Minimal clinically important difference of carpal tunnel release in diabetic and nondiabetic patients

Platelet-rich plasma (PRP) in nerve repair

Platelet-rich plasma (PRP) has the capability of assisting in the recovery of damaged tissues by releasing a variety of biologically active factors to initiate a hemostatic cascade reaction and promote the synthesis of new connective tissue and revascularization. It is now widely used for tissue engineering repair. In addition, PRP has demonstrated nerve repair and pain relief, and has been studied and applied to the facial nerve, median nerve, sciatic nerve, and central nerve. These suggest that PRP injection therapy has a positive effect on nerve repair. This indicates that PRP has high clinical value and potential application in nerve repair. It is worthwhile for scientists and medical workers to further explore and study PRP to expand its application in nerve repair, and to provide a more reliable scientific basis for the opening of a new approach to nerve repair.

Anchor-based minimal important difference values are often sensitive to the distribution of the change score

PURPOSE

Anchor-based studies are today the most popular approach to determine a minimal important difference value for an outcome variable. However, a variety of construction methods for such values do exist. This constitutes a challenge to the field. In order to distinguish between more or less adequate construction methods, meaningful minimal requirements can be helpful. For example, minimal important difference values should not reflect the intervention(s) the patients are exposed to in the study used for construction, as they should later allow to compare interventions. This requires that they are not sensitive to the distribution of the change score observed. This study aims at investigating to which degree established construction methods fulfil this minimal requirement.

METHODS

Six constructions methods were considered, covering very popular and recently suggested methods. The sensitivity of MID values to the distribution of the change score was investigated in a simulation study for these six construction methods.

RESULTS

Five out of six construction methods turned out to yield MID values which are sensitive to the distribution of the change score to a degree that questions their usefulness. Insensitivity can be obtained by using construction methods based solely on an estimate of the conditional distribution of the anchor variable given the change score.

CONCLUSION

In future the computation of MID values should be based on construction methods avoiding sensitivity to the distribution of the change score.

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis

BACKGROUND

The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR.

METHODS

The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire.

RESULTS

A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery.

CONCLUSION

Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

A Logistic Regression Analysis of Factors Associated with Guarded Outcome after Carpal Tunnel Release in Symptomatic Carpal Tunnel Syndrome

BACKGROUND

The Boston Carpal Tunnel Questionnaire (BCTQ) is a validated measurement tool to assess the severity of carpal tunnel syndrome, and improvements in the BCTQ after carpal tunnel release (CTR) have been demonstrated to influence patient satisfaction. The authors hypothesized that patient-related factors influence response in BCTQ subscales, including the Symptom Severity Scale and the Functional Status Scale, after CTR.

METHODS

Patients who underwent surgery with follow-up BCTQ were identified from a prospectively maintained database. Paired t tests were used to compare BCTQ subscales at each follow-up time point. Minimal clinically important differences were set. Patients below these thresholds were deemed as having failure to improve after CTR. Univariate analysis was used to identify risk factors for failure to improve after CTR. Multivariate logistic regression was used to identify independent predictors for failure to improve after CTR.

RESULTS

A total of 106 patients met inclusion criteria. Patients demonstrated significant improvements at all follow-up time points. The factor most associated with improvement beyond the minimal clinically important differences was a more severe score in the respective domain assessed. Other independent factors that influenced outcome after CTR included race, concomitant cubital tunnel release, sex, and age.

CONCLUSIONS

CTR results in significant improvements in BCTQ and its subscales, with improvements stabilizing after 6 weeks. In a select cohort of patients, failure to improve after CTR occurs with factors independently associated with a lower degree of improvement. Identification of patients with these risk factors will provide a basis for counseling and increased monitoring of patients at risk for a guarded prognosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The effectiveness of nerve mechanical interface treatment for entrapment neuropathies in the limbs: A systematic review with metanalysis

BACKGROUND

Neurodynamic approach employs neural mobilization and mechanical nerve interface techniques. While published studies investigated the efficacy of neural mobilization, it is currently unknown whether manual treatment of the nerve mechanical interface is effective in the treatment of people with entrapment neuropathies.

OBJECTIVES

Assess the effectiveness of mechanical interface treatment, including joint and soft tissue techniques, on pain and function in people with peripheral entrapment neuropathies.

DESIGN

Intervention systematic review with metanalysis.

METHODS

the databases MEDLINE, CINAHL, AMED, APA PsycINFO, SPORTDiscus, PubMed and ScienceDirect were searched from their inception to October 2022. Randomized controlled trials investigating mechanical interface treatment in isolation in patients with peripheral entrapment neuropathies were included. Two independent reviewers performed study selection, data extraction and risk of bias assessment using the Cochrane RoB 2.0 tool. Certainty of evidence for each outcome was judged using the GRADE framework.

RESULTS

11 studies were included in the review, all investigating carpal tunnel syndrome (CTS). Due to high heterogeneity of interventions and comparators, only five studies were pooled in a random-effects meta-analysis. There was evidence of mechanical interface techniques being more effective in reducing pain than sham (MD -2.47 [-3.94;-0.99]) and similarly effective as neural mobilization (MD -0.22 [-0.76; 0.33]) in CTS, albeit with low to very low certainty in the results.

CONCLUSION

mechanical interface techniques are effective for improving pain and function in people with CTS. However, the marked heterogeneity of included interventions and comparators prevents clinical recommendation of specific treatments.

Minimal Clinically Important Differences in Hand Pain Intensity (Numerical Pain Rate Scale) and Related-Function (Boston Carpal Tunnel Questionnaire) in Women With Carpal Tunnel Syndrome

OBJECTIVE

To calculate the minimal clinically important differences (MCIDs) for hand pain intensity and the Boston Carpal Tunnel Questionnaire (BCTQ) in a sample of women with carpal tunnel syndrome (CTS).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

A Hospital Rehabilitation Unit.

PARTICIPANTS

One hundred twenty women with clinical and electromyographic diagnosis of CTS who were randomly assigned into 2 groups (N=120).

INTERVENTIONS

One group received 3 sessions of manual physical therapy (n=60) and the other group received surgery (n=60).

MAIN OUTCOME MEASURES

Mean and the worst pain intensity (numerical pain rate scale, 0-10 points) and functional status and symptoms' severity subscales of the BCTQ questionnaire were assessed before and 1 month after treatment. The Global Rating of Change (GROC) was used as the anchor variable for determining the MCID.

RESULTS

A change of 1.5 and 2.5 points in mean and the worst pain intensity represents the MCID for Numerical Pain Rating Scale, whereas a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for each subscale of the BCTQ. All variables showed acceptable discrimination between patients classified as "improved" and those classified as "stable/not improved" (area under the curve≥0.72). Mean pain intensity (Youden index, 0.53; sensitivity: 73.3%; specificity: 80%) and symptoms' severity (Youden index, 0.69; sensitivity: 90%; specificity: 77.8%) showed the best discriminative ability expressed as a percentage of prediction. Participants classified as "improved" had significantly greater improvements in pain intensity, functional status, and symptoms' severity compared with those classified as "stable/not improved".

CONCLUSION

A change of 1.5 and 2.5 points in mean and the worst pain and a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for pain intensity and BCTQ in women with CTS 1 month after treatment.

Best-Evidence Systematic Review and Meta-Analysis of Mini-Open Carpal Tunnel Release

Purpose

This study aimed to evaluate the safety and effectiveness of mini-open carpal tunnel release (mOCTR) using best-evidence synthesis methods.

Methods

We systematically searched for prospective studies published from January 2013 to July 2023 that reported outcomes from a minimum of 50 mOCTR cases. The outcomes included Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), pain visual analog scale (VAS), complication rate, and reoperation rate. Data analysis was performed using a random-effects meta-analysis, with metaregression to identify the associations between patient- and study-level factors with surgical outcomes.

Results

The meta-analysis included 23 studies with 2,303 patients followed for median durations ranging from 6 to 12 months depending on the outcome. Mini-open carpal tunnel release resulted in statistically significant and clinically important improvements in Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (mean difference = -25.5; 95% confidence interval [CI]: -36.4 to -14.5; P < .001), BCTQ-SSS (mean difference = -2.2; 95% CI: -2.5 to -1.9; P < .001), BCTQ-FSS (mean difference = -2.1; 95% CI: -2.4 to -1.7; P < .001), and pain VAS (mean difference = -5.1; 95% CI: -6.2 to -4.1; P < .001). The sole predictor of improvement in BCTQ-SSS, BCTQ-FSS, and pain VAS was a higher preoperative score for the respective variable (all P < .001). The risk of complications (mainly short-term pillar pain or scar complications) was 8.9% (95% CI: 4.0%-13.8%) and increased with longer incision lengths (P = .008). Revision carpal tunnel release was performed in 0.6% (95% CI: 0.1%-1.0%) of the cases during follow-up. No cases of median nerve transection were reported.

Conclusions

Based on a best-evidence meta-analysis of contemporary studies, mOCTR significantly improved function and pain, with a relatively low risk of mainly temporary complications. Patient outcomes after mOCTR were influenced by patient symptomatology and surgical incision length.

Clinical relevance

Mini-open carpal tunnel release is an effective surgical option that significantly improves symptoms and function, especially for patients with more severe baseline dysfunction. Surgeons should use the shortest incision that allows adequate visualization to safely divide the transverse carpal ligament.

An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery

Background

This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes.

Methods

A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed.

Results

In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles.

Conclusions

There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.

Best-Evidence Systematic Review and Meta-Analysis of Endoscopic Carpal Tunnel Release Outcomes

Purpose

The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of endoscopic carpal tunnel release (ECTR) using best-evidence synthesis methods.

Methods

A systematic search of multiple databases was conducted for prospective contemporary studies published between January 2013 and January 2023 with at least 50 ECTR cases. Outcomes included the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) measured on a 0-100 scale, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS) on a 1-5 scale, pain visual analog scale on a 0-10 scale, conversion to open carpal tunnel release (CTR), complications, and reoperations. Outcomes were analyzed using a random-effects meta-analysis model. Metaregression was used to determine the association of patient- and study-level factors with ECTR outcomes.

Results

A total of 17 studies with 1,632 patients treated with ECTR were included. Median follow-up durations ranged from 4 to 7 months depending on the outcome. Statistically significant and clinically important improvements were noted after ECTR for Q-DASH, BCTQ-SSS, BCTQ-FSS, and pain visual analog scale scores, with mean differences from baseline of -28.8, -1.8, -1.5, and -5.1, respectively (P < .001 for all). In metaregression, the strongest predictor of improvement in Q-DASH, BCTQ-SSS, and BCTQ-FSS was a greater preoperative score for that variable (all P ≤ .005), indicating that patients with worse symptoms improved the most. The risks of conversion to open CTR, complications, and revision CTR were 0.7%, 0.7%, and 0.5%, respectively.

Conclusions

In a best-evidence synthesis of contemporary studies, ECTR resulted in significant improvements in function and pain, with a low risk of conversion to open surgery, complications, and reoperations over short-term follow-up.

Clinical relevance

Patients treated with ECTR can expect generally favorable clinical outcomes over the short term. However, long-term outcomes after ECTR are not well characterized.

Patient-Reported Outcome Measurement and Minimal Clinically Important Difference for Hand Surgeons

Patient-reported outcome measurement (PROM) tools are used to evaluate health status and response to treatment and have been integral in the effort to improve the quality of care provided. Patient reported outcomes (PROs) have garnered additional attention since becoming a priority of the National Institutes of Health in the early part of this century, and their use in both clinical practice and research has subsequently increased. In the upper extremity, a variety of PRO instruments exist that can assist physicians in their ability to track and/or prognosticate outcomes, make comparisons between treatments as well as strengthen research methodologies, and help determine the value of care. A more complete interpretation of the clinical significance of patient-reported outcome measurements is informed by parameters such as minimal clinically important difference, substantial clinical benefit and patient acceptable symptom state.

Exploring the role of biopsy-proven diabetic axonal neuropathy in outcomes of carpal tunnel release in diabetic and non-diabetic populations

BACKGROUND

Carpal tunnel release outcomes in diabetic and non-diabetic patients are conflicting, possibly due to lack of differentiating patients with axonal neuropathy and those without axonal neuropathy.

MATERIALS AND METHODS

Sixty-five diabetic and 106 non-diabetic patients who failed conservative treatment and then underwent carpal tunnel release from 2015 to 2022 were selected from a hand surgeon's patient database. Diagnosis was established with parameters established with the CTS-6 Evaluation Tool, and electrodiagnosis when indicated. Patient outcomes were evaluated using preoperative and postoperative Disabilities of Arm Shoulder and Hand (DASH), Brief Pain Inventory (BPI), Boston Carpal Tunnel Questionnaire, Numeric Pain Scale, and Wong-Baker Pain Scale. Postoperative evaluations were taken 6 months to a year post-surgery. Skin biopsies for nerve fiber density and morphology were taken from 50 diabetic patients. Another 50 were taken from non-diabetic patients with carpal tunnel syndrome and served as controls. Biopsy-proven axonal neuropathy was used as a confounding variable in the assessment of diabetic patients' recovery RESULTS: When comparing diabetics with biopsy-proven axonal neuropathy to diabetics without axonal neuropathy, the recovery outcomes are increasingly better for diabetics without neuropathy. Diabetics with biopsy-proven neuropathy have an improvement in recovery outcomes as well; however, not to the level of non-diabetics.

CONCLUSION

Patients with increased scale scores or clinical suspicion for axonal neuropathy can be offered the option of undergoing a biopsy, and counseled about the risks for increased time to meet outcomes comparable to non-diabetics and diabetics without axonal neuropathy.

Protocol of a Multicenter Prospective Trial of Office-Based Carpal Tunnel Release With Ultrasound Guidance (ROBUST)

Background Carpal tunnel release (CTR) is a common surgical procedure for patients with severe or refractory carpal tunnel syndrome (CTS) symptoms. Historically, CTR procedures have been performed in a hospital or an ambulatory surgery center (ASC). However, due to advancements in techniques, greater patient demand, and concerns about growing healthcare costs, there is a distinct trend toward performing CTR procedures in an office-based setting. Several small studies with limited follow-up duration have demonstrated the feasibility of CTR with ultrasound guidance (CTR-US) when performed in an office-based setting. The objective of this study is to evaluate the safety and effectiveness of office-based CTR-US in a large cohort of patients (n=140) with symptomatic CTS followed for two years post-treatment. Design and methods ROBUST is a prospective multicenter observational study in which 140 subjects at up to 12 sites in the United States will be treated with CTR-US in an office-based setting. The primary endpoint of the study is the change in the Boston Carpal Tunnel Questionnaire Symptom Severity Scale score. Secondary endpoints include time to return to normal daily activities, time to return to work among employed subjects, change in the Boston Carpal Tunnel Questionnaire Functional Status Scale score, change in the Michigan Hand Questionnaire overall and domain scores, change in the Numeric Pain Scale score, change in the EuroQoL-5 Dimension 5-Level score, global satisfaction scores, and the incidence of device or procedure-related adverse events. The primary analysis of study endpoints will occur three months post-treatment. Patient follow-up in this study will continue for two years. Conclusions A central institutional review board approved the study protocol, and a data safety monitoring board will provide study oversight. The authors plan to report study results at medical conferences and in peer-reviewed medical journals. The outcomes of ROBUST will provide physicians, patients, and payors with important safety and effectiveness data regarding the clinical utility of CTR-US when performed in an office setting.

Minimally Invasive Carpal Tunnel Release Using a Hook Knife through a Small Transverse Carpal Incision: Technique and Outcome

Background

Compared to the classic open technique, limited exposure techniques have the advantages of less scar pain, more grip and pinch strength, and earlier return to daily life. We evaluated the effectiveness and safety of our novel method of minimally invasive carpal tunnel release using a hook knife through a small transverse carpal incision.

Methods

This study included 111 carpal tunnel decompressions in 78 patients who underwent carpal tunnel release from January 2017 to December 2018. We performed carpal tunnel release using a hook knife through a small transverse incision just proximal to the wrist crease under local infiltration of lidocaine with tourniquet inflation in the upper arm. All patients were tolerable during the procedure and discharged following the procedure on the same day.

Results

At an average of 29.4 months of follow-up (range, 12-51 months), all but one patient (99%) revealed complete or near complete symptomatic recovery. The average of the symptom severity score on the Boston questionnaire was 1.31 ± 0.30 and the average of the functional status score was 1.19 ± 0.26. The final mean Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) score was 8.66 (range, 2-39). There was no superficial palmar arch injury or nerve injury of the palmar cutaneous branch, recurrent motor branch, or median nerve itself as a complication of the procedure. No patient showed any wound infection or wound dehiscence.

Conclusions

Our carpal tunnel release using a hook knife through a small transverse carpal incision performed by an experienced surgeon is a safe and reliable method that is expected to have the benefits of simplicity and minimal invasiveness.

Trial of ultrasound guided carpal tunnel release versus traditional open release (TUTOR)

BACKGROUND

Carpal tunnel release (CTR) is a surgical treatment option for patients with carpal tunnel syndrome (CTS) symptoms that are unresponsive to conservative treatment. Most patients experience symptomatic relief after CTR regardless of the surgical technique. However, direct comparisons of the safety and effectiveness between CTR surgical techniques are limited. The purpose of this randomized controlled trial is to compare the safety and effectiveness of CTR with ultrasound guidance (CTR-US) versus mini-open CTR (mOCTR) in subjects with symptomatic CTS.

DESIGN AND METHODS

TUTOR (Trial of Ultrasound guided CTR versus Traditional Open Release) is a randomized controlled trial in which 120 subjects at up to 12 sites in the United States will be randomized (2:1) to receive CTR-US or mOCTR. The primary endpoint of the study is the percentage of patients who return to normal daily activities within 3 days of the procedure. Secondary endpoints of the study are median time to return to normal daily activities, percentage of patients who return to work within 3 days of the procedure, median time to return to work, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) change score at 3 months, BCTQ Functional Status Scale (BCTQ-FSS) change score at 3 months, Numeric Pain Scale change score at 3 months, EuroQoL-5 Dimension 5-Level (EQ-5D-5L) change score at 3 months, and the incidence of device- or procedure-related adverse events at 3 months. Patient follow-up in this trial will continue for 1 year.

ETHICS AND DISSEMINATION

This study was approved by a central institutional review board and ongoing trial oversight will be provided by a data safety monitoring board (DSMB). The authors intend to report the results of this trial at medical conferences and peer-reviewed journals. The outcomes of TUTOR will have important clinical and economic implications for all stakeholders involved in treating patients with CTS.

STUDY REGISTRATION

ClinicalTrials.gov (https://clinicaltrials.gov): NCT05405218.

LEVEL OF EVIDENCE

1.

Comparação intraindividual dos resultados da liberação aberta ou com retinaculótomo de Paine na síndrome do túnel do carpo bilateral

O principal objetivo desta pesquisa foi fazer uma comparação intraindividual dos resultados entre as técnicas de incisão ulnar aberta e retinaculótomo de Paine com incisão palmar em pacientes com síndrome do túnel do carpo (STC) bilateral. Os pacientes foram submetidos à cirurgia aberta em uma mão e cirurgia com retinaculótomo de Paine na mão contralateral. Os pacientes foram avaliados com o Boston carpal tunnel questionnaire, escala visual analógica para dor e força de preensão palmar, pinça lateral, pinça polpa-polpa e trípode. As duas mãos foram examinadas antes da cirurgia e 2 semanas, 1 mês, 3 e 6 meses após a cirurgia. Dezoito pacientes (36 mãos) foram avaliados. As pontuações da escala de gravidade dos sintomas (EGS) foram maiores no pré-operatório nas mãos submetidas à cirurgia com retinaculótomo de Paine (p = 0,023), mas menores no 3° mês após o procedimento (p = 0,030). As pontuações da escala de estado funcional (EEF) foram menores às 2 semanas, 3 meses e 6 meses (p = 0,016) nas mãos submetidas à cirurgia com retinaculótomo de Paine. Em um estudo de módulo de diferença de dois grupos, o grupo submetido à cirurgia com retinaculótomo de Paine apresentou pontuações médias de EGS na 2ª semana e 1° mês e de EEF na segunda semana inferiores a 0,8 e 1,2 pontos, respectivamente, em comparação ao grupo submetido ao procedimento aberto. As mãos submetidas à cirurgia com retinaculótomo de Paine apresentaram escores significativamente menores de EGS em 3 meses e de EEF em 2 semanas, e aos 3 e 6 meses após a cirurgia em comparação a técnica aberta.

Electromyographic and Clinical Investigation of the Effect of Platelet-Rich Plasma on Peripheral Nerve Regeneration in Patients with Diabetes after Surgery for Carpal Tunnel Syndrome

Background Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Studies have shown that results of CTS surgery are poorer in patients with diabetes. In this study, the effect of platelet-rich plasma (PRP) on nerve regeneration was investigated through clinical and electromyographic findings in patients with diabetes who underwent CTS surgery.

Methods A retrospective analysis of 20 patients with diabetes who had surgically decompressed CTS was conducted. Patients were divided into two groups. The study group received PRP treatment following surgery. The control group did not receive any treatment. Patients were assessed using electromyography and the Boston Carpal Tunnel Syndrome Questionnaire preoperatively as well as postoperatively at 3-month, 6-month, and 1-year follow-ups visits.

Results There was a decrease in complaints and an improvement in sensory and motor examinations in both groups. The Boston Carpal Tunnel Syndrome Questionnaire scores did not show any statistically significant differences between the two groups. However, electromyographic findings showed that there were statistical differences between preoperative and postoperative (3 months, 6 months, and 1 year) results in both groups. When the two groups were compared using preoperative and postoperative (3 months, 6 months, and 1 year) electromyographic values, no statistically significant differences were seen.

Conclusion Single injections of PRP did not have a significant impact on median nerve regeneration following CTS surgery in patients with diabetes. The effectiveness of multiple PRP injections can be investigated in patients with diabetes in future studies.

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

INTRODUCTION

Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment.

PURPOSE OF THE STUDY

This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients.

METHODS

Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements.

RESULTS

Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist-middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = -4.31, 95% CI = -5.89 to -2.74, P < .001 and MD = -2.74, 95% CI = -5.32 to -0.16, P = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies.

CONCLUSION

Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.

Minimally invasive ultrasound-guided vs open release for carpal tunnel syndrome in working population: A randomized controlled trial

PURPOSE

To compare the clinical effectiveness of minimally invasive ultrasound (US)-guided vs open release for carpal tunnel syndrome.

METHODS

In an open randomized controlled trial, 47 employed patients were allocated to US-guided carpal tunnel release (USCTR) and 42 to an open carpal tunnel release (OCTR) procedure. The main outcome was symptom severity measured by the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ-S). Secondary outcomes were hand functionality (BCTQ-F), nerve conduction, two-point discrimination, handgrip and pinch strength, pain (visual analog scale), work leave and complications. For BCTQ-S and BCTQ-F, minimal clinically important differences (MCID) were also considered. Follow-up duration was 12 months.

RESULTS

Mixed model analyses detected no significant differences between the two treatment arms in BCTQ-S (P = .098) while BCTQ-F scores were significantly better in the USCTR group (P = .007). This benefit was, however, not supported by the MCID data. Remaining variables were similar in the two groups except pain which was lower in USCTR at 3 months follow-up. All variables but two-point discrimination showed significant improvement after 3 months.

CONCLUSIONS

Our findings reveal similar symptom relief benefits following OCTR or USCTR in these patients. The patients in our USCTR group, however, reported better hand functional status and less pain.

Using Carpal Tunnel Questionnaire in clinical practice: A systematic review of its measurement properties

INTRODUCTION

Carpal Tunnel Questionnaire (CTQ) is widely used for assessing condition-specific impairments in individuals with carpal tunnel syndrome (CTS) or for assessing outcomes after carpal tunnel surgery (carpal tunnel release [CTR]). A systematic review of its measurement properties can greatly facilitate its evidence-based use in clinical practice. The purpose of this study was to systematically locate, appraise, and synthesize the evidence concerning the reliability, responsiveness, validity, minimal detectable change (MDC), and minimal clinically important difference (MCID) for the CTQ and its scales.

STUDY DESIGN

This is a systematic review of measurement properties.

METHODS

Using predefined keywords, PubMed, CINAHL, PsychInfo, and ProQuest were searched to locate primary studies that assessed measurement properties of the CTQ. The methodological quality of the included studies was assessed using a standardized tool. Data concerning the measurement properties were extracted and synthesized. The pooled estimates for the indices of test-retest reliability, standard error of measurement, responsiveness, MDC, and MCID were calculated from the included studies.

RESULTS

A total of 34 articles were deemed eligible and included in this review. The methodological quality of these 34 studies was generally good. Most studies suggested that the CTQ and its scales had good test-retest reliability and internal consistency. However, few studies found that the Symptom Severity Scale had more than one factor. The responsiveness of the CTQ and its scales was excellent across the studies. The pooled estimates for the MDC₉₀ and MCID for Symptom Severity Scale/Functional Status Scale were 0.72/0.79 and 1.05/1.13, respectively.

DISCUSSION

The results of this review support the use of CTQ and its scales in assessing conditions-specific impairments in individuals with CTS or after CTR. However, an effort should be made to review and modify the content of the symptom severity scale due to multiple reports challenging its unidimensional structure.

CONCLUSIONS

The totality of evidence emerging from this systematic review suggests that the CTQ and its scales provide reliable and valid estimate of impairments resulting from CTS or after CTR.

Outcomes of Mini-Open Carpal Tunnel Release in Patients With Unrecordable Preoperative Nerve Conduction Potentials at a Minimum of 5 Years

Background: The aim of this study is to assess the outcomes of carpal tunnel release (CTR) in a cohort of patients with preoperatively unrecordable median nerve sensory and motor potentials in comparison with historical controls at minimum 5-year follow-up. Methods: We retrospectively identified 1297 patients who underwent CTR at a tertiary care referral center from July 2008 to June 2013. After exclusion criteria and review of available preoperative nerve conduction studies, 24 patients who underwent CTR with preoperative unrecordable sensory and motor nerve potentials were identified. Fifteen living, mentally capable patients were contacted by telephone for follow-up. Our primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Secondary outcome measures included Disabilities of the Arm, Shoulder, and Hand (DASH) score, pain on a 0 to 10 Likert scale, and satisfaction on a 0 to 10 Likert scale. Results: Our response rate was 80% (12 out of 15) of eligible patients. Mean follow-up was 6.9 years in our study (range, 5.4-9.5 years). The mean BCTQ symptom score was 1.4, and the mean BCTQ functional score was 1.8. Mean DASH score was 15.2. On average, patient-reported pain was 0.3 and satisfaction was 8.3. No difference was found in outcomes of CTR in patients with end-stage carpal tunnel syndrome compared with historical means. Conclusions: Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after CTR compared with the general population. Unrecordable nerve potentials are not a contraindication for CTR.

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.

A Comparison of Open Carpal Tunnel Release Outcomes Between Procedure Room and Operating Room Settings

Purpose

Carpal tunnel release (CTR) surgical costs are minimized when performed in the procedure room (PR) setting, compared with the operating room. However, it remains unclear whether outcomes differ between surgical settings. Our purpose was to compare outcomes at 1 year or greater follow-up after open CTR between patients treated in PR versus operating room settings using the Boston Carpal Tunnel Questionnaire (BCTQ).

Methods

A change in clinical care protocols at our institution occurred in 2014. Before this, all CTRs were performed in the operating room; thereafter, these were transitioned to the PR. Adult patients who underwent isolated unilateral or bilateral open CTR in either surgical setting were considered for inclusion, in which procedures were conducted between January 2014 and October 2018 for the PR group and January 2009 and March 2014 for the operating room group. The Functional Status Scale (FSS) and the Symptom Severity Scale (SSS) components of the BCTQ were collected for all eligible patients at a minimum of 1 year after surgery. We used univariate and multivariable linear regression to determine whether postoperative BCTQ scores were equivalent between PR and operating room groups within a threshold of one-fourth of the lowest estimates of the minimal clinically important difference.

Results

No differences in demographics, comorbidities, or insurance type were observed between the 104 PR and 112 operating room patients. Survey response rate was 25% and 25% for the PR and operating room patients, respectively. At a mean follow-up of 3 ± 1 years, FSS and SSS scores were equivalent between PR and operating room groups on bivariate analysis. The multivariable equivalence test also demonstrated equivalent FSS and SSS scores between PR and operating room groups within a one-fourth minimal clinically important difference threshold while controlling for age, sex, presence of diabetes or thyroid disease, unilateral versus bilateral CTR, and surgeon.

Conclusions

Clinical outcomes did not differ between PR and operating room settings after open CTR. Type of study/level of evidence: Therapeutic III.

Subjective Outcomes of Carpal Tunnel Release in Patients with Diabetes and Patients without Diabetes

Introduction  This study aims to compare the subjective outcomes of carpal tunnel surgery in the patients with diabetes and patients without diabetes, and it tries to determine the difference between insulin-dependent and noninsulin-dependent patients. Materials and Methods  This retrospective cohort study compares subjective outcomes of 35 patients with type 2 diabetes and 35 patients without diabetes who had a unilateral carpal tunnel release. None of the patients with diabetes had neuropathy. All the patients had surgery by a single surgeon with miniopen incision under local anesthesia. The patients were evaluated before surgery and 6 months after surgery using two Brigham and Women's Carpal Tunnel Questionnaires Results  Carpal tunnel release was improved based on symptom severity scale (SSS) and functional status scale scores in patients with diabetes and nondiabetic patients. However, the mean SSS scores were higher in patients without diabetes 6 months after the surgery. Comparison between the mean SSS scores of the patients with diabetes showed higher scores in noninsulin-dependent patients. In patients with diabetes, SSS scores were positively correlated with carpal tunnel syndrome and diabetes durations. Conclusion  The outcomes of carpal tunnel release were improved in both patients with diabetes and patients without diabetes suffering from median nerve compression at the wrist. However, the duration of diabetes and its treatment can be related to the severity of the disease symptoms after the carpal tunnel releasing surgeries. In some diabetic patients, the severity of the symptoms was persistent. Level of Evidence  This is a prognostic level IV study.

Median Nerve Transverse Mobility and Outcome after Carpal Tunnel Release

Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a novel approach in which nerve movement and the association with short-term patient-reported outcome are assessed. Ultrasound images at the carpal tunnel inlet were acquired during finger and wrist flexion. Linear regression models were used with the Boston Carpal Tunnel Questionnaire as main outcome. Eighty-five patients were included; 93% completed the 3-mo follow-up. Pre-surgical mean nerve area was 14.5 ± 4.2 mm2 and decreased to 13.3 ± 3.8 mm2 (p < 0.001). Displacement in dorsal direction with wrist flexion increased from 1.9 ± 1.3 to 2.4 ± 1.3 mm (p < 0.01). A pre-surgical larger nerve area was associated with more functional improvement (β = -0.024, p = 0.02), but baseline mobility was not. Change in excursion with finger flexion was associated with symptomatic improvement, but with a small effect (β = -0.05, p = 0.01). This indicates that there is limited prognostic potential for dynamic transverse ultrasound in carpal tunnel syndrome.

Minimal Clinically Important Difference After Carpal Tunnel Release Using the PROMIS Platform

PURPOSE

In light of recently-proposed quality measures for carpal tunnel release (CTR), elucidating the minimal clinically important difference (MCID) for selected outcome measures will be important when interpreting treatment responses. Our purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) following CTR.

METHODS

Adult patients undergoing isolated unilateral CTR between July 2014 and October 2016 were identified. Outcomes included the PROMIS Upper Extremity (UE) Computer Adaptive Test (CAT), Physical Function (PF) CAT, QuickDASH, and Pain Interference (PI) CAT. For inclusion, pretreatment baseline (within 60 days of surgery) and postoperative (6-90 days) UE or PF CAT scores were required, as well as a response on a 5-point Likert scale to the question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" The MCID was calculated using SD and minimum detectable change (MDC) distribution methods.

RESULTS

In response to the Likert scale question, 88.6% of patients reported improvement at a mean of 14.8 days after surgery. The infrequency of patients reporting no change (5 of 44; 11.4%) precluded calculation of a statistically sound anchor-based MCID value. The MCID values, as calculated using the one-half SD method, were 3.6, 4.6, 10.4, and 3.4 for the UE CAT, PF CAT, QuickDASH, and PI CAT, respectively.

CONCLUSIONS

We have calculated MCID values for the UE CAT, PF CAT, QuickDASH, and PI CAT for patients undergoing CTR. Although the small number of patients reporting no change and minimal change after surgery precluded an anchor-based MCID calculation, we report estimates using the one-half SD method for the MCID following CTR.

CLINICAL RELEVANCE

These MCID estimates will be helpful when interpreting CTR clinical outcomes and for powering prospective trials.

Minimal Clinically Important Differences for PROMIS Physical Function, Upper Extremity, and Pain Interference in Carpal Tunnel Release Using Region- and Condition-Specific PROM Tools

PURPOSE

Uncertainty exists about what change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores represents a clinically relevant improvement (minimal clinically important difference [MCID]) in hand surgery care. Using a region-specific patient-reported outcome measure (PROM) (Michigan Hand Question [MHQ]) and a condition-specific PROM (Boston Carpal Tunnel Questionnaire [BCTQ]), MCID values were determined for PROMIS Physical Function (PF), Upper Extremity (UE), and Pain Interference (PI) computerized adaptive testing among patients undergoing carpal tunnel release (CTR).

METHODS

Patients undergoing CTR with a single surgeon from November 2014 to April 2017 were asked to complete the BCTQ, MHQ, and PROMIS PF, UE, and PI at each visit. Patients who had completed questionnaires both at a preoperative and either a 6-week or a 3-month postoperative visit were included. The PROMIS PF, UE, and PI MCID values were calculated using previously determined MCID estimates in the literature with both region- (ie, MHQ) and condition-specific (ie, BCTQ) PROM anchors. The PROMIS domain MCID estimates were also determined using the distribution-based method.

RESULTS

A total of 70 patients fit our inclusion criteria. Using MHQ Function and Pain, PROMIS UE, PF, and PI MCIDs were 6.3, 1.8, and -8.9, respectively. Using the average of the 2 BCTQ domains, PROMIS UE, PF, and PI MCIDs were 8.0, 2.8, and -9.7, respectively. Using the distribution-based method, PROMIS UE, PF, and PI MCIDs were 4.2, 2.7, and -4.1, respectively.

CONCLUSIONS

Using region- and condition-specific PROMs, we were able to provide MCID estimates of PROMIS UE, PF, and PI for patients undergoing CTR.

CLINICAL RELEVANCE

Estimating PROMIS UE, PF, and PI MCIDs in CTR using validated region- and condition-specific PROMs provides hand surgeons a way to evaluate CTR outcomes not previously described in the literature. Surgeons should understand that these values are only estimates and future work is needed to verify whether they reflect clinical improvement.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

Minimal clinically important difference for the Boston Carpal Tunnel Questionnaire: new insights and review of literature

No consensus exists about the minimal clinically important difference for the Boston Carpal Tunnel Questionnaire, which hampers its clinical application. This study assessed the minimal clinically important difference of this questionnaire. The Boston Carpal Tunnel Questionnaire was completed by 180 patients, with clinically defined carpal tunnel syndrome, preoperatively and at about 8 months follow-up after carpal tunnel release, together with a six-point scale for perceived improvement. Receiver operator characteristics curves showed that relative changes in Symptom Severity Scale and Functional Status Scale scores correspond better to a clinically relevant improvement than absolute changes. The minimal clinically important difference should be individually calculated from baseline Symptom Severity Scale and Functional Status Scale scores, as patients experiencing more symptoms require more improvement to notice a clinically important difference. By taking this into account, the Boston Carpal Tunnel Questionnaire is more meaningful as an outcome measure in research and clinical practice.

A meta-analysis of surgical decompression in the treatment of diabetic peripheral neuropathy

BACKGROUND

Over the last decade, surgical decompression procedures have been commonly used in the treatment of diabetic peripheral neuropathy (DPN). However, the effectiveness of them remains to be proved.

METHODS

A comprehensive literature search of databases including PubMed-Medline, Ovid-Embase, and Cochrane Library was performed to collect the related literatures. The Medical Subject Headings used were "diabetic neuropathy," "surgical decompression," and "outcomes." The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. Analyses were performed with Review Manager (Version 5.3, The Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, 2014).

RESULTS

A total of 12 literatures (including 8 prospective and 4 retrospective) encompassing 1825 patients with DPN were included in the final analysis. Only 1 literature was identified as a randomized-controlled trial. The remaining 11 literatures were observational studies; 7 of them were classified as upper-extremity nerve decompression group and 4 of them were classified as lower-extremity nerve decompression group. Meta-analysis shows that Boston questionnaire symptom severity and functional status of upper extremities, and distal motor latency and sensory conduction velocity of median nerve of DPN patients are significantly improved after carpal tunnel release. Besides, visual analog scale and 2-point discrimination are considered clinically and statistically significant in lower extremities after operation.

CONCLUSIONS

The findings from our review have shown the efficacy of surgical decompression procedures in relieving the neurologic symptoms and restoring the sensory deficits in DPN patients. As there are few high-quality randomized-controlled trials or well-designed prospective studies, more data are needed to elucidate the role of surgical procedures for DPN treatment in the future.

Effectiveness of ultrasonography and nerve conduction studies in the diagnosing of carpal tunnel syndrome: clinical trial on accuracy

BACKGROUND

The aim of this study was to evaluate the effectiveness of two diagnostic tests routinely used for diagnosing carpal tunnel syndrome (CTS)-ultrasonography (US) and nerve conduction studies (NCS)-by comparing their accuracy based on surgical results, with the remission of paresthesia as the reference standard.

METHODS

We enrolled 115 patients, all of the female gender with a high probability of a clinical diagnosis of CTS. All patients underwent US and NCS for a diagnosis and subsequent surgical treatment. As a primary outcome, the accuracy of the US and NCS diagnoses was measured by comparing their diagnoses compared with those determined by the surgical outcomes. Their accuracy was secondarily evaluated based on before and after scores of the Boston Carpal Tunnel Questionnaire (BCTQ).

RESULTS

Overall, 104 patients (90.4%) were diagnosed with CTS by the surgical reference standard, 97 (84.3%) by NCS, and 90 (78.3%) by US. The concordance of NCS and surgical treatment (p < 0.001; kappa = 0.648) was superior to that of US and surgical treatment (p < 0.001; kappa = 0.423). The sensitivity and specificity of US and NCS were similar (p = 1.000 and p = 0.152, respectively: McNemar's test). The BCTQ scores were lower after surgery in patients diagnosed by both US and NCS (p < 0.001and p < 0.001, respectively: analysis of variance).

CONCLUSIONS

US and NCS effectively diagnosed CTS with good sensitivity but were not effective enough to rule out a suspicion of CTS.

TRIAL REGISTRATION

This study was registered at September, 10 th, 2015, and the registration number was NCT02553811 .

Outcome of Carpal Tunnel Release and the Relation With Depression

PURPOSE

To examine the relation between depressive symptoms and outcome of carpal tunnel release (CTR).

METHODS

Prospective study in a general hospital with data collection at baseline and 3 and 12 months after CTR. We quantified depressive symptoms using the Center for Epidemiologic Studies Depression (CES-D) scale and performed multivariable analyses on 2 outcome measures: (1) carpal tunnel syndrome (CTS) symptoms (Boston Carpal Tunnel Questionnaire [BCTQ]) and (2) palmar pain, focusing on preoperative CES-D and BCTQ score, sex, age, alcohol use, diabetes, and severity of nerve conduction abnormalities.

RESULTS

We included 227 patients. Before surgery, patients with depression had a higher BCTQ score than patients without depression. After 1 year, depressed patients had a higher BCTQ score and more palmar pain. The CES-D decreased by a median of 2 points from baseline to 1 year. This correlated with the decrease in BCTQ score. Multivariable analyses showed that preoperative depression had a small but statistically significant influence on palmar pain, but not on postoperative BCTQ score.

CONCLUSIONS

Depression is not an independent predictor of residual CTS symptoms 1 year after CTR. Depressive symptoms in patients with CTS decrease after CTR, along with a decrease in CTS symptoms. The nature of this relationship is unknown. Patients with CTS and depression may expect a somewhat higher degree of palmar pain after CTR, the clinical relevance of which is small.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Treatment outcome in patients with clinically defined carpal tunnel syndrome but normal electrodiagnostic test results: a randomized controlled trial

Little is known about treatment effect of carpal tunnel release in patients with clinically defined carpal tunnel syndrome (CTS), but normal electrodiagnostic test results (EDX). The aim of this study was to determine whether this category of patients will benefit from surgical treatment. 57 patients with clinically defined CTS and normal EDX were randomized for surgical treatment (n = 39) or non-surgical treatment (n = 18). A six-point scale for perceived improvement as well as the Boston Carpal Tunnel Questionnaire was completed at baseline and at follow-up after 6 months. A significant improvement of complaints was reported by 70.0% of the surgically treated patients and 39.4% reported full recovery 6 months after surgery. Furthermore, both Functional Status Score and Symptom Severity Score improved significantly more in the surgically treated group (p = 0.036 and p < 0.001, respectively). This study demonstrates that most patients with clinically defined CTS and normal EDX results will benefit from carpal tunnel release. Therefore, this group of CTS patients must not a priori be refrained from surgery.

A Randomized Prospective Comparison of Ultrasound-Guided and Landmark-Guided Steroid Injections for Carpal Tunnel Syndrome

PURPOSE

The aim of this study was to compare the clinical and electrodiagnostic efficacy of ultrasound (US)-guided versus landmark (LM)-guided steroid injections in patients with carpal tunnel syndrome (CTS).

METHODS

This randomized clinical trial included 47 patients (60 affected hands) with moderate CTS (30 hands in each group). All clinically suspected patients with CTS who met the inclusion criteria confirmed by electrodiagnostic tests were enrolled. The subjects received 40 mg of methylprednisolone either with the US-guide or the LM-guided injection technique. They were evaluated using the Boston Carpal Tunnel Questionnaire (symptom/function/total) and 6 electrodiagnostic findings at the baseline and 12 weeks after injection.

RESULTS

Symptom severity scores and functional status scores and electrodiagnostic parameters were significantly improved within each group at week 12 after treatment (P < 0.05), except for compound muscle action potential amplitude and motor nerve conduction velocity (P > 0.05). The improvement in symptom severity scores and functional status scores in the US-guided group was more than in the LM-guided group after 12 weeks, but there was no statistically significant difference (P = 0.79 and 0.64). The mean changes in electrodiagnostic parameters were also not different between groups except for the higher sensory nerve action potential amplitude in LM-guided group (P = 0.003).

CONCLUSIONS

Both US-guided and LM-guided steroid injections were effective in reducing the symptoms, improving the function and electrodiagnostic findings of CTS. Although there was better symptomatic improvement with US-guided injections and better increase in sensory nerve action potential amplitude with LM-guided injection, a significant difference was not generally observed between US-guided and LM-guided CTS injections.

Interpretation of the QuickDASH score after open carpal tunnel decompression: threshold values associated with patient satisfaction

We studied the correlation between change in the QuickDASH score and the absolute post-operative QuickDASH score with patient satisfaction after open carpal tunnel decompression. Threshold values in the QuickDASH score, the point at which the sensitivity and specificity are maximal in predicting patient satisfaction, were identified. During the study period, outcome data were compiled for 937 carpal tunnel decompressions, which included 219 (23%) male and 718 (77%) female patients with a mean age of 58 years (standard deviation (SD) 14). There was a significant improvement (mean difference 32, 95% confidence interval (CI) 30 to 34) in the QuickDASH from a mean of 54 (SD 20) to 22 (SD 23) at 1 year after surgery. There were 808 (86%) patients who defined their outcome as satisfactory at 1 year. The identified threshold values for the post-operative QuickDASH score (⩽34 points) and the change (⩾20 points) in the score were highly predictive of patient satisfaction. However, these threshold values varied significantly according to the baseline pre-operative score. The threshold values identified in the QuickDASH can be used to interpret the score. However, the influence of the pre-operative baseline score should be taken into account when comparing different cohorts of patients or using the values to power future studies.

LEVEL OF EVIDENCE IV

Prognosis, observational cohort study.

Minimal important changes and differences in elective hand surgery

Minimal important changes and differences describe the smallest changes and differences between individuals that are relevant to patients following treatment. Minimal important differences may vary between conditions, treatments and lengths of follow-up, and can be calculated in different ways. Minimal important differences for elective hand surgery were reviewed. A total of 99 minimal important differences were identified in 29 articles. The conditions, treatments, outcome measures used and follow-up periods are discussed. The Disabilities of the Arm, Shoulder and Hand had the most estimates of minimal important differences, but these varied. The methods used in the included studies were reviewed and appraised. Most minimal important differences were calculated using retrospective anchors. Future research directions in this area are suggested.

LEVEL OF EVIDENCE

II.

Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome

BACKGROUND

Current literature demonstrates that patients with carpal tunnel syndrome (CTS) have a higher prevalence of hypothyroidism and diabetes. The British Society for Surgery of the Hand (BSSH) advises screening CTS patients for thyroid and glucose dysfunction before surgery. This study aimed to analyze the current departmental practice for patients listed for carpal tunnel decompression (CTD) with respect to preoperative assessment of diabetic and thyroid status.

METHOD

A retrospective review of all patients who underwent surgery for CTS under one team over a 3 year period (2009-2011) in a UK teaching hospital was performed. Patients' medical records and pathology results were reviewed.

RESULTS

A total of 103 procedures were performed in 100 patients. Preoperative thyroid function was checked in 63/100 patients with an abnormal result in 3/63 patients. Two of these patients were subsequently diagnosed with hypothyroidism. Similarly blood glucose was checked in 67/100 patients. This resulted in the new diagnosis of three patients with diabetes.

CONCLUSION

The results are consistent with the view that CTS is associated with thyroid dysfunction and diabetes and screening helps in diagnosing new cases of these conditions in this select group. The cost of diagnosing new cases of hypothyroidism and diabetes can be considered as money well spent.

Endoscopic release for severe carpal tunnel syndrome in octogenarians

PURPOSE

To investigate the clinical outcomes of endoscopic carpal tunnel release for severe carpal tunnel syndrome in octogenarians compared with a younger cohort.

METHODS

Fifty-five hands in 48 patients were enrolled in this study. There were 27 hands in 24 octogenarians and 28 hands in 24 patients in a younger group with average ages of 83 and 60 years, respectively. Postoperative follow-ups were 8.5 and 7.2 months, respectively. Clinical evaluation included documentation of subjective symptoms and Semmes-Weinstein testing before surgery, 3 months after surgery, and at final follow-up. Symptom severity and function outcomes scores and compound muscle action potential of abductor pollicis brevis as an electrophysiological assessment were evaluated before surgery and at the final follow-up.

RESULTS

Nocturnal pain and paresthesias were improved in all patients. The octogenarians had poorer recovery of Semmes-Weinstein testing score and better improvement of outcomes scores than the younger group. There was no difference of the results in postoperative electrophysiological improvement between the groups.

CONCLUSIONS

Endoscopic release for severe carpal tunnel syndrome relieved symptoms and improved activities of daily living in octogenarians.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Carpal tunnel release in patients with diabetes: a 5-year follow-up with matched controls

PURPOSE

To compare clinical outcomes 5 years after carpal tunnel release among patients with and without diabetes.

METHODS

In a prospective consecutive series, 35 patients with diabetes (median age, 54 y; 15 type 1 and 20 type 2 diabetes) with carpal tunnel syndrome were age- and sex-matched with 31 control patients without diabetes (median age, 51 y) with idiopathic carpal tunnel syndrome. Exclusion criteria were other nerve entrapment, cervical radiculopathy, inflammatory joint disease, thyroid disorder, previous wrist fracture, and long-term exposure to vibrating tools. Participants were examined independently at baseline, 1 year, and 5 years after surgery for sensory function (Semmes-Weinstein), motor function (abductor pollicis brevis muscle strength and grip strength), cold intolerance, and completion of the Boston Carpal Tunnel Questionnaire symptom severity and functional status score.

RESULTS

Five years after surgery, the overall attendance rate for clinical examinations and completion of the Boston Carpal Tunnel Questionnaire were 86% and 95%, respectively. Between 1 and 5 years after surgery, there was a tendency toward a decrease in sensory function but an increase in motor function, with no statistically significant difference between groups. Cold intolerance demonstrated long-term significant improvement for patients with diabetes. The improvement in symptom severity and functional status score, as well as the large effect size, were maintained at 5 years in both patient groups.

CONCLUSIONS

Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes. Furthermore, improvement in cold intolerance in patients with diabetes suggests the potential for the long-term regeneration of small nerve fibers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.