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PALLIATIVE TREATMENT FOR PARALYSIS OF INTRINSIC MUSCLES OF THE FINGERS
Ph. Bellemere 1.2, F. Chaise 1.2.3, B. Chabaud 2.4.
Article Summary

INTRODUCTION
Prerequisites to surgery
Surgical techniques
A- STABILISATION OF METACARPOPHALANGEAL JOINTS
B- Restoration of intrinsic muscles
Indications for type of palliative treatment
1. Bouvier’s manoeuvre.
2. More general criteria
Particular case of the little finger
CONCLUSION
1. Nantes Assistance Main, Clinique Jeanne d’Arc (Nantes)
2. Association Mains du Monde
3. Ordre de Malte
4. Clinique Kennedy, Montélimar
 

INTRODUCTION

 

Paralyses of the intrinsic muscles of the fingers are the result of nerve damage, infectious nerve diseases (leprosy, polio) or degenerative diseases affecting at least the ulnar nerve. These paralyses cause deformity of the fingers and functional disability due to imbalance between the intrinsic and extrinsic muscle apparatus of the fingers. [1,2]

The deformity is a clawing of the fingers which is typically seen during active extension of the fingers with hyperextension of the first phalanx because the metacarpophalangeal joints are not stabilised while the 2nd and 3rd phalanges remain in flexion (Fig. 1). This attitude only concerns the 4th and little finger in the case of isolated ulnar nerve paralysis because the lumbrical muscles of the 2nd and 3rd fingers, innervated by the median nerve, can suffice to prevent deformation in these fingers. The claw deformity will be all the more marked if nerve damage is low down, retaining innervation of the long flexor muscles, or that the extensor apparatus is weak. It increases during extension of the wrist and decreases during flexion which sometimes causes patients to adopt an attitude of flexion deformity of the wrist.

The functional disability translates into an impossibility to bend the fingers in sequence from proximal to distal, and a weakening of grasp strength. With intrinsic paralysis, the flexion mechanism of the finger is reversed and begins with the distal interphalangeal joint, then the proximal interphalangeal joint and lastly the metacarpophalangeal joint. It is impossible to flex the metacarpophalangeal joint while keeping the fingers in extension. These functional disorders have a considerable impact on the ability to carry out a palmar pinch or grasp and its strength (Fig. 2). In addition, by favouring the use of non fingerpad zones for grasping, severe trophic disorders can occur, all the more so that it is often the desensitised hands of patients living in a precarious environment that are involved (leprosy patients). [2]
The aim of palliative treatment is therefore to restore certain functions of the fingers and in particular to correct the claw deformity.

 

 Figure 1 : Typical claw finger deformity

 Figures 2 : Function disorder of flexion of fingers during grasping.

 

Prerequisites to surgery

Whatever the surgical procedure chosen, optimal conditions for success need to prevail. The infrastructure providing pre and postoperative patient management must have a unit for re-education and provision of orthotic devices. Longstanding damage will see a stiffening of joints and these need to be softened somewhat before any surgical operation. The aim is to recover through physiotherapy and, if necessary, through static or dynamic orthotic device, not only the fullest passive interphalangeal extension possible along with passive flexion of the metacarpophalangeal joints, but also good, active mobility of the wrist in flexion-extension. Preparation of the skin includes softening through massages and treatment of any local infection. The time in preparation will enable patient education and reinforce their support of the postoperative rehabilitation programme.

 

Surgical techniques

There are two main types of technique: those aimed at stabilising the metacarpophalangeal joints and those aimed at restoring the interosseous muscles and each has its indications.

A- STABILISATION OF METACARPOPHALANGEAL JOINTS

 

The aim of these techniques is to stabilise the metacarpophalangeal joints in slight flexion. This will correct the claw deformity in some selected cases but will not restore sequential flexion of the fingers because the imbalance between the intrinsic and extrinsic muscle apparatus will persist.
Three methods can be used: capsulodesis or capsuloplasty, tenodesis, and “lasso” procedures.

 

1.  Capsulodesis and capsuloplasty

 

These consist in shortening the volar plate of the metacarpophalangeal joint by capsuloplasty or by capsulorrhaphy. Bourrel combines with this procedure an opening of the A1 pulley (advancing the pulley) so as to modify the moment when the flexor moves into action which facilitates metacarpophalangeal flexion (Fig. 3). [4] Transosseous fixation seems to be more solid and the use of a mini-intraosseous anchor certainly makes this procedure rapid and reliable (Fig. 4). [1, 5]
The advantage of the capsulodesis or capsuloplasty techniques is that it preserves the tendon capital of the patient and that it does not cause any change in grasp strength. Although these techniques correct the claw finger, they do not restore flexion of the metacarpophalangeal joints with fingers in extension. The disadvantages of the techniques are represented on the one hand by the risk of tendinous adhesions of the flexors which impose immediate mobilisation in flexion- extension of the fingers, and on the other by the risk of secondary slackening, meaning that a dorsal metacarpophalangeal splint will need to be worn for at least the first 6 weeks after the operation. Intraosseous fixation nevertheless offers good prevention of the problems of secondary slackening.

 

 Figure 3 : Technique of Bourrel’s capsuloplasty with pulley advance

 Figure 4 : A. Claw deformity
B. Correction with capsuloplasty and fixation with mini-anchor
C. Result

2. Passive Tenodesis

A great number of techniques have been described by many authors (Fowler, Tsuge, Riordan, Brunnel, etc.). [1,3] These are more complex than capsuloplasties. The simplest is that of Srinivasan who uses grafts of the palmaris brevis fixed on the extensor apparatus with a route in front of the intermetacarpal ligament (Fig. 5). [6] These techniques of passive tenodesis can be used if capsuloplasty fails. They share the same advantages and disadvantages.

 Figure 5 : Srinivasan’s Tenodesis

3. The "lasso" technique

 

This technique described by Zancolli has become very popular because of its simplicity and its effectiveness. [7,8] It is in fact an active tenodesis which uses the flexor carpi superficialis tendon sectioned in the digital canal then sutured firmly to itself after a loop around A1 pulley, the metacarpophalangeal joints being flexed in the region of 30 to 40° (Fig. 6).
The approach is through a transversal incision in the palm, completed eventually by a short digital approach or by a longitudinal approach, rectilinear or broken. The flexor carpi superficialis must be sectioned upstream of Camper’s chiasm so as to protect the ligaments which ensure the vascularisation of the flexor carpi profundis. In addition, this will prevent haematoma, a source of intracanalicular adherences. It is possible to use one flexor carpi superficialis for 2 fingers thanks to each of its strips. [9]
A dorsal protection splint which will permit flexion movements of the fingers should be worn for 4 weeks.
Due to the active pull-off effect of the flexor carpi superficialis around the A1 pulley, this technique allows for excellent correction of the claw deformity and very effective flexion of the metacarpophalangeal joints with fingers in extension. However, it can have disadvantages which the surgeon needs to be aware of. Harvesting the flexor carpi superficialis can theoretically cause a decrease in grasp strength but this did not seem to be true in the various series. [10,11] Active flexion of PI by the lasso in fact restores grasp strength. However, preoperatively, the presence of a strong flexor carpi profundis should be verified before harvesting the flexor carpi superficialis. In addition, in case of constitutional laxity in hyperextension of the proximal interphalangeal joint, a swan-neck deformity may occur following the use of the flexor carpi superficialis. This can be prevented by a tenodesis of the proximal interphalangeal joint with one of the two flexor carpi superficialis strips. Lastly, the adherences of the distal tendon remnant of the flexor carpi superficialis can be responsible for an after effect in the form of a flexion deformity of the proximal interphalangeal joint which needs to be screened out through regular postoperative check-ups and be anticipated with immediate re-education by the patient himself in the first weeks after the operation.
To alleviate these potential drawbacks related to the harvesting of the flexor carpi superficialis, some surgeons carry out the lasso procedure with a different motor, such as the flexor carpi radialis or the extensor carpi radialis brevis extended by a graft which, however, considerably complicates the operation. [12]

 

 Figure 6 : Diagram of Zancolli’s "lasso" technique

 Figure 7 : Result of the "lasso" technique showing good flexion of the metacarpophalangeal joints with fingers in extension.

 

B- Restoration of intrinsic muscles

Numerous techniques have been described along with everything that can be used as a motor for a tendon transfer. These various motors nevertheless differ in their path and their strength which more or less approaches that of the interosseous muscles, their length which can require for some an extension with a graft (flexor carpi radialis in most cases, or the small plantar or the fascia lata), and their seat in relation to the wrist, enabling either a reinforcement of their action through an effect of tenodesis in flexion-extension of the wrist or, on the contrary, their attenuation in the case of stiffness of the wrist in flexion (Table I).

 Table I. Principal active effectors used in the revival of intrinsic muscles and their biomechanical characteristics compared to intrinsic muscles.

1. Technical principles for tendon transfer.

Whatever tendon transfer is chosen, it should meet four surgical requirements (Fig. 8).

Figure 8. Technical principals for tendon transfer in revival of intrinsic muscles. The termination point is carried out with a dorsolateral incision at the base of each finger. The active effector must pass in front of the transverse intermetacarpal ligament and its distal insertion is located on the terminal tendon of the interosseous muscle.

 

a) Path: this is the key element in revival of intrinsic muscles. The active effector must pass in front of the transverse intermetacarpal ligament in the lumbrical canal or in the path of the palmar interosseous muscle.
b) Termination point: it is situated on the external edge of the first phalanx of the last 3 fingers and more ulnar on the index so as to avoid too much abduction which can be awkward for picking things out of a water bowl, or picking up very fine elements (rice, seeds, coins, etc.).
c) Distal insertion: this is carried out on the back (transverse fibres of the lateral strip) or the terminal part of the conjoint tendon of the interosseous muscle and can extend along the extensor apparatus at the level of the lateral strip or the median strip. The more the terminal insertion is median and distal, the more the transfer will have an extension effect on the proximal interphalangeal joint. This effect may be volontarily sought when there is a certain degree of stiffness of the proximal interphalangeal joint in flexion, or if active extension is weakened, or if there is a pre-existing distension of the extensor apparatus.
d) Regulating tension: this is always carried out with the metacarpophalangeal joint in flexion at approximately 60-70° and with flexion of the wrist at approximately 30-45°. The tension of each transfer needs to be distributed harmoniously for each finger while respecting the slant of the fingers from the index to little finger (Fig. 9).

 

 Figure 9. Tension of the transfer is carried out with the metacarpophalangeal joint and the wrist in flexion, while respecting the slant of the fingers.

2. Various tendon transfers

 

The choice will depend on the mechanical characteristics sought (Table I), whether there is an effective motor or not (flexor carpi superficialis for the Bunnel-Littler technique), the symptom characteristics of the intrinsic paralysis (claws more or less stiffened, weakness of extensor apparatus), and the medical-surgical environment into which the patient is taken in, with, in particular, the possibility of specific re-education or adapted orthotic device. [13] In addition, some transfers are technically more complex than others and the experience of the surgeon will also be a consideration. If the advantages of the revival transfers are undeniable (correction of claw, restoration of flexion in sequence and rebalancing of intrinsic and extrinsic apparatus of the fingers), the surgeon needs to know the disadvantages and complications so as to avoid them. Adherences can be met all the more frequently that the transfer is extended by a graft (Brand or Giraudeau), or that the path is indirect, passing from back to front. In all cases, early re-education is essential to limit them as much as possible. Tears are often related to flaws in the technique for fixation of the fine strips of the transfer to their insertion zone which is often very thin. A defect in flexion of the finger can occur if care has not been taken to check for the presence of a powerful flexor carpi profundis in the case where a flexor carpi superficialis is used for the transfer. Lastly, hypercorrection which translates as a swan-neck deformity can be caused by a transfer which is too powerful, tension which is too strong, an insertion which is too distal, constitutional laxity of the proximal interphalangeal joint in extension, or a weakness in the extensor apparatus through distension of the median strip.
We will only mention the most frequently used transfers. [14-18]
Bunnel-Littler’s Transfer (Fig. 10). Initially described with 2 flexor carpi superficialis (Bunnel), in general it uses only one flexor carpi superficialis separated into 4 strips (Littler), that of the middle finger or that of the ring finger harvested distally by a short digital incision on P2. The strips are carefully freed up from Camper’s chiasm. The tendon is externalised through a counter incision in the palm and each strip divided into two. Each of the 4 strips is then tunnelled to the base of a finger, passing in front of the transverse intermetacarpal ligament before being fixed on the back.
This is a powerful transfer, particularly indicated if there is a claw finger with stiffness of the proximal interphalangeal joint or a weakness of the extensor, in low ulnar or medioulnar paralysis. Its use has not shown a decrease in grasp strength but it seems to provide less strength than the other types of transfer. [11]

 

 Figure 10. Bunnel-Littler transfer with flexor carpi superficialis of the middle finger.

Brand's Transfer (Fig. 11 a.b.c.d.e.f.g.). This uses one of the two radial extensors of the wrist harvested at its distal insertion, externalised upstream of the ring finger ligament and extended by a tendon graft (small plantar, small palmar or fascia lata) divided into 4 strips. Two versions are possible depending on the path in relation to the wrist: either dorsal using the 2nd radial (extensor carpi radialis brevis) [Brand I] where each strip is then passed into the intermetacarpal space, or palmar using the 1st radial (extensor carpi radialis longus) [Brand II] passed in front through the interosseous membrane of the forearm then into the carpal tunnel.

This transfer provides very good results in correcting the claw deformity and grasp strength. It is technically more difficult and longer to carry out than the Bunnel-Littler transfer and is not without risk of postoperative adherences so that postoperative re-education must be sustained and attentive. If there is a preoperative tendency to flexion deformity of the wrist, the palmar version (Brand II) is less effective through slackening of the transfer. It is particularly indicated in the case of high medioulnar damage where no flexor is available.

 

11 a
11 b
11 c
11 d
11 e
11 f
11 g

 

Figure 11. Diagram of the two variations of Brand’s transfer with the radial extensors of the wrist: a-b-c-d: with the 2nd radial (extensor carpi radialis brevis), Brand I.
e-f-g: with 1st radial (extensor carpi radialis longus), Brand II.

Giraudeau’s Transfer (Fig. 12). This uses the flexor carpi radialis tendon extended by a graft passing in the carpal tunnel that sometimes needs to be opened which means that this direct transfer loses the pulley effect of the retinaculum. It is particularly indicated in the case of low medioulnar damage, such as in leprosy.

 Figure 12. Giraudeau’s Transfer using the flexor carpi radialis.

 

Lennox Antia’s Transfer. This uses the tendon of the petit palmaire extended by a graft (small plantar or fascia lata) passed in the carpal tunnel. But this direct transfer seems to provide results identical to the Brand II transfer with, however, a less laborious period of re-education. [19]
Fowler’s Transfer. This uses the extensor indicis proprius of the index and little finger, each divided in 2 strips. It has the advantage of preserving the capital of the flexor, but the transfer is often short with the risk of too much tension causing a swan-neck deformity. [1,3] It is indicated in the case of high medioulnar damage.

 

 

Indications for type of palliative treatment

They will depend on 2 criteria: the possibility of correcting the claw deformity with Bouvier’s manoeuvre, and the general criteria (Table II).

Table II. Tree diagram for operative indications.

1. Bouvier’s manoeuvre.

 

This manoeuvre consists in stabilizing the metacarpophalangeal joints at 0° or a few degrees of flexion with the hand of the examiner and asking the patient to extend their fingers.
It is essential to carry out this manoeuvre before proposing any treatment. It will determine 3 types of claw finger (Fig. 13). [3]
- a supple claw: the extension deficit of the proximal interphalangeal joint can be fully reduced.
- a stiffened and reducible claw: extension of the proximal interphalangeal joint is actively incomplete and passively complete. This means a loss of the extensor apparatus (distension or weakened) in particular of the median strip, as is found in long-standing claw fingers.
- a stiff or fixed claw: the loss of extension is passively and actively irreducible. This means a stiffening of the joints and/or adherences and tendon contraction.
The indications for treatment will therefore depend on the type of claw finger involved. Any stiffness requires first of all a period of limbering up through physiotherapy and fitting of an orthotic device.

 

13 A 13 A'
13 b13 c

 

 Figure 13 : Bouvier’s Manoeuvre and the 3 types of claw finger.
A- supple claw
B- stiffened claw
C- fixed claw

2. More general criteria

 

Their analysis will enable operative indications to be refined, oriented by the type of claw finger.
- the functional requirements of the patient, depending on whether they wish a simple correction of the claw finger deformity or whether they wish to regain grasp strength.
- cause (paralysis due to trauma, neurological disorder, leprosy, etc.). The muscles which might serve as a tendon transfer may be affected by the cause, as may the flexor muscles of the fingers.
- the type of paralysis: ulnar or medioulnar, high or low, dissociated or not. This will determine the extent of the claw deformity, the amount of decrease in strength as well as the choice of transfers possible. In the case of high ulnar paralysis, the flexor carpi superficialis of the 4th and little finger will not be able to be used because the deep flexors will be paralysed.
- the need to associate revival of the thumb can limit the choice of tendon transfer for revival of the fingers, in particular if a flexor superficialis has been chosen to revive the thumb.
- the presence, or not, of joint stiffness after re-education. If residual stiffness is not significant, a strong tendon transfer may be justified. If the stiffness is inveterate, a solution to rescue function through arthrodesis of the proximal interphalangeal joint may be necessary and be associated with advancing the pulley (sectioning of proximal pulleys) to facilitate metacarpophalangeal flexion under the action of the flexor muscles.

 

 

Particular case of the little finger

Permanent abduction of the little finger (Wartenberg’s symptom) is frequently met in paralysis of the intrinsic muscles (Fig. 14). [20] It means there is an imbalance in the frontal plane of the intrinsic and extrinsic apparatus of the little finger. It is manifested only in extension of the finger and may be badly tolerated because of constant catching. The correction of this deformity is often obtained by just treating the claw or by revival of the intrinsic muscles through tendon transfer. However, in some cases, particularly in the case of incomplete or dissociated paralysis, it may be the only functional impairment felt by the patient.

 Figure 14 : Wartenberg’s symptom: permanent abduction of little finger.

 

The type of correction for Wartenberg’s symptom will depend on whether it is associated or not with a claw deformity.
- Wartenberg without claw (Fig. 15): the correction can be carried out conventionally using a full transfer, or a strip from the extensor proprius of the little finger on the radial side of the extensor communis, or of the radial lateral ligament of the 5th metacarpophalangeal joint. [21,22] The full transfer of the tendon gains adduction strength by taking it out of its own compartment under the dorsal retinaculum of the wrist to re-route it in the more radial compartment of the extensor communis. [23]

 

 
15 a 15b >>>      
         
 Figure 15. Techniques for correcting Wartenberg’s symptom without claw.

15 A- Simple transfer of extensor proprius.
15 B- Transfer of extensor proprius re-routed radially under the annular ligament.

- Wartenberg with claw (Fig. 16): An ulnar or median strip of the extensor of the 4th finger can also be used by fixing it after its passage under the intermetacarpal ligament either on the radial lateral ligament of the 5th metacarpophalangeal joint or on the back-strap of the interosseous muscles. [24] Belmahi uses an original technique, a modified “tie” lasso, using the flexor carpi superficialis of the 4th finger where one of the 2 strips is used as a lasso, as in Zancolli’s technique to correct the claw of the 4th finger, and the other strip is passed like a tie from radial to ulnar around the base of the 1st phalanx then sutured to itself and to the radial back-strap of the interosseous muscles. [25]

B

Figure 16. 

Techniques for correcting Wartenberg’s symptom with claw.
A- with extensor proprius or extensor communis.
B - the modified “tie” lasso procedure

 

CONCLUSION

Surgery for intrinsic paralysis of the fingers following on from nerve injury has become rare with the widespread development of nerve microsurgery. However, in countries where leprosy is endemic this type of surgery is still a topical question. The indication for this type of surgery will be based on a detailed analysis of the symptoms of the handicap as well as the needs of the patient. Its performance supposes a medical and surgical environment which will permit management of the patient in the pre and post surgical stages for the care, therapy and fitting of orthotic devices which are an integral part of the treatment and which largely determine the quality of the final result.

REFERENCES

[1] Tubiana R. Le traitement de la griffe cubitale. Ann Chir main, 1984, 3, 2, 173-87.
[2] Bourrel P. Paralysies lépreuses des intrinsèques. Ann Chir Main. 1986;5(3):226-28.
[3] Bourrel P. Interventions palliatives pour correction des griffes des doigts. Ann Chir Main. 1986;5(3):230-41.
[4] Bourrel P.  Raccourcissement capsulaire et avancement de la poulie des fléchisseurs dans la paralysie des muscles intrinsèques des doigts. Ann Chir Plast1970 ;15 :27- 33.
[5] Belmahi A.M, Gharib N, Abbassi A. Une technique originale de stabilisation des métacarpophalangiennes des mains cubitales : « La capsuloplastie transosseuse à forage antéro-postérieur ». Chir Main. 2001; 20:378-83
[6] Srinavasan H. The extensor diversion graft operation for correction of intrinsic minus fingers in leprosy. J Bone Joint  Surg, 1973, 55A-13, 1, 58-65.
[7] Zancolli E. Intrinsic paralysis of the ulnar nerve-physiopathology of the claw hand. In Zancolli E, ed. Structural and dynamic bases of hand surgery. 2nd ed. Philadelphia : JB Lippincott, 1979 :159-206.
[8] Oberlin C. Zancolli's "lasso" operation in intrinsic palsy of leprous origin. A study of twenty-six cases. Ann Chir Main. 1985;4:22-30.
[9] Boucher P. Correction de la griffe ulnaire lépreuse par le procédé du « lasso » de Zancolli, Chirurgie 1982 ; 198 : 754--57.
[10] BelmahiA. M., Gharib N., El Mazouz S., Assiobow A., Oufkir A. Faut-il réanimer ou juste stabiliser les métacarpo-phalangiennes des doigts et du pouce des mains ulnaires. Chir Main 2002 ; 21: 235-41.
[11] Ozkan T, Ozer K, Gulgonen A. Three tendon transfer methods in reconstruction of ulnar nerve palsy. J Hand Surg, 2003 ;28A:35-43.
[12] Malaviya GN. Comparative evaluation of effectiveness of different motor muscles in modified lasso procedure for correction of finger clawing. J Hand Surg, 2003,28B :597-601.
[13] Brandsma JW, Brand PW. Claw-finger correction. Considerations in choice of technique. J Hand Surg. 1992;17B:615-21.
[14] Bunnel S. Surgery of the intrinsic muscle of the hand other than producing opposition of the thumb. J Bone Joint Surg 1942;24:1-31.
[15] Brand PW. Paralytic claw hand with special reference to paralysis in leprosy and treatment by the sublimis transfer of Stiles and Bunnell. J. Bone Joint Surg 1958, 40-B : 618-32.
[16] Littler JW. Tendon transferts and arthrodeses in combined median and ulnar nerve paralysis. J Bone Joint Surg 1949;31A: 225-34.
[16] Brand PW. Tendon grafting illustrated by a new operation for intrinsic paralysis of the fingers. J Bone Joint Surg 1961; 43-B : 444-53.
[17] Giraudeau P, Carayon A. Traitement palliatif des paralysies des muscles intrinsèques des doigts par le grand palmaire prolongé par quatre bandelettes de fascia lata. A propos de 23 observations. Rev Chir Orthop, 1971 ,57, 2, 145-150.
[18] Antia NEI. The palmaris longus motor for lumbrical replacement. Hand 1969; 1: 139-40.
[19] Taylor NL, Raj AD, Dick HM, Solomon S. The correction of ulnar claw fingers: a follow-up study comparing the extensor-to-flexor with the palmaris longus 4-tailed tendon transfer in patients with leprosy. J Hand Surg. 2004 ;29A:595-604.
[20] Wartenberg R. A sign of ulnar palsy. JAMAA, 1939, 112, 1688.
[21] Dellon A.L. Extensor digiti minimi tendon transfert to correct abducted small finger in ulnar dysfunction. J Hand Surg, 1991, 16A ; 819-23.
[22] Blacker GJ, Lister GD, Kleinert HE. The abducted little finger in low ulnar palsy. J Hand Surg, 1976, 1 : 190-6.
[23] Bellan N, Belkhiria F, Touam C, Asfazadourian H, Oberlin C. Extensor digiti minimi tendon « rerouting » transfert in permanent abduction of the little finger. Ann Chir Main, 1998, 17, 4, 325-33.
[24] Voche, P, Merle M. Wartenberg’s sign. A new method of surgical correction. J Hand Surg, 1995, 20B, 49-52.
[25] Belmahi A.M, Gharib N.E, El Mazouz S. Le « lasso en cravate » : une nouvelle technique pour le traitement simultané du signe de Wartenberg et des déformations en griffe des mains atteintes de paralysies cubitales. Chirurgie de la main, 2004, 23 ; 190-5.

Maîtrise Orthopédique n° 165 - June 2007
 
 
 
 
 
 
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