Ultrasound-Guided WALANT Technique in Carpal Tunnel Decompression Surgery* / Técnica WALANT guiada por ultrassom na cirurgia de descompressão do túnel do carpo

Abstract Carpal tunnel syndrome (CTS) is the most common compressive neuropathy in the human body. Its symptoms result from compression of the median nerve in the carpus. The treatment can be conservative, with medications and/or infiltrations that alleviate the symptoms, or surgical, which is more effective, with decompression of the median nerve by surgical section of the flexor retinaculum of the carpus. The anesthetic technique varies according to the anesthesia method: sedation, venous locoregional anesthesia and, more recently, wide-awake local anesthesia no tourniquet (WALANT), which can be performed by the surgeons themselves. The WALANT technique uses local anesthesia with a vasoconstrictor, and does not require the use of a tourniquet on the upper limb nor sedation. The median nerve block in ultrasound-guided WALANT provides better accuracy to the technique, with greater patient safety; in the present article, its use in the performance of carpal tunnel decompression is described, and the literature is reviewed.

Resumo A síndrome do túnel do carpo (STC) é a neuropatía compressiva mais comum do corpo humano. Seus sintomas decorrem da compressão do nervo mediano no carpo. O tratamento pode ser incruento, com medicações e/ou infiltrações que amenizam os sintomas, ou cruento, mais eficaz, com a descompressão do nervo mediano pela seção cirúrgicadoretináculodos flexores do carpo. A técnica anestésica varia de acordo com o serviço de anestesia: sedação, anestesia locorregional venosa e, mais recentemente, a anestesia local com o paciente acordado e sem torniquete (wide-awake local anesthesia no tourniquet, WALANT), que pode ser realizada pelo próprio cirurgião. Por utilizar anestesia local com vasoconstritor, essa técnica dispensa o uso de torniquete no membro superior e a necessidade de sedação. O bloqueio do nervo mediano na WALANT guiada por ultrassonografiaconfere melhor precisão àtécnica,e mais segurança ao paciente, e, neste artigo seu uso na realização da descompressão do túnel do carpo é descrito, e a literatura, revisada.

An Intraindividual Comparison of Open versus Paine Retinaculotome Release for Bilateral Carpal Tunnel Syndrome / Comparação intraindividual dos resultados da liberação aberta ou com retinaculótomo de Paine na síndrome do túnel do carpo bilateral

Abstract The main purpose of this research was to do an intraindividual comparison of outcomes between the open ulnar incision (OUI) and the Paine retinaculotome with palmar incision (PRWPI) techniques in patients with bilateral carpal tunnel syndrome (CTS). The patients underwent OUI surgery on one hand and PRWPI surgery on the contralateral hand. The patients were evaluated with the Boston carpal tunnel questionnaire, visual analogue scale for pain, palmar grip strength, and fingertip, key, and tripod pinch strengths. Both hands were examined in the preoperative and postoperative periods after 2 weeks, 1 month, and 3 and 6 months. Eighteen patients (36 hands) were evaluated. The symptoms severity scale (SSS) scores were higher, in the preoperative period, in the hands that underwent surgery with PRWPI (p-value =0,023), but lower in the 3rd month postoperative (p-value = 0.030). The functional status scale (FSS) scores were lower in the periods of 2 weeks, 3 months, and 6 months (p-value = 0,016) on the hands that underwent surgery with PRWPI. In a different two-group module study, the PRWPI group presents the SSS scores average on the 2nd week and 1st month, and the FSS scores average on the 2nd week, less 0.8 and 1.2 points respectively comported to open group. The hands that underwent surgery with PRWPI presented significantly lower SSS scores at 3 months postoperative, and lower FSS scores at 2 weeks, and 3 and 6 months postoperative, compared to open surgery group.

Resumo O principal objetivo desta pesquisa foi fazer uma comparação intraindividual dos resultados entre as técnicas de incisão ulnar aberta e retinaculótomo de Paine com incisão palmar em pacientes com síndrome do túnel do carpo (STC) bilateral. Os pacientes foram submetidos à cirurgia aberta em uma mão e cirurgia com retinaculótomo de Paine na mão contralateral. Os pacientes foram avaliados com o Boston carpal tunnel questionnaire, escala visual analógica para dor e força de preensão palmar, pinça lateral, pinça polpa-polpa e trípode. As duas mãos foram examinadas antes da cirurgia e 2 semanas, 1 mês, 3 e 6 meses após a cirurgia. Dezoito pacientes (36 mãos) foram avaliados. As pontuações da escala de gravidade dos sintomas (EGS) foram maiores no pré-operatório nas mãos submetidas à cirurgia com retinaculótomo de Paine (p = 0,023), mas menores no 3° mês após o procedimento (p = 0,030). As pontuações da escala de estado funcional (EEF) foram menores às 2 semanas, 3 meses e 6 meses (p = 0,016) nas mãos submetidas à cirurgia com retinaculótomo de Paine. Em um estudo de módulo de diferença de dois grupos, o grupo submetido à cirurgia com retinaculótomo de Paine apresentou pontuações médias de EGS na 2ª semana e 1° mês e de EEF na segunda semana inferiores a 0,8 e 1,2 pontos, respectivamente, em comparação ao grupo submetido ao procedimento aberto. As mãos submetidas à cirurgia com retinaculótomo de Paine apresentaram escores significativamente menores de EGS em 3 meses e de EEF em 2 semanas, e aos 3 e 6 meses após a cirurgia em comparação a técnica aberta.

Failure factors for carpal tunnel syndrome surgical treatment: When and how to perform a revision carpal tunnel decompression surgery / Fatores de insucesso do tratamento cirúrgico da síndrome do túnel do carpo: Quando e como revisar a cirurgia de descompressão do túnel do carpo

Abstract Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Resumo Apesar de ser um procedimento amplamente utilizado em todo o mundo e com elevadas taxas de remissão dos sintomas, o tratamento cirúrgico da síndrome do túnel do carpo pode apresentar resultados não satisfatórios ao paciente. Esse resultado não satisfatório pode se manifestar clinicamente pela não remissão dos sintomas, remissão dos sintomas mas recorrência desses após um período de tempo da cirurgia ou aparecimento de diferentes sintomas após a cirurgia. Diferentes fatores estão relacionados a esse insucesso do tratamento cirúrgico da síndrome do túnel do carpo (ITCSTC). A prevenção pode ser conseguida por meio de minuciosa avaliação clínica do paciente no período pré-operatório. Dessa forma o cirurgião poderá fazer diagnósticos diferenciais ou diagnósticos concomitantes, assim como identificar fatores ligados a insatisfação do paciente. Os fatores per-operatórios incluem a correta identificação das estruturas anatômicas para completa descompressão do nervo mediano. Inúmeros procedimentos têm sido descritos para o tratamento dos fatores que ocorrem no período pós-operatório. Desses o mais comum, a formação de aderências em torno do nervo mediano, tem sido tratado com relativo sucesso utilizando diferentes retalhos vascularizados ou cobertura com o uso de tecido autólogo ou homólogo. Descreveremos a abordagem do ITCSTC com maiores detalhes no texto.

Prevalence of Anatomical Variations in Patients with Carpal Tunnel Syndrome Undergoing Classical Open Carpal Tunnel Release / Prevalência de variações anatômicas encontradas em pacientes com síndrome do túnel do carpo submetidos a liberação cirúrgica por via aberta clássica

Abstract Objective To evaluate the prevalence of anatomical variations encountered in patients with carpal tunnel syndrome who underwent carpal tunnel classical open release. Methods A total of 115 patients with a high probability of clinical diagnosis for carpal tunnel syndrome and indication for surgical treatment were included. These patients underwent electroneuromyography and ultrasound for diagnostic confirmation. They underwent surgical treatment by carpal tunnel classical open release, in which a complete inventory of the surgical wound was performed in the search and visualization of anatomical variations intra- and extra-carpal tunnel. Results The total prevalence of anatomical variations intra- and extra-carpal tunnel found in this study was 63.5% (95% confidence interval [CI]: 54.5-72.4). The prevalence of the carpal transverse muscle was 57.4% (95% CI: 47.8-66.6%), of the bifid median nerve associated with the persistent median artery was 1.7% (95% CI: 0.0-4.2%), and the median bifid nerve associated with the persistent median artery and the transverse carpal muscle was 1.7% (95% CI: 0.0-4.2%). Conclusion The most prevalent extra-carpal tunnel anatomical variation was carpal transverse muscle. The most prevalent intra-carpal tunnel anatomical variation was median bifid nerve associated with the persistent median artery. The surgical finding of an extra-carpal tunnel anatomical variation, such as the transverse carpal muscle, may indicate the presence of other associated carpal intra tunnel anatomical variations, such as the bifid median nerve, persistent median artery, and anatomical variations of the recurrent median nerve branch.

Resumo Objetivo Avaliar a prevalência de variações anatômicas encontradas em pacientes com síndrome do túnel do carpo submetidos a liberação cirúrgica por via aberta clássica. Métodos Foram incluídos um total de 115 pacientes com alta probabilidade de diagnóstico clínico de síndrome do túnel do carpo, com indicação para o tratamento cirúrgico. Estes pacientes realizaram eletroneuromiografia e ultrassonografia para confirmação diagnóstica. Foram submetidos ao tratamento cirúrgico por via aberta clássica, no qual foi realizado um inventário completo da ferida operatória na busca e visualização de variações anatômicas intra e extra túnel do carpo. Resultados A prevalência total das variações anatômicas intra e extra túnel do carpo encontradas neste estudo foi de 63,5% (intervalo de confiança [IC]95%: 54,5-72,4%). A prevalência do músculo transverso do carpo foi de 57,4% (IC95%: 47,8-66,6%), do nervo mediano bífido associado à artéria mediana persistente foi de 1,7% (IC95%: 0,0-4,2%) e do nervo mediano bífido associado à artéria mediana persistente e ao músculo transverso do carpo foi de 1,7% (IC95%: 0,0-4,2%). Conclusão A variação anatômica extra túnel do carpo mais prevalente foi o músculo transverso do carpo e a variação anatômica intra túnel do carpo mais prevalente foi o nervo mediano bífido associado à artéria mediana persistente. O achado cirúrgico de uma variação anatômica extra túnel do carpo, como o músculo transverso do carpo, pode nos indicar a presença de outras variações anatômicas intra túnel do carpo associadas, como nervo mediano bífido, artéria mediana persistente e variações anatômicas do ramo recorrente do nervo mediano.

Túnel carpiano con anestesia local versus WALANT / Carpal tunnel with local anesthesia versus WALANT

Objetivo: Las cirugías con WALANT han ganado gran popularidad hoy en día. La ventaja principal que ofrece esta técnica es la de prescindir del torniquete y así eliminar las molestias que este genera. Nuestra hipótesis es que la descompresión del túnel carpiano con anestesia local y manguito neumático, realizada por un cirujano experimentado, en un tiempo quirúrgico corto, permite obtener similares resultados que con la cirugía con WALANT. materiales y métodos:Se diseñó un estudio de cohortes prospectivo comparativo clínico. Se incluyeron 23 pacientes (30 manos) con síndrome del túnel carpiano. Se asignó a los pacientes en forma aleatorizada, a 2 grupos: grupo 1, operados con anestesia local y grupo 2, operados con WALANT. Se realizó un análisis estadístico. Resultados:Todas las variables mostraron diferencias estadísticamente significativas respecto a los valores preoperatorios para los dos grupos. Respecto a la relación entre los dos grupos, los resultados funcionales de dolor y grado de satisfacción posoperatorios no mostraron diferencias con significancia estadística. Conclusiones: En nuestro estudio, la descompresión del túnel carpiano con anestesia local y torniquete y la realizada con WALANT arrojaron similares resultados. En cirujanos con experiencia posiblemente la anestesia local con torniquete sea suficiente para realizar el procedimiento, y así evitar las bajas, pero complejas complicaciones de la epinefrina. Nivel de Evidencia: II

Objective: Surgeries with the WALANT technique have recently become popular. The main advantage of this technique is that it avoids using the tourniquet and eliminates the discomfort it generates. We hypothesize that carpal tunnel decompression with local anesthesia and a pneumatic tourniquet, performed by an experienced surgeon in a short surgical time, allows us to obtain similar outcomes to the WALANT technique surgery. Materials and methods: We designed a prospective clinical comparative cohort study. We included twenty-three patients (30 hands) with carpal tunnel syndrome. Two groups of patients were randomized. Group 1 consisted of patients operated on with local anesthesia, and Group 2 included those operated on with the WALANT technique. We carried out a statistical analysis. Results: All the variables showed statistically significant differences concerning the preoperative values for the two groups. Regarding the relationship between those two groups, the functional outcomes of pain and degree of postoperative satisfaction did not show statistically significant differences. Conclusions: In our study, carpal tunnel decompression performed with local anesthesia with a tourniquet and those achieved with the WALANT technique had similar outcomes. In the hands of experienced surgeons, local anesthesia with a tourniquet may be sufficient to perform the procedure, thus avoiding the few but complex complications of epinephrine. Level of Evidence: II

WALANT versus intravenous regional anesthesia for carpal tunnel syndrome: a randomized clinical trial

ABSTRACT BACKGROUND: There are several anesthetic techniques for surgical treatment of carpal tunnel syndrome (CTS). Results from this surgery using the "wide awake local anesthesia no tourniquet" (WALANT) technique have been described. However, there is no conclusive evidence regarding the effectiveness of the WALANT technique, compared with the usual techniques. OBJECTIVE: To evaluate the effectiveness of the WALANT technique, compared with intravenous regional anesthesia (IVRA; Bier's block), for surgical treatment of CTS. DESIGN AND SETTING: Randomized clinical trial, conducted at Hospital Alvorada Moema and the Discipline of Hand Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. METHODS: Seventy-eight patients were included. The primary outcome was measurement of perioperative pain through a visual analogue scale (VAS). The secondary outcomes were the Boston Questionnaire score, Hospital Anxiety and Depression Scale (HADS) score, need for use of analgesics, operating room times, remission of paresthesia, failures and complications. RESULTS: The WALANT technique (n = 40) proved to be superior to IVRA (n = 38), especially for controlling intraoperative pain (0.11 versus 3.7 cm; P < 0.001) and postoperative pain (0.6 versus 3.9 cm; P < 0.001). Patients spent more time in the operating room in the IVRA group (59.5 versus 46 minutes; P < 0.01) and needed to use more analgesics (10.8 versus 5.7 dipyrone tablets; P = 0.02). Five IVRA procedures failed (5 versus 0; P = 0.06). CONCLUSIONS: The WALANT technique is more effective than IVRA for CTS surgery.

Ulnar two-point discrimination following endoscopic carpal tunnel release / La liberación endoscópica del túnel carpiano y la prueba de discriminación de dos puntos del nervio cubital

Abstract Carpal tunnel syndrome is median nerve symptomatic compression at the level of the wrist, characterized by increased pressure within the carpal tunnel and decreased nerve function at the level. Carpal tunnel release decreases pressure in Guyon's canal, via open techniques, with symptom and two-point discrimination improvement in the ulnar nerve distribution. We hypothesize that endoscopic carpal tunnel release improves two-point discrimination in the ulnar nerve distribution as well. This study includes 143 patients who underwent endoscopic carpal tunnel release between April 2016 to June 2019 in a single, community-based teaching hospital. A comprehensive retrospective chart review was performed on patient demographics, preand post-operative two-point discrimination test results, and complications. The effects of sex, age, and diabetes mellitus in the ulnar and median nerve territories with two-point discrimination tests were analyzed. As well as the differences in two-point discrimination among patient's based on their smoking status. There were significant post operative improvements in both the median (7.7 vs 4.4 mm, p < 0.001) and ulnar (5.7 vs 4.1 mm, p < 0.001) nerve territories. Smoking status, sex, age and diabetes did not significantly affect two-point discrimination outcomes. In conclusion the endoscopic release of the transverse carpal ligament decompresses the carpal tunnel and Guyon's canal, demonstrating improvement in two-point discrimination in both the ulnar and median nerve distributions.

Resumen El síndrome de túnel carpiano es la compresión sintomática del nervio mediano al nivel de la muñeca. Se caracteriza por un aumento de presión dentro del túnel y una disminución de la función del nervio a ese nivel. La liberación del túnel carpiano descomprime el canal de Guyon, con mejoría sintomática y en la prueba de discriminación de dos puntos en la distribución del nervio cubital. Hipotetizamos que la liberación endoscópica mejora de la misma manera en la distribución del nervio cubital. Este trabajo incluye 143 pacientes que tuvieron liberación endoscópica del túnel carpiano entre abril del 2016 y junio del 2019 en un hospital Universitario de la comunidad. Se evaluaron retrospectivamente las historias clínicas para los datos demográficos, los resultados pre y post quirúrgicos en la prueba de discriminación de dos puntos y complicaciones. Se analizaron los efectos del sexo, edad, tabaco y diabetes en los resultados de la prueba de discriminación de dos puntos para los nervios cubital y mediano. Hubo mejoría significativa post quirúrgica en la prueba de discriminación de dos puntos para los nervios mediano (7.7 vs 4.4 mm, p < 0.001) y cubital (5.7 vs 4.1 mm, p < 0.001). Fumadores, sexo, edad, y diabetes no afectaron de forma significativa. Concluimos que la liberación endoscópica del ligamento transverso del carpo descomprime el túnel carpiano y el canal de Guyon con mejoría en la prueba de discriminación de dos puntos para los nervios cubital y mediano.

Resultados funcionales a largo plazo de la cirugía abierta de liberación del túnel carpiano / Long-term functional outcomes of open carpal tunnel release surgery

Introducción: El síndrome del túnel carpiano es la neuropatía por atrapamiento más común que genera compresión del nervio mediano. La cirugía de liberación abierta del nervio mediano tiene un papel importante, especialmente, en pacientes que no responden al manejo conservador o con diagnóstico de síndrome del túnel carpiano con criterios de gravedad. El propósito de este estudio fue describir los resultados funcionales, la satisfacción y la fuerza objetiva a mediano (6-24 meses) y largo plazo (>24 meses) con la técnica abierta convencional en la población local. Materiales y métodos: Estudio observacional descriptivo con datos retrospectivos de resultados clínicos funcionales a mediano y largo plazo en pacientes sometidos a cirugía de liberación abierta del nervio mediano como tratamiento del síndrome del túnel carpiano. Se determinaron el nivel funcional según el BCTQ y la FSS, la fuerza de agarre con un dinamómetro electrónico y la satisfacción. Resultados: Se realizaron 100 procedimientos entre mayo de 2012 y septiembre de 2018, con un seguimiento posoperatorio >6 meses. La mayoría eran mujeres (83%) con una mediana de la edad de 59 años. El 97% obtuvo resultados buenos y excelentes a mediano plazo y el 90%, a largo plazo, con una mediana de fuerza de 17 kg (RIC 7,4) y una satisfacción de 90 (RIC 20) a mediano y largo plazo. Conclusiones: La cirugía abierta de liberación del nervio mediano en pacientes con síndrome del túnel carpiano logra resultados buenos y excelentes a mediano y largo plazo en cuanto a funcionalidad, fuerza y satisfacción. Nivel de Evidencia: IV

Introduction: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy that causes compression of the median nerve. Open median nerve release surgery plays an important role, especially in patients with failed conservative management or with a diagnosis of severe CTS. The purpose of the following study is to describe the functional outcomes, satisfaction, and objective strength in the medium (6 to 24 months) and long term (greater than 24 months) with the conventional open technique in the local population. Materials and methods: Descriptive observational study based on retrospective data of functional clinical outcomes in the medium and long term in patients undergoing open release surgery of the median nerve as a treatment for CTS. Functional level according to the BCTQ and FSS, grip strength with an electronic dynamometer, and satisfaction were determined. Results: 100 procedures were performed between May 2012 and September 2018, with a follow-up of more than 6 months. The majority were women (83%) with a total median age of 59 years showing good to excellent results in the 97% in the medium term and 90% in the long term, with a median strength of 17 kg (Interquartile range: 7.4) and satisfaction of 90 (Interquartile range: 20). Conclusions: Open surgery to release the median nerve in patients with CTS shows good to excellent functional outcomes, satisfaction, and strength in the medium and long term. Level of Evidence: IV

Mejoría del sueño en los pacientes operados por síndrome del túnel carpiano / Improvement of sleep quality after carpal tunnel release

Introducción: Los pacientes con síndrome del túnel carpiano suelen tener síntomas nocturnos que alteran la calidad del sueño y, muchas veces, son el motivo de consulta. Se estudiaron en profundidad los cambios objetivos luego de la liberación del túnel carpiano. Sin embargo, la evidencia sobre la mejoría del sueño tras la cirugía es escasa. Consideramos que la mejoría de la calidad del sueño está directamente relacionada con el procedimiento; nuestro objetivo primario fue comprobarlo. Como objetivo secundario se evaluó si los cambios en el sueño varían según factores constitucionales o de severidad del síndrome del túnel carpiano. Materiales y métodos: Serie prospectiva de 67 casos con síndrome del túnel carpiano e indicación de cirugía. Se dividieron grupos según edad, sexo y severidad del síndrome por electrodiagnóstico. Se evaluó la calidad del sueño con la Escala de Insomnio de Atenas antes de la cirugía y cuatro días después. Resultados: El 74,62% de los pacientes tenía alteraciones de la calidad del sueño antes de la cirugía. Se comprobó una mejoría significativa en la calidad del sueño después de la operación, en todos los casos (p <0,05). No hubo diferencias significativas en los resultados entre los grupos. Conclusiones: Clásicamente el éxito de la liberación del túnel carpiano se resume en los cambios sensitivo-motores. Sin embargo, no se apunta a la mejoría de la calidad del sueño, aunque sea el generador de la consulta. La descompresión del túnel carpiano mejora el sueño, independientemente de la edad, el sexo o la gravedad del cuadro. Nivel de Evidencia: II

Introduction: Sleep disturbances caused by night pain and paresthesia are usual symptoms in carpal tunnel syndrome (CTS), and are often the cause of medical consultation. Objective changes following the Carpal Tunnel Release (CTR) have been tho-roughly analyzed. However, evidence related to improvement in sleep quality is lacking. We consider that the immediate improvement in sleep quality is directly related to CTR. The main purpose of this study is to assess these changes following this procedure. The secondary objective is to evaluate if the severity of the median nerve compression or patient-related factors could have an impact on sleep quality. Materials and methods: Prospective case study of 67 patients diagnosed with CTS who underwent CTR procedure. We grouped all cases based on age, sex, and nerve conduction study (NCS) results. Sleep quality was evaluated with the Athens Insomnia Score before surgery and in the fourth follow-up day, asking specifically about symptoms from the first night after the procedure. Results: Sleep disorders were found in 74.62% of cases before surgery. After CTR, sleep quality improved in all cases (p<0.05). We found no relation between sleep quality improvement and sex, age, or NCS severity. Conclusions: CTR is commonly indicated to stop nerve damage, and to improve sensitive and motor symptoms. However, sleep disturbances are not the main indication for it, even if it is a frequent reason for medical consultation. Sleep quality improves from the first night after CTR, and this outcome is independent of age, sex, or severity of CTS. Level of Evidence: II

Clinical observation of arthroscopic single channel treatment of carpal tunnel syndrome with self-made instruments / 中国骨伤

OBJECTIVE@#To investigate the efficacy of self-made arthroscopic single channel in the treatment of carpal tunnel syndrome.@*METHODS@#Sixty patients with primary carpal tunnel syndrome treated from January 2014 to December 2019 were divided into arthroscopic group and traditional open operation group. There were 30 cases in arthroscopic group, including 12 males and 18 females, aged (47.5±4.5) years and the course of disease was (6.6±4.2) months. There were 30 cases in the traditional operation group, including 10 males and 20 females, aged (48.5±3.5) years, and the course of disease was (5.6±4.4) months. Both groups were unilateral. According to the anatomy of wrist joint and the characteristics of transverse carpal ligament and arthroscopy, the instruments including cannula, inner heart and hook knife were designed. The patients in two groups were treated with decompression of transverse carpal ligament using arthroscopy combined with self-made instruments and traditional open sergery. The incision length, operation time, intraoperative bleeding, hospitalization cost, hospitalization time and recovery time of the two groups were observed and compared. Boston Carpal Tunnel Questionnaire (BCTQ) score was used to evaluate the clinical efficacy of arthroscopy combined with self made instruments in the treatment of carpal tunnel syndrome.@*RESULTS@#Compared with the traditional group, the arthroscopic group had significant advantages in incision length, operation time, intraoperative bleeding and hospital stay, but the total cost of hospitalization was increased. The Boston score was significantly higher in the arthroscopic group than that in the traditional group at 1 month after operation, but not at 3 and 6 months after operation.@*CONCLUSION@#Arthroscopy combined with self-made instruments in the treatment of carpal tunnel syndrome is more reliable, minimally invasive and simplified than open surgery, but the patients should be clearly diagnosed and appropriately selected before operation to achieve satisfactory clinical effect.

The Influence of the Type of Surgical Thread and Suture in the Open Carpal Tunnel Syndrome Surgery

Carpal tunnel syndrome (CTS) is the result of compression and/or traction of the median nerve in the carpal tunnel. It is the most frequent compressive neuropathy of the upper limbs and it is usually idiopathic. Diagnosis is essentially clinical, defined by symptoms and provocative tests. Decompression of themedian nerve by section of the transverse carpus ligament is the treatment of choice, but the lack of consensus on the type of suture and surgical thread to be used in the open carpal tunnel decompression surgery justifies the importance of evaluating the comparative results of existing studies, aiming to describe the influence of different types of sutures and surgical threads to guide the professionals about the most appropriate conduct. This is a systematic review of the international and national literature. Four studies comparing the influence of surgical threads and one study evaluating the influence of the type of suture were found. From the comparative studies, it was observed that there is advantage in the use of nonabsorbable suture due to the lower occurrence of inflammation and postoperative wound complications. When using Donatti sutures, wound edge inversion is less likely to occur comparedwith single individual sutures, but they are also related to longer postoperative pain.

Síndrome do túnel do carpo associada à amiloidose / Carpal tunnel syndrome associated with amyloidosis

Introdução: A amiloidose é caracterizada pela deposição de proteínas nos órgãos e tecidos, e tem sido associada à síndrome do túnel do carpo (STC) quando ocorre no punho. O objetivo é descrever uma série de casos de pacientes submetidos à cirurgia para STC associado à amiloidose. Métodos: O estudo incluiu 12 pacientes que se submeteram à cirurgia para tratar a STC cuja biópsia identificou amiloidose; o seguimento foi de cinco anos. Os pacientes foram avaliados por testes clínicos, eletroneuromiografia, imagens radiológicas e biópsia. Resultados: Todos os pacientes apresentaram queixas musculoesqueléticas, sintomas severos de compressão do nervo mediano, alterações nos testes neurofisiológicos. Realizou-se a cirurgia, sinovectomia e biópsia. No pós-operatório, cinco pacientes (41%) desenvolveram dor crônica e distrofia simpático-reflexa. Conclusão: Observou-se maior frequência de dor pós-operatória na amostra, o que revela a necessidade de atenção na abordagem e tratamento dessa associação.

Introduction: Amyloidosis features protein deposition in the organs and tissues and has been associated with carpal tunnel syndrome (CTS) when it occurs in the wrist. The objective is to describe a case series of patients undergoing surgery for CTS associated with amyloidosis. Methods: The study included 12 patients who underwent surgery to treat CTS in whom amyloidosis was proven by biopsy; the follow-up period was 5 years. The patients were evaluated by clinical tests, electroneuromyography, radiological images, and biopsy. Results: All patients presented with musculoskeletal complaints, severe symptoms of median nerve compression, and changes on neurophysiological tests. Surgery, synovectomy, and biopsy were performed. In the postoperative period, five patients (41%) developed chronic pain and reflex sympathetic dystrophy. Conclusion: A higher frequency of postoperative pain was observed in the patients, demonstrating the need for caution in the approach and treatment of this association.

Fuerza y función de mano antes y después de liberación de túnel del carpo en pacientes con diabetes mellitus tipo 2 por abordaje abierto y endoscópico. Estudio de casos y controles / Strength and function of hand before and after release of carpal tunnel in patients with type 2 diabetes mellitus by open and endoscopic approach. Case-control study

Resumen: Antecedentes: El síndrome del túnel del carpo (STC) es la neuropatía más frecuente de la extremidad superior a nivel mundial. Los tratamientos dirigidos para el atrapamiento del nervio mediano en el túnel del carpo son más complicados y los resultados menos prometedores e insatisfactorios en pacientes diabéticos. El objetivo de este estudio es comparar los resultados de fuerza y función de la mano en pacientes sanos contra pacientes con diabetes mellitus tipo 2 (DM2) con diagnóstico de STC antes y después de la liberación abierta y endoscópica del túnel del carpo. Material y métodos: Se diseñó un estudio observacional, retrospectivo y descriptivo durante un período de cinco años en el que se evaluaron pacientes sanos y con DM2 con diagnóstico de STC que fueron sometidos a tratamiento quirúrgico por abordaje abierto o endoscópico y a quienes se les aplicó el cuestionario DASH, mediciones de fuerza de prensión y pinza fina, presencia de hipoestesias, dolor y complicaciones. Resultados: Los resultados de los 86 pacientes evaluados mostraron una asociación estadística en la disminución de los puntajes de la escala funcional DASH con ambos abordajes, asociación entre la remisión de hipoestesias en pacientes sanos con cualquiera de los dos abordajes a diferencia de los pacientes diabéticos y asociación entre padecer DM2 y tener complicaciones a corto plazo. Conclusión: Ambos abordajes mejoran los síntomas y función de la mano en pacientes sanos y diabéticos, pero el primer grupo presentará casos de remisión completa a diferencia del grupo de pacientes diabéticos.

Abstract: Background: Carpal tunnel syndrome (CTS) is the upper extremity neuropathy more frequent. Treatments led to the entrapment of the median nerve in the carpal tunnel are more complicated and the results less promising and unsatisfactory in diabetic patients. The objective of this study is to compare the results of strength and hand function in healthy patients against patients with diabetes mellitus type 2 (DM2) with a diagnosis of CTS before and after the open and endoscopic release of the carpal tunnel. Material and methods: This is an observational, retrospective and descriptive study for a period of five years where we evaluated the results in healthy patients and with DM2, with diagnosis of CTS who underwent surgical treatment by open or endoscopic approach; we applied the DASH questionnaire, force grip and clamp fine measurements, presence of infection, pain and complications. Results: The results of 86 patients evaluated, showed a statistical association in the decrease in scores on the functional scale DASH with both approaches, association between remission of hypoesthesias in healthy patients with either of the two approaches as opposed to diabetic patients and association between developing DM2 and complications in the short term. Conclusion: Both approaches improve symptoms and function of the hand in healthy and diabetic patients, but the first group will present cases of complete remission in contrast to the group of diabetic patients.

Descompresión endoscópìca del túnel carpiano. Resultados y complicaciones en 126 casos / Endoscopic decompression of carpal tunnel. Results and complications in 126 cases

Objetivo: Evaluar los resultados y las complicaciones de la descompresión endoscópica del túnel carpiano utilizando la técnica de dos portales realizadas por un mismo cirujano. Materiales y Método: Se realizó un estudio retrospectivo que incluyó 126 pacientes consecutivos en los que se realizó la descompresión endoscópica del túnel carpiano con técnica de dos portales, entre enero de 2013 y abril de 2017. Los datos demográficos y hallazgos del examen físico fueros tomados de las historias clínicas. El seguimiento promedio fue de 40.98 meses (rango 13-66). Se evaluaron los resultados clínicos y funcionales mediante el puntaje Quick DASH pre y postoperatorio, el cuestionario de Boston postoperatorio. Asimismo, se evaluó el dolor postoperatorio (EVA), el grado de satisfacción del paciente y se documentaron las complicaciones. Resultados: El puntaje de Quick DASH medio preoperatorio fue de 33.7 puntos (DE11.05) y de 6.8 para el postoperatorio (DE 6.44) P< 0.001. El puntaje medio de Boston postoperatorio para síntomas fue de 1.24 puntos (DE 0.26) y para función fue de 1.18 (DE 0.22). Un caso fue convertido a cirugía abierta por visualización inadecuada del ligamento anular. Se registraron siete complicaciones menores (5.5%).. No hemos registrado ninguna complicación mayor. Ningún paciente debió ser reintervenido. Conclusión: La descompresión endoscópica del túnel carpiano mediante la técnica de dos portales con utilización de un tubo transparente para evaluar la descompresión es un método seguro, eficaz y predecible para el tratamiento del síndrome del túnel carpiano. El índice de complicaciones es bajo cuando es realizada por un cirujano entrenado en la técnica. Tipo de estudio: Serie de casos. Nivel de evidencia: IV

Objectives: To report the results and complications of a two portal endoscopic carpal tunnel release (ECTR) with the use of a clear tube for assessing the quality of decompression of the median nerve. Methods: Retrospective analysis of 126 consecutive cases (126 patients) where a two portal ECTR was performed. The demographic and physical examination data were obtained from the medical history. For evaluation, the preoperative and postoperative Quick DASH and the Boston Questionnaire were used and the complications were recorded. Results: The Quick DASH average score was 33.7 preoperative (SD 11.05) and 6.8 postoperative (SD 6.44) P<0.001. The Boston Questionnaire´s median average was 1.24 (SD 0.26) for symptoms and 1.18 (SD 0.22) for function. We recorded seven minor complications (5.5%): two cases of transient hypoesthesia and a permanent one of the third web space, three cases of superficial infection, and one case of postoperative neuropathic pain. No major complications or reoperations were documented. Conclusion: Two portal ECTR with the use of a clear tube for assessing the quality of decompression is a safe, effective, predictable and reproducible technique for treatment of idiopathic carpal tunnel syndrome. The complication rate is low when performed by a trained surgeon Type of Study: Case series. Level of Evidence: IV

Variantes anatómicas del canal carpiano y distancias de estructuras vasculares en ecografía / Anatomical variants the carpal tunnel and distances of vascular structures in ultrasound

El síndrome de canal carpiano es una patología frecuente. Si bien el diagnóstico es clínico, la ecografía cumple un rol en caso de duda diagnóstica y como apoyo a proce-dimientos intervencionales.Existen variables anatómicas y distancias de estructuras vasculares útiles de conocer antes de planear un gesto quirúrgico o de infiltración para disminuir el riesgo de lesiones secundarias, en donde la ecografía podría tener un rol.Estudiamos una muestra de 267 ecografías de muñeca con especial hincapié en va-riantes neurogénicas, vasculares o tendinosas que podrían resultar lesionadas en relación a algún procedimiento.

Carpal tunnel syndrome is a frequent pathology. Although the diagnosis is clinical, ultrasound plays a role in case of diagnostic doubt and as support and guide for inter-ventional procedures.There are anatomical variants and distances of vascular structures that may be useful to know before planning a surgical or infiltration procedure to reduce the risk of iat-rogenic injuries, where ultrasound could play a role.We studied a sample of 267 wrists ultrasounds with special emphasis on neurogenic, vascular or tendinous variants that could be injured in relation to procedures.

Effect of preoperative gabapentin on pain intensity and development of chronic pain after carpal tunnel syndrome surgical treatment in women: randomized, double-blind, placebo-controlled study / Efeito da gabapentina pré-operatória na intensidade da dor e desenvolvimento de dor crônica após o tratamento cirúrgico da síndrome do túnel do carpo em mulheres: estudo randomizado duplo-cego controlado com placebo

ABSTRACT CONTEXT AND OBJECTIVES: Effective postoperative analgesia is important for reducing the incidence of chronic pain. This study evaluated the effect of preoperative gabapentin on postoperative analgesia and the incidence of chronic pain among patients undergoing carpal tunnel syndrome surgical treatment. DESIGN AND SETTINGS: Randomized, double-blind controlled trial, Federal University of São Paulo Pain Clinic. METHODS: Forty patients aged 18 years or over were randomized into two groups: Gabapentin Group received 600 mg of gabapentin preoperatively, one hour prior to surgery, and Control Group received placebo. All the patients received intravenous regional anesthesia comprising 1% lidocaine. Midazolam was used for sedation if needed. Paracetamol was administered for postoperative analgesia as needed. Codeine was used additionally if the paracetamol was insufficient. The following were evaluated: postoperative pain intensity (over a six-month period), incidence of postoperative neuropathic pain (over a six-month period), need for intraoperative sedation, and use of postoperative paracetamol and codeine. The presence of neuropathic pain was established using the DN4 (Douleur Neuropathique 4) questionnaire. Complex regional pain syndrome was diagnosed using the Budapest questionnaire. RESULTS: No differences in the need for sedation, control over postoperative pain or incidence of chronic pain syndromes (neuropathic or complex regional pain syndrome) were observed. No differences in postoperative paracetamol and codeine consumption were observed. CONCLUSIONS: Preoperative gabapentin (600 mg) did not improve postoperative pain control, and did not reduce the incidence of chronic pain among patients undergoing carpal tunnel syndrome surgery.

RESUMO CONTEXTO E OBJETIVOS: Analgesia pós-operatória eficaz é importante para reduzir a incidência de dor crônica. Este estudo avaliou o efeito da gabapentina pré-operatória na analgesia pós-operatória e na incidência de dor crônica em pacientes submetidos à cirurgia para tratamento da síndrome do túnel do carpo. DESENHO E LOCAL: Randomizado, duplo cego, Universidade Federal de São Paulo. MÉTODOS: Os 40 pacientes com 18 anos ou mais de idade foram distribuídos aleatoriamente em dois grupos: o Grupo Gabapentina recebeu 600 mg de gabapentina no pré-operatório uma hora antes da cirurgia, e o Grupo Controle recebeu placebo. Todos os pacientes receberam anestesia regional intravenosa com lidocaína a 1%. Midazolam foi utilizado para sedação, se necessário. Paracetamol foi administrado para analgesia pós-operatória, conforme necessário, e codeína, se o paracetamol fosse insuficiente. Foram avaliados: a intensidade da dor pós-operatória (durante seis meses), a incidência de dor neuropática pós-operatória (durante seis meses), a necessidade de sedação intra-operatória e o uso de paracetamol e codeína no pós-operatório. A presença de dor neuropática foi estabelecida utilizando-se o questionário DN4 (dor neuropática 4). Síndrome de dor regional complexa foi diagnosticada através do questionário Budapeste. RESULTADOS: Não foram observadas diferenças na necessidade de sedação, no controle da dor pós-operatória e na incidência de síndromes dolorosas crônicas (neuropáticas ou síndrome de dor regional complexa). Não foram observadas diferenças no consumo de paracetamol e codeína. CONCLUSÕES: Gabapentina pré-operatória (600 mg) não melhorou o controle da dor pós-operatória e não reduziu a incidência de dor crônica em pacientes submetidos à cirurgia para tratamento da síndrome do túnel do carpo.

Tratamiento quirúrgico del síndrome de túnel del carpo en adultos mayores / Surgical treatment of carpal tunnel syndrome in older adults / Traitement chirurgical du syndrome du canal carpien chez les personnes âgées

INTRODUCCIÓN: el síndrome del túnel del carpo constituye el diagnóstico más común para cirujanos de mano. Se han descrito diversos métodos quirúrgicos para su tratamiento, con reportes de buenos resultados. OBJETIVO: mostrar los resultados del tratamiento quirúrgico del síndrome del túnel del carpo, con empleo de anestesia local, incisión razonable y movilidad precoz en pacientes mayores de 65 años de edad. MÉTODO: estudio de intervención longitudinal prospectivo con pacientes mayores de 65 años de edad diagnosticados e intervenidos por síndrome del túnel del carpo entre el 1ro. de enero 2010 y el 1ro. de julio del 2014, y evaluados 1 año después de dicho tratamiento en el CITED. RESULTADOS: serie constituida por 194 pacientes, predominó el sexo femenino (81,44 %), se encontró asociación de síndrome del túnel del carpo con: realización de actividades manuales previas, posibilidad de afectación bilateral, antecedente de fractura de radio distal ipsilateral, comorbilidad con otras enfermedades como diabetes, artritis reumatoide y afecciones de tendones y sus vainas. La mejoría en síntomas, dolor y función al año fue superior al 98 %. CONCLUSIONES: el tratamiento quirúrgico del síndrome del túnel del carpo, con empleo de anestesia local, incisión de piel razonable y movilidad precoz, ocasiona significativa mejoría de los síntomas, del dolor y la función en adultos mayores de 65 años de edad.

INTRODUCTION: Carpal tunnel syndrome is the most common diagnosis for hand surgeons. They described various surgical methods for treatment, with reports of good results. OBJECTIVE: Show the results of surgical treatment of carpal tunnel syndrome using local anesthesia, reasonable incision and early mobility in patients older than 65 years old. METHOD: Prospective longitudinal intervention study with patients older than 65 years of age diagnosed and surgically treated for carpal tunnel syndrome from January 2010 to July 2014 and they were evaluated one year after treatment at CITED. RESULTS: In the series consisting of 194 patients, women predominated (81.44%). Association of carpal tunnel syndrome was found with holding prior manual activities, the possibility of bilateral involvement, history of fracture of ipsilateral distal radius, comorbidity with other diseases such as diabetes, rheumatoid arthritis and diseases of tendons. The improvement of symptoms, pain and function after a year was higher than 98%. CONCLUSIONS: Surgical treatment of carpal tunnel syndrome using local anesthesia, reasonable skin incision and early mobility causes significant improvement in symptoms, pain and function in adults older than 65 years old.

INTRODUCTION: Le syndrome du canal carpien est le diagnostic le plus souvent trouvé par les chirurgiens spécialisés en main. Plusieurs techniques chirurgicales ont été décrites pour son traitement, avec de très bons résultats. OBJECTIFS: Ce travail a le but de montrer les résultats du traitement chirurgical du syndrome du canal carpien à l'aide de l'anesthésie locale, d'une incision raisonnable et d'une mobilité précoce chez les patients âgés de plus de 65 ans. MÉTHODE: Une étude interventionnelle, longitudinale et prospective de patients âgés de plus de 65 ans, diagnostiqués et traités pour syndrome de canal carpien entre le 1er janvier 2010 et le 1er juillet 2014, et évalués un an après, a été effectuée au CITED. RÉSULTATS: Dans une série de 194 patients, où le sexe féminin était en majorité (81,44 %), on a trouvé que le syndrome du canal carpien était associé aux activités manuelles, à un possible trouble bilatéral, à une histoire de fractures du radius distal ipsilatéral, et à une comorbidité avec d'autres maladies telles que le diabète, l'arthrite rhumatoïde et les atteintes des tendons et leurs gaines. Les symptômes, la douleur et la fonction ont amélioré un an après l'opération dans 98 % de cas. CONCLUSIONS: En utilisant de l'anesthésie locale, une incision raisonnable et une mobilité précoce, le traitement chirurgical du syndrome du canal carpien entraîne une significative amélioration des symptômes, de la douleur et de la fonction chez les personnes âgées de plus de 65 ans.

Principales causas de recidivas en el túnel del carpo / Principal causes for recurrent carpal tunnel syndrome

Resumen: Se analizaron las causas frecuentes del síndrome del túnel del carpo recidivante. Seguimiento de una serie de casos del 1 de Enero al 31 Diciembre 2011; se estudiaron nueve pacientes mediante examen físico y de gabinete. A todos se les evaluó el dolor con escala visual análoga, cuestionario de Brigham and Women's Hospital para conocer la discapacidad. Siete pacientes correspondieron al género femenino y dos al masculino, con un promedio de edad de 52 años. Entre las principales causas de recidiva se encontró la fibrosis postquirúrgica acompañada de una liberación incompleta en siete pacientes; en dos pacientes se observó una liberación incompleta y se les realizó abordajes mínimos invasivos. Tres pacientes de los nueve presentaron cicatrices retráctiles. La principal causa de recidiva es la fibrosis postquirúrgica asociada al abordaje mínimamente invasivo.

Abstract: The frequent causes of relapsing carpal tunnel syndrome were analyzed. Nine patients were followed-up from January 1st to December 31st, 2011. They underwent a physical exam and imaging tests. Pain was measured in all of them with the VAS, and the Brigham and Women's Hospital questionnaire was used to assess disability. Patients included seven females and two males; mean age was 52 years. Major causes for relapse included postoperative fibrosis with incomplete release in seven patients and incomplete release in two patients in whom minimally invasive approaches were used. Three of the nine patients had retractile scars. The main cause of relapse was postoperative fibrosis associated with the minima­lly invasive approach.

Retalho tenar adipofascial reverso para cobertura do nervo mediano hipertrofiado em macrodactilia / The reverse adipofascial thenar flap for coverage of the hypertrophied median nerve in macrodactyly

A macrodactilia é uma anomalia congênita infrequente, caracterizada pelo crescimento desproporcional dos tecidos ósseo, gorduroso, nervoso, vascular e dérmico nos dedos das mãos ou dos pés. Existem muitas teorias sobre a sua etiopatogenia, sendo a mais aceita a hiperestimulação por fatores de crescimento enviados através dos nervos. Foram descritos alguns casos associados com a síndrome do túnel do carpo. Apresenta-se um caso clínico de síndrome do túnel do carpo por hipertrofia do nervo mediano, evidenciando um aumento de conteúdo dentro do retináculo flexor, o qual foi tratado cirurgicamente com sucesso pela realização de uma retinaculotomia do ligamento anular do carpo junto a um retalho de transposição tenar adipofascial reverso da região tenariana hipertrofiada visando à cobertura do nervo mediano na região do punho.

Macrodactyly is a rare congenital anomaly characterized by the disproportionate growth of bone, fat, nervous, vascular, and dermal tissue in the digits . There are many different theories about its etiopathogenesis, the most accepted being a hyperstimulation by growth factors conducted through nerves. A few cases have been described in conjunction with carpal tunnel syndrome. Here, a clinical case of carpal tunnel syndrome due to hypertrophy of the median nerve is presented, showing an increase of content within the flexor retinaculum. Successful surgical treatment was accomplished by conducting a retinaculotomy of the anterior annular ligament along with a reverse transposition adipofascial flap of the hypertrophied thenar region for coverage of the median nerve at the wrist.