Endoscopic carpal surgery in carpal tunnel syndrome: A systematic review

Objective

Endoscopic carpal tunnel release has become increasingly popular and has shown the advantage of early recovery of hand function with minimal morbidity. In this systematic review, we aimed to summarize the currently available data and describe the reported advantages and disadvantages of endoscopic carpal tunnel surgery for treating carpal tunnel syndrome.

Methods

In this study, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, which is a set of reporting requirements for systematic reviews and meta-analyses. The search strategy with MeSH terms was "MeSH (carpal tunnel syndrome) AND (endoscopic)" Filters: in the last 5 years, English-on February 27th, 2022. A total of 131 articles fulfilled the first screening criteria. A detailed analysis of those articles identified 39 that matched the criteria, of which 14 were considered appropriate for this analysis after applying the complete inclusion and exclusion criteria.

Results

A total of 14 studies met the eligibility criteria. Analysis of those studies found that all types of portals in endoscopic carpal tunnel release reduced postoperative pain at a short-term follow-up. There was no evidence to suggest the superiority of the single- or two-portal techniques in terms of outcomes. In terms of pain relief, symptom resolution, patient satisfaction, duration to return to work, and adverse events, this early use of endoscopic carpal tunnel release produced satisfactory outcomes. Further studies comparing the number of portals are needed.

Conclusion

Endoscopic carpal tunnel surgery for treating carpal tunnel syndrome is effective and both single- and dual-portal techniques provide advantages in terms of early recovery and minimal morbidity.

Minimally invasive carpal tunnel release: A clinical case study and surgical technique

Introduction and importance

Carpal tunnel syndrome (CTS) is the most prevalent type of median nerve entrapment neuropathy. CTR surgery with a single limited incision is becoming more widely accepted. A better recovery, less pillar pain, less scarring, and an earlier return to work are the key benefits of single limited incision. This study provides an inquiry report on the surgical method, surgical advice, and outcomes of single limited incision minimally invasive carpal tunnel release for CTS.

Case presentation

A 60-year-old female developed carpal tunnel syndrome (CTS). Patient received minimally invasive carpal tunnel release using single limited incision following the failure non operative treatment and the patient was able to return to work with excellent 1-year outcomes. The patient was extremely satisfied with this operative technique.

Clinical discussion

This case highlights a successful outcome of a minimal invasive surgery in CTS. Visual efficiency during surgery and full transverse carpal ligament release are both improved with this technique which requires only a single limited incision. The transverse carpal ligament is totally released with this approach. During the operation, median nerves and superficial palmar arches are not injured.

Conclusion

This technique has been shown to be effective and safe for minimal invasive surgery. This technique could be of interest to surgeons performing minimal invasive surgery who treat CTS.

A Preliminary Report on Augmented Reality Assisted Carpal Tunnel Release

Augmented reality (AR) refers to the use of technology to enhance a real-world environment by computer generated visual, auditory, haptic, somatosensory and/or olfactory stimuli. We developed an augmented reality-assisted surgery (ARAS) for carpal tunnel syndrome (CTS). It generates a virtual image of the operative field that the surgeon can view. This enhances the operative experience. We report the use of ARAS in performing limited open carpal tunnel release. Level of Evidence: Level V (Therapeutic).

Multiple carpometacarpal joint fracture-dislocation from the second to fifth: A case report

Introduction

and importance: Herein we present a rare case of multiple second to fifth carpometacarpal joint fracture-dislocations. It is important in such cases to be aware of a high-velocity impact etiology of the fractures, which will ensure proper imaging, diagnosis and treatment.

Case presentation

A 34-year-old male presented with severe pain in his left hand following a motorcycle accident. He was diagnosed as multiple second to fifth carpometacarpal joint fracture-dislocations. He was successfully treated with closed reduction with multiple Kirshner wires fixation under general anesthesia. A one-year follow up confirmed excellent clinical results.

Clinical discussion

There are various surgical options including casting, closed reduction and percutaneous pinning (CRPP), and open reduction internal fixation, however, the optimal treatment is still controversial. The closed reduction is recommended in all CMC joint dislocations. Adding a K-wire fixation can create a secure fixation and achieve an excellent outcome.

Conclusion

Multiple carpometacarpal joint fracture-dislocations is a very rare injury. Careful clinical examination is important for an accurate diagnosis and plain radiographic studies are necessary. Standard fracture dislocation treatment can be used. Simple closed reduction with the K-wires fixation technique is easy to perform and in our case achieved successful treatment in terms of clinical and radiographic outcomes.

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Multiple carpometacarpal joint fracture-dislocations is a very rare injury.

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Careful clinical examination is important for an accurate diagnosis and plain radiographic studies are necessary.

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Simple closed reduction with the K-wires fixation technique is easy to perform and achieved successful treatment.

Biomechanical study of a newly developed continuous double knots technique compared with the 4-strand double-modified Kessler technique for flexor tendon repair

PURPOSE

In this study we compare the biomechanical properties of a novel suture technique that we developed called the continuous double knots technique for repairing flexor tendon injuries with the standard 4-strand double-modified Kessler technique.

METHODS

This was an experimental study. Eighty porcine flexor digitorum profundus tendons were harvested and divided randomly into two groups of 40. The first group (N = 40) was repaired using the 4-strand double modified Kessler technique and the second group (N = 40) was repaired using our new continuous double knots technique. The two groups were randomly divided and the ultimate failure load (n = 20) and cyclic testing to failure (n = 20) were compared.

RESULTS

The mean ultimate failure load was 25.90 ± 7.11 (N) and cyclic testing to failure 88 ± 47.87 (cycles) for the 4-strand double modified Kessler technique and 34.56 ± 6.60 (N) and 189 ± 66.36 (cycles) for our new continuous double knots technique. The T-test revealed a significant difference between the 2 techniques (p < 0.05). In terms of biomechanical properties in tendon repair, the continuous double knots technique group had a higher tensile strength than the 4-strand double-modified Kessler technique group. There were also significant differences between the ultimate failure load and cyclic testing to failure for the flexor tendon sutures.

CONCLUSIONS

The continuous double knots technique suture technique had significantly higher maximum tensile strength and cyclic testing than the 4-strand double modified Kessler technique in an in vitro study, and in thus an optional technique for flexor tendon repair.

Carpal Tunnel Surgery Using a Wireless Endoscopic Visualization Instrument: A Cadaveric Study

Background: Endoscopic carpal tunnel release is a common treatment for moderate to severe carpal tunnel syndrome. Recently there have been various new techniques which offer improved accuracy and decreased recovery time. In this study, orthopedic surgeons and biomedical engineers from the Faculty of Medicine and Faculty of Engineering, Prince of Songkla University, designed a wireless endoscopic carpal tunnel release with a single portal technique and tested the efficacy and safety of the new technique in a cadaveric study. Methods: Ten fresh cadaveric forearms were used in the study. The surgical technique began with a surgical incision 15-20 mm above the wrist crease on the line between the middle finger and ring finger. The palmaris longus aponeurosis was retracted by Senn retractors. A visual enhancer was inserted to improve the internal visual field in order to see the flexor retinaculum clearly. The flexor retinaculum was cut distally to create an entry and the flexor retinaculum was cut by the scalpel. The flexor retinaculum length was observed until the release was completed. The median nerve was observed. Results: Each flexor retinaculum was cut completely. All of the median nerves were carefully observed during the operation and none were injured. This technique showed the effectiveness and safety of minimally invasive carpal tunnel surgery. Conclusions: The study found that the new device using this technique is effective for carpal tunnel syndrome (CTS) surgery in terms of minimally invasive endoscopic carpal tunnel surgery.

Challenges of Implementing an mHealth Application for Personalized Physical Activity Counselling in Primary Health Care: A Qualitative Study

Introduction

A mobile health (mHealth) technology has the potential to facilitate personalized physical activity (PA) counselling. We aimed to explore the feasibility and challenges of implementing a newly developed mHealth application (PAC app) for personalized PA counselling.

Material and Methods

A qualitative design employed a descriptive phenomenology approach. Data were collected through focus group discussions (FGDs) with primary health care (PHC) providers and were analyzed using a deductive thematic approach.

Results

A total of 16 participants participated in four FGDs. Four major themes were found: application for personalized PA counselling, barriers to the use of the application by providers, patient involvement, and impact on PHC services.

Discussion

The results showed that the new mHealth application can potentially facilitate PA counselling. However, its use in PHC settings requires an understanding of the context of service delivery; the challenges faced by providers and patients and effects on services must be considered.

Conclusion

Future research should focus on the long-term use of PAC app and its impact on behavioral and health outcomes.

Primary Health Care Providers' Perspectives on Developing an eHealth Tool for Physical Activity Counselling: A Qualitative Study

Purpose

Physical inactivity is a global health concern. Physical activity (PA) counselling is an effective intervention for promoting PA in primary health care (PHC) settings. The use of electronic health (eHealth) technology has the potential to support PA counselling. This study aimed to explore PHC providers’ perspectives on the development of an eHealth tool to aid PA counselling in the resource-limited settings.

Methods

This qualitative study employed interpretive phenomenology. The study was conducted at hospital-based PHC clinics among physicians and registered nurses. Data collection involved in-depth interviews (IDIs) and focus group discussions (FGDs). An inductive thematic approach was used to analyze the data.

Results

Three physicians participated in three IDIs and 12 nurses participated in four FGDs at three hospitals. The median age of the participants was 43 years. Participants saw 15–100 patients/day (median 40) and spent 2–20 min with each patient (median 5). Three themes emerged. Theme 1: requirements for PA counselling: the participants reflected the needs and characteristics of eHealth tool that may support PA counselling. Theme 2: enabling an eHealth tool for PA counselling: the eHealth should be easy to use, provide PA prescription function, and support follow-up PA counselling. Theme 3: reducing barriers to PA counselling: the eHealth tool was expected to help reduce service and workforce barriers and patients’ limitations.

Conclusion

A well-designed and practical eHealth tool has the potential to improve PA counselling practice in PHC settings. The eHealth tool may affect an indirect mechanism to reduce barriers to PA counselling. Future research should focus on the usability and utility as well as the process evaluation of the PA counselling eHealth tool that will be implemented in resource-limited settings.

Biomechanics Study of the Holding Power between Tendon and Suture Using Different Techniques

Background: The holding power of a repaired flexor tendon injury is related to surface sutures, suture material and different techniques. Nowadays, a barbed suture material offers the possibility of knotless flexor tendon repair but many hospitals use non-barbed suture materials. The purpose of this study was to compare a barbed suture material and a non-barbed suture material for primary stability under static loading and increased knots in the non-barbed suture material (knot technique) for increased holding power of tendons in animal testing. Methods: Forty-five fresh porcine tendons were randomized into three groups: Group 1 (grasping technique group) used a four-strand core suture grasping a four-strand modified Kessler suture by non-barbed suture material [Non-absorbable monofilament polybutester 3-0] was used to repair the tendon with a surgical knot; in Group 2 (knot technique group) a four-strand core suture used the knot technique by non-barbed suture material [Non-absorbable monofilament polybutester 3-0] to repair the tendon with a continuous suture adding surgical knots in the same place as the surgical knot at the repair sites; and Group 3 (knotless technique group) used a four-strand core suture with the knotless technique in modified Kessler suture with barbed suture material [Non-absorbable monofilament polybutester 3-0] to repair the tendon without a knot. Our objective was to compare the ultimate tensile strength between the groups. Results: The mean tensile strength was 30.38 ± 5.04 N for group 1, 41.71 ± 2.62 for group 2 and 47.53 ± 4.89 for the group 3. The ANOVA test revealed a significant difference among the various techniques (p < 0.05). The highest tensile strength was found in the knotless technique using barbed suture material group. Conclusions: The knotless technique using barbed suture material demonstrated the highest tensile strength in suture repairs. The maximum tensile strength was significantly higher in this group.

Prevalence of asymptomatic radiographic vertebral fracture in postmenopausal Thai women

We aim to investigate the nationwide prevalence of asymptomatic radiographic vertebral fracture in Thailand. We found 29% of postmenopausal women had at least one radiographic vertebral fracture. The prevalence was significantly higher among women with osteoporosis at the total hip (TH) region which implies that TH bone mineral density is a determinant of vertebral fracture risk.

INTRODUCTION

Radiographic vertebral fracture is associated with an increased risk of osteoporotic fracture and mortality in postmenopausal women. We designed a study to determine the prevalence of asymptomatic vertebral fractures in postmenopausal Thai women.

METHODS

The study was designed as a cross-sectional investigation at five university hospitals so as to achieve representation of the four main regions of Thailand. Radiographs were taken from 1062 postmenopausal women averaging 60 years of age. The presence of vertebral fracture was assessed by the Genant's semiquantitative method with three independent radiologists. Respective bone mineral density was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar spine (LS), femoral neck (FN), and total hip (TH).

RESULTS

Among the 1062 women, 311 were found to have at least one radiographic vertebral fracture-yielding a prevalence of 29% (95% CI 23.6-32.0%)-and 90 (8.5%, 95% CI 6.8-10.2%) had at least two fractures. The prevalence of vertebral fracture increased with advancing age. Most fractures occurred at one vertebra (71%) and only 29% at multiple vertebrae. The prevalence of vertebral fracture was significantly higher among women with osteoporosis compared with non-osteoporosis at the TH region. There was no significant difference in the prevalence among women with or without osteoporosis at the LS or FN.

CONCLUSIONS

Radiographic vertebral fractures were common among Thai postmenopausal women (~ 29%). These findings suggest that approximately one in three postmenopausal women has undiagnosed vertebral fracture. Radiographic diagnosis should therefore be an essential investigation for identifying and confirming the presence of vertebral fractures.

Overview of Physical Activity Counseling in Primary Care

Physical inactivity is a global health burden. Promoting physical activity in primary care through physical activity counseling is an effective intervention. This article provides an overview of and perspectives on physical activity counseling in primary care. The identification of physical inactivity as a health problem may increase the awareness of physical inactivity among patients and primary care providers, which will lead to an action plan. The contents of physical activity counseling should be based on evidence-based recommendations. Safety issues should be evaluated appropriately to optimize the utilization of primary care services. Physical activity counseling methods should be "tailored" for an individual using appropriate counseling methods and setting-specific resources. Multilevel barriers to physical activity counseling in primary care (i.e., healthcare providers, patients, and systems) must be addressed. Setting-specific strategies to overcome these barriers should be implemented to maximize the effectiveness of physical activity counseling in primary care.

Minimally Invasive Carpal Tunnel Release (CTR) Using the Wongsiri Technique with MiniSURE

INTRODUCTION

The standard open technique for carpal tunnel surgery has wound problems and complications significantly more than minimally invasive surgery using the Wongsiri technique with MiniSURE Kit® (Surgical Innovation Healthcare Co., Ltd, Bangkok, Thailand) and in particular, the open technique surgery requires a longer time for return to work. CTR surgery with endoscopic devices improves the results with fewer wound problems when compared with the commonly used open technique; however, nerve complications and injury are more prevalent with endoscopic surgery than with the open technique. The Wongsiri technique produces good results with new medical devices such as the MiniSURE View, for improved vision and line-of-sight, and the MiniSURE Cut for improved and complete cutting via the supraretinacular technique that may reduce the nerve problems associated with endoscopic tooling in the carpal tunnel.

PURPOSE

To evaluate the results of the operation and postoperative outcomes of the Wongsiri technique with a MiniSURE Kit®.

METHODS

20 patients underwent carpal tunnel release using the Wongsiri technique and a MiniSURE Kit® with a five-step surgery: MIS starts when the surgeon makes a 1.5-1.8 cm incision, creates a working space, inserts the visual tube of MiniSURE View, inserts the freer, and then cuts the transverse carpal ligament by using the MiniSURE Cut.

RESULTS

All 20 successes of the Wongsiri technique and MiniSURE Kit® surgery occurred within 6.8 minutes operative time and a 12 mm wound size. A single outlier, in one case (6.7%), the patient experienced pillar pain which abated within one month. Patients can return to work in 7.3 days.

CONCLUSIONS

The Wongsiri technique with the MiniSURE Kit® demonstrated good outcomes similar to the endoscope. By contrast with the endoscopic surgery, the Wongsiri technique with the MiniSURE Kit® reduced preop, operating, and postop time, many resources, and significant costs and resulted in no nerve problems or complications.

Physical activity counselling among GPs: a qualitative study from Thailand

Background

Physical activity (PA) counselling is an intervention to promote PA among patients in primary care, yet it remains limited in this clinical setting. This study aimed to explore PA counselling practices among general practitioners (GPs), as well as barriers to and recommendations for improving PA counselling.

Methods

This qualitative study employed a descriptive approach. Data were collected by in-depth interviews and analysed by thematic analysis. The study was conducted in district hospitals in Nakhon Si Thammarat, Thailand, from February 2017 to February 2018. The study participants were GPs who worked at district hospitals.

Results

Seventeen GPs (6 males and 11 females, mean age 29.8 ± 3.4 years) from 6 district hospitals were interviewed. Their clinical experience ranged from 2 to 12 years (mean 4.7 ± 2.9). The GPs saw 30–80 outpatients/day (mean 56.2 ± 14.1) and spent 1–8 min (mean 3.8 ± 1.8) with each patient. They emphasised PA in patients with poorly controlled non-communicable diseases (NCDs) using the word ‘exercise’ in the Thai language as well as discussing time and frequency of exercise. PA was considered a non-pharmacological treatment in the management of NCDs, which improved patient health and quality of life. Barriers to PA counselling among GPs included time constraints, insufficient knowledge, and lack of opportunities to follow-up previously counselled patients. GPs suggested that training in PA counselling was required.

Conclusions

GPs concurred that PA counselling is essential in the treatment of NCDs. Physicians’ recommendations to improve the quality of PA counselling in primary care include 3 Ts: training in PA counselling, tools for prescribing PA, and teams of healthcare professionals. Implementing use of written PA prescriptions may encourage patients to increase PA. Multidisciplinary teams should be developed to support PA counselling in the clinical setting. Further studies should focus on appropriate techniques to implement PA counselling and overcome existing barriers.

Value and validation of RCOST and TOPF clinical practice guideline for osteoporosis treatment

OBJECTIVE

To determine the percentage of postmenopausal women who need treatment using the various criteria as set out in clinical practice guideline published by the Royal College of Orthopaedic Surgeons of Thailand (RCOST) and the Thai Osteoporosis Foundation (TOPF).

MATERIAL AND METHOD

A cross-sectional investigation conducted at five university hospitals around Thailand, evaluated three categories of criteria according to the RCOST and the TOPF guideline for treatment in postmenopausal women, (1) bone mineral density (BMID) measured by DXA, (2) combined quantitative ultrasonography (QUS) measurement and clinical risk indices (CRI), and (3) FRAX or CRI plus spine radiography.

RESULTS

One thousand sixty two woman averaging 60 years of age were recruited for this study. Of those, women with osteoporosis according to DXA, osteopenia plus FRAX, or one major or two minor risk factors comprised between 1 and 22% (category I). Using the QUS T-score in combination with CRI (OSTA or KKOS score < or = -1) or nomogram criteria, between 11 and 14.4% needed treatment (category II). Using the BMI-based FRAX calculation or CRI (OSTA score of < -4 or KKOS probability of > or =80%) plus osteopenia by spine radiograph, between 2.6 and 15.7% needed treatment (category III).

CONCLUSION

Using the RCOST and TOPF clinical practice guideline, only one-fifth of postmenopausal Thai women would be eligible to receive treatment.

A new tool for mini-open carpal tunnel release - the PSU retractor

Background

Mini-open carpal tunnel release has become increasingly popular for the treatment of carpal tunnel surgery. The main advantages are shortening recovery time and return-to-work time. However, the risk of neurovascular injury still remains worrisome.

Methods

In this study, we developed a new retractor (herein called the PSU retractor) modified from the widely used Senn retractor, with the aim of decreasing the risk of neurovascular problems from normal procedure. 3-Dimensional computer design software (SolidWorks^® Office Premium 2007 SP3.1) was used to construct a 3-D PSU retractor prototype. An amputated arm from a 30-year-old woman diagnosed as synovial sarcoma at the shoulder was used to test the maximal visual length. A mini-surgical incision was performed at 3 cm distal to the transverse wrist crease and a tiny flexible ruler was inserted through the tunnel beneath the skin to measure the maximal visual length.

Results

Our new retractor showed significantly better maximal visual length compared to the Senn retractor (47.7(8.1) mm vs. 39.2(6.5) mm). In addition, most assessors expressed a higher satisfaction rate with the PSU retractor than with the Senn retractor (7.3 (1.9) vs. 6.3 (1.1)).

Conclusion

In conclusion, we have developed a promising new retractor using a computer design program, which appears to be an improvement on the currently available equipment used for mini-open carpal tunnel surgery. However, further clinical studies are needed to confirm our initial findings.

Genetic Differentiation of the Giant Honey Bee (Apis dorsata) in Thailand Analyzed by Mitochondrial Genes and Microsatellites

Genetic diversity and population differentiation of the giant honey bee (Apis dorsata) in Thailand were examined. Six PCR-RFLP mitotypes were generated from digestion of the COI-COII, Cytb-tRNA(ser), ATPase6-8, and lrRNA genes with Dra I and Hin fI. Low genetic diversity (h=0.074, pi=0.032%) and a lack of genetic population differentiation between A. dorsata originating from geographically different regions were observed from mtDNA polymorphisms (P > 0.05). In contrast, microsatellite (A14, A24, and A88) polymorphisms revealed a relatively high level of genetic diversity in A. dorsata (H (o)=0.68-0.74, average number of alleles per locus=6.0-9.0). Both A24 and A88 indicated significant population differentiation between bees from the north-to-central region (north, northeast, and central regions), peninsular Thailand, and Samui Island.

Social parasitism by workers in queenless and queenright Apis cerana colonies

We examined worker reproduction in queenless and queenright Apis cerana colonies to determine if they are parasitized by workers from other nests. The results demonstrate that 2-6% of workers in queenright colonies are from another nest (non-natal), but these workers are not statistically more likely to have activated ovaries than natal workers, and are therefore unlikely to be active parasites. However, in queenless colonies we found a significant difference between the proportion of non-natal (72.7%) and natal (36.3%) workers with activated ovaries. Non-natal workers also had significantly higher reproductive success than natal workers: 1.8% of workers were non-natal, but these laid 5.2% of the eggs and produced 5.5% of the pupae. Unlike A. florea, the proportion of non-natal workers does not increase in queenless nests.