Ryuichi Nakahara

Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis

The aim of this report was to review the use of orthopedic surgeries performed to manage rheumatoid arthritis (RA). Our review of studies published in English indicates that there has been a decrease in RA-associated surgeries in Western countries. Improvements in medical treatment may partly explain the reduction in numbers of orthopedic joint surgeries, which also suggests a worldwide trend toward improved long-term outcomes. However, the results of our multicenter study in Japan indicate that the number of RA-associated operations has not decreased, and that the numbers of operations performed annually have been relatively stable from 1998 to 2008. Although there definitely has been a decline in the numbers of synovectomy surgeries, the numbers of operations on the upper limbs and foot arthroplasties have increased. With the trend toward milder disease because of improved medical treatment, we speculate that RA patients may want and need better function for the activities of daily living. The combination of medical treatment and surgical intervention is thought to improve outcomes in RA patients who will develop joint destruction. Additional studies, including analyses of RA databases containing long-term data on a variety of surgical interventions, are needed.

Abatacept management during the perioperative period in patients with rheumatoid arthritis: report on eight orthopaedic procedures

1 Department of Human Morphology, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan, 2 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan, and 3 Department of Orthopaedic Surgery, Kurashiki Sweet Hospital, Kurashiki City, Okayama, Japan

Time–concentration profile of serum etanercept in Japanese patients with rheumatoid arthritis after treatment discontinuation before orthopedic surgery

The treatment strategy for rheumatoid arthritis (RA) has changed dramatically over the past decade with the introduction of biologic agents [1]. In Japan, three inhibitors of tumor necrosis factor-alpha (TNFa), infliximab, etanercept, and adalimumab, and the anti-interleukin (IL)-6 receptor antibody tocilizumab are available as new treatment options for RA. Surgical-site infections (SSIs) are the major concern in orthopedic surgery for RA patients treated with biologic agents [2]. Most national guidelines suggest withholding biologic agents before surgery and restarting them postoperatively if there is no evidence of infection and delayed wound healing. In general, it was accepted that orthopedic surgery could be carried out relatively safely in the middle of the 8-week interval in which infliximab was administered at 3 mg/kg [3]. However, perioperative management in patients using etanercept has not reached a general consensus because of the lack of information about the pharmacokinetics of the serum concentration of etanercept after treatment discontinuation in patients with RA. In the present study, all subjects gave their written informed consent and the study was approved by the ethics committees of two institutes (Okayama University, number 410; and Kurashiki Kosai Hospital). Seven patients with RA undergoing orthopedic surgery were the study population. The patients’ characteristics are summarized in Table 1. Patients were treated with etanercept (25 mg, s.c.) twice a week for a mean duration of 12.7 months (range, 3–23 months). Blood samples were obtained 1, 4, 7, 11, 14, and 21 days after treatment discontinuation. The samples were centrifuged, and the serum compartments were stored at -80 C before analyses. Etanercept concentrations were measured by a validated enzyme-linked immunosorbent assay (ELISA) method at SRL (Tokyo, Japan). This ELISA method utilized a ‘‘sandwich’’ format to measure etanercept, as previously reported [4, 5]. Table 2 presents the mean and median ± SD values for the serum concentration of etanercept (ng/mL) at each time-point after discontinuation. The revised guidelines from the Japan College of Rheumatology in 2008 suggest that treatment with infliximab, etanercept, and adalimumab should be withheld 2–4 weeks before major surgical procedures. Treatment may be restarted postoperatively if there is no evidence of infection and once wound healing is deemed satisfactory [6]. Guidelines from the British Society for Rheumatology for prescribing TNFa blockers in adults with RA also suggest the same protocol for discontinuation [7]. However, long-term discontinuation of etanercept may induce flareup of the disease, and a shorter discontinuation period before surgery may be associated with the risk of SSI and delayed wound healing. The interruption of etanercept K. Nishida (&) Department of Human Morphology, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, Okayama 700-8558, Japan e-mail: knishida@md.okayama-u.ac.jp

Risk factors for surgical site infection and delayed wound healing after orthopedic surgery in rheumatoid arthritis patients

Abstract Objective: To investigate the prevalence and the risk factors of surgical-site infection (SSI) and delayed wound healing (DWH) in patients with rheumatoid arthritis (RA) underwent orthopedic surgery. Methods: We reviewed the records of 1036 elective orthopedic procedures undertaken in RA patients. Risk factors for SSI and DWH were assessed by logistic regression analysis using age, body mass index, disease duration, pre-operative laboratory data, surgical procedure, corticosteroid use, co-morbidity, and use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and biological DMARDs (bDMARDs) as variables. Results: SSI and DWH were identified in 19 cases and 15 cases, respectively. One case of SSI and three cases of DWH were recorded among 196 procedures in patients using bDMARDs. Foot and ankle surgery was associated with an increased risk of SSI (odds ratio (OR), 3.167; 95% confidence interval (CI), 1.256–7.986; p = 0.015). Total knee arthroplasty (TKA; OR, 4.044; 95% CI, 1.436–11.389; p = 0.008) and disease duration (OR, 1.004; 95% CI, 1.000–1.007; p = 0.029) were associated with an increased risk of DWH. Conclusions: Our results indicated foot and ankle surgery, and TKA and disease duration as risk factors for SSI and DWH, respectively. bDMARDs was not associated with an increased risk of SSI and DWH.

Architecture of the Subendothelial Elastic Fibers of Small Blood Vessels and Variations in Vascular Type and Size

Most blood vessels contain elastin that provides the vessels with the resilience and flexibility necessary to control hemodynamics. Pathophysiological hemodynamic changes affect the remodeling of elastic components, but little is known about their structural properties. The present study was designed to elucidate, in detail, the three-dimensional (3D) architecture of delicate elastic fibers in small vessels, and to reveal their architectural pattern in a rat model. The fine vascular elastic components were observed by a newly developed scanning electron microscopy technique using a formic acid digestion with vascular casts. This method successfully visualized the 3D architecture of elastic fibers in small blood vessels, even arterioles and venules. The subendothelial elastic fibers in such small vessels assemble into a sheet of meshwork running longitudinally, while larger vessels have a higher density of mesh and thicker mesh fibers. The quantitative analysis revealed that arterioles had a wider range of mesh density than venules; the ratio of density to vessel size was higher than that in venules. The new method was useful for evaluating the subendothelial elastic fibers of small vessels and for demonstrating differences in the architecture of different types of vessels.

The clinical course of patients with rheumatoid arthritis who underwent orthopaedic surgeries under disease control by tofacitinib

Keiichiro Nishida, Ryozo Harada, Yoshihisa Nasu, Ayumu Takeshita, Ryuichi Nakahara, Masamitsu Natsumeda and Toshifumi Ozaki Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan; Department of Orthopaedic Surgery, Kurashiki Sweet Hospital, Okayama, Japan; Department of Medical Materials for Musculoskeletal Reconstruction, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan; Department of Musculoskeletal Traumatology, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan; Mabi Memorial Hospital Rheumatic Disease Center, Kurashiki, Japan

Short-term results of the PROSNAP linked elbow prosthesis with a snap-in structure and modular flange for the reconstruction of severely damaged rheumatoid elbows

BACKGROUND We aimed to evaluate the early clinical results of the reconstruction of problematic elbow joints due to rheumatoid arthritis (RA) using a PROSNAP linked elbow prosthesis (Kyocera Medical, Osaka, Japan) for total elbow arthroplasty. METHODS Seventeen elbows in 14 RA patients were replaced with a PROSNAP elbow with cement fixation. The patients comprised 1 man and 13 women, with a mean age of 63.9 years (range, 52-83 years) at the time of surgery. The preoperative conditions of the elbows were arthritis mutilans (n = 10), an ankylosed or stiff elbow with a preoperative range of motion of 45° or less (n = 4), and loosening of a primary total elbow arthroplasty (n = 3). The mean follow-up period was 47.7 months (range, 32-69 months), with a 100% follow-up rate. The clinical outcome of the elbows was evaluated by the Mayo Elbow Performance Index (maximum, 100 points). RESULTS The mean postoperative Mayo Elbow Performance Index score improved from 57.6 points to 97.1 points. Preoperatively, 3 of the 17 elbows were judged as good, 7 as fair, and 7 as poor; at final follow-up, 16 elbows were judged as excellent and 1 as good. Complications were noted in 1 elbow (6%), which had undergone a postoperative fracture. CONCLUSIONS The PROSNAP elbow prosthesis can be safely implanted through a relatively easy procedure and provides satisfactory short-term clinical outcomes for the reconstruction of severely damaged RA elbows. LEVEL OF EVIDENCE Level IV, case series, treatment study.

Outcomes of Resection and Joint-Preserving Arthroplasty for Forefoot Deformities for Rheumatoid Arthritis

Background: We investigated the clinical outcomes of resection and joint-preserving arthroplasty for forefoot deformities in patients with rheumatoid arthritis. Methods: Sixteen feet of 14 women (average age, 67.1 years; range, 53-82) underwent resection arthroplasty of the metatarsal head (resection group), and 18 feet of 15 women (average age, 61.3 years; range, 40-73) underwent a metatarsophalangeal joint-preserving procedure with shortening oblique metatarsal osteotomies of the lesser toes (joint preservation group). The mean disease duration in the resection and joint preservation groups was 23.6 and 19.1 years, and the average follow-up period was 37.3 and 33.5 months, respectively. The classification of Larsen was used to assess the severity of destruction of the metatarsophalangeal (MTP) joint. Preoperative and postoperative clinical evaluation included Japanese Society for Surgery of the Foot (JSSF) score and postoperative complications. Results: The number of preoperative radiographic destruction of the MTP joints (Larsen grade II, III, IV, and V) was 0, 29, 39, and 12 joints in the resection group and 13, 67, 9, and 1 joints in the joint preservation group. The mean JSSF score improved significantly from 61.3 to 83.9 points in the resection group (P < .001) and from 62.2 to 90.8 points in the joint preservation group (P < .001). In the resection group, recurrence of callosities and claw toe deformity was observed in 6 and 3 feet, respectively. In the joint-preserving group, recurrence of callosities and hammer toe deformity was observed in 1 foot each. Conclusion: The resection arthroplasty and joint-preserving procedure showed satisfactory clinical outcomes. However, whether both procedures can maintain the good clinical results without the recurrence of forefoot deformity will require longer follow-up. Level of Evidence: Level III, retrospective comparative series.

Clinical and radiographic study of partial arthrodesis for rheumatoid wrists

Objectives. To retrospectively investigate the clinical and radiographic results of partial arthrodesis for the wrists with rheumatoid arthritis (RA). Methods. Forty-one wrists with RA were treated by radiolunate (RL) or radiolunotriquetral (RLT) arthrodesis with ulnar head resection. The average follow-up period after surgery was 7.1 years. Preoperative radiographs of all wrists were classified according to Schulthess classification. We performed RL arthrodesis for all Type II (n = 26) and Type III wrists (n = 7), and RLT arthrodesis for Type III wrists (n = 8). Pre- and postoperative pain score (visual analog scale), grip strength, range of motion, and radiographic parameters were statistically compared. Results. Pain scores in all groups were significantly improved at final follow-up (P < 0.05). Grip strength increased from 5.9 to 12.4 (kg) significantly in Type II wrists (P < 0.01), from 7.2 to 9.1 in Type III wrists after RLT arthrodesis, but decreased from 6.9 to 6.0 in Type III wrists after RL arthrodesis. In all groups, the arc of pronation and supination improved significantly (P < 0.05), and all radiographic parameters improved. Conclusions. RL arthrodesis for Type II wrists showed satisfactory clinical results. RLT arthrodesis would be a reliable method in case of unstable wrist joint.

Consensus-based identification of factors related to false-positives in ultrasound scanning of synovitis and tenosynovitis.

Abstract Introduction: We aimed to identify causes of false-positives in ultrasound scanning of synovial/tenosynovial/bursal inflammation and provide corresponding imaging examples. Methods: We first performed systematic literature review to identify previously reported causes of false-positives. We next determined causes of false-positives and corresponding example images for educational material through Delphi exercises and discussion by 15 experts who were an instructor and/or a lecturer in the 2013 advanced course for musculoskeletal ultrasound organized by Japan College of Rheumatology Committee for the Standardization of Musculoskeletal Ultrasonography. Results: Systematic literature review identified 11 articles relevant to sonographic false-positives of synovial/tenosynovial inflammation. Based on these studies, 21 candidate causes of false-positives were identified in the consensus meeting. Of these items, 11 achieved a predefined consensus (≥ 80%) in Delphi exercise and were classified as follows: (I) Gray-scale assessment [(A) non-specific synovial findings and (B) normal anatomical structures which can mimic synovial lesions due to either their low echogenicity or anisotropy]; (II) Doppler assessment [(A) Intra-articular normal vessels and (B) reverberation)]. Twenty-four corresponding examples with 49 still and 23 video images also achieved consensus. Conclusions: Our study provides a set of representative images that can help sonographers to understand false-positives in ultrasound scanning of synovitis and tenosynovitis.