Clinical and electrophysiological comparison of different methods of soft tissue coverage of the median nerve in recurrent carpal tunnel syndrome

Patient-Reported Outcomes Improve after Hypothenar Fat Flap for the Treatment of Recurrent Carpal Tunnel Syndrome

Background: Recalcitrant carpal tunnel syndrome (CTS) can present with persistent or recurrent symptoms after carpal tunnel release (CTR). A common aetiology for recurrent CTS is the development of perineural adhesions due to excess scarring. The hypothenar fat pad flap (HFPF) has been described to decrease the amount of scarring formed after revision CTR. Herein, we present a prospective evaluation of these patients. Methods: A prospective series of consecutive patients by a single surgeon with recurrent CTS was conducted. All patients had at least 3 months follow-up. Patients received a revision open CTR with HFPF. The primary outcome was the Boston Carpal Tunnel Questionnaire (BCTQ). Secondary outcomes included pain and satisfaction on visual analogue scale, range of motion, grip strength, patient-reported outcomes and complications. Clinical outcomes were compared between preoperative and postoperative intervals using paired t-tests, with significance defined as p < 0.05. Results: Fifteen wrists (14 patients) were recruited for the study. Patients were predominantly male (n = 9; 66%). Revision open CTR with HFPF was performed a median of 42 months (range: 4-300 months) post primary CTR. Patients demonstrated improved patient-reported outcomes with significantly improved BCTQ pain score (p < 0.01), Patient-Rated Wrist and Hand Evaluation (p < 0.01) and QuickDASH (p < 0.001). Two patients in the series reported postoperative complications; however, there was no incidence of donor site morbidity recorded. Conclusions: Revision open CTR with hypothenar fat pad flap is associated with decreased pain, high patient satisfaction and improved functional measures compared to pre-operative status. Level of Evidence: Level IV (Therapeutic).

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

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

Surgery of True Recurring Median Carpal Tunnel Syndrome with Synovial Flap by Wulle Plus Integument Enlargement Leads to a High Patient's Satisfaction and Improved Functionality

This prospective study was conducted to investigate electrophysiological qualities and patient’s satisfaction of a synovial gliding tissue flap in treating true recurring carpal tunnel syndrome. In 14 patients (11 women, three men), 15 median nerves were included in this retrospective study. For all 15 nerves, motor and sensory nerve conduction velocity, compound muscle action potential, a Visual Analogue Scale-score (VAS-score) questionnaire and an adapted Levine-Test were evaluated pre- and postoperatively. All participants underwent operative neurolysis of the median nerve, which was then enwrapped by a synovial gliding tissue flap. Eleven procedures were completed by integument enlargement. Follow-up period was 12 months. Postoperatively, distal latency decreased significantly by 15.6%. Compound muscle action potential and sensory nerve conduction velocity did not improve significantly. VAS score regarding pain reduced highly significantly with 74.1%. The adapted Levine-Test function score improved highly significantly with 39.2%. The synovial gliding tissue flap lead to an excellent patient’s satisfaction for treating true recurring carpal tunnel syndrome. Primary wound closure should be completed with integument enlargement if needed.

Distally Based Pedicled Flexor Carpi Ulnaris Muscle Flap: An Anatomical Study and Clinical Application

BACKGROUND

Proximally based, pedicled flexor carpi ulnaris (FCU) muscle flap has been described previously for soft tissue coverage of the proximal forearm and elbow. No studies have been done on the distal muscular perforators and its use as a distally based flap.

METHODS

Ten fresh-frozen cadaveric dissections were done. Specimens were injected with latex to facilitate identification of the perforators. Distal muscular perforators were dissected and distances of the pedicles from the distal wrist crease and ulnar styloid were measured and recorded. A clinical case is also presented where a distally based FCU muscle flap was used for coverage in a patient with median nerve neuroma.

RESULTS

A distal muscular perforator and a second more proximal perforator were identified in all specimens. The average distance from the most distal muscular perforator to the ulnar styloid was 3.0 cm. The average distance to the wrist crease was 4.6 cm. The more proximal perforators had an average distance to the ulnar styloid and wrist crease of 7.3 cm and 8.8 cm, respectively. At 7 months post-op, the patient who underwent median nerve neurolysis and coverage with pedicled FCU flap had much improved sensation, with complete resolution of pain and tingling, and without any functional deficits.

CONCLUSIONS

The use of a distally based FCU muscle flap is a good option for soft tissue coverage of the distal forearm, wrist, and hand. The distal muscular perforators from the ulnar artery exhibit a relatively consistent anatomy.

Abductor Digiti Minimi Flap for Vascularized Coverage in the Surgical Management of Complex Regional Pain Syndrome Following Carpal Tunnel Release

BACKGROUND

The development of Complex Regional Pain Syndrome (CRPS) represents a potentially devastating complication following carpal tunnel release. In the presence of a suspected incomplete release of the transverse carpal ligament or direct injury to the median nerve, neurolysis as well as nerve coverage to prevent recurrent scar has been shown to be effective.

METHODS

Retrospective chart review and telephone interview was conducted for patients who underwent abductor digiti minimi flap coverage and neurolysis of the median nerve for CRPS following carpal tunnel release.

RESULTS

Fourteen wrists in 12 patients were reviewed. Mean patient age was 64 years (range, 49-83 years), and the mean follow-up was 44 months. Carpal tunnel outcome instrument scores were 47.4 ± 6.8 preoperatively and 27.1 ± 10.6 at follow-up ( P < .001). Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores at follow-up were 29.4 ± 26. No significant postoperative complications were identified.

CONCLUSIONS

The abductor digiti minimi flap is a reliable option with minimal donor site morbidity. It provides predictable coverage when treating CRPS following carpal tunnel syndrome.

The Adipofascial Radial Artery Perforator Flap: A Versatile Reconstructive Option in Upper Limb Surgery

BACKGROUND

Flaps have been used in upper limb surgery for varied indications including coverage of soft tissue defects, interposition and to provide a pliable bed for gliding structures among others.

METHODS

We report our use of the radial artery perforator based adipofascial flap in nine patients, five with rigid radioulnar synostosis, three with recalcitrant carpal tunnel syndrome and one with a soft tissue defect.

RESULTS

All our patients with radioulnar synostosis regained good functional rotations of the forearm with no recurrence at follow up. The patients with recalcitrant carpal tunnel also had resolution of symptoms with no recurrence. The flap healed well in all the patients.

CONCLUSIONS

We propose this flap as a viable, versatile reconstructive option for the hand and upper limb.

Complications of compressive neuropathy: prevention and management strategies

Compressive neuropathies of the upper extremity are common and can result in profound disability if left untreated. Nerve releases are frequently performed, but can be complicated by both iatrogenic events and progression of neuropathy. In this review, we examine the management of postoperative complications after 2 common nerve compression release procedures: carpal tunnel release and cubital tunnel release.

Recurrent carpal tunnel syndrome

Carpal tunnel release is a common procedure with a high rate of alleviating the patient's symptoms. The incidence of recurrent or persistent carpal tunnel syndrome is rare, although likely underestimated. Complaints of worsening numbness, tingling, or weakness should alert the physician to possible nerve injury and need for early exploration. The overall results of revision carpal tunnel procedures are less successful than primary surgery; however, surgery should be performed when indicated, as it may alleviate or improve symptoms.

Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes

PURPOSE

To evaluate intraoperative findings and outcomes of revision carpal tunnel release (CTR) and to identify predictors of pain outcomes.

METHODS

We performed a retrospective cohort study of all adult patients undergoing revision CTR between 2001 and 2012. Patients were classified according to whether they presented with persistent, recurrent, or new symptoms. We compared study groups by baseline characteristics, intraoperative findings, and outcomes (strength and pain). Within each group, we analyzed changes in postoperative pinch strength, grip strength, and pain from baseline. Predictors of postoperative average pain were examined using both multivariable linear regression analyses and univariable logistic regression to calculate odds ratios of worsened or no change in pain.

RESULTS

We performed revision CTR in 97 extremities (87 patients). Symptoms were classified as persistent in 42 hands, recurrent in 19, and new in 36. The recurrent group demonstrated more diabetes and a longer interval from primary CTR, and was less likely to present with pain. Incomplete release of the flexor retinaculum and scarring of the median nerve were common intraoperative findings over all. Nerve injury was more common in the new group. Postoperative pinch strength, grip strength, and pain significantly improved from baseline in all groups, apart from strength measures in the recurrent group. Persistent symptoms and more than 1 prior CTR had higher odds of not changing or worsening postoperative pain. Higher preoperative pain, use of pain medication, and workers' compensation were significant predictors of higher postoperative average pain.

CONCLUSIONS

Carpal tunnel release may not always be entirely successful. Most patients improve after revision CTR, but a methodical approach to diagnosis and adherence to safe surgical principles are likely to improve outcomes. Symptom classification, number of prior CTRs, baseline pain, pain medications, and workers' compensation status are important predictors of pain outcomes in this population.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.