Mini-open blind carpal tunnel release via 1- centimeter transverse incision above the wrist crease versus open release

Carpal tunnel release has become one of the most popular forms of hand surgery with high success rates. However, scar and post-operative morbidity accounts for most of the reported complications due to the presence of rich cutaneous nerves across the palm liable for iatrogenic injury and releasing of the superficial structures to the transverse carpal ligament as the subcutaneous fat palmar fascia, and palmaris brevis muscle. Minimally invasive surgical techniques employing endoscopic instruments or special mini-open techniques aimed at avoiding or minimising surgical scars in the palm, reducing scar morbidity, and post-operative pain, whilst enabling earlier and better functions. Between September 2006 and September 2007, a prospective comparative study evaluating the safety and effectiveness of a mini-open technique for blind [not under direct vision] carpal tunnel release using a 1 centimeter transverse incision proximal to the wrist crease, assisted with a 6 mm kuntscher nail and arthroscopic scissors for releasing the transverse carpal ligament, compared with limited open release. Twelve female patients and three male patients [30 wrists], with bilateral carpal tunnel syndrome aged [32-55 years], clinically and electro-physiologically diagnosed, with failed conservative management, were enrolled in this study. All cases were done under local anesthesia. Right hands underwent mini-open procedure, while the left hands underwent limited open release procedure. Details of the technique, patient satisfaction and outcomes are presented. This study revealed that the patients' right hands [mini-open CTR], have an easier postoperative course in comparison with their left hands [limited OCTR], reporting excellent improvement in symptoms severity, functional and cosmetic status post-operatively with high satisfaction, plus no encountered neurovascular or major complications. This technique is effective, simple and safe and cost effective. It can be used where endo-scopic release is expensive and not widely available

Single-portal endoscopic versus open carpal tunnel release

Open release of the transverse carpal ligament [TCL] has been the gold standard surgical treatment for patients with carpal tunnel syndrome for the past several decades. However, significant concerns are the transient post-operative [pillar pain] scar tenderness and the length of recovery time. There has been widespread misunderstanding and confusion regarding endoscopic carpal tunnel release [ECTR] owing to different techniques with different complications and efficacy being viewed as one technique. This prospective randomized study was carried out to compare the single-portal ECTR and open carpal tunnel release [OCTR]. Between May 2006 to May 2007 Thirty-one patients with 60 wrists clinically diagnosed and electrophysiologically confirmed idiopathic CTS, and nonresponded to non-operative treatment were assigned to this study. Singleportal ECTR was performed in 16 patients with 30 wrist [14 bilateral CTS patients and 2 cases with right side CTS] and OCTR was performed in 30 wrists [15 bilateral CTS patients]. All cases were available for follow-up at 3 weeks, 3 and 6 months post-operatively. Outcome measures were evaluated such as CTS symptoms improvement, time needed to resume activities of daily living [ADL] and return to work and complications. Early onset of CTS symptoms relief was prevalent in single-portal ECTR group [66.5% within 3 days]. During the first three months post-operatively, patients sustained to the single-portal ECTR procedure were better symptomatically and functionally. Local wound problems in terms of painful scar or palm was reported by 10 wrists [33%] in the OCTR group, whereas non in the single-portal ECTR group, occasional pain with ADL reported in 3 wrists [10%] of the OCTR group. The average time to return to work was appreciably less in the single-portal ECTR [12 days] compared to 25 days in the OCTR group. No significant difference was observed between the two groups as regard to symptoms improvement, electrophysiological studies and complications at the end of six months. In conclusion, Singleportal ECTR is a safe and effective treatment of CTS, was associated with less post-operative pain, more quickly good clinical outcomes and patient satisfaction than OCTR. Hence the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain

Interposition arthroplasty and reconstruction of the extensor apparatus in severe boutonniere deformity

Injuries of the hand finger joints can often lead to severe functional disability and rapid development of stiff joints. Although; Splinting and arthrodesis have been recommended because of the random results achieved by other reconstructive procedures, atrhrodesis for the young active patients should be reserved for limited causes and other arthroplasty techniques restoring joint mobility should be considered. A technique for interposition arthroplasty of the proximal inter-plalangeal [PIP] joint in sever type boutonniere deformity is described in this current study. It involves minimal resection of intra-articular adhesions and the use of autogenous fascia lata, and reconstruction of the extensor apparatus. Between May 2006 and May 2007 at the Orthopaedic Surgery Department of Mansoura University Hospital, 6 autogenous fascia lata interposition arthroplasties conducted on PIP joints of six patients of chronic post-traumatic sever type [stage III] boutonniere deformity according to Nalebuff and Millender classification [Terrono et al., 1990]. The resulted total active range of motion of the operated PIP joints ranged from 45 to 75 degrees. The restored range of motion constitutes from 42.9% to 71.4% of the normal range of motion of the PIP joint [Hume et al., 1990]. The operated PIP joints were stable and the restored motion was pain-free. All our patients were satisfied with both the functional and cosmetic outcomes. The method is simple, safe, and easily reproducible. In selected cases itcan offer restoration of pain-free active motion

Percutaneous interlocking nailing of tibial shaft fractures: Technique and outcomes

Closed interlocking tibial nailing is a well accepted method of treating tibial fractures. There are advantages to perfoming surgery via smaller incisions. This study provides a method for percutaneous interlocking nailing of tibial shaft fractures intended to improve the technique, functional results and also reduces the problem of anterior knee pain, by avoiding injury to the infrapatellar nerve and/or iatrogenic trauma to, or dissection around, the patellar tendon. The main difference in the technique is the use of a 6 cm-long k-wire fixed temporarily in the anterior cortex of the tibial tuberosity to indicate the midline for medullary canal opening, a small stab incision of an average length of 2.5 cm reaching the tibial cortex midway between the lower pole patella and tibial tuberosity, an invented bone awl for opening the medultary canal at the entry point [sweet spot], inserting an invented graded guide pin into the medullary channel and Slide an invented sleeve over the guide pin till it hits the entry point to check the actual needed nail length through the graded guide pin [depth gauge]. Between March 2004 and March 2007 a prospective trial on 40 patients with unilateral closed tibial diaphyseal fractures was done at the Orthopaedic Surgery Department of Mansoura University Hospital. All were followed up for one year. There were twenty-five men and fifteen women with a mean age of 40 +/- 9 years, two female patients were excluded from the results because of lost follow up with them shortly postoperative. Early perioperative complications, including compartment syndrome, and pulmonary embolism, were checked, but no patients had such complications. Patients began full weight bearing at an average of 14 +/- 4 weeks postoperatively; the median time for fracture healing was 17 +/- 4 weeks, 34% out of our patients experienced different degrees of anterior knee pain, 2.5% grade zero, 7.9% grade 1, 7.9% grade 2 and 15.8% grade 3 according to the Functional Assessment Score [FAS]. At the time of final follow-up, there were 20 excellent, 16 good results, one fair and one poor result according to Johner and Wruh's Criteria [Johner et al., 1983]. This modified technique and devices for percutaneous interlocking tibial nailing provide significant advantages when compared with the standard technique so that the time to union, the functional outcome and incidence of anterior knee pain,are significantly improved