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Ekhtiari S, Phillips M, Dhillon D, Shahabinezhad A, Bhandari M. Understanding the Learning Curve of Carpal Tunnel Release With Ultrasound Guidance: A Review. Cureus 2023; 15:e41938. [PMID: 37588328 PMCID: PMC10425578 DOI: 10.7759/cureus.41938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is the most common compressive neuropathy and can be treated through carpal tunnel release (CTR) if nonoperative treatments fail. CTR can be performed through a variety of techniques, including traditional open, mini-open, endoscopic, and CTR with ultrasound guidance (CTR-US). The evidence on endoscopic CTR is mixed, due to a higher potential for nerve injury with endoscopic CTR compared to traditional open CTR. CTR-US offers the potential advantage of allowing the visualization of all key anatomical structures, combined with a very small incision and minimal soft tissue insult. As with any ultrasonographic technique or procedure, the learning curve needs to be considered for any provider considering adopting CTR-US. However, literature on ultrasound use around the wrist, including early evidence on the learning curve of CTR-US specifically, demonstrates this skill can be learned relatively quickly by providers with a wide range of prior experience in ultrasound and CTR. Overall, there is a need for high-quality studies comparing different CTR techniques, particularly CTR-US, as it offers the potential for considerable cost savings.
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Affiliation(s)
- Seper Ekhtiari
- Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Mark Phillips
- Health Research Methodology, McMaster University, Hamilton, CAN
| | - Dalraj Dhillon
- Faculty of Health Sciences, McMaster University, Hamilton, CAN
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Castro-Menéndez M, Balvís-Balvís P, Oiartzabal-Alberdi I, Ferradás-García L, González-Rodríguez E, Yañez-Calvo J. [Translated article] Percutaneous ultrasound-guided section of the transverse carpal ligament vs. open surgery for the surgical treatment of carpal tunnel syndrome (CTS). Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T297-T308. [PMID: 36863516 DOI: 10.1016/j.recot.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/15/2022] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The gold standard of carpal tunnel syndrome (CTS) treatment is the section of the transverse carpal ligament, the most common technique being the palmar cutaneous incision. Percutaneous techniques have been developed, although their risk/benefit ratio remains controversial. OBJECTIVE To analyse the functional outcome of patients undergoing CTS percutaneously ultrasound-guided and compare it with those of open surgery. MATERIAL AND METHOD Prospective observational cohort study of 50 patients undergoing CTS (25 percutaneous with WALANT technique and 25 by open surgery with local anaesthesia and tourniquet). Open surgery was performed using a short palmar incision. The percutaneous technique was performed anterograde using the Kemis H3® scalpel (Newclip). A preoperative and postoperative assessment was performed at 2 weeks, 6 weeks and 3 months. Demographic data, presence of complications, grip strength and Levine test score (BCTQ) were collected. RESULTS The sample consists of 14 men and 36 women with a mean age of 51.4 years (95% CI: 48.4-54.5). Percutaneous technique was performed anterograde using the Kemis H3® scalpel (Newclip). All patients improved from their CTS clinic without obtaining statistically significant differences in BCTQ score, nor in the presence of complications (p>0.05). Patients operated on percutaneously recovered faster grip strength at 6 weeks, but it was similar in the final review. CONCLUSIONS In view of the results obtained, percutaneous ultrasound-guided surgery is a good alternative for the surgical treatment of CTS. Logically, this technique requires its learning curve and familiarisation with the ultrasound visualisation of the anatomical structures to be treated.
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Affiliation(s)
- M Castro-Menéndez
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain.
| | - P Balvís-Balvís
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
| | - I Oiartzabal-Alberdi
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
| | - L Ferradás-García
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
| | - E González-Rodríguez
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
| | - J Yañez-Calvo
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
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Castro-Menéndez M, Balvís-Balvís P, Oiartzabal-Alberdi I, Ferradás-García L, González-Rodríguez E, Yañez-Calvo J. Percutaneous ultrasound-guided section of the transverse carpal ligament vs open surgery for the surgical treatment of carpal tunnel syndrome (CTS). Rev Esp Cir Ortop Traumatol (Engl Ed) 2022:S1888-4415(22)00365-4. [PMID: 36565804 DOI: 10.1016/j.recot.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/24/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The gold standard of carpal tunnel syndrome (CTS) treatment is the section of the transverse carpal ligament, the most common technique being the palmar cutaneous incision. Percutaneous techniques have been developed, although their risk/benefit ratio remains controversial. OBJECTIVE To analyze the functional outcome of patients undergoing CTS percutaneously ultrasound-guided and compare it with those of open surgery. MATERIAL AND METHOD Prospective observational cohort study of 50 patients undergoing CTS (25 percutaneous with WALANT technique and 25 by open surgery with local anesthesia and tourniquet). Open surgery was performed using a short palmar incision. The percutaneous technique was performed anterograde using the Kemis® H3 scalpel (Newclip). A preoperative and postoperative assessment was performed at 2 weeks, 6 weeks and 3 months. Demographic data, presence of complications, grip strength and Levine test score (BCTQ) were collected. RESULTS The sample consists of 14 men and 36 women with a mean age of 51.4 years (95% CI: 48.4-54.5). Percutaneous technique was performed anterograde using the Kemis® H3 scalpel (Newclip). All patients improved from their CTS clinic without obtaining statistically significant differences in BCTQ score, nor in the presence of complications (p> 0.05). Patients operated on percutaneously recovered faster grip strength at 6 weeks, but it was similar in the final review. CONCLUSIONS In view of the results obtained, percutaneous ultrasound-guided surgery is a good alternative for the surgical treatment of CTS. Logically, this technique requires its learning curve and familiarization with the ultrasound visualization of the anatomical structures to be treated.
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Affiliation(s)
- M Castro-Menéndez
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España.
| | - P Balvís-Balvís
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - I Oiartzabal-Alberdi
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - L Ferradás-García
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - E González-Rodríguez
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - J Yañez-Calvo
- Unidad de Miembro Superior, Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
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Krigers A, Kriwan F, Freyschlag CF, Thomé C, Fritsch H. The distance between the distal margin of the flexor retinaculum and the radiocarpal joint as a landmark in CTS surgery: a cadaver study. Ann Anat 2022; 245:152003. [PMID: 36183941 DOI: 10.1016/j.aanat.2022.152003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The most frequent peripheral entrapment neuropathy is compression of the median nerve in the carpal tunnel, known as carpal tunnel syndrome. The most effective treatment is surgery, where the flexor retinaculum (FR1) is divided. Nevertheless, after this operation, a significant number of patients suffer from persistent symptoms due to incomplete FR distal release. It may be difficult to identify the distal boundary of the FR due to the minimal skin incision. We aimed to identify an anatomical landmark to avoid incomplete distal FR release. The radiocarpal (RC2) joint can be palpated, and lies in close proximity to the boundaries of the FR. Thus, the distance between the RC joint space and the distal FR margin - the RC-FR distance - could be a reliable and individual morphologic measurement from easily acquired regional anthropological measurements. METHODS During this study, 39 radiocarpal regions of 23 embalmed cadavers were dissected, and measurements were taken. Linear regression corresponding to the ulnar length and the RC-FR distance was established. RESULTS The mean RC-FR distance from the RC joint space to the distal FR margin was 3.8cm (95% CI 3.5-4.0), and the range was 2.3 to 5.1cm. This distance was 1.1cm (95% CI 0.8-1.4) longer in males than in females (p < 0.00001), and there were no side-specific differences. The individual projection of the distal FR margin in centimeters can be calculated by measurement of the ipsilateral ulnar length divided by 4 and reduced by 2.9, p < 0.005. CONCLUSIONS The side-equal and sex-specific position of the distal flexor retinaculum margin could be calculated from the palpable radiocarpal joint space based on the ipsilateral ulnar length.
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Affiliation(s)
- Aleksandrs Krigers
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria; Division of Clinical & Functional Anatomy, Medical University of Innsbruck, Muellerstrasse 59, 6020, Innsbruck, Austria.
| | - Fabian Kriwan
- Division of Clinical & Functional Anatomy, Medical University of Innsbruck, Muellerstrasse 59, 6020, Innsbruck, Austria
| | - Christian F Freyschlag
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Helga Fritsch
- Division of Clinical & Functional Anatomy, Medical University of Innsbruck, Muellerstrasse 59, 6020, Innsbruck, Austria
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de la Fuente J, Aramendi JF, Ibañez JM, Blasi M, Vazquez A, Aurrekoetxea JJ, Dávila F. Minimally invasive ultrasound-guided vs open release for carpal tunnel syndrome in working population: A randomized controlled trial. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:693-703. [PMID: 34046894 DOI: 10.1002/jcu.23019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 04/20/2021] [Accepted: 05/03/2021] [Indexed: 06/12/2023]
Abstract
PURPOSE To compare the clinical effectiveness of minimally invasive ultrasound (US)-guided vs open release for carpal tunnel syndrome. METHODS In an open randomized controlled trial, 47 employed patients were allocated to US-guided carpal tunnel release (USCTR) and 42 to an open carpal tunnel release (OCTR) procedure. The main outcome was symptom severity measured by the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ-S). Secondary outcomes were hand functionality (BCTQ-F), nerve conduction, two-point discrimination, handgrip and pinch strength, pain (visual analog scale), work leave and complications. For BCTQ-S and BCTQ-F, minimal clinically important differences (MCID) were also considered. Follow-up duration was 12 months. RESULTS Mixed model analyses detected no significant differences between the two treatment arms in BCTQ-S (P = .098) while BCTQ-F scores were significantly better in the USCTR group (P = .007). This benefit was, however, not supported by the MCID data. Remaining variables were similar in the two groups except pain which was lower in USCTR at 3 months follow-up. All variables but two-point discrimination showed significant improvement after 3 months. CONCLUSIONS Our findings reveal similar symptom relief benefits following OCTR or USCTR in these patients. The patients in our USCTR group, however, reported better hand functional status and less pain.
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Affiliation(s)
- Javier de la Fuente
- Department of Orthopedic Surgery, Clínica Pakea-Mutualia, San Sebastián, Spain
| | - Jose F Aramendi
- Primary Care Department, Clínica Pakea-Mutualia, San Sebastián, Spain
| | - Jose M Ibañez
- Department of Physical Medicine and Rehabilitation, Clínica Pakea-Mutualia, San Sebastián, Spain
| | - Marc Blasi
- Plastic Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Alberto Vazquez
- Department of Occupational Medicine, Clínica Pakea-Mutualia, San Sebastián, Spain
| | | | - Fernando Dávila
- Department of Orthopedic Surgery, Clínica Pakea-Mutualia, San Sebastián, Spain
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Wise A, Pourcho AM, Henning PT, Latzka EW. Evidence for Ultrasound-Guided Carpal Tunnel Release. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-020-00305-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Carpal Tunnel Syndrome Surgery: What You Should Know. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2692. [PMID: 32537349 PMCID: PMC7253261 DOI: 10.1097/gox.0000000000002692] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/15/2020] [Indexed: 12/31/2022]
Abstract
Carpal tunnel release (CTR) surgery continues to evolve. Carpal tunnel syndrome remains a primarily clinical diagnosis, although ultrasound has supplemented electrodiagnostic testing as a confirmatory tool. Magnetic resonance imaging of the carpal tunnel has also showed some promise as an alternative method for the examination of the median nerve. Open CTR surgery remains the traditional, and most popular, method of CTR. Wide-Awake, with Local Anesthesia only, and No Tourniquet CTR has emerged as a means to decrease cost and improve pain control and convenience for patients. Endoscopic CTR is increasing in popularity due to its more rapid recovery. The safety profile of endoscopic CTR has improved, and recent studies show similar rates of major complications between open and endoscopic techniques. Nonsurgeon operated ultrasound-guided techniques for release of the transverse carpal ligament have emerged. While promising in early studies, the current evidence in their favor is limited in terms of patient numbers and direct comparison with other techniques. The outcomes of CTR continue to be excellent. Recent research has demonstrated that nerve conduction continues to recover postoperatively over a longer period of time than previously believed. Patient psychological factors play a significant role in outcomes after surgery but do not appear to limit the improvement provided by intervention.
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Hattori S, Alvarez CAD, Canton S, Hogan MV, Onishi K. Ultrasound-Guided Ankle Lateral Ligament Stabilization. Curr Rev Musculoskelet Med 2019; 12:497-508. [PMID: 31749104 DOI: 10.1007/s12178-019-09592-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique. RECENT FINDINGS To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve. In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.
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Affiliation(s)
- Soichi Hattori
- Department of Sports Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba Prefecture, 2968602, Japan. .,Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Carlo Antonio D Alvarez
- Department of Sports Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba Prefecture, 2968602, Japan
| | - Stephen Canton
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Macalus V Hogan
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Kentaro Onishi
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
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