Tatsuya Tajima

Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure

Forty-three rheumatoid wrists in 43 patients with bilateral wrist involvement were treated with synovectomy of the extensor tendons and wrist joint combined with a Darrach procedure in the period from 1966 to 1986. Clinical and radiologic assessment of the wrists was carried out after an average follow-up period of 11 years, with comparison of the treated and the opposite untreated wrists. The authors confirmed what others have concluded regarding the operation: pain was generally decreased, forearm rotation increased, and wrist extension and palmar flexion changed little. Radiologically, carpal collapse and palmar carpal subluxation progressed nearly parallel to the opposite wrists, but ulnar carpal shift was much greater in the surgically treated wrists. Therefore it is suggested that some measure to prevent ulnar carpal shift, such as Claytons tendon transfer or radiolunate arthrodesis, should be included in this operation.

Reconstruction of a congenital hypoplastic thumb with use of a free vascularized metatarsophalangeal joint

Reconstruction of a Blauth type-IIIB hypoplastic thumb with use of a free vascularized metatarsophalangeal joint was performed in four patients (four hands). Several tendon transfers also were performed, either primarily or secondarily, to mobilize the reconstructed thumb. Three patients (three hands) were followed for at least two years after the reconstruction; the results for these three patients were compared with those for four patients (six hands) who had been managed with pollicization of the index finger because of a similar deformity of the thumb. The patients were evaluated with regard to grip strength, key-pinch strength, and the range of motion of the joints of the thumb in the operatively treated and contralateral hands as well as with regard to skill in performing activities of daily living as assessed with use of the Kobe hand-function test. Although the appearance of the thumb was closer to normal in the group that had had the pollicization procedure, total function of the hand and grip strength were greater in the group that had had the transfer procedure. We believe that reconstruction of an unstable hypoplastic (Blauth type-IIIB) thumb with use of a vascularized metatarsophalangeal joint is an acceptable alternative to pollicization of the index finger.

Free nail bed graft for treatment of nail bed injuries of the hand

Free full-thickness grafts of nail bed of the lesser toes or an amputated fingertip were successfully performed on 11 fingers of 10 patients since 1979. In nine patients in whom the nail beds had been severely crushed or lost, but the nail matrix was intact, the end results of this technique were excellent. In one patient in whom both the nail bed and matrix had been lost, free grafting of the toenail bed and matrix was performed, with a good result. The procedure can be used when restoring the length of the tip in fingertip amputation if used in combination with local skin flaps such as V-Y advancement or local rotation flaps.

Microsurgical toenail transfer to the hand.

Free nonvascularized toenail grafts have been used to reconstruct congenital or traumatic nail defects of the thumb or finger. Unfortunately, these transfers often result in deformity or atrophy. To avoid these undesirable results, microsurgical free vascularized toenail transfer was performed in 10 patients, 3 for congenital nail absence and 7 for traumatic nail defects. Patient age averaged 17 years (range 2 to 32 years). In contrast with previous reports, the whole big or second toenail complex without pulp was used in reconstruction. All 10 nails were successfully transferred with complete survival. No digits required reexploration. There were no donor-or recipient-site problems. Follow-up averaged 3 years, with a range of 14 months to 5 years and 4 months. Appropriate nail growth occurred in the congenital patients. No atrophy of the nail complex was found as long as sufficient bony support was present (9 of 10 cases). Whole free vascularized toenail transfers for reconstruction of congenital and traumatic nailbed defects achieve excellent aesthetic results while maintaining normal hand function.

Treatment of long-standing dislocation of the radial head in neglected monteggia fractures

Long-standing dislocation of the radial head can result from a neglected Monteggia fracture or a congenital anomaly? Remodeling of the ulnar fracture site in Monteggia lesions can obscure the differential diagnosis from congenital dislocations of the radial head. Stability of the elbow joint depends on the congruity of the ulnohumeral joint and the ulnar collateral ligament. In the wrist joint, stability depends on the congruity of the radiocarpal joint and the palmar radiocarpal ligaments. The radiohumeral joint would thus appear to be less important than the ulnohumeral joint. However, in the extended elbow, 60% of the longitudinal forces are transmitted through the radiohumeral joint due to the carrying angle 2 (Fig. 1). Therefore, reduction of the radial head, either following a Monteggia fracture or in congenital cases, is considered very important.

HISTOCHEMICAL, IMMUNOHISTOCHEMICAL AND ULTRASTRUCTURAL INVESTIGATIONS OF GIANT CELL TUMORS OF BONE

The origin and characteristics of so‐called stromal cells (stromal cell) and the osteoclast‐like giant cell series of 19 cases of giant cell tumor (G.C.T.) of bone were studied. Immunohistochemically, two interesting cases were found. The stromal cells of one case were α‐1‐antitrypsin positive and those of the other case were α‐1‐antichymotrypsin positive. The histiocytic stromal cells of the latter case seemed to be surely neoplastic since they showed mild to moderate cell atypism. There were foci consisting of fibroblastic cells or osteoid and osteoblasts within the tumor. Those cells in the foci were apparently continuous with the surrounding stromal cells, and they were, therefore, also considered to be neoplastic. These findings strongly indicate that the stromal cells originate from the undifferentiated mesenchymal cells in the bone marrow and may differentiate to osteoblastic, fibroblastic, and histiocytic cells. All cells of these three series were not stained for a high stable form of acid phosphatase (SAPhase). SAPhase activity was demonstrated only in osteoclast‐like giant cells and some mononuclear cells, which are recently believed to be non‐neoplastic. Therefore, the cell atypia of SAPhase negative stromal cells is considered to have a prognostic value.

Both stump area and volume of distal sensory nerve segments influence the regeneration of sensory axons in rats

We examined the influence of both stump area and volume of a distal sensory nerve segment on neurotropic induction of regenerating sensory axons in a rat saphenous nerve model. In group 1 (n = 10) the proximal stump of the severed saphenous nerve was inserted into the proximal channel, and a 2 cm free nerve segment and a double-barrelled 1 cm free nerve segment were inserted into the distal two channels of a silicone Y-chamber. In group 2 (n = 10), 2 cm and 1 cm free nerve segments were inserted into the distal two channels of a Y-chamber. The gap between the stumps was set at 4 mm. After six weeks, we counted and compared the number of regenerated myelinated sensory axons in the distal two channels. Significantly more axons regenerated in the wider stump area channel of group 1 and in the larger volume channel of group 2 than in the opposite channel in either group (p < 0.05 in each case).

An epidermoid cyst of the tendon

An epidermoid cyst in the flexor superficialis tendon of the right middle finger of a child limited extension of the finger by preventing the distal gliding of the tendon at the inlet of the flexor tendon sheath. Full extension was regained by excising the tendon.