Koichiro Kawamura

Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-α blockers: perioperative interruption of tumour necrosis factor-α blockers decreases complications?

OBJECTIVE TNF-alpha blockers reportedly increase the risk of complications in rheumatic patients following surgery. Whereas deep venous thrombosis (DVT) is a significant complication after orthopaedic surgery of the lower limbs, the risk for DVT in RA patients receiving TNF blockers remains unclear. The aim of this study was to identify complications that can be attributed to the use of TNF-alpha blocker therapy. METHODS In a retrospective 1:1 pair-matched case-control study, 64 anti-TNF-treated RA surgeries (TNF group) and 64 surgeries treated with conventional DMARDs (DMARDS group) were evaluated for surgical site infection (SSI), DVT and recurrence of arthritis (flare-up). Multivariate logistic regression analysis was performed to test the association of SSI or DVT with the putative risk factors. RESULTS Regression analysis identified the use of TNF blockers as a risk factor for SSI [P = 0.036; odds ratio (OR) = 21.80] and development of DVT (P = 0.03; OR = 2.83) after major orthopaedic surgery: 12.5% (8/64) of the patients in the TNF group had SSI, whereas 2% (1/64) of those in the DMARDs group had SSI. Fifty-one per cent (23/45) of the TNF group, but only 26% (12/45) of the DMARDs group was DVT positive. Flare-ups during the perioperative period were found in 17.2% (11/64) of all patients, and no delay in wound healing occurred in either group. CONCLUSIONS These data suggest that the use of TNF blockers is a likely cause of SSI and DVT development in RA patients following major orthopaedic surgery.

Decrease in orthopaedic operations, including total joint replacements, in patients with rheumatoid arthritis between 2001 and 2007: data from Japanese outpatients in a single institute-based large observational cohort (IORRA)

Several studies from different countries show that the rate of orthopaedic surgery has decreased for patients with rheumatoid arthritis (RA) in recent years. In Sweden, there was a decrease in RA-related lower limb surgical procedures between 1987 and 2001,1 and in RA-related upper limb surgery between 1998 and 2004.2 Denmark has reported a decrease in the incidence of total hip arthroplasties due to RA,3 and the number of total joint replacement (TJR) operations and synovectomies decreased in the Norwegian population from 1994 to 2004.4 Japan has also reported the declining use of synovectomy surgery for patients with RA.5 These changes may reflect trends in disease severity, management and health outcomes in each country. Meanwhile, Sokka et al reported that the rate of TJR …

Declining use of synovectomy surgery for patients with rheumatoid arthritis in Japan

Several studies from different countries suggest that the rates of orthopaedic surgery have decreased for patients with rheumatoid arthritis (RA) in recent years. From the Rochester Epidemiology Project, there was a reduction in the overall rates for all types of joint-related surgery inpatients.1 The California State Hospitalization Database for 1983–2001 reported a decrease in the rate of total knee arthroplasty for patients with RA.2 From Scandinavian countries, there was a decrease of RA-related surgical procedures to the lower limbs in Swedish patients between 1987 and 2001,3 from Denmark a decrease in the incidence rate of total hip arthroplasties due to RA was reported,4 …

Iliopsoas bursitis-associated femoral neuropathy exacerbated after internal fixation of an intertrochanteric hip fracture in rheumatoid arthritis: a case report

We present the case of a 63-year-old woman with a six-year history of rheumatoid arthritis (RA) and a left iliopsoas bursitis. Radiography had detected destructive changes in her hip joint associated with her bursitis, and she had reported some paresthesia along the left anterior distal thigh. Her pain and numbness remained tolerable, and her disease activity was well controlled until she accidentally fell on the floor, which resulted in an unstable intertrochanteric fracture of left femur with displacement of the proximal portion. The fracture was successfully treated with open reduction and internal fixation, but after the surgery, her femoral nerve palsy worsened. She subsequently underwent bursa excision after the failure of conservative treatment. Accordingly, after bursa excision, the postoperative course was uneventful, and her neurological symptoms gradually disappeared. We would recommend that bursa excision be considered even in cases of iliopsoas bursitis associated with mild femoral neuropathy when destructive changes in the hip joint are also present.

Return of infliximab efficacy after total knee arthroplasty in a patient with rheumatoid arthritis

Dear Editor, We have read with interest the article by Kanbe and Inoue [1] concerning the treatment of synovectomy combining with infliximab for rheumatoid arthritis (RA). We encountered the case of total knee arthroplasty (TKA) inducing treatment success with infliximab in a RA patient after an infliximab secondary response failure. The present case was a 45-year-old Japanese woman who was diagnosed with RA at 38 years of age. She was treated for 2 years with methotrexate (MTX) and prednisolone (PSL) after taking other disease-modifying antirheumatic drugs. However, the disease activity remained high in spite of those medications. The patient presented to our hospital, and infliximab (3 mg/kg) was added to PSL and MTX at weeks 0, 2, and 6, followed by administration every 8 weeks. She initially had a significant decrease in disease activity, fulfilling the moderate response criteria by the European League Against Rheumatism grading system. However, the effect gradually decreased, and in particular, the right knee joint was markedly swollen and tender. Therefore, the dose of MTX was increased to 17.5 mg with the same dose of infliximab (3 mg/kg) because increasing the dose of infliximab above 3 mg/kg is not approved by the Japanese Ministry of Health, Labor and Welfare. Nevertheless, she felt more pain in her right knee joint, and after almost 3 years on infliximab, she underwent TKA after the 21st infliximab infusion. Laboratory findings showed erythrocyte sedimentation rate (ESR) 89 mm/h, C-reactive protein (CRP) 5.75 mg/dl, and Disease Activity Score in 28 joints (DAS28) 4.33 just before the operation. These data were dramatically improved after surgery: ESR=13 mm/h, CRP=0.08 mg/dl, and DAS28=2.82 at 32 weeks post operation. Thereafter, infliximab was administered for 1 year at the same dose and interval without relapse of the high disease activity. Most swollen and tender joints became asymptomatic. The blockade of tumor necrosis factor (TNF) has had a significant impact on the therapy for RA after the impressive clinical and radiological benefits observed in clinical trials. Despite the success of these therapies, a significant proportion of patients treated with infliximab fail to respond [2]. In particular, Buch et al. reported that about half of patients treated with infliximab demonstrate secondary nonresponse in the first year [3]. To overcome these response failures, several studies have sought to address the value of dose escalation of infliximab. Both the ATTRACT [2] and ASPIRE [4] studies suggest that additional efficacy can be gained from higher dosage, increased frequency of infusions [5], or switching to other TNF-alpha antagonists [6, 7]. Otherwise, the inflamed synovium in RA produces many cytokines and chemokines, which promote joint cartilage destruction, and it was thought likely that surgically removing the synovium and lavaging the joint would reduce the total amount of cytokines and chemokines. Therefore, it is possible that synovectomy can effectively be combined with infliximab treatment in RA patients with decreased infliximab efficacy or in primary nonresponders [1]. In TKA, excision of the synovial tissue is usually performed, and the pathological articular cartilage is replaced with the components. The right knee joint in this case was the primary inflamed joint after failing to respond Clin Rheumatol (2008) 27:549–550 DOI 10.1007/s10067-008-0858-4

Neglected spontaneous rupture of the Achilles tendon in elderly patients with rheumatoid arthritis.

Spontaneous Achilles tendon rupture associated with rheumatoid arthritis (RA) is a very rare complication. In this report, we have experienced neglected spontaneous rupture of the Achilles tendon in 5 elderly RA patients, and report its clinical features and management. These patients had taken corticosteroids for a long time for RA control. Moreover, they did not show any signs, such as click or impact on the rear foot at the moment of the rupture, and had few complaints or obvious symptoms around their ankles or the rear of the foot after the rupture. This suggests that the lack of severe symptoms prevented the early diagnosis of the Achilles tendon rupture, and that this injury had been neglected during treatment for RA. Therefore, careful diagnosis of the Achilles tendon rupture is needed in elderly patients with RA, even if they have little or no history of trauma.

Multiple Rheumatoid Bursal Cysts With Invasion Into the Calcaneus

A 64-year-old Japanese woman diagnosed with rheumatoid arthritis at 48 years of age was treated for 2 years with methotrexate and prednisolone after taking other disease-modifying antirheumatic drugs. However, disease activity remained high despite treatment. Cysts first became apparent in 2003 in the right forefoot, left elbow, left hindfoot, and in the left armpit. There were 2 cysts on the hindfoot: one on the inside of the calcaneus which was palpable and 7 5 cm in size, with a smooth surface and no tenderness. Aspiration yielded 25 mL fluid which was sterile on culture. The second hindfoot cyst was at the base of the calcaneus and not palpable externally. Computer tomography revealed a large mass on the inside of the left calcaneus, and a large defect in the calcaneal bone mass (Fig.1a, b). MRI indicated that the cyst had penetrated from the base of the calcaneus into the bone marrow, with an intensity graded as low on T1WI (Fig. 1c, d). These cysts were resected in September 2006. They had the form of fibrous capsules enveloping synovium and fluid. This case was unique so that this bursitis from the subcalcaneal bursa, not from the subtalal joint synovium, invaded into the calcaneus.1–3 Histologic analysis showed a fibrous tissue-like membrane which had infiltration of lymphocytes and fibrosis around a vessel that was interpreted as rheumatoid arthritis synovium.