The Canaletto®™ implant for reconstructing transverse carpal ligament in carpal tunnel surgery. Surgical technique and cohort prospective study about 400 Canaletto cases versus 400 cases with open carpal tunnel surgery

Revision surgery for carpal tunnel syndrome: a retrospective study comparing the combination of Canaletto® and Dynavisc® gel versus Dynavisc® gel alone

The aim of this study was to assess the value of using a Canaletto® implant in combination with a gel composed of carboxymethylcellulose and polyethylene oxide in the surgical treatment of recurrent carpal tunnel syndrome (CTS). The case series included 31 patients with 32 hands operated for the second time for recurrent (22 cases) or recalcitrant (9 cases) CTS by neurolysis. The average patient age was 62 years. Dynavisc® gel alone was applied around the median nerve in the first 16 cases (Group I). The Canaletto® implant combined with Dynavisc® gel was used in the last 16 cases (group II). With an average follow up of 8 months (for group I) and 11 months (for group II), the pre/postoperative variation in pain assessed with a visual analog scale was 1.38/10 (group I) and 2.04/10 (group II), the QuickDASH score was 20.1/100 (Group I) and 20.48/100 (Group II), grip strength was 8% (Group I) and 20% (Group II), sensory nerve conduction speed was 23.20 m/s (group I) and 15.51 m/s (group II) and distal motor latency was 1.55 m/s (group I) and 1.21 m/s (group II). Ten patients recovered from hypoesthesia in both groups, 6 patients in group I and 2 patients in group II regained good trophicity of their superficial thenar muscles. Two patients from group II had not improved clinically although their electromyography had become normal. One patient from group II suffered a postoperative infection that required removal of the Canaletto® implant. He subsequently improved slightly. Our study found that for recurrent or recalcitrant CTS, the combination of Dynavisc® anti-adhesion gel around the median nerve and a Canaletto implant® after neurolysis results in outcomes that are as good as Dynavisc® alone, with a significant improvement of the QuickDASH score without the Canaletto®. In conclusion, the use of Dynavisc® gel alone around the median nerve after neurolysis seems to be as effective as other techniques described in literature but less invasive or time-consuming, and not associated with donor site morbidity such as the flexor tendon sheath.

Carpal tunnel release with versus without flexor retinaculum reconstruction for carpal tunnel syndrome at short- and long-term follow up-A meta-analysis of randomized controlled trials

Background

Carpal tunnel syndrome is a common neuropathy disorder for which surgical treatment consists of release and reconstruction of the flexor retinaculum. Reports of postoperative clinical outcomes after carpal tunnel release with or without flexor retinaculum reconstruction in several studies are controversial. This meta-analysis aimed to compare the efficacy and safety of carpal tunnel release with or without flexor retinaculum reconstruction.

Methods

The PubMed, EMBASE, Web of Science, Ovid, Cochrane Library and Clinical Tri Org databases were searched for randomized controlled trials that compared carpal release with and without transverse carpal ligament reconstruction for carpal tunnel syndrome. Outcomes included postoperative Boston Carpal Tunnel Questionnaire Symptom Severity Scale (SSS), Functional Status Scale (FSS), grip strength and complications. The follow-up time was categorized into short-term (0-3mon) and long-term(>3mon).

Results

A total of 7 studies with 613 patients met the inclusion criteria and were analyzed in detail. Statistical analysis showed no significant difference between two groups on postoperative long-term grip strength (MD 5.85, 95% CI -1.05 to 12.76) long-term SSS (MD -0.31, 95% CI -0.75 to 0.13) and occurrence of complications (RR 1.14, 95% CI 0.84 to 1.54), whereas statistically significant difference was found between groups regarding short-term grip strength (MD 1.51, 95% CI 0.86 to 2.17) and long-term FSS (MD -0.34, 95% CI -0.47 to -0.21).

Conclusion

Carpal tunnel release with flexor retinaculum reconstruction for carpal tunnel syndrome may result in improved long-term functional status while there’s no advantage regarding grip strength, symptom severity and safety over individual carpal tunnel release in short- and long-term outcomes.

Sickness absence after carpal tunnel release: a systematic review of the literature

Objectives The aim of this systematic review was to provide an overview of time to return to work (RTW) after carpal tunnel release (CTR), including return to different occupations and working patterns. Methods A systematic search from inception to 2016 was conducted using nine electronic databases, trial registries and grey literature repositories. Randomized controlled trials and observational studies reporting RTW times after CTR were included. Study risk of bias was assessed using Cochrane risk of bias assessment tools. Time to RTW was summarized using median and range. Results A total of 56 relevant studies were identified: 18 randomized controlled trials and 38 observational studies. Only 4 studies were rated as having a low risk of bias. Reported RTW times ranged from 4-168 days. Few studies reported occupational information. Among 6 studies, median time to return to non-manual work was 21 days (range 7-41), compared with 39 days for manual work (range 18-101). Median time to return to modified or full duties was 23 days (ranges 12-50 and 17-64, respectively), as reported by 3 studies. There was no common method of defining, collecting or reporting RTW data. Conclusions This review highlights wide variation in reported RTW times after CTR. Whilst occupational factors may play a role, these were poorly reported, and there is currently limited evidence to inform individual patients of their expected duration of work absence after CTR. A standardized definition of RTW is needed, as well as an agreed method of collecting and reporting related data.

Which surgery should be offered for carpal tunnel syndrome in a patient who was previously treated for recurrence on the contralateral side? Preliminary study of 13 patients with the Canaletto® implant

There are no published studies on the management of carpal tunnel syndrome (CTS) patients who have already been operated for recurrent CTS on the contralateral side. The aim of this study was to evaluate 13 patients with CTS who underwent primary release using a Canaletto^® implant. The 13 patients had all been operated for recurrent CTS previously. On the contralateral side, they all had subjective signs, and two of them already had complications. All were operated with the Canaletto^® implant according to Duché's technique, in a mean of 20minutes. After a mean 19.3-month follow-up, paresthesia, pain, and QuickDASH scores were significantly improved, even in one patient who underwent revision at another facility. This preliminary study suggests that use of a Canaletto^® implant as first-line treatment for CTS in patients who already underwent revision surgery on the other side is a simple and safe technique, without worsening of symptoms. These findings should be assessed with a prospective randomized controlled trial.

Carpal tunnel release with subneural reconstruction of the transverse carpal ligament compared with isolated open and endoscopic release

We report a new surgical technique of open carpal tunnel release with subneural reconstruction of the transverse carpal ligament and compare this with isolated open and endoscopic carpal tunnel release.

Between December 2007 and October 2011, 213 patients with carpal tunnel syndrome (70 male, 143 female; mean age 45.6 years; 29 to 67) were recruited from three different centres and were randomly allocated to three groups: group A, open carpal tunnel release with subneural reconstruction of the transverse carpal ligament (n = 68); group B, isolated open carpal tunnel release (n = 92); and group C, endoscopic carpal tunnel release (n = 53).

At a mean final follow-up of 24 months (22 to 26), we found no significant difference between the groups in terms of severity of symptoms or lateral grip strength. Compared with groups B and C, group A had significantly better functional status, cylindrical grip strength and pinch grip strength. There were significant differences in Michigan Hand Outcome scores between groups A and B, A and C, and B and C. Group A had the best functional status, cylindrical grip strength, pinch grip strength and Michigan Hand Outcome score.

Subneural reconstruction of the transverse carpal ligament during carpal tunnel decompression maximises hand strength by stabilising the transverse carpal arch.

Cite this article: Bone Joint J 2015;97-B:221–8

Carpal tunnel syndrome - Part II (treatment)

The treatments for non-deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini-open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long-term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2-0.5%.

Canaletto implant in revision surgery for carpal tunnel syndrome: 21 case series

Revision carpal tunnel surgery varies from 0.3% to 19%. It involves a delayed neurolysis and prevention of perineural fibrosis. Despite numerous available procedures, the results remain mediocre. The aim of this study is to evaluate the results of the Canaletto implant in this indication. Our series includes 20 patients (1 bilateral affection) reoperated for carpal tunnel between October 2008 and December 2009. After the first operation, the symptom-free period was 112 weeks, on average. The average incision was 27 mm. After neurolysis, the Canaletto implant was placed in contact with the nerve. Immediate postoperative mobilization was commenced. Sensory (pain, DN4, and hypoesthesia), motor (Jamar, muscle wasting), and functional (disabilities of the arm, should, and hand; DASH) criteria were evaluated. Nerve conduction velocity (NCV) of the median nerve was measured. Average follow up was 12.1 months. All measurements were improved after insertion of the Canaletto implant: pain (6.45-3.68), DN4 (4.29-3.48), Quick DASH (55.30-34.96), Jamar (66.11-84.76), NCV (29.79-39.06 m/s), hypoesthesia (76.2-23.8%), wasting (42.9-23.8%). Nevertheless, four patients did not improve, and pain was the same or worse in six cases. Our results show that in recurrent carpal tunnel syndrome, Canaletto implant insertion gives results at least as good as other techniques, with the added advantage of a smaller access incision, a rapid, less invasive technique, and the eliminated morbidity of raising a flap to cover the median nerve.