Laminar configuration of the transverse carpal ligament

We investigated the laminar configuration of the transverse carpal ligament, using 77 hands from 44 donated cadavers. According to the running directions and attachments of the fiber bundles composing the ligament, we identified four basic bundle patterns: proximal transverse, distal transverse, radial oblique, and ulnar oblique. Although these patterns often coexisted and the bundles were somewhat intermingled, a specific pattern was very evident in several laminae. Laminae with the distal transverse bundle pattern were the thickest and were reinforced by additional fibers which originated from the palmar aponeurosis and were deeply inserted into the lamina. Based on the laminar configurations of the superficial and deep layers and their composite fiber bundles, we classified the ligaments into four types. Type I, in which distal transverse and ulnar oblique laminae predominated in every layer, was the most common (44.2%), while another large group (41.6%) exhibited type II ligaments, comprising distal transverse and ulnar oblique laminae in the superficial layer and proximal transverse and radial oblique laminae in the deep layer. Thus, in almost half of the patients (type II), the strong distal transverse lamina is likely to be excised during the final step of endoscopic carpal tunnel release because of its superficial localization. This could be a major reason for the frequent occurrence of incomplete release. Moreover, the almost universal superficial ulnar oblique bundle pattern (observed in type I, II, and III ligaments), predisposes to scarring, which may cause radial shifting of the ulnar neurovascular bundle and may affect the palmar branch of the median nerve. We conclude that the interindividual variability seen in the results of endoscopic carpal tunnel release, including minor complications, depends partly on configurational variations in the laminar arrangement of the transverse carpal ligament. Received: June 4, 2001 / Accepted: September 9, 2001     

Treatment of pachyonychia congenita with plantar injections of botulinum toxin

Pachyonychia congenita (PC) is a rare genodermatosis which may be associated with painful, focal hyperkeratosis on the soles. Plantar sweating at high ambient temperatures increases the blistering of the callosities. We report three patients with PC who had great problems in walking, especially during summer time. They were treated with intracutaneous plantar injections of botulinum toxin type A (Dysport, 100 U mL(-1); Ipsen, Slough, U.K.) after prior intravenous regional anaesthesia of the foot with a low tourniquet and 25 mL prilocaine (5 mg mL(-1)). Within a week all three patients experienced dryness and a remarkable relief of pain from plantar pressure sites. The effect duration was 6 weeks to 6 months. Repeated injections over a 2-year period confirmed the good results, with no side-effects or tachyphylaxis noted.     

胸腔镜一孔法治疗手汗症

目的通过胸腔镜一孔法切断胸交感神经干治疗多汗症,总结其安全性和有效性。方法自1996年6月至2008年12月,46例多汗症患者在全麻双腔插管下通过胸腔镜一孔法行胸交感神经切除术。治疗方法采用电凝毁损胸2交感神经节。结果术后多汗症状全部消失,11例（39．5％）病人出现上肢以外的代偿性多汗,但基本可以忍受,不影响生活,不需进一步治疗。全组无复发病例,无手术死亡,效果满意。结论胸腔镜胸交感神经切除术是当今外科治疗手汗症的金标准,单一孔切口更加符合现代美容要求,创伤性更小,其手术技巧至关重要。     

Treatment of axillary hyperhidrosis with botulinum toxin type A reconstituted in lidocaine or in normal saline: a randomized, side-by-side, double-blind study

BACKGROUND: Botulinum toxin type A represents a safe and effective treatment for primary axillary hyperhidrosis. One of the most troublesome disadvantages associated with this therapy is pain at the injection sites. Reconstitution of botulinum toxin A in a solution of lidocaine could be an easy alternative procedure to reduce the discomfort associated with those injections. However, the current recommendations are that botulinum toxin A should be reconstituted in normal saline. OBJECTIVES: To compare the efficacy and tolerance profile of saline-diluted botulinum toxin A and lidocaine-diluted botulinum toxin A in patients with axillary hyperhidrosis. METHODS: In a double-blind, side-by-side, controlled, randomized clinical trial, 29 patients were injected with 100 mouse units of botulinum toxin A (Botox); Allergan Pharmaceuticals Ireland, Westport, Ireland) reconstituted in lidocaine into one axilla and with the same dosage of the toxin, reconstituted in an equal volume of saline, into the other axilla. The patients were followed up for 8 months. Quantification of sweat production was performed by iodine-starch tests and by the patients' own rating of sweating. The intensity of pain associated with the botulinum toxin intracutaneous injections was self-assessed by the patients and was evaluated using a 100-mm visual analogue scale. RESULTS: Botulinum toxin A diluted in normal saline and botulinum toxin A diluted in lidocaine were similarly effective in terms of control of onset of sweat production, duration of effect and subjective percentage of mean decrease in sweating. Both treatments were well tolerated, and there were no lasting or severe adverse effects. However, the mean +/- SD pain score during the procedure was significantly lower in the axillae treated with lidocaine-reconstituted botulinum toxin than in the axillae treated with saline-reconstituted botulinum toxin (29.3 +/- 20.1 vs. 47.5 +/- 24.0; P = 0.0027). CONCLUSIONS: Short- and long-term results show the equal effectiveness of botulinum toxin A reconstituted in saline or in lidocaine. However, because injections of botulinum toxin A reconstituted in lidocaine are associated with significantly reduced pain, lidocaine-reconstituted botulinum toxin A may be preferable for treating axillary hyperhidrosis.     

Fabry disease and the skin: data from FOS, the Fabry outcome survey

BACKGROUND: Fabry disease (also known as Anderson-Fabry disease) is a rare, X-linked lysosomal storage disorder that is characterized by accumulation of globotriaosylceramide throughout a range of tissues in the body. OBJECTIVES: To ascertain the prevalence and nature of cutaneous manifestations in patients with Fabry disease and to relate these to the severity of systemic manifestations of the disease. METHODS: We have documented the dermatological features of this disease with reference to data from 714 patients (345 males, 369 females) registered on the Fabry Outcome Survey (FOS), a multicentre European database. RESULTS: We confirm that the commonest disease manifestation is angiokeratoma. Overall, 78% of males and 50% of females had one or more dermatological abnormality, the commonest being angiokeratoma (66% males, 36% females), hypohidrosis (53% males, 28% females), telangiectasia (23% males, 9% females) and lymphoedema (16% males, 6% females). We demonstrate for the first time that the presence of cutaneous vascular lesions correlates with the severity of the systemic manifestations of the disease (pain, renal failure, cardiac disease, premature cerebrovascular disease) as assessed by a severity scoring system. Although the condition is X linked, there is a surprisingly high prevalence of abnormalities in females. CONCLUSIONS: The FOS database is a useful epidemiological tool in establishing the variety and relevance of cutaneous manifestations in Fabry disease. The present study confirms that the presence of dermatological manifestations appears to be a marker of greater severity of systemic disease, which emphasizes the importance of the dermatological assessment of these patients.     

Couverture d’une perte de substance palmaire par un lambeau synovial des fléchisseurs superficiels des doigts

Post-traumatic palmar soft tissue defects are a difficult problem in plastic surgery and many techniques have been described. We report the case of a 41-year-old patient with a large palmar soft tissue defect of the right hand due to a work accident. The classical flaps used in this indication were not usable. So, we chose the synovial flap of the Flexor digitorum superficialis to cover this palmar defect. We discuss the coverage possibilities for a hand palmar defect in emergency, and the use of the synovial flap in this indication. This case report shows that the synovial flap could be an option for the coverage of palmar soft tissue defects.     

Another Look at the Relationship of Electrodermal Activity to Electrode Contact Area

The present study was undertaken lo reexamine the hypothesis that the relationship between skin conductance and electrode size is monotonic and linear. Skin conductance activity was recorded from 48 right-handed male subjects using 6 different sixes of electrode collars ranging in exposed surface area from .131 cm² to .786 cm². The dependent measures were skin conductance level (SCL); skin conductance response (SCR) amplitude to a series of 8 loud tones; latency, rise time, and recovery half-time of the first tone elicited response; (he largest self-generated SCR; and the number of nonspecific responses. The results indicated a significant linear relationship between contact area and SCL, stimulus and self-generated SCR amplitude, and the number of nonspecific responses. Latency was not affected by electrode size although the other time-based measures were. Differences in skin conductance activity were found among different palmar recording sites. The observed linear relationship between electrode size and electrodermal measures has implications for current models of electrodermal activity and for the comparison of results across studies in which different electrode contact areas are used.     

胸腔镜下胸交感神经链切断术治疗手汗症的临床应用

目的探讨胸腔镜下胸交感神经链切断术治疗手汗症的疗效及安全性。方法 2008年8月～2009年8月,对13例患者行胸腔镜下胸交感神经链切断术,术中监测双手温度变化,术后随访,评价手汗症的消失情况。结果 13例患者手术全部成功。术中监测胸交感神经链切断术前后手掌温度平均升高2.8℃。平均手术时间（42.3±8.6）min,术后2～5d出院。术后患者手掌多汗的症状均消失,4例腋汗及足汗消失,1例减轻,1例术后出现代偿性多汗。随访1～12个月,平均5.3个月,无1例多汗复发。结论胸腔镜下胸交感神经链切断术是治疗手汗症的一种安全有效的手段。