論文

Background: Previous studies have shown that the shoulder internal rotation elbow flexion (SIREF) test, which is a modified elbow flexion (EF) test, has significantly higher sensitivity than the EF test in patients with cubital tunnel syndrome (CubTS). Here, we hypothesized that this increase in sensitivity was due to increase in the ulnar nerve strain around the elbow introduced by the additional shoulder position. Methods: Ulnar nerve strain at the elbow was intraoperatively measured at both the EF test and SIREF test positions in 20 patients with CubTS before simple decompression. Statistical analysis was performed with the Wilcoxon signed rank test at a confidence level of 99% (. P < .001). Results: Mean ulnar nerve strain in the EF test position was 18.9% ± 12.1%, whereas that in the SIREF test position was 24.7% ± 14.0%. Ulnar nerve strain was higher in the SIREF than in the EF test position in all cases, and the difference was significant (mean, 5.8% ± 0.9%; 95% confidence interval, 3.90%-7.73%). Conclusion: This study indicated that increased sensitivity in the SIREF test compared with the EF test was due to the increase in ulnar nerve strain around the elbow. To the best of our knowledge, this is the first study showing that shoulder position changes the ulnar nerve strain around the elbow in living patients with CubTS.

Objective. This retrospective study was designed to evaluate the outcomes of four different surgical reconstructions for extensor tendon ruptures in ulnar three fingers in 48 patients with rheumatoid arthritis. Methods. The following four techniques were performed; palmaris longus tendon grafting (PL group; n = 9), extensor indicis proprius (EIP) tendon transfers (EIP group; n = 8), end-to-side transfers with tension-reduced early mobilization (End-to-side group; n = 16), and a combination of end-to-side and EIP transfers (Combination group; n = 15). Loss of extension was evaluated to determine the mean postoperative range of motion of the metacarpophalangeal (MP) joint and clinical outcomes were categorized using modified Geldmacher criteria. Results. Combination group demonstrated the best mean MP joint extension (− 3°), followed by End-to-side group (− 12°), EIP group (− 16°), and PL group (− 21°). Combination group yielded the best clinical outcomes with all cases showing good results. Conclusions. The combination of end-to-side and EIP transfer was an effective surgical reconstruction procedure for triple fingers extension loss.

Ulnar deviation is a common complication in patients with rheumatoid arthritis (RA). We report a case of an unusual radial deviation of the middle finger caused by an occult intramuscular ganglion of the second interosseous muscle (IOM) in a patient with RA. The resection of the ganglion did not resolve the problem, and the full range of motion of the metacarpophalangeal (MP) joint was achieved through dissection of the tendon of the second dorsal IOM.

We present a rare case of radial perilunate trans-styloid fracture dislocation, in which the scaphoid invaginated radially into the fractured radial styloid.

This case report describes a patient with elbow contracture due to phlebosclerosis induced by anti-cancer drug infusion. Limitation of elbow extension was completely relieved by surgical excision of the sclerotic vein.

Dislocations involving the four ulnar carpometacarpal joints are rare. These complex dislocations are considered to be due to the application of a hyperflexion force on the metacarpal heads. In the present case, an indirect hyperextension force on the metacarpal bones created a lever-arm effect resulting in rupture of the firm ligament complex of the carpometacarpal joints, inducing complete dislocations of the second to fifth carpometacarpal joints.

Background: Cigarette smoking adversely affects endochondral ossification during the course of skeletal growth. Among a plethora of cigarette chemicals, nicotine is one of the primary candidate compounds responsible for the cause of smoking-induced delayed skeletal growth. However, the possible mechanism of delayed skeletal growth caused by nicotine remains unclarified. In the last decade, localization of neuronal nicotinic acetylcholine receptor (nAChR), a specific receptor of nicotine, has been widely detected in non-excitable cells. Therefore, we hypothesized that nicotine affect growth plate chondrocytes directly and specifically through nAChR to delay skeletal growth. Methodology/Principal Findings: We investigated the effect of nicotine on human growth plate chondrocytes, a major component of endochondral ossification. The chondrocytes were derived from extra human fingers. Nicotine inhibited matrix synthesis and hypertrophic differentiation in human growth plate chondrocytes in suspension culture in a concentration-dependent manner. Both human and murine growth plate chondrocytes expressed alpha7 nAChR, which constitutes functional homopentameric receptors. Methyllycaconitine (MLA), a specific antagonist of alpha7 nAChR, reversed the inhibition of matrix synthesis and functional calcium signal by nicotine in human growth plate chondrocytes in vitro. To study the effect of nicotine on growth plate in vivo, ovulation-controlled pregnant alpha7 nAChR +/- mice were given drinking water with or without nicotine during pregnancy, and skeletal growth of their fetuses was observed. Maternal nicotine exposure resulted in delayed skeletal growth of alpha7 nAChR +/+ fetuses but not in alpha7 nAChR -/- fetuses, implying that skeletal growth retardation by nicotine is specifically mediated via fetal alpha7 nAChR. Conclusions/Significance: These results suggest that nicotine, from cigarette smoking, acts directly on growth plate chondrocytes to decrease matrix synthesis, suppress hypertrophic differentiation via alpha7 nAChR, leading to delayed skeletal growth. © 2008 Kawakita et al.

Cartilage disorders of the finger joint may influence hand function. Loss of integrity of the finger joint may severely compromise its stability and may lead to degenerative arthritis. Anatomical reduction of the finger cartilage should be as precise as possible in treating cartilage defects due to trauma and other causes. We have repaired cartilage defects in finger joints by arthroplasty with costal osteochondral grafting in 29 patients (30joints) since 1997. Three patients underwent total joint reconstruction using costal osteochondral grafting for complete bony ankylosis (1 metacarpophalangeal joint and 2 proximal interphalangeal joints). The purpose of this study was to describe the history, indications, and surgical techniques of the costal osteochondral graft for cartilage disorders or defects in the metacarpophalangeal and proximal interphalangeal joints. © 2008 Lippincott Williams & Wilkins, Inc.

This paper reports an isolated dorsal fracture-dislocation of the scaphoid at its waist with the proximal fragment dislocated dorsally. Such a fracture-dislocation is extremely rare. We believe the pathomechanics of this injury to have been a flexion and radial deviation with an axial force on the wrist. © 2008 The British Society for Surgery of the Hand. Published by SAGE. All rights reserved.

The objective of the treatment for osteochondritis dissecans of the humeral capitulum is to prevent the occurrence of osteoarthritis and to allow the patients to return to throwing activities. In repairing osteochondral defects in advanced osteochondritis dissecans of the humeral capitulum after free body removal, we have performed block-shaped costal osteochondral grafting in 18 elbows since 1997. A block-shaped graft harvested from the transitional area between the rib and its associated cartilage was implanted to the osteochondral defect. This method allows the osteochondral defect to be repaired with uniform hyaline cartilaginous articular surface without any effect to other joints. Donor site no longer causes pain at 2 or 3 days after surgery. The purpose of this study is to describe the history, indications, and the surgical techniques of costal osteochondral grafting for advanced osteochondritis dissecans of the capitulum. © 2008 Lippincott Williams & Wilkins.

Purpose: For the purpose of achieving anatomical reduction as precisely as possible, we performed osteochondral grafting from the costo-osteochondral junction in 16 patients (17 joints) with posttraumatic articular cartilage injury or avascular necrosis in finger joints. The purpose of this study was to review our series of costal osteochondral grafts in order to determine the practicality, effectiveness, and functionality of this grafting technique in a clinical setting. Methods: Patients were followed for at least 18 months postoperatively (18-57 months; average, 28 months). The injured joints included 3 metacarpophalangeal, 9 proximal interphalangeal, 3 distal interphalangeal, and 2 thumb interphalangeal joints. The defect accounted for 50% to 100% of the articular surface (average, 63%). Results: The average time until bone union of the graft was 58 days. The mean arc of motion was 13° before surgery versus 58° after surgery, with a mean increase of 45°. In 7 patients (8 joints), an extremely small portion (approximately 1 × 1 mm in size and thinner than 0.1 mm) of the implanted cartilage was obtained via biopsy using a scalpel with the consent of the patient at the time of screw removal and was used to prepare histologic specimens, which revealed scattered chondrocytes within the matrix without differences from normal hyaline cartilage in any. The chondrocytes in the grafts appeared viable, and the reconstruction of the joint surface could be confirmed histologically. Conclusions: Osteochondral grafting from the costo-osteochondral junction achieves excellent reconstruction of the injured joint without affecting other joints. This technique is particularly beneficial in cases where it is difficult to obtain allograft donors, as is often the case in Japan. Despite these encouraging findings in this small series, we believe that it is necessary to conduct further studies of this method over a longer period. Type of study/level of evidence: Therapeutic IV. © 2008 American Society for Surgery of the Hand.

Calcium deposition in the skin, known as calcinosis cutis, is an uncommon disorder caused by an abnormal deposit of calcium phosphate in the skin. We report a case of idiopathic calcinosis cutis in fingertip treated with surgical excision followed by the occlusive dressing using aluminum foil, and obtained significant pain relief and round-shaped fingertip which looked normal.

Pathophysiology of cubital tunnel syndrome (CubTS) is still controversial. Ulnar nerve strain at the elbow was measured intraoperatively in 13 patients with CubTS before simple decompression. The patients were divided into three groups according to their accompanying conditions: compression/adhesion, idiopathic, and relaxation groups. The mean ulnar nerve strain was 43.5 ± 30.0%, 25.5 ± 14.8%, and 9.0 ± 5.0% in the compression/adhesion, idiopathic, and relaxation groups respectively. The mean ulnar nerve strains in patients with McGowan's classification grades I, II, and III were 18.0 ± 4.2%, 27.1 ± 22.7%, and 33.7 ± 24.7%, respectively. The Jonckheere-Terpstra test showed that there were significant reductions in the ulnar nerve strain among the first three groups, but not in the three groups according to McGowan's classification. Our results suggest that the pathophysiology, not disease severity, of CubTS may be explained at least in part by the presence of ulnar nerve strain.

Purpose: Magnetic resonance (MR) imaging offers the highest sensitivity for detecting bone necrosis. We evaluated osteonecrosis in rabbit models by calculating the percentage of fat to (fat + water) [F/(F+W)] on MR spectroscopy (MRS) and compared MR spectroscopy and imaging findings with corresponding histological results. Methods: To model the natural course of articular osteonecrosis, we removed the fourth tarsal bone in 45 rabbits, froze it for 5 min in liquid nitrogen to produce complete cellular necrosis, and then replaced the bone into the knee joint. We performed Carr-Purcell- Meiboom-Gill proton spectroscopic imaging to assess necrotic bone at 3 days and one, 2, 3, 4, 8, 12, 16, and 20 weeks after osteonecrosis and calculated the percentage of F/ (F+W) of each bone. We also performed conventional T1- and T2-weighted imaging and compared all data to histological findings to analyze the natural course of necrosis. Results: T1-weighted MR imaging demonstrated obvious low signal intensity at 2 to 8 weeks and recovery at 12 to 20 weeks, whereas T2-weighted imaging demonstrated inconsistent intensities throughout the period. The postoperative percentage of F/(F+W) measured using line scan MRS decreased to 8.88% at 3 weeks, 6.22% at 8 weeks, and 34.40% at 20 weeks results that were mostly consistent with MR imaging findings. Histological findings demonstrated complete absence of osteocyte nuclei and loss of osteoid-osteogenesis at 3 to 8 weeks. Recovery of bone marrow was identified as an increase in the area of fat after 12 weeks. Conclusion: Osteonecrosis delineated by T1-weighted MR imaging demonstrated fat content in the bone marrow that correlated with histology. The present MRS modality can be used to calculate the percentage of F/(F+W) of osteonecrosis to enable objective assessment of recovery and quantification of osteonecrosis to provide a numerical value for osteonecrosis.

Background: Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC.Questions/purposes: The purposes of this study were (1) to compare preoperative and postoperative TFC thickness and TFC angle on MR images to quantitatively evaluate the effect of ulnar shortening osteotomy on disc regeneration and the suspension effect on the TFC; and (2) to assess whether changes in TFC thickness and TFC angle correlated with the Mayo wrist score.Methods: Between 1995 and 2008, 256 patients underwent ulnar shortening osteotomy for TFCC injuries. The minimum followup was 24 months (mean, 51 months; range, 24–210 months). A total of 79 patients (31%) with complete followup including preoperative and postoperative MR images and the Mayo wrist score was included in this retrospective study. Evaluation of the postoperative MR images and the Mayo wrist score were performed at the final followup. The remaining 177 patients did not undergo postoperative MRI, or they had a previous fracture, large tears of the disc proper, or were lost to followup. Two orthopaedists, one of whom performed the surgeries, measured the TFC thickness and the TFC angle on coronal MR images before and after surgery for each patient. Correlations of the percent change in the TFC thickness and the magnitude of TFC angle change with age, sex, postoperative MR images, extent of ulnar shortening, preoperative ulnar variance, and postoperative Mayo wrist score were assessed.Results: Stepwise regression analysis showed a correlation between the percent change in TFC thickness and preoperative ulnar variance (R2 = 0.21; β = −0.33; 95% CI, −0.11 to 0.01; p = 0.01) and between the magnitude of change in the TFC angle and the extent of ulnar shortening (R2 = 0.18; β = −0.29; 95% CI, −5.8 to 0.29; p = 0.03). The Mayo wrist score was not correlated with the percent change in TFC thickness or the magnitude of change in the TFC angle.Conclusions: These results suggest that, in patients with TFCC injury with a smaller preoperative ulnar variance, a high residual potential for regeneration in the disc proper was seen after ulnar shortening osteotomy, and correlated with the extent of ulnar shortening and the suspension effect on TFC. However, there was no correlation between disc regeneration or the suspension effect on TFC and the Mayo wrist score.Level of Evidence: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

There are still no factors that predict the prognoses of patients with spontaneous posterior interosseous nerve palsies who are in an early phase of the illness. This paper reviewed 39 patients with this type of palsy. Seventeen patients who requested surgery for possible earlier recovery underwent interfascicular neurolysis because no signs of recovery were seen more than 3 months after onset. A Medical Research Council muscle power grade over 4 at their final visit was considered a good result, while a power less than grade 4 was considered a poor result. The clinical outcomes were significantly worse for the patients who had palsies with slow progressions (for more than 1 month) compared with those who had palsies with rapid progressions (completed within 1 month), regardless of their treatment. No significant difference was seen between the prognoses of patients with complete and incomplete palsies. We, therefore, recommend that interfascicular neurolysis is performed together with tendon transfer as the primary surgical procedures for patients with palsies with slow progression. © 2013 Informa Healthcare.

Purpose To assess the outcomes of our technique involving oblique headless compression screw for arthrodesis of the thumb interphalangeal joint and the distal interphalangeal joints of the other digits. Methods A total of 28 joints (19 thumb interphalangeal and 9 distal interphalangeal) in 23 patients with a mean age of 65 years (range, 58-74 y) were retrospectively analyzed. All operations were performed with the Acutrak2 micro-screw. After the resection of synovium and joint cartilage by a dorsal approach, a 0.88-mm diameter guide wire was inserted at the ulnar side of the proximal phalanx in the thumb and radial side of the middle phalanx in the other digits from proximal to distal to fix the joint obliquely. We verified its position under fluoroscopic control and placed the cannulated screw from proximal to distal over the guide wire. Results Intraoperative rigid fixation was obtained except for 1 case, which required additional K-wire fixation. The overall union rate was 96%. Average time to fusion was 11 weeks (range, 8-30 wk), with 76% achieving union within 3 months. There were 2 complications, 1 nonunion and 1 late infection. Other complications such as dorsal skin necrosis, nail deformity, and paresthesia did not occur. Conclusions Efforts to avoid invasion of the nailbed can be technically demanding. We believe that our proximal to distal technique with oblique placement of the headless compression screw is a straightforward and effective method with a relatively low risk of complication. Type of study/level of evidence Therapeutic IV. © 2013 by the American Society for Surgery of the Hand. All rights reserved.

Relationship between dorsal tilt of the distal radius and distal radioulnar joint stability was examined. Stiffness in dorsopalmar displacement of the radius (distal radioulnar joint stiffness) was recorded at 10° intervals until 30° of dorsal angulation from 10° of palmar tilt. Tests were repeated after partial sectioning of the radioulnar ligament, then after complete sectioning of the radioulnar ligament. All data were compared with control (intact triangular fibrocartilage complex, 10° of palmar tilt). The distal radioulnar joint stiffness in dorsal translation decreased significantly with dorsal tilt 10° and 20° in pronation. Partial sectioning of the radioulnar ligament indicated a decrease of the distal radioulnar joint stiffness in the dorsal translation at neutral tilt to 20° of dorsal tilt in the neutral position and in pronation. Distal radioulnar joint stiffness decreased significantly in both dorsal and palmar translations in all forearm positions at 10° and 20° of dorsal tilt. From these findings, the dorsal angulation of the radius should be corrected to less than 10° of dorsal tilt. © 2013 The Author(s).