Chojo Futenma

Very Distal Radius Wedge Osteotomy for Kienböck’s Disease: Case Series

BACKGROUND Radius osteotomy is one of the standard surgical procedures for the treatment of Kienböcks disease. Unfortunately, radius osteotomy can result in an incongruous distal radio-ulnar joint (DRUj) postoperatively, because the procedure is performed proximal to the DRUj. METHODS A very distal radius wedge osteotomy was performed as a 15-degree lateral closing wedge osteotomy with the apex of the wedge distal to that of conventional lateral closing wedge osteotomy; this procedure was developed to avoid postoperative incongruous DRUj. We performed this procedure on 6 patients (stage III-A: 1, stage III-B: 5) with a mean age of 49 years. Clinical and radiographic evaluations were performed at a mean follow-up of 32 months. RESULTS Wrist pain disappeared in all patients. Mean grip strength improved from 35% to 87% of the contralateral side (p = 0.0255). Mean range of motion, measured as flexion-extension arc, improved from 93 to 128 degrees. Nakamuras score was good in all patient. Mean lunate covering ratio increased from 61% to 90% (p = 0.0151) and mean sigmoid notch inclination angle, a radiographic parameter of DRUj congruency, was not significantly different between pre-operative and final follow-up evaluation. No clinical or radiographic DRUj osteoarthritis findings were observed. CONCLUSIONS Our procedure of very distal radius wedge osteotomy provided satisfactory clinical results without an incongruous DRUj. This technique might prevent the occurrence of postoperative DRUj osteoarthritis.

Tension Reduced Early Active Mobilization after Bridge Tendon Graft for Rupture of the Little Finger Flexor Tendon: A Case Report

陳旧性小指屈筋腱皮下断裂に対して，橋渡し腱移植後に減張位早期自動運動を行い，良好な成績を得た1例を経験したので報告する．症例は66歳，男性．ゴルフ練習中に練習場のマットを強打した後から左手掌に疼痛があり，近医を受診したが骨折の診断は得られなかった．受傷から1カ月後，左小指の屈曲が困難となり，握力低下と徐々にゴルフのドライバー飛距離も落ちてきた．受傷から3カ月後，手術加療目的に当科に紹介され，有鉤骨鉤偽関節に伴う小指深指屈筋（FDP）腱皮下断裂と診断された．手術は偽関節となった有鉤骨鉤を切除し，断裂したFDP腱に対し長掌筋腱を用いた橋渡し腱移植術を行った．術後2日目より環指の掌側に小指を重ねた減張位バディテーピングにて早期自動運動療法を3週間行った．術後3年の現在，可動域は ％ total active motion 84％と日本手の外科学会評価法でGoodであり，握力とドライバー飛距離の改善も得られた．

Veno-Accompanying Artery Fasciocutaneous (VAF) Flap for Coverage of Skin Defects of the Leg and Ankle

The veno-accompanying artery fasciocutaneous (VAF) flap and veno-neuro-accompanying artery fasciocutaneous (V-NAF) flap are fasciocutaneous flaps receiving arterial blood supply from accompanying arteries of the cutaneous vein and nerve (Nakajima, 1999). These skin flaps can cover skin defects of the extremities as pedicle flaps. These authors reported the results of these flaps used to cover skin defect of the leg. Since 1996, 17 flaps were used in 17 patients. The mean age of 14 men and 3 women was 42 years (range: 3 to 71 years). Cases involved skin defects in 6 patients, traumatic bone and skin defects in 5, and skin defects after tumor resection and after contracture release in 3 patients each. Four patients had combined osteomyelitis and were treated simultaneously with antibiotic-impregnated bone cement. The size of the skin defect ranged from 4 cm × 3.5 cm to 15 cm × 8 cm. The sural or saphenous nerve was used in V-NAF flaps. Currently, the authors spare these nerves, especially the saphenous nerve, in the proximal leg because it runs under the fascia and makes less of a contribution to the blood supply to the leg. There were 13 flaps containing the small saphenous vein and 4 flaps containing the great saphenous vein. Five proximally-based flaps were used to cover proximal skin defects, as proximal as the popliteal fossa and the prepatellar region. Twelve distally-based flaps were used to cover distal skin defects, as distal as the stump of Chopart amputation. Follow-up ranged from 1 year to 6 years (mean: 2 years). All flaps survived completely. The donor sites of these flaps were closed primarily in 6 and with a skin graft in 11 cases. All osteomyelitis cases healed without any problems. Skin defects exposing bone in the leg and ankle are difficult to treat. Free vascularized flaps used to be required in many cases. However, free flap transfer may be difficult in elderly patients or in patients having disease or damage to major arteries of the leg. The VAF and V-NAF flaps are pedicle flaps, relatively easy to dissect and with no need to sacrifice the major arteries of the leg. They are useful for covering skin defects of the leg and ankle.