LectureModification of intra-carpal tunnel pressure after Z-lengthening of the transverse carpal ligament
Introduction
Traditional surgical treatment of carpal tunnel syndrome (CTS) involves division of the flexor retinaculum (FR) to relieve pressure on the median nerve (Amadio, 1995; Kohanzadeh et al., 2012), and this approach has long proven to be effective. However, some patients experience postoperative scar sensitivity, pillar pain (Ludlow et al., 1997; Roux, 2004), or grip weakness (Katz et al., 1995; Netscher et al., 1998), among other complications, delaying their return to work or normal activities.
The precise causes of adverse events related to carpal tunnel release (CTR) remain unclear, but they may be attributable to biomechanical alterations caused by FR disruption (Brooks et al., 2003; Gartsman et al., 1986; Ludlow et al., 1997; Morrell et al., 2014).
FR reconstruction after its complete division (Jakab et al., 1991; Kapandji, 1990; Karlsson et al., 1997; Lluch, 2002) or simply Z-lengthening of the FR (Castro-Menéndez et al., 2016; Simonetta, 1977) (Fig. 1) has been proposed to save FR continuity, primarily aimed at preserving the first flexor tendon pulley.
Some authors reported better results of manual function and short-term grip strength with preserving FR continuity techniques than in carpal release without carpal ligament reconstruction (Faour-Martín et al., 2014; Gutiérrez-Monclus et al., 2018; Martín et al., 2003). Conversely, other researchers found no significant differences in pillar pain, long-term grip strength, safety or functional status outcomes between complete division and FR lengthening or elongated reconstruction (Castro-Menéndez et al., 2016; Dias et al., 2004; Sike et al., 2019), in such way that any identifiable benefit in preserving the flexor retinaculum continuity when decompressing the carpal tunnel is questioned. Furthermore, it is believed that achievement of sufficient carpal tunnel decompression may be jeopardized by the preservation of FR continuity because of an erroneous similarity to a partial division, given that incomplete splitting is a prime cause of CTS persistence or recurrence (Amadio, 2009; Jones et al., 2012).
Researchers have addressed the effect on intracarpal tunnel pressure of division of the transverse carpal ligament, recording pressures in CTS before and after ligament release in patients (Goss and Agee, 2010; Sanz et al., 2005; Schuind, 2002) and cadaver specimens (Kim et al., 2013; Li et al., 2011; Nakao et al., 1998). However, although this procedure is frequently performed to relieve CTS symptoms, its effectiveness and the underlying biomechanical mechanisms remain unclear, and pressure values appear to be influenced by the compliance (Kim et al., 2013; Li, 2005; Tung et al., 2010), cross-sectional area, and carpal tunnel morphology (Li et al., 2011).
The effectiveness of FR Z-lengthening on median nerve release is solely based on symptom relief. No data are available on changes in intra-carpal tunnel pressures after FR-lengthening. The objective of this study was to compare the decrease obtained in intra-carpal tunnel pressure between complete division and Z-lengthening of the FR in a cadaveric model of CTR. We hypothesized that FR Z-lengthening and complete division would be equally effective to reduce carpal tunnel pressure.
Section snippets
Material and methods
We performed an experimental study of carpal tunnel pressure after surgical FR modification in a cadaveric model (Fig. 1). Ten forearm and hand specimens were used from ten fresh-frozen cadavers of persons (5 males and 5 females) aged between 53 and 75 years at death, who had all given informed consent to their use for scientific purposes (McHanwell et al., 2008; Riederer et al., 2012). The specimens had no previously documented wrist injuries or surgeries. All specimens were dissected, after
Results
Table 1 exhibits the mean carpal tunnel pressure values (± standard deviations) at each FR continuity stage as a function of SS infusion volume. Pressures increased with higher SS infusion volume, while mean pressures were lower after Z-lengthening or complete split of the FR than at baseline.
Fig. 5A depicts pressure curves as a function of SS infusion volume at each FR continuity stage, showing higher pressure with greater infusion volume. It can be observed in Fig. 5B that the slope of the
Discussion
To our best knowledge, this is the first study to measure the effects on carpal tunnel pressure of a CTR technique that preserves the FR. Pavlidis et al. (2010) investigated the effect of FR reconstruction by four different techniques in carpal tunnel volume, but did not take any pressure measurements. In our cadaveric model of CTR, both Z-lengthening of the FR and its complete division produced a statistically significant reduction in carpal tunnel pressure in comparison to baseline values
Declaration of competing interest
The authors declare that they have not competing interests.
Acknowledgements
Richard Davies for language review of the manuscript.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Authors’ contributions
Substantial contributions to research design and interpretation of data: Pedro Hernández-Cortés, Olga Roda.
Acquisition and analysis of data: Patricia Hurtado-Olmo.
Drafting the paper: Pedro Hernández-Cortés, Olga Roda, Indalecio Sánchez-Montesinos.
Statistics and interpretation of data: Francisco O'Valle, Miguel Pajares-López, Andrés Catena.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
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