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All Clinical Applications

Karan A. Desai, MD

Orthopedic Surgery - Elbow, Orthopedic Surgery, Surgery - Orthopedics, Orlando Health, Orlando, FL

Introduction

Carpal and cubital tunnel releases are among the most commonly performed procedures in hand surgery, with approximately 500,000 carpal tunnel releases and 100,000 cubital tunnel releases performed every year in the United States.1-3 The reported rate of recurrent nerve compression requiring surgical intervention ranges from 0.7% to 4.8% per year for carpal tunnel release and from 3.7% to 19% within the first postoperative year for cubital tunnel release, respectively.4-8 Attributing a precise cause for recurrence is challenging, as it is often multifactorial. The most common factor is incomplete release, while secondary causes include perineural and epineural fibrosis, which can exert additional pressure around the nerve.6 Postoperative scarring and fibrosis may contribute to recurrence by causing direct nerve compression, restricting nerve mobility through tethering, and impairing vascular supply to the nerve.9 Revision decompression and neurolysis are often more challenging than primary surgery due to dense scar formation and distortion of normal anatomic landmarks around the nerve, compounded by the technical difficulty of removing adhesions while preserving nerve integrity.6,10-12 Revision surgery is often associated with less predictable outcomes, primarily due to the risk of recurrent scar formation, traction-related pain, or additional nerve injury.11,12

Several adjunctive barrier options may be utilized in the setting of revision neurolysis to maintain separate tissue planes and help mitigate adverse outcomes. Recently, placental tissue-derived membranes have become of particular interest, such as ACMShield. In the present case series, we demonstrate the technique for employing ACMShield in both revisional carpal tunnel and cubital tunnel syndromes. We also secondarily review the outcomes of five patients with recurrent nerve compression symptoms after previous carpal and cubital tunnel releases that were treated with neurolysis and the use of ACMShield as a temporary protective barrier

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0136-MKT-164-A

References

  1. Palmer DH, Hanrahan LP. Social and economic costs of carpal tunnel surgery. Instr Course Lect. 1995;44:167-172.
  2. Westenberg RF, Oflazoglu K, de Planque CA, Jupiter JB, Eberlin KR, Chen NC. Revision Carpal Tunnel Release: Risk Factors and Rate of Secondary Surgery. Plast Reconstr Surg. 2020;145(5):1204-1214.
  3. Brogan DM, Landau AJ, Olsen MA, Nickel KB, Buss JL, Dy CJ. Direct Economic Burden of Cubital Tunnel Surgery in the United States: Total Payments and Components of Cost. J Hand Surg Am. Published online September 3, 2024. doi:10.1016/j.jhsa.2024.07.011
  4. Adkinson JM, Zhong L, Aliu O, Chung KC. Surgical Treatment of Cubital Tunnel Syndrome: Trends and the Influence of Patient and Surgeon Characteristics. J Hand Surg Am. 2015;40(9):1824-1831.
  5. Carroll TJ, Dussik CM, Clary Z, Hoffman S, Hammert W, Mahmood B. Endoscopic Versus Open Carpal Tunnel Surgery: Risk Factors and Rates of Revision Surgery. J Hand Surg Am. 2023;48(8):757-763.
  6. Wessel LE, Gu A, Asadourian PA, Stepan JG, Fufa DT, Osei DA. The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period. J Hand Surg Am. 2021;46(9):758- 764.
  7. Pripotnev S, Mackinnon SE. Revision of Carpal Tunnel Surgery. J Clin Med. 2022;11(5). doi:10.3390/ jcm11051386
  8. Byun YS, Lee SU, Park IJ, Im JH, Hong SA. Comparison of in-situ release and submuscular anterior transposition of ulnar nerve for refractory cubital tunnel syndrome, previously treated with subfascial anterior transfer-A retrospective study of 24 cases. Injury. 2023;54(12):111061.
  9. McCall TD, Grant GA, Britz GW, Goodkin R, Kliot M. Treatment of recurrent peripheral nerve entrapment problems: role of scar formation and its possible treatment. Neurosurg Clin N Am. 2001;12(2):329-339.
  10. Krogue, J. D., Aleem, A. W., Osei, D. A., Goldfarb, C. A., & Calfee, R. P. (2015). Predictors of surgical revision after in situ decompression of the ulnar nerve. Journal of Shoulder and Elbow Surgery, 24(4), 634-639.
  11. Yushan M, Abula A, Ren P, Alike Y, Chen E, Ma C, et al. Outcomes of revision neurolysis of the ulnar nerve and ulnar groove plasty for persistent and recurrent cubital tunnel syndrome-A retrospective study of 21 cases. Injury. 2020;51(2):329-333.
  12. Filippi R, Charalampaki P, Reisch R, Koch D, Grunert P. Recurrent cubital tunnel syndrome. Etiology and treatment. Minim Invasive Neurosurg. 2001;44(4):197-201.
  13. Buentello-Volante B, Molina-Medinilla M, AguayoFlores E, Magaña-Guerrero FS, Garfias Y. Comparison of amniotic membrane transplantation and carpal tunnel syndrome release surgery (CTRS) and CTRS alone: Clinical outcomes at 1-year follow-up. J Tissue Eng Regen Med. 2020;14(5):714-722.
  14. Gaspar MP, Kane PM, Vosbikian MM, Ketonis C, Rekant MS. Neurolysis with Amniotic Membrane Nerve Wrapping for Treatment of Secondary Wartenberg Syndrome: A Preliminary Report. J Hand Surg Asian Pac Vol. 2017;22(2):222-228.
  15. Gaspar MP, Abdelfattah HM, Welch IW, Vosbikian MM, Kane PM, Rekant MS. Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping. J Shoulder Elbow Surg. 2016;25(12):2057-2065.

Please note: Case reports and white papers are company funded and not peer reviewed.