Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 193–196
Original article
Arterial vascularization of the flexor digitorum superficialis synovial flap. An anatomical study Vascularisation artérielle du lambeau synovial des tendons fléchisseurs superficiels des doigts. Étude anatomique P. Pelissier a,*, J.-M. Alet a, A. Morchikh b, H. Choughri a, V. Casoli a,c a
Service de chirurgie plastique-brûlés-main, centre F.X.-Michelet, groupe hospitalier Pellegrin, 33076 Bordeaux, France b Orthopôle, 53 bis, avenue Maryse-Bastié, 33520 Bruges, France c Laboratoire d’anatomie, université de Bordeaux, 146, rue Léo-Saignat, 33076 Bordeaux, France Received 2 February 2015; received in revised form 15 April 2015; accepted 19 April 2015 Available online 2 July 2015
Abstract Among the various techniques proposed to protect the median nerve from scarring and to provide it with a vascular supply, the synovial flap represents a simple and effective method. The flap is taken from the flexor tendons sheath and results in a thin and richly vascularized tissue that will act as a barrier to scarring and provide neovascularization to improve nerve regeneration and gliding. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. An anatomic study was carried out on 24 fresh upper limbs infused with colored and radiopaque solutions before or after flap elevation. Anatomical findings showed the synovial flap to be supplied by a consistent vascular pedicle arising from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone and running between the flexor tendons of the ring and little fingers. The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: Carpal tunnel syndrome; Recurrence; Flap; Synovial
Résumé Parmi toutes les techniques proposées pour protéger le nerf médian du tissu cicatriciel et lui apporter une vascularisation, le lambeau synovial représente une méthode simple et efficace. Le lambeau est prélevé sur la gaine synoviale des tendons fléchisseurs et fournit en un tissu fin et richement vascularisé, à même de protéger le nerf de la cicatrice, d’apporter une vascularisation qui favorisera la régénération nerveuse, mais également un plan de glissement. Le but de cette étude était de décrire la vascularisation de ce lambeau pour en évaluer la fiabilité. L’étude anatomique a été menée sur 24 membres supérieurs frais, injectés avec une solution colorée et radio-opaque, avant ou après dissection du lambeau. Le lambeau synovial était vascularisé de façon constante par un pédicule naissant de l’artère ulnaire deux à cinq centimètres proximalement à l’os pisiforme, puis cheminant entre les tendons fléchisseurs superficiels des 4e et 5e doigts. Le lambeau synovial était connu comme une technique simple et efficace de couverture du nerf médian. Cette étude montre que sa vascularisation constante en fait une technique fiable. Nous pensons que cette technique présente un intérêt certain lors du traitement des récidives de syndrome du canal carpien. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Syndrome du canal carpien ; Récidive ; Lambeau ; Synovial
* Corresponding author. E-mail address: [email protected] (P. Pelissier). http://dx.doi.org/10.1016/j.main.2015.04.004 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved.
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P. Pelissier et al. / Chirurgie de la main 34 (2015) 193–196
1. Introduction Recurrent carpal tunnel syndrome is a potentially difficult challenge. The most common causes revolve around scarring of the median nerve to the surrounding structures. Many surgical options have been described in the literature to protect the released median nerve such as nerve wrapping (using dermal grafts [1], vein grafts [2,3], or synthetic membranes [4]), local flaps (abductor digiti minimi muscle [5], pronator quadratus muscle [6], palmaris brevis muscle [7], hypothenar fat flap [8,9] and synovial flap) or more complex pedicled or free flaps [10,11]. A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome reveals that decompression with the addition of vascularized flap coverage appears to have a higher success rate than simple repeated decompression [12]. These flaps should allow gliding of the previously scarred nerve and help to revascularize the ischemic nerve. Among the available techniques, the synovial flap described by Wulle seems to meet these requirements and to be as effective as other techniques [13]. Moreover, the procedure seems simple, fast and reproducible [14–16]. The flap is square-shaped and taken from the synovial sheath of the superficial flexor tendons at the level of the carpal tunnel. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. 2. Material and methods Dissections were performed on 24 upper limbs of fresh adult cadavers, free of any malformation or degenerative bone disease. A colored latex solution was injected in the radial and ulnar arteries of 18 upper limbs prior to dissecting the flap. Six other specimens were infused with a radiopaque mixture of 250 mL barium sulfite (MicropaqueTM, Guerbet, Roissy, France), 12 g gelatin (Vahine, Nestlé, France) and 10 mL blue dye through a catheter in the radial and ulnar arteries. Specimens were then preserved at 4 8C overnight before dissection. Half of the specimens were dissected after infusion of either the colored latex (n = 9) solution or the radiopaque solution (n = 3). The other specimens (n = 12) were dissected and then infused with the radiopaque or colored mixture. The flap was raised using smooth scissors and 2.5 loop magnification, so as to divide the synovial sheath from the superficial flexor tendon of the index finger that represents the flap’s lateral edge. Then, the transversal proximal and inferior margins of the flap were incised over the flexor tendons of the index, middle and ring fingers. The flap was elevated radial to ulnar by dividing the synovial sheath from the tendons. The dissection was extended to the level of the flexor tendon of the ring finger that represents the medial edge (or base) of the flap. A square synovial flap was then raised (Fig. 1). In clinical practice, this flap could be passed over the anterior aspect of the median nerve and secured to the radial sheet of the previously divided flexor retinaculum.
Fig. 1. Elevation of the synovial flap. Double arrow indicates the region of the carpal tunnel.
Once the dissection was completed, the flaps taken from specimen injected with the radiopaque solution were radiographed. The diameter of the vessels was measured using a micrometric screw. 3. Results Dissections performed after the limb was injected showed the flap to be richly vascularized and to be supplied by a direct branch of the ulnar artery (Fig. 1). This branch originated from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone. This artery was consistently observed and was found running between the flexor tendons of the ring and little fingers. Identification of the artery was possible in all cases as far as the level of the superficial palmar arch. Mean artery diameter was 0.8 mm (range 0.6 to 1.2 mm). Dissection of the flap before the limb was injected demonstrated the same vascular pattern. The specimens infused with the radiopaque solution were radiographed to better define the flaps’ microvascularization. This revealed the vascular network within the flap (Fig. 2). The mean flap length was 4.8 cm (range 4.2 to 6 cm) and the mean width was 3.5 cm (range 3.1 cm to 4.5 cm). 4. Discussion Recurrence of carpal tunnel syndrome is often related to perineural or intraneural fibrosis of the median nerve. While there is no good treatment for intraneural fibrosis, numerous procedures have been developed in an attempt to treat perineural fibrosis which restricts nerve gliding. These include procedures to isolate the nerve from scar tissue as well as procedures to bring neovascularization to the median nerve [17]. Many surgical procedures have been proposed to protect the released median nerve from recurrent scarring. Some procedures aim to protect the median nerve from scarring by encompassing and isolating the nerve with either autograft or synthetic material. A second approach is to provide both a
P. Pelissier et al. / Chirurgie de la main 34 (2015) 193–196
195
Fig. 2. Arterial vascularization of the synovial flap from the ulnar artery. Anatomical specimen (a). Double arrow indicates the region of the carpal tunnel. Radiograph of the same specimen (b).
barrier and neovascularization to improve nerve regeneration and gliding. Muscle flaps such as those from the abductor digiti minimi muscle [5], pronator quadratus muscle [6], palmaris brevis muscle [7] are believed to provide a better vascularization to the nerve. Although these flaps can lead to nearly 80% satisfactory results, these procedures are technically demanding and result in donor site sequelae [5]. Adipofascial flaps are easier to handle and can be based on either the radial or ulnar artery [8]. Although similar clinical results can be achieved, the aesthetic sequelae are greater at the donor site and the flap often becomes bulky. In clinical series where a hypothenar fat flap was used, subjective improvement was reported in all cases but persistent pain at the donor site was found in 20% of the cases [8,9]. Therefore, the synovial flap described by Wulle [14–16] seems interesting as it represents a simple, reliable technique that generates no sequelae at the donor site since the latter is also the recipient site. Practically, the procedure is easy to carry out and the flap harvested quickly. Vascularization of the flexor tendons and their synovial sheath has been widely studied but is generally focused on the inner distribution of the vessels. Among these studies, Zbrodowski et al. [18] reported that the synovial sheath at the level of the wrist and carpal tunnel was mostly supplied by direct branches of the radial and ulnar arteries. In some rare cases, the vascularization arose from the artery of the median nerve or the anterior transverse artery of the carpus. The superficial palmar arch seemed to be predominant at the distal part of the carpal tunnel to vascularize the flexor tendons. De la Garza et al. [19] described the same pattern of vascularization and mentioned a branch issuing from the ulnar artery that supplied the medial part of the synovial flexor tendons sheath but did not provide further description of this artery.
This study shows that the synovial flap is consistently supplied by a vascular pedicle arising from the ulnar artery above the proximal border of the flexor retinaculum. This vascular pattern was observed after infusion of the specimen with a colored mixture but also when the mixture was injected following harvesting of the flap, which indicates that the vascularization was preserved by the dissection. Although Wulle did not describe the vascularization of the flap, the author recommended raising the synovial sheath based on the ulnar side of the flexor retinaculum. It should be emphasized that the vascular pedicle lies between the superficial flexor tendons of the ring and little fingers so that elevation of the flap has to be stopped over the tendon of the ring finger. The flexibility of the synovial sheath is likely to provide a wide flap that precludes the need for more extensive dissection. Moreover, the dimensions of the flap allow it to be wrapped over the median nerve without excessive tension. This point is critically important in clinical practice once the flap is secured to the radial sheet of the flexor retinaculum. The fingers should be passively mobilized in flexion–extension to ensure the distal end of the flap does not place any tension over the nerve. In this study, only the arterial blood flow was investigated. It was impossible to opacify the venous network. Given our clinical experience and the absence of venous congestion when harvesting the flap, we assume that the venous outflow parallels the arterial inflow. The procedure results in a thin and richly vascularized tissue that will provide both a scarring barrier and neovascularization to improve nerve regeneration and gliding. 5. Conclusion The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study
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P. Pelissier et al. / Chirurgie de la main 34 (2015) 193–196
shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] McLinton MA. The use of dermal-fat grafts. Hand Clin 1996;12:357–64. [2] Pizzillo MF, Sotereanos DG, Tomaino MM. Recurrent carpal tunnel syndrome: treatment options. J South Orthop Assoc 1999;8:28–36. [3] Varitimidis SE, Riano F, Vardakas DG, Sotereanos DG. Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous vein wrapping. J Hand Surg Br 2000;25:271–5. [4] Bilasy A, Facca S, Gouzou S, Liverneaux PA. Canaletto implant in revision surgery for carpal tunnel syndrome: 21 case series. J Hand Surg Eur Vol 2012;37:682–9. [5] Reisman NR, Dellon AL. The abductor digit minimi muscle flap: a salvage technique for palmar wrist pain. J Plast Reconstr Surg 1983;72:859–65. [6] Dellon AL, Mackinnon SE. The pronator quadratus muscle flap. J Hand Surg Am 1984;9:423–7. [7] Rose EH. The use of Palmaris brevis flap in recurrent carpal tunnel syndrome. Hand Clin 1996;12:389–95. [8] Mathoulin C, Bahm J, Roukoz S. Pedicled hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome. Hand Surg 2000;5:33–40.
[9] Strickland JW, Idler RS, Lourie GM, Plancher KD. The hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome. J Hand Surg Am 1996;21:840–8. [10] Tham SK, Ireland DC, Riccio M, Morrison WA. Reverse radial artery fascial flap: a treatment for the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg Am 1996;21:849–54. [11] Goitz RJ, Steichen JB. Microvascular omental transfer for the treatment of severe recurrent median neuritis of the wrist: a long-term follow-up. Plast Reconstr Surg 2005;115:163–71. [12] Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ. A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plast Reconstr Surg 2013;132:114–21. [13] Jones NF, Ahn HC, Eo S. Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release. Plast Reconstr Surg 2012;129:683–92. [14] Wulle C. Die Synoviallappenplastik beim Rezidiv eines Medianus-Kompressions-Syndroms. Z Plast Chir 1980;4:266–71. [15] Wulle C. Treatment of recurrence of the carpal tunnel syndrome. Ann Chir Main 1987;6:203–9. [16] Wulle C. The synovial flap as treatment of the recurrent carpal tunnel syndrome. Hand Clin 1996;12:379–88. [17] Abzug JM, Jacoby SM, Osterman AL. Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis. Hand (N Y) 2012;7: 23–9. [18] Zbrodowski A, Gajisin S, Bednarkiewicz M. La vascularisation de la gaine synoviale commune et des tendons fléchisseurs dans le canal carpien. Ann Chir Main Memb Super 1996;15:248–56. [19] de la Garza O, Lierse W, de los Angeles-García M, Elizondo R, Guzmán S. The arterial blood supply for the synovial tendon sheaths of the hand. Rev Invest Clin 2008;60:31–6.
ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 193–196
Original article
Arterial vascularization of the flexor digitorum superficialis synovial flap. An anatomical study Vascularisation artérielle du lambeau synovial des tendons fléchisseurs superficiels des doigts. Étude anatomique P. Pelissier a,*, J.-M. Alet a, A. Morchikh b, H. Choughri a, V. Casoli a,c a
Service de chirurgie plastique-brûlés-main, centre F.X.-Michelet, groupe hospitalier Pellegrin, 33076 Bordeaux, France b Orthopôle, 53 bis, avenue Maryse-Bastié, 33520 Bruges, France c Laboratoire d’anatomie, université de Bordeaux, 146, rue Léo-Saignat, 33076 Bordeaux, France Received 2 February 2015; received in revised form 15 April 2015; accepted 19 April 2015 Available online 2 July 2015
Abstract Among the various techniques proposed to protect the median nerve from scarring and to provide it with a vascular supply, the synovial flap represents a simple and effective method. The flap is taken from the flexor tendons sheath and results in a thin and richly vascularized tissue that will act as a barrier to scarring and provide neovascularization to improve nerve regeneration and gliding. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. An anatomic study was carried out on 24 fresh upper limbs infused with colored and radiopaque solutions before or after flap elevation. Anatomical findings showed the synovial flap to be supplied by a consistent vascular pedicle arising from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone and running between the flexor tendons of the ring and little fingers. The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: Carpal tunnel syndrome; Recurrence; Flap; Synovial
Résumé Parmi toutes les techniques proposées pour protéger le nerf médian du tissu cicatriciel et lui apporter une vascularisation, le lambeau synovial représente une méthode simple et efficace. Le lambeau est prélevé sur la gaine synoviale des tendons fléchisseurs et fournit en un tissu fin et richement vascularisé, à même de protéger le nerf de la cicatrice, d’apporter une vascularisation qui favorisera la régénération nerveuse, mais également un plan de glissement. Le but de cette étude était de décrire la vascularisation de ce lambeau pour en évaluer la fiabilité. L’étude anatomique a été menée sur 24 membres supérieurs frais, injectés avec une solution colorée et radio-opaque, avant ou après dissection du lambeau. Le lambeau synovial était vascularisé de façon constante par un pédicule naissant de l’artère ulnaire deux à cinq centimètres proximalement à l’os pisiforme, puis cheminant entre les tendons fléchisseurs superficiels des 4e et 5e doigts. Le lambeau synovial était connu comme une technique simple et efficace de couverture du nerf médian. Cette étude montre que sa vascularisation constante en fait une technique fiable. Nous pensons que cette technique présente un intérêt certain lors du traitement des récidives de syndrome du canal carpien. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Syndrome du canal carpien ; Récidive ; Lambeau ; Synovial
* Corresponding author. E-mail address: [email protected] (P. Pelissier). http://dx.doi.org/10.1016/j.main.2015.04.004 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved.
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P. Pelissier et al. / Chirurgie de la main 34 (2015) 193–196
1. Introduction Recurrent carpal tunnel syndrome is a potentially difficult challenge. The most common causes revolve around scarring of the median nerve to the surrounding structures. Many surgical options have been described in the literature to protect the released median nerve such as nerve wrapping (using dermal grafts [1], vein grafts [2,3], or synthetic membranes [4]), local flaps (abductor digiti minimi muscle [5], pronator quadratus muscle [6], palmaris brevis muscle [7], hypothenar fat flap [8,9] and synovial flap) or more complex pedicled or free flaps [10,11]. A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome reveals that decompression with the addition of vascularized flap coverage appears to have a higher success rate than simple repeated decompression [12]. These flaps should allow gliding of the previously scarred nerve and help to revascularize the ischemic nerve. Among the available techniques, the synovial flap described by Wulle seems to meet these requirements and to be as effective as other techniques [13]. Moreover, the procedure seems simple, fast and reproducible [14–16]. The flap is square-shaped and taken from the synovial sheath of the superficial flexor tendons at the level of the carpal tunnel. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. 2. Material and methods Dissections were performed on 24 upper limbs of fresh adult cadavers, free of any malformation or degenerative bone disease. A colored latex solution was injected in the radial and ulnar arteries of 18 upper limbs prior to dissecting the flap. Six other specimens were infused with a radiopaque mixture of 250 mL barium sulfite (MicropaqueTM, Guerbet, Roissy, France), 12 g gelatin (Vahine, Nestlé, France) and 10 mL blue dye through a catheter in the radial and ulnar arteries. Specimens were then preserved at 4 8C overnight before dissection. Half of the specimens were dissected after infusion of either the colored latex (n = 9) solution or the radiopaque solution (n = 3). The other specimens (n = 12) were dissected and then infused with the radiopaque or colored mixture. The flap was raised using smooth scissors and 2.5 loop magnification, so as to divide the synovial sheath from the superficial flexor tendon of the index finger that represents the flap’s lateral edge. Then, the transversal proximal and inferior margins of the flap were incised over the flexor tendons of the index, middle and ring fingers. The flap was elevated radial to ulnar by dividing the synovial sheath from the tendons. The dissection was extended to the level of the flexor tendon of the ring finger that represents the medial edge (or base) of the flap. A square synovial flap was then raised (Fig. 1). In clinical practice, this flap could be passed over the anterior aspect of the median nerve and secured to the radial sheet of the previously divided flexor retinaculum.
Fig. 1. Elevation of the synovial flap. Double arrow indicates the region of the carpal tunnel.
Once the dissection was completed, the flaps taken from specimen injected with the radiopaque solution were radiographed. The diameter of the vessels was measured using a micrometric screw. 3. Results Dissections performed after the limb was injected showed the flap to be richly vascularized and to be supplied by a direct branch of the ulnar artery (Fig. 1). This branch originated from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone. This artery was consistently observed and was found running between the flexor tendons of the ring and little fingers. Identification of the artery was possible in all cases as far as the level of the superficial palmar arch. Mean artery diameter was 0.8 mm (range 0.6 to 1.2 mm). Dissection of the flap before the limb was injected demonstrated the same vascular pattern. The specimens infused with the radiopaque solution were radiographed to better define the flaps’ microvascularization. This revealed the vascular network within the flap (Fig. 2). The mean flap length was 4.8 cm (range 4.2 to 6 cm) and the mean width was 3.5 cm (range 3.1 cm to 4.5 cm). 4. Discussion Recurrence of carpal tunnel syndrome is often related to perineural or intraneural fibrosis of the median nerve. While there is no good treatment for intraneural fibrosis, numerous procedures have been developed in an attempt to treat perineural fibrosis which restricts nerve gliding. These include procedures to isolate the nerve from scar tissue as well as procedures to bring neovascularization to the median nerve [17]. Many surgical procedures have been proposed to protect the released median nerve from recurrent scarring. Some procedures aim to protect the median nerve from scarring by encompassing and isolating the nerve with either autograft or synthetic material. A second approach is to provide both a
P. Pelissier et al. / Chirurgie de la main 34 (2015) 193–196
195
Fig. 2. Arterial vascularization of the synovial flap from the ulnar artery. Anatomical specimen (a). Double arrow indicates the region of the carpal tunnel. Radiograph of the same specimen (b).
barrier and neovascularization to improve nerve regeneration and gliding. Muscle flaps such as those from the abductor digiti minimi muscle [5], pronator quadratus muscle [6], palmaris brevis muscle [7] are believed to provide a better vascularization to the nerve. Although these flaps can lead to nearly 80% satisfactory results, these procedures are technically demanding and result in donor site sequelae [5]. Adipofascial flaps are easier to handle and can be based on either the radial or ulnar artery [8]. Although similar clinical results can be achieved, the aesthetic sequelae are greater at the donor site and the flap often becomes bulky. In clinical series where a hypothenar fat flap was used, subjective improvement was reported in all cases but persistent pain at the donor site was found in 20% of the cases [8,9]. Therefore, the synovial flap described by Wulle [14–16] seems interesting as it represents a simple, reliable technique that generates no sequelae at the donor site since the latter is also the recipient site. Practically, the procedure is easy to carry out and the flap harvested quickly. Vascularization of the flexor tendons and their synovial sheath has been widely studied but is generally focused on the inner distribution of the vessels. Among these studies, Zbrodowski et al. [18] reported that the synovial sheath at the level of the wrist and carpal tunnel was mostly supplied by direct branches of the radial and ulnar arteries. In some rare cases, the vascularization arose from the artery of the median nerve or the anterior transverse artery of the carpus. The superficial palmar arch seemed to be predominant at the distal part of the carpal tunnel to vascularize the flexor tendons. De la Garza et al. [19] described the same pattern of vascularization and mentioned a branch issuing from the ulnar artery that supplied the medial part of the synovial flexor tendons sheath but did not provide further description of this artery.
This study shows that the synovial flap is consistently supplied by a vascular pedicle arising from the ulnar artery above the proximal border of the flexor retinaculum. This vascular pattern was observed after infusion of the specimen with a colored mixture but also when the mixture was injected following harvesting of the flap, which indicates that the vascularization was preserved by the dissection. Although Wulle did not describe the vascularization of the flap, the author recommended raising the synovial sheath based on the ulnar side of the flexor retinaculum. It should be emphasized that the vascular pedicle lies between the superficial flexor tendons of the ring and little fingers so that elevation of the flap has to be stopped over the tendon of the ring finger. The flexibility of the synovial sheath is likely to provide a wide flap that precludes the need for more extensive dissection. Moreover, the dimensions of the flap allow it to be wrapped over the median nerve without excessive tension. This point is critically important in clinical practice once the flap is secured to the radial sheet of the flexor retinaculum. The fingers should be passively mobilized in flexion–extension to ensure the distal end of the flap does not place any tension over the nerve. In this study, only the arterial blood flow was investigated. It was impossible to opacify the venous network. Given our clinical experience and the absence of venous congestion when harvesting the flap, we assume that the venous outflow parallels the arterial inflow. The procedure results in a thin and richly vascularized tissue that will provide both a scarring barrier and neovascularization to improve nerve regeneration and gliding. 5. Conclusion The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study
196
P. Pelissier et al. / Chirurgie de la main 34 (2015) 193–196
shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] McLinton MA. The use of dermal-fat grafts. Hand Clin 1996;12:357–64. [2] Pizzillo MF, Sotereanos DG, Tomaino MM. Recurrent carpal tunnel syndrome: treatment options. J South Orthop Assoc 1999;8:28–36. [3] Varitimidis SE, Riano F, Vardakas DG, Sotereanos DG. Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous vein wrapping. J Hand Surg Br 2000;25:271–5. [4] Bilasy A, Facca S, Gouzou S, Liverneaux PA. Canaletto implant in revision surgery for carpal tunnel syndrome: 21 case series. J Hand Surg Eur Vol 2012;37:682–9. [5] Reisman NR, Dellon AL. The abductor digit minimi muscle flap: a salvage technique for palmar wrist pain. J Plast Reconstr Surg 1983;72:859–65. [6] Dellon AL, Mackinnon SE. The pronator quadratus muscle flap. J Hand Surg Am 1984;9:423–7. [7] Rose EH. The use of Palmaris brevis flap in recurrent carpal tunnel syndrome. Hand Clin 1996;12:389–95. [8] Mathoulin C, Bahm J, Roukoz S. Pedicled hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome. Hand Surg 2000;5:33–40.
[9] Strickland JW, Idler RS, Lourie GM, Plancher KD. The hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome. J Hand Surg Am 1996;21:840–8. [10] Tham SK, Ireland DC, Riccio M, Morrison WA. Reverse radial artery fascial flap: a treatment for the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg Am 1996;21:849–54. [11] Goitz RJ, Steichen JB. Microvascular omental transfer for the treatment of severe recurrent median neuritis of the wrist: a long-term follow-up. Plast Reconstr Surg 2005;115:163–71. [12] Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ. A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plast Reconstr Surg 2013;132:114–21. [13] Jones NF, Ahn HC, Eo S. Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release. Plast Reconstr Surg 2012;129:683–92. [14] Wulle C. Die Synoviallappenplastik beim Rezidiv eines Medianus-Kompressions-Syndroms. Z Plast Chir 1980;4:266–71. [15] Wulle C. Treatment of recurrence of the carpal tunnel syndrome. Ann Chir Main 1987;6:203–9. [16] Wulle C. The synovial flap as treatment of the recurrent carpal tunnel syndrome. Hand Clin 1996;12:379–88. [17] Abzug JM, Jacoby SM, Osterman AL. Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis. Hand (N Y) 2012;7: 23–9. [18] Zbrodowski A, Gajisin S, Bednarkiewicz M. La vascularisation de la gaine synoviale commune et des tendons fléchisseurs dans le canal carpien. Ann Chir Main Memb Super 1996;15:248–56. [19] de la Garza O, Lierse W, de los Angeles-García M, Elizondo R, Guzmán S. The arterial blood supply for the synovial tendon sheaths of the hand. Rev Invest Clin 2008;60:31–6.
