Endoscopic Release of the First Dorsal Extensor Tendon Compartment

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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CHAPTER 32 Endoscopic Release of the First Dorsal Extensor Tendon Compartment

Rationale

One might ask if arthroscopic first dorsal compartment release is a triumph of technology over reason, given that the open release is usually considered straightforward and effective. However, upon closer examination there are several reasons to consider this approach. First, although traditional open release gives generally good results complications (due to the approach) do occur and are most likely underreported. One study by Harvey et al. documented scar adherence to the underlying tendon in 2 of 20 surgical patients, 1 minor wound infection, and temporary parathesias of the radial sensory nerve in 3 patients.1 Another study by Arons et al. documents in 16 consecutive patients 14 complications, including 2 neuromas, 3 adhesions, 1 tendon subluxation, and 3 hypertrophic painful scars.2 A study by Ta et al. documented a 5% recurrence rate, 2% sensory nerve injury, and 2% with severe scar tenderness out of 43 patients.3 There have been other case reports of palmar subluxation of the tendon following operative release.4 Clearly, although an open release of the first extensor compartment is perceived as a safe, simple, and effective surgical procedure when examined closely there is room for improvement.

Second, the 45 patients in our initial series experienced a faster return to pain-free activity. Third, when considering treatment one must fully understand the pathophysiology of the disease process. We believe that not only is there mechanical constriction from the restrictive tendon sheath but an element of peripheral nerve hypersensitivity.

We hypothesize that an arthroscopic approach allows for an extensive neurectomy of the tiny branches of the superficial radial nerve, which may innervate the first dorsal compartment. In addition, the endoscopic approach allows us to keep our incisions outside the hypersensitized zone of injury. Therefore, the minimally invasive approach along with this neurectomy may result in faster and more complete pain relief—with less risk for painful scar development. Last, with the proper training we believe this to be a safe technique. We must be clear that at this point the neurectomy component of the procedure is strictly a working hypothesis and not yet substantiated by substantial basic science and clinical research.