Letter to the Editor
Osteonecrosis of the Lunate Associated With Systemic Sclerosis: Report of 4 Cases
Osteonecrosis del semilunar asociada con esclerosis sistémica. Presentación de 4 casos
Sixto Zegarra-Mondragón
, María Llop-Vilaltella, Walter Alberto Sifuentes-Giraldo, Carlos de la Puente Bujidos
Corresponding author
Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Presentación de 4 casos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e70" "paginaFinal" => "e71" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Osteonecrosis of the Lunate Associated With Systemic Sclerosis: Report of 4 Cases" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 624 "Ancho" => 1250 "Tamanyo" => 90365 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiografía simple del carpo izquierdo correspondiente al caso 3 que muestra marcada esclerosis del hueso semilunar (A, flecha). RM del carpo derecho (secuencia T1) correspondiente al caso 2, en la que se evidencia señal hipointensa en el hueso semilunar (B, flecha).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sixto Zegarra-Mondragón, María Llop-Vilaltella, Walter Alberto Sifuentes-Giraldo, Carlos de la Puente Bujidos" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sixto" "apellidos" => "Zegarra-Mondragón" ] 1 => array:2 [ "nombre" => "María" "apellidos" => "Llop-Vilaltella" ] 2 => array:2 [ "nombre" => "Walter Alberto" "apellidos" => "Sifuentes-Giraldo" ] 3 => array:2 [ "nombre" => "Carlos" "apellidos" => "de la Puente Bujidos" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574318301746" "doi" => "10.1016/j.reumae.2018.12.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574318301746?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X17302693?idApp=UINPBA00004M" "url" => "/1699258X/0000001500000005/v1_201910230648/S1699258X17302693/v1_201910230648/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173574319301054" "issn" => "21735743" "doi" => "10.1016/j.reumae.2017.10.005" "estado" => "S300" "fechaPublicacion" => "2019-09-01" "aid" => "1144" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Reumatol Clin. 2019;15:e72-e73" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Linear atrophy and hypopigmentation after intralesional corticosteroid injection" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e72" "paginaFinal" => "e73" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Atrofia e hipopigmentación lineal cutánea por inyección intraarticular de corticosteroide" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1180 "Ancho" => 1400 "Tamanyo" => 214991 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Hypopigmented atrophic patch on the elbow, with linear extension along the upper arm.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ignacio Hernández Aragüés, C. 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Presentación de 4 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 624 "Ancho" => 1250 "Tamanyo" => 90365 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plain X-ray of the left carpus corresponding to case 3 which shows marked sclerosis of the lunate bone (A, arrow). MR of the right carpus (T1 sequence) corresponding to case 2, which shows hypointensity signals in the lunate bone (B, arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Osteonecrosis (ON) is a relatively common complication in systemic autoimmune diseases, including that of systemic sclerosis (SS),<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> where multiple factors are involved, including hypergoagulability stages (which include antiphospholipid syndrome) and prior therapy with glucocorticoids.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Cases and short series of ON with the lunate, also called Kienböck's disease, have been reported, in patients with SS, which would appear to suggest that this location of ON is frequent in this disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present our department's experience relating to ON of the lunate associated with systemic sclerosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We carried out a retrospective review of 115 cases of monographic consultation of SS in our centre and identified 4 patients who had developed ON of the lunate (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Mean patient age was 59.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.6 years, and all patients were females. Two of the cases corresponded to limited cutaneous SS and 2 to diffuse cutaneous SS. None of the cases presented with antiphospholipid antibodies nor had any previous thrombotic events. The mean course of the disease was 13.5 years (range: 7–17 years). One patient was an ex-smoker and none of the patients had alcohol habits. It is of note that all of the patients had serious vascular compromise (Raynaud phenomenon [RP] with digital ulcers, treated with endothelin antagonists and intravenous infusion of prostaglandins, and one case presented with critical digital ischaemia); all of the patients had calcinosis in their upper extremities, in addition to joint (2), lung (2) and gut (4) involvement. They had all received prolonged treatment with glucocorticoids at low doses (5–10<span class="elsevierStyleHsp" style=""></span>mg/day prednisone) prior to the diagnosis of ON. Presentation of ON of the lunate was unilateral in 3 cases and bilateral in 1, which in one case required surgery (proximal carpectomy). The patients stated they mainly suffered from mechanical pain, of insidious onset and progressive in nature, of several months duration in the affected joint. Diagnosis was confirmed by plain X-ray, bone scan and/or magnetic resonance (MR) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In one case MR showed extensive synovitis in the carpus and in another the collapse of the lunate with displaced fragment and major bone oedema.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In our review of the medical literature (Pubmed) we found 15 published cases of ON of the lunate in patients with SS.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3–7</span></a> The majority were women (73%), all with a history of RP, 10 of them had digital ulcers and in 3 there was Doppler ultrasound (DUS) detection of occlusion of the ulnar artery. The location of the ON of the lunate was unilateral in 60% of cases. In under 50% there had been a background of therapy with glucocorticoids. Surgery had been performed in 20% of cases.</p><p id="par0025" class="elsevierStylePara elsevierViewall">An important factor which may impact the development of ON of the lunate in SS is the severity of the arterial vasculopathy. Vascularisation of the lunate bone is inconstant and depends on the branches of the ulnar artery, the anterior interosseous artery and the radial artery.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Occlusion of the ulnar artery is a relatively common finding in patients with SS, and is detected in up to 21.5% of cases by DUS. It is bilateral in the majority of cases and is correlated to the appearance of digital ulcers.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> It has been suggested that RP could also affect the carpus and in particular the lunate bone, leading to bony ischaemia during episodes and increasing the risk of developing ON.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> This has been corroborated by the fact that, both in our series and in the literature, it is rare for these patients to have other standard risk factors for ON of the lunate, such as traumas and that, despite treatment received with glucocorticoids they do not develop ON in other more common locations such as the hip.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To conclude, ON of the lunate appears to be a relatively common complication of SS, the cause of which could be linked to underlying vasculopathy to this condition and to the anatomical peculiarities of lunate bone blood supply. As a result, this entity should be considered in patients with SS who have pain and/or limitation in the carpi which could be erroneously interpreted as arthritis since in some cases it may also present with associated inflammatory symptoms.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zegarra-Mondragón S, Llop-Vilaltella M, Sifuentes-Giraldo WA, de la Puente Bujidos C. Osteonecrosis del semilunar asociada con esclerosis sistémica. Presentación de 4 casos. Reumatol Clin. 2019;15:e70–e71.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 624 "Ancho" => 1250 "Tamanyo" => 90365 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plain X-ray of the left carpus corresponding to case 3 which shows marked sclerosis of the lunate bone (A, arrow). MR of the right carpus (T1 sequence) corresponding to case 2, which shows hypointensity signals in the lunate bone (B, arrow).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AAC: anticentromere antibodies; ANA: antinuclear antibodies; ATA-<span class="elsevierStyleSmallCaps">I</span>: anti topoisomerase I antibodies; SS: systemic sclerosis; GC: glucocorticoids; ON: osteonecrosis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case 2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case 3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case 4 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Autoantibodies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ANA (1/320)ATA-<span class="elsevierStyleSmallCaps">I</span>Anti-cardiolipin (−) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ANA (1/640)AACAnti-cardiolipin (−) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ANA (1/640)ATA-<span class="elsevierStyleSmallCaps">I</span>Anti-cardiolipin (−) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ANA (1/320)ATA-<span class="elsevierStyleSmallCaps">I</span>Anti-cardiolipin (−) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SS subtype \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limited cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diffuse cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diffuse cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limited cutaneous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Course disease duration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Raynaud phenomnon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digital ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Concomitant arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Visceral compromise \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive, lung \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive, lung \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does of GC/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prednisone 10<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prednisone 10–15<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prednisone 5<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prednisone 5<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Concomitant treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Azatioprin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rituximab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location of ON of the lunate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ON treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2151629.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Features of Osteonecrosis of the Lunate Cases in Patients With Systemic Sclerosis in Our Centre.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of systemic sclerosis: incidence, prevalence, survival, risk factors, malignancy, and environmental triggers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Barnes" 1 => "M.D. Mayes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BOR.0b013e32834ff2e8" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Rheumatol" "fecha" => "2012" "volumen" => "24" "paginaInicial" => "165" "paginaFinal" => "170" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22269658" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skeletal manifestations of systemic autoimmune diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.L. Kamen" 1 => "J.D. Alele" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MED.0b013e328340533d" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Endocrinol Diabetes Obes" "fecha" => "2010" "volumen" => "17" "paginaInicial" => "540" "paginaFinal" => "545" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20962632" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bilateral aseptic necrosis of the lunate in systemic sclerosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 2 | 9 |
| 2024 October | 77 | 19 | 96 |
| 2024 September | 81 | 23 | 104 |
| 2024 August | 123 | 44 | 167 |
| 2024 July | 84 | 32 | 116 |
| 2024 June | 102 | 42 | 144 |
| 2024 May | 90 | 34 | 124 |
| 2024 April | 85 | 36 | 121 |
| 2024 March | 87 | 29 | 116 |
| 2024 February | 63 | 21 | 84 |
| 2024 January | 75 | 19 | 94 |
| 2023 December | 49 | 23 | 72 |
| 2023 November | 78 | 29 | 107 |
| 2023 October | 65 | 25 | 90 |
| 2023 September | 113 | 36 | 149 |
| 2023 August | 71 | 24 | 95 |
| 2023 July | 68 | 21 | 89 |
| 2023 June | 62 | 21 | 83 |
| 2023 May | 72 | 18 | 90 |
| 2023 April | 66 | 7 | 73 |
| 2023 March | 83 | 22 | 105 |
| 2023 February | 65 | 18 | 83 |
| 2023 January | 53 | 11 | 64 |
| 2022 December | 92 | 24 | 116 |
| 2022 November | 75 | 30 | 105 |
| 2022 October | 89 | 31 | 120 |
| 2022 September | 68 | 29 | 97 |
| 2022 August | 74 | 54 | 128 |
| 2022 July | 67 | 40 | 107 |
| 2022 June | 65 | 29 | 94 |
| 2022 May | 60 | 38 | 98 |
| 2022 April | 60 | 35 | 95 |
| 2022 March | 84 | 44 | 128 |
| 2022 February | 96 | 27 | 123 |
| 2022 January | 78 | 28 | 106 |
| 2021 December | 54 | 44 | 98 |
| 2021 November | 61 | 40 | 101 |
| 2021 October | 89 | 51 | 140 |
| 2021 September | 52 | 45 | 97 |
| 2021 August | 43 | 40 | 83 |
| 2021 July | 63 | 34 | 97 |
| 2021 June | 59 | 23 | 82 |
| 2021 May | 44 | 51 | 95 |
| 2021 April | 109 | 143 | 252 |
| 2021 March | 68 | 25 | 93 |
| 2021 February | 51 | 25 | 76 |
| 2021 January | 54 | 26 | 80 |
| 2020 December | 36 | 18 | 54 |
| 2020 November | 31 | 11 | 42 |
| 2020 October | 33 | 18 | 51 |
| 2020 September | 38 | 25 | 63 |
| 2020 August | 29 | 24 | 53 |
| 2020 July | 35 | 22 | 57 |
| 2020 June | 23 | 8 | 31 |
| 2020 May | 22 | 15 | 37 |
| 2020 April | 18 | 16 | 34 |
| 2020 March | 3 | 0 | 3 |
| 2019 November | 2 | 0 | 2 |
| 2019 January | 5 | 2 | 7 |
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