Revision of Carpal Tunnel Release for Revision of Carpal Tunnel - - PowerPoint PPT Presentation

Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Revision of Carpal Tunnel Release for Revision of Carpal Tunnel Release for Persistent or Recurrent Persistent or Recurrent Carpal Tunnel Syndrome Carpal Tunnel Syndrome

Chao-Ming Wu, Yu-Te Lin, Bon-Yun Chou, Chih-Hao Chen, Han-Tsung Liao, Cheng-Hung Lin, Chung-Chen Hsu, Jiun- Ting Yeh Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan ** Nothing to disclose **

2014 ASPS 2014 ASPS

Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Introduction Introduction Open and Endoscopic Carpal Tunnel Release Open and Endoscopic Carpal Tunnel Release (OCTR / ECTR) (OCTR / ECTR)

n nAdvantages of OCTR:

Advantages of OCTR:

Direct visualization of TCL and median nerve Direct visualization of TCL and median nerve

n nECTR:

ECTR:

n nHigher persistence and higher recurrence rate

Higher persistence and higher recurrence rate

n nPotentially increased risk of an

Potentially increased risk of an incomplete release incomplete release

Dina L. Dina L. Hulsizer Hulsizer, Michael P. , Michael P. Staebler Staebler, Arnold-Peter C. Weiss, et al., J Hand , Arnold-Peter C. Weiss, et al., J Hand Surg Surg 1998; 23A: 865-869 1998; 23A: 865-869 * *

Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Persistent / Recurrent CTS Persistent / Recurrent CTS

n n Recurrent CTS:

Recurrent CTS:

n n Reappearance three months

Reappearance three months following the surgery following the surgery

Raimbeau Raimbeau G, G, Chirurgie Chirurgie de la main. 2008;27:134–145 de la main. 2008;27:134–145

n n Persistent CTS:

Persistent CTS:

n n No improvement after surgery

No improvement after surgery

Mosier BA, Hughes TB, Hand Mosier BA, Hughes TB, Hand Clin

• Clin. 2013;29:427

. 2013;29:427

  Repeat TCL release and median nerve Repeat TCL release and median nerve neurolysis neurolysis   May not relieve symptoms as primary CTR May not relieve symptoms as primary CTR

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Purpose Purpose

Analyze the patients, persistent or recurrent symptoms Analyze the patients, persistent or recurrent symptoms

n n After carpal tunnel release, from single surgeon

After carpal tunnel release, from single surgeon

n nBaseline data

Baseline data

n nPrior operation method (ECTR or OCTR)

Prior operation method (ECTR or OCTR)

n nTechnique applied in the revision surgery

Technique applied in the revision surgery

n nOutcomes

Outcomes

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Materials and Methods Materials and Methods

n n Sep 2011 - Sep 2013

Sep 2011 - Sep 2013

n n 21 consecutive patients

21 consecutive patients

n n All received revision CTR (ECTR or OCTR)

All received revision CTR (ECTR or OCTR)

n n Followed in the clinics until the end-point

Followed in the clinics until the end-point

n n confirmation of subjective symptoms with or

confirmation of subjective symptoms with or without improvement without improvement

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Results: Baseline Data Results: Baseline Data

n n 9 males / 12 females

9 males / 12 females

n n Mean age: 57.7 years

Mean age: 57.7 years

n n 17 Recurrent / 9 Persistent (total 26 hands)

17 Recurrent / 9 Persistent (total 26 hands)

n n CTS and Chronic renal failure (hands)

CTS and Chronic renal failure (hands)

n n CRF: 13 (hemodialysis for average 22.4 years)

CRF: 13 (hemodialysis for average 22.4 years)

n n Non-CRF: 13

Non-CRF: 13

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Primary surgery

OCTR OCTR ECTR ECTR

Total Total Recurrent Recurrent

17 17 17 17

Persistent Persistent

5 5 4 4 9 9

Total Total

5 5 21 21 26 26

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n n Average interval between the first and our

Average interval between the first and our CTR: 5.9 years (53 days -10.4 years) CTR: 5.9 years (53 days -10.4 years)

n n Mean follow-up duration: 90 days

Mean follow-up duration: 90 days

n n Pre-operative NCV study: 24 hands

Pre-operative NCV study: 24 hands

n n Positive findings: 100%

Positive findings: 100%

n n Recurrent: 15 / Persistent: 8

Recurrent: 15 / Persistent: 8

Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Results: Revision of Carpal Tunnel Release Results: Revision of Carpal Tunnel Release

n n OCTR: 10 (8) / ECTR: 16 (18)

OCTR: 10 (8) / ECTR: 16 (18)

n n Shifted to OCTR intra-operatively: 2

Shifted to OCTR intra-operatively: 2

n n TCL completely released during endoscopic approach

TCL completely released during endoscopic approach

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Results: Operative Findings Results: Operative Findings

TCL incomplete release (20): TCL incomplete release (20): Intact TCL at distal Intact TCL at distal tunnel tunnel

• bserved
• bserved by endoscopy

by endoscopy

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

n n Only one hand without improvement (Recurrent case)

Only one hand without improvement (Recurrent case)

n n Left recurrent CTS revised by OCTR

Left recurrent CTS revised by OCTR  improved improved

n n Right recurrent revised by ECTR

Right recurrent revised by ECTR  no improvement no improvement   Re-revised ( Re-revised (OCTR) 3 months later OCTR) 3 months later   No improvement at final follow-up ( No improvement at final follow-up (49 days) 49 days)

Operative Method No Numbness Improvement No Improvement Recurrent (17)

ECTR 4 6 OCTR 6 1

Persistent (9)

ECTR 5 OCTR 1 3

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Discussion: Recurrent CTS following CTR Discussion: Recurrent CTS following CTR

n n Reported frequency of reoperation: 0.3 to 12%

Reported frequency of reoperation: 0.3 to 12%

n n Incomplete transection of the TCL / flexor

Incomplete transection of the TCL / flexor retinaculum: frequent cause retinaculum: frequent cause

Amadio Amadio PC. J Hand

• PC. J Hand Surg

Surg, 2009;34A , 2009;34A Luria S, Luria S, Waitayawinyu Waitayawinyu T, T, Trumble Trumble TE.

• TE. Plast

Plast Reconstr Reconstr Surg. 2008;121:2029

• Surg. 2008;121:2029

n n Iatrogenic nerve lesions or active flexor tenosynovitis

Iatrogenic nerve lesions or active flexor tenosynovitis

n n Perineural

Perineural fibrosis fibrosis

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

n n Persisting or recurrent prevented in 83%

Persisting or recurrent prevented in 83%

n n Skilled surgeons by thorough operative technique

Skilled surgeons by thorough operative technique

n n Based on exact knowledge of the anatomy

Based on exact knowledge of the anatomy

STÜTZ N, GOHRITZ A, VAN SCHOONHOVEN J et al. J Hand Surg. 2006;31 STÜTZ N, GOHRITZ A, VAN SCHOONHOVEN J et al. J Hand Surg. 2006;31

n n Repeat operations

Repeat operations

n n Continue symptoms: 43 - 90%, No relief: 20%

Continue symptoms: 43 - 90%, No relief: 20%

n n In our study: revision by

In our study: revision by endoscopic endoscopic approach approach

• Overall successful rate: 88.9%

Overall successful rate: 88.9%

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Endoscopic Release of Recurrent CTS Endoscopic Release of Recurrent CTS

n n Limitations:

Limitations:

n n Nerve injury suspected

Nerve injury suspected

n n An extensive primary approach--

An extensive primary approach-- difficulty in locating entry difficulty in locating entry

n n Several previous open revisions

Several previous open revisions--

• - contraindication: possible

contraindication: possible variations in the anatomy or extensive scarring variations in the anatomy or extensive scarring

n n Results:

Results:

n n Comparable to those achieved with open revision

Comparable to those achieved with open revision

Luria S, Luria S, Waitayawinyu Waitayawinyu T, T, Trumble Trumble TE.

• TE. Plast

Plast Reconstr Reconstr Surg. 2008;121:2029

• Surg. 2008;121:2029

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Chang Gung Memorial Hospital Chang Gung Memorial Hospital Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery Department of Plastic & Reconstructive Surgery, Division of Trauma Plastic Surgery

Primary CTR Primary CTR Recurrent Numbness Recurrent Numbness Persistent Numbness Persistent Numbness NCV NCV CTS CTS Non-CTS Non-CTS

Refer to Refer to neurologist neurologist

< 3 months < 3 months > 3 months > 3 months NCV NCV Observation and Observation and NCV at 3 NCV at 3rd

rd Month

Month Compare NCV to prior study Compare NCV to prior study Not improved Not improved Improved Improved

Observation Observation

Endoscopic approach Endoscopic approach TCL (+) TCL (+) TCL (-) TCL (-)

ECTR ECTR OCTR OCTR

Limitation for endoscopic approach Limitation for endoscopic approach

(+) (+) (-) (-)

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