Can You Get Carpal Tunnel Again After Surgery
J Hand Microsurg. 2012 Jun; four(one): one–half-dozen.
Recurrent Carpal Tunnel Syndrome––Analysis of the Impact of Patient Personality in Altering Functional Event Post-obit a Vascularised Hypothenar Fat Pad Flap Surgery
K. Karthik
aneDepartment of Orthopaedic Surgery, Queen Elizabeth Hospital, Woolwich, London, United kingdom of great britain and northern ireland SE184QH
Rajesh Nanda
iiNorth Tees and Hartlepool NHS Trust, University Hospital of North Tees, Hardwick Rd., Stockton on Tees, United kingdom TS19 8PE
John Stothard
3James Cook University Hospital, Marton Route, Middlesbrough, Uk TS43BW
Received 2011 Jun 12; Accepted 2011 Aug three.
Abstruse
We retrospectively analysed 25 patients (27 hands) who had both clinical and electrophysiological confirmation of true recurrent carpal tunnel syndrome from Jan 2004 to December 2009. In all the patients, afterwards releasing the nervus a vascularised fatty pad flap was mobilised from the hypothenar region and sutured to the lateral cut end of flexor retinaculum. The patient characteristics, co-morbidities, duration of symptom, interval between start release and revision surgery and intra-operative findings were assessed against postal service-operative relief of hurting, recovery of sensory and motor dysfunction. The average age of the patients was 58 years (43–81) and the ascendant hand was involved in 22 patients. Intra-operatively the nerve was compressed by scar tissue connecting the previously divided ends of the retinaculum in eighteen and nine had scar tissue and fibrosis effectually the nerve. Following surgery xvi patients had complete recovery (asymptomatic at the first follow-upwards), eight had delayed recovery (fractional recovery of symptoms at terminal follow-up) and three had a poorer upshot (persistence of preoperative symptoms at the terminal follow-upwards). The patients with delayed recovery/poorer outcome had a) Early recurrence; b) Diabetes mellitus; c) Obesity; d) Cervical spine bug; due east) Interest of non-ascendant hand; and f) Intraoperative scar tissue and fibrosis. The hypothenar fatty pad transposition flap provides a reliable source of vascularised local tissue that can exist used in patients with recurrent carpal tunnel syndrome. The factors that were associated with poorer/delayed recovery were involvement of not-ascendant mitt, recurrence within a year from the previous surgery, intra-operatively scar tissue in the carpal tunnel and associated co-morbidities, similar obesity diabetes mellitus and cervical spine problems.
Keywords: Hypothenar fat pad flap, Patient factors, Prediction of outcome, Recurrent carpal tunnel syndrome
Introduction
Recurrence of carpal tunnel syndrome following surgical release is not uncommon [1 , 2]. The recurrence rate in the literature ranges from 3% to 25% [3 – 6]. The outcome after the 2d surgery is variable with authors reporting persistent symptoms in up to 95% of the patients [vii]. A recent study showed that 20% of these patients go no relief after second surgery [eight]. The drawback with most of these studies is that they deal with a heterogeneous population of both recurrent and persistent carpal tunnel syndrome, the findings of which cannot exist generalised to a patient population with recurrence.
Various methods of treatment have been described for the treatment of these patients. Recent studies have favoured the use of a hypothenar fat pad flap (HTFPF) every bit it has consistently produced better results [ix – 13]. From its starting time description in 1985 [xiv] many modifications have been suggested in the technique of HTFPF to further meliorate the functional result in these patients [ix , eleven , 12]. All the studies we can identify on HTFPF accept looked at surgical factors and none of them have assessed patient characteristics against the surgical results [nine – 13]. Shortly, there is insufficient evidence in the literature to predict the result after this technique in patients with true recurrent carpal tunnel syndrome. The aim of our written report was to evaluate the patient factors and to predict the effect of these in altering functional effect after HTFPF in patients with recurrent carpal tunnel syndrome.
Materials and Methods
The study included 25 patients (27 easily) who underwent HTFPF for recurrent carpal tunnel syndrome from January 2004 to Dec 2009. Inclusion and exclusion criteria for the selection of cases are listed in Tabular array1. All the patients included in the study had a symptom free interval following the primary surgery and had recurrence of symptoms. The clinical diagnosis of recurrence was also confirmed by electrophysiological studies. Nerve conduction studies showed abnormal conduction velocity and prolonged latency in both motor and sensory values in all the patients. The patients having problems related to wrist and CMC joint were not taken up for the study. Four patients who had second surgery post-obit incomplete main release were excluded from the study.
Table 1
Inclusion and exclusion criteria
| Inclusion criteria | Exclusion criteria |
|---|---|
| Presence of clinical symptoms | No symptom free interval |
| Symptom costless interval betwixt surgeries | Normal electrophysiological studies. |
| Electrophysiological confirmation | Secondary causes, eg Fracture, tumour |
| Failure of conservative treatment | Incomplete primary release |
Tinel's sign was positive over the carpal tunnel region in 23 easily and Phalen'due south test (the provocation of median paraesthesias by flexion of the wrist to ninety° for lx s) was positive in all the patients. Numbness and tingling was present in all the patients with wakening dysesthesias in 24 hands. All patients had a trial of conservative handling with NSAIDS and wrist splints before surgical intervention. None of the patients had evidence of injury to the palmar cutaneous branch of the median nerve following.
Surgical Technique
The revision surgery was performed as a day case procedure. Ii pct lignocaine was used for local amazement together with an arm tourniquet. An incision was fabricated through the previous scar. This was deepened to accomplish the level of the retinaculum or its remnants that when present were incised while protecting the median nerve (Fig.1). Whatever overlying scar tissue or fibrosis around the nervus was besides removed to release the nervus. Internal neurolysis was non performed in any of our patients. For closure the hypothenar fat pad was mobilised with an intact base and of sufficient length to comprehend the nerve after release (Fig.2). The mobilised fat pad was sutured to the under-surface of the lateral edge of cut flexor retinaculum (whole length) with iii–0 vicryl (Fig.3). Subsequently haemostasis the pare was closed with iv–0 nylon sutures.
Through an incision over the previous scar the reformed retinaculum/scar tissue (blue arrows) was released and the nerve (yellow arrow) was freed
The hypothenar fat pad flap was mobilised with an intact base and of sufficient length to cover the nerve after release
The mobilised fat pad was sutured to the under-surface of the lateral edge of cutting flexor retinaculum
The patients were immune to movement the wrist and perform activities as tolerated after the surgery. The sutures were removed at 2 weeks and the patients were assessed for pain and neurological recovery in 2 weeks, 6 weeks, 3 months and every 6 months until recovery. Complete recovery was defined as the complete absenteeism of preoperative symptoms after the surgery at the outset follow-upward visit. Delayed recovery was divers equally partial recovery of preoperative symptoms at final follow-up and poorer event was defined equally the persistence of preoperative symptoms at the concluding follow-up.
The patient characteristics, co-morbidities, duration of symptoms, interval between primary and 2nd surgery and intra-operative findings were assessed confronting post-operative relief of pain, recovery of sensory and motor dysfunction. Details were nerveless retrospectively in the regular follow-upward notes after surgery (till the last follow-up).
Results
Of the 25 patients 15 were female and 10 were male. The ascendant hand was affected in 22 patients. The average age was 58 years (range 43–81 years). The average follow-up was 22 months (range 10.v–62.5 months). The average duration of symptoms earlier the surgery was 5.8 months (range 3–21 months). The average fourth dimension interval between the outset and second surgery was 56 months (range 5–262 months). Intra-operatively 18 patients had a reformed retinaculum with scar tissues bridging the cut ends of previous surgery, nine had scar tissue and fibrosis around the nerve. 16 (lx%) patients had consummate recovery immediately after surgery and the remaining 11 (twoscore%) patients had delayed/poorer recovery. No patient deteriorated afterward the surgery.
Analysis of the two sub groups (Complete recovery–sixteen patients; delayed/poorer recovery–11 patients) is shown in Table2. There was no difference betwixt the groups in relation to the age, sex or elapsing of symptoms before the 2nd surgery. . The boilerplate interval between the first and the second surgery was most 7 years in the group with complete recovery and information technology was less than i yr in the group with delayed/poorer recovery, implying that a longer symptom gratuitous interval is good news. Four out of five patients in our series with involvement of the non-dominant hand had delayed/poorer recovery. Both the patients with bilateral involvement had delayed/poorer recovery on the non-dominant mitt. The patients with diabetes mellitus (all were type 2), obesity (BMI >30) and cervical spine problems (degenerative spondylosis with C5-vi radiculopathy in five and myelopathy in one) had a high possibility of delayed/poorer recovery. Intra-operatively scar tissue with fibrosis around the nervus was associated with a loftier probability for delayed/poorer recovery.
Table two
Complete recovery vs delayed/poorer recovery
| Complete recovery (xvi) | Delayed (8) or poorer (3) consequence | |
|---|---|---|
| Age (Years) | 59.iv (43–81) | 56 (47–76) |
| Sex (Female person: Male)a | nine:seven | 7:4 |
| Duration of symptoms (months) | 5.5 (3–16) | 6 (iv–21) |
| Interval between 1st & 2nd surgery (months) | 86.5 (23–262) | 11.iii (5–26) |
| Non dominant hand | ane/16 (half-dozen%) | four/11 (36.6%) |
| Diabetes | 2/xvi (12.5%) | 6/eleven (54.5%) |
| Obesity (BMI >30) | four/16 (25%) | seven/eleven (63.half-dozen%) |
| Cervical spine bug | 1/sixteen (six%) | 5/11 (45%) |
| Intra-operative findings | Scar tissue – two Reformed retinaculum - xiv | Scar tissue and fibrosis effectually nervus – 2 Scar tissue - 5 Reformed retinaculum - 4 |
aIncludes two bilateral patients
Post surgically Tinel'south sign was negative in 20 of the 23 patients and in the remaining three patients they had progressive Tinel's sign indicating some degree of nerve regeneration. Hurting disappeared in all except 3 patients at the terminal follow-up of 22 months (range 10.5–62.5 months).
Of the xi hands with delayed/poorer recovery, eight patients had consummate relief of pain with varying degrees of neurological recovery at the terminal follow-upward. In eight hands with delayed recovery, pain and wakening dysesthesia disappeared in all the patients, tingling disappeared in vi patients and numbness disappeared in four easily at the final follow-up and all these 8 patients were happy with the final functional outcome. Three patients out of the 27 continued to have pain and neurological symptoms and were non keen on further investigations or whatsoever farther intervention. At the final follow-upward 89% (24/27) of the operated hands had achieved splendid to expert results.
Give-and-take
Since the time when Sir James Paget first described the clinical manifestations of carpal tunnel syndrome in 1854 [xv], it has become the commonest surgically treated entrapment neuropathy with a prevalence of 3-7% in the general population [16 , 17]. Though the results after principal surgery are excellent, the frequency of re-operation can be up to 12% [viii]. The commonly cited causes for initial failure include incomplete release of the transverse carpal ligament, mail-operative adhesions, tenosynovitis, and intraneural fascicular scarring [18]. The majority of the patients who undergo secondary surgery were due to incomplete release. Bagauter in a report on 26 patients identified that the secondary surgery was considering of inadequate release in 23 and no release in 3 patients [19]. Thus the present publications on recurrent carpal tunnel syndrome are confounded past patients who practice non have a true recurrence.
Non-operative treatment of recurrent symptoms may provide symptomatic relief for a small number of patients but fail to benefit nigh patients in the long term. In our series none of the patients benefitted. In 1963, Paine was the offset to study on re-exploration for true recurrent carpal tunnel syndrome. Since then diverse surgical options have been described in the literature. Elementary decompression with neurolysis is not favoured by many authors because of poor outcome [four , 20 , 21]. The utilize of muscle flaps, fascial flaps, vein wrapping and omental transfer has been described in the literature with practiced results [22 – 28]. However these options were not followed universally because of various drawbacks associated with these techniques. These include, donor site morbidity, apply of microscope, usually performed by surgeons working in specialist centres, technically demanding, increased theatre time and cost, poor cosmetic results, small patient grouping and finally the results were not superior to HTFPF. The apply of HTFPF offset described by Cramer and further modified by various authors has stood the test of time from 1985 [9 – xiv]. The advantage in using the flap is that information technology is locally bachelor, easily performed and the results are equivalent or better than the other techniques. HTFPF does not improve the results of chief surgery [29]. There seems to be conflicting bear witness regarding routine internal neurolysis after carpal tunnel surgery [xxx , 31]. In this written report none of the patients underwent internal neurolysis.
Results after a revision carpal tunnel surgery are variable [7 , 8 , 12 , 32]. The reason for these differences in outcome has been attributed to the surgical factors and various authors have described different methods of handling [22 – 28] or modifications of a technique [9 – 13]. Even so the results were variable, with authors reporting upwardly to 40% poor results [32] and 95% persistent symptoms [seven] after re-exploration.
As all the studies in the literature analysed the surgical factors, we analysed the patient characteristics confronting the surgical outcome. The age, sex and duration of symptoms did not impact the functional outcome in our patients. However the subtract in time interval between the master and revision surgery was a major risk factor for delayed/poorer recovery. These findings have not been previously reported and the authors believe that these patients with early recurrence are more prone for scar tissue formation. In keeping with this belief involvement of not-dominant hand was rare. However, when information technology occurred we noted delayed/poorer recovery (though the numbers are too modest to describe any conclusions), but interestingly in 2 patients with bilateral recurrence, the not-dominant hand did not recover well after the revision surgery. It is well known that the result after carpal tunnel decompression is unpredictable if the patient has double crush syndrome [33 , 34]. Forty five % (5/xi) of the patients with cervical spine problems did poorly after the surgery. Contempo show showed that outcome after primary carpal tunnel decompression in patients with diabetes is no dissimilar from other patients [35]. However, 54.5% (half-dozen/11) of our diabetic patients did not have prompt relief of symptoms with the 2d surgery. We accept the view of Al-Quattan et al. that diabetes is a risk cistron for poor outcome [36]. Though obesity was considered as a run a risk cistron for CTS [37], its role in influencing the issue after surgical release is uncertain. In 63.6% (vii/11) of our patients with poorer issue, obesity was present.
In our study merely 60% (sixteen/27) had complete recovery immediately afterward the surgery, in the remaining 11 patients (forty%) with delayed/poorer recovery, eight patients improved post surgically. We accept the view of Clarke et al. (1993) that if the comeback was not obtained by 24 hours, a good outcome was all the same possible but a poor outcome becomes more probable [38].
A limitation of this study is that the report is retrospective with a minor number of patients and no command grouping. All the same our inclusion and exclusion criteria dictated that we were treating a small-scale subgroup of patients with truthful recurrent symptoms. A recent report from the Mayo clinic identified 28 sequent patients with true recurrent carpal tunnel syndrome in a bridge of 9 years, which demonstrates the rarity of these patients [ten]. In their written report, though the results were good after treatment with HTFPF, they did not analyse the patient factors that are associated with the recovery. As HTFPF is a trust worthy process for recurrent carpal tunnel syndrome [ix – xiv] and since the written report concentrated more than on patient variables the need for a command group is negated. As there is only limited evidence bachelor in the handling of recurrent carpal tunnel syndrome, the authors suggest that in hereafter a randomized control trial should exist performed to evaluate the various methods of treatment.
Although this study cannot provide statistically meaning show, the results help the operating surgeon to explicate to each patient about the predictable results after the surgery by analysing the patient characteristics and intra-operative findings.
Decision
We conclude that the hypothenar fat pad is a reliable source of vascularised local tissue that can be used favourably in patients with recurrent carpal tunnel syndrome. The factors associated with poorer/delayed recovery are early recurrence (<1 year), involvement of non-dominant manus, intra-operatively fibrosis and scar tissue around the nerve and associated co-morbidities of obesity, diabetes mellitus and cervical spine problems.
References
ane. Botte MJ, Schroeder HP, Abrams RA, Gellman H. Recurrent carpal tunnel syndrome. Hand Clin. 1996;12:731–743. [PubMed] [Google Scholar]
2. Fusetti C, Garavaglia Thou, Mathoulin C, Petri JG, Lucchina S. A reliable and uncomplicated solution for recalcitrant carpal tunnel syndrome: the hypothenar fat pad flap. Am J Orthop. 2009;38:181–186. doi: 10.1007/s00132-008-1369-3. [PubMed] [CrossRef] [Google Scholar]
three. Kulick MI, Gordillo G, Javidi T, Kilgore ES, Jr, Newmeyer WL., 3 Long-term assay of patients having surgical handling for carpal tunnel syndrome. J Hand Surg (Am) 1986;11:59–66. [PubMed] [Google Scholar]
iv. Langloh ND, Linscheid RL. Recurrent and unrelieved carpaltunnel syndrome. Clin Orthop Relat Res. 1972;83:41–47. doi: 10.1097/00003086-197203000-00008. [PubMed] [CrossRef] [Google Scholar]
v. Luchetti R, Amadio P (2007) Carpal tunnel syndrome. 1st edn, Springer
6. MacDonald RI, Lichtman DM, Hanlon JJ, Wilson JN. Complications of surgical release for carpal tunnel syndrome. J Hand Surg (Am) 1978;3:seventy–76. [PubMed] [Google Scholar]
7. Strasberg SR, Novak CB, Mackinnon SE, Murray JF. Subjective and employment outcome following secondary carpal tunnel surgery. Ann Plast Surg. 1994;32:485–489. doi: x.1097/00000637-199405000-00008. [PubMed] [CrossRef] [Google Scholar]
8. Raimbeau One thousand. Recurrent carpal tunnel syndrome. Chir Main. 2008;27:134–145. doi: x.1016/j.chief.2008.07.001. [PubMed] [CrossRef] [Google Scholar]
9. Chrysopoulo MT, Greenberg JA, Kleinman WB. The hypothenar fatty pad transposition flap: a modified surgical technique. Tech Hand Up Extrem Surg. 2006;x:150–156. doi: 10.1097/01.bth.0000225004.56982.42. [PubMed] [CrossRef] [Google Scholar]
10. Craft RO, Duncan SFM, Smith AA. Management of recurrent carpal tunnel syndrome with microneurolysis and the hypothenar. Fat Pad Flap Paw. 2007;two:85–89. [PMC complimentary article] [PubMed] [Google Scholar]
xi. Mathoulin C, Bahm J, Roukoz S. Pedicled hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome. Manus Surg. 2000;five:33–40. doi: 10.1142/S0218810400000120. [PubMed] [CrossRef] [Google Scholar]
12. Strickland JW, Idler RS, Lourie GM, Plancher KD. The hypothenar fat pad flap for direction of recalcitrant carpal tunnel syndrome. J Manus Surg Am. 1996;21:840–848. doi: 10.1016/S0363-5023(96)80201-2. [PubMed] [CrossRef] [Google Scholar]
thirteen. Tollestrup T, Berg C, Netscher D. Management of distal traumatic median nerve painful neuromas and of recurrent carpal tunnel syndrome: hypothenar fat pad flap. J Hand Surg Am. 2010;35:1010–1014. doi: 10.1016/j.jhsa.2010.03.035. [PubMed] [CrossRef] [Google Scholar]
fourteen. Crammer LM. Local fat coverage for the median nerve. In: Lankford LL (ed): correspondence newsletter for Hand surgery, 1985, 35.
fifteen. Pfeffer GB, Gelberman RH, Boyes JH, Rydevik B. The history of carpal tunnel syndrome. J Hand Surg Br. 1988;13:28–34. doi: 10.1016/0266-7681(88)90046-0. [PubMed] [CrossRef] [Google Scholar]
xvi. Ashworth NL (2007) Carpal tunnel syndrome. Clin Evid (Online). 1114 [PubMed]
17. Atroshi I, Gummesson C, Johnsson R, Ornstein East, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282:153–158. doi: 10.1001/jama.282.2.153. [PubMed] [CrossRef] [Google Scholar]
18. Stütz N, Gohritz A, Schoonhoven J, Lanz U. Revision surgery after carpal tunnel release–assay of the pathology in 200 cases during a 2 year menstruation. J Paw Surg Br. 2006;31:68–71. [PubMed] [Google Scholar]
nineteen. Bagatur AE. Analysis of the causes of failure in carpal tunnel syndrome surgery and the results of reoperation. Acta Orthop Traumatol Turc. 2002;36:346–353. [PubMed] [Google Scholar]
twenty. Dahlin LB, Salö Grand, Thomsen Due north, Stütz N. Carpal tunnel syndrome and handling of recurrent symptoms. Scand J Plast Surg Manus Surg. 2010;44:4–11. doi: 10.3109/02844310903528697. [PubMed] [CrossRef] [Google Scholar]
21. Smet L. Recurrent carpal tunnel syndrome: clinical testing indicating incomplete section of the flexor retinaculum. J Hand Surg (Br) 1993;xviii:189. doi: 10.1016/0266-7681(93)90105-O. [PubMed] [CrossRef] [Google Scholar]
22. Dellon AL, Mackinnon SE. The pronator quadratus muscle flap. J Manus Surg Am. 1984;9:423–427. [PubMed] [Google Scholar]
23. 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;115:163–171. [PubMed] [Google Scholar]
24. Reisman NR, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for palmar wrist pain. Plast Reconstr Surg. 1983;72:859–865. doi: 10.1097/00006534-198312000-00025. [PubMed] [CrossRef] [Google Scholar]
25. Rose EH. The utilize of the palmaris brevis flap in recurrent carpal tunnel syndrome. Paw Clin. 1996;12:389–395. [PubMed] [Google Scholar]
26. Tham SK, Republic of ireland DC, Riccio M, Morrison WA. Reverse radial artery fascial flap: a handling for the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Mitt Surg (Am). 1996;21:849–854. doi: 10.1016/S0363-5023(96)80202-4. [PubMed] [CrossRef] [Google Scholar]
27. 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 Paw Surg Br. 2000;25:271–275. doi: 10.1054/jhsb.2000.0379. [PubMed] [CrossRef] [Google Scholar]
28. Vögelin E, Bignion D, Constantinescu M, Büchler U. Revision surgery after carpal tunnel release using a posterior interosseous avenue isle flap. Handchir Mikrochir Plast Chir. 2008;40:122–127. doi: ten.1055/s-2007-989475. [PubMed] [CrossRef] [Google Scholar]
29. Jones SM, Stuart PR, Stothard J. Open carpal tunnel release. Does a vascularized hypothenar fat pad reduce wound tenderness? J Hand Surg Br. 1997;22:758–760. doi: 10.1016/S0266-7681(97)80442-one. [PubMed] [CrossRef] [Google Scholar]
30. Rhoades CE, Mowery CA, Gelberman RH. Results of internal neurolysis of the median nerve for astringent carpal-tunnel syndrome. J Bone Articulation Surg Am. 1985;67:253–256. [PubMed] [Google Scholar]
31. Lowry Nosotros, Jr, Follender AB. Interfascicular neurolysis in the astringent carpal tunnel syndrome. A prospective, randomized, double-blind, controlled study. Clin Orthop Relat Res. 1988;227:251–254. [PubMed] [Google Scholar]
32. O'Malley MJ, Evanoff Chiliad, Terrono AL, Millender LH. Factors that decide reexploration handling of carpal tunnel syndrome. J Hand Surg Am. 1992;17:638–641. doi: 10.1016/0363-5023(92)90307-B. [PubMed] [CrossRef] [Google Scholar]
33. Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;18:359–362. doi: 10.1016/S0140-6736(73)93196-vi. [PubMed] [CrossRef] [Google Scholar]
34. Hurst LC, Weissberg D, Carroll RE. The relationship of the double shell to carpal tunnel syndrome (an analysis of 1,000 cases of carpal tunnel syndrome) J Hand Surg Br. 1985;10:202–204. doi: ten.1016/0266-7681(85)90018-Ten. [PubMed] [CrossRef] [Google Scholar]
35. Niels OB, Thomsen MD, Cederlund R, Björk J, Dahlin LB. Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-upward with matched controls. J Paw Surg Am. 2009;34:1177–1187. doi: 10.1016/j.jhsa.2009.04.006. [PubMed] [CrossRef] [Google Scholar]
36. Al-Quattan MM, Manktelow RT, Bowen CVA. Outcome of carpal tunnel release in diabetic patients. J Hand Surg (Br) 1994;19:626–629. doi: 10.1016/0266-7681(94)90131-vii. [PubMed] [CrossRef] [Google Scholar]
37. Krom MCTF, Kester A, Knipschild P, Spaans F. Gamble factors for carpal tunnel syndrome. Am J Epidemiol. 1990;132:1102–1110. [PubMed] [Google Scholar]
38. Clarke AM, Stanley D. Prediction of the outcome 24 h afterwards carpal tunnel decompression. J Hand Surg (Br) 1993;18:180–181. doi: ten.1016/0266-7681(93)90101-Thou. [PubMed] [CrossRef] [Google Scholar]
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