Efficacy of extracorporeal shock wave therapy for pillar pain after open carpal tunnel release: a double-blind, randomized, sham-controlled study

Background

Pillar pain may develop after carpal tunnel release surgery (CTRS). This prospective double-blinded randomized trial investigated the effectiveness of extracorporeal shock wave therapy (ESWT) in pillar pain relief and hand function improvement.

Methods

The sample consisted of 60 patients with post-CTRS pillar pain, randomized into two groups. The ESWT group (experimental) received three sessions of ESWT, while the control group received three sessions of sham ESWT, one session per week. Participants were evaluated before treatment, and three weeks, three months, and six months after treatment. The pain was assessed using the visual analogue scale (VAS). Hand functions were assessed using the Michigan hand outcomes questionnaire (MHQ).

Results

The ESWT group showed significant improvement in VAS and MHQ scores after treatment at all time points compared to the control group (P < 0.001). Before treatment, the ESWT and control groups had a VAS score of 6.8 ± 1.3 and 6.7 ± 1.0, respectively. Three weeks after treatment, they had a VAS score of 2.8 ± 1.1 and 6.1 ± 1.0, respectively. Six months after treatment, the VAS score was reduced to 1.9 ± 0.9 and 5.1 ± 1.0, respectively. The ESWT group had a MHQ score of 54.4 ± 7.7 before treatment and 73.3 ± 6.8 six months after. The control group had a MHQ score of 54.2 ± 7.1 before treatment and 57.8 ± 4.4 six months after.

Conclusions

ESWT is an effective and a safe non-invasive treatment option for pain management and hand functionality in pillar pain.

Management of painful scar-tethered cutaneous nerves of the upper limb

We report the results of treatment by division and proximal relocation of 44 painful, scar-tethered cutaneous nerves of the upper limb in 22 patients. In all patients, neuropathic pain had developed either following surgery or trauma, but without apparent direct nerve injury. The mean duration of pain symptoms prior to relocation was 17 (range 7-44) months. Adequate treatment involved relocation of 35 nerves at a first operation for each of the 22 patients, with six patients requiring further surgery to relocate 9 nerves. At a minimum follow-up of 6 months, nerve relocation resulted in complete resolution of all forms of pain at the primary site in 21/22 (95%) patients and no pain or hypersensitivity at the final relocation site in 19 of the 22 patients (86%).

Preventing falls in the operating room: a technique tip for safely tilting the operating table

BACKGROUND

Many articles have been published to address the topic of in-hospital falls; however, there is considerably less literature that focuses specifically on the topic of falls from the operating room table. The lay press and legal filings contain reports of such incidents, which can result in considerable morbidity, lawsuits, and occasional death.

TECHNIQUE

When tilting the operating table, a simple technique for preventing falls is through the use of posts. Posts are regularly used during knee and hip arthroscopy to facilitate valgus positioning or access into the joint. These posts can be positioned below the axilla and at the level of the greater trochanter to supplement patient safety straps when tilting the table.

DISCUSSION

Falls that occur during a hospital admission can lead to serious injury and prolonged hospital stays. Furthermore, falls that occur off the operating table are particularly disastrous and in some cases have resulted in death. Our proposed technique is simple and particularly useful for patients with large or small body habitus or when operating procedures necessitate significant tilting of the operating table.

LEVELS OF EVIDENCE

Level V.

Use of the Accordion Severity Grading System for negative outcomes of carpal tunnel syndrome

A universal classification of the negative outcomes of carpal tunnel release surgery does not, as yet, exist. In order to avoid the use of arbitrary factors we have applied the Accordion Severity Grading System, which uses rigorously defined qualitative terms to classify complications. It also provides a uniform manner for grading the severity of complications, enabling outcome comparisons between centres. We analysed the negative outcomes of 500 device-assisted carpal tunnel releases performed over a 2-year period in the author's department. In order to establish a standardised list of complications we used the terms employed within the guidelines of the American Academy of Orthopaedic Surgeons. Most of these terms were subsequently defined using the data variables and definitions taken from the American College of Surgeons National Surgical Quality Improvement Program or the Medical Subject Headings of the National Library of Medicine. We also adopted the quantitative severity weighting, as proposed by the Accordion system, in order to determine the postoperative morbidity index for our assisted carpal tunnel releases. The most common complications were pain and reversible damage to peripheral nerves. Other common negative events, other than complications, included hand weakness, which we classified as a sequela of the procedure, and incomplete retinaculum release, which we classified as failure to cure. The overall postoperative morbidity index for complications was 0.014. Although the Accordion system was developed for more complex procedures, it may also be adopted for carpal tunnel release surgery where it provides an objective and universal method for the classification of complications.

Pseudoaneurysm of ulnar artery after endoscopic carpal tunnel release

The authors present an extremely rare case of a pseudoaneurysm of the ulnar artery as a complication of a two-portal endoscopic carpal tunnel release (ECTR). A 70-year-old man with chronic renal failure and on maintenance hemodialysis with a left arteriovenous fistula presented with paresthesia of his right hand. A clinical diagnosis of right carpal tunnel syndrome was confirmed by ultrasonography and an electrophysiologic study. He underwent two-portal ECTR, and the paresthesia was much improved. However, he presented to us one month after operation with severe pain, a tender mass distal to the right wrist crease and more aggravation of the paresthesia in the ulnar nerve distribution. Doppler ultrasound was performed and revealed a hypoechoic lesion 20 mm in diameter in the right palm, with arterial Doppler flow inside connected to the palmar segment of the ulnar artery. An ulnar artery pseudoaneurysm was diagnosed and treated by ultrasound-guided percutaneous thrombin injection. Transverse color Doppler ultrasound image showed complete thrombosis of the pseudoaneurysm and flow cessation after a total injection of 500 units of thrombin. The symptoms were also improved.

Syndrome du canal carpien: information et consentement éclairé

Patients must be informed of the benefits and risks before any surgical procedure. This information must be clear, honest, specific and complete in order that the patient can give his or her informed consent. This information has to be given face to face, however paper may be used to emphasize certain points and aid retention of information. We studied information sheets for carpal tunnel release given out in ten different hand surgery centres. Different points were identified to analyse each form. From this analysis, a literature review and recent law texts, we propose a new information sheet for carpal tunnel release.