Endoscopic Carpal Tunnel Release Without Invading the Tunnel: A New Transretinacular Technique

Abstract

Established endoscopic carpal tunnel release (ECTR) techniques carry a not entirely eludible risk of iatrogenic complications, mainly because of incomplete view of the cutting blade and intraoperative pressure increase inside the carpal tunnel (CT). We describe a novel single-portal ECTR method, conceived to reduce these risks, by optimizing visual control and avoiding dilatation of the CT. After incising the well exposed proximal third of the transverse carpal ligament (TCL), transection of the remainder is completed using a pediatric urethrotome. This small caliber instrument is moved in the plane of the TCL, without invading the tunnel, and provides detailed view of the TCL and any crossing anatomical structures at any given moment. We present the technique and the results of a retrospective case series of 33 patients with CT syndrome who underwent the procedure, after failing to respond to conservative treatment. Because of improved view and the avoidance of intraoperative pressure trauma to structures passing through the CT, the described approach may contribute to prevent iatrogenic complications and represent a valid improvement over conventional ECTR procedures.

Endoscopic carpal surgery in carpal tunnel syndrome: A systematic review

“…In 14 studies, the average age was 53.6 years (range 29–60.5 years). The maximum average age, 60.5 years, was in the studies by Degeorge et al 20 and Tarfusser et al, 31 while the minimum average age was 29 years in the study by Kempton et al, 18 which studied surgical learning modules. Twelve studies had a predominance of females over males.…”

“…Two studies were RCT studies by Kempton et al 18 and Truelove et al 19 . Seven studies were prospective studies, the most prevalent research design, including studies by Degeorge et al, 20 Li et al, 21 Trung et al, 22 Grandizio et al, 23 Ng et al, 24 , 25 and Rooij et al 26 Only five retrospective studies were identified, by Satteson et al, 27 Hein et al, 28 Liu and Wu, 29 Wellington et al, 30 and Tarfusser et al 31 …”

“…Anesthetic and endoscopic technique of the 12 publications that reported on anesthetic aspects, most reported the use of regional or local anesthesia. A monitored anesthesia care technique was added by Hein et al, 28 while Tarfusser et al 31 used only the wide-awake, local anesthesia, no tourniquet (WALANT) technique in all samples. Wellington et al 30 compared the outcome of monitored anesthesia care with tourniquet, (MT) 43 local anesthesia with tourniquet (LT), and WALANT.…”

“…Liu and Wu 29 used a new technique using a plastic shield created from a standard syringe that offers a 360° view of the carpal tunnel and provides protection for the median nerve in single-portal endoscopic techniques. Another single-portal method using a transretinacular technique was demonstrated in a study by Tarfusser et al 31 A two-portal endoscope method was used by Li et al 21 via the Chow technique, a transbursal approach, while both of Ng et al's 24,25 studies used the portal to divide the flexor retinaculum with a retrograde hook knife. Grandizio et al 23 and Wellington et al 30 did not report the number of endoscopic portals.…”

“…Those using the Agee technique did not report any complications, although a single case of superficial infection of the operated site (1.7% of patients) was reported by Degeorge et al 20 Another single-portal technique used in the study by van Rooij et al 26 which employed the technique described by Fechner et al ( 2013) 44 and stated that postoperative functional status increased significantly on a daily basis, and that the mean BCTQ score decreased gradually from intense difficulty to little difficulty in daily tasks over a period of 7 days. Tarfusser et al 31 using another single-portal via transretinacular technique stated that all patients reported rapid recovery, pain subsidence, and return to daily activity within a few days, although one patient did not experience measurable improvement of grip strength or sensory function, but only disappearance of pain and discomfort at 2 weeks after surgery. Liu and Wu 29 used a new plastic shield portal technique and reported that DASH, BCTQ, and VAS were statistically significantly decreased compared to preoperation.…”