Acute destruction of the hip joints and rapid resorption of femoral head in patients with rheumatoid arthritis

We report three rheumatoid arthritis (RA) cases with acute destruction of hip joint and rapid resorption of femoral head. The condition occurred in less than 6 months and closely resembled rapid destructive coxarthrosis. All three patients were postmenopausal women with active RA who had been taking steroids. Two of the patients were taking prednisolone (PSL) of over 20 mg as maximum dose per day, and all patients were resistant to disease-modifying anti-rheumatic drugs (DMARDs). Other than the problems of their hip joints, one had a giant bursitis around the pathological side of the hip joint, another had multiple rheumatoid nodules and skin infarction, and the other suffered from insufficiency fracture of the contralateral femoral subcapital lesion. As a result, all of them had total hip arthroplasty. We recommend taking repetitive radiographs for RA patients with continuing severe hip pain.     

Proximal femoral fracture in patients with rheumatoid arthritis

Abstract

Hip fracture occurrence was examined cross-sectionally in Japanese patients with rheumatoid arthritis (RA). Between January 2005 and June 2006 we studied RA outpatients with a past history of hip fractures. Patients included 1 man and 25 women. As 3 women had bilateral hip fractures, the total number was 29. Age at the time of fracture was 72.1 ± 4.5 years. Of the 29 fractures, 22 were cervical and 7 were trochanteric. Four fractures were spontaneous while the others occurred in falls. 24 fractures were associated with oral steroid administration. All 5 fractures unassociated with prednisolone were cervical. Of the 26 patients, 8 were taking bisphosphonate when fracture occurred. Cervical fracture was treated with total hip arthroplasty in 1 patient whose hip showed RA changes. In others whose hip joint lacked RA change, procedures included osteosynthesis in 2 patients with good function over 6 years; and hemiarthroplasty with a bipolar system in 19 displaced fractures, with good function over 4.1 years. Osteosynthesis was performed for all 7 trochanteric fractures. Trabeculae were thin, and fewer transverse trabeculae could be found in specimens from cervical fracture. Hip fracture in RA patients occurred 10 years earlier than in the general population, and many fractures were cervical.     

A case of femoral nerve palsy caused by iliopectineal bursitis associated with rheumatoid arthritis

Abstract

We report the case of a 46-year-old woman with rheumatoid arthritis who developed femoral nerve palsy caused by an enlarged iliopectineal bursa. Surgical excision revealed that the iliopectineal bursa was connected with the hip joint. The patient showed good recovery from the femoral nerve palsy after surgery. It was considered that iliopectineal bursitis had developed following the synovial inflammation of the hip joint.     

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

Abstract

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.     

Synovial cyst of the hip in a patient with rheumatoid arthritis

A 67-year-old woman with rheumatoid arthritis (RA; Steinblocker stage IV, class 4) who had RA onset at 34 years of age had anterior thigh pain, femoral neuropathy and lower abdominal pain. Physical examination showed multidirectional limit of motion, and radiographic examination showed destruction of the hip joint. MRI and arthrography indicated a cystic lesion that communicated with the hip joint. The rheumatoid synovial cyst was removed during total hip arthroplasty. The symptoms were relieved, and the mass was reduced in size.     

Clinical and radiological results of non-cement impaction bone-graft method of total hip arthroplasty for rheumatoid arthritis

Abstract

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.     

Severe erosive arthropathy requiring surgical treatments in systemic lupus erythematosus

Abstract

We report a case of 43-year-old woman with an overlap syndrome of systemic lupus erythematosus (SLE) and dermatomyositis who developed erosive arthritis with extracapsular cysts involving multiple joints. An extensive synovectomy for the left wrist joint and a total joint replacement for the right hip joint were required to achieve complete symptom relief. She was not diagnosed with rheumatoid arthritis (RA). This was a rare case of SLE manifesting non-RA erosive arthritis that required surgical interventions.     

Development of large pseudocysts adjacent to the knee joint in rheumatoid arthritis. Assessment of radiological and histopathological approaches

Abstract

?This study examined the pathogenesis of large pseudocysts adjacent to knee joints in rheumatoid arthritis (RA). The radiological and histopathological features of 17 large subarticular pseudocysts in 12 knee joints of 10 patients were analyzed. Nine of the 10 patients were classified as class 2 according to Steinbrocker's functional class. Eight large pseudocysts were located at the lateral femoral condyle, seven were at the proximal part of the tibia, one was at the medial femoral condyle, and one was at the patella. The large pseudocysts were divided into two groups according to whether they did or did not connect with the joint cavity. Serial radiographs revealed that all large pseudocysts in communication with the joint cavity had enlarged gradually over the past several months. They extended from the subarticular area toward the bone marrow. Histopathological findings confirmed that holes allowing communication were located at a transitional zone between the ligament and the hyaline cartilage, and that rheumatoid granulation tissue invaded the large pseudocyst through these holes. The results of this study indicate that large pseudocysts are formed by the extension of articular inflammation. Moreover, repeated extrinsic mechanical stress due to walking and the aggressive inflammatory nature of rheumatoid arthritis play important roles in the formation of large pseudocysts.     

Long-term clinical and radiographic results of cementless total hip arthroplasty for patients with rheumatoid arthritis: minimal 10-year follow-up

Abstract

Objectives. The aim of this study was to clarify the long-term clinical and radiographic results of cementless total hip arthroplasty (THA) for patients with rheumatoid arthritis (RA).

Methods. Twenty-eight total hip arthroplasties in 24 patients with a diagnosis of RA were performed from October 1992 to October 1996. All components were titanium alloy with a circumferential porous coating. Six patients (six hips) died before the 10-year follow-up, and one patient (one hip) was lost to follow-up, leaving 21 joints of 17 patients for review at a minimum 10-year follow-up after surgery. There were 3 men and 14 women with an average age of 55.0 years. The average duration of RA at the time of the operation was 12.6 years, and the average follow-up period was 12.2 years. We evaluated the Japanese Orthopaedic Association (JOA) hip scores, radiographic changes and survivor rates of components.

Results. Compared with the preoperative JOA hip scores, there was significant improvement in the postoperative scores. Spot welds consistent with bone ingrowth were identified in 95.0% of the femoral components. No femoral components showed radiographic loosening or required revision for aseptic loosening, but two acetabular revisions were performed because of aseptic loosening. The 14-year survivor rates of the stem and cup with the end point of loosening were 100% and 88.2%, respectively.

Conclusions. Cementless THA with this component design in patients with RA appears to be a promising treatment.     

Knee and/or hip joint destruction in rheumatoid arthritis is associated with HLA-DRB1*0405 in Japanese patients

To determine the prognostic factors for knee and/or hip joint destruction in rheumatoid arthritis (RA) patients, we typed 379 RA patients for HLA-DRB1 alleles and analysed the antigen frequencies. The DRB1^*0405 antigen frequency in RA patients who underwent total knee replacement and/or total hip replacement was significantly higher than in those who did not have replacements, which meant that DRB1^*0405 was associated with knee and/or hip joint destruction. This finding may be of value for predicting knee and/or hip joint destruction in RA.     

Survival after total joint arthroplasty in patients with rheumatoid arthritis. Comparison of the postoperative life expectancies and survival by initial operative years: 1970s and 1980s group versus 1990s group

Abstract

A total of 867 patients with rheumatoid arthritis (RA) underwent 1764 total joint arthroplasties (total hip arthroplasty and/or total knee arthroplasty) over three decades from 1970 to 1999. A survey on their postoperative survival was conducted in December 2000 in which these patients were divided into two groups. The patients who had their initial arthroplasty in the period 1970 to 1989 were classified as the “70s and 80s group,” and those who had their initial arthroplasty from 1990 to 1999 were classified as the “90s group.” Using the Kaplan–Meier method, their cumulative survival rates were compared. The survival rates of the 70s and 80s group, consisting of 433 patients, were 84.8% at the 5th postoperative year, 60.1% at the 10th year, and 45.3% at the 15th year. Although the survey period of the 90s group is shorter than that of the 70s and 80s group, their survival rates were 90.2% at the 5th year and 84.3% at the 10th year. At present, the life expectancies of the 90s group are good, and their cumulative survival rate is significantly greater than that of the 70s and 80s group (P < 0.01). It seems that this improvement has been contributed to by the recent increase in the number of RA patients with good prognoses and the well-timed application of arthroplasty, which decreases the number of patients with poor risk.     

Efficacy of golimumab for preventing large joint destruction in patients with rheumatoid arthritis as determined by the ARASHI score

Objectives: The objective of this study is to investigate the inhibitory effect of golimumab on large joint destruction in patients with rheumatoid arthritis.

Methods: We recruited 45 patients with rheumatoid arthritis and evaluated the radiographic severity of large joint destruction using the assessment of rheumatoid arthritis by scoring of large joint destruction and healing in radiographic imaging (ARASHI) score. We evaluated 450 large joints including the elbow, shoulder, hip, knee, and ankle at baseline and 52 weeks after treatment with golimumab. Rapid radiographic progression (RRP) and rapid radiographic improvement (RRI) were calculated and the correlation between large joint destruction and clinical factors was analyzed.

Results: The mean age of the study population was 61.29?±?14.71 years old, and most patients (91.1%) were female. The mean disease duration was 12.6?±?12.48 years. The cohort included patients in all clinical stages of disease as defined by the Steinbroker criteria (I:7, II:10, III:9, IV:19) as well as clinical classes 2 (n?=?18), 3 (n?=?26), and 4 (n?=?1) and the mean disease activity score-CRP (DAS28-CRP) was 4.431?±?1.044. Patients were treated with methotrexate (mean dose 6.44?±?1.78?mg/week), prednisolone (PSL) (mean dose 1.078?±?1.871?mg/d), and golimumab (44.4% of 100?mg). RRP was evident in 20% of the large joints treated with golimumab, and, therefore, golimumab was effective at inhibiting large joint destruction in 80% of joints. RRI was evident in 33.3% of large joints following golimumab treatment. We also observed that EULAR response criteria significantly correlated with the ARASHI change score at 52 weeks after treatment. The total ARASHI status score significantly correlated with the Sharp–van der Heijde score, but not with the delta total sharp score. Multiple regression analyses revealed that the total ARASHI change score was only correlated with EULAR response criteria significantly.

Conclusions: Golimumab therapy was effective at inhibiting large joint destruction of RA patients who have good clinical response, including higher improvement of the shoulder and ankle joints than other large joints.     

Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis

Objective

Prosthetic joint infection is one of the most dreaded complications after total joint arthroplasty, a common procedure in patients with rheumatoid arthritis (RA). We conducted a study to evaluate potential risk factors of prosthetic joint infection and to clarify if RA is an independent predictor of this complication.

Methods

This study included all patients with RA who underwent total hip or knee replacement at the Mayo Clinic Rochester between January 1996 and June 2004. The association of potential risk factors with prosthetic joint infection was examined using Cox models. A matched cohort of patients with osteoarthritis (OA) was assembled to determine whether RA is an independent risk factor for prosthetic joint infection.

Results

We identified 462 patients with RA who underwent a total of 657 hip or knee replacements. Overall, 23 (3.7%) joint arthroplasties were complicated by an infection during a mean ± SD followup of 4.3 ± 2.4 years. Revision arthroplasty (hazard ratio [HR] 2.99, 95% confidence interval [95% CI] 1.02–8.75) and a previous prosthetic joint infection of the replaced joint (HR 5.49, 95% CI 1.87–16.14) were significant predictors of postoperative prosthetic joint infection. Comparison of RA patients with a matched cohort of OA patients identified an increased risk of prosthetic joint infections (HR 4.08, 95% CI 1.35–12.33) in patients with RA.

Conclusion

Patients with RA who undergo total hip or knee replacement are at increased risk of prosthetic joint infection, which is further increased in the setting of revision arthroplasty and a previous prosthetic joint infection. These findings highlight the importance of perioperative prophylactic measures and vigilance during the postoperative period.     

MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica

Abstract

Objectives. The purpose of this study is to evaluate magnetic resonance imaging (MRI) findings of the shoulder and hip joint in patients with polymyalgia rheumatica (PMR).

Methods. MR images of a total of 25 PMR patients (23 shoulders and 6 hips), 43 rheumatoid arthritis (RA) patients (22 shoulders and 22 hips), and 50 control patients (25 shoulders and 25 hips) were examined. The following MRI findings were evaluated: In the shoulder, thickness and abnormalities of the supraspinatus tendon, effusion around the glenohumeral joint, subacromial-subdeltoid bursa, and the biceps tendon; In the hip, effusion around the acetabulofemoral joint, iliopsoas bursa, and trochanteric bursa. Periarticular soft-tissue edema and bone findings were also analyzed.

Results. The supraspinatus tendon was significantly thicker in PMR patients than in RA patients and control patients (p < 0.05). Severe rotator cuff tendinopathy was frequently observed in PMR patients (p = 0.002). The scores for the amount of effusions (joint, bursa, and tendon sheath in the shoulder and bursa in the hip) were much higher in PMR patients (p < 0.05). Periarticular soft tissue edema was detected more frequently in PMR patients than in RA patients and control patients (p < 0.05).

Conclusions. Thick supraspinatus tendon, severe rotator cuff tendinopathy, effusion around the joints, and periarticular soft tissue edema can be good indicators for the diagnosis of PMR.     

Proximal femoral fracture in patients with rheumatoid arthritis

Hip fracture occurrence was examined cross-sectionally in Japanese patients with rheumatoid arthritis (RA). Between January 2005 and June 2006 we studied RA outpatients with a past history of hip fractures. Patients included 1 man and 25 women. As 3 women had bilateral hip fractures, the total number was 29. Age at the time of fracture was 72.1 ± 4.5 years. Of the 29 fractures, 22 were cervical and 7 were trochanteric. Four fractures were spontaneous while the others occurred in falls. 24 fractures were associated with oral steroid administration. All 5 fractures unassociated with prednisolone were cervical. Of the 26 patients, 8 were taking bisphosphonate when fracture occurred. Cervical fracture was treated with total hip arthroplasty in 1 patient whose hip showed RA changes. In others whose hip joint lacked RA change, procedures included osteosynthesis in 2 patients with good function over 6 years; and hemiarthroplasty with a bipolar system in 19 displaced fractures, with good function over 4.1 years. Osteosynthesis was performed for all 7 trochanteric fractures. Trabeculae were thin, and fewer transverse trabeculae could be found in specimens from cervical fracture. Hip fracture in RA patients occurred 10 years earlier than in the general population, and many fractures were cervical.     

Bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis: Its characteristics and relationship to the clinical findings

Objectives: The purpose of this study was to clarify the characteristics of bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis (RA) patients who required cervical spine surgery, and its relationship to the clinical findings.

Methods: Eighty consecutive RA patients with cervical spine disorder who received initial surgery were reviewed. The occurrence of bony ankylosis of the facet joint of the cervical spine was investigated using computed tomography (CT) before surgery. We also evaluated the severity of neurological symptoms and the plain wrist radiographs taken before surgery; furthermore, we evaluated each patient’s medical history for total knee arthroplasty (TKA) or hip arthroplasty (THA).

Results: The preoperative CT imaging demonstrated bony ankylosis of the facet joint of the cervical spine in 45 facet levels of 19 cases (BA?+?group). In all patients, responsible instability or stenosis was demonstrated just caudal or on the cranial side of those bony ankylosis. Before surgery, the BA?+?group included significantly more patients showing severe cervical myelopathy (p?p?p Conclusions: Bony ankylosis of the facet joint of the cervical spine may be a risk factor of instability or stenosis at the adjacent disc level and severe cervical myelopathy. Furthermore, its ankylosis was demonstrated in RA patients with severe destroyed joints.     

Indications of total ankle arthroplasty for rheumatoid arthritis: evaluation at 5 years or more after the operation

Abstract

The postoperative results of total ankle arthroplasty (TAA) were surveyed, and the indications of TAA for rheumatoid arthritis (RA) were examined. We have performed TAA in properly selected patients with indication of ankle joint destruction due to RA. The subjects were 18 RA patients (20 joints) who underwent TAA between April 1988 and April 1996. Type-ND or type-TNK Bioceram was used without cement for possible revision of TAA. No destruction of large joints was found in 8 patients, and TAA was used as part of multiple arthroplasty in 10 patients. After the operation, decrease in or disappearance of joint pain was obtained, and range of motion and improved ability to walk were secured. The clinical results were superior to those obtained for 17 joints of 17 patients who underwent ankle arthrodesis during the same period. However, a radiolucent zone was observed an X-ray examination in every case, after 8 years on average (range 5–12 years) after operation. Under present conditions, ankle arthrodesis should be used for younger patients. When no destruction of the hip or knee joint is found and the patient is 65 years of age or older, we believe TAA is indicated. In cases of multiple arthroplasty or with bilateral ankle joint destruction, TAA appears to be useful if patients are young, considering their better life expectancy and quality of life.     

Quantitation of human synovial mast cells in rheumatoid arthritis and other rheumatic diseases

We examined sections of synovial membranes from 14 patients with rheumatoid arthritis (RA), 7 with other rheumatic diseases, and 10 with no apparent joint disease. Patients with RA and other rheumatic diseases had significantly more synovial mast cells/vessel than patients with no joint disease (0.49 and 0.20, respectively, versus 0.03). They also had significantly more total mast cells/10 fields than patients with no joint disease (9.9 and 5.0, respectively, versus 0.4). Within the rheumatoid group, patients with active disease had more total mast cells/10 fields than patients clinically considered to have end-stage disease (P < 0.05). Synovial basophils were not identified in any patient. Synovial vascularity was similar for all groups (2.3 vessels/field). The role of the synovial mast cell in RA and other rheumatic diseases remains to be determined.     

Total hip arthroplasty with bone graft for acetabular protrusion in rheumatoid arthritis

 Twenty-five hips in 19 rheumatoid arthritis (RA) patients with protrusio acetabuli were followed up, both clinically and radiographically, for more than 9 years after total hip arthroplasty (THA), that was performed with a bone graft to reinforce the medial acetabular wall. Radiographs were taken preoperatively and every 6 months postoperatively. Clinical assessments of pain, gait, and range of motion of the hips were obtained preoperatively and every year postoperatively using the Japanese Orthopaedic Association hip-scoring system. Radiographs showed that bony union had occurred in all cases. Six acetabular components were loose, but no femoral components became loose during the 9-year period. The clinical evaluation showed that relief of pain was very significant. The range of motion of the hip joints also improved from 12 points to 16.6 points after 9 years. Walking ability improved, but is becoming worse as time goes by. The radiographic results were compared with the results of a THA group with RA that had not had a bone graft. The rate of loosening of the THA without a bone graft was significantly higher than that of THA with a bone graft. We concluded that bone grafting for protrusio acetabuli was a very useful procedure. Received: September 21, 2001 / Accepted: February 1, 2002 Correspondence to: K. Kondo     

Comparative assessment of hepatitis C virus-related arthritis and rheumatoid arthritis: Relation to clinical,serologic and ultrasonographic characteristics

BackgroundExtrahepatic manifestations of hepatitis C virus (HCV) infection includes HCV-related arthritis (HCV-A) that may mimic rheumatoid arthritis (RA). Musculoskeletal ultrasound (MSUS) can aid in discriminating both conditions.Aim of the workTo study the clinical, serological and imaging (Xray, MSUS) characteristics of HCV-A and compare them to RA.Patients and methodsThe study included 30 patients with HCV-A and 30 age- and sex-matched RA patients negative for HCV. Ritchie articular index (RAI), tender joint count (TJC) and swollen joint count (SJC) assessed arthritis. Patient global health assessment (PGHA) and modified health assessment questionnaire (MHAQ) were evaluated. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) and serum cryoglobulins were measured. Radiologic assessment included short Larsen score (SLS) and MSUS using 7-joint ultrasound score (US7).ResultsThe mean age of the HCV-A patients was 45.8 ± 4.7 years; RA was 43.3 ± 5.6 years; F:M was 27:3 in HCV-A patients; 29:1 in RA; HCV-A patients had no subcutaneous nodules, joint deformities or bone erosions. US7 showed that Gray-Scale (GS)/Power Doppler (PD) synovitis and tenosynovitis had higher mean values in RA versus HCV-A patients (p < 0.001; p < 0.001; p = 0.011; p = 0.008 respectively). A significant correlation was found between SJC with GS and PD synovitis in both groups.ConclusionHCV-A differ from RA features as being non nodular, non-deforming, non-erosive and aid in the predilection of HCV-A diagnosis. MSUS can offer a useful imaging modality elucidating inflammatory components of HCV-A and highlighting the spectrum of the condition.