Atsunori Tokushige

Rotational Acetabular Osteotomy for Habitual Hip Dislocation With Posterior Acetabular Wall Deficiency in Patients With Down Syndrome

Hip dislocation associated with Down syndrome is relatively rare. Hip dislocation can progress to severe subluxation or habitual dislocation if the initial therapy is improperly performed. However, definitive treatment guidelines for conservative and surgical therapy for hip dislocation in patients with Down syndrome have not been established. This article describes a case of a 12-year-old girl with Down syndrome with nontraumatic habitual hip dislocation. Her hip joint was associated with acetabular dysplasia and hypoplasia of the posterior acetabular wall. Although conservative therapy was initially performed, no effects were observed. Rotational acetabular osteotomy and capsular plication were performed to reconstruct the posterior acetabular wall. No postoperative redislocation occurred, and the treatment effects were favorably sustained for 2 years. In Down syndrome, few cases of developmental dysplasia and hypoplasia of the posterior acetabular wall have been reported. In previous reports, these morphological abnormalities were rarely taken into consideration when determining the treatment strategy, and to our knowledge, no other reports demonstrate therapy involving rotational acetabular osteotomy for hip dislocation complicated with Down syndrome. Whether the acetabulum had posterior wall deficiency was thought to be important for conservative and surgical therapies in hip dislocation in patients with Down syndrome. Rotational acetabular osteotomy could be an effective surgical procedure for reconstruction of the acetabulum by posterolateral rotation of the osteotomized acetabulum.

Postpartum pyogenic sacroiliitis with methicillin-resistant Staphylococcus aureus in a healthy adult: A case report and review of the literature

OBJECTIVE Back and buttock pain during pregnancy and the postpartum period generally improves spontaneously and rarely causes problems. However, such pain is infrequently induced by pyogenic sacroiliitis. CASE REPORT We herein present a 37-year-old female patient with no previous medical history who developed pyogenic sacroiliitis with severe right buttock pain 7 days after cesarean delivery. Arthrocentesis was performed, and a culture revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA). After 6 weeks of treatment with intravenous antibiotics, her infection became quiescent. Eight cases of pyogenic sacroiliitis during the postpartum period and seven cases during pregnancy have been reported, but most of the causative pathogens were methicillin-sensitive Staphylococcus or Streptococcus species. CONCLUSION This report describes the first case of postpartum pyogenic sacroiliitis caused by MRSA. The frequency of infection with MRSA has recently increased, and community-acquired MRSA, which affects even healthy young people, has also become a problem. Antibiotics for empirical therapy after a diagnosis of pyogenic sacroiliitis, including anti-MRSA antibiotics, should be carefully selected.

Risk Factors Associated With Short-term Clinical Results After Total Hip Arthroplasty for Patients With Rheumatoid Arthritis

Clinical outcomes of total hip arthroplasty for rheumatoid arthritis are reportedly worse than those of total hip arthroplasty for osteoarthritis of the hip. The authors examined pre- and postoperative factors associated with the modified Harris hip score (mHHS). Fifty-one joints of 48 rheumatoid arthritis patients who underwent total hip arthroplasty were studied retrospectively. The authors examined the correlation between preoperative rheumatoid arthritis disease activity (Disease Activity Score in 28 joints-C-reactive protein and C-reactive protein) and mHHS at 1 year after total hip arthroplasty. Furthermore, pre- and postoperative mHHS values were compared between patients with other affected joints and patients with no affected joints in the lower limbs. The mean mHHS improved to 73.5 points postoperatively from 36.4 points preoperatively. Preoperative Disease Activity Score in 28 joints-C-reactive protein and C-reactive protein values were negatively correlated with pre- and postoperative mHHS values. Preoperative mHHS was not significantly different between the affected and not affected groups; however, postoperative mHHS was significantly lower in the affected group than in the not affected group. Total hip arthroplasty showed good clinical results for rheumatoid arthritis at short-term follow-up. However, pre- and postoperative mHHS values were influenced by preoperative rheumatoid arthritis disease activity. Moreover, the presence of additional affected joints in the lower limbs preoperatively resulted in a lower postoperative mHHS. Unlike patients with osteoarthritis, patients with rheumatoid arthritis often have multiple affected joints, which may contribute to a lower mHHS. Comprehensive treatment, including surgery for the other affected joints in the lower limbs, may improve a patients postoperative mHHS. [Orthopedics. 2018; 41(6):e772-e776.].

Weight bearing joints destruction in rheumatoid arthritis.

In many cases of rheumatoid arthritis (RA) joints of the upper extremities are affected. However, involvement of weight bearing joints of the lower extremities is strongly associated with a decreased activities of daily living ability such as gait disorder. Once the progression of weight bearing joint destruction occurs, lower extremity function will decrease even if RA disease activity is improved by pharmacotherapy. In this article, we investigated joint destruction suppressing effects of pharmacotherapy on the hip and knee joints, as well as risk factors for joint destruction. We also discuss surgical treatment strategies and clinical outcomes for progressive joint destruction.

Morning Stiffness in Rheumatoid Arthritis: Investigating its Relationship with Disease Activity as Assessed by Power Doppler Ultrasonography and Composite Scores

Abstract Objective: This study investigated potential associations of morning stiffness (MS) with rheumatoid arthritis (RA) disease activity and ultrasonography (US). Methods: We conducted a cross-sectional analysis of 100 consecutive patients with RA divided into MS-positive group (n = 38) and MS-negative group (n = 62). US findings, disease activity score in 28 joints (DAS28) and Clinical Disease Activity Index (CDAI) were compared. Results: DAS28, CDAI and the number of power Doppler (PD) signal-positive joints were significantly higher in the MS-positive group (p < 0.01). The number of patients who did not achieve the DAS28 or CDAI remission criteria was significantly higher in the MS-positive group (p < 0.01). When cut-off points were applied, MS duration of ≥10 min was associated with PD signal-positive joints, with a sensitivity of 47.5% and a specificity of 92.3% (area under curve = 0.7087, chi-square test: p < 0.0001). Conclusion: This study showed that in patients with MS duration of ≥10 min, there was a high probability of PD-positive joints in the hand.

AB0319 Is DAS28 a Useful Tool for Evaluating Hip Joint Disorders in Rheumatoid Arthritis

Background The 28-joint disease activity score (DAS28) is a particularly widely-used tool because it enables the physician to easily understand the state of RA. However, DAS28 assessment is primarily targeted to the joints of the upper extremity, being limited in the lower extremities to only the knee joints. Hip joints are weight bearing and their spherical shape tends to concentrate the load onto the weight-bearing area, where rapid joint distraction is often reported. Therefore, early diagnosis and treatment are essential. However, hip joints are located deep within the body, often making it difficult to obtain physical findings, such as swelling, thereby leading to delayed diagnosis. Objectives In our present study, we examined the relationship between the histological severity of synovitis in the hip joint and the DAS28 score. We also evaluated whether DAS28 is useful for hip joint assessment. Methods We studied 31 joints of 27 patients with rheumatoid arthritis of the hip who had undergone total hip arthroplasty. In all cases, the hip joint removed during the operation was histologically evaluable for synovitis. The subject population had a mean age of 66.3 years and mean disease duration of 13.4 years. As preoperative assessment, disease activity of RA was evaluated using DAS28 using C-reactive protein (DAS28-CRP) and CRP, and hip joint function was evaluated by the Japanese Orthopaedic Association (JOA) score for hip function. A perfect JOA score is 100 and the worst score is 0. In addition, the severity of synovitis was assessed employing the synovitis score for hematoxylin-eosin stained specimens as proposed by Krenn et al. and the correlations among individual parameters were tested for statistical significance. Results In the preoperative assessment, mean DAS28-CRP was 2.94±0.79, mean CRP was 1.85±0.36 mg/dL, and the mean JOA score was 39.0±13.1 points. The DAS28-CRP correlated negatively with the JOA score (r=-0.6188, P=0.0002). The mean synovitis score was 3.97±0.32 points, and correlated positively with both DAS28-CRP and CRP (r=0.4565, P=0.0098)(r=0.4509, P=0.0109). Furthermore, the synovitis score did not correlate with the JOA score. Conclusions We found significant negative correlations between preoperative DAS28 and JOA score in RA patients. The result suggests that DAS28 without hip joint assessment can indirectly represent the status of hip joints. In addition, the histological severity of synovitis in the hip joint showed positive correlations with both DAS28-CRP and CRP, supporting the usefulness of DAS28 as an indirect assessment tool for hip joints. In patients with highly active disease, physical findings may not be significant, but screening employing not only X-rays but also ultrasonography and magnetic resonance imaging, focusing on potential hip joint disorders, is anticipated to contribute to early diagnosis and prevention of hip joint destruction. References Krenn V et al. Synovitis score: discrimination between chronic low-grade and high-grade synovitis. Histopathology 49;358-64,2006 Disclosure of Interest None declared

FRI0595 Association Between Morning Stiffness and Disease Activity and Assessment of Ultrasonography in Rheumatoid Arthritis

Background Duration of morning stiffness (MS) was part of the American classification criteria for rheumatoid arthritis (RA) (1), but MS was excluded from its recent update and is now regarded as a less valuable measure to assess RA. However, MS is a common symptom associated with RA, Mattila (2) reported that RA-related MS reduces ability of patients to work and contributes to their retirement. Therefore, MS is an important symptom in patients with RA. Objectives Purpose of our study was investigation of association between MS and disease activity and assessment of ultrasonography (US) in RA. Methods We conducted a retrospective analysis of 100 consecutive patients with RA (32 males, 68 females; mean age, 63.7±1.1 years; range 35–86 years; mean disease duration, 104±12 months; range 0–564 months). Patients were routinely assessed by US of the wrists, metacarpo-phalangeal and proximal interphalangeal joints. US, estimation of duration of MS (minutes) and clinical and laboratory examinations of all patients were performed on the same day. Patients were divided into the following two groups: “MS positive group” and “MS negative group”, and the US findings, SJC, TJC, CRP, DAS28-CRP, CDAI and SDAI were compared. Prior to US, all patients were checked for clinical disease activity by a consultant rheumatologist. Power Doppler examination was performed by the same rheumatologist. Blood was sampled from each patient by a cannula inserted into the vein on the same day as US and clinical assessment. Blood samples were analysed to determine the serum C-reactive protein level. Results MS was positive in 38 of 100 patients and the following parameters were significantly higher in the MS positive group as compared with the MS negative group: number of SJC, number of TJC, PGA, EGA, DAS28-CRP, CDAI, SDAI and number of PD signal-positive joints. Number of patients who did not achieve DAS28-CRP, CDAI or SDAI remission was significantly higher in the MS positive group (Table1). By logistic regression analysis, CDAI and number of PD signal-positive joints were associated with presence of MS (CDAI, P=0.0191, 95% confidence interval (CI), −0.50 to −0.05; number of PD signal-positive joints, P=0.0482, 95% CI, −0.78 to −0.02). We performed a receiver-operating characteristic (ROC) analysis to determine if MS could predict the remission of CDAI not being achieved or the presence of PD signal-positive joints in the hand. When cut-off points determined by ROC analysis were applied, MS ≥10 was found to be associated with synovitis in hand, with a sensitivity of 47.5% and a specificity of 92.7% (AUC =0.7438, chi-square test; P<0.0001, 95% CI; 0.6222 to 0.7823), and MS ≥3 was found to be associated with remission of CDAI not being achieved, with a sensitivity of 49% and a specificity of 93% (AUC =0.7087, chi-square test; P<0.0001, CI; 0.6713 to 0.8050). Conclusions MS is a useful clinical finding for predicting synovitis in hand joints as well as not achieving remission of CDAI in patients with RA. References Arnett FC1, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.Arthritis Rheum. 1988; 31:315-24. Mattila K, Buttgereit F, Tuominen R. Impact of morning stiffness on working behaviour and performance in people with rheumatoid arthritis. Rheumatol Int. 2014; 34:1751-8 Disclosure of Interest None declared

AB0294 Preoperative Factors Associated with Outcomes of Total Hip Arthroplasty in Rheumatoid Arthritis

Background Although the outcomes of total hip arthroplasty (THA) for rheumatoid arthritis (RA) is reported to be comparable with osteoarthritis (OA) patients in terms of fixation of implants, symptoms are often observed in multiple joints in cases of RA, unlike OA. It is assumed that postoperative function of the lower limbs is affected by many factors in RA. Objectives In this study, RA patients who had undergone THA were retrospectively surveyed to examine the association of the pre- and postoperative function of the hip joint with disease activity of RA, affected joints except operated hip, and severity of destruction of the hip joints. Methods Out of patients who underwent THA for RA, this study included 25 patients with 31 joints. The subjects were all female. The mean age at the time of surgery was 65.9 years. The preoperative mean values of the 28-joint disease activity score using C-reactive protein (DAS28-CRP), CRP, and the Japanese Orthopedic Association (JOA) score for hip function were 3.12, 2.41 mg/dl, and 39.4 points, respectively. The median Larsen grade of the operated joints was grade 5. The JOA scores were compared between before and one year after surgery, and it was investigated how the JOA scores were correlated with DAS28-CRP, CRP, swollen joint count (SJC), tender joint count (TJC), and Larsen grade. Moreover, the evaluation targeting 44 joints revealed 16 patients with affected joints except operated hip joint in the lower limbs. The JOA scores were compared between the patients with affected joints except operated hip joint and those with no affected joints in the lower limbs. Results The JOA scores one year after surgery averaged 74.1 points and were improved in all cases. The preoperative JOA scores were negatively correlated with preoperative CRP and DAS28-CRP. However, Larsen grade and the JOA scores were not correlated. Preoperative JOA scores were positively correlated with postoperative JOA scores. Preoperative DAS28-CRP, CRP, and TJC were negatively correlated with postoperative JOA scores. However, there was no correlation between preoperative SJC and postoperative JOA scores. Moreover, the postoperative JOA scores were significantly lower in those with preoperative affected lower limb joints except operated hip joint. Conclusions Singh JA et al. reported that although there was no significant difference in the improvement of pain, the outcomes for daily activities were significantly worse in the RA patients than in the OA patients. In the present study, the preoperative DAS28-CRP, CRP, and TJC were significantly and negatively correlated with the postoperative JOA scores, indicating that the preoperative disease activity of RA affected the postoperative outcomes. We also demonstrated that the involvement of the other joint of the lower limbs at the time of THA led to poor postoperative function of the hip. RA is an inflammatory disease of multiple joints, unlike OA. In order to improve the surgical outcomes in RA patients undergoing THA, preoperative control of the disease activity of RA, particularly tenderness and treatment of the affected joints of the lower limbs are important. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4963

AB0352 Patellar non-resurfacing in total knee arthroplasty for rheumatoid arthritis

Background Patellar resurfacing in total knee arthroplasty (TKA) remains controversial. However, a number of authors have recommended routine patellar resurfacing of patella in patients with rheumatoid arthritis. Objectives To investigate whether patellar resurfacing in TKA is appropriate in patients with rheumatoid arthritis. Methods A total of 20 primary TKAs without a resurfacing patella were studied in 14 patients with rheumatoid arthritis. TKAs were performed at our institution between January 2000 and December 2007. All patients were females, and the mean age at the time of surgery was 65.5 years (range 51–74 years). The mean follow-up period after surgery was 7.0 years (range 4–10 years). The components Nexgen LPS-flex (Zimmer), Advance (Wright Medical), Scorpio PS (Stryker Orthopedics) and Vanguard PS (Biomet) were used in 7, 7, 4 and 2 knees, respectively. Clinical assessments after surgery were evaluated by a Knee Society score and patella-specific questions at all intervals. Questions included the presence of anterior knee pain, the relationship of pain with stair climbing and arising from a chair and the presence of patellar crepitus. Radiological evaluations were performed immediately after the surgery and at the time of follow-up examination. Results The mean knee score was 82.5 ± 11.6 (range 52–100) and the mean function score was 55.9 ± 31.6 (range 0–100) at follow-up. The rate of occurrence of anterior knee pain was 5% (1 case) and that of rising from a chair or stair climbing was 10% (2 cases) at follow-up. During the follow-up period, no patient underwent revision surgery for symptoms related to the patellofemoral joint. Radiographic evaluations are displayed in Table 1. Image/graph Conclusions For the rheumatoid arthritis, patellar resurfacing was recommended at the time of TKA 1, 2). However, few studies report highly satisfactory results in terms of pain relief and function in rheumatoid arthritis and recommended non-resurfacing TKA to avoid the potential complications associated with prosthetic patellar replacement3,4). In this study, there was no change in patellar thickness and congruencies with time, and no patient underwent revision surgery for symptoms related to the patellofemoral joint. A non-resurfacing patella in TKA for rheumatoid arthritis could obtain good mid-term results. However, patellofemoral joint space narrowing progressed significantly; therefore, further study on long-term results is essential. References Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Am. 2003 Feb;85-A(2):212-7. Kawakubo M, Matsumoto H, Otani T, Fujikawa K. Radiographic changes in the patella after total knee arthroplasty without resurfacing the patella. Comparison of osteoarthrosis and rheumatoid arthritis. Bull Hosp Jt Dis. 1997;56(4):237-44. Holt G, Miller N, Kelly MP, Leach WJ. Retention of the patella in total knee arthroplasty for rheumatoid arthritis. Joint Bone Spine. 2006 Oct;73(5):523-6. Epub 2006 Apr 19. Deehan DJ, Phaltankar PM, Pinder IM. Do we need to replace the patella in knee arthroplasty for rheumatoid disease? Acta Orthop Belg. 2008 Aug;74(4):478-82. Disclosure of Interest None Declared