Opponensplasty using the extensor indicis proprius tendon for severe carpal tunnel syndrome in 40 patients

Current Insights into Carpal Tunnel Syndrome: Clinical Strategies for Prevention and Treatment

BACKGROUND

Carpal tunnel syndrome (CTS) is a condition that is caused by medial nerve compression, resulting in symptoms such as numbness, tightness, or weakness in the hand.

OBJECTIVES

The aim of the study was to find out the genetic modulation, mechanism, available treatment, and recommendation for carpal tunnel syndrome at its specific stage.

METHODS

Almost 200 papers were searched for this review article, and 145 articles were selected. The literature was collected from different sources like Google scholar, PubMed, a directory of open-access journals, and science.gov by using keywords, such as treatment, risk factors, recommendation, and clinical features of carpal tunnel syndrome.

RESULTS

The most efficient non-surgical treatment is methylprednisolone acetate, which reduces inflammation by acting on the glucocorticoid receptor in conjunction with immunofilling. It has also been used successfully as a second-line drug for the treatment of patients with mild or moderate conditions in order to provide relief. New non-pharmacological options include laser therapy in acupuncture, transcutaneous electric nerve stimulation (TENS), and sham therapy. Modern treatments like TENS, laser therapy, splints, and injections of methylprednisolone acetate have been demonstrated to be helpful in sporadic situations. For patients with mild and moderate problems, more research should be conducted that includes the combination of these surgical and non-surgical treatments.

CONCLUSION

We propose a multifunctional panel construct and define standard data items for future research into carpal tunnel syndrome. A discussion on idiopathic carpal tunnel syndrome, risk factors, combination of therapies, using guidelines-based recommendations and treatment should be initiated.

Wide-awake local anesthesia no tourniquet and dexamethasone (WALANT-D) for modified Camitz opponens plasty in severe carpal tunnel syndrome-a retrospective study of 30 cases

Background

To analyze the outcome of modified Camitz opponens plasty using the wide-awake local anesthesia no tourniquet with dexamethasone (WALANT-D) technique in severe carpal tunnel syndrome (CTS).

Methods

A retrospective review was performed in 30 hands of 27 patients who underwent Camitz opponens plasty for severe CTS between 2019 and 2021. All patients had 8 mg of dexamethasone mixed with WALANT. Preoperative active palmar abduction, grip strength, side, and pulp pinch strength, Kapandji score, and electrophysiological assessment of compound muscle action potential (CMAP) for abductor pollicis brevis (APB) were compared with the postoperative values. The palmaris longus had dual insertion into the abductor pollicis brevis and extensor expansion. The time interval of post-operative pain-free was noted. The Disabilities of the Arm, Shoulder, and Hand (DASH) and Carpal Tunnel Syndrome instrument (CTSI) also assessed the functional outcome.

Results

The mean age of patients was 35 years (range 32-58 years). There were five male and 22 female patients. Of the female patients, three females had severe bilateral CTS. Twenty right and ten left hands were affected. The mean follow-up of our study was 12.5 months (range 10-14 months). The patients were pain-free for an average of 19.5 h postoperatively. There was a significant improvement in the thumb palmar abduction, grip strength, side, and pulp pinch strength, DASH score, CTSI, and APB-CMAP (p < 0.05) at the final follow-up.

Conclusions

Modified Camitz opponens plasty with a dual insertion into APB and extensor expansion effectively improves thumb opposition and daily activities. The tendon tensioning, checking the pulley impingement, appreciation of active movements, and a comfortable patient operative experience are advantages of the WALANT. Adding dexamethasone as an adjuvant to WALANT prolongs the analgesia and duration of the nerve block.

Level of evidence

IV, Retrospective case study.

Feasibility of the abductor pollicis longus hemitendon transfer for thumb opposition: An anatomical study

INTRODUCTION

The abductor pollicis longus (APL) presents two muscle bellies and multiple accessory tendons available for transfer, amongst these an accessory tendon inserting on the thenar aponeurosis (APLTh). Edgerton described an opponensplasty using the whole APL tendon, but its results were limited due to the short size of the donor tendon.

HYPOTHESIS

The purpose of this study is to assess the feasibility of transferring the APLTh for thumb opposition.

MATERIAL AND METHODS

Eleven cadaver upper limbs were dissected to assess the presence of the two heads of the APL as well as their main and accessory tendon insertions. The accessory tendon of the APL inserting on the thenar aponeurosis (APLTh) was harvested with a slip of the thenar aponeurosis. The length of the transplant, the number of tendon slips and their location, as well as pre and postoperative radial and palmar abduction provided by the APL were assessed.

RESULTS

The APL was present in all cadavers whereas its insertion on the thenar aponeurosis was absent in 18% of the cases. When the APLTh was present and could be used for opponensplasty, the mean gain in palmar abduction was 16 degrees, and the mean loss in radial abduction was 21 degrees.

DISCUSSION

Although the experiments revealed a variability in APL anatomy, when present, the APLTh represents a suitable donor for the restoration of thumb opposition. In some cases of high median nerve palsies, thumb opposition can't be restored using median innervated muscles. In these cases, when the APLTh is present, it can be used to restore thumb opposition without functional loss.

LEVEL OF EVIDENCE

IV; anatomical feasibility study.

Anomalous Extensor Indicis Proprius Muscle Extending Beyond the Extensor Retinaculum: A Case Report

CASE

During dissection of the upper limb of a cadaver in preparation for a first-year anatomy course, an extensor indicis proprius (EIP) variant was discovered with its muscle belly extending distal to the extensor retinaculum and beyond what has been previously described in the literature.

CONCLUSION

EIP is commonly used as a tendon transfer for extensor pollicis longus rupture. Few anatomic variants of EIP have been reported in the literature, but such variants should be considered because of their consequences to the success of tendon transfer and potential implications for diagnosis of an otherwise unexplained mass of the wrist.

Revision of Carpal Tunnel Surgery

Carpal tunnel release is one of the most commonly performed upper extremity procedures. The majority of patients experience significant improvement or resolution of their symptoms. However, a small but important subset of patients will experience the failure of their initial surgery. These patients can be grouped into persistent, recurrent, and new symptom categories. The approach to these patients starts with a thorough clinical examination and is supplemented with electrodiagnostic studies. The step-wise surgical management of revision carpal tunnel surgery consists of the proximal exploration of the median nerve, Guyon’s release with neurolysis, the rerelease of the transverse retinaculum, evaluation of the nerve injury, treatment of secondary sites of compression, and potential ancillary procedures. The approach and management of failed carpal tunnel release are reviewed in this article.