5th International Conference of Orthopedic Surgeons and Rheumatology

Biography

Biography: Manuel Villanueva

Abstract

Introduction: Carpal tunnel syndrome is the most surgically treated entrapment neuropathy. It aff ects 1 million adults in the United States annually. Several studies suggest smaller incisions related to lower rates of scar tenderness, pillar pain rates and earlier return to work. Ultrasound-guided ultraminimally invasive release is performed with 1 mm incision, in an ambulant regimen, with local anesthesia, without the need for ischemia. Simultaneous bilateral release is possible even in patients with diseases considered contraindications for classic techniques. Material and methods: Th e instrument set included long needles (a 16-gauge, 1.7-mm diameter Abbocath, USA), a V-shaped straight curette, a blunt dissector, a hook knife (Aesculap 2,3 mm), and an ultrasound device (Alpinion ECube15) with a 10-17–MHz linear transducer and the Needle Vision Plus™ soft ware package. Th e patient is placed supine, with the hand on a table and the palm up. We do not use ischemia. We delineate the midpoint between the nerve and the ulnar vessels, trying to defi ne Nakamichi zone´s midpoint. At the selected midpoint at the forearm, we insert a large spinal needle with local anesthesia and check we pierce the deepest fi bers and are beneath the transverse carpal ligament. Color-doppler function may help us to safely determine the superfi cial palmar arch and guide the distal limit of our instruments. We insert the small and medium V-shaped straight curette guided by the needle. Th e release starts 2-3 mm proximal to the superfi cial palmar arch and proximally we extend the release proximal to the pisiform. We remove the hook knife following the curve of the blade so as not to enlarge the incision. Th e mobility of fi ngers is immediately checked. No stitches are required. We use adhesive-strips and a padded dressing. Th e procedure takes 10 minutes. Results: In 20 cadavers we have checked this procedure to be safe, preserving the nerve and vessels and eff ective. We have operated on 31 hands in 20 patients (11 bilateral cases), 16 women and 4 men. Th e age ranged from 39 to 74 years. One case was a recurrence of open surgery. Patients required “pain killers” for 1-2 days and returned to activities of daily living or work aft er 3 days (1-15 days). Th e Phalen test, Tinel test, reverse Phalen test, carpal compression test, and grip strength signifi catively improved. Quick DASH score improved from 57 pre-op (25-89) to 4post-op (0-9). Th ere were no infections nor nerve damage. Minor superfi cial hematomas were common. Two patients had residual numbness and thenar atrophy despite clinical improvement. Discussion: Better outcomes (in terms of pain, strength, function, and cosmetic aspects) have been reported as dissection was reduced from classic to endoscopic to mini or ultra-minimally invasive approaches. Ultrasound-guided surgery seems to be safe, helpful and successful for carpal tunnel release. It gives the surgeon direct control of the main structures. Since they can be performed on an outpatient basis under local anesthesia and without a tourniquet, complications and contraindications are minimized. As it causes minimal pain and swelling, recovery is quicker.