Clinical Outcomes of Revision Carpal Tunnel Release Treated with Adipofascial Flap and Nerve Wrapping
Sneha R Rao, MD1, Steven L Zeng, BA1, Alexandra Krez, BS1, David S Ruch, MD1, Christopher S Klifto, MD2 and Suhail K. Mithani, MD3, (1)Duke University, Durham, NC, (2)Duke Univeristy Hospital, Durham, NC, (3)Plastics and Reconstructive Surgery, Duke University Medical Center, Durham, NC
Nearly 40% of patients report persistent symptoms after revision carpal tunnel release. The desire to minimize further scarring around the median nerve has inspired the use of nerve wraps along with the hypothenar adipofascial flap. We hypothesize that patients who underwent revision carpal tunnel release with median nerve wrapping using a biological conduit have equivalent clinical outcomes to patients who underwent hypothenar fat flap at the time of revision.
We performed a retrospective chart review of 77 patients who underwent revision carpal tunnel release (CTR) with either nerve wrap or hypothenar adipofascial flap for recalcitrant carpal tunnel symptoms. For pre-operative outcomes, we measured the presence of paresthesias or nighttime symptoms, and clinical exam findings of median nerve compression. For post-operative measures, we obtained post-op VAS pain scores, PROMIS scores, and improvement of parathesias and night-time symptoms.
A total of 77 patients underwent revision CTR, with 51 (66%) receiving adipofascial flap coverage and 26 (34%) nerve wrap. In the nerve wrap cohort, 17 patients (70.8%) had recurrent symptoms and 7 (29.2%) had persistent symptoms following index CTR. Of the patients in the hypothenar fat flap cohort, 37 (73%) patients had recurrent symptoms and 14 (27.5%) had persistent symptoms. There was no significant difference in the rate of preoperative paresthesias, clinical tests for compressive median neuropathy, or thenar atrophy. Patients who underwent fat flaps had significantly higher rate of pre-operative nighttime symptoms (100%) compared to the nerve wrap cohort, 32% (p<0.0001). Intraoperatively, 4 patients in hypothenar fat flap cohort were noted to have nerve compression at the antebrachial fascia or proximal, compared to 8 patients in the nerve wrap cohort. The mean follow-up time was 4.3 months and 6.7 months for the adipofascial flap and nerve wrap cohorts, respectively. Both groups showed improved paresthesia symptoms with 72.5% and 70% of patients in the adipofascial flap and nerve wrap cohorts, respectively, reporting improved or resolved symptoms. There was no significant difference in post-operative parathesias/nighttime symptoms and pain score. Nerve wrap patients had higher post-operative PROMIS scores (p=0.005). The results of this study suggest that both hypothenar fat flap and nerve wrap may warrant consideration for use in revision carpal tunnel release in patients suffering from recalcitrant CTS following CTR. The nerve wrap may help provide coverage of the median nerve when the primary site of nerve compression is proximal to the TCL, where soft tissue cannot be mobilized for coverage.
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