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In recent years, advances in pharmacotherapy for rheumatoid arthritis (RA) have dramatically improved the control of disease activity. However, a significant number of patients still develop forefoot deformity. The purpose of this study was to investigate the results of more than 20 years' follow-up of metatarsal neck shortening oblique osteotomy (SOO) for forefoot deformity in patients with RA.The metatarsal neck SOO was performed on 163 feet in 108 patients between January 1985 and December 1996 in the authors' hospital. For the patients, who met the survey criteria, an observational study was performed clinically and radiologically at the baseline and at more than 20 years after surgery.A retrospective cohort study was conducted on 36 feet in 22 patients, all of whom were female, and the mean age at surgery was 45.6 (35.0-63.0) years old. The follow-up period was 25.1 (21.0-31.0) years. The presence of painful callosities in the surgically treated feet without revised surgeries decreased from 32 feet (100%) to 4 feet (12.5%) at the last follow-up with mild pain that did not cause any footwear problems. Re-osteotomy at the metatarsal of the lessor toe was performed on four feet in two patients. Radiologically, among 128 toes without revised surgeries, 85% were able to have the joint space preserved, and 89% maintained a pain-free condition without any recurrence of deformity. The mean total Japanese Society for Surgery for the Foot (JSSF) RA foot and ankle score was 64.0/100, and the visual analogue scale (VAS) of overall satisfaction was 62 (0: dissatisfied, 100: highly satisfied). The overall satisfaction had a positive correlation with calcaneal pitch and negative correlation with joint space narrowing at the talocrural joint.Metatarsal neck SOO appeared to be effective for patients with RA. The deformity was corrected and retained for a long time.

Objective Treatment of elderly patients with rheumatoid arthritis (RA) has been controversial because they often have serious comorbidities and cannot use methotrexate (MTX). In Japan, golimumab (GLM) 100 mg without MTX is approved. We investigated the effectiveness and safety of GLM in elderly patients with RA. Methods The GLM survival rate was evaluated using the Kaplan-Meier method. Disease activities, laboratory findings, and treatments were evaluated. Patients We enrolled 168 patients with RA in our hospital. Using age ≥75 years old to identify elderly patients, younger (n=111) and elderly (n=57) groups were established. Elderly patients were divided into 2 groups according to the MTX treatment status (with, n=27; without, n=25). Results The GLM survival rates were 80.8% and 82.3% in elderly and younger patients, respectively (p=0.762). At 52 weeks, the Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) was improved in elderly patients (4.26 vs. 3.31, p0.001); the Health Assessment Questionnaire Disability Index (HAQ-DI) was unchanged (1.12 vs. 0.88, p=0.694). When elderly patients were compared according to the MTX treatment status, the DAS28-ESR had improved in both groups (with MTX: 3.82 vs. 2.68, p0.001; without MTX: 4.76 vs. 4.25, p=0.026); however, the HAQ-DI had not. The GLM survival rates at 52 weeks were 85% and 76% in patients with and without MTX, respectively. Conclusion In elderly patients with RA, GLM was effective, regardless of MTX treatment status, but it did not affect the HAQ-DI. GLM survival rates were comparable between elderly and younger patients. GLM may be a suitable option for elderly patients with RA who cannot use MTX.

Objectives To investigate the outcomes of the modified Thompson–Littler (m-TL) method, a corrective surgical method utilising a dynamic tenodesis, in patients with rheumatoid swan-neck deformity. Methods Twenty-seven fingers in 10 patients with rheumatoid arthritis (RA) underwent surgical correction. The mean age at the time of surgery was 60.3 (45–77) years, the mean duration of RA was 19.3 (4–34) years, and the mean postoperative follow-up period was 2.4 (0.5–6) years. Results The deformity was corrected and the proximal interphalangeal (PIP) joint pain disappeared in all operated fingers. The mean pinch power between the thumb and the operated finger increased. The active extension decreased, the active flexion increased, and the total arc of motion decreased. Comparing the range of motion by Nalebuff’s type classification, the postoperative arc of motion decreased as the type advanced. Conclusions The m-TL method provided a favourable outcome in cases of Type ≤III rheumatoid swan-neck deformity without severe joint deterioration at the PIP joint. Aesthetic and functional improvements were observed and the patients were satisfied with the operation.

Objective To evaluate the effectiveness and drug retention rate of golimumab (GLM) for long-term use in daily practice for patients with rheumatoid arthritis (RA). Methods Patients with RA who started GLM therapy with a minimum follow-up period of 52 weeks were included. The patients were divided into a biologic-naive group and switch group. The disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) (DAS28-ESR), grip power, and Japanese version of the health assessment questionnaire (J-HAQ) score were assessed. In addition, the treatment continuation rate was evaluated at the final follow-up. Patients Sixty-five patients (58 women and 7 men; median [range] age, 69 [61-74] years; median [range] disease duration, 9 [5-16] years) were included. Twenty-eight patients were biologic-naive (naive group), and 37 were switched to biologics (switch group). Results The median (range) follow-up period was 134 (58-162) weeks. The DAS28-ESR improved from a median (range) of 4.31 (3.52-5.25) to 2.65 (2.28-3.77) in the naive group and from 4.27 (3.19-4.89) to 2.89 (2.49-3.88) in the switch group. The grip power improved in both groups (p

A 54-year-old woman suspected of having localised systemic sclerosis (SSc) started steroid treatment around 40 years old. She had Jaccoud's arthropathy in her right hand with severe deformities but no bone erosion. The metacarpophalangeal (MP) joint of the index through the little fingers was dislocated palmo-ulnarly with flexion contracture of about 120° and a swan-neck deformity. The palmar skin crease was digging deeply into the skin and was soggy. Severe boutonniere deformity of the thumb was also noted. Due to her severely deformed hand, she could not grasp large objects or show her hand in public. Reconstructive surgery was performed in two stages using finger joint arthroplasty or fusion at the digital joints. After surgery, the appearance as well as the function of the hand was successfully restored. She was able to grasp the steering wheel of her car and was extremely satisfied with the results of the surgery.

Objectives The incidence of femoral localized periosteal thickening (LPT), which can precede atypical femoral fracture (AFF), is not low (1–10%) in Japanese patients with autoimmune inflammatory rheumatic diseases (AIRDs). We explored the associations between underlying AIRDs and the prevalence of LPT. Methods We conducted post hoc analyses of two cohorts that included a total of 280 Japanese women, 105 of whom had AIRDs and had been taking bisphosphonate (BP) and prednisolone (PSL) and 175 of whom had rheumatoid arthritis (RA). Results LPT was detected in a total of 18 patients (6.4%) and 3 (1.1%) developed AFFs. RA was negatively correlated with LPT. A disease other than RA requiring glucocorticoid treatment, BP use ≥5 years, PSL use ≥7 years, and a PSL dose ≥5.5 mg/day were positively correlated with LPT. After adjusting for age, diabetes mellitus, and BP duration or daily PSL dose, RA was no longer associated with LPT. Conclusions LPT in Japanese patients with AIRDs was associated with BP and glucocorticoid treatment rather than underlying AIRDs. When PSL dose ≥5.5 mg/day is required long-term [typically combined with long-term BP treatment (≥5 years)], clinicians need to pay particular attention in cases LPT and AFF as well as glucocorticoid-induced osteoporosis.

This retrospective study aimed to investigate the risk factors associated with delayed wound healing (DWH) after orthopedic surgery in rheumatoid arthritis (RA) patients treated with biological disease-modifying antirheumatic drugs (bDMARDs).We reviewed medical records of 276 orthopedic procedures for 187 RA patients treated with bDMARDs. As a preoperative nutritional status assessment, we evaluated body mass index, prognostic nutritional index (PNI), and controlling nutritional status (CONUT). We evaluated DAS28-CRP, DAS28-ESR, face scale, global health, and HAQ-DI to assess the disease activity. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors for DWH.In 276 procedures, DWH was identified in 24 patients (8.7%). Disease duration, foot and ankle surgery, and preoperative use of tocilizumab were significant in the univariate analyses. These variables were entered into a multivariate model, and it was revealed that preoperative use of tocilizumab and procedures in the foot and ankle were associated with an increased risk of DWH.The current retrospective study suggested that preoperative use of tocilizumab and procedures in the foot and ankle were risk factors for DWH.

Hepcidin, a major regulator of iron metabolism and homeostasis, is regulated by inflammation. Recent studies have suggested that hepcidin and iron metabolism are involved in osteoporosis, and the aim of this study was to determine whether serum hepcidin levels are correlated with the degree of osteoporosis in patients with rheumatoid arthritis (RA). A total of 262 patients with RA (67.5 ± 11.4 years; 77.5% female) were enrolled. Serum iron, ferritin, and hepcidin levels were positively correlated each other. Multiple regression analyses revealed that the serum iron level was positively correlated with femoral T and Z scores, whereas the serum hepcidin level was not. Serum hepcidin level was correlated with the serum 25-hydroxy vitamin D level, which was in turn positively related to the femoral Z score. Serum hepcidin and serum iron were indirectly and directly related to osteoporosis in patients with RA.

Objective To evaluate the effectiveness and drug retention rate of golimumab (GLM) for long-term use in daily practice for patients with rheumatoid arthritis (RA). Methods Patients with RA who started GLM therapy with a minimum follow-up period of 52 weeks were included. The patients were divided into a biologic-naïve group and switch group. The disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) (DAS28-ESR), grip power, and Japanese version of the health assessment questionnaire (J-HAQ) score were assessed. In addition, the treatment continuation rate was evaluated at the final follow-up. Patients Sixty-five patients [58 women and 7 men; median (range) age, 69 (61-74) years; median (range) disease duration, 9 (5-16) years] were included. Twenty-eight patients were biologic-naïve (naïve group), and 37 were switched to biologics (switch group). Results The median (range) follow-up period was 134 (58-162) weeks. The DAS28-ESR improved from a median (range) of 4.31 (3.52-5.25) to 2.65 (2.28-3.77) in the naïve group and from 4.27 (3.19-4.89) to 2.89 (2.49-3.88) in the switch group. The grip power improved in both groups (p

Background: The objective of this retrospective study was to evaluate the outcomes of ulnar stump stabilization after ulna head resection using the FCU tendon by investigating the rate of postoperative extensor tendon rupture and click on forearm rotation.Methods: Wrist synovectomy (distal radioulnar joint (DRUJ), radiocarpal and midcarpal joints) and ulnar head resection combined with ulnar stump stabilizing procedure were performed in 58 wrists of 53 patients with RA in our hospital. Before operation, the dorsal subluxation ratio (DSR) of the ulnar head was measured with a multi-slice computed tomography (CT) images. The stabilization of ulnar stump after head resection was performed by the value of the DSR or the instability before the operation.Results: There was neither extensor tendon rupture nor click on forearm rotation in all the patients. Smooth forearm rotation was achieved by ulnar head resection and stabilizing procedure for the ulnar stump. The active range of forearm supination and pronation increased significantly from 68° ± 23° (mean ± SD) to 80° ± 10°, and from 69° ± 17° to 74° ± 13°. The grip power increased from 117 ± 62 mmHg to 185 ± 55 mmHg. In the assessment using 3DCT, the preoperative DSR of 54% improved to 8% on the whole (n = 58). In the wrists with extensor tendon rupture (n = 36), the preoperative DSR of 58% improved to 12%. In the wrists without tendon rupture (n = 22), the preoperative DSR of 46% improved to 2%.Conclusions: The operative technique of ulnar stump stabilization using the FCU tendon was one of the suitable procedure to prevent complications after ulnar head resection.

Objectives: To evaluate changes in radiographic findings and plantar pressure distribution after rheumatoid forefoot surgery.Methods: This study was performed on patients with rheumatoid arthritis (RA) who underwent Swanson implant arthroplasty for the 1st metatarsophalangeal (MTP) joint combined with shortening oblique osteotomy at the 2nd through 5th metatarsal necks (group Sw, 55 feet). The following two groups were used as controls: group NS, consisting of 75 feet in RA patients without scheduled forefoot surgery, and group HC, consisting of 24 feet in healthy female subjects. Plantar pressure distribution, and radiographic findings of hallux valgus angle, the angle between the metatarsal bones, talocalcaneal angle, calcaneal pitch angle and calcaneo-first metatarsal angle (CFMA) were measured pre- and one year postoperatively. Peak pressure was measured in nine sections.Results: Calcaneal pitch angle decreased and CFMA increased in group Sw. Peak pressure at the 1st interphalangeal joint (IP) and the 2nd and 3rd MTPs in group Sw decreased, while that at midfoot increased.Conclusion: While the clinical outcome in group Sw was favorable, postoperative longitudinal arch decreased. Postoperative peak pressure at the 2nd through 5th MTPs was comparable with that in group NS; however, it was significantly lower than that in group HC.

Objective To investigate the clinical outcomes of rheumatoid arthritis (RA) patients who discontinued infliximab (IFX) treatment at our hospital. Methods Among 249 patients receiving IFX from 2007 to 2015, we retrospectively investigated the clinical courses of 18 who discontinued IFX after achieving the 28-joint disease activity score based on the erythrocyte sedimentation (DAS28-ESR) clinical remission (CR) and whose clinical courses were available continuously for 96 weeks after discontinuation. Results At IFX introduction, the median age was 56.9 (range 36.1-72.4) years, and the disease duration was 5.2 (0.4-25.6) years. The median duration of maintaining either CR or a low disease activity (LDA) with IFX was 37.2 (4.0-91.4) months, and the total duration of IFX therapy was 45.8 (17.1-96.9) months. After discontinuation, 8 patients (44.4%) maintained CR/LDA for 96 weeks (no-flare group), and 10 (55.6%) experienced flares (DAS28-ESR≥3.2) within 96 weeks (flare group). In the no-flare group, six patients receiving intensified conventional synthetic disease-modifying antirheumatic drug (csDMARD) therapy to prevent flare ups simultaneously either with or immediately after discontinuing IFX. In the flare group, four patients received intensified csDMARD therapy. Six patients restarted biological DMARDs (bDMARDs), and all achieved CR again. Ultimately, 12 patients (66.7%) maintained a Bio-free disease control for 96 weeks. A comparison of the clinical backgrounds between the flare and no-flare groups showed no marked difference in their disease duration, IFX dosage, duration of maintaining CR with IFX, or concomitant csDMARDs use. Conclusion Irrespective of the RA disease duration, more than half of all patients maintained a Bio-free condition for 96 weeks. Continuing LDA with IFX for a sufficiently long period of time before discontinuation and preventive intensification of csDMARD therapy may help maintain a Bio-free condition.

Although biological disease-modifying antirheumatic disease drugs (bDMARDs) have represented a paradigm shift in the treatment of rheumatoid arthritis (RA), their high cost is a burden for patients...

Objective To investigate the clinical outcomes of rheumatoid arthritis (RA) patients who discontinued infliximab (IFX) treatment at our hospital. Methods Among 249 patients receiving IFX from 2007 to 2015, we retrospectively investigated the clinical courses of 18 who discontinued IFX after achieving the 28-joint disease activity score based on the erythrocyte sedimentation (DAS28-ESR) clinical remission (CR) and whose clinical courses were available continuously for 96 weeks after discontinuation. Results At IFX introduction, the median age was 56.9 (range 36.1-72.4) years, and the disease duration was 5.2 (0.4-25.6) years. The median duration of maintaining either CR or a low disease activity (LDA) with IFX was 37.2 (4.0-91.4) months, and the total duration of IFX therapy was 45.8 (17.1-96.9) months. After discontinuation, 8 patients (44.4%) maintained CR/LDA for 96 weeks (no-flare group), and 10 (55.6%) experienced flares (DAS28-ESR≥3.2) within 96 weeks (flare group). In the no-flare group, six patients receiving intensified conventional synthetic disease-modifying antirheumatic drug (csDMARD) therapy to prevent flare ups simultaneously either with or immediately after discontinuing IFX. In the flare group, four patients received intensified csDMARD therapy. Six patients restarted biological DMARDs (bDMARDs), and all achieved CR again. Ultimately, 12 patients (66.7%) maintained a Bio-free disease control for 96 weeks. A comparison of the clinical backgrounds between the flare and no-flare groups showed no marked difference in their disease duration, IFX dosage, duration of maintaining CR with IFX, or concomitant csDMARDs use. Conclusion Irrespective of the RA disease duration, more than half of all patients maintained a Bio-free condition for 96 weeks. Continuing LDA with IFX for a sufficiently long period of time before discontinuation and preventive intensification of csDMARD therapy may help maintain a Bio-free condition.

A pain-free stable wrist is a prerequisite for patients with rheumatoid arthritis to improve their activity of daily life. The present study investigated whether or not radiocarpal arthrodesis yielded good results for more than 20 years.A retrospective study was performed on 20 unstable wrists in 17 patients with rheumatoid arthritis. Radiocarpal arthrodesis combined with synovectomy and the Darrach procedure was performed. Wrist pain, grip power, the range of motion, pharmacotherapy, ESR, CRP, and serial radiographs were investigated at the baseline and 20 years after the operation. Patient-reported outcomes using the mHAQ, DASH and patient's satisfaction level were investigated at the final follow-up.Pain had disappeared completely in all patients at 20 years after the operation. The average grip power increased in 16 wrists (80%) and decreased in 4 wrists (20%). Wrist extension and flexion significantly decreased, and supination and pronation remained within the functional range. Radiographically, ulnar shift and palmar subluxation initially improved and remained unchanged for a long time. Fourteen patients (82.4%) with 17 wrists were satisfied with this operation.Radiocarpal arthrodesis for rheumatoid wrists provided painless stability for a long period for 20 years or more.

Digital joints affected by rheumatoid arthritis often have severe deformity and/or dislocation, and arthrodesis in a functional position is required.Arthrodesis was performed using intraosseous wiring (modified Lister's method) from January 2011 to December 2015, and we investigated the union rate, postoperative complications, and patient satisfaction with the operation at the final follow-up. The DASH score, grip power, and pinch power were also investigated before the operation and at the final follow-up.Arthrodesis was performed for 90 digital joints in 56 patients. Bone union was obtained in 85 of 89 joints (96%). Wire removal was needed due to subcutaneous protrusion in 20 joints and superficial infection in five joints. The mean preoperative DASH score of 50.5 improved to 45.2 at the final follow-up. The pulp pinch power of the index fingers through the little fingers changed significantly. In the questionnaire regarding the operated digit using a visual analogue scale (VAS, 0 [worst] to 100 [best]), the overall satisfaction was 70.With this approach, we achieved painless stability as well as deformity correction. A restored prehensile pattern and improvement in the activities of daily life can thus be expected after surgery.

Aim A retrospective questionnaire survey was conducted to investigate the long-term outcomes of elbow, wrist and hand surgery for rheumatoid arthritis (RA). Methods One hundred and thirteen RA patients underwent primary elective elbow, wrist or hand surgery at our hospital between January 2002 and December 2003. To evaluate the outcomes at 10 years after surgery, the patient-reported outcomes were assessed using an original questionnaire that inquired about the site of treatment; the modified Stanford Health Assessment Questionnaire (mHAQ) was also used. Results Responses were obtained from 67 patients (98 sites). In the 10 years after surgery, the Disease Activity Score of 28 joint - erythrocyte sedimentation rate (4) and the modified Health Assessment Questionnaire scores of the patients showed significant improvement. Nearly 85% of patients were satisfied with the outcome at the surgical site. The most frequent reason for perceived improvement was 'pain relief' (all surgical sites). An 'improved appearance' was frequently reported after finger surgery and 'increased power' was frequently reported after wrist and thumb surgeries. With regard to elbow surgery, 30% of the patients were satisfied with the increase in motion and power. In contrast, approximately 20% of patients complained of decreased power around the surgical site after elbow and thumb surgeries. Conclusions Our original patient-reported outcome assessment tool revealed that elbow, wrist and hand surgery provided long-lasting benefits in RA patients. While the efficacy differed in some of the surgical sites, pain relief was the most favorable effect. Altered medical therapy may also have impacted the patient-perceived outcomes of surgery at 10 years.

To clarify systemic effects of orthopedic surgical intervention in patients with rheumatoid arthritis (RA).A prospective observational cohort study was performed in RA patients who were scheduled to have primary elective orthopedic surgeries. Assessments were performed at baseline, 6 and 12 months after surgery using J-HAQ, General Health, EQ-5D, BDI-II, DAS28-CRP(4) and CRP for all registered patients, DASH and grip power for patients with upper-extremity surgeries, TUG for patients with lower-extremity surgeries, and JSSF for patients with ankle and forefoot surgeries.There were 294 sites in 276 patients whose average age was 64 (19-89) years and average disease duration was 16 (1-60) years. Surgical site was shoulder in six patients, elbow in 26, wrist in 74, hand in 63, hip in 13, knee in 50, ankle in 12, and forefoot in 50. In total, physical function (J-HAQ, grip power, DASH, TUG, JSSF), quality of life (J-HAQ, General Health, EQ-5D) and depression (BDI-II) improved and disease activity (CRP, DAS28-CRP(4)) decreased significantly 6 and 12 months after surgery (p.01), despite some differences in their outcomes by the preoperative disease activity and the surgical site.Overall benefits were provided by orthopedic surgical intervention generally in patients with RA.

The present study aims to evaluate changes in plantar pressure distribution after joint-preserving surgery for rheumatoid forefoot deformity. A retrospective study was performed on 26 feet of 23 patients with rheumatoid arthritis (RA) who underwent the following surgical combination: modified Mitchell’s osteotomy (mMO) of the first metatarsal and shortening oblique osteotomy of the lateral four metatarsals. Plantar pressure distribution and clinical background parameters were evaluated preoperatively and one year postoperatively. A comparison of preoperative and postoperative values indicated a significant improvement in the visual analog scale, Japanese Society for Surgery of the Foot scale, and radiographic parameters, such as the hallux valgus angle. A significant increase in peak pressure was observed at the first metatarsophalangeal joint (MTPJ) (0.045 vs. 0.082 kg/cm2, p &lt, 0.05) and a significant decrease at the second and third MTPJs (0.081 vs. 0.048 kg/cm2, 0.05, 0.097 vs. 0.054 kg/cm2, 0.05). While overloading at the lateral metatarsal heads following mMO has been reported in previous studies, no increase in peak pressure at the lateral MTPJs was observed in our study. The results of our study show that this surgical combination can be an effective and beneficial surgical combination for RA patients with mild to moderate joint deformity.

The objective of this study is to clarify the surgical indication for rheumatoid forefoot deformity according to background characteristics and plantar pressure.Patients with rheumatoid arthritis were divided into a non-surgical group (group N) and a surgical group (group S). The former consisted of 225 ft, and the latter consisted of 88 ft. DAS28, Japanese Society for Surgery of the Foot rheumatoid arthritis foot and ankle scale (JSSF scale) and hallux valgus angle (HVA) were evaluated as background characteristics. Distribution of peak pressure as plantar pressure was measured in nine sections.In groups N and S, the mean DAS28 was 3.6 and 3.0, the mean JSSF scale was 81.1 and 63.0, and the mean HVA was 19.9° and 35.3°, respectively. The mean peak pressure of group S at the first and third metatarsophalangeal joints was significantly higher compared with group N. Significant differences between the two groups were also seen in Δ pressure (the difference between the maximum and minimum peak pressure values). The cut-off values were 75.0 for JSSF scale, 24.9° for HVA and 3.94 kg/cmThe combined assessment of HVA and Δ pressure was found to be useful as an indication for surgical treatment of the forefoot.

We experienced four cases of rheumatoid arthritis (RA) complicated with acute hepatitis caused by hepatitis E virus (HEV). All of them were asymptomatic, but they showed sudden deterioration of the liver function. No cases ate raw meat, including raw pork or deer. One case was using etanercept (ETN) with methotrexate (MTX). Two cases were using MTX but not biological disease-modifying antirheumatic drugs (bDMARDs). One case was not using either MTX or bDMARDs. When their liver dysfunction was revealed, MTX and ETN were discontinued. It was subsequently clarified that the subjects were infected with HEV. Liver dysfunction recovered in all cases, and MTX and ETN were restarted without any problems. When RA patients developed sudden-onset liver dysfunction, they might have been misdiagnosed with drug-induced liver injury. It is also possible that MTX, the anchor drug of the treatment of RA, would not be used any more if rheumatologists did not notice hepatitis E and misdiagnosed as MTX-induced liver ...

Objectives: The aim of this study was to identify the risk factors associated with severe infection in RA patients, with a particular focus on the association of the nutritional status.Methods: We ...

Background In the treatment of Rheumatoid arthritis (RA), early diagnosis and early treatment with tight control have become increasingly important with the advent of biological therapy. Ultrasonography (US) of the various joints enables the real-time evaluation of synovial hypertrophy, effusion and bone erosion, Power Doppler (PD) ultrasound is able to identify both subclinical synovitis and early erosive disease. Objectives The objectives of this study were to investigate whether the image of US at the operated joint reflect synovium histological findings or clinical indicators, and to compare the results in the patient treated by non-biological agent (NonBio) and biological agent (Bio) Methods RA related orthopaedic surgery was performed at 1287 joints including 17 shoulders, 160 knees, 96 elbows, 378 wrists, 364 fingers, 38 ankles and 234 toes during the period between January 2011 and December 2018 at our rheumatic center. Preoperatively, ultrasound evaluations were performed and grade of PD signal was determined at the part with the highest signal. PD signal consists 4 grades from grade 0 to 3. The operations were performed within one week after the ultrasound evaluations. Rooney score of the synovium histology, DAS28-ESR(4), MMP-3, CRP were investigated. Rooney score represents the histologic features in the synovium of RA. It includes 6 features i.e. synoviocytes hyperplasia, fibrosis, proliferating blood vessels, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, diffuse infiltrates of lymphocytes. They were scored separately on a scale of 1-10.The treatments that the patients received included: biological agents (Bio) (n=389 30%), etanercept (ETN) (n= 102), tocilizumab (TCZ) (n=105), infliximab (IFX) (n=29), adalimumab (ADA) (n=28), certlizumab pegol (CZP) (n=12), golimumab (GLM) (n=56), and abatacept (ABT) (n=55), tofacitinib (TOF) (n=2). Results PD signal (0.97±0.88), DAS28 (3.23±1.13), CRP(0.5±1.25 mg/dL), MMP-3 (119.0±119.0 ng/mL) and Rooney score (23.5±7.7) in the patients treated with Bio were significantly lower than those (1.39±0.95, 3.66±1.07, 0.78±1.37 mg/dL, 146.3±150.0ng/dL, 28.5±9.26) in the patients treated with NonBio. Rooney score fibrosis (9.57±1.44) in patients treated with Bio was significantly higher than those (8.64±2.48) in patients treated by NonBio. Rooney score, synoviocyte hyperplasia (1.16±1.26) and three items of lymphocyte (1.59±2.91, 1.68±2.54, 1.11±2.20) in patients treated with Bio were lower than those (1.72±1.30, 3.79±3.56, 3.73±3.53, 2.40±2.98) in patients treated with NonBio. TCZ, ADA, ABT and IFX had some significant differences for Rooney score and Rooney item score between the patients treated with NonBio. Conclusion The activity of RA synovitis at operated site was suppressed in patients treated with Bio. There were some differences in clinical data, histological score, PD signal and DAS28 among Bio. Disclosure of Interests None declared

Background Sarcopenia is characterized by a loss of muscle mass and strength, which leads to a reduced physical ability, poor quality of life (QoL), frailty and mortality. Rheumatoid arthritis (RA) is considered a cause of secondary sarcopenia. Objectives To clarify the effectiveness of biologic disease-modifying anti-rheumatic drugs (bDMARDs) on sarcopenia, including the physical ability, body composition and nutritional status. Methods This was a prospective cohort study including consecutive 41 patients (11 men, 30 women, 63.6±16.1 years old) with RA who started bDMARDs for the first time at Niigata Rheumatic Center. The diagnosis of secondary sarcopenia was made according to the diagnostic algorithm of the Asian Working Group for Sarcopenia (AWGS), excluding the criteria about older age. We observed the disease activity of RA, physical ability, body composition, nutritional status and QoL at baseline and 6 months. The disease activity was assessed by the disease activity score-28 joint count erythrocyte sedimentation rate (DAS28-ESR) and clinical disease activity index (CDAI). The physical activity was determined using the health assessment questionnaire (HAQ), 10-m walking test (10MWT) and timed up and go test (TUG). The nutritional status was determined based on the controlling nutrition status (CONUT) score and prognostic nutritional index (PNI). The overall QoL was measured by European quality of life scale- 5 dimensions (EQ-5D). Results Among 41 patients who started bDMARDs, 19 were classified as having sarcopenia, and 7 were classified as having pre-sarcopenia. The bDMARD was certolizumab pegol in 10 patients, adalimumab in 7, abatacept in 7, golimumab in 6, tocilizumab in 5, infliximab in 3 and etanercept in 3. The DAS28-ESR (4.7±1.3 vs. 2.6±1.3, p Conclusion After 6 months of bDMARDs therapy, the physical ability, nutritional status and QoL were significantly ameliorated. While the muscle mass was not markedly increased, the proportion of patients with sarcopenia showed a decreasing trend. The administration of bDMARDs might be useful for preventing secondary sarcopenia in RA patients. Disclosure of Interests Eriko Hasegawa: None declared, Satoshi Ito Speakers bureau: Mitsubishi Tanabe Pharma Corporation., Yoichi Kurosawa: None declared, Daisuke Kobayashi: None declared, Asami Abe: None declared, Hiroshi Otani: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

Background The treatment aim of rheumatoid arthritis (RA) is achieving and maintaining functional remission via tight medical control. However, if adequate medication is not administered in the very early stage of the disease, surgical reconstruction for the structurally damaged hand and wrist is sometimes required. Objectives To evaluate the effect of surgical treatment of the hand and wrist(1) and to set the target of functional remission using grip power and patient-reported outcome measures (PROs) at baseline. Methods A prospective observational cohort study was performed in RA patients who were scheduled to have primary hand and/or wrist surgeries. Assessments were performed at baseline and 12 months after surgery using grip power (GP), pain visual analogue scale (pain VAS), general health (GH), disease activity score 28- C-reactive protein(4) (DAS28-CRP(4)), disabilities of the arm, shoulder and hand (DASH), European quality of life scale with five dimensions (EQ-5D), Beck depression inventory -II (BDI-II) and health assessment questionnaire- disability index (HAQ-DI) for all registered patients. Baseline data for each item in the group with HAQ remission (HAQ-DI≤0.5) at 12 months (REM) were compared with those in the group without remission at 12 months (non-REM). Results There were 137 sites (63 hands, 74 wrists) in 119 patients whose average age was 62 (19-88) years and average disease duration was 14 (1-45) years. Overall, the physical function (GP, pain VAS, DASH, HAQ-DI), quality of life (HAQ-DI, GH, EQ-5D), depression (BDI-II) and disease activity (DAS28-CRP(4)) had significantly improved at 12 months (p Conclusion GP and other four PROs were validated as good objective tools for assessing the physical function after hand and wrist surgeries. It would be helpful for rheumatologists to consider the timing of surgery in RA patients based on the cut-offs determined in this study(2). References [1] Ishikawa H. The latest treatment strategy for the rheumatoid hand deformity. J Orthop Sci. 2017; 22: 583-592. [2] Kojima T, Ishikawa H, Tanaka S, et al. Target setting for lower limb joint surgery using the timed up and go test in patients with rheumatoid arthritis: A prospective cohort study. Int J Rheum Dis. 2018; 21: 1801-1808. In the other items, there was not a significant difference between two groups Disclosure of Interests Hajime Ishikawa: None declared, Asami Abe: None declared, Toshihisa Kojima: None declared, Masayo Kojima: None declared, Yoichi Kurosawa: None declared, Eriko Hasegawa: None declared, Satoshi Ito Speakers bureau: Mitsubishi Tanabe Pharma Corporation., Naoki Ishiguro: None declared, Akira Murasawa: None declared

Objective Rheumatoid arthritis (RA) is a chronic inflammatory disease accompanied by periarticular and systemic osteoporosis. Fibroblast growth factor 23 (FGF23), which is mainly produced by osteocytes, circulates to the kidneys and regulates bone metabolism. We herein assessed serum FGF23 and its relationship to inflammation and osteoporosis in patients with RA. Methods Sixty-one patients with RA were included. Serum concentrations of FGF23 were determined using a sandwich enzyme-linked immunosorbent assay. Results The mean (± standard deviation) serum FGF23 concentration was 34.9±9.2 (range, 21.0-61.0) pg/mL. The serum FGF23 level was significantly and positively correlated with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, disease activity score-28 based on the ESR (DAS-28 ESR) and DAS-28 CRP (r=0.261, p=0.044, r=0.280, p=0.029, r=0.409, p=0.001 and r=0.421, p=0.001, respectively). The serum matrix metalloproteinase-3 level was also significantly and positively correlated with the serum FGF23 level (r=0.331, p=0.015). Concentrations of type I collagen cross-linked N-telopeptide in the serum was significantly correlated with the serum FGF23 level (r=0.272, p=0.034). Neither the bone mineral density in the femoral neck nor lumbar was significantly correlated with the serum FGF23 level. Serum phosphate, calcium, 25-hydroxy vitamin D, and intact parathyroid hormone were not related to the serum FGF23 level. Conclusion In patients with RA, serum FGF23 is correlated with inflammation, the disease activity of RA, and bone absorption markers. Serum FGF23 may be associated with abnormal bone absorption related to RA inflammation. Further studies are necessary to clarify the mechanism underlying this association.

Background:It has been suggested that perioperative use of biological disease-modifying anti-rheumatic drugs (bDMARDs) in rheumatoid arthritis (RA) patients carries risks for the surgical-site infection and the delayed wound healing (DWH); however, the risk of DWH with perioperative use of bDMARDs has not reached a general consensus.Objectives:This retrospective study aimed to investigate the risk factors associated with DWH after orthopedic surgery in RA patients treated with bDMARDs.Methods:We reviewed medical records of 277 orthopedic procedures for 188 RA patients treated with bDMARDs between from 2014 to 2017 in Niigata Rheumatic Center. As preoperative nutritional status assessment, we evaluated body mass index (BMI), prognostic nutritional index (PNI), and CONtrolling NUTritional status (CONUT). In addition, we evaluated DAS28-CRP, DAS28-ESR, face scale for pain, global health (GH), and Health Assessment Questionnaire-Disability Index (HAQ-DI) to assess the disease activity. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factor for DWH.Results:The major characteristics of the patients in 277 procedures were mean age of 63.2 years old and mean disease duration of 18.2 years. Surgical site were hand and wrist (145 procedures), foot and ankle (76), hip and knee (31), elbow and shoulder (24), and spine (1). Seventy-four patients were treated with tocilizumab, 62 with etanercept, 55 with golimumab, 49 with abatacept, 16 with infliximab, 15 with adalimumab, and 6 with certolizumab. According to nutritional assessment in PNI and CONUT, 63% (n=175) and 47% (n=130) were normal nourished patients, respectively.In 277 procedures, DWH were identified in 24 patients (8.6%). The following variables were significant in the univariate analyses: disease duration (OR 1.053; 95% CI 1.010–1.099; p=0.016), foot and ankle surgery (OR 7.091; 95% CI 2.130–23.603; p=0.001), tocilizumab (OR 0.286; 95% CI 0.093–0.881; p=0.029) (Table 1). These variables were entered into a multivariate model, and it was revealed that pre-operative use of tocilizumab (OR 0.265; 95% CI 0.074–0.953; p=0.042) and procedures in the foot and ankle (OR 6.915; 95% CI 1.914–24.976; p=0.003) were associated with an increased risk of DWH (Table 1).Conclusion:As previous study on tocilizumab described, the current retrospective study suggested that pre-operative use of tocilizumab and procedures in the foot and ankle were risk factors for DWH. Pre-operative disease activity and nutritional status were not independent risk factors for an increase in the prevalence of DWH.References:[1] Momohara S, Hashimoto J, Tsuboi H et al. Analysis of perioperative clinical features and complications after orthopaedic surgery in rheumatoid arthritis patients treated with tocilizumab in a real-world setting: Results from the multicentre tocilizumab in perioperative period (TOPP) study. Modern rheumatology. 2013, 23: 440-9.Disclosure of Interests:Shunji Okita: None declared, Hajime Ishikawa: None declared, Asami Abe: None declared, Satoshi Ito Speakers bureau: Abbvie,Eisai, Akira Murasawa: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Toshifumi Ozaki: None declared

Background:Sarcopenia is characterized by loss of muscle mass and strength, which lead to lower physical ability, less quality of life (QoL), frailty and mortality. Rheumatoid arthritis (RA) is considered to be one of the causes of sarcopenia.Objectives:To clarify the effectiveness of biologic disease modifying anti-rheumatic drugs (bDMARDs) on sarcopenia, including physical ability, body composition and nutritional status.Methods:This is a prospective cohort study including consecutive 48 patients (male 11, female 37, age 64.2±15.1) with RA who started bDMARDs in Niigata Rheumatic Center. Diagnosis of sarcopenia was according to the diagnostic algorithm of European Working Group on Sarcopenia in Older People (EWGSOP). We monitored disease activity of RA, physical ability, body composition, nutritional status and QoL at baseline, 6 months and at 12 months. Disease activity was measured by disease activity score-28 joint count based on erythrocyte sedimentation rate (DAS28-ESR), clinical disease activity index (CDAI). Physical activity was measured by Health Assessment Questionnaire (HAQ), 10m walking test (10MWT). Nutritional status was measured by controlling nutrition status (CONUT) score, and prognostic nutritional index (PNI). Overall QoL was measured by EuroQol 5 dimentions (EQ5D).Results:Among 48 patients who started bDMARDs, 21 patients were classified as having sarcopenia. The bDMARDs used were adalimumab in 10 cases, certolizumab pegol in 9 cases, abatacept in 9 cases, golimumab in 7 cases, tocilizumab in 5 cases, infliximab in 5 cases and etanercept in 3 cases. DAS28-ESR (4.7±1.4 vs. 2.7±1.0, p < 0.001) and CDAI (18.4±9.4 vs. 7.4±5.5, pConclusion:Twelve months of bDMARDs therapy significantly ameliorated disease activity, nutritional status and physical activity. In RA patients with sarcopenia, bDMARDs significantly increased skeletal muscle and may be effective for treatment of sacrcopenia.Disclosure of Interests: :Eriko Hasegawa: None declared, Satoshi Ito Speakers bureau: Abbvie,Eisai, Yoichi Kurosawa: None declared, Shinji Taniguchi: None declared, Daisuke Kobayashi: None declared, Asami Abe: None declared, Hiroshi Otani: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

Background:Although methotrexate is the anchor drug, it took some days to check contraindications, such as interstitial pneumonia, hepatitis B virus infection, and latent tuberculosis infection. Therefore, we sometimes start rheumatoid arthritis (RA) treatment with other disease-modifying antirheumatic drug (DMARD) in daily clinical setting. Iguratimod (IGU) is a newly developed DMARD approved in Japan in September 2012, and the efficacy of IGU for DMARD naïve patients has not been thoroughly evaluated.Objectives:The aim of this prospective single-center study was to demonstrate the efficacy and safety of IGU when used as a first-line daily DMARD for patients with RA in a clinical setting.Methods:Enrolled patients included those diagnosed with RA according to the 2010 American College of Rheumatology/European League against Rheumatism (ACR/EULAR) classification criteria who took IGU as a first-line DMARD at Niigata Rheumatic Center between April 2016 and December 2018 (IGU group). There were no constraints regarding the addition or withdrawal of other DMARDs. Details of the patients’ background, clinical parameters, and laboratory findings were obtained, including C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), matrix metalloprotease-3 (MMP-3), rheumatoid factor (RF), Disease Activity Score for 28-joint counts based on the erythrocyte sedimentation rate (DAS28-4[ESR]), Clinical Disease Activity Index (CDAI), and Health Assessment Questionnaire Disability Index (HAQ-DI). The efficacy of IGU was evaluated at week 24. The IGU group’s data were then compared with 64 patients who took salazosulfapyridine or bucillamine as first-line DMARD in our hospital (other DMARD group). The data were expressed as median values. Comparisons between the parameters were performed using nonparametric method.Results:Forty-three patients (15 males, 28 females) received IGU as a first-line DMARD for RA. The age was 69.0 years and the duration of disease was 2.0 months. Twenty patients received prednisolone (PSL) concomitantly at a median dose of 5.0 mg/day. At 24 weeks medications were utilized in patients as follows: IGU in 36 (83.7 %), methotrexate in 18 (41.2%), PSL in 17 (39.5%), BUC in 10 (23.2 %), and biological DMARD in 7 (15.2 %) patients. Although 7 patients discontinued taking IGU due to liver enzyme elevation (n=4), nausea (n=1), creatinine elevation (n=1), and skin rash (n=1) during the 24-week period, serious adverse events requiring hospitalization were not observed. Clinical parameters that improved from baseline after 24 weeks of treatment included: ESR from 42.0 mm/h to 16.0 mm/h with p < 0.001; CRP from 0.70 mg/dL to 0.10 mg/dL with p< 0.001; MMP-3 from 136 ng/mL to 91.5 ng/mL with a p value of 0.11; RF went from 18.0 IU/mL to 8.00 IU/mL with p < 0.001; DAS28(4)-ESR dropped from 5.13 to 2.73 with p< 0.001; CDAI dropped from 20.0 to 5.00 with p< 0.001, and HAQ-DI decreased from 0.55 to 0.00 with p< 0.001. Patients who achieved a good or moderate response based on EULAR response at 24 weeks, included 90.7% in the IGU group versus 70.5% in the other DMARD group (Fisher`s exact test, p=0.046). The retention rate of the IGU group was 81.4 %, roughly equivalent to the 81.2% retention rate in the other DMARD group (Log-rank test, p=0.733).Conclusion:Our study indicates IGU is safe and effective for DMARD naïve RA patients. Starting treatment with IGU might be a new and effective strategy for RA patients without previous use of a DMARD.Disclosure of Interests:Daisuke Kobayashi: None declared, Eriko Hasegawa: None declared, Yoko Wada: None declared, Satoshi Ito Speakers bureau: Abbvie,Eisai, Asami Abe: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

Background:Biological disease-modifying antirheumatic drugs (bDMARDs) caused a paradigm shift in the treatment of rheumatoid arthritis (RA). However, their high cost is a burden for patients and the national medical economy.Objectives:To analyze the long-term outcomes of patients with RA who achieved a bio-free condition (BF) with adalimumab (ADA).Methods:We followed 25 patients (male 6, female 19) who discontinued ADA with clinical remission (CR), and one female with a low disease activity (LDA), over 19.4 ±7.8 months of ADA treatment1). At the introduction of ADA, the average age was 51.2 ± 11.9 years old, and the average disease duration was 45.1 ± 48.4 months. The disease activity measured by disease activity score based on C-reactive protein (DAS28-CRP) was defined as follows: CR, 4.1, since the DAS28-CRP tends to be lower than the DAS28-based on the erythrocyte sedimentation rate in Japanese patients2).Results:We lost one patient with a transfer to another hospital. Four patients re-started ADA due to flare (DAS28-CRP>2.7) but achieved CR (in BF) again with the intensification of the treatment (dose increase or initiation of prednisolone [PSL] and/or conventional synthetic [cs] DMARDs such as tacrolimus or iguratimode). The DAS28-CRP significantly decreased from 3.45 ± 1.32 at base line (BL) to 1.55 ± 0.41 (pConclusion:BF can be sustained with an adequate dose of MTX and combination of csDMARDs.References:[1]Ito S, et al. An analysis of the biological disease-modifying antirheumatic drug-free condition of adalimumab-treated rheumatoid arthritis patients. Intern Med 58: 511-519, 2019[2]Inoue E, et al. Comparison of Disease Activity Score (DAS)28-erythrocyte sedimentation rate and DAS28- C-reactive protein threshold values. Ann Rheum Dis. 66:407-409, 2007.Disclosure of Interests:Satoshi Ito Speakers bureau: Abbvie,Eisai, Shunsuke sakai: None declared, Yoichi Kurosawa: None declared, Daisuke Kobayashi: None declared, Ryo Okabayashi: None declared, Asami Abe: None declared, Hiroshi Otani: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

Objectives The present study was performed with the aim of analyzing the biological disease-modifying antirheumatic drug (bDMARD)-free (Bio-free) condition of adalimumab (ADA)-treated rheumatoid arthritis (RA) patients in a real-world setting. Methods ADA was used in the treatment of 130 (male, n=21; female, n=109 females) RA patients. Among them, 26 patients (20.0%) discontinued ADA due to a good response. We analyzed 20 patients who were followed up for more than 6 months after the discontinuation of ADA. The Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) and modified health assessment questionnaires (mHAQs) were evaluated. Results The mean age of the patients was 53.4±11.1 years. The mean disease duration was 4.5±4.3 years. Sixteen patients were bDMARD-naive, while 4 switched from bDMARDs to ADA. At 6 months after the discontinuation ADA, 19 patients had achieved a clinical remission, and 1 had achieved a low disease activity. The Bio-free period was 26.4±15.5 months. The dose of prednisolone was significantly reduced from baseline (3.45±3.17 mg/day) at 6 months after the discontinuation of ADA (2.63±2.78 mg/day). The dose of methotrexate was unchanged. The number of conventional synthetic DMARDs (csDMARDs) was significantly increased (0.8±0.6 to 1.4±1.06). The mHAQ values were significantly ameliorated by ADA and remained good in patients with a Bio-free condition. A multivariate analysis showed that the dose of methotrexate (MTX) was an important factor for achieving a Bio-free condition. Conclusion A sustainable Bio-free condition in a real clinical setting can be achieved and may be a suitable way of reducing medical costs. The dose of MTX and the additional administration of csDMARDs is therefore thought to be important for ensuring a good outcome in these patients.

Background In the treatment of rheumatoid arthritis (RA), the early diagnosis and early medical treatment via tight control have become increasingly important with the advent of biological therapy. In addition, the existence of inflammation without bone destruction on magnetic resonance imaging has been found to be significantly associated with symptoms in the patient standpoint type inspection of early RA patients. Objectives This study was conducted to clarify the differences between the joint synovium and tendon sheath synovium, local disease activity using ultrasonography (US) and the findings on a synovial histopathological evaluation. Methods Between March 2011 and November 2017, 663 synovectomies were surgically treated, and synovial biopsies were performed at the time of surgery. Among them, 75 tendon sheath synovia and 588 joint synovia were investigated. A total of 81 men and 582 women were examined, with an average age of 64 years old. We examined the finger in 312 cases (39 tendons, 273 joints), wrist in 323 cases (33 tendons, 290 joints) and ankle in 28 cases (3 tendons, 25 joints). There were no cases with both tendon sheath synovium and joint synovium. Just before surgery, the US probe was placed on the dorsal and palmar/plantar aspect of the joint or the tendon sheath to evaluate the activity of local synovitis. The maximum grade of power Doppler (PD) signal was determined, ranging from 0 to 3. The serum C reactive protein (CRP), matrix metalloproteinase-3 (MMP-3) and DAS28 values were also examined just before surgery. A histopathological examination of the gathered synovium at the surgical site was performed using the Rooney score (RS). Results For the tendon sheath synovium, PD0, 14 cases; PD1, 32 cases; PD2, 19 cases and PD3, 10 cases were observed, with an average score of 1.33. For the joint synovium, PD0, 114 cases; PD1, 179 cases; PD2, 209 cases and PD3, 86 cases were observed, with an average score of 1.45. Regarding the DAS28, for the tendon sheath synovium, the average score was 3.59, and for the joint synovium, the average score was 3.61. Regarding the CRP, for the tendon sheath synovium, the average score was 0.64, and for the joint synovium, the average score was 0.66. Regarding the MMP-3, for the tendon sheath synovium, the average score was 113, and for the joint synovium, the average score was 123. There were no marked differences in the grade of PD, DAS28, CRP or MMP-3 between the synovia. The rate of synoviocytes hyperplasia did not differ between the synovia, but the rates of fibrosis and proliferating blood vessels were significantly high in the tendon sheath synovium, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, diffuse infiltrates of lymphocytes was significantly high in joint synovium. Conclusions There was no marked difference in the US findings and the disease activity between the tendon sheath synovium and the joint synovium. However, there were differences in the local disease activities between the synovia. These results show that the tendon sheath synovium lacked acute inflammation. Disclosure of Interest None declared

Background Depression is the most frequently seen comorbidity in the patients with rheumatoid arthritis (RA) 1). Inflammatory mediators, including TNF-α, interleukin-1 and interleukin-6, affect serotonin transporters in the brain and promote low stress tolerance and depression 2). Objectives To investigate the effect of orthopaedic surgery on the mental condition of patients with RA by assessing the Beck depression inventory II (BDI-II) and to investigate the factors associated with changes in the BDI-II. Methods A prospective cohort study was performed in 294 sites of primary elective surgery in 276 patients with structural damage due to RA. The average (range) age was 6419–89 years old, and the average (range) disease duration was 161–60 years. The surgical site was the shoulder in 6 patients, elbow in 26, wrist in 74, hand in 63 (with wrist in 18), hip in 13, knee in 50, ankle in 12, and forefoot in 50. The BDI-II, EuroQol 5 dimensions (EQ-5D), Japanese version of the Stanford Health Assessment Questionnaire (J-HAQ), and disease activity score 28 using C-reactive protein4 (DAS28-CRP4) were assessed at the baseline and at 12 months after surgery. During the observational period, the number of patients using methotrexate (MTX), prednisolone (PSL), and biological disease-modifying anti-rheumatic drugs (bDMARDs) did not change significantly. The mean dose of MTX and PSL was reduced by 0.4 mg/w and 0.2 mg/d, respectively, at 12 months after surgery. Results In total, the mean BDI-II significantly improved from 13.0 to 11.5 at 12 months after surgery (p Conclusions Depression was ameliorated by surgical intervention in patients with RA. The mental condition is associated with the quality of life and physical function. References [1] Dougados M, et al. Ann Rheum Dis2014;73:62–8. [2] Mclnnes IB, Schett G. N Engl J Med2011;365:2205–19. [3] Ishikawa H. Orthop Sci. 2017;22:583–92. Disclosure of Interest None declared

Background Grip power is known to be a simple and useful objective index that can be used in the self-assessment of disease activity in patients with rheumatoid arthritis (RA) 1) . However, the clinical significance of this physical function is unknown. Objectives The objective of this study was to clarify the relationship between the grip power and the level of activities of daily living (ADL). Methods The grip power was measured in 221 inpatients of our hospital with RA using a mercury dynamometer. The independence level (0: impossible, 1: incomplete and not practical, 2: practical but the means thereof are unusual, 3: normal) for 44 ADL items, including most daily activities was investigated. For each item, the site with the problem (shoulder, elbow, forearm, wrist, thumb, fingers, lower extremity and trunk) and cause of disability (pain, loss of power, decreased range of motion, abnormal prehensile pattern and fatigue) were investigated by interviewing the patient. There were 33 male and 188 female patients. The average age of the patients was 64.6 years, and the average duration of the disease was 13.3 years. Biological therapy had been given to 23% of the patients. The average grip power of the right and left hands was used. Results There were 14 items requiring others’ assistance (level 0 or 1) in more than 10% of patients. For these 14 items of ADL, the grip power increased with the increase in the independence level (p 2 . The site with a problem was, in order of frequency, the fingers (26.1%), wrist (14.8%) and lower extremity (14.0%). The cause of disability was, in order of frequency, pain (38.8%), loss of power (32.8%) and a decreased range of motion. Based on the results of a stepwise regression analysis, the first factor, consisting mainly of “reaching function”, including “hair dressing”, “washing one’s body”, “taking on and off one’s shoes”, “clipping nails”, “buttoning”, etc., was most strongly related to a loss of grip power and problems at the elbow, the shoulder and the wrist. The second factor, consisting mainly of the “prehensile function”, including “opening a plastic bottle”, “opening lids”, “squeezing towels”, etc., was most strongly related to a loss of grip power and problems at the wrist and the thumb. The third factor, consisting mainly of “activities involving changing body position and transfer”, including “getting in and out of the bathtub”, “standing and sitting”, etc., was most strongly related to ageing and problems with the lower extremities and at the elbow and the wrist. In the receiver operating characteristic (ROC) curve, the grip power with the maximum Youden index was 136.5 mmHg (11.8 kg) in females and 152.5 mmHg (13.5 kg) in males. Most activities were performed independently with the grip power more than 136.5 mmHg in females (figure 1). The explanatory variables for the grip power in the female patients were ageing; a long disease duration; a high disease activity score (DAS) 28; problems at the fingers, the thumb and the elbow; decreased flexion at the shoulder and a decreased range of forearm rotation. Conclusions The grip power was a determinant of independent daily living in patients with RA in our study. References [1] Espinoza F, et al. Rheumatology (Oxford)2016;55:897–901. [2] Thyberg I, et al. Arthritis Rheum2005;53:886–96. Disclosure of Interest None declared

Objective To investigate the efficacy of minodronate in the treatment of glucocorticoid-induced osteoporosis (GIO). Methods The study population included patients in whom the administration of minodronate (50 mg, once every 4 weeks) had been newly started for the treatment of GIO in Niigata Rheumatic Center from 2012 to 2015. Patients who were bisphosphonate-naive and those who switched from other bisphosphonates were classified into the naive and switch groups, respectively. The changes in the bone mineral density (BMD) and bone metabolic markers after one year of minodronate treatment were retrospectively evaluated. We also compared the BMD and bone turnover marker changes of minodronate-naive patients with those in whom alendronate or risedronate had been prescribed as a first bisphosphonate (control group). Results Minodronate was prescribed to 142 patients, and data were successfully obtained from 120 patients. New vertebral fractures were observed in 5 of the 142 patients; 1 fracture occurred during the cessation of minodronate for dental treatment, and 3 patients already had multiple vertebral fractures before the initiation of minodronate. The patients' tartrate-resistant acid phosphatase 5b (TRACP-5b) (-27.0%, p

Background: MP joint arthroplasty is one of the treatment options for the rheumatoid thumb with boutonniere deformity. The use of flexible hinge toe implant for MP joint reconstruction was introduced; however, the outcome of flexible toe implantation for the reconstruction of the MP joint has not as yet been reported in detail. Therefore, in this study, we retrospectively investigated the clinical outcome and radiological findings. Methods: We assessed 56 Swanson implant arthroplasties that used flexible hinge toe implants with grommets to address boutonnière deformity of the thumb MP joint. The minimum follow-up period was 6 months. Pain, the range of motion, grip strength, pinch strength, General health Visual analogue scale and DASH (Disabilities of Hand, Shoulder and Hand) were assessed. Results: For most of the patients, the procedure provided painless motion and stability to the thumb. In the radiological assessments, the preoperative flexion angles at the MP joint were 45° improved to 17°. The origin of arc was shifted toward the extended position and the average arc of motion was 21°, with a flexion arc from 23° to 44°. The severity of boutonniere deformity was improved in most cases. The average grip strength changed from 110 to 121 mmHg and the average side pinch power changed from 1.5 to 2.2 kgf. General health VAS improved from 40 to 29 (p = 0.019), and the DAS28-CRP decreased from 3.3 to 2.4 (p < 0.001). Infection occurred in one case, and there were no implant fractures. Conclusions: Swanson flexible hinge toe implant arthroplasty with grommets applied to the MP joint of the thumb was one of the recommended procedures for the reconstruction of boutonnière deformity of the thumb.

Methotrexate (MTX) is the first choice disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA) and is referred to as an "anchor drug"; its use has been steadily increasing annually. However, MTX-related lymphoproliferative diseases (MTX-LPDs) have emerged as important complications in the patients with RA. There have been no reports of intra-articular MTX-LPDs of the patients with RA. Atypical cells were found in the patient's joint fluid by cytological examinations, and MTX-LPDs were suspected. The patient discontinued MTX and open synovectomy was performed. The histological findings and immunohistochemical staining of the specimens confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL) of MTX-LPDs. After the operation of the patient's left knee joint, pains and swollen joint disappeared with no relapse. The cytological examinations of the synovial fluid followed by knee operation were effective for early diagnosis of MTX-LPD. MTX discontinuation with no chemotherapy followed up with a knee operation improved the recovery of the MTX-LPD.

Although biological agents are of considerable benefit to patients with rheumatoid arthritis (RA), the potential for opportunistic infections is a critical issue. It is therefore important to achieve a balance between treatment efficacy and controlling opportunistic infection. We herein report the successfully managed case of a 53-year-old patient with RA who developed pulmonary Mycobacterium abscessus infection during treatment with tocilizumab and methotrexate.