Use of the Extensor Carpi Ulnaris Half-Slip for Treating Chronic Neglected Volar Dislocation of the Distal Radioulnar Joint

Volar dislocation of the distal radioulnar joint (DRUJ) is a rare injury. Furthermore, few reports exist regarding DRUJ dislocation with simultaneous elbow dislocation. Elbow dislocation is easily diagnosed and reduced, whereas a DRUJ dislocation is easily missed because of an inaccurate or missed examination of the wrist, which results in a chronic condition. We experienced a case of simultaneous elbow and volar DRUJ dislocation; the latter was found 2 months postinjury. To treat chronic volar dislocation of the DRUJ, surgical methods should include reconstruction of the triangle fibrocartilage complex because of scar tissue and severe instability. In this paper, we describe triangle fibrocartilage complex reconstruction by using the extensor carpi ulnaris half-slip. It is the first report of applying this technique for chronic volar DRUJ dislocation. This technique has a role in creating strong stabilization of the DRUJ and can be an effective treatment option.

Is it really safe to evaluate symptomatic extensor carpi ulnaris tendon instability by magnetic resonance imaging (MRI)?

The extensor carpi ulnaris (ECU) tendon is in the sixth extensor compartment of the wrist and is isolated from other tendons by a different sheath. Extensor carpi ulnaris pathologies are characterized by pain locally localized to the wrist ulnar side. Outpatient records and wrist MRI (magnetic resonance imaging) tests were retrospectively scanned between January 2018 and July 2019. By examining the anamnesis and examination notes of the patients in the outpatient clinic records, patients with wrist ulnar side pain, pain or sensitivity on the ulnar styloid and provocation test (synergy) were assigned to the first study group (Group 1).The second study group was composed of patients who underwent wrist MR for the diagnosis or differential diagnosis of a synovial cyst around the wrist, without ulnar side pain (Group 2).While evaluating MR images in the axial plane, the depth and width of the ulnar groove, thickness of the ECU tendon were measured. The position of the ECU tendon relative to the ulnar groove and the forearm rotation during the shooting were recorded.105 cases evaluated, there were 41 cases in the symptomatic subgroup and 64 cases in the asymptomatic subgroup. Among all patients, the mean patient age was 38.05.In the evaluation according to whether cases were symptomatic or not, there was no significant relationship between being symptomatic and the degree of instability and MR withdrawal position. Our study suggests that ECU instability in MR is not a specific condition, and detection of MR in instability may not be associated with a patient’s symptoms.

OP0146 TENOSYNOVITIS, SYNOVIAL HYPERTROPHY AND FEET BURSITIS ARE USEFUL ULTRASOUND BIOMARKERS FOR PREDICTING ARTHRITIS DEVELOPMENT IN A POPULATION AT-RISK FOR RHEUMATOID ARTHRITIS

Background:Musculoskeletal ultrasound (MSUS) evaluation of individuals at risk for developing rheumatoid arthritis (RA) having Anti-Citrullinated Protein Antibody (ACPA) positivity and musculoskeletal complaints, may play an important role in the very early detection of RA.Objectives:We aimed to identify which ultrasound markers could predict arthritis development.Methods:Individuals with musculoskeletal complaints with a positive anti-CCP2 test were referred to the rheumatology department for a detailed clinical (68 joint count) and MSUS examination of the hands, feet and any symptomatic joints. Only those without clinical and/or MSUS detected arthritis were included in the RISK RA prospective cohort and followed-up over 3 years/ or until arthritis onset. Using EULAR-OMERACT guidelines1, MSUS markers for synovial hypertrophy (SH) and hyperemia (Doppler activity) were documented for each visit. Finger and wrist tendons were screened for any signs of tenosynovitis (TS), and between metatarsal joints for bursitis. Association of MSUS biomarkers with arthritis development was tested (comparing proportions) using Chi-Squared or Fisher’s exact tests.Results:288 individuals were included from January 2014 to October 2019 (79% female, 35% RF positive, median age 48 years: IQR: 36-58). Within a median of 38 months (IQR: 1-72) since recruitment, 84 individuals (28%) developed an arthritis diagnosis.Prior to obtaining any diagnosis (at inclusion and/or follow-up visit), 95 of the 288 individuals (33%) had at least one type of MSUS anatomical modification present (around the tendons, joint synovium and/or within bursal cavities), and 56% (53/95) of these individuals eventually developed arthritis. Of the remaining 193 that did not present with any obvious MSUS changes, 16% progressed towards arthritis development.The presence of tenosynovitis was detected in 64 of 288 individuals scanned prior to diagnosis and were more frequent in those developing arthritis (44%, 37/84) as compared to those with TS not developing arthritis (13%, 27/204), p<0.0001. The extensor carpi ulnaris wrist tendons were mostly involved. Sonographic changes within the synovium were noted in 11% (32/288) of all individuals, mostly affecting the metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints. There was a higher incidence of synovial hypertrophy detected in those developing arthritis (22%, 18/24), as compared to those that remained arthritis free (7%, 14/204), p<0.0001. The MCP joints with synovial hypertrophy were more prone to arthritis development as compared to the MTP’s. Furthermore, we observed a higher frequency of bursitis between the MTP joints in individuals developing arthritis, as compared to individuals having a bursitis who did not develop arthritis (13%, 11/84 versus 7%, 14/204, p=0.009).Conclusion:Ultrasound biomarkers such as tenosynovitis of the extensor carpi ulnaris, synovial hypertrophy of the MCP joints and feet bursitis have good potential to predict arthritis development in a population at-risk for rheumatoid arthritis.References:[1]Maria-Antonietta D’Agostino et al. RMD Open 2017;3:e 000428Acknowledgements:All study participants and patients, including researchers that are part of the multidisciplinary laboratory, clinical and academic teams of the RISK RA study group, as well as all assisting this research in one form or the other are greatly acknowledged.Disclosure of Interests:None declared

POS0572 THE ASSOCIATED FACTORS OF ULTRASONOGRAPHIC TENOSYNOVITIS IN PATIENTS WITH RHEUMATOID ARTHRITIS IN REMISSION

Background:Tenosynovitis is a common manifestation of rheumatoid arthritis (RA), but, is difficult to assess appropriately by clinical examination. In clinical remission, musculoskeletal ultrasound (MSUS) showed a predictive value of tenosynovitis for flares and joint destruction in RA (1).Objectives:To assess the prevalence, the characteristics, and the factors associated with tenosynovitis in ultrasound examination of patients with RA in clinical remission.Methods:A Cross-sectional study including patients with RA in clinical remission (DAS28 ESR ≤ 2.6) for at least 6 months. MSUS of 20 tendons (in wrists, hands and ankles) was performed in mode B and power Doppler (PD). Tenosynovitis was defined and scored according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT). A total score for the tenosynovitis in B-mode (TBI) and PD (TDI) was calculated by summing the grades for each patient. SDAI and CDAI were calculated. Functional disability was assessed by the Health Assessment Questionnaire (HAQ). For the radiographic evaluations, we used the Van der Heijde score.Results:Thirty-seven patients were enrolled, the mean age was 54.2 years±12.7 years and the sex ratio was 0.37. The mean disease duration was 8.1 years±5.1. The mean remission duration was 36.5 months ± 32.7. The prevalence of tenosynovitis was 40.5% in B-mode and 13.5% for PD. The most affected tendons were: extensor carpi ulnaris (B-mode: 21.6%, PD: 8.1%), tibialis posterior (B-mode: 10%, PD: 2.7%), peroneal (B-mode: 8.1%, PD: 2.7%), flexor digitorum superficialis and profundus (B-mode: 5.4%, PD: 0%) and extensor digitorum (B-mode: 2.7%, PD: 2.7%). Tenosynovitis was most frequently grade1 in B-mode (32.4%) and grade 2 in PD (10.8%). Grade 3 was identified only in B-mode in the peroneal tendons. The mean of TBI was 7.1±5.3 and the mean of TDI was 2.2.±3.1. We found a significant association between remission duration and PD tenosynovitis (mean: 16.2 vs 39.7 months, p = 0.05). Tenosynovitis, in B-mode and PD, weren’t associated with the swollen joints, the tender joints, the patient global health assessment, the HAQ, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-cyclic citrullinated peptide, DAS28, CDAI, SDAI, biologic treatment and radiographic structural damage. Multivariate logistic regression analysis didn’t show any association.Conclusion:Ultrasound tenosynovitis was commonly found in RA in remission and the extensor carpi ulnaris tendon was most involved. A shorter duration of remission was associated with PD tenosynovitis in univariate analysis. The MSUS assessment of tendons can be an additional feasible method to assess clinical remission.References:[1]Janta I, Stanciu D, Hinojosa M, Nieto-González JC, Valor L, Bello N, et al. Structural damage in rheumatoid arthritis: comparison between tendon damage evaluated by ultrasound and radiographic damage. Rheumatology (Oxford). 2016;55(6):1042-6.Disclosure of Interests:None declared

Use of Tendon Allograft for Recurrent Extensor Carpi Ulnaris Instability in Ehlers–Danlos Syndrome: A Case Report

Background Subluxation of the extensor carpi ulnaris (ECU) tendon can be a challenging problem to the surgeon, with no options described for failure following autologous reconstruction. It is our intention to provide guidance on technique by describing our experience in a 20-year-old male with Ehlers–Danlos syndrome. Case Description The patient presented with pain and snapping of the ECU tendon, and failed both immobilization and ECU reconstruction with autologous extensor retinaculum. A gracilis tendon allograft was used to reconstruct the ECU sheath, in addition to ulnar groove deepening. At 1-year follow-up, the patient had no pain and the ECU was stable without recurrent subluxation. Literature Review To the authors' knowledge, the use of tendon allograft for stabilization of recurrent ECU subluxation following surgical repair or reconstruction has not been previously described in the medical literature. Clinical Relevance Utilization of tendon allograft is a viable technique to stabilize the ECU tendon while minimizing the risk in relying on compromised autologous tissue. This report represents the first account of successful reconstruction following failed autologous reconstruction.