Naoki Maegawa

Indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head

BackgroundThe present study aimed to determine the indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head.MethodsSeventy-one hips (60 patients) were clinically followed for a minimum of 3 years. Average follow-up period was 7 years. Etiologies were alcohol abuse in 31 hips, steroid use in 27, idiopathic in 7 and trauma in 6. Preoperative staging of the necrotic lesion was done using the Steinbergs classification system. The outcomes of free vascularized fibular grafting were determined clinically using the Harris hip-scoring system, radiographically by determining progression, and survivorship by lack of conversion to total hip replacement.ResultsThe average preoperative Harris hip score was 56 points and the average score at the latest follow-up examination was 78 points. Forty-seven hips (67%) were clinically rated good to excellent, 4 hips (6%) were rated fair, and 20 hips (28%) were rated poor. Thirty-six hips (51%) did not show radiographic progression while 35 hips (49%) did, and with an overall survivorship of 83% at 7 years. Steroid-induced osteonecrosis was significantly associated with poor scores and survival rate (68%). Preoperative collapse was significantly associated with poor scores, radiographic progression and poor survival rate (72%). A large extent of osteonecrosis greater than 300 degrees was significantly associated with poor scores, radiographic progression and poor survival rate (67%). There was no relationship between the distance from the tip of the grafted fibula to the subchondral bone of the femoral head and postoperative radiographic progression.ConclusionIn conclusion, small osteonecrosis (less than 300 degrees of the femoral head) without preoperative collapse (Steinbergs stages I and II) is the major indication for free vascularized fibular grafting. Steroid-induced osteonecrosis is a relative contraindication. Large osteonecrosis (greater than 300 degrees) with severe preoperative collapse (greater than 3 mm) is a major contraindication. Hips with 2 negative factors such as severe preoperative collapse and a large extent of osteonecrosis, require hip replacements.

Oberlin partial ulnar nerve transfer for restoration in obstetric brachial plexus palsy of a newborn: case report

An 8 month old male infant with Erbs birth palsy was treated with two peripheral nerve transfers. Except for rapid motor reinnervations, elbow flexion was obtained by an Oberlins partial ulnar nerve transfer, while shoulder abduction was restored by an accessory-to-suprascapular nerve transfer. The initial contraction of the biceps muscle occurred two months after surgery. Forty months after surgery, elbow flexion reached M5 without functional loss of the ulnar nerve. This case demonstrates an excellent result of an Oberlins nerve transfer for restoration of flexion of the elbow joint in Erbs birth palsy. However, at this time partial ulnar nerve transfer for Erbs birth palsy is an optional procedure; a larger number of cases will need to be studied for it to be widely accepted as a standard procedure for Erbs palsy at birth.

Total talar replacement following collapse of the talar body as a complication of total ankle arthroplasty: A case report

Collapse of the talar body is a serious complication of total ankle arthroplasty. As the degree of osteoporosis increases, collapse is more likely, especially in patients with rheumatoid arthritis1. A paucity of revision implants, poor soft-tissue coverage and vascularity, and decreased bone stock make revision of a failed total ankle arthroplasty more challenging than revision of a failed hip or knee arthroplasty2. Kotnis et al.2 reported that revision is inadvisable in the presence of large osseous defects because they increase the chances of malalignment and instability, with resultant early failure. Johl et al.3 recommended a tibiotalocalcaneal arthrodesis with a short retrograde femoral nail as the treatment for aseptic loosening after a total ankle replacement with extensive bone loss because of the stability that is created and the low risk of pseudarthrosis. However, the major disadvantages of a tibiotalocalcaneal arthrodesis are a certain degree of shortening and a stiff foot4. In the case reported here, to restore the range of motion and to prevent degenerative changes in the distal joints such as the tarsometatarsal and metatarsophalangeal joints, we replaced a collapsed talar body and previous implants with a total talar prosthesis. The patient was informed that data concerning the case would be submitted for publication, and she consented. A fifty-six-year-old woman who had been managed for rheumatoid arthritis for twenty years presented to our institution because she had had increasing pain and loss of function in the left ankle for the previous year. Extensive changes in the ankle and subtalar joints that were typical of rheumatoid arthritis were verified with radiography, and a total ankle …

Pedicled Vascularized Bone Graft from the Medial Supracondylar Region of the Femur for Treatment of Femur Nonunion

A free vascularized bone graft harvested from the supracondylar region of the femur was used to treat patients with nonunion but without a massive bone defect. This graft is vascularized by the descending genicular artery (DGA). In patients with femur nonunion, pedicled vascularized bone grafts are usable in some cases. To confirm the applicable range of this graft, we performed dissection of the DGAs in 16 lower limbs of eight embalmed cadavers. A pedicled bone graft from the supracondylar region of the femur was harvested and rotated proximally to the femur as far as possible. The distance from the apex of the medial epicondyle to the central point of the transferred bone (DMEB) was measured. DMEBs ranged from 13.0 to 20.0 cm (mean, 17.3). Dividing the DMEB by femoral length we defined as the transposition ratio. Transposition ratios ranged from 0.48 to 0.70 (mean, 0.60). These results showed we could transfer enough graft to a distal half of the femur. This technique has a good indication for intractable nonunion without significant bone defects of the distal half of the femur where conventional techniques are not practical.

Investigation of segmental carpal tunnel pressure in patients with idiopathic carpal tunnel syndrome--is it necessary to release the distal aponeurotic portion of the flexor retinaculum in endoscopic carpal tunnel release surgery?

Segmental carpal tunnel pressure was measured in 12 hands of 11 idiopathic carpal tunnel syndrome patients before and after two-portal endoscopic carpal tunnel release. We aimed to determine at which part of the carpal tunnel the median nerve could be compressed, and to evaluate whether carpal tunnel pressure could be reduced sufficiently at all segments of the carpal tunnel after the surgery. Pressure measurements were performed using a pressure guide wire. The site with the highest pressure corresponded to the area around the hamate hook; the pressure in the area distal to the flexor retinaculum could be pathogenically high (more than 30 mmHg) before the surgery. The two-portal endoscopic carpal tunnel release achieved sufficient pressure reduction in all segments of the carpal tunnel when the flexor retinaculum and the fibrous structure between the flexor retinaculum and the palmar aponeurosis were completely released.

Wrist arthrodesis with vascularized fibular grafting.

Six patients underwent wrist arthrodesis using vascularized fibular grafting for treatment of a segmental bone defect across the wrist. Five patients had defects resulting from excision of a giant cell tumor at the distal radius, and one patient had a defect after debridement of a chronic infection. In all cases, bone union was achieved within 3 to 6 months after vascularized fibular grafting without additional procedures. Measurement of postoperative roentgenograms revealed that the average of fixed wrist angle was 13 degrees extension. Postoperatively, average grip strength on the affected side was 59% of that on the unaffected side, and the average range of forearm rotation was 123 degrees. The mean Enneking functional score was 84% at a mean follow-up period of 64 months. There was no recurrence of a tumor or infection. Wrist arthrodesis using vascularized fibular grafting is a useful procedure for the treatment of a segmental bone defect across the wrist.

Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≥ 3. SEI was defined as AIS ≥ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≤ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.

Septic arthritis of the wrist caused by Mycobacterium intracellulare: a case report

Abstract Septic arthritis of the wrist is rare entity, especially; atypical mycobacterial infection of the wrist is extremely rare. We report a case of septic arthritis of the wrist caused by Mycobacterium intracellulare, which was successfully treated by radical debridement followed by wrist arthrodesis using vascularised fibular grafting.

Functional reconstruction of bilateral injuries to the dorsum of hand using radial forearm tendocutaneous flaps.

Abstract We treated a patient with skin and tendon defects of both hands as a result of injury by a heat press. There have been no reports of bilateral hand injuries being treated using simultaneous bilateral tendocutaneous flaps. In this case, we reconstructed the injured tissue using simultaneous bilateral radial forearm tendocutaneous flaps, with satisfactory results.