Yoshihide Nakamura

Treating to target matrix metalloproteinase 3 normalisation together with disease activity score below 2.6 yields better effects than each alone in rheumatoid arthritis patients: T-4 Study

Objectives To assess whether therapy to achieve both a disease activity score in 28 joints (DAS28) less than 2.6 and matrix metalloproteinase (MMP) 3 normalisation offers better outcomes than either target alone in early rheumatoid arthritis (RA) at 56 weeks: Treating to Twin Targets (T-4) Study. Methods 243 early RA patients were randomly allocated to one of four strategy groups: routine care (R group; n=62); DAS28-driven therapy (D group; n=60); MMP-3-driven therapy (M group; n=60); or both DAS28 and MMP-3-driven therapy group (twin; T group; n=61). Medication was started with sulfasalazine (1 g/day) in all intervention groups. Targets were DAS28 less than 2.6 for the D group, MMP-3 normalisation for the M group and both DAS28 less than 2.6 and MMP-3 normalisation for the T group. If the value in question did not fall below the previously measured level, medication was intensified, including methotrexate, other disease-modifying antirheumatic drugs and biological agents. Primary, secondary and outcome measures consisted of the proportions of patients showing clinical remission (DAS28 <2.6), radiographic non-progression (Δmodified total Sharp score ≤0.5), normal physical function (modified health assessment questionnaire score 0), or comprehensive disease remission defined as the combination of clinical remission, radiographic non-progression and normal physical function. Results Clinical remission at 56 weeks was achieved by more patients in the T group (56%) than in the R group (p<0.0005) or M group (p<0.0005). Conclusions Results of the T-4 Study reveal that a twin target strategy can achieve a high clinical remission rate in early RA.

Femoral Nerve Palsy Associated with Iliacus Hematoma Following Pseudoaneurysm After Revision Hip Arthroplasty

Iliacus hematoma associated with femoral nerve palsy is a very rare but considerable complication of hip arthroplasty. A 76-year-old woman had femoral nerve palsy 6 months after revision hip arthroplasty using a reinforcement plate. Computed tomography and selective angiography revealed the pseudoaneurysm on an extension of one of the screws fixing the hardware. Transcatheter arterial embolization proximal to the aneurysm was performed to resolve the aneurysm and to prevent further bleeding. Surgical removal of the hematoma was successfully achieved, as was full functional recovery. This case report describes our diagnosis and treatment of this rare condition and also the therapeutic usefulness of the radiologic intervention to control further bleeding before and after surgical removal of the hematoma.

Total Hip Arthroplasty Using a Cylindrical Cementless Stem in Patients With a Small Physique

We performed total hip arthroplasty using an anatomic medullary locking cementless stem for small-physique patients from 1988 to 1995. We conducted a retrospective study of 50 joints in 44 cases, including 40 developmentally dysplastic hips followed for 12 to 20 years (average, 15.1 years). Average height and body weight were 152 cm and 56 kg (5.0 ft and 124 lb), respectively, with an average body mass index of 24.2. Twelve joints (24%) were revised for acetabular-sided failures. Forty-eight stems (96%) showed bone ingrowth fixation, and there were no unstable stems. The simple cylindrical shape of the distal portion of the AML stem was less affected by deformity of the proximal femur of developmental dysplasia of the hip in patients with a small physique, and both clinically and radiologically good results were confirmed at long-term follow-up.

Synovial Osteochondromatosis of the Hip Treated Through a Surgical Dislocation

We report a case of osteochondromatosis in the hip joint treated through a surgical dislocation and describe the use and safety of the procedure confirmed by postoperative magnetic resonance imaging. A 44-year-old man had right hip pain with moderate limitation of the range of motion. Plain radiographs and computed tomography showed calcified loose bodies in the hip with mild joint degeneration. Magnetic resonance imaging showed remarkable expansion of the capsule containing joint fluid and loose bodies below the femoral head. Complete removal of loose bodies and synovectomy were performed through a surgical dislocation. Three months after the operation, the patient had fully recovered and returned to his job. Magnetic resonance imaging performed 5 months after surgery revealed full removal of the loose bodies and no recurrence of the disease including synovial proliferation. It also showed no evidence of avascular necrosis, meaning that the procedure had been performed safely.

Spontaneous femoral neck fracture associated with a low serum level of vitamin D

Vitamin D deficiency causes osteomalacia and has a mineralization defect. Osteomalacia is characterized by accumulation of increased amounts of unmineralized osteoid and a decrease in the rate of bone formation. Osteomalacia often causes insufficiency fracture, and the detection of osteomalacia is important since it may influence subsequent management of the fracture. We present the case of a young adult woman with a femoral neck fracture that occurred secondary to vitamin D deficiency caused by an extremely unbalanced diet. The purpose of this report is to caution that femoral neck fracture in young adults should be investigated for underlying pathology. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Identification of a novel COL2A1 mutation (c.1744G>A) in a Japanese family: a case report

IntroductionMutations in the gene encoding the type II collagen gene (COL2A1) have been found to affect the entire skeletal system. Recently, inheritable skeletal dysplasia caused by novel COL2A1 mutations has been linked to an inherited disease of the hip joint that neither involves the entire skeletal system nor is characterized by the presence of concomitant disorders, such as spinal or ocular abnormalities.Case presentationA 27-year-old Japanese woman previously diagnosed with avasucular necrosis (AVN) of the femoral head on the basis of radiological findings was referred to the study site for surgical management of a painful hip joint. She had no history of disease but suffered from bilateral hip joint lesions. Analysis of her pedigree revealed that bilateral hip joint lesions affected more than three generations of her family. Based on these findings, haplotype analysis of her and her family members was performed by examining select candidate genes from the critical interval for epiphyseal dysplasia of the femoral head on 12q13 and sequencing the promoter and exonic regions of COL2A1.ConclusionA novel COL2A1 mutation (c.1744G>A) was identified within one Japanese family.

Rotational acetabular osteotomy with resection of the capital drop and double floor for advanced osteoarthritis of the hip.

Rotational acetabular osteotomy (RAO) is an established joint preservation technique for early stage osteoarthritis (OA). To extend the application of RAO for advanced OA with significant osteophyte formation, we added intraarticular procedures including removal of the double floor and the capital drop to create medialisation and better coverage of the femoral head. The procedures were performed for seven joints with advanced OA. The average age of patients at surgery was 39 years. The follow-up periods ranged from five to 23 years. The capital drop was resected in five joints and both the capital drop and the double floor were removed in the other two joints. The Japanese Orthopaedic Association Hip Score improved from 53 points before surgery to 69 at the latest follow-up. The range of flexion was decreased. The centre-edge angle, Sharp angle and acetabular head index were significantly improved. The femoral head was medialised 5 mm by surgery. Three joints (43%) showed progression of osteoarthritis. One joint (14%) needed replacement at seven years after RAO. Resection of the capital drop and curtain osteophyte with RAO improved joint congruity and medialisation of the femoral head, but decreased the range of motion of the joint due to increased bony coverage. Progression of degeneration of the joint is not preventable. We abandoned these procedures for advanced osteoarthritis of the hip joint especially in older patients who were suitable for replacement arthroplasty.

SAT0157 Discontinuation of etanercept in rheumatoid arthritis patients in clinical remission: Two-year outcome

Background Tumor necrosis factor (TNF) inhibitors enable tight control of disease activity in patients with rheumatoid arthritis (RA). Discontinuation of TNF inhibitors after achievement of clinical remission is important for safety and economic reasons. However there is limited data to confirm the effectiveness and safety over a longer time period after discontinuation of etanercept (ETN). Objectives We studied 2-year outcome in RA patients who achieved clinical remission (Disease activity score in 28 joints (DAS28) <2.6) by ETN and maintained without ETN to evaluate the clinical, radiographic and functional progression rate. Methods After patients had achieved DAS28<2.6, informed consent to discontinue ETN was obtained from 23 patients. Mean of characteristics at ETN addition time were as follows: age, 63.1 years; duration of disease, 49.9 months; CRP, 1.83 mg/dl; ESR, 30.6 mm/h; DAS-28, 4.93; simplified disease activity index (SDAI), 24.0; percentage taking methotrexate, 78% (mean dose, 6.19 mg/week); percentage taking prednisolone, 22% (mean dose, 4.0 mg/day); percentage taking DMARDs, 26%. After ETN was discontinued, DAS was measured every one to three months for 2 years. The following data were collected: relapse rate at year 2; the rate of radiographic remission (Dmodified total Sharp score (DTSS) ≤0.5) and functional remission (modified health assessment questionnaire score (mHAQ) <0.5) of patients with continued remission and those with relapse. Re-treatment with TNF inhibitors (including ETN) was considered as clinical relapse. TSS was determined using modified van der Heijde-sharp score. Results 9 (39.1%) patients maintained clinical remission and clinical relapse was observed in 14 patients (60.9%) at 2years. Re-treatment with TNF inhibitors in 4 patients (2 patients, ETN; 2 patients, adalimumab) was effective and the majority of patients reached DAS28<2.6 within 8weeks. Mean DAS, SDAI, mHAQ and TSS of patients with continued remission at year 2 were 2.03, 3.82, 0.09, and -2.26 respectively, those of patients with relapse were 3.11, 7.36, 0.27, and 0.37. Radiographic and functional remission rates of patients with continued remission at year 2 were 55.6%, 77.8% respectively, those of patients with relapse were 50%, 64.3%. Conclusions Some patients could maintain clinical, radiographic and functional remission upto two years after discontinuation of ETN. This study result proves that discontinuation of ETN after achieving of DAS<2.6, subsequently could lead to the possibility of bio-free remission in RA. Even if relapse occurred, remission could be achieved again with monitoring of disease activity and adequate treatment after ETN discontinuation. References Brocq O, Millasseau E, Albert C, et al. Effect of discontinuing TNFalpha antagonist therapy in patients with remission of rheumatoid arthritis. Joint Bone Spine. 2009;76:350-5. Miyamura T, Sonomoto K, Nakamura M, et al. Discontinuationof etanercept in patients with rheumatoid arthritis who were in clinical remission. Clin Rheumatol. 2010;29:87-90. Tanaka Y, Takeuchi T, Mimori T, et al. Discontinuation of infliximab after attaining low disease activity in patients with rheumatoid arthritis: RRR (remission induction by Remicade in RA) study. Ann Rheum Dis. 2010;69:1286-91. van Vollenhoven RF. Unresolved issues in biologic therapy for rheumatoid arthritis. Nat Rev Rheumatol. 2011;7:205-15. Disclosure of Interest None Declared