MRI of brachial plexus using diffusion tensor imaging: a pilot study for the use of resolve sequence surgical and radiologic anatomy.

BACKGROUND: Clinical exam is the goldstandard for surgical indication. ENMG and conventional MRI are insufficient to understand the highly variable clinical presentation of brachial plexus (BP) lesions. DTI is based on motion of water molecules and can explore nerve function. PURPOSE: This pilot study of healthy subjects aimed to develop RESOLVE sequence for BP exploration using diffusion MRI. The main objective was to provide complete precise information from DTI cartography associated with anatomical data. METHODS: Six healthy volunteers were scanned using 3T PRISMA scanner with anatomic 3D STIR SPACE and RESOLVE diffusion sequences. Diffusion parametric maps of fractional anisotropy (FA) were extracted from RESOLVE acquisitions. A reproducible method for roots volumes and angles measurements was created using 3DSlicer. ROI were segmented on Mean B0 sequences. FA measurements were obtained with ROI on Mean B0 sequences. RESULTS: RESOLVE sequence was adapted to the BP. Mean FA was 0.30. Angles measurements on 3D STIR SPACE sequences showed increasing values from proximal to distal roots with an 0.6 ICC. Volume measurements on anatomic sequences varied widely from one root to another but did not show any significant difference on laterality. CONCLUSIONS: A new and reproducible method for BP exploration was developed, using MRI RESOLVE DTI sequences. Complete mapping was obtained but a low resolution of track density imaging did not allow to exploit distal nerves. Deterministic tractography principal limit was the lack of resolution. Extraction of diffusion, volumetric and angular parameters of the plexus roots, and scripts creation for image processing was adapted to the healthy BP.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy.

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.

Treatment of congenital syndactyly.

Defined as the union of two adjacent digits, syndactyly is one of the most common congenital deformities. The severity of the malformation depends on the fusion level, the tissues involved in the union, and whether it is isolated or syndromic. In order to improve the hand's appearance and function, surgery is recommended in the great majority of cases, ideally during early childhood (i.e., before entering school). Web space reconstruction is done using local flaps. Depending on the flap design, digital resurfacing can be done with or without skin grafts. While graftless techniques have shorter operating times and no morbidity associated with skin harvesting, their cosmetic outcomes seem to be worse than those of traditional grafting techniques, with more postoperative complications; furthermore, such techniques cannot be used in all cases, especially those with osteoarticular fusions. When the fingertip is involved, paronychial reconstruction is carried out with pulp flaps. The prognosis for these deformities directly depends on their severity, with excellent outcomes in cases of cutaneous fusion, and much less predictable ones when osteoarticular and/or tendinous tissues are involved.

Factitious disorders in the hand-Main diagnostic traps highlighted with 3 cases.

Every doctor can be confronted, during his career, with patients presenting symptoms they created themselves. Because it is easily accessible, the hand is a favored target organ for these self-inflicted injuries. The diagnosis of factitious disorder of the hand is very difficult, rarely suggested and widely under-estimated. The real issue is detecting it early on to develop a cohesive diagnostic and therapeutic approach. The three clinical cases reported in this article illustrate the difficulty of caring for this pathology at all stages, from diagnosis to treatment. These disorders must be distinguished from malingering. A psychiatrist must be part of the treatment team. The prognosis of factitious disorders is poor. It is vital to maintain contact with the patient once the diagnosis is established. The risk is that the patient consults with other professionals, restarting a new cycle. The featured clinical cases were chosen to remind surgeons that factitious disorders of the hand are a recognized psychiatric disease. It must be evoked in the context of an unusual injury with a vague history. Everything possible must be done to confirm the diagnosis and avoid surgery.

Wrist arthrodesis in adolescents with cerebral palsy.

UNLABELLED: Twenty adolescents with severe spastic deformities of the wrist (Zancolli type 3) and poor function on the House score were operated on between 2009 and 2014, and included in this retrospective cohort study. All were treated by wrist arthrodesis combining a proximal row carpectomy, curetting of the distal radius in order to imbed the capitate and a dorsal locking plate. The primary endpoint was improvement in the House score. Secondary endpoints included pre- and postoperative wrist flexion deformity, bone union, patient satisfaction regarding appearance and complications. The mean follow-up was 22 months. The mean age at the time of surgery was 16.2 years. Additional soft-tissue release was necessary in eight wrists. The mean House score improved significantly from 0.9 to 2.7. Average flexion deformity improved significantly from 66° to 10°. Bony union was achieved in all patients within 6 months. Four of the 20 patients required hardware removal because of fixed extension of the middle metacarpal. Wrist arthrodesis combining proximal row carpectomy with the use of a dorsal locking plate is a safe and reliable technique to improve function and appearance. LEVEL OF EVIDENCE: IV.

Allograft integration in a rabbit transgenic model for anterior cruciate ligament reconstruction.

BACKGROUND: Tissue engineering strategies include both cell-based and cell homing therapies. Ligamentous tissues are highly specialized and constitute vital components of the musculoskeletal system. Their damage causes significant morbidity and loss in function. HYPOTHESIS: The aim of this study is to analyze tendinous graft integration, cell repopulation and ligamentization by using GFP+/- allografts in GFP+/- transgenic New Zealand white (NZW) rabbits. MATERIAL AND METHODS: Graft implantation was designed to closely mimic anterior cruciate ligament (ACL) repair surgery. Allografts were implanted in 8 NZW rabbits and assessed at 5 days, 3 weeks and 6 weeks through: (1) arthroCT imaging, (2) morphological analysis of the transplanted allograft, (3) histological analysis, (4) collagen type I immunochemistry, and (5) GFP cell tracking. Collagen remodeling was appreciated at 3 and 6 weeks. RESULTS: Graft repopulation with host cells, chondrocyte-like cells at the tendon-bone interface and graft corticalization in the bone tunnels were noticed at 3 weeks. By contrast we noticed a central necrosis aspect in the allografts intra-articularly at 6 weeks with a cell migration towards the graft edge near the synovium. DISCUSSION: Our study has served to gain a better understanding of tendinous allograft bone integration, ligamentization and allograft repopulation. We believe that both cell-based therapies and cell homing therapies are beneficial in ligament tissue engineering. Future studies may elucidate whether cell repopulation occurs with pre-differentiated or progenitor cells. We believe that both cell-based therapies and cell homing therapies are beneficial in ligament tissue engineering. LEVEL OF EVIDENCE: Level V (animal study).

Tendon lengthening and transfer.

Tendon lengthening and transfer are usually indicated for certain neuromuscular disorders, peripheral or central nerve injury, congenital disorder or direct traumatic or degenerative musculotendinous lesion. In musculotendinous lengthening, technique depends on muscle anatomy, degree of correction required, and the need to avoid excessive loss of force. Lengthening within the muscle or aponeurosis is stable. In the tendon, however, it may provide greater gain but is not stable and requires postoperative immobilization to avoid excessive lengthening. Tendon transfer consists in displacing a muscle's tendon insertion in order to restore function. The muscle to be transferred is chosen according to strength, architecture and course, contraction timing, intended direction, synergy and the joint moment arm to be restored. Functions to be restored have to be prioritized, and alternatives to transfer should be identified. The principles of tendon transfer require preoperative assessment of the quality of the tissue through which the transfer is to pass and of the suppleness of the joints concerned. During the procedure, transfer tension should be optimized and the neurovascular bundle should be protected. The method of fixation, whether tendon-to-bone or tendon-to-tendon suture, should be planned according to local conditions and the surgeon's experience.

[Congenital foot abnormalities]. / Anomalies des pieds à la naissance.

The foot may be the site of birth defects. These abnormalities are sometimes suspected prenatally. Final diagnosis depends on clinical examination at birth. These deformations can be simple malpositions: metatarsus adductus, talipes calcaneovalgus and pes supinatus. The prognosis is excellent spontaneously or with a simple orthopedic treatment. Surgery remains outstanding. The use of a pediatric orthopedist will be considered if malposition does not relax after several weeks. Malformations (clubfoot, vertical talus and skew foot) require specialized care early. Clubfoot is characterized by an equine and varus hindfoot, an adducted and supine forefoot, not reducible. Vertical talus combines equine hindfoot and dorsiflexion of the forefoot, which is performed in the midfoot instead of the ankle. Skew foot is suspected when a metatarsus adductus is resistant to conservative treatment. Early treatment is primarily orthopedic at birth. Surgical treatment begins to be considered after walking age. Keep in mind that an abnormality of the foot may be associated with other conditions: malposition with congenital hip, malformations with syndromes, neurological and genetic abnormalities.

Postoperative perceived health status in adolescent following idiopathic scoliosis surgical treatment: results using the adapted French version of Scoliosis Research Society Outcomes questionnaire (SRS-22).

PURPOSE: Assessing functional outcome from patient-based outcomes questionnaires are essential to the evaluation of adolescent idiopathic scoliosis surgical treatment METHODS: At the minimum follow-up of 2 years, 45 operated on adolescent idiopathic scoliosis patients were mailed the French version of the Scoliosis Research Society Outcome Instrument (SRS-22) questionnaires containing items on pain, activities of daily living, and satisfaction. RESULTS: Mean values of the SRS-22 domains were 3,66 for the Pain domain, 3,85 for the Self-perceived image domain, 4,32 for the Function domain, 3,52 for the Mental health domain and 4,12 for the Global satisfaction with management domain. Mean value of the global SRS-22 score was 3,88. We showed no differences in functional SRS-22 health status in patients according to the type of curve (Lenke classification). We showed statistically significant correlations between the gain of Cobb angle and Patients self-image and function domain scores. There was a statistically significant correlation between preoperative Cobb angle and patient satisfaction with management. CONCLUSIONS: Even if Function and Self-image scores in our patients are close to control group values, indicating good short to mid-term outcome of surgical treatment, scores for pain and mental health status were significantly lower in patients than controls. Long-term follow-up studies conducted by multiple surgeons over successive generations are mandatory to assess clinical significance of these differences. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Open elbow dislocation with distal ischemia: a therapeutic emergency]. / Luxation ouverte du coude avec ischémie distale : une urgence thérapeutique.

We report the case of a 13-year-old boy with a traumatic elbow dislocation, open stage 2 (Cauchoix and Duparc), with distal ischemia. Exposure of the neurovascular humeral bundle through the wound accentutated the clinical emergency. This clinical observation consisted of elbow dislocation with all severity criteria: (i) opening of the skin, (ii) association with a fracture of the medial humeral epicondyle, and (iii) neurological deficit in the territory of the median nerve. The purpose of this report is to remind physicians that no investigation should delay surgery in elbow dislocation. Despite initial distal ischemia, no vascular exploration is required. Early reduction of the disloction is the key point of care.

Electric pulses increase the immunogenicity of an influenza DNA vaccine injected intramuscularly in the mouse.

Vaccination by intramuscular injection of naked DNA is very efficient in the mouse, but immunogenicity of DNA vaccines needs to be improved in man. The aim of our study was to determine in BALB/c mice if suitable electric pulses delivered to the muscle after DNA injection--a procedure called electrotransfer--could improve the immunogenicity of suboptimal doses of a DNA vaccine expressing the influenza hemagglutinin protein. The results show a significant enhancement of the cellular and antibody responses following electrotransfer for the 1- and 10-microg DNA doses, respectively, but no effect on a lower dose. At the 10-microg dose, the IgG and hemagglutination inhibition mean titres were increased 25-fold and the inter-individual variability was markedly reduced.

Beta galactosidase release as an alternative to chromium release in cytotoxic T-cell assays.

In the present report, we describe a beta galactosidase release (BGR) assay to evaluate cytotoxic T lymphocyte (CTL) activity against specific targets. Transient expression of beta galactosidase (beta gal) was obtained by infection with recombinant beta gal vaccinia virus. Incubation of target cells with effector cells resulted in the release of beta gal depending on the infection time and the effector/target cell ratio. BGR was evaluated using the chemiluminescent substrate, AMPGD (3-¿4-Methoxyspiro[1,2-dioxetane-3, 2'-tricyclo(3.3.1.1(3,7))decan]-yl¿phenyl-b-D-galactopyra nos ide), a phenylgalactose-substituted 1,2-dioxetane compound. The use of a digenic vector carrying two genes coding for the beta gal gene and the antigen, respectively, permits expression of the two proteins in the same cell. Coinfection of target cells with two different vectors, carrying beta gal and antigen genes, respectively, was demonstrated to be as efficient as digenic vector when using high multiplicity of infection (MOI). The BGR assay was compared to the standard 4 h 51chromium (51Cr) release assay both in mouse and human models and showed comparable sensitivity. The BGR assay, therefore, provides a simple, specific and responsive method for measuring cell-mediated cytotoxic activity.

t(2;18) and t(18;22) variant chromosomal translocations in B cell malignancies.

Variant translocations (2;18 and 18;22) are described in this review. The chromosomal and molecular findings of these translocation of BCL2 and their effect on possible BCL2 gene activation is discussed. Unanswered questions still remain and these include why this is so rare compared to the 25% incidence recorded for translocations in Burkitt's lymphoma. Further studies are obviously still needed in order to determine the true frequency of these findings and their distribution in the various B-cell disorders.

Cytogenetic experience in prenatal fra(X) detection on amniotic fluid cultures.

Since 1987, we have had experience with 13 prenatal diagnoses of 11 women at risk for the fragile X syndrome by cytogenetic studies on amniotic fluid cultures. The induction method included TC 199 medium and methotrexate. Results were obtained in all cases. Ten were males and three were prenatally diagnosed as being affected. Three were females and none of them was fra(X)-positive. Results were confirmed in 10/13 cases. In these cases, we had neither false-positive nor false-negative results.

Chromosome studies in stimulated lymphocytes of 50 patients with B-cell chronic lymphocytic leukemia.

The chromosome constitutions of stimulated lymphocytes from 50 B-cell chronic lymphocytic leukemia patients were studied using different stimulation systems, i.e., TPA alone or associated with different cytokines. Adequate metaphases were obtained in 44 subjects (88%). Among 20 patients with abnormal karyotypes (45.5%), 7 had trisomy 12. The most frequent structural abnormality was a 14q+ resulting from translocations including one t(11;14) and two t(14;17), while deletions on the long arms of chromosomes 6 and 13 constituted a second common alteration. The most important finding in this series was the recurrence of a t(18;22) observed in two cases.

Balanced complex chromosomal rearrangements with more than four breakpoints: report of a new case.

Congenital complex chromosomal rearrangement (CCR) compatible with life are rare in man. We report on a new case of apparently balanced CCR in a 30-month-old boy with mental retardation and minor anomalies. This CCR consists in a 3-way reciprocal translocation (2;3;16) and an insertion (6;7), as it was analyzed by different banding and high resolution techniques. It involves 6 breakpoints: 2q11, 13q12, 16p11, 6p21.3, 7q21.3 and 7q35.

[Skin reactions to topical agents]. / Réactions cutanées aux produits de contact

The author desires to attract attention to the disadvantages of drugs for external use which are more and more widely used. The two main reactions observed are contact dermatitis and photosensitisation, but practically all skin lesions may be produced. She then rapidly recapitulates the various responsible agents insisting on dermo-corticoids and the precautions which should be taken in their use.