鈴木 崇根

【目的】本研究の目的は長期plate固定された前腕骨骨幹部骨折患者における骨萎縮の程度を評価すること。【方法】前腕骨骨幹部骨折に対してplate固定術(locking plate(以下、L群)またはconventional plate(以下、C群))の術後5年以上経過した患者を対象とした。両側前腕全長のCTを撮影し、皮質骨厚と骨密度を計測。さらに有限要素解析を用いて骨強度を測定し、2群間で比較検討した。【結果】L群8本、C群7本で平均経過観察期間はそれぞれ79.5ヵ月、105.0ヵ月であった。皮質骨の厚さは2群間に有意な差を認めなかったが、骨密度の患健側比はL群で有意に低かった。骨強度の患健側比はいずれも有意に低下していたが、L群はC群と比較し有意に萎縮していた。【結語】前腕骨骨幹部骨折にlocking plateを長期固定することで、骨萎縮をきたすことが示唆された。(著者抄録)

SAPHO症候群は滑膜炎,ざ瘡,膿疱症,骨化症,骨炎を呈する症候群である。我々はアレンドロネートの週1回内服による治療が奏功した患者を経験したので報告する。症例は34歳の男性で,1年間の繰り返す右前腕の尺側部痛を主訴とする患者である。レントゲンとCTにて尺骨骨幹部に骨過形成を伴う硬化像と一部に骨透瞭像を認めた。さらに骨シンチにおいて,同部位と胸鎖関節,仙腸関節に集積像を認めた。これらの画像所見に伴い,骨掻爬術が施行された。病理学的には慢性の骨髄炎を呈しており,細菌培養は陰性であったため,SAPHO症候群と診断した。術後2年間,痛みは消失していたが再発したため,アレンドロネート35mg製剤を週1回内服開始した。約3週間で尺側部痛は完全に消失した。13ヶ月後に内服を中止したが,その後も1年にわたり寛解状態を維持している。骨シンチでも骨集積像は改善を維持している。アレンドロネートは抗炎症作用により早期の鎮痛を促し,骨リモデリングを抑えることで長期にわたる効果を得られている可能性がある。アレンドロネートはSAPHO症候群の治療薬として非常に有用であった。(著者抄録)

Purpose To compare the mechanical properties of sliding lengthening (SL) and Z-lengthening (ZL) for flexor tendon elongation used for conditions such as Volkmann contracture, cerebral palsy, and poststroke spasticity. Methods We harvested 56 flexor tendons, including flexor pollicis longus tendons, flexor digitorum superficialis tendons (zones II to IV), and flexor digitorum profundus tendons (zones II to V) from 24 upper limbs of 12 fresh cadavers. Each tendon was harvested together with its homonymous tendon from the opposite side of the cadaver and paired. We used 28 pairs of tendons and divided them randomly into 4 groups depending on the lengthening distance (20 or 30 mm) and type of stitching (single or double mattress sutures). Then we divided each pair into either the SL or ZL group. Each group was composed of 7 specimens. The same surgeon lengthened all tendons and stitched them with 2-0 polyester sutures. We tested biomechanical tensile strength immediately after completing lengthening and suturing in each group. Results Ultimate tensile strengths were: 23 N for the SL 20-mm lengthening and single mattress suture and 7 N for the ZL 25 N for the SL 20-mm lengthening and double mattress suture and 10 N for the ZL 15 N for the SL 30-mm lengthening and single mattress suture and 8 N for the ZL and 18 N for the SL 30-mm lengthening and double mattress suture and 10 N for the ZL. Conclusions The SL technique may be a good alternative to the ZL technique because it provides higher ultimate tensile strength. Clinical relevance Because of its higher ultimate tensile strength, the SL technique may allow for earlier rehabilitation and reduced risk of postoperative complications.

Background: Lumbar floating fusion occasionally causes postoperative adjacent segment disorder (ASD) at lumbosacral level, causing L5 spinal nerve disorder by L5-S1 foraminal stenosis. The disorder is considered to be one of the major outcomes of L5-S1 ASD, which has not been evaluated yet. The present study aimed to evaluate the incidence and risk factors of postoperative L5 spinal nerve disorder after lumbar interbody fusion extending to the L5 vertebra. Methods: We evaluated 125 patients with a diagnosis of spondylolisthesis who underwent floating fusion surgery with transforaminal lumbar interbody fusion with average postoperative period of 25.2 months. The patients were regarded as symptomatic with postoperative L5 spinal nerve disorder such as radicular pain/numbness in the lower limbs and/or motor dysfunction. We estimated and compared the wedging angle (frontal view) and height (lateral view) of the lumbosacral junction in pre- and postoperative plain X-ray images and the foraminal ratio (ratio of the narrower foraminal diameter to the wider diameter in the craniocaudal direction) in the preoperative magnetic resonance image. Risk factors for the incidence of L5 spinal nerve disorder were explored using multivariate logistic regression. Results: Eight of the 125 patients (6.4 %) were categorized as symptomatic, an average of 13.3 months after surgery. The wedging angle was significantly higher, and the foraminal ratio was significantly decreased in the symptomatic group (both P < 0.05) compared to the asymptomatic group. Multivariate logistic regression analysis of possible risk factors revealed that the wedging angle, foraminal ratio, and multileveled fusion were statistically significant. Conclusions: Higher wedging angle and lower foraminal ratio in the lumbosacral junction were significantly predictive for the incidence of L5 nerve root disorder as well as multiple-leveled fusion. These findings indicate that lumbosacral fixation should be considered for patients with these risk factors even if they have few symptoms from the L5-S1 junction.

Background Semaphorins (SEMAs) consist of a large family of secreted and membrane-anchored proteins that are important in neuronal pathfinding and axon guidance in selected areas of the developing nervous system. Of them, SEMA7A has been reported to have a chemotactic activity in neurogenesis and to be an immunomodulator; however, little is known about the relevance of SEMA7A in the behaviors of oral squamous cell carcinoma (OSCC). Methods We evaluated SEMA7A expression in OSCC-derived cell lines and primary OSCC samples using quantitative reverse transcriptase-polymerase chain reaction, immunoblotting, and semiquantitative immunohistochemistry (sq-IHC). In addition, SEMA7A knockdown cells (5hSEMA7A cells) were used for functional experiments, including cellular proliferation, invasiveness, and migration assays. We also analyzed the clinical correlation between SEMA7A status and clinical behaviors in patients with OSCC. Results SEMA7A mRNA and protein were up-regulated significantly (P<0.05) in OSCC-derived cell lines compared with human normal oral keratinocytes. The shSEMA7A cells showed decreased cellular growth by cell-cycle arrest at the G1 phase, resulting from up-regulation of cyclin-dependent kinase inhibitors (p21c1P1 and p27KiP1) and down-regulation of cyclins (cyclin Dl, cyclin E) and cyclin-dependent kinases (CDK2, CDK4, and CDK6); and decreased invasiveness and migration activities by reduced secretion of matrix metalloproteases (MMPs) (MMP-2, proMMP-2, pro-MMP-9), and expression of membrane type 1MMP (MT1-MMP). We also found inactivation of the extracellular regulated kinase 1/2 and AKT pathways, an upstream molecule of cell-cycle arrest at the G1 phase, and reduced secretion of MMPs in shSEMA7A cells. sq-IHC showed that SEMA7A expression in the primary OSCCs was significantly (P = 0.001) greater than that in normal counterparts and was correlated with primary tumoral size (P = 0.0254) and regional lymph node metastasis (P = 0.0002). Conclusion Our data provide evidence for an essential role of SEMA7A in tumoral growth and metastasis in OSCC and indicated that SEMA7A may play a potential diagnostic/therapeutic target for use in patients with OSCC.

手根管症候群(CTS)の病態には様々な要因が考えられる.そのひとつに本来疎な結合組織であるsubsynovial connective tissue(SSCT)が線維化・肥厚・増生することによって手根管内圧が上昇し,さらにSSCTでの炎症が起こることにより正中神経障害が引き起こされると考えられている.本研究は,CTSによる神経障害性疼痛に対して,TNF-α阻害薬であるエタネルセプトを投与し,その効果を検討することを目的とした.装具・手根管内ステロイド注射が無効であった10名に対して,エタネルセプト10mg+1%リドカイン1mlを投与.投与後4週間経過観察が可能であった9例(前例女性,平均年齢60.6歳)に関して検討をおこなった.visual analog scale,quick-DASH,運動神経遠位潜時いずれも投与前後で有意差を認めなかった.(著者抄録)

RESULTS.: Of 77 patients, 41 (mean age: 14.6 yr 33 adolescent boys/8 adolescent girls) had ESS and 36 (mean age: 14.3 yr 20 adolescent boys/16 adolescent girls) were considered to have NS-LBP. Respective traditional VAS and Oswestry Disability Index scores were 4.9, 16.1 in the ESS group, and 6.2, 26.3 in the NS-LBP group. Both scores were significantly higher in the NS-LBP group. The results of the detailed VAS revealed that the ESS group showed significantly greater pain intensity while in motion than while standing or sitting (4.2, 2.0, and 2.0, respectively), whereas the NS-LBP group showed similar pain intensities in all 3 postural situations (5.3, 4.0, and 4.9, respectively). CONCLUSION.: This study revealed that LBP characteristics may provide important information for distinguishing ESS from other low back disorders. Because early diagnosis is essential for the treatment of ESS, MRI examination is recommended for patients showing severe pain in motion, but less pain when standing or sitting. STUDY DESIGN.: Retrospective comparative cohort study. OBJECTIVE.: To elucidate the characteristics of low back pain (LBP) in adolescent patients with early-stage spondylolysis (ESS). SUMMARY OF BACKGROUND DATA.: ESS is a common cause of acute LBP in adolescents. When treating patients with ESS, early diagnosis is important however, early diagnosis is difficult without magnetic resonance imaging. METHODS.: Adolescent patients (n = 77) with acute LBP showing no pathological findings on plain radiography were included (&lt 1 m after onset). Patients were divided into ESS and nonspecific LBP (NS-LBP) groups by conducting magnetic resonance imaging patients showing no pathological findings that explain the cause of LBP were classified as NS-LBP. LBP was evaluated using a traditional visual analogue scale (VAS 0-10 cm), Oswestry Disability Index, and a detailed VAS scoring system in which pain is independently evaluated in 3 different postural situations (in motion, standing, and sitting) the values were compared between the 2 groups.

Introduction: Spinal cord stimulation (SCS) is sometimes preferable in some refractory chronic lower back pain (LBP) pathologies. SCS involves an insertion of electrode leads into the epidural space in the prone position under local anesthesia, followed by neurostimulator implantation under local/general anesthesia. These continuous procedures can cause transient post-operative LBP exacerbation and to make temporary pockets that will store redundant leads in it with some risk of subcutaneous irritation and infection in addition to making extra incisions. We introduce a modified simpler method for SCS implantation, systematically designed to be performed only under local anesthesia in a decubitus, non-prone position. Materials and methods: An 81-year-old patient with FBSS was treated. A physician was able to insert SCS leads with ease while the patient was in a decubitus position. The patient was comfortable, under totally local anesthesia, and the procedure produced no extra subcutaneous pockets. Result: The patient felt almost no LBP and reported no pain exacerbation during the operation. The SCS installation provided the patient with great improvement in both her lower back (NRS from 8 to 0-1) and leg (from 7 to 2) pain with a great improvement in her daily life activities. No adverse events were observed during the perioperative period. Conclusion: The modified SCS insertion method enabled us to achieve both intraoperative pain relief and complete SCS implantation in a minimally invasive manner.

Background: The detailed mechanisms of knee osteoarthritis (OA) pain have not been clarified, but involvement of inflammatory cytokines such as tumor necrosis factor-alpha (TNF) has been suggested. The present study aimed to investigate the more detailed neurological involvement of TNF in joint pain using a TNF-knockout mouse OA model. Methods: The right knees of twelve-week-old C57BL/6J wild and TNF-deficient knockout (TNF-ko) mice (n=15, each group) were given a single intra-articular injection of 10 mu g monoiodoacetate in 10 mL sterile saline. The left knees were only punctured as the control. Evaluations were performed immediately after the injection (baseline) and at 7, 14, and 28 days after the injection with a subsequent intra-articular injection of neurotracer into both knees. The animals were evaluated for immunofluorescence of the lumbar dorsal root ganglia (DRG) innervating the knee joints. The injected knees were observed macroscopically and mouse pain-related behaviors were scored. Results: Macroscopic observation showed similar knee OA development in both wild and TNF-ko mice. Calcitonin gene-related peptide (CGRP, a neuropeptide identified as a inflammatory pain-related biomarker) was significantly increased in DRG neurons innervating OA-induced knee joints with significantly less CGRP expression in TNF-ko animals. Pain-related behavior scoring showed a significant increase in pain in OA-induced joints, but there was no significant difference in pain observed between the wild and TNF-ko mice. Conclusions: The result of the present study indicates the possible association of TNF-alpha in OA pain but not OA development.

尺骨鉤状突起骨折骨接合におけるHotchkissのover-the-topアプローチの具体的な手技を確立するため、新鮮凍結屍体6体12肢(男2体・女4体、平均84.7歳)を用いて解剖学的検討を行った。内側筋間中隔を切除し、上腕筋を剥離・翻転して屈筋回内筋群を尺側手根屈筋との境界で剥離挙上して関節包を切開し、アプローチ手技に関連する各部の測定を行った。その結果、内側上顆から正中神経までの最短距離は平均31.3mm、屈筋回内筋群切離方向での内側上顆から正中神経までの距離は45.5mm、尺骨鉤状突起から正中神経までの最短距離は8.1mm、尺骨鉤状突起尖端から鋼線を刺入した際に必要な屈筋回内筋群剥離長は47.0mmであった。上腕筋尺骨停止部幅は26.6mmで、停止部近位より正中神経までの最短距離は13.4mm、停止部遠位より正中神経までの最短距離は5.9mmであった。

Background: Distal radius fracture, which often occurs in the setting of osteoporosis, can lead to permanent deformity and disability. Great effort has been directed toward developing noninvasive methods for evaluating the distal radius strength, with the goal of assessing fracture risk. The aim of this study was to evaluate distal radius strength using a finite element model and to gauge the accuracy of finite element model measurement using cadaver material. Methods: Ten wrists were obtained from cadavers with a mean age of 89.5 years at death. CT images of each wrist in an extended position were obtained. CT-based finite element models were prepared with Mechanical Finder software. Fracture on the models was simulated by applying a mechanical load to the palm in a direction parallel to the forearm axis, after which the fracture load and the site at which the fracture began were identified. For comparison, the wrists were fractured using a universal testing machine and the fracture load and the site of fracture were identified. Results: The fracture load was 970.9 N in the finite element model group and 990.0 N in the actual measurement group. The site of the initial fracture was extra-articular to the distal radius in both groups. The finite element model was predictive for distal radius fracture when compared to the actual measurement. Conclusion: In this study, a finite element model for evaluation of distal radius strength was validated and can be used to predict fracture risk. We conclude that a finite element model is useful for the evaluation of distal radius strength. Knowing distal radius strength might avoid distal radius fracture because appropriate antiosteoporotic treatment can be initiated.

近年,橈骨神経損傷に対し橈側手根屈筋(FCR)枝を後骨間神経(PIN)へ,浅枝屈筋(FDS)枝を短橈側手根伸筋(ECRB)枝へ移行する正中-橈骨神経移行術の報告がある.良好な臨床成績が報告されるが解剖学的検討の報告は少ない.本研究の目的は正中-橈骨神経移行術の手技を確立するための解剖学的検討を行うことである.新鮮凍結屍体10肢の解剖を行った.ドナーであるFCR枝,FDS枝の分枝数は1.3枝,3.6枝,神経幅は1.3mm,1.2mm,移行可能な神経長は46.0mm,38.8mmであった.レシピエントであるPINの神経幅は3.1mm,ECRB枝の神経幅及び神経長は1.3mm,48.2mmであった.FCR枝はPINへ回外筋筋膜上で到達可能であったため,効果器至近で移行するために回外筋筋膜切離量を計測したところ,16.8mmであった.FDS枝はECRB枝に到達可能であり,到達位置は内外上顆を結んだ線より遠位に48.2mm,前腕中心線より橈側に23.1mmであった.組織学的検討としてFCR枝,PIN,FDS枝,ECRB枝の神経断端の軸索数を計測したところ,1501,5162,885,548であった.(著者抄録)

インクジェット式積層造形方式の3Dプリンタ(Connex 500)を用い、新鮮献体骨(橈骨骨幹部)のCTデータに基づいて樹脂製の擬似骨を製造し、その圧縮特性を造形方向で比較した。樹脂はStratasys社製のVeroWhiteを用い、試験片を50×20×8mmとして圧縮試験をクロスヘッド速度5mm/minで行った。X方向(長軸方向)に造形した場合、最大強度点を経過した後に座屈状態となり、ある程度の強度を保持していた。しかしZ方向(短軸方向)に積み上げて造形した場合は、最大強度点後に破断した。献体骨の圧縮試験での破断強度は3386.5Nで、擬似骨は献体骨の平均皮質厚み3.5mmで作製した場合は4503.4Nと実測値よりも高く、2mmとした場合は3254.1Nと実測値に最も近くなった。なお献体骨は破断しても骨折線が入るのみであったが、擬似骨は破断と同時に粉砕した。

Purpose Patients with idiopathic carpal tunnel syndrome are commonly treated by steroid injections into the carpal tunnel. We administered triamcinolone (Tr) to chronic constriction injury model rats. We hypothesized that Tr administration would have both favorable behavioral effects and quantifiable immunohistological effects on compressed nerves. Methods Thirty-six male Wister rats were used. For rats to be treated with Tr, we loosely ligated their right sciatic nerves at 4 sites. Sham rats had their nerves exposed without ligation. On postoperative day 7, we reexposed their ligated nerves, after which we delivered either 0.1 mg of Tr (0.1-mg group), 0.5 mg of Tr (0.5-mg group), or normal saline (saline group) around the nerve fibers at the injured sites. Gait was analyzed, and allodynia was assessed with von Frey hairs, before surgery and on postoperative days 3, 7, 10, 14, and 21. The right sciatic nerve was resected and stained using hematoxylin-eosin, and the fourth and fifth lumbar dorsal root ganglia (DRG) were removed and assessed by immunohistochemistry for calcitonin gene-related peptide (CGRP) and activating transcription factor 3 (ATF3) on postoperative day 21. In addition, interleukin-1 beta (IL-1 beta) in sciatic nerve was quantified using enzyme-linked immunosorbent assays. Results Mechanical allodynia was significantly decreased in the 0.5-mg group compared with the saline group. In hematoxylin-eosin sections, the extent of inflammation-induced edema between the nerve fibers and infiltration of inflammatory cells was significantly reduced in the 0.5-mg group compared with the saline group. IL-1 beta levels at the sciatic nerve in the 0.5-mg group were significantly lower than those in the saline group. Conclusions Tr-treated chronic constriction injury rats exhibited significant alleviation of sensory disturbance, edema, inflammation, and pain-related peptide upregulation. These phenomena suggest the validity of Tr administration as a treatment affecting the nerve itself. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved.

Background: Although efficacious clinical results have been reported after vein wrapping for the treatment of recurrent compressive neuropathy, the mechanism of nerve protection remains uncertain. Methods: Eight-week-old male Wistar rats (n = 90) were randomly divided into three groups: sham procedure, chronic constriction injury, and chronic constriction injury plus vein wrapping. Mechanical withdrawal thresholds and walking patterns were measured with use of von Frey filaments and the CatWalk system, respectively. We investigated L4-L5 dorsal root ganglia immunohistochemically at fourteen days postsurgery and sciatic nerves histologically at fourteen days and again five months postsurgery. Concentrations of several sciatic neurotrophic factors in the ligated sciatic nerves were quantified with use of ELISA (enzyme-linked immunosorbent assay). Results: In behavioral tests, the rats in which the chronic constriction injury had been followed by vein wrapping displayed significantly greater pain responses than the sham group, and the group with untreated chronic constriction injury showed greater pain responses than the vein-wrapping group (both p &lt 0.05). Immunoreactive markers of inflammation and nerve damage, calcitonin gene-related peptide (CGRP) and activating transcription factor-3 (ATF3), were upregulated in dorsal root ganglion neurons in the constriction-injury and vein-wrapping groups compared with those in the sham group, with greater upregulation in the constriction-injury group than in the vein-wrapping group (both p &lt 0.01). Histologic observation showed marked nerve degeneration and scar tissue formation around the sciatic nerve in the constriction-injury group, but these effects were prevented to some extent in the vein-wrapping group. Vascular endothelial growth factor (VEGF) levels at one and three days postsurgery and hepatocyte growth factor (HGF) levels at three, seven, fourteen, and twenty-eight days postsurgery were significantly higher in the vein-wrapping group than in the other groups (p &lt 0.05). Conclusions: Vein wrapping decreased pain-associated behavior and nerve damage caused by chronic constriction injury. VEGF and HGF produced in response to vein grafts may play a mechanistic role. Clinical Relevance: These findings may lead to development of new therapies employing growth factors, with or without other materials, that simulate vein wrapping. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

We conducted an anatomical study to determine the best technique for transfer of the anterior interosseous nerve (AIN) for the treatment of proximal ulnar nerve injuries. The AIN, ulnar nerve, and associated branches were dissected in 24 cadaver arms. The number of branches of the AIN and length available for transfer were measured. The nerve was divided just proximal to its termination in pronator quadratus and transferred to the ulnar nerve through the shortest available route. Separation of the deep and superficial branches of the ulnar nerve by blunt dissection alone, was also assessed. The mean number of AIN branches was 4.8 (3 to 8) and the mean length of the nerve available for transfer was 72 mm (41 to 106). The transferred nerve reached the ulnar nerve most distally when placed dorsal to flexor digitorum profundus (FDP). We therefore conclude that the AIN should be passed dorsal to FDP, and that the deep and superficial branches of the ulnar nerve require approximately 30 mm of blunt dissection and 20 mm of sharp dissection from the point of bifurcation to the site of the anastomosis. The use of this technique for transfer of the AIN should improve the outcome for patients with proximal ulnar nerve injuries.

Purpose Patients with idiopathic carpal tunnel syndrome are commonly treated by steroid injections into the carpal tunnel. We administered triamcinolone (Tr) to chronic constriction injury model rats. We hypothesized that Tr administration would have both favorable behavioral effects and quantifiable immunohistological effects on compressed nerves. Methods Thirty-six male Wister rats were used. For rats to be treated with Tr, we loosely ligated their right sciatic nerves at 4 sites. Sham rats had their nerves exposed without ligation. On postoperative day 7, we reexposed their ligated nerves, after which we delivered either 0.1 mg of Tr (0.1-mg group), 0.5 mg of Tr (0.5-mg group), or normal saline (saline group) around the nerve fibers at the injured sites. Gait was analyzed, and allodynia was assessed with von Frey hairs, before surgery and on postoperative days 3, 7, 10, 14, and 21. The right sciatic nerve was resected and stained using hematoxylin-eosin, and the fourth and fifth lumbar dorsal root ganglia (DRG) were removed and assessed by immunohistochemistry for calcitonin gene-related peptide (CGRP) and activating transcription factor 3 (ATF3) on postoperative day 21. In addition, interleukin-1β (IL-1β) in sciatic nerve was quantified using enzyme-linked immunosorbent assays. Results Mechanical allodynia was significantly decreased in the 0.5-mg group compared with the saline group. In hematoxylin-eosin sections, the extent of inflammation-induced edema between the nerve fibers and infiltration of inflammatory cells was significantly reduced in the 0.5-mg group compared with the saline group. IL-1β levels at the sciatic nerve in the 0.5-mg group were significantly lower than those in the saline group. Conclusions Tr-treated chronic constriction injury rats exhibited significant alleviation of sensory disturbance, edema, inflammation, and pain-related peptide upregulation. These phenomena suggest the validity of Tr administration as a treatment affecting the nerve itself. © 2014 by the American Society for Surgery of the Hand. All rights reserved.

尺骨神経高位損傷に対する前骨間神経移行術は良好な成績が報告されおり、今後は治療の第一選択となる可能性があることから、今回、その手術手技を確立する目的で解剖学的検討を行った。方法は、新鮮凍結屍体14肢を用いて、前骨間神経の分枝数や、移行可能な神経長などを計測し、移行経路の探索を行った。その結果、移行経路は深指屈筋の背側を通過させることが唯一の経路であり、移行の際には尺骨神経の運動枝と感覚枝とを約20mmにわたり鋭的に分離しなければならないことが分かった。

Background: Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described. Methods: The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases. Results: The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications. Conclusions: A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Clinically, neuropathic pain is frequent and intense following brachial plexus injury. It is thought that brachial plexus pain is not generated by avulsed roots, but rather by non-avulsed roots, since the avulsed root could not possibly transmit action potentials to central nerves. The aim of this study was to evaluate pain behavior and activation of sensory neurons in a brachial plexus avulsion (BPA) model in rats. Fifteen male Wistar rats were used. In the BPA group, the C8-T1 roots were avulsed from the spinal cord with forceps at the lower trunk level (n = 5). In the na < ve group, rats did not receive any procedures (n = 5). In the sham-operated group, the lower trunk was simply exposed (n = 5). Mechanical hyperalgesia of forelimbs corresponding to C6 and C7 dermatomes was measured using von Frey filaments every third day for 3 weeks. Activation of DRG neurons was immunohistochemically examined using anti-ATF3 (a marker for neuron activation) antibodies 21 days after surgery. Von Frey and immunohistochemical data between groups were analyzed using a Kruskal-Wallis test, followed by Mann-Whitney U tests. Bonferroni corrections were performed. Animals in the BPA group displayed significant mechanical hyperalgesia at the dermatome innervated by uninjured nerves continuing through day 21 compared with animals in the sham-operated group. ATF3-immunoreactive small and large DRG neurons were significantly activated in the BPA group (10.6 +/- A 9.5 and 5.2 +/- A 4.1 %, 39.7 +/- A 6.7 and 25.2 +/- A 10.3 %, 78.0 +/- A 9.1 and 53.7 +/- A 29.3 %) compared with the sham-operated group (0.7 +/- A 0.9 and 0 +/- A 0 %, 2.8 +/- A 2.0 and 1.0 +/- A 2.0 %, 3.9 +/- A 2.7 and 8.6 +/- A 10.1 %) at every level of C5, 6, and 7. In the na < ve group, no DRG neurons were activated. ATF3-immunoreactive small and large DRG neurons were significantly activated at the level of C7 compared with C6 and C5, and significantly activated at the level of C6 compared with C5 in the BPA group. Expression of ATF3 in uninjured DRG neurons may contribute to pain following brachial plexus avulsion injury. Consequently, spared spinal sensory nerves may represent therapeutic targets for treatment of this pain.

Purpose Brachial plexus pain is thought to be generated not by avulsed roots but rather by nonavulsed roots, because avulsed roots could not transmit action potentials to central nerves. The aim of this study was to evaluate pain-related behavior and the extent of glial activation in a model of brachial plexus avulsion (BPA). Methods We used 24 male Wistar rats. For rats in the BPA group, the C8-T1 roots were avulsed from the spinal cord at the level of the lower trunk (n = 10). Rats in a sham-surgery group had a similar surgery without the root avulsion (n = 7). Rats in an untreated group had no surgery (n = 7). Mechanical hyperalgesia of the forelimb plantar surfaces corresponding to C6 and C7 dermatomes was evaluated using a Semmes-Weinstein monofilament test every third day for 3 weeks (n = 15). Activation of astrocytes and microglia was examined immunohistochemically using anti-glia fibrillary acidic protein and anti-Iba1 antibodies 3 days after surgery (n = 9). Results When compared with rats in the sham-surgery and naive control groups, rats in the BPA group displayed significant mechanical hyperalgesia in the dermatome innervated by uninjured nerves both ipsilaterally and contralaterally and continuing through day 21. Iba1-immunoreactive microglia and glia fibrillary acidic protein immunoreactive astrocytes were significantly activated on the ipsilateral side in the BPA group from levels C3 to T3 compared with the sham-surgery and untreated groups of rats. Conclusions Activation of glia at uninjured levels of the dorsal horn may facilitate pain transmission following BPA injury. Consequently, spared spinal glial cells may represent therapeutic targets for treatment of pain related to BPA injury.

【目的】ラット坐骨神経損傷モデルに対するvein wrappingの効果と作用機序を調べること.【方法】CCIモデルを用い,Sham(S),CCI(C),CCI+vein wrapping(V)群の3群(各群30匹)を使用した.疼痛行動としてvon Frey testを術後28日目まで,CatWalkによる歩行解析を術後14日目まで行った(各群4匹).組織学的評価は術後14日目にL4-5DRGでのCGRP(炎症のマーカー),ATF-3(神経傷害のマーカー)の免疫染色を行い(各群4匹),術後5ヵ月目に坐骨神経の病理組織評価を行った(各群2匹).ELISA法で坐骨神経でのNGF・VEGF・HGFの濃度を術後28日目まで調べた(各群20匹).【結果】行動評価ではC・V群はS群に比しいずれの時期でも有意に疼痛過敏を呈したが,V群ではC群に比し術後早期よりほとんどの時期において有意に軽度であった.術後14日目におけるDRGでのCGRPとATF-3陽性細胞数は,C・V群でS群と比し増加(炎症や神経傷害が増加)したが,V群でC群に比し低かった.坐骨神経の病理組織ではV群ではC群に比し軸索変性,脱髄が抑制されELISAではV群でVEGFは術後1-3日の間で,HGFは術後3-28日の間で高値であった.【考察および結論】CCIモデルにvein wrappingを用いることで疼痛行動,炎症性疼痛,神経障害等の発現を抑制できた.veinから放出されるVEGF,HGFがその機序に関わっている可能性が示唆された.(著者抄録)

Study design.: We measured the response of the behavior and spinal glial activation to anti-nerve growth factor receptor (p75 neurotrophin receptor [p75NTR]) antibodies in the rat brachial plexus avulsion (BPA) model. Objective.: The aim of this study was to investigate the effect of anti-p75NTR antibodies on nociceptive behavior and activation of spinal microglia in the rat BPA model. Summary of background data.: Tanezumab (anti-nerve growth factor antibody) treatment is associated with pain reduction and improvement in function, but with several complications. Methods.: Thirty male Wistar rats were used. In the BPA group, the C8-T1 roots were avulsed from the spinal cord with forceps at the lower trunk level and 10 μL of saline was applied locally (n = 10). In the anti-p75NTR group, the C8-T1 roots were avulsed and 10 μL of anti-p75NTR antibody was applied locally (n = 10). In a sham-operated group, the lower trunk was simply exposed (n = 10). Mechanical hyperalgesia and pain-induced walking patterns were measured using von Frey filaments (Stoelting, Wood Dale, IL) and the CatWalk gait analysis (Noldus Information Technology, the Netherlands) system every third day for 3 weeks. Activation of astrocytes and microglia was immunohistochemically examined in the spinal cord using anti-glial fibrillary acidic protein (GFAP) and anti-Iba1 antibodies both 7 and 21 days after surgery. Results.: Animals in the BPA group displayed significant mechanical hyperalgesia that continued through day 21 compared with animals in the sham-operated group, and mechanical hyperalgesia in the anti-p75NTR group was significantly improved 6 days after the operation. Regarding pain-induced gait analysis via CatWalk, animals in the BPA group displayed a significantly greater pain-like gait pattern than the p75 group for up to 3 weeks. Levels of GFAP-immunoreactive astrocytes and Iba1-immunoreactive microglia in the anti-p75NTR group were significantly reduced compared with the BPA group. Conclusion.: Our results suggest that p75NTR contributes to neuropathic pain associated with BPA, and that inhibition of p75NTR reduces neuropathic pain. Copyright © 2013 Lippincott Williams &amp Wilkins.

Purpose: The Fowler tenotomy, adjusting the balance of the extensor mechanism by central slip and lateral band detachment, is a common surgical technique for chronic mallet finger. The purpose of this study was to determine how much tendon to detach from the middle phalanx by measuring the extensor lag of the distal interphalangeal (DIP) joint following the procedure and to quantify how often a boutonniere deformity occurred as a consequence of the procedure. Methods: Sixteen fingers were obtained from 8 fresh-frozen cadaver hands. We made mallet finger deformity models by terminal tendon elongation. We detached the central slip and lateral band from the middle phalanx by one-third, one-half, and two-thirds of the phalangeal length and measured extensor lag of the DIP and proximal interphalangeal joints before and after this procedure. Results: In these models, the average extensor lag of the DIP joint was 44° (range, 40° to 50°). After central slip and lateral band detachment over one-third of the phalangeal length, the average residual extensor lag of the DIP joint was 19° (range, 0° to 40°). With one-half detachment, the average lag was 13° (range, 0° to 35°), and with two-thirds detachment, the average lag was 6° (range, 0° to 15°). Extensor lag at the proximal interphalangeal joint occurred in 4 fingers, with an average lag of 8° (range, 5° to 15°). Conclusions: In the Fowler tenotomy models, detachment of the central slip and lateral band from the middle phalanx reduced extensor lag of the DIP joint. Detachment of up to two-thirds of the phalangeal length was effective in this model and did not cause any boutonniere deformity. Clinical relevance: Controlled clinical application of our cadaveric results might yield improved active motion for chronic mallet extensor lag. © 2012 American Society for Surgery of the Hand. All rights reserved.

The aim of this study was to investigate the correlation of wrist extension strength (WES) and grip strength (GS) using a radial nerve block, and to determine the WES required to prevent the "wrist flexion phenomenon" (antagonistic WES) when making a fist. We tested 14 arms in seven healthy males. WES and GS were measured before blocking as standard WES and standard GS. All participants then had radial nerve blocks with mepivacaine hydrochloride. During the recovery process from radial nerve blockade, WES and GS were recorded every 5 minutes. There was a very strong correlation between WES and GS (p &lt 0.0001). The mean antagonistic WES was 51% of standard WES, and the mean GS, recorded at the same time, was 66% of standard GS. © The Author(s) 2012.

Purpose Although the end-to-side nerve repair technique has been used clinically, it has not yet produced consistent motor and sensory recovery in patients. The aim of this study was to investigate whether end-to-side double nerve grafts display more axonal regeneration compared with a single nerve graft in a rat lower limb preparation. Methods The lower limbs of 96 Wister rats were used in experiments comparing single and double end-to-side nerve grafts. Left peroneal nerves were harvested and grafted between the right peroneal and tibial nerves. A single graft was attached end-to-side to the peroneal and tibial nerves through an epineural window (single graft group, n = 24). Two grafts were performed in the same manner in the double graft group (n = 24). The peroneal nerve was exposed in positive controls (n = 24) and no graft was performed in negative controls (n = 24). We recorded action potentials and moist weights of the left tibialis anterior muscle at each time point. Fluoro-Gold-labeled (Fluorochrome, Denver, CO) dorsal root ganglion neurons from L1 to L6 were counted using fluorescence microscopy and compared among the 4 groups. Results In both single and double groups, the amplitude and the tibialis anterior muscle weight increased significantly compared with negative controls but remained lower than those measured in positive controls. There was no significant difference between single and double groups. In Fluoro-Gold-labeled neurons, there was also no significant difference between single and double groups. Conclusions The study showed that regeneration of motor and sensory nerve fibers was possible using 2 end-to-side nerve grafts. However, there was no significant difference between single and double grafts. This might suggest a therapeutic limitation of nerve transplants using 2 end-to-side nerve grafts. Clinical relevance Double end-to-side repair attracts both motor and sensory axons, and this results in a medium degree of recovery of function; however, double end-to-side nerve grafting does not appear to offer any advantage over a single end-to-side graft. (J Hand Surg 2012;37A:261-269. Copyright (C) 2012 by the American Society for Surgery of the Hand. All rights reserved.)

Study Design. Prospective trial. Objective. To examine the difference in bone union and clinical results after one-, two-, and three-level instrumented posterolateral fusion surgery using a local bone graft. Summary of Background Data. The iliac crest bone graft technique for lumbar posterolateral fusion surgery is widely used; however, donor site problems such as pain and sensory disturbance have been reported. Local bone has been used for fusion surgery; however, its reliability as a graft for multiple segments has not been fully reported. Methods. One hundred twenty-two patients diagnosed with degenerated spondylolisthesis were divided into three groups [spondylolisthesis at 1 level (n = 42), at 2 levels (n = 40), and at 3 levels (n = 40)]. All patients underwent decompression and instrumented posterolateral fusion with a local bone graft. The amount of bone graft, proportion of patients with (rate) and duration of bone union, Visual Analog Scale (VAS) score, Japanese Orthopedic Association Score (JOAS), and Oswestry Disability Index (ODI) were evaluated before and 2 years after therapy. Results. VAS score, JOA score, and ODI were not significantly different among the three groups before and after surgery (P > 0.05). Average amount of local bone graft used for one segment significantly decreased in proportion to the number of fusion levels (P < 0.05). The rate of bone union was 88% in the one-level group, 85% in the two-level group, and 62.5% in the three-level group, which was significantly lower than that in the one- and two-level groups (P < 0.05). Conclusion. If one- and two-level posterolateral fusion were performed, the local bone graft technique provides a good and uniform bone union rate; however, for three-level fusion poor results were obtained because of an insufficient amount of local bone.

前腕骨骨折変形治癒後の骨性アライメント不良により生じたと考えられる前腕回旋障害に対して著者等は、三次元実体模型を用いて手術シミュレーションを行ったうえで矯正骨切り術を施行している。その方法を紹介し、これまでに施行した8例の治療成績を報告した。全例でシミュレーションどおりの矯正ができ、良好な可動域が得られた。代表例1例を提示した。

15歳女。はしごから転落して左手を受傷し、救急病院にて橈骨遠位端骨折・尺骨茎状突起骨折の診断で非観血的整復を施行された。2日後に前医を紹介受診し、骨片の背側転位が残存していたため非観血的整復、経皮鋼線固定術を施行された。ギプス固定後に関節可動域訓練を開始されたが、著明な回外制限を呈したため当科紹介受診となった。前腕回旋可動域が回内90度に対し、回外は0度と著明な制限を認め、X線で橈骨遠位端骨折の骨癒合は良好で、前腕全長側面像では一見して橈骨に背側凸のbowingと尺骨頭の相対的な背側亜脱臼を認めた。bowingによる骨性アライメント変化が回旋障害の原因と考え、矯正骨切り術のシミュレーションを目的に三次元実態模型を作製した。その結果、橈骨には回内方向への塑性回旋変形が生じたものと判断し、回外制限の病態としては橈骨の回旋変形に伴う遠位橈尺関節の不適合によるものと診断し、橈骨の矯正骨切り術を計画した。三次元実態模型を用いて回旋変形の変形中心である橈骨骨間部中央で50度の減捻骨切りを施行して手術シミュレーションし、受傷後6ヵ月に橈骨の回旋骨切り術を施行し、plate固定した。術後1ヵ月時点で回内外80度、3ヵ月時点で回内外90度を達成し、術後1年現在、回内外可動域はfullで、骨癒合も良好である。

健常人5名10肢40指(全例男、年齢30〜39歳)を対象にPIP関節の伸展における内在筋および外在筋の関与を検討した。MP関節伸展位での内在筋の平均寄与率は示指33.4%、中指45.9%、環指48.8%、小指40.9%で、示指と中指、示指と環指、環指と小指間に有意差を認めた。また、MP関節屈曲位ではPIP関節伸展力は全ての指で測定下限値以下であった。内在筋をブロックした4肢16指ではMP関節伸展位での外在筋寄与率は示指64.2%、中指49.5%、環指50.4%、小指52.4%で、内在筋寄与率との合計値は概ね100%であった。以上より示指と小指では内在筋寄与率が低い傾向があった。

握力を最大限に発揮できる肢位は軽度背屈位である。従って橈骨神経完全麻痺例ではPower Grip時に手関節は掌屈位をとり、握力は著明に低下する。一方、橈骨神経麻痺に対してRiordan変法を施行された症例や手関節背屈筋力が十分に残存する橈骨神経深枝麻痺例においても、徒手筋力検査で手関節背屈筋力が4程度であるにもかかわらずPower Grip時には手関節掌屈位となり、握力が十分に発揮できない症例をしばしば経験する。この現象は手関節背屈力がPower Grip時の手指屈筋の手関節掌屈作用に抗して軽度背屈位を維持できないために生じると考えられる。そこで著者らは、手指屈筋の手関節掌屈力に拮抗できる背屈力を知るために、橈骨神経ブロック後の回復過程を利用して、背屈力と握力との関係について検討した。健常男性5名を対象に検討した結果、背屈力と握力との間には高い相関関係が認められた。拮抗背屈力は基準背屈力の51±8%であり、その時に記録された握力は基準握力の67±7%であった。

男性50名(平均28歳)および女性58名(平均27歳)の計108名の健常者を対象として、握力、ピンチ力の利き手と非利き手の差(比)と相関関係を検討した。対象は全例non manual workerで、利き手は右104名、左4名であった。握力測定にはJAMAR握力計を、ピンチ力測定には油圧式ピンチメーターを用い、ともに測定肢位は立位にて肩関節は自然下垂し、伸展0度、回旋中間位、前腕は回内外中間位、手関節は軽度背屈とした。肘関節は90度屈曲位で行った。母集団として少ない左利きは除外し、右利きに限定して調査した。結果、男性における利き手と非利き手の比較では、非利き手を100%とした場合、利き手の握力は110±14%、ピンチ力は107±10%であった。女性における利き手と非利き手の比較では、非利き手を100%とした場合、利き手の握力は113±11%、ピンチ力は105±10%であった。また男性、女性ともに同側手において握力とピンチ力は高い相関を示した。

60歳女。左環指中手指節(MP)関節の疼痛と可動域制限を主訴とした。転倒して同関節に痛みを認め、単純X線像にて環指MP関節掌側脱臼を指摘され、徒手整復を受けた。受傷後5週目の単純X線像で再脱臼が判明し、当科紹介となった。局所麻酔下に再度徒手整復を試みたが整復不能であり、受傷後6週で観血整復を行った。関節内の瘢痕切除と伸筋腱固定を行い、術後3週で可動域訓練を開始した。術後4ヵ月でMP関節の自動関節可動域は伸展-10°、屈曲65°であった。MP関節掌側に軽度の圧痛を認めたが、運動時痛はなかった。単純X線像では関節症性変化と亜脱臼を認めた。

股関節に発生した滑膜骨軟骨腫症の1例を経験したので、若干の文献的考察を加え報告する。症例は47歳男性で13年前より右股関節痛が出現し、2005年6月当科を受診した。JOA scoreは71点であった。右股関節の内側下方に斑状の石灰化を認め、腫瘤は股関節の前方に位置しており、股関節臼底には腫瘤は認めなかった。大転子を切離し腫瘤摘出術を行った。骨頭軟骨に不整を認め、既に股関節症性変化が始まっていた。Milgram分類ではIII期であった。術後JOA scoreは、94点に改善し、再発はみられていない。治療指針として我々は、診断がつき次第、早期に手術治療を行うべきと考えている。CTにて、臼底の遊離体の有無を評価することが重要であり、臼底に遊離体が存在する場合には脱臼操作を行うべきである。術後の病理診断でII期であった場合には、滑膜切除を行っていても、再発に注意して経過観察を行う必要がある。(著者抄録)