Minimally invasive surgical treatment for carpal tunnel syndrome with synovial hyperplasia / 中华显微外科杂志

Objective To explore the clinical effect of endoscopic treatment of carpal tunnel syndrome(CTS) with subsynovial hyperplasia.Methods Thirty-eight wrists of idiopathic CTS (control group) without subsynovial connective tissue (SSCT) hyperplasia and 41 wrists of idiopathic CTS with SSCT hyperplasia (experimental group) were surgically treated under endoscope from May,2000 to September,2015,and they were retrospectively studied at clin ic.The endoscopic release of the transverse ligament of wrist was done in the control group.While in the experimental group,the SSCT around the flexor tendons in the carpal tunnel was removed additionally after transverse ligament re lease through the same incision.The varieties of sensory nerve conduction velocity (SNCV),distal motor lantacy(DML),two points of discrimination (TP).Tinel sign,Phalen sign,grip and pinch force before and after operation in both groups were statistically calculated and compared,then the excellent and good rate according to Kelly classification was calculated.The difference was considered as statistically signifcant when P＜0.05.Results For the control group and experimental group:①According to Kelly classification,the overall excellent and good rate were 94.7％ and 95.1％ respectively.There was no statistical difference between 2 groups (P＞0.05).②The positive rate of Tinel sign and Phalen sign were significantly reduced to 2.6％ and 2.4％ respectively (P＜0.05).But there was no statistical difference between 2 groups (P＞0.05).③The average TP were (3.7±1.1) mm and (3.5±0.9) mm respectively.There was no statistical difference between 2 groups (P＞0.05).④The SNCV of the 2 groups were (14.3±5) m/s and (16.1±6) m/s,and the DML of the 2 groups were (0.8±0.3) ms and(0.7±0.4) ms respectively,while there was no statistic differences regarding SNCV and DML before and after operation between the 2 groups (P＞0.05).Conclusion Similar and satisfactory recent clinical effect can be harvested with cutting transverse ligament under endoscope and removing SSCT around the flexor tendons for idiopathic CTS with SSCT hyperplasia or not.Classical open operation is not necessary for idiopathic CTS with SSCT hyperplasia.

Relaxin Modulates the Expression of MMPs and TIMPs in Fibroblasts of Patients with Carpal Tunnel Syndrome

PURPOSE: The aim of this study was to investigate the anti-fibrotic effect of relaxin in subsynovial fibroblasts activated by transforming growth factor beta (TGF-β). MATERIALS AND METHODS: To test the anti-fibrotic effect of an adenovirus-relaxin construct (Ad-RLN) on subsynovial fibroblasts in vitro, cells from subsynovial connective tissue of patients with carpal tunnel syndrome were activated with TGF-β1 and exposed to Ad-RLN (as a therapeutic gene) or adenovirus-lacZ construct (as a marker gene) for four hours. Subsynovial fibroblast cultures without adenoviral exposure served as controls. RESULTS: We observed induction of gene expressions of collagen I, III and IV, as well as the abatement of alpha-smooth muscle actin (a-SMA) synthesis, Smad2 phosphorylation, and fibronectin at the protein level, in comparison to controls. In addition, protein expressions of matrix metalloproteinase (MMP) I was significantly induced, whereas the protein expressions of tissue inhibitor of metalloproteinases (TIMP) I and IV were reduced due to relaxin expression. CONCLUSION: RLN prevents excessive synthesis of extracellular matrix by reducing the expressions of its components, such as fibronectin, a-SMA, and phosphorylated Smad2, by increasing the expression of MMPs; and by decreasing the expression of TIMPs.

Pathologic Changes of Blood vessels and Extracellular Matrix in the Subsynovial Connective Tissue of Idiopathic Carpal Tunnel Syndrome / 대한정형외과연구학회지

PURPOSE: The purpose of this study is to investigate pathologic changes of blood vessels and perivascular tissue in subsynovial connective tissue (SSCT) of idiopathic carpal tunnel syndrome (CTS) by examining elastin distribution and vascular morphology and by observing ultrasturctural changes of extracellular matrix using transmission electron microscope (TEM). MATERIALS AND METHODS: The Verhoeff-van Gieson stain was used to identify histopathology and to localize elastin in the SSCT of the middle finger flexor digitorum superficialis (FDS) within the carpal tunnel in ten CTS patients and ten cadaver specimens as control group. In each specimen, the elastin density within and around vessels was calculated with image analyzing software including Adobe photoshop 6.0 and Scion image analysis. The vessel number per unit area and the mean thickness of vessel walls were also calculated. The ultrastructural changes of SSCT were compared between the specimens of both groups by TEM. RESULTS: The mean elastin density within vessels was 0.10 +/- 0.03 (p=0.001) in the CTS group and 0.18 +/- 0.04 in the control group. The mean elastin density around vessels was 0.15 +/- 0.04 in the CTS group and 0.23 +/- 0.04 in the control group (p=0.002). The mean number of vessels per unit area (0.00155 mm2) was 0.36 +/- 0.12 in the CTS group and 0.15 +/- 0.10 in the control group (p=0.002). The mean thickness of blood vessels was 38.10 +/- 20.60 micrometer in the CTS group and 18.90 +/- 3.68 micrometer in the control group (p=0.023). In general, the severer the vascular hypertrophy and obstruction, the less elastin noted within and around blood vessels. The TEM showed some important ultrastructural changes in SSCT of CTS. Generally, SSCT contained two kinds of cells, fibroblast-like cells and macrophage-like cells. And these cells and elastin were dispersed among collagen fibrils. In SSCT of control group, the collagen fibrils showed round margin and uniform diameter in transverse section, and showed similar thickness in longitudinal section. However, in SSCT of CTS, the collagen fibrils had irregular margin called "spiraled collagen"and variable diameter in transverse section, and uneven thickness in longitudinal section. In addition, the elastolysis and the phagocytosis of the changed collagen fibrils were observed. CONCLUSION: SSCT of CTS showed significant decrease of elastin density within and around vessels along with degenerative histopathological vascular changes. In addition TEM revealed ultrastructural abnormalities like metamorphosis of collagen fibrils, phagocytosis of spiraled collagen fibrils and elastolysis. Therefore, it is suggested that pathology of CTS may involve active cellular processing related to ischemic cellular environmental changes in carpal tunnel as well as well known pathology of nerve.