ASL Roma EPolo Ospedaliero “Villa Betania”

Ortopedia e TraumatologiaUnità Operativa Chirurgia della Mano

Endoscopic carpal tunnel release:fourteen years’ experiencewith the MENON technique

ALFREDO DELL’UOMO M.D.

44° Congresso Nazionale Mano with Japanese Soc. - Milano, 13 ottobre 2006

The major thrust for endoscopic carpal tunnel release (E.C.T.R.), is based on the hypothesis that

by selectively transecting T. C. ligament the post-op morbidity can be minimized allowing early return to

A.D.L.

ADVANTAGES & PECULIARITY

Ulnarly located oblique incision: usually lies on the ulnar aspect of thepalmaris longus tendon

It can be anatomically extended distally

to perform anopen procedure if

technical difficult arise

Tunnel is progressively dilataded using blunt dilatators,

along the line of the fourth metacarpal

Identification and continous visualizationof the distal margin of T.C. ligament

Original cannula “D” shaped in cross-section,prevents rotation of the cannula

once inserted into the carpal tunnel.The distal end is blunt and closed.

The transverse carpal ligament is dividedby pushing the knife

in a proximal to distal direction

The knife is with central concave cutting edge of 2,3mm, with blunt corners

Due to the configuration of the carpal tunnel,the tip of the cannula tends to point radially:

pressure on the proximal part of the cannula…..

…..will ensure that the tip rests against the hook of the hamate,

thus preventig…..

…..inadvertent pressure on the commondigital nerve of the long and ring finger.

This tecnique can be performed with the equipment available in any standard o. r.

CONTROINDICATIONS

•Recurrent carpal syndrome

• Rheumatoid arthritis

•Secondary C.T. syndrome due to space occupying lesions

•Inadeguate intraoperative visualization

Clinical data

• 1007 hands (870 pz)

• Age: 22 88 years (51 years)

• Follow-up: 4 180 months

• Open release on the opposite side: 88 Pz

• Average operating time: 4-7 min

• Endo to open (14 hands-1,35%)

Criteria for evaluation of surgical outcome

• Post operative pain

• Resolution of sintoma (97%)

• Post operative complication

• Recovery of grip strenght

• Appearance of new sintoma

• Subjective evaluation

F.E.S.S.H.Fourth Congress 1997

E.C.T.R. by Menon single portal technique:E.C.T.R. by Menon single portal technique:

clinical & M.R.I evaluation after 160 casesclinical & M.R.I evaluation after 160 cases

A. Dell’Uomo, M. Mastantuono

B. Congresso Europeo Chirurgia della Mano

M.R.I. measurements of the morphologicalchanges after E.C.T.R. show that the

volume increase parallels that open C.T.R.Follow-up show that the volume

Increase is long lasting

POSTPRE

COMPLICATIONS“Sindrome del tunnel carpale”

Verduci 2002- Springer Verlag 2006 Prof. P. Bedeschi

• Persistence of sintoma• Recurrence of sintoma• Appearance of new sintoma - “skin scar” - “pillar pain” - neurological - vascular - etc

Personal complications

• 6 Neuroapraxia 3° digital nerve +/- communicating branch ulnar nerve • 18 Hypotenar-pillar pain

• 1 Superficial arch injury

• 3 Second surgery

Second surgery

1. Incomplete release –neuroapraxia 3° NEUROLYSIS complete relief 2. Incomplete release –abundant scarring NEUROLYSIS no improvement

3. Partial lesion of third digital nerve NEUROLYSIS + DIRECT REPAIR improvement

Complcations of endoscopic and open carpal tunnel releaseA.K.Palmer – Journal of Hand Surgery (1999)

Questionnaries to 1253 members of the American Society for Surgery of the Hand

“… report ONLY on complications that they had themselves treated surgically”.

NEUROLOGICAL COMPLICATIONS (5 YEARS)

LACERATIONS: •MEDIAN NERVE•ULNAR NERVE•DIGITAL NERVE

E.C.T.R.265

O.C.T.R.230

“The data support the conclusion that carpal tunnel release, be it endoscopic or open is not a safe and

simple procedure”

FINAL CONSIDERATIONS

•E.C.T.R. with the Menon technique is a reliable alternative treatment to open release•Based on the data available, E.C.T.R. has less morbidity in the post-op period, than traditional release•Surgeons unfamiliar with arthroscopic techniques may find the procedure tecnically demanding• T.C.L. can be adequate and safely sectioned, with high success rate and very few complications •If visualization is inadequate the surgeon must be prepared to performe an open release and should not risk injury to neurovascolar structures