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T R A I T E M E N T D E S R I C ID IV ESD U S Y N D R O M E D U C A N A L C A R P I E N

T R E A T M E N T O F R E C U R R E N C EO F T H E C A R P A L T U N N E L S Y N D R O M E

C. WULLE

W U L L E C . - - T r a i t e m e n t d e s r 6 c id i v e s d u s y n d r o m e d u c a n a lc a r p i e n . (En Fra n f a i s e t An g l a i s ).A n n C h i r M a i n , 1 9 8 7 , 6 , 'n 3 , 2 0 3 - 2 0 9 .W U L L E C . - - T r e a t m e n t o f re c u r r en c e o f t he c a rp a l t u n n el s y n-d r o m e . (In French and Engl i sh) .A n n C h i r M a i n , 1 9 8 7 , 6 , n 3 , 2 0 3 - 2 0 9 .

RI~SUMI~ : D6fini tion exacte de la r6cidive du syn- SUM MARY : Exact defin ition of the recurrent car-drome du canal carpien. Pr6sentat ion des mdthod es pal tunnel syndrome. Presentation of the methods ofde traitement op6ratoire employ6es, selon les indi- :loperation for the recurrent carpal tunnel syndromcations, en raison des causes donn6es, y compris la corresponding to the indication basing on the causesplastie en lambeau de tissu synovial que nous avons of the recurrences.ddj~ d6crite. Analyse des r6sultats des visites decontr61es de 23 patients.M O T S - C L I ~ S : R 6 c i d i v e d u s y n d r o m e d u c a n a l c a r p ie n . - - K E Y - W O R D S : R e c u r r e n c e o f c a r p a l t u n n e l s y n d r o m e . - -P l a s t i e e n l a m b e a u d e t i s s u s y n o v i a l . S y n o v i a l f l a p p l a s t i e .

Qu'est-ce q u'un e rOcidive du synd rom e du canalcarpien ?L'ouverture du canal carpien a 6t6 faite. Le ma-lade se plaint de nouvea u de troubles. I1 existe al or strois situations de d6part diff6rentes :

- - Le ligament du canal carpien a 6t6 sectionn6de fa~on incomplete.Apr6s l'op6ration, les symptOmes persistent soitcompl6tement soit en partie, ils sont m6me 6ven-tuellement plus forts qu'auparavant.-- Apr6s une section complete du ligament ducanal carpien suivie d'une diminution ou m6med'une disparition des troubles, une autre cause aprovoqu6 de nouveau un syndrome du tunnel car-pien (fracture distale du radius, synovite chroniquedes tendons fldchisseurs). C'est-~-dire qu'on a une

absence de troubles apr6s l'op6ration, puis une r6ap-parition des douleurs et des troubles de la sensibilit6et motricit6.

-- Apr6s section compl6te du ligament carpien,une forte fibrose a provoqu6 la vdritable r6cidive.Apr6s disparition compl6te ou partielle des trou-bles, rdapparition lente de ces derniers peu de tempsapr~s l'intervention, au bout de quelques semainesou mois.I1 ne s'agit pas de v6ritable r6cidive du syndromedu canal carpien, quand le nerf m6dian ou ses rami-fications ont 6t6 traumatis6s pendant la premi6re in-tervention ; ces 16sions entraine nt des per tes locali-s6es de la sensibilit6 ou de la motricit6, 6ventuelle-ment accompagndes de douleurs dues au n6vrome.

( * ) D 6 d i 6 a u D o c t e u r E r l e r ~ l 'o c c a s i o n d e s o n 8 8 a n n i v e r -s a l r e .D~partement de Chirurgie de la main et de Chirurgie plastique,C l i n iq u e s d u D r Er l e r, K o n t u m a zg a r t e n 4 -18 , D 8 5 0 0 N U RE M -B E R G 8 0 .M a n u s c r i t r e (~ u ~ , l a R d d a c t i o n l e 2 9 o c t o b r e 1 9 8 6 ,


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20 4 THE CARPAL TUNNEL SYNDROME ANNALES DE CHIRURGIEDE LA MAIND e l a m ~ m e f a ~ o n i l n e s ' a g i t p a s d e r 6 c i d i v e ,q u a n d u n e d e u x i 6 m e c o m p r e s s i o n s e p r o d u i t p a re x e m p l e a u n i v e a u d u r o n d p r o n a t e u r , o u a u n iv e a ud e l ' e x p a n s i o n a p o n 6 v r o t i q u e d u b i c e p s o u a u n i -v e a u d u p a s s a g e e n t r e s c a l en e m o y e n e t a n t 6 r i e u r o us i d ' a u t r e s c a u s e s p r o v o q u e n t d e s d o u l e u r s l o c a l i -s6es :- - a r t h r o s e d e l ' a r t i c u l a t i o n t r a p d z o - m 6 t a c a r -p i e n n e o u rh i z a r t h r o s e ;- - a r t h r o s e t r i s c a p h o i d i e n n n e ;- - i n s ta b i l it 6 c a r p i e n n e ;- - b r a c h i a l g i e p a r p r o t r u s i o n d ' u n d i s q u e c e r v ic a lo u a r t h r o s e a u n i v e a u d u r a c h i s c e r v i c a l ;o u s ' il e x i s t e d ' a u t r e s a f f e c t i o n s n e u r o l o g i q u e s :- - s c l d ro s e l a t 6 ra l e a m y o t r o p h i q u e ;- - s y r i n g o m y 6 1 i e ;- - p o l y n e u r o p a t h i e o u- - s y n d r o m e e e r v i c o - th o r a c o - b r a c h i a l ( t h o ra c i co u t l e t ) .P o u r u n d i a g n o s t i c p rO c is l ' 6 1 e c t ro m y o - e t n e u r o -g r a p h i e e s t i n d i s p e n s a b l e . S i l e s t r o u b l e s s o n t d u sd e s c i c a t r i c e s o u d e s n d v r o m e s , l ' 6 1 e c t r o m y o g r a -p h i e m o n t r e r a u n e a m 6 1 i o r a t i o n . U n e r d i n t e r v e n -t i o n n ' e s t c o n s e i l l d e q u e l o r s q u e I ' E M G a p r o u v 6u n e d 6 t 6 r i o r a t i o n c r o i s s a n t e ; l e m a l a d e s e p la i n ta l o r s d ' u n e a g g r a v a t i o n d e s t r o u b l e s p e r s i s t a n t e .

L e s c h i r u r g i e n s , e n v i s a g e a n t u n e i n t e r v e n t i o n s u rl a r 6 c i d i v e d ' u n s y n d r o m e d u c a n a l c a r p i e n , s e p o s e -r o n t l a q u e s t i o n s u i v a n t e : s e r a - t - il p o s s i b l e d e c o u -v r i r le n e f f m d d i a n d ' u n t is s u f in e t b i e n i r r ig u 6 ?M I ~ T H O D E S D E T R A I T E M E N T

C e t t e q u e s t i o n e s t p e u i m p o r t a n t e e n p r 6 s en c ed ' u n e s e c t i o n in s u f f i s a n t e d u l i g a m e n t ; l a se c t i o nc o m p l e t e d e c e li g a m e n t d o n n e r a s u f f i s a m m e n t d ' e s-p a c e ( f ig . 1 ) . I1 s u f f i t a l o r s d ' a j o u t e r u n e n e u r o l y s e6 p i n e u r a l e .Q u a n d l a t 6 n o s y n o v i t e p r o l i f 6 r a t iv e e s t l a c a u s ed e s n o u v e a u x t r o u b l e s o u q u ' u n t r a u m a t i s m e l e s ap r o v o q u d s , l a s y n o v e c t o m i e a p r6 s n e u r o l y s e d o n -n e r a c e r t a i n e m e n t a s s e z d ' e s p a c e d a n s l e c a n a l c a r -p i en ( f i g . 2 a e t b ) .O n a a f f a i r e ~ l a s i t u a t i o n l a p l u s d i f f i c il e q u a n du n e f i b r o s e p r o g r e s si v e a p r o v o q u 6 d e n o u v e a u u n ec o m p r e s s i o n d u n e f f m 6 d i a n . C ' e s t l a v r a i e r 6 c id i v e( fi g . 3 a , d ) . A p r 6 s a v o i r d 6 g a g 6 a v e c p r 6 c a u t i o n l en e f f d u t i s s u c i c a t r i c i e l , o n a a l o r s u n e d e s i n d i c a -t i o n s e x t r 6 m e m e n t r a r e s p o u r l a n e u r o l y s e i n te r f a s c i-c u l a i r e a u m i c r o s c o p e .C e n e r f n e u r o l y s 6 d o i t 6 t r e r e c o u v e r t a v e c u n t is s ub i e n i r r i g u 6 q u i n ' e s t p a s 6 p a i s e t q u i n e r d d u i t p a sd a v a n t a g e l ' e s p a c e d u c a n a l c a r p i e n .

What i n f ac t i s a r ecu r r ence o f t he ca r pa l t unne l syn -d r o m e ?A n o p e r a t i o n h a s b e e n p e r f o r m e d , b u t t h e p a t i e n t h a sc o m p l a i n t s a g a i n . T h e r e c a n b e t h r e e d i f f e r e n t c a u s e s f o rt h i s :- - T h e l i g a m e n t u m c a r p i t r a n s v e r s u m w a s n o t s e p a r a -t e d c o m p l e t e l y .A f t e r t h e o p e r a t i o n c o m p l a i n t s s u b s i d e d o n l y p a r t i a l ly o rn o t a t a ll , p o s s i b l y t h e y a r e w o r s e t h a n b e f o r e .- - A f t e r t h e c a r p a l li g a m e n t h a d b e e n f u l ly s e p a r a t e dc o m p l a i n t s s u b s i d e d o r d is a p p e a r e d , b u t th e n a n o t h e rr e a s o n f o r t h e c a r p a l t u n n e l s y n d r o m e o c c u r r e d ( d i s ta lf r a c t u r e o f r a d i u s , c h r o n i c a l l y p r o l i f e r a t iv e s y n o v i t i s o f t h ef l e x o r t e n d o n s ) .S o t h e p a t ie n t w a s f r e e o f c o m p l a i n t s a f t e r th e o p e r a -t io n , f o l l o w e d b y a r e n e w e d o n s e t o f p a i n a n d a n i m p a i r -m e n t o f s e n s i b i l i t y .- - A f t e r t h e c a r p a l l ig a m e n t h a d b e e n f u l ly s e p a r a t e d ,t h e r e a l r e c u r r e n c e w a s c a u s e d b y s e v e r e f ib r o s i s .A l t h o u g h c o m p l a i n t s a t f i rs t s u b s i d e d f u l l y o r i n p a rt ,t h e y s l o w l y r e c u r b r i e f l y a f te r t h e o p e r a t i o n o r a f t e r a f e ww e e k s .W e a r e n o t d e a l i n g w i th a r e c u r r e n c e o f t h e c a r p a l t u n -n e l s y n d r o m e , i f t h e m e d i a n n e r v e o r o n e o f i t s b r a n c h e sw a s i n ju r e d d u r i n g t h e f i r s t o p e r a t i o n ; t h i s w o u l d c a u s el o c a l d is r u p t i o n s o f s e n s i b i l it y o r m o b i l i ty , p o s s i b l y a c c o m -p a n i e d b y n e u r o m a c o m p l a i n ts .N e i t h e r d o e s i t c o n s t i t u t e a r e c u r r e n c e , i f a s e c o n dc o m p r e s s i o n e . g . b e l o w t h e p r o n a t o r te r e s o r t h e l a c e r t u s

f i b r o s u s o r t h e s c a l e n u s e x i s t s o r if lo c a l p a i n i s c a u s e d b yo t h e r fa c t o r s s u c h a s :- - a r t h r os i s o f t he f i r s t c a r po - m e t ac a r pa l j o i n t o r a t r i s c a -pho i d a r t h r os i s ;

- - c a r pa l i n s t ab i l i t y ;- - b r a c h i a l g i a b y d is c p r o t ru s i o n o r a r t h r o s is o f t h e c e r -v i c a l s p in e ;o r i f a d d i t i o n a l d i a g n o s e s e x i s t :- - m y a t r o p h i c l a t e r a l s c l e r o s i s ;- - s y r i n g o m y e l i a ;- - p o l y n e u r o p a t h y o r t h e- - t h o r a c i c o u t l e t s y n d r o m e .I n o r d e r t o d e f i n e t h e c o m p l a i n t s p r e c i s e l y e l e c t ro m y o -g r a p h y t o d e t e r m i n e t h e v e l o c i t y o f n e r v e c o n d u c t i o n i s i n -d i s p e n s i b l e . I t t h e c o m p l a i n t s r e s u l t f ro m s c a r s o r n e u r o -m a s , t h e E M G w i ll s h o w a n im p r o v e m e n t . A s e c o n d o p e -

r a t io n i s in d i c a t e d , i f t h e E M G ' s d e t e r m i n a t i o n o f t h e v e l o -c i t y o f n e r v e c o n d u c t i o n s h o w s s t e a d y d e t e r i o r a t i o n a n dt h e p a t i e n t s u f f e r s f r o m r e n e w e d i m p a i r m e n t o f s e n s i b i l i t yw i th h y p o e s t h e s ia , d y s e s t h e s i a o r e v e n a n e s t h e s i a a n d ad e t e r i o r a t io n o f m o t o r s t re n g t h a f t e r th e s e f a c t o r s h a d f i rs ti m p r o v e d o r s u b s i d e d .B e f o r e a r e c u r r e n c e o p e r a t i o n a n y s u r g e o n w i l l a s kh i m s e l f :

- - H a s a n e p i n e u r a l o r i n t e r f a s c i c u l a r n e u r o l y s i s b e e np e r f o r m e d d u r i n g t h e f ir s t o p e r a t i o n ?- - C a n t h e m e d i a n n e r v e b e c o v e r e d b y ti s s u e w e l ls u p p l i e d w i t h b l o o d ?


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VOLUME 6No 3 - - 1987 SYNDROME DU CANAL CARPIEN 205

Fig. 1. -- Chez ce malade, le nerf presente une compressionimportante sou s la partie du ligam ent qui n'a pas (~te sec-tionnee au cours de ia premiere intervention, accompagneed'une importante hyperemie reactive apparue apres la sec-tion du ligament.Fig, 1, - - The median nerve is extreme ly compressed under theligament which was not fully separated during the first operation,After separation of the ligament there is a clear reactive hyper-emia.

Cr am er [2] a d6c r i t en 1985 la p la s t i e en l am bea us o u s - c u ta n 6 e d e l '6 m i n e n c e h y p o t h d n a r ; R e i s m a n n e ta l . [5 ] on t d6c r i t en 1983 la t ranspos i t ion de l ' adduc -teur de l ' au r icu la i re ; De l lon [3 ] a d6c r i t en 1984 lat r a n s p o s i t i o n d u c a r r 6 p r o n a t e u r e t P o e l l et a l . [4 ] e n1 9 8 5 l ' i n t e r p o s i t i o n d u l a m b e a u a n t 6 b r a c h i a l r a d i a l .N o u s n ' a v o n s p a s e x p 6 r i m e n t 6 c e s m 6 t h o d e s .

M E T H O D S O F T R E A T M E N TSuch questions are immaterial , i f there was mere ly aninsuff ic ient sect ion of the l igament and separat ing i t ful lywi l l make suff ic ient room so that al l that remains to bedone is external decompression of the nerve.This pat ient 's nerve (f ig. 1) is extremely compressedbelow the part of the l igam ent that had been left or iginal lyand shows conside rable reac t ive hyperaemia after the se-parat ion of the l igament.I f the recurrence of the symptom s is caused by prol i fe-rat ive hypertrophic tenosynovit is or by trauma, enoughroom can certainly be created in the carpal tunnel bymeans of a synovectomy after exposing the nerve again(fig. 2 a and b). In order to have the nerve covered by tis-sue that shows a minimum of scars such sect ioning of thetunnel should be done as far ulnar as possible, which, ofcourse, appl ies to any operat ion of this kind.The most complex si tuat ion is a real recurrence of thecarpal tunnel syndrome caused by increased f ibrosis ( f ig.3 a-d). After separat ing the nerve careful ly from the scar-red t issue this is one of the extremely rare indicat ions fora microscopic interfascicular neurolysis.This neurolysed nerve is to be covered subsequentlyby t issue wel l suppl ied with blood which does not repre-sent any weight and wi l l not confine the lumen of the car-pal canal an y further.

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Fig. 2. -- a) Compres sion du nerf median dans le tiers distaldu canal carpien avec hyperemie reactive. Deux ramifica-tions du nerf median perforent le retinaculum dans la pattieproximale. Synovite fibroplastique importante, b) R(~sultatapres avoir effectue une synovectomie. On reconnaff aussimaintenant le point de compression a ia hauteur du pli distalde flexion du poignet et du tiers proximal du canal carpien.Fig. 2. - - a) Median nerve compressed in the distal third of thecarpal tunnel with reactive hyperemia. Two branches of the me-dian nerve are perforating the retinaculum in the proximal part.Significant fibroplastic synovitis, b) Condition after synovectomy.The compression area near the rascetta (distal flexion crease ofthe wrist) and in the proximal third of the carpal tunnel is visiblehere.

Cramer [2] described the subcutis-f lap-plasty from thehypothenar in 1985 ; Reismann et al . [5) the transposit ionof the adductor digiti minimi in 1983 ; Dellon [3] the trans-posit ion of the pronator quadratus in 1984 ; and Poel l etal. [4] the interposition from the radial-forearm-flap.

We have no experience with these methods.From the surgery of extensor and f lexor tendons weknow of the attempt to transplant paratenon in order toease the sl iding of the transplanted tendons. In the car-pal tunnel a great amount of synovial t issue is avai lablefor the same purpose [6].The synovial f lap is prepared as an ulnar pedicle f lapwhich is as wide as possible in proximal distal direct ion.Thereafter i t can be f ixed palmar and radial to the nerve(f ig. 4 a-d). The essential factor being that when the


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A N N A L E S D E C H I R U R G I E206 T H E C A R P A L T U N N E L S Y N D R O M E D E L A M A I N

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F i g . 3 . - - Patient de 83 ans presentant une latence dista lequi n 'est p lus mesurable ; a) f ibrose importante. R esultatb) pendant et c) apres neurolyse (une neurolyseinterfasciculaire n'a pas ete effectuee) et d) pr(~parationd'une plasUe en lambeau de t issu synovia l . Le seulmalade, qui n 'a pas montre une amel iorat ion de I 'EMG,avait cependant une amel iorat ion subject ive.

Fig. 3. -- For this 83-year old patient motor distal latencycannot be measured anym ore ; a) considerable synovial fibro-sis. Findings b) during and c) after neurolysis (no interfascicu-lar neurolysis was performed) and d) synovial flap plasty. Theonly patient whos e EMG va lues did not improve, w hile he subjecti-vely felt an improvement.

Fig. 4 a-d. -- De scr ipt ion detaill ee, v oir text e page 207. Fig. 4 a-d. -- For detailed explanations, please see text page 207.


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VOLUME 6 SYNDROME DU CANAL CARPIEN 20 7No 3 -- 1987

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Fig. 5 a et b. m Patient de 37 ans pr(~sentant avant la se-conde operation une latence distale motrice de 5,7 ms.Apres la reintervention avec un lambeau de tissu synoviai,elle a refuse un EMG de contr61e a cause de guerison sub-jective.Fig. 5 a and b. -- Prior to the recurrence oper ation this 37-yearold patient had a motor distal latency of 5.7 ms. After synovialf lap p lasty in a second operat ion she refused to hav e a new EMGexamination as she was convinced of having been cured.

Nous connaissons par la chirurgie des tendonsl'essai de transplanter du paratendon pour obtenirun meilleur glissement des tendons greff6s. Dans lecanal carpien le tissu synovial se pr6te de fa~onid6ale ~ cette in tervention [6].Un lambeau de tissu synovial est bas6 sur un p6di-cule cubital que l'on pr6pare le plus large possible,allant de proximal ~ distal. Ce lambeau synovial est

ensuite fix6 ~ la paroi du tunnel carpien du c6t6 pal-maire et radial du n er f m6dian (fig. 4 a-d). I1 estalors important qu'au cours de l'extension et de laflexion passives des doigts par le mouvement destendons fl6chisseurs, il ne se forme pas de bridesdans le tissu synovial. Cette intervention est toutfait r6alisable quand on a un tissu synovial normalfig. 5 a-b), m~me en cas de fibrose mod6r6efig. 6 a-c). Si au contrair e le tissu est modifi6 d'un efaqon prolif6rative hyperplastique, comme parexemple dans le cas de maladies rhumatoi'des ouquand il pr6sente des 6paississements ganglionnai-res, il ne peut pas 6tre employ6 pour cette interven-tion.) ,

Fig. 6 a-c. - - Patiente de 72 ans, avant I 'operation lalatence distale motrice n 'etait pas mesurable. Une plastieen lambeau de t issu synovial, m algre la f ibrose importanteeffectu(~e. 30 m ois ap res la r (Hntervention la latence distalemotrice etait 9,1 ms.Fig. 6. - - Pr ior to the operat ion m otor d istal la tency could notbe meas ured for th is 72-year o ld pat ient. S ynovia l f ibrosis existe dand synovia l f lap p lasty was performed. 30 months after the se-cond operat ion a d ista l motor la tency of 9.1 ms could be deter-mined.

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208I ~ T U D E D E C A S

T H E C A R P A L T U N N E L S Y N D R O M E

D e 1 9 7 6 ~ 1 9 8 6 n o u s a v o n s r 6 a l i s 6 1 5 8 9 o p 6 r a -t i o n s d e s e c t i o n d u c a n a l c a r p i e n , d o n t 2 3 , e n t r em a r s 1 9 7 9 e t f 6 v r i e r 1 9 8 6 , 6 t a l e n t d e s c a s d e r 6 c i d i v ed u s y n d r o m e d u c a n a l c a rp i e n . D a n s d e u x c a s n o u sa v i o n s r d a l i s 6 l a p r e m i e r e o p 6 r a t i o n /~ l a s u i t e d ' u nf o r t 6 c r a s e m e n t d e l a m a i n a c c o m p a g n 6 d e f r a c tu r e s( a c c i d e n t d u t r a v a i l ) . U n e f i b r o s e s e c o n d a i r e a v a i tp r o v o q u 6 u n e v 6 r i t a b l e r 6 c i d i v e . D a n s l e s 2 1 a u t r e sc a s , la p r e m i 6 r e o p 6 r a t i o n a v a i t 6 t6 r 6 a l is d e d a n s u na u t r e h 6 p i t a l.L ' 6 c a r t s d p a r a n t l a p r e m i e r e e t l a d e u x i 6 m e o p a l -r a t i o n a v a r i 6 d e 1 m o i s ~ 4 a n s e t d e m i , e t a 6 t 6 e nm o y e n n e d e 1 7 m o i s . L ' 6 c a r t s d p a r an t l a d e u x i 6 m eo p 6 r a t i o n e t l a v i s i te d e c o n t r 6 1 e a v a r i 6 d e 1 m o i s5 a n s e t 1 0 m o i s , i l a 6 t6 e n m o y e n n e d e 2 2 m o i s .L ' f i g e d e s 2 3 p a t i e n t s o p d r 6 s e n t r e m a i 1 9 7 9 e t f 6 -v r i e r 1 9 8 6 a v a r i 6 e n t r e 2 5 e t 8 3 a n s , l a m o y e n n e6 t a n t d e 5 6 a n s. L e r a p p o r t h o m m e / f e m m e 6 t a i t d e1 6 ~ 7 e t le r a p p o r t m a i n d r o i t e / m a i n g a u c h e d e 1 013.I1 e s t h r e m a r q u e r q u e s ix m a l a d e s , a p r ~ s la p r e -m i e r e i n t e r v e n t i o n , n e r e s s e n t a i e n t p l u s l e s d o u l e u r sn o c t u r n e s t y p i q u e s d u s y n d r o m e d u c a n a l c a r p ie n , e t

A N N A L E S D E C H I R U R G I ED E L A M A I N

q u e l e s a u t r e s r e s s e n t a i e n t d e s d o u l e u r s n e t t e m e n tp l u s f o r t e s . L a s e n s i b i l i t 6 s ' 6 t a i t , d a n s t o u s l e s c a s ,d 6 t 6 r i o r d e d e f a ~ o n i m p o r t a n t e , j u s q u ' ~ l ' i n s e n s ib i -l it 6 c o m p l 6 t e . L a f o r c e a v a i t d i m i n u 6 .A I ' E M G o n p o u v a i t da n s to u s l e s c a s r e m a r q u e re t c o n s t a t e r u n e d d t 6 r i o r a t i o n d e s r 6 s u l t a t s .

C A U S E S D E S 2 3 R I ~ C ID I V E SD a n s d e u x c a s , i l y a e u u n e n o u v e l l e a f f e c t i o n( f r a c t u r e d u ra d i u s e t r 6 c i d iv e d ' h 6 m a n g i o m e ) . D a n s1 5 c a s l e li g a m e n t n ' 6 t a i t p a s d u t o u t s e c t i o n n 6 o u d ef a ~o n i n c o m p l e t e , a c c o m p a g n 6 e n p a r t ie d ' u n e f i -b r o s e s u p p l d m e n t a i r e d u t i s su s y n o v i a l . D a n s 9 c a su n e f i b r o s e 6 t e n d u e 6 t a i t l a s e u l e c a u s e d e l a rd c i -d i v e .

T R A I T E M E N TA p r 6 s a v o i r s e c t i o n n 6 c o m p l ~ t e m e n t l e l i g a m e n t ,n o u s a v o n s e f fe c t u 6 la n e u r o l y s e e x t e r n e d u n e r f m 6 -d i a n , c o m p l 6 t 6 e d a n s 6 c as p a r l a s y n o v e c t o m i e p a r-t i e l l e o u t o t a l e e t d a n s 9 c a s l a p l a s t i e p a r l a m b e a us y n o v i a l , q u e n o u s a v o n s d 6 c r i t e , a 6 t6 p r a t i q u d e .

f inge rs a re pa ss i ve l y ex t ended and f l exed such move-ment of the f lexor tendons wi l l not cause any cord forma-t ion in the synovia l t i ssue. This operat ion can be easi l ype r f o rmed as an y no rma l syno v i a l t i ssue i s ra the r t ender(f ig. 5 a and b), i t is, however, also possible to use t issuethat has been s l ight l y modi f ied by f ibros is ( f ig . 6 a-c) .I f the t i ssue has been a l tered pro l i ferat i ve ly hypert rophicas e.g. happens in the case of rheumat ic d iseases or inthe case of a gangl ion- type indurat ion, i t cannot be usedin th is wa y.C A S E S S T U D Y

From 1976 to 1986 we d id 1,589 carpal tunnel sec-t ions. In the per iod between March 1979 and February1986 we performed 23 recurrence operat ions. 21 pa-t ients had been operated e lsew here. Two recurrenceopera t i ons became necessary a f t e r f ir s t ope ra t ions i n ou rown c l in ic for severe contus ions which in turn had produ-ced st rong f ibros is , th is gave r i se to the t rue recurrence.

Between the f i rs t and the second operat ion 1 month to4 1 / 2 years e l apsed , the ave rage pe r i od was 17months. The seco nd operat ion was betw een 1 month and5.10 years before the fo l low-up examinat ion, 22 monthson ave rage . The age o f the 23 pa t i en ts we ope ra t ed va -r i ed be t ween 25 and 83 years , t he ave rage age was 56years . The rat io of men to wom en w as 16:7 ; that o f r ighthand to lef t hand was 10:13.I t was remarkable that s ix o f the pat ients d id notcomp la in about the pa ins at n ight which a re typ ica l for thecarpa l t unne l syndrome a f t e r t he i r f i r s t ope ra t i on , a l l

o t he rs sa id t ha t t he pa i n had becom e cons i de rab l y worse .Sen sib i l it y has s ign i f i cant ly deter iorated in a l l cases, up toactual numbnes s. Pa t ients had lost s trength.In a l l cases the EMG showed, i .e . proved that thevalues had deter iorated.In two cas es a rene wed a f fect ion had occurred ( f ractureo f the rad i us and ha emang i oma recu r rence) ; i n 15 casesthe ret inaculum had not been sect ioned or not been sec-t ioned co mp lete ly w i th a p ar t ia l f ibros is of the syn ovia l i s inaddi t ion and in n ine cases exte ns ive f ibros is was the so lecause .

T R E A T M E N TAf t e r separa t ing t he re t inacu l um com p l e t e l y we neuro l i-sed t he med i an ne rve , 6 t i mes a synovec t omy o r pa r t i a lsynove c t omy and 9 t i mes t he synov i a l f lap p l as t y wasper f o rmed .

R E S U L T SAl l pat ients were complete ly f reed of the nerve painscaused by t he compress i on . 13 pa t ien t s ob t a ined n o rma lsensib i l i t y , 8 pa t ients s t il l had paraes thesia or hypo esthe-s ia but less than before. 6 pat ients compla ined aboutpains f rom the scars.Excep t f o r one case t he EMG cons i s t en t l y showed animprovement of motor ic d is ta l la tency ( tab le I ) . For one83-year o ld pat ient i t was s t i l l not poss ib le to measurethese va lues. He cont inued to have a c lear hypoesthesiabut the hy pera lge s ia was cons iderably reduced.


7/7

V O L U M E 6N o 3 - - 1 9 8 7 S Y N D R O M E D U C A N A L C A R P IE N 2 0 9R I ~ S U L T A T S C O N C L U S I O N S

L e s d o u l e u r s d u e s /~ l a c o m p r e s s i o n d u n e f f o n td i s p a r u d a n s t o u s l e s c a s. L a s e n s ib i li t6 s ' e s t n o r m a -l is 6 e c h e z 13 m a l a d e s , c h e z 8 m a l a d e s d e s p a r e s t h 6 -s ie s o u d e s h y p o e s t h 6 s i e s p e r s i s t e n t , c e p e n d a n t m o i n sf o r t e s q u ' a u p a r a v a n t . L ' E M G a m o n t r 6 ( t a b l e a u I )c h e z t o u s l e s m a l a d e s , g l ' e x c e p t i o n d ' u n s e u l, u n ea m 6 1 i o r a t i o n d e l a l a t e n c e d i s t a l e m o t r i c e . C h e z c ed e r n i e r m a l a d e f i g 6 d e 8 3 a n s , e l l e n ' d t a i t p a s m e s u -t a b l e . U n e h y p o e s t h d s i e a p e r s i s t6 , a v e c c e p e n d a n tu n e a m 6 1 i o r a t i o n i m p o r t a n t e d e l ' h y p e r a l g 6 s i e e t d el a f o n c t i o n .T A B L E I

Dis ta l la tency I Contro l pos top . Dis ta l la tencyb e fo r e r e c id . OP (m o n th s ) p o s to p e ra t io n Op e r a t io nL a t e n c e d i s t a l e C o n t nS l e L a t e n c em o t r i c e a v a n t a p r e s d i s t a l el a s e c o n d e I ' o p e r a ti o n m o t r i c e O p e r a t i o nopera t ion (mois ) apres I 'op6ra t ion

1 0 , 5 1 R e f u s e d - S y n o v i a l - f la psubj . improv.N o n r e c o r d a b l e 3 0 9 , 1 S y n o v i a l - f la p

4 , 9 1 R e f u s e d -sub j . improv .5 , 7 7 0 R e f u s e d - S y n o v i a l - f la psub j . care5 , 9 6 5 3 , 2 S y n o v i a l - f la p6,8 21 - Syno v ia l - f l ap7,2 61 3 ,06 , 9 5 7 3 , 8 S y n o v i a l - f la p

N o n r e c o r d a b l e 5 5 , 01 0 , 6 1 R e f u s e d -subj . improv.10,0 31 4 ,5

9 , 9 2 8 6 , 47 , 2 2 6 4 , 2 S y n o v i a l - f la p7,3 7 6 ,5 Par t . synov ec t .7 , 4 1 6 5 , 3 S y n o v e c t o r n y5,7 8 4 ,3

N o n r e c o r d a b l e 7 6 , 6 S y n o v e c t o r n yN o n r e c o r d a b l e 5 1 0 , 2 S y n o v e c t o m y

1 0 , 5 5 5 , 7 S y n o v e c t o r n y5,5 16 4 ,8

N o n r e c o r d a b l e 2 7 N o n r e c o r d a b l e S y n o v i a l - f la p4 , 5 1 4 , 0 S y n o v i a l - f l a p5,6 44 - Par t . syno vec t .

L e s t r o i s t y p e s d ' i n t e r v e n t i o n e n c a s d e r 6 c i d i v ed u c a n a l c a r p i e n :- - s e c t io n c o m p l 6 t e d e s s t r u c t u r e s l i g a m e n t a i r e sa v e c n e u r o l y s e ,- - s y n o v e c t o m i e s u p p l 6 m e n t a i r e ap r 6 s n e u r o l y s e ,- - p l a s t ie e n l a m b e a u d e t i ss u s y n o v i a l s u p p l 6 -m e n t a i r e a p r6 s n e u r o l y s e ,n e p e r m e t t e n t p a s d ' 6 t a b l i r u n e r e l a t i o n s t a t i s t i q u ea v e c l a q u a l i t 6 d e s r 6 s u l t a t s .A c o n d i t i o n d ' a v o i r u n e i n d i c a t i o n c o r r e c t e , l ep r o n o s t i c d e l a r 6 i n t e r v e n t i o n e s t b o n ; i l e s t c e p e n -d a n t l e p l u s m a u v a i s e n c a s d e f i b r o s e p r i m a i r e( B i t c h i e r [ 1 1 ) .D a n s l e d o m a i n e d e l a p l a s t i e e n l a m b e a u d e t i s s us y n o v i a l , d e u x q u e s t i o n s p e u v e n t 6 t r e p o s 6 e s :- - e s t -c e q u e , e n c a s d e si m p l e f e r m e t u r e d e l 'i n -c i s i o n a p r 6 s n e u r o l y s e , l a r 6 g 6 n 6 r a t i o n s e s e r a i t f a i t ea u s s i b i e n ?- - Q u e l e s t l ' a s p e c t d u n e f f e n d e s s o u s d e c e l a m -b e a u , l e c a s - - r 6 c i d iv e i td r a t i v e - - n e s ' e s t p a s e n -c o r e p r 6 s e n t 6 j u s q u ' / l m a i n t e n a n t .

C O N C L U S I O NN o r e l a t i o n t o t h e p o s i t i v e s u b j e c t i v e a n d o b j e c t i v e r e -s u l t s c a n b e e s t a b l i s h e d f o r e it h e r o f t h e t h r e e o p e r a t i o n sf o r t h e r e c i d i v a t io n o f t h e c a r p a l t u n n e l s y n d r o m e i .e .

- - O n l y s e p a r a t i n g l i g a m e n t s t r u c t u r e s s t i ll in t a c t a n dn e u r o l y s i s ; '- - a d d i t i o n a ll y p e r f o r m i n g a s y n o v e c t o m y a f t e r t h en e u r o l y s i s ;- - a d d i t i o n a l ly p e r f o r m i n g s y n o v i a l f la p p l a s ty a f te r t h en e u r o l y s i s .I f t h e i n d i c a t io n i s d e t e r m i n e d e x a c t l y t h e p r o g n o s i s f o ra s e c o n d o p e r a t i o n i s q u i t e g o o d , i t i s w o r s e i n t h e c a s eo f a p r i m a r y f i b r o s i s .T w o q u e s t i o n s r e m a i n o p e n r e g a r d i n g s y n o v i a l f la pp l a s t y :- - W o u l d r e g e n e r a t io n h a v e b e e n j u s t a s p o s it i ve i f t h ew o u n d h a d s i m p l y b e e n c l o s e d a f t e r t h e n e u r o ly s i s ?- - W h a t d o e s t h e m e d i a n n e r v e l o o k l ik e a ft e r a s y n o -v i a l f l a p p l a s t y .

R E F E R E N C E S1 . B U C H L E R U . , G O T H D . , H A U S S M A N N P . , L A N Z U . , M A R T I N IA . K . , W U L L E C . - - K a r p a l t u n n e l s y n d r o m : B e r i c ht f i b e r 5 6 N a c h -o p e r a t i o n e n . Handchirurgie , 1 9 8 3 , 15 , s u p p l . , 3 - 1 2 .2 . C R A M E R L . M . - - L o c a l f a t c o v e r a g e f o r th e m e d i a n n e r v e . C o r r e s -p o n d e n c e N e w s l e t t e r 3 5 A S ' S H , 1 9 8 5 .3 . D E L L O N A . L . , M A C K I N N O N S . E . - - T h e p r o n a t o r q u a d r a t u s m u s -c l e f l a p . J Hand S. .urg, 1 9 8 4 , 9 A , 4 2 3 - 4 2 7 .4 . P O E L L J . G . , B U C H L E R U . - - A n w e n d u n g d es r a di a le n V o r d e r ar m -l a p p e n s b e i m R e z i d i v - K T S . V o r t r a g a u f d e r J a h r e s t a g u n g d e r S e h w e iz e -r i s c h e n G e s e l l s c h af t f f ir P l a s ti s c h e u n d R e k o n s t r u k t i v e C h i r u r g i e , 1 9 8 5 ,5 . R E I S M A N N . R . , D E L L O N A . L . - - T h e a b d u c t o r di g it m i n im i m u sc l ef l a p : a s a l v a g e t e c h n i q u e f o r p a l m a r w r i s t p a i n . J P las t Recons t r Sur e ,1 9 8 3 , 72 , 8 5 9 - 8 6 5 .6 . W U L L E C . - - D i e S y n o v i a ll a p p e n p la s t ik b e i m R e z i d iv e i n e M e d i an u s -K o m p r e s s i o n s - S y n d r o m s . Plastische Chirurgie, 1 9 8 0 , 4/4 , 2 6 6 - 2 7 1 .

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