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Westenberg RF, DiGiovanni PL, Schep NWL, Eberlin KR, Chen NC, Coert JH. Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis. Plast Reconstr Surg 2024; 153:746e-757e. [PMID: 37189245 DOI: 10.1097/prs.0000000000010682] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR. METHODS The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire. RESULTS A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery. CONCLUSION Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.
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Affiliation(s)
- Ritsaart F Westenberg
- From the Massachusetts General Hospital
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht
| | | | | | | | | | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht
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Muramatsu K, Tani Y, Yamashita Y, Corpus-Zuñiga FM, Sugimoto H, Tec LM. Causes of Iatrogenic Median Nerve Injury after Endoscopic Carpal Tunnel Release. J Hand Surg Asian Pac Vol 2023; 28:634-641. [PMID: 38073414 DOI: 10.1142/s2424835523500662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon's experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated. Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes-Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively. Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side. Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- Keiichi Muramatsu
- Department of Hand Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | - Yasuhiro Tani
- Department of Hand Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | - Yosuke Yamashita
- Department of Hand Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | | | - Hideaki Sugimoto
- Department of Hand Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | - Lou Mervyn Tec
- Department of Hand Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
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Biglari F, Sabaghzadeh A, Sadighi M, Ebrahimpour A, Davoodi Bojd M, Jafari Kafiabadi M. Initial Outcomes of a Novel Modification of Looped Threaded Carpal Tunnel Release Method. Tech Hand Up Extrem Surg 2023; 27:132-135. [PMID: 36571155 DOI: 10.1097/bth.0000000000000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Various surgical techniques are available for the alleviation of symptoms in carpal tunnel syndrome and each of them has its pros and cons. This study was designed and performed to present a novel approach for cutting transverse carpal ligament by the thread looping technique without the use of ultrasonography. The novel modification of looped threaded carpal tunnel release was performed on 10 hands of 10 patients. The disabilities of arm, shoulder, and hand score, visual analog scale, and 2-point discrimination were used for assessing the outcomes. No patients developed pillar pain or scar discomfort after surgery. Complete elimination of paresthesia, pain, and numbness occurred in all patients. There was a significant reduction in the disabilities of arm, shoulder, and hand and visual analog scale scores ( P value<0.05). This technique is safe, available, and effective for carpal tunnel release and minimizes postoperative complications, such as pillar pain, and scar discomfort with avoiding unnecessary injuries to the surrounding soft tissue.
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Affiliation(s)
- Farsad Biglari
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e-Tajrish Hospital
| | - Amir Sabaghzadeh
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e-Tajrish Hospital
| | - Mehrdad Sadighi
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e-Tajrish Hospital
| | - Adel Ebrahimpour
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e-Tajrish Hospital
| | - Maryam Davoodi Bojd
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e-Tajrish Hospital
| | - Meisam Jafari Kafiabadi
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e-Tajrish Hospital
- Physiotherapy Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Pace V, Marzano F, Placella G. Update on surgical procedures for carpal tunnel syndrome: What is the current evidence and practice? What are the future research directions? World J Orthop 2023; 14:6-12. [PMID: 36686281 PMCID: PMC9850791 DOI: 10.5312/wjo.v14.i1.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Valerio Pace
- Department of Trauma & Orthopaedics, AOSP Terni - University of Perugia, Terni 05100, Italy
| | - Fabrizio Marzano
- Department of Trauma & Orthopaedics, University of Perugia, Perugia 06100, Italy
| | - Giacomo Placella
- Department of Trauma and Orthopaedics, IRCSS San Raffaele Hospital, Milan 20132, Italy
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Mujadzic T, Friedman HI, Atwez A, Botonjic H, Mujadzic MM, Chen E, Gilstrap JN, Mujadzic MM. Palmar Creases and Their Implication on Carpal Tunnel Surgery. Ann Plast Surg 2022; 88:S495-S497. [PMID: 35690945 DOI: 10.1097/sap.0000000000003123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND A thorough knowledge of normal and variant anatomy of the wrist and hand is fundamental to avoiding complications during carpal tunnel release. The purpose of this study was to document variations of the surface anatomy of the hand to identify a safe zone in which the initial carpal tunnel incision could be placed. The safe zone was identified as the distance between the radial side of hook of hamate and the ulnar edge of the origin of the motor branch of the median nerve (MBMN). METHODS Kaplan's cardinal line and other superficial markers were used to estimate the size of the safe zone, in accordance to prior published anatomical studies. The presence of a longitudinal palmar crease (thenar, median, or ulnar creases) within the safe zone was recorded. RESULTS Of the 150 participants (75 male, 75 female) examined, the average safe zone widths were 10.85 (right) and 10.28 (left) mm. In all the hands examined, 86.33% of the safe zones (259 of 300) contained a longitudinal palmar crease. In the White population (n = 50), the average safe zone widths were 11.49 (right) and 10.01 (left) mm; in the African American population (n = 50), the average safe zone widths were 12.27 (right) and 12.01 (left) mm; and in the Asian population (n = 50), the average safe zone widths were 8.79 (right) and 8.82 (left) mm. On overage, males had a larger safe zone width than females by 4.55 mm. CONCLUSIONS Although there seems to be variability between race and sex with regard to safe zone width, finding 86.33% of longitudinal palmar creases within the safe zone suggests that, for most patients, the initial carpal tunnel surgery incision may be hidden within the palmar crease while minimizing the risk of motor branch of the median nerve injury. Overall, the safe zone width is on average up to 10.5 mm measured from the hook of the hamate along Kaplan's cardinal line.
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Affiliation(s)
- Tarik Mujadzic
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
| | - Harold I Friedman
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
| | - Abdelaziz Atwez
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
| | - Hata Botonjic
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
| | | | - Elliott Chen
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
| | - Jarom N Gilstrap
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
| | - Mirsad M Mujadzic
- From the Prisma Health/University of South Carolina School of Medicine, Columbia, SC
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Wu YX, Yin H, Lin JY, Jiang HJ, Han F, Liu SD, Qu W. Our 15-year experience of complications of Chow's technique for endoscopic carpal tunnel releasing. Neurol Res 2022; 44:761-765. [PMID: 35262469 DOI: 10.1080/01616412.2022.2051134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Our objective in this study was to summarize our 15-year experience treating carpal tunnel syndrome released with Chow technique, focusing on the complications and how to avoid them. METHOD We systematically evaluated the postoperative complications in 211 patients who underwent endoscopic carpal tunnel release (ECTR) with Chow technique. We recorded the incidence of complex regional pain syndrome type I (CRPS I), median nerve and digital nerve injury, superficial palmar arch injury, and tendon injury. RESULT The overall incidence of complications was 5.6%, and involved 10 cases of CRPS I, 1 case of median nerve trunk injury, and 1 case of superficial palmar arch injury. No other complication occurred. We used oral pregabalin and neurotropin to relieve CRPS I symptoms, and performed second operations for the other two complications. CONCLUSIONS Our study revealed that ECTR could reduce structural and cutaneous complications, but increase the incidence of nerve injury. we speculated that the incidence of CRPS I may be higher in the Asian population.
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Affiliation(s)
- Yu-Xuan Wu
- Department of Orthopaedics, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, Liaoning, P. R. China.,Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
| | - He Yin
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
| | - Jia-Yi Lin
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
| | - Hua-Jun Jiang
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
| | - Feng Han
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
| | - Si-da Liu
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
| | - Wei Qu
- Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, P. R. China
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Teh KK, Gunasagaran J, Choo CH, Ahmad TS. A Novel Supraretinacular Endoscopic Carpal Tunnel Release: Surgical Technique, Clinical Efficacy and Safety (A Series of 48 Consecutive Cases). JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:329-334. [PMID: 35415581 PMCID: PMC8991636 DOI: 10.1016/j.jhsg.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kok Kheng Teh
- Department of Orthopaedic Surgery, Faculty of Medicine, National Orthopaedic Centre of Excellence for Research & Learning, University of Malaya, Kuala Lumpur, Malaysia
- Sunway Medical Centre, Selangor, Malaysia
- Sunway University, Selangor, Malaysia
- Corresponding author: Kok Kheng Teh, MD, MS Orth, Sunway Medical Centre, No. 5, Jalan Lagoon Selatan, Bandar Sunway, 47500 Selangor, Malaysia.
| | - Jayaletchumi Gunasagaran
- Department of Orthopaedic Surgery, Faculty of Medicine, National Orthopaedic Centre of Excellence for Research & Learning, University of Malaya, Kuala Lumpur, Malaysia
| | - Ch’ng Hwei Choo
- Department of Orthopaedic Surgery, Faculty of Medicine, National Orthopaedic Centre of Excellence for Research & Learning, University of Malaya, Kuala Lumpur, Malaysia
| | - Tunku Sara Ahmad
- Department of Orthopaedic Surgery, Faculty of Medicine, National Orthopaedic Centre of Excellence for Research & Learning, University of Malaya, Kuala Lumpur, Malaysia
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Chen Z, Liu J, Yuan TB, Cai DW, Wang XX, Qin J. Comparison of clinical outcomes between open and modified endoscopic release for carpal tunnel syndrome. Exp Ther Med 2021; 22:861. [PMID: 34178134 PMCID: PMC8220677 DOI: 10.3892/etm.2021.10293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/26/2020] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate a novel technology, requiring only a single portal and no special equipment, to perform endoscopic treatment of carpal tunnel (CT) syndrome (CTS). This novel technique involves a surgical approach and standard operating procedures and is designed to minimize the potential for complications. Patients with CTS were randomly assigned using a computer-generated random allocation and stratified by site to either the modified endoscopic CT release (MECTR) group (n=48) or open CT release (OCTR) group (n=46). Various medical indexes were compared between the two groups, including operative time, hospitalization time, the time required to resume a normal life or work, intraoperative complications, incision infection rate, the amelioration of symptoms (Kelly grading), post-operative scar pain score, recovery of grip strength and pinch strength, two-point discrimination and the presence of sympathetic dystrophy. The results revealed that all patients had grade A wound healing and the symptoms were completely relieved. No significant differences were observed between the two groups with regards to the incision infection rate, intraoperative complications, grip strength, pinch strength, two-point discrimination, presence of sympathetic dystrophy and clinical symptom amelioration. In addition, compared with the OCTR group, the MECTR group had a decreased operative and hospitalization time, post-operative scar pain score and time required to resume a normal lifestyle. Post-operative electromyographic examination also revealed that the median nerve sensory conduction speed increased compared with that prior to surgery in both groups. In conclusion, the use of MECTR for the treatment of CTS achieved higher patient satisfaction, a shorter operative time and hospitalization time, an earlier return to work time or resumption of a normal life, as well as less post-operative scar pain compared with OCTR. Thus, these results suggested that MECTR may be an effective method for the treatment of idiopathic CTS. Trial registration no. ChiCTR2000041165, retrospectively registered 20th December 2020.
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Affiliation(s)
- Zhong Chen
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, P.R. China
| | - Jun Liu
- Department of Orthopedics, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Tang-Bo Yuan
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, P.R. China
| | - Da-Wei Cai
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, P.R. China
| | - Xiao-Xu Wang
- Department of Orthopedics, The Second Affiliated Hospital of Nanhua University, Hengyang, Hunan 421001, P.R. China
| | - Jian Qin
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu 211100, P.R. China
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Ng AWH, Griffith JF, Tsoi C, Fong RCW, Mak MCK, Tse WL, Ho PC. Ultrasonography Findings of the Carpal Tunnel after Endoscopic Carpal Tunnel Release for Carpal Tunnel Syndrome. Korean J Radiol 2021; 22:1132-1141. [PMID: 33987990 PMCID: PMC8236373 DOI: 10.3348/kjr.2020.1039] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 02/03/2023] Open
Abstract
Objective To investigate changes in the median nerve, retinaculum, and carpal tunnel on ultrasound after successful endoscopic carpal tunnel release (ECTR). Materials and Methods This prospective study involved 37 wrists in 35 patients (5 male, 30 female; mean age ± standard deviation [SD], 56.9 ± 6.7 years) with primary carpal tunnel syndrome (CTS). An in-house developed scoring system (0–3) was used to gauge the clinical improvement after ECTR. Ultrasound was performed before ECTR, and at 1, 3, and 12 months post-ECTR. Changes in the median nerve, flexor retinaculum, and carpal tunnel morphology on ultrasound after ECTR were analyzed. Ultrasound parameters for different clinical improvement groups were compared. Results All patients improved clinically after ECTR. The average clinical improvement score ± SD at 12 months post-ECTR was 2.2 ± 0.7. The median nerve cross-sectional area proximal and distal to the tunnel decreased at all time intervals post-ECTR but remained swollen compared to normal values. Serial changes in the median nerve caliber and retinacular bowing after ECTR were more pronounced at the tunnel outlet than at the tunnel inlet. The flexor retinaculum had reformed in 25 (68%) of 37 wrists after 12 months. Conclusion Postoperative changes in median nerve and retinaculum parameters were most pronounced at the tunnel outlet. Even in patients with clinical improvement after ECTR, nearly all ultrasound parameters remain abnormal at one year post-ECTR. These ultrasound parameters should not necessarily be relied upon to diagnose persistent CTS after ECTR.
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Affiliation(s)
- Alex Wing Hung Ng
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - James Francis Griffith
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Carita Tsoi
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Raymond Chun Wing Fong
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Michael Chu Kay Mak
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Lim Tse
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Pak Cheong Ho
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Liu B, Wu F. Initial Outcomes of a Novel High-Visibility Endoscopic Carpal Tunnel Release Technique. J Wrist Surg 2021; 10:64-69. [PMID: 33552698 PMCID: PMC7850806 DOI: 10.1055/s-0040-1715089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
Background A large variety of endoscopic carpal tunnel release methods have been described in efforts to shorten recovery time, reduce scar discomfort, and allow earlier return to work. The majority of existing techniques are the modifications of the Agee, Chow, and Menon techniques, all of which require dedicated equipment that can increase facility and surgical fees for the patient and institution. We present a novel high-visibility endoscopic carpal tunnel release technique that uses common hand surgery instruments available in all surgical units, without requiring disposable or custom devices. Description of Technique The cases were performed under local anesthesia using routine reusable instruments and a conventional 2.5-mm 30-degree small joint arthroscope. Following proximal dissection, a clear, colorless, plastic shield was created from a standard syringe that offered a 360-degree vision of the carpal tunnel and protection of the median nerve. Release of the transverse carpal ligament was performed under full arthroscopic vision using Metzenbaum dissection scissors. Methods This pilot study analyses the first nine cases in eight patients who were operated on using this technique, with a minimum of 6 months of follow-up. Results No peri- or postoperative complications were encountered. All patients demonstrated significant improvements in the Disabilities of the Arm, Shoulder, and Hand score, the Boston Carpal Tunnel Questionnaire score, and a visual analog score for pain. Conclusion The high-visibility endoscopic carpal tunnel release technique is safe and effective, and offers a viable cost-reducing alternative to the existing endoscopic methods for carpal tunnel syndrome. Future comparative trials are required to validate these findings in a larger series. Level of Evidence This is a Level IV study.
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Affiliation(s)
- Bo Liu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Feiran Wu
- Department of Orthopaedics, University Hospitals Birmingham, Birmingham, United Kingdom
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Orhurhu V, Orman S, Peck J, Urits I, Orhurhu MS, Jones MR, Manchikanti L, Kaye AD, Odonkor C, Hirji S, Cornett EM, Imani F, Varrassi G, Viswanath O. Carpal Tunnel Release Surgery- A Systematic Review of Open and Endoscopic Approaches. Anesth Pain Med 2020; 10:e112291. [PMID: 34150584 PMCID: PMC8207842 DOI: 10.5812/aapm.112291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 12/31/2022] Open
Abstract
CONTEXT Carpal tunnel syndrome (CTS) is the most frequent peripheral compression-induced neuropathy observed in patients worldwide. Surgery is necessary when conservative treatments fail and severe symptoms persist. Traditional Open carpal tunnel release (OCTR) with visualization of carpal tunnel is considered the gold standard for decompression. However, Endoscopic carpal tunnel release (ECTR), a less invasive technique than OCTR is emerging as a standard of care in recent years. EVIDENCE ACQUISITION Criteria for this systematic review were derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two review authors searched PubMed, MEDLINE, and the Cochrane Database in May 2018 using the following MeSH terms from 1993-2016: 'carpal tunnel syndrome,' 'median nerve neuropathy,' 'endoscopic carpal tunnel release,' 'endoscopic surgery,' 'open carpal tunnel release,' 'open surgery,' and 'carpal tunnel surgery.' Additional sources, including Google Scholar, were added. Also, based on bibliographies and consultation with experts, appropriate publications were identified. The primary outcome measure was pain relief. RESULTS For this analysis, 27 studies met inclusion criteria. Results indicate that ECTR produced superior post-operative pain outcomes during short-term follow-up. Of the studies meeting inclusion criteria for this analysis, 17 studies evaluated pain as a primary or secondary outcome, and 15 studies evaluated pain, pillar tenderness, or incision tenderness at short-term follow-up. Most studies employed a VAS for assessment, and the majority reported superior short-term pain outcomes following ECTR at intervals ranging from one hour up to 12 weeks. Several additional studies reported equivalent pain outcomes at short-term follow-up as early as one week. No study reported inferior short-term pain outcomes following ECTR. CONCLUSIONS ECTR and OCTR produce satisfactory results in pain relief, symptom resolution, patient satisfaction, time to return to work, and adverse events. There is a growing body of evidence favoring the endoscopic technique for pain relief, functional outcomes, and satisfaction, at least in the early post-operative period, even if this difference disappears over time. Several studies have demonstrated a quicker return to work and activities of daily living with the endoscopic technique.
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Affiliation(s)
- Vwaire Orhurhu
- University Of Pittsburgh Medical Center, Williamsport, PA, USA
| | - Sebastian Orman
- Department of Orthopedics, Georgetown University School of Medicine, Washington, DC, USA
| | - Jacquelin Peck
- Department of Anesthesiology, Mt. Sinai Medical Center of Florida, Miami Beach, Florida, USA
| | - Ivan Urits
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
- Southcoast Health, Southcoast Physicians Group Pain Medicine, Wareham, MA, USA
| | - Mariam Salisu Orhurhu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mark R. Jones
- Weill Cornell Medicine, Weill Cornell Medicine Division of Pain Management, New York, NY, USA
| | | | - Alan D. Kaye
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Charles Odonkor
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Pain, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sameer Hirji
- Departments of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elyse M. Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Omar Viswanath
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
- Valley Anesthesiology and Pain Consultants Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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Sharp E, Roberts M, Żurada‐Zielińska A, Zurada A, Gielecki J, Tubbs RS, Loukas M. The most commonly injured nerves at surgery: A comprehensive review. Clin Anat 2020; 34:244-262. [DOI: 10.1002/ca.23696] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Elizabeth Sharp
- Department of Internal Medicine Mount Sinai Health System New York New York USA
| | - Melissa Roberts
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
| | | | - Anna Zurada
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
- Department of Radiology, Collegium Medicum, School of Medicine University of Warmia and Mazury Olsztyn Poland
| | - Jerzy Gielecki
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
- Department of Radiology, Collegium Medicum, School of Medicine University of Warmia and Mazury Olsztyn Poland
| | - Richard Shane Tubbs
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
- Department of Neurosurgery and Ochsner Neuroscience Institute Ochsner Health System New Orleans Louisiana USA
- Department of Structural & Cellular Biology Tulane University School of Medicine New Orleans Louisiana USA
- Department of Neurosurgery Tulane University School of Medicine New Orleans Louisiana USA
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
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Minimally Invasive Open Surgical Approach and Outcomes for Carpal Tunnel Syndrome. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 53:247-251. [PMID: 32377090 PMCID: PMC7192267 DOI: 10.14744/semb.2019.94759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/17/2019] [Indexed: 12/31/2022]
Abstract
Objectives: The most common peripheral neuropathy is carpal tunnel syndrome. The present study aims to describe our minimally invasive open surgical approach for carpal tunnel syndrome and evaluate surgical outcomes. Methods: We included 217 patients who were operated in our clinic for carpal tunnel syndrome by minimally invasive open surgical approach. Visual Analogue Scale and Functional Outcome Scale scores were obtained preoperative, postoperative at one month and three months to determine surgical outcomes. Results: The mean age of the patients was 55.4±12.8 years (32 to 69), 175 (80.6%) were women and 42 (19.4%) were men. The assessment of carpal tunnel syndrome’s etiology showed that 189 (%87.1%) of the cases were idiopathic, 19 (8.8%) had hypothyroidism, 5 (2.3%) had rheumatoid arthritis and 4 (1.8%) were due to pregnancy. The average improvement of VAS between preoperatively and late postoperatively was 5.41±1.05. The average improvement FOS was 17.44±3.06. They were statistically significant. Conclusion: The minimally invasive open surgical approach for carpal tunnel syndrome (an average of 1 cm skin incision) is performed with local anesthesia and successful surgical outcomes are achieved.
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Egger A, Tosti A. Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice. J Am Acad Dermatol 2020; 83:1724-1729. [PMID: 32199899 DOI: 10.1016/j.jaad.2020.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 01/17/2023]
Abstract
Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.
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Affiliation(s)
- Andjela Egger
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida.
| | - Antonella Tosti
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Effectiveness of Surgical Treatment in Carpal Tunnel Syndrome Mini-Incision Using MIS-CTS Kits: A Cadaveric Study. Adv Orthop 2020; 2020:8278054. [PMID: 32110451 PMCID: PMC7042533 DOI: 10.1155/2020/8278054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/21/2019] [Accepted: 01/08/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction. Carpal tunnel syndrome (CTS) is caused by the compression of the median nerves in the wrist. Patients have pain and numbness in the hands. According to the records of Songklanagarind Hospital from 2015 to 2018, of 800 patients, 196 or 24.5% were treated with surgery. The novel tool of minimally invasive surgery for carpal tunnel syndrome (MIS-CTS) was developed to improve effectiveness and safety.
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AlHakeem N, Ouellette EA, Travascio F, Asfour S. Surgical Intervention for Spastic Upper Extremity Improves Lower Extremity Kinematics in Spastic Adults: A Collection of Case Studies. Front Bioeng Biotechnol 2020; 8:116. [PMID: 32154240 PMCID: PMC7047100 DOI: 10.3389/fbioe.2020.00116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Spasticity of the upper extremity often occurs after injury to the upper motor neurons (UMN). This condition can greatly interfere with the hand positioning in space and the functional use of the arm, affecting many daily living activities including walking. As gait and balance involve the coordination of all segments of the body, the control of upper limbs movement is necessary for smooth motion and stability. The purpose of this study was to assess the effects of surgical interventions on upper extremity spasticity to gait patterns in three spastic patients, as a way to assess the effect on patient's mobility. METHODS Three patients with an anoxic brain injury, upper extremity spasticity, and an altered gait participated in this study. A specific treatment plan based on the patient was tailored by the orthopedic hand surgeon to help release the contractures and spastic muscles. Three-dimensional gait analysis was performed before surgery, 3, 6, and 12 months postoperatively. During each experimental session, the patient walked at a self-selected pace in a straight line across four force plates embedded into the floor (Kistler®). Motion data were acquired using Vicon® Motion Capturing System. Spatiotemporal measurements as well as bilateral kinematics of the hip, knee and ankle were studied. The results from matched non-disabled controls were included as reference. RESULTS Overtime, clinical assessment displayed recovery in hand functions and restored sensation in the fingers. Gait analysis results demonstrated overall improvements in spatiotemporal parameters, specifically in cadence and walking speed. Improvements in kinematics of the lower limbs were also evident. CONCLUSION The results of this study indicated that, within a timeframe of one year, gait patterns improved in all patients. These observations suggest that, over time, upper limb surgery has the potential to improve the biomechanics of gait in spastic patients.
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Affiliation(s)
- Nojoud AlHakeem
- Biomechanics Research Laboratory, Department of Industrial Engineering, University of Miami, Coral Gables, FL, United States
| | - Elizabeth Anne Ouellette
- Miami Orthopedics & Sports Medicine Institute, Baptist Health South Florida, Coral Gables, FL, United States
- Department of Orthopedics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
| | - Francesco Travascio
- Musculoskeletal Biomechanics Laboratory, University of Miami, Coral Gables, FL, United States
- Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, Miami Beach, FL, United States
- Department of Orthopaedic Surgery, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Shihab Asfour
- Biomechanics Research Laboratory, Department of Industrial Engineering, University of Miami, Coral Gables, FL, United States
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Waitayawinyu T, Numnate W, Boonyasirikool C, Niempoog S. Outcomes of Endoscopic Carpal Tunnel Release With Ring Finger Flexor Digitorum Superficialis Opponensplasty in Severe Carpal Tunnel Syndrome. J Hand Surg Am 2019; 44:1095.e1-1095.e7. [PMID: 31072662 DOI: 10.1016/j.jhsa.2019.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 01/01/2019] [Accepted: 02/11/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the outcomes of endoscopic CTR with ring finger flexor digitorum superficialis (FDS) opponensplasty for the treatment of patients with severe carpal tunnel syndrome (CTS). METHODS We prospectively studied 52 patients who were graded as having severe CTS by physical examination and electrodiagnostic studies and who underwent endoscopic CTR-ring finger FDS opponensplasty. Preoperative and postoperative data were collected for active perpendicular thumb abduction; Kapandji score for thumb opposition; grip, key, and tip pinch strength; Medical Research Council score on sensory and motor recovery; Semmes-Weinstein monofilament testing; thenar muscle bulk recovery; and work status. RESULTS Follow-up was 17.5 months on average (range, 7-34 months). Thumb abduction improved significantly from 13.2° (±4.6°) before surgery to 61.7° (±6.4°) afterward. Mean thumb opposition (as measured by Kapandji score) improved significantly from grade 1.5 to 8.7. Tip pinch strength significantly improved from 38.9% to 72.9% of the contralateral side. Medical Research Council scores improved to S3+ and S4 in 85% of patients and to M4 and M5 in 96% of patients. Sensory threshold recovery to 3.61 and 4.31 monofilament occurred in 85% of patients. We observed thenar muscle bulk recovery in 51.9% of patients. Time to return to work was 5 weeks after surgery, on average. Two patients reported scar pain, 2 reported pillar pain, and we found ring finger proximal interphalangeal joint contracture in 3. CONCLUSIONS Endoscopic CTR with FDS opponensplasty provides satisfactory outcomes of improved thumb abduction and opposition, sensory and motor recovery, and early return to work in patients with severe CTS. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Thanapong Waitayawinyu
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand.
| | - Wuthidetch Numnate
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | - Sunyarn Niempoog
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Elsobky H, Kassem M, Youssif T, Abd-Elkhalek A, Khalil AF. Ultrasound Role in Diagnosis of Carpal Tunnel Syndrome and Postoperative Evaluation in Endoscopic Carpal Tunnel Release. OPEN JOURNAL OF MODERN NEUROSURGERY 2019; 09:248-257. [DOI: 10.4236/ojmn.2019.93024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Satteson ES, Cunningham TC, Gerard J, Person DW, Tannan SC. Single surgeon series of outcomes of 897 consecutive endoscopic carpal tunnel releases stratified by disease severity. J Plast Reconstr Aesthet Surg 2018; 72:137-171. [PMID: 30424977 DOI: 10.1016/j.bjps.2018.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 10/14/2018] [Accepted: 10/28/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ellen S Satteson
- Wake Forest University School of Medicine, Department of Plastic & Reconstructive Surgery, Winston-Salem, NC, USA
| | - Teresa C Cunningham
- Wake Forest University School of Medicine, Department of Plastic & Reconstructive Surgery, Winston-Salem, NC, USA
| | - Jessica Gerard
- Wake Forest University School of Medicine, Department of Plastic & Reconstructive Surgery, Winston-Salem, NC, 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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Eroglu U, Ozgural O, Yakar F, Kahiloğulları G. Endoscopic carpal tunnel decompression: Comparison of mid- and long-term outcomes of 30 endoscopic and 30 standard procedure carpal tunnel decompression operations. Asian J Neurosurg 2017; 12:534-536. [PMID: 28761537 PMCID: PMC5532944 DOI: 10.4103/1793-5482.210002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Carpal tunnel syndrome is the most frequently seen trap neuropathy leads to pain, paresis, and weakness of hands. Methods: Totally, 60 patients who underwent endoscopic or standard CTS surgery in İbni Sina Hospital, Medical Faculty of Ankara university in the period of 2009 and 2012 were enrolled in this prospective study. Results: During 36 months, 60 patients had undergone hand surgery. Totally, 14 male and 46 female patients of this serial had an average age of 51.24 (22-74) years. A number of 26 patients (43%) had left and 34 had (57%) right hand surgery. Complete relief of nocturnal paresis and pain has been shown in the 6th, 12th, and 24th month analyses of endoscopic surgery group results. Two patients in open surgery group underwent second operation due to relapse. The patients in the endoscopic group reported higher satisfaction cosmetically. Conclusion: Endoscopic carpal tunnel syndrome treatment is alternative and considerable option against standard open methods and due to low morbidity rates its performance is highly prevalent in recent years.
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Affiliation(s)
- Umit Eroglu
- Department of Neurosurgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Onur Ozgural
- Department of Neurosurgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Fatih Yakar
- Department of Neurosurgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Gökmen Kahiloğulları
- Department of Neurosurgery, Faculty of Medicine, Ankara University, Ankara, Turkey
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Peters S, Johnston V, Hines S, Ross M, Coppieters M. Prognostic factors for return-to-work following surgery for carpal tunnel syndrome. ACTA ACUST UNITED AC 2016; 14:135-216. [DOI: 10.11124/jbisrir-2016-003099] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ohuchi H, Hattori S, Shinga K, Ichikawa K, Yamada S. Ultrasound-Assisted Endoscopic Carpal Tunnel Release. Arthrosc Tech 2016; 5:e483-7. [PMID: 27656366 PMCID: PMC5021238 DOI: 10.1016/j.eats.2016.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 01/27/2016] [Indexed: 02/03/2023] Open
Abstract
Various surgical procedures for carpal tunnel syndrome exist, such as open release, ultrasound-guided percutaneous release, and endoscopic release. Postoperative pain, scarring, and slow recovery to normal function are reported complications of open release. Damage to vessels and the median nerve and its branches underlying the transverse carpal ligament is a reported complication of ultrasound-guided percutaneous release. Damage to the superficial palmar arch and incomplete release are reported complications of endoscopic release. By performing endoscopic carpal tunnel release with ultrasound assistance, we could visualize neurovascular structures directly with the endoscope and also indirectly with ultrasound to minimize complications. We could also evaluate the morphologic changes of the median nerve dynamically before and after the release. We discuss the technique for this procedure and outline pearls and pitfalls for success.
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Affiliation(s)
- Hiroshi Ohuchi
- Address correspondence to Hiroshi Ohuchi, M.D., Ph.D., Department of Sports Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa-shi, Chiba-ken, 296-8602, Japan.Department of Sports MedicineKameda Medical Center929 Higashi-choKamogawa-shiChiba-ken296-8602Japan
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Orak MM, Gümüştaş SA, Onay T, Uludağ S, Bulut G, Börü ÜT. Comparison of postoperative pain after open and endoscopic carpal tunnel release: A randomized controlled study. Indian J Orthop 2016; 50:65-9. [PMID: 26955179 PMCID: PMC4759877 DOI: 10.4103/0019-5413.173509] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Results of open and endoscopic carpal tunnel surgery were compared with many studies done previously. To the best of our knowledge, difference in pain after endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) has not been objectively documented in literature. The aim of the study was to compare the pain intensity in the early postoperative period in patients undergoing OCTR versus those undergoing ECTR. MATERIALS AND METHODS Fifty patients diagnosed with carpal tunnel syndrome were randomized into two groups using "random number generator" software (Research Randomizer, version 3.0); endoscopic surgery group [(21 female, 1 male; mean age 49 years (range 31-64 years)] and open surgery group [(25 female, 3 male; mean age 45.1 years (range 29-68 years)] and received carpal tunnel release. Surgery was performed under regional intravenous anesthesia. The patients' pain level was assessed at the 1(st), 2(nd), 4(th), and 24(th) postoperative hours using a visual analog scale (VAS) score. RESULTS Mean age, gender and duration of symptoms were found similar for both groups. Boston functional scores were improved for both groups (P < 0.001, P < 0.001). Pain assessment at the postoperative 1(st), 2(nd), 4(th) and 24(th) hours revealed significantly low VAS scores in the endoscopic surgery group (P = 0.003, P < 0.001, P < 0.001, P < 0.001). Need for analgesic medication was significantly lower in the endoscopic surgery group (P < 0.001). CONCLUSION Endoscopic carpal tunnel surgery is an effective treatment method in carpal tunnel release vis-a-vis postoperative pain relief.
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Affiliation(s)
- Mehmet Müfit Orak
- Department of Orthopaedics and Traumatology, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Turkey
| | - Seyit Ali Gümüştaş
- Department of Orthopaedics and Traumatology, Adıyaman University, Adıyaman Education and Research Hospital, Adiyaman, Turkey
| | - Tolga Onay
- Department of Orthopaedics and Traumatology, Marmara University Pendik Education and Research Hospital, İstanbul, Turkey
| | - Serkan Uludağ
- Department of Orthopaedics and Traumatology, American Hospital, İstanbul, Turkey
| | - Güven Bulut
- Department of Orthopaedics and Traumatology, Kartal Lütfi Kırdar Education and Research Hospital, İstanbul, Turkey
| | - Ülkü Türk Börü
- Department of Neurology, Kartal Lütfi Kırdar Education and Research Hospital, İstanbul, Turkey
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Gümüştaş SA, Ekmekçi B, Tosun HB, Orak MM, Bekler Hİ. Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1253-60. [PMID: 26319124 DOI: 10.1007/s00590-015-1696-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 08/21/2015] [Indexed: 12/31/2022]
Abstract
This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.
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Affiliation(s)
- Seyit Ali Gümüştaş
- Department of Orthopaedics and Traumatology, Yavuz Selim Bone Disease and Rehabilitation Hospital, Trabzon, Turkey.
| | - Burcu Ekmekçi
- Department of Neurology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey.
| | - Haci Bayram Tosun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey.
| | - Mehmet Müfit Orak
- Department of Orthopaedics and Traumatology, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey.
| | - Halil İbrahim Bekler
- Department of Orthopaedics and Traumatology, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey.
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Means KR, Dubin NH, Patel KM, Pletka JD. Long-term outcomes following single-portal endoscopic carpal tunnel release. Hand (N Y) 2014; 9:384-8. [PMID: 25191172 PMCID: PMC4152435 DOI: 10.1007/s11552-014-9614-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is limited published information about long-term outcomes and recurrence rates following single-portal endoscopic carpal tunnel release. METHODS We reviewed symptom and function outcomes from a prospectively collected database of patients who underwent single-portal endoscopic carpal tunnel release at a minimum of 8 years follow-up. Out of 207 patients in the original database, we were able to confirm correct current contact information for 106 patients. Of these, 91 patients with 115 single-portal endoscopic carpal tunnel releases agreed to participate. All of these patients were eligible for this long-term follow-up study based on documented preoperative and 6-month postoperative Levine-Katz questionnaire scores. Patients then completed a current update of the Levine-Katz questionnaires to assess function and symptom outcomes at latest follow-up. RESULTS The average 6-month postoperative scores were significantly lower compared with the average preoperative scores and were maintained at long-term follow-up. There were no significant differences in average change in scores at long-term follow-up compared to 6-months postoperative. CONCLUSIONS Single-portal endoscopic carpal tunnel release is an effective surgical treatment for carpal tunnel syndrome. Low recurrence rates and maintenance of low symptom and function scores can be expected at 8 to 10 years following this technique.
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Affiliation(s)
- K. R. Means
- The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218 USA
| | - N. H. Dubin
- The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218 USA
| | - K. M. Patel
- The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218 USA
| | - J. D. Pletka
- The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218 USA
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Aslani H, Zafarani Z, Najafi A, Alizadeh K, Farjad R, Ghahremani S, Mosavvari M, Lahiji FA. Comparison of morphologic consequences of open and endoscopic carpal tunnel release. Clin Neurol Neurosurg 2014; 120:96-8. [PMID: 24731585 DOI: 10.1016/j.clineuro.2014.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 02/23/2014] [Accepted: 02/24/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The objective of this study is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. METHODS 48 Patients with CTS were enrolled in our prospective trial. Participants were classified in 2 groups: 24 patients underwent open surgery technique and 24 underwent endoscopic carpal tunnel decompression. Carpal canal shape and volume, configuration and position of contents, were analyzed by using imaging techniques. RESULTS Preoperative carpal canal volume in endoscopic patient group averaged 5.7±1.4 cc and 7.3±2.9 cc at 6 weeks postoperatively (28%±7%, p=0.018). In contrast preoperative carpal canal volume in open carpal tunnel release group averaged 4.9±1.1 cc (and increased to 6.2±1.7 cc at 6-week follow up investigation (36%±5%, p=0.002). Preoperative carpal arch width calculation in endoscopic carpal tunnel release group averaged 21.7±1.1mm and 21.5±1.9mm in open carpal tunnel release patients (p=0.6575). Postoperative carpal arch width measurements in endoscopic carpal tunnel decompression group averaged 22.6±4.1mm and 22.1±2.9mm in open carpal tunnel release patient population at 6-week follow-up investigation (p=0.628). CONCLUSION Endoscopic approach causes an increment in carpal canal volume comparable to open technique and provides equivalent anatomic outcomes and will produce at least equivalent long-term clinical relief.
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Affiliation(s)
| | - Zohreh Zafarani
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arvin Najafi
- Tehran University of Medical Sciences, Tehran, Iran
| | - Khalil Alizadeh
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Farjad
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
BACKGROUND When performed alone, endoscopic carpal tunnel release and endoscopic cubital tunnel release are safe and effective surgical options for the treatment of carpal and cubital tunnel syndromes, respectively. However, there is currently no literature that describes the performance of both procedures concomitantly. We describe the results of 17 cases in which dual endoscopic carpal and cubital tunnel releases were performed for the treatment of concurrent carpal and cubital tunnel syndromes. METHODS A retrospective review of all patients in a single surgeon practice that presented with concomitant ipsilateral carpal and cubital tunnel syndromes was performed. Within an 8-month period, 17 patients had undergone 19 concomitant ipsilateral endoscopic carpal and cubital tunnel releases after failing conservative treatment. Pre- and postoperative measurements included subjective numbness/tingling; subjective pain; manual muscle testing of the abductor pollicis brevis (APB), intrinsics, and flexor digitorum profundus (FDP); static two-point discrimination; quick-DASH (Disabilities of the Arm, Shoulder and Hand) scores; grip strength; chuck pinch strength; and key pinch strength. Complete data are available for 15 patients and 17 total procedures. RESULTS Thirteen male and four female patients (average age of 50.5) underwent dual endoscopic cubital and carpal tunnel release. Two patients were lost to follow-up and eliminated from data analysis. Pre- and postoperative comparisons were completed for median DASH scores, grip strength, chuck pinch strength, and key pinch strength at their preoperative visit and at 12 weeks. DASH scores improved significantly from a median of 67.5 to 16 (p = 0.002), grip strengths improved from 42 to 55.0 lbs (p = 0.30), chuck pinch strengths improved significantly from 11 to 15.5 lbs (p = 0.02), and key pinch strengths increased significantly from 13 to 18 lbs (p = 0.003). Average static two-point discrimination decreased from 5.9 to 4.8 mm. In terms of pain, 82 % of patients had complete resolution of pain, and the remaining 18 % experienced pain only with strenuous activity. In terms of numbness/tingling, 100 % of patients had complete resolution of median nerve symptoms; 88 % of patients had substantial improvement of numbness and tingling symptoms, and 12 % had residual ulnar nerve symptoms. In terms of muscle strength, 92 % of patients had improvement to 5/5 APB strength, while 100 % of patients had improvement to 5/5 intrinsic and FDP strengths. Two minor complications occurred, including one superficial hematoma and one superficial cellulitis. CONCLUSIONS Preliminary data demonstrate that dual endoscopic carpal and cubital tunnel release is a safe and effective treatment option for patients who present with concurrent cubital and carpal tunnel syndromes recalcitrant to non-surgical management. Postoperative results and complications are comparable to endoscopic carpal and cubital tunnel releases performed alone.
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Affiliation(s)
- Danielle Cross
- St. Luke’s Orthopaedic Specialists, St. Luke’s University Hospital, PPHP-2, 801 Ostrum Street, Bethlehem, PA 18015 USA
| | - Kristofer S. Matullo
- St. Luke’s Orthopaedic Specialists, St. Luke’s University Hospital, PPHP-2, 801 Ostrum Street, Bethlehem, PA 18015 USA
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Yu-Chen Ho S, Lin YT. Comparing the effectiveness of endoscopic carpal tunnel release between idiopathic and long-term hemodialysis patients. FORMOSAN JOURNAL OF SURGERY 2014. [DOI: 10.1016/j.fjs.2013.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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30
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Abstract
ECTR is an elegant minimally invasive operative treatment of CTS, providing a rapid rehabilitation without increasing the risk of complications. However, there is a significant learning curve and the cost of the operation is significantly higher than with conventional open technique. However, the faster rehabilitation and the probability of reducing sick leave may lead to ECTR being overall more cost-effective than open CTR.
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Affiliation(s)
- Torben B Hansen
- Section of Hand Surgery, Department of Orthopaedics, Regional Hospital Holstebro, Laegaardvej 12, Holstebro DK-7500, Denmark; Department of Clinical Medicine, Aarhus University, Brendstrupgårdvej 100, 8200 Aarhus N, Aarhus C DK-8000, Denmark.
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Uchiyama S, Nakamura K, Itsubo T, Murakami H, Hayashi M, Imaeda T, Kato H. Technical difficulties and their prediction in 2-portal endoscopic carpal tunnel release for idiopathic carpal tunnel syndrome. Arthroscopy 2013; 29:860-9. [PMID: 23538043 DOI: 10.1016/j.arthro.2013.01.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 01/22/2013] [Accepted: 01/25/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to identify technical difficulties encountered during 2-portal endoscopic carpal tunnel release (ECTR) and to determine their incidence. Furthermore, we assessed the possibility of preoperatively predicting such technical difficulties. METHODS We retrospectively reviewed the records of 311 hands of 311 patients with idiopathic carpal tunnel syndrome who underwent ECTR with our modified Chow 2-portal technique. Any technical difficulties during the procedure were reviewed and correlated with preoperative physical findings, nerve conduction studies, and magnetic resonance imaging findings, by use of the t test, χ(2) test, and binary regression analysis. RESULTS One or more difficulties were encountered in 139 of 311 hands (44.7%), whereas surgery in the remaining 172 hands (55.3%) was performed without any difficulties. Technical difficulties encountered were as follows: tight access in 61 hands, difficulty in identifying the distal part of the transverse carpal ligament through the exit portal in 35 hands, synovial tissue being caught at the cannula tip when pulling it out of the carpal tunnel in 39 hands, steep angle of the cannula assembly with difficulty in emerging from the exit portal in 29 hands, and other difficulties. Postoperative worsening of symptoms was observed in 8 hands (2.6%), in all of which technical difficulties were encountered. Tight access was noted in younger patients and those with a small cross-sectional area at the hook-of-hamate level. The entire ECTR procedure for older female patients was more likely to be easily performed. CONCLUSIONS The surgeon may face a variety of technical difficulties during ECTR. Technical difficulties were most often encountered during introduction of the cannula assembly into the carpal tunnel and pulling it out of the exit portal. Older female patients may be the best candidates for 2-portal ECTR. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Shigeharu Uchiyama
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
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Kwon JY, Kim JY, Hong JT, Sung JH, Son BC, Lee SW. Position Change of the Neurovascular Structures around the Carpal Tunnel with Dynamic Wrist Motion. J Korean Neurosurg Soc 2011; 50:377-80. [PMID: 22200022 DOI: 10.3340/jkns.2011.50.4.377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 08/23/2011] [Accepted: 10/13/2011] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine the anatomic relationships between neurovascular structures and the transverse carpal ligament so as to avoid complications during endoscopic carpal tunnel surgery. METHODS Twenty-eight patients (age range, 35-69 years) with carpal tunnel syndrome were entered into the study. We examined through wrist magnetic resonance imaging in three different positions (neutral, radial flexion, and ulnar flexion) and determined several anatomic landmark (distance from the hamate hook to the median nerve, ulnar nerve, and ulnar vessel) based on the lateral margin of the hook of the hamate. The median nerve and ulnar neurovascular structure were studied with the wrist in the neutral, ulnar, and radial flexion positions. RESULTS The ulnar neurovascular structures usually passed just over or ulnar to the hook of the hamate. However, in 12 hands, a looped ulnar artery coursed 0.6-3.3 mm radial to the hook of the hamate and continued to the superficial palmar arch. The looped ulnar artery migrates on the ulnar side of Guyon's canal (-5.2-1.8 mm radial to the hook of the hamate) with the wrist in radial flexion. During ulnar flexion of the wrist, the ulnar artery shifts more radially beyond the hook of the hamate (-2.5-5.7 mm). CONCLUSION It is appropriate to transect the ligament greater than 4 mm apart from the lateral margin of the hook of the hamate without placing the edge of the scalpel toward the ulnar side. We would also recommend not transecting the transverse carpal ligament in the ulnar flexed wrist position to protect the ulnar neurovascular structure.
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Affiliation(s)
- Jae Yoel Kwon
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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Cavallo AV, Slattery PG, Barton RJ. ENDOSCOPIC CARPAL TUNNEL RELEASE AND CONGENITAL ANOMALIES OF THE MEDIAN NERVE. ACTA ACUST UNITED AC 2011; 8:265-70. [PMID: 15002109 DOI: 10.1142/s0218810403001753] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2003] [Accepted: 10/23/2003] [Indexed: 12/31/2022]
Abstract
Endoscopic release has been shown to be a safe and effective means of carpal tunnel decompression. The surgeon needs to be aware of the variations in the anatomy of the median nerve in order to minimise the risk of nerve injury. In this series of 748 endoscopic carpal tunnel releases, six were found to have variations in the median nerve anatomy, in two patients conversion to open release was necessary.
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Affiliation(s)
- Andrew V Cavallo
- The Alfred Hospital, Commercial Road, Prahran 3181, Melbourne, Australia
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Teoh LC, Tan PL. ENDOSCOPIC CARPAL TUNNEL RELEASE FOR RECURRENT CARPAL TUNNEL SYNDROME AFTER PREVIOUS OPEN RELEASE. ACTA ACUST UNITED AC 2011; 9:235-9. [PMID: 15810113 DOI: 10.1142/s0218810404002327] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Accepted: 06/14/2004] [Indexed: 12/31/2022]
Abstract
Recurrent carpal tunnel syndrome from various causes has been shown to occur in up to 19% of patients. Endoscopic carpal tunnel release has been used to decompress the median nerve in carpal tunnel syndrome for many years. However, endoscopic release for recurrent carpal tunnel syndrome after previous surgical release has not been reported. Nine hands in six patients had recurrent carpal tunnel syndrome five to 20 years after previous open carpal tunnel release. All the cases were successfully treated with endoscopic release.
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Affiliation(s)
- Lam Chuan Teoh
- Department of Hand Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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35
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Keiner D, Tschabitscher M, Welschehold S, Oertel J. Anterior interosseous nerve compression syndrome: is there a role for endoscopy? Acta Neurochir (Wien) 2011; 153:2225-9. [PMID: 21786008 DOI: 10.1007/s00701-011-1091-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 07/14/2011] [Indexed: 12/27/2022]
Abstract
BACKGROUND Anterior interosseous nerve syndrome is characterized by paralysis of the flexor digitorum profundus, the flexor pollicis longus and the pronator quadratus muscles without sensory loss. Extended exploration of the anterior interosseous nerve is the surgical treatment of choice. The present study evaluates the feasibility of an endoscopic approach for nerve decompression. METHODS Preparation of the anterior interosseous nerve was performed in ten human cadaver arms. Subsequently, one female patient suffering from anterior interosseous nerve syndrome was endoscopically operated on. FINDINGS A skin incision of 3-4 cm in the proximal direction was made at the forearm, and the median nerve was visualized between the pronator teres muscle and the flexor digitorum superficialis. Subsequently, the anterior interosseus nerve branch was identified, followed distally and decompressed under endoscopic view. The procedure could be accomplished in all cases under endoscopic view. Due to the very steep surgical angle, a branch of the anterior interosseus nerve was injured in one cadaver case. In all other cases, no adverse effects were observed. In the clinical case, the anterior interosseus nerve was endoscopically identified and decompressed, but a skin incision of 5 cm was required. CONCLUSIONS The results demonstrate that an endoscopic decompression of the anterior interosseus nerve is possible. Several difficulties occurred: Due to the depth of the surgical approach, especially in case of bulky muscles and very small skin incisions, the view is limited, harboring a higher risk of nerve injury. With more experience and specially designed endoscopes, application of this technique in anterior interosseus nerve compression syndrome might become more feasible.
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Affiliation(s)
- Doerthe Keiner
- Neurochirurgische Klinik, Universitaetsklinikum des Saarlandes, Homburg Saar, Germany
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36
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Duché R, Trabelsi A. 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. ACTA ACUST UNITED AC 2010; 29:352-9. [DOI: 10.1016/j.main.2010.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 09/29/2010] [Accepted: 10/01/2010] [Indexed: 11/26/2022]
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Pereira EE, Miranda DA, Seré I, Arce G. Endoscopic release of the carpal tunnel: a 2-portal-modified technique. Tech Hand Up Extrem Surg 2010; 14:263-265. [PMID: 21107228 DOI: 10.1097/bth.0b013e3181f42562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Endoscopic carpal tunnel release has been popularized since 1989 when Okutsu described it for the first time. Several surgeons have followed his principles and described their own techniques. These were developed in an attempt to decrease the well-known complications related to the open technique. Single and 2-portal techniques have been described. Indications include patients with moderate Carpal tunnel syndrome (CTS) and failed conservative treatment. A modified Tsai 2-portal technique is used creating a "fixed surgical tunnel" for decompression and a custom made plastic tube is used to check the quality of release. A specific instrumentation is needed (A.M. Surgical, Smithtown, NY). Few complications are associated, finding it a reliable technique for the decompression of the carpal tunnel.
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Uchiyama S, Yasutomi T, Momose T, Nakagawa H, Kamimura M, Kato H. Carpal tunnel pressure measurement during two-portal endoscopic carpal tunnel release. Clin Biomech (Bristol, Avon) 2010; 25:893-8. [PMID: 20655638 DOI: 10.1016/j.clinbiomech.2010.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 06/12/2010] [Accepted: 06/29/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although there remain concerns of median nerve damage during endoscopic carpal tunnel release for carpal tunnel syndrome, carpal tunnel pressure variations during Chow's two-portal technique have not been well investigated. METHODS We performed a modified two-portal endoscopic carpal tunnel release on 30 patients by inserting a catheter pressure transducer into the carpal tunnel for continuous pressure measurement during the procedure. Grip and pinch strengths, Semmes-Weinstein monofilament test, and nerve conduction studies were examined preoperatively and at postoperative 1, 3, and 6 months. Numbness and the Disabilities of the Arm, Shoulder and Hand score were also evaluated pre and postoperatively. FINDINGS Subjective symptoms and nerve conduction study findings improved uneventfully. The pressure was always observed to be maximum pressure immediately before the cannula was withdrawn from the exit portal, and carpal tunnel pressure >300 mm Hg was recorded in most of the patients. INTERPRETATION A transient increase in the carpal tunnel pressure occurred in all the patients; however, it did not correlate with their clinical outcome or with increased risk of peri-operative complications. Since time-pressure threshold of the median nerve during endoscopic carpal tunnel release is still unknown, our results did not guarantee its safety.
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Affiliation(s)
- S Uchiyama
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
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Yilmaz N, Akdemir G, Gezici AR, Basmaci M, Ergungor MF, Asalanturk Y, Beskonakli E, Ucar D. Electrophysiological and Clinical Assessment of Response to Surgery in Carpal Tunnel. Int J Neurosci 2010; 120:261-4. [DOI: 10.3109/00207451003615748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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40
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Uchiyama S, Itsubo T, Nakamura K, Kato H, Yasutomi T, Momose T. Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation. J Orthop Sci 2010; 15:1-13. [PMID: 20151245 DOI: 10.1007/s00776-009-1416-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Accepted: 09/22/2009] [Indexed: 12/31/2022]
Abstract
The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.
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Affiliation(s)
- Shigeharu Uchiyama
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Japan
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Flores LP, Cavalcante TFP, Neto ORM, Alcântara FS. Quantitative analysis of the variation in angles of the carpal arch after open and endoscopic carpal tunnel release. J Neurosurg 2009; 111:311-6. [DOI: 10.3171/2008.9.jns08457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Previous studies have demonstrated that the volume of the carpal canal increases after open and endoscopic surgery in patients with carpal tunnel syndrome. There is some controversy regarding the contribution of the postoperative widening of the carpal arch to the increment in carpal canal volume. The objectives of this study were to: 1) evaluate the degree of variation in the angles formed by the borders of the carpal arch following the surgical division of the transverse carpal ligament; and 2) determine if there are differences in the variation of these angles after the classical open surgery versus endoscopic carpal tunnel release.
Methods
The authors prospectively studied 20 patients undergoing carpal tunnel syndrome surgery: 10 patients were treated via the standard open technique, and 10 underwent endoscopic carpal tunnel release. The angles of the carpal arch were measured on CT scans of the affected hand obtained before and immediately after the surgical procedures. Measurements were performed at the level of the pisiform-scaphoid hiatus and at the level of the hook of the hamate-trapezium hiatus.
Results
There was widening of the postoperative angles of the carpal arch after open and endoscopic division of the flexor retinaculum; however, the difference between pre- and postoperative angulations reached statistical significance only in those patients treated by means of the open procedure. The mean (± SD) values for the postoperative increase in the angles at the level of the pisiform-scaphoid hiatus were 5.1 ± 0.4° after open surgery and 2.5 ± 0.3° after the endoscopically assisted procedure (p < 0.05). At the level of the hook of the hamate-trapezium hiatus, the mean values for the widening of the angles were 6.2 ± 0.6° for the open surgery group and 1.2 ± 0.4° for those patients treated by means of the endoscopic technique (p < 0.05).
Conclusions
The widening of the postoperative angles of the carpal arch is a phenomenon observed at the proximal and distal levels of the carpal canal, and it can be noted after both open and endoscopically assisted carpal tunnel release. The endoscopic procedure yielded less increase in these angles than the open surgery.
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Okutsu I, Hamanaka I, Yoshida A. Pre- and postoperative Guyon's canal pressure change in endoscopic carpal tunnel release: correlation with transient postoperative Guyon's canal syndrome. J Hand Surg Eur Vol 2009; 34:208-11. [PMID: 19282410 DOI: 10.1177/1753193408100122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Perioperative Guyon's canal and carpal canal pressure in one-forearm portal endoscopic carpal tunnel release surgery were measured in resting position and during active power gripping in 66 hands. This was done using the continuous infusion technique with a local anaesthetic and without pneumatic tourniquet. Immediate mean postoperative Guyon's canal and carpal canal pressure decreased in both measurements. During active power gripping, postoperative Guyon's canal pressure was less than 40 mmHg in 61 hands, however, this increased to over 40 mmHg in five hands. In these five hands, Guyon's canal syndrome did not develop. Guyon's canal and carpal canal pressures were only correlated during postoperative active power gripping. It remains unclear whether immediate postoperative Guyon's canal pressure correlates with higher pressures a few days later as reported in cases of transient postoperative Guyon's canal syndrome.
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Affiliation(s)
- I Okutsu
- Okutsu Minimally Invasive Orthopaedic Clinic, Tokyo, Japan.
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Abrams R. Endoscopic versus open carpal tunnel release. J Hand Surg Am 2009; 34:535-9. [PMID: 19258154 DOI: 10.1016/j.jhsa.2009.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2009] [Accepted: 01/11/2009] [Indexed: 02/02/2023]
Affiliation(s)
- Reid Abrams
- University of California, San Diego School of Medicine, Department of Orthopedic Surgery, Division of Hand and Microvascular Surgery, San Diego, CA 92103-8894, USA.
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44
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Avoiding Iatrogenic Nerve Injury in Endoscopic Carpal Tunnel Release. Neurosurg Clin N Am 2009; 20:65-71, vi-vii. [DOI: 10.1016/j.nec.2008.07.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Keiner D, Gaab MR, Schroeder HW, Oertel J. LONG-TERM FOLLOW-UP OF DUAL-PORTAL ENDOSCOPIC RELEASE OF THE TRANSVERSE LIGAMENT IN CARPAL TUNNEL SYNDROME. Neurosurgery 2009; 64:131-7; discussion 137-8. [PMID: 19145161 DOI: 10.1227/01.neu.0000335784.90217.9d] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract
OBJECTIVE
The long-term efficacy of dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome is still being debated. In this study, the authors present 94 endoscopic carpal tunnel surgery cases with long-term follow-up data.
METHODS
The study includes 72 patients aged 17 to 86 years (mean age, 53.4 years); bilateral surgery was performed in 22 of these patients. Seventy-two hands of female patients and 22 hands of male patients were included. All procedures were performed with a dual-portal set according to the Chow technique. All patients were examined 2 to 3 months after surgery. The long-term follow-up evaluation was based on telephone interviews 5 to 12 years (mean, 8.2 years) after surgery.
RESULTS
From a cohort of 214 cases that were treated surgically between 1995 and 2002, 94 cases (44%) could be evaluated for long-term follow-up. Four of these patients had to be excluded from long-term follow-up because of a switch to an open technique and early open revision (3–6 months after the first surgery), owing to persistent symptoms. A good to optimal postoperative outcome with improvement of neurological signs and subjective patient satisfaction was observed in 84 (93.3%) of the remaining 90 cases. There were no recurrences.
CONCLUSION
The study shows that dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome is a valuable technique that produces very good long-term results and high patient satisfaction and does not result in a significant recurrence rate.
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Affiliation(s)
- Doerthe Keiner
- Department of Neurosurgery, Hannover Nordstadt Hospital, Affiliated Hospital Hannover Medical School, Hannover, Germany
| | - Michael R. Gaab
- Department of Neurosurgery, Hannover Nordstadt Hospital, Affiliated Hospital Hannover Medical School, Hannover, Germany
| | | | - Joachim Oertel
- Department of Neurosurgery, Hannover Nordstadt Hospital, Affiliated Hospital Hannover Medical School, Hannover, Germany
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Means KR, Parks BG, Lee SK, Segalman KA. Release of the transverse carpal ligament alone is associated with elevated pressure beneath the distal volar forearm fascia in a cadaver model of carpal tunnel syndrome. J Hand Surg Am 2007; 32:1533-7. [PMID: 18070640 DOI: 10.1016/j.jhsa.2007.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 08/14/2007] [Accepted: 08/27/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to determine whether release of the distal volar forearm fascia (DVFF) is necessary at the time of median nerve decompression for carpal tunnel syndrome. METHODS Five fresh-frozen cadaver specimens were mounted vertically with the hand dependent and a 2.27-kg weight suspended from the fingers. A pressure sensor wire was used to measure pressures starting just distal to the transverse carpal ligament (TCL). The wire was withdrawn proximally in 5-mm increments and into the forearm until pressure was below 10 mm Hg. An incision in the forearm was extended distally until the pressure sensor was found. The distance from this point to the distal volar wrist crease was measured. The TCL was released, keeping the DVFF intact, and the experiment was repeated. Paired t-tests determined whether there were statistically significant differences between measurements before and after TCL release. RESULTS Average peak pressure under the intact TCL was 57.8 +/- 10.1 mm Hg. Average peak pressure under the DVFF with the TCL intact was 61.2 +/- 43.6 mm Hg. Following release of the TCL, average peak pressure beneath the TCL significantly decreased to 14.0 +/- 9.0 mm Hg, whereas average peak pressure at the intact DVFF increased to 64.8 +/- 48.7 mm Hg. Average locations where DVFF pressure became less than 10 mm Hg with an intact TCL and with released TCL were 4.30 +/- 1.8 cm and 4.00 +/- 1.8 cm proximal to the distal volar wrist crease, respectively. There was no significant difference between DVFF pressures before or after TCL release. CONCLUSIONS In a cadaver model of carpal tunnel syndrome, release of the TCL alone is associated with persistent pressures >30 mm Hg in the region of the DVFF. Release of the TCL did not significantly change the location of the pressure drop-off under the DVFF.
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Affiliation(s)
- Kenneth R Means
- Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD 21218, USA.
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Uchiyama S, Yasutomi T, Fukuzawa T, Nakagawa H, Kamimura M, Kato H. Reducing neurologic and vascular complications of endoscopic carpal tunnel release using a modified chow technique. Arthroscopy 2007; 23:816-21. [PMID: 17681201 DOI: 10.1016/j.arthro.2007.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 02/06/2007] [Accepted: 02/08/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To reduce the rate of median nerve injury occurring during Chow's original 2-portal technique, we developed a modified procedure. The surgical technique was introduced, and the results were evaluated with regard to the clinical findings, nerve conduction studies, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. METHODS We analyzed 119 hands of 119 patients with idiopathic carpal tunnel syndrome who underwent our procedure, wherein a cannula assembly was inserted after a partial division of both distal and proximal parts of the transverse carpal ligament through the entry and exit portals. Postoperative examinations, including evaluation of numbness, grip strength, pinch strength, tenderness over and around the wounds, and nerve conduction studies, were performed at 1 month (n = 119), 3 months (n = 119), 6 months (n = 102), and 12 months (n = 39). The DASH score was also evaluated preoperatively and at 3, 6, or 12 months postoperatively. The rate of structural damage to the median nerve, the tendon, and the artery was calculated. RESULTS The patients resumed their daily activities or work by 13 days postoperatively. Tenderness around the wounds was detected in 66% of patients by 3 months postoperatively. Numbness disappeared or decreased in 99% of patients by 6 months postoperatively. The DASH score was available for 82 patients, and it improved from 28.2 to 18.3 points postoperatively. Nerve conduction studies indicated a significant decrease in motor distal latency postoperatively. Temporal worsening of median nerve function was observed in 2 patients; however, no structural damage to the nerve, tendon, or artery was observed. CONCLUSIONS We found no injury to the tendon or artery and no laceration to the nerve in all 119 patients. However, temporal worsening of median nerve function was observed in 2 patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Oertel J, Schroeder HWS, Gaab MR. Dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome: results of 411 procedures with special reference to technique, efficacy, and complications. Neurosurgery 2006; 59:333-40; discussion 333-40. [PMID: 16883173 DOI: 10.1227/01.neu.0000223500.25131.99] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Endoscopic release of carpal tunnel syndrome is still under debate. The main advantages of the technique are considered to be minor postoperative pain and a more rapid postoperative recovery. Disadvantages are thought to be the impossibility of a direct median nerve neurolysis and a higher surgical complication rate, including injury to the median nerve. METHODS The results of 411 consecutive endoscopic carpal tunnel procedures performed between March 1995 and September 2004 are presented. All patients were prospectively followed. RESULTS In the present series, a success rate of 98.05% was observed. There was no permanent morbidity and, in particular, there was no injury of the median nerve. In four (0.97%) patients, the preoperative symptoms did not improve. In two (0.49%) of these patients, an incomplete release of the carpal ligament occurred. In another four patients (0.97%), a switch to open surgery was required. CONCLUSION The present data prove that the endoscopic technique is a safe and reliable technique for carpal tunnel surgery. The data do not support the current discussion of a higher risk of median nerve injury with endoscopic carpal tunnel surgery. Thus, for our group, the endoscopic technique represents the therapy of choice for the primary idiopathic carpal tunnel syndrome.
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Affiliation(s)
- Joachim Oertel
- Department of Neurosurgery, Hannover Nordstadt Hospital, Hannover Medical School, Hannover, Germany.
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