Carpal tunnel syndrome (CTS) is the most common compressive neuropathy in the general
population. Surgical treatment by open or endoscopic carpal tunnel release (CTR) is the first
choice of treatment and has clinical success rates of 75% to 90%.The rate of recurrence after
primary median nerve release is 3-19% [1,2]. Between 0.3% and 12% of cases require surgical
revision [2,3]. The risk factors for surgical revision for secondary release are male gender,
staged or simultaneous bilateral carpal tunnel release, endoscopic release, smoking and
rheumatoid arthritis.
Treatment failures after primary CTR are classified as persistent CTS, recurrent CTS, or new
symptoms. Recurrent symptoms are uncommon and are defined by a symptom-free interval after
surgery. Persistent symptoms are relatively common, particularly in elderly patients and in
patients with concurrent nerve compression or medical conditions that affect nerve function,
such as diabetes. Persistent or recurrent CTS principally results from incomplete release of
the transverse carpal ligament but may be accompanied by perineural scarring, leading to
compression or tethering of the median nerve.
New symptoms may be caused by iatrogenic nerve injury. Surgical treatment of recurrent or
persistent CTS after primary CTR usually involves open revision CTR, extended proximally into
unscarred tissue, and has also included internal or external neurolysis. Unsatisfactory
results following revision CTR are common.
A second compression site, or double-crush syndrome, may clinically present as RCTS or PCTS .
Thorough preoperative clinical examination may uncover signs of a second compression site,
which can then be confirmed on electroneuromyography (ENMG) of the entire arm.
To improve outcomes of revision CTR, recent studies have emphasized the importance of median
nerve coverage by well-vascularized soft tissue to enhance nerve healing, to prevent
tethering in surrounding scar tissue, and to optimize nerve gliding in the carpal tunnel.
Several local flaps (hypothenar fat pad flap, tenosynovial flap), regional flaps (posterior
interosseous artery flap, reverse radial artery fascial flap, flexor digitorum superficialis
flap), and free flap techniques have been described, but consensus for specific flap has not
been reached. Following potential iatrogenic median nerve injury and reexploration for a
painful neuroma incontinuity, flap coverage may also be beneficial.
In 1988, Becker and Gilbert introduced a Fasciocutaneous pedicled flap based on a consistent
dorsal perforator of the ulnar artery (absent in 1 % of population) named the dorsal ulnar
artery (DUA) flap or simply the Becker flap. The authors described open revision CTR with
nerve coverage by a DUA flap in 3 patients with recurrent CTS and reported good results as
well as a quick and easy-to-perform dissection with low donor site morbidity and preservation
of the radial andulnar artery. Since this introduction, additional studies describing
fasciocutaneous DUA flaps have mostly focused on its use for reconstruction of hand or wrist
wounds. Despite the original described benefits, additional studies of DUA flaps for the
treatment of recurrent or persistent CTS have remained limited.
