Orthopaedics Today Europe spoke with some international experts on hand surgery in order to know what the latest techniques in the field are.
Do not injure median nerve
According to Grey Giddins, FRCS (Orth), EDHS, of the Hand Clinic, in Bath, United Kingdom, regardless of whether a carpal tunnel syndrome (CTS) is new or old, orthopedics should ideally select a treatment that releases the transverse carpal ligament (TCL) completely.
“Researchers are looking at how many discreet moves it takes to do it; that may improve the technique and be a measure of progress in training,” Giddins said.
The anatomy can be surprising and the canal very tight. There is a risk of the median nerve being injured with incisions that are too small, so surgeons must take whatever steps they can to avoid such injuries that might be disproportionate to any small gain from a small incision.
Classic vs short incisions
Lars B. Dahlin, MD, PhD, of the Department of Translational Medicine – Hand Surgery, Lund University, Skane University Hospital in Malmö, Sweden, believes the skin incision of the (CTS) surgery is not as much a concern as how well the CTS surgery is managed.He said time is the key to successful CTS surgery in his patients rather than other factors, such as the length of the incision or surgical instrument used.
Surgeons who treat CTS open or endoscopically now perform a superficial carpal tunnel release (CTR).
Giddins mentioned a recent study by Ecker and colleagues in which they reported results with a supraretinacular endoscopic CTR, which is different from the infraretinacular approach some hand surgeons currently use.
Since the endoscope is inserted superficialyl to the flexor retinaculum, the median nerve is not compressed before division of the retinaculum and, as a result, they did not observe any cases of the transient median nerve deficits like have been reported using infraretinacular endoscopic techniques.
Back in 2013, Larsen and colleagues found no advantages to CTS surgeries done with short incision open and endoscopic surgical techniques in their study, which included 90 patients with 24 weeks of follow-up.
The outcomes indicated that the endoscopic procedure was safe and had the benefit of a faster recovery and return to work.
Giddins said that, based on his experience, the indications for endoscopic releases and open releases are largely the same.
Variations on TCL cutting, devices and ultrasound
Jeremy D.P. Bland, MB ChB, FRCP, a consultant in clinical neurophysiology at East Kent Hospitals University NHS Foundation Trust, told Orthopaedics Today Europe that there is a “new and effective” treatment for CTS, with some interesting variations on how to cut the TCL, like the more ingenious ultrasound-guided division.
There are various devices which have been introduced throughout the years for minimally invasive approaches to surgical CTR that aid with the release or better illuminate the procedure.
One of the doctors, Dahli, has no experience in ultrasound and has some hesitation about adopting this treatment approach since there is a possibility that some small fibers of the distal, deeper part of the TCL may remain and may not be seen as well as using conventional open CTS technique. He states, “I think it is extremely important that the resolution is good [so] that you can see all the parts, that you could divide the ligament.”