Carpal tunnel release under wide awake local anesthesia with no tourniquet in hemodialysis patients with arteriovenous shunt.

INTRODUCTION: Long-term hemodialysis patients experience many hand diseases caused by dialysis-related amyloidosis (DRA), with carpal tunnel syndrome (CTS) being the most common. For the patients with arteriovenous (AV) shunt, surgical decompression remains challenging because of the contraindications of a tourniquet. A technique called wide-awake local anesthesia with no tourniquet (WALANT), in which epinephrine provides hemostasis instead of the tourniquet, can be a good option for hemodialysis patients. The purpose of this study was to assess the prevalence of CTS and related factors in hemodialysis patients, and to establish the efficacy and safety of WALANT on hemodialysis patients with AV shunt. MATERIALS AND METHODS: This prospective study included 275 hemodialysis patients between March 2013 and July 2019. 43 patients were diagnosed with CTS, involving surgical treatment on 70 wrists. We performed mini-open carpal tunnel release using WALANT on the AV shunt arm (defined as the WALANT group), while using lidocaine and a tourniquet on the arm without an AV shunt (defined as the tourniquet group). The operative time, surgical field bleeding (blood loss and hemostasis score), surgical pain (injection pain and tourniquet pain), outcomes, complications, and satisfaction were compared between the two groups. RESULTS: The incidence of CTS in hemodialysis patients was 15.6%. Longer dialysis durations were related to higher proportions of patients with CTS. There was no significant difference in blood loss (p=0.184) and hemostasis score (p=0.165) between the two groups. Clinical symptoms improved in all patients, and there were no severe complications. The WALANT group had a significantly longer preparation time of approximately 20minutes, but they had low injection pain and no tourniquet pain. There was also no significant difference in terms of satisfaction levels (p=0.212). DISCUSSION: CTS is a very common disease among hemodialysis patients. WALANT provided sufficient hemostasis without a tourniquet, despite the patients' high bleeding tendency. The technique also had the advantages of low injection pain, no tourniquet pain, and no major complications. In this respect, WALANT can be a good choice for hemodialysis patients with AV shunt. LEVEL OF EVIDENCE: II.

Analysis of the Anatomical Factors Associated with Cubital Tunnel Syndrome.

BACKGROUND: Previous studies demonstrated that soft tissues, such as retinaculum, fibrous band, and anconeus, cause ulnar nerve compression, whereas other studies showed that the bony structures strain the ulnar nerve that runs directly behind the medial epicondyle constituting the boundary of the cubital tunnel during elbow flexion. However, no studies have reported the association of the shape of the bony structure with cubital tunnel syndrome symptoms. Are computed tomography (CT) and magnetic resonance imaging (MRI)-measured parameters of the bony cubital tunnel related to idiopathic cubital tunnel syndrome symptoms? HYPOTHESIS: We hypothesized that CT and MRI-measured parameters of the bony cubital tunnel were related to idiopathic cubital tunnel syndrome symptoms. We aimed to investigate the relationship between the radiographic parameters based on CT and MRI and idiopathic cubital tunnel syndrome symptoms. PATIENTS AND METHODS: We analyzed 224 elbows (77 affected elbows of patients with idiopathic cubital tunnel syndrome, 77 unaffected elbows of patients with cubital tunnel syndrome, 70 elbows of patients without cubital tunnel syndrome symptoms) using CT and MRI. Cubital tunnel cross-sectional area, cubital tunnel volume, and ulnar nerve cross-sectional area were measured in the three groups at flexion and extension. A new cubital tunnel center with a new boundary was proposed that could play a role in ulnar nerve compression symptoms. RESULTS: The cross-sectional areas and volumes of the cubital tunnel measured in the elbow flexion state were the smallest among the group with the affected elbows in patients. There was no difference between unaffected elbows and the non-patient group. The cross-sectional area of the ulnar nerve highly correlated with cubital tunnel symptoms in the flexion state. DISCUSSION: The shape of the cubital tunnel is an important factor in cubital tunnel syndrome, and normal variations in the volume and cross-sectional area of the cubital tunnel and ulnar nerve could influence the occurrence of idiopathic cubital tunnel syndrome. LEVEL OF EVIDENCE: III, Therapeutic study.