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Role of pronator release in revision carpal tunnel surgery

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      Abstract

      Introduction: The purpose of this study was to compare the result of treatment of patients with failed primary carpal tunnel surgery who suspected pronator teres syndrome (PTS) by performing revision carpal tunnel release (CTR) with pronator teres release (PTR) and revision CTR alone. Methods: Retrospective chart review in patients who required revision CTR and suspected PTS. Group 1, treated by redo CTR with PTR and group 2, treated by redo CTR alone. Intraoperative findings, pre and postoperative numbness (2-PD), pain (VAS score), and grip strength were studied. Results: There were 17 patients (20 wrists) in group 1 and 5 patients (5 wrists) in group 2. Patients in group 1 showed more chance of fully recovery of numbness and pain than group 2 (60% vs. 0%, p < 0.05 and 55.0% vs. 0%, p < 0.05, respectively). Mean grip strength was increased 16.0% in group 1 and increase 11.7% in group 2. Most common pathology at the elbow were deep head of pronator teres 90% (18/20 elbows) and lacertus fibrosus 50% (10/20 elbows). The most common finding at carpal tunnel was the reformed transverse carpal ligaments (80%, 20/25 wrists) and scar adhesion around the median nerve (40%, 10/25 wrists). Discussion: Intraoperative findings from our study confirmed that there were pathology in both carpal tunnel and pronator area in failed primary CTR with suspected PTS. Our study showed that combined PTR with revision CTR provided higher chance of completely recovery from numbness and pain more than redo CTR alone.

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      Most cited references 19

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      The pronator teres syndrome: compressive neuropathy of the median nerve.

      Thirty-nine patients with a clinical diagnosis of the pronator teres syndrome were seen during a seven-year period. They typically complained of aching discomfort in the forearm, weakness in the hand, and numbness in the thumb and index finger. Cyclic stress usually brought on the symptoms. The distinctive physical finding was tenderness over the proximal part of the pronator teres, which was aggravated by resisted pronation of the forearm, flexion of the elbow, and occasionally by resisted contraction of the flexor superficialis of the long finger. Electrophysiological testing of the median nerve showed abnormalities in a few patients, but localization of the abnormality was possible only rarely. Intraoperative recordings showed some improvement shortly after release of the median nerve in six of the ten forearms that were tested. Surgical exploration of thirty-six forearms in thirty-two patients showed intramuscular tendinous bands in the pronator, indentation of the muscle belly of the flexor superficialis in most forearms. Vascular and muscular abnormalities were seen occasionally. Of the thirty-six operations, twenty-eight gave good or excellent results; five, fair; and in three patients the symptoms were unchanged. The cause of failure was either inadequate decompression or misdiagnosis.
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        Entrapment neuropathies of the median nerve at and above the elbow.

        Three surgically verified cases of median nerve entrapment at and above the elbow are reported: one involved a compression of the nerve beneath the Struthers ligament in absence of supracondylar bony spur, and two concerned a compression beneath the lacertus fibrosus bicipitis (aponeurosis musculi bicipitalis brachii). Of the two latter cases, the first entrapment was caused by a hematome and the second the nerve was found to be entrapped between the lactertus and an underlying hypertrophic brachial muscle. The compression mechanisms and clinical and electromyographic findings are presented.
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          Predicting the outcome of carpal tunnel release.

          To test the hypothesis that the result of steroid injection in the carpal tunnel provides a better predictor of the outcome of later surgery. We also explored other possible factors that might predict the outcome directly or interact with the results of steroid injection to better predict the outcome.
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            Author and article information

            Affiliations
            [1 ] Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University 1873 Rama 4 Road 10330 Pathumwan, Bangkok Thailand
            [2 ] Christian M Kleinert Institute for Hand and Microsurgery 225 Abraham Flexner Way, Suite 850 40202 Louisville KY USA
            Author notes
            [* ]Corresponding author: pobeong@ 123456yahoo.com
            Journal
            SICOT J
            SICOT J
            sicotj
            SICOT-J
            EDP Sciences
            2426-8887
            2016
            16 March 2016
            : 2
            : ( publisher-idID: sicotj/2016/01 )
            27163098
            4849221
            10.1051/sicotj/2016006
            sicotj150062 10.1051/sicotj/2016006
            © The Authors, published by EDP Sciences, 2016

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Counts
            Figures: 3, Tables: 3, Equations: 0, References: 21, Pages: 6
            Categories
            Upper Limb
            Original Article
            Keywords:

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