Biomedical subjects
Publications and source records attributed to D Della Santa.
Acute or chronic wrist pain is a relatively frequent complaint that may involve all age groups. The pain may be of osseous, articular, periarticular, neurologic, vascular origin, or be referred from the cervical spine, shoulder or elbow. The diagnosis should be oriented by a precise history and clinical examination. More specialised exams will be required according to clinical findings. Psychosocial and environmental influences need to be taken into consideration.
Cyclooxygenase (COX)-2 is an inducible enzyme linked to tumor growth and angiogenesis. Its expression occurs in a wide range of preneoplastic and neoplastic conditions in humans, including colon and breast carcinomas. We evaluated the role of COX-2 as a mediator of angiogenesis in feline and canine invasive carcinomas (IMCs) and its role as a prognostic indicator. COX-2 expression was assessed in neoplastic samples and healthy mammary glands by immunohistochemistry, and related to the following clinicopathological parameters: age, tumor size, histologic type, tumor grading, vessel invasion, estrogen (ER) and progesterone receptor (PR) status, Ki-67, HER-2 overexpression, microvessel density (MVD), VEGF expression and overall survival (OS). In both species, COX-2 immunoreactivity was not observed in healthy tissues, whereas 96% of feline and 100% of canine invasive carcinomas scored positive. In queens, COX-2 overexpression was significantly correlated to ER-negative status (p=0.04) and to increased PR (p=0.038) expression, and angiogenesis assessed by VEGF expression (p=0.002). In bitches an increased COX-2 expression was significantly correlated to HER-2 overexpression (p=0.013) and to tumor dedifferentiation (p=0.03). In both species increased levels of COX-2 were correlated to poorer prognosis (p=0.03 in dogs and p=0.002 in cats). COX-2 is expressed in mammary tissues during tumorigenesis and its expression is associated with a poorer prognosis in bitches and queens. The correlation of COX-2 expression and angiogenesis provides support for a potential role of COX-2 inhibitors for the prevention and the treatment of feline IMCs via their anti-angiogenic properties. In the canine species, moreover, COX-2 may be important for mediating HER-2 induced mammary tumors.
Step-cut shortening osteotomy of the ulna for impingment of the distal ulna relies on the principles enunciated by Desanfans 1953. We recommend the plate be placed on either the palmar or the dorsal aspect of the ulna. Used since 1990 this technique has enabled primarily bony healing by 6 months in all the 18 cases operated upon. A significant clinical improvement as measured by the scoring system of Chun and Palmer was noted at a median follow-up of 95.7 months. Shortening did not unfortunately, appear to stabilize the distal ulna and those patients with residual clinical radioulnar instability had significantly worse results. We conclude that the technique presented gives reliable bone healing. It is a versatile and simple technique that requires no special instrumentation but does demand skill and precision.
We report the results of a new bone-tendon ligamentoplasty for the reconstruction of chronic injuries of the ulnar collateral ligament at the metacarpophalangeal joint of the thumb. The mean follow-up period was 36 months. Using the Glickel grading system, seven patients had excellent results and one patient had good results. The mean loss of pinch strength was 10% compared with the contralateral thumb. The mean loss of motion at the MP joint was 8%. This technique successfully restores the desired long lasting stability while maintaining mobility of the thumb's metacarpophalangeal joint.
The role of c-erbB-2 protooncogene status in feline invasive mammary carcinomas (FMCs) was assessed through the HER-2 receptor immunohistochemical expression. The HER-2 overexpression was then correlated with some relevant histologic parameters and with the clinical course of the disease during a 2-year follow-up. Forty-seven FMCs from surgically treated queens were considered. Tumors were classified according to the WHO criteria and stromal or lymphatic invasion (or both) and histologic grading were recorded. The immunohistochemical staining was performed on paraffin sections and a well-defined scoring system based upon numbers of HER-2 receptors expressed on the cell surface was applied according to standard guidelines. Overall survival (OS) distributions were generated with the Kaplan-Meier method. HER-2 overexpression was detected in 28 of the 47 carcinomas (59.6%). This parameter was demonstrated to be significantly correlated with the shorter OS (P = 0.02). However, the HER-2 overexpression did not show significant correlation with histologic type, tumor grading, or presence of lymphatic invasion. Furthermore, the HER-2 overexpression appeared with a higher percentage in FMCs than what is reported in canine or human mammary carcinomas. The significant correlation with a shorter OS suggests a possible role of HER-2 as an additional marker of malignancy in FMCs and as a reliable prognostic indicator. As in the human oncology practice, the identification of the FMCs that overexpress HER-2 may also promote new therapeutic strategies.
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This retrospective study compares 94 distal radius fractures. Sixty one women (median age 66) and 33 men (median age 42) were reviewed clinically and radiologically by a surgeon not involved in treatment. Fractures were classified into three AO groups. Standard X-rays were used for radiological evaluation. Fractures of the distal ulna were evaluated separately. Chi-square tests, Wilcoxon, Mann-Whitney and Fisher's tests were used for statistical evaluation. Women presented mainly "A" type fractures. They were treated by intramedullary pinning. Forty two fractures were grafted, using autogenous bone for young patients and bone substitute for the elderly. Twelve scapholunate dissociations were recorded, all but one were detected in women, 50 years of age or more. Four were painfree, two presented climatic pain and six claimed pain during effort; none had snapping. Radio-ulnar laxity was similar with or without styloid fractures. External fixator and autogenous grafts appeared the most efficient technique for maintaining radial length. Ulnar head fractures were related to a significant higher incidence of sympathetic dystrophy with reduced prono-supination, a correlation not previously noted to your knowledge. This suggests that radius and ulnar head fracture should be classified independently. The amount of pain was not related to classification, internal fixation or gender.
Contrary to Colles'opinion which pretended the fracture of the distal radius would heal without sequellae, many studies devoted to this problem showed that complications will affect one third of the cases (malunion, nerve compression, dystrophy, tendon rupture). It is important for the surgeon to know well the different fracture types, the general condition of his patient as well as his osteoarticular state to make the good choice of treatment. Our study shows that the nonoperative treatment will be chosen for any fracture type as far as it concerns an old or crippled patient, especially if there is an osteoporosis. On the contrary, for a young and active patient with a good bone quality, non operative treatment will be chosen as far as the fracture will be reducible and stable. If it is not, an osteosynthesis has to be done. Many studies already published tend to demonstrate that there is a correlation between anatomical and functional results. However, concerning elderly, this correlation tend to disappear with time.
The aim of the present retrospective study was to evaluate the performance of bone graft substitutes currently in use. After exclusion of those with inadequate data for comparison, 70 out of the 101 operated fractures remained available for statistical analysis. Grafts were used in 38 cases: 23 were bone substitutes and 15 autogenous grafts. Distal radial inclination and lateral angles showed no significant difference. Analysis of ulnar variance showed the relative inability of intramedullary pinning to maintain radial length in the absence of graft. In contrast external fixators preserved radial length both with and without bone grafts, and with all types of graft material. TCH (hydroxyapatite and calcium phosphate) or autogenous bone grafts allowed intramedullary pinning to maintain radial length; whereas collagen matrix material was ineffective. We conclude that TCH and autogenous bone grafts have equivalent effectiveness despite potential bias in this study.
INTRODUCTION: Primary repair of flexor tendons in zone II of the hand and early post-operative rehabilitation is no longer challenged. However, early rehabilitation methods vary from one unit to another. Although currents techniques such as of Kleinert's and Duran's have brought considerable improvements in functional outcomes, they do not allow early active motion of repaired flexor tendons. METHODS: A promising method of active controlled mobilization has been proposed by the Bordeaux Hand Unit and adopted by our rehabilitation unity since 1995. The aims of this method are: to avoid of proprioceptive inhibition linked to passive methods and prevention of adhesions. This method has been assessed by a prospective study of 22 consecutive patients with average follow-up of 11.8 months. RESULTS: Our rating was based on the Strickland scoring technique. 81% of good and excellent results were observed. Our score rates confirm the results published by others authors who have applied the same active protocols. The results observed in our series tend to confirm the advantages of early controlled active mobilization techniques and lead us to pursue their application in the future.
Fourteen extension osteotomies were performed in 13 patients with angular metacarpal malunion. Surgery was indicated by the limitation of mobility, the reduction in gripping capacity, and pain following digitopalmar grasping movements. After surgery, the patients regained good articular mobility. However, in 60% of cases a teno-arthrolysis was required upon removal of consolidation hardware to restore digital function. The operation allowed pain relief in two-thirds of the patient population; in the remaining subjects, pain was experienced when making grasping movements. At the final examination, in the majority of cases gripping strength was similar to that of the contralateral hand. In conclusion, correction of angular malunion by extension osteotomy is a demanding procedure, and whenever possible should be avoided by a precise reduction of the metacarpal fracture during initial surgery. A fractured metacarpal with a palmar angulation of over 15 degrees should systematically be reduced and fixed if unstable.
During our collaboration with the Hand Surgery Unit (HCUG), we have managed trauma patients presenting lesions of the upper limb of varying degrees of severity. We were particularly interested in patients who had undergone amputations. We observed that late psychiatric interventions were generally poorly accepted by the patients and were of no use to these patients. In the light of these findings, we therefore elaborated a new strategy of intervention in collaboration with our surgeon colleagues. Patients with severe upper limb trauma were referred to us immediately after their admission. This approach presents three major advantages. Firstly, patients accept support more easily, knowing that they will be faced with psychologically difficult moments; secondly, we can help them to talk about their fears in relation to the future and thereby verbally express their anxieties and can therefore help them to face the future as effectively as possible; thirdly, we play a role in the communication between the surgical team, nursing team and the patient. We believe that this type of intervention improves the conditions of hospitalization and, in the long-term, should decrease the risks of a negative psychiatric outcome.
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We reviewed 20 patients with 23 displaced extraarticular fractures of the distal end of the long metacarpals, treated by fasciculated pinning. At a mean follow-up of 5 years, all the patients were subjectively satisfied with the result. All the patients but one, who fractured four metacarpals, had a normal range of motion. The average grip strength was 43.4 kg for the operated side compared to 43.4 kg for the uninjured hand. Radiologically, the fractured fifth metacarpal had a shortening of 2.2 mm compared to a control group, whereas the volar angulation was 16.6 degrees (13.2 degrees for the control group). The technique of intramedullary fasciculated pinning is a reliable alternative when conservative treatment of fractures of the metacarpal neck has failed or is inappropriate. The procedure provides sufficient stability to allow early mobilization and a good functional result.
The surgical treatment of chronic sprain of the distal radio-ulnar joint remains a difficult problem. Some authors have proposed a radio-ulnar stabilization procedure which involves some loss of mobility of the forearm. Other, more radical authors, have suggested partial or complete resection of the ulnar head. In this case, they restore mobility in prono-supination, but often with a loss of stability and discomfort or pain. Hui and Lindscheid modified a technique of tenodesis which had been previously proposed by Bunnell. They perfected a tenodesis based on the use of the flexor carpi ulnaris tendon. We feel that this procedure should ensure stability of the distal radio-ulnar joint, while preserving its mobility. We used this technique in 9 patients who were reviewed with a follow-up of 2.7 years. The authors obtained 2/3 of good and very good results. This procedure will be compared with other techniques currently used and differences of the results will be discussed. Unfortunately, few articles have been published on this subject.
We present a retrospective survey of the mechanism and the lesions caused by escalators in Genevan children. Though these accidents are rare, they are often very serious. They occur primarily among children around the age of three and affect especially the hand. It is not economically feasible to replace or modify current escalators. It is therefore important that the current warning signs on escalators be improved. As there is a specific risk to children of catching fingers in the escalator and most parents are unaware of this type of danger, a warning sign with an explicit illustration could be of value. Also an insertion of a plastic bar just above the moving stairs on each lateral wall would block any potential extremities from being caught in the gap between the steps and the side of the staircase.
Radio-lunate arthrodesis of the rheumatoid wrist is an established technique which has been in use for more than 12 years. The evolution of 26 operated wrists and 20 non-operated wrists has been studied with a mean follow-up of 5 years. The results show that although radio-lunate arthrodesis can prevent dislocation of an unstable wrist, it cannot prevent deterioration. Collapse, ulnar translation, tilt of the lunate, and the inter-carpal instability continued with time, whether the wrists were operated on or not. The speed of deterioration was dependent on the type of rheumatoid arthritis and is faster in the disintegration type than in the osteoarthritis or the ankylosis type. The technique is applicable to the osteoarthritis type of rheumatoid arthritis, in the middle stage (2 to 4a according to the Larsen-Alnot classification). At that stage, the ankylosis type and the disintegration type, and the osteoarthritis type at an advanced stage, are better treated by total arthrodesis or total prosthetic arthroplasty.
The admixture of clonidine or epinephrine to lidocaine for brachial plexus block was studied with regard to duration of block, postoperative analgesia, and plasma concentrations of lidocaine. Thirty-three patients of ASA physical status I and II received an admixture of either clonidine (150 micrograms; n = 15) or epinephrine (200 micrograms; n = 18) to 40 mL of 1% lidocaine in a randomized, double-blind fashion. Bone surgery predominated in those patients receiving clonidine and soft-tissue surgery in those receiving epinephrine (P less than 0.05). Onset and duration of block were not different between the groups. With the admixture of clonidine, fewer patients were completely pain free for greater than 12 h (13.3%) and pain scores (visual analogue scale 0-10) were higher 6 h after the block (median 4; range 0-6) than with epinephrine (61.1%; median 2; range 0-7, respectively; P less than 0.05). In patients who had received clonidine, peak plasma concentrations of lidocaine were higher (10.29 +/- 2.96 mumol/L) and occurred earlier (23.7 +/- 9.3 min; mean +/- SD) than in those treated with epinephrine (6.9 +/- 1.71 mumol/L; 72.5 +/- 56.2 min; P less than 0.05). This indicates the absence of a local vasoconstrictor effect of clonidine and implies a reduced margin of safety with regard to local anesthetic toxicity. Although clonidine does not offer advantages compared with epinephrine, it may be a useful adjunct to local anesthetics in those patients in whom the administration of epinephrine is contraindicated.