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of the distal TCL. Next, the distal edge of the TCL is identified.
Usingascalpel, thedistaledgeofthe TCLisincised for
approximately 1.0cminadistal-to-proximaldirection and
along aline that is ulnar to the longitudinal midline of the
wrist so as to avoid the underlying tendons and median nerve.
Before using the Indiana To me preparatory instrumentation, it is possible to determine whether atransligamentous
motor branch of the median nerve is present. If the origin of the
thenarmusclesismoreulnar than expected upon initial
dissection and is in line with the path of release of the TCL,
this should raisesuspicion for apossibletransligamentous
motor branch. If this is the case, blunt scissors are used to
decide whether such abranch exists and should be protected.
Theblu nt pilot(Fig. 4) is introduced beneaththe TCL
distally.The surgeonsho ulddropthe instrumenthandle
towardthe patient’s hand during introduction such that the
tip of the blunt pilot is angled in avolar direction, thus hugging
the undersurface of the TCL. Passage of this blunt pilot should
be smooth and not at all aggressive.All of the instruments
should be passed longitudinally along theimaginaryline
extending proximally from the radial border of the ring finger.
As the blunt pilot is passed, the tip will be felt as it exits the
undersurface of the TCL proximally.Asurgical pen is then used
to mark the skin overlying the pilot tip, roughly two fingerbreadths proximal to the proximal volar wrist crease (Fig. 5).
This skin marking is used as atarget for later instrument passes
and ensures release of the TCL and the distal forearm fascia.
The palmar stripper is the next tool to be used (Fig. 6). It
consists of ablunt skid, which is longer,and asharp blade,
which is shorter.The palmar stripper should be oriented such
that the blunt skid will be inserted in adeeper position than the
sharp blade. The blunt skid is passed under the TCL in the
identical pathway as the previously passed blunt pilot, sliding
along the undersurface of the TCL. This allows the sharp blade
of the palmar stripper to pass superficial to the TCL and to free
the dense connections to the overlying palmar fascia (Fig. 7).
The palmar stripper is passed proximally until the blunt skid
hits the skin target marked earlier on the volar forearm.
The double pilot is the final instrument to be passed in
preparation for the cutting tome (Fig. 8). It has two blunt skids
to straddle the TCL superficiallyand deep.The skids are
slightlywider than the cuttingtome, therefore preparing a
pathwayfor smoothpassage of thecutting tome (3). The
double pilot is passed in the same distal-to-proximal direction,
with the skids straddling the TCL, until the tip is again seen and
felt at the volar forearm skin mark.
The single-use cutting tome may now be safely employed
(Fig. 2). The longer blunt skid of the tome is inserted just deep to
the TCL. The vertically oriented cutting blade is allowed to
engage the axilla of the incision of the previously released distal
edge of the TCL. Using asingle, smooth, steady motion, the
tome is passed proximally until the blunt skid reaches the skin
mark, thus releasing the TCL and the distal volar forearm fascia.
Anymeetingofresistanceshouldalert thesurgeontothe
FIGURE 1 The single pilot, double pilot, and palmar stripper. Source:From Ref. 3.
FIGURE 2 The single-use cutting tome. Source:From Ref. 3.
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Means et al.
possibility that the cutting tome is drifting from the pathway
defined by the preparatory instruments. Again, it is absolutely
critical that the cutting tome, as with the preparatory tools, be
passed along the same line visualized as extending proximally
from the radial border of the ring finger.
Once the cutting tome is removed from the wound, the TCL
may be inspected under direct visualization to ensure complete
release. Also, the carpal tunnel can be explored to evaluate for
tenosynovitis, masses, and median nerve condition (3).
For closure, tourniquet release is at the surgeon’s discretion. We do not routinely let down our tourniquet prior to
closure. Skin is closed with asuture of the surgeon’s choice.
No deep structures are repaired. Asplint may be used if the
surgeon desires, though we typically do not use one. Instead,
we allowthe patient to beginactiverange of motion in a
postoperativesoftdressingappliedtothe hand andwrist.
Stitches are removed in one to two weeks and activities are
gradually increased as tolerated. Patients may return to work
whencomfortable,somepreferringtoreturnevenprior to
thefirstpostoperative visit if heavylabor is notpartof
their profession.
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COMPLICATIONS
As with any procedure, complications may be divided into
major and minor categories. Complications that would likely be
considered minor would includesuperficial wound healing
difficulties, superficial infections, scar sensitivity,incomplete
symptom relief, and pillar pain. Major complications would
include deep infection, wound dehiscence, and nerve, tendon,
or arterialvessel injury.Iftheseproblems are encountered,
standardtreatments may be implemented as theyare for
open carpal tunnel release postoperative complications. The
outcomes section below discusses published series that define
complicationrateswith the LICTR syst em.Asmentioned
above, themosteffective manner of eliminating iatrogenic
damage to major structuresistofollow the steps as outlined.
If atechnical impasse is encountered during the procedure,
the surgeon must recognize the situation and either correct it so
that the technique may proceed or transition into acomplete
open carpal tunnel release. As with any “minimally invasive”
technique, we discuss with patients preoperatively the possibilityofconversiontoalarger exposure open procedure if
obstacles arise.
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OUTCOMES
Literaturereports regarding outcomes and complications for
therange of carpal tunnel release procedures vary widely.
Resolution of preoperative symptoms with LICTR using the
Indiana Tome hasbeencomparable to those obtained with
open or endoscopic carpal tunnel release. Several studies have
presented preoperativesymptom resolutionrates over 90%
with LICTR using the Indiana Tome (4–7). Recurrence rates
with LICTR have likewise been similar to those obtained with
other carpal tunnel release options. Yung et al. reported no
recurrences requiring repeat operation in 58 LICTRs after one
to two years (4). Botte et al. described a1%to11% recurrence
rate for traditional openrelease procedures necessitating
FIGURE 3 Operative markings of limited palmar incision and distal
border of thenar/hypothenar arch.The curved line represents the
distal margin of the pressure-bearing region of the carpal arch. The
LICTRprocedure maintains the integrity of this arch. Abbreviation :
LICTR, limited incision carpal tunnel release. Source:From Ref. 3.
FIGURE 4 The blunt pilot. Source:From Ref. 3.
FIGURE 5 Marking the position of the blunt pilot tip to create agoal for
orientation for subsequent instrumentation. Source:From Ref. 3.
FIGURE 6 The palmar stripper. Source:From Ref. 3.
Carpal Tunnel Release with the Indiana Tome
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295
reexploration (8). Interestingly,they noted multiple studies in
which the most common cause for recurrence was incomplete
sectioning of the distal portion of the TCL. The LICTR with the
Indiana Tome starts at the most distal aspect of the TCL, thus
minimizing this potential cause for recurrence or incomplete
symptom resolution while still allowing release of the distal
antebrachial fascia (2).
The most recent study regarding LICTR found that pillar
pain was present in 21% at three months, and 9% at one year (4).
This is similar to aprevious report which found that pillar pain
and scar tenderness werepresent in 14% at three months
following LICTR(5).These rates compare favorablywith
thosedescribed forendoscopicCTR and open CTR(9,10).
Many of the difficulties in determining the incidence of pillar
pain fordifferent procedures come from thenumerous
definitions and criteria for its diagnosis that exist (9).
As with all surgical interventions, every possible route to
carpal tunnel release has had reports of iatrogenicdamage to
structures.InLee and Strickland’s report of 694 LICTRs, there
weretwo (0.29%) cases of median nerve laceration, one with
partial injury and one with complete transection (2). These two
events occurred early in their usage of the Indiana Tome and
prompted achange in their release protocolinwhich more than
one pass with the cutting tome is not allowed. There is also a
case report of median nervetransectionusing theLICTR
Indiana Tome (11) following asinglepasswiththe cutting
tome. In this case, it was felt that injury may have occurred by
allowing the cutting tome to drift in aradial direction, based on
the orientation of the transection at the time of exploration.
Theauthors referenceabiomechanical cadaverstudy by
Gutowthatshowed 158 or more of radial deviationofthe
cuttingtomeled to mediannerve injuries in 50%oftheir
specimens. Conversely,keeping the tome in line with the long
axis of the ring finger,asdescribed in this chapter,led to no
nerveortendonlacerations (12).Atiketal. performed a
cadaverinves tigationthatconfirmed a“safe zone”inline
with the middle/ring finger axis for limited incision release
procedures (7). Theyalsoestablished that workingina
distal-to-proximal directionenhances thesafetyofthese
surgical interventions.
Palmer et al. found in aprospective, nonrandomized trial
of 211carpaltunnelreleases that ulnarnerve parasthesias
developed in 10%ofAgeesingleportal endoscopiccarpal
tunnel release (ECTR) patients, 13% of Chow double portal
ECTR patients, and 10% of open release patients (10). They had
no instances of nerve, vessel, or tendon lacerations with any
of the techniques used. In aprospective, randomized comparison of 192 hands using either the Agee single portal ECTR or
standard open release, Trumble et al. showed better results for
the first three months in the ECTR group (13). There was no
significant difference in complicationrates or cost between
the two methods. Boeckstyns and Sorensen did an analysis
of publishedseriesconcerningendoscopicand open
carpal tunnel release (14). They determined that ECTR had an
increasedriskoftransient nervedisturbances(4. 3%)over
open releases (0.9%) in prospective randomizedstudies.
However,their report also showed that the rate of permanent
nervedamage following ECTR wasequivalent to that for
open release (0.3% vs. 0.2% respectively). They stressed, nevertheless, that the potential devastating complications of ECTR
must be avoided by proper training and conversion to open
release when there is poor visibility with the endoscope.
In asurvey of members of the ASSH, Palmer and To ivonen
noted asurprisingly high number of median, ulnar,and digital
nerve lacerations as well as vessel and tendon lacerations which
surgeons had reported following open and endoscopic carpal
tunnel releases that either they had performed or they had
explored following referral from institutions outside of their
own (15). Out of 616 responses regarding open release, there
were 230 nerve, 34 vessel,and 19 tendon lacerations. The
authorsconcluded that carpal tunnel releaseregardlessof
technique may not be as safe as previously thought and that
surgeons must be “ever mindful of structures that lie within the
carpal tunnel.”
We are aware of asinglereportcomparing ECTR and
LICTR with the Indiana To me.Wongetal. investigated 30
patientswithbilateral CTSinaprospective, randomized
fashion(16). Patients were randomly assigned to have one
side treated with the modified Chow two-portal ECTR technique and the opposite hand with the LICTR method, or limited
open carpal tunnel release (LOCTR), as it is referred to in the
article. The investigators found statistically significantless
early postoperative pain and less pillar symptoms for those
in the LOCTR group. At one year,these differences did not
persist. At eight weeks postoperatively,there was anotable
patient preference for the LOCTR procedure. This predilection
for LOCTR showed only atrend at six months to one year
postoperatively.There were no majorcomplications in
either group.
FIGURE 7 Using the palmar stripper, the TCL is dissected free of its
dense connectionswith the overlying palmar fascia. Abbreviation:TCL,
transverse carpal ligament. Source:From Ref. 3.
FIGURE 8 The double pilot. Source:From Ref. 3.
296
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Means et al.
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SUMMARY
Overall, LICTR with the Indiana Tome is as effective and as safe
as other minimally invasive practices for carpal tunnel release.
It is arelativelystraightforwardskill to learnand maybe
reliably reproduced. Future studieswillnodoubthelpto
elucidate the most successful, safest, and most cost-effective
means of carpal tunnel release. However,aswith most surgical
endeavors, therelikelywill re mainroomfor individual
surgeons to decide what applicationworksbestintheir
hands. We feel the LICTR combines the reduced postoperative
pain and rapid recovery of other minimally invasive systems
with the safety and low cost of traditional open release.
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SUMMATION POINTS
Indications
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Primary idiopathic CTS.
Outcomes
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Comparable to open and otherminimally invasive
procedures.
Complications
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Similar to open and other minimally invasive techniques.
However,significant nerve or other structural injuries are
possible if the surgeon is not properly trained in the technique.
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REFERENCES
1. Concannon MJ, Brownfield ML, Puckett CL. The incidence of
recurrence after endoscopic carpal tunnel release. Plast Reconstr
Surg 2000; 105:1662–5.
2. Lee WP,Plancher KD, Strickland JW.Carpal tunnel release with a
small palmarincision. Hand Clin 1996; 12:271–84.
3. Higgins JP,Graham TJ.Carpal tunnel release via limited palmar
incision.Hand Clin 2002; 18:299–306.
4. Yung PS,Hung LK, Tong CW,HoPC. Carpal tunnel release with a
limited palmar incision: clinical results and pillar pain at 18
monthsfollow-up. Hand Surg 2005; 10(1):29–35.
5. Lee WP,Strickland JW.Safe carpal tunnel release via alimited
palmarincision. Plast Reconstr Surg 1998; 101:418–24.
6. Serra JM, Benito JR, Manner J. Carpal tunnel release with ashort
incision.Plast Reconstr Surg 1997; 99:129–35.
7. Atik TL ,Smith B, Baratz ME. Risk of neurovascular injury with
limited-open carpal tunnel release: defining the “safe-zone”.
JHand Surg [Br] 2001; 26(5):484–7.
8. Botte MJ, von Schroeder HP,Abrams RA, GellmanH.Recurrent
carpal tunnel syndrome. Hand Clin 1996; 12(4):731–43.
9. Ludlow KS, Merla JL, Cox JA, Hurst LN. Pillar pain as apostoperative complication of carpal tunnel release: areview of the
literature. JHand Ther 1998; October/December:277–82.
10. Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK ,Olson JD.
Endoscopic carpal tunnel release: acomparison of two techniques
with open release. Arthroscopy 1993; 9(5):498–508.
11.Chapman CB, Ristic S, RosenwasserMP. Complete median nerve
transection as acomplication of carpal tunnel release with acarpal
tunnel tome. Am JOrthop 2001; 30(8):652–3.
12. Gutow AP.Cadaveric evaluation of minimal incision carpal tunnel
release using the Biomet Indiana Tome carpal tunnel release
system. In: Annualmeeting of ASSH. Minneapolis, MN,
September 10–12, 1998.
13. Trumble TE,Diao E, Abrams RA, Gilbert-Anderson MM. Singleportal endoscopiccarpal tunnel release compared with open
release; aprospective, randomized trial. JBone Joint Surg Am
2002; 84(7):1107–15.
14. BoeckstynsMEH, Sorensen AI. Does endoscopic carpal tunnel
release have ahigher rate of complications than open carpal
tunnel release? JHand Surg[Br] 1999; 24(1):9–15.
15. Palmer AK, Toivonen DA. Complications of endoscopic and open
carpal tunnel release. JHand Surg [Am] 1999; 24:561–5.
16. Wong KC, Hung LK, Ho PC ,Wong JMW.Carpal tunnel release: a
prospective, randomised study of endoscopic versus limited-open
methods. JBone Joint Surg Br 2003; 85:863–8.
Carpal Tunnel Release with the Indiana Tome
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38
Minimally Invasive Carpal Tunnel Release Using the
Security Clipe
James W. Strickland and Lance A. Rettig
Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.
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INTRODUCTION
Carpal tunnel syndrome (CTS) results from irritation of the
median nerve at the level of the wrist (1). Any process that
increases the contents of the carpal canal can lead to higher
interstitial pressure and compression of the median nerve (2,3).
Treatmentsare designed to increase the space available for
the nerve. First line treatment includes splinting the wrist in
aneutral position. Kuo, utilizing ultrasound studies, demonstrated that positioning the wrist in neutral lowers compression
of themediannerve (4). Additional non-surgicaltreatment
options includesteroid injection, ac tivity modifications,
tendon gliding exercises and the administration of anti-inflammatary medications (5).
When symptoms are recalcitrant to conservative management surgical intervention is indicated. The goal of surgery is
to decompress the median nerve in the carpaltunnelby
transectingthe deep transverse carpal ligament (TCL).
Surgical options include open or endoscopic division of the
TCL. Open techniques are performed through alongitudinal
incision in the proximal palm with or without extensions
across the wrist. Dissection is carried out until all or part of
theTCL has been exposed. The entire ligament is then
carefully transected.
Limited or short palmar incisions have evolved because
thesemethodsare thought to result in reducedmorbidity
comparedtomoreextensive approaches that violate all tissue
planes over agreater distance. Decreased palmar sensitivity or
pillar pain may be reduced in acarpal tunnel released with a
limited incision (6). Instrumentation has beendeveloped to
allow for safe division of the TCL through asmall incision (7).
Design changes have taken place to decrease the chance of
mediannerve injury.The Security Clipe (Biome t, Warsaw
Indiana, U.S.A.) was designed as amethod of enclosing the
ligament before passing the transecting knife in order to prevent
any adjacent structures from entering the cutting path.
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INDICATIONS
Patients whose CTS symptoms are unresponsive to conservative treatment after two to three months may be considered
for operative releaseusi ng theSecurity Clip or astandard
open incision. Contraindications for the Security Clip include
patientswithaknownpalmar carpal canalmass, previous
displaced wristfracture, or any otherconditionthat may
have alteredwrist morphology.Arelativecontraindication
is apatient requiringconcomitant open palmar flexor
tenosynovectomy.
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CONSIDERATIONS FOR PREOPERATIVE PLANNING
Physical exam findings, symptoms, and neurodiagnostic tests
are all helpful in the diagnosis of CTS. CTS must be differentiated from amore proximal median nerve compression such
as cervical radiculopathy or pronator syndrome.
Phalen’smaneuver and median nervecompression
test can help localize embarrassment of the median nerve at
the wrist level (8). Abnormally expanded two-point sensory
exam and thenar muscle wasting suggests chronic and severe
compressionofthe nerve. Nerveconductionand electromyographic studies are the principle objective tools used to
evaluate CTS (9). These tests can also be helpful in clinical
staging of CTS.
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SURGICAL TECHNIQUE
Carpal tunnel release (CTR) with the Security Clip system is
performed as an outpatient using local, regional, or general
anesthesia. Instruments required for the procedureinclude a
hand set, asmall Holzheimer type self-retaining retractor,the
soft tissue preparatory instruments, the Security Clip and the
disposable blade that tracks in the Clip. The patient is placed
supine on the operating table. Awell- padded tourniquet is
placed around the brachium. The operated arm is then placed
on ahand table.
TentoFifteen cc’sof1%local anesthesia withoutepinephrine are placed into the midline of the proximal palm
and across the wrist and distal forearm. Additional anesthetic
is administeredinto the deeper tissues palmar to the TCL. Three
to five cc’s of local anesthetic should also be placed within the
carpal canal staying ulnar to the midline to avoid injury to the
median nerve.
Thelandmarksfor thesurgical incision arethe distal
border of the thenar muscles and the radial border of the ring
finger.Aline is drawn over the proximal extent of the TCL in
line with the longitudinal axis of the radial border of the ring
finger.Asecond line is drawn diagonally from the proximal
thenar musculature. The point of intersection of the two lines
approximates the most distal edge of the TCL (Fig. 1). The skin
incision is approximately 1.5 cm in length. It is designed to be
about two-thirds proximal and one-thirddistal to the extended
thenar muscle line.
The arm is elevated briefly or an Esmarch wrap is utilized
and the tourniquet usually inflated to 250 mmHg. The skin is
inciseddownthrough thepalmarfascia. Aselfretaining
retractor (Holtzheimer or Biomet CTR retractor) is positioned
in the wound. The Biomet (Biomet, Warsaw,Indiana, U.S.A.)
retractor has aslight palmar bend which is helpful for the
slightly extended wrist. The retractor is gradually deepened
by pushingthe tissuewalls away with an elevatorand
repositioning. The proximal component of the Biomet retractor
or aRagnellretractorisutilizedtoretractthe soft tissue
proximally ex posingthe leadingedgeofthe TCL. With
careful dissectionwithinthe distal portionofthe carpal
canal, anomalous or penetrating branches of the recurrent
motor branch of the median nerve are identified. The superficial palmar arterialarch is usuallyvisualizedand easily
protected throughout the procedure.
When the distal portion of the TCL has been identified a
scalpel blade is then used to longitudinally divide the distal
ulnar 1.5 cm of the ligament under direct vision (Fig. 2). Three
instruments are utilized to clear any tissues adherent to the
TCL. The first instrument the blunt single pilot, has asmooth
edge and flat plane (Fig. 3). The purpose of the tool is to create a
clear plane between the ligament and the underlying contents
of the carpal tunnel. The pilot is placed just deep to the “V”
shaped notch created by incising the distal 1.5 cm of the TCL.
The instrument is passed from distal to proximal deep to the
ligament. The pilot and all subsequent instruments must be
directedslightly ulnarwardtoavoid injury to theradially
vectored median nerve.
After removal of the pilot, the palmar stripper is placed into
thewound.Itisadouble sidedinstrumentwith ablunt
lower skid andasharpenedupper edge 15 mm in length
(Fig. 4A). The tool is designed to prepareachannel through
the dense connective tissue immediately palmar to the ligament.The distancebetween thetwo skids is 3mm
approximating the thickness of the ligament at its distal third.
This allows the instrument to straddle the ligament as it is
passed from distal to proximal. Under direct visualization, the
tool is inserted into the notch created by distal division of the
ligament. The lower skid is placed deep to the ligament and
passed proximally.The sharper shorter upper skid will pass
palmar to the ligament. The stripper is passed until the blunt
center post meets the edge of the “V” shaped defect of the
ligament (Fig. 4B). After withdrawing the palmar stripper,the
double pilot is introduced. The tool has long blunt upper and
lower skids (Fig. 5A). There are no sharp edges on the skids
whichcouldinjuresurrounding anatomical structures.The
double pilot enters the “V” notch created by the incision in
the distal ligament. It straddles the ligament and is passed
proximally to establish apathway for the Security Clip. The
tool is passed until the blunt center post is fully engaged against
the distal edge of the ligament (Fig. 5B). It is critical that the
instruments arepassedsequentially using thesameulnar
vector.All instruments aremoistened priortopassage to
provide better slidingcharacteristics. If some difficultyis
encountered when passing the double pilot, it may be passed
several times in aslightly different direction to be sure that there
is an adequate channel for Security Clip passage.
The Security Clip is designed to protect the soft tissues on
both the palmar and dorsal sides of the ligament. The lower skid
has the same length as that of the double pilot. An upper skid is
present which converges on the lower skid terminally (Fig. 6A).
The distance between the proximal end of the clip and the
terminal closureofthe upper skid is 3.5 cm. With this configuration, the Security Clip straddles the ligament creating aclosed
system that is consistent with the usual morphology of the TCL;
thin proximally andthicker distally.Prior to passing the
SecurityClip,astylus is introduced into itscentral track
creatinga3mmseparation betweenthe lower andupper
FIGURE 1 Landmarks for the surgical incision. The incision is about
two-thirds proximal and one-third distal to the extended thenar muscle
line and slightly ulnar to the midpoint betweenthe two creases.
FIGURE 2 Incision of the distal 1.5 cm of the transverse carpal ligament
under direct vision. The specially designed, three-sidedBiomet retractor
facilitatesexposure.
FIGURE 3 The blunt pilot is passed beneath the carpal ligament.
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Stricklandand Rettig
skids (Fig. 6B). This facilitates positioning of the Security Clip
into the prepared channel across the ligament. As the assembly
is advanced from distal to proximal across the TCL the stylus
will automatically be backed out by the edge of the ligament,
and the distal tips of the instrument will close together on the
ligament (Fig. 6C). When fully seated, the Security Clip will
contain the entire TCL between its skids and all other adjacent
tissues will be safely out of harm’s way (Fig. 6D).
With the Security Clip straddling the ligament adisposable
blade is inserted into the track of the device and passed from
distal to proximal between the upper and lower skids (Fig. 7A).
The blade is passed down the Security Clip completely dividing
the TCL. The upper and lower skids serve to protect the tissues
dorsal and palmar to the ligament. Advancement of the blade
continues until the disposable device fits flush with the Security
Clip (Fig. 7B,C). Once the blade is fully seated, it is withdrawn.
The Security Clip is then removed from the wound.
The softtissues arecarefully retractedproximallyto
confirm complete decompression of the TCL. AFreer elevator
may also be used to confirm the interval between the transected
edges of the TCL. Hemostasis is achieved with bipolar cautery.
Thewoundisirrigated andthe skin closed with 5.0non-
absorbable horizontal mattress sutures. Awell padded dressing
is applied with the fingers left free for full motion and the
tourniquet is deflated.
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POSTOPERATIVE REHABILITATION
Early digital range of motion is encouraged within the confines
of the dressing.
At 10 to 14 days following surgery,the sutures are removed
and active range of motion of the wrist is initiated. Motion and
strengthening exercises are begun at two to four weeks postoperation. At one month, patients are permitted to start wrist
strengthening and return to moderate activities. In most cases,
patients are able to return to work related activities including
heavy labor vocations at six weeks.
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COMPLICATIONS AND THEIR MANAGEMENT
The overall complication rate of open CTR is estimated to vary
between 2% and 10% (10–12). Reported complications include:
median, ulnar,and digital nerve lacerations, vessel and tendon
injuries (13). Although the Security Clip is designed for protection of the surrounding anatomical structures, the possibility
of median nerve injury still exists. There are two important
technical tips to help minimize the risk of median nerve injury.
No instrumentation should be passed until the distal portion
of the TCL is well visualized and divided. The pilots and the
Security Clip should always be angled slightly ulnar to the
midline when passed from distal to proximal.
If at any time there is concern regarding the possibility
of nerve injurythenthe limitedpalmarincision shouldbe
extended proximally for exploration. CTR utilizing astandard
incision should be performed if an anomalous branch of the
median nerve or an intracarpal ganglion cyst is discoveredat
the time of the operation.
Occasionally,someres istancemay be noted while
attempting to pass the Security Clip. In these cases, the steps
of ligament preparationare repeated with passage of the palmar
stripper and double pilot. Once again the Security Clip is passed
making sure to maintain the same passageway and direction
created by the pilots. If necessary,the skin incision may be
lengthened proximally for ashort distance and the incision into
the distal TCL extended proximally.
(A)
(B)
FIGURE 4 ( A )The configuration of the palmar stripper with its short
sharpupper component and long blunt lower skid. ( B )Drawing of
completed passageofthe palmar stripperafter it hasprepared a
channel through the dense palmar connective tissue.
(A)
(B)
FIGURE 5 ( A )Introduction of the double pilot with its blunt upper and
lower skids. ( B )Drawing of completed passage of the double pilot with
the skids straddling the transverse carpal ligament.
Carpal Tunnel Release Using the Security Clipe
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OUTCOMES
Previous published results of CTR utilizing alimited incision
technique have demonstrated good relief of symptoms with
minimal risk of nerve injury (6,7,14). Proposed advantages of
using alimited incision are decreased pillar tenderness and
earlier return to work or avocational activities (6,7). Hallock
found similar results when comparing the mini-open technique
to the endoscopic CTR (15). We have performed over 500 CTRs
utilizing the Security Clip device. Asingle patient was thought
to have sustained adigital nerve partial laceration. Postoperatively,the patientwas found to haveexpanded two-point
discrimination over the distribution of the ulnar digital nerve
of the middle finger.The amount of pillar tenderness and time
to return to activities has compared favorably with open CTR
using alimited palmar incision (6,7,14).
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SUMMARY
Open CTR through alimited open incision using the Security
Clip is an effective device for complete division of the TCL. The
(A)
(B)
(C)
(D)
FIGURE 6 ( A )The appearance of the Security Clip with the stylus in
place ( upper ). The disposable blade fits into the midline of the Clip
device. ( B )The Security Clip with the stylus in place is passed from distal
to proximal, positioningthe lower skid deep into the transverse carpal
ligament. ( C )Asthe Security Clip is fully seated the stylus is automatically backed out of the device. ( D )Drawing of the Security Clip fully
engaged with the TCL contained between the upper and lower skids.
(A)
(B)
(C)
FIGURE 7 ( A )The disposable blade is positioned into the clip and
passed distal to proximal betw een theupper and lower skids.(B )
Advancementofthe blade continues until it is fully seated within the
Security Clip. ( C )Drawing of the Security Clip with the disposableblade
fully seated within the device. The blade is positioned between the upper
and lower skids protecting the surrounding tissue. The transverse carpal
ligament has been transected at this point.
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Stricklandand Rettig
upper and lower skids protect the adjacent anatomic structures
to allow for safe transection of the ligament.
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SUMMATION POINTS
Indications
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CTS based upon physical exam and/or electrical studies
with recalcitrantsymptomsfollowing conservative
management.
Outcomes
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92% achieve near complete relief of preoperative symptoms
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6% improved but symptoms still present
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2% unchanged
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Only slight pillar sorenessnoted at six to eight weeks
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Return to most activities at six weeks (7)
Complications
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Median, digital, ulnar nerve injury
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Tendon/arterial laceration
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FUTURE DIRECTION OF TECHNIQUE
Instrumentation should continually be developed to increase
the safety margin for release of the TCL. Refinements in the
techniquedescribed here will incl udedesignchangesto
improve the ease of instrument passage and methods to better
confirm the complete division of the TCL.
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REFERENCES
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Carpal Tunnel Release Using the Security Clipe
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