This article has Open Peer Review reports available.
A new tool for mini-open carpal tunnel release – the PSU retractor
- Sunton Wongsiri1Email author,
- Porames Suwanno†1,
- Boonsin Tangtrakulwanich†1,
- Varah Yuenyongviwat†1 and
- Ekkarin Wongsiri†2
© Wongsiri et al; licensee BioMed Central Ltd. 2008
Received: 11 April 2008
Accepted: 22 September 2008
Published: 22 September 2008
Mini-open carpal tunnel release has become increasingly popular for the treatment of carpal tunnel surgery. The main advantages are shortening recovery time and return-to-work time. However, the risk of neurovascular injury still remains worrisome.
In this study, we developed a new retractor (herein called the PSU retractor) modified from the widely used Senn retractor, with the aim of decreasing the risk of neurovascular problems from normal procedure. 3-Dimensional computer design software (SolidWorks® Office Premium 2007 SP3.1) was used to construct a 3-D PSU retractor prototype. An amputated arm from a 30-year-old woman diagnosed as synovial sarcoma at the shoulder was used to test the maximal visual length. A mini-surgical incision was performed at 3 cm distal to the transverse wrist crease and a tiny flexible ruler was inserted through the tunnel beneath the skin to measure the maximal visual length.
Our new retractor showed significantly better maximal visual length compared to the Senn retractor (47.7(8.1) mm vs. 39.2(6.5) mm). In addition, most assessors expressed a higher satisfaction rate with the PSU retractor than with the Senn retractor (7.3 (1.9) vs. 6.3 (1.1)).
In conclusion, we have developed a promising new retractor using a computer design program, which appears to be an improvement on the currently available equipment used for mini-open carpal tunnel surgery. However, further clinical studies are needed to confirm our initial findings.
Carpal tunnel syndrome (CTS) is the most common nerve entrapment problem faced by orthopaedists. Surgical treatment is generally recommended in cases which fail to respond to conservative measures. Surgical treatment  normally involves cutting the transverse carpal ligament to reduce the carpal tunnel pressure. Open carpal tunnel release (OCTR) remains the accepted standard operation , but newer procedures include endoscopic or semi-blind mini-incision techniques are being increasingly performed. Postoperative pain and late recovery are the main drawbacks to OCTR [3–6]. Mini-incision carpal tunnel release using various types of tool such as the Indiana Tome (Biomet, Warsaw, USA), the KnifeLight (Stryker Instruments, Kalamazoo, Michigan, USA) and the "Safeguard" system (KMI, Inc., San Diego, USA) have recently been gaining popularity and are aimed to reduce the problems that result from this open surgery. However, these newer techniques cannot allow the surgeon to fully visualize all important structures and thus there is a somewhat increased risk of neurovascular injury to the median nerve, the recurrence branch of the median nerve or the superficial palmar arch artery [7, 8]. In order to avoid such potentially preventable complications, an instrument to assist in mini-incision techniques would be of benefit. Recent advances in computer-assisted design programs, such as SolidWorks, are very useful in designing and developing new instruments, including medical instruments, and are commonly used for 3-dimensional tool design by engineers. These programs provide animation together with mechanical testing within the program. In this study, we demonstrate the method we used to develop a new instrument for mini-open carpal tunnel release and also show some preliminary results of using this new retractor, we call the PSU retractor.
Design and development of PSU retractor
Comparison of maximum visual length
All analyses were performed using SPSS software (Software Package for Social Sciences, version 13; SPSS Inc., Chicago, IL). The student t-test was used for comparison of maximal visual lengths and satisfaction scores between the Senn and PSU retractors. All continuous data was tested for normal distribution using Kolmogorov-Smirnov test.
By using 3-dimensional computer design software (SolidWorks® Office Premium 2007 SP3.1), a 3-dimensional computer model can be constructed (details in Figures 1A and 1B) which could show the designed object from any perspective, and rotate it, including oblique views, cross sections, perspective or isometric views. The main differences between the new PSU retractor and the Senn retractor are shown in Figures 2, 3 and 4.
Finite element analysis
Visual length test
With the maximum visual length of the PSU retractor from 8 assessors, the mean maximum visual length was 47.7 (8.1) mm, which was statistically significantly better (p value less than 0.05) than the Senn retractor (39.2 (6.5) mm).
Satisfaction of instruments
After using the instruments, all assessors weigh the level of satisfaction score by visual analogue scale. The mean level of satisfaction score of the PSU retractor was 8.5 (0.5), which was statistically significant higher (p value less than 0.05) than the satisfaction level the doctors expressed with the Senn retractor (6.4 (1.2)).
We have developed a new instrument called the PSU retractor to be used for mini-incision carpal tunnel release using a computer program popular with engineers. Our preliminary results showed that this new retractor significantly improved maximal visual length compared to the currently popular Senn retractor during surgical release of the deep transverse carpal ligament, and finite element analysis showed that the new retractor had comparable mechanical properties comparable to the Senn retractor. Most of the assessors who tested the instrument were satisfied with it.
Nowadays, there are a number of 3-dimentional computer-aided design programs available on the market such as SolidWorks and AutoCAD. These programs can be used to model virtually any images or designs and also have some mechanical testing applications. This is quite useful for orthopaedic surgeons, who use many sophisticated instruments in their practice but are always looking for better ones to improve their patient outcomes. In this study, we used the SolidWorks program to design a new retractor, because this is an easy program to learn and easy to adapt to different uses. Furthermore, additional options of this program include modified surfacing, finite analysis, flow analysis, mechanical motion and animation. Our study confirmed its utility in the design and modelling of our new instrument.
Mini-incision carpal tunnel operations using assisting tools such as the Indiana Tome, the KnifeLight and the "Safeguard" system have been increasingly used because they are simpler procedures with less scarring, less postoperative pain and faster recovery [9–12]. Recently, Chapman, et al. reported a case of a complete median nerve transection from a carpal tunnel release using the Indiana Tome. Abouzahr, et al  also demonstrated 1 palmar arch injury from 28 cadavers. Our new retractor improves visual length, which should be useful in reducing or preventing potential neurovascular complications from blind mini-incision techniques.
Carpal tunnel syndrome is the most common disease in orthopaedic practice. More than 200,000 operations of carpal tunnel surgery are reported each year in the US, at a cost per procedure of between 5,500 and 11,900 US dollars  with a total of more than 1 billion US dollars [14–16]. The new PSU instrument could have a significant financial benefit as it reduces the need for the current costly special cutting tools or sophisticated endoscopic procedures [17–19]. The carpal tunnel release mini-surgery can also be performed under local anesthesia, which will again reduce both the cost and risk of anesthesia.
However, our study is only a preliminary report using one carpal tunnel with a group of assessors, so further studies need to be done in actual clinical settings to compare the new instrument with other instruments and in different settings for both efficacy and safety.
The PSU retractor was developed using a CAD program (SolidWorks) and demonstrates promising properties which should be useful in mini-incision carpal tunnel release procedures. However further clinical studies are required to confirm our results.
The work was funded by the Department of Orthopaedic Surgery and Physical Medicine of the Faculty of Medicine, Prince of Songkla University located in Songkhla, Thailand. The authors would like to thank the chief of the department for her support and also for being an excellent model researcher and physician. The authors would like to extend special thank to the great dedication of the research assistance, Miss Naruemon Buangam, who sacrificed her valuable time to support this study. And finally we would like to thank Mr. David Patterson of the Faculty of Medicine International Affairs Office for his assistance with English proofreading.
- Jerosch-Herold C, Leite JC, Song F: A systematic review of outcomes assessed in randomized controlled trials of surgical interventions for carpal tunnel syndrome using the international classification of functioning, disability and health (ICF) as a reference tool. BMC Musculoskelet Disord. 2006, 7: 96-10.1186/1471-2474-7-96.View ArticlePubMedPubMed CentralGoogle Scholar
- Taleisnik J: The palmar cutaneous branch of the median nerve and the approach to the carpal tunnel. An anatomical study. J Bone Joint Surg Am. 1973, 55 (6): 1212-1217.PubMedGoogle Scholar
- Citron ND, Bendall SP: Local symptoms after open carpal tunnel release. A randomized prospective trial of two incisions. J Hand Surg [Br]. 1997, 22 (3): 317-321.View ArticleGoogle Scholar
- Geere J, Chester R, Kale S, Jerosch-Herold C: Power grip, pinch grip, manual muscle testing or thenar atrophy – which should be assessed as a motor outcome after carpal tunnel decompression? A systematic review. BMC Musculoskelet Disord. 2007, 8: 114-10.1186/1471-2474-8-114.View ArticlePubMedPubMed CentralGoogle Scholar
- Jugovac I, Burgic N, Micovic V, Radolovic-Prenc L, Uravic M, Golubovic V, Stancic MF: Carpal tunnel release by limited palmar incision vs traditional open technique: randomized controlled trial. Croat Med J. 2002, 43 (1): 33-36.PubMedGoogle Scholar
- Nancollas MP, Peimer CA, Wheeler DR, Sherwin FS: Long term results of carpal tunnel release. J Hand Surg [Br]. 1995, 20 (4): 470-474.View ArticleGoogle Scholar
- Abouzahr MK, Patsis MC, Chiu DT: Carpal tunnel release using limited direct vision. Plast Reconstr Surg. 1995, 95 (3): 534-538. 10.1097/00006534-199503000-00015.View ArticlePubMedGoogle Scholar
- Chapman CB, Ristic S, Rosenwasser MP: Complete median nerve transection as a complication of carpal tunnel release with a carpal tunnel tome. Am J Orthop. 2001, 30 (8): 652-653.PubMedGoogle Scholar
- Nathan PA, Meadows KD, Keniston RC: Rehabilitation of carpal tunnel surgery patients using a short surgical incision and an early program of physical therapy. J Hand Surg [Am]. 1993, 18 (6): 1044-1050. 10.1016/0363-5023(93)90401-N.View ArticleGoogle Scholar
- Hwang PYK, Ho CL: Minimally invasive carpal tunnel decompression using the KnifeLight. Neurosurgery. 2007, 60: 162-169. 10.1227/01.NEU.0000249249.33052.7E.Google Scholar
- Avci S, Sayli U: Carpal tunnel release using a short palmar and a new knife. J Hand Surg [Br]. 2000, 25 (4): 357-360.View ArticleGoogle Scholar
- Cellocco P, Rossi C, Bizzarri F, Patrizio L, Costanzo G: Mini-open blind procedure versus limited open technique for carpal tunnel release: a 30-month follow-up study. J Hand Surg [Am]. 2005, 30 (3): 493-499. 10.1016/j.jhsa.2005.02.007.View ArticleGoogle Scholar
- Vasen AP, Kuntz KM, Simmons BP, Katz JN: Open versus endoscopic carpal tunnel release: a decision analysis. J Hand Surg [Am]. 1999, 24 (5): 1109-1117. 10.1053/jhsu.1999.1109.View ArticleGoogle Scholar
- Chung KC, Walters MR, Greenfield ML, Chernew ME: Endoscopic versus open carpal tunnel release: A cost-effectiveness analysis. Plast Reconstr Surg. 1998, 102 (4): 1089-1099. 10.1097/00006534-199809040-00026.View ArticlePubMedGoogle Scholar
- Hudson AR, Wissinger JP, Salazar JL, Kline DG, Yarzagaray L, Danoff D, Fernandez E, Field EM, Gainsburg DB, Fabi RA, Mackinnon SE: Carpal tunnel syndrome. Surg Neurol. 1997, 47 (2): 105-114. 10.1016/S0090-3019(97)89908-9.View ArticlePubMedGoogle Scholar
- Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN: A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993, 75 (11): 1585-1592.PubMedGoogle Scholar
- Hallock GG, Lutz DA: Prospective comparison of minimal incision "open" and two-portal endoscopic carpal tunnel release. Plast Reconstr Surg. 1995, 96 (4): 941-947. 10.1097/00006534-199509001-00027.View ArticlePubMedGoogle Scholar
- Hybbinette CH, Mannerfelt L: The carpal tunnel syndrome: A retrospective study of 400 operated patients. Acta Orthop Scand. 1975, 46 (4): 610-620.View ArticlePubMedGoogle Scholar
- Klein RD, Kotsis SV, Chung KC: Open carpal tunnel release using a 1-cm incision: Technique and outcomes for 104 patients. Plast Reconstr Surg. 2003, 111 (5): 1616-1622. 10.1097/01.PRS.0000057970.87632.7e.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/9/126/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.