ASL Roma E
Polo Ospedaliero “Villa Betania”
Ortopedia e Traumatologia
Unità Operativa Chirurgia della Mano
Endoscopic carpal tunnel release:
fourteen years’ experience
with the MENON technique
ALFREDO DELL’UOMO M.D.
44° Congresso Nazionale Mano with Japanese Soc. - Milano, 13 ottobre 2006
The major thrust for endoscopic carpal tunnel release
(E.C.T.R.), is based on the hypothesis that by selectively
transecting T. C. ligament the post-op morbidity can be
minimized allowing early return to A.D.L.
ADVANTAGES & PECULIARITY
Ulnarly located oblique incision:
usually lies on the ulnar aspect of thepalmaris longus tendon
It can be anatomically
extended distally
to perform an
open procedure if
technical difficult arise
Tunnel is progressively dilataded
using blunt dilatators,
along the line of the fourth metacarpal
Identification and continous visualization
of the distal margin of T.C. ligament
Original cannula “D” shaped in cross-section,
prevents rotation of the cannula
once inserted into the carpal tunnel.
The distal end is blunt and closed.
The transverse carpal ligament is divided
by pushing the knife
in a proximal
to distal direction
The knife is with central concave cutting edge of 2,3mm,
with blunt corners
Due to the configuration of the carpal tunnel,
the tip of the cannula tends to point radially:
pressure on the proximal part of the cannula…..
…..will ensure that the tip rests
against the hook of the hamate,
thus preventig…..
…..inadvertent pressure on the common
digital nerve of the long and ring finger.
This tecnique can be performed with the equipment
available in any standard o. r.
CONTROINDICATIONS
•Recurrent carpal syndrome
• Rheumatoid arthritis
•Secondary C.T. syndrome due to space
occupying lesions
•Inadeguate intraoperative visualization
Clinical data
• 1007 hands (870 pz)
• Age: 22
88 years (51 years)
• Follow-up: 4
180 months
• Open release on the opposite side: 88 Pz
• Average operating time: 4-7 min
• Endo to
open (14 hands-1,35%)
Criteria for evaluation of surgical outcome
• Post operative pain
• Resolution of sintoma (97%)
• Post operative complication
• Recovery of grip strenght
• Appearance of new sintoma
• Subjective evaluation
F.E.S.S.H.
Fourth Congress 1997
E.C.T.R. by Menon single portal technique:
clinical & M.R.I evaluation after 160 cases
A. Dell’Uomo, M. Mastantuono
B. Congresso Europeo Chirurgia della Mano
M.R.I. measurements of the morphological
changes after E.C.T.R. show that the
volume increase parallels that open C.T.R.
Follow-up show that the volume
Increase is long lasting
PRE
POST
COMPLICATIONS
“Sindrome del tunnel carpale”
Verduci 2002- Springer Verlag 2006
Prof. P. Bedeschi
• Persistence of sintoma
• Recurrence of sintoma
• Appearance of new sintoma
- “skin scar”
- “pillar pain”
- neurological
- vascular
- etc
Personal complications
•6
Neuroapraxia 3° digital nerve +/communicating branch ulnar nerve
• 18
Hypotenar-pillar pain
•1
Superficial arch injury
•3
Second surgery
Second surgery
1. Incomplete release –neuroapraxia 3°
NEUROLYSIS
complete relief
2. Incomplete release –abundant scarring
NEUROLYSIS
no improvement
3. Partial lesion of third digital nerve
NEUROLYSIS + DIRECT REPAIR
improvement
Complcations of endoscopic and open carpal tunnel release
A.K.Palmer – Journal of Hand Surgery (1999)
Questionnaries to 1253 members of the
American Society for Surgery of the Hand
“… report ONLY on complications that they had
themselves treated surgically”.
NEUROLOGICAL COMPLICATIONS (5 YEARS)
LACERATIONS:
E.C.T.R.
265
•MEDIAN NERVE
•ULNAR NERVE
•DIGITAL NERVE
O.C.T.R.
230
“The data support the conclusion that carpal tunnel
release, be it endoscopic or open is not a safe and
simple procedure”
FINAL CONSIDERATIONS
•E.C.T.R. with the Menon technique is a reliable alternative
treatment to open release
•Based on the data available, E.C.T.R. has less morbidity in
the post-op period, than traditional release
•Surgeons unfamiliar with arthroscopic techniques may find
the procedure tecnically demanding
• T.C.L. can be adequate and safely sectioned, with high
success rate and very few complications
•If visualization is inadequate the surgeon must be
prepared to performe an open release and should not risk
injury to neurovascolar structures