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.

Synovectomy of the elbow in young hemophilic patients.

Synovectomy of twenty-three elbows was done in eighteen patients, eight to twenty-five years old, who had severe hemophilia and were followed for eighteen to seventy months. Episodes of bleeding recurred in four elbows, and moderate pain persisted in three. A significant improvement in mobility was observed for pronation-supination in nine elbows and for flexion-extension in fourteen. No radiographic evidence of arthritis was seen. Synovectomy of the elbow, performed through a single lateral incision, appears to be a valuable surgical procedure in hemophiliacs in whom non-operative treatment has failed, and resection of the radial head should be done in adults when there is moderate or severe damage to the cartilage of the radial head.

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.

[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.

[Ultrasonic study of the soft tissues of the hand. I. Study technic and normal anatomy of the palm]. / Exploration ultrasonographique des parties molles de la main. I. Technique d'examen et anatomie normale de la paume de la main.

Ultrasound enables a worthwhile static and dynamic study of the soft tissues of the hand, provided that a high-resolution real-time is used. Accurate examinations are feasible after a several months of training because of the difficulty of the anatomy. The authors, studying 200 normal hands, describe their technique based upon the use of a 7.5 MHz multifocused linear phased-array real-time transducer and the normal ultrasonic anatomy.

[Ultrasonic study of the soft tissues of the hand. II. Tumors and pseudotumors of soft tissues. Preliminary results apropos of 12 surgically treated cases]. / Exploration ultrasonographique des parties molles de la main. II. Tumeurs et pseudo-tumeurs des parties molles. Résultats préliminaires à propos de 12 cas opérés.

Thirty patients underwent a sonographic examination of the hand because of nodular masses. In 12 out of these, the surgical removal exhibited 5 benign tumors (2 giant cell tumors, 1 angioma, 1 lipoma, 1 myoma), 5 pseudo-tumors (1 granulomatous tenosynovitis, 1 nodular tendinitis, 2 sebaceous cysts, 1 synovial cyst) and 2 congenital abnormalities of the lumbrical muscles. Except the lipoma and the nodular tendinitis, all the masses were hypoechoic or anechoic. The major interest of sonography in such a disease is a precise localization of the mass and the description of its connections with the surrounding anatomical structures.

[Ultrasonic study of the soft tissues of the hand. III. Traumatic and inflammatory pathology of the flexor tendons of the fingers]. / Exploration ultrasonographique des parties molles de la main. III. Pathologie traumatique et inflammatoire des tendons fléchisseurs des doigts de la main.

The accuracy of the high-resolution real-time ultrasonic examination of the flexor tendons of the fingers of the hand has been tested on the retrospective study of 27 patients treated surgically. The method is sensitive and specific in the rupture of the tendons (8 cases), except when the latter is partial. Ultrasound enables the discrimination between palmar masses developed extrinsically (8 cases) and those involving the tendons (4 cases). A fluid collection inside the tendon's sheath has been detected in all the 5 cases of tenosynovitis, without false positive. The post-operative follow-up of operated tendons is easier by ultrasound.

[Echography of the flexor tendons of the fingers]. / Exploration échographique des tendons fléchisseurs des doigts de la main.

The accuracy of high-resolution real-time ultrasonic examination of the flexor tendons of the fingers was tested in a retrospective study of 27 patients treated surgically. In ruptured tendons (8 cases) the method proved sensitive and specific, except in cases of partial rupture. Ultrasound made it possible to distinguish between extrinsically developed palmar masses (8 cases) and masses involving the tendons (4 cases). A fluid collection inside the tendon sheath was detected in 5 cases of tenosynovitis, without false-positive results. The post-operative follow-up of surgically treated tendons (2 cases) was easier with ultrasound.

[Method for reconstructing the circular metacarpophalangeal trochlea of the thumb]. / Un procédé de reconstruction de la poulie annulaire métacarpo-phalangienne du pouce.

The consequences of the division of the pulley of the flexor hallucis longus are described. This division may be necessary for the repair of tendon or in the treatment of trigger thumb. After division, the pulley cannot be sutured and the flexor tendon remains displaced anteriorly. The authors describe a technique of repair using a flap detached from the tendon of the adductor pollicis. 6 cases have been operated on with good results.

[Carpal tunnel syndrome and pseudarthrosis of the scaphoid. Apropos of 2 cases]. / Syndrome du canal carpien et pseudarthrose du scaphoïde. A propos de deux cas.

Two cases were seen in elderly patients in which a carpal tunnel syndrome was present in association with an ununited scaphoid fracture. The carpus had remodelled and the lunate was dorsi-flexed. Its upper end bulged into the tunnel and was the cause of the nerve compression. It was aggravated by associated osteoarthrosis. The two cases were treated surgically by neurolysis and division of the carpal ligament and partial resection of the lunate to restore the normal concavity of the carpus.

[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.

[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.

[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.

[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".