To analyze the course of remission in RA patients, after treatment with Infliximab, we investigated 8 patients with previously established RA who had gone into remission and discontinued infliximab. Infliximab was discontinued when a negative CRP level, below 2.6 points of DAS 28, was continuously obtained for more than 6 months. Of the eight cases, one case (Stage III) showed increased CRP levels 18 months after discontinuing infliximab. Another case (Stage II) underwent complete remission without need of further infliximab or MTX 12 months after discontinuing infliximab. The other cases showed negative CRP, negative RF, and negative MMP-3 levels for 7.9 months on average after discontinuing infliximab. The MMP-3 levels significantly decreased to within normal range compared with those before treatment. Therefore, in remission after infliximab for early RA, not only prevention of further bone destruction but also increase in CRP levels were observed.

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Objective: To evaluate the impact of tacrolimus monotherapy on health related quality of life (HRQOL) in rheumatoid arthritis (RA) patients.
Methods: Twenty-three adult patients were enrolled in a 52-week, open-label, non-comparative study. Tacrolimus was orally administered at doses of 1.5-3.0 mg once daily, and serum levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured as clinical markers. HRQOL was examined by using Short Form-8 (SF-8) before and after administration of tacrolimus.
Results: CRP and ESR were significantly decreased at three months of taking tacrolimus, and continuous improvement was observed throughout the study. As to the HRQOL survey, all domains of SF-8 were improved with tacrolimus, and the improvements of physical functioning, role physical, bodily pain, general health, vitality and mental health domains were significant. Both physical and mental component summaries were also continuously improved throughout the study, and marked improvement was especially observed in the physical component summary.
Conclusion: Tacrolimus therapy was effective for improvement of HRQOL in RA patients.

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Objective: To assess the effect of infliximab (IFX) on joint destruction in patients with rheumatoid arthritis (RA) .
Methods: We evaluated changes in X-ray images of the hands and feet of RA patients treated with IFX for at least one year. Twenty-five cases (10 males and 15 females) were evaluated. The mean age and disease duration were 52.2 ± 12.1 (range: 25-66) and 9.6 ± 6.3 (range: 1.7-24) years, respectively. The distributions of Steinbrocker's stage and class were I : 2, II : 10, III: 4, IV: 9 and 1: 10, 2: 10, 3: 4, 4: 2 respectively, and the American College of Rheumatology (ACR) responses were ACR 0×9, ACR 20×5, ACR 50×4, ACR 70×7 at one year. We evaluated the hands of one patient by compact magnetic resonance imagines (cMRI) before and after IFX treatment (6 times, 30 weeks) .
Results: No worsening was observed in 20 cases (80.0%) in the hands and in 22 cases (88.0%) in the feet. After 1.5, 2 and 2.5 years, 7 (63.6%) and 8 (72.7%) cases out of 11, 3 (37.5%) and 5 (62.5%) cases out of 8, and 1 (16.7%) and 4 (66.7%) cases out of 6, respectively, did not exhibit worsening in the hands and feet respectively. Six cases showed worsening after one year, with ACR responses of ACR 0×1, ACR 20×1, ACR 50×3, and ACR 70×1. In the case examined by cMRI, erosions had improved dramatically.
Conclusion: IFX appears to prevent joint destruction to some extent. Joint destruction may not be related to the ACR response, and further analysis using cMRI is required to assess this possibly.

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Early detection and treatment of deep vein thrombosis are important in total hip and knee arthroplasty to reduce the risks of pulmonary embolism. We performed preoperative color Doppler ultrasound for rheumatoid arthritis patients who underwent performed total knee arthroplasty. DVTs were found in 16.8% preoperation and 12.3% post-operation. One risk factor found in examination was obesity.

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Objective: Orthopaedic surgeons have various choices in their management of displaced intracapsular fracture of non-arthritic hips of rheumatoid arthritis patients. The purpose of this investigation was to assess the middle-term results of bipolar hemiarthroplasty (BHA) for displaced femoral neck fractures in the unaffected hips of rheumatoid arthritis patients.
Methods: We retrospectively reviewed 9 rheumatoid arthritis patients (10 hips) who underwent hemiarthroplasty for the treatment of femoral neck fracture. All the patients were female, and the average age of patients was 66.8 years (range, 54 to 77 years) . The average follow-up period was 6.8 years (range, 5 to 12 years) . At 1 week after operation and at the latest follow-up, hip radiographs were made to evaluate any bipolar shell migration, measuring vertical distance from the teardrop line to the center of the inner-head of each prosthesis, the horizontal distance between the teardrop and the center of the inner-head, and the distance of the outer-head of each prosthesis from the Köhler's line.
Results: Nine of the ten hips did not demonstrate any radiographic evidence of protrusion of the bipolar shell, and only one hip had radiographic evidence of moderate migration of the bipolar shell by 2 millimeters.
Conclusion: Bipolar hemiarthroplasty may be an effective procedure of treatment for displaced femoral neck fractures in non-arthritic hips of rheumatoid arthritis patients.

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Objective: To clarify the most reliable choice of prosthesis in Osaka University Model TEA.
Patients and Methods: Fifty-three RA patients who underwent TEA at Osaka Rosai Hospital between 1998 and 2005 were reviewed. They were divided into 3 groups by their types of prostheses. They were Group A: 16 patients with a press fitted humeral prosthesis with short stem, Group B: 21 patients with a standard stem, and Group C: 16 patients with a superficially cemented humeral prosthesis with standard stem and cemented ulnar prosthesis. Operative records and clinical and radiological assessments were investigated retrospectively, and statistically analyzed between those groups.
Results: Great functional amelioration was observed in each group, with no significant difference between groups. Bone quality of the distal humerus was a key factor for implant survival. Two of 16 humeral prostheses in Group A required revision surgery due to aseptic loosening. The press-fitted contact between bone and implant was unreliable in those cases due to their poor bone quality, while a better radiological prognosis was seen in the cases with good bone-implant contact. Two of 37 ulnar prostheses in Group A and B showed radiolucent lines under 2 mm wide, but did not require revision surgery.
Conclusion: Reconstruction of distorted RA elbows with Osaka University Model TEA was mostly good and comparable with other non-constrained prostheses. Our results for short-stem humeral prostheses used in Group A justified their further use as long as bone implant contact can be achieved, but we recommend a standard stem for all RA patients for a more reliable outcome.

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Severe joint destruction found in patients suffering from nerve disorders such as tabes dorsalis was called“Charcot joint”. Fracture near the joint was thought to be important as an initial lesion of Charcot joint and was named “Charcot fracture”. We present a case of Charcot fracture of a tibial plateau, in a patient who had received a total knee arthroplasty (TKA) .
A 53-year-old woman, who was in our hospital for treatment of diabetic retinopathy, complained of gait disturbance. Although there was severe instability in her left knee, she had little knee pain. Tibial plateau fracture was found on X-ray, and moreover it seemed to be old. Stress X-ray confirmed that the instability was caused at the fracture site .We diagnose this situation as Charcot fracture in the diabetic patient. Granulation was found between fragments, and intensity change was found in the proximal fragment by MRI. We considered bone union difficult and performed TKA using bone graft, metal augmentation, and stem extension. Now, 1 year after operation, she can walk without help and has no complaints.
When Charcot fracture is diagnosed early, it can be treated as a usual fracture, namely bone union can be hoped for. However, if diagnosis is delayed, bone union becomes difficult and the fracture should be treated as a Charcot joint is. Charcot joint of a knee used to be treated by arthrodesis, and TKA was thought to be contraindicated. However, good results of TKA for Charcot joints have recently been reported. When appropriate techniques such as good ligament balancing, bone defect compensation with bone graft or metal augmentation, and implant stabilization by stem extension are performed, good results can be gained even in Charcot joints.

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A case of fibrous displasia (FD) in the acetabulum with mild hip dysplasia treated with curettage, bone graft and rotation acetabular osteotomy of the pelvis is reported. A 21-year-old female complained of left hip pain. Plain x-rays showed well-defined rarefaction in the acetabulum. The size was 21mm in length and 17mm in width. The plain x-rays also showed mild acetabular hypoplasia with 19 degrees of center-edge angle and 48 degrees of acetabular angle. 3D CT showed obvious hypoplasia in the anterior acetabulum. Eight years after surgery, there has been no re-currence of FD and no progression of osteoarthritis of the hip.

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Dysphagia is the commonest complaint with an ossified cervical anterior longitudinal ligament (ALL) and a number of case reports regarding this complaint describe the benefits of surgical resection of the ossified lesion. However, dyspnea has rarely been reported. We report a rare case of dysphagia and dyspnea caused by ossification of the cervical anterior longitudinal ligament. An 81-year-old man was referred for severe dysphagia and dyspnea. He had a few years' history of gradually increasing dysphagia. A few weeks before hospital admission, the patient had noted severe dyspnea while eating. At the time of hospital admission, the patient had manifest respiratory distress with stridor. Radiographs of his cervical spine disclosed marked cervical ossification of the anterior longitudinal ligament. Computed tomography of cervical spine disclosed an ossification lesion at the C3-C7 level that was most pronounced and 14mm in thickness at the C4-C5 level, with anterior occlusion of the esophagus and airway. A barium swallow test revealed a pool at the laryngopharynx and flowing into the trachea of contrast medium. A protrusion of the dorsal pharyngeal wall was found under laryngoscopy. Magnetic resonance imazing disclosed spinal stenosis at the C2/3, C4/5, and C5/6 levels, but there was no neurological anormality. Resection of the ossified lesion was undertaken from C3 to C7 through an anterior approach. After operation, dysphagia and dypnea were improved and a barium swallow test revealed that contrast medium flowed smoothly into the esophagus. Patients with dyspnea benefit from surgical resection of such an ossified lesion.

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We performed total knee arthroplasty for osteoarthritis of the right knee in a 94-year-old patient. There was limited range of motion and genu valgum of the right knee. The JOA score was 40 points. TKA was performed using a NexGen LPS Flex. At present, the patient can walk smoothly without pain in the right knee, and is well satisfied with the outcome.
Our strategy regarding TKA for patients in their 90s is that this procedure is considered when the patient has a strong desire to live independently for the rest of his/her life and is relatively active. We may undertake this surgery for patients selected on the basis of their past history, a thorough medical examination, and granting of fully informed consent prior to the operation.
In this 94-year-old patient, TKA alleviated pain and improved the QOL, so the results were satisfactory.

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