Purpose of the study: Basal joint osteoarthritis remains one of the most invalidating degenerative diseases of the upper limb. Most patients are women and the main symptom is pain. Several surgical approaches can be used: total trapeziectomy with or without a ligament reconstruction for intermetacarpal stabilization associated or not with tendon interposition (possibly with a synthetic insert); cemented or non-cemented trapezio-metacarpal prosthesis and arthrodesis. The purpose of this work was to report our experience with the modified Eaton-Littler technique and determine the current contribution of total trapeziectomy – ligament reconstruction – tendon interposition.

Material and methods: We report a series of 26 patients who underwent surgery between 1994 and 2002 for trapezium resection associated with intercarpal ligamentoplasty and «anchovy» interposition using a flexor carpi radialis hemi-tendon. The series involved 21 patients, 16 women and 5 men, with invalidating basal joint osteoarthritis unresponsive to medical treatment. The Dell classification was stage II and III. Mean age was 58.6 years. Five patients underwent surgery on both wrists. One patient had had a prior operation on one side and a Swanson implant on the other. The mean follow-up was 66.1 months (range 25–131 months).

Results: For these 22 cases, outcome at last follow-up was satisfactory with complete resolution of pain, excellent joint mobility with a mean Kapandji score of 9.5/10 (range 8–10). Half of the wrists exhibited deficient pinch and grasp force. Mean postoperative force was 20 kg (range 8–28 kg). Radiographically, scaphometacarpal collapse was nearly complete in all cases. For four cases, outcome was considered poor because of nearly constant pain with reduced mobility and a mean Kapandji score of 5/10. Three patients developed a reflux dystrophy: one of these patients achieved a final satisfactory result. There had been no revisions at last follow-up.

Discussion: All the proposed techniques appear to give good results in terms of pain relief. Trapiezectomy with ligamentoplasty appears to provide good results at mean six months follow-up, results which are reliable and sustained over time. Trapezio-metacarpal prostheses give good immediate results in selected patients but the rate of failure at mid-term remains high, mainly due to loosening. Second generation cemented prostheses are promising. Trapezial implants have specific complications. Trapeiometacarpal arthrodesis gives good stability of the thumb column and is particularly indicated for young active patients with less consideration on the esthetic aspect of their hand, keeping in mind the significant rate of nonunions.

Conclusion: Despite the significant progress achieved with trapeziometacarpal prosthetic arthroplaasty, we still believe that complete resection of the trapezium with ligament reconstruction associated with tendon interposition remains the gold standard in terms of patient satisfaction and reliable results for the surgical treatment of basal joint osteoarthritis.

Purpose: Meralgia paraesthetica is usually caused by entrapment of the lateral femoral cutaneous nerve (LFCN) at the inguinal ligament. We present our experience with 114 patients who underwent surgical management for meralgia paraesthetica.

Material: We reviewed 114 patients (48 men, 66 women, five bilateral cases) who underwent surgery for meralgia paraesthetica between 1987 and 1999; local anaesthesia was used for neurolysis in most cases. We identified five aetiologies: idiopathic (n=69, three bilateral), abdominal surgery (n=19), iliac graft harvesting (n=12, one bilateral), hip surgery (n=7), trauma (n=7, one bilateral).

Methods: We analysed outcome at more than two years follow-up for the entire series and by aetiology using a standard 12-point evaluation scale accounting for residual pain, sensorial disorders, and patient satisfaction.

Results: The overall results were good, mean score 9/12 (range 1–12). Ninety-two patients were very satisfied or satisfied. Among the 27 patients who were not satisfied, five developed recurrence. Mean time to full pain relief was 70 days (range 1 – 364 days). Recovery of thigh sensitivity was noted at 128 days (range 1 – 364).

Discussion: The essential criteria of poor prognosis were duration of the meralgia before surgery and its aetiology. Neurolysis of an LFCN injured by trauma or iliac graft harvesting provided less satisfactory results (scores 7 and 6 respectively) than for idopathic meralgia paraesthetica or abdominal-surgery injury (scores 9 and 10 respectively). Eight of the neurolysis procedures in this series did not provide satisfactory results (score 5).

Conclusion: Neurolysis appears to be the surgical treatment of choice for mearlgia paraesthetica. In skilled hands, neurolysis can be performed under local anaesthesia, although certain difficulties can be encountered: obesity, modified anatomy due to prior operations, nerve variability (frequent). Knowledge of these different elements is essential not only to achieve neurolysis but also prevent iatrogenic injury.

Purpose: Mucoid pseudocysts are infrequent benign tumours affecting all peripheral nerves near joints. Reported for the first time in 1891, these cysts raise an unresolved question as to their nature. Identifying the origin of these cysts could have an impact on management and the risk of recurrence.

Material and methods: Twenty-three patients (21 men two women), mean age 38 years, were followed for a mean six years. The mucoid cyst was located at the level of the common fibular at the neck of the fibula in 16 cases, the tibial nerve at the knee in one, the medial nerve in one, the ulnar nerve in three and the supra-scapular nerve in two. Pain was local in 18 patients, irradiated to the concerned territory in 20. In 17 patients, the nerve lesion was discovered due to development of motor deficit. An EMG was performed in all cases, an ultrasound exploration in 15, a CT scan in seven and an MRI in ten. All patients underwent surgery with neurolysis under microscopy for intraneural cysts. A pedicle communicating with the joint was search for during each intervention.

Results: An articular communication was found in 17 cases. Mean delay to recovery of motor force was five months with recovery of normal sensitivity in 16 cases at seven months. Total lack of recovery was noted in one patient. There was one recurrence requiring tibiofibular arthrodesis.

Discussion: Three theories have been put forward. Besides the cystic degeneration of certain schwannomas, degeneration of the nerve sheath connective tissue, the joint theory appears to be the most probable. The presence of a pedicle linking the cyst to the joint in more than 60% of the cases, the periarticular situation of the nerves involved and sometimes the migration along an articular nerve as well as the mucoid content of the cysts is in favour of an articular origin. The notion of recurrrence after complete minute resection is also in favour of a joint disease.

Conclusion: A mucoid cyst is a likely diagnosis for neruological lesions lying near a joint. Search for an articular communication both before and during the surgical procedure is important to limit the risk of recurrence.