Revision Carpal Tunnel Release

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • Loupes recommended

2

Room setup and equipment

  • standard operative table with hand table

3

Patient positioning

  • supine position
G

Superficial Dissection

1

Make incision

  • make an incision through the previous incision and extend it proximally and distally
H

Expose TCL

1

Expose the TCL

  • use a scalpel or scissors to dissect through the subcutaneous fat and palmar tissue
  • the palmaris brevis muscle is often seen superficial to the TCL
  • incise and feather the palmaris brevis muscle from the TCL to allow adequate visualization
  • use a mosquito clamp or Carroll elevator into the carpal canal just deep to the TCL
  • this space defines the undersurface of the TCL and the hamate hook

2

Visualize the superficial surface of the TCL

  • place a right angle retractor
  • this is placed to protect the critical structures that are located between the skin and the ligament
I

Release TCL

1

Release the most ulnar aspect of the TCL

  • identify the most ulnar aspect of the TCL in the canal close to the hook of hamate
  • release the TCL under direct visualization
  • make sure to release proximally and distally
  • use scissors, scalpel or mini meniscotome type beaver blade
  • keep the radial leaflet of the TCL over the median nerve

2

Release the distal forearm fascia proximally

  • this is a common secondary site of compression

3

Confirm release of the TCL proximally and distally

J

Release Scarring and Check Integrity of Nerve

1

Separate the TCL from the median nerve

  • scarring is expected and puts the median nerve at risk during this entire procedure
  • completely release the TCL while protecting the motor branch of the median nerve

2

Perform external epineurotomy

  • perform an external epineurotomy to expose the bands of the fontana on the surface fascicles on the median nerve
K

Explore Nerve to Ensure Decompression

1

Check nerve

  • palpate and visual any signs of compression on the nerve
L

Hypothenar Fat Pad (optional)

1

Excise Fat Pad

  • dissect the fat pad to the level of the ulnar nerve and artery
  • advance the radial edge of the fat pad to cover the median nerve

2

Suture edge of the fat pad to the radial flap of the TCL

N

Wound Closure

1

Use 3-0 nylon for skin closure

Postoperative Patient Care
 

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