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Miller LE, Hammert WC, Chung KC. Best-Evidence Systematic Review and Meta-Analysis of Endoscopic Carpal Tunnel Release Outcomes. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:768-773. [PMID: 38106929 PMCID: PMC10721515 DOI: 10.1016/j.jhsg.2023.07.011] [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] [Received: 07/07/2023] [Accepted: 07/15/2023] [Indexed: 12/19/2023] Open
Abstract
Purpose The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of endoscopic carpal tunnel release (ECTR) using best-evidence synthesis methods. Methods A systematic search of multiple databases was conducted for prospective contemporary studies published between January 2013 and January 2023 with at least 50 ECTR cases. Outcomes included the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) measured on a 0-100 scale, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS) on a 1-5 scale, pain visual analog scale on a 0-10 scale, conversion to open carpal tunnel release (CTR), complications, and reoperations. Outcomes were analyzed using a random-effects meta-analysis model. Metaregression was used to determine the association of patient- and study-level factors with ECTR outcomes. Results A total of 17 studies with 1,632 patients treated with ECTR were included. Median follow-up durations ranged from 4 to 7 months depending on the outcome. Statistically significant and clinically important improvements were noted after ECTR for Q-DASH, BCTQ-SSS, BCTQ-FSS, and pain visual analog scale scores, with mean differences from baseline of -28.8, -1.8, -1.5, and -5.1, respectively (P < .001 for all). In metaregression, the strongest predictor of improvement in Q-DASH, BCTQ-SSS, and BCTQ-FSS was a greater preoperative score for that variable (all P ≤ .005), indicating that patients with worse symptoms improved the most. The risks of conversion to open CTR, complications, and revision CTR were 0.7%, 0.7%, and 0.5%, respectively. Conclusions In a best-evidence synthesis of contemporary studies, ECTR resulted in significant improvements in function and pain, with a low risk of conversion to open surgery, complications, and reoperations over short-term follow-up. Clinical relevance Patients treated with ECTR can expect generally favorable clinical outcomes over the short term. However, long-term outcomes after ECTR are not well characterized.
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Affiliation(s)
| | - Warren C. Hammert
- Department of Orthopaedic Surgery, Division of Hand Surgery, Duke University Medical Center, Durham, NC
| | - Kevin C. Chung
- University of Michigan Comprehensive Hand Center, Michigan Medicine, Ann Arbor, MI
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Neumann A, Kponton T. [Endoscopic release of the carpal tunnel using the Agee technique modified by Neumann]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023:10.1007/s00064-023-00804-y. [PMID: 37097461 DOI: 10.1007/s00064-023-00804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Decompression of the median nerve by complete endoscopic release of the transverse carpal ligament (TCL) and the distal antebrachial fascia. Minimization of surgical trauma results in decreased postoperative morbidity and earlier return to work and daily activities. INDICATIONS Symptomatic carpal tunnel syndrome. CONTRAINDICATIONS Revision surgery after open or endoscopic procedure, rheumatic diseases. SURGICAL TECHNIQUE Small transverse incision at the ulnar border of the palmaris longus tendon, and proximal to the distal wrist flexion crease. Exposure and incision of the antebrachial fascia, dilatation of the carpal tunnel and dissection of synovial tissue from the undersurface of the TCL. With the wrist in extension, the endoscopic blade assembly with integrated camera is inserted into the canal. Exposure of TCL and short incision in the middle portion. Gradually, dissection of the distal portion of the TCL then completion by retraction of the blade distally to proximally. POSTOPERATIVE MANAGEMENT Slightly compressive dressing, selfcare on day 1 after procedure. RESULTS More than 25 years of experience, more than 8000 treated patients, and 3 documented cases with intraoperative lesions of the median nerve requiring revision. High acceptance and patient satisfaction in AQS1 patient-reported surveillance.
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Affiliation(s)
- A Neumann
- Praxisklinik Orthopädie und Handchirurgie München West, Fürstenriederstr. 69-71, 80686, München, Deutschland.
| | - T Kponton
- Praxisklinik Orthopädie und Handchirurgie München West, Fürstenriederstr. 69-71, 80686, München, Deutschland
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De Kleermaeker FGCM, Meulstee J, Bartels RHMA, Verhagen WIM. Long-term outcome after carpal tunnel release and identification of prognostic factors. Acta Neurochir (Wien) 2019; 161:663-671. [PMID: 30783807 DOI: 10.1007/s00701-019-03839-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/08/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The effectiveness of the surgical treatment of carpal tunnel syndrome (CTS) is well known on short term. However, limited data is available about long-term outcome after carpal tunnel release (CTR). The aims of this study were to explore the long-term outcome after CTR and to identify prognostic factors for long-term outcome. METHODS Patients with clinically defined CTS underwent CTR and completed the Boston Carpal Tunnel Questionnaire at baseline (T0), at about 8 months (T1), and after a median follow-up of 9 years (T2), as well as a 6-point scale for perceived improvement (at T1 and T2). Potentially prognostic factors were identified by logistic regression analysis and correlation. RESULTS At long-term follow-up, 87 patients (40.3%) completed the questionnaires. Mean score on Symptom Severity Scale (2.87 to 1.54; p < 0.001) and Functional Status Scale (2.14 to 1.51; p < 0.001) improved at 8 months and did not change significantly after 8 months. A favorable outcome was reported in 81.6%. A good treatment outcome after 8 months and to a lesser extent a lower FSS score at T0 were associated with a better long-term outcome. CONCLUSIONS CTR is a robust treatment for CTS and its effect persists after a period of 9 years. The most important factor associated with long-term outcome is treatment outcome after about 8 months and to a lesser extent functional complaints preoperatively. Outcome is independent of patient characteristics, electrodiagnostic test results, or findings at the initial neurological examination.
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Affiliation(s)
| | - Jan Meulstee
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532, SZ, Nijmegen, The Netherlands
| | - Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wim I M Verhagen
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532, SZ, Nijmegen, The Netherlands
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Groin anatomy, preoperative pain, and compression neuropathy in primary inguinal hernia: What really matters. Am J Surg 2019; 217:873-877. [PMID: 30878217 DOI: 10.1016/j.amjsurg.2019.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 02/09/2019] [Accepted: 02/11/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Enlargement of the ilioinguinal nerve distal to the inguinal ring is common in primary open inguinal herniorrhaphy and is histologically consistent with compression neuropathy. However, the origin of this neuropathy has not been thoroughly studied in primary inguinal hernia. METHODS In this prospective study, 143 primary inguinal herniorrhaphies were performed. Prior to surgery, all patients completed a preoperative pain questionnaire from the Carolina Comfort Scale and Visual Analog Scale-evaluating pain with various activities. Pain scores were statistically compared with several different anatomical surgical observations. RESULTS When each variable is individually compared with pain scores, a significant positive correlation exists between nerve enlargement and increased pain compared to those without enlargement for preoperative "most of the time pain" (P < 0.0017). There is also a statistically significant positive correlation between nerve enlargement and external ring fibrosis (P < 0.001). 81% of patients with enlargement have histological abnormalities. CONCLUSION Preoperative pain in primary inguinal hernia is correlated with ilioinguinal nerve enlargement, which is also correlated with fibrosis of the external oblique fascia at the external ring.
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Tofte JN, Anthony CA, Polgreen PM, Buckwalter JA, Caldwell LS, Fowler TP, Ebinger T, Hanley JM, Dowdle SB, Holte AJ, Arpey NC, Lawler EA. Postoperative care via smartphone following carpal tunnel release. J Telemed Telecare 2018; 26:223-231. [PMID: 30428766 DOI: 10.1177/1357633x18807606] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based ‘virtual visit’ for CTR could be safe, effective and convenient for the patient. Methods Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. Results Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23–63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. Discussion Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.
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Affiliation(s)
- Josef N Tofte
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Christopher A Anthony
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Philip M Polgreen
- Innovation Laboratory, Signal Center, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Joseph A Buckwalter
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Lindsey S Caldwell
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Timothy P Fowler
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | | | - Jessica M Hanley
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Spencer B Dowdle
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Andrew J Holte
- Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Nicholas C Arpey
- Department of Orthopaedic Surgery, Northwestern University, Chicago, USA
| | - Ericka A Lawler
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, USA
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Calandruccio JH, Thompson NB. Carpal Tunnel Syndrome: Making Evidence-Based Treatment Decisions. Orthop Clin North Am 2018; 49:223-229. [PMID: 29499823 DOI: 10.1016/j.ocl.2017.11.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Carpal tunnel syndrome (CTS) is one of the most common musculoskeletal disorders of the upper extremity. Comorbidities associated with the development of CTS include diabetes and obesity. Although a high rate of repetitive hand/wrist motions is a risk factor, there is insufficient evidence to implicate computer use in the development of CTS. Initial treatment generally is nonoperative, with the strongest evidence supporting bracing/splinting. Strong evidence supports operative treatment, regardless of technique, as superior to nonoperative treatment. Complications are infrequent and most are minor and transient.
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Affiliation(s)
- James H Calandruccio
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
| | - Norfleet B Thompson
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
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Tang CQY, Lai SWH, Tay SC. Long-term outcome of carpal tunnel release surgery in patients with severe carpal tunnel syndrome. Bone Joint J 2017; 99-B:1348-1353. [DOI: 10.1302/0301-620x.99b10.bjj-2016-0587.r2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 05/15/2017] [Indexed: 11/05/2022]
Abstract
Aims Few studies have examined the long-term outcome of carpal tunnel release (CTR). The aim of this study was to evaluate the patient-reported long-term outcome of CTR for electrophysiologically severe carpal tunnel syndrome (CTS). Patients and Methods We reviewed the long-term outcome of 40 patients with bilateral severe CTS who underwent 80 CTRs (46 open, 34 endoscopic) between 2002 and 2012. The outcomes studied were patient-reported outcomes of numbness resolution, the Boston Carpal Tunnel Questionnaire (BCTQ) score, and patient satisfaction. Results The mean follow-up was 9.3 years. Complete resolution of numbness was reported by 93.8% of patients, persistent numbness by 3.8%, and recurrent numbness by 2.5%. The mean BCTQ symptom score was 1.1 (sd 0.3; 1.0 to 2.55) and the mean Boston function score was 1.15 (sd 0.46; 1.0 to 3.5). 72.5% of patients were asymptomatic and had no functional impairment. Men had poorer outcomes than women and patients < 55 years had poorer outcomes than patients ≥ 55 years. All patients who had undergone endoscopic CTR reported complete resolution of numbness compared with 89.1% of those who had undergone open release (p = 0.047). There was no significant difference in outcome between dominant and non-dominant hands. Patient satisfaction rates were good. There were no adverse events. Conclusion CTR has a favourable outcome and good rates of satisfaction, even in patients with bilateral severe CTS at a mean of nine years after surgery. Endoscopic CTR has a higher rate of numbness resolution than open surgery. There were no significant differences in outcome between the dominant and non-dominant hand. Cite this article: Bone Joint J 2017;99-B:1348–53.
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Affiliation(s)
- C. Q. Y. Tang
- Yong Loo Lin School of Medicine, National
University of Singapore, 1E Kent Ridge Road, NUHS
Tower Block, 119228, Singapore
| | - S. W. H. Lai
- Yong Loo Lin School of Medicine, National
University of Singapore, 1E Kent Ridge Road, NUHS
Tower Block, 119228, Singapore
| | - S. C. Tay
- Singapore General Hospital, The
Academia, 20 College Road, 169856, Singapore
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Wright R, Born DE, D'Souza N, Hurd L, Gill R, Wright D. Pain and compression neuropathy in primary inguinal hernia. Hernia 2017; 21:715-722. [PMID: 28819736 DOI: 10.1007/s10029-017-1641-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 08/06/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Enlargement of the ilioinguinal nerve at the external inguinal ring is observed in 34% of patients undergoing primary open inguinal herniorrhaphy; in 88% of patients it occurs at the fascial edge where the hernia mushrooms with abdominal pressure. Compression neuropathy occurs near many anatomical nerve constriction sites and is associated with enlargement of the peripheral nerve accompanied by sensory changes. METHODS In this prospective study, Carolina Comfort Scale (CCS) questionnaire data was collected for 35 primary hernia repairs. Each patient underwent primary inguinal herniorrhaphy that included ilioinguinal neurectomy. All nerves were sampled proximal to the external inguinal ring. Any nerves with grossly increased overall diameter to any degree distal to the external ring were additionally sampled in the thickened portions. A neuropathologist performed histologic evaluation of the H&E-stained cross sections. RESULTS Paired comparison of proximal and distal nerves revealed a greater overall diameter and greater measured nerve-specific diameter in distal nerve segments. Nerves with increased overall diameter were also found to have a statistically significant positive correlation with four of eight pain measures. Additionally, increased nerve-specific diameter correlates with increased pain on four of eight pain values, but age effect on nerve diameter blunts this finding. CONCLUSIONS Increased preoperative CCS pain values in primary open inguinal hernia are significantly correlated with gross enlargement of the overall diameter and nerve-specific diameter of the ilioinguinal nerve beyond the external inguinal ring. This is consistent with a compression neuropathy.
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Affiliation(s)
- R Wright
- Cascade Hernia Institute, 208 17th Ave SE Suite 201, Puyallup, WA, 98372, USA.
| | - D E Born
- Department of Pathology, Stanford University, 300 Pasteur Dr., Stanford, CA, 94305, USA
| | - N D'Souza
- Pacific Northwest University of Health Sciences, Yakima, USA
| | - L Hurd
- Pacific Northwest University of Health Sciences, Yakima, USA
| | - R Gill
- Creighton University, Omaha, USA
| | - D Wright
- University of Denver, Denver, USA
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Efficacy of Keyhole Approach to Carpal Tunnel Syndrome under Ambulatory Strategy. Neurol Res Int 2017; 2017:3549291. [PMID: 28484650 PMCID: PMC5397629 DOI: 10.1155/2017/3549291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/03/2017] [Accepted: 01/22/2017] [Indexed: 11/22/2022] Open
Abstract
The carpal tunnel syndrome is one of the most common entrapment neuropathies found in humans. Currently, the gold standard is surgical treatment using different modalities. The minimally invasive strategy with high resolution capacity and less morbidity is still a challenge. Methods. Prospective nonrandomised clinical trial in which a minimally invasive microsurgical approach was used following the keyhole principle in 55 consecutive patients and 65 hands under local anesthesia and ambulatory strategy. They were evaluated with stringent inclusion criteria with the Levine severity and functional status scale and with a 2-year follow-up. Results. 90% showed immediate improvement dropping to grades 1-2 in all items of the scale referring to pain and numbness. 97% reported improvement, as of the first month, and 3% reported persistence of symptoms, although at a lesser degree and with no functional limitation. No incidents were identified during the procedure and 98% of patients were discharged within an hour after the surgical procedure. Conclusions. The microsurgical approach described following the keyhole principle is a treatment option that, under local anesthesia and ambulatory management, may represent an alternative strategy of an effective treatment reducing the morbidity. This trial is registered with Clinical Trials Protocol Identifier NCT03062722.
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Wright R, Born DE, D'Souza N, Hurd L, Gill R, Wright D. Why do inguinal hernia patients have pain? Histology points to compression neuropathy. Am J Surg 2017; 213:975-982. [PMID: 28388973 DOI: 10.1016/j.amjsurg.2017.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/31/2017] [Accepted: 03/16/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study is to describe the known soft tissue neuro-histology factors associated with compression neuropathy in relation to the incidence of preoperative pain in primary inguinal hernia. Enlargement of the ilioinguinal nerve occurs in 63% of patients with primary inguinal hernia; compression neuropathy has similar gross features. METHODS Patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. During routine inguinal hernia repair, nerve segments were sampled for histologic evaluation. RESULTS Twenty-two thickened nerve segments (63% of total) with proximal and distal specimens were resected for examination and comparison. We quantified various histologic indicators including nerve diameter, fascicle count, myxoid content within the epineurium, perineurium and endoneurium. Increased preoperative patient pain scores correlate with increased nerve diameter, increased fascicle count and increased myxoid material both within the perineurium and endoneurium. CONCLUSION These findings support the concept that preoperative hernia pain is associated with compression neuropathy.
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Affiliation(s)
| | - Donald E Born
- Department of Pathology, Stanford University, School of Medicine, Stanford, CA, USA.
| | - Natasha D'Souza
- Pacific Northwest University of Health Sciences, Yakima, WA, USA.
| | - Larissa Hurd
- Pacific Northwest University of Health Sciences, Yakima, WA, USA.
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Low OW, Cheah AEJ. Concurrent Minimally Invasive Carpal Tunnel Release Techniques in Distal Radius Open Reduction Internal Fixation. J Hand Surg Asian Pac Vol 2016; 21:121-4. [PMID: 27454517 DOI: 10.1142/s2424835516710016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Carpal tunnel syndrome is a common complication associated with distal radius fractures. Open carpal tunnel release in the same setting as open reduction and internal fixation of distal radius fractures is widely accepted. In this paper, we describe the technical details of a minimally invasive carpal tunnel release in the same setting as the fixation of a distal radius fracture via the same incision. Two options of minimally invasive techniques are described: The Knifelight® (Stryker, Kalamazoo, Michigan, USA) instrument and the single portal carpal tunnel release system (Agee, 3M Healthcare, St Paul, Minnesota, USA). Being well known and accepted techniques of carpal tunnel release, we believe that the techniques described in this paper provide a viable alternative for carpal tunnel release in the setting of distal radius fracture fixation; with the added advantages of the original minimally invasive techniques.
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Affiliation(s)
- O-Wern Low
- 1 Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, Singapore
| | - Andre E J Cheah
- † Department of Hand and Reconstructive Microsurgery, University Orthopaedic and Hand Reconstructive Microsurgery Cluster, National University Health System, Singapore
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