Patients with juvenile idiopathic arthritis（JIA）are usually diagnosed in the pediatric setting and are usually referred to non-pediatric department during the transition period. While family members often provide support for patients in the pediatric setting, patients are expected to be independent in the adult department; and the relationship between patients, family members, and health care providers also changes. Therefore, without adequate preparation for the transition, patients and family members often feel anxious and confused. On the other hand, rheumatologists in adult departments also often feel anxious about addressing patients with transitional JIA, and the reasons for this are lack of knowledge and experience, and lack of preparation for patient acceptance.

  In 2017, “EULAR/PReS standards and recommendations for the transitional care of young people with juvenile-onset rheumatic diseases” was published. In this article, we also introduced key point of these recommendations in addition to challenges and efforts to support the transition of JIA patients in Japan. Although it is preferable for patients with transitional JIA to be transferred to adult departments after they are able to receive care independently, there are many cases in which continued transitional support is required. Healthcare professionals in pediatric and adult departments are expected to not only acquire basic knowledge of JIA, but also to recognize the importance of psychosocial support, and to collaborate with other professionals, including doctors, in this field.

Rheumatoid arthritis（RA）is a disease whose pathogenesis is still not fully understood; it is recognized as an immune disorder causing joint damage and dysfunction. With the advent of various disease-modifying anti-rheumatic drugs（DMARDs）, achieving remission has now become a realistic therapeutic goal. Consequently, previously challenging-to-control inflamed synovitis has subsided, leading to a significant decrease in the indications for synovectomy. However, there are still many cases that meet remission criteria but have unmet needs, making them difficult to treat. Even after the inflammation has subsided, functional impairment persists, and the need to improve quality of life（QOL）is growing as the overall disease settles and a higher level of function is necessary. Furthermore, despite current drug treatment, there is a specific subgroup of patients with progressive joint destruction requiring surgery. Performing surgical interventions aimed at enhancing the quality of life at the right time is as crucial as ever. The major challenge now is how to improve Patient Reported Outcomes（PROs）, and the proportion of small joint surgeries in the fingers and toes has recently increased. Early diagnosis and initiation of appropriate treatment are necessary to prevent the development of refractory RA（D2T RA）. However, additional surgical treatment strategies to increase patient satisfaction are still required, and orthopedic surgeons will continue to play a significant role.

When an orthopaedic surgery is conducted in a patient with rheumatoid arthritis, rheumatologists should know the risk factors for perioperative complications; one of the risk factors is the disease itself, anti-rheumatic drugs can affect the degrees of the risks in various ways, backgrounds such as age, sex, and past history are the risks respectively, and some of the operative procedures can raise the possibility of the complications more than the others. Orthopaedic surgeons, working with rheumatologists, should carefully access the conditions and state of the patient before the operation, take as many countermeasures against the complications as possible, and establish the system to perform comprehensive approach to the complication with medical professionals of other clinical departments when occurs.

With the advancement of pharmacotherapy, there is a decreasing trend in rheumatoid arthritis（RA）-related surgeries, yet the indications are evolving, and there is a growing demand for small joint surgeries. In the context of total elbow arthroplasty（TEA）in Japan, historical efforts have been directed toward developing and improving unlinked types, resulting in favorable treatment outcomes. However, the challenge lies in the high incidence of complications. In recent years, computer-assisted surgery has been introduced and surgical approaches have been improved. For wrist joints, implant arthroplasty became clinically available in 2017, introducing a new therapeutic option. Given the complex anatomy of the carpal bones, achieving secure implant fixation is crucial for favorable surgical outcomes, highlighting the significant role of computer-assisted surgeries. Hand and elbow prostheses are an area where progress in implant development and technology is slow due to the limited number of cases. Nevertheless, further advancements in implants and surgical techniques are anticipated to reduce complications and improve long term clinical outcomes.

Foot and ankle disorders resulting from Rheumatoid Arthritis（RA）can cause severe deformities. Once joint deformations occur, they become irreparable through conservative treatments. Deformities in the foot have a direct correlation with functional impairments, namely a decline in walking ability. Deformity corrections for maintaining patientsʼ daily activities are very important.

  Among an overall decrease in the number of RA surgeries, one notable exception over the past two decades has been the significant increase in foot and ankle surgeries in our institution. Several factors contribute to this phenomenon, including evolving patient needs shifting from pain relief and ADL maintenance to functional improvement, enhanced quality of life, and improvement of appearance. Additionally, the foot and ankle are not included within the standard 28-joint assessment for RA management, and advancements in surgical techniques have played a role.

  RA forefoot surgery is one of the surgeries that has been remarkable progress in recent years among RA-related surgeries. In our country, a dramatic shift from joint-sacrificing surgery to joint-preserving surgery has occurred over the past 15 years. Joint-preserving surgery involves the preservation of the metatarsal head through metatarsal osteotomy and concomitant soft tissue reconstruction. Preservation of the joint is expected to yield functional recovery compared to joint non-preservation surgery.

  As for surgeries for ankle joint destruction, arthrodesis has demonstrated stable long-term outcomes and are commonly regarded as the primary choice. However, in recent years, Total Ankle Arthroplasty（TAA）has garnered attention, particularly in RA patients with lower levels of daily activity compared to those with degenerative joint diseases. Given that many RA patients already exhibit joint destruction in adjacent joints, preserving the range of motion to the greatest extent possible is considered pivotal in RA treatment.

With the advancement in pharmacological treatments for Rheumatoid Arthritis（RA）, the role of joint surgery within the RA treatment framework has significantly transformed, necessitating improvements in physical function and quality of life based on patient-reported outcomes. When considering surgical intervention, it is crucial to reflect on the content of these subjective evaluations, which aligns with the “careful physical function assessment” stipulated in the “JCR Rheumatoid Arthritis Clinical Guidelines 2020” for non-pharmacological and surgical treatment algorithms. To aim for better treatment outcomes, not only pain but also objective physical measurements such as range of motion and speed of movement are important. Thus, both subjective and objective evaluations are necessary.

Background: An elbow joint with severe bone destruction and instability in a patient with rheumatoid arthritis（RA）is referred to as a “mutilans type” deformity. To date, there are no reports of mutilans-type joint septic arthritis. Here, we report two cases of mutilans-type elbow joint septic arthritis which were successfully treated with continuous local antibiotics perfusion（CLAP）.

Case 1: A 76-year-old female with a 52-year history of RA developed sudden onset swelling and a fistula in her left elbow during treatment with tocilizumab, and was diagnosed with septic elbow arthritis（methicillin-sensitive Staphylococcus aureus）. In addition to treatment with systemic antibiotics, she underwent synovial tissue debridement, and distal humeral resection, and was treated with CLAP with gentamicin for 2 weeks, after which her infection subsided.

Case 2: A 79-year-old woman with a 40-year history of RA developed septic elbow arthritis during treatment with abatacept. Six months after the treatment, she developed a fistula in the same elbow and was diagnosed with recurrent septic arthritis（methicillin-resistant coagulase-negative staphylococcus）. She was treated with the same treatment regimen as in case 1, CLAP with gentamicin for 1 week, and improved with no infection recurrence.

Conclusion: In the mutilans-type elbow joint septic arthritis, systemic antibiotics and surgical debridement in combination with CLAP, in which high-concentration aminoglycosides can be administered to local joints where systemic antibiotics have poor penetration, could be an effective therapeutic regimen.

A 86-year-old woman who was diagnosed with granulomatosis polyangiitis（GPA）2 years ago developed lung adenocarcinoma（Stage IA）but she was successfully treated with radiation therapy and remained in remission. After 3 months of the radiation therapy, pituitary enlargement with panhypopituitarism developed, and the patient was treated with high-dose glucocorticoids for GPA with this lesion. However, the lesion did not improve after the treatment. Finally, she underwent pituitary biopsy and pituitary biopsy showed pituitary metastasis of lung cancer. Our case indicated that aggressive histological evaluation is very important in GPA patients with pituitary lesions.