IC40-R: Management of Recalcitrant Carpal Tunnel Syndrome
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IC40-R: Management of Recalcitrant Carpal
Tunnel Syndrome
Moderator: Alexander Lauder, MD
Faculty: Duretti T. Fufa, MD, Fraser J. Leversedge, MD and Suhail K. Mithani, MD
Session Handouts
OnDemand
76TH ANNUAL MEETING OF THE ASSH
SEPTEMBER 30 – OCTOBER 2, 2021
SAN FRANCISCO, CA
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: meetings@assh.org
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement
or presentation made is to be regarded as dedicated to the public domain.
7/30/2021
Introduction
Management of • Clinical challenge
• Understanding of anatomy and pathophysiology
Recalcitrant Carpal • Conservative management
Tunnel Syndrome • Surgical management
• Revision neuroplasty
Alexander Lauder, MD
Duretti Fufa, MD • Neurolysis
Fraser Leversedge, MD • Reconstruction
Suhail Mithani, MD • Flap coverage
1 2
Carpal tunnel syndrome Revision carpal tunnel release
• Most frequent compressive neuropathy • Less successful than primary CTR
• incidence 1-3.5 per 100,000 person-years • Up to 40% have unfavorable outcomes
• Prevalence 3-10% (variations with region, sex, occupation)
• >500,000 CTR performed annually
• Economic impact >$2 billion
• High success with CTR; persistence or recurrence in 3-20%
HAND 2012;7:242
PRS 2001;107:1830 JHS 2013;38:1530
3 4
Outline
• Pertinent Anatomy, Classification, and Differential Diagnosis
• Diagnostic Considerations and Workup (Fufa)
• Surgical Management (Leversedge)
• Flap Options, Management, and Outcomes (Mithani)
Case
5 6
1
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43 year old lady 57 year old man
• oCTR 1 year ago • oCTR 1 year ago
• Never had significant improvement • Numbness & tingling resolved; night symptoms improved
• Symptoms may have worsened after CTR • Pain/dysesthesias over the palm of the hand
• Tried OT, desensitization, splinting, no relief • Hypersensitivity
• Exam: + tinel median nerve prox. wrist crease, +compression, +phalen • Tried OT, desensitization, splinting, no relief
• Repeat EDS: no significant change from pre-op exam • Exam: + tinel at the FCR/wrist crease, neg compression, neg phalen
• Repeat EDS: conduction improvement along median nerve
7 8
Anatomy, Disclosures
pathophysiology, • None
differential
Alexander Lauder, MD
9 10
Anatomy:
Neck
• Nerve roots C5-T1
Anatomy: • Medial/lateral cords
median nerve Axilla
• Median nerve
Arm
• Descends adj to brachial
artery (brachialis/biceps)
11 12
2
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Anatomy Anatomy
Elbow Forearm
• medial to brachial artery • Pronator teres
• deep to lacertus
Leversedge, Goldfarb, Boyer, Primus manus 2010 Leversedge, Goldfarb, Boyer, Primus manus 2010
13 14
Anatomy Anatomy
Forearm Forearm
• Deep to FDS • PL, FCR,
• FDS/FDP FDS, +/-FDP
• AIN
Leversedge, Goldfarb, Boyer, Primus manus 2010 Leversedge, Goldfarb, Boyer, Primus manus 2010
15 16
Anatomy Anatomy
Forearm Forearm
• AIN deep to FDP • FDS/FDP interval
• Innervates
PQ/wrist
Leversedge, Goldfarb, Boyer, Primus manus 2010
Leversedge, Goldfarb, Boyer, Primus manus 2010
17 18
3
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Anatomy Anatomy
Wrist/Hand: Wrist/Hand
• FDS/FCR • PCBMN (PL/FCR)
interval 4-10cm • Innervates skin overlying thenar
proximal to wrist
• PCBMN
(PL/FCR)
Leversedge, Goldfarb, Boyer, Primus manus 2010 Leversedge, Goldfarb, Boyer, Primus manus 2010
19 20
Anatomy Anatomy
• Variations in PCBMN Wrist/Hand
• RMBMN → thenar musculature
• Extraligamentous (B)
• Subligamentous (D)
• Transligamentous (F)
• Digital nerves Th→ radial RF
Leversedge,
PLoS ONE 10(8):Goldfarb,
e0136477 Boyer, Primus manus 2010
21 22
Anatomic variations Carpal tunnel anatomy
• Volar: TCL
• Pisaform
• Hamate hook
• Scaphoid
• Trapezium
• Dorsal: Carpus/extrinsic ligaments
• Radial: scaphoid/trapezium
• Ulnar: triquetrum/hamate
Leversedge, Goldfarb, Boyer, Primus manus 2010
23 24
4
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Compressive neuropathy
• Acute (traumatic)
• Chronic
• Acquired
Pathophysiology • Mechanical deformation
• Ischemia
25 26
Compressive neuropathy
Prolonged compression
Reduction in venous return
Endoneurial
edema Increased endoneurial P
Stasis
Loss of
Extraneural Demyelination
perineural
resilience edema
Decreased
Decreased
microcirculation
Axonal
Classification
Ischemia degradation
axonal
transport Fibrosis Neuological
symptoms Recalcitrant CTS
JAAOS 2019 1;27(15):551
27 28
Categories
• Persistent symptoms (no relief after surgery)
• Recurrent symptoms (after a period of symptomatic relief)
• New symptoms (different from preoperative symptoms)
Persistent
No relief
29 30
5
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Persistent symptoms Persistent symptoms - Differential
• No relief after initial CTR Incomplete release of TCL 50-58% revision CTR
• Account for 43% of patients undergoing revision CTR
• Etiologies
• Incomplete release
• Other sites of compression
• Irreversible nerve pathology
• Inaccurate initial diagnosis
JAAOS 2019 1;27(15):551
JHS 2013;38:1530 PRS 2012;129:683
31 32
Persistent symptoms - Differential Persistent symptoms - Differential
Incomplete release of TCL 50-58% revision CTR Incomplete release of TCL 50-58% revision CTR
Other sites of compression 37% release of site Other sites of compression 37% release of site
• C-spine
• Brachial plexus Irreversible nerve pathology unknown symptomatic
• Pectoralis minor
• Ligament Struthers • Review co-morbidities, age, duration of compression
•
•
Lacertus fibrosus
Pronator teres
• DM, thyroid disease, gout, RA → slower improvement
• FDS arch • Polyneuropathy, diabetic neuropathy, chemotherapy/radiation
• Anomalous muscles
• Gantzer’s muscle AH-FPL
• Palmaris profundus
• FCR brevis
J Peripher Nerv Syst 2000;5:191
33 34
Persistent symptoms - Differential
Incomplete release of TCL 50-58% revision CTR
Other sites of compression 37% release of site
Irreversible nerve pathology unknown symptomatic
Inaccurate initial diagnosis 10-15% correct diagnosis Recurrent
After a period of symptomatic relief
35 36
6
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Recurrent symptoms Recurrent symptoms
• Considered after ~6mo of symptom free interval • Perineural adhesions 88% Revision CTR
• Incidence 4-57% (inconsistency in prior reporting)
• Etiologies
• Perineural adhesions
• Reconstitution of TCL
• Development of secondary compressive conditions
JAAOS 2019 1;27(15):551
37 38
Recurrent symptoms Recurrent symptoms
• Perineural adhesions 88% Revision CTR • Perineural adhesions 88% Revision CTR
• Reconstitution of the TCL unknown neurolysis • Reconstitution of the TCL unknown neurolysis
• Secondary Conditions ~20% optimize environment
Orthopedics. 2015; 38(1):e72
39 40
New symptoms
• New symptoms different from initial presenting symptoms
• Etiologies
• Iatrogenic complication
New • Incomplete decompression with a focal compressive site
Different from preoperative symptoms
41 42
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New symptoms
• Iatrogenic complication 15-67%
• Nerve 53% Nerve repair/reconstruction
• Vascular 21% Repair/hemostasis
• Tendon 12% Tenolysis/repair Thank you!
JHS 2013;38:1530.
PRS 2012;129:683.
CORR 2015;473:1120.
PRS 2001;107:1830
43 44
References References
• • Cagle PJ, Jr., Reams M, Agel J, Bohn D: An outcomes protocol for carpal tunnel release: a comparison of outcomes in patients with and without medical comorbidities. The Journal of hand surgery 2014;39:2175-2180.
• 1. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ: Carpal tunnel syndrome. The Journal of the American Academy of Orthopaedic Surgeons 2007;15:537-548. • 24. Gelberman RH, Pfeffer GB, Galbraith RT, Szabo RM, Rydevik B, Dimick M: Results of treatment of severe carpal-tunnel syndrome without internal neurolysis of the median nerve. The Journal of bone and joint surgery American volume 1987;69:896-903.
• 2. Louie D, Earp B, Blazar P: Long-term outcomes of carpal tunnel release: a critical review of the literature. Hand 2012;7:242-246. • 25. Nolan WB, 3rd, Alkaitis D, Glickel SZ, Snow S: Results of treatment of severe carpal tunnel syndrome. The Journal of hand surgery 1992;17:1020-1023.
• 3. Tung TH, Mackinnon SE: Secondary carpal tunnel surgery. Plastic and reconstructive surgery 2001;107:1830-1843; quiz 1844,1933. • 26. Verdu E, Ceballos D, Vilches JJ, Navarro X: Influence of aging on peripheral nerve function and regeneration. J Peripher Nerv Syst 2000;5:191-208.
• 4. Beck JD, Brothers JG, Maloney PJ, Deegan JH, Tang X, Klena JC: Predicting the outcome of revision carpal tunnel release. The Journal of hand surgery 2012;37:282-287. • 27. Kanatani T, Nagura I, Kurosaka M, Kokubu T, Sumi M: Electrophysiological assessment of carpal tunnel syndrome in elderly patients: one-year follow-up study. The Journal of hand surgery 2014;39:2188-2191.
• 5. Zieske L, Ebersole GC, Davidge K, Fox I, Mackinnon SE: Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes. The Journal of hand surgery 2013;38:1530-1539. • 28. Hattori Y, Doi K, Koide S, Sakamoto S: Endoscopic release for severe carpal tunnel syndrome in octogenarians. The Journal of hand surgery 2014;39:2448-2453.
• 6. Leversedge FJ, Goldfarb CA, Boyer MI: A pock etbook manual of hand and upper extremity anatomy : primus manus. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2010, pp viii, 136 p. • 29. Mosier BA, Hughes TB: Recurrent carpal tunnel syndrome. Hand clinics 2013;29:427-434.
• 7. Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K: Incidence of an Anomalous Course of the Palmar Cutaneous Branch of the Median Nerve During Volar Plate Fixation of Distal Radius Fractures. The Journal of hand surgery 2016;41:841-844. • 30. Tollestrup T, Berg C, Netscher D: Management of distal traumatic median nerve painful neuromas and of recurrent carpal tunnel syndrome: hypothenar fat pad flap. The Journal of hand surgery 2010;35:1010-1014.
• 8. DaSilva MF, Moore DC, Weiss AP, Akelman E, Sikirica M: Anatomy of the palmar cutaneous branch of the median nerve: clinical significance. The Journal of hand surgery 1996;21:639-643. • 31. Sayegh ET, Strauch RJ: Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials. Clinical orthopaedics and related research 2015;473:1120-1132.
• 9. Roy J, Henry BM, PA PE, et al.: Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Muscle Nerve 2016;54:36-47. • 32. Tapadia M, Mozaffar T, Gupta R: Compressive neuropathies of the upper extremity: update on pathophysiology, classification, and electrodiagnostic findings. The Journal of hand surgery 2010;35:668-677.
• 10. Seiler JG, 3rd, Daruwalla JH, Payne SH, Faucher GK: Normal Palmar Anatomy and Variations That Impact Median Nerve Decompression. The Journal of the American Academy of Orthopaedic Surgeons 2017;25:e194-e203. • 33. Schreiber JE, Foran MP, Schreiber DJ, Wilgis EF: Common risk factors seen in secondary carpal tunnel surgery. Annals of plastic surgery 2005;55:262-265.
• 11. Lundborg G, Myers R, Powell H: Nerve compression injury and increased endoneurial fluid pressure: a "miniature compartment syndrome". J Neurol Neurosurg Psychiatry 1983;46:1119-1124. • 34. Thoomes EJ, van Geest S, van der Windt DA, et al.: Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J 2017.
• 12. Mackinnon SE: Pathophysiology of nerve compression. Hand clinics 2002;18:231-241. • 35. Hagert E: Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study. Hand 2013;8:41-46.
• 13. Rempel DM, Diao E: Entrapment neuropathies: pathophysiology and pathogenesis. J Electromyogr Kinesiol 2004;14:71-75. • 36. Unglaub F, Wolf E, Goldbach C, Hahn P, Kroeber MW: Subjective and functional outcome after revision surgery in carpal tunnel syndrome. Archives of orthopaedic and trauma surgery 2008;128:931-936.
• 14. Reinke JM, Sorg H: Wound repair and regeneration. Eur Surg Res 2012;49:35-43. • 37. Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell TD: Predicting the outcome of carpal tunnel release. The Journal of hand surgery 2003;28:255-261.
• 15. Jones NF, Ahn HC, Eo S: Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release. Plastic and reconstructive surgery 2012;129:683-692. • 38. AAOS: Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline Accessed December 1, 2017.
• 16. Stutz N, Gohritz A, van Schoonhoven J, Lanz U: Revision surgery after carpal tunnel release--analysis of the pathology in 200 cases during a 2 year period. Journal of hand surgery 2006;31:68-71. • 39. Stutz NM, Gohritz A, Novotny A, Falkenberg U, Lanz U, van Schoonhoven J: Clinical and electrophysiological comparison of different methods of soft tissue coverage of the median nerve in recurrent carpal tunnel syndrome. Neurosurgery 2008;62:194-199; discussion 199
• 17. Luria S, Waitayawinyu T, Trumble TE: Endoscopic revision of carpal tunnel release. Plastic and reconstructive surgery 2008;121:2029-2034; discussion 2035-2026. • 40. Amadio PC: Interventions for recurrent/persistent carpal tunnel syndrome after carpal tunnel release. The Journal of hand surgery 2009;34:1320-1322.
• 18. Mimura T, Uchiyama S, Hayashi M, Uemura K, Moriya H, Kato H: Flexor carpi radialis brevis muscle: A case report and its prevalence in patients with carpal tunnel syndrome. J Orthop Sci 2017;22:1026-1030. • 41. Opanova MI, Atkinson RE: Supracondylar process syndrome: case report and literature review. The Journal of hand surgery 2014;39:1130-1135.
• 19. Keese GR, Wongworawat MD, Frykman G: The clinical significance of the palmaris longus tendon in the pathophysiology of carpal tunnel syndrome. Journal of hand surgery 2006;31:657-660. • 42. Fowler JR, Cipolli W, Hanson T: A Comparison of Three Diagnostic Tests for Carpal Tunnel Syndrome Using Latent Class Analysis. The Journal of bone and joint surgery American volume 2015;97:1958-1961.
• 20. Dailiana ZH, Bougioukli S, Varitimidis S, et al.: Tumors and tumor-like lesions mimicking carpal tunnel syndrome. Archives of orthopaedic and trauma surgery 2014;134:139-144. • 43. Fowler JR, Maltenfort MG, Ilyas AM: Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis. Clinical orthopaedics and related research 2013;471:932-937.
• 21. Schmid AB, Coppieters MW: The double crush syndrome revisited--a Delphi study to reveal current expert views on mechanisms underlying dual nerve disorders. Man Ther 2011;16:557-562. • 44. Page MJ, Massy-Westropp N, O'Connor D, Pitt V: Splinting for carpal tunnel syndrome. The Cochrane database of systematic reviews 2012:CD010003.
• 22. Wessel LE, Fufa DT, Canham RB, La Bore A, Boyer MI, Calfee RP: Outcomes following Peripheral Nerve Decompression with and without Associated Double Crus h Syndrome: A Case Control Study. Plastic and reconstructive surgery 2017;139:119-127. • 45. Ballestero-Perez R, Plaza-Manzano G, Urraca-Gesto A, et al.: Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review. J Manipulative Physiol Ther 2017;40:50-59.
• 46. Griffin JW, Hogan MV, Chhabra AB, Deal DN: Peripheral nerve repair and reconstruction. The Journal of bone and joint surgery American volume 2013;95:2144-2151.
45 46
References
• Cho MS, Rinker BD, Weber RV, et al.: Functional outcome following nerve repair in the upper extremity using processed nerve allograft. The Journal of hand surgery 2012;37:2340-
2349.
• 48. Means KR, Jr., Rinker BD, Higgins JP, Payne SH, Jr., Merrell GA, Wilgis EF: A Multicenter, Prospective, Randomized, Pilot Study of Outcomes for Digital Nerve Repair in the
Hand Using Hollow Conduit Compared With Processed Allograft Nerve. Hand 2016;11:144-151.
• 49. Pederson WC: Median nerve injury and repair. The Journal of hand surgery 2014;39:1216-1222.
• 50. Varitimidis SE, Vardakas DG, Goebel F, Sotereanos DG: Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein
insulator. The Journal of hand surgery 2001;26:296-302.
• 51. Abzug JM, Jacoby SM, Osterman AL: Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis. Hand 2012;7:23-29.
• 52. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ: Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper
extremity. Annals of plastic surgery 2014;72:572-578.
• 53. Strickland JW, Idler RS, Lourie GM, Plancher KD: The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. The Journal of hand surgery
1996;21:840-848.
• 54. Murthy PG, Abzug JM, Jacoby SM, Culp RW: The tenosynovial flap for recalcitrant carpal tunnel syndrome. Techniques in hand & upper extremity surgery 2013;17:84-86.
• 55. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ: A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome.
Plastic and reconstructive surgery 2013;132:114-121.
• 56. Wichelhaus A, Mittlmeier T, Gierer P, Beck M: Vascularized Hypothenar Fat Pad Flap in Revision Surgery for Carpal Tunnel Syndrome. J Neurol Surg A Cent Eur Neurosurg
2015;76:438-442.
• 57. Djerbi I, Cesar M, Lenoir H, Coulet B, Lazerges C, Chammas M: Revision surgery for recurrent and persistent carpal tunnel syndrome: Clinical results and factors affecting
outcomes. Chir Main 2015;34:312-317.
• 58. O'Malley MJ, Evanoff M, Terrono AL, Millender LH: Factors that determine reexploration treatment of carpal tunnel syndrome. The Journal of hand surgery 1992;17:638-641.
47
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Evaluation of Recalcitrant CTS
History and Physical Examination
Diagnostic Workup and Considerations
for Recalcitrant Carpal Tunnel
Syndrome Electrodiagnostic Studies
Duretti Fufa, MD
Associate Orthopaedic Surgeon
Hospital for Special Surgery
Imaging Modalities
Associate Professor of Orthopaedic Surgery
New York Presbyterian Hospital – Weill Cornell Medical College
Injection
ASSH 76th Annual Meeting 2021
2
1 2
History and Physical Examination Alternative Sites of Compression
History Physical Examination • Cervical
• Preoperative work up • Proximal sites (forearm, neck) • Thoracic outlet (vascular, pec minor)
• Injection? • Ligament of Struthers
• Surgical wound
• What % improvement and for how long?
• Muscle atrophy • Lacertus fibrosus
• Electrodiagnostics?
• Ulnar collateral artery
• Patient expectations/comorbid conditions • Objective testing
• Pronator teres
• Symptom resolution
• FDS fibrotic arch
• Same -> irreversible disease, wrong
diagnosis • Gantzer’s muscle
• Better -> incomplete release, new diagnosis • Anomalous muscles in the distal forearm (palmaris
profundis or FCR brevis)
• Worse -> surgical complication
Confidential & Proprietary 3 Confidential & Proprietary 4
3 4
Electrodiagnostic Studies Imaging
Radiographs
• Comparison to preoperative EDX • Arthritis Ganglion
• Incomplete improvement in 25%
• Supracondylar process
• Evaluate for distinct sites of
Ultrasound and MRI
compression
• Soft tissue structures
• Nerve morphology/architecture
• Double crush phenomenon
• Secondary pathology
Schwannoma
Confidential & Proprietary 5 Confidential & Proprietary 6
5 6
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Imaging Findings in Recalcitrant CTS Incomplete Release of TCL
• Space occupying lesion MN
• Median nerve anatomy and variants
• Nerve injury
• PCBMN
• Recurrent motor branch
• Perineural fibrosis Proximal
Distal →
• Nerve morphology
• Incomplete release versus reconstituted ligament
Proximal
Carpal Row
Confidential & Proprietary 7
7 8
Summary of Evaluation and Findings for Distinct Causes
Diagnostic Injection of Recalcitrant CTS
• Lidocaine versus corticosteroid
• Period of symptomatic relief
• Suspected neuroma -> Lidocaine Incomplete release or • Imaging confirmation (+/- EDX)
• Suspected incomplete release/reconstituted TCL -> corticosteroid
Reconstitution of TCL • Diagnostic and therapeutic injection
• Counsel patients on feedback needed from injection • No improvement
• % improvement and duration Alternative pathology • Physical examination
• Pain log or Advanced disease • EDX +/- Imaging confirmation
• Confirmatory diagnostic injection
• US-Guidance
• Symptoms worse postoperatively
• Physical examination
Nerve Injury • Imaging confirmation (+/- EDX)
Confidential & Proprietary 9
• +/- selective lidocaine injection Confidential & Proprietary 10
9 10
Online
Recalcitrant carpal tunnel syndrome presents a clinical challenge. Potential etiologies of persistent or recurrent
symptoms following primary carpal tunnel release include incomplete nerve decompression, secondary sites of nerve
compression, unrecognized anatomic variations, irreversible nerve pathology associated with chronic compression
neuropathy, perineural adhesions, conditions associated with secondary nerve compression, iatrogenic nerve injury, or
an inaccurate preoperative diagnosis. Understanding the pertinent surgical anatomy and pathophysiology is essential
towards developing an effective diagnostic and treatment strategy. A thorough clinical history and examination guide
a comprehensive diagnostic evaluation that includes serial examinations, neurophysiologic testing, and imaging
Thank You studies. Conservative treatment may provide symptomatic relief, however, surgical management involving revision
neuroplasty, neurolysis, nerve reconstruction, and/or local soft-tissue flap augmentation may be indicated in refractory
cases.
LEARNING OBJECTIVES
At the conclusion of this program, the attendee will:
• Describe the prevalence and differential diagnosis for persistent and recurrent carpal tunnel syndrome (CTS).
• Understand the diagnostic evaluation with ultrasound, electrodiagnostic studies, and injection for workup of
recalcitrant CTS.
• Discuss options for the surgical management of recalcitrant disease and considerations for management of the
peineural environment.
• Understand the local options for flap coverage and their outcomes in recalcitrant CTS.
Confidential & Proprietary 11 Confidential & Proprietary 12
11 12
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Proximal Distal →
Transverse US images of the median nerve (blue arrows) across the carpal tunnel after carpal tunnel release. A segment of
the transverse carpal ligament remains intact at the proximal carpal tunnel (orange arrows), with regional flattening of the
nerve. The transverse carpal ligament is visibly released distally (white arrows).
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Surgical management: decompression, neurolysis, managing Disclosures: Fraser J. Leversedge, MD
the perineural environment, and tendon transfers for
advanced neuropathy
Axogen - Dr. Leversedge receives fees for
IC40: Management of recalcitrant carpal tunnel syndrome
consulting and educational activities
Axogen – Dr. Leversedge has received institutional
Fraser J. Leversedge, MD
support for research studies
Wolters Kluwer – Dr. Leversedge receives royalties
Professor and Chief: for publications
Section of Hand, Wrist & Elbow Surgery
Department of Orthopedic Surgery
www.cuortho.org www.cuortho.org
University of Colorado
1 2
Define: Advanced Neuropathy ASSESSMENT
❖ COMPREHENSIVE HISTORY
• medical history
• diabetes mellitus
• mucopolysaccharidoses
• amyloidosis
• peripheral neuropathies
• surgical history
• perioperative history
• gains / deficits
www.cuortho.org www.cuortho.org
3 4
Preoperative Assessment
CLUES…
• subjective symptoms
➢ pre vs immediate vs post
• diagnostic imaging
➢ ultrasound
• electrodiagnostic studies
www.cuortho.org www.cuortho.org
5 6
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Preoperative Assessment Preoperative Assessment
• FUNCTIONAL ASSESSMENT • FUNCTIONAL ASSESSMENT
• MOTOR: APB* ANATOMIC CLUES …
• SENSORY: document!
Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K.
• SUBJECTIVE GOALS Incidence of an Anomalous Course of the Palmar
Cutaneous Branch of the Median Nerve During Volar
Plate Fixation of Distal Radius Fractures.
• NCS / EMG J Hand Surg Am. 2016;41:841-4.
• ULTRASOUND
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI www.cuortho.org © 2004 Leversedge FJ, Goldfarb CA, Boyer MI www.cuortho.org
7 8
Case: 52yo s/p ORIF Distal Radius Median Nerve: GOALS OF TREATMENT
S/P ORIF DISTAL RADIUS
1. DECOMPRESS NERVE
• direct compression
• tethering associated with
adhesions / scar
2. PREVENT RECURRENCE
3. IMPROVE FUNCTION
NORMAL
www.cuortho.org
9 10
Surgical Strategies Surgical Strategies
• expose MN to normal tissue • expose MN to normal tissue
planes, proximally and distally planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis • EXTERNAL v INTERNAL neurolysis
• IDENTIFY: PCBMN + motor br. • IDENTIFY: PCBMN + motor br.
• EPINEURIUM: evaluate integrity • EPINEURIUM: evaluate integrity
• ASSESS: perineural environment • ASSESS: perineural environment
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
• Reconstruction options © 2004 Leversedge FJ, Goldfarb CA, Boyer MI
• Reconstruction options
www.cuortho.org www.cuortho.org
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External vs Internal Neurolysis External vs Internal Neurolysis
13 14
Surgical Strategies
• expose MN to normal tissue
planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis
• IDENTIFY: PCBMN + motor br.
• EPINEURIUM: evaluate integrity
• ASSESS: perineural environment
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI • Reconstruction options
www.cuortho.org
15 16
Surgical Strategies Surgical Strategies
• expose MN to normal tissue • expose MN to normal tissue
planes, proximally and distally planes, proximally and distally
* • EXTERNAL v INTERNAL neurolysis • EXTERNAL v INTERNAL neurolysis
• IDENTIFY: PCBMN + motor br. • IDENTIFY: PCBMN + motor br.
• EPINEURIUM: evaluate integrity • EPINEURIUM: evaluate integrity
• ASSESS: perineural environment • ASSESS: perineural environment
• Reconstruction options • Reconstruction options
www.cuortho.org © 2004 Leversedge FJ, Goldfarb CA, Boyer MI www.cuortho.org
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Surgical Strategies Neuroplasty + ________ ?
• expose MN to normal tissue
planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis
• IDENTIFY: PCBMN + motor br.
• EPINEURIUM: evaluate integrity
• ASSESS: perineural environment
• Reconstruction options
www.cuortho.org www.cuortho.org
19 20
THE IDEAL BARRIER Influencing the Perineural Environment
Barriers to nerve adhesions
from Dy CJ, et al. JHS-Am 2018
1. minimal or no chance of rejection or inflammatory rxn
• local tissue flap (adipofascial or muscle)
2. sufficient porosity to facilitate diffusion of nutrients • distant tissue transfer (free flap)
without allowing axonal escape • autologous vein
3. avoidance of scar induced ischemia • biologic wraps
4. promote nerve gliding • Type 1 collagen
5. minimal or no donor site morbidity • Porcine small intestinal mucosa
6. minimal cost or supply restraints • Hyaluronic acid – carboxymethylcellulose (Seprafilm)
• Hyaluronic acid – alginate (Versawrap)
www.cuortho.org www.cuortho.org
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BIOLOGIC WRAPS LOCAL TISSUE FLAP
• there are no meaningful clinical trials that Barriers to nerve adhesions
compare outcomes of revision / severe median
• HYPOTHENAR FAT PAD FLAP
neuroplasty at the wrist with vs without
• PALMARIS BREVIS FLAP
biologic ‘wrap’
• TENOSYNOVIAL FLAP
• possible benefit following neurolysis where SIS • FOREARM ADIPOFASCIAL FLAP
may serve as an ecm “scaffold” for damaged
epineurium
www.cuortho.org www.cuortho.org
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JHand Surg 1996;21A:840-848.
• first described by Cramer
(Correspondence Newsletter,1985)
• modified by senior author
• 62 pts / 66 hands
www.cuortho.org
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DISTANT TISSUE TRANSFER
Microvascular free tissue transfer
• Omental flap
Techniques in Hand & Upper Extremity Surgery Volume 17, Number 2, June 2013
• ALT flap
• retrospective review of 45 procedures in 41 pts
• follow up / methodology limited
www.cuortho.org www.cuortho.org
27 28
Surgical Strategies Tendon transfers
Principles of Musculotendinous Transfer (Brand)
• expose MN to normal tissue
• mature wound, straight line of pull, one function
planes, proximally and distally
• EXTERNAL v INTERNAL neurolysis Restore Function
• IDENTIFY: PCBMN + motor br.
• Palmar abduction
• EPINEURIUM: evaluate integrity
• Opposition
• ASSESS: perineural environment
• Reconstruction options
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Camitz Transfer Camitz Transfer
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31 32
APB to FCR Advancement APB to FCR Advancement
Danoff, et al. JHS-Eur 2014
• outcomes survey in 14 pts
• exam for 7 pts
• mean follow up = 2.8 yrs
• ALL pts able to palmar abduct
• 71% able to oppose to SF base
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
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Ring Finger FDS Transfer SUMMARY
• Confirm condition
• history, exam, imaging, neurodiagnostic studies
• Assess functional deficit(s)
• Patient education essential!! (reasonable expectations)
• Surgical principles
• zone of ‘injury’, optimize perineural environment
• Post-operative rehabilitation
© 2004 Leversedge FJ, Goldfarb CA, Boyer MI
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Overview
• Recurrent Carpal Tunnel
• Causes
Flap Options, Management, and • Associated Findings
• Indications for Extrinsic Protection of the Median
Outcomes Nerve
• Options
Suhail K. Mithani, MD • Wraps
Associate Professor of Plastic Surgery • Conduit Wrapping
Associate Professor of Orthopaedic Surgery • Vein Wrapping
• Flaps
Duke University Medical Center
• Hypothenar Fat Flap
• Synovial Flap
• Intervention Selection
1 2
Symptoms Associated with Failure of Carpal Tunnel Release Conditions Associated with Recurrent Carpal Tunnel
• Systemic Conditions
• Local Conditions
• Tenosynovitis
Persistent Recurrent New/Worsening Symptoms • Postoperative Infection • Collagen-vascular disorders
• Acromegaly
1.Incomplete Release 1. Fibrosis/Scarring 1. Iatrogenic injury • Postoperative Hematoma • Malignancy
2.Incorrect Diagnosis 2. Extrinsic 2. Incomplete Release • Tenosynovitis • Amyloidosis
compression due to • TB
• May reflect systemic or • Kidney Disease
associated condition
response to trauma/overuse • Gout: Tophus Compression
• Mucopolysaccharoidosis (Pediatric Carpal
Tunnel)
JAAOS 27(15):551-562, 2019.
3 4
Why Flap or Wrap after Revision CTR?
Indications for Flap or Wrap after Revision CTR
Multiple studies have shown perineural adhesion at the time of revision CTR
J Hand Surg 2006;31:68-71. J Hand Surg Am 2013;38:1530-1539
• Idiopathic Recurrent Carpal Tunnel
• Systemic Conditions Associated with Fibrosis
• Mucopolysaccharoidosis
• Amyloidosis
• Renal Disease
• Scleroderma
• Superimposed Peripheral Neuropathy
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Techniques to prevent recurrent scarring Vein Wrapping
J Hand Surg Am 2001;26:296-302.
• Provide a barrier between the nerve and its environment • Studies demonstrate
decreased scar formation
• Implants/Grafts
and neovascularization in
• Biologic Conduit chronic CTS
• Vein Wrapping • “Tennis racket” wrap of
• Vascularized Tissue saphenous vein
• Improved Nerve
• Hypothenar Fat Pad
Conduction velocity after
• Synovial Flap recurrent CTR
7 8
Vein Wrapping Outcomes Biologic Wrapping for Recurrent CTR
J Hand Surg Am 2001;26:296-302.
• In conjunction with extensile CTR ±
tenosynovectomy/Neurolysis
• Wrapping of median nerve with
biologic conduit
• Porcine
• Collagen
15 patients: Retrospective Review • Amniotic membrane
Clinical Improvement • Hyaluronic Acid
Improvement in 2 point and conduction J Hand Surg Am 2001;26:296-302.
All demonstrate diminished scarring in
velocity with 43 month followup preclinical models
JHS. 2018 Apr;43(4):360-367
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Hypothenar Fat Pad Flap
• Several studies have
Vascularized tissue Transfer for Recurrent CTR described its use for
recurrent CTS
• Open Extensile • Choices for Flaps
• Several different methods of
Approach/Neurolysis • Hypothenar Fat Pad flap harvest and inset
• Decrease recurrent scarring • Synovial Flap • Goal is to transpose
with vascularized tissue
• Forearm Perforator vascularized fat between the
• Local and free options median nerve and the radial
• Palmaris Brevis
described leaflet of the carpal tunnel
• Abductor Digiti Minimi
• Blood supply: Segmental
• Free Flap
ulnar artery perforators Techniques in Hand & Upper Extremity
Surgery10(3):150-156, September 2006.
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Hypothenar Fat Pad Flap
Variations in Elevation
Technique Technique
Techniques in Hand & Upper Extremity
Surgery10(3):150-156, September 2006. Techniques in Hand & Upper Extremity Surgery10(3):150-156, 2006.
13 14
Anatomic Basis of Tenosynovial
Flap
Synovial Flap
• Tenosynovium is
elevated from
flexor tendon
while preserving
its ulnar
attachements
• Transposed over
median nerve
and sutured to
radial leaflet Techniques in Hand & Upper Extremity
Surgery17(2):84-86, June 2013. Plastic and Reconstructive Surgery139(5):1165-1174, May 2017.
15 16
Conclusions
Comparison of Various Techniques • Idiopathic recurrent CTS is typically associated with fibrosis and
adherence of the median nerve to the radial leaflet of the TCL
• In addition to revision CTR and neurolysis, some type of “protection” for
the median should be considered
PRS: July 2013 - Volume 132 - Issue 1 - p 114-121
• Vascularized soft tissue transposition may be superior to wrapping with
autologous vein or biologic conduit
Meta Analysis
Much heterogeneity between study designs
Most consistent success with revision open
CTR and hypothenar fat flap
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