Recurrent Carpal Tunnel Syndrome––Analysis of the Impact of Patient Personality in Altering Functional Outcome Following a Vascularised Hypothenar Fat Pad Flap Surgery

We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological confirmation of true recurrent carpal tunnel syndrome from January 2004 to December 2009. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from the hypothenar region and sutured to the lateral cut end of flexor retinaculum. The patient characteristics, co-morbidities, duration of symptom, interval between first release and revision surgery and intra-operative findings were assessed against post-operative relief of pain, recovery of sensory and motor dysfunction. The average age of the patients was 58?years (43?C81) and the dominant hand was involved in 22 patients. Intra-operatively the nerve was compressed by scar tissue connecting the previously divided ends of the retinaculum in 18 and nine had scar tissue and fibrosis around the nerve. Following surgery 16 patients had complete recovery (asymptomatic at the first follow-up), eight had delayed recovery (partial recovery of symptoms at final follow-up) and three had a poorer outcome (persistence of preoperative symptoms at the final follow-up). The patients with delayed recovery/poorer outcome had a) Early recurrence; b) Diabetes mellitus; c) Obesity; d) Cervical spine problems; e) Involvement of non-dominant hand; and f) Intraoperative scar tissue and fibrosis. The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that can be used in patients with recurrent carpal tunnel syndrome. The factors that were associated with poorer/delayed recovery were involvement of non-dominant hand, recurrence within a year from the previous surgery, intra-operatively scar tissue in the carpal tunnel and associated co-morbidities, like obesity diabetes mellitus and cervical spine problems.     

Pedicled fat flap coverage of the median nerve after failed carpal tunnel decompression

We reviewed 14 patients treated with either an ulnar or a hypothenar fat flap for recurrent carpal tunnel syndrome and scar tenderness. Nine patients were satisfied and there were few complications. One patient had delayed skin healing and another developed a hypertrophic scar.     

Recurrent carpal tunnel syndrome: treatment options

Many techniques are available to the surgeon confronted with a patient with recurrent nerve entrapment/traction neuritis. The advantage of local muscle or fat flaps like the ADQ, pronator quadratus, and hypothenar fat flap is the ease at which each can be elevated. The size is very limited, however. Circumferential vein wrapping has been studied extensively and is efficacious despite the absence of vascularity, but length requirements may limit the indications to short nerve segments, as might be expected with recurrent carpal tunnel syndrome. Despite the increased complexity of a pedicled flap and free tissue transfer, the tissue availability, girth, and source of vascularity make these sophisticated techniques more attractive. Such flap transfers should be used only after the more simple techniques have been ruled out as options or failed and only if residual pain and hypersensitivity are due to localized neuritis as opposed to a more generalized dystrophic symptomatology.     

The hypothenar fat-pad flap for reconstructive repair after scarring of the median nerve at the wrist joint

Because of the loss of mobility, scarring of the median nerve in the carpal tunnel can lead to chronic pain syndrome of the wrist joint, with reduced sensation, muscular dystrophy and severe limitation of the use of the hand. This syndrome most often appears following open carpal tunnel release. Nine patients with scarring of the median nerve in the carpal tunnel were treated with a hypothenar fat-pad flap. Eight of them showed a significant reduction in pain, with improved sensation, trophism and strength. The procedure is suitable as a salvage procedure for restoring a sliding pathway and for cushioning the median nerve in the presence of recurrent lesions in the carpal tunnel.     

Anatomical study of the pre-retinacular fat pad of the wrist: application to a new surgical approach to the carpal tunnel

INTRODUCTION: Decompression of the median nerve in the carpal tunnel by section of the flexor retinaculum is the generally accepted treatment for carpal tunnel syndrome and is usually effective in relieving the symptoms. Following postoperative observations we proposed the hypothesis that incisional pain following open carpal tunnel release could be partly explained by injury to the fat pad situated between the palmar carpal ligament and the flexor retinaculum. METHOD: We performed an anatomical study on 20 fresh adult latex injected upper limbs. RESULTS: The sus-retinacularis fat pad is a real anatomical structure, clearly delineated and located inside a defined fibrous space with its own innervation from the ulnar nerve. It lies in the path of the normal carpal tunnel approach. DISCUSSION: Although most postoperative scar tenderness is attributed to neuroma formation because of injury to transverse branches of the palmar cutaneous nerves, we nevertheless consider that injury to the preretinacular fat pad also plays a part. We propose a modified approach to the carpal tunnel. This is a safe and simple method which respects the integrity of the sus-retinacularis fat pad so as to minimise the extent of scar tenderness.     

Use of the palmaris brevis flap for preventing recurrent median nerve compression in mucolipidosis.

In a patient with severe, recurrent bilateral carpal tunnel syndrome secondary to mucolipidosis, the 'turnover' palmaris brevis flap was used in conjunction with internal neurolysis. The procedure was effective in alleviating symptoms of recurrent carpal tunnel compression in both hands.     

Flexor digitorum sublimis flap for recalcitrant carpal tunnel surgery

Carpal tunnel release is commonly performed to treat paresthesias, pain, and hand or wrist dysfunction. Despite it being a highly successful procedure, on occasion some patients may continue to suffer from persistent or recurrent symptoms after surgery. Techniques to manage recurrent symptoms range from nonoperative care including injections, splinting, and medications to revision surgery that may include a number of options such as local or distant flap coverage of the median nerve, nerve conduit placement, and/or utilization of vascularized tissues. This paper describes the technique of using a vascularized rotational muscle flap harvested from the flexor digitorum sublimis as a viable option to envelop the median nerve and promote healing during carpal tunnel revision surgery.     

Free anterolateral thigh flap with vascularized lateral femoral cutaneous nerve for the treatment of neuroma‐in‐continuity and recurrent carpal tunnel syndrome after carpal tunnel release

Treatment of recurrent carpal tunnel syndrome (CTS) is challenging, especially in a case with recurrent CTS and a neuroma formation. Resection of the neuroma causing the syndrome, reconstruction of the nerve gap of the median nerve, and covering up the reconstructed median nerve with well‐vascularized soft tissue for prevention of CTS re‐recurrence are the essential procedures. We report a case of recurrent CTS with severe pain due to a neuroma‐in‐continuity successfully treated using a free anterolateral thigh (ALT) flap with a vascularized lateral femoral cutaneous nerve (LFCN). A 2 cm neuroma existed in the median nerve and was resected. The nerve gap was repaired using a vascularized LFCN included in the ALT flap. The ALT flap was transferred to the wrist to cover the median nerve. The severe pain disappeared completely and the sensory and motor impairment of the median nerve improved 5 months after the free flap surgery, as the Tinel's sign moved distally away from the wrist and disappeared. The result of the Semmes‐Weinstein test improved from 5.08 to 4.31 and she was able to flex and extend the right wrist and fingers without pain. CTS did not recur 15 months after the surgery. A free ALT flap with vascularized LFCN allows nerve reconstruction for the median nerve gap created after neuroma resection and coverage of the median nerve with well‐vascularized soft tissue to prevent adhesion and CTS recurrence. © 2013 Wiley Periodicals, Inc. Microsurgery 34:145–148, 2014.     

Management of true recurrent carpal tunnel syndrome: is it worthwhile to bring vascularized tissue?

Since 1989, 13 consecutive cases of true recurrent carpal tunnel have been operated on. Average delay before reoperation was 20 months (3 to 60 months). Intraoperative findings were univocal: extensive fibrosis with nerve adhesion to the roof of the carpal tunnel and a lack of nerve gliding. Surgery performed was: extensive external neurolysis from distal forearm to distal to carpal tunnel to allow a complete freedom of the nerve. A vascularized flap was never performed. Mean follow-up was 27.5 months (range 4 to 74 months). Results were: complete relief of symptoms in 75%; improvement with complete disappearance of nocturnal symptoms but persistent dysesthesia in 17%; no improvement in one patient (Sudeck's dystrophy). Interests of this study are: homogeneous population (only true recurrence), no bias from work compensation, consecutive cases, one surgeon, standardized surgical procedure and one independent observer. Results suggest that main factor for true recurrent carpal tunnel syndrome is lack of normal gliding of the nerve and that an extensive neurolysis helps to restore this gliding.     

Management of Recurrent Carpal Tunnel Syndrome with Microneurolysis and the Hypothenar Fat Pad Flap

A retrospective chart review for the period between 1998 and 2006 was conducted to evaluate microneurolysis combined with a hypothenar fat pad flap (HTFPF) for patients at Mayo Clinic, Scottsdale, Arizona, who were being treated for recurrent carpal tunnel syndrome. After exclusion of patients with incomplete release of the transverse carpal ligament at the time of the original operation, 28 consecutive patients were identified. Their average age was 68.5 years (range 43–89 years). The average interval between the original carpal tunnel release and reexploration was 82 months (range 5–298 months). The average follow-up was 10.5 months (range 3–48.4 months). The preoperative two-point discrimination tests averaged 7 mm (range 5–12 mm). At surgery, all patients were found to have fibrosis surrounding the median nerve with adherence of the nerve to the radial leaf of the transverse carpal ligament. After surgery, the Tinel sign disappeared in 26 of 28 patients and two-point discrimination improved to an average of 6 mm (range 4–8 mm). Postoperative grip strength averaged 20 kg, compared with 11 kg preoperatively. Pain completely disappeared in 83% of patients (average improvement 93%, range 5–100%). Numbness completely disappeared in 42% of patients (average improvement 82.9%, range 5–100%). Tingling disappeared in 50% of patients (average improvement 84.7%, range 5–100%). No patient reported being worse after reoperation. These results suggest that the combination of microneurolysis and HTFPF can restore median nerve gliding and provide soft-tissue coverage, improving symptoms in patients with recurrent carpal tunnel syndrome. Oral presentation at the 71st Annual Meeting of the American Academy of Orthopedic Surgeons, San Francisco, California, March 10–14, 2004. Oral presentation at the 2005 Annual Meeting of the American Association for Hand Surgery, Fajardo, Puerto Rico, January 12–15, 2005. Poster presentation at the 60th Annual Meeting of the American Society for Surgery of the Hand, San Antonio, Texas, September 22–24, 2005.     

Transverse carpal ligament reconstruction with polyesterurethane patch for prevention of recurrence in therapy of failed primary carpal tunnel surgery

A small group of patients with carpal tunnel syndrome (CTS) can present recurrences and persistent symptoms of CTS after its surgical release. If recurrence is due to scarring between median nerve and surrounding tissue (true recurrence of CTS, transverse carpal ligament [TCL] reconstruction with transposition flap technique is available but it presents poor results: This 48-year-old woman presented a recurrence of CTS 3 months after open standard incision. At operation, a scar was detected that did not permit normal median nerve gliding during wrist movements. External neurolysis restored normal gliding and non-absorbable polyesterurethane patch was used to reconstruct TCL. At 2-year follow-up the patient was in good health and returned to her manual usual job without pain and sensitive and motor deficits. Implantation of unresorbable poliesterurethane patch for TCL reconstruction after external neurolysis appears to be more advantageous than TCL reconstruction with transposition flap technique because it takes little time, causes minimal adhesion formation, does not need of wide incision and provides the same favourable conditions of the transposition flap as mechanical stabilization of the tranverse carpal arch, prevention of bowstringing of the flexor tendons, increase of postoperative grip strength and good protection of the median nerve. However, more cases should be studied before considering TCL reconstruction with poliesterurethane patch as a useful option in secondary surgery of true recurrence of CTS.     

无覆盖带蒂颊脂垫瓣在修复口腔缺损中的应用

目的：介绍无覆盖带蒂颊脂垫瓣用于口腔缺损修复的实践。方法：将颊脂垫瓣转移到相应的口腔缺损区,暴露的颊脂垫瓣表面无需植皮,可以自行上皮化。结果：共治疗口腔缺损病例13例,均获成功,颊脂垫瓣封闭效果好。结论：无覆盖带蒂颊脂垫瓣作为局部区域性组织转移瓣,对口腔内颊部、软腭和牙槽等部位软组织缺损的修复尤为适宜,是一种口腔内软组织缺损理想的充填材料。     

Practical anatomy of the carpal tunnel

The carpal tunnel is most narrow at the level of the hook of the hamate. The median nerve is the most superficial structure. It has specific relationships to surrounding structures within the carpal tunnel to the ulnar bursa, flexor tendons, and endoscopic devices placed inside the canal. The importance of the ring finger axis is stressed. Knowledge of topographical landmarks that mark the borders of the carpal tunnel, the hook of the hamate, superficial arch, and thenar branch of the median nerve ensure appropriate incision placement for endoscopic as well as open carpal tunnel release surgery. Anatomy of the transverse carpal ligament, its layers and relationships to adjacent structures including the fad pad, Guyon's canal, palmar fascia, and thenar muscles has been discussed. Fibers derived primarily from thenar muscle fascia with connections to the hypothenar muscle fascia and dorsal fascia of the palmaris brevis form a separate fascial layer directly palmar to the TCL and can be retained. This helps to preserve postoperative pinch strength. The fat pad in line with the ring finger axis overlaps the deep surface of the distal edge of the TCL and must be retracted in order to visualize the distal end of the ligament. Whereas the ulnar artery within Guyon's canal is frequently located radial to the hook of the hamate, injury to this structure has not been a problem during ECTR surgery. Variations of the median nerve and its branches, as well as the palmar cutaneous nerve distribution, have been reviewed. A rare ulnar-sided thenar branch from the median nerve, interconnecting branches between the ulnar and median nerves located just distal to the end of the TCL, and transverse ulnar-based cutaneous nerves can be injured during open or ECTR surgery. Anomalous muscles, tendons or interconnections, and the lumbricals during finger flexion may be seen within the carpal tunnel. These structures can be the cause of compression of the median nerve. The anatomy of the carpal tunnel and surrounding structures have been reviewed with emphasis on clinical applications to endoscopic and open carpal tunnel surgery. A thorough knowledge of the anatomy of the carpal tunnel is essential in order to avoid complications and to ensure optimal patient outcome. An understanding of the contents and their positions and relationships to each other allows the surgeon to perform a correct approach and accurately identify structures during procedures at or near the carpal tunnel.     

Anomalous flexor digitorum superficialis muscle transposition for vascular coverage of the median nerve in recurrent carpal tunnel syndrome

Recurrent carpal tunnel syndrome is uncommon yet troublesome. Significant adhesions and scarring around the median nerve can render it relatively ischemic. A number of vascular flaps have been described to provide vascular coverage in attempts to decrease further cicatricial adhesions and to improve local blood supply around the median nerve. A rare case of an anomalous muscle in the distal forearm used as tissue to provide good vascularized coverage of the median nerve that was severely scarred in its bed is reported. The anomalous muscle was distal to the flexor digitorum superficialis tendon and inserted in the palmar fascia on the ulnar aspect of the hand. Referring branches from the ulnar artery provided vascular supply to the anomalous muscle. The muscle on these vascular pedicles was transposed over the median nerve, providing good, stable, unscarred coverage. The patient had an excellent result with resolution of the carpal tunnel symptoms. The redundant anomalous muscle provided a unique vascularized source for coverage of the median nerve in recurrent carpal tunnel syndrome.     

带血管骨移植在四肢骨肿瘤治疗中的应用

目的临床观察带血管骨移植修复四肢骨肿瘤瘤段切除后骨缺损的治疗价值。方法对４８例不同类型的骨肿瘤行局部彻底切刮除,或骨膜外瘤段切除后所致的骨缺损分别采用带血管蒂髂骨瓣转位移植６例,游离移植３例;带血管胫骨瓣游离移植１例;带血管蒂腓骨瓣同侧顺逆行转位移植９例,游离腓骨移植２２例,双腓骨瓣组合移植４例,腓骨皮瓣游离移植３例进行修复治疗。结果移植骨与主骨均获得愈合,时间为２５～４２个月,平均３５个月。并经０５～１２年（平均４７年）的随访,４５例治愈,;３例复发,复发的３例病人中２例为骨肉瘤,１例为动脉瘤样骨囊肿恶性变,最终行了截肢术。结论证明带血管骨移植用于修复病变广泛的良性骨肿瘤或低变恶性骨肿瘤瘤段切除后的骨缺损疗效可靠,恶性肿瘤者较差。     

"Square sail" flap in median nerve lesions at the wrist. Anatomical elements and review of twenty operated cases

INTRODUCTION: Following an anatomical study on the vascular supply of the upper limb, we propose a new adipo-fascial flap at the wrist. The fat pad of pronator quadratus lies over the muscle and is vascularised by a recurrent branch arising from the anastomotic "cross-road" of the anterior interosseous, radial and ulnar arteries, at the radio-carpal joint. The peripheral extensions of the adipose tissue have to be anchored to the palmar fascia of the muscle in order to hoist the flap as a "square sail". The flap is then distally rotated in order to cover the traumatized median nerve segment at the wrist, for 2.5-3 cm of length. METHODS: The authors present a review of the clinical applications (1995-2001) on painful neuromas of the median nerve at the wrist, where traumatic and iatrogenic injuries frequently occur. The surgical procedure consists of external neurolysis followed by coverage of the nerve using this vascularised flap. RESULTS: The results confirm the usefulness of vascularised fat flaps in creating an optimal perineural environment in terms of biological and mechanical quality. The advantage offered by this particular local flap is that it can be speedily raised. Because of its limited length the flap is only able to cover the median nerve at the level of the carpal tunnel: its indications are therefore very selective but not rare, due to the frequency of median nerve injuries at this level. DISCUSSION: Clinical results were very satisfactory: in the twenty cases reviewed, resolution of the symptoms of algodystrophy and causalgia was consistently observed, sometimes to an extraordinary degree, and associated with an improvement in the neurological deficit.     

The composite meniscal-capsular-fat pad flap in a lateral approach to the fixed valgus knee: an anatomical study

We present an anatomical study on the vascular supply to the patellar fat pad. Forty knees from fresh cadavers were dissected after injecting the femoral artery with colored latex. In all cases, the vascular supply to the fat pad depended essentially on the lateral inferior genicular artery, which enters this structure at its posterolateral extent. In the cases in which the fat pad flap was raised before the injection of latex, we observed good vascularization of the flap by the lateral genicular artery. This is a safe vascularized flap that offers an optimal covering of knee prostheses in fixed valgus knee deformities. An optimal procedure for raising the flap is proposed.     

Median innervated hypothenar muscle: anomalous branch of median nerve in the carpal tunnel

A hypothenar motor branch of the median nerve in the carpal tunnel was observed and its motor function was documented by direct intraoperative nerve stimulation in two patients having carpal tunnel releases. The hypothenar branch left the median nerve at the midcarpal tunnel area. It crossed the tunnel superficial to the flexor tendons and penetrated the transverse carpal ligament ulnarly to innervate the abductor digiti quinti. Such branching of the median nerve at this level has not been reported previously. Good visualization of the carpal tunnel and careful dissection of its content even in the so called safe zone ulnar to long axis of palmaris longus tendon is recommended.     

Buccal fat pad pedicle flap for midface augmentation.

Midface aging is characterized by soft-tissue ptosis with loss of cheek projection. Subperiosteal midface lifts may reposition the soft-tissue mounds and improve the tear trough, but may not fill the lateral cheeks in patients with significant jowls or poor bony support. Correction with alloplastic implants is helpful, but may not be accepted by many patients. During subperiosteal midface lifts, the author often excises Bichat's fat pad to decrease the jowl and to diminish face fullness. He has modified this approach and used a vascularized Bichat's fat flap to aid lateral cheek projection while still improving lower face fullness and the jowl. For the last 4 years, close to 150 patients undergoing subperiosteal midface lifts have had vascularized Bichat's fat pad flaps. The jowls were marked preoperatively. All patients had complete cheek undermining either through a buccal sulcus incision or through a crow's-foot incision, or through a muscle-sparing limited lower blepharoplasty incision. Bichat's fat pad is identified in its pocket medial to the masseter tendon. Mobilization of Bichat's fat pad is done by blunt dissection, preserving its thin fascial envelope. The "hernial saclike" pocket, excluding Stensen's duct and the buccal branches of the facial nerve, is identified and protected. Suspension is accomplished by fixation with 3-0 polydioxanone sutures either to the temporalis fascia (via the temporal incisions), to the arcus marginalis, or to the suborbicularis oculi fat pad. Fixation technique is dependent on where the fat pad is needed and the surgeon's preference. Fat pad repositioning is accomplished with a minor learning curve. The most common problems are tearing of the fat pad during fixation and temporary numbness of the long buccal nerve. Attention to leaving the capsule intact and gentle handling is essential to fixation. Nevertheless, in some patients with poor-quality fat pads, fixation is extremely difficult. Four-year results have been excellent. Further studies with magnetic resonance imaging of postoperative patients are necessary to assess longevity. Bichat's fat pad provides autologous vascularized tissue for midface fill. Placement may be lateral for cheek augmentation or medial for deep nasolabial folds. Jowl improvement also occurs with the removal of Bichat's fat pad from its pocket.     

Effect of the Hoffa fat pad on revascularization of the ruptured anterior cruciate ligament. A histologic study of the rabbit model

After intersection of anterior cruciate ligament both ends were stitched together again. In group A the ligament was surrounded by a flap of fat pad, whereas in control group B the intersected ligament just was sutured. Postoperative the leg was immobilised by cast from 4 to 8 weeks. After that time intraarterial injection by Romeis method was performed, the bone-ligament-bone block was fixed in paraffine and the histological investigation followed. All ligament blocks of group A (n12) showed an intact anterior cruciate surrounded by well vascularized soft tissue which has been transformed from the fat pad. Ligaments of group B did not heal and where regressive changed.