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      Role of pronator release in revision carpal tunnel surgery

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      1 , * , 2 , 1 , 1
      SICOT-J
      EDP Sciences
      Pronator syndrome, Pronator release, Revision, Carpal tunnel, Decompression

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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 references23

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          Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release.

          Carpal tunnel release is one of the most frequently performed hand operations. However, persistent, recurrent, or completely new symptoms following carpal tunnel release remain a difficult problem.
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            Pronator syndrome and anterior interosseous nerve syndrome.

            Dysfunction of the median nerve at the elbow or proximal forearm can characterize two distinct clinical entities: pronator syndrome (PS) or anterior interosseous nerve (AIN) syndrome. PS is characterized by vague volar forearm pain, with median nerve paresthesias and minimal motor findings. AIN syndrome is a pure motor palsy of any or all of the muscles innervated by that nerve: the flexor pollicis longus, the flexor digitorum profundus of the index and middle fingers, and the pronator quadratus. The sites of anatomic compression are essentially the same for both disorders. Typically, the findings of electrodiagnostic studies are normal in patients with PS and abnormal in those with AIN syndrome. PS is a controversial diagnosis and is typically treated nonsurgically. AIN syndrome is increasingly thought to be neuritis and it often resolves spontaneously following prolonged observation. Surgical indications for nerve decompression include persistent symptoms for >6 months in patients with PS or for a minimum of 12 months with no signs of motor improvement in those with AIN syndrome.
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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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                Author and article information

                Journal
                SICOT J
                SICOT J
                sicotj
                SICOT-J
                EDP Sciences
                2426-8887
                2016
                16 March 2016
                : 2
                : ( publisher-idID: sicotj/2016/01 )
                : 9
                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
                Article
                sicotj150062 10.1051/sicotj/2016006
                10.1051/sicotj/2016006
                4849221
                27163098
                684aa5ee-06c0-4678-85ac-5c9b33ce2363
                © 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.

                History
                : 19 April 2015
                : 23 January 2016
                Page count
                Figures: 3, Tables: 3, Equations: 0, References: 21, Pages: 6
                Categories
                Upper Limb
                Original Article

                pronator syndrome,pronator release,revision,carpal tunnel,decompression

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