2014 ASPS 2014 ASPS 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 ** 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) Advantages of OCTR: n Advantages of OCTR: n Direct visualization of TCL and median nerve Direct visualization of TCL and median nerve ECTR: n ECTR: n Higher persistence and higher recurrence rate n Higher persistence and higher recurrence rate n Potentially increased risk of an incomplete release incomplete release n Potentially increased risk of an n 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 Dina L. 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 Recurrent CTS: Recurrent CTS: n n Reappearance three months Reappearance three months n following the surgery following the surgery Raimbeau G, G, Chirurgie Chirurgie de la main. 2008;27:134–145 de la main. 2008;27:134–145 Raimbeau n Persistent CTS: Persistent CTS: n n No improvement after surgery No improvement after surgery n 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 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 After carpal tunnel release, from single surgeon After carpal tunnel release, from single surgeon n Baseline data n Baseline data n Prior operation method (ECTR or OCTR) n Prior operation method (ECTR or OCTR) n Technique applied in the revision surgery n Technique applied in the revision surgery n Outcomes n Outcomes n 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 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 n without improvement without improvement 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 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 n 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
OCTR ECTR OCTR ECTR Primary surgery Total Total 0 17 17 0 17 17 Recurrent Recurrent 5 4 9 5 4 9 Persistent Persistent 5 21 26 5 21 26 Total Total n Average interval between the first and our Average interval between the first and our n CTR: 5.9 years (53 days -10.4 years) CTR: 5.9 years (53 days -10.4 years) 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 n 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 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 n 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 tunnel tunnel Intact TCL at distal observed by endoscopy by endoscopy observed 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
Operative No Improvement No Improvement Method Numbness ECTR 4 6 Recurrent (17) OCTR 6 1 ECTR 5 Persistent (9) OCTR 1 3 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 n Re-revised (OCTR) 3 months later OCTR) 3 months later Re-revised ( No improvement at final follow-up (49 days) 49 days) No improvement at final follow-up ( 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 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 n retinaculum: frequent cause retinaculum: frequent cause Amadio PC. J Hand PC. J Hand Surg Surg, 2009;34A , 2009;34A Amadio Luria S, Waitayawinyu Waitayawinyu T, T, Trumble Trumble TE. TE. Plast Plast Reconstr Reconstr Surg. 2008;121:2029 Surg. 2008;121:2029 Luria S, n Iatrogenic nerve lesions or active flexor tenosynovitis Iatrogenic nerve lesions or active flexor tenosynovitis n n Perineural Perineural fibrosis fibrosis n 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 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 n 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 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 n Overall successful rate: 88.9% Overall successful rate: 88.9% • • 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
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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