The Simonetta Technique for Carpal Tunnel Syndrome:
Immediate Postoperative Evaluation and Long-Term Comparative Study
Omar Faour-Martn, Miguel Ángel Martn-Ferrero, Jose Antonio Valverde Garcia, Patricia Zuil-Acosta,
Luis Amigo-Liñares, Javier Alarcn-Garca, Mara Angeles de la Red gallego
Omar Faour-Martn, Luis Amigo-Liñares, Javier Alarcn-Garca, Service of Traumatology and Orthopaedic
Surgery, Hospital of Ávila, Spain
Jose Antonio Vega-Castrillo, Chairman Service
of Traumatology and Orthopaedic
Surgery, Hospital of Ávila, Spain
Miguel Ángel Martn-Ferrero, Service of Traumatology and Orthopaedic Surgery, Clinic Universitary
Hospital of Valladolid, Spain
Patricia Zuil-Acosta, Department of Orthopaedics, Hospital Severo-Ochoa,
Legans, Spain
Mara Angeles de la Red gallego, Service of Traumatology and Orthopaedic
Surgery, Santander-Spain
Correspondence to: Omar Faour Martn, Service of Traumatology and Orthopaedic Surgery, Hospital of Ávila, Spain.
Email: ofmartin@msn.com
Telephone: +34- 630081151
Received: June 14,
2014
Revised: August 11, 2014
Accepted: August 16, 2014
Published online: September 29, 2014
ABSTRACT
AIM: Carpal tunnel release by opening the flexor retinaculum
is considered a satisfactory treatment. However, in some patients, all the
symptoms are not resolved. The objective of our study is to compare two
surgical techniques.
Material and methods:
We have carried out a clinical, electromyographic and dynamometric evaluation
of more than a hundred patients that received surgical treatment for Carpal
Tunnel Syndrome, in a comparative analysis of the techniques used four weeks
and ten years after surgery. Transverse ligament lengthening according to the
Simonetta technique and mini-open decompression of the median nerve with an
entire section of transverse ligament were compared.
Results: The Simonetta
technique, in the immediate postoperative period as well as ten years after
surgery, contributes to better results of manual function and grip strength,
with a higher presence of numbness and tingling than decompression with
complete section of the flexor retinaculum.
Conclusion: The technique
of Simonetta is a surgical option to be considered for carpal tunnel syndrome.
It does appear to result in less pillar pain and may be an option in heavy
labourers who are willing to accept ongoing nerve symptoms, but it is not clear
that this should be recommended over open decompression, unless this is in
patients presenting perhaps with EMG negative disease, or minimally-mild
positive nerve studies.
© 2014 ACT. All rights reserved.
Key words: Carpal tunnel; Lengthening; Transverse ligament; Long term
Faour-Martn O, Martn-Ferrero
MA, Jose Antonio Valverde Garcia, Zuil-Acosta
P, Amigo-Liñares L, Alarcn-Garca
J, de la Red gallego MA. The Simonetta
Technique for Carpal Tunnel Syndrome: Immediate Postoperative Evaluation and
Long-Term Comparative Study. International Journal of Orthopaedics 2014; 1(3):
107-114 Available from: URL:
http://www.ghrnet.org/index.php/ijo/article/view/725
INTRODUCTION
Carpal tunnel syndrome is the most common compressive neuropathy of the
upper extremity[1-7]. In general, surgery of this disease is the
most frequent surgical intervention of the hand[2]. Despite its high
incidence and prevalence in our society, uncertainty is still present at this
time, regarding which can be the best way to diagnosis and treatment, or
surgical technique used for this condition.
Treatment of
this disorder by splitting the transverse ligament is considered a successful
procedure. However, symptoms are not completely resolved in all cases[3].
Pain in the hypothenar and thenar areas corresponding to the end of the flexor
retinaculum after its entire section and persistent weakness of grip, have been
described as common complications of classical decompression of the median
nerve[8-10].
In order to
reduce such complications, different techniques of ligament lengthening have
been proposed[11]. We present the short and long-term evaluation of
the Simonetta technique, including a comparison of its clinical, functional and
electromyographic results with the mini-open decompression of the median nerve
with complete section of the transverse ligament.
PATIENTS
AND METHODS
We undertook a historical prospective cohorts study based on the
evaluation of 117 patients who fulfilled the following inclusion criteria: (1)
patients underwent surgery for carpal tunnel syndrome performed by the same
specialist between the years 2002 and 2003; (2) pre-operative clinical
diagnosis according to Graham's criteria CTS-6[12], i.e. numbness
and tingling in the median nerve distribution, nocturnal numbness, weakness
and/or atrophy of the thenar musculature, positive Tinels sign, positive
Phalen test, loss of two point discrimination; (3) positive electromyographic
diagnosis before surgery (4) absence of re-interventions in later years. The
presence of a previous carpal tunnel surgery was used as exclusion criteria.
During the
time period studied, two different techniques were performed, due to
introduction of the Simonetta technique in 2001, in the unit of hand surgery
where this study took place. To make sure that selection bias was controlled, a
randomized list of numbers of the surgeries expected to be performed in the
period of time studied was created (numbers 1 to 122, referring to 122
surgeries). The first number generated from the randomized list was assigned
the Simonetta technique; the second was assigned the technique with a complete
section of the transverse ligament; and the third, the Simonetta technique, and
so on in a consecutive manner. The software used to achieve this statistical
generation was Microsoft Excel 1997. This method is commonly used in our
institution when there is the possibility to study a new treatment in a
comparative study.
Surgical
procedures were performed as follows (Figure 1):
Mini-open decompression of the median nerve with entire section of the
transverse ligament (FR division group: 58 patients): after the placement of
the tourniquet of ischemia in the arm of the affected extremity, a palmar
incision of 2.5 centimetres was made, following the ulnar edge of the nail of
the fourth finger with the distal interphalangeal joint in a flexion of 90
degrees. The transverse ligament was cut completely, in a longitudinal way in
its ulnar side. The medium palmar fascia was sutured and skin was closed with a
re-absorbable suture of 5-0.
Transverse
ligament lengthening according to the Simonetta technique (Simonetta group: 59
patients): under the same perioperative, a palmar incision of 3 centimetres was
made, following the ulnar edge of the nail of the fourth finger with the distal
interphalangic joint in a flexion of 90 degrees. After exposure of the flexor
retinaculum, two parallel cuts were made ~0.5 centimetres apart in the middle
third. The radial cut was extended to the proximal margin, while the ulnar cut
was extended to the distal margin. The medium palmar fascia was sutured and the
skin was closed using a re-absorbable suture of 5-0.
All surgeries
were carried out under local anesthesia, without antibiotic prophylaxis, and a
palmar splint was placed during the first fifteen days of the postoperative
period.
The number of
patients excluded from our study because of reoperation in later years was one
(1.72%) in the case of decompression with complete section of the transverse
ligament, and two (3.39%) in the case of patients who underwent lengthening of
the flexor retinaculum. Another two patients assigned to the FR division group
were excluded because of previous carpal tunnel surgery (3.29%).
In the year
2013, as in the pre-operative period and four weeks after surgery, patients
were evaluated as follows
Clinical and functional assessment by using the Specific Questionnaire
of Levine et al[13]. The Levine Symptom Score is determined
by 11 questions regarding different attributes of pain, tingling and numbness
with each answer scoring between 1 (normal) and 5 (most abnormal). The Levine
Functional Score takes into account eight daily activities and indicates the
ability to perform each one, from 1 (normal) to 5 (most abnormal). The results
are expressed as a mean score of the questions answered.
Pillar pain
assessment using two different methods[14]: (a) application of
direct pressure on the thenar and hypothenar regions; (b) leaning on a table
with the patients weight on his/her hands placed on the tables edge (table
test). The patient stands approximately 40 cm from the foot of the table, then
with elbows straight, leans over and places both hands on the edge of the exam
table.
Dynamometric
evaluation. Grip strength of studied hands was measured by an analogical
dynamometer, with a graduated scale of 0 to 1 bars of pressure, at intervals of
0.05 bars (one bar is equivalent to 1.019 kgF/cm2).
Electromyographic evaluation. The studies were performed using a Nicolet
Viking Select (Madison, WI, USA) electromyograph. Surface recording and
stimulation were used for all studies, collecting values of distal motor
latency and sensory velocity conduction of the median nerve. The criteria of
the American Electrodiagnosis Association were considered for gradation of
carpal tunnel syndrome[15]. A sensory velocity of less than 48
meters per second, and a motor latency greater than 4.2 milliseconds for an
interval of 7 centimetres, was considered a pathological cut-off value.
We were
granted informed consent of all patients and permission from the Hospital
Ethics Commission.
For
statistical analyses, we used the calculation formula sample size for the
comparison of means and percentages, the Chi-square and the Fishers Test for
qualitative variables, and for quantitative variables the t-test of
comparison of averages for paired or unpaired data, as well as the general
lineal model of repeated measures.
A sample size
of 49 patients in each group was estimated as needed to detect a difference of
20% in the clinical and functional outcomes. Before analysing the values
obtained, a normal distribution of the variables studied was verified, as well
as the absence of differences between the two groups considered, depending on
the surgical technique used, such as in epidemiological or clinical variables
that could behave as confusion factors (Table 1).
RESULTS
No significant differences were registered between the groups studied
for each evaluation in the preoperative period (Figure 2).
In relation to
the outcomes recorded four weeks after surgery (Figure 3), favourable data was
obtained and compared with the preoperative evaluation. Levines Clinical scale
showed a higher improvement in the group of patients with entire section of the
transverse ligament for questions referring to numbness and tingling
sensations. In contrast, a higher improvement was found in the Simonetta group
as far as weakness and functional scale (Tables 2 and 3). The preoperative grip
strength of the operated hand was, on average, 0.525 bars (equivalent to 0.535
KgF/cm2) (standard deviation 0.11) for the Simonetta group, and
0.494 bars (equivalent to 0.504 KgF/cm2) (standard deviation 0.09)
for the FR division group, without statistical differences between groups (p=0.103).
The dynamometric evaluation four weeks after surgery showed significant
favourable data for the Simonetta group, with a mean value of grip strength in
the operated hand of 0.502 bars (equivalent to 0.512 kgF/cm2) (sd
0.13), and in the case of FR section group of 0.374 bars (equivalent to 0.381
KgF/cm2) (sd 0.16), p<0.0001. Pillar pain assessed by direct pressure
on the thenar and hypothenar areas was registered in 27 patients of the FR
section group (46.55%) and in four patients of the Simonetta group (6.78%) (p<0.0001).
When it was assessed using the table test, a positive result was recorded in
33 patients of the FR section group (56.90%) and in five patients of the
Simonetta group (8.47%) (p<0.0001). In the case of the
electromyographic findings, the improvement in the sensory conduction velocity
and distal motor latency of the median nerve was significantly higher in
patients who underwent an entire section of the transverse ligament than in the
Simonetta group (Table 4).
The long term
postoperative results of Levines Questionnaire (Figure 4), pillar pain and
grip strength referred to an average follow-up period of 10.42 years for the
Simonetta group (standard deviation 0.75) and of 10.28 years for the FR
division group (standard deviation 0.61). No differences in this respect were
found (p value: 0.296).
In relation to
Levines Questionnaire, favourable data was obtained from most patients ten years
after surgery, with a global average value between lack of affectation and the
slightest discomfort. For questions 6, 8 and 9 of the clinical scale (numbness
and paresthesias), the improvement experienced by the patients in the long-term
postoperative period regarding preoperative results was significantly higher in
the FR division group; however, for question 7 (manual weakness), it was
significantly higher in the Simonetta group.
In the case of
the functional score, significant differences in favour of the Simonetta group
were found in activities such as carrying bags, gripping a telephone receiver
and opening jars. In the rest of the questions regarding clinical and
functional scores, no significant differences were found between the groups
(Tables 2 and 3).
The
postoperative long-term grip strength (year 2013) of the operated hand was
0.511 bars (equivalent to 0.521 KgF/cm2) (standard deviation 0.12)
for patients undergoing ligamentoplasty and 0.375 bars (equivalent to 0.382
KgF/cm2) (standard deviation 0.08) for patients with a complete
section of the transverse carpal ligament. The decrease in grip strength
compared with the preoperative evaluation was significant in the latter group (p=0.001),
but was not in the Simonetta group (p=0.715). Results in grip strength
showed significant differences between groups in the long term (p=0.000).
No differing
results were registered between the evaluation four weeks after surgery, and
the values obtained in the long term in relation to Levines Questionnaire and
the dynamometric evaluation. No significant changes between groups were
registered when comparing both postoperative evaluations.
The presence
of pillar pain ten years after surgery was registered in no patients when it
was assessed by direct pressure of the thenar and hypothenar areas. In the case
of the table test assessment, no patients of the Simonetta Group had a
positive result, while one patient with an entire section of the transverse
ligament (1.72%), without statistical differences, (p=0.49).
In the case of
the long term electromyographic evaluation, the follow-up period was 10.49
years for the Simonetta group (standard deviation 0.63) and 10.67 years for the
FR complete section group (standard deviation 0.72), without statistical
differences between either (p=0.259). Findings in 2013 showed positive
differences in most patients compared to the pre-operative data. However, the
improvement in the parameters of sensory conduction velocity and distal motor
latency of the median nerve in patients who underwent an entire section of the
transverse ligament was higher than in the Simonetta group. The same may be
said about electromyographic diagnosis, i.e. the mild carpal tunnel syndrome
was most frequent in patients who underwent ligamentoplasty, and normal in
patients with a complete section of flexor retinaculum. In addition, changes
between the four week postoperative evaluation to the long term assessment were
significantly favourable in the case of the FR group compared with the
Simonetta group (Table 4) (Figure 5).
In relation
with recidivism, as it was exposed previously, the number of patients excluded
from our study because of reoperation in later years was one (1.72%) in the
case of decompression with complete section of the transverse ligament, and two
(3.39%) in the case of patients who underwent lengthening of the flexor
retinaculum. Those patients were re-operated with an open entire section of the
transverse ligament, in a time of 22 months after surgery in the case of the FR
division group, and in a mean postoperative time of 18.6 months in the case of
the Simonetta group. (sd: 5.4).
The rate of
patients treated occasionally with oral painkillers ten years after surgery was
of 15.7 % in the case of the Simonetta group and 7.2 % in the case of FR
division group.
DISCUSSION
A short and long-term evaluation of the transverse ligament lengthening
according to Simonetta has been exposed. Few studies have examined this
technique[8,16]. In fact, in an extensive review of the literature
we failed to find an immediate postoperative evaluation together with long-term
outcomes. Dias et al[8] showed in their study of 52 patients
over 25 weeks of follow-up, no advantage of this technique over the complete
section of the transverse ligament regarding the recovery of neurological
symptoms, functional outcomes and postoperative pain.
In our
evaluation, no differences were registered in relation to pillar pain between
groups in the postoperative long term. However, rates favourable to the
transverse ligament lengthening showed four weeks after surgery is data to be
taken into account in surgery of carpal tunnel syndrome[14]. This
syndrome is characterized by the usual triad of pain, stiffness and tumefaction
that lead to limited functionality.
Netcher et
al[17] described that transverse ligament lengthening
constitutes a surgical alternative to the open conventional decompression of
the median nerve and, as it displays the advantages of avoiding the volar
displacement of the nerve. In addition, a greater evolution of time free of
symptoms has been described for this kind of technique, where the transverse
ligament is conserved or reconstructed after its initial section[17].
However, we consider that the optimal size of the resulting bandelet during the
ligament lengthening and the exact crossing of the cuts in the flexor
retinaculum to guarantee a satisfactory decompression of the median nerve
remain to be determined.
We have been able to show significant differences in some items of
Levines Questionnaire when comparing the two studied techniques that were
maintained at the two postoperative periods studied: a greater clinical
improvement (numbness, tingling) in patients who underwent surgery with a
complete section of the transverse ligament, and a greater functional
improvement (grip strength and performing of daily activities) in the group of
patients operated on according to the Simonetta technique. Savornin et al[18]
described a review of surgery for carpal tunnel syndrome, as well as a
telephone survey of 78 patients that had undergone treatment with a complete
section of the transverse ligament. After twenty four months of follow-up, one
third of the patients stated that they experienced a decrease in grip
strength.
In relation to this finding, we have found favourable dynamometric data
in the group of patients with the transverse ligament conserved. This result
seems to correspond to the best referred values of functional capacity observed
in our evaluation, for example, in habitual activities like carrying a grocery
basket or holding a telephone receiver and opening bottles. This data has
special relevance in our sample of patients, where a clear predominance of
manual workers was presented.
The differences found in the electromyographic diagnosis four weeks
after surgery and in 2013, in favour of the patients operated on with an entire
section of the transverse ligament, as well as in the parameters of distal
motor latency and sensory conduction velocity of the median nerve, suggest that
this technique is able to maintain a better decompression of the medium nerve
than with the use of ligament lengthening according to Simonetta.
Independently
of the surgical technique for median nerve decompression, nowadays it may be
considered an interesting option using microscopic devices that permit a better
visualization and assessment of the epineural adhesions and coagulation of the
flexor retinaculum after be incised and avoiding epineural fibrotic scarring.
In summary,
the technique of Simonetta is a surgical option to be considered for carpal
tunnel syndrome. It does appear to result in less pillar pain, better results
of manual force and may be an option in heavy labourers who are willing to
accept ongoing nerve symptoms. It is not clear that this technique should be
recommended over mini-open decompression with entire section of the transverse
ligament, with exception of patients presenting perhaps with EMG negative
disease, or minimally-mild positive nerve studies.
ACKNOWLEDGMENTS
All patients gave
written informed consent to be included in this study, and the study was
authorized by the local ethical committee and performed in accordance with the
ethical standards of the 1964 Declaration of Helsinki as revised in 2000.There
are no conflicts of interest with regard to the present study.
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Peer
reviewers: Santino Ottavio Tomasi, MD, Department of Neurosurgery,
Christian-Doppler-Medical Center, Laboratory for Microsurgical Neuroanatomy,
Paracelsus Medical University, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria;
Antonios Kerasnoudis, Department of Neuroimmunological, St. Luke Hospital,
Panorama-Thessaloniki, 55236, Greece; Scott Martin Fried, The Upper Extremity
Institute, 1515 DeKalb Pike, Suite 100, Blue Bell, Pennsylvania, 19422, the
United States.
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