Lateral collapse of the tarsal navicular in patients with rheumatoid arthritis: Implications for pes planovarus deformity.

OBJECTIVES: In patients with rheumatoid arthritis (RA), the talonavicular joint is commonly involved and midfoot collapse can lead to progressive flattening of the arch. Despite a general awareness of the important structural role of the talonavicular joint in rheumatoid foot disease, details of its destructive pattern have not been elucidated. METHODS: We cross-sectionally investigated 176 RA patients (342 feet) and classified their feet into the following five groups according to radiographic findings: arthritis (RA changes with normal navicular shape), Müller-Weiss Disease (MWD) (collapse of the lateral aspect of the tarsal navicular), flat (flattened navicular), ankylosis (ankylosis of the talonavicular joint), and normal. We compared medical histories and radiographic measurements among all five groups. RESULTS: The arthritis group comprised 91 feet, 36 in the MWD group, nine in the flat group, 12 in the ankylosis group, and 194 classified as normal. The MWD group demonstrated a trend towards pes planovarus deformity in contrast to pes planovalgus deformity in the arthritis group. Corticosteroid use and the mean daily dosage were the highest in the MWD group. CONCLUSIONS: This report revealed a high prevalence of MWD-like changes to the navicular in RA patients and its association with pes planovarus deformity and corticosteroid usage.

Severe pes planovalgus successfully treated in a patient with mutilating rheumatoid arthritis using a new surgical approach involving medial malleolar resection and medial displacement of the talus: A case report.

We report the case of a 56-year-old female with mutilating rheumatoid arthritis, who developed severe pes planovalgus. The foot was successfully reconstructed through a combination of osteotomies, including medial displacement of the talus accompanied by resection of the medial malleolus. This maneuver enabled a ∼1-cm medial displacement of the hindfoot while minimizing the adverse effect on forefoot rotation.

Foaling rate of mares that were rebred after pregnancy loss in Hidaka, Japan.

The purpose of this study was to evaluate foaling rates of mares that were rebred after the pregnancy loss in same reproductive season and to examine factors influencing them in Hidaka, Japan. The study included 82 Thoroughbred mares that had experienced pregnancy loss. The foaling rate of the mares that were rebred after pregnancy loss was 57.3%. The foaling rate decreased as the period until detection of pregnancy loss increased. Aging and lower body condition score of mares decreased the foaling rate.

Radiologic Patterning of Hallux Deformity in Rheumatoid Arthritis and Its Relationship to Flatfoot.

Hallux deformities other than hallux valgus, especially those in the sagittal plane, have not yet been elucidated in the feet of patients with rheumatoid arthritis. The objectives of the present study were to classify rheumatoid arthritis hallux deformity in both the horizontal and the sagittal planes and investigate its relationship with flatfoot. Using a cross-sectional study design, we assessed patients with rheumatoid arthritis (527 feet in 274 patients) using radiographs and classified the deformity patterns of the great toes using cluster analysis. Of the 274 patients, the range of motion in the metatarsophalangeal joint was clinically investigated in 44 (16.1%) patients. The great toes could be divided into 5 clusters according to the characteristic configuration as follows: cluster I (normal type), cluster II (hallux valgus type), cluster III (boutonniere type), cluster IV (boutonniere with hallux valgus type), and cluster V (swan-neck type). Radiographic measurements revealed the characteristic deformities of each cluster, including splayed foot for cluster II; flat foot, metatarsal primus elevatus, and plantar displacement of the proximal phalanx for cluster III; and a mixture of these characteristics for cluster IV. Plantar displacement of the proximal phalanx, which was a specific characteristic of the boutonniere deformity, correlated significantly with the decreased dorsiflexion in the metatarsophalangeal joint. Our classification method revealed the relationship of hallux deformity in the sagittal plane to flatfoot and also demonstrated the usefulness of measuring basal phalanx displacement in predicting the range of motion of the metatarsophalangeal joint.

Partial transmalleolar approach for lateral impingement after total ankle arthroplasty: a case report.

Advances in implant technology have made total ankle arthroplasty an increasingly popular alternative to arthrodesis for the management of ankle arthritis. However, a frequent complication of the procedure is nerve impingement related to either to heterotrophic bone growth or the prosthesis itself. Successful resolution of this complication presents a challenge to clinicians. We present a case of lateral impingement following total ankle arthroplasty that was successfully treated using a partial transmalleolar approach to effect a partial osteotomy of the lateral malleolus and create a fragment attached to the anterior talofibular and calcaneofibular ligaments. This approach provides a good operative field in the lateral gutter with minimal soft tissue impairment. It also facilitates curettage, and resolution of tissue impingement. The osteotomy site healed fully by 3 months postoperative, and the pain around the lateral malleolus resolved. Furthermore, the patient's score on the Japanese Society for Surgery of the Foot Ankle/Hindfoot Scale improved from 33 preoperatively to 82 at 6 months postoperative.

Correlation between knee and hindfoot alignment in patients with rheumatoid arthritis: The effects of subtalar joint destruction.

OBJECTIVES: Compensatory hindfoot alignment for deformities at the knee level has been demonstrated in patients with knee osteoarthritis. However, this phenomenon has not been elucidated in patients with rheumatoid arthritis (RA). The aim of this study is to investigate the relationship between knee deformity and hindfoot alignment and the effect of subtalar joint destruction in patients with RA. METHODS: We retrospectively investigated RA patients (110 patients, 205 limbs) using radiographs in the standing anteroposterior knee, standing lateral foot, and hindfoot alignment views. The grade of destruction at the knee and subtalar joints was assigned using Larsen's grading system. The correlation between the femorotibial and tibiocalcaneal angles and the effect of joint destruction on this correlation were analyzed using Pearson's correlation coefficients. RESULTS: There was moderate correlation between the femorotibial and tibiocalcaneal angles in a group of knees with a Larsen grade of ≥ 4 (r = 0.544, p = 0.0239). This correlation was stronger in a group with less damaged subtalar joints with a Larsen grade of ≤ 3 (r = 0.705, p = 0.0049). CONCLUSION: These findings emphasized the importance of examining foot and ankles in patients with RA who undergo total knee arthroplasty.

Simultaneous bilateral posterior interosseous nerve palsy caused by rheumatoid synovitis of the elbows.

A 60-year-old woman with rheumatoid arthritis (RA) developed bilateral posterior interosseous nerve palsy. Her left side recovered after conservative treatment. However, her right side, which had been affected previously, did not recover and required surgery. Although conservative therapy, including administration of biologic agents, should be conducted for tight control of RA activity, we recommend surgical treatment when there is recurrence of the disease.

Rupture of the gastrocnemius muscle in neonatal thoroughbred foals: a report of three cases.

Rupture of the gastrocnemius muscle is occasionally found in neonatal foals associated with dystocia and assisted delivery. In this report, 3 cases of gastrocnemius muscle disruption in newborn Thoroughbred foals (6, 5 and 2 days old) are reported. In all cases, the foals were presented with inability to rise unassisted postpartum, a dropped tarsus and swelling in the caudal aspect of the thigh accompanied by a hematoma. Ultrasonography, radiography, computerized tomography (CT) and subsequent autopsy were performed to confirm the clinical and pathological features of these cases.

Distal interphalangeal joint arthrodesis with the reverse fix nail.

PURPOSE: Arthrodesis of distal interphalangeal (DIP) and thumb interphalangeal (IP) joints is a well-established procedure for the treatment of pain, deformity, and instability associated with arthritis and traumatic conditions. Fixation with various headless compression screws has become increasingly common and with favorable outcomes. However, there are still characteristic complications, such as hardware prominence with the distal end of the screw incompletely buried in the distal phalanx. The purpose of this study was to review the outcomes and complications associated with the arthrodesis of DIP and thumb IP joints using the Reverse Fix Nail (Tact Medical, Inc., Tokyo, Japan), a headless compression screw designed for DIP and thumb IP joint arthrodesis. METHODS: We retrospectively reviewed 89 cases involving 60 patients, in which arthrodesis with the Reverse Fix Nail was performed for DIP and thumb IP joints. We referenced medical charts, radiographs, and operative records to investigate the complications and postoperative periods to bone union. RESULTS: Of the 89 consecutive cases, 86 (97%) achieved bone union. Complications included 1 case of prominent hardware and 3 cases of nonunion (1 was asymptomatic and the other 2 were symptomatic, requiring secondary surgery). CONCLUSIONS: The Reverse Fix Nail is a favorable implant for DIP joint or thumb IP joint arthrodesis with a comparable bone union rate and lower risk of hardware prominence than other implants.

Relationship between the Placental Retention Time and the Reproductive Performance at the Foal Heat in Thoroughbred and a Comparison with Heavy Draft.

The aim of this study was to clarify the relationship between the placental retention time (PRT) and the reproductive performance following mating at the foal heat in Thoroughbreds. For this purpose, we interviewed 292 farmers over a period of 3 years with questionnaires evaluating foaling, expulsion of placenta and reproductive performance at the foal heat in 1,432 mares. The obtained data were later compared with a previous study of heavy draft mares. The average of the PRT of the 1,432 Thoroughbred mares was 58 ± 88 min (mean ± SD). The mean PRT of Thoroughbreds was significantly shorter than that of the148 min of heavy draft mares. The incidences of retained placenta (RP) occurring in the Thoroughbred mares were 5.2 and 4.0%, for over 3 and 4 hr after foaling, respectively. The incidence of RP over 4 hr was significantly lower than that of 25% in heavy draft mares. The pregnancy rate at foal heat of the mares in which PRT was less than 3 hr was 37%, and it significantly decreased to 11% for those with PRT of more than 3 hr. In the comparison of the reproductive performance between Thoroughbred and heavy draft mares, the pregnancy rate of Thoroughbreds dropped drastically to 10% when PRT exceeded 40, and in consequence, the pregnancy rate of Thoroughbreds was significantly lower than the 30% of heavy draft mares, which had a PRT of over 4 hr. In conclusion, the Thoroughbred mares had a low incidence of RP, however, a PRT exceeding 3 hr severely affected the reproductive performance at the foal heat.

Spontaneous bilateral femoral neck fractures associated with a low serum level of vitamin D in a young adult.

Bilateral femoral neck fracture is an extremely rare injury in young adults. We report a young adult with bilateral femoral neck fracture after minimal stress. The current case did not demonstrate any abnormality on laboratory data, except for a low serum level of vitamin D(3). Although, in our case, the patient underwent bilateral femoral head arthroplasty, early diagnosis could have been helpful to avoid further displacement of the fracture and surgical treatment.

Wrist Arthrodesis in Rheumatoid Arthritis Using an LCP Metaphyseal Locking Plate versus an AO Wrist Fusion Plate.

OBJECTIVES: Although wrist arthrodesis using a plate is an established treatment with a well-documented successful union rate for severely destroyed wrists, plate-related complications are a matter of great concern. METHODS: We retrospectively compared wrist arthrodesis using an AO wrist fusion plate in nine and a locking compression plate (LCP) metaphyseal plate in seven cases of rheumatoid arthritis. RESULTS: The mean follow-up was 40.6 months in the AO wrist fusion plate group and 57.2 months in the LCP metaphyseal plate group. Bone union at the arthrodesis site was achieved in all cases in both groups. Comparison of the original position of the fusion on the immediate postoperative radiographs and the position on the most recent follow-up radiographs demonstrated good stability in both groups. Plate-related complications occurred in four cases in the AO wrist fusion plate group and no cases in the LCP metaphyseal plate group. Complications included pain over the plate, wound dehiscence and infection, extensor tendon adhesion, and fracture in one case each. CONCLUSION: Wrist arthrodesis using an LCP metaphyseal plate was favorable for rheumatoid arthritis patients with comparable stability to that of and a lower risk of plate-related complications than an AO wrist fusion plate.

[Apperceptive form visual agnosia caused by anti-TNFalpha therapy to rheumatoid arthritis].

TNFalpha plays an important role as an inflammatory mediator in both several autoimmune diseases and multiple sclerosis. Anti-TNFalpha antibody has been widely used to treat rheumatoid arthritis and Crohn's disease. On the. other hand, anti-TNFalpha antibody treatment increased recurrence rate in clinical trials for multiple sclerosis. We report a patient with rheumatoid arthritis without past history of any neurological disorders, who developed diplopia, ataxia, and visual agnosia specific to line drawing in the course of anti-TNFalpha antibody treatment. MRI studies detected multiple demyelinating lesions in the cerebral white matter and brainstem. The present case indicates that careful observation of neurological symptoms is important in the course of anti-TNFalpha antibody treatment, even in patients without past history of demyelinating diseases.

Abnormal pregnancies associated with deviation in progestin and estrogen profiles in late pregnant mares: A diagnostic aid.

Measurement of progestines and estrogens in maternal plasma has been advocated as an indicator of foeto-placental function. The goals of the present study were as follows: to determine progestin and estrogen concentrations in mares with normal and abnormal pregnancies during late gestation, evaluate the diagnostic value of hormone concentrations, and investigate the relationship between hormone concentrations after treatment and the survival of foals. Blood samples were collected monthly from 459 pregnant mares between Day 201 of gestation and foaling. Progestin and estrogen concentrations were measured using a time-resolved fluoroimmunoassay with anti-progesterone and anti-17ß-estradiol antibodies. The cutoff values of hormone concentrations that best discriminated between healthy foals and foal loss groups were determined using receiver-operating characteristic (ROC) curve analysis. Mares with compromised pregnancies are treated with progestins, tocolytics and antibiotics according to clinical signs, ultrasonographic examination and hormonal test. We investigated the relationship between the restoration of hormone concentrations after treatment and the survival rate of the foals of 62 compromised mares. Maternal serum progestin and estrogen concentrations on Days 241-320 of gestation differed significantly between healthy foals and foal loss of each group. Predictions of pregnancy outcomes were based on ROC curve analysis that established cutoff values of serum progestin and estrogen concentrations for each 20-day interval during gestation. All mares with improved concentrations of progestins or estrogens after treatment delivered healthy foals. When hormone concentrations got worse after treatment, the rate of loss was higher when treatment was administered during Days 201-290 of gestation than after Day 290. Mares with high progestin and low estrogen concentrations were likely to deliver aborted/dead foals during mid-to-late gestation. These results suggest that measurement of progestin and estrogen concentrations may be useful for diagnosing abnormal pregnancy and implementing early treatment strategies.

New-onset demyelination induced by infliximab therapy in two rheumatoid arthritis patients.

Therapies aimed at inhibiting tumor necrosis factor, a proinflammatory cytokine implicated in autoimmune disease, are effective for rheumatoid arthritis (RA) and Crohn's disease. We report two patients who newly developed multiple demyelinating lesions in the central nervous system in the course of infliximab therapy for active RA. Neurological symptoms and the number of gadolinium-diethylenetriamine pentaacetic acid-enhanced lesions in magnetic resonance imaging gradually diminished with steroid treatment.

[Sequential combined liver-kidney transplantation for a one-year-old boy with infantile primary hyperoxaluria type 1].

We present the case of a one-year-old male patient with infantile primary hyperoxaluria type 1 (PH1). The patient visited hospital because of growth delay and poor feeding when he was six months old, and was diagnosed as PH1 with chronic renal failure. He underwent peritoneal dialysis until receiving a living-related liver transplantation when he was seventeen months old, and after the operation, underwent hemodialysis or hemodiafiltration four times per week. Six months after the liver transplantation, his serum oxalate level decreased to around 20 micromol/l and a living-related kidney transplantation was successfully performed. Nine months have passed since the kidney transplantation, and the patient's liver and kidney functions have been good and his growth and development much better than before the sequential liver and kidney transplantation. However, his serum and urine oxalate levels remained high and he has required high dose hydration to prevent deposition of calcium oxalate crystals in his grafted kidney. The key-points for treating infantile PHI patients are summarized as follows; 1) make a precise diagnosis as soon as possible, 2) perform a combined liver-kidney transplantation successfully, 3) conduct careful monitoring of the serum and urine oxalate levels and continue adequate hydration after kidney transplantation until the serum and urine oxalate levels normalize. Furthermore, cooperation between the medical staff and the patient's family seems to be essential.

Kidney transplantation after liver transplantation from the same donor: four cases of successful steroid withdrawal.

BACKGROUND: Administration of corticosteroids to kidney recipients has hampered the complete clinical success of kidney transplantation. Because most organ transplantation in Japan is living-related, we had the experience of performing kidney transplantation (KT) after liver transplantation (LT) from the same donor in four patients and successfully withdrew corticosteroid administration. METHODS: Three pediatric and one adult patient received kidney allografts from 3 to 10 months after LT from the same donor. The immunosuppressive regimen consisted of a corticosteroid and tacrolimus. The steroid was withdrawn after KT in all four patients. After complete withdrawal of the steroid, DNA was extracted from two recipients and examined by polymerase chain reaction to detect microchimerism. A mixed lymphocyte reaction (MLR) and cell-mediated lymphocytotoxicity assay (CML) were performed to test for donor-specific hyporesponsiveness. RESULTS: Steroid withdrawal was successfully accomplished after KT in every patient. No steroid-withdrawal-associated complications were observed. In the three pediatric patients, remarkable catch-up growth was observed after steroid withdrawal. In the two patients tested, donor DNA was not detected by polymerase chain reaction, suggesting the absence of microchimerism. MLR and CML showed that recipient lymphocytes reacted against donor lymphocytes at the same level as against the third-party lymphocytes. CONCLUSION: Steroid withdrawal was successfully achieved in four kidney recipients who had received a liver allograft from the same donor. The MLR and CML findings indicated the absence of donor-specific hyporesponsiveness in vitro. Although the precise mechanism is not yet clear, KT after LT from the same donor should be considered as a method that allows steroids to be withdrawn from the immunosuppressive regimen of KT.

A combined low-density lipoprotein apheresis and prednisone therapy for steroid-resistant primary focal segmental glomerulosclerosis in children.

BACKGROUND: Treatment of steroid-resistant (SR) primary focal segmental glomerulosclerosis (FSGS) remains a major challenge in nephrology. A prospective study was conducted to clarify the therapeutic role of low-density lipoprotein apheresis (LDL-A) in 11 nephrotic children with SR and cyclosporine A (CsA)-resistant primary FSGS. METHODS: Based on entry criteria, all 11 eligible patients had biopsy-proven primary FSGS presenting with nephrotic syndrome (NS) and were resistant to steroid and conventional-dose CsA therapy. LDL-A was performed twice a week for 3 weeks (first course), then weekly for 6 weeks (second course). Beginning from the second LDL-A course, a dosage of 1 mg/kg/d of prednisone was administered for 6 weeks, then tapered. RESULTS: Seven patients experienced remission of NS, 5 of whom achieved complete remission within 4 weeks after initiating prednisone therapy with LDL-A. These 5 patients maintained normal renal function during follow-up (median, 4.4 years). Of 2 patients with partial remission, 1 patient maintained stable renal function during follow-up (4.5 years), whereas the other patient showed a gradual decline in renal function and progressed to end-stage renal failure (ESRF) 7.8 years after LDL-A therapy. Four patients who were considered to experience treatment failure had persistent NS and progressed to ESRF in 1.3 years (median) after LDL-A therapy. Complete remission (n = 5) was associated with significantly more highly selective proteinuria compared with treatment failure (n = 4). CONCLUSION: This study suggests that combined LDL-A and prednisone therapy can be a valuable addition to therapeutic options for treating patients with SR-FSGS. The role of LDL-A in treating these patients deserves to be assessed further in larger randomized controlled trials.

Urinary acidification in extremely low birth weight infants.

Premature infants often present metabolic acidosis without protein load in the early neonatal period, around days 4-6. In order to elucidate the cause of acidosis, we investigated urinary acidification of infants in the early neonatal period. Urine pH, fractional excretion of HCO(3)(-) (FEHCO(3)), excretion of HCO(3)(-) and NH(4)(+) of the appropriate-for-date infants were measured on days 0-2 and on days 4-6 of life. Extremely low birth weight (ELBW) infants showed higher urine pH than more than 1500 g birth weight infants. FEHCO(3) and HCO(3)(-) excretion were of high values in ELBW infants on days 0-2, but decreased on days 4-6. Urine NH(4)(+) excretion rate was lower in ELBW infants than in birth weight more than 1000 g on days 0-2 of life and still remained at a low rate on days 4-6. These data indicated that insufficiency of NH(4)(+) excretion is the main cause for metabolic acidosis of ELBW infants in the early neonatal period.

A case of chronic relapsing ANCA-associated microscopic polyangiitis successfully treated with plasma exchange.

We report the case of a 4.5-year-old girl with microscopic polyangiitis (MPA) manifesting antineutrophil cytoplasmic autoantibody (ANCA)-positive necrotizing crescentic glomerulonephritis and pulmonary hemorrhage. She was initially on induction therapy with corticosteroids and azathioprine. Plasma exchange (PE) combined with immunosuppressants was used to treat an episode of recurrent pulmonary hemorrhage, and achieved remission. At 9.8 years of age her kidney disease relapsed, associated with renal dysfunction and increased proteinuria. To minimize the toxic effects of immunosuppressants, she was treated with PE again, and her renal dysfunction resolved. Plasma exchange was effective in reducing the risk of death and preserving long-term renal function without the severe adverse effects of immunosuppressants. Our preliminary results indicate that PE is likely to be a treatment option for children in acute phase of ANCA-associated MPA, who should be protected from the toxic effects of immunosuppressants.