Role of ancillary procedures in surgical management of carpal tunnel syndrome: epineurotomy, internal neurolysis, tenosynovectomy, and tendon transfers

Case Series: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT) for Camitz Transfer

Background: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT), with the benefit of simplicity and a low complication rate, is a well-recognised procedure in orthopaedic surgery. To date, there is no report using WALANT technique with the Camitz transfer procedure. The aim of this study is to determine the early outcomes of using WALANT for Camitz transfer and compare these with outcomes of similar procedures in literature. Methods: Between January 2012 and January 2018, all patients with severe carpal tunnel syndrome (CTS) with thenar muscle atrophy who underwent the Camitz transfer procedure as day surgery under the WALANT technique at the Thammasat University Hospital were included. With the WALANT technique, the 10 mL of prepared anaesthesia was injected into the area around the palmaris longus tendon from 5-cm proximal to the distal wrist crease to the distal palmar crease, while an additional 10 mL was injected from the radial side of the metacarpophalangeal joint of the thumb to the distal wrist crease before the operation. Upon completion of the operation, the patients' hand was placed in a thumb spica splint. Patient demographic data, visual analogue scale (VAS) during injection and during procedure, operative time, blood lost and complications were recorded. Results: Thirty-six patients (8 males and 28 females) were included. The average age of the patients was 65.9 (37-87) years old. The average VAS score during the anaesthetic injection was 6.22 (5-8). The average VAS pain score during the operation was 0.52 (0-3). The average operative time was 27.06 (17-47) minutes. The mean intraoperative blood loss was 3 (2.4-6.8) mL. All patients underwent the procedure without any complications. Conclusions: The WALANT technique is safe and can be used as alternative anaesthesia for the Camitz transfer. Level of Evidence: Level IV (Therapeutic).

Update on surgical procedures for carpal tunnel syndrome: What is the current evidence and practice? What are the future research directions?

Carpal tunnel syndrome (CTS) is a multifactorial compression neuropathy. It is reported to be very common and rising globally. CTS’s treatment varies from conservative measures to surgical treatments. Surgery has shown to be an effective method for more severe cases. However few unclear aspects and room for further research and improvements still remains. We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS. The simple algorithm of leaving the choice of the surgical method to surgeons’ preference and experience (together with consideration of patients’ related factors) seem to be the best available option, which is supported by the most recent metanalysis and systematic reviews. We suggest that surgeons (unless in presence of precise indications towards endoscopic release) should tend to perform a minimally invasive open approach release, favoring the advantage of a better neurovascular structures visualization (and a consequent higher chance to perform a complete release with long term relief of symptoms) instead of favoring an early reduction (in the first postoperative days) of immobilization and pain. Research towards a universally accepted standardization should be aimed for by the researchers, who have failed to date to sufficiently limit bias and limitations.

Analysis of the Long-Term Outcome in Open Carpal Tunnel Release Surgeries with and without External Neurolysis of Median Nerve, Using Boston Carpal Tunnel Questionnaire (BCTQ)-Hindi Version

Background  The effectiveness of open carpal tunnel release (OCTR) in treating carpal tunnel syndrome (CTS) is well known. However, the role of ancillary external neurolysis of the median nerve is not well-documented. The Boston carpal tunnel questionnaire (BCTQ) is a commonly used disease-specific outcome instrument for CTS, which is validated across major languages of the world. No such validated Hindi version of BCTQ exists.

Objectives  To analyze and compare the long-term outcome in patients who underwent OCTR alone and OCTR with external neurolysis of the median nerve, using BCTQ–Hindi version, while checking its validity.

Materials and Methods  A retrospective, cross-sectional study was conducted at a tertiary care institute. The BCTQ was translated into Hindi language by a language expert. Eighty-four consecutive patients who underwent either unilateral/bilateral OCTR, with or without external neurolysis of the median nerve, between 2009 and 2019 were included in the study. Outcome analysis was done using BCTQ–Hindi version and patient satisfaction scoring. BCTQ–Hindi version was examined for statistical validity. Subgroup analysis of the outcome based on surgical technique (OCTR vs. OCTR with external neurolysis) used was carried out.

Results  Response rate was 80.9%. Total hands evaluated were 108. BCTQ–Hindi version showed statistical validity. Overall symptom severity score (SSS) and functional severity score (FSS) were 1.14 ± 0.4 and 1.12 ± 0.35, respectively. Subgroup analysis of outcome revealed statistically significant results in favor of OCTR with external neurolysis of the median nerve.

Conclusions  BCTQ–Hindi version is statistically validated. OCTR with external neurolysis of the median nerve is a promising avenue in surgical management of CTS. Further prospective studies are warranted.

Flexor Tenosynovectomy for Recurrent Carpal Tunnel Syndrome: A Retrospective Case Series of 108 Hands

Background: The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery. Fibrosis and hypertrophy have been identified in the flexor tenosynovium in these patients. The authors use flexor tenosynovectomy (FTS) for recurrent CTS after primary carpal tunnel release and present a review of these patients. Methods: A retrospective chart review was performed of 108 cases of FTS for recurrent CTS from 1995 to 2015 by 4 attending surgeons at one institution. Demographic information, symptoms, and outcomes were among the data recorded. A phone survey was conducted on available patients where the shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and satisfaction were assessed. Results: Average office follow-up was 12 months. Average age was 57.5 years. A total of 104 (96%) reported symptom improvement and 48 (44%) reported complete symptom resolution. Forty patients were available for long-term follow-up at an average 6.75 years postoperatively via phone interview. Average QuickDASH score was 31.2 in these patients. Thirty-six (90%) of 40 patients were initially satisfied at last office visit, and 31 (78%) of 40 were satisfied at average 6.9 years, a maintenance of satisfaction of 86%. Satisfied patients were older (58 years) than unsatisfied patients (51 years). Conclusion: Both long-term satisfaction and QuickDASH scores in our cohort are consistent with or better than published results from nerve-shielding procedures. The authors believe a decrease in both carpal tunnel volume and potential adhesions of fibrotic or inflammatory synovium contributes to the benefits of this procedure. This remains our procedure of choice for recurrent CTS.

The Camitz transfer and its modifications: a review

The Camitz procedure involves transfer of the insertion of the palmaris longus tendon with a strip of the palmar aponeurosis to the insertion of abductor pollicis brevis in order to improve thumb opposition, and is usually done when severe carpal tunnel syndrome results in complete wasting of the thenar muscles. We carried out a systematic review of the published reports of this procedure. Analysis of available outcome data showed improvement in overall hand function in 86-100% of patients undergoing the original Camitz procedure. Several modifications of the original Camitz transfer have been described, with most focusing on the incorporation and placement of pulleys. All studies are limited by their small sample sizes. Overall, there is a lack of studies comparing the Camitz transfer with other opponensplasty techniques and comparing the various modifications of the original procedure.

LEVEL OF EVIDENCE

IV.

Comparison of the histopathological findings of patients with diabetic and idiopathic carpal tunnel syndrome

PURPOSE

This study is aimed to investigate whether there are any histopathological differences between diabetic and idiopathic carpal tunnel syndromes.

METHODS

The biopsy specimens were taken from transverse carpal ligament (TCL), tenosynovium adjacent to median nerve and epineurium of median nerve and evaluated in 47 patients (21 diabetic and 26 idiopathic) who were diagnosed with carpal tunnel syndrome (CTS) and treated surgically with open carpal tunnel release. Fibroblast proliferation, fibrosis, perivascular inflammation, oedema, vascular proliferation and vascular wall thickness were determined and scored in all specimens.

RESULTS

There weren't any histopathological abnormalities in TCL specimens of both groups. Synovial hyperplasia, fibrosis and perivascular inflammation were not observed in tenosynovial analysis of both groups. Diabetic CTS patients, when compared with idiopathic CTS patients, had higher rates of synovial edema (idiopathic CTS 57 %, diabetic CTS 87 %), vascular proliferation (idiopathic CTS 30.8 %, diabetic CTS 90.5 %) and increased vascular wall thickness (idiopathic CTS 11.5 %, diabetic CTS 90.5 %). There was no oedema, fibrosis and perivascular inflammation of the epineurium in specimens of either group. But increases in vascular proliferation (idiopathic CTS 7.7 %, diabetic CTS 71.4 %) and vascular wall thickness (idiopathic CTS 3.8 %, diabetic CTS 71.4 %) was seen in the epineurium of diabetic patients and these differences were statistically significant (p < 0.05).

CONCLUSION

Because of the severe synovial and epineurial histopathological abnormalities and inadequate neural regeneration capacity, surgical open carpal tunnel decompression should be planned earlier in diabetic CTS patients. Further studies should be considered to evaluate the histopathological features of diabetic CTS patients early in the course of the disease.

Transfer of the flexor carpi radialis to the abductor pollicis brevis tendon for the restoration of tip-pinch in severe carpal tunnel syndrome

In patients with severe thenar atrophy secondary to carpal tunnel syndrome, we hypothesize that following open carpal tunnel release, concomitant transfer of the abductor pollicis brevis (APB) origin to the flexor carpi radialis (FCR) tendon will lead to improved patient function restoring palmar abduction and thumb opposition. We evaluated 14 patients through questionnaires and seven patients through additional physical examination (thumb range of motion, ability to tip pinch, grip/pinch strength) for a mean follow-up of 2.8 years. All patients showed evidence of palmar abduction with 71% demonstrating the ability to oppose the thumb to the tip and base of the small finger. The transfer of the APB origin to the FCR tendon can restore thumb abduction and opposition for thenar paralysis secondary to severe carpal tunnel syndrome. Patients experience good functional outcomes with the majority experiencing restored thumb opposition.

A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome

BACKGROUND

Recurrent and persistent carpal tunnel syndrome is an uncommon but potentially difficult surgical dilemma. Many surgical treatment options have been described in the literature without comparative data on outcome.

METHODS

A systematic review on recurrent carpal tunnel syndrome was performed for all articles from 1946 to 2012 in MEDLINE, EMBASE, CENTRAL, and hand-searched reference lists from all identified articles. Twenty-three articles were screened and identified from the time period 1972 to 2012, representing two general treatment groups: decompression with flap interposition and repeated open decompression. A meta-analysis was then performed, generating forest and funnel plots of the data.

RESULTS

In total, 294 patients from 14 studies in the flap arm of the meta-analysis had a weighted success rate of 86 percent (95 percent CI, 0.75 to 0.96), and 364 patients from nine studies in the nonflap arm had a weighted 75 percent success rate (95 percent CI, 0.66 to 0.84). Heterogeneity was statistically analyzed and revealed low heterogeneity with the I statistic. Forest plots were created and analyzed between subgroups, and chi-square analysis revealed a highly statistically significant difference (p = 0.001). The odds ratio of success in the nonflap group was 0.50 (95 percent CI, 0.33 to 0.75).

CONCLUSIONS

Decompression with the use of vascularized flap coverage appears to have a higher success rate over simple repeated decompression. The relevance of these data is pertinent to all hand surgeons, as they could have an impact on treatment guidelines for this relatively uncommon but problematic condition, but further prospective study is needed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective

PURPOSE

In 1987, Duncan et al.(1) reported on a survey of the members of the American Society for the Surgery of the Hand (ASSH) about their practices in treating carpal tunnel syndrome (CTS). To better understand changes in the treatment of CTS over the past 25 years, we repeated the survey while incorporating present-day controversies.

METHODS

With the approval of the ASSH, an Internet-based survey was e-mailed to all members of the Society. This included 33 primary questions focusing on 4 areas of study: surgeon demographic information, nonoperative treatment, surgical technique, and postoperative care. A total of 1,463 surveys were delivered and 707 surveys were completed and returned, for a response rate of 48%. Responses were compared with the responses from Duncan et al. published 25 years ago.(1)

RESULTS

In contrast to the practice patterns identified 25 years ago, this survey identified several changes in current clinical practices including the following statistically significant findings: Preoperatively, surgeons have increased the use of splints and corticosteroid injections, treat nonoperatively longer, and have narrowed their surgical indications. Regarding surgical technique, surgeons now are using tourniquets less, infiltrate the carpal tunnel with corticosteroids less, and place deep sutures less often. Furthermore, performing concomitant procedures along with release of the transverse carpal ligament has decreased. Orthotic use and duration postoperatively also decreased.

CONCLUSIONS

Although significant differences are evident between management of CTS between 1987 and 2011, no consensus has emerged.

Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery

BACKGROUND

Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.

METHODS

We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).

RESULTS

Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.

CONCLUSIONS

We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.

Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis

PURPOSE

To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery.

METHODS

We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection.

RESULTS

The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients).

CONCLUSIONS

The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Pick-up test: an indication for opponensplasty in patients with severe carpal tunnel syndrome

PURPOSE

To use a pick-up test to assess thenar motor deficit and results of opponensplasty.

METHODS

Eight consecutive patients with idiopathic severe carpal tunnel syndrome and severe thenar motor deficit were identified. All were females aged 39 to 60 (mean, 53) years and right-hand dominant. The severity of thenar motor deficit was assessed using the pick-up test. Failure to pick up a coin with the thumb and index finger only in a normal pulp-to-pulp pincer grip was an indication for an opponensplasty (in addition to open carpal tunnel release) to hasten recovery of thumb abduction. Treatment outcome was assessed using the pick-up test at 6, 8, and 12 weeks.

RESULTS

Preoperatively, all patients were unable to perform the pick-up test. At postoperative 6 weeks, all patients could pick up the coin with no difficulty and were satisfied with the result of opponensplasty. There was no relapse at subsequent follow-ups and no donor-site morbidity in terms of cosmesis, scar pain or infection. Grip strength and the range of wrist motion were 63% and 92% of the normal side, respectively.

CONCLUSION

The pick-up test is a simple and reliable means of identifying those in need of an opponensplasty.

Unusual complication of an opposition tendon transfer at the wrist: ulnar nerve compression syndrome

Restoration of thumb opposition by tendon transfer may be necessary in cases of severe thenar atrophy caused by long-standing carpal tunnel syndrome. Routing the extensor indicis proprius transfer subcutaneously around the ulna to reanimate thumb opposition is an accepted procedure and is considered safe. Ulnar nerve compression leading to palsy is possible, however, as shown in the patient presented. Neurolysis failed to improve the palsy. Rerouting of the transfer deep to the ulnar nerve was necessary to treat the iatrogenic condition. Possible nerve compression should be kept in mind when planning a tendon transfer around the ulnar side of the forearm or carpus and when following up with the patient. Early intervention is necessary to prevent permanent sequelae.