Zancolli's procedure: technique and indications.

Anatomical variations in the distal insertion of the abductor pollicis longus (APL) muscle onto the 1st metacarpal bone and around the 1st carpometacarpal joint led Eduardo Zancolli to introduce a surgical yet conservative partial APL tenotomy targeting its accessory or supernumerary distal bundles. Following an anatomical and pathophysiological review, we will describe the surgical technique for this minimally invasive extra-capsular procedure. Results and operative indications of this very simple technique are reported as well, which can be performed in Dell stage I or II of trapeziometacarpal osteoarthritis when well-conducted conservative medical treatment has failed to achieve pain relief.

[Entrapment neuropathies involving the ulnar nerve at the wrist (and into the hand) and the peroneal nerve]. / Neuropathies compressives du nerf ulnaire au poignet (et dans la main) et du nerf fibulaire commun. Données récentes.

We report our experience with patients who underwent surgery for entrapment neuropathies involving the ulnar nerve at the wrist and into the hand and the peroneal nerve. For the ulnar nerve, the cause of the lesion was identified in all patients, generally a cyst which had developed in the Guyon canal. The patients usually recovered completely. For the peroneal nerve, there was a wide variety of causes, with mucoid cysts frequently involved. Recovery was often incomplete, because of the very marked initial axonal damage. We emphasized the need for rapid diagnosis and surgical treatment.

[Poor influence of surgery on upper limb lymphedema volume in patients after breast cancer treatment]. / Effet délétère d'un acte chirurgical sur le volume d'un lymphoedème du membre supérieur après cancer du sein.

OBJECTIVES: Secondary upper lymphedema occurs in 15 to 20% of patients after breast cancer treatment. Surgery may be required on lymphedematous limb. The aim of our study was to analyze the effects of surgery on lymphedema volume. METHODS: Nine women with upper limb lymphedema after breast cancer treatment were recruited. Mean age at time of breast cancer was 45.6 +/- 8 years. Breast cancer was localized at right side and was treated with mammectomy (n=4), radiotherapy (n=8), chemotherapy (n=4) and antiestrogen (n=5). Mean duration of lymphedema before upper limb surgery was 10 years. Six patients reported one or more previous cellulitis. Surgery was indicated for carpal tunnel syndrome (n=6), forearm (n=2) or humeral (n=1) fracture. Lymphedema volume, calculated by the difference of volume between the lymphedematous and the contralateral arm, was compared before and after surgery. RESULTS: Six patients had carpal tunnel release by transecting the transverse carpal ligament under local anesthesia with short total time tourniquet. Humeral and forearm fractures were treated with osteosynthesis. Before surgery, lymphedema volume of upper limb was 747 +/- 315 ml. Lymphedema management included low stretch bandages, elastic sleeve, manual lymph drainage. After 8 months follow up, lymphedema volume was significantly higher, 858 +/- 293 ml (p=0.012). Mean absolute variation of lymphedema volume was 111 ml (CI 95%: 32 to 109 ml), i.e. 15% of pre surgery lymphedema volume. CONCLUSION: Surgery of carpal tunnel syndrome or osteosynthesis for fractures may lead to increased lymphedema volume in patients previously treated for breast cancer despite compressive therapy.

Systemic exposure, tolerability, and efficacy of pimecrolimus cream 1% in atopic dermatitis patients.

AIMS: To measure pimecrolimus blood concentrations and to evaluate tolerability and efficacy in children and infants treated topically for atopic dermatitis with pimecrolimus cream 1% for three weeks. METHODS: Three open label, non-controlled, multiple topical dose studies were conducted in children aged 8-14 years (study A, ten patients), and in infants aged 8-30 months (study B, eight patients) and 4-11 months (study C, eight patients). Pimecrolimus blood concentrations were determined on days 4 and 22 of treatment, and at end of study. Efficacy was assessed using the Eczema Area and Severity Index (EASI). RESULTS: Pimecrolimus blood concentrations were consistently low, typically (81%) below 1 ng/ml, with more than half of the measurements below the assay limit of quantitation (0.5 ng/ml) in studies A and B. The highest blood concentration measured throughout the three studies was 2.6 ng/ml. The cream was well tolerated, locally and systemically. The most common adverse event suspected to be related to study medication was a transient mild to moderate stinging sensation at the application site in 5/26 patients. There was no indication of any systemic adverse effect. The patients responded well to therapy with a rapid onset of action, usually within four days. Median reductions of EASI from baseline at day 22 were 55% (study A), 63% (study B), and 83% (study C). CONCLUSION: Three weeks treatment of children and infants with extensive atopic dermatitis, using pimecrolimus cream 1% twice daily, is well tolerated and results in minimal systemic exposure, at which no systemic effect is expected.

[Surgical treatment of chronic mallet finger by shortening--suture of the tendon scar. Sixty six cases]. / Traitement chirurgical du doigt en maillet invétéré par accourcissement--suture du cal tendineux. A propos de 66 cas.

Acute mallet fingers are commonly treated by splinting. Treatment of chronic injuries is more debated. Since 1989, a "shortening and suture" technique have been used for such chronic injuries on the elongated tendon scar. Sixty six of 77 patients treated on a 10 years period were reviewed with a mean follow-up of 21 months. The mean active extension lag at the distal interphalangeal (DIP) joint was 4.5 degrees (41 degrees of improvement) with 52% of fingers which recovered a full extension, representing 77% of good and excellent results according to Abouna's and Brown's modified criteria. There were two failures which lead to reoperation, and no complication (2 painful scars and 20% of cold intolerance). We propose this safe and simple technique for chronic mallet fingers if deformity exceeds 30 degrees, for patients untreated (after the second month), or when splinting has failed. "Swan-neck" deformities were improved by an associated Fowler procedure. In case of failure, a new "shortening and suture" or a DIP arthrodesis can be discussed.

[Traumatic dislocation of the pisiform bone: a case report and review of the literature]. / Luxation traumatique du pisiforme: à propos d'un cas et revue de la littérature.

Traumatic dislocation of the pisiform bone is uncommon. The authors report a case treated by primary excision with a good result. The literature is reviewed and treatment choices are discussed.

Use of human skin equivalent Apligraf for in vitro assessment of cumulative skin irritation potential of topical products.

The main goal of the present study was to investigate the response of the human skin equivalent Apligraf in vitro to the application of irritant substances and its predictivity as a screening tool for cumulative skin irritant potential in humans. Vaseline, calcipotriol, trans-retinoic acid, and sodium lauryl sulfate were applied to Apligraf in vitro for 24 h. Cell viability (lactate dehydrogenase leakage), release and mRNA expression of the proinflammatory cytokines IL-1alpha and IL-8, and morphological changes were assessed. The same products were applied to 30 healthy volunteers in a double-blind, randomized, vehicle-controlled within-subject study. The skin reactions after repeated 24-h applications over 3 weeks under Finn chamber patches were monitored by visual scoring and biophysical methods (trans-epidermal water loss, chromametry, and blood flow). Sodium lauryl sulfate was cytotoxic to Apligraf, and increased the release and expression of cytokines at low (0.2%, 0. 4%), but not at high (0.8%, 1%) concentrations. It induced severe irritancy in vivo. Trans-retinoic acid increased the expression and release of cytokines with no detectable cytotoxicity and showed moderate irritancy in humans. Although calcipotriol did neither affect cell viability nor the production of cytokines, it induced morphological signs of irritation and was mildly irritant for healthy volunteers. Vaseline was innocuous in vivo and induced no changes in Apligraf. In conclusion, the cumulative skin irritation potential of the tested products could be predicted with Apligraf in a sensitive and specific manner, by monitoring cytotoxicity, proinflammatory cytokines, and morphological changes.

[Iatrogenic tumor metastasis to the pelvis after treatment for hand osteosarcoma. A case report]. / Inoculation tumorale iatrogène du bassin après cure d'un ostéosarcome de la main. A propos d'un cas.

In this study, the case has been examined of a 49-year old male who initially presented with a pathological fracture of the second metacarpal. This was first treated by curettage, iliac bone graft and internal fixation, without any complementary investigation being carried out, i.e., no preliminary biopsy and histological diagnosis were made. The results of this inadequate approach were poor: neither satisfactory fixation of the fracture nor control of the primary lesion were obtained. Moreover, the definitive diagnosis was only made four months later, when biopsy findings confirmed the presence of an osteosarcoma. After neoadjuvant chemotherapy, an en-bloc resection of the second metatarsal and the trapezoid bone was carried out. At ten months post-surgery, one and a half years after the original fracture, the hand was found to be disease-free and functioning satisfactory. However, nearly a year later the discovery of a large tumor mass at the site where the iliac bone graft was originally taken necessitated resection of the hemi-pelvis, with chemotherapy prior to resection and radiotherapy following surgery. Unfortunately, this salvage procedure did not limit the spread of the disease, and subsequent pulmonary and vertebral metastases were found, leading to the death of the patient three years after the initial fracture. This particular case underlines the fact that the basic rules for the management of malignant tumors should be taken into consideration from the onset, so that a catastrophic prognosis such as that described can be avoided.

Predictivity of an in vitro model for acute and chronic skin irritation (SkinEthic) applied to the testing of topical vehicles.

An in vitro human reconstructed epidermis model (SkinEthic) used for screening acute and chronic skin irritation potential was validated against in vivo data from skin tolerability studies. The irritation potential of sodium lauryl sulfate (SLS), calcipotriol and trans-retinoic acid was investigated. The in vitro epidermis-like model consists of cultures of keratinocytes from human foreskin on a polycarbonate filter. The modulation of cell viability, the release and gene expression of proinflammatory cytokines, interleukins 1alpha and 8, and morphological changes were evaluated during 3 days as endpoints representative for an inflammatory reaction. The cumulative irritation potential of the topical products was evaluated in a human clinical study by visual scoring and biophysical measurement of inflammatory skin reaction after repeated 24 h applications over 3 weeks under Finn chamber patches. All topical products that were nonirritating in the human study were noncytotoxic and did not induce cytokine expression in the in vitro acute model (day 1 exposure). All irritating controls exhibited specific cell viability and cytokine patterns, which were predictive of the in vivo human data. The ranking of mild to moderate skin irritation potential was based on the lack of cytotoxicity and the presence of cytokine patterns including gene expression specific for each irritant, using the chronic in vitro model (up to 3 days exposure). The human reconstructed epidermis model SkinEthic was shown to be a reliable preclinical tool predicting the irritation potential of topical products. Moreover, it is a useful model in a two-step tiered strategy for screening acute and chronic irritation potential for the selection of vehicles for new topical drugs.

[What's new in surgery of flexor tendons?]. / Quoi de neuf en chirurgie des tendons fléchisseurs?

After revealing tendon healing and the international classification adopted in 1980 for flexor tendon lesions, the author reviews the primary tendon repair procedures and the various postoperative mobilization protocols. The current tendency is towards early active mobilization with a protection orthosis. The various secondary surgical procedures are then critically discussed: secondary suture, tendon release, one-stage or two-stage tendon graft, total anterior tenoarthrolysis, tendon transfer, vascularized tendon graft, active tendon implants.

[Results of flexor tendon repair using the Tsuge technic. Apropos of a series of 95 fingers]. / Résultats de la réparation tendineuse des fléchisseurs selon la technique de Tsuge. A propos d'une série de 95 doigts.

The authors review a series of 76 patients with 95 fingers involved, 66.6% of them occurring in zone II. The core stitch was performed according to the Tsuge technique (type II) combined with a peritendinous running suture. Results based on TAM were excellent or good in 60%, fair in 22%, and poor in 18%. Influencing factors were associated lesions, mainly vascular and lesions in zone II. Rupture occurred in 5% and adhesion in 22% of cases. Providing similar results to those of other techniques published in the current literature, the Tsuge techniques is preferred because it is simpler and faster to perform.

[Sprains of the wrist: current data and therapeutic orientations]. / Entorses du poignet: données récentes et orientations thérapeutiques.

Despite the high incidence of wrist trauma, severe sprains with disruption of the ligaments are actually rare, apart from lesions of the scapholunate joint line. However, the diagnosis of severity should now be established, if not as an emergency, at least soon after the trauma, as deterioration of carpal instability always leads top osteoarthritis after a variable interval of time. When a ligament lesion is suspected, initial pain-free immobilisation, plain and dynamic x-rays followed by at least arthrography of CT arthrography, should be performed. After describing scapholunate sprain, the commonest form, the other varieties are reviewed: pyramidolunate, midcarpal, scaphotrapezoid, radiocarpal and finally inferior radioulnar sprains.

[High pressure injection accident of the hand]. / Accident d'injection sous haute pression dans la main.

High pressure injection injuries of the hand are rare, but very severe. The material injected acts in two ways: chemical irritation as a result of its toxicity, and physical distension of tissues of the finger, which are not normally distensible, as a result of the pressure of injection of the liquid which may reach 700 kg/cm2. The main complications were necrosis and infection ending in amputation in thirty percent of the cases. Often the conserved fingers suffered cold intolerance. Therefore, the gravity of this accident has led us to believe that it is the "most urgent of hand emergencies".

[The contribution of MRI in the study of glomus tumors]. / Apport de l'IRM dans l'exploration des tumeurs glomiques.

The glomus tumors of the finger tip are benign. Their diagnosis is clinic but their precise localization is quite difficult by classic imaging. MRI with gadolinium injection seemed a good method to check exactly this lesion and have been tested on 20 patients suspected suffering of glomus tumor. On 18 glomus tumors surgically and histologically confirmed MRI examination have been positive for 16. In two cases MRI and surgery were negative. A good correlation seems observed with surgery for the size (7 tumor of 2 mm) the localization and osseus extension. Addition of T2 and T1 before and after injection weighted acquisitions improved the results. Precise informations on topography and size seems improved the surgical approach.

Pharmacokinetic and pharmacodynamic data and models in clinical trials.

There is current emphasis for extended integration of pharmacokinetics (PK) and pharmacodynamics (PD) into all phases of new drug development, including large-scale clinical trials. In this paper, we focus on study design and data analysis issues for the investigation of pharmacokinetic/pharmacodynamic and blood level/effect relationships in patients. The application of descriptive and model-based regression statistical methodology for including sparse drug systemic concentration data in the analysis of efficacy and safety is illustrated by examples chosen from diverse therapeutic areas. The population approach, based on mixed-effects modelling, is one such methodology, which also provides new tools for analysis of response vs dose and response vs time data. The existence of a variety of statistical techniques for handling complex PK/PD time-varying data should increase the impact of such data analysis on future drug development.

[Traumatic luxation of the extensor apparatus of the dorsum of the metacarpophalangeal joint of the little finger. Six cases]. / Luxation traumatique de l'appareil extenseur au dos de l'articulation métacarpo-phalangienne de l'auriculaire. A propos de six cas.

Dislocation of the extensor tendon over the MP joint as a result of trauma is a rare and unrecognized injury as our six patients were only operated subsequently. The diagnosis is simple: flexion is possible, while extension is not. The patient is able to hold the extension despie resistance if the dislocation is reduced by artificial extension. X-rays eliminate any possible fracture. Six cases have revealed two different assumptions: either the two tendons (extensor digitorum communis and extensor digiti quinti proprius) are simultaneously dislocated together on the ulnar side, or they are dislocated on either sides of the joint. In the first assumption, the injury occurred ulnar-wise tearing the sagittal band. This case concerns the three older patients. The dislocation was reduced and stabilized by the Michon surgery method. The second assumption concerns the three youngest patients who suffered from a direct axial shock. This separation was reduced by suture of the two tendons on the dorsal base of the joint. The postoperative care was ensured in all cases by a splint attached to the palm, keeping the MP joint in extension and enabling immediate web-fingered reeducation. This therapeutic technique has given satisfactory results as over an average period of six years no recurrence of stiffness has been observed.

[Treatment of recurrent Dupuytren's disease by scalar incision and firebreak graft]. / Traitement des récidives de la maladie de Dupuytren par incision scalaire et greffe "coupe-feu".

We report our experience of the use of a scalar type incision associated with a total skin graft in the treatment of recurrences of Dupuytren's contracture. This is not an original technique, but one described by Hueston in 1984, which consists of a "Fire Break" skin graft after a simple transverse incision of recurrent Dupuytren's contracture. We attribute the absence of recurrence with this graft to the impossibility of the disease to affect the thin tissue between the skin graft and the underlying tendons. Our series is composed of 25 patients, all male. The majority of these patients had undergone surgery on a single occasion before treatment of recurrences with an average time interval of seven years. In a great majority of cases the little finger was deformed and generally severely (stage III or IV). All of our patients were reviewed with a mean follow-up of 28 months after surgery, and we did not observe any recurrences under the graft. In this series, which remains too small and too recent, 67% of cases presented an acceptable result with nearly complete extension and satisfactory grasp. We do not apply this technique to the treatment of all cases of recurrent Dupuytren's contracture, but we reserve it preferentially for elderly patients, operated on several occasions for ulnar fingers especially the little finger, in digital or digito-palmar forms in which the deformity predominates on the proximal interphalangeal joint with marked digital infiltration.