Hepinstall Matthew S, Yang S Steven
Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY 10021, USA.
J Hand Surg Am. 2008 Sep;33(7):1057-62. doi: 10.1016/j.jhsa.2008.03.009.
In patients having basal joint arthroplasty, rates of concomitant carpal tunnel syndrome may exceed 43%. Excision of the trapezium during basal joint arthroplasty partially releases the transverse carpal ligament. The objective of this study was to determine whether indirect release of the remaining fibers of the ligament at its insertion on the scaphoid tubercle through the same incision would adequately decompress the carpal canal. This would avoid the morbidity of a second incision.
We retrospectively reviewed 10 consecutive patients treated over a 2-year period who had concurrent ligament reconstruction, tendon interposition basal joint arthroplasty of the thumb with complete trapezial resection, and indirect carpal tunnel release through a single incision. Self-reported postoperative pain relief was documented. Preoperative and postoperative evaluations of light touch sensibility, Tinel's sign, Phalen's test, median nerve compression test, and Weinstein Enhanced Sensory Test monofilament testing were analyzed. All patients had preoperative electrodiagnostic testing.
At mean 12 month follow-up (range, 5-35 months), numbness and paresthesias resolved in all cases: 9 patients had good or excellent pain relief and 1 reported fair pain relief despite transient postoperative reflex sympathetic dystrophy. Tinel's, Phalen's, and median nerve compression tests were each positive in 9 patients preoperatively and 0 patients postoperatively. Diminished light touch sensibility was present in 7 preoperatively and 1 postoperatively. WEST monofilament thresholds improved postoperatively in 8 patients. These improvements were statistically significant. One patient had postoperative nerve conduction studies performed to evaluate an ulnar nerve lesion at the elbow; the preoperative median nerve abnormalities had normalized.
Carpal tunnel syndrome can be successfully managed with indirect release of the transverse carpal ligament during basal joint arthroplasty, thus avoiding a second incision, reducing operating time, and potentially reducing the possibility of perineural adhesions, recurrent motor branch injury, palmar cutaneous nerve damage, weakness, stiffness, and pillar pain.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
在接受第一腕掌关节置换术的患者中，合并腕管综合征的发生率可能超过43%。第一腕掌关节置换术中切除大多角骨可部分松解腕横韧带。本研究的目的是确定通过同一切口在舟骨结节处间接松解韧带剩余纤维是否能充分减压腕管。这将避免二次切口带来的并发症。
我们回顾性分析了连续10例在2年期间接受治疗的患者，这些患者同时进行了韧带重建、带肌腱植入的拇指第一腕掌关节置换术并完全切除大多角骨，以及通过单一切口间接松解腕管。记录患者术后自我报告的疼痛缓解情况。分析术前和术后的轻触觉敏感性、Tinel征、Phalen试验、正中神经压迫试验以及Weinstein增强感觉试验单丝测试结果。所有患者术前均进行了电诊断测试。
平均随访12个月（范围为5 - 35个月）时，所有病例的麻木和感觉异常均消失：9例患者疼痛缓解良好或极佳，1例尽管术后出现短暂的反射性交感神经营养不良，但报告疼痛缓解尚可。Tinel征、Phalen试验和正中神经压迫试验术前在9例患者中呈阳性，术后均为阴性。术前7例患者轻触觉敏感性降低，术后1例。8例患者术后Weinstein增强感觉试验单丝阈值有所改善。这些改善具有统计学意义。1例患者术后进行了神经传导研究以评估肘部尺神经病变；术前正中神经异常已恢复正常。
在第一腕掌关节置换术中通过间接松解腕横韧带可成功治疗腕管综合征，从而避免二次切口，减少手术时间，并可能降低神经周围粘连、运动分支反复损伤、掌侧皮神经损伤、无力、僵硬和支柱痛的可能性。
研究类型/证据水平：治疗性IV级
