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Surgical Options for Managing Recurrent and Persistent Carpal Tunnel Syndrome
Pobe Luangjarmekorn, MD; Christine M. Kleinert Institute for Hand and Microsurgery; Tsu-Min Tsai, MD; University of Louisville
Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA

Introduction

Recurrent or persistent carpal tunnel syndrome (CTS) is difficult to manage. Some authors recommend a redo carpal tunnel release (redoCTR) and using a tissue interposition for better results. Our hypothesis is that recurrent or persistent symptoms mostly come from proximal compression at the pronator, combined with inadequate release and scar formation at carpal tunnel. This study compares the surgical outcomes of redoCTR and pronator teres release (PTR) versus solely redoCTR.

Materials and Methods

This is a retrospective chart review of 29 redoCTR operations in 26 patients performed by a single surgeon, all with a 2-incision technique, between September 1996 – August 2011.

Results

There were 7 redoCTR and 22 redoCTR with concurrent PTR. Numbness was completely resolved by 28.57%, and partially resolved in 71.44% in redoCTR alone and completely resolved in 36.36% and partially resolved 54.55% in redoCTR with PTR. Pain in redoCTR was completely gone in 20% of patients and partially improved in 80%. In the redoCTR with PTR group, pain was completely gone in 33.33% of patients, and partially improved in 61.9%. Mean grip strength in the redoCTR alone group had 21.26% improvement versus 41.03% in the redoCTR with PTR group.

Five of the seven cases in the redoCTR group are suspected to have had proximal nerve compression, rather than additional problems at the carpal tunnel. This is suspected because of positive Tinel’s signs at the pronator, a positive pronation stress test, or steroid injection did not help. This subgroup showed no “complete improvement”, and all 5 only showed “partial improvement” in numbness or pain

Conclusions

This study shows better results when treating recurrent or persistent CTS by redoCTR with PTR. There are better rates of complete numbness resolution (36.63% vs. 28.57%), complete pain resolution (33.33% vs. 20.00%) and improved grip strength (mean improvement 41.03% vs.21.26%). In the subgroup that had suspected proximal compression, none showed complete improvement in numbness/pain when treated with redoCTR alone. We propose that surgeons should only do only redoCTR when clinical diagnostics (positive Tinel at carpal tunnel, positive Phalen’s, improvement with steroid injection) indicate the carpal tunnel is the only site of compression. However, all other recurrent or persistent CTS should be treated with redo CTR + PTR. Invasive procedures, such as flap interposition surgery in the carpal tunnel, are unnecessary because we believe that recurrent / persistent CTS mostly comes from a proximal site of compression rather than the carpal tunnel.


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