Can I Get Carpal Tunnel Again After Surgery
J Hand Microsurg. 2012 Jun; 4(i): 1–6.
Recurrent Carpal Tunnel Syndrome––Analysis of the Touch on of Patient Personality in Altering Functional Outcome Post-obit a Vascularised Hypothenar Fat Pad Flap Surgery
Yard. Karthik
aneDepartment of Orthopaedic Surgery, Queen Elizabeth Infirmary, Woolwich, London, UK SE184QH
Rajesh Nanda
2North Tees and Hartlepool NHS Trust, University Hospital of North Tees, Hardwick Rd., Stockton on Tees, UK TS19 8PE
John Stothard
3James Cook University Hospital, Marton Road, Middlesbrough, UK TS43BW
Received 2011 Jun 12; Accepted 2011 Aug iii.
Abstract
We retrospectively analysed 25 patients (27 easily) who had both clinical and electrophysiological confirmation of true recurrent carpal tunnel syndrome from Jan 2004 to December 2009. In all the patients, later releasing the nerve a vascularised fatty pad flap was mobilised from the hypothenar region and sutured to the lateral cutting end of flexor retinaculum. The patient characteristics, co-morbidities, duration of symptom, interval between get-go release and revision surgery and intra-operative findings were assessed confronting mail-operative relief of hurting, recovery of sensory and motor dysfunction. The average historic period of the patients was 58 years (43–81) and the dominant hand was involved in 22 patients. Intra-operatively the nervus was compressed by scar tissue connecting the previously divided ends of the retinaculum in 18 and nine had scar tissue and fibrosis around the nerve. Following surgery xvi patients had complete recovery (asymptomatic at the first follow-upwards), eight had delayed recovery (fractional recovery of symptoms at final follow-up) and three had a poorer outcome (persistence of preoperative symptoms at the final follow-up). The patients with delayed recovery/poorer result had a) Early recurrence; b) Diabetes mellitus; c) Obesity; d) Cervical spine issues; e) Involvement of non-dominant manus; and f) Intraoperative scar tissue and fibrosis. The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that can be used in patients with recurrent carpal tunnel syndrome. The factors that were associated with poorer/delayed recovery were interest of non-dominant hand, recurrence within a twelvemonth from the previous surgery, intra-operatively scar tissue in the carpal tunnel and associated co-morbidities, similar obesity diabetes mellitus and cervical spine issues.
Keywords: Hypothenar fatty pad flap, Patient factors, Prediction of consequence, Recurrent carpal tunnel syndrome
Introduction
Recurrence of carpal tunnel syndrome post-obit surgical release is not uncommon [1 , two]. The recurrence charge per unit in the literature ranges from 3% to 25% [iii – 6]. The issue after the second surgery is variable with authors reporting persistent symptoms in upward to 95% of the patients [vii]. A recent report showed that 20% of these patients get no relief subsequently second surgery [8]. The drawback with most of these studies is that they deal with a heterogeneous population of both recurrent and persistent carpal tunnel syndrome, the findings of which cannot be generalised to a patient population with recurrence.
Various methods of handling accept been described for the treatment of these patients. Contempo studies have favoured the use of a hypothenar fat pad flap (HTFPF) as it has consistently produced amend results [9 – thirteen]. From its first description in 1985 [14] many modifications take been suggested in the technique of HTFPF to further ameliorate the functional issue in these patients [9 , eleven , 12]. All the studies we tin can identify on HTFPF have looked at surgical factors and none of them have assessed patient characteristics against the surgical results [9 – xiii]. Presently, there is insufficient prove in the literature to predict the consequence after this technique in patients with true recurrent carpal tunnel syndrome. The aim of our written report was to evaluate the patient factors and to predict the effect of these in altering functional upshot after HTFPF in patients with recurrent carpal tunnel syndrome.
Materials and Methods
The study included 25 patients (27 hands) who underwent HTFPF for recurrent carpal tunnel syndrome from January 2004 to December 2009. Inclusion and exclusion criteria for the selection of cases are listed in Tabular arrayane. All the patients included in the report had a symptom free interval following the master surgery and had recurrence of symptoms. The clinical diagnosis of recurrence was as well confirmed by electrophysiological studies. Nerve conduction studies showed abnormal conduction velocity and prolonged latency in both motor and sensory values in all the patients. The patients having problems related to wrist and CMC joint were not taken upwardly for the written report. 4 patients who had second surgery following incomplete main release were excluded from the study.
Table 1
Inclusion and exclusion criteria
| Inclusion criteria | Exclusion criteria |
|---|---|
| Presence of clinical symptoms | No symptom costless interval |
| Symptom complimentary interval between surgeries | Normal electrophysiological studies. |
| Electrophysiological confirmation | Secondary causes, eg Fracture, tumour |
| Failure of conservative treatment | Incomplete primary release |
Tinel'southward sign was positive over the carpal tunnel region in 23 hands and Phalen's exam (the provocation of median paraesthesias by flexion of the wrist to 90° for lx s) was positive in all the patients. Numbness and tingling was present in all the patients with wakening dysesthesias in 24 hands. All patients had a trial of conservative treatment with NSAIDS and wrist splints before surgical intervention. None of the patients had testify of injury to the palmar cutaneous branch of the median nerve following.
Surgical Technique
The revision surgery was performed every bit a day case procedure. 2 percent lignocaine was used for local anaesthesia together with an arm tourniquet. An incision was fabricated through the previous scar. This was deepened to reach the level of the retinaculum or its remnants that when present were incised while protecting the median nervus (Fig.1). Any overlying scar tissue or fibrosis around the nervus was besides removed to release the nervus. Internal neurolysis was not performed in any of our patients. For closure the hypothenar fatty pad was mobilised with an intact base and of sufficient length to encompass the nerve after release (Fig.2). The mobilised fatty pad was sutured to the nether-surface of the lateral edge of cutting flexor retinaculum (whole length) with three–0 vicryl (Fig.3). After haemostasis the pare was closed with 4–0 nylon sutures.
Through an incision over the previous scar the reformed retinaculum/scar tissue (blue arrows) was released and the nerve (xanthous arrow) was freed
The hypothenar fat pad flap was mobilised with an intact base of operations and of sufficient length to cover the nervus after release
The mobilised fatty pad was sutured to the under-surface of the lateral edge of cut flexor retinaculum
The patients were allowed to movement the wrist and perform activities every bit tolerated after the surgery. The sutures were removed at 2 weeks and the patients were assessed for pain and neurological recovery in 2 weeks, six weeks, 3 months and every vi months until recovery. Consummate recovery was divers as the complete absence of preoperative symptoms after the surgery at the first follow-up visit. Delayed recovery was defined as partial recovery of preoperative symptoms at terminal follow-upwards and poorer result was defined every bit the persistence of preoperative symptoms at the concluding follow-up.
The patient characteristics, co-morbidities, elapsing of symptoms, interval between principal and 2nd surgery and intra-operative findings were assessed against post-operative relief of pain, recovery of sensory and motor dysfunction. Details were collected retrospectively in the regular follow-up notes after surgery (till the final follow-upwardly).
Results
Of the 25 patients 15 were female person and 10 were male. The dominant mitt was affected in 22 patients. The average age was 58 years (range 43–81 years). The boilerplate follow-upward was 22 months (range x.5–62.v months). The average duration of symptoms before the surgery was 5.viii months (range 3–21 months). The average fourth dimension interval between the showtime and second surgery was 56 months (range 5–262 months). Intra-operatively 18 patients had a reformed retinaculum with scar tissues bridging the cut ends of previous surgery, nine had scar tissue and fibrosis around the nerve. xvi (lx%) patients had consummate recovery immediately afterward surgery and the remaining xi (40%) patients had delayed/poorer recovery. No patient deteriorated subsequently the surgery.
Analysis of the ii sub groups (Consummate recovery–16 patients; delayed/poorer recovery–eleven patients) is shown in Table2. There was no difference between the groups in relation to the historic period, sex or duration of symptoms before the second surgery. . The average interval between the start and the 2nd surgery was about 7 years in the group with consummate recovery and it was less than one year in the group with delayed/poorer recovery, implying that a longer symptom costless interval is good news. Four out of five patients in our serial with involvement of the non-dominant hand had delayed/poorer recovery. Both the patients with bilateral involvement had delayed/poorer recovery on the not-dominant hand. The patients with diabetes mellitus (all were type Ii), obesity (BMI >xxx) and cervical spine issues (degenerative spondylosis with C5-six radiculopathy in 5 and myelopathy in one) had a loftier possibility of delayed/poorer recovery. Intra-operatively scar tissue with fibrosis around the nerve was associated with a high probability for delayed/poorer recovery.
Tabular array 2
Consummate recovery vs delayed/poorer recovery
| Complete recovery (xvi) | Delayed (eight) or poorer (3) outcome | |
|---|---|---|
| Age (Years) | 59.4 (43–81) | 56 (47–76) |
| Sex activity (Female person: Male)a | nine:7 | seven:4 |
| Elapsing of symptoms (months) | 5.5 (3–16) | half-dozen (4–21) |
| Interval between 1st & 2nd surgery (months) | 86.v (23–262) | 11.3 (5–26) |
| Not dominant hand | 1/16 (6%) | 4/11 (36.six%) |
| Diabetes | ii/16 (12.5%) | 6/xi (54.five%) |
| Obesity (BMI >30) | 4/sixteen (25%) | 7/xi (63.six%) |
| Cervical spine bug | one/xvi (vi%) | 5/xi (45%) |
| Intra-operative findings | Scar tissue – 2 Reformed retinaculum - 14 | Scar tissue and fibrosis around nerve – 2 Scar tissue - 5 Reformed retinaculum - 4 |
aIncludes 2 bilateral patients
Mail service surgically Tinel's sign was negative in 20 of the 23 patients and in the remaining iii patients they had progressive Tinel's sign indicating some caste of nerve regeneration. Pain disappeared in all except 3 patients at the final follow-upwards of 22 months (range 10.5–62.5 months).
Of the 11 hands with delayed/poorer recovery, eight patients had complete relief of hurting with varying degrees of neurological recovery at the concluding follow-upward. In eight easily with delayed recovery, pain and wakening dysesthesia disappeared in all the patients, tingling disappeared in half-dozen patients and numbness disappeared in four easily at the final follow-up and all these eight patients were happy with the final functional outcome. Three patients out of the 27 connected to have hurting and neurological symptoms and were not great on further investigations or whatever further intervention. At the last follow-up 89% (24/27) of the operated easily had achieved excellent to good results.
Discussion
Since the time when Sir James Paget showtime described the clinical manifestations of carpal tunnel syndrome in 1854 [fifteen], it has become the commonest surgically treated entrapment neuropathy with a prevalence of 3-7% in the general population [sixteen , 17]. Though the results after primary surgery are excellent, the frequency of re-operation can exist up to 12% [eight]. The commonly cited causes for initial failure include incomplete release of the transverse carpal ligament, post-operative adhesions, tenosynovitis, and intraneural fascicular scarring [18]. The majority of the patients who undergo secondary surgery were due to incomplete release. Bagauter in a report on 26 patients identified that the secondary surgery was because of inadequate release in 23 and no release in iii patients [19]. Thus the present publications on recurrent carpal tunnel syndrome are confounded by patients who exercise non have a true recurrence.
Not-operative treatment of recurrent symptoms may provide symptomatic relief for a small number of patients but fail to do good most patients in the long term. In our series none of the patients benefitted. In 1963, Paine was the outset to study on re-exploration for true recurrent carpal tunnel syndrome. Since then various surgical options have been described in the literature. Uncomplicated decompression with neurolysis is not favoured by many authors considering of poor outcome [4 , twenty , 21]. The use of muscle flaps, fascial flaps, vein wrapping and omental transfer has been described in the literature with good results [22 – 28]. However these options were non followed universally because of various drawbacks associated with these techniques. These include, donor site morbidity, utilize of microscope, normally performed by surgeons working in specialist centres, technically demanding, increased theatre time and cost, poor corrective results, small patient group and finally the results were not superior to HTFPF. The use of HTFPF first described by Cramer and farther modified by various authors has stood the exam of time from 1985 [9 – fourteen]. The advantage in using the flap is that it is locally available, easily performed and the results are equivalent or better than the other techniques. HTFPF does not meliorate the results of primary surgery [29]. At that place seems to be conflicting evidence regarding routine internal neurolysis after carpal tunnel surgery [30 , 31]. In this study none of the patients underwent internal neurolysis.
Results later on a revision carpal tunnel surgery are variable [seven , eight , 12 , 32]. The reason for these differences in outcome has been attributed to the surgical factors and various authors have described different methods of treatment [22 – 28] or modifications of a technique [ix – 13]. Nonetheless the results were variable, with authors reporting upwards to forty% poor results [32] and 95% persistent symptoms [seven] after re-exploration.
As all the studies in the literature analysed the surgical factors, we analysed the patient characteristics against the surgical issue. The age, sex and duration of symptoms did non bear upon the functional outcome in our patients. However the decrease in time interval between the chief and revision surgery was a major risk factor for delayed/poorer recovery. These findings have not been previously reported and the authors believe that these patients with early recurrence are more decumbent for scar tissue formation. In keeping with this conventionalities involvement of not-dominant hand was rare. However, when information technology occurred we noted delayed/poorer recovery (though the numbers are too pocket-size to depict any conclusions), simply interestingly in 2 patients with bilateral recurrence, the non-ascendant hand did non recover well after the revision surgery. It is well known that the consequence afterwards carpal tunnel decompression is unpredictable if the patient has double vanquish syndrome [33 , 34]. Xl v % (5/11) of the patients with cervical spine problems did poorly later the surgery. Recent bear witness showed that outcome after main carpal tunnel decompression in patients with diabetes is no different from other patients [35]. However, 54.5% (6/xi) of our diabetic patients did not accept prompt relief of symptoms with the second surgery. Nosotros accept the view of Al-Quattan et al. that diabetes is a risk factor for poor upshot [36]. Though obesity was considered as a risk factor for CTS [37], its office in influencing the outcome after surgical release is uncertain. In 63.6% (vii/11) of our patients with poorer result, obesity was present.
In our study only 60% (16/27) had complete recovery immediately after the surgery, in the remaining 11 patients (forty%) with delayed/poorer recovery, eight patients improved post surgically. Nosotros accept the view of Clarke et al. (1993) that if the improvement was not obtained past 24 hours, a good issue was still possible but a poor outcome becomes more than likely [38].
A limitation of this report is that the study is retrospective with a small number of patients and no control grouping. However our inclusion and exclusion criteria dictated that we were treating a modest subgroup of patients with true recurrent symptoms. A recent study from the Mayo clinic identified 28 consecutive patients with true recurrent carpal tunnel syndrome in a span of 9 years, which demonstrates the rarity of these patients [10]. In their study, though the results were good later on treatment with HTFPF, they did not analyse the patient factors that are associated with the recovery. As HTFPF is a trust worthy procedure for recurrent carpal tunnel syndrome [9 – xiv] and since the study concentrated more than on patient variables the need for a control group is negated. As there is only limited prove available in the handling of recurrent carpal tunnel syndrome, the authors suggest that in future a randomized control trial should exist performed to evaluate the various methods of treatment.
Although this study cannot provide statistically significant evidence, the results aid the operating surgeon to explain to each patient about the anticipated results after the surgery by analysing the patient characteristics and intra-operative findings.
Determination
We conclude that the hypothenar fat pad is a reliable source of vascularised local tissue that can be used favourably in patients with recurrent carpal tunnel syndrome. The factors associated with poorer/delayed recovery are early recurrence (<ane twelvemonth), involvement of not-dominant hand, intra-operatively fibrosis and scar tissue around the nervus and associated co-morbidities of obesity, diabetes mellitus and cervical spine problems.
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