論文

17歳男性。野球強豪校の投手で、投球により増悪する右示・中指の冷感、投球時痛を主訴とした。近医の整形外科を受診し、局所安静と内服治療により症状は改善したが、投球再開直後に再燃した。保存的加療では効果なく、症状が増悪したため、発症から約7ヵ月で当院へ紹介となった。初診時、右示・中指指尖に小潰瘍が認められ、血管造影検査を行ったところ、虫様筋管症候群による手指循環障害と診断された。治療として虫様筋管開放術を行った結果、術後は症状が著明に改善し、術後3週より投球を再開し、術後3ヵ月で完全復帰することができた。

© 2017 by The Keio Journal of Medicine. Unlinked total elbow arthroplasty (TEA), which has no mechanical connection between the humeral and ulnar components, has theoretical advantages based on its near-normal elbow kinematics and the preservation of bone stock. Unlinked TEA is appropriate only for patients who have limited bone loss or limited deformity and good ligamentous function. This is because postoperative instability has been a major complication of unlinked prostheses. The concept and goal of unlinked TEA is to share the loading stress on the bone implant interface with the surrounding tissues. Although the loosening rate of unlinked prostheses theoretically should be lower than that of linked prostheses (which have a mechanical connection between the humeral and ulnar components), there is no clear evidence that unlinked TEAs are superior to linked TEAs in this respect. However, we believe that primary TEA should be performed using an unlinked TEA, especially for younger patients, because revision surgery for unlinked TEA results in longer prosthesis survival than revision surgery for linked TEA. Improvement of the design of unlinked prostheses and the introduction of less invasive surgical techniques are required to reduce postoperative instability.

Background The biomechanical properties of the capitohamate (CH) ligament are equivalent to those of the scapholunate (SL) interosseous ligament. We reconstructed the SL ligament using the CH bone-ligament-bone substitute for chronic injury of the SL ligament. Patients and Methods Beginning in 2008, 15 wrists of 14 patients with an average age of 38 years underwent this procedure with a minimum follow-up of 2 years. Thirteen wrists had an SL joint gap more than 3 mm, and two had a complete SL ligament disruption with a severe dorsal intercalated segment instability (DISI) deformity. Kirschner wires (K-wires) were removed 8 weeks after the surgery, then active ROM exercise began. Pain (on visual analog scale [VAS]), wrist motion (angle), radiographic characteristics, such as SL gap (mm) and SL angle, and Modified Mayo Wrist Score (MMWS) were evaluated. Technique The SL joint was reduced by manipulation or with the use of joysticks, then temporary fixed with K-wires. A dorsal trough was then made between the scaphoid and the lunate. The proximal half of the CH ligament was harvested with attached bone from the capitate and hamate (CH bone-ligament-bone), inset into the SL trough, and fixed firmly with 1.2-mm diameter titanium screws in the scaphoid and lunate, respectively. Results The VAS improved from 77 preoperatively to 12 postoperatively. The average wrist extension/flexion was 74 degrees /60 degrees . There was no ossification of the reconstructed SL at the final follow-up. The SL gap improved from an average of 4.8 mm to an average of 2.1 mm, and the SL angle changed from 67 degrees to 55 degrees . The MMWS improved to 82 points postoperatively from a preoperative average of 47 with eight excellent, five good, and two fair results.

INTRODUCTION: The aim of this study was to validate the potential association between cigarette smoking and cubital tunnel syndrome (CubTS). METHODS: One hundred patients with CubTS were compared with 100 controls with ulnar abutment syndrome matched for age, gender, and body mass index. The smoking status was compared between patients and controls using the sign test and the Wilcoxon signed rank test. Conditional logistic regression was used to calculate the association between CubTS and pack-years smoked. RESULTS: A significant association was found between increased pack-years smoked and CubTS. A significant difference in the number of never smokers and ever smokers was observed between the patients with CubTS and controls. The difference in mean pack-years in the patients and controls was highly significant. A dose-dependent association with pack-years was found between patients and controls. CONCLUSIONS: High cumulative cigarette smoking is associated with CubTS. Muscle Nerve 54: 1136-1138, 2016.

PURPOSE: To assess the outcomes of a modified extensor pollicis longus (EPL) rerouting technique for boutonniere deformity of the thumb in patients with rheumatoid arthritis. METHODS: A total of 21 thumbs in 18 patients with a mean age of 63 years were retrospectively analyzed after an average follow-up period of 3.2 years. The preoperative deformities were classified as either mild (5 thumbs) or moderate (16 thumbs). After either metacarpophalangeal (MCP) joint synovectomy or implant arthroplasty, the ulnarly dislocated EPL tendon was reduced dorsally and sutured to the dorsal base of the proximal phalanx. If the interphalangeal (IP) joint extended with manual traction on the proximal portion of the extensor pollicis brevis tendon, no further treatment was considered. If the IP joint did not extend with this maneuver, the insertion of the extensor pollicis brevis tendon was dissected and transferred to the distal portion of the EPL tendon. RESULTS: The average MCP joint extensor lag improved from 62 degrees (range, 32 degrees to 85 degrees ) before surgery to 17 degrees (range, active extension 12 degrees to extensor lag 70 degrees ) at the final follow-up (P < .05), whereas average MCP joint flexion decreased from 83 degrees (range, 52 degrees to 95 degrees ) to 68 degrees (range, 30 degrees to 90 degrees ) (P < .05). Hyperextension at the IP joint was improved from 30 degrees (range, 10 degrees to 50 degrees ) before surgery to an average extensor lag of 2 degrees (range, extensor lag 24 degrees to hyperextension 20 degrees ) at the final follow-up. The average combined MCP and IP motion did not significantly change. The boutonniere deformity was improved in 18 of 21 thumbs. The 3 failures all had moderate-stage deformity prior to treatment. CONCLUSIONS: A modified EPL rerouting technique provided satisfactory results together with a low risk of IP joint extension loss. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

BACKGROUND: An imbalance in cytokine homoeostasis is thought to have a key role in the neuropsychiatric syndromes of systemic lupus erythematosus (NPSLE), and recently, a role for chemokines has been noted. OBJECTIVE: To compare concentrations of monocyte chemotactic protein-1 (MCP-1)/CCL2 in cerebral spinal fluid (CSF) of patients with SLE, and with and without neuropsychiatric symptoms. METHODS: CSF was obtained from 185 patients with SLE: 96 with NPSLE and 89 patients with SLE without neuropsychiatric symptoms (non-NPSLE patients). MCP-1/CCL2 concentrations were measured with an ELISA. RESULTS: The average concentration of CSF MCP-1/CCL2 in patients with NPSLE was 1959 pg/ml, and in non-NPSLE patients 712 pg/ml. The average MCP-1/CCL2 concentration was significantly higher in the NPSLE group than in the non-NPSLE group (p<0.001). In one representative patient with NPSLE, MCP-1/CCL2 levels in the CSF decreased in parallel with a decline in neuropsychiatric symptoms. CONCLUSIONS: CSF MCP-1/CCL2 levels are higher in patients with NPSLE than in non-NPSLE patients. MCP-1/CCL2 may have an important role in the expression of NPSLE. These results indicate that CSF MCP-1/CCL2 reflects an inflammatory activity in the brain, suggesting that it might be used as a diagnostic tool and a monitor for therapeutic responses in patients with NPSLE.

The treatment of rheumatoid arthritis (RA) has improved dramatically with the advent of the latest generation of disease-modifying antirheumatic drugs. Despite these advances, in some patients inflammation is not diminished sufficiently to prevent irreversible musculoskeletal damage, thereby necessitating surgical intervention to reduce pain and improve function. For RA treatment, Japanese orthopedic surgeons also prescribe medication. In this study, we examined whether this Japanese system is effective for RA treatment. We analyzed the clinical condition of RA patients treated by rheumatologists and those treated by orthopedists in a linked registry study using information from a large observational cohort of RA patients followed every half year from 2000 to 2010 (the IORRA cohort). Two groups of patients were compared: patients treated by rheumatologists (rheumatologic group) and patients treated by orthopedists (orthopedic group). The results revealed that patients in the orthopedic group were older, more likely to be female, and had a longer disease duration than patients in the rheumatologic group. The proportion of patients with a history of joint surgery was also much higher in the orthopedic group than in the rheumatologic group. The average scores on the Japanese version of the Health Assessment Questionnaire, and the remission ratio determined using a Boolean-based definition gradually increased from 2000 until 2010, and these findings were consistently better in the rheumatologic group than in the orthopedic group. These data suggest that patients treated primarily by orthopedists are more likely to have long-standing RA compared to patients treated by rheumatologists. Therefore, it is critical for rheumatologists and orthopedists to complement each other medically in the treatment of RA patients.

関節リウマチにおける手指変形は多種多様であり、使用機種の選択にも一定の見解は得られていないのが現状である。本邦において最も使用されているのはシリコンインプラントであり、MP関節における尺側偏位の治療として機能的・整容的改善により良好な成績が得られている。一方、PIP関節ではシリコンインプラントの成績不良例も報告されており、表面置換型の人工関節も多く使用される。手術に際しては変形の解剖学的機序を理解したうえで、変形の程度、各指の機能を考慮して人工関節の適応を決定し、いずれのインプラントを使用する場合でも十分な軟部組織再建を併用することが重要である。(著者抄録)

関節リウマチの治療は早期からの強力な薬物治療により寛解を導入し関節破壊の進行を抑制することが目標となってきている.疾患活動性を十分にコントロールすることで,破壊された関節が修復する可能性も示されており,手術適応も変化してきている.傾向として滑膜切除術は漸減している一方で,足趾の関節形成術,手指の人工関節といった小関節の形成手術が増加しており,より高い目標に向けた機能回復へと今後さらに変遷していくものと思われる.しかしながら生物学的製剤使用下での手術は感染の発症に十分な注意が必要であり,術前術後に一定期間の休薬を行うことが望ましいが,いずれの生物学的製剤に関しても休薬期間に関するエビデンスが不足しており,整形外科医からの情報発信が必要である.(著者抄録)

The aim of this report was to review the use of orthopedic surgeries performed to manage rheumatoid arthritis (RA). Our review of studies published in English indicates that there has been a decrease in RA-associated surgeries in Western countries. Improvements in medical treatment may partly explain the reduction in numbers of orthopedic joint surgeries, which also suggests a worldwide trend toward improved long-term outcomes. However, the results of our multicenter study in Japan indicate that the number of RA-associated operations has not decreased, and that the numbers of operations performed annually have been relatively stable from 1998 to 2008. Although there definitely has been a decline in the numbers of synovectomy surgeries, the numbers of operations on the upper limbs and foot arthroplasties have increased. With the trend toward milder disease because of improved medical treatment, we speculate that RA patients may want and need better function for the activities of daily living. The combination of medical treatment and surgical intervention is thought to improve outcomes in RA patients who will develop joint destruction. Additional studies, including analyses of RA databases containing long-term data on a variety of surgical interventions, are needed.

関節リウマチ(rheumatoid arthritis:RA)治療のパラダイムシフトに伴い、2008年に米国リウマチ学会(American College of Rheumatology:ACR)より、疾患修飾性抗リウマチ薬(disease-modifying antirheumatic drugs:DMARDs)使用のための推奨が発表された。罹病期間、疾患活動性、予後不良因子の有無により分類し、非生物学的および生物学的DMARDsの選択に関する推奨、使用禁忌および安全性のモニタリングに関しての推奨が示された。しかしながら、このACR2008推奨はあくまで「推奨」であり、個々の症例のおかれている状況を考慮に入れながら、臨床医が自らその適応を検討し最終決定すべきである。(著者抄録)