Comparison of effectiveness of methotrexate in patients with late-onset versus younger-onset rheumatoid arthritis: Real-world data from an inception cohort in Japan (NICER-J).

OBJECTIVE: To compare the effectiveness of methotrexate (MTX) as initial therapy in patients with late-onset and younger-onset rheumatoid arthritis (LORA and YORA). METHODS: Of 114 patients with YORA and 96 patients with LORA, defined as RA occurring at ≥65 years of age, enrolled in a multicentre RA inception cohort study, 71 and 66 patients who had been followed up to 6 months after starting MTX treatment were included in this study. RESULTS: Proportions of patients on MTX treatment at 6 months were 96% and 92% in the YORA and LORA groups, respectively. Despite lower doses of MTX in the LORA group compared with the YORA group, no significant difference was observed in clinical disease activity index scores between the two groups throughout the follow-up period. The proportion of patients in clinical disease activity index remission at 6 months was 35% in both groups. Logistic regression analysis revealed that knee joint involvement and high Health Assessment Questionnaire-Disability Index were significant negative predictors of achieving clinical disease activity index remission at 6 months in the LORA group. CONCLUSION: Observations up to 6 months revealed that the effectiveness of MTX administered based on rheumatologist discretion in patients with LORA is comparable to that in patients with YORA in clinical settings.

How long will it take to reach the gender diversity goal for orthopaedics in Japan?

BACKGROUND: In Japan, orthopaedics is one of the medical fields with the lowest proportion of women. This study analyses the change in gender diversity over the past decade and estimates the time required to achieve the 30% gender diversity goal, according to the critical mass in Japan in 2020. METHODS: We investigated the demographic composition of orthopaedic surgeons in 2020 by age group, the gender ratio of the main clinical fields from 2010 to 2020, and estimated the time required for the bottom 10 (i.e., least diverse) medical departments in Japan to reach the proportion of 30% women. We used simple linear regression analyses to clarify the number of years. RESULTS: In 2020, the population pyramid of orthopaedic surgeons showed that those in their 50s were the largest component with 24.1%, followed by those in their 40s and 30s with 22.3% and 19.4%, respectively. The percentage of women orthopaedic surgeons increased slightly from 4.1% in 2010 to 5.7% in 2020. This means that to achieve the proportion of 30% women at the current annual increase rate, orthopaedics would require up to 160 years, cardiovascular 149 years, and neurosurgery 135 years. CONCLUSION: Contrary to the recent increase in the number of women physicians, there has been only a slight increase in the number of women orthopaedic surgeons over the past decade. Moreover, the number of young male orthopaedic surgeons has decreased. As current orthopaedic surgeons age and retire, Japan will soon face an overall shortage of orthopaedic surgeons. Issues that must still be addressed in Japanese orthopaedics include educating men and women about gender diversity and bias, changing stereotypes about surgical lifestyles, improving work-life balance, and diligent and collaborative efforts at both the individual and community levels.

Choice of and response to treatment in patients with early-diagnosed rheumatoid arthritis: Real-world data from an inception cohort in Japan (NICER-J).

OBJECTIVE: Various guidelines recommend that patients with early rheumatoid arthritis (RA) try to achieve clinical remission within 6 months, and early therapeutic intervention is important to this end. This study aimed to investigate short-term treatment outcomes of patients with early-diagnosed RA in clinical practice and to examine predictive factors for achieving remission. METHODS: Of the 210 patients enrolled in the multicenter RA inception cohort, 172 patients who were followed up to 6 months after treatment initiation (baseline) were included. Logistic regression analysis was used to examine the impact of baseline characteristics on achievement of Boolean remission at 6 months. RESULTS: Participants (mean age, 62 years) initiated treatment after a mean of 19 days from RA diagnosis. At baseline and 3 and 6 months after treatment initiation, proportions of patients using methotrexate (MTX) were 87.8%, 89.0%, and 88.3%, respectively, and rates of Boolean remission were 1.8%, 27.8%, and 34.5%, respectively. Multivariate analysis revealed that physician global assessment (PhGA) (Odds ratio (OR): 0.84, 95% confidence interval (CI): 0.71-0.99) and glucocorticoid use (OR: 0.26, 95% CI: 0.10-0.65) at baseline were independent factors that predicted Boolean remission at 6 months. CONCLUSION: After a diagnosis of RA, satisfactory therapeutic effects were achieved at 6 months after the initiation of treatment centered on MTX according to the treat to target strategy. PhGA and glucocorticoid use at treatment initiation are useful for predicting the achievement of treatment goals.

Mid-term clinical outcomes and complications of primary total knee arthroplasty in hemodialysis patients: a retrospective comparative cohort study.

BACKGROUND: Numerous patients who receive hemodialysis (HD) undergo total knee arthroplasty (TKA) due to advanced knee joint arthritis. However, there are few studies that describe the clinical outcomes and complications of TKA in HD patients. This study investigated the mid-term results of TKA in patients undergoing HD. METHODS: This single-center retrospective study compared clinical and surgical outcomes following TKA in patients who were receiving HD with those who were not. We used propensity scores to match 21 knees of 18 patients who received HD to 706 knees of 569 patients who had not received HD, from a total of 727 knees (587 patients) that underwent primary unilateral TKA. The clinical outcomes were evaluated using the American Knee Society Score-knee (AKSS-knee) and AKSS-function scores. The primary surgical outcome measure was the number of knees with postoperative complications. RESULTS: In both the HD and non-HD groups, postoperative AKSS-knee and function scores significantly improved when compared to preoperative values. Postoperative AKSS-knee and function scores were not significantly different between the groups. The number of knees with postoperative complications was larger in the HD group than the non-HD group within the first postoperative month, 0-12 months, 12-24 months, 0-24 months, and two years after surgery. Additionally, in the HD group, more complications occurred in the first month than any subsequent month in the two years after surgery. CONCLUSIONS: TKA improves AKSS-knee and function scores equivalently for HD patients and non-HD patients. However, HD patients develop more complications after TKA, especially within the first month. Therefore, surgeons who perform TKA for HD patients should obtain informed consent after explaining the possible complications, and HD patients should be carefully observed following TKA.

Factors associated with joint survival after transposition osteotomy of the acetabulum in patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia.

Aims: The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia. Methods: We reviewed patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia who underwent TOA between November 1998 and December 2019. Patient demographic details, osteotomy-related complications, and the modified Harris Hip Score (mHHS) were obtained via medical notes review. Radiological indicators of hip dysplasia were assessed using preoperative and postoperative radiographs. The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors of failure. Results: This study included 127 patients (137 hips). Median follow-up period was ten years (IQR 6 to 15). The median mHHS improved from 59 (IQR 52 to 70) preoperatively to 90 (IQR 73 to 96) at the latest follow-up (p < 0.001). The survival rate was 90% (95% CI 82 to 95) at ten years, decreasing to 21% (95% CI 7 to 48) at 20 years. Fair joint congruity on preoperative hip abduction radiographs and a decreased postoperative anterior wall index (AWI) were identified as independent risk factors for failure. The survival rate for the 42 hips with good preoperative joint congruity and a postoperative AWI ≥ 0.30 was 100% at ten years, and remained at 83% (95% CI 38 to 98) at 20 years. Conclusion: Although the overall clinical outcomes of TOA in patients with advanced osteoarthritis are suboptimal, favourable results can be achieved in selected cases with good preoperative joint congruity and adequate postoperative anterior acetabular coverage.

Age-adjusted 5-factor modified frailty index as a valuable tool for patient selection in bilateral simultaneous total knee arthroplasty.

Although bilateral simultaneous total knee arthroplasty (BSTKA) is an effective treatment for bilateral knee osteoarthritis, safety concerns and lack of precise patient selection criteria persist. The purpose of this retrospective study was to determine the complication rate and the role of frailty in patient selection for BSTKA. We analyzed data from 434 patients who underwent BSTKA between February 2012 and January 2021, examining demographic factors and preoperative blood test results. Complications occurred in 77 patients (18%), with anemia requiring transfusion being the most common (26 patients, 5.9%). In the univariate analysis, age ≥ 75 years, age-adjusted Charlson Comorbidity Index ≥ 5, age-adjusted 5-factor modified Frailty Index (aamFI-5) ≥ 3, hemoglobin ≤ 11.0 g/dL, albumin ≤ 3.5 g/dL, estimated glomerular filtration rate < 45 ml/dl/1.73 m2, and D-dimer ≥ 2.0 µg/mL contributed to postoperative complications (p < 0.05). Multivariate analysis identified aamFI-5 ≥ 3 as an independent risk factor (p = 0.002). Our findings underscore the practical utility of aamFI-5 in predicting complications after BSTKA, providing valuable guidance to surgeons in the selection of BSTKA candidates and ultimately improving clinical outcomes.

Academic Engagement of Women as Orthopaedic Surgeons at the Annual Meetings of the Japanese Orthopaedic Association From 2012 to 2022.

BACKGROUND: Higher gender diversity correlates with higher patient satisfaction, higher-quality medical education, increased research productivity, and higher revenues. Although the field of Japanese orthopaedic surgery includes the lowest proportion of women and lags in gender diversity, reports on the current gender diversity status in academic activities are scarce. We investigated changes in women's participation in academic activities at the Japanese Orthopaedic Association (JOA) annual meetings over the past 11 years. METHODS: Data on the percentage of women in the JOA membership during 2012-2022 were analyzed to ascertain the proportion of women as first authors of oral and poster presentations, abstract reviewers, invited lecturers, seminar lecturers, general abstract oral chairpersons, symposium chairpersons, and speakers. Regarding the ratio of women among the JOA members during 2012-2022, we relied on data provided by the JOA. Data related to other categories were collected from the abstract book presented at the JOA Annual Meetings between 2012 and 2022. We analyzed the time trend for women's proportions using the Cochran-Armitage trend test. A p-value < 0.05 was considered statistically significant. RESULTS: During 2012-2022, the percentage of female members (4.9-6.7%), poster first authors (2.7-4.3%), abstract reviewers (0-1.5%), general abstract oral chairpersons (0-2.3%), symposium chairpersons (0-3.6%), and symposium speakers (1.6-6.8%) had increased significantly (p < 0.05). Oral first authors (2.2-4.1%), invited lecturers (0-6.8%), or seminar lecturers (0%-6.7%) showed no trend. Women engaged in academic activities at all annual association meetings did not exceed the women's proportion among the association members. CONCLUSION: Although the proportion of women members of the JOA has gradually increased and more women are involved in its annual meetings, the proportion of female presenters, invited speakers, symposiasts, and chairpersons of oral and poster presentations is generally lower than that of women as JOA members. Members should be asked to raise awareness, including more active education of women as physicians in educational institutions and the creation of positive actions to select women as physicians for more important roles (chairpersons, educational speakers, and symposiasts) in the organization of annual meetings.

Comparison of Gender Diversity Among Spine Surgeons in the Japanese Society for Spine Surgery and Related Research and the Neurospinal Society of Japan: A Descriptive Study Through Secondary Analysis of Aggregated Data.

STUDY DESIGN: This was a descriptive study through secondary analysis of aggregated data. PURPOSE: This study aimed to describe changes in women's membership in the Japanese Society for Spine Surgery and Related Research (JSSR) for orthopedic surgery and the Neurospinal Society of Japan (NSJ) for neurosurgery over the past decade and make predictions for the future. OVERVIEW OF LITERATURE: Although the ratio of women physicians in the field of spine surgery is known to be low worldwide, there is a lack of detailed surveys in Japan. METHODS: We sent emails to the JSSR and NSJ secretariats to verify membership information (gender and age) from 2013 to 2022. Using ordinary least squares, we projected the years it would take for the JSSR and NSJ to achieve a gender diversity ratio of 30%. RESULTS: In 2013, the percentage of women in JSSR and NSJ was 2.3% and 2.7%, respectively. However, after 2018, the percentage of women in NSJ will be higher than in JSSR, rising to 2.7% in JSSR and 4.7% in NSJ by 2022. It would require 101 years for the NSJ and more than 1,000 years for the JSSR to realize 30% gender diversity. CONCLUSIONS: JSSR and NSJ have low percentages of women. Improving gender diversity is an important issue for both societies, and they may collaborate on finding a good solution. Both the JSSR and NSJ societies need to actively address gender diversity and become more attractively represented in society for the next generation of spine surgeons.

A new era in the management of spinal metastasis.

Despite the recent advances in cancer treatment, the incidence of patients with spinal metastases continues to grow along with the total number of cancer patients. Spinal metastases can significantly impair activities of daily living (ADL) and quality of life (QOL), compared with other types of bone metastases, as they are characterized with severe pain and paralysis caused by skeletal-related events. Reduced ADL can also lead to treatment limitations as certain anticancer agents and radiation therapy are not compatible treatments; thus, leading to a shorter life expectancy. Consequently, maintaining ADLs in patients with spinal metastases is paramount, and spine surgeons have an integral role to play in this regard. However, neurosurgeon, orthopedic and spinal surgeons in Japan do not have a proactive treatment approach to spinal metastases, which may prevent them from providing appropriate treatment when needed (clinical inertia). To overcome such endemic inertia, it is essential for 1) spine surgeons to understand and be more actively involved with patients with musculoskeletal disorders (cancer locomo) and cancer patients; 2) the adoption of a multidisciplinary approach (coordination and meetings not only with the attending oncologist but also with spine surgeons, radiologists, rehabilitation specialists, and other professionals) to preemptive treatment such as medication, radiotherapy, and surgical treatment; and 3) the integration of the latest findings associated with minimally invasive spinal treatments that have expanded the indications for treatment of spinal metastases and improved treatment outcomes. This heralds a new era in the management of spinal metastases.

Gender Diversity of the Japanese Society for Spine Surgery and Related Research Annual Meetings from 2013 to 2022.

Introduction: There are no reports that have examined the annual trends of the percentage of women who are members of the Japanese Society for Spine Surgery and Related Research (JSSR) or their roles at annual meetings. Furthermore, the status of gender diversity in the JSSR remains unclear. This study aims to identify gender diversity in the JSSR by quantifying the role of women at annual meetings over the past decade. Methods: We performed a retrospective review to explore gender role in the JSSR annual meeting by examining the meeting programs for 2013-2022. The gender ratios were surveyed each year for the following: (1) first authors of general application abstracts (oral and poster), (2) meeting guest speakers, (3) meeting moderators, and (4) program editors of the abstracts. We also investigated the availability of gender equality symposiums. Results: The percentage of women applying (1.1%-2.1%) and those who were invited as participants [guest speaker (0%-0.9%), moderator (0%-5.8%), and program editor (0%-0.6%)] at the annual JSSR meetings was low, with no significant increase over the past decade. In addition, there has never been a symposium promoting gender equality at the annual JSSR meeting. Conclusions: Our findings suggest that a strong and active role for institutional leaders and senior members to support the scholarly activities of women spine surgeons is important for adopting gender diversity in the JSSR academia. The absence of gender equality symposiums and the few invited women participants at the JSSR annual meeting may be due to a lack of gender diversity awareness among conference organizers or unconscious gender bias. Monitoring the role of women in the JSSR annual meetings may solve the gender diversity problem.

Bilateral Wrist Tenosynovitis owing to Acute Conversion of Adult T-Cell Leukemia-Lymphoma in a Patient with Rheumatoid Arthritis.

Human T-cell leukemia virus type 1- (HTLV-1-) associated arthritis is a relatively common disease. However, tenosynovitis owing to adult T-cell leukemia-lymphoma (ATL) is a rare condition. To the best of our knowledge, there have been no reports of tenosynovitis caused by conversion to acute ATL from one of the other ATL types. We present the case of a 60-year-old woman with rheumatoid arthritis (RA) with bilateral wrist tenosynovitis owing to the conversion to acute ATL from one of the other ATL types. She had swelling around the bilateral wrist joint under well controlled RA inflammation. She had no symptoms, physical findings, or laboratory findings indicative of conversion to acute ATL from one of the other ATL types. She underwent tenosynovectomy on the volar and dorsal sides of the left wrist joint to diagnose the cause of swelling around the bilateral wrist joint. Pathological analysis revealed diffuse proliferation of medium-sized atypical CD4(+) lymphocytes. Interestingly, she was diagnosed with wrist tenosynovitis caused by an acute ATL type. This diagnosis suggested that clinicians must consider ATL in connection with atypical wrist tenosynovitis in HTLV-1-endemic areas.

Lower Limbs Alignment in Patients with a Unilateral Completely Dislocated Hip.

BACKGROUND: Severe hip osteoarthritis is known to lead to secondary osteoarthritis of the knee joint. It is not clear whether contracture or a leg length discrepancy is more important in determining the knee alignment. METHODS: In this study, 48 hips in 48 patients with a unilateral completely dislocated hip (Crowe IV) were recruited. The patients were divided into two groups (Crowe IVa and IVb). The Crowe IVa group had completely dislocation with psudo-articulation, and the Crowe IVb group had completely dislocation without psudo-articulation. The lower limb alignment was divided into three patterns according to the femorotibial angle; varus (≥176 degrees), neutral(170 to 175 degrees) and valgus(≤169 degrees). RESULTS: The combination of valgus alignment on the affected side and varus alignment on the unaffected side, so-called "windswept deformity" was observed in 12.5% of the patients; this included 18.2% and 7.7%, in the Crowe IVa and Crowe IVb groups, respectively. The valgus alignment on the unaffected side, namely "long leg arthropathy," was found to have occurred in 6.3% of the patients, including 13.6% of the patients in the Crowe IVa group; there were no cases of long "leg arthropathy" in the Crowe IVb group. CONCLUSION: The lower limb alignment on the unaffected side had a tendency to be varus in the Crowe IV patients. The "windswept deformity" was observed in each of the groups; however, "long leg arthropathy" was only found in the Crowe IVa group.

Subcutaneous single injection digital block with epinephrine.

The aim of this study was to investigate the anesthetic effect and risk of epinephrine for subcutaneous single injection digital block. Either 3.0 mL 1.0% Lidocaine or a 3.0 mL 1.0% Lidocaine with (1 : 100,000) epinephrine was injected into the subcutaneous space at the middle point of the palmar digital crease of the 18 middle fingers of 9 healthy volunteers. The SpO(2) of the fingers decreased to a maximum of 97. No subjects showed any symptoms of ischemic injury. The time to anesthesia for the fingers was significantly shorter (P < 0.05), and the duration of anesthesia was significantly longer (P < 0.01) for the fingers in the epinephrine group. In conclusion, a subcutaneous single injection digital blocks with 3.0 mL of 1.0% Lidocaine and (1 : 100,000) epinephrine were safe, reducing the time to the onset of anesthesia, while also markedly prolonging the anesthesia.

Seasonal trends in the incidence of hip osteoarthritis in Japanese patients.

PURPOSE: There is an association between winter birth and developmental dysplasia of the hip, formerly termed congenital dislocation of the hip. The purpose of this study was to clarify the relationship between the month and season of birth and hip osteoarthritis in Japanese patients who had undergone total hip arthroplasty or transpositional osteotomy of the acetabulum. METHODS: One thousand eight hundred and 52 female patients that presented for the surgical treatment of hip osteoarthritis between 1999 and 2005 were included in this study. Female out-patients who were seen at the initial visit during same period were used as controls to correct the bias of the month of birth. RESULTS: There was a significant deviation of the observed number of births from the expected values calculated on a monthly basis (p<0.001). A comparison by seasons (periods of 3 months) revealed more births than expected in winter (p<0.001). The risk of hip osteoarthritis was significantly associated with the month of birth. Namely, it was highest for births in January (p<0.001). CONCLUSIONS: These data clearly revealed that the prevalence of hip osteoarthritis was significantly higher in those patients born in winter. The seasonal trend in hip osteoarthritis might be due to the winter prevalence of congenital dislocation of the hip in childhood.