The adipofascial flap based on an ulnar artery perforator: an alternative option for recurrent carpal tunnel syndrome

A case series of seven patients with recurrent median nerve neuropathy treated by the revision surgery of median nerve neurolysis and wrapping with radial artery perforator adipose flap

Adhesion neuropathy of the median nerve with persistent pain can be a challenging problem. Currently, coverage of the median nerve with a well-vascularized soft tissue is deemed necessary after secondary neurolysis. Herein, we reviewed the outcomes of seven patients with a persistent median nerve neuropathy after a primary open carpal tunnel release or a median nerve repair, treated with neurolysis and median nerve wrapping with radial artery perforator adipose flaps. During the revision surgery, after a careful and complete neurolysis of the scarred median nerve, the distally based radial artery perforator adipose flap without its fascia was raised and rotated to wrap the median nerve. The mean size of the perforator flap was 1146 mm², which was enough to wrap the median nerve in all patients. At 26 months postsurgery, both the visual analog scale score for pain with tingling, and the patient-reported outcome measures improved. There was no recurrence of the median nerve adhesion neuropathy and no major complications were noted. Tinel's sign at the palmar wrist completely disappeared in four patients and was relieved in three patients. The median distal motor latency becomes recordable, and closer to a normal compound motor action potential postoperatively in all patients. Secondary neurolysis and median nerve wrapping with a radial artery perforator adipose flap, which was modified to be softer and thinner than the radial artery perforator adipofascial flap, was a successful treatment for the recurrent median nerve neuropathy in terms of both pain relief and restoration of the hand function.

Treatment of painful median nerve neuromas with radial and ulnar artery perforator adipofascial flaps

PURPOSE

To review the outcomes of 8 patients with painful median nerve neuromas at the wrist treated with external neurolysis and covered with pedicled perforator adipofascial flaps.

METHODS

Between 2004 and 2010, we treated 8 patients, who had a mean age of 37 years, and who had posttraumatic painful median nerve neuromas at the level of the wrist but with retained median nerve function . All of them reported neuropathic pain and had a positive Tinel's sign over the site of the presumed neuroma. The surgical procedure included external neurolysis and coverage with an ulnar artery perforator adipofascial flap (4 patients) or with a radial artery perforator adipofascial flap (4 patients). Patients were reviewed after a mean follow-up of 41 months (range, 18-84 mo). Preoperative and postoperative pain was measured with a visual analog scale.

RESULTS

Pain improved from a preoperative mean value of 7.8 to a postoperative mean value of 3.6. There was complete resolution of pain in 5 patients, mild pain persisted in 2 patients, and 1 patient reported no improvement. No complications occurred at the donor site.

CONCLUSIONS

Vascularized soft tissue coverage of painful median nerve neuromas is an effective treatment. We do not believe that a free flap is of any particular advantage over a local pedicle flap which we suggest using to protect the median nerve.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.