Aims

The sensitivity and specificity of electrodiagnostic parameters in diagnosing carpal tunnel syndrome (CTS) have been reported differently, and this study aims to address this gap.

Purpose of the study: We reviewed traumatic distal leg amputations managed in our unit between 1990 and 1993. Reimplantation or unilateral emergency revascularization were undertaken in five cases. Material and methods: The initial loss of length was considerable (range 8.5–12 cm) allowing direct internal fixation, protected with an external fixator bridging the ankle, and direct vasculonervous suture. Secondary lengthening was undertaken early in the proximal metaphyseal zone before sensorial recovery was complete. Results: Healing was achieved within a normal delay in all cases. Nerve regeneration was monitored from the site of the microsuture by following the progression of the Tinel sign along the repaired nerve trunks; this defined the rate of regeneration. Our observations showed that nerve lengthening above the site of the microsurgical suture did not hinder nerve regeneration and even appear to stimulate it. Conclusion: This strategy of extensive initial debridement compensated for by significant but well-tolerated secondary lengthening enabled us to broaden indications for unilateral leg reimplantations. The quality of the functional results at follow-up extending up to 15 years is probably one of the reasons justifying this strategy

A schwannoma is a benign nerve sheath tumour originating from schwann cells. It is the most commonly occurring peripheral nerve sheath tumour. The common sites of occurrence are the head and neck followed by the upper and lower limbs. Diagnosis is straightforward and is made clinically. Schwannomas of the tibial nerve pose a problem. The literature describes them as causes of chronic, intractable lower limb pain because their diagnosis is often delayed for several years. The main reason postulated is that a lump is not always palpable in the early phases and hence chronic cramping pain in the calf or foot is attributed to lumbosacral radiculopathy or local neuropathy. We report the largest case series of twenty-five patients diagnosed with a tibial nerve schwannoma. Only three cases were diagnosed within a year of initial presentation. The mean time to diagnosis was eighty-six months. The most common site of pain was the sole of the foot (eighteen cases). A Tinel's sign was elicited in nineteen cases. MRI confirmed the diagnosis in all the twenty cases where it was performed. Surgical resection was performed in all cases yielding excellent results. Only one patient required further neurolysis for persisting pain. In patients with a long history of neuropathic lower limb pain, where lumbar and pelvic lesions have been excluded, a high index of suspicion should be maintained for a peripheral nerve tumour. Delay in diagnosis is commonly due to lack of familiarity with peripheral nerve pathology and the absence of a palpable lump. The delay can result in numerous unnecessary medical and surgical interventions in this group of distressed patients. The Tinel's sign is the key to identifying a tumour of neural origin in the absence of a palpable lump. Surgical resection of the tumour remains safe and effective in providing symptomatic relief

Introduction. Nerve conduction studies are considered to be the investigation of choice for the diagnosis of Carpal Tunnel Syndrome. However they are expensive and can be painful. We scored patients based on a ten point scoring system; four symptoms (Katz Hand Diagram – Classic and Probable pattern for tingling and numbness, nocturnal paresthesia, bilateral symptoms), four signs (weak thumb abduction test, Tinel sign, Phalen sign, Hypoalgesia in median nerve territory) and two risk factors (age more than 40 years and female sex). This was done in an effort to predict the severity of carpal tunnel syndrome and to correlate it with nerve conduction studies. Method. A prospective study of 59 patients was performed between May 2009 and March 2010. For every patient in the study we completed a scoring system based on ten points and correlated it with the severity (normal, mild, moderate and severe) result from the nerve conduction studies. Results. There were 61 completed data sets (59 patients, two patients had bilateral carpal tunnel release). The mean age of patients was 60 years (range: 37–91 years). The mean duration of symptoms was 17 months. The female to male ratio was 2.3:1. All scores greater than seven matched with nerve conduction study of moderate to severe intensity apart from three scores which were greater than seven that matched with a normal result. Conclusion. Based on this study, we believe that patients who score less than eight may require nerve conduction studies to confirm the diagnosis of carpal tunnel syndrome. However patients who score more than seven have a 93% chance of having moderate to severe carpal tunnel syndrome on nerve conduction studies

Purpose: Lateral hypoaesthesia of the knee following peroperative section of an infrapatellar sensorial branch during anteromedial access for knee surgery is a well-known phenomenon. Development of a painful neurinoma at this level is much more exceptional but can be the cause of persistent pain, often becoming violent in the anteromedial region of the proximal tibia which may often evoke the diagnosis of mechanical failure of the prosthesis due to superficial conflict or loosening. There is relatively little in the French orthopaedic literature on this topic. We wanted to draw attention to this often missed diagnosis. Material and methods: We report the cases of three patients with degenerative knee disease who underwent total knee arthroplasty using a posterior stablised prosthesis implanted via an anteromedial approach. Persistent pain which developed over more than six months led these patients to consult. Several surgeons evoked a “classical” cause of postoperative pain resulting from postoperative loosening but the x-ray and scintigraphy findings were inconclusive. Physical examination demonstrated dysaesthesia in the lateral infra-pateller region with a positive Tinel sign on the anteromedial aspect of the knee immediately below the tibial implant suggestive of a neurinoma of the infrapatellar branch of the saphenous nerve. An anatomic study conducted on ten knees enabled us to identify the anatomic bases necessary to achieve local anaesthesic blocks providing the pretherapeutic diagnosis. The diagnostic tests were performed with injection of 5 ml xylocaine in the subcutaneous tissue over the medial aspect of the knee upstream from the suspected neurinoma. Complete resolution of pain evaluated 10 minutes after injection led to proposing neurotomy of the infra-patellar nerve via a separate medial incision. Results: Denervation provided immediate relief in three patients. For two, the pain and dysaesthesia regressed completely. Substantial improvement in hyperaesthesia was noted in one patient. Discussion: The anatomic studies demonstrated that one or more branches of the infra-patellar nerve cross the mid line from the apex of the patella to the anterior tibial tuberosity in 98% of the cases. In ongoing work during revision procedures for total knee arthroplasty, we have noted hypoaesthesia or anaesthesia in the infra-patellar nerve territory in 15% of the patients. Dell reported a series of 70 patients with postoperative neurinomas of the knee and obtained 86% good results after denervation. Conclusion: Hyperalgic iatrogenic neurinoma of an infra-patellar branch of the saphenous nerve is a certain but rare cause of pain after knee surgery, generally for prosthesis. Misdiagnosis of a mechanical complication is not uncommon. The clinically suggested diagnosis is easy to confirm by a subcutaneous local anaesthesia test. Neurotomy of the infra-patellar nerve can be proposed after failure of drug and physical treatments