Arthroscopic Surgery Unit

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E.C.T.R Endoscopic Carpal Tunnel
Release Enthusiasm, Disappointments, Facts and
Future
Arthroscopic Surgery Unit Edith Wolfson Medical
Center Holon - Israel
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History
Sir James Paget 1863 - Anatomy of the Carpal
Tunnel Moersh 1938 - Named as
C.T.S Cannon and Love 1946 - First series of
patients with median
nerve compression
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O.C.T.R - some of the reports about
COMPLICATIONS
Phalen J.B.J.S 1966
212 cases (2)
Ariyan Plast.Reconstr.Surg. 1977 429
cases (1.4)
MacDonald J Hand Surg 1978 186
cases (18)
Lichtman J Hand Surg 1979 100
cases (7)
For about 50 years, being the only surgical
solution, Open Carpal Tunnel Release (OCTR) was
accepted as an excellent procedure!
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Enthusiasm 1989-1992
First description of the single portal
endoscopic carpal tunnel release.Okutsu et al -
Arthroscopy 511-18 1989
Primary reports of Okutsu, Chow, Agee, Palmer
and Brownwere encouraging.
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Disappointment 1992-1994
Secondary reports of complications led to some
disappointment and doubt about the safety of this
new surgical technique.
Arner 1994 73p 18.9 Injury to Ulnar artery
Rowland 1994 24p 4.2 Injury to Median
Nerve 4.2 Injury to ulnar artery 4.2 Laceration
of Flexor tendon
Palmer 1993 72p 12.5 Ulnar nerve neuropraxia
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A Stigma was rooted!!!
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Mirza (1995) 475 patients 0.6 minor comp.
Chow (1994) 1154 patients 0.5 minor comp.
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The Real Problem
ECTR calls for considerable eye-to-hand
coordination.
Therefore it is difficult for surgeons who lack
Endoscopic Background.
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Carpal tunnel release - techniques
ECTR
LIT
OCTR
Prox 1 portal
2 portal
2 incis.
1 incis.
Dist 1 portal
Chow Reznick Brown Others
Naso Bromley
Blyani Wilson
Okutsu Agee Menon
Mirza
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Facts about the ECTR procedure
ECTR is not free of complications
Malek et all ..inverse relationship between the
number of procedures performed and the rate of
complications.
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ECTR is a demanding surgical exercise that
requires exacting knowledge of the anatomy of the
hand and it is not something that should be
carried out by surgeon who does an occasional
carpal tunnel release
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Reasonable Conclusion
The complications are Surgeons Skills-Related
and not Surgical Technique- Related
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Complications in our group
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In our group
1993-2000 450 p
27 conversion to open 22 learning curve 5
anatomical variant
6 temporary flexor synovitis (m/p chemical)
42 palmar discomfort for more than 2 weeks ( 34
more than 3 weeks, 7 more than 4 weeks, 1
reoperated after 6 weeks)
4 reoperated (1 worsening of pre operative
condition, 3 no relief of pre-operative
symptoms)
7 temporary neuralgia of digital nerve
(4-th ray)
4 trigger finger (3 fourth, 1 third)
2 superficial wound infections
1 permanent injury to the 4th digital nerve
Sub Cutaneous Haematoma (Some cases)
1 RSD
0 tendon injury
vascular injuries0
3rd POD
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Facts
The complication rate ofE.C.T.R compares
favorablywith those reported for O.C.T.R
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Facts about the ECTR procedure
Small incision
Single suture
Better cosmetic result
Fast rehabilitation
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Facts
PATIENTS WHO HAVE UNDERGONE BILATERAL CARPAL
TUNNEL OPERATIONS HAVE ROUTINELY PREFERRED
ENDOSCOPIC RELEASE TO THE OPEN PROCEDURE
OCTR 1 M post op
ECTR 8 d post op
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Facts
E.C.T.R has a significantly shorter
rehabilitation period 9 14 days (for
ECTR) 39-45 days (for OCTR)
9 14 days (for ECTR) 39-45 days (for OCTR)
9 14 days (for ECTR) 39-45 days (for OCTR)
9 14 days (for ECTR) 39-45 days (for OCTR)
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Future
ECTR will probably become the gold standard in
the surgical treatment of C.T.S
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Is there a place for O.C.T.R
Future
YES!!!
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Conclusions
The training should always start with the open
procedure. Surgeon who lacks previous experience
with the open technique should never try the
endoscopic one.
Rather, he should use an operative technique
according to his skills.
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Conclusions
While using an open technique, the surgeon must
keep in mind that there are better solutions.
The possibility to master another technique
should not be rejected, however those techniques
should never be used without sufficient training.

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Thank you for your attention