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Carpal Tunnel Release through Mini Transverse Approach CTRMTA (Sayed Issa’s Approach)

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  • Independent Researcher

Abstract

The idea of CTRMTA technique is enforcement carpal tunnel release through endoscopic carpal tunnel release incision; not using endoscopic instruments but conventional surgical instruments.
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Introduction
CTRMTA (Sayed Issa’s Approach) 1 can be used by experienced
hand surgeons especially in countries where endoscopic release is
expensive and not available, as in our country Syria with a set of war
circumstances.
CTRMTA is a mini transverse approach technique for carpal
tunnel release; the approach is about 1.5cm (Figure 1) through distal
palmar wrist skin crease incision.
Figure 1 CTRMTA is about 1.5cm through distal palmar wrist skin crease
incision.
CTRMTA acquires good rehabilitation achievements on a shorter
time, more rapid return to work and daily activities, short healing
period, less surgical traumatic incision, less tissues dissection, and
less scar tenderness, than in open carpal tunnel release OCTR, or in
endoscopic carpal tunnel release ECTR, it causes gentle scar, and very
good cosmetic skin healing, the procedure takes about 10 minutes.
The disadvantages of endoscopic carpal release includes:
costly equipment required, costly surgery, prolonged procedure
time (30-45minutes). Most importantly, there have been many
reported complications in association with the procedure, including
neuropraxia, transection of the median nerve or its branches, ulnar
nerve injury, supercial palmar arch injury. Incomplete division of
the transverse carpal ligament has been noted in cadaveric studies and
clinical series.2
The surgical tools of CTRMTA
A. One scalpel with blade No. 15
B. Two Senn retractors
C. One curved hemostats
D. One straight Metzenbaum scissors
E. One needle holder
F. One Adson tissue forceps
G. One straight blunt-blunt scissors for cutting the suture
H. One 3/0 nylon suture
MOJ Orthop Rheumatol. 2018;10(3):175178. 175
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Carpal Tunnel Release through Mini Transverse
Approach CTRMTA (Sayed Issa’s Approach)
Volume 10 Issue 3 - 2018
Sayed Issa Abdulhamid
Professor, Adults Nursing Department and Traumatic and
Orthopaedics Nursing Faculty, School of Nursing and Midwifery
of Aleppo, Syria
Correspondence: Sayed Issa Abdulhamid, Dr. Abdulhamid
Sayed Issa’s clinic, Al Nile Street, Aleppo, Syria, Tel 00963-
944838097, 00963-993806391, Email orthoasi@yahoo.com
Received: March 16, 2018 | Published: May 16, 2018
Abstract
Introduction: The idea of CTRMTA technique is enforcement carpal tunnel release
through endoscopic carpal tunnel release incision; not using endoscopic instruments
but conventional surgical instruments.
Methods: Clinical experience with this technique consists of 43 cases and 48 hands
over a period of three years, five cases were bilateral release in the same session, this
study were from February 2013 to March 2016. All cases were done as outpatient and
under local anesthesia.
Results: The mean duration of the operation was 10 minutes, and the minimum
duration was 8 minutes. There was no major nerve or vascular injury in all cases. This
technique is simple, safe, and highly cosmetically satisfactory for all patients who
previously experienced the open standard palmar incision in the other hand, and it is
cost effective. Two older than 65 years old female patients suffered pain during first
six weeks after surgery, and one of them stopped visiting us after six weeks of surgery,
she was not happy because of wrist pain and tenderness after surgery.
Conclusion: It can be used by experienced hand surgeons, especially in countries
where endoscopic release is expensive and not available. This technique is simple,
safe, cosmetically satisfactory and cost effective.
Keywords: carpal tunnel syndrome, carpal tunnel surgery, carpal tunnel release, ctr,
mini-open release, mini incision release, carpal tunnel release through mini transverse
approach, ctrmta, endoscopic carpal tunnel release, ectr, open carpal tunnel release,
octr, safety, cosmetic, rehabilitation, complications, syria, war, surgery, satisfaction
MOJ Orthopedics & Rheumatology
Research Article Open Access
Carpal Tunnel Release through Mini Transverse Approach CTRMTA (Sayed Issa’s Approach) 176
Copyright:
©2018 Abdulhamid.
Citation: Abdulhamid SI. Carpal Tunnel Release through Mini Transverse Approach CTRMTA (Sayed Issa’s Approach). MOJ Orthop Rheumatol;10(3):175178.
DOI: 10.15406/mojor.2018.10.00409
Surgical technique
The operations were performed through a transverse incision at
the distal crease of the wrist on palmar side (Figure 2); we prefer to
do it under local anesthesia, to estimate the abnormal sudden pain
during ligament cutting to avoid median nerve Irritation. Without
using a tourniquet, it is more comfortable from the patient side, but
it takes little longer to proceeds because of the few blood Seepage
through the incision. It is useful to use a surgical headlight. The wrist
is placed in extension over a rolled towel. A 1.5cm transverse incision
is performed at the distal crease of the wrist in the middle and ulnar
to the palmaris longus tendon. The palmaris longus is isolated and
retracted radially by putting two Senn retractors; one proximally and
the other distally at the ulnar side of palmaris longus, and to retract
the skin incision proximally and distally, the antebrachial fascia lying
deep to palmaris longus is exposed where it is continuous with the
proximal edge of the transverse carpal ligament distally. The anatomic
plane between palmaris longus and palmar fascia supercially and the
antebrachial fascia and the carpal ligament deeply is opened carefully
with scalpel, about 3-5mm longitudinal incision is made with the
scalpel on the proximal third of the carpal ligament; taking care not to
damage the median nerve, thus allowing access to the carpal tunnel.
The closed curved hemostats is inserted under the ligament; the tip
of curved hemostats is up, and advanced proximally to establish an
extrabursal path, where the proximal part of the carpal ligament and
the distal portion of the antebrachial fascia are, then incised with a
straight Metzenbaum scissors under direct vision, now the proximal
edge of the carpal ligament is seen end on, thus one is able to visualize
supercial and immediately deep to the carpal ligament. The closed
curved hemostats (the tip of curved hemostats is up) is inserted under
the ligament and advanced distally to establish an extrabursal path.
The proximal edge of the transverse carpal ligament is divided under
direct vision by opening the hemostats for more safety, and cutting
the ligament by straight Metzenbaum scissors, also it can be made
without using the hemostats. In addition, by retracting the palmar skin
and fascia volarly, thus providing improved visibility of the distal
portion of the carpal ligament, the distal part is transected with the
straight Metzenbaum scissors. The transection proceeds snip by snip,
at this time ask the patient to ex and extend his ngers to make sure
the deeper tip of the scissors are not going inside the deeper tissue,
and slips over the exor sheaths, and carefully with the scissors are
directed in the longitudinal axis between the third and the fourth ray.
Upon completing the release.
Figure 2 operations were performed through a transverse incision at the
distal crease of the wrist on palmar side.
The way to have a safe mini transverse open procedure that we
used in the present study is to push the scissors gently towards the
longitudinal axis while the tip of the scissors directed volarly and to
stop immediately when the ligament resistance suddenly decreases.
The incision is also ulnar to the tendon of palmaris longus, which
avoids the palmar cutaneous branch of the median nerve. This mini
transverse approach is easy to master and have a short learning
curve, which contribute to its low morbidity and post-operative
complications.
Finally, we check the completeness of the release by introducing
the tip of the closed curved hemostats distally, beyond the distal edge
of the retinaculum, and withdrawing it slowly while the tip is directed
volarly. If the release is incomplete, the surgeon will feel a step;
otherwise, withdrawal should be smooth. At this stage, the median
nerve will be seen clearly throughout the tunnel.
At the end, the skin incision is closed with one mattress 3-0 nylon
suture (Figure 3), and dressed. The patient is advised to start gentle
active nger movement immediately, to keep the hand elevated for the
rst 24 hours, to take a pain killer and NSAID for the next ve days
and to take an antibiotic for two weeks if necessary for prevention of
infection, and to come back after rst ve days to check the wound,
and after two weeks to remove the stitch.
From February 2013 to March 2016; we performed 48 carpal
tunnel releases on 43 patients (ve cases were bilateral released on
the same session), using the CTRMTA. The diagnosis of carpal tunnel
syndrome was clinical and then it was conrmed by electrodiagnostic
studies in not clear cases. Patients with secondary causes were
excluded. All patients had failed prior conservative treatment for at
least 3 months before the procedure, except one male patient had a
very clear symptoms, including weakness in the hand grip, and a clear
rst three ngers trembling (thumb, index, and the middle nger).
Figure 3 the skin incision is closed with one mattress 3-0 nylon suture, and
dressed.
Results
The mean duration of the operation was 10minutes (8-12minutes).
No single major complication, wound or neurovascular, was recorded
in any of the patients. Minor complications were observed including:
seven supercial wound infections, ve wound hematomas resolved
Carpal Tunnel Release through Mini Transverse Approach CTRMTA (Sayed Issa’s Approach) 177
Copyright:
©2018 Abdulhamid.
Citation: Abdulhamid SI. Carpal Tunnel Release through Mini Transverse Approach CTRMTA (Sayed Issa’s Approach). MOJ Orthop Rheumatol;10(3):175178.
DOI: 10.15406/mojor.2018.10.00409
over the third week without sequel, parasthesia in ulnar nerve
distribution in six patients resolved over two months.
Fibrous adhesion effective between subcutaneous tissue from one
side and median nerve and tendons sheath in the other side at the
skin incision zone, the transverse incision is perpendicularly with the
longitudinal axis of carpal tunnel tendons and median nerve; so it is
purposive for minimum postoperative brosis adhesion.
After a six months follow-up evaluation, all patients were satised
with their cosmetic results, except one female patient stopped visiting
us after six weeks.
Postoperative cosmetic appearance of the palm is an important
issue related to skin incision. Our results showed clearly that the
CTRMTA we used is good satisfactory and comparable to endoscopic
approach. The over all patient satisfaction with the procedure was also
excellent at the nal follow-up visit after eight months. The longer
follow-up period is needed to assess the long term results of this
approach regarding the possibility of recurrence of the disease, which
was not done in our study.
Discussion
Various open techniques using small incisions have been
described.3-12 Carter3 published CTR using a transverse wrist incision,
with no complications in 100 cases. Bromley9 used a short palmar
incision, with excellent results. Wilson12 used double palmar incisions,
with excellent results, using a conventional scissors.
Abouzahr et al.7 made CTR in cadavers with a transverse wrist
incision, and in one of 28 hands injured the supercial palmar arch, he
reported a low complication rate. Hallock et al.8 did a comparison of
71 hands which underwent open release using a minimal incision with
66 hands who had ECTR. They found no differences between the two
techniques by scar length, complications, and rehabilitation.
Our results show that large improvement in symptoms and function
occurred in the rst three weeks after surgery, and further improvement
continued up to two months postoperatively. These improvements are
comparable with those after OCTR and after ECTR.13,14
The Average operating time in our series was 10 minutes (range
8-12 minutes). It is almost similar to the operating times reported by
other authors used the same small incision technique.6,11 The reduced
scar, pillar pain and tenderness of ECTR were better than in the
OCTR.14–19 In our patients results, were similar to Lee et al.11 results.
Reviewing the results of authors who used the mini- open, semi-
blind approaches revealed major complication rates of 0% - 0.3%.3–12
Our series showed similar results. The way to have a safe semi-blind
open procedure that we used in the present study is to push the scissors
gently towards the longitudinal axis between the third and fourth rays
while the tip of the scissors directed volarly and to stop immediately
when the ligament resistance suddenly decreases. The incision is
also ulnar to the tendon of palmaris longus, which avoids the palmar
cutaneous branch of the median nerve. These mini-open approaches
are easy to master and have a short learning curve, which contribute to
their low morbidity and post-operative complications.
Postoperative cosmetic appearance of the palm is an important
issue related to skin incision. Our results showed clearly that the
CTRMTA we used is highly satisfactory and comparable to endoscopic
approach. The over all patient satisfaction with the procedure was also
excellent at the nal follow-up visit.
Conclusion
Based on our study and on the results of previous studies, the mini
transvers approach technique is simple, easy to master, safe and cost
effective. The outcomes which are comparable to endoscopic carpal
tunnel release, in many aspects, to open carpal tunnel release justify its
use by experienced hand surgeons,20,21 especially in countries where
endoscopic release is expensive and not widely available.
Acknowledgements
None.
Conict of interest
Authors declare there is no conict of interest in publishing the
article.
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DOI: 10.15406/mojor.2018.10.00409
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... When the release was complete, a snap was felt. Another easier way was to use a new instrument invented by our team during the work on this study called "the scissor guide for carpal tunnel release," which facilitates cutting the flexor retinaculum while protecting the structures in the carpal tunnel and speeds up the surgery while overcoming the blindness of the technique when cutting the distal part of the retinaculum [7,13,14] (Fig. 1). ...
... In comparison to traditional decompression, the benefits of this surgical procedure include reduced post-operative pain, earlier strength recovery, hand grip, and an early return to daily life activities with fewer complications [10]. The use of a minimum surgical procedure to cut the carpal tunnel ligament with a tiny incision produces better results than the classical [11], [12]. Following surgical divisions of the carpal ligament and flexor retinaculum to decompress the median nerve, diabetics and those of the female sex Since 2002 have a greater relapse risk [13], [14], [15]. ...
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Background: Results of open and endoscopic carpal tunnel surgery were compared with many studies done previously. To the best of our knowledge, difference in pain after endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) has not been objectively documented in literature. The aim of the study was to compare the pain intensity in the early postoperative period in patients undergoing OCTR versus those undergoing ECTR. Materials and Methods: Fifty patients diagnosed with carpal tunnel syndrome were randomized into two groups using “random number generator” software (Research Randomizer, version 3.0); endoscopic surgery group [(21 female, 1 male; mean age 49 years (range 31–64 years)] and open surgery group [(25 female, 3 male; mean age 45.1 years (range 29–68 years)] and received carpal tunnel release. Surgery was performed under regional intravenous anesthesia. The patients’ pain level was assessed at the 1st, 2nd, 4th, and 24th postoperative hours using a visual analog scale (VAS) score. Results: Mean age, gender and duration of symptoms were found similar for both groups. Boston functional scores were improved for both groups (P < 0.001, P < 0.001). Pain assessment at the postoperative 1st, 2nd, 4th and 24th hours revealed significantly low VAS scores in the endoscopic surgery group (P = 0.003, P < 0.001, P < 0.001, P < 0.001). Need for analgesic medication was significantly lower in the endoscopic surgery group (P < 0.001). Conclusion: Endoscopic carpal tunnel surgery is an effective treatment method in carpal tunnel release vis-a-vis postoperative pain relief.
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