Supervisors info:
Αναπληρωτής Καθηγητής Ιωάννης Γκρινιάτσος (Επιβλέπων), Καθηγητής Χρήστος Π. Τσιγκρής, Καθηγητής Θεόδωρος Διαμαντής
Summary:
Surgical treatment of Carpal Tunnel Syndrome (CTS) consists of the division of
the transverse carpal ligament which reduces the pressure on the median nerve
by increasing the space in the carpal tunnel (130). Surgery is recommended for
most patients with moderate to severe CTS. There are two different categories
of methods used for surgical treatment of CTS: open release and endoscopic
release. Open carpal tunnel release consists of the standard method of open
release, as well as several modified methods. Modifications to the standard
open carpal tunnel release (OCTR) include new incision techniques, such as the
mini-open release, and addition of other procedures such as epineurotomy
(131,132). The standard open carpal tunnel release consists of a longitudinal
incision at the base of the hand and in line with this incision, the incision
of the subcutaneous tissue, the superficial palmar fascia and the muscle of the
palmaris brevis (132) . The mini-open carpal tunnel release is a relatively new
technique that consists of a longitudinal incision that varies from 1.5-3.0 cm,
placed in line with the radial border of the ring finger(132) . Different tools
have been used for the mini-open carpal tunnel release, such as the Indiana
Tome (132) . Endoscopic carpal tunnel release (ECTR) is another new technique
that was developed by Okutsu and colleagues since 1986 (134) . The two most
commonly used methods of endoscopic carpal tunnel release are the single-portal
and dual-portal technique; techniques that differ based on the number of ports
used to access the carpal tunnel (135) . The
single portal technique consists of the release of the transverse carpal
ligament by using a single incision at the wrist. The double-portal technique
consists of two incisions, one at the wrist and one at the palm of the hand.
Several studies have tried to compare the efficiency and outcomes of the
techniques involving carpal tunnel release procedures. Open carpal tunnel
release and endoscopic carpal tunnel release have been shown to have no
significant differences in outcomes within 12 week of surgery (136) and within
1 and up to 5 years of surgery (132) . Mini-open carpal tunnel release and
standard open carpal tunnel release have shown no significant differences
within 4 months of surgery (137) and within 6 months of surgery (139) ;
however, mini-open carpal tunnel release has been shown to have better outcomes
in earlier stages after surgery (138). ECTR release is sometimes favored over
OCTR as dividing the skin from below preserves the muscle and overlying skin,
thus facilitating return to work; however, it has an increased risk of nerve or
artery injury because of limitations in visualization (132) . ECTR has been
shown to have better outcomes in muscle strength within 12 wk of surgery (132)
and better outcomes compared to both standard open and mini-open release within
4 week of surgery (137)
The Agee ECTR technique represents a single-portal, minimally invasive
procedure to treat patients with median nerve compression at the wrist who meet
the criteria for surgery. General advantages of this technique over open CTR
include:
- less scar tenderness
- decreased pillar pain
- faster recovery of pinch and grip strength, and
- earlier return to work and daily activities.
Moreover, the Agee technique has the advantage of being a single incision
technique that utilizes a blade system that readily attaches to the standard
endoscopic equipment that is widely available in most medical centers. However,
as in any surgical and especially endoscopic procedure, safety and success are
dependent upon patient selection, thorough knowledge of the surface and
surgical anatomy, adequate training, and familiarity with the use and
capabilities of the instrumentation. Surgeons who are not familiarized with
endoscopic equipment and technique may give rise to major iatrogenic
complications. Open A1 pulley release is a standard surgical procedure for
treatment of trigger finger. The disadvantages of the open technique include
injury to the soft tissue, developing a painful palmar scar and patients
requiring an extended recovery time since the procedure is more complex.
Another technique used for treatment of trigger finger is percutaneous release.
This technique offers the benefits of smaller incision, faster recovery time
and an easier procedure compared to the open technique. The A-Knife is a new
specially designed invention for percutaneous trigger finger release.(163)
Therefore, percutaneous trigger finger release is believed to be the indicated
treatment of choice for:
- cases that failed conservative treatment,
- cases when the symptoms last for more than four months,
- Grade 3 (locking but passively correctable), and
- Grade 4 (a locked digit) triggering is present. The advantages of the
procedure are short operative time, safety and ease as an office procedure. The
patient will have a rapid recovery period and less post-operative pain.
DeQuervain’s tenosynovitis is a common problem that often requires surgical
treatment. The classic open approach for release of the first dorsal
compartment is not without complications and results are not uniformly
excellent. Controversies that exist include location and orientation of the
incision and the amount of retinaculum removed. Endoscopic treatment of this
tendinopathy may be helpful in minimizing these problems.
