA studies.

Multiple subcutaneous xanthogranuloma at juxta-articular sites with bone cystic changes resembling rheumatoid arthritis: A case report.

Xanthogranuloma is a benign disease represented as histiocytosis with lipoid deposition which usually occurs in children, but rarely in adults. We report a case of an adult patient with multiple subcutaneous xanthogranuloma at juxta-articular sites with bone cystic changes, manifesting similar clinical profiles to rheumatoid arthritis. Although very rare, we should consider the possibility of xanthogranulomatosis in the diagnosis of rheumatoid arthritis, especially in atypical cases.

Association of CD8+ T-cells with bone erosion in patients with rheumatoid arthritis.

AIM: Bone erosion is a major problem worsening quality of rheumatoid arthritis (RA) patients' lives. However, causal factors responsible for bone erosion in RA have remained unclear. We aimed to examine genetic variants conferring bone erosion in RA using a Korean genome-wide association study (GWAS) and to search for possible biological mechanisms underlying the development of bone erosion. METHOD: We obtained genome-wide single nucleotide polymorphism (SNP) data for 711 Korean RA patients using Illumina HapMap 550v3/660W arrays. Associations between SNPs and bone erosion status based on the Steinbrocker staging system were examined using multivariate logistic regression. Cell-type-specific enrichment of the epigenomic chromatin annotation H3K4me3 at the bone erosion associated variants was further investigated using National Institute of Health Roadmap Epigenomics data. RESULTS: As we tested the associations between 439 289 SNPs and bone erosion in 385 patients with erosive RA and 326 with non-erosive RA, none of the tested SNPs reached the genome-wide significance threshold, although many loci showed modest genetic effect on bone erosion status with suggestive association (e.g., rs2741200 [P = 3.75 × 10-6 ] in the SLA-TG locus and rs12422918 [P = 4.13 × 10-6 ] in SRGAP1). However, the top-ranked SNPs and their linked proxies, which were mostly located in non-coding variants, were significantly co-localized with the highly tissue-specific regulatory marker H3K4me3 in CD8+ memory T-cells (P = 0.014). CONCLUSION: Although, there was no large-effect variants associated with bone erosion in our GWAS, we have shown that CD8+ memory T-cells may have relevance with bone erosion in patients with RA through the analysis of ChiP-seq data.

Occupational manual activity is reflected on the patterns among hand entheses.

OBJECTIVES: In anthropological sciences, entheses are widely utilized as occupational stress markers. However, the reaction of entheseal surfaces to mechanical loading is not well understood. Furthermore, previous studies on entheses relied on the individuals' occupation-at-death. Past research by one of us has identified two patterns among hand entheses, proposing that they reflect two synergistic muscle groups. Here, we investigate the association between these patterns and habitual manual activity using an extensively documented skeletal sample and a three-dimensional system of quantification. MATERIALS AND METHODS: The hand bones utilized belong to 45 individuals from mid-19th century Basel. These were male adults (18 to 48 years old) who were not directly related, showed no manual pathological conditions, and whose occupational activities during their lifetime were clearly documented and could be evaluated according to historical sources. The patterns of entheses were explored using principal component analysis on both raw and size-adjusted variables. The influence of age-at-death, body mass, and bone length was assessed through correlation tests. RESULTS: The analysis showed that the previously proposed patterns of entheses are present in our sample. Individuals with the same or comparable occupations presented similar entheseal patterns. These results were not considerably affected by entheseal overall size, age-at-death, body mass, or bone length. DISCUSSION: Individuals involved in intense manual labor during their lifetime presented a distinctive pattern of hand entheses, consistent with the application of high grip force. By contrast, individuals with less strenuous and/or highly mechanized occupations showed an entheseal pattern related to the thumb intrinsic muscles.

Five cases of acrometastasis to the hand from a carcinoma and review of the literature.

Metastases in the hand bones are a rare form of cancer presentation. Their appearance as a sign of carcinoma is even rarer and is associated with a poor prognosis. While amputation is recommended in cases of isolated metastases in patients with at least a few months of survival, radiation therapy may be useful for treating pain and partially restoring function. We conducted a retrospective review of 5 consecutive patients (2 male, 3 female; mean age of 46 years) presenting with metastases in the hand bones who had lung (n=2), skin, uterus and kidney cancers. Conservative treatment was performed in three cases, transmetacarpal amputation in one case and distal phalanx amputation in one case. All patients died within a few months of the diagnosis (mean: 5.2months). Because acrometastases generally are related to widespread disease, the prognosis of patients with acrometastases is poor. These cases illustrate the rapid progression of the disease when acrometastases in the hand are present.

Morphometric patterns among the 3D surface areas of human hand entheses.

OBJECTIVES: This study aimed to put forth a new and precise methodology for calculating the 3D areas of hand entheses. Furthermore, it investigated some of the factors affecting hand entheses development through an assessment of their correlations and morphometric patterns. MATERIALS AND METHODS: Fifty individuals from late-medieval San Pablo were studied. The sample consisted of high-definition 3D models of 17 entheses from the first, second, and fifth hand rays. A new methodology was introduced for quantifying their areas. Precision was verified using intraobserved and interobserver tests. Both raw and relative entheseal size (ratio of entheseal size to total bone surface size) were calculated. Bivariate analyses assessed the effect of age-group on entheses as well as the correlations across entheses of muscles that act synergistically, bone length, and articular surface size. The morphometric patterns among hand entheses were explored using a multivariate analysis. RESULTS: The methodology presented no significant error. Age-group variation does not seem to affect hand entheses. In relative size, only particular pairs presented significant association and the entheses involved were not correlated with bone length or articular surface size. The multivariate analysis demonstrated high sexual dimorphism in overall entheseal size as well as two morphometric trends among hand entheses. DISCUSSION: The proposed methodology can set the basis for further morphological 3D analysis of entheses. If biomechanical stress affects hand entheses, its impact would possibly be greater on their relative size. The morphometric patterns among entheses seem to reflect the performance of prehensile grips. Am J Phys Anthropol 160:694-707, 2016. © 2016 Wiley Periodicals, Inc.

MRI evidence of persistent joint inflammation and progressive joint damage despite clinical remission during treatment of early rheumatoid arthritis.

OBJECTIVES: To determine the value of magnetic resonance imaging (MRI) of bones and joints in patients with recent-onset rheumatoid arthritis (RA) treated for 2 years from diagnosis with disease-modifying anti-rheumatic drugs (DMARDs) and glucocorticoids. METHOD: Thirteen patients with early RA were treated according to clinical practice and followed with MRI, radiographs, and Disease Activity Score calculated on 28 joints (DAS28) at inclusion (baseline) and after 1, 4, 7, 13, and 25 months. MRI of the dominant wrist and metacarpophalangeal (MCP) joints were assessed for synovitis, bone oedema, and erosions using the RA MRI Score (RAMRIS) and for tenosynovitis by an MRI tenosynovitis scoring method. Radiographs were assessed by the van der Heijde modified Sharp score (SHS). Clinical remission was defined by a DAS28 < 2.6. RESULTS: MRI at baseline detected inflammation in joints and tendons in all patients as well as erosions in 10 out of 13 patients. Over time, the erosion score increased while the synovitis and tenosynovitis scores remained almost unchanged. Bone oedema strongly correlated with synovitis. Synovitis and tenosynovitis correlated well with the erosion score at baseline but not thereafter. The MRI changes showed that joint damage started early and continued in the presence of persistent synovial and tenosynovial inflammation. CONCLUSIONS: The observations made in this small study suggest that the treatment goal of 'clinical remission' should be supplemented by a 'joint remission' goal. To this end, MRI is an appropriate tool. Further studies are needed to evaluate the optimal use of MRI in early RA.

Increasing synovitis and bone marrow lesions are associated with incident joint tenderness in hand osteoarthritis.

OBJECTIVES: To explore whether changes of MRI-defined synovitis and bone marrow lesions (BMLs) are related to changes in joint tenderness in a 5-year longitudinal study of the Oslo hand osteoarthritis (OA) cohort. METHODS: We included 70 patients (63 women, mean (SD) age 67.9 (5.5) years). BMLs and contrast-enhanced synovitis in the distal and proximal interphalangeal joints were evaluated on 0-3 scales in n=69 and n=48 patients, respectively. Among joints without tenderness at baseline, we explored whether increasing/incident synovitis and BMLs were associated with incident joint tenderness using generalised estimating equations. Among joints with tenderness at baseline, we explored whether decreasing or resolution of synovitis and BMLs were associated with loss of joint tenderness. We adjusted for age, sex, body mass index, follow-up time and changes in radiographic OA. RESULTS: Among joints without tenderness at baseline, increasing/incident synovitis and BMLs were seen in 45 of 220 (20.5%) and 47 of 312 (15.1%) joints, respectively. Statistically significant associations to incident joint tenderness were found for increasing/incident synovitis (OR=2.66, 95% CI 1.38 to 5.11) and BMLs (OR=2.85, 95% CI 1.23 to 6.58) independent of structural progression. We found a trend that resolution of synovitis (OR=1.72, 95% CI 0.80 to 3.68) and moderate/large decreases of BMLs (OR=1.90, 95% CI 0.57 to 6.33) were associated with loss of joint tenderness, but these associations were non-significant. CONCLUSIONS: The Oslo hand OA cohort is the first study with longitudinal hand MRIs. Increasing synovitis and BMLs were significantly associated with incident joint tenderness, whereas no significant associations were found for decreasing or loss of synovitis and BMLs.

Re-evaluation of bone pain in patients with type 1 Gaucher disease suggests that bone crises occur in small bones as well as long bones.

Bone crises in type 1 Gaucher disease are reported in long bones and occasionally in weight bearing bones and other bones, but rarely in small bones of the hands and feet. We retrospectively examined the incidence of bone pain in patients followed at the Rabin Medical Center, Israel, before and following the initiation of enzyme replacement therapy (ERT) and evaluated them for bone crises. Of 100 type I Gaucher disease patients, 30 (30%) experienced one or more bone crises. Small bone crises represented 31.5% of all bone crises and were always preceded by crises in other bones. While the incidence of long bone crises reduced after the initiation of ERT, small bone crises increased. Almost 60% of patients with bone crises were of the N370S/84GG genotype suggesting a greater susceptibility of N370S/84GG patients to severe bone complications. These patients also underwent the greatest number of splenectomies (70.6% of splenectomised patients). Splenectomised patients showed a trend towards increased long and small bone crises after surgery. Active investigation of acute pain in the hands and feet in patients in our cohort has revealed a high incidence of small bone crises. Physicians should consider imaging studies to investigate unexplained pain in these areas.