2010年から2019年までに当院で舟状骨偽関節に対して手術治療を行った13例（全例男性）について治療成績を検討した．手術時年齢は18～70（平均36）歳，骨折部位は体部11例，近位2例，Filan-Herbert分類はD1 1例，D2 10例，D3 2例，受傷から手術までの期間は受傷時期不明の2例を除き，2か月～2年8か月（平均8.3か月）であった．全例で遊離自家骨移植（腸骨11例，橈骨遠位1例，肘頭1例）を行い，headless compression screwで固定した．1例で骨癒合が得られず再度

を行い，最終的に全例で骨癒合が得られた．今回の症例は殆どが体部骨折でD1，D2症例であったが，これらにおいては遊離自家骨移植にて諸家の報告する血管柄付き骨移植術の成績とも差のない成績が得られており，症例を吟味すれば遊離自家骨移植は今後も有力な選択肢となるものと考えた．一方骨癒合が得られにくいとされるD3，D4症例では，血管柄付骨移植術を考慮する必要があると思われた．

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For past 7 years, we have performed vascularized bone graft on 28 patients. Nineteen of them were vascularized free bone graft, 7 were vascularized pedicle bone graft and 2 were combined operation of both vascularized free bone and pedicle bone graft. As a donor bone, 25 fibulae, 4 iliac bones and a rib were used.
All of 10 cases except one of traumatic massive bone defect or pseudarthrosis, completed bone union. But in these cases, 2 needed conventional iliac bone grafting, because of delayed union due to unstable fixation of grafted bone. Four of 6 cases of avascular necrosis of the femoral head showed good X-ray appearance and clinical results. One case failed and another case is at a short time after operation to evaluate the result. In the cases of wide spinal lesions, spinal tuberculosis and neurofibromatosis, vascularized bone grafts were indicated. This procedure was used for limb salvage operations of malignant tumors of the tibia (adamantinoma), femur (osteosarcoma), and humerus (osteosarcoma, Ewing' sarcoma). Two cases of congenital pseudarthrosis of the tibia underwent free vascularized fibular graft. Both cases had additional operations: one required correction osteotomy and another patient needed Sofield procedure because of fatigue fracture. Vascularized bone graft was also used for arthrodesis, for example, of Charcot joint or infected joint in which the union of the bone was troublesome.

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舟状骨近位部骨折は血流障害によりしばしば偽関節を生じ治療に難渋する．今回，術前造影MRIにて舟状骨偽関節術後の舟状骨近位端骨壊死が評価困難であった症例を経験したので報告する．症例は20歳女性．サッカー中に左手を受傷し手関節痛が出現．受傷3カ月後に前医受診，陳旧性舟状骨骨折の診断で

・観血的骨接合術が施行された．外来加療継続するも偽関節となり，造影MRIでは舟状骨遠位骨片は造影効果を認めるも，近位骨片はインプラントのアーチファクトで正確な評価困難であった．初回術後11カ月後にZaidemberg法に準じた血管柄付き骨移植術を施行，術中評価では近位骨片に血行を認めなかった．近位骨片への血流評価に関しては，舟状骨近位端の骨壊死に対する造影MRIの特異度が高い一方，感度は低いという報告もあり，本症例のような内固定術後の画像による血流評価に関しては留意する必要があると考えられた．

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Twenty-five Chiari pelvic osteotomies for advanced stage osteoarthritis of the hip joint were studied with follow-up periods of 4.1 years on an average. The mean Japanese Orthopaedic Association score was 63 before surgery and 87 after. Postoperative remodeling of the acetablum was classified according to X-ray findings, and there was significant correlation between the degree of acetabular remodeling and acetabular head index (AHI) . The hips with non-spherical heads showed better acetabular remodeling than the hips with spherical heads. These observations suggest that Chiari pelvic osteotomy is useful for advanced stage osteoarthritis of the hip joint.

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【はじめに】有鉤骨の壊死症は手根骨壊死症の中では稀な疾患である．今回我々は有鉤骨壊死症と思われる症例を経験したので報告する．【症例】70歳男性，右利き，職業は漁師．明らかな外傷の既往もなく，4，5年前から左手関節痛を認め2カ月前より仕事を休んでいた．今回仕事復帰を目的に当科受診した．左手関節に圧痛があり，X線にて有鉤骨近位部に淡い骨透亮像を認めていた．MRIでは同部にT1 low，T2 highの病変を認め有鉤骨壊死症を疑い，病巣掻爬及び遊離骨移植を行った．病理検査は骨壊死の診断であった．術後3カ月のMRIで異常信号はほぼ消失しており，仕事にも復帰している．【考察】術後3カ月で仕事復帰を果たし経過は良好であるが，長期成績は不明であり今後も経過観察が必要である．本疾患の診断・治療判定にはMRIが有効であった．

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Dysplasia of the ankle malleolus is uncommon but it may result in osteoarthritis. We developed a new treatment for dysplasia of the ankle malleolus using the Ilizarov apparatus. In the reconstruction of medial malleolus, a rectangular fragment is osteomized from the tibia and then it is moved medially and distally in the Ilizarov apparatus. When the fragment comes to the correct anatomical position, it is united to the medial cortex of the tivia with an Ilizarov olive wire. In the reconstruction of the lateral malleolus, the shortened fibula is osteomized and lengthened distally in the apparatus. Two patients had their ankle reconstructed using this technique with very satisfactory results. Although dysplasia of the ankle malleolus is often associated with leg length discrepancy and foot deformity, the simultaneous correction cannot be done with the conventional procedures reported by Gruca, Serafin and other authors. We conclude that this procedure be considered as the definitive operation because these conditions can be treated at one stage.

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目的：舟状骨偽関節で近位部に骨壊死をきたす症例では，通常の遊離腸骨移植術の骨癒合率は低いとの報告が多い。手関節の舟状骨偽関節に対する鏡視下手術（Arthroscopic法，以下AS法）は低侵襲であり，良好な治療成績が報告されているが，術前に骨壊死が予想される症例には適さないとされていた。今回，術前MRI画像にて壊死が疑われた症例に対し，鏡視下手術を施行した症例の治療成績を報告する。

方法：術前MRIにて全例で近位骨片に骨壊死が疑われたが，骨欠損部が小さく，AS法にて対応可能と思われた舟状骨偽関節13例を対象とした。受傷から手術までの期間は3.5（2～7）か月，平均年齢が18.9（16～25）歳，骨折部は腰部8例，近位部5例，経過観察期間は12.8か月であった。これらの骨癒合率，臨床評価としてMayo Wrist Scoreを評価した。

結果：全例で骨癒合は得られ，術前MRIはT1強調画像で近位骨片は全例でiso signalであったが，T2強調画像は症例によってさまざまであった。術後掌背屈の可動域およびMayo Wrist Scoreで改善を認め，術後成績は良好であった。

考察：術前MRI T1強調像にて骨壊死が疑われた症例であっても，遊離骨移植であるAS法で骨癒合が得られ，良好な成績が得られた。AS法により骨膜などの周囲組織を可及的に温存したことが有利に働いたと思われ，骨欠損が小さければ，骨壊死が疑われてもAS法は有効と思われた。MRI画像と壊死との関連性や適応症例の詳細についてはさらなる検討が必要ではあるが，特に若年者が対象のAS法の適応はさらに広がる可能性がある。

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下顎骨切除後の下顎骨の再建においては, 歯槽再建が必須である. 多孔質ヒドロキシアパタイトブロックは自由に, 独特な下顎骨の形態の付与が可能である。その材料の脆さは金属プレートとの併用により克服できる。また遊離皮弁のうち前腕皮弁は現在では最も薄い大型皮弁であり, 口腔粘膜の大欠損に十分対応できる。われわれはこの両者を用いた下顎歯槽再建法を1985年以来39例に行ってきた。今後さらに改良すべき点もあるが, 顎義歯でない通常の歯科補綴物が装着可能となってきている。今回は最近の症例を提示してわれわれの歯槽再建法について述べた。

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顎骨再建を目的として, 血管柄付は広く応用されているが, 解剖学的理由などによりdonor採取部位が限定されることが多い。そのため, 骨, 骨膜, 骨髄細胞, 人工骨などを用いて新たなdonor作製の実験的研究が試みられているが, 人工材料であるコラーゲンと生体材料を使用して作製するbone graftに関する報告は少ない。そこで今回, 血管柄付骨膜, アテロコラーゲンスポンジ, 骨髄細胞の組み合わせにより骨形成を生じさせるprefabricated vascularized bone graft作製の可能性とその形成過程を観察するため実験的研究を行った。

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The clinical course of secondary transplanted iliac bone for reconstructive surgery of the mandible was evaluated.Secondary transplanted iliac bone after surgery of oral malignant tumor showed a satisfactory bony union by either bridge bone grafting or by elongation bone grafting and by either free bone grafting or by revascularized bone grafting.
However, it was difficult to wear dentures on the transplanted bone because of tension of primary sutured oral mucosa.The cases with immediate reconstructive surgery of the mandible by AO plate and soft tissue by MC flap or by fore arm flap, showed some advantage for preventing facial asymmetry and for pre-prothetic surgery.
On the other hand, limited stability of denture on the transplanted iliac bone was recognized, if there were few of resudial teeth.
Application of osseointegrated implants for functional reconstructive surgery of the mandible may produce better results than ordinary dentures.For osseo-integrated implantation revascurarized living iliac crest grafting will be much better than non-vascurarized one because of its better nourishment.

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顎関節雑音はこれまでクリックを主体とした数多くの関節雑音に関する報告がなされてきたが, それらは顎機能異常者を対象とした可聴音に対する周波数解析が主であり, その比較, 対照となる正常者の顎関節運動音についての報告はあまりなされていない。本研究は, 顎関節内部の状態の変化を顎関節運動音の変化により評価することを目的として, 正常者を対象に前後的に実験的下顎位を付与し, 顎関節内部に負荷を与えたことで, 正常者の顎関節運動音がどのように変化するかについて検討を行った。

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In this study, I attempted to analyze osteoinductive activity in prefabricated neovascularized bone flap using an experimental model of autologous bone and allogenic freeze-dried bone, in rats.
Wistar rats were divided into two groups according to transplanted bone that is autologous iliac bone and allogenic freeze-dried bone.
All flaps were reharvested at 2, 4, 8, and 12 weeks after transplantation for radiographic, histological, and immunohistochemical examinations.
The results obtained were as follows:
1. In the autologous iliac bone group, osteogenesis was observed at the second week after transplantation. Immunohistochemical expression of osteopontin was observed in new bone matrix.
2. In the allogenic freeze-dried bone group, weak osteoinduction, such as endochondral bone formation, was observed at the fourth week after transplantation. However, transplanted bone chips were absorbed at the twelfth week after transplantation.
3. In the autologous iliac bone group, new bone formation with bone bridges between bone chips was observed around the vascular bundle. The newly formed bone expressed osteocalcin immunohistochemically at the twelfth week after transplantation.
4. The method of prefabricated neovascularized bone flap using autologous iliac bone chips was found to be a useful axial pattern flap with osteoinductive properties, and possibility of clinical application in bone reconstruction was shown.

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The leg consisted of a tight skin envelope directly covering bone and musculotendinous structures. Soft tissue defects in this area were difficult to repair because of the poor blood supply to the skin and the limitations imposed in designing reliable flaps. Several kinds of new reconstructive procedures for coverage of the leg were introduced.
11 patients were treated with different flap transfers for soft tissue defects of the leg, between 1980 and 1983 at the Yamaguchi University School of Medicine.
There were 5 free flaps, 4 pedicle skin flaps and 2 muscle flaps. All patients were male and their ages ranged between 20 and 65 year-old. Types of the free flaps used included free latissimus dorsi (2), free groin flap (2), and free peroneal flap (1), The pedicle flaps consisted dorsalis pedis flap (1), peroneal flap (1), bipedicle gastrocnemius M-C flap (1) and cross leg fasciocutaneous flap (1). The muscle flaps used the peroneus longs, brevis and the abductor hallucis (1), and the gastrocnemius (1). All flaps survived and any sequelae of the skin and tibia bone did not occur.
The authors emphasized the superiority of the free latissimus dorsi, free peroneal flap, pedicle peroneal flap and cross leg fasciocut aneous flap for coverage of soft tissue defect of the leg.

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Vascularized free fibular flaps, raised with associated skin island, has been used to reconstruct a large mandibular defect including the middle third of the mandible in two cases. Although additional surgical procedure to correct the shape of the graft was needed in one patient, a fibular bone could be molded to the appropriate contour by means of osteotomies and fixations with miniplates in both cases. The small skin island was used for the purpose of monitoring the blood supply to the bone graft in one patient, and the large skin island was employed for covering the skin defect of the recipient site in the other. In the former patient, in spite of partial necrosis of the monitoring skin island, the bone graft survived completely. The latter had no trouble in the recipient site with survival of the bone and skin grafts. However the latter patient had trouble in the donor site with a slight functional deficit caused by prolonged wound infection.
These two cases have taught us that vascularized free fibular graft is useful in reconstruction of mandibular defect particularly in such a large segment as this; however, the problems relating to the skin island or management of the donor site must be considered.

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今回,私たちは強度に萎縮した中間顎により広い顎裂を有した両側唇顎口蓋裂患者を治療する機会を得たので報告する.患者は33歳の女性で咀囎障害および鼻部の悪臭を主訴に当科来院した.そこで,まず最初に遊離自家腸骨移植により上顎骨を形成し,ついで口腔前庭拡張術の後,歯科インプラントによる咬合の改善を行った.その結果,口唇鼻部の形態および咀囎機能は満足いくものとなった.

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