Release Of Transverse Carpal Ligament Research Articles

USG-Guided Percutaneous Thread Carpal Tunnel Release.

Ultrasonography (USG) is utilized for the diagnostic and interventional management of patients with carpal tunnel syndrome (CTS). The management of patients with severe and/or refractory CTS includes the surgical (open/endoscopic) release of transverse carpal ligament. With the advancements in the resolution of USG, the release of transverse carpal ligament can be done safely with the help of transecting/cutting devices. We discuss the technical report on the principle of percutaneous thread carpal tunnel release with the help of surgical grade thread.

Ultrasound-guided interventions in primary carpal tunnel syndrome: perineural injection to thread carpal tunnel release.

Carpal tunnel syndrome (CTS), the most common entrapment neuropathy, is compression of the median nerve deep to transverse carpal ligament at wrist. Ultrasonography and electrophysiological study are complementary in the diagnosis and grading of CTS in appropriate clinical settings. The initial management of patients with CTS is conservative with medical therapy and splinting. However, surgical interventions are indicated in patients in whom medical management has failed. With evolution of the concept of safe zone on ultrasonography and identification of the sonoanatomical landmarks of carpal tunnel in greater detail, Ultrasonography-guided interventions are safer and preferred over surgical management in CTS. The primary ultrasonography-guided interventions include perineural injection, perineural hydrodissection and ultrasonography-guided release of transverse carpal ligament. This review article presents the principles of ultrasonography-guided perineural injection, perineural hydrodissection in CTS, the merits and demerits of injectant used in perineural injection/ hydrodissection, and percutaneous ultrasonography-guided thread release of transverse carpal ligament utilizing the concept of safe zone of the ultrasonography-guided interventions for CTS.

A comparative study on efficacy of modified endoscopic minimally invasive treatment and traditional open surgery for primary carpal tunnel syndrome

Background and ObjectiveCarpal tunnel syndrome (CTS) is the most common type of median nerve entrapment neuropathy. This study aims to comparatively assess the effectiveness and clinical efficacy of modified transforaminal endoscopic minimally invasive incision of transverse carpal ligament against traditional open incision of transverse carpal ligament in the treatment of CTS.MethodThe clinical data of 35 patients (57 wrists) with primary CTS treated in Shanxi Bethune Hospital, China, were retrospectively analyzed. The patients were divided into observation group (21 cases, 33 wrists) and control group (14 cases, 24 wrists), respectively, who underwent modified endoscopic minimally invasive incision of transverse carpal ligament and traditional open incision of transverse carpal ligament release. The Boston Carpal Tunnel Questionnaire (BCTQ) was assessed at for points: before the operation; 2 weeks; 1 month; and 3 months after operation. The BCTQ scores of the two groups were compared on all four points. The incidence of intraoperative and postoperative complication was used as the evaluation index. The study variables were comparatively assessed before and postoperation and also between the groups.ResultsThe BCTQ scores at 2 weeks, 1 month and 3 months after the operation were significantly lower than preoperative BCTQ scores (P < 0.005) for both the groups. There was no significant difference in BCTQ scores between the two groups at the four assessment points (P > 0.005). The scar size and wound healing time were significantly better with modified transforaminal endoscopic minimally invasive transverse carpal ligament incision.ConclusionThe clinical effects of both modified transforaminal minimally invasive incision of transverse carpal ligament and traditional open incision of transverse carpal ligament are significant, while the treatment efficacy of modified transforaminal minimally invasive transverse carpal ligament incision is better in terms of operation time, wound size, postoperative scar size and incision healing time.

Electrophysiological Changes in Patients with Carpal Tunnel Syndrome after Open Carpal Tunnel Release

Objective: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy affecting the upper limbs. Various treatment methods exist for this disease, but only a few reports have compared the effects of various treatments using objective indicators. This study analyzed the changes in electrophysiological parameters after carpal tunnel release.Methods: In patients planning to undergo surgical treatment for CTS, electrophysiological studies, including nerve conduction studies and electromyography (EMG), of both upper extremities were performed before and 6 to 8 weeks after mini-open transverse carpal ligament release and median nerve neurolysis.Results: After surgical intervention, the onset latency and amplitude of the sensory nerve action potential (SNAP) and the onset latency of the compound muscle action potential (CMAP) of the median nerve improved. Additionally, the grade of abnormal spontaneous activity in needle EMG of the abductor pollicis brevis (APB) and the severity of the electrodiagnostic study results significantly decreased after the intervention compared to the initial evaluation.Conclusion: This study shows that the onset latency of SNAP and CMAP, the amplitude of SNAP of the median nerve, and EMG findings in the APB can be useful electrodiagnostic parameters for postoperative monitoring in CTS patients.

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

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. 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. 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. 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.

Trigger Wrist with Carpal Tunnel Syndrome Accompanied with Trifid Median Nerve: A Case Report and Literature Review.

Trigger wrist, characterized by a clicking or snapping sensation around the wrist joint during finger or wrist motion, and bifid or trifid median nerve, which occurs in carpal tunnel syndrome along with anatomical variation of median nerve, are rare conditions. We report the case of a patient with a thickened tendon caused by severe tenosynovitis and flexor tendon subluxation to the hamate hook due to bowing of the flexor retinaculum, thereby resulting in trigger wrist as well as an anatomical median nerve variation (bifid median nerve in the right wrist and trifid median nerve in the left wrist). A 59-year-old housewife visited our hospital with bilateral fingertip numbness, tingling sensation, and aggravated severe night cramping that began 2 months ago. She also complained about trigger wrist during small finger flexion. Based on magnetic resonance imaging, ultrasonography, and nerve conduction study, trifid median nerve and bilateral severe median nerve neuropathy of the wrist were diagnosed; therefore, transverse carpal tunnel release and exploration under wide-awake anesthesia were planned. Intraoperative findings showed trifid and bifid median nerves in left and right wrists, respectively. Additionally, bowing of flexor retinaculum and severe flexor tendon tenosynovitis were observed. Tenosynovitis with thickened flexor sheath resulted in subluxation of the small finger flexor tendon above the hamate hook. After transverse carpal ligament release with antebrachial fascia release and tenosynovectomy, subluxation of the flexor tendon was resolved. At 6 months postoperatively, the tingling and dullness in fingertips also resolved, and no trigger wrist or any other complications were noted.

Analysis of Mechanoreceptors and Free Nerve Endings of the Transverse Carpal Ligament.

Background: The treatment of carpal tunnel syndrome (CTS) by sectioning the transverse carpal ligament (TCL) is not exempt from complications. Some nerve branches may be damaged by the incision. The aim of this study is to identify and map the TCL nerve endings, serving as a guide for sectioning this structure in a zone with less nerve ending density. Methods: Ten TCLs were obtained from fresh frozen cadavers. The TCLs were measured, divided into 3 equal bands (radial, central, and ulnar), and submitted to cryostat sectioning. The sections were subjected to immunofluorescence with the protein gene product (PGP) 9.5 and confocal microscopy analysis. Results: All the specimens contained type I and type IV mechanoreceptors. Neural elements occupied 0.695 ± 0.056% of the ligament area. The density of the neural elements was greater in the radial, followed by the ulnar and central bands, with 0.730 ± 0.083%, 0.686 ± 0.009%, and 0.669 ± 0.031%, respectively. Conclusion: The present findings suggest that the region with the least potential for neural element injury during TCL release is the central third near the transition with the ulnar third. When performed distally to proximally with a slight inclination from the radial to the ulnar, this release compromises the lowest nerve element density. Topographically, the proximal limit of the release is the distal wrist crease, while the distal limit is the intersection of Kaplan cardinal line and the axis of the third webspace.

Minimally Invasive Carpal Tunnel Release

Background. The surgical therapy modalities for carpal tunnel syndrome, vary from open transverse carpal ligament release TCLR, to different surgical treatment options, Minimal invasive release, endoscopic release, and sonographically guided release, with no consensus about any of them. Aim of the work. To evaluate the end results and efficacy after minimally invasive carpal tunnel syndrome. Patient and methods, Twenty patients with severe carpal tunnel syndromes, were treated at Al-Azhar University Hospitals between 2015-2017, with percutaneous technique, will be described in detail. There were 2 males and 18 females, 45.9 years of age on average with an average follow-up of about 12 months. Results. All patients were satisfied except three patients. two of them suffered from recurrence and one from scar formation. There was no difficulty with this technique for all patients except for one female patient with marked obesity. In our study, we will compare our results to the open technique. No adjacent structures were damaged Conclusion. This study demonstrated that minimal invasive carpal tunnel release is potentially a safe, secure, quick, and effective procedure to transect the transverse carpal ligament and may be an alternative option to traditional surgical treatment of carpal tunnel syndrome and need more accurate knowledge of district anatomy and more experience.

Presentation and outcome of carpal tunnel syndrome with mini incision open carpal tunnel release.

Background: To document the clinical presentation of carpal tunnel syndrome (CTS) and evaluate the outcome of mini-incision open carpal tunnel release in terms of surgical complications, relief/persistence of symptoms at 4 months, and recurrence at 1 year. Methods: This prospective case series included patients of all genders and ages who presented with CTS. They underwent release of transverse carpal ligament (TCL) under local anesthesia and tourniquet control on day care basis. Mini-incision of 2 cm to 2.5 cm was employed. The data were subjected to statistical analysis using SPSS version 21 (SPSS Inc). The percentages of key categorical variables were compared by employing the chi square test, and a P value of less than.05 was regarded as statistically significant. Results: There were 67 patients with 77 CTS affected wrists. A Significant majority of the patients (n = 54; 80.59%) were females, whereas 13 (19.40%) patients were males. The age range was 26 to 69 years, with a mean age of 41.01 ± 11.70 years. The CTS was found to be moderate among 34 (44.15%) and severe among 43 (55.84%) patients. The majority of patients had no operative complications. At 4 months follow-up, the majority of patients (n = 74; 96.10%) reported symptomatic relief, whereas 3 (3.89%) patients continued to have persistent severe symptoms. All the cases with persistent symptoms had diabetes mellitus of more than 5 years duration. There was no case of recurrence at one year follow-up. Conclusion: CTS predominantly affected women aged 30 to 45 years. The open carpal tunnel release with mini-incision yielded good results in terms of relieving symptoms among the majority of patients and was associated with no critical complications or recurrence at 1 year.

Trigger wrist: A case report

Trigger wrist is a rare disorder affecting the wrist and should not be confused with trigger finger. A detailed preoperative evaluation includes a good Clinico-radiological evaluation and tests for median nerve compression. Surgical release of transverse carpal ligament along with excision of the offending mass relieves the symptoms. This report is a case of triggering at the wrist along with median nerve compression in a 28 years old female. After detailed pre-operative evaluation surgical treatment was done and the patient got relieved of the condition.

Effectiveness and Safety in Closed Mini-Transverse Incision with Hydro-Dissection Technique in Carpal Tunnel Release: A Cadaveric Study.

Background: Closed mini-wrist transverse incision for carpal tunnel release has been reported in decreasing surgical scar problems, but there were few cadaveric studies that proved the effectiveness and safety in this technique without protective instrument to the median nerve. Hydro-dissection was previously showed to separate median nerve and deep structures during percutaneous ultrasound guided transverse carpal ligament release. This cadaveric study aims to demonstrated effectiveness and safety of closed transverse carpal ligament (TCL) release though the mini-transverse incision at distal wrist crease combined with hydrodissection technique. Neither special instrument nor retractor was used to protect neurovascular structures. Methods: Twelve fresh frozen cadaveric wrists were included in this study. Completeness of TCL release and injury to the adjacent neurovascular structures were assessed by direct visualization. Thickness of TCL, TCL length and distance from incision to adjacent neurovascular structures were also recorded. Results: Complete release of TCL was demonstrated in all 12 (100%) wrists underwent the mini-transverse incision TCL release at distal wrist crease and hydro-dissection technique. No injury to the adjacent neurovascular structures was found in all 12 wrists. Mean of thickness of TCL and TCL length were 3 mm and 28.7 mm, respectively. The ulnar artery was the nearest structure to the incision (mean = 3.7 mm). Conclusions: The closed mini-transverse incision TCL release at distal wrist crease with hydro-dissection technique demonstrated completeness of TCL division and safety to the neurovascular structures without protecting retractor or special instrument.

Ultrasound Evaluation for Incomplete Carpal Tunnel Release.

Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Z-Elongation of the transverse carpal ligament vs. complete resection for the treatment of carpal tunnel syndrome

BackgroundCarpal tunnel syndrome is treated successfully by surgical release of the transverse carpal ligament (TCL). However, persistent weakness of grip and pain over the thenar and hypothenar ends of this ligament, and “pillar pain”, are reported to be common complications. In order to reduce these complications, different ligament reconstruction or lengthening techniques have been proposed. ObjectiveThe purpose of this study is compare effectiveness and complications of TCL z-lengthening technique with complete TCL section. MethodsA prospective, randomised, intervention trial was conducted on 80 patients. The patients were divided into 2 groups: (1) complete release of TCL; (2) z-lengthening of TCL according to a modified Simonetta technique.Grip strength, pillar pain and clinical and functional assessment were carried out using the Levine et al. questionnaire. ResultsNo significant differences were observed (P>.05) in the postoperative reviews between the two groups as regards grip strength loss and pillar pain. There were significant differences between preoperative and postoperative mean Levine scores, but there was no difference in the mean scores of the two procedures at any time. DiscussionIn conclusion, according to the results, TCL z-lengthening is more effective than simple division, but there is no identifiable benefit in z-lengthening for avoiding complications.

Elongación en Z del ligamentum carpi transversum vs. apertura completa para el tratamiento del síndrome del túnel del carpo

BackgroundCarpal tunnel syndrome is treated successfully by surgical release of the transverse carpal ligament (TCL). However, persistent weakness of grip and pain over the thenar and hypothenar ends of this ligament, and “pillar pain”, are reported to be common complications. In order to reduce these complications, different ligament reconstruction or lengthening techniques have been proposed. ObjectiveThe purpose of this study is compare effectiveness and complications of TCL z-lengthening technique with complete TCL section. MethodsA prospective, randomised, intervention trial was conducted on 80 patients. The patients were divided into 2 groups: 1) complete release of TCL; 2) z-lengthening of TCL according to a modified Simonetta technique.Grip strength, pillar pain and clinical and functional assessment were carried out using the Levine et al. questionnaire. ResultsNo significant differences were observed (p>.05) in the postoperative reviews between the two groups as regards grip strength loss and pillar pain. There were significant differences between preoperative and postoperative mean Levine scores, but there was no difference in the mean scores of the two procedures at any time. DiscussionIn conclusion, according to the results, TCL z-lengthening is more effective than simple division, but there is no identifiable benefit in z-lengthening for avoiding complications.

A Cadaveric Study for the Improvement of Thread Carpal Tunnel Release

The thread carpal tunnel release (TCTR) technique has been improved and offers more precise control in dissecting thread placement. The purpose of this cadaveric study was to test the procedure operationally and verify the modified TCTR anatomically. Eleven unembalmed cadaver wrists underwent the transverse carpal ligament (TCL) release by using the modified TCTR technique. An experienced observer dissected each specimen and assessed for completeness of release under direct visual assessment. Injury to the superficial palmar aponeurosis (SupPA), the Berrettini and common digital nerve branches were also recorded as a secondary outcome. Eleven out of 11 wrists (100%) underwent the modified TCTR with complete release of the TCL. All 11 wrists were released without damage to any vital neurovascular structure including the Berrettini branch and the common digital nerves. The SupPA remained intact in all 5 wrists performed with the preservation steps. The modified TCTR technique demonstrated complete division of the TCL while protecting the SupPA as well as the Berrettini and common digital nerve branches. The modified TCTR has the potential to offer a clinically safe and effective minimally invasive procedure for complete carpal tunnel release.

Changes in carpal tunnel compliance with incremental flexor retinaculum release.

BackgroundFlexor retinaculum transection is a routine surgical treatment for carpal tunnel syndrome, yet the biomechanical and clinical sequelae of the procedure remain unclear. We investigated the effects of flexor retinaculum release on carpal tunnel structural compliance using cadaveric hands.MethodsThe flexor retinaculum was incrementally and sequentially released with transections of 25, 50, 75, and 100 % of the transverse carpal ligament, followed by the distal aponeurosis and then the antebrachial fascia. Paired outward 10 N forces were applied to the insertion sites of the transverse carpal ligament at the distal (hamate-trapezium) and proximal (pisiform-scaphoid) levels of the carpal tunnel. Carpal tunnel compliance was defined as the change in carpal arch width normalized to the constant 10 N force.ResultsWith the flexor retinaculum intact, carpal tunnel compliance at the proximal level, 0.696 ± 0.128 mm/N, was 13.6 times greater than that at the distal level, 0.056 ± 0.020 mm/N. Complete release of the transverse carpal ligament was required to achieve a significant gain in compliance at the distal level (p < 0.05). Subsequent release of the distal aponeurosis resulted in an appreciable additional increase in compliance (43.0 %, p = 0.052) at the distal level, but a minimal increase (1.7 %, p = 0.987) at the proximal level. Complete flexor retinaculum release provided a significant gain in compliance relative to transverse carpal ligament release alone at both proximal and distal levels (p < 0.05).ConclusionsOverall, complete flexor retinaculum release increased proximal compliance by 52 % and distal compliance by 332 %. The increase in carpal tunnel compliance with complete flexor retinaculum release helps explain the benefit of carpal tunnel release surgery for patients with carpal tunnel syndrome.

A Comparison of Hand Pain and Hand Function after Z-plasty Reconstruction of the Transverse Carpal Ligament with Traditional Median Neurolysis in Carpal Tunnel Syndrome.

Carpal tunnel syndrome is the most common focal mono-neuropathy. A study was designed to compare the effects of traditional open carpal tunnel release with median neurolysis and Z-plasty reconstruction of the transverse carpal ligament on post-operative hand pain and hand function in patients with idiopathic carpal tunnel syndrome. Fifty-two patients with idiopathic carpal tunnel syndrome entered the study. The patients were randomly assigned into two groups to undergo simple transverse carpal ligament release or division of the ligament with Z-lengthening reconstruction. Forty-five patients completed the study. Two patients of the simple open surgery group and 5 patients of the Z-plasty reconstruction group did not complete the follow up course. After the procedure, the patients were followed to assess post-operative pain and hand function during a 12-week period. The scores of hand pain on the first day after surgery were not statistically different between the two groups (P=0.213). But the score of hand pain was significantly lower in the Z-plasty reconstruction group at week 1, week 3, and week 6 after surgery (P<0.001). However, at week 12, no patient complained of hand pain in both groups. Considering hand function, no patient had normal hand grip after the first week, but after three weeks, a significantly higher proportion of patients in the Z-plasty reconstruction group had reached near normal hand grip (76.1% vs. 29.1%;). However, at weeks 6 and 12, the differences were not statistically different between the two groups. We observed significant reduction in hand pain, shorter duration of hand pain and shorter period of time to reach normal hand grip by Z-plasty reconstruction of the TCL.

ID 184 – Effect of carpal tunnel syndrome on the ulnar nerve at the wrist: Electrophysiologic and ultrasonographic studies

Objectives The aim of this study is to compare the ulnar nerve by electrophysiologic and ultrasonographic study between patients with carpal tunnel syndrome (CTS) and controls. We also compare the cross sectional area (CSA) of ulnar nerve before and after carpal tunnel release in CTS. Methods We recruited 41 hands with CTS and 37 hands of controls. Electrophysiologic study of ulnar nerve was done in all participants. CSA of median and ulnar nerve at the wrist was evaluated by ultrasonography. Fifteen hands with CTS who underwent carpal tunnel release were evaluated with ultrasound after the operation. Results The ulnar nerve CSA of the patients of CTS (5.16 ± 1.04) was statistically significant larger than control (3.56 ± 0.52). After transverse carpal ligament release operation, the CSA of ulnar nerve after operation (4.20 ± 0.84) was statistically significant smaller compared with that of prior to surgery (5.23 ± 1.02). The CSA of median nerve was significant correlation with the CSA of ulnar nerve. Conclusions CSA of ulnar nerve as well as medan nerve increased in patients with CTS. Ulnar nerve is affected by carpal tunnel syndrome.

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS. The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery. After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (-) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year. Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.

Surgical Treatment of Malunited Fractures of Radius Distal Metaepiphysis

Sixty three patients with malunited distal radius were treated on from 2008 through 2012. Out of them complex regional pain syndrome was diagnosed in 12 and carpal canal syndrome — in 4 patients. Basing on the examination results the roentgenologic classification of malunited distal radius that enabled to determine the surgical tactics was suggested. Main type of surgical intervention was corrective osteotomy. When radius shortening exceeded 3 mm bone graft from the crest of upper flaring portion of the ilium was used. In patients with complex regional pain syndrome paravasal sympathectomy was performed additionally. In I—II stage of carpal canal syndrome only corrective osteotomy was performed while in II-III stages additional release of hypertrophic transverse carpal ligament and neurolysis in the zone of compression and ischemia were performed. In 12 months after surgery mean score by DASH scale decreased from preoperative 62.2±8.0 to 19.6±7.0 (p