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STUDY DESIGN A retrospective cohort study. OBJECTIVE To examine factors related to severe aggravation of pre-existing cervical lesions in patients with rheumatoid arthritis (RA) under current pharmacologic treatments with biologics. SUMMARY OF BACKGROUND DATA Advanced RA cervical lesions carry a risk of irreversible damage to the spinal cord; however, risk factors for aggravation are unclear after the use of biologics became more popular. METHODS Of 166 patients with pre-existing cervical lesions at baseline, 87 who had cervical X-ray images taken at baseline and at the final visit (with an interval of more than 1 year) were evaluated retrospectively. Aggravated instabilities determined at the final visit were defined as follows: atlantoaxial subluxation (AAS) = atlantodental interval ≧ 10 mm; vertebral subluxation (VS) = a Ranawat value < 10 mm; and sub-axial subluxation (SAS) = an anterior vertebral slip ≧ 4 mm or a multi-level slip ≧ 2 mm. Patients were divided into two groups based on the radiographic results: severe aggravation and non-severe aggravation. Explanatory variables were gender, age of RA onset, duration of disease, average observation period, Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) at baseline, drug treatment history, presence of mutilating deformities in the hands, presence of RA-related joint surgery, and the prevalence of each cervical lesion at baseline. RESULTS The severe group comprised 14 patients (16.1%). There was no significant difference between the two groups with respect to demographic data. Multivariate logistic regression analysis revealed that pre-existing SAS lesions (odds ratio: 7.59, 95% confidence interval: 1.16-49.6) and no history of biologic treatment (odds ratio, 0.10; 95% confidence interval, 0.17-0.58) were associated with aggravation. CONCLUSIONS Pre-existing SAS lesions were associated with aggravation. Meanwhile, biologics may be effective at preventing aggravation.Level of Evidence: 3.

Objective: This study evaluated the effect of surgical intervention on disease activity and factors associated with postoperative disease activity in patients with rheumatoid arthritis (RA).Methods...

Objectives To evaluate the cost-effectiveness of biologics and methotrexate (MTX) for rheumatoid arthritis (RA) using the number needed to treat (NNT) concept and total actual health care cost. Methods This study included 121 RA patients with newly prescribed biologics and/or MTX between 2012 and 2017. The NNT was calculated based on the 24 week remission rate of Disease Activity Score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR) and Clinical Disease Activity Index (CDAI). Results Remission rates were 76.4% for DAS28-ESR and 45.4% for CDAI in the biologics group and 63.6% and 24.2%, respectively, in the MTX group. The NNT was calculated as 6.4 and 4.2 in the biologics group and 34.2 and 35.2 in the MTX group, respectively. Mean total actual health care costs were 1,044,066 JPY (9835 US$)/24 weeks per treated patient in the biologics group and 75,860 JPY (715 US$)/24 weeks in the MTX group. Although the effectiveness of biologics was superior to MTX from the standpoint of NNT, the mean total health care cost and mean cost per NNT were much higher in the biologics group. Conclusions Cost-effectiveness is clearly higher for MTX than biologics from the standpoint of mean total health care cost per adjusted NNT under the Japanese health insurance system.

Purpose To investigate the prevalence and risk factors of cervical lesions in patients with rheumatoid arthritis (RA) under current pharmacological treatments with biological agents. Methods One hundred and eighty-five consecutive patients with RA who underwent both cervical plain radiography and bone mineral density (BMD) scanning were enrolled. RA cervical lesions included atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS). We assigned patients with AAS, VS, or SAS to the cervical-lesion group, and all other patients to the non-cervical-lesion group. Radiological findings, BMD, and clinical data on RA were collected. We used multivariate logistic regression analyses to assess the risk factors of cervical lesions in patients with RA. Results The cervical-lesion and non-cervical-lesion groups included 106 and 79 patients, respectively. There were 79 patients with AAS, 31 with VS, and 41 with SAS. The cervical-lesion group had younger age of onset, longer RA disease duration, and lower femoral neck BMD than those in the non-cervical-lesion group. Multivariate analyses showed that the risk factors of RA cervical lesions were RA disease duration, prednisolone usage, biological agents, and femoral neck BMD. Femoral neck BMD in patients with VS was lower than in those without VS. Conclusions Cervical lesions were confirmed in 57% of the patients. RA duration, prednisolone usage, biological agents, and femoral neck BMD were significant risk factors of cervical lesions in patients with RA. The general status of osteoporosis might contribute to the development of VS.

Background Few reports have described the association between rheumatoid arthritis (RA) cervical lesions and osteoporosis, especially in patients with vertical subluxation (VS) that could be induced by the collapse of lateral masses in the upper cervical spine. Therefore, this study aimed to investigate the prevalence and risk factors for cervical lesions in patients with RA under current pharmacological treatments with biological agents, and to investigate the relationship between osteoporosis and VS development. Methods One hundred eighty-five consecutive patients with RA who underwent both cervical plain radiography and bone mineral density (BMD) scanning were enrolled. RA cervical lesions included atlantoaxial subluxation (AAS), VS, and subaxial subluxation (SAS). We assigned patients with AAS, VS, or SAS to the cervical-lesion group, and all other patients to the non-cervical-lesion group. Radiological findings, BMD, and clinical data on RA were collected. We used multivariate logistic regression analyses to assess the risk factors for cervical lesions in patients with RA. Results The cervical-lesion and non-cervical-lesion groups included 106 and 79 patients, respectively. There were 79 patients with AAS, 31 with VS, and 41 with SAS. The cervical-lesion group had a younger age of RA onset, longer RA disease duration, higher RA stage, and lower femoral neck BMD than the non-cervical-lesion group. Multivariate analyses showed that the risk factors for RA cervical lesions were prednisolone usage, biological agent usage, and higher RA stage. Prednisolone usage and femoral neck BMD were the risk factors for VS. Conclusions Cervical lesions were confirmed in 57 % of the patients. Prednisolone usage, biological agent usage, and higher RA stage were significant risk factors for cervical lesions in patients with RA. The general status of osteoporosis might contribute to the development of VS.

Objectives: This retrospective, single-center study aimed to compare leg morphology between patients with rheumatoid arthritis (RA) and those with osteoarthritis (OA) undergoing total knee arthropl...

Objective.To investigate whether abatacept (ABA) causes more adverse events (AE) than conventional synthetic disease-modifying antirheumatic drugs (csDMARD) after orthopedic surgery in patients with rheumatoid arthritis (RA).Methods.A retrospective multicenter nested case–control study was performed in 18 institutions. Patients receiving ABA (ABA group) were matched individually with patients receiving csDMARD and/or steroids (control group). Postoperative AE included surgical site infection, delayed wound healing, deep vein thrombosis or pulmonary embolism, flare, and death. The incidence rates of the AE in both groups were compared with the Mantel-Haenszel test. Risk factors for AE were analyzed by logistic regression model.Results.A total of 3358 cases were collected. After inclusion and exclusion, 2651 patients were selected for matching, and 194 patients in 97 pairs were chosen for subsequent comparative analyses between the ABA and control groups. No between-group differences were detected in the incidence rates of each AE or in the incidence rates of total AE (control vs ABA: 15.5% vs 20.7% in total, 5.2% vs 3.1% in death).Conclusion.Compared with csDMARD and/or steroids without ABA, adding ABA to the treatment does not appear to increase the incidence rates of postoperative AE in patients with RA undergoing orthopedic surgery. Large cohort studies should be performed to add evidence for the perioperative safety profile of ABA.

Objectives: The purpose of this study was to clarify the effect of forefoot arthroplasty on plantar pressure, pain, gait, and disability within 1 year after arthroplasty in patients with RA.Methods...

Background:Iguratimod (IGU) was started development as new non-steroidal anti-inflammatory drugs (NSAIDs), but it was changed for development as disease modifying antirheumatic drugs (DMARDs) because it showed suppression of inflammatory cytokine and inflammatory parameter which was not to be found in existing NSAIDs in the early stage of pharmacological study of drug efficacy. Although the clinical efficacy and the safety of IGU were already reported, the efficacy for elderly cases was not sufficiently analyzed.Objectives:In this study, we compared the efficacy of IGU in elderly group with the non-elderly group.Methods:190 patients who were able to continuously administer IGU more than three months was included. Cases were divided into two groups. Group A (75 years or older) includes 57 patients, and Group B (younger than 75 years) includes 133 patients. The patients background, the use of methotrexate (MTX) and glucocorticoid, the change of serum CRP, and the DAS28-ESR (before, 6, 12, and 24 months) as an evaluation of the disease activity were compared between two groups. The study protocol was approved by our institutional review board. All the patients were required to give written informed consent.Results:The average age at the beginning of IGU was 79.9±4.1 years old in Group A, and 59.9±10.6 years old in Group B. The average disease duration was 14.8±16.5 year in Group A and 8.5±10.6 year in Group B (pConclusion:From the results of this study, the efficacy of IGU for elderly patients was confirmed and did not show differences with non-elderly people. IGU is an inexpensive drug with enough efficacy and thought to be possible substitute for cases with insufficient reaction with other DMARDs.References:[1]Nozaki Y, et al. Modern Rheumatology 1439-7595, 2019.[2]Yoshikawa A, et al. Mod Rheumatol 28: 227-234, 2018.Disclosure of Interests:None declared

Background Recently biologic agents are widely used for patients with rheumatoid arthritis (RA). Biologic agents are reported to have higher effectiveness than other disease-modifying anti-rheumatic drugs (DMARDs) including methotrexate (MTX), however, those new agents are more expensive. Objectives This study evaluated the cost-effectiveness of biologic agents for RA using number needed to treat (NNT) method. NNT is an index for determining the number of patients who need to be treated in order to reach a patient toward to clinical goal when a new treatment is introduced. Methods Fifty-three patients with RA was included in this study. These patients were introduced biologic agents between September 2012 to ,March 2017and continued same agent up to 24 weeks. NNT was calculated based on disease activity score (DAS28-ESR) and clinical disease activity index (CDAI) at 24 weeks. Ninety-four patients were investigated as a control group who treated with DMARDs. In addition, actual healthcare cost including doctor’s fee, laboratory examination, prescription fee, and cost of biologic agents in each patient were calculated based on hospital’s medical receipt, then averaged and compared between two groups. Results In biologic group, tocilizumab (TCZ) were used for 20 patients, golimmab (GLM) for 14 patients, etanercept (ETN) for 13 patients, and other biologics for six patients. In control group, 66 patients administered MTX and/or conventional DMARDs (csDMARDs), and 28 patients administered only csDMARDs. In biologic group, 53 patients (79.2%) achieved remission in DAS28-ESR, and 24 patients (45.2%) achieved remission in CDAI. On the other hand, the rate of remission was 61.7% and 23.4% respectively in control group. NNT was 1.26 (DAS28) and 2.21 (CDAI) in biologic group, and 1.62 and 4.27 respectively in control group. In biologic group, NNT based on DAS28-ESR of each agent was 1.11 of TCZ, 1.30 of ETN, 1.40 of GLM, and 1.50 of others (table 1). The total actual healthcare cost in the study period was 7,812.5 Euro (1044066 JPY; 1 Euro=133.6 JPY, in December 2017) in biologic group and 583.8 Euro (78020 JPY) in control group. Conclusions The total actual health care cost of biologic group was much higher than DMARDs group, however, the cost-effectiveness of biologics was superior to DMARDs from the stand point of NNT. Reference [1] Alberto B, et al. Efficacy and Treatment Costs of Monotherapy with bDMARDs in the Treatment of Rheumatoid Arthritis in Patients Intolerant to or Inappropriate to Continue Treatment with Methotrexate. Adv Ther2016;33:1360–73. Disclosure of Interest K. Harigane: None declared, Y. Mochida: None declared, K. Sahara Grant/research support from: Takeda Pharmaceutical Company Limited, Daiichi Sankyo Company, Limited, Mitsubishi Tanabe Pharma Corporation, Teijin Limited Chugai Pharmaceutical Co., Ltd, Astellas Pharma Inc., N. Mitsugi: None declared

Background: Abatacept (ABT) is clinically used as the only T-cell modifier available for rheumatoid arthritis treatment and has shown similar efficacy as tumour necrosis factor inhibitors and a safer profile, especially a lower infection ratio in registry data. Latourte et al. recently published the results of perioperative complications of orthopaedic and other types of surgery in patients using ABT. However, they did not compare the complication rates with those in patients who received csDMARDs. It remains unknown whether ABT is associated with more postoperative complications than conventional synthetic DMARDs (csDMARDs). Objectives: The aims of this study were to investigate whether ABT is associated with more adverse events after orthopaedic surgery compared with csDMARDs and, if so, to identify significant risk factors for those events. Methods: A retrospective multicenter nested case–control study was performed in 18 institutions. Patients receiving ABT were matched individually with patients receiving csDMARDs and/or steroid. Serious adverse events were defined as surgical site infection, delayed wound healing, deep vein thrombosis or pulmonary embolism, flare-up, serious infection in other organs. The incidence rates of serious adverse events in both groups were compared with Mantel-Haenzel test. Risk factors for serious adverse events in the ABT group were analyzed by logistic regression model. Results: A total of 3358 cases were collected. After inclusion and exclusion, 2651 patients were selected for matching, and 194 patients in 97 pairs were chosen for subsequent comparative analyses between the ABT and control groups. No between-group differences were detected in the incidence rates of each adverse event or in the combined incidence rate of adverse events. The odds ratio of the history of serious infection for serious adverse events was 12.6 (95%CI 1.12–141, P=0.04) in patients who received ABT and underwent orthopaedic surgery. Conclusions: Compared with csDMARDs and/or steroid without ABT, adding ABT to the treatment does not appear to increase the incidence rates of postoperative adverse events in rheumatoid arthritis patients undergoing orthopaedic surgery. A history of serious infection is a significant risk factor for both infection and other serious adverse events, and such patients should be treated with particular caution. Reference [1]Latourte A, et al. Safety of surgery in patients with rheumatoid arthritis treated by abatacept: data from the French Orencia in Rheumatoid Arthritis Registry. Rheumatology (Oxford)2017Apr 1;56(4):629–637. Disclosure of Interest: H. Ito Grant/research support from: BMS, ONO Pharmaceutical, S. Tsuji: None declared, M. Nakayama: None declared, Y. Mochida: None declared, K. Nishida: None declared, H. Ishikawa: None declared, T. Kojima: None declared, T. Matsumoto: None declared, A. Kubota: None declared, T. Mochizuki: None declared, K. Sakuraba: None declared, I. Matsushita: None declared, A. Nakajima: None declared, R. Hara: None declared, A. Haraguchi: None declared, T. Matsubara: None declared, K. Kanbe: None declared, N. Nakagawa: None declared, M. Haraguchi: None declared, S. Momohara: None declared

Background Several studies reported that development of phaemacological treatment for rheumatoid arthritis (RA) contributed to decreased number of orthopaedic surgery. [1–3] Surgical treatment is, however, still required in many cases, and the impact of orthopaedic surgery on disease activity remain unclear. Objectives This study evaluated the effect of total knee arthroplasty (TKA) with capsulosynovectomy on chenges of disease activity and medication in patients with RA. Methods Seventy-seven serial patients with RA (61 female and 16 male) who underwent primary TKA with more than one year of follow-up were retrospectively reviewed to assess postoperative disease activity and drug administration. The mean age at the time of surgery was 68.3 years old. The disease activity of RA was measured using Disease Activity Score in 28 Joints (DAS28). To evaluate the effects of medication on preoperative and postoperative disease activity, outcomes at before surgery and one year after surgery were separately investigated following two groups; patients who were treated with the same or reduced medication (same group) and patients who were administered with additional or altered medication (change group). Results Seventy-two patients (97.3%) were administered with at least one DMRDs before or after surgery. The mean dose of methotrexate (MTX) was 7.7mg/week before surgery and 8.0mg/week after surgery respectively. The number of patients who were treated with biological DMARDs was increased after surgery (17 patients vs.21 patients), however there was not significant differences. RA disease activity was significantly decreased in DAS28-CRP one year after surgery. (3.9 vs. 2.7, p Conclusions TKA with capsulosynovectomy improves disease activity after surgery in patients with RA. Based on the results, patients with higher disease activity before surgery required further medication after surgery. References Dusad A et al. Impact of Total Knee Arthroplasty as Assessed Using Patient-Reported Pain and Health-Related Quality of Life Indices: Rheumatoid Arthritis Versus Osteoarthritis. Arthritis Rheumatol. 2015; 67: 2503–11. Yano K et al. Effect of total knee arthroplasty on disease activity in patients with established rheumatoid arthritis: 3-year follow-up results of combined medical therapy and surgical intervention. Mod Rheumatol. 2010; 20: 452–7. Oh K et al. Effects of surgical intervention on disease activity of rheumatoid arthritis: cases of surgery for rheumatoid arthritis of the lower limbs treated with biologics. Mod Rheumatol. 2014; 24: 606–11. Disclosure of Interest None declared

Background Several studies reported that development of phaemacological treatment for rheumatoid arthritis (RA) contributed to decreased number of orthopaedic surgery. [1–3] Surgical treatment is, however, still required in many cases, and the impact of orthopaedic surgery on disease activity remain unclear. Objectives The aims of current study was to evaluate the effect of total knee arthroplasty (TKA) with capsulosynovectomy on changes of disease activity and knee function after TKA in patients with RA. Methods Seventy-seven serial patients with RA (61 female and 16 male) who underwent primary TKA with more than one year of follow-up were retrospectively reviewed to assess postoperative disease activity and knee function. The mean age at the time of surgery was 68.3 years old. The disease activity of RA was measured using Disease Activity Score in 28 Joints (DAS28). Clinical outcome was measured by treatment score for RA knee of the Japanese Orthopaedic Association (JOA) score. To evaluate the effects of disease activity on knee function, outcomes at before and one year after surgery were separately investigated following two groups; patients who had remission or low disease activity in DAS28-CRP (good controlled group), and patients who had moderate or high disease activity (poor controlled group) one year after surgery. Results The disease activity of RA was significantly decreased in DAS28-CRP one year after surgery. (3.9 vs. 2.7, p Conclusions TKA with capsulosynovectomy improves both knee function and disease activity in patients with RA. Based on the results, knee function after TKA is influenced with disease activity. References Dusad A et al. Impact of Total Knee Arthroplasty as Assessed Using Patient-Reported Pain and Health-Related Quality of Life Indices: Rheumatoid Arthritis Versus Osteoarthritis. Arthritis Rheumatol. 2015; 67: 2503–11. Yano K et al. Effect of total knee arthroplasty on disease activity in patients with established rheumatoid arthritis: 3-year follow-up results of combined medical therapy and surgical intervention. Mod Rheumatol. 2010; 20: 452–7. Oh K et al. Effects of surgical intervention on disease activity of rheumatoid arthritis: cases of surgery for rheumatoid arthritis of the lower limbs treated with biologics. Mod Rheumatol. 2014; 24: 606–11. Disclosure of Interest None declared

Background and purpose Synovectomy is an effective procedure for management of the rheumatoid elbow at radiographically early stages (Larsen grades 1 and 2). However, its efficacy for advanced stages (Larsen grades 3–5) is controversial. We investigated the outcome of synovectomy for advanced stages of the rheumatoid elbow. Methods Between May 1985 and September 1994, synovectomy was performed for 67 rheumatoid elbows in 59 patients (mean age 52 (26–72) years, 54 women). 3 elbows (3 patients) were lost to follow-up after mean 15 (10–23) years. Thus, 64 elbows were evaluated clinically and radiographically. Results The mean Mayo elbow performance score (MEPS) improved from 42 (15–75) points preoperatively to 78 (45–100) points at the final follow-up examination. In cases of Larsen grade 5, the mean MEPS at final follow-up examination (69 points) was lower than those of Larsen grade 3 and 4 cases (80 and 79 points, respectively) (p < 0.01). Recurrence of synovitis was obvious in 20/67 elbows. 12 cases had a...

Since biologic agents were introduced to treat rheumatoid arthritis (RA) in 2003, the number of orthopedic surgical procedures under treatment with biologic agents has been increasing in Japan. However, whether biologic agents cause an increase in the prevalence of postoperative complications is as yet unknown. The Committee on Arthritis of the Japanese Orthopedic Association investigated the prevalence of postoperative complications in patients with RA in teaching hospitals in Japan.Between January 2004 and November 2008, surveillance forms about medications and surgical procedures in patients with RA were sent to 2,019 teaching hospitals. Data were analyzed by the Rheumatoid Arthritis Committee.Biologic agents were administered to RA patients in 632 of 1,245 hospitals (50.8%); 430 of the 1,245 hospitals (34.5%) used surgical intervention under treatment with biologic agents. The number of surgical procedures under treatment with biologic agents was 3,468, and the prevalence of infection was 1.3% (46 cases). The prevalence of infection was 1.0% (567 procedures) in 56,339 procedures under treatment with nonbiologic disease-modifying anti-rheumatic drugs. There were no significant differences between biological and nonbiological treatment groups with respect to the prevalence of infection. In the joint arthroplasty group, the number of procedures under biological and nonbiological treatment was 1,626 and 29,903, and the prevalence of infection was 2.1% (34 procedures) and 1.0% (298 procedures), respectively. There was a significant difference between groups. The odds ratio was 2.12 (95% confidence interval 1.48-3.03, P0.0001).The chance of having biological treatment with joint arthroplasty was more than twofold greater in patients with surgical-site infections compared with those treated with nonbiologic agents. Caution is required for surgical procedure, perioperative course, and obtaining consent for joint arthroplasty for patients with RA undergoing surgery under biological agents.

Total elbow arthroplasty (TEA) with the GSB III prosthesis was performed in 32 patients (36 elbows) with rheumatoid arthritis between 2001 and 2009. At final follow-up, 31 patients (35 TEAs) were available for clinical and radiological evaluation. The mean follow-up period was 6.3 (2.0-10.3) years, with a minimum follow-up of 2 years. The mean Mayo elbow performance score was significantly improved from 48 points preoperatively to 83 points at final follow-up. The radiographic loosening rate was 14.3% for humeral components and 5.7% for ulnar components. There were 4 cases of intraoperative fracture and 1 case of humeral shaft fracture at 4 months after surgery. The rates for loosening and fracture were relatively low when compared with those in other studies of linked TEA. There were 2 cases of ulnar nerve palsy, but there was no deep infection or triceps disruption. The clinical results of TEA using the GSB III prosthesis in patients with rheumatoid arthritis were found to be satisfactory.

The correction angle after high tibial osteotomy (HTO) depends on an accurate preoperative planning and an accurate intraoperative technique. We hypothesized that the use of a navigation system in opening wedge HTO would improve the intraoperative target angles in the coronal and sagittal planes.Postoperative femoro-tibial angle (FTA) and tibial posterior slope (TPS) in 28 knees with navigated opening wedge HTO were compared to those in 31 knees with the conventional method. Intraoperative correction angle was determined by the predicted medial opening width in the conventional group, and by the change of hip-knee-ankle angle in the navigated group. We defined lateral unstable knee as the knees with lateral cortex breakage or lateral tibial plateau fracture.Mean postoperative FTA was higher in the conventional group than in the navigated group (P0.037). In the conventional group, 4 lateral unstable knees were corrected to 174.6°. In the navigated group, 5 lateral unstable knees were corrected to 170.3° and no knees showed FTA173°. Mean change in TPS was greater in the conventional group than in the navigated group (P = 0.001).The navigation system in opening wedge HTO might reduce undercorrection in the knees with lateral cortex breakage or lateral tibial plateau fracture, and provide the better intraoperative FTA and TPS.III.

We report a rare case of dystrophic calcinosis in a patient with rheumatoid arthritis in bilateral buttock lesions and the right elbow joint. The calcinosis was surgically removed because it caused severe local pain, possible infection, and difficulty in sitting. Because no recommended standard pharmacotherapy exists for dystrophic calcinosis, surgical treatment should be taken into consideration when calcinosis causes severe local pain or restricts activities of daily life.

We report a case of primary cervical epidural malignant lymphoma with rheumatoid arthritis. Because of the acute progression of paralysis in both legs, surgical decompression and stabilization of the cervical spine were performed. The resected specimen showed proliferation of lymphoblastic cells diagnosed as malignant lymphoma. Four series of chemotherapy were administered after surgery, and the patient recovered from paralysis.

Introduction: Orthopaedic lower limb surgeries are often performed for joint pain or destruction in rheumatoid arthritis (RA), however, there were few studies for incidences and risk factors of falls after lower limb surgeries in RA. The aim of current study was to examine the incidences of falls and to analyze the risk factors for falls in patients with RA after lower limb surgeries. Methods: Self-reported questionnaires were completed by 141 patients. The incidence of falls in patients who underwent lower limb surgeries (71 cases, 1 surgery) were compared to patients with no history of surgery. Results: The incidence rate of falls in surgery group was significantly fewer when compared to no-surgery group (9.8% vs. 38.6%, p

Background: Alendronate is a pyrophosphate analogue of bisphosphonate that has been shown to inhibit osteoclastic bone resorption. Bone formation and remodeling are necessary to establish initial fixation of uncemented implants, especially those coated with a bioactive surface such as hydroxyapatite. Because the process of bone-remodeling that culminates in new-bone formation is thought to be initiated by osteoclastic bone resorption, it is appropriate to test the influence of osteoclast-inhibiting medications on bone apposition to hydroxyapatite-coated implants. Methods: Twelve dogs underwent staged bilateral total hip arthroplasty, with twenty weeks between the first and second operations, with use of a titanium-alloy femoral stem that had a proximal macrotextured surface and a plasma-sprayed hydroxyapatite coating. Six of the dogs received oral alendronate therapy from the time of the surgery until they were killed; the other six dogs were untreated controls. The animals were killed four weeks after the second operation. Sections from matched implant sites (proximal, middle, and distal) were histologically analyzed. The linear extent of bone apposition, the linear extent and the thickness of the hydroxyapatite coating, and the total amount of cortical and trabecular bone were measured with the use of an interactive image analysis system. Results: There were no significant differences in radiographic or histologic findings between the two groups at either four or twenty-four weeks. Although the extent of the hydroxyapatite coating decreased significantly with time in both groups (p < 0.01), we identified no significant influence of alendronate on the extent of bone apposition, the extent or thickness of the hydroxyapatite coating, or the cortical or trabecular bone area around the implants. Conclusions: Many patients who are receiving alendronate for osteoporosis or other disorders may also be candidates for cementless total joint arthroplasty. Although bone formation is generally thought to be initiated by and coupled with bone resorption, our results suggest that alendronate has no discernible effect on the initial fixation of or the short-term bone-remodeling around hydroxyapatite-coated femoral total joint implants.

A prospective and quantitative animal study was performed to evaluate the production of wear particles from a spinal fixation device, and to test the hypothesis that the concentration of wear debris particles adjacent to spinal fixation hardware is correlated with the stiffness of the spinal fusion construct and local bone formation at the fusion site. An established canine segmental spinal fusion model with three interfacet fusions was used in this study. Several bone substitute materials were grafted to the area of the interfacet fusion. Internal fixation was performed on both sides of the spinous processes at each site using a stainless steel plate system in 19 dogs. After 12 weeks, spinal segments were excised, then 3-dimensional computerized tomography was used to measure bone volume and bone area of the individual fusion sites. The stiffness of each segment was tested using a servohydraulic materials testing machine. Biopsies were obtained from the soft tissues immediately around the plate system, and wear particles were collected and characterized using an electrical resistance particle analyzer, light and scanning electron microscopy (SEM) with energy-dispersive X-ray spectroscopy (EDX). Biopsies from para-spinal tissue from adjacent, unoperated spinal levels served as negative controls. Histologically, 24 of 57 specimens (42.1%) showed only fibrous tissue with no recognizable macrophages, inflammation, or debris. Fourteen of 57 specimens (24.6%), however, contained many particles that were composed of Fe, Cr, and Ni, corresponding to elements found in the fixation hardware. Another 19 specimens showed only occasional particles. The mean concentration of particles from the tissue around the plate system was 2.8 x 10(9) per gram dry tissue weight, compared to 0.5 x 10(9) particles per gram for controls (p < 0.05). Statistical analyses showed significant inverse correlation between the log particle number and stiffness (r = -0.41, p < 0.01), bone volume (r = -0.28, p < 0.05), and bone area (r = -0.34, p < 0. 05) of the corresponding segments. The concentration of particles in the tissue showed a significant inverse correlation with stiffness, bone volume, and bone area of the fusion constructs.

Background The mobile bearing knee system was introduced to lessen contact stress on the articular bearing surface and reduce polyethylene wear. The purpose of the current study was to investigate the mid-term results of patients undergoing total knee arthroplasties (TKAs) using Scorpio Plus Mobile Bearing Knee System (Stryker, Mahwah, NJ), and compare the outcomes between patients with osteoarthritis and osteonecrosis (OA·ON group) and patients with rheumatoid arthritis (RA group). Methods Eight males and 58 females were followed up for a period of 4.4- 7.6 years from June 1, 2003 to December 31, 2005. There were 53 knees with osteoarthritis, 17 knees with rheumatoid arthritis, and 6 knees with osteonecrosis. Clinical and radiographic follow- up was done using The Japanese Orthopedic Association knee rating score (JOA score) and Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Results With regard to the JOA score, there was significant improvement in both groups. The postoperative range of motion was between 0.8°and 116.8° in OA·ON group, and between 0.0° and 113.7° in RA group. There were no significant differences with the radiographic evaluation between two groups. Spontaneous dislocation of a polyethylene insert occurred in one patient, and deep infection was occurred in one patient. Conclusion There was significant improvement with regard to the clinical and radiographic results of patients undergoing TKAs using the model. The risk of polyethylene insert dislocation related to the mobile bearing TKA is a cause for concern.

Porous tantalum is a biomaterial newly applied for artificial joints. We present here 5-years follow-up report of a multicenter clinical trial of total hip arthroplasties (THA) with porous tantalum modular acetabular component (modular PTC).Study participants received 82 hips in 79 cases, with 61.2 months follow-up on average. Age at operation was 60.9 years. Clinical results were evaluated using Merle d'Aubigne Postel score. Presence of implant loosening, periacetabular radiolucency, osteolysis, and gap filling were examined for radiographic results.Merle d'Aubigne Postel score improved from 10.0 to 16.4 points. All PTC were radiographically stable, with no evidence of progressive radiolucencies. Average polyethylene wear rate was 0.004 mm/year, with no periacetabular osteolysis. Fifteen hips (18.3%) showed a gap1 mm; however, all showed bone filling within 12 months. PTC with oversized reaming was significantly less likely to have a gap. No implant failure was noted related to modularity. Resulting survival rate of modular PTC was 100% at 5 years.Modular PTC showed excellent results at 5-years of follow-up. Some hips showed periacetabular gaps, which were filled with bone within 1 year. Further follow-up was needed to determine long-term efficacy.

The purpose of this study was to evaluate the change in pelvic tilt angle (PA) in the sagittal plane in the standing and supine positions for 2 to 4 years after total hip arthroplasty (THA). Anteroposterior pelvic radiographs of 21 male and 65 female patients were investigated before and after THA yearly over 2 to 4 years. Both the standing and supine PA significantly posteriorly tilted after THA. The difference in PA between the standing and supine positions (dPA) significantly increased after THA. Although the PA in the standing and supine positions plateaued 1 year after THA, the dPA gradually increased. In addition, the percentage of patients who showed a difference of more than 10° in dPA tended to increase yearly. In particular, elderly female patients who showed posterior tilt in PA in the standing or supine positions or a large dPA before THA tended to show a dPA of more than 10° after THA.

We performed total hip arthroplasty using the non-cement impaction auto-bone-grafting method with the resected femoral head for acetabular protrusion that is not combined with the destruction of acetabular rim or dysplasia of the hip joint. Ten patients (eight women and two men) with rheumatoid arthritis who showed acetabular protrusion underwent total hip arthroplasty using this method. All patients were able to walk with full weight within 5 days after surgery. The short-term results of our cases were very good. The postoperative periods of the radiographic-bone incorporation of the grafting bone were 2 months after surgery in four joints, 3 months after surgery in four joints, and 4 months after surgery in three joints. There were no cases that showed any migration or radiolucency around the acetabular component at the time of follow-up. Our operative technique is simple and easy, and it is a useful method for the treatment of protrusion in patients with rheumatoid arthritis.

We histologically analyzed tissue biopsy specimens obtained from 4 cases of revised cementless ceramic knee prostheses. Particles were isolated from the specimens, and their size and composition were determined. Implants were removed for aseptic loosening at an average of 64 months. Histologically, polyethylene particles were seen in all cases. The concentration of the particles showed wide variation among cases. The concentration of the particles also showed a wide variation among different biopsy locations, suggesting that the particles were not distributed uniformly around the knee prostheses. Although we analyzed only 4 cases, our results show good correlation between radiographic evidence of geographic osteolysis and the concentration of wear particles. Multiple biopsy specimens may be necessary to characterize adequately particle migration around knee prostheses.

Orthopedic wear debris has been thought to be an important factor associated with osteolysis and loosening of total joint arthroplasties. Previous in vitro studies have reported that particles of wear debris induce the release of pro-inflammatory cytokines and other inflammatory mediators from macrophages and other cells. Several recent investigations, however, have suggested that the wear particles themselves may not be primarily responsible for the inflammatory cellular responses, but that the observed cytokine release in vitro may be caused by endotoxin adsorbed to commercially available particle preparations. The intracellular pathways involved in macrophage signal transduction also are poorly understood. The purposes of this study are to use isolated orthopedic wear debris particles to evaluate pro-inflammatory cytokine release and nuclear factor kappa B (NFκB) activation from macrophages. Cells from human monocyte/macrophage cell line (THP-1) were differentiated and incubated with particles of debris that had been isolated from a failed human total hip arthroplasty. The titanium-alloy particles did not evoke release of TNF-α or IL-1β whereas lipopolysaccharide (LPS) or LPS-treated debris particles induced both TNF-α and IL-1β. LPS-treated particles, but not particles alone, stimulated NFκB activation. Our results suggest that at the concentrations tested in this study, endotoxin-free wear debris particles may not themselves initiate inflammatory cellular responses in differentiated THP-1 cells. It is unclear whether adsorbed endotoxin is clinically associated with osteolysis and/or loosening in total joint arthroplasties, but several factors, including adsorbed endotoxin, need to be investigated to explore the cellular responses responsible for osteolysis and/or loosening. © 2001 Wiley Periodicals, Inc. J Biomed Mater Res 59: 507–515, 2002

In an effort to improve the surface and wear characteristics of ultra-high molecular weight polyethylene, an enhanced ultra-high molecular weight polyethylene (Hylamer; DePuy-DuPont Orthopaedics, Wilmington, Delaware)6 was introduced in 1991. It was anticipated that the wear characteristics of a Hylamer acetabular surface in combination with a ceramic modular femoral head would improve the long-term performance of prostheses in young, active patients4,25. Several recent reports, however, have described wear and early osteolysis in association with Hylamer acetabular liners coupled with cobalt-chromium modular femoral heads manufactured by various companies3,15. The purpose of the current report is to describe rapid wear and early osteolysis following use of a Hylamer acetabular liner in combination with a ceramic femoral head made by the same manufacturer. In April 1994, a total hip arthroplasty was performed on a thirty-three-year-old woman (height, 167 centimeters; weight, fifty-two kilograms) who had arthritis due to congenital dysplasia of the left hip. The patient's preoperative work activities as an accountant had required frequent climbing and descending of multiple sets of stairs, which had greatly aggravated the problems with the hip. The work environment subsequently was modified to better accommodate the patient. The arthroplasty was performed with use of components from the same manufacturer. These included a femoral component (Stability; DePuy Orthopaedics, Warsaw, Indiana) measuring twelve by 150 millimeters, which was inserted without cement; an acetabular shell (Duraloc; DePuy Orthopaedics) with a diameter of fifty-two millimeters, also inserted without cement; a Ti-6Al-4V bone-screw (Low Profile; DePuy Orthopaedics) with a diameter of 6.5 millimeters and a length of thirty millimeters, for augmentation of the cup; and a neutral Hylamer liner measuring fifty-two by twenty-eight millimeters with a thickness of eight millimeters. Because of the patient's young age, activity level, and life expectancy, an aluminum-oxide-ceramic modular …

Background Recent studies showed that biologic agents (biologics) may increase the risk of perioperative complications. However, there were limited reports that investigated detailed perioperative clinical features in patients with rheumatoid arthritis (RA) treated with biologics. Objectives The purposes of this study were to investigate perioperative clinical features and complications in RA patients treated with biologics. These data were compared to patients treated without biologics. Clinical features and complications were also analyzed according to surgical procedure. Methods Between 2007 and 2011, patients who underwent orthopaedic surgeries treated with biologics were reviewed (Group A; 53 females and 4 males). We also selected patients who were treated without biologics during same time period with adjusting the age and the ratio of male and female (Group B; 55 females and 3 males). In addition, patients in Group A were divided into major surgery (28 patients; total hip, knee, elbow, and ankle arthroplasty) or with minor surgery (29 patients; other orthopaedic joint surgery). In both groups, perioperative general conditions and orthopaedic complications (surgical site infection; SSI, delayed wound healing) were investigated. As the assessments of perioperative clinical features, the levels of C-reactive protein (CRP), white blood cell (WBC), total protein (TP), albumin (Alb), aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine (Cr), and MMP-3 were examined. As the assessments of recovery of patient’s general status after surgery, the %recovery of TP (%TP), %recovery of Alb (%Alb), and %recovery of Hb (%Hb) were examined. The %recovery was defined as follows: (2-week postoperative level/preoperative level)×100%. Results Perioperative laboratory data showed no statistical significant difference between two groups at any study period. There were also no statistical significant differences in %TP, %Alb, and %Hb between two groups. In Group A, mean level of CRP at 1 week after surgery (3.9mg/dl) were significantly higher in patients with major surgery than in patients with minor surgery (1.1mg/dl) (p Conclusions Most of orthopaedic surgeries in RA patients treated with biologics were performed safely when compared with the patients treated without biologics. In patients treated with biologics, perioperative complications and clinical features showed no conspicuous difference regardless of surgical procedure. The treatment with biologics also did not affect the recovery of patient’s general status after surgery. Disclosure of Interest None Declared

Background Recent treatment of rheumatoid arthritis (RA) was dramatically improved after introducing biological agents. Although there are limited number of reports that analyzed the effect of biological agents from the view point of histopathology, the specific findings and the significance of biological agents on histological changes of joint synovium is remained uncertain. Objectives The purpose of this study was to compare the histopathological findings of synovium in patients with RA between 2 groups with and without use of the biological agents. Methods 79 biopsy specimens of synovium were obtained during joint surgery from 67 cases of RA. The histopathological findings of synovium in each specimen were evaluated and scored for detailed findings such as synoviocyte hyperplasia, fibrosis, proliferating blood vessels, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, and diffuse infiltrates of lymphocytes using the histological score of the synovium by Rooney et al. For immunohistochemistry, tissue sections were stained with TNF-a mouse monoclonal antibody and IL-6 rabbit polyclonal antibody. Then each microscope slides was assessed and compared between two groups. Group with the use of biological agents (Group A) included 30 cases with 39 joint specimens. In Group A, 12 cases (15 joints) used etanercept, 12 cases (15 joints) used infliximab, 3 cases (4 joints) used tocilizumab, and 3 cases (5 joints) used adalimumab at the time of surgery. Group without use of biological agents (Group B) included 37 cases with 37 joints. These cases underwent surgery during same study period as Group A. The variations of surgery in both group was similar. The background data such as age, averaged duration of disease, CRP, MMP-3, DAS-28 score, and mean dose of methotrexate (MTX) and prednisolone (PSL) were not different between two groups. Results Group A showed significantly decreased scores in synovial hyperplasia, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, diffuse infiltrates of lymphocytes and also total score than in the Group B. In contrast, Group A showed significantly increased scores in fibrosis. No correlation between total Rooney’s score and age, Larsen’s classification, Steinblocker’s classification, duration of disease, or preoperative values of CRP and MMP-3 was found in each group. In Group A, no difference of total Rooney’s score was found by variety of biologics, additionally, there was no correlation between total Rooney’s score and the duration of administration of biologics. Although no correlation was found between mean dose of MTX and total Rooney’s score in each group, Group A showed negative correlation between dose of PSL and total Rooney’s score (p=0.015). The results of immunohistochemistry showed that Group A had significantly less cases stained with TNF-a than in Group B (p Conclusions Based on these results, fibrosis around the synovium was thought to be one of specific findings of the effect of biological agents for RA. The negative correlation between dose of PSL and total Rooney’s score in Group A may suggest some synergistic effect of PSL and biologics. Disclosure of Interest None Declared

Background Some studies reported that patients with rheumatoid arthritis (RA) have a high risk of falls compared with healthy aged people1)2). Pain in the lower extremities and impairment in walking were reported to be associated with falls in patients with RA2)3). Orthopaedic lower limb surgeries are often performed for joint pain or deformation. After surgery, the incidence of falls might decrease, however, there were few studies about the incidences and risk factors of falls in patients with RA after lower limb surgeries. Objectives The aims of current study were to examine the incidences of falls and to analyze the risk for falls in RA patients in association with lower limb surgeries. Methods Self-reported questionnaires were performed for 141 patients (121 female and 20 male) who came to our hospital for regular visit from July 2010 to April 2011. Patients who underwent surgery within a year or could not walk were excluded. The incidences of falls in patients who underwent lower limb surgeries (71 cases, 115 surgeries) were compared to patients with no history of surgery (70 cases). With regard to procedures, total knee arthroplasty was performed in 44 cases, toe plasty was in 28 cases, total hip arthroplasty was in 14 cases, and others were 29 cases. Results The incidence rate of falls in patients who underwent lower limb surgery was significantly fewer than in patients with no history of surgery (9.8% vs. 38.6%, p Conclusions The rate of falls was decreased in 30% of the patients after surgery. Also, walking ability clearly improved after surgery in 34% of the patients, which may resulted in decreased incidence of falls. Some patients had high disease activity even after surgery, which may be the reason why the frequenciy of falls increased in 6% of the patients after surgery. Tender joint counts and DAS28-CRP(4) were significant risk factors for falls, on the other hand, history of lower limb surgery was negative risk factor. References Kaz Kaz H et al. Fall-related risk factors and osteoporosis in women with rheumatoid arthritis. Rheumatology 2004 43: 1267-71 T Furuya et al. Associated factors for falls and fear of falling in Japanese patients with rheumatoid arthritis. Clin Rheumatol 2009 28: 1325-30 M Hayashibara et al. Incidence and risk factors of falling in ambulatory patients with rheumatoid arthritis: a prospective 1-year study. Osteoporos Int. 2010 21(11): 1825-33 Disclosure of Interest None Declared

To compare the properties of wear debris between ceramic-on-ceramic and ceramic-on-polyethylene total hip prostheses, particles were isolated and characterized from tissue biopsies obtained at revision arthroplasty or autopsy from two similar uncemented modular hip systems. Group A hips (11 patients; mean, 31 months in vivo) had titanium shells with alumina inserts, alumina femoral heads, and titanium alloy stems. Group B hips (seven patients; mean, 42 months) were the same as Group A but with polyethylene acetabular inserts. Particles were characterized using an electrical resistance particle analyzer, scanning electron microscope, and energy dispersive xray spectroscope. Most of the particles in Group A were ceramic, whereas most of the particles in Group B were polyethylene. Metal particles from the femoral stem and the acetabular shell also were present. If one Group A hip with impingement is excluded, the rate of particle production is significantly lower in the ceramic-on-ceramic group than in the ceramic-on-polyethylene group. With the number of samples available, no significant difference in average size could be detected among the different types of particles or among the groups.