A Clinical Study of the Modified Thread Carpal Tunnel Release

Danqing Guo, Danzhu Guo, Joseph Guo, Steven C Schmidt, Rachel M Lytie, Danqing Guo, Danzhu Guo, Joseph Guo, Steven C Schmidt, Rachel M Lytie

Abstract

Background: Previous studies have indicated that the thread carpal tunnel release (TCTR) is a safe and effective technique. Through a study on 11 cadaveric wrists, the TCTR procedure was modified and the needle control accuracy was improved to 0.15 to 0.2 mm, which is precise enough to preserve superficial palmar aponeurosis (SupPA), Berrettini branch, and common digital nerves. The aim of the present study was to verify the modified TCTR clinically.

Methods: The modified TCTR was performed on 159 hands of 116 patients. The Boston Carpal Tunnel Syndrome Questionnaire was used for assessing the outcomes. Statistical analyses were used to compare the outcomes with the available data from the literature for the open and endoscopic techniques.

Results: TCTR led to significant improvement in the short-term results, and the outcomes were better in long-term results compared with the open or endoscopic release. The SupPA, Berrettini branch, and common digital nerves were protected. There was no neurovascular complication for any case. Significant relief of symptoms was observed 3 to 5 hours post procedure. Most patients used their hands on the day of the procedure for simple daily activity. Patients reported their sleep quality was improved on the surgical day. Most patients with office jobs were able to return to work on postoperative day 1, and those with repetitive jobs returned to work in about 2 weeks. The statistical evidence proves that the modified TCTR procedure results in improved clinical outcomes as compared with open carpal tunnel release (CTR) and endoscopic CTR.

Conclusions: The TCTR procedure has been shown to be a safe and effective technique for CTR. The modified TCTR procedure minimizes postoperative complications, such as pillar pain, scar tenderness, or functional weakness, by avoiding unnecessary injuries to the surrounding structures around the transverse carpal ligament during the procedure.

Keywords: carpal tunnel release; carpal tunnel syndrome; percutaneous procedure; thread dissecting procedure; ultrasound-guided procedure.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Joseph Guo has financial interest in the device for TCTR. Others have no conflict of interest.

Figures

Figure 1.
Figure 1.
Duck’s beak (distal on left). Note. The TCL blends with the superficial palmar aponeurosisas to show a hyperechoic area like a DB. The DB overlies the palmar fat pad, seen as a hypoechoic area between the DB and the flexor tendons. DB = the duck’s beak; SC = subcutaneous fibroadipose tissue of the palm; SPA = superficial palmar arterial arch; SupPA = superficial palmar aponeurosis; fd = fat pad; TCL = transverse carpal ligament; FDS = flexor digitorum superficialis tendons; FDP = flexor digitorum profundus tendons; MC = metacarpal bone; C = capitate bone.
Figure 2.
Figure 2.
The routing needle traveled between the entry and exit points.
Figure 3.
Figure 3.
The routing path of thread with SupPA (top) or without SupPA (bottom) in the loop (distal on right). Note. SupPA = superficial palmar aponeurosis; PS level = plane of the line connecting the pisiform and scaphoid bones; SC = subcutaneous fibroadipose tissue of the palm; HT level = plane of the line connecting the hook of hamate and trapezium tuberosity bones; SPA = superficial palmar arterial arch; DeepPA = deep palmar aponeurosis; TCL = transverse carpal ligament; FDS = flexor digitorum superficialis tendons; FDP = flexor digitorum profundus tendons; R = radius; L = lunate bone; C = capitate bone; MC = metacarpal bone.
Figure 4.
Figure 4.
The 27G needle passed over the SPA. Note. SPA = superficial palmar arterial arch; SC = subcutaneous fibroadipose tissue of the palm; SupPA = superficial palmar aponeurosis; DB = the duck’s beak; fd = fat pad; FDS = flexor digitorum superficialis tendons; FDP = flexor digitorum profundus tendons; MC = metacarpal bone.
Figure 5.
Figure 5.
The 27G needle passed through the SupPA at the tip of DB. Note. SupPA = superficial palmar aponeurosis; DB = the duck’s beak; SC = subcutaneous fibroadipose tissue of the palm; TCL = transverse carpal ligament; SPA = superficial palmar arterial arch; FDS = flexor digitorum superficialis tendons; FDP = flexor digitorum profundus tendons; MC = metacarpal bone.
Figure 6.
Figure 6.
The 18G needle in the first pass. Note. SupPA = superficial palmar aponeurosis; TCL = transverse carpal ligament; DB = the duck’s beak; SPA = superficial palmar arterial arch; FDS = flexor digitorum superficialis tendons; FDP = flexor digitorum profundus tendons; MC = metacarpal bone.
Figure 7.
Figure 7.
The sonographical view of the completed routing loop with (top) or without (bottom) the SupPA included. Note. SupPA = superficial palmar aponeurosis; TCL = transverse carpal ligament; FDS = flexor digitorum superficialis tendons; FDP = flexor digitorum profundus tendons.

References

    1. Agee JM, Peimer CA, Pyrek JD, Walsh WE. Endoscopic carpal tunnel release: a prospective study of complications and surgical experience. J Hand Surg Am. 1995;20(2): 165-171.
    1. Bande S, De Smet L, Fabry G. The results of carpal tunnel release: open versus endoscopic technique. J Hand Surg Br. 1994;19(1):14-17.
    1. Bas H, Kleinert JM. Anatomic variations in sensory innervation of the hand and digits. J Hand Surg Am. 1999;24(6): 1171-1184.
    1. Biyani A, Downes EM. An open twin incision technique of carpal tunnel decompression with reduced incidence of scar tenderness. J Hand Surg Br. 1993;18(3):331-334.
    1. Bonnel F, Vila RM. Anatomical study of the ulnar nerve in the hand. J Hand Surg Br. 1985;10(2):165-168.
    1. Brooks JJ, Schiller JR, Allen SD, Akelman E. Biomechanical and anatomical consequences of carpal tunnel release. Clin Biomech (Bristol, Avon). 2003;18(8):685-693.
    1. Brown RA, Gelberman RH, Seiler J, et al. Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods. J Bone Joint Surg Am. 1993;75(9):1265-1275.
    1. Buchanan RT, Blair WF, Higgs PE, Hurst LN, Nathan PA. Method, education and therapy of carpal tunnel patients. Hand Surg Quart. 1995.
    1. Dumontier C, Sokolow C, Leclercq C, Chauvin P. Early results of conventional versus two-portal endoscopic carpal tunnel release. A prospective study. J Hand Surg Br. 1995;20(5):658-662.
    1. Ferrari GP, Gilbert A. The superficial anastomosis on the palm of the hand between the ulnar and median nerves. J Hand Surg Br. 1991;16(5):511-514.
    1. Foucher G, Braga DSJ. [Endoscopic opening of the carpal canal]. Chirurgie. 1993;120(12):100-104.
    1. Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res. 2001;383:41-46.
    1. Griot JPWD, Van Kooten EO, Zuidam JM, Prose LP, Hage JJ. Internal anatomy of the communicating branch between the ulnar and median nerves in the hand and its relevance to volar digital sensibility. J Hand Surg Am. 2002;27(1):143-146.
    1. Guo D, Guo D, Guo J, Malone DG, Wei N, McCool LC. A cadaveric study for the improvement of thread carpal tunnel release. The Journal of Hand Surgery. 2016;
    1. Guo D, Tang Y, Sun T, Guo J, Guo D. Non-scalpel technique for minimally invasive surgery: percutaneously looped thread transection of the transverse carpal ligament. Hand (N Y). 2015;10(1):40-48.
    1. Hong JT, Lee SW, Han SH, et al. Anatomy of neurovascular structures around the carpal tunnel during dynamic wrist motion for endoscopic carpal tunnel release. Neurosurgery. 2006;58(suppl):ONS127-133.
    1. Katz JN, Gelberman RH, Wright EA, Abrahamsson SO, Lew RA. A preliminary scoring system for assessing the outcome of carpal tunnel release. J Hand Surg Am. 1994;19(4):531-538.
    1. Kolic Z, Micovic V, Zamolo G, Golubovic V, Uravic M, Stancic M F. The anatomy of the Berrettini branch: implications for endoscopic carpal tunnel release. Neurosurg Focus. 1997;3(1):E9.
    1. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993;75(11):1585-1592.
    1. Lewis C, Mauffrey C, Newman S, Lambert A, Hull P. Current concepts in carpal tunnel syndrome: a review of the literature. Eur J Orthop Surg Traumatol. 2010;20:445-452.
    1. Ludlow KS, Merla JL, Cox JA, Hurst LN. Pillar pain as a postoperative complication of carpal tunnel release: a review of the literature. J Hand Ther. 1997;10(4):277-282.
    1. MalcicGürbüz J, Özdoĝmuş Ö, Ĉavdar S. Unusual anatomic variation of palmar sensory branches of the ulnar nerve: a case report. J Hand Surg Am. 2002;27(1):147-149.
    1. Mannerfelt L. Studies on the hand in ulnar nerve paralysis. A clinical-experimental investigation in normal and anomalous innervation. Acta Orthop Scand. 1966;37(suppl 87):31-76.
    1. Meals RA, Shaner M. Variations in digital sensory patterns: a study of the ulnar nerve-median nerve palmar communicating branch. J Hand Surg Am. 1983;8:411-414.
    1. Menon J. Endoscopic carpal tunnel release: preliminary report. Arthroscopy. 1994;10(1):31-38.
    1. Mirza MA, King ET, Tanveer S. Palmar uniportal extrabursal endoscopic carpal tunnel release. Arthroscopy. 1995;11(1): 82-90.
    1. Morrell NT, Harris A, Skjong C, Akelman E. Carpal tunnel release: do we understand the biomechanical consequences? J Wrist Surg. 2014;3(4):235-238.
    1. Oertel J, Schroeder HW, Gaab MR. Dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome: results of 411 procedures with special reference to technique, efficacy, and complications. Neurosurgery. 2006;59(2):333-340.
    1. Olave E, Del Sol M, Gabrielli C, Mandiola E, Rodrigues CFS. Biometric study of the relationships between palmar neurovascular structures, the flexor retinaculum and the distal wrist crease. J Anat. 2001;198(6):737-741.
    1. RojoManaute JM, CapaGrasa A, RodríguezMaruri GE, Moran LM, Martínez MV, Martín JV. Ultra-minimally invasive sonographically guided carpal tunnel release: anatomic study of a new technique. J Ultrasound Med. 2013;32(1):131-142.
    1. Seitz WH, Jr, Lall A. Open carpal tunnel release with median neurolysis and Z-plasty reconstruction of the transverse carpal ligament. Curr Orthop Pract. 2013;24(1):53-57.
    1. Stancić MF, Mićović V, Potocnjak M. The anatomy of the Berrettini branch: implications for carpal tunnel release. J Neurosurg. 1999;91:1027-1030.
    1. Sunderland SIRS. Nerves and Nerve Injuries. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 1978.
    1. Trumble TE, Diao E, Abrams RA, GilbertAnderson MM. Single-portal endoscopic carpal tunnel release compared with open release. J Bone Joint Surg Am. 2002;84(7):1107-1115.
    1. Wilson JN. Profiles of the carpal canal. J Bone Joint Surg Am. 1954;36A:127-132.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever