Current Rheumatology Reviews - Volume 16, Issue 3, 2020

Wrist pain is a common patient complaint with a myriad of clinical conditions that can explain the underlying cause. Short of wrist arthroscopy, no technique other than formal wrist arthrotomy exists for direct examination of the hyaline cartilage coating the articular surfaces of the carpal bones. Magnetic resonance imaging (MRI) has been proven accurate in evaluating joint surfaces of large joints such as the shoulder, hip, and knee with articular cartilage surface thickness is in excess of 1 mm. However, in the carpus the thickness of the cartilage and the contours present have precluded accurate imaging. Advances in MRI technology over the last several decades are now making imaging of small joint surfaces, such as the carpus, an area worth revisiting. Herein we provide a review of these efforts with a specific focus on the evaluation of the wrist.

Background: The carpus is a complicated and functionally challenged mechanical system, advancements in the understanding of which have been compromised by the recognition that there is no standard carpal mechanical system and no typical wrist. This paper covers components of a larger project that seeks to develop a kinetic model of wrist mechanics to allow reverse analysis of the specific biomechanical controls or rules of a specific patient’s carpus. Those rules, unique to each patient, could be used to create a forward synthesis mathematical model to reproduce the individual’s anatomical motion in a virtual environment. Objective and Methods: Based on the previous observations, the carpus essentially moves with only two degrees of freedom-pitch (flexion/extension) and yaw (radial deviation/ulnar deviation)-while largely preventing roll (pronation/supination). The objective of this paper is, therefore, to present the background and justification to support the rules-based motion (RBM) concept, which states that the motion of a mechanical system, such as the wrist, is the net interplay of four rules: morphology, constraint, interaction, and load. The stable central column theory (SCCT) of wrist mechanics applies the concept of RBM to the carpus, and by using a reverse engineering computational analysis model, a consistent pattern of isometric constraints was identified, creating a “two-gear four-bar” linkage. This study assessed the motion of the carpus using a 3D (three-dimensional) dynamic visualization model. The hypothesis was that the pattern and direction of motion of the proximal row and the distal row with respect to the immediately cephalad carpal bones or radius would be similar in all directions of wrist motion. To identify the unique motion segments, 3D models were created from five normal wrists that underwent CT scanning in multiple positions of radial and ulnar deviation as well as flexion and extension. Each carpal row (proximal and distal) was animated in a virtual environment with the cephalad carpal bones or radius held immobile. The rotational axis and position of each bone and each row were then compared in sagittal (flexion-extension) and coronal (radial and ulnar deviation) motion. Results: The carpus appeared to have only two degrees of freedom, and yet was stable in those arcs with the loads applied proximally in the forearm. The proximal row moved in a singular arc, but with a varying extent during sagittal and coronal motion. The isometric constraints were consistent in both directions. The distal row moved on an axis formed by a pivot joint laterally (between the trapezium and scaphoid) and a saddle joint medially (between hamate and triquetrum). The sagittal and coronal alignment of this axis changed as the proximal row moved. This created a distinct pattern of row motion to achieve the various required positions of wrist function. On wrist radial deviation, the scaphoid (with the proximal row) was flexed and the distal row was extended, whereas, in wrist flexion, the scaphoid flexed (with the proximal row) and so did the distal row. The pattern was reversed in the opposite wrist movements. While the general direction of motion of each row was consistent, the extent was quite variable. Conclusion: This review supports the SCCT of carpal mechanics and the carpus acting as a twogear four-bar linkage, as well as the concept of RBM as a means to understand the biomechanics of the wrist, and how this is translated into specific functional tasks. More sophisticated 3D modelling will be required to further understand the specifics of carpal motion; however, reverse engineering of the specific rules that define each individual wrist can also be applied to a mathematical model to provide a “what if” test of particular surgical interventions for a variety of wrist injuries. The use of quantitative 3D Computed Tomography Scan (CT) analysis, surgical planning and virtual surgical intervention allows potential surgical solutions to be applied to a computer model of an injured wrist to test the possible outcomes and prognosis of a proposed treatment.

Variation in lunate morphology can exist based on the absence (Type I) or presence (Type II) of medial facet on the distal articular surface of the lunate that contacts the proximal pole of the hamate. This additional lunatohamate articulation can affect load transmission across the radiocarpal joint and exert an influence on carpal kinematics. A Type II lunate is protective against carpal instability patterns associated with scaphoid nonunions and scapholunate dissociations. It may also play a role in the progression of carpal collapse that occurs in Kienböck disease. This review summarizes the effect of lunate morphology in the outcomes of non-operative and operative treatment of carpal disorders.

The study of contact biomechanics of the wrist is a challenge. This is partly due to the relatively small size of the joint as well as the lack of space in the radiocarpal joint which makes the delivery of investigative materials such as pressure sensitive film without causing artifact, difficult. Fortunately, a number of authors have studied the intact wrist, the scapholunate ligament injured wrist, the proximal row carpectomy and the scaphoid excision, four bone fusion. Despite some contrasting findings, there are some general concepts that we understand about wrist mechanics.

Computer modeling of the wrist has followed other fields in the search for descriptive methods to understand the biomechanics of injury. Using patient-specific 3D computer models, we may better understand the biomechanics of wrist fractures in order to plan better care. We may better estimate fracture morphology and stability and evaluate surgical indications, design more adequate or effective surgical approaches and develop novel methods of therapy. The purpose of this review is to question the actual advances made in the understanding of wrist fractures using computer models.

Background: Scapholunate interosseous ligament (SLIL) injury following a fall on an outstretched hand may lead to carpal instability and in some cases require long-term rehabilitation following repair. Rehabilitation, especially in athletes, may include pushups, but little is known as to what type of pushup may be safer. Objective: To determine biomechanical differences between two pushup positions (neutral or extended). Methods: Six fresh cadaver wrists with pre-existing SLIL damage were uni-axially loaded in neutral and extension in order to simulate two different pushup styles. The motions of the scaphoid and lunate in relation to the radius were measured. The dorsal, proximal, and volar insertion sites of the SLIL were identified and, using the collected kinematic data, gap distances were calculated for each site. Results: Gap distance between the proximal SLIL insertion points was significantly greater in neutral than in extension. There was a trend that the dorsal and volar SLIL insertion points were also greater in neutral than in extension. After the wrist was extended 90o, the scaphoid extended 70.1o and the lunate extended 28.6o compared to their positions with the wrist in neutral. Conclusion: The larger gap distances between the scaphoid and lunate in neutral suggest that a neutral style pushup could put higher forces on a wrist with pre-existing SLIL damage and may thus hinder recovery for a person with a repaired SLIL. A pushup in extension, in these injured wrists, may be less detrimental.

Background: The purpose of this study was to investigate scaphoid motion within the scapho-trapezio-trapezoidal (STT) joint during wrist motion in the presence of STT joint osteoarthritis (OA). Methods: We studied 11 wrists with STT OA and 5 normal wrists. Computed tomography (CT) images were acquired in five wrist positions (maximum active flexion, extension, radial deviation, ulnar deviation, and neutral position). The 3-dimensional surface models of the radius and scaphoid were constructed and the motion of scaphoid relative to the radius was calculated. Results and Conclusions: During wrist flexion/extension motion, the scaphoid rotated mostly in the flexion/extension plane. The angle tended to be smaller in STT OA than in normal. During wrist radioulnar deviation, the scaphoid was in an extended position in neutral wrist in STT OA. The motion of scaphoid in STT OA was divided into two types: a rigid type and mobile type. The mobile type rotated closer to the flexion/extension plane than the rigid type. Taking into account scaphoid motion during wrist movement before surgery may provide better results in the treatment of STT OA.

Background: Morphology may provide the basis for the understanding of wrist mechanics. Methods: We used classification systems based on cadaver dissection of lunate and capitate types to evaluate a normal database of 70 wrist radiographs in 35 subjects looking for associations between bone shapes. Kappa statistics and a log-linear mixed -effects model with a random intercept were used. Results: There were 39 type-1, 31 type- 2 lunates, 50 spherical, 10 flat and 10 V-shaped capitates. There was a significant difference in lunate and capitate shape between the hands of the same individual p <0.001. This may be due to different loads on the dominant vs. nondominant hands in the same individual. Conclusion: Further study to better understand the development of radiographic parameters of the midcarpal joint may aid in our understanding of the morphology and mechanics of the wrist.

This review highlights the issue of psychosomatic conditions in rheumatoid arthritis, paying special attention to new researches and trends in this field. Emerging concepts in all the major parts of the problem are covered consecutively, from the impact of chronic musculoskeletal pain on the emotional state to disease influence over quality of life, socio-psychological, and interpersonal relationships. Chronic pain is closely related to emotional responses and coping ability, with a pronounced positive effect of psychotherapeutic interventions, family and social support on it. Psychosexual disorders, anxiety, depression also commonly coexist with rheumatoid arthritis, leading to further decrease in quality of life, low compliance, and high suicide risk. Influence of psychosomatic conditions on the overall treatment effect is usually underestimated by rheumatologists and general practitioners. Psychosomatic considerations are of great importance for up-to-date management of rheumatoid arthritis, as they strongly influence the quality of life, compliance, and thereby disease outcomes. Two major approaches of psychological rehabilitation exist, both coping with pain through the regulation of emotion and psychotherapeutic intervention, which not only helps patients in coping with the disease, but also aimed at improving the overall adaptation of the patient. It includes techniques of relaxation, cognitive-behavioral therapy, and biofeedback therapy. Current data about the efficacy of the additional correcting therapies for patients with rheumatoid arthritis, both emerging and common ones, are discussed in the review.

Objective: Analysis and generalization of data related to visfatin involvement in the pathogenesis of inflammation at various stages of rheumatoid arthritis. Data Synthesis: Visfatin is an adipocytokine which has also been identified in non-adipose tissues. It influences directly on the maturation of B cells, which are involved in autoantibody production and T cell activation. Visfatin can promote inflammation via regulation of pro-inflammatory cytokines including TNF, IL-1β and IL-6. The concentration of circulating visfatin in rheumatoid arthritis patients is higher compared to healthy individuals. Several studies suggest that visfatin level is associated with rheumatoid arthritis activity, and its elevation may precede clinical signs of the relapse. In murine collagen-induced arthritis, visfatin levels were also found to be elevated both in inflamed synovial cells and in joint vasculature. Visfatin blockers have been shown to confer fast and long-term attenuation of pathological processes; however, most of their effects are transient. Other factors responsible for hyperactivation of the immune system can participate in this process at a later stage. Treatment of rheumatoid arthritis with a combination of these blockers and inhibitors of other mediators of inflammation can potentially improve treatment outcomes compared to current therapeutic strategies. Recent advances in the treatment of experimental arthritis in mice as well as the application of emerging treatment strategies obtained from oncology for rheumatoid arthritis management could be a source of novel adipokine-mediated anti-rheumatic drugs. Conclusion: The ongoing surge of interest in anticytokine therapy makes further study of visfatin highly relevant as it may serve as a base for innovational RA treatment.

Background: According to the new classification criteria developed by The Assessment of SpondyloArthritis International Society, patients with axial spondyloarthritis (axSpA) can be classified in 2 subgroups: Patients with radiographic axial spondyloarthritis: ankylosing spondylitis patients (AS) and those with non-radiographic axial spondyloarthritis (nr-axSpA). Objective: The aim of the present study is to describe and discuss the differences and similarities between the two subgroups. Patients and Methods: A cross-sectional study was conducted in a single rheumatology hospital in Morocco. These included patients diagnosed as having axial spondyloarthritis according to ASAS criteria 2010, during a period of 6 years. The AS and the nr-axSpA subgroups were compared for the various axSpA-related variables. Results: Of the 277 patients with a diagnosis of axial SpA who were included in this study, 160 had AS and 117 had nr-axSpA. AS and nr-ax-SpA shared a similar age at diagnosis, similar prevalence of low back pain, lumbar stiffness, extra-articular manifestations, BASDAI and BASFI. In the multivariate analysis, AS patients were mainly male with cervical stiffness, enthesitis, coxitis and high level of ESR (erythrocyte sedimentation rate). The females generally had a family history of SpA and arthritis and were associated to the nr-axSpA form in the univariate analysis. Conclusion: This was the first study to characterise patients with AS and nr-axSpA in Morocco. Consistent with other studies published, this study showed that patients with nr-axSpA and patients with AS shared a comparable degree of disease burden.

Background: Lupus nephritis is one of the major manifestations of SLE. Poor adherence to medications is an important cause of not achieving treatment targets. Methods: We assessed patients’ adherence to immune-suppressive medications in patients with Lupus nephritis using the Morisky, Green, and Levine (MGL) Adherence Scale. The aim was to study the effect of non-adherence on the occurrence of renal flares. Results: We recruited 104 patients with lupus nephritis. Sixty-six patients had flares of LN. There was a high prevalence of non-adherence to medications (n=68). Patients who were non-adherent to treatment had more renal flares (p= 0.02). Duration of lupus since diagnosis was significantly higher in patients who had renal flares. Using regression analysis, non-adherence to medications was associated with 3.7 higher risk of developing a single renal flare and 4.9 higher risk of developing more than one renal flare. Causes of non-adherence were medications side effects in 43% of patients, financial issues in 31% or forgetfulness in 26%. Conclusion: Non-adherence to immunosuppressive medications has a high prevalence in patients with lupus nephritis and is correlated with the number of renal flares.

Aim: The aim of this study was to evaluate the relationship between Interleukin-6 (IL-6) serum level and the severity and activity of Rheumatoid Arthritis (RA). Methods: In this cross-sectional study, 120 RA patients referred to the rheumatology clinic, the patients were diagnosed by rheumatologists according to ACR / EULAR 2010 criteria. Based on DAS28 score the patients were divided into 4 groups: Remission, Mild, Moderate and Severe. Each group contained 30 patients. Serum levels of Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), anti-Cyclic Citrullinated Peptide (anti-CCP) and Rheumatoid Factor (RF) and serum levels of IL-6, were measured. The relationship between these factors was measured and compared to the relationship between IL-6 and these factors, and the activity of the disease was evaluated based on DAS-28. Results: This study showed that the serum level of IL-6 has a significant relationship with RA activity according to DAS-28 (P value <0.001). There is also a significant relationship between the ESR level, the number of painful joints, and the number of swollen joints, and the severity of the disease based on VAS. Conclusion: Generally the findings of this study indicate that serum level of IL-6 plays an important role in the severity and activity of RA disease and can be considered as a determining factor in evaluating the severity of RA in RA patients and it is a good guide for a step up or down of treatment.