Abstract
Background
To analyze the outcome of modified Camitz opponens plasty using the wide-awake local anesthesia no tourniquet with dexamethasone (WALANT-D) technique in severe carpal tunnel syndrome (CTS).
Methods
A retrospective review was performed in 30 hands of 27 patients who underwent Camitz opponens plasty for severe CTS between 2019 and 2021. All patients had 8 mg of dexamethasone mixed with WALANT. Preoperative active palmar abduction, grip strength, side, and pulp pinch strength, Kapandji score, and electrophysiological assessment of compound muscle action potential (CMAP) for abductor pollicis brevis (APB) were compared with the postoperative values. The palmaris longus had dual insertion into the abductor pollicis brevis and extensor expansion. The time interval of post-operative pain-free was noted. The Disabilities of the Arm, Shoulder, and Hand (DASH) and Carpal Tunnel Syndrome instrument (CTSI) also assessed the functional outcome.
Results
The mean age of patients was 35 years (range 32–58 years). There were five male and 22 female patients. Of the female patients, three females had severe bilateral CTS. Twenty right and ten left hands were affected. The mean follow-up of our study was 12.5 months (range 10–14 months). The patients were pain-free for an average of 19.5 h postoperatively. There was a significant improvement in the thumb palmar abduction, grip strength, side, and pulp pinch strength, DASH score, CTSI, and APB-CMAP (p < 0.05) at the final follow-up.
Conclusions
Modified Camitz opponens plasty with a dual insertion into APB and extensor expansion effectively improves thumb opposition and daily activities. The tendon tensioning, checking the pulley impingement, appreciation of active movements, and a comfortable patient operative experience are advantages of the WALANT. Adding dexamethasone as an adjuvant to WALANT prolongs the analgesia and duration of the nerve block.
Level of evidence
IV, Retrospective case study.
Keywords: Camitz, Opponens plasty, Severe carpal tunnel syndrome, WALANT-D, Good outcome
1. Introduction
Severe carpal tunnel syndrome (CTS) patients have thenar muscle wasting and difficulty in thumb opposition. The common presentations to the clinic are the inability of the thumb to pinch, grasp, and other complex hand movements, indirectly affecting their daily activities.1, 2, 3, 4 Surgeons prefer open or endoscopic carpal tunnel release and tendon transfer to restore thumb abduction.5 Palmaris longus (PL), half-palmaris longus, extensor indicis proprius, and flexor digitorum superficialis are the most used tendons for thumb abductor plasty in CTS.5, 6, 7, 8 These tendon transfer acts as an internal orthosis and thumb abductor and improves the daily activities of the thumb.1, 2, 3, 4, 5
However, Camitz palmaris longus tendon transfer improves abduction and does not provide true opposition because of weak flexion and protonation of the carpometacarpal thumb joint.
Therefore, the authors modified the direction of the tendon transfer by using a small pulley from the flexor retinaculum. The line of pull is from the pisiform to the thumb MCP joint to create the best mechanical advantage of thumb positioning in abduction and opposition.1, 2, 3, 4, 5
The wide-awake local anesthesia without a tourniquet has become popular in tendon repair, tenolysis, and tendon transfers. Adjusting the tendon tension, appreciating the active tendon excursion, and checking the tenodesis action is advantageous to the WALANT.9, 10, 11, 12 WALANT mixture contains 1% lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate. Lidocaine used in the WALANT has an onset of action in 45–90 s and lasts for 10–20 min.13 A long-duration procedure might cause pain and discomfort even in wide-awake anesthesia without a tourniquet. A systematic study reported that analgesia (sensory block) and motor block duration are increased to 18.4–23.4 h when 8 mg of dexamethasone injection is added in a supraclavicular or interscalene block for upper limb surgeries.14 Dexamethasone improves the quality and duration of peripheral nerve blockade over lidocaine alone. It reduces the inflammatory mediator's release and neuronal discharge and inhibits potassium channel-mediated discharge of nociceptive C- fibers.14 The current study involves carpal tunnel release, median nerve decompression, and a tendon transfer for severe thenar atrophy. Therefore, the author added dexamethasone into the mixture, which will have prolonged median nerve blockade and deliver prolonged intra and postoperative analgesia. The mixture of dexamethasone with the existing WALANT coined the term WALANT-D.
A tendon transfer restores one active function and provides an additional and different passive function. Based on this concept, the author has performed open carpal tunnel release and a modified opponensplasty procedure by dual insertion of the PL to APB and the extensor expansion of the thumb in patients with severe CTS. The study aimed to analyze the outcome of this procedure using the WALANT-D technique.
2. Materials and methods
2.1. Patients, setting, and ethics
A retrospective study approved by the institutional ethical committee review board analyzed 30 hands of 27 patients who underwent Camitz opponens plasty for severe CTS under the WALANT-D technique between 2019 and 2021 (Fig. 1). The CTS was classified as mild, moderate, and severe based on the Stevens Classification.15
Fig. 1.
The flow chart of patient selection.
Inclusion criteria: The study included severe CTS diagnosed with physical examination and electrophysiological assessment using the compound muscle action potential (CMAP).
Exclusion criteria: The study excluded mild or moderate CTS patients, severe CTS with absent palmaris longus tendon, and surgery under traditional anesthesia.
The study noted the patient demographics, clinical findings, and preoperative electrophysiological study. The compound muscle potential of the APB was found unrecordable in all severe CTS cases. The preoperative thumb palmar abduction, grip, and side and pulp pinch strength were recorded. The study collected the patient's data and took pictures with consent (Fig. 3, Fig. 4). The time interval of post-operative pain-free was noted.
Fig. 3.
A- Pre-operative pictures showing the thenar atrophy and palmaris longus in a 30-year-old woman with severe CTS. B- Picture showing poor thumb abduction and opposition movements.
Fig. 4.
The follow-up clinical picture of the same patient shows good thumb abduction and opposition (A, B).
2.2. Surgical technique (Video 1)
Supplementary video related to this article can be found at https://doi.org/10.1016/j.jcot.2023.102228
The following is the supplementary data related to this article:
. The video demonstrates the surgical technique of modified Camitz opponens plasty in a 50-year-old woman with severe CTS under WALANT-D.1
The patient is supine on a stretcher to prevent vasovagal or fainting attacks. The injection site over the palm, carpal tunnel, and distal forearm are marked in the patient's waiting room or the surgical preparation room. The WALANT-D mixture contains 10 ml of 1% lidocaine with 1:100,000 epinephrine, 1 ml of 8.4% sodium bicarbonate,6,7 and 8 mg of dexamethasone. The maximum dose of infiltration is < 7 mg/kg. A 25 or 27-gauze needle infiltrates under the skin from proximal to the palm and is injected by standard techniques.9, 10, 11, 12 The procedure usually requires a 50 ml solution. When WALANT solution is required more (50–100 ml), the total dose is diluted with saline to a concentration of 0.5% with 1:200,000 epinephrine and 16 mg dexamethasone. A 25 or 27-gauze needle infiltrates under the skin and the distal forearm fascia, where 5–10 ml is injected. Up to 20 ml of the same solution goes into the hand and the carpal tunnel area, starting with 10 ml over the carpal tunnel, then 10 ml over the palm. Five to 10 ml in the thumb radial aspect of the metacarpophalangeal joint and proximal phalanx injection point just under the skin to numb the digital nerves. Additionally, 5–10 ml is injected into the thenar region. The injected area becomes numb in about 15–20 min. The surgical field is cleaned, prepared, and draped hand, which will take 15 min. The optimal hemostatic effect of 30 min is achieved from the first injection, and the skin incision is made over the marked area.
A longitudinal incision is made from the distal forearm over the palmaris longus tendon, continued over the carpal tunnel, and thenar crease up to the palm. The palmaris longus tendon is dissected in continuity with the longitudinal slip of palmar aponeurosis.16 The flexor retinaculum is released, and the median nerve is decompressed. A small hole in the radial side of the retinaculum will form a pulley that directs the palmaris longus tendon to be transferred in a straight line with the APB. The reason for the radial side pulley is that the ulnar side pulley may cause median nerve compression when crossing over the median nerve to the APB insertion.1,17 This will also re-orient the Camitz tendon transfer technique, which is too radial to the ideal axis for an opposition transfer.1 The PL is transferred through this pulley and sutured to the insertion of the APB. An active thumb abduction under WALANT-D will help decide the suture tension. The author prefers dual insertion and sutures PL to the thumb extensor expansion. This is done by passing the PL under the thumb extensor expansion and suturing back to the APB (Fig. 2). This creates a pull over the extensor function of the thumb and shifts the supinated thumb to more protonation and abduction. This dual insertion improves active opposition, passively stabilizes the MCP joint, and restricts the IP joint flexion. This is well appreciated by the active movement of the thumb with the WALANT-D.
Fig. 2.
A- The illustrative picture of normal thumb anatomy with abductor pollicis brevis (APB), Extensor pollicis brevis (EPB), extensor pollicis longus (EPL), and adductor.
B- The illustrative picture of palmaris longus (PL) dual insertion to the APB and the extensor expansion.
2.3. Postoperative care
Since all patients had prolonged analgesia, oral paracetamol 15 mg/kg was given thrice daily for three days in addition to oral antibiotics. None required opioids or other nonsteroidal anti-inflammatory drugs (Diclofenac, Aceclofenac). The hand was placed in a thumb spica plaster of Paris cast at 45° palmar abduction of the thumb with a neutral wrist position for four weeks. The cast was removed, and active and passive range of motion exercises for the thumb and wrist were started. Normal activities were allowed thereafter.
2.4. Follow-up
The thumb palmar abduction, side and pulp pinch, and grip strength were measured using a goniometer and Jamar® Hydraulic Hand Dynamometer (Model J00105) (Sammons Preston, Bolingbrook, Illinois). The Kapandji opposition score assessed the thumb opposition. The patient-reported outcome was measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and the Carpal Tunnel Syndrome Instrument (CTSI). The patient's experience with the WALANT-D was also considered comfortable or uncomfortable. The postoperative APB-CMAP was obtained in all patients. A value of >1.8 mV was considered a useful spontaneous recovery of the APB.
2.5. Statistics
The data were analyzed with CDC epi info software and expressed as mean and standard deviation. Mann-Whitney U test was used for statistical analysis, and p-values of 0.05 or less were considered significant.
3. Results
3.1. Patients and deformity characteristics
Our study's mean age of patients was 35 years (range 32–58 years). There were five male and 22 female patients. Of the female patients, three females had severe bilateral CTS. Twenty right and ten left hands were affected. All patients were discharged home on the same day. The WALANT-D provided effective anesthesia. The patients were pain-free for an average of 19.5 h postoperatively, and all patients had comfortable experiences. All patients returned to the previous work at the final follow-up.
3.2. Outcomes
The mean follow-up of our study was 12.5 months (range 10–14 months). The active palmar abduction, grip strength, pulp pinch strength, Kapandji's score, abductor pollicis brevis CMAP, DASH score, and CTSI were significantly improved after the surgery (p < 0.05) (Table 1). There were no complications (Fig. 2, Fig. 3). None of the patients required re-surgery or developed complex regional pain syndrome. None of the patients had pulley adherence or bowstring in the follow-up.
Table 1.
Clinical results of the modified Camitz opponensplasty.
| Outcomes | Preoperative mean (SD) | Postoperative mean (SD) | P value | |
|---|---|---|---|---|
| Grip strength (Kg) | 6.7 (2.1) | 20.7 (5.1) | P < 0.05 | |
| Side pinch (Kg) | 2.1(0.07) | 3.1(0.05) | P < 0.05 | |
| Pulp pinch (Kg) | 0.5 (0.02) | 1.4 (0.02) | P < 0.05 | |
| Palmar abduction (degrees) | 22.6 (3.1) | 43.5 (3.43) | P < 0.05 | |
| Kapandji score | 4.7 (0.41) | 8.6 (1.63) | P < 0.05 | |
| DASH | 44.5 (43.9) | 12.2 (2.5) | P < 0.05 | |
| CTSI | Symptom severity score (points) | 2.2 (0.08) | 0.8 (0.03) | P < 0.05 |
| Function score (points) | 3.9 (30.2) | 1.5 (0.01) | P < 0.05 | |
| APB-CMAP | 0 | 6.5 (2.4) | P < 0.05 | |
DASH- Disability of the Arm, Shoulder and Hand.
CTSI- carpal tunnel syndrome instrument.
APB-CMAP- Abductor pollicis brevis Compound muscle action potential.
4. Discussion
The WALANT technique for flexor tendon transfer is advantageous over regional or general anesthesia because the desired tension and the thumb position can be appreciated intraoperatively.12 Various studies reported significantly prolonged analgesia with the addition of dexamethasone in axillary, inter-scalene, and supraclavicular brachial plexus block.18,19 The author added dexamethasone and injected the WALANT-D mixture around and in the carpal tunnel (median nerve), which felicitated prolonged analgesia during and after the surgery.
In this series, the author transferred the PL to the APB. The patient's active movement showed good abduction, but the thumb remained supinated, adducted, and flexed at the IP joint. This was because of the thumb flexors (flexor pollicis longus), adductors, and extensors (extensor pollicis brevis and longus). Therefore, the author performed dual insertion of the PL to the APB and the thumb extensor expansion. This line of pull shifted the orientation of the thumb from supination to protonation and abduction. This modification stabilized the MCP joint limiting the IP joint flexion. This dual insertion achieved flexion and protonation at the thumb CMC joint. Additionally, there was a good thumb opposition, which was not achieved in any of the reported series of Camitz abductor plasty.1, 2, 3, 4 The patients remained pain-free in the post-operative period averaging 19.5 h. None required opioids or other nonsteroidal anti-inflammatory drugs (Diclofenac, Aceclofenac) in the follow-up.
Dexamethasone inhibits nociceptive C- fiber transmission and spares motor function.14 When added to the WALANT, dexamethasone delivers prolonged analgesia (WALANT-D). Additionally, the patients can make active thumb movements, and the surgeon can check the thumb position and adjust the suture tension. These cannot be achieved in regional or general anesthesia. At the same time, the orientation of the transferred PL (straight line) and the pulley impingement, if any, can be assessed in awake patients when actively moved. Sometimes, surgeons face overtightening, laxity, and pulley impingement because of traditional anesthesia. WALANT-D can overcome this. Moreover, all patients in this series had a comfortable experience with the WALANT-D and were discharged on the same day. The awake patient's thumb movements intraoperatively educate the patient about the surgery and rehabilitation.20
There was a significant improvement in the thumb palmar abduction, grip strength, side, and pulp pinch strength, DASH score, CTSI, and abductor pollicis brevis compound muscle action potential (p < 0.05) at the final follow-up. Literature reported that the surgery cost is reduced in WALANT procedures.11
The study's strength is the dual insertion of the PL that pulls the thumb into protonation and stabilizes the thumb MCP joint in severe CTS. Adding dexamethasone to the WALANT mixture improved the quality and duration of median nerve blockade over lidocaine alone. The study documented that the modified Camitz opponens plasty with dual insertion of the palmaris longus using the WALANT-D technique can achieve desired thumb opposition, active movements, and prolonged analgesia. All patients were discharged home on the same day and had a comfortable experience. The patients regained good movements in the thumb at the follow-up with no opioids or NSAIDs.
Our study's limitations are the small sample size, retrospective design, and lack of a control group. Since we did not have a comparative study between the WALANT-D and traditional anesthesia, claiming superiority won't be easy. Also, we need large studies on including dexamethasone in the WALANT mixture and its role in other parts of limb surgeries. There is a controversy over whether to use a pulley and, if so, the type and location of the pulley. Additionally, there is a concern about how a superficially situated PL tendon will work as a pulley. Many authors have tried to address these issues using pulley modifications and biomechanical, retrospective, and comparative cohort studies. From these studies, with various modifications in Camitz opponensplasty, we are sure that the superficial PL tendon is expendable, synergistic with APB, and have achieved good thumb opposition with the efficacy of the pulley.
However, despite these limitations, this study documented that our modified Camitz opponens plasty combined with open carpal tunnel decompression in severe CTS achieves a good opposition, palmar abduction, grip, pinch strength, and functional outcome. Dexamethasone as an adjuvant to the existing WALANT mixture prolongs intra and postoperative analgesia. Large prospective studies may help evaluate the dual insertion of PL under WALANT-D and the long-term benefits in severe carpal tunnel syndrome.
Author contribution
J. Terrence Jose Jerome: Roles/writing – original draft, Data curation, Conceptualization, Writing – review & editing.
Disclosure of interest
The authors declare that they have no competing interests.
Informed consent
Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.
Ethical approval
Ethical approval for this study was obtained from the Ethical Committed Board of OHRC Approved. No 18/2023.
Funding
None.
“Provenance and peer review
Not commissioned, externally peer-reviewed.
Funding
There was no funding for this study.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgment
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
. The video demonstrates the surgical technique of modified Camitz opponens plasty in a 50-year-old woman with severe CTS under WALANT-D.1