Larsen Grade Research Articles

Three once-weekly intra-articular injections of Hylan G-F 20 significantly improve pain relief compared with placebo in patients with chronic idiopathic knee osteoarthritis: a single-centre, evaluator-blinded and patient-blinded, randomized controlled trial.

Clinical trials on the use of viscosupplementation with hyaluronic acid (HA) in patients with knee osteoarthritis (KOA) are inconsistent, making it challenging to determine its value in clinical practice. One issue is the availability of various HA products on the market; differences in their chemical features can impact patient outcomes. Herein, we assess the efficacy and safety of three once-weekly intra-articular (IA) injections of Hylan G-F 20, a high-molecular-weight and highly crosslinked HA product, in patients with KOA. We hypothesized that Hylan G-F 20 would provide significant pain relief with no increased safety risk compared with IA saline (placebo). This was a 26-week, patient-blinded and evaluator-blinded, single-centre, randomized placebo- controlled trial. Men or women ≥18 years of age with Larsen grade II or III KOA were included. Patients received IA injections of either Hylan G-F 20 or placebo once a week for 3 weeks. The primary endpoints were the week 12 and 26 visits. Primary efficacy outcomes included visual analogue scale (VAS) pain scores, patient activity level and an overall assessment of clinical condition. Secondary outcomes included adverse events (AEs) that emerged during treatment. The primary analysis included the intention-to-treat population. An alpha level of 0.05 was used in the statistical analysis. Thirty patients were included in the intention-to-treat population (15 per group). All efficacy outcomes were statistically significant in favour of Hylan G-F 20, except night pain and inactivity stiffness, for both patient- assessed (all p=0.0001 at week 12) and evaluator-assessed (all p=0.0001 at week 12 and p=0.0004-0.0180 at week 26) measurements. There was also a greater proportion of symptom-free patients and those with a >50% improvement in their VAS scores, except night pain, in the Hylan G-F 20 group (p=0.001-0.003 in patient-assessed scores and p<0.0001 to 0.002 in evaluator-assessed scores at week 12). Two patients, one in each group, experienced an AE; no sequelae occurred, and no special treatment was required for either AE. No patients withdrew from the study prematurely due to an AE. In patients with chronic idiopathic KOA, Hylan G-F 20 provides significant improvements in pain relief compared with placebo with no added safety concerns.

Long-term outcomes of Kudo type-5 unlinked surface-replacing total elbow arthroplasty for rheumatoid arthritis: a 15-year average follow-up study

Total elbow arthroplasty (TEA) has been used for various conditions including rheumatoid arthritis (RA). While the Kudo TEA has been associated with favorable short-term outcomes, there is limited information on the longer term outcomes of this device. The aim of this study was to investigate the average 15-year outcome of Kudo type-5 TEA in patients with RA. For this retrospective cohort study, we reviewed 29 elbows in 28 patients (Larsen grade III, n=8; IV, n=19; V, n=2) with RA who underwent Kudo type-5 TEA between 1999 and 2010. The patients were followed up for a mean of 15 (range: 10-21) years. We investigated the survival with setting revision/removal as the endpoints. The risk factors for revision/loosening were assessed. There was a significant improvement in elbow flexion after Kudo TEA. Preoperative and postoperative Mayo Elbow Performance Score improved significantly from 60.3 to 94.7. Complications included intraoperative medial humeral epicondyle fracture (n=2), postoperative dislocations (n=4), deep infections (n=1), and persistent ulnar nerve neuropathy (n=1). Aseptic loosening was observed in 7 elbows (24.1%; humerus, n=3; ulna, n=3; both sides, n=1). The causes of the 5 revisions were postoperative dislocation (n=1), deep infection (n=1), aseptic loosening of the humerus (n=2), and aseptic loosening of the ulna (n=1). All 5 elbows underwent revision of the ulnar component (n=2) or the linked TEA (n=3). The survival rate was 81% at 15years after surgery with setting revision/removal as the endpoints. A deviation of ulnar component insertion angle of over 5° in any plane was associated with more revision compared to those with accurately placed implants. The Kudo type-5 elbow showed good results for up to 15years of follow-up. However, excessive deviation of insertion angle of the ulnar component (over 5°) was associated with more revision. Due to the small sample size, robust statistical analysis of risk factors for postoperative complications or revision could not be performed, and further research is warranted to resolve this limitation.

Evaluation of articular changes using a rat mono-iodoacetate-induced shoulder arthritis model by histology and radiology.

The rat mono-iodoacetate (MIA) arthritis model has been used in studies on the hip, knee, and ankle joints. Few studies have explored its utility in shoulder arthritis research, and none have evaluated the effects of time and different MIA doses on arthritis progression. Therefore, we developed a rat MIA shoulder arthritis model to evaluate articular changes through radiological and histological analyses. Sprague-Dawley rats (n = 108) were equally divided into groups that were intra-articularly injected with 0.5 mg of MIA (in 50 µL of purified water), 2.0 mg of MIA (in 50 µL of purified water), or purified water (50 µL; sham group). Throughout the study period, 18 rats (six per group) were evaluated by computed tomography and assessed using the Larsen's classification system; 90 rats were further evaluated histologically using the Osteoarthritis Research Society International scoring system. Computed tomography revealed that the groups injected with MIA developed arthritis and osteophytes 14 days after injection, which progressed temporally. The Larsen's grades worsened over time; at all time points, the scores were higher in the group injected with 2.0 mg of MIA than in the group injected with 0.5 mg of MIA. Furthermore, concurrent with the worsening Larsen's grades, the Osteoarthritis Research Society International scores also significantly increased over time; at all time points, they were higher in the group injected with 2.0 mg of MIA than in the group injected with 0.5 mg of MIA. Our rat MIA shoulder arthritis model revealed radiologically and histologically confirmed temporal and MIA dose-dependent arthritic changes.

Clinical course in patients with chronic undifferentiated arthritis of the elbow after arthroscopic synovectomy

Surgical treatment can be considered for patients with undifferentiated arthritis (UA) limited to the elbow joint. The purpose of this study was to analyze the clinical outcomes of arthroscopic synovectomy. Nineteen patients who underwent arthroscopic synovectomy for chronic UA of the elbow between 2006 and 2019 were enrolled in this study. One patient was excluded because of evidence of tuberculosis in the biopsy. Chronic UA of the elbow was defined as (1) localized synovitis diagnosed by magnetic resonance imaging, (2) no specific cause, and (3) no response to conservative treatment for >3months. We compared baseline characteristics and clinical outcomes between the remission and disease progression groups. Postoperatively, synovitis was controlled in 13 patients. In 5 patients, the symptoms disappeared after surgery without any medical treatment. Four patients discontinued disease-modifying antirheumatic drugs. Nine patients were classified as in remission. The disease progression group had a longer symptom duration, elevated rheumatoid markers, and higher Larsen grading. However, the difference was not statistically significant. Arthroscopic synovectomy achieved remission in approximately 47% of patients with chronic UA of the elbow. Although arthroscopic synovectomy did not prevent RA, it can be considered for rapid resolution of synovitis and diagnostic purposes.

Radiographic study of the distal ulna in rheumatoid arthritis with extensor digitorum communis ruptures.

Extensor digitorum communis (EDC) rupture of the wrist often occurs in patients with rheumatoid arthritis (RA). Early operation is desirable for patients with a high risk of rupture; therefore, rheumatologists should diagnose it during daily examinations. This study aimed to clarify radiographic changes in the distal ulna and related factors associated with EDC rupture in patients with RA. We analysed plain radiographs of 40 patients with RA associated with EDC rupture and 62 healthy controls. We investigated the deformation of the distal ulna, Larsen grades, and radiological parameters such as ulnar variance (UV), ulnar bowing angle, dorsal protrusion (DP), and dorsal bowing angle. The ratios of the ulna head deformation, Larsen grades, UV, DP, and dorsal bowing angle were significantly larger in the ruptured group than in the control group. Multiple logistic regression analysis revealed that DP and Larsen grades were significantly associated with EDC rupture. Deformity of the distal ulna is evident in patients with an EDC rupture. Ulnar head deformation, high Larsen grades, and large DP are the potential risk factors for EDC rupture.

Ankle arthrodesis using a retrograde intramedullary rod with fins for highly destructive joints in elderly patients with rheumatoid arthritis: A report of two cases

Herein, we present two cases of older adult patients with highly destructive changes in ankle joints (Larsen grade IV) who underwent retrograde intramedullary ankle nail fixation with fins. In both patients, bony union was achieved, and full weight‐bearing was attained at 3 months after surgery.

Association of Decreased Physical Activity with Rheumatoid Mid-Hindfoot Deformity/Destruction.

Foot/ankle problems remain important issues in rheumatoid arthritis (RA) patients. Although forefoot deformity generally takes a major place in surgical treatment, concomitant mid-hindfoot deformity is also commonly seen. In this situation, it can be easy to overlook that mid-hindfoot deformity can also induce or exacerbate clinical problems behind the forefoot events. Thus, the relationship between mid-hindfoot deformity/destruction and physical activity/ADL was investigated. Radiographic findings of 101 lower limbs (59 patients) were retrospectively evaluated. Alignment parameters in the lower extremity and joint destruction grade (Larsen grade) were measured. The timed-up-and-go (TUG) test, modified health assessment questionnaire (mHAQ), pain, self-reported scores for the foot and ankle (SAFE-Q), and RA disease activity were investigated to assess clinical status. The relationships among these parameters were evaluated. Subtalar joint destruction was correlated with TUG time (r = 0.329), mHAQ score (r = 0.338), and SAFE-Q: social functioning (r = 0.332). TUG time was correlated with the HKA (r = −0.527), talo-1st metatarsal angle (r = 0.64), calcaneal pitch angle (r = −0.433), M1-M5A (r = −0.345), and M2-M5A (r = −0.475). On multivariable linear regression analysis, TUG time had a relatively strong correlation with the talo-1st metatarsal angle (β = 0.452), and was negatively correlated with calcaneal pitch angle (β = −0.326). Ankle joint destruction was also correlated with TUG time (β = 0.214). Development of structural problems or conditions in mid-hindfoot, especially flatfoot deformity, were related with decreased physical activity in RA patients. Wearing an insole (arch support) as a preventative measure and short foot exercise should be considered from the early phase of deformity/destruction in the mid-hindfoot in the management of RA.

Bone Histomorphometry of Femoral Head Cancellous Bone in Patients Who Underwent Total Hip Arthroplasties due to Destructive Hip in Rheumatoid Arthritis.

Rheumatoid arthritis (RA) affects the hip joints. The microarchitecture of the cancellous bone in RA-affected hip joints has been unclear. Here we investigated the bone metabolism changes in the subcapital cancellous bone of destructive hips of RA patients (n=26 patients; 28 hip joints) which were classified by Larsen grade on X-ray into the groups: destructive hip (Des) (Larsen grade IV, n=18) and neck fracture (Fx) (Larsen grade 0 or 1, n=10). The femoral heads of the Des-group showed significantly higher trabecular thickness versus those of the Fx-group (179±30.8 vs. 151±23.5 μm, p=0.02). The Des-group had significantly higher osteoid volume/tissue volume (OV/TV) and osteoid volume/bone volume (OV/BV) ratios than the Fx-group (OV/TV: 0.72±0.70% vs. 0.27±0.32%, p=0.028; OV/BV: 2.96±2.85% vs. 1.24±1.31%, p=0.039). The osteoblast and osteoclast surface areas of the Des-group were remarkably higher than those of the Fx-group (9.80±10.9 vs. 0.15±0.15%, p=0.0005; 0.34±0.48 vs. 0.06±0.06%, p=0.0285, respectively). The T-scores of hip (femoral neck) bone mineral density (BMD) of the Fx-group were significantly lower versus those of the Des-group (-3.1±0.76 vs. -1.6±1.17, p<0.01). Increased osteoid and resorption parameters and higher femoral neck BMD demonstrate a high bone-turnover state in response to destructive changes in the hips of RA patients.

Evaluating various radiographic methods of shoulder joint damage in patients with rheumatoid arthritis receiving biological disease-modifying antirheumatic drugs.

Objectives This study aims to clarify shoulder joint damage in rheumatoid arthritis patients receiving biological disease-modifying antirheumatic drugs (bDMARDs) and the relationship between joint damage and clinical factors.Patients and methods In this retrospective study conducted between April 2005 and December 2008, 36 shoulders in 19 patients (2 males, 17 females; mean age: 58.9 years; range 42 to 75 years) were evaluated at baseline and two years after the initiation of bDMARD therapy with infliximab (n=14) or etanercept (n=5). Standard anteroposterior radiographs of the shoulder joints were taken at baseline and two years after institution of biological therapy. Structural damage in the shoulder joints was assessed using the Larsen scoring method, the medial displacement index (MDI), and the upward migration index (UMI).Results There was a significant correlation between MDI, UMI, and Larsen grade before biological therapy. Univariate analysis revealed that the disease activity score 28-count erythrocyte sedimentation rate (ESR) at baseline (odds ratio [OR]: 4.298) was associated with progression of MDI. But multivariate logistic regression revealed that there was no association with the progression of MDI. Univariate analysis revealed that ESR at baseline (OR: 0.967) and matrix metalloproteinase-3 (MMP-3) at baseline (OR: 0.996) were associated with the progression of UMI. Multivariate logistic regression revealed that MMP-3 at baseline (OR: 0.994) was independently associated with the progression of UMI.Conclusion Medial displacement index and UMI correlated with the Larsen grade of the shoulder joint strongly and moderately, respectively. This study suggests that MDI and UMI may help to evaluate radiographic progression of damage in shoulder joints in patients on bDMARDs, which is difficult to detect using the Larsen grade.

Periarticular osteophyte formation protects against total knee arthroplasty in rheumatoid arthritis patients with advanced joint damage.

Periarticular osteophyte formation is observed during the repair of damaged joints in rheumatoid arthritis (RA); however, little is known about its clinical and functional roles. This study aimed to determine the influence of periarticular osteophyte formation on the incidence of total knee arthroplasty (TKA) (a surrogate for long-term outcomes of joint destruction) in patients with RA. This retrospective longitudinal study included a total of 130 symptomatic (tender and/or swollen) knee joints in 80 patients starting biologics. Cumulative incidences of TKA were compared according to the presence or absence of osteophyte on plain anteroposterior radiograph (osteophyte (±)) and the extent of advanced joint damage as defined by Larsen's grading system (0-II vs. III-V). Kaplan-Meier estimates showed a significantly lower cumulative incidence of TKA for the osteophyte (+) group (n = 33) compared with the osteophyte (-) group (n = 31) in the Larsen grades III-V group (38 vs. 74% at 10years, P =0.010), whereas no significant difference was observed between the osteophyte (+) (n = 11) and osteophyte (-) (n = 55) groups in the Larsen grades 0-II group (9 vs. 10% at 10years). Multivariate Cox proportional hazards analysis revealed that older age (hazard ratio (HR), 1.04 per 1year; 95% confidence interval (CI), 1.01-1.08) and osteophyte formation (HR, 0.39; 95% CI, 0.19-0.79) independently predicted TKA in the Larsen grades III-V group, whereas none of the assessed variables predicted TKA in the Larsen grades 0-II group. Osteophyte formation reduces the incidence of TKA in patients with RA who have advanced joint damage. Key Points • Older age and Larsen grade were independent predictors of total knee arthroplasty (TKA) in rheumatoid arthritis (RA) patients. • Periarticular osteophyte formation reduced the incidence of TKA in RA patients with Larsen grades III-V.

Effects of malalignment and disease activity on osteophyte formation in knees of rheumatoid arthritis patients.

Rheumatoid arthritis (RA) patients with secondary osteoarthritis (OA) in a knee joint following a total knee arthroplasty (TKA) procedure have been increasing. Here, we investigated osteophyte formation in knee joints of RA patients and associated factors. We retrospectively examined findings of 35 knees in 30 RA patients (26 females, 4 males; mean age: 63.0 years; median disease duration: 15 years) who underwent TKA, including preoperative anteroposterior view radiographs of the knee joint. Using the ImageJ software package, osteophyte size in the medial femur (MF), medial tibia (MT), lateral femur (LF), and lateral tibia (LT) regions was also determined. The mean femorotibial angle was 179°, while Larsen grade was 2 in 1, 3 in 12, 4 in 18, and 5 in 2 patients. Osteophyte sizes in the MF, MT, LF, and LT regions were 37.2, 17.0, 27.2, and 4.57 mm2, respectively, and significantly greater in the medial compartment (MC; MF+MT) than the lateral compartment (LC; LF+LT) (p < 0.001). In varus cases, osteophyte size in the MC was significantly larger than normal and valgus cases (p = 0.0016). Furthermore, osteophyte size in the MC was negatively correlated with the inflammatory markers C-reactive protein (r = -0.492, p = 0.0027) and erythrocyte sedimentation rate (r = -0.529, p = 0.0016), whereas that in the LC was negatively correlated with disease activity (r = -0.589, p = 0.0023). Our results suggest that alignment and disease activity influence osteophyte formation in RA patients, with secondary OA a more prominent symptom in RA patients with controlled inflammation.

Oral steroid decreases the progression of joint destruction of large joints in the lower extremities in rheumatoid arthritis.

To identify the risk factors for destruction of large joints in the lower extremities in patients with rheumatoid arthritis (RA) during a 4-year follow-up period in a prospective study.We enrolled consecutive patients who participated in both 2012 and 2016. Clinical data, disease activity, and types of medication were collected in 2012. Standard anteroposterior radiographs of weight-bearing joints (hips, knees, and ankles) were taken in 2012 and 2016. Radiographic progression was defined as progression in the Larsen grade or the need for joint arthroplasty or arthrodesis. The association between baseline characteristics and the incidence of radiographic progression was statistically assessed.A total of 213 patient were enrolled, and, after exclusion, 186 patients were analyzed. Sixty 9 patients (37.1%) showed radiographic progression in 1 of the large joints in the lower extremities. Multivariate regression analysis showed that radiographic progression was associated with older age, higher disease activity, and the presence of radiographic destruction at the baseline. The lower dosage of oral prednisolone was a significant risk factor compared with higher dosage when used.Patients with the risk factors should be followed closely to limit the progression of large joint destruction in the lower extremities.

Predictive factors for radiographic progression of large joint damage in patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs (bDMARDs): Results of 3 to 4 years of follow-up

Objectives: Little information is available regarding long-term follow-up of radiographic progression of damage (RPD) to large joints during treatment of rheumatoid arthritis (RA) with biological disease-modifying antirheumatic drugs (bDMARDs). We evaluated 3- to 4-year follow-up results and the associations between RPD and patient background and Larsen grade (LG) of joints.Methods: Seventy-one RA patients receiving bDMARDs for 3 to 4 years or who achieved bDMARD-free status were included. The mean age and disease duration at the start of bDMARDs were 62.4 years and 10.8 years, respectively. A total of 314 joints, including shoulders, elbows, hips, knees, and ankles, were evaluated to determine whether RPD was present by comparing radiographs before and after treatment.Results: RPD was observed in 24 patients (33.8%) and 34 joints (10.8%). Joints with an LG of III or higher had significantly higher rates of RPD than those with LGs I and II. Multivariate logistic regression analysis revealed that stage and health assessment questionnaire (HAQ) score at 18-months were independent risk factors for RPD (cut-off value: 2.5, odds ratio: 7.222 for stage; cut-off value: 0.9375, odds ratio: 6.278 for HAQ at 18-months).Conclusion: Stage, HAQ at 18-months, and LG at the start of bDMARDs were predictive of RPD after 3 to 4 years. bDMARDs should be started before both stage and LG exceed III and the therapeutic strategy should be determined so that HAQ does not exceed 1.0 during treatment.

Combined synovectomy and extensor carpi radialis longus transfer to realign and stabilise the rheumatoid wrist

BackgroundIn patients with rheumatoid arthritis, the surgical treatment of wrist lesions relies on synovectomy combined with stabilisation and realignment of the carpal bones. The objective of this study was to evaluate the outcomes and define the indications of extensor carpi radialis longus (ECRL) transfer to the extensor carpi ulnaris (ECU) as described by Clayton and Ferlic. HypothesisECRL-to-ECU transfer combined with synovectomy can prevent the development and/or progression of rheumatoid deformities at the wrist. Material and methodsA retrospective observational study was performed in 16 wrists. The following data were collected before and after surgery: pain, synovitis, range of motion, carpal height, ulnar translocation and radial deviation of the carpal bones, and Larsen's grade of the radio-carpal and mid-carpal joints. ResultsAfter a mean follow-up of 42.5 months after surgery, pain relief was noted in 14 cases and synovitis resolution in 10 cases. Mean mobility gains were 19.7° in extension and 5.7° in flexion. The radiographs showed a decrease in carpal height, whereas radial deviation and ulnar translocation were unchanged. No change was seen in the radio-carpal and mid-carpal joint lines. In the 3 wrists that required mid-carpal arthrodesis due to advanced disease before surgery, the radio-carpal joint line was unchanged and outcomes were the same as in the overall population. DiscussionECRL-to-ECU transfer combined with synovectomy provides pain relief and prevents radio-carpal destabilisation. The main indication of ECRL transfer is reducible radial deviation and ulnar translocation. ECRL is also indicated in combination with mid-carpal arthrodesis in the small minority of patients who have predominant mid-carpal involvement with a Larsen grade greater than 2. Level of evidenceIV, retrospective observational study.

Health assessment questionnaire-disability index (HAQ-DI) score at the start of biological disease-modifying antirheumatic drug (bDMARD) therapy is associated with radiographic progression of large joint damage in patients with rheumatoid arthritis

Objectives: Radiographic progression of damage (RPD) to large joints in patients with rheumatoid arthritis (RA) has not been fully studied. We previously demonstrated that Larsen grade of the large joints was associated with RPD of large joints in patients treated with biological disease-modifying anti-rheumatic drugs (bDMARDs); however, no factors associated with background characteristics of patients were identified.Methods: A total of 400 large joints in the upper and lower extremities, including the shoulder, elbow, knee, and ankle, of 88 patients with RA treated with bDMARDs for 1–3 years were investigated. Radiographs of tender and/or swollen large joints were acquired at least twice during the study period (mean, 16.4 months), and the RPD was evaluated.Results: A multivariate analysis revealed that health assessment questionnaire-disability index (HAQ-DI) score at the start of bDMARD treatment was associated with RPD. The cutoff value that discriminated progression from non-progression, determined by a receiver operating characteristic (ROC) curve, was 1.4375 (sensitivity: 0.778, specificity: 0.894).Conclusions: HAQ-DI score at the start of bDMARD treatment was associated with RPD to large joints during a therapeutic period of 1–3 years. Progressive damage is expected to increase when functional disability exceeds an HAQ-DI score of 1.5.

Correlation in the Coronal Angle between Knee and Hindfoot Was Observed in Patients with Rheumatoid Arthritis Unless Talocrural Joint Was Destroyed.

The purpose of this study is to investigate the compensatory correlation between knee and hindfoot in patients with rheumatoid arthritis (RA). This cross-sectional study included 218 patients (407 lower extremities). Radiographs of the hindfoot and full-length posteroanterior hip-to-calcaneus standing radiographs were evaluated. The destruction of the hindfoot was evaluated using the Larsen grading system. The coronal angular deformity of the knee and hindfoot was evaluated by the femorotibial angle (FTA) and the angle between the tibial shaft and the entire hindfoot (tibiohindfoot angle, THFA). The correlation between FTA and THFA was determined by Pearson's coefficient. For all patients, FTA correlated to THFA (R = 0.28, p < 0.001). The correlation was observed as long as the talocrural joint was preserved (Larsen grade ≤ 2), even if the subtalar joint had been destroyed (Larsen grade ≥ 3). However, the correlation was not observed when the talocrural joint was destroyed (Larsen grade ≥ 3, R = −0.02, p = 0.94). The pain in the hindfoot did not correlate with FTA or THFA. In conclusion, a compensatory deformity of the hindfoot against the deformity of the knee was observed in RA, and the correlation was lost when talocrural joint was destroyed.

Predictive factors associated with the progression of large-joint destruction in patients with rheumatoid arthritis after biologic therapy: A post-hoc analysis using FDG-PET/CT and the ARASHI (assessment of rheumatoid arthritis by scoring of large-joint destruction and healing in radiographic imaging) scoring method

Objective: To investigate the associations between large-joint damage and findings on fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) using the “assessment of rheumatoid arthritis by scoring of large-joint destruction and healing in radiographic imaging (ARASHI)” scoring system.Methods: A total of 270 large joints (shoulders, elbows, hips, knees, and ankles) in 27 rheumatoid arthritis patients were assessed. FDG-PET/CT was performed at the initiation of biologics. Radiographs at baseline and at 3 years were evaluated using the ARASHI score.Results: Radiographic progression of damage was detected in 35 by Larsen grade vs. 87 by the ARASHI score. The maximum standardized uptake value (SUVmax) at baseline, Steinbrocker stage at baseline, concomitant prednisolone use, and disease activity score in 28 joints based on erythrocyte sedimentation rate (DAS28-ESR) at 6 months were significantly higher in the radiographic progression group. An SUVmax higher than 1.65 at baseline was a significant predictive factor for progressive damage at 3 years.Conclusions: The ARASHI score may allow more detailed evaluation of large joints than the Larsen method. Joint destruction is likely to have progressed at 3 years in large joints, which had a higher SUVmax at the initiation of biologics.

The anconeus-triceps lateral flap approach for total elbow arthroplasty in rheumatoid arthritis.

The posterior approaches to the elbow are considered as to allow an excellent joint exposure for total elbow arthroplasty. One complication that is well recognized is the insufficiency of the extensor mechanism in particular with the patients with poor tendon quality as in the rheumatoid diseases. The purpose of this paper is to present a new triceps-splitting exposure for total elbow arthroplasty used in rheumatoid patients with their preliminary results. Fifteen consecutive patients with rheumatoid disease at grades III to V of the Larsen grading scale underwent total elbow replacement using the new triceps-splitting exposure called anconeus-triceps lateral flap and it preserves the integrity of the medial proper triceps tendon. The assessments were performed with a minimum follow-up of 2years. The mean Mayo Elbow Performance Score increased from 24 points to 95 points at a mean follow-up of 38months. The pain was calculated using the visual analogue score, it had a mean pre-operative value of 8.9 points and it became 0.5 points. Although elbow motion in flexion-extension and pronosupination was allowed from the day after surgery, we did not observe any insufficiency or secondary detachments of the triceps tendon reporting grade 4 to 5 according to the Medical Research Council scale. These preliminary outcomes suggest that the decision to preserve the medial proper triceps tendon insertion allows to start an earlier active unrestricted rehabilitation programme. This new triceps management improves the surgical exposure of the olecranon surface. Level IV.

Surgical Treatment for the Shoulder Joint in Rheumatoid Patients

Rheumatoid arthritis (RA) is a systemic disease with medication as the treatment of choice. However, surgical treatment is recommended when no improvement is noted despite aggressive conservative treatment. Synovectomy provides desirable outcomes for RA patients in the early stage with a glenohumeral joint of Larsen grade II or less; conversely, arthroplasty is recommended for patients with a glenohumeral joint of grade III or higher. RA patients often have attenuation and dysfunction of the rotator cuff, and reverse shoulder arthroplasty has been proven to provide favorable outcomes in some patients. RA is often complicated with osteoporosis and bony deformity; therefore, close attention is necessary to prevent fractures during shoulder arthroplasty.

Radiographic changes and factors associated with subsequent progression of damage in weight-bearing joints of patients with rheumatoid arthritis under TNF-blocking therapies—three-year observational study

Objectives: The long-term effects of tumor necrosis factor (TNF)-blocking therapies on weight-bearing joints in patients with rheumatoid arthritis (RA) have not been fully characterized. The purpose of this study was to assess the radiographic changes of weight-bearing joints in patients with RA during 3-year of TNF-blocking therapies and to identify factors related to the progression of joint damage.Methods: Changes in clinical variables and radiological findings in 243 weight-bearing joints (63 hips, 54 knees, 71 ankles, and 55 subtalar joints) in 38 consecutive patients were investigated during three years of treatment with TNF-blocking agents. Multivariate logistic regression analysis was used to identify risk factors for the progression of weight-bearing joint damage.Results: Seventeen (14.5%) of proximal weight-bearing joints (hips and knees) showed apparent radiographic progression during three years of treatment, whereas none of the proximal weight-bearing joints showed radiographic evidence of improvement or repair. In contrast, distal weight-bearing joints (ankle and subtalar joints) displayed radiographic progression and improvement in 20 (15.9%) and 8 (6.3%) joints, respectively. Multivariate logistic analysis for proximal weight-bearing joints identified the baseline Larsen grade (p < 0.001, OR:24.85, 95%CI: 5.07–121.79) and disease activity at one year after treatment (p = 0.003, OR:3.34, 95%CI:1.50–7.46) as independent factors associated with the progression of joint damage. On the other hand, multivariate analysis for distal weight-bearing joints identified disease activity at one year after treatment (p < 0.001, OR:2.13, 95%CI:1.43–3.18) as an independent factor related to the progression of damage.Conclusions: Baseline Larsen grade was strongly associated with the progression of damage in the proximal weight-bearing joints. Disease activity after treatment was an independent factor for progression of damage in proximal and distal weight-bearing joints. Early treatment with TNF-blocking agents and tight control of disease activity are necessary to prevent the progression of damage of the weight-bearing joints.