座長：石黒 隆（いしぐろ整形外科）
2-1-EL2 キーンベック病の成因と治療
Etiology and Treatment of Kienböck Disease
上羽 康夫（認定NPO法人 健康医療評価研究機構、京都大学医療短大名誉教授）
［先人達の業績］KienböckがLunatomalaciaの概念を確立させ，その後に多くの優れた研究業績が集 積された．この病気の原因として骨折・血流障害・血栓などが推測されたが，月状骨がどうして壊死 に陥るのか，そして何故X線像で種々なStage変化を示すかについては十分に解明されなかった．「摘 出月状骨標本の所見」晩期キーンベック病症例から摘出した月状骨を調査した．月状骨は変形し，表 層軟骨は変性摩耗していた．月状骨表面には大骨折線が見られ，内部には多くの小骨折が認められた．
大骨折線は走行により3型に分類された．月状骨内には壊死部と生存部とが混在し，境界に新生骨の 形成が認められた．［成因論］Lichtman分類のX線像stageと標本組織所見とを勘案すると，キーン ベック病の発生機序は下記の如くである．手関節炎による関節内圧の上昇により微小静脈は閉塞さ れ，月状骨内に鬱血が起こり，動脈流が減少し，酸素供給が途絶える．その結果，骨細胞は死滅し，
月状骨壊死が起こる．骨内カルシウムは濃縮され，骨芽細胞によるappositionalbone形成が起こり，
Ｘ線で骨硬化像を呈する，関節炎が治まり，血流が再開されると一旦壊死に陥った月状骨の修復が始 まり，肉芽侵入に伴って骨強度は低下し，骨折が起こり易くなる．変形した月状骨はやがて関節症を 誘発する．［今後の治療方針］手関節内圧の上昇期には関節穿刺などを行い，関節内圧を下げる．月 状骨壊死期には血流促進や骨細胞増殖を促す．修復期には月状骨々折を予防するために創外固定など を行う，骨折が起これば，骨癒合を促進させ，形状を復帰させる手術を行う．関節症が生じた場合に は，変形した月状骨の治療のみならず変性摩耗した軟骨の修復術が必要であろう．
上羽 康夫（うえば やすお）
略歴：
1960年 京都大学医学部医学科卒業 1961年 横須賀米国海軍病院インターン修了
1962年～1966年 米国留学
そのうち
1965年7月～1966年 6月 Hand Fellow
（Prof. Robert E. Carroll at New York Columbia︲Presbyterian Medical Center） 1966年～1987年 京都大学医学部整形外科助手，講師，助教授
Room 1 15:10～16:10
招待講演 6
座長：土井 一輝（小郡第一総合病院）
2-1-IL6 Hand and Brain
The connections of the periphery with the centre
Joerg Gruenert, Prof. Dr. med.
（Chairman, Department of Hand, Plastic and Reconstructive Surgery, Kantonsspital St. Gallen, Switzerland）
In all our daily activities we use our hands to explore our environment, to touch our surrounding and to experience our opposite. We manipulate with the power grip and touch with the pinch- and key-grip objects that surround us and shape and arrange our environment new. With the help of tools we are even in the position to move and shape even bigger objects, on the other hand we can also perform microsurgical manipulations on tiny objects. Very often the capability of our hands enables our activities of daily living and garantees our daily living. With our hands work we earn our salary, we communicate with our hands using many gestures and please our minds playing music instruments. For all these activities we need our hands with their 42 muscles and 27 bones, but it won`t work without its connections via the 400.000 nerve fibres through the brachial plexus and the brain with its 100 billion nerve cells in the cortex representing our whole body according its functional importance (homunculus). There are many different sensory organs needed in the finger tips and manifold connections not only to the contralateral, but also to the ipsilateral cortex of the brain. These representations are plastic and correspond to the functional demands and their training. Neuroplasticity defines the adaptation to use or non-use of a motor function or somatic quality. In experimental research alterations in cortical representation can rapidly been found after immobilisation, peripheral anaesthesia, nerve transsections and nerve repair. Rapid cortical reorganisations and functional shifts are the consequences. 57% of all patients with peripheral nerve injuries are between 16 and 35 years of age and 1.5 year after the injury at least 25% of the patients did not return to their former workplace.
Besides that the economic costs for one median nerve injury amount for about 51.000 Euro. After nerve transsections there will be expected central neuron degeneration the more proximal a lesion occurs (27% in proximal versus 7% in distal lesions). Can also Wallerian degeneration been influenced by therapeutic measures? From a neuroscientific point of view there are many factors working in the brain and in the periphery which influence nerve regeneration and functional recovery. A historical overview will demonstrate the manifold ways of action and response in the brain, which determine the change of regeneration. From physiologic observations in musicians and from reports in pathological circumstances we can learn many relevant matters of how the brain is working and interacting with the periphery. Brain processes which are connected to learning and experience processing are important. These mechanisms can be optimized during the rehabilitaton period by multisensory inputs (e.g. tactile and therapeutic meals), the use of sensory-gloves and other neuroscientific measures to improve lost functions. Here the knowledge of the mirror neurons plays an important role and after nerve injuries besides the microsurgical nerve reconstruction the use of mirror therapy supports and improves rehabilitation in these patients. For the hand surgeon the scope has broadened and the results of surgical restoration of nerve injuries not only depend on the surgical skills of the surgeon, but to a major degree also on how he manages to integrate the newest developments of neuroscience in the rehabilitation.
Born: 26.02.1959 in Münster (Northern Germany)
Medical School at Münster university (Germany) and Berne university (Switzerland) from 1979 until 1985 Junior House Officer at Canniesburn Hospital, Glasgow with Ian McGregor and Gus McGrouther 1985/1986
Room 1
Training in General Surgery, Traumatology, Hand Surgery, Plastic Surgery, Maxillofacial Surgery at Münster university 1986 until 1993
Hand Surgery with Prof. Ueli Büchler in Berne (Switzerland) 1993 until 1995 1995 Professor of microsurgery – University of Münster (Germany)
1995-2001 Professor of Hand- and Plastic Surgery, head of Department University of Erlangen-Nuremberg (Germany)
2001 until present Chairman of Department of Hand, Plastic and Reconstructive Surgery, Kantonsspital, St. Gallen, Switzerland
Since 2004 chairman of section Limb&Spine at the IBRA (International Bone Research Association) Member of German, Swiss, British and Japanese Society for Surgery of the Hand
University affiliation with Westfälische Wilhelms-University Münster/Germany Friedrich-Alexander University Erlangen-Nürnberg/Germany
University Zürich/Switzerland University of Birmingham/GB
Special interests: Reconstructive microsurgery, congenital malformations, nerve regeneration Hand/Brain-connection, radius fractures