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A Case of Foreign Body-Mediated Carpal Tunnel Syndrome: An Unrecognized Complication of LRTI
Jacob C Maus, MD1, Cassandra Driscoll, MD1 and Benjamin R Graves, MD2, (1)Wake Forest Department of Plastic and Reconstructive Surgery, Winston Salem, NC, (2)Wake Forest Department of Orthopedic Surgery, Winston Salem, NC

Introduction:
CMC arthritis is a pervasive condition, seen in 75% of post-mortem joints.1,2 Symptomatic patients may experience debilitating pain or loss of thumb prehension in advanced cases. Trapeziectomy with ligament reconstruction/tendon interposition (LRTI) is a highly effective treatment with low revision rates.3,4 In recent years, interference screws and other hardware have been employed to accomplish fixation of the autologous donor tendon to the first metacarpal in LRTI.5,6

Materials and Methods:
We report a case of acute carpal tunnel syndrome as a complication of LRTI fixated with an interference screw, in which extrusion of the screw resulted in acute carpal tunnel requiring carpal tunnel release. Discussed herein are the patient's presentation, diagnostic workup, intra-operative findings, and post-operative course.

Results:
The patient of interest presented for evaluation of progressive median neuropathy in the setting of previous CMC arthroplasty performed by another surgeon. Five months prior, he underwent trapeziectomy with LRTI utilizing FCR, fixated to the first metacarpal with an interference screw. The operative records documented a fracture at the metacarpal base tunnel with loss of the screw, which was not accounted for at the end of the case.
Examination revealed a palpable mass at the palmar base of the left thumb, numbness in the median nerve distribution, and thenar intrinsic weakness. Carpal compression test was positive. MRI revealed a retained foreign body palmar to the transverse carpal ligament (Fig 1a, b). Surgical removal of the retained screw was performed with palmar median and ulnar neurolysis. Intra-operatively, a 4x10mm tenodesis screw (Arthrex, Naples FL) was removed from the palmar tissue overlying the transverse carpal ligament (Fig 2). The patient had complete resolution of his symptoms post-operatively.

Conclusion:
CMC arthroplasty is a mainstay of any elective hand practice. Though many strategies have been employed, there is no consensus ‘best' operation. As new techniques utilizing hardware emerge, the surgeon should be cognizant of potential hardware-related complications. Hardware malposition is a preventable, technical error; thus, the onus is on the surgeon to meticulously ensure proper application.



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