Maintenance treatment using abatacept with dose reduction after achievement of low disease activity in patients with rheumatoid arthritis (MATADOR) - A prospective, multicenter, single arm pilot clinical trial.

OBJECTIVES: To preliminarily evaluate the feasibility of maintenance therapy with reduced dose of intravenous abatacept (ABT) to 250 mg/body/month after achieving remission or low disease activity (LDA). PATIENTS AND METHODS: RA patients treated with ABT at 13 sites were enrolled in this prospective interventional pilot study during the period between March 2013 and March 2015. Inclusion criteria were (1) age at 20 years or older, (2) under treatment with monthly intravenous ABT at approved doses, (3) DAS28-CRP lower than 2.7 at least for 6 months, (4) agreed to join this trial with written informed consent and (5) body weight under 125 kg. Enrolled patients were maintained with intravenous monthly ABT at a reduced dose of 250 mg/body (MATADOR protocol). The primary end point was the proportion of the patients continued with MATADOR protocol at week 48. MATADOR protocol was discontinued upon disease flare or other reasons such as patients' request or severe adverse event (AE). Disease activities and structural changes were also evaluated. RESULTS: Fifty-three patients fulfilled the entry criteria and were followed for 1-year. MATADOR protocol was continued for 1-year in 43 (81%) of the evaluated patients. Three patients experienced severe AEs. Mean DAS28-CRP and remission rate were 1.56 and 88% when ABT reduced and 1.80 and 81% at 1-year, respectively. Structural remission was achieved in 34 out of 42 evaluated patients. CONCLUSIONS: Reduced dose of intravenous ABT was proposed as a feasible choice for maintenance therapy for RA after achievement of remission/LDA, although further randomized trials would be awaited.

Radial shortening osteotomy for Kienböck disease: minimum 10-year follow-up.

PURPOSE: To clarify long-term clinical and radiological results more than 10 years after radial shortening osteotomy for Kienböck disease. METHODS: Eleven wrists of 10 patients that had been classified as Lichtman stages 3A (2 wrists), 3B (8 wrists), and 4 (1 wrist) underwent radial shortening for Kienböck disease. The mean follow-up period was 14.3 years (range, 10-21 y). Clinical outcomes were quantified using the Japanese version of the Disabilities of the Arm, Shoulder, and Hand questionnaire and the modified Mayo wrist score. Radiographic and magnetic resonance imaging studies were performed for 9 of the 10 patients preoperatively and all 10 patients at follow-up. RESULTS: At follow-up, 6 wrists were asymptomatic and the remaining 5 had mild occasional pain. The mean range of extension and grip strength significantly improved. The mean modified Mayo wrist score and Disabilities of the Arm, Shoulder, and Hand scores were 92 (range, 80-100) and 5 (range, 0-18), respectively. At follow-up, no progression of the Lichtman stage was found in any patient. There was no significant progressive lunate collapse in any patient. The magnetic resonance imaging in 7 wrists showed increased signal intensity of the lunate; the remaining 3 wrists had no alteration in signal intensity of the bone. CONCLUSIONS: Our study demonstrated satisfactory clinical results after 10 or more years in patients who underwent radial shortening for Kienböck disease. Although we found no improvement in signal intensity of the lunate in 3 wrists, unloading of the diseased lunate after radial shortening gives long-lasting symptom relief and may prevent lunate collapse. TYPE OF STUDY/LEVEL OF DISEASE: Therapeutic IV.

Radial overgrowth after radial shortening osteotomies for skeletally immature patients with Kienböck's disease.

PURPOSE: We hypothesized that radial shortening osteotomy (radial shortening) for skeletally immature patients with Kienböck's disease would induce overgrowth of the radius. The purpose of this study was to determine the effect of radial shortening on radial growth in skeletally immature patients with Kienböck's disease and to clarify the relationship between the postoperative growth alterations and the clinical results. METHODS: Eight wrists of 8 skeletally immature patients with Kienböck's disease were treated with radial shortening. There were 3 boys and 5 girls, ranging in age from 11 to 18 (mean, 14) years old. All patients presented with open physis and negative ulnar variance. The length of the radial shortening equaled the amount of negative ulnar variance. Clinical assessment was based on the modified Nakamura scoring system. Radiographic assessment, including Lichtman's stages, ulnar variance, carpal height ratio, radial inclination, and volar tilt, was performed before surgery, immediately after surgery, and at follow-up. A difference in ulnar variance of more than 2 mm between these 3 measurements was considered to be overgrowth. Statistical comparisons were performed using paired t-tests. RESULTS: At a mean follow-up period of 69 months, the mean clinical score was 19.7 of 21 maximum points, with all wrists rated as excellent. Radiographically, no progression of Lichtman stage was found in any patient. At follow-up, the x-ray and magnetic resonance imaging findings indicated lunate revascularization in all patients. Four of the 8 had overgrowth in the operated radius. On the other hand, other radiographic parameters showed no significant changes at follow-up. The occurrence of postoperative radial overgrowth did not notably affect the clinical scores. CONCLUSIONS: The current results suggest the probability of overgrowth of the radius in skeletally immature patients with Kienböck's disease treated with radial shortening. The postoperative radial overgrowth after this osteotomy had no effect on clinical and other radiographic outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Postoperative Infection Related with the Total Elbow Arthroplasty (Kudo's Prosthesis) in Rheumatoid Arthritis.

BACKGROUND: Total Elbow Arthroplasty (TEA) for the rheumatoid arthritis (RA) has been popularized since 1980s. The outcomes of TEA using any type of implant design for RA has been satisfactory. On the other hand, many orthopedicians experience several postoperative complications. Among them, postoperative infection has still being the most troublesome and difficult to treat. This study is to clarify the causes of postoperative infection of TEA using Kudo's prosthesis for RA and discuss how to manage and prevent infection. METHODS: 421 TEAs were performed for 405 cases with RA at the authors' institute during the period between 1982 and 2007. They were followed up for 1~25 years (Av. 12.3 years). The authors examined pain, the range of motion, roentgenograms and complications postoperatively. We were able to start treatment within 4 weeks after occurrence of infection. For surgical management of infected TEAs, debridement of the synovium and removal of the prosthesis with loosening were performed for all cases. In addition, all cases have been regularly and strictly followed-up with the elbow protector to prevent recurrence of infection since 2008. RESULTS: There were 98 TEAs with the postoperative complications (23.3%). Eight out of 98 TEAs were infected (1.9%). Five of eight infected TEAs were primarily at the surgical scar site infection (SSSI) (60%), unknown causes in two, hematogenous course in 1. It's obvious that surgical scar site infection (SSSI) was the leading cause of postoperative infection in this study. Thus, the authors made the elbow proctor to avoid injuries of the skin around surgical scar site (SSS). Since 2008, all of the TEAs and revised TEAs have been applied with this protector. CONCLUSIONS: The authors reported 8 infected TEAs: 5 cases were revised, 2 with the brace, 1 had above the elbow amputated. The regular and meticulous follow up and application of the elbow protector were useful to prevent infection of post-TEAs using Kudo's prosthesis in RA. Since 2008, there have been no infection of post TEAs and revised TEAs.

Clinical outcomes of excision arthroplasty for Kienbock's disease.

We have carried out a replacement of the lunate in 12 patients with advanced Kienböck's disease, with excision of the lunate and insertion of an iliac bone flap wrapped into palmaris longus. The aims of this study were to determine the effect of this procedure for advanced Kienböck's disease. At a mean follow-up period of 45.3 months, the mean clinical score was excellent in all cases. Radiographically, progression of osteoarthritis (OA) in the radiocarpal joint was found in two patients. At follow-up, the X-ray findings indicated a reduced of osseous core in four patients. On the other hand, carpal height ratio showed no significant change at follow-up. Excision arthroplasty using a tendon ball with osseous core for advanced Kienböck's disease leads to OA progression in some cases. However, clinical results were excellent in all cases. Therefore, this current study provides effective therapeutic procedure for advanced Kienböck's disease.

Factors affecting results of ulnar shortening for ulnar impaction syndrome.

Although ulnar shortening osteotomy is the most frequently performed operation for ulnar impaction syndrome, little attention has been given to detect certain preoperative factors affecting clinical outcomes of this procedure. We asked whether preoperative factors influenced the postoperative score of ulnar shortening osteotomy combined with arthroscopic debridement of the triangular fibrocartilage complex. We retrospectively reviewed 51 patients (53 wrists) with ulnar impaction syndrome treated with this procedure. There were 28 males and 23 females ranging in age from 14 to 67 years (mean, 37.5 years). The minimum followup was 12 months (mean, 26.3 months; range, 12-95 months). At last followup, we determined a modified Mayo wrist score for each patient. Preoperative factors affecting the clinical score were identified using multiple regression analysis. The clinical score ranged from 40 to 100 points (mean, 84.5 points). A long duration of symptoms and workers' compensation predicted worse clinical scores. We recommend considering these two factors when deciding whether to perform this procedure.

Radial osteotomies for teenage patients with Kienböck disease.

Age seems to affect the efficacy of radial osteotomies for Kienböck disease. We questioned whether an osteotomy would produce acceptable results in teenagers. We retrospectively identified 11 patients (six males and five females) between 11-19 years of age who were treated with radial osteotomies for Kienböck disease. Preoperatively, three patients had Lichtman Stage II disease, two patients had Stage IIIA disease, and six patients had Stage IIIB disease. Two patients with zero or positive ulnar variance had lateral closing wedge osteotomies, and nine patients with negative ulnar variance had radial shortenings. All patients were evaluated clinically and radiographically. At a mean followup of 50 months, 10 of 11 patients were free from pain, and the remaining one patient had moderate wrist pain during strenuous activity. All patients except one, who had Stage IIIB disease, had an excellent clinical outcome. Radiographic improvement, indicating lunate revascularization, was seen for eight patients. Despite Stage IIIB disease, radial osteotomies produced excellent clinical results in five of six teenage patients. The current results indicate that radial osteotomies are effective in improving not only short-term clinical outcomes, but also radiographic findings in teenage patients with Kienböck disease.

A total wrist arthroplasty in rheumatoid arthritis: a case followed for 24 years.

Abstract We report a case of rheumatoid arthritis treated with a total wrist arthroplasty. A Meuli-type total wrist arthroplasty was performed on the left wrist in 1979. We have treated the patient's rheumatoid arthritis with disease-modifying antirheumatic drugs (DMARDs) (Actarit 100 mg and Mijoribine 50 mg) and nonsteroidal anti-inflammatory drugs (NSAIDs) for a total of 26 years before and after the total wrist arthroplasty. The activity of the rheumatoid arthritis has been kept at a low level. The operated wrist was followed up for 24 years postoperatively. It is thought that the antirheumatic treatments over a long period have been very successful in preventing the destruction of the operated wrist.

Posterior interosseous nerve palsy secondary to rheumatoid cyst of the elbow joint: case report.

A 73-year-old woman with rheumatoid arthritis had lost the ability to extend the digits on her right hand. A rheumatoid cyst in the elbow caused the posterior interosseous nerve palsy. Decompression was performed, and she recovered extension of the thumb and fingers completely within 3 weeks after the operation.