29 Closed Technique With Paine Retinaculotomeand Modified Retinaculotome MDCA. Mantovani, L. De Cristofaro, A. Ciaraldi

Introduction

It has been proven that flexor tenosynovectomy andmedian neurolysis are practically not useful in thetreatment of “essential” carpal tunnel syndrome andshould be reserved for specific indications [13, 19, 36].The fact that the improvement in function followingsurgery has to be attributed completely to the divisionof the transverse carpal ligament [36] has been recog-nized only recently. Closed techniques for decompres-sion of the median nerve at the wrist in carpal tunnelsyndrome, along with endoscopic methods, have re-ceived particular attention towards the end of the1980s. Yet, Paine had already designed and presentedthe use of his retinaculotome [31] in 1955. It is really ev-idence of genius as only a few dozen cases of carpal tun-nel syndrome had been recognized and treated by opendecompression up to 1950 [3]! In his series published in1983 [32], Paine reported remarkable results with aminimal rate of recurrence, early resumption of use ofthe operated hand and, above all, absence of iatrogeniclesions. We were among the first few surgeons in Italy toadopt this technique since 1990. We presented our ini-tial results [22] in 1991, certain modifications in theprocedure [23] in 1994, a videocassette recording [21]in 1995, and a larger series of cases [24] in 1997.

Other significant reports of this method include theseries presented by Pagnanelli [33] in 1991 and that ofGrangie [14] who compared it with results obtained us-ing the traditional open technique of carpal tunnel re-lease in 1992. In 1995, Carneiro [4] presented his resultsat the 6th Congress of the International Federation ofSocieties for the Surgery of the Hand (IFSSH) at Helsin-ki. He described the use of the retinaculotome in thedisto-proximal direction, i.e., with an incision in thepalm. However, this entails identification and isolationof the structures in the palm before division of the flex-or retinaculum and cannot be considered an exampleof the original Paine technique, which involves an ap-proach at the wrist.

We have examined this approach and studied a se-ries of 100 patients, operated upon by the same sur-geon, 50 of which were treated by the original Painetechnique and the remaining 50 by the palmar ap-

proach. The results of this study were analyzed and pre-sented in the 33rd Congress of the Italian Hand Societyat Brescia in 1995 [20]. This was part of a multicentricstudy with a common protocol for evaluation of vari-ous techniques in the surgical treatment of carpal tun-nel syndrome. We prefer to use the retinaculotome inthe proximo-distal direction with an approach at thewrist.

Technique

The retinaculotome (Fig. 29.1) consists of a spatulamade of stainless steel with rounded edges. It is 1.5 mmthick, 7 mm wide, and 4.4 cm long. The handle of the in-strument is angled at 30°. A 3.3-mm-high vertical bladeemerges at the center of the spatula. Its superior borderis rounded and protrudes 1.5 mm beyond the cuttingedge of the blade. This peculiar shape enables us to per-form a true “closed” section of the transverse carpal lig-ament as long as we strictly adhere to the sequence ofsteps of the procedure. For surgeons beginning to usethis instrument, we would recommend performing anopen release for the first few cases. This would allow thesurgeon to visualize the relationship between the pas-sage of the retinaculotome and the surrounding anatom-ical structures and to become familiar with the “feel” ofcomplete division of the transverse carpal ligament.

Proper knowledge of the local anatomy is essential.Some authors [15, 16] consider the transverse carpalligament to be synonymous with the flexor retinacu-lum. Despite being a localized thickening of the centralsegment of the flexor retinaculum, the transverse car-pal ligament is a discrete anatomical structure withspecific bony attachments [6]. The flexor retinaculum,in its turn, is just a distal prolongation of the deep fasciaof the forearm that ends as the interthenar fascia in thepalm [6] (Fig. 29.2).

As we proceed in the proximo-distal direction, onecan distinguish three segments of the flexor retinacu-lum: the first segment is a thickening of the deep fasciaof the forearm, the central segment constitutes the truetransverse carpal ligament, while the third segment isthe interthenar fascia [6].

Chapter 29

Fig. 29.1. Photograph and design of the Paine retinaculotome (distributed in Italy by DIMA, Vicenza)

Fig. 29.2. A transverse section at the wrist and longitudinal section of the carpal tunnel along the axis of the fourth ray. The flexorretinaculum consists of three consecutive segments: the localized thickening of the deep fascia of the forearm (1), the transversecarpal ligament (2) and the interthenar fascia (3) in the proximo-distal direction. The superficial fascia of the forearm continuesdistally as the palmar aponeurosis and is separated from the flexor retinaculum by adipose interfascial tissue. FCR: tendon offlexor carpi radialis; FPL: tendon of flexor pollicis longus; PL: tendon of palmaris longus; T: flexor tendons of the fingers; M: me-dian nerve

The flexor retinaculum represents the first pulley thathelps transmit and amplify the force exerted by the flex-or tendons on the phalanges of the fingers and, at thesame time, the roof of the carpal tunnel. In three-di-mensional terms, the carpal tunnel is not a true cylinderbut resembles a clepsydra with the point of maximalnarrowing at the level of the hook of the hamate [6].

The tendon of the palmaris longus provides theguide to the operation of carpal tunnel release using theclosed technique of Paine. It passes superficially to theflexor retinaculum and continues as the palmar apo-neurosis. This overlies the transverse carpal ligament

and the interthenar fascia and is separated from themby a layer of fatty tissue [29] (Fig. 29.2).

According to some authors [12, 27], the palmar apo-neurosis is separated from the flexor retinaculum byanother interthenar fascia in addition to the layer offatty tissue described above. However, this fascia isclosely adherent to the transverse carpal ligament andcannot be isolated and protected during the surgery forcarpal tunnel release using the retinaculotome in theproximo-distal direction. The contents of the carpaltunnel include the eight flexor tendons of the fingersenveloped by the folds of their common synovial lining

29 Closed Technique With Paine Retinaculotome and Modified Retinaculotome MDC 201

while the flexor pollicis longus has its separate synovialsheath. These synovial folds do not surround the medi-an nerve, while lies “extrabursal” with respect to theflexor tendons [2] (Fig. 29.2). The carpal tunnel iscompletely filled with the flexor tendons and theirsheaths so that the extrabursal space within the canal isonly potential.

The median nerve always occupies a radial positionalong its course proximal to as well as within the carpaltunnel: proximally, it lies between the tendons of thepalmaris longus and that of the flexor carpi radialiswhile, within the carpal tunnel, it courses between thetendon of the flexor digitorum superficialis to the mid-dle finger and that of the flexor pollicis longus [2], i.e.,towards the radial side of the carpal tunnel (Fig. 29.2).In addition, the palmar cutaneous branch of the medi-an nerve, which emerges in the subcutaneous planeproximal to the flexor retinaculum, runs radially closeto the tendon of the flexor carpi radialis [37]. It is obvi-ous, then, that the approach for closed section of thetransverse carpal ligament should lay ulnar and deep tothe palmaris longus tendon. The ulnar nerve and ves-sels are retracted medially. The Guyon’s canal lies su-perficial and ulnar to the carpal tunnel and the contentsof the Guyon’s canal are involved only partially in theproximal portion of the Paine technique.

We recommend use of regional anesthesia and atourniquet for the initial cases. Once the surgeon hasbecome familiar with the technique, it is better to per-form the surgery under local anesthesia (1% Lidocainewith adrenaline) and without application of a tourni-quet, as recommended by other authors [35, 38]. Infact, the reflex perfusion following the release of thetourniquet could result in the formation of local hema-tomas.

The limb is prepared and draped. The local anes-thetic agent is injected with a thin needle (no. 26G or

Fig. 29.3. Essential surfacemarkings for decompressionof the median nerve usingthe Paine technique. Thecontinuous red line indicatesthe site of the skin incision.The dotted red line indicatesthe line of action of the reti-naculotome (explained intext). FCR: tendon of theflexor carpi radialis; PL: ten-don of the palmaris longus;P: cutaneous projection ofthe site of the pisiform bone

finer). It is first injected in the subcutaneous tissue atthe site of incision, i.e., at the distal wrist flexion crease.In practice, the lidocaine is not injected within the car-pal tunnel or towards the median nerve as the surgicalapproach courses in a plane superficial to the nerve.The wrist is held in the neutral position and not in hy-perextension so that the contents of the carpal tunnelare not compressed against the transverse carpal liga-ment.

The surgeon sits in a position that would allow himto operate using his dominant hand, i.e., a right-hand-ed surgeon would sit on the ulnar side of the patient’shand while operating upon the right carpal tunnel andon the radial side for surgery for the left carpal tunnel.

The incision lies along the distal wrist flexion crease,close to the palmaris longus tendon and extending ul-narward for 2 cm up to the palpable border of the pisi-form bone (Fig. 29.3). Hence, the approach passes inthe space between the palmaris longus and the ulnarneuro-vascular bundle and between the superficial anddeep fasciae of the forearm (Fig. 29.2).

There are no major anatomical structures at this siteapart from small vessels and terminal cutaneousbranches of the median and ulnar nerves, which can beeasily retracted along with the local fatty tissue to ex-pose the underlying edge of the flexor retinaculum.This can be isolated well by careful retraction of the in-terfascial fatty tissue, already infiltrated with lidocaine,in the proximo-distal direction following the tendon ofthe palmaris longus as a guide. The superficial fascia ofthe forearm is thickened at this level to form the roof ofthe Guyon’s canal. It is called the palmar carpal liga-ment [8] (Fig. 29.4). Division of this ligament helpsopen the Guyon’s canal superficially.

A flat retractor is inserted to retract the tendon of thepalmaris longus and another helps retract the ulnarneurovascular pedicle medially. Instruments of a size

202 III Treatment

Fig. 29.4. The flexor retinaculumin relation to the neuro-vascularbundle in the Guyon’s canal dur-ing the surgical approach by thePaine technique. Division of thevolar carpal ligament opens themouth of the Guyon’s canal su-perficially. It is opened on itsdeep aspect when a buttonholeis made under vision in theproximal portion of the flexorretinaculum. The Paine retina-culotome is introduced into thecarpal tunnel through this but-tonhole and the remaining por-tion of the flexor retinaculum isdivided by a closed techniquealong the direction of the arrowshown, which corresponds tothe axis of the fourth ray. Theinstrument rests on the hook ofthe hamate in its passage alongthis course. A: ulnar artery;M: median nerve; U: ulnarnerve; S: sensory branch of theulnar nerve; T: flexor tendons ofthe fingers; P: pisiform bone; H: hook of the hamate; PL: tendon of palmaris longus; PA: palmar aponeurosis; VCL: divided volarcarpal ligament; PHL: piso-hamate ligament; FCR: tendon of flexor carpi radialis; FCU: tendon of flexor carpi ulnaris; 1-2-3:3 consecutive segments of the flexor retinaculum

suitable for this surgery are essential. The blades ofeach of these right-angled retractors should be 5 mmwide and 1 mm thick. The retractor placed under thepalmaris longus tendon should be 2 cm long while thatused to retract the ulnar nerve and vessels should be2.5 cm long. Both these retractors should be applied inthe proximo-distal direction. Proper retraction of theinterfascial fat using the two retractors exposes theproximal two thirds of the flexor retinaculum. A longi-tudinal incision is made over the ulnar aspect of theflexor retinaculum using a no. 15 blade. This incisionshould be extended distally for 1.5–2 cm under com-plete visual control. Thus the division of the transversecarpal ligament is started under vision, taking care toavoid injury to the underlying synovial sheath of theflexor tendons. At this stage, the assistant plays a vitalrole by proper retraction of the fatty tissue superficiallyso that the plane of the transverse carpal ligament islifted off the synovium, which is then visible throughthe buttonhole made in the flexor retinaculum(Figs. 29.4. 29.5).

One must mention that the beginning of the releaseof the transverse carpal ligament also implies release ofthe proximal part of the Guyon’s canal. The roof of theGuyon’s canal is opened by division of the superficialforearm fascia and the palmar carpal ligament beforeplacement of the retractors during the exposure of theflexor retinaculum while division of the portion of thetransverse carpal ligament that lies between the pisi-form and the hook of the hamate produces a release ofthe floor of the Guyon’s canal (Fig. 29.4).

Fig. 29.5. The buttonhole made in the first part of the flexor ret-inaculum is visible through the wound in the skin. The Paineretinaculum is inserted through this buttonhole

At this stage, one has to inject a further dose of localanesthetic agent into the interfascial fatty tissue to-wards the palm. The insulin needle is directed along thefourth ray and is placed superficial to the plane of thetransverse carpal ligament. An additional dose of lido-caine is allowed to drip through the buttonhole in theligament while the patient is instructed to execute

29 Closed Technique With Paine Retinaculotome and Modified Retinaculotome MDC 203

movements of complete flexion and extension of thefingers repeatedly. Throughout this procedure, care istaken to maintain retraction to expose the rent made inthe transverse carpal ligament.

Additional anesthetic is allowed to drip throughthe buttonhole in the flexor retinaculum and the pa-tient is instructed to flex and extend his fingers re-peatedly while the traction on the retractors is main-tained. Thus the synovial sheath is bathed in anes-thetic fluid without being infiltrated with it. The ac-tive movements facilitate diffusion of the fluid. Infil-tration of local anesthetic would produce swellingand compromise the space in the canal that is alreadylimited.

One can now introduce a thin and smooth retractorwith a handle angulated at 30° (similar to the retinacu-lotome) under the flexor retinaculum in order to sepa-rate the synovial sheaths from it. This, too, is passed inthe direction of the fourth ray. The passage of this in-strument serves three objectives: the local anestheticfluid is pushed deeper and toward the median nerve; itprepares the path for the passage of the retinaculotomesubsequently; the surgeon gets a “feel” of the degree ofstenosis he will encounter while attempting division ofthe retinaculotome.

It is interesting to note that this step does not pro-duce pain as it is performed in the presence of local an-esthetic fluid and because the instrument does notcome in contact with the median nerve, which gets dis-placed radially. In practice, one does not look for the

Fig. 29.6. Transverse sectionof the wrist at the level of thehamate during carpal tunneldecompression by the Painetechnique. Placement of theretinaculotome on the hookof the hamate ensures thatthe transverse carpal liga-ment is divided at a site awayfrom the median nerve sothat the resultant scar doesnot cover it. In addition, theinstrument occupies minimalspace within the carpal tun-nel that is already tight. Ad-vancement of the retinaculo-tome progressively enlargesthe canal

median nerve as the transverse carpal ligament is di-vided along its ulnar portion (Fig. 29.6).

Finally, after these indispensable steps, one can in-troduce the retinaculotome into the buttonhole in theflexor retinaculum. The vertical blade immediately en-counters the distal angle of the buttonhole. Before pro-ceeding with the division of the ligament, one must en-sure that the flat portion of the instrument rests on theulnar bony insertion of the flexor retinaculum, i.e., thehook of the hamate (Fig. 29.6) and, having confirmedthis, one can push the retinaculum distally along theaxis of the ring finger and complete the division of thetransverse carpal ligament. The force applied on the in-strument will depend upon the sharpness of the bladeand the resistance encountered, which varies from onepatient to the next. This step requires the same degreeof attention as one applies while incising through dif-ferent types of skin (one must avoid excessive pres-sure). Hence, it is advisable to acquire a “feel” of com-plete section of the transverse carpal ligament by doingit with an open technique initially. One will learn, thus,to stop pushing the retinaculotome as soon as there is asudden decrease in the resistance to the passage.

The edges of the transverse carpal ligament remainvisible after this selective division, even in the distalpart if the traction on the retractors is maintained. Theedges are pulled apart approximately 1 cm and one canconfirm the increase in space within the canal and thatthe nerve is decompressed. One can introduce anysmooth instrument, with its end turned towards the

204 III Treatment

palm, in order to confirm complete division of the liga-ment in the portion distal to that visible in the wound.This step becomes superfluous once the surgeon hasdeveloped confidence with this technique. One can alsovisualize the median nerve but this would be futile asno further procedures on the nerve are planned.

The surgeon can wash the wound with saline and an-tibiotics according to his or her choice. The wound isthen closed with three interrupted everting sutures orwith an intradermal suture using absorbable material.A simple local adhesive dressing usually suffices. Use oflidocaine with adrenaline results in minimal bleedingduring surgery and postoperative hematomas are rare.Hence, we have abandoned application of compressivedressings immediately after surgery, which was ourpractice earlier and which was recommended by Paine.In addition, use of antibiotics following the operationwas found to be futile [22] as the surgery is performedin a proper operation theatre under strict aseptic con-ditions. It is preferable to obtain access to a vein on theopposite upper limb for administration of intravenousmedications, if necessary, before the patient is wheeledinto the operation theatre. The patient usually does notneed hospitalization and the surgery is performed as a“day surgery” procedure.

Finally, we recommend maintenance of the sharp-ness of the blade of the retinaculotome by rubbingalong its cutting edge with fine sandpaper wrappedaround a Kirschner wire after every 10 operations.

Indications and Contraindications

The Paine technique implies closed division of thetransverse carpal ligament without exploration of thecarpal tunnel or visualization of the median nerve.Hence, it is essential to avoid demeaning this operationby adhering to strict indications and by proper selec-tion of the patients. One must be certain that the condi-tion is “essential” carpal tunnel syndrome and not“secondary” to space-occupying lesions within the car-pal tunnel. For this reason, we evaluate each of our pa-tients according to a standardized pre- and postopera-tive protocol [25], which includes all the data derivedfrom clinical examination and investigations that areaimed at identification of other pathology as well asother levels of nerve compression.

Thus, we consider the Paine technique to be contra-indicated in the following conditions:

1. Polyarticular rheumatoid arthritis: here completeflexor tenosynovectomy is essential in addition todivision of the transverse carpal ligament.

2. Gout and tuberculous tenosynovitis: here oneneeds to excise the inflamed tenosynovium and tosend a sample for histopathological evaluation.

3. Suspected cases of nerve tumors or tumors of othertissues within the carpal tunnel.

4. Recurrent carpal tunnel syndrome: here exposure ofthe median nerve is essential as the regional anato-my may be altered following the earlier surgery.

5. The rare cases of acute carpal tunnel syndrome inwhich open exploration of the median nerve wouldbe necessary.

On the other hand, the selective and minimally invasivetechnique using the retinaculotome makes it the meth-od of choice in diabetics and in patients undergoing he-modialysis following renal failure. However, open teno-synovectomy is preferred for dialyzed patients with hy-pertrophied flexor tenosynovium. In addition, the Pai-ne retinaculotome can be utilized in cases of posttrau-matic carpal tunnel syndrome with displaced carpalfractures or intercarpal dislocations. However, theclosed technique is contraindicated if there exist post-traumatic bony deformities that need to be corrected.

Double-level compression of the median nerve, atthe wrist as well as at the elbow or in the neck, is not acontraindication for the Paine technique. However, thepatient must be warned about the possibility of incom-plete relief from his symptoms following surgery.

Use of the Paine technique is also justified in elderlypatients with long-standing symptoms and persistentpain, even if the thenar muscles are already atrophied.In fact, it has been shown that some clinical and elec-tromyographic improvement does occur even follow-ing such delayed decompression of the carpal tunnel[28]. We feel that use of a minimally invasive techniqueis more important than exploration and neurolysis ofthe median nerve.

Finally, we strongly advise against doing the surgeryon both hands during the same operation, even thoughthe simplicity of the procedure makes it feasible. Disap-pearance of the symptoms in the opposite hand follow-ing surgery on one side is well known [26]. We call thisphenomenon the “reset” effect, which enables the pa-tient to resume normal activities very quickly and torehabilitate the operated hand.

Surgery on the opposite hand can be considered lat-er if the “reset” effect proves transitory and the symp-toms recur or become disconcerting.

In a recent study of 362 operated cases [26], we notedthat the “reset” effect persisted until 20 days after theoperation in 120 cases (33%) and at 7 months in 160cases (44%). However, the same study revealed wors-ening of symptoms on the opposite side following uni-lateral surgery in 47 patients (13%) at 20 days and in111 cases (31%) at 7 months.

Finally, an interesting and practical suggestionwould be to exclude all cases of unilateral carpal tunnelsyndrome if it cannot be conclusively proved to be “pri-mary” or due to repetitive stress to that hand at work.

29 Closed Technique With Paine Retinaculotome and Modified Retinaculotome MDC 205

In fact, one must look for conditions other than prima-ry carpal tunnel syndrome in all cases with unilateralsymptoms. To this end, one can utilize investigationssuch as radiographs, ultrasonography, MRI, and/or he-matological tests necessary to determine any second-ary cause of median nerve compression.

Apart from carpal tunnel syndrome due to excessiveuse of one hand, unilateral cases are extremely uncom-mon. In fact, the large majority of cases of carpal tunnelsyndrome are “primary” in origin, i.e., due to a consti-tutional stenosis of the carpal tunnel. The symptomsoccur mainly in the dominant hand or the hand that ismore involved at work. This is supported by a recentobservation [30] that 87% of patients with symptomsof carpal tunnel syndrome present with bilateral affec-tion while the remaining 13% of cases with unilateralsymptoms show evidence of median nerve compres-sion on electrophysiological tests in the opposite hand,indicating subclinical involvement. Other authors [1, 9,34] have shown with CT scan measurements that pa-tients with carpal tunnel syndrome have a significantlynarrower canal as compared to normal controls. In thiscontext, one must emphasize that the retinaculotomedivides the transverse carpal ligament progressively inits passage along the carpal tunnel so that an additionalinstrument does not compromise the narrow spacewithin the canal at any stage of the procedure. It differsfrom other closed techniques in this respect; all otherprocedures involve insertion of an instrument (al-though smooth) within the restricted space of the canalprior to decompression. In practice, the use of the reti-naculotome is truly atraumatic for the median nerve aswell as the other adjacent structures.

Complications and Results

The safety of the Paine technique is due to the qualitiesof the instrument as well as the care taken in each stepof the procedure. The smooth and blunt superior bor-der above the blade pushes aside structures superficialto the transverse carpal ligament and helps protecteven anomalous tissues such as a communicatingbranch between the median and ulnar nerves [10, 11](Fig. 29.7). Such a branch and all its variant formswould be more susceptible to injury in carpal tunnel re-lease by the open or by an endoscopic technique [10]rather than with the Paine method.The flattened spatula below the blade retracts and pro-tects the underlying flexor tendons and their synovialsheaths (Fig. 29.7). Resting the base on the ulnar aspectof the carpal tunnel allows us to run the instrumentalong the hook of the hamate so that the transverse car-pal ligament is divided close to its ulnar insertions.This provides protection to the median nerve, whichlies radially, as well as its motor branch (in all its varia-

Fig. 29.7. The possible anatomical variations of the median andulnar nerves [33–35] with respect to the division of the trans-verse carpal ligament using the Paine retinaculotome. TCL:transverse carpal ligament; R: Paine retinaculotome; 1: palmarcutaneous branch of the median nerve; 2: transligamentousvariant of the motor branch (23%); 3: subligamentous variantof the motor branch (31%); 4: extraligamentous variant of themotor branch (46%); 5: communicating branch in the palmbetween the median and the ulnar nerves

tions) [18] and the palmar cutaneous branch [37](Fig. 29.7). In addition, the defect in the transverse car-pal ligament and the consequent scarring does notoverlie the median nerve. This could explain the low in-cidence of recurrent symptoms as well as the minimalloss of grip strength following this procedure. Finally,the superficial palmar arch lies 2–26 mm beyond thedistal edge of the flexor retinaculum [7] and there is norisk of injury from the blade of the retinaculotome.

We presented a large series of cases in 1997 [24] inwhich we found that there were no complications suchas iatrogenic lesions (of any type), hematomas, postop-erative sepsis or reflex sympathetic dystrophy in 853patients operated upon by five different surgeons be-tween 1990 and 1996. There were 28 failures (3%) ofwhich 8 had incomplete relief. Two of these eight pa-tients suffered from diabetes mellitus while the remain-ing six had median nerve compression at two levels(double-crush).

There were 16 cases of early recurrence of symptoms(2%) that appeared within 3 months following surgery.In each of them, the cause of failure was found to be in-complete division of the transverse carpal ligament,which was revealed during secondary decompressionby the open technique. These incidents of incompleterelease could be attributed to the inexperience of theoperating surgeon as the rate of failure progressively

206 III Treatment

decreases when the surgeon has performed a largenumber of such procedures.

Late recurrence of symptoms (appearing beyond ayear from the operation) was noted in 4 cases (0.5%).The cause of the recurrence was not evident during thesecond operation, which, in each case, produced com-plete and permanent relief from the symptoms.

We could hypothesize that the cause could be a de-fect in the technique employed in the first operation. Ifthe site of section of the transverse carpal ligament wasnot adequately ulnar, the resulting scar could overliethe median nerve and produce perineural fibrosis andconstriction. This, in turn, could be responsible for therecurrent symptoms. We have never found it necessaryto convert the closed procedure to an open techniquedue to intraoperative problems. This indicates the sim-plicity of the Paine technique.

The so-called pillar syndrome [5] was a minor com-plication that we noted in 145 (17%) operated patients[26]. This refers to painful swelling in the interthenarregion slightly toward the ulnar side, i.e., along thecourse of the blade of the retinaculotome. This compli-cation occurred gradually after 15–30 days followingthe operation with complete absence of paresthesias.There was painful induration of the scar deep to theskin, apparently arising from the interfascial plane inwhich the retractors were placed. This is an irritatingcondition, at times alarming to the patient, especiallyas it is a new symptom that has appeared after surgery.However, it is always transitory and disappears gradu-ally over a few months without compromising the resultof surgery. Hence, it has been considered as a minorcomplication.

Another minor complication is a slight decrease ingrip strength due to the division of the first and mostimportant pulley for the flexor tendons. It occurs fol-lowing carpal tunnel release by any technique and thepatient must be warned in advance about its occur-rence. In addition, it is always temporary. In our study[26], using the Jamar dynamometer, we constantly not-ed an average loss of grip strength of 1.6 kg for the righthand and 1.3 kg for the left hand at 20 days followingsurgery. However, at 7 months from the operation, wefound an average increase in grip strength of 1.8 kg forthe right hand and 2.2 kg for the left hand with respectto the values noted before surgery. Other authors [17]have shown a progressive increase in grip strength upto 2 years after the operation.

Even the thumb-index pinch grip decreases in theimmediate postoperative period and, then, recovers toa level higher than the preoperative value. However,these variations are over a few grams and the patient isusually not informed about them [26].

The patient usually resumes work around 1–3 weeksafter the operation with the Paine technique and thedelay depends upon the type of work. It is very impor-

tant to encourage the patients to resume some lightwork with the wrist in extension in order to prevent ad-hesions around the tendons and the median nerve. Thepatient is encouraged to resume normal activities ofdaily living with respect to the operated hand from theday of surgery itself and to take care to keep the wristextended in all movements.

Thus, occupational rehabilitation is started veryearly taking care to instruct the patients to increasetheir activities gradually in order to avoid evoking a re-active tenosynovitis.

In patients who have been properly informed, wehave noted excellent compliance with respect to thesurgery and postoperative therapy. This occurs despitethe fact that most of these patients are operated upon in“day surgery” and drive home the same day. In addi-tion, we feel that it is very important to re-evaluatethese patients clinically at periodic intervals. We reviewour patients on the day following surgery, after8–10 days and at a month after the operation. We ad-vise the patients to come back for review if any newsymptoms occur or, in any case, at a year with an elec-tromyogram of the opposite hand.

We also warn the patients about the possibility offlexor tenosynovitis in all the fingers due to the over-loading of the pulleys following division of the flexorretinaculum. If such tenosynovitis is noted, with orwithout triggering of the finger, we infiltrate a locallyacting steroid solution into the tendon sheath and thisusually provides relief without recourse to surgery. Wefound this problem in 11% of our cases operated uponby the Paine technique [26].

In conclusion, we are convinced that the excellent re-sults obtained following carpal tunnel release using thePaine retinaculotome depend upon the qualities of theinstrument itself, application of precise indications,and rigorous adherence to the details of the surgicalprocedure. Thus, the procedure becomes safer, selec-tive, and can be performed at very low cost.

The Modified Retinaculotome MDC

In April, 2003, when Dr. Luchetti requested us to pro-vide a translation of our chapter in English, we had re-cently started using a modified version of the retinacu-lotome. It was designed for patients whose hands wereof a smaller size than the average. We decided to call itthe MDC after the initials of the names of the authors.We would now like to elaborate the modifications madein the version of the retinaculotome described earlier.

We had already noted that the Paine retinaculotomeenabled us to operate upon any patient with carpal tun-nel syndrome. However, in patients with very smallwrists, particularly in women of short stature, we feltthat the original retinaculotome occupied too much

29 Closed Technique With Paine Retinaculotome and Modified Retinaculotome MDC 207

space in the canal with respect to the size of the wrist.For this reason, we decided to modify the instru-

ment in order to adapt to the smaller size of the canal insuch patients. The new design is represented inFig. 29.8. It is slightly smaller than the Paine retinaculo-tome but the height of the blade remains the same. Thebroad base of the blade, too, is tapered. In addition, wehave introduced a curve in this base and increased theangulation of the handle of the instrument. These sim-ple modifications help adapt the retinaculotome to thealtered conditions in smaller wrists so that the instru-ment follows the course of the flexor retinaculum. Infact, the tapered base of the blade allows the instru-ment, which rests on the hook of the hamate, to con-stantly maintain the course of section of the flexor reti-naculum along its ulnar aspect even as it widens distal-ly (Fig. 29.9). The curved form of the instrument en-ables it to follow the inclination of the flexor retinacu-lum (Fig. 29.10). Finally, the greater vertical angulationof the handle improves the execution of the operationas it ensures that the surgeon’s hand does not impingeon the patient’s forearm.

In the 73 cases operated upon using the MDC during2003, with, however, a short follow-up, we have ob-tained results similar to those seen using the classical

Fig. 29.8. Comparative photograph of the Paine retinaculotome and retinaculotome MDC technical design (distributed in Italy byDIMA)

Paine retinaculotome. Thus, we maintain that the MDCis a refined instrument more adapted to suit surgery forpatients with smaller wrists. In such cases, the modifi-cations have proved to be very important in facilitatingthe execution of this operation, which has often beentermed as minor surgery or as surgery of well-being.Although this operation does not save lives, it does,however, improve the quality of life for the patientsand, hence, cannot be trivialized. In fact, partial im-provement is not acceptable in such cases and modifi-cations in the described surgical techniques are neces-sary and justified.

Acknowledgements. The authors thank Dr. Anil Bha-tia for his help in translating this article into English,Andrea Bozzetti for the technical designs and Frances-co Mantovani for his help with the computer.

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208 III Treatment

Fig. 29.9. A central coronalsection of the left carpal tun-nel containing the retinacu-lotome MDC (R) and its lineof action (C).Due to theshape of the canal, the nar-rowest part lies at the level ofthe hook of the hamate (H)[17]. The figures in millime-ters refer to the average val-ues for the dimensions of thecarpal tunnel [17]. The in-strument is pushed in theproximo-distal directionalong the axis of the fourthdigital ray (B), resting on the hook of the hamate. The tapering base of the blade ensures that the flexor retinaculum is dividedalong a course that occupies the most ulnar portion of the retinaculum, i.e., along the line C while the instrument is directedalong the axis B. A: central axis of the carpal tunnel. B: axis of the retinaculotome MDC and of the fourth digital ray. C: line ofsection of the flexor retinaculum

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