Clinical features of the posterior horn tear in the medial meniscus

INTRODUCTION

A lower threshold of suspicion is necessary for the appropriate diagnosis of a posterior horn tear in the medial meniscus. In these cases, radial tears or meniscus detachment from its insertion follow minor trauma and precipitate severe knee pain in middle-aged and elderly patients. The purpose of this paper is to demonstrate the key points for diagnosis through examination of the clinical features of this tear.

MATERIALS AND METHODS

Arthroscopic examination of 250 knees with medial meniscus tears (and no ligamentous injuries; over 40 years old) identified 26 knees (26 tears) with a posterior horn tear. Of these 26 tears, 16 were radial, and 10 were detached.

RESULTS

Eighty-five percent of patients could recall discrete events that preceded the pain. They described these events as a click or a feeling of shock. Afterwards, most patients complained of severe pain or giving way. Hydrarthrosis involving more than 5 ml was present in 81%. Most radiographs (92%) appeared nearly normal.

CONCLUSION

It is important to note that this type of tear of the posterior horn in the medial meniscus is not rare. Because this area is difficult to visualize arthroscopically, it may be overlooked unless the threshold of suspicion is lowered.

Effects of growth hormone (GH) on mRNA levels of uncoupling proteins 1, 2, and 3 in brown and white adipose tissues and skeletal muscle in obese mice

We have investigated whether GH treatment influences the expression of UCP1, 2 and 3 mRNA in a KK-Ay obese mouse model. KK-Ay mice (n = 10) and C57Bl/6J control mice (n = 10) were injected subcutaneously with human GH (1.0 mg/kg/day and 3.5 mg/kg/day) for 10 days, and compared with mice injected with physical saline. The KK-Ay obese mice weighed significantly less (p < 0.01 : 1.0 mg/kg/day, p < 0.05 : 3.5 mg/kg/day) and had smaller inguinal subcutaneous and perimetric white adipose tissue (WAT) pads (p < 0.05 : 3.5 mg/kg/day), but increased skeletal muscle weight (p < 0.05). The brown adipose tissue (BAT) weight did not change significantly. Not only plasma free fatty acid and glucose levels but also plasma insulin levels decreased. The reduced HOMA-IR (homeostasis model assessment-insulin resistance) values suggested that insulin resistance was improved by GH treatment. UCP1 mRNA levels increased after the 3.5 mg GH treatment by 2.8-fold (p < 0.01 vs. saline controls) and 2.0-fold (p < 0.05 vs. 1 mg GH treatment) in BAT, and by 6.0-fold in subcutaneous WAT (p < 0.05 vs. controls). UCP2 mRNA levels increased 2.2-fold (p < 0.05 vs. control) and 2.1-fold (p < 0.05 vs. 1 mg GH treatment) in BAT, and 2.0-fold (p < 0.05 vs. controls) in skeletal muscle. One mg GH administration also stimulated UCP1 mRNA expression by 2.5-fold (p < 0.05 vs. controls) and UCP3 mRNA expression by 2.8-fold (p < 0.05 vs. controls) in the muscle. On the other hand, lean mice showed no significant difference in body composition or plasma parameters. UCP1, 2 and 3 mRNA expression in lean mice did not show any significant change after treatment with GH. We conclude that GH treatment increased mRNA levels for not only UCP1, but also UCP 2 and 3 in BAT, WAT and muscle in a KK-Ay obese mouse model. These findings suggest that GH-induced thermogenesis may contribute to the reduction in WAT and energy expenditure.

Which cartilage is regenerated, hyaline cartilage or fibrocartilage? Non-invasive ultrasonic evaluation of tissue-engineered cartilage

OBJECTIVE

To investigate ultrasonic evaluation methods for detecting whether the repair tissue is hyaline cartilage or fibrocartilage in new cartilage regeneration therapy.

METHODS

We examined four experimental rabbit models: a spontaneous repair model (group S), a large cartilage defect model (group L), a periosteal graft model (group P) and a tissue-engineered cartilage regeneration model (group T). From the resulting ultrasonic evaluation, we used %MM (the maximum magnitude of the measurement area divided by that of the intact cartilage) as a quantitative index of cartilage regeneration. The results of the ultrasonic evaluation were compared with the histological findings and histological score.

RESULTS

The %MM values were 61.1 +/- 16.5% in group S, 29.8 +/- 15.1% in group L, 36.3 +/- 18.3% in group P and 76.5 +/- 18.7% in group T. The results showed a strong similarity to the histological scoring.

CONCLUSION

The ultrasonic examination showed that all the hyaline-like cartilage in groups S and T had a high %MM (more than 60%). Therefore, we could define the borderline between the two types of regenerated cartilage by the %MM.

Can ultrasound predict histological findings in regenerated cartilage?

OBJECTIVE

To evaluate regenerated articular cartilage quantitatively by introducing an ultrasonic probe into the knee joint under arthroscopy and analysing the A-mode echogram by means of wavelet transformation.

METHODS

Three experimental rabbit models (spontaneous repair model, large cartilage defect model, treatment model) were examined using our ultrasonic evaluation system and a histological grading scale. From resulting wavelet map, the percentage of maximum magnitude was selected as the quantitative index of the ultrasonic evaluation system.

RESULTS

The percentage maximum magnitude in the spontaneous repair model was 61.1%, that in the large defect model was 29.8% and that in the treatment model was 36.3%. There was modest correlation between the percentage maximum magnitude and the histological grading scale (r = -0.594)

CONCLUSION

Our findings indicate that ultrasound analysis can predict the microstructure of regenerated cartilage.

Orientation and distribution of collagen fibers in the sagittal plane of the human adult calcaneus

Human right calcaneus bone, consisting of hydroxyapatite and collagen fibers, was cut in the sagittal plane which was parallel to the long axes of the calcaneus bone and the human lower limb, into samples approximately 1.5 mm thick. The angular dependence of transmitted microwave intensity at 12 GHz was measured for each sample, using Osaki's microwave method. The direction and the degree of collagen-fiber orientation for the cut specimens changed with changing position from the heel end to the anterior, along to the long axis of the calcaneus bone. The direction of orientation deviated by about -60 degrees from the direction of the long axis of the human lower limb, in the region between the heel end and the middle, and by about 60 degrees near the anterior. The position at which the orientation angle changed drastically from negative to positive corresponded to the neck defined as the position where a posterior face of the talus contacts the calcaneus. The results suggest that the mechanical stress applied to the neck of the calcaneus bone from the lower limb may effectively disperse, on average, in two different directions where the collagen fibers are oriented at the neck.

Static scapholunate dissociation diagnosed by scapholunate gap view in wrists with or without distal radius fractures

This prospective study investigated static scapholunate dissociation (SLD) in wrists associated with distal radius fractures. SLD was detected as a widening of the scapholunate (SL) joint interval by SL gap view. Ninety-six distal radius fractures and 154 normal wrists were investigated by SL gap view, which is better for detecting SLD than the standard posteroanterior (PA) view. Incidences of non-symptomatic SLD detected by SL gap view in normal wrists increased by age. In the young age bracket, incidences of SLD in distal radius fractures were significantly higher than in normal wrists. Our results indicated that in patients younger than 30 years old, SLD in distal radius fractures was a fracture-caused abnormality. In those over 30, ascribing SLD to the fracture was difficult. Close examinations, like arthroscopy and dynamic cineradiography, need to be made in patients with SLD associated with distal radius fractures, especially in those younger than 30.

The role of tissue macrophages in the induction of proinflammatory cytokine production following intravenous injection of lipoplexes

Recent studies have demonstrated that intravenous administration of a plasmid DNA-cationic liposome complex (lipoplex) induced significant proinflammatory cytokine production in blood and inhibited transgene expression in pulmonary endothelial cells. In this study, we examined the effects of gadolinium chloride (GdCl(3)) pretreatment on the biodistribution and induction of proinflammatory cytokine production and transgene expression after intravenous injection of a lipoplex in mice. GdCl(3) is known to transiently deplete liver Kupffer cells and spleen macrophages after intravenous administration. Intravenous administration of a lipoplex triggers high levels of proinflammatory cytokine production, such as TNF-alpha, IFN-gamma and IL-12 in serum and a large amount of (32)P-labeled lipoplex accumulates in the liver 1 h after intravenous administration. However, pretreatment with GdCl(3) dramatically reduces serum levels of these cytokines and liver accumulation of the lipoplex. RT-PCR analysis showed that mRNA expression of TNF-alpha greatly increases in the liver and spleen after lipoplex injection and that pretreatment with GdCl(3) reduces mRNA expression in these organs. Messenger RNA expression of TNF-alpha in the liver occurs in non-parenchymal cells (sinusoidal endothelial cells and/or Kupffer cells). Inhibition of cytokine production by pretreatment with GdCl(3) leads to recovery of transgene expression in the lung following the second injection of lipoplex, which was reduced following the first injection of lipoplex. Thus, the present study demonstrates that tissue macrophages involving liver Kupffer cells and spleen macrophages are closely involved in TNF-alpha production following i.v. administration of the lipoplex. It is also suggested that avoiding lipoplex uptake and subsequent cytokine production by these cells would be a useful method of maintaining a high level of gene expression in the lung after repeated injections.

Pharmacokinetic analysis of lectin-dependent biodistribution of fucosylated bovine serum albumin: a possible carrier for Kupffer cells

To examine the potential utility of fucosylation of drug carriers for targeted drug delivery to Kupffer cells, the pharmacokinetics of (111)In-labeled fucosylated bovine serum albumin (Fuc-BSA) with different numbers of fucose residues (11, 16, 25, 31 or 41) was studied. After intravenous injection in mice, all (111)In-Fuc-BSAs were mainly delivered to the liver and their hepatic uptake became saturated when the dose was increased. Of these derivatives, only (111)In-Fuc41-BSA showed a slow plasma elimination at low doses, suggesting an interaction with blood components. Examination of binding conditions as well as electrophoretic analysis of the binding components indicated that the serum-type mannan binding protein (MBP) is responsible. Kupffer cells, which possess fucose receptors, showed the highest uptake of (111)In-Fuc41-BSA, followed by endothelial cells and hepatocytes. The hepatic uptake of (111)In-Fuc41-BSA was inhibited by co-injection of Gal42-BSA, but not by Man46-BSA. On the other hand, excess Fuc41-BSA inhibited the hepatic uptake of (111)In-Man46-BSA, while (111)In-Gal42-BSA did not: These findings suggest that not only the fucose receptors on Kupffer cells but also other lectins are involved in the biodistribution of Fuc-BSAs. To understand how the degree of fucose modification affects the binding affinity of Fuc-BSA with hepatic lectins and serum MBP, a pharmacokinetic analysis was performed based on a physiological model. The Michaelis constant of the hepatic uptake of (111)In-Fuc-BSA decreased with an increasing number of fucose units, and the intrinsic hepatic clearance of (111)In-Fuc25-, (111)In-Fuc31- and (111)In-Fuc41-BSAs was close to, or much greater than, the hepatic plasma flow rate, indicating efficient hepatic uptake of these derivatives. These results suggest that fucosylation is a potentially useful method making drug carriers selective for Kupffer cells, although extensive modification might result in retarded delivery due to binding to other lectins like MBP.

The functional anatomy of the human anterior talofibular ligament in relation to ankle sprains

The anterior talofibular ligament is the most commonly injured ligament in the ankle. Despite considerable interest in the clinical outcome of treatment protocols, we do not know whether the distinctive pattern of localization of the injuries relates to regional differences in the structure and molecular composition of the ligament. To address this issue, ligaments were examined by histology and immunohistochemistry. Differences in the structure of its two attachments (i.e. entheses) were evaluated with quantitative, morphometric techniques, and regional differences in the distribution of collagens, glycosaminoglycans and proteoglycans were determined qualitatively by immunolabelling. Morphometric analyses showed that bone density was less at the fibular attachment, but that enthesis fibrocartilage was more prominent. Immunohistochemistry revealed the presence of a fibrocartilage (containing type II collagen and aggrecan) at the site where the ligament wraps around the lateral talar articular cartilage in a plantarflexed and inverted foot: the fibrocartilage is regarded as an adaptation to resisting compression. We propose that avulsion fractures are less common at the talar end of the ligament because (1) bone density is greater here than at the fibular enthesis, and (2) stress is dissipated away from the talar enthesis by the 'wrap-around' fibrocartilaginous character of the ligament near the talar articular facet.

Collateral sprouting mechanism after end-to-side nerve repair in the rat

The collateral sprouting mechanisms of axons from an uninjured donor nerve after end-to-side nerve repair was investigated in motor nerves of rats, with special reference to the neurotrophins related to nerve regeneration. In addition, growth cone formation at the tip of the regenerating nerve was examined. A transected medial gastrocnemius nerve (MGN) was transferred to the side of an intact lateral gastrocnemius nerve (LGN) using a Y-shaped silicone tube. At 3, 7, or 14 days later, the MGN with the LGN was transected and was stained immunohistologically. Expression of neurotrophin-3 (NT-3) and Trk C (receptor of NT-3) was most significantly observed 3 days postoperatively around the site of coaptation. Brain-derived neurotrophic factor (BDNF) and Trk B (receptor of BDNF) was weakly detected at the coaptation site 3 days after-operation. Growth-associated protein 43 (GAP-43), which is a marker of growth cone formation, was observed at the site of coaptation in the LGN 7 days postoperatively and in the MGN at the site of coaptation at 14 days. We concluded that motor nerve regeneration due to collateral sprouting of axons after end-to-side nerve repair is possible. We thus demonstrated the involvement of at least one neurotrophin, NT-3, in the process of collateral sprouting of motor nerves.

Fixation of osteochondral lesions of the talus using cortical bone pegs

We have treated osteochondral lesions of the talus using cortical bone pegs. We examined 27 ankles (27 patients) after a mean follow-up of 7.0 years (2 to 18.8). The mean age of the patients was 27.8 years (12 to 62). An unstable osteochondral fragment or osteosclerotic changes in the bed of the talus were regarded as indications for the procedure.

The clinical results were good in 24 ankles (89%) and fair in three (11%); none had a poor result. There was also radiological improvement in 24 ankles. Repair of the articular surface and stability of the lesion can be achieved even in unstable chronic lesions.

Fixation of osteochondral lesions of the talus using cortical bone pegs

We have treated osteochondral lesions of the talus using cortical bone pegs. We examined 27 ankles (27 patients) after a mean follow-up of 7.0 years (2 to 18.8). The mean age of the patients was 27.8 years (12 to 62). An unstable osteochondral fragment or osteosclerotic changes in the bed of the talus were regarded as indications for the procedure. The clinical results were good in 24 ankles (89%) and fair in three (11%); none had a poor result. There was also radiological improvement in 24 ankles. Repair of the articular surface and stability of the lesion can be achieved even in unstable chronic lesions.

Viability of hypothermic preserved muscle determined by gene expression levels

We report a muscle viability index (MVI) that reflects mRNA degradation. The viability of hypothermically preserved (48C) rat skeletal muscle was evaluated using this MVI. To evaluate the hypothermic ischaemic insult of the muscle, 21 hind limbs of Fischer rats (three subgroups of seven limbs each) were hypothermically preserved for 1h, 3h and 6h, before harvesting the tibialis anterior muscle. To investigate reperfusion injury after hypothermic preservation, an additional 28 limbs were transplanted to recipient Fischer rats after hypothermic ischaemia for either 3h or 6h. The transplanted muscles were harvested on either day 3 or day 7 after transplantation. Seven fresh muscles were also harvested, and used as controls. In the 3h ischaemia group, the MVIs of both the hypothermic-ischaemia and the ischaemia-reperfusion subgroups were comparable to the controls. Likewise, there were no significant differences between the controls and the 6h hypothermic ischaemia and ischaemia-reperfusion subgroups. These results show that muscle viability is maintained with hypothermic preservation of up to 6h, and after reperfusion. Therefore, in clinical replantations the amputated extremity should be preserved under hypothermic conditions from the time of injury to the time of surgery.

Subtalar arthrography in recurrent instability of the ankle

Subtalar arthrography was done in 37 feet of 35 patients in whom recurrent instability of the ankle was diagnosed. There were 16 male and 19 female patients, with a mean age of 29.1 years (range, 11-56 years). The mean interval between the injury and arthrography was 4 years 3 months (range, 6 months-22 years). Anteroposterior, lateral, and oblique radiographs were obtained for all patients. Any leakage during arthrography into the ankle, tendon sheaths, or sinus tarsi was recorded. An oblique view of the microrecess along the interosseous ligament and an anteroposterior view of the lateral recess just under the end of the fibula were examined. At surgery, 13 feet had combined injuries of the anterior talofibular and calcaneofibular ligaments, and 24 feet had isolated injury of the anterior talofibular ligament. The findings of the two groups were significantly different when examined for leakage into the ankle, leakage into the peroneal tendon sheath, and the presence of the lateral recess. Presence of contrast medium in at least two of these three positive arthrographic findings showed 92.3% sensitivity and 87.5% specificity in making the diagnosis of calcaneofibular ligament injury. Subtalar arthrography is valuable in making the diagnosis of calcaneofibular ligament injury in recurrent instability of the ankle.

Surface hydrophobicity of particles is not necessarily the most important determinant in their in vivo disposition after intravenous administration in rats

The in vivo disposition of polystyrene microsphere (MS) with the particle size of 50 nm (MS-50) and lecithin-coated MS-50 (LMS-50) after intravenous administration to rats was characterized. While a rapid elimination from the systemic circulation was observed for MS-50, much more prolonged circulating property was observed for LMS-50. In addition, this in vivo disposition property of LMS-50 was suggested to be ascribed to its lower affinity to the liver, which is the determining organ of the in vivo disposition of MS-50. The evaluation of surface hydrophobicity of MS-50 and LMS-50 in buffer solution revealed that the surface of MS-50 is more hydrophobic than that of LMS-50. However, LMS-50 was oppositely found to be more hydrophobic than that of MS-50 in rat serum. The profiles of serum proteins associated with MS-50 and LMS-50 were also examined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). The results showed that the amounts of some adsorbed proteins are greatly different between MS-50 and LMS-50. From these findings, it was suggested that the substantial difference in the in vivo disposition between MS-50 and LMS-50 would not be attributed to the difference in their surface hydrophobicity in the blood, but the difference in the type of serum proteins associated with them.

Distal cement mantle thickness with a triangular distal centralizer inserted into the stem tip in cemented total hip arthroplasty

Fifty-seven hips undergoing a primary cemented total hip arthroplasty with use of a triangular distal centralizer inserted into the stem tip were investigated, with a special focus on distal cement mantle thickness. The subjects were 43 women and 3 men. When evaluated on conventional anteroposterior and lateral radiographs, the relative incidence of thin cement mantles in zones 3 or 5 owing to the distal centralizer was 15.8% (9 hips). Unsatisfactory findings were that the distal centralizer and distal part of the stem shifted to the cortex in 7 hips and bent or failed at the inserted site in 2 hips. There is risk of generating a thin cement mantle with use of the triangular centralizer and its insertion into the stem tip.

Synthesis and pharmacological activity of a novel water-soluble hepatocyte-specific polymeric prodrug of prostaglandin E(1) using lactosylated poly(L-glutamic hydrazide) as a carrier

A novel polymeric prodrug of prostaglandin E(1) (PGE(1)) was synthesized using lactosylated poly(L-glutamic hydrazide) (Lac-NH-PLGA) as a targetable carrier to hepatocytes. Poly(L-glutamic hydrazide) (PLGA-HZ) was prepared by reacting poly(gamma-benzyl-L-glutamate) with hydrazine monohydrate, followed by coupling with lactose via a hydrazone linkage. Then the lactosylated PLGA-HZ was reduced by sodium cyanoborohydride (NaBH(3)CN) in order to make the linkage irreversible (Lac-NH-PLGA). Finally, PGE(1) was bound to hydrazide moieties remaining in Lac-NH-PLGA without any condensing agent under weakly acidic conditions (pH 5) where PGE(1) would be chemically most stable at room temperature (PGE(1) conjugate). The PGE(1) conjugate prepared was sufficiently water-soluble in spite of the hydrophobic nature of its backbone (-NH-CH-CO-) and PGE(1) itself. After intravenous injection in mice, the [111In]PGE(1) conjugate rapidly accumulated in the liver, whereas [111In]PLGA-HZ did not, suggesting the involvement of a galactose-specific mechanism in the uptake of the [111In]PGE(1) conjugate. Fractionation of liver cells revealed that the [111In]PGE(1) conjugate was preferentially taken up by liver parenchymal cells. The pharmacological activity was examined in mice with fulminant hepatitis induced by intraperitoneal injection of carbon tetrachloride. Intravenous injection of the PGE(1) conjugate at a dose of 1 mg (0.065 mg PGE(1))/kg effectively inhibited the increase in plasma glutamic pyruvic transaminase (GPT) activity compared with that of free PGE(1) at a dose of 0.065 or 0.65 mg/kg. These results suggest that the PGE(1) conjugate is an excellent prodrug for the treatment of fulminant hepatitis.

Cell-specific delivery of genes with glycosylated carriers

Cationic liposomes and polymers have been accepted as effective non-viral vectors for gene delivery with low immunogenicity unlike viral vectors. However, the lack of organ or cell specificity sometimes hampers their application and the development of a cell-specific targeting technology for them attracts great interest in gene therapy. In this review, the potential of cell-specific delivery of genes with glycosylated liposomes or polymers is discussed. Galactosylated liposomes and poly(amino acids) are selectively taken up by the asialoglycoprotein receptor-positive liver parenchymal cells in vitro and in vivo after intravenous injection. DNA-galactosylated cationic liposome complexes show higher DNA uptake and gene expression in the liver parenchymal cells in vitro than DNA complexes with bare cationic liposomes. In the in vitro gene transfer experiment, galactosylated liposome complexes are more efficient than DNA-galactosylated poly(amino acids) complexes but they have some difficulties in their biodistribution control. On the other hand, introduction of mannose residues to carriers resulted in specific delivery of genes to non-parenchymal liver cells. These results suggest advantages of these glycosylated carriers in cell-specific targeted delivery of genes.

[Beta 3-adrenergic receptor agonists--past, present and future]

beta 3-Adrenergic receptors (beta 3-AR) play an important role in the thermogenesis in brown adipose tissue and lipolysis in white adipose tissue. beta 3-AR agonists developed in the early stages produced marked weight reduction and an anti-diabetic effect in rats and mice, but did not in humans, because of the difference in the chemical structure of the beta 3-AR. In 1995, a naturally occurring variant (Trp64Arg) of the human beta 3-AR gene was shown to be correlated with obesity and insulin resistance in Pima Indians. Moreover, the fact that white adipocytes produce various hormones and cytokines that cause life-style-related disease was recently made clear. Because the reduction of the visceral fat is thought to be important to prevent these diseases, the expectations for the human beta 3-AR agonist having a novel anti-obesity effect are rising. Some interesting findings were recently reported with beta 3-AR agonists: the difference of the lipolysis was dependent on the existence of the Trp64Arg mutation and the up-regulation effect of the UCP1 and beta 3-ARs themselves in the adipose tissue and skeletal muscle. Therefore, we introduce informations (past, present and future) on beta 3-AR agonists in this paper.

Primary osteogenic sarcoma of a finger proximal phalanx: a case report and literature review

Osteogenic sarcoma of the small bones of the hand is rare with only 15 cases documented. We describe a 12-year-old boy with an osteogenic sarcoma of the proximal phalanx of the middle finger. Wide excision in the form of ray amputation with a wide surgical margin was performed after neoadjuvant chemotherapy consisting of combined high-dose methotrexate, doxorubicin, ifosfamide, and cisplatin. To restore maximum function the index ray was transferred to the base of the third metacarpal. Adjuvant chemotherapy was administered subsequently. At 28-month follow-up evaluation there was no evidence of local recurrence of disease or distant metastasis and both function and appearance were good.

Clinical application of the reversed pedicled venous flap containing perivenous areolar tissue and/or nerve in the hand

A reversed pedicled venous flap containing perivenous areolar tissue and/or nerve was used to cover traumatic skin defects of seven fingers in six patients. The series consisted of six men, ranging in age from 20 to 57 years (average: 39 years). The reconstructed sites were four dorsal skin defects and three volar skin defects of the finger. The flap was designed on the dorsum of the hand, in such a way as to place a vein at the centre of the flap and not to involve the dorsal metacarpal artery. The flap contained a dorsal vein, perivenous areolar tissue and fascia of the interosseous muscle. Cutaneous nerves were present in three of the seven flaps. The pedicle of the flap was dissected distally to the finger web space and the flap was transferred to the skin defect. The size of the flap ranged from 1.4x4.5 cm to 6.0x7.0 cm. The average length of the pedicle was 1.6 cm. Skin grafting was needed at the donor site in one case (flap size: 6.0x7.0 cm), but primary closure was possible in the remaining cases. Postoperatively, the largest flap showed superficial necrosis, although it survived. The remaining flaps survived completely. This suggests that in a large flap the skin should be attached to the pedicle to prevent congestion. The flap can be elevated without reference to the dorsal metacarpal artery at the ulnar side of the dorsum of the hand. The flap is an effective option to reconstruct skin defects of the finger, especially the little finger.