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[ABSTRACT]Methotrexate-related lymphoproliferative disorder (MTX-LPD) is a serious complication of methotrexate (MTX) treatment in patients with rheumatoid arthritis. We treated 3 patients with MTX-LPD associated with rheumatoid arthritis. Patient 1 was a 55-year-old woman whose chest X-ray showed abnormal shadows 16 years after she started MTX treatment. Patient 2 was a 63-year-old woman who had signs/symptoms of viral rhinitis and whose chest X-ray showed multiple shadows and lung infiltrates. A definitive diagnosis of MTX-LPD was obtained from a bronchoscopic biopsy specimen. Patient 3 was a 44-year-old woman whose chest computed tomography scans showed incidental bilateral axillary lymphadenopathy after anaphylactic shock associated with an injection of a biosimilar of infliximab. After MTX discontinuation, the LPD resolved in all 3 patients and has not recurred through up to 5 years of follow-up.

[ABSTRACT]【Objective】The purpose of this study was to document the long-term results of femoral curved varus osteotomy (CVO) for osteonecrosis of the femoral head (ONFH) and to identify a predictive factor for the outcome.【Methods】From April 1997 through April 2018, 32 patients (39 hips) underwent CVOs for idiopathic ONFH. Mean age at surgery was 33.0 years (standard deviation [SD] 8.9). Potential causative factors of ONFH were corticosteroid in 30 hips, alcohol in five hips, and “idiopathic” causes in four hips. 【Results】Survival rates after CVO were 96% at 5 and 10 years and 84% at 15 years with total hip arthroplasty (THA) as the endpoint. Survival rates after CVO were 68% at 5 years, 46% at 10 years, and 28% at 15 years with osteoarthritic change as the endpoint. The Japanese Orthopaedic Association hip score significantly improved from 67.5 (SD 19.1) points before surgery to 86.5 (13.6) points one year after CVO and 93.0 (20.7) points at the final follow-up (p = 0.0002). 【Conclusion】The long-term results of CVO for ONFH were favorable with ten-year survival rates of 96% using conversion to THA as the endpoint. The postoperative intact ratio was suggested to be a predictive factor for OA change after CVO.

[ABSTRACT]【Purpose】The incidence of Tandem Spinal Stenosis (TSS) is increasing rapidly with population aging, though its pathophysiology and pathogenesis are not clear. There is no consensus whether a one-stage or two-stage procedure is better. We compared preoperative skeletal muscle mass, clinical symptoms, and surgical results between TSS patients who underwent simultaneous cervical and lumbar decompression and lumbar spinal stenosis (LSS) patients who underwent lumbar decompression. The characteristics of the TSS patients and the surgical outcomes of one-stage surgery were evaluated.【Methods】There were 118 patients (mean age 66.3 years, 71 men) who received surgical treatment. Of these, 9 patients had TSS (mean age 74.3 years, 4 men) and 109 had LSS (mean age 65.7 years, 67 men). A bioelectric impedance analyzer (BIA) was used to measure systemic skeletal muscle mass and phase angle, an index of cell membrane aging. The visual analog scale (VAS) score for low back pain (LBP) and leg pain and leg numbness, the Japanese Orthopaedic Association scoring system (JOA score), the Roland-Morris Disability Questionnaire (RDQ), the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and the Oswestry Disability Index (ODI) were used to evaluate clinical symptoms. Preoperative skeletal muscle mass, phase angle, clinical symptoms, and surgical results were compared between the groups. 【Results】Operative time was significantly longer in the TSS group than in the LSS group (p < 0.05), but the amount of bleeding was not significantly different between the groups. The height, trunk muscle mass, and phase angle of the trunk and both lower limbs were significantly lower in the TSS group than in the LSS group (p < 0.05). JOA scores were significantly lower in the TSS group (p < 0.05), and 88% of TSS patients had difficulty in climbing stairs, significantly more than in the LSS group (28%, p < 0.05). Although clinical symptoms in both groups improved after surgery, there was no significant difference in the degree of clinical improvement (p > 0.05). 【Discussion】TSS was associated with decreased trunk muscle mass and decreased phase angle of the trunk and both lower limbs, suggesting the progression of trunk muscle atrophy due to decreased activity. In addition, about 90% of TSS patients had difficulty in climbing stairs. A one-stage minimally invasive operation was performed for TSS and the amount of intraoperative bleeding was equivalent to that of LSS alone. The one-stage approach seems to be effective.

[ABSTRACT]【Background】 For patients with Parkinson's disease, it is difficult to treat hip joint disorders because of postural abnormalities and muscle rigidity. Advances in spine surgery have led to an increase in the use of long-range fusion procedures, and their impact on pelvic alignment has been gaining attention. We report the case of a patient with Parkinson's disease and spinal long fusion who required bilateral revision surgery for irreducible dislocation of total hip arthroplasties in rapidly destructive coxarthropathy.【Case report】 A woman with severe Parkinson's disease underwent spinal long-range fusion from Th3 to S for spinal deformity and lumbar spinal canal stenosis at 71 years of age. Three years later she developed severe right hip pain and difficulty walking due to progressive narrowing of the joint space due to posterior pelvic tilt (right Japanese Orthopaedic Association (JOA) score 21). The patient underwent right total hip arthroplasty via a direct anterior approach while supine on a traction table. Although the implant alignment was in a safe zone and intraoperative muscle tension was stable, the patient dislocated the hip anteriorly on the fourth postoperative day when transferring from a wheelchair to a bed. Manual reduction under general anesthesia was attempted but failed because of the muscle rigidity. Revision surgery was required on the seventh day after the initial surgery. She was able to walk with a cane and was dischargedfrom the hospital. However, 6 months later, the contralateral left hip became painful and she needed a wheelchair again（left JOA score 19）. By her strong request, we performed left total hip arthroplasty. However, one week after the surgery, she felt discomfort in her left hip joint when she was going to sit on the toilet, which caused the stem to sink and posterior twisting. Two days later, when she tried to put on her shoes, she dislocated posteriorly with a periprosthetic fracture. Revision surgery was required 2 weeks later. The patient was discharged home 2 months postoperatively and was able to walk alone 3 months postoperatively. Five years after surgery, both hips have recovered to the point where she can walk alone without pain and without redislocation, and she is highly satisfied with the outcome (JOA score: right 68, left 63). 【Conclusion】Dislocation can occur even with appropriate implant placement. This is because the pelvic alignment changes with posture such as lying down, standing, and sitting. Especially in patients with spinal long fusion, immobility decreases and implant impingement is easy, and dislocation can occur both anteriorly and posteriorly. Additionally, in Parkinson’s disease, not only is it difficult to reduce intraoperatively due to muscle rigidity, but manual reduction is also difficult if the patient dislocates their hip after surgery, and open reduction may be necessary. Although the artificial hip joint of Parkinson’s disease is intractable, patient satisfaction is high.