Luc De Smet

Prospective Study to Assess Short-Term Intra-Articular and Tenosynovial Changes in the Aromatase Inhibitor–Associated Arthralgia Syndrome

PURPOSE Arthralgia is an adverse class effect of aromatase inhibitors (AIs). To date, its exact mechanism remains unclear. The purpose of this study was to investigate the changes in clinical rheumatologic features and magnetic resonance imaging (MRI) of hands and wrists in AI and tamoxifen users. PATIENTS AND METHODS This is a prospective single-center study including 17 consecutive postmenopausal patients with early breast cancer receiving either tamoxifen (n = 5) or an AI (n = 12). At baseline and after 6 months, patients filled in a rheumatologic history questionnaire and a rheumatologic examination including a grip strength test was done. At the same time points, MRI of both hands and wrists was performed. The primary end point was tenosynovial changes from baseline on MRI. Secondary end points were changes from baseline for morning stiffness, grip strength, and intra-articular fluid on MRI. Wilcoxon signed ranks was used to test changes from baseline and the Spearman correlation coefficient to assess the association between rheumatologic and MRI changes from baseline. RESULTS At 6 months, patients on AI had a decrease in grip strength (P = .0049) and an increase in tenosynovial changes (P = .0010). The decrease in grip strength correlated well with the tenosynovial changes on MRI (P = .0074). Only minor changes were seen in patients on tamoxifen. AI users reported worsening of morning stiffness and showed an increase in intra-articular fluid on MRI. CONCLUSION The functional impairment of hands in the AI-associated arthralgia syndrome is characterized by tenosynovial changes on MRI correlating with a significant decrease in hand grip strength.

Debilitating musculoskeletal pain and stiffness with letrozole and exemestane: associated tenosynovial changes on magnetic resonance imaging

ObjectiveArthralgia, skeletal and muscle pain have been reported in postmenopausal women under treatment with third generation aromatase inhibitors (AIs). However, the pathogenesis and anatomic correlate of musculoskeletal pains have not been thoroughly evaluated. Moreover, the impact of AI-induced musculoskeletal symptoms on normal daily functioning needs to be further explored.Patients and methodsWe examined 12 consecutive non-metastatic breast cancer patients who reported severe musculoskeletal pain under a third generation AI; 11 were on letrozole and 1 on exemestane. Clinical rheumatological examination and serum biochemistry were performed. Radiological evaluation of the hand/wrist joints were performed using ultrasound (US) and/or magnetic resonance imaging (MRI).ResultsThe most common reported symptom was severe early morning stiffness and hand/wrist pain causing impaired ability to completely close/stretch the hand/fingers and to perform daily activities and work-related skills. Six patients had to discontinue treatment due to severe symptoms. Trigger finger and carpal tunnel syndrome were the most frequently reported clinical signs. US showed fluid in the tendon sheath surrounding the digital flexor tendons. On MRI, an enhancement and thickening of the tendon sheath was a constant finding in all 12 patients.ConclusionsMusculoskeletal pains in breast cancer patients under third generation AIs can be severe, debilitating, and can limit compliance. Characteristic tenosynovial, and in some patients joint changes on US and MRI were observed in this series and have not been reported before.

Grip strength in children.

The grip strength in a group of 487 healthy children aged between 5 years and 15 years was measured. There was a clear correlation between age and grip strength. Up to the age of 12 years, there was a striking parallellism between boys and girls. From the age of 13 years, boys developed a 25% stronger grip force than girls. The difference between the dominant and nondominant hand grip was not significant, but was constantly stronger in the right hand for right-hand dominant children. There was a high variation in grip forces (from 6.9 kg to 38.4 kg).

Effect of severity of Dupuytren contracture on disability.

The aim of this study was to investigate the correlation between the severity of Dupuytren contracture and disability. The American Medical Association (AMA) guidelines were used to assess the impairment for each involved hand. The disability of the arm, shoulder and hand (DASH) questionnaire was used for evaluating the disability. Eighty patients with 102 involved hands were enrolled. The mean total flexion contracture was 119°/hand or 65°/ray. The mean DASH score was 15 (range 0–69). There was no significant correlation between the DASH score on one hand and the total flexion contracture, the mean flexion contraction/finger, the mean flexion contracture of the proximal interphalangeal (PIP), the mean flexion contracture of the metacarpophalangeal (MCP), the number of involved hands, fingers or joints, and the AMA impairment rating on the other hand.

Diagnosis, management, and complications of glomus tumours of the digits in neurofibromatosis type 1

Background Glomus tumours are benign painful tumours of the glomus body, a thermoregulatory shunt in the digits. Glomus tumours of the fingers and toes are associated with the monogenic disorder neurofibromatosis type 1 (NF1) and are recently recognised as part of the NF1 phenotype. Methods and Results A multi-institutional experience with 15 individuals with NF1 and glomus tumours of the fingers or toes is reported. The majority of individuals presented with at least two of the symptoms in the classic triad of localised tenderness, severe paroxysmal pain, and sensitivity to cold. Appearance of the nail and finger or toe is often normal. Women are affected more often than men. Multifocal tumours are common. There is often a delay in diagnosis of many years and clinical suspicion is key to diagnosis, although magnetic resonance imaging may be useful in some scenarios. Surgical extirpation can be curative; however, local tumour recurrence and metachronous tumours are common. Three of our patients developed signs and symptoms of the complex regional pain syndrome. Conclusions Glomus tumours in NF1 are more common than previously recognised and NF1 patients should be specifically queried about fingertip or toe pain.

Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome

Twenty-eight patients were treated by ulnar shortening osteotomy for static or dynamic ulnar impaction syndrome. Ulnar variance was measured on a true anteroposterior radiograph. There were 25 wrists that were too long, two neutral, and one that was short. Bones were shortened by a mean of 3.5 mm. Mean follow-up time was 29 months (range 7–60), all with confirmed consolidation. At final follow-up mean grip strength had improved from 67% to 75%, mean Disabilities of the Arm, Shoulder, and Hand (DASH) score from 40 (range 12–83) to 26 (range 0–61) and mean range of movement from 80% (range 40%–100%) to 88% (range 50%–100%). Smoking, age at operation, type of osteotomy (transverse or oblique), dominance of hand, and sex did not influence consolidation or functionality. Special attention was paid to the anatomy of the distal radioulnar joint and the inclination of the sigmoid notch of the radius. There was no correlation between the anatomy and the functional outcome scores. Mean consolidation time (10 months) (range 2–32) and return to work were longer than in similar studies. Our findings confirm the usefulness of ulnar shortening osteotomy in the relief of ulnocarpal impingement symptoms.

Responsiveness of the DASH score in surgically treated basal joint arthritis of the thumb: preliminary results

The responsiveness of the DASH score in a consecutive cohort of surgically treated basal joint osteoarthritis of the thumb was studied in 15 patients. The effect size (=1.27) and standardized response (0.84) means that, as well as the high correlation with patient satisfaction, the DASH score is a useful tool to evaluate the outcome of surgical treatment for basal joint osteoarthritis.

Outcome of proximal row carpectomy

Fifty-one patients who had had proximal row carpectomy between 1992 and 2002 with a minimum follow-up of one year were followed up clinically and radiologically retrospectively. Their diagnoses included Kienböck disease (n=21), avascular necrosis of the scaphoid (n=4), nonunion of the scaphoid with osteoarthritis (n=9), and scapholunate advanced collapse (n=17). The mean follow-up was 5 years, 8 months. The mean “disabilities of the arm, shoulder and hand” (DASH) score was 18. The mean patient-rated wrist evaluation (PRWE) score list was 25% of maximum disability for the function and pain score. Thirty-four patients (87%) were able to return to work a mean of six months after operation (range 3 weeks – 35 months). Nine patients (11%) required arthrodesis of the wrist and are considered as failures. Mean flexion of the wrist was 66%, extension 73%, radial deviation 74%, ulnar deviation 76%, and grip force 70% of the opposite side. Excision of the proximal row provided predictable and durable pain relief, restored functional movement and grip strength, and allowed returned to gainful employment in most of the patients.

Grip force reduction in patients with tennis elbow: Influence of elbow position

Grip force was measured in 55 consecutive patients with chronic tennis elbow. Grip force was markedly reduced at the pathological side, but there was also a striking reduction of the grip force at the pathological side when the grip force was measured with a straight elbow, compared with the standard position of 90 degrees flexion. This reduction was highly significant at the pathological side but not at the normal control side.

Acute carpal tunnel syndrome caused by hydroxyapatite crystals: A case report

Acute carpal tunnel syndrome is an uncommon condition. The literature consists almost entirely of case reports: The most common causes are local trauma, pregnancy, acute rheumatoid arthritis, burns, spontaneous hemorrhage, acute pyogenic infection, gout, tumoral calcinosis, and pseudogout. 1-3 We report a case in which a mass of hydroxyapatite crystals on the palmar aspect of the wrist caused acute carpal tunnel syndrome. The differential diagnoses--gout and septic arthrit i s a r e difficult to distinguish from acute carpal tunnel syndrome.