Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods

A comparative meta-analysis between mini-transverse and longitudinal techniques in the management of carpal tunnel syndrome

Background

Due to the gap and the controversy regarding whether to use the traditional open technique or the minimally invasive technique in carpal tunnel syndrome, we carried out this systematic review and meta-analysis to compare the two techniques regarding their outcomes.

Methods

A systemic computer-based search was carried out to find relevant articles. We searched the following databases: PubMed, Scopus, and Web of Science. The search was carried out from inception until April 2024 using the following search terms: "Transverse" OR "Mini-transverse" AND "Carpal tunnel syndrome" AND "Longitudinal." No filters were applied and reference lists of included papers were searched to try and include further relevant papers that were not identified during the search.

Results

The mini-transverse technique was associated with a lower functional status scale (FSS) and symptoms severity scale (SSS) compared to the longitudinal technique with mean difference [MD] of -0.32 (95% confidence interval [CI]: -0.52, -0.12, P = 0.002), and -0.43 (95% CI: -0.6, -0.25, P < 0.00001), respectively. Furthermore, the mini-transverse technique was associated with a lower pain score with MD of -0.5 (95% CI: -0.71, -0.3, P < 0.00001). Moreover, the time needed to return to work was statistically significantly lower in the mini-transverse group compared to the longitudinal group with an MD of -9.34 (95% CI: -13.55, -3.13, P = 0.002). No significant difference was observed between either group regarding the duration of operation (MD: -6.96, [95% CI: -16.66, 2.74, P = 0.16]) and the incidence of complications (odds ratio: 0.46, [95% CI: 0.15, 1.4, P = 0.17]).

Conclusion

The efficacy and safety outcome measures of the mini-transverse and longitudinal surgical approaches utilized on carpal tunnel syndrome patients were compared in the current study. Mini-transverse procedures yielded superior results in this study than longitudinal techniques, as they were statistically significant in relation to decreased FSS, SSS, pain score, and time required to return to work. However, in terms of the length of the procedure and the frequency of complications, both methods were similar.

A comparative meta-analysis of mini-transverse versus longitudinal techniques in the treatment of carpal tunnel syndrome

Background

Carpal tunnel syndrome (CTS) is a common nerve entrapment condition, and there is ongoing debate regarding the superiority of traditional open versus minimally invasive carpal tunnel surgery.

Methods

This meta-analysis reviewed six studies involving 478 patients to compare recovery and functional outcomes between the traditional longitudinal technique and the minimally invasive mini-transverse technique. The primary outcomes included the functional status scale (FSS), symptoms severity scale (SSS), pain scores, time to return to work, duration of operation, and incidence of complications.

Results

The mini-transverse technique was associated with lower FSS and SSS scores compared to the longitudinal technique, with mean differences (MD) of -0.32 (95% confidence level [CI]: -0.52, -0.12, P = 0.002) and -0.43 (95%CI: -0.6, -0.25, P < 0.00001), respectively. Pain scores were also lower with the mini-transverse technique (MD) of -0.5 (95%:CI: -0.71, -0.3, P < 0.00001). The mini-transverse group had a statistically significant shorter time to return to work (MD) of -8.34 (95%CI: -13.55, -3.13, P = 0.002). No significant differences were found in the duration of surgery (MD) of -6.96 (95%CI: -16.66, 2.74, P = 0.16) or incidence of complications (MD) of 0.46 (95%CI: 0.15, 1.4, P = 0.17).

Conclusion

The mini-transverse approach for CTS resulted in better outcomes, including less pain, faster recovery, and improved hand function. There was no significant difference in surgery time or complications compared to the traditional technique, suggesting it may be the preferable option.

Anatomical Study of the Relationship between the Riché-Cannieu Anastomosis and the Kaplan Cardinal Line

Objective  To identify the location of the Riché-Cannieu anastomosis (RCA) in relation to the Cardinal Kaplan Line (KCL) and the Y line. Methods  A total of 20 hands of 10 recently-deceased adult male cadavers aged between 27 and 66 years were dissected for the investigation of the relationship of the most distal point of the RCA with the KCL and with the Y line, drawn from the axis of the third metacarpal head, following the longitudinal axis of the hand. Results  In 20 limbs, the most distal point of the nerve communication was positioned distally in relation to the KCL. The Y line was positioned on the radial side in relation to the most distal point of the RCA in 14 limbs, and it was positioned on the ulnar side in relation to the Y line in 6 limbs. The crossing between the KCL and the Y line occurred proximal to the RCA in 18 limbs; in 1 hand, it was positioned distal to the intersection between these lines; and in another hand, the KCL was positioned exactly on the RCA. Conclusion  Knowledge of these anatomical relationships can prevent damage to nerve branches and thus also prevent paralysis of intrinsic muscles in surgical procedures in the palm of the hand.

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.

Quality of ChatGPT Responses to Frequently Asked Questions in Carpal Tunnel Release Surgery

Background

Although demonstrating remarkable promise in other fields, the impact of artificial intelligence (including ChatGPT in hand surgery and medical practice) remains largely undetermined. In this study, we asked ChatGPT frequently asked patient-focused questions surgeons may receive in clinic from patients who have carpel tunnel syndrome (CTS) and evaluated the quality of its output.

Methods

Using ChatGPT, we asked 10 frequently asked questions that hand surgeons may receive in the clinic before carpel tunnel release (CTR) surgery. Included questions were generated from the authors' own experiences regarding conservative and operative treatment of CTS.

Results

Responses from the following 10 questions were included: (1) What is CTS and what are its signs and symptoms? (2) What are the nonsurgical options for CTS? (3) Should I get surgery for CTS? (4) What is a CTR and how is it preformed? (5) What are the differences between open and endoscopic CTR? (6) What are the risks associated with CTR and how frequently do they occur? (7) Does CTR cure CTS? (8) How much improvement in my symptoms can I expect after CTR? (9) How long is the recovery after CTR? (10) Can CTS recur after surgery?

Conclusions

Overall, the chatbot provided accurate and comprehensive information in response to most common and nuanced questions regarding CTS and CTR surgery, all in a way that would be easily understood by many patients. Importantly, the chatbot did not provide patient-specific advice and consistently advocated for consultation with a healthcare provider.

Comparison of early clinical outcome in carpal tunnel release - mini-open technique with palmar incision vs. endoscopic technique with wrist crease incision

BACKGROUND

The purpose of this study was to examine two techniques for Carpal Tunnel Syndrome, mini-Open Carpal Tunnel Release (mini-OCTR) and Endoscopic Carpal Tunnel Release (ECTR), to compare their therapeutic efficacy.

METHODS

Sixteen patients who underwent mini-OCTR in palmar incision and 17 patients who underwent ECTR in the wrist crease incision were included in the study. All patients presented preoperatively and at 1, 3, and 6 months postoperatively and were assessed with the Visual Analogue Scale (VAS) and the Disabilities of Arm, Shoulder and Hand Score (DASH). We also assessed the pain and cosmetic VAS of the entire affected hand or surgical wound, and the patient's satisfaction with the surgery.

RESULTS

In the objective evaluation, both surgical techniques showed improvement at 6 months postoperatively. The DASH score was significantly lower in the ECTR group (average = 3 months: 13.6, 6 months: 11.9) than in the mini-OCTR group (average = 3 months: 27.3, 6 months: 20.6) at 3 and 6 months postoperatively. Also, the pain VAS score was significantly lower in the ECTR group (average = 17.1) than in the mini-OCTR group (average = 36.6) at 3 months postoperatively. The cosmetic VAS was significantly lower in the ECTR group (average = 1 month: 15.3, 3 months: 12.2, 6 months: 5.41) than in the mini-OCTR group (average = 1 month: 33.3, 3 months: 31.2, 6 months: 24.8) at all time points postoperatively. Patient satisfaction scores tended to be higher in the ECTR group (average = 3.3) compared to the mini-OCTR group (average = 2.7).

CONCLUSIONS

ECTR in wrist increase incision resulted in better pain and cosmetic recovery in an early postoperative phase compared with mini-OCTR in palmar incision. Our findings suggest that ECTR is an effective technique for patient satisfaction.

State of the art review. Complications after carpal tunnel release

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Outcomes of Endoscopic Carpal Tunnel Release Surgery With Home Guided Hand Therapy Versus No Hand Therapy: A Prospective Randomized Controlled Trial After Endoscopic Carpal Tunnel Release

BACKGROUND

The most recent American Academy of Orthopaedic Surgeons Clinical Practice Guidelines found no high-quality evidence comparing home therapy to no therapy following carpal tunnel release surgery (CTRS). Therefore, this study's purpose is to compare the outcomes of patients receiving home therapy and patients receiving no therapy following endoscopic CTRS.

METHODS

A single-blinded prospective randomized controlled trial was performed. Patients were randomized to receive home hand therapy or no therapy postoperatively. Patients were assessed at baseline, 2, 6, and 12 weeks postoperatively. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores and Boston Carpal Tunnel Questionnaire (BCTQ) scores were evaluated as primary outcome measures. Grip strength, pinch strength, numerical pain rating scale (NRS), static 2-point discrimination, and hand circumference were also measured.

RESULTS

Fifty patients were randomized to home therapy while 55 patients were randomized to no therapy. The QuickDASH, BCTQ functional status scale (FSS), and BCTQ symptom severity scale (SSS) improved over time in both treatment groups. As-treated and intention-to-treat analysis showed no difference in improvement of QuickDASH, BCTQ FSS, or BCTQ SSS between treatment groups. Additionally, there was no significant difference between treatment groups in grip strength, chuck and key strength, NRS, hand circumference, and static 2-point discrimination.

CONCLUSIONS

This blinded, prospective randomized controlled study shows no significant difference in improvement of QuickDASH, BCTQ SSS, and BCTQ FSS scores between patients receiving no therapy and home therapy following endoscopic CTRS. Consideration should be given to releasing patients without supervised therapy in the postoperative setting.

LEVEL OF EVIDENCE

Level II Therapeutic.

Open versus Single- or Dual-Portal Endoscopic Carpal Tunnel Release: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Compared to the traditional open carpal tunnel release (OCTR), the additional safety and efficacy benefits of endoscopic carpal tunnel release (ECTR) remains unclear. The aim of this study is to evaluate the outcomes of ECTR versus conventional OCTR as well as determine if a difference exists between the 2 most common endoscopic techniques: the single-portal and the dual-portal endoscopic technique.

METHODS

We conducted a systematic literature search of Medline, Embase, PubMed, and the CENTRAL. Additional articles were identified by handsearching reference lists. We included all randomized controlled trials that compared outcomes of ECTR with OCTR technique. Outcomes assessed included length of surgery, patient reported symptom and functional measures, time to return to work, and complications. A sub-group analysis was performed to indirectly compare single- versus dual-portal endoscopic approaches. Statistical analysis was performed via a random-effects model using Review Manager 5 Software.

RESULTS

A meta-analysis of 23 studies revealed a significantly higher incidence of transient postoperative nerve injury with ECTR, regardless of the number of portals, as compared with OCTR, although overall complication and re-operation rates were equivalent. Scar tenderness was significantly diminished with dual-portal endoscopic release when compared to single-portal and open methods. The rates of pillar pain, symptom relief, and patient reported satisfaction did not differ significantly between treatment groups.

CONCLUSIONS

Although endoscopic surgery may be appealing in terms of reduced postoperative morbidity and a faster return to work for patients, surgeons should be mindful of the associated learning curve and higher incidence of transient nerve injury. Further study is required to identify if an advantage exists between different endoscopic techniques.

STUDY OF THE MEDIAN AND ULNAR NERVOUS BRANKS TO KAPLAN'S LINE

Objective

This study aims to present lines A1 and A2 in association with Kaplan's cardinal line (LCK), and relate them to the thenar motor branch of the median nerve (RMTNM) and to the deep branch of the ulnar nerve (RPNU).

Methods

Ten hands of five adult cadavers were dissected.

Results

The RMTNM origin was positioned proximal to the LCK in all limbs. In two, the RMTNM was positioned exactly on the A1 line; in seven, it was on the ulnar side in relation to A1. In one, it was on the radial side relative to the A1. The origin of the RPNU was identified between the pisiform and the LCK in nine limbs; in one, the RPNU was positioned from the ulnar nerve in relation to A2; and in two, the A2 passed exactly at the point of division of the ulnar nerve into superficial branches and deep. We did not identify the positioning of the RPNU on the radial side of the A2 line.

Conclusion

The impact of this study was to identify the anatomical trajectory of these nerves by detaching A1 and A2 along with the KCL, avoiding iatrogenic lesions during surgical procedures. Level of Evidence IV, Case Series.

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.

Treatment of Peripheral Nerve Compression Syndromes of the Upper Extremities: a Systematic Review

BACKGROUND

Nerve compression syndromes are referred to as chronic irritation or pressure palsies of peripheral nerves in areas of preformed anatomical constriction. Carpal tunnel syndrome is the most common nerve compression syndrome, followed by cubital tunnel syndrome. In addition, less frequent nerve compression syndromes of the upper extremities that affect the median, ulnar or radial nerves have been described. This review provides an overview of current treatment options for nerve compression syndromes of the upper extremities.

STUDY DESIGN

Systematic overview.

METHODS

Based on established national (AWMF) and international guidelines as well as the Cochrane Library, we performed a systematic literature search on PubMed (NLM), focusing on randomised controlled trials.

RESULTS

Over the research period (2012 - 2020), there were 43 randomised trials that investigated surgical carpal tunnel release methods, 68 that compared different conservative therapies and 12 that compared surgical versus conservative treatments. Furthermore, eight studies analysed surgical techniques and four analysed conservative techniques for cubital tunnel syndrome. No randomised trials were conducted on the less common peripheral nerve compression syndromes, but case reports and observational studies were conducted.

CONCLUSION

For carpal and cubital tunnel syndromes, there are evidence-based diagnostic methods as well as therapeutic recommendations based on randomised and controlled trials. When diagnosis is made after clinical examination and supported by radiological and electrophysiological evaluation, surgical treatment is considered superior to conservative treatment. In particular, excellent long-term results can be achieved by surgery for carpal and cubital tunnel syndromes. More controlled studies are needed to establish evidence-based therapeutic recommendations for the less common nerve compression syndromes, which are somewhat controversially and inconsistently defined.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review

OBJECTIVES

The aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research.

METHODS

A systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy.

RESULTS

Fifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported.

CONCLUSIONS

This review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

Ultrasound-Guided Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analyses

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.

The Association of Insurance Status and Complications After Carpal Tunnel Release

BACKGROUND

Carpal tunnel release (CTR) is one of the most commonly performed procedures in hand surgery. Complications from surgery are a rare but significant patient dissatisfier. The purpose of this study was to determine whether insurance status is independently associated with complications after CTR.

METHODS

We retrospectively identified all patients undergoing CTR between 2008 and 2018 using the Indiana Network for Patient Care, a state-wide health information exchange, and built a database that included patient demographics and comorbidities. Patients were followed for 90 days to determine whether a postoperative complication occurred. To minimize dropout, only patients with 1 year of encounters after surgery were included.

RESULTS

Of the 26 151 patients who met inclusion criteria, 2662 (10.2%) had Medicare, 7027 (26.9%) had Medicaid, and 16 462 (62.9%) had commercial insurance. Compared with Medicare, Medicaid status (P < .001) and commercial insurance status (P < .001) were independently associated with postoperative CTR complications. The overall complication rate was 2.23%, with infection, wound breakdown, and complex regional pain syndrome being the most common complications. Younger age, alcohol use, diabetes mellitus, hypertension, and depression were also independently associated with complications.

CONCLUSIONS

The incidence of complications after CTR is low. Insurance status, patient demographics, and medical comorbidities, however, should be evaluated preoperatively to appropriately risk stratify patients. Furthermore, surgeons can use these data to initiate preventive measures such as working to manage current comorbidities and lifestyle choices, and to optimize insurance coverage.

The Reliability of Kaplan's Cardinal Line as a Potential Surface Marker for the Superficial Palmar Arch During Carpal Tunnel Release: An Anatomical Study With Surgical Perspective

Purpose Kaplan's cardinal line (KCL) provides a more accurate reference point to the superficial palmar arch (SPA). The aim was to determine the KCL-SPA distances and their relationship with the other defined superficial landmarks, such as distal wrist crease (DWC) or distal portion of the transverse carpal ligament (TCL) or DWC-TCL distance. The objective was to determine the distal limit of the incision made during carpal tunnel release (CTR). Methods Sixty hands were dissected after KCL was drawn on each hand using standard methods. The distance from KCL to the SPA was measured along the radial and ulnar borders of the ring finger and recorded as radial and ulnar KCL-SPA distance, respectively. The distance between the DWC and the distal portion of the TCL was also measured (DWC-TCL). Correlation analysis was done between the DWC-TCL and KCL-SPA distance. The ratios between the radial and ulnar KCL-SPA distance and DWC-TCL distance were calculated and mentioned as radial and ulnar Kaplan cardinal index, respectively. Results KCL-SPA distance was 6.8±3.7 mm along the radial border and 6.6±3.6 mm along the ulnar border of the ring finger. The DWC-TCL distance was 29.4±1.2 mm. The means of radial and ulnar Kaplan cardinal indices were 0.23 and 0.22, respectively. A significant correlation was found between the DWC-TCL distance and the KCL-SPA distances. Conclusion Clinically, KCL can be appraised as a predictable surface landmark in limiting the distal-most extent of the incision during CTR and protecting SPA from transection. The SPA was found to lie at a variable distance from the KCL, and the minimum distance was found to be 3.3 mm. This should be considered as the maximum permissible extension of CTR incision beyond KCL.

Ultrasound-guided percutaneous release procedures in the transverse carpal ligament by acupotomy: A cadaveric study

Objective

This study aimed to determine the safety and accuracy of ultrasound-guided acupotomy percutaneous loosening of the transverse carpal ligament.

Methods

The 100 upper limb specimens were equally divided into the ultrasound-guided acupotomy group (U) and the nonultrasound-guided acupotomy group (N). For the U group, we simulated ultrasound-guided acupotomy loosening of the transverse carpal ligament in a human specimen, and for the N group, we performed the loosening of the transverse carpal ligament through the same approach under nonultrasound-guided conditions. The safety and accuracy of the two methods were compared through measurement.

Results

In the ultrasound-guided group, the injury rate of nerves, blood vessels and tendons caused by needle-knife release was 0%. In the non-ultrasound-guided group, the rate of nerve, blood vessel and tendon damage was 6 percent, 12 percent and 20 percent, respectively. χ ² test (Fisher exact test) was performed for the nerve and blood vessel damage rates in the two groups (P_N  > 0.05, P_A  < 0.05), the difference in nerve damage rates was not statistically significant, but the difference in blood vessel damage rates was statistically significant. Pearson's χ ² test was performed on the tendon injury rates of the two groups (P_F  < 0.05), and the difference was statistically significant. In the ultrasound-guided group, the proportion of acupotomy marks greater than or equal to half of the width of the transverse carpal ligament was 86%, and the non-ultrasound-guided group was 36%. The accuracy of the two surgical methods was tested by Pearson's χ ² test (P_L  < 0.05), and the difference was statistically significant. According to the measurement, the ultrasound-guided acupotomy technology had high safety and accuracy.

Conclusion

In this study, we designed a new method for cutting the transverse carpal ligament under ultrasound guidance, which is different from surgery. These results indicate that this is a safe and accurate method of interventional treatment of carpal tunnel syndrome.

Surgeons' Recommendations for Return to Work After Carpal Tunnel Release

BACKGROUND

Recommendations and expectations regarding return to work (RTW) after carpal tunnel release (CTR) are often inconsistent. The study aim was to describe preferences of American Society for Surgery of the Hand (ASSH) members for perioperative management of patients following CTR, emphasizing surgeon preference regarding RTW.

METHODS

A survey was sent to all ASSH members with active e-mail addresses. The primary outcome was the recommended time frame for patients to RTW full duty. Secondarily, associated factors with RTW were evaluated.

RESULTS

In total, 4109 e-mail surveys were sent with 632 responses (15%). The highest proportion of respondents perform >100 CTRs per year (43.2%), have been practicing for >20 years (38.1%), and perform CTR using standard, open approach at outpatient surgery centers. The primary surgeon made recommendations about RTW in 99.5% of cases. For desk-based duties, the median recommended RTW time was 3 days; for duties requiring repetitive, light lifting of <10 lbs, the median recommended RTW time was 10 days; and for heavy manual duties, the median recommended RTW time was 30 days after CTR, according to the respondents. The 3 factors considered most influential for RTW were type of work, employer support, and financial considerations.

CONCLUSIONS

Our study demonstrates consistency among ASSH members in the perioperative management of CTR patients. The most important factors affecting RTW were type of work performed, employer support, and financial considerations. This study provides a meaningful foundation to manage expectations and guide patients, medical providers, and employers on the amount of time likely to be missed from work after CTR.

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects

PURPOSE

Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor.

METHODS

Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW.

RESULTS

Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW.

CONCLUSIONS

In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Patient-Centred Outcomes Following Open Carpal Tunnel Release: A Systematic Review of the Current Literature

Background: Patients’ individual interpretations of their own health outcomes are becoming increasingly important metrics in defining clinical success across all specialties, especially in hand surgery. However, there is a relative paucity of data using validated health-related quality of life (HR-QoL) assessments for carpal tunnel release (CTR). The purpose of this study was to review published outcomes on traditional open CTR to formally assess the current need for more accurate, validated assessment tools to evaluate CTR-specific HR-QoL.

Methods: PubMed, MEDLINE and Cochrane Library databases were queried according to PRISMA guidelines for all studies investigating patient-reported outcomes following traditional open CTR. Analysis focused on HR-QoL, symptomatic relief, functional status, overall satisfaction and return to work or activities of daily living (ADLs).

Results: In total, 588 unique articles were screened, and 30 studies met selection criteria. HR-QoL was formally assessed in only 3 studies using the validated 36-Item Short Form Survey. Symptomatic relief was measured in 29 (97%) studies, making it the most frequently reported item, whereas functional ability was reported by 19 (63%) studies. The Boston Carpal Tunnel Questionnaire was the most frequently utilised tool to assess symptomatic relief (13/30) and functional improvement (11/30). Using unvalidated custom surveys, 14 studies (47%) reported patient satisfaction and 12 studies (40%) documented time to return to work/ADLs.

Conclusion: There is a dearth of studies utilising HR-QoL assessment tools to evaluate outcomes following traditional open CTR. The creation and validation of new CTR-specific HR-QoL tools accounting for both physical and psychological health is warranted.

Level of Evidence: Level II (Therapeutic)

Preoperative Evaluation of Thenar Muscles in Carpal Tunnel Syndrome by Ultrasonography

This article aims to evaluate the usefulness of ultrasonography for the measurement of thenar muscles in carpal tunnel syndrome (CTS). A total of 85 patients with CTS who had a carpal tunnel release procedure were included in this study. The transducer was applied onto the palmar surface of the hand perpendicularly to the longitudinal axis of the first metacarpal bone. Thenar atrophy was evaluated visually and classified using the visual grading scale. A nerve conduction test was performed and classified according to the electrophysiological severity scale. This technique is more precise than visual evaluation because it is a quantitative assessment.

A Systematic Review of Randomised Control Trials Evaluating the Efficacy and Safety of Open and Endoscopic Carpal Tunnel Release

INTRODUCTION

Carpal tunnel syndrome is the most prevalent form of nerve compression syndrome of the upper limb; therefore, it is of clinical significance to critique treatment methods. There is an ongoing debate amongst clinicians as to which surgical method-open or endoscopic carpal tunnel release-provides better overall symptom relief and faster recovery time. This systematic review aimed to investigate the evidence from randomised control trials to evaluate the effectiveness and safety of open and endoscopic carpal tunnel release surgery.

METHODS

Database searches were carried out to identify literature. An inclusion and exclusion criteria was applied to only include randomised control trials which compared open and endoscopic surgery. Publications were then selected according to PRISMA guidelines, risk of bias was assessed and patient outcome was assessed.

RESULTS

Twenty-three studies were selected for this systematic review. It was found that for improvement to grip strength and symptom severity, the endoscopic group had more significant improvement in the short term, resulting in a quicker return to work time compared to the open group. The complication rate for both intervention groups was low despite more severe and irreversible complications such as prolonged pain and wound infections being observed in the open group; however, the endoscopic group reported a higher risk of needing repeat surgery.

CONCLUSION

The quicker recovery time, improved cosmetic result and less severe complications observed with the endoscopic technique suggest that it should be used more often. However, this review found no convincing evidence of a significantly superior technique in the long term.

Mini-open transverse flexor crease incision versus limited longitudinal palmar incision carpal tunnel release: A short term outcome study

OBJECTIVE

To compare the outcome of carpal tunnel release using the limited longitudinal palmar incision technique and mini open transverse flexor crease incision technique.

MATERIALS AND METHODSL

Between October 2017 and September 2019, we performed Carpal Tunnel release procedures on 122 consecutive patients with unilateral idiopathic CTS. Patients in Group A (64 patients) had a palmar mini open longitudinal incision at wrist. Patients in Group B (58 patients) had a small flexor crease transverse incision. In the non palmar transverse incision group, we used a blunt ended facelift scissors to cut the flexor retinaculum after placing a dural retractor between the retinaculum and median nerve. The preoperative and postoperative (2 weeks,6 weeks,3 months, 6 months and 1 year) patient statuses were evaluated with the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) scores, VAS, grip strength and return to work days.

RESULTS

The BCTSQ symptom severity scale and functional status scale showed significant improvement following surgery in Group B compared to Group A at 2 weeks,6 weeks and 3 months (p < 0.05). At 6 months and 1 year follow up, both the symptom severity and functional status scale were comparable in both the groups. Grip strength, pillar pain and scar tenderness showed significant improvement in transverse flexor incision group compared to longitudinal palmar incision group at 6 weeks and 3 months and were comparable later on.

CONCLUSION

We conclude that the mini open transverse flexor crease incision technique using the conventional instruments is simple, safe and cost-effective mode of treatment of idiopathic CTS when compared to the limited palmar incision technique. Though the long term outcomes are comparable in both groups, the flexor crease transverse incision group patients had better pain relief, better cosmesis and shorter recovery period than the palmar incision group.

Optimizing Costs and Outcomes for Carpal Tunnel Release Surgery: A Cost-Effectiveness Analysis from Societal and Health-Care System Perspectives

BACKGROUND

It is unclear which carpal tunnel release (CTR) strategy (i.e., which combination of surgical technique and setting) is most cost-effective. A cost-effectiveness analysis was performed to compare (1) open CTR in the procedure room (OCTR/PR), (2) OCTR in the operating room (OCTR/OR), and (3) endoscopic CTR in the operating room (ECTR/OR).

METHODS

A decision analytic model was used to compare costs and health utilities between treatment strategies. Utility and probability parameters were identified from the literature. Medical costs were estimated with Medicare ambulatory surgical payment data. Indirect costs were related to days out of work due to surgical recovery and complications. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses and one-way sensitivity analyses were performed. Cost-effectiveness was assessed from the societal and health-care system perspectives with use of a willingness-to-pay threshold of $100,000/QALY.

RESULTS

In the base-case analysis, OCTR/PR was more cost-effective than OCTR/OR and ECTR/OR from the societal perspective. The mean total costs and QALYs per patient were $29,738 ± $4,098 and 0.88 ± 0.08 for OCTR/PR, $30,002 ± $4,098 and 0.88 ± 0.08 for OCTR/OR, and $41,311 ± $4,833 and 0.87 ± 0.08 for ECTR/OR. OCTR/PR was also the most cost-effective strategy from the health-care system perspective. These findings were robust in the probabilistic sensitivity analyses: OCTR/PR was the dominant strategy (greater QALYs at a lower cost) in 55% and 61% of iterations from societal and health-care system perspectives, respectively. One-way sensitivity analysis demonstrated that OCTR/PR and OCTR/OR remained more cost-effective than ECTR/OR from a societal perspective under the following conditions: $0 surgical cost of ECTR, 0% revision rate following ECTR, equalization of the return-to-work rate between OCTR and ECTR, or 0 days out of work following ECTR. OCTR/OR became more cost-effective than OCTR/PR with the median nerve injury rate tripling and doubling from societal and health-care system perspectives, respectively, or if surgical direct costs in the PR exceeded those in the OR.

CONCLUSIONS

Compared with OCTR/OR and ECTR/OR, OCTR/PR minimizes costs to the health-care system and society while providing favorable outcomes.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

Patient Willingness to Pay for Faster Return to Work or Smaller Incisions

Background: Value-based health care models such as bundled payments and accountable care organizations can penalize health systems and physicians for excess costs leading to low-value care. Health systems can minimize these extra costs by constraining diagnostic (eg, magnetic resonance imaging utilization) or treatment options with debatable necessity in the setting of clinical equipoise. Instead of restricting more expensive treatments, it is plausible that health systems could instead recoup the extra costs of these treatments by charging patients supplementary out-of-pocket charges (cost sharing). The primary aim of this exploratory study was to assess hand surgery patient willingness to pay supplementary out-of-pocket charges for a procedure that theoretically leads to an earlier return to work or smaller incisions when there are 2 procedures that lead to similar results (clinical equipoise). Methods: A total of 122 patients completed a questionnaire that included demographic information, a financial distress assessment, a series of scenarios asking patients the degree to which they are willing to pay extra for the procedure choice, as well as their perspective of how much insurers should be responsible for these additional costs. Results: Patients were willing to pay out-of-pocket to some degree for a procedure that leads to earlier return to work and smaller incision size when compared with a similar alternative procedure, but noted that insurers should bear a greater burden of costs. Approximately 10% of patients were willing to pay maximum amounts ($2500+) for earlier return to work (3, 7, and 14 days earlier) and smaller incision sizes of any length. Conclusions: Some patients may be willing to pay out-of-pocket and cost share for procedures that lead to earlier return to work and smaller incisions in the setting of clinical equipoise. As such, when developing and implementing alternative payment models, health systems could potentially offer services with debatable necessity in the setting of equipoise for a supplementary out-of-pocket charge.

Early Outcomes of Endoscopic Versus Open Carpal Tunnel Release

PURPOSE

To compare the short-term outcomes of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR), including patient-reported outcomes, pain and satisfaction scores, return to work, and postoperative prescription pain medication use.

METHODS

We included all patients over 18 years of age undergoing carpal tunnel release at a single hand center between January 2018 and December 2019. The carpal tunnel release method was driven by variations in surgeon practice. Data from patient-reported outcomes measurement information system (PROMIS) questionnaires and brief Michigan hand outcomes questionnaires and data on patient-reported pain levels, satisfaction with care, return to work, and postoperative prescription pain medication use were collected at preoperative visits and the first follow-up visit between postoperative days 7 and 14.

RESULTS

We included 678 (586 ECTR and 92 OCTR) patients. The median age was 58 years, and 75% of the patients were women. At early follow up, patients who underwent OCTR reported significantly lower postoperative PROMIS upper-extremity scores than those who underwent ECTR (median, 32 vs 36 points, respectively) but similar postoperative PROMIS pain interference, global physical health, global mental health, and brief Michigan hand outcomes questionnaire scores. The postoperative pain and satisfaction scores were similar between the 2 groups. In multivariable models, patients who underwent OCTR had 62% lower odds of returning to work and 30% greater odds of remaining on a postoperative pain prescription at the first follow-up visit.

CONCLUSIONS

This study found no evidence suggesting the definitive superiority of 1 surgical technique with regard to clinical outcomes in the early postoperative period. However, OCTR was associated with lower postoperative PROMIS upper-extremity scores of unclear clinical significance, higher odds of remaining on pain medication, and lower odds of returning to work by the first postoperative visit. Endoscopic carpal tunnel release may be preferred in patients who need to return to work within the first 2 weeks after the procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Minimally Invasive Ultrasound-Guided Carpal Tunnel Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome

BACKGROUND. Ultrasound guidance allows performance of carpal tunnel release with smaller incisions and quicker recovery than traditional open or endoscopic surgery. OBJECTIVE. The purpose of this study was to evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. METHODS. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed on 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. The procedures were performed with a single-use transection device and local anesthesia at an outpatient radiology office. Patients answered three questionnaires (Quick Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire-the symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) to assess the function of and discomfort in the affected wrist immediately before and 2 weeks and at least 1 year after the procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Preprocedure and postprocedure scores were compared by paired Wilcoxon signed rank tests. RESULTS. The 46 patients (25 women, 21 men; mean age, 60.6 years; range, 21-80 years) had median preprocedure scores of 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. The median scores 2 weeks after the procedure were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. All scores decreased (p < .001) from preprocedure scores and surpassed reference standards for clinically important difference in scores. Follow-up questionnaires obtained for 90% (55/61) of wrists a median of 1.7 years (range, 1.0-2.8 years) after the procedure showed further declines (p < .001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up evaluation, 96% (52/54) of wrists had lower QDASH and 98% (53/54) had lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS) scores compared with the preprocedure scores. Among the patients who participated in the survey, 93% (37/40) were satisfied or very satisfied with the long-term outcomes. No immediately postoperative complications occurred. Two patients needed surgical intervention 8 and 10 days after surgery, one for infection after injury and one for posttraumatic compartment syndrome. CONCLUSION. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persists beyond 1 year. CLINICAL IMPACT. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.

Five Wrist Operations That Give the Best Results

LEARNING OBJECTIVES

After reading this article and viewing the videos, the participant should be able to: 1. Recognize the following five wrist operations as consistent options for different wrist injuries: carpal tunnel release, medial femoral condyle bone flap for scaphoid nonunion associated with carpal collapse and avascular necrosis, scaphocapitate arthrodesis for Kienböck disease, percutaneous screw fixation of nondisplaced scaphoid fracture, and four-corner arthrodesis. 2. Know the state-of-the-art of these five procedures. 3. State the indications of each operation. 4. List the surgical steps of these five procedures.

SUMMARY

The wrist is a complex joint that concentrates different types of tissues (e.g., bone, cartilage, ligaments, nerves, vessels) and a broad different spectrum of diseases. Treatment of wrist injuries has improved during recent years, mainly because of improvement in strategy, techniques, microsurgical equipment, understanding anatomy and improvements in technology. In this article, we present the five operations (i.e., carpal tunnel release, medial femoral condyle bone flap for scaphoid nonunion associated with carpal collapse and avascular necrosis, scaphocapitate arthrodesis for Kienböck disease, percutaneous screw fixation of nondisplaced scaphoid fracture, and four-corner arthrodesis) that have consistently given good outcomes in patients suffering from different wrist injuries/maladies.

Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release

BACKGROUND

Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR.

METHODS

We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs).

RESULTS

ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations.

CONCLUSIONS

From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Carpal Tunnel Release Surgery- A Systematic Review of Open and Endoscopic Approaches

CONTEXT

Carpal tunnel syndrome (CTS) is the most frequent peripheral compression-induced neuropathy observed in patients worldwide. Surgery is necessary when conservative treatments fail and severe symptoms persist. Traditional Open carpal tunnel release (OCTR) with visualization of carpal tunnel is considered the gold standard for decompression. However, Endoscopic carpal tunnel release (ECTR), a less invasive technique than OCTR is emerging as a standard of care in recent years.

EVIDENCE ACQUISITION

Criteria for this systematic review were derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two review authors searched PubMed, MEDLINE, and the Cochrane Database in May 2018 using the following MeSH terms from 1993-2016: 'carpal tunnel syndrome,' 'median nerve neuropathy,' 'endoscopic carpal tunnel release,' 'endoscopic surgery,' 'open carpal tunnel release,' 'open surgery,' and 'carpal tunnel surgery.' Additional sources, including Google Scholar, were added. Also, based on bibliographies and consultation with experts, appropriate publications were identified. The primary outcome measure was pain relief.

RESULTS

For this analysis, 27 studies met inclusion criteria. Results indicate that ECTR produced superior post-operative pain outcomes during short-term follow-up. Of the studies meeting inclusion criteria for this analysis, 17 studies evaluated pain as a primary or secondary outcome, and 15 studies evaluated pain, pillar tenderness, or incision tenderness at short-term follow-up. Most studies employed a VAS for assessment, and the majority reported superior short-term pain outcomes following ECTR at intervals ranging from one hour up to 12 weeks. Several additional studies reported equivalent pain outcomes at short-term follow-up as early as one week. No study reported inferior short-term pain outcomes following ECTR.

CONCLUSIONS

ECTR and OCTR produce satisfactory results in pain relief, symptom resolution, patient satisfaction, time to return to work, and adverse events. There is a growing body of evidence favoring the endoscopic technique for pain relief, functional outcomes, and satisfaction, at least in the early post-operative period, even if this difference disappears over time. Several studies have demonstrated a quicker return to work and activities of daily living with the endoscopic technique.

Pre-operative Two-Point Discrimination Predicts Response to Carpal Tunnel Release

BACKGROUND

Limited evidence informs whether pre-operative values of two-point discrimination (2PD) in patients with carpal tunnel syndrome predict response to surgery.

QUESTIONS/PURPOSES

The primary aim of this study was to determine the predictive value of pre-operative 2PD scores on outcomes following carpal tunnel release (CTR). In particular, we sought to evaluate whether a clinically relevant 2PD threshold exists that can predict symptomatic response after surgery.

METHODS

Patients who underwent CTR between 2014 and 2018 were retrospectively reviewed. Static 2PD scores in each digit, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Levine-Katz scores, were collected from pre- and post-operative records. Pearson correlation coefficients assessed the relationship between pre-operative 2PD, early post-operative 2PD, and patient-reported outcome scores. Poor 2PD was defined as 2PD greater than 10 mm.

RESULTS

Eighty-nine hands in 73 patients with a mean follow-up of 1.8 years were analyzed. Mean pre- and post-operative 2PD was 7.2 mm and 6.4 mm, respectively, in the most affected digit when measurable. Twenty patients had poor 2PD scores pre-operatively and 14 post-operatively. There was a positive correlation between pre- and early post-operative 2PD scores but no correlation between pre-operative 2PD score and final post-operative functional scores. Only 30% of patients with poor pre-operative 2PD scores demonstrated improvement, compared with 69% of patients with measurable 2PD.

CONCLUSION

We found that greater pre-operative 2PD scores predicted greater early post-operative 2PD scores but did not lead to worse functional outcome scores post-operatively. Patients with poor pre-operative 2PD scores were likely to demonstrate improvement in functional outcomes scores, while having less reliable improvement in 2PD after CTR. Patients with poor 2PD should be counseled that improvement of tactile perception is less predictable.

Endoscopic Carpal Tunnel Release: One-Portal Technique

With the 1-portal technique for endoscopic carpal tunnel release, the incision is less tender and patients have less postoperative need for analgesics, and return to activities of daily living and work seems to be earlier. The literature also confirms an earlier return to work. Surgical time can be shorter as less time is spent in making and closing the incision.

Description

The 1-portal technique, as described by Agee et al., is performed with the patient under general anesthesia, supplemented with only a small amount of local anesthesia in the beginning to blunt the pain response during the incision. Then, once the patient is fully anesthetized, the endoscope is inserted, and the carpal ligament is visualized and incised. The incision is closed and the dressing is applied.

Alternatives

Another surgical alternative is open carpal tunnel release. Nonsurgical alternatives include corticosteroid injection, splinting, nonsteroidal anti-inflammatory drugs, and ergonomics.

Rationale

The incision is smaller and less painful than the incision utilized during open carpal tunnel release. There is less need for analgesia. Unlike the incision utilized during open carpal tunnel release, the incision in this procedure is not made in a weight-bearing surface of the hand and generally is not firm and tender. Studies also show an earlier return to work with this technique. The endoscopic technique is only for a primary release. Surgical intervention for recurrent carpal tunnel syndrome needs to be performed with the open technique. Because of the need for deep sedation, only patients who are healthy enough for general sedation are candidates for the 1-portal technique. The risk of nerve injury with this technique is higher than with open carpal tunnel release.

Expected Outcomes

Generally, the patient will have very rapid resolution of the preoperative paresthesia. The incision typically heals very well; however, when closing the 1.5-cm incision with skin glue and Steri-Strips (3M), there may be cases of delayed wound-healing if the patient is overly physically active in the first 2 weeks after the procedure.

Important Tips

Make sure that the endoscope is properly set up and that the patient is supine and the arm is abducted 90° at the shoulder with the hand and forearm fully supinated. Seating of the surgeon and assistant(s) and placement of the monitor are important.Make sure that the patient is fully anesthetized, particularly when the endoscope is being used. If the patient moves during the endoscopic incision of the ligament, other structures (i.e., vessels, nerves, and tendons) could be injured.Difficulty with the insertion of the scope can result in injuries. The carpal ligament must be visualized with the scope prior to any attempts at cutting the ligament. Convert to an open procedure if there are any difficulties with endoscope insertion or visualizing the carpal ligament.

Open versus endoscopic carpal tunnel release: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) both have advantages and disadvantages for the treatment of carpal tunnel syndrome (CTS). We compared the effectiveness and safety of ECTR and OCTR based on evidence from a high-level randomized controlled trial.

METHODS

We comprehensively searched PubMed, EMBASE, Cochrane Library, Web of Science, and Medline to identify relevant articles published until August 2019. Data regarding operative time, grip strength, Boston Carpal Tunnel Questionnaire scores, digital sensation, patient satisfaction, key pinch strength, return to work time, and complications were extracted and compared. All mean differences (MD) and odds ratios (OR) were expressed as ECTR relative to OCTR.

RESULTS

Our meta-analysis contained twenty-eight studies. ECTR was associated with significantly higher satisfaction rates (MD, 3.13; 95% confidence interval [CI], 1.43 to 4.82; P = 0.0003), greater key pinch strengths (MD, 0.79 kg; 95% CI, 0.27 to 1.32; P = 0.003), earlier return to work times (MD, - 7.25 days; 95% CI, - 14.31 to - 0.19; P = 0.04), higher transient nerve injury rates (OR, 4.87; 95% CI, 1.37 to 17.25; P = 0.01), and a lower incidence of scar-related complications (OR, 0.20; 95% CI, 0.07 to 0.59; P = 0.004). The permanent nerve injury showed no significant differences between the two methods (OR, 1.93; 95% CI, 0.58 to 6.40; P = 0.28).

CONCLUSIONS

Overall, evidence from randomized controlled trials indicates that ECTR results in better recovery of daily life functions compared to OCTR, as revealed by higher satisfaction rates, greater key pinch strengths, earlier return to work times, and fewer scar-related complications. Our findings suggest that patients with CTS can be effectively managed with ECTR.

The relationship of mental health status to functional outcome and satisfaction after carpal tunnel release

We studied whether mental health status is significantly correlated to patient reported functional outcomes and satisfaction after carpal tunnel release. Over a 7-year period, 809 patients completed Short Form-12 (SF-12) questionnaires which allowed calculation of the SF-12 mental component summary 1 year postoperatively, 780 (96%) completed a satisfaction questionnaire and 777 (96%) completed a QuickDisabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Median QuickDASH score was 55 preoperatively (interquartile range [IQR] 28) and 14 postoperatively (IQR 32). A total of 674 patients were satisfied. Patients with mental disability had worse QuickDASH scores (median 34, IQR 41) and a higher incidence of dissatisfaction (52/245, 21%) than those without mental disability (n = 9, IQR 20, 10%, both p < 0.001). Regression analyses indicated scores in the SF-12 mental component summary were significantly related to postoperative QuickDASH score (p < 0.001) and satisfaction (p = 0.02). We concluded that patients with mental disability report poorer outcomes and lower satisfaction rates; however, the majority still exhibit significant improvements and are satisfied. Level of evidence: II.

Carpal tunnel surgery: predictors of clinical outcomes and patients' satisfaction

Background

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. Moreover, carpal tunnel release (CTR) surgery generally has excellent results. The present study aimed to investigate the predictors of clinical outcomes and satisfaction in patients with CTR.

Methods

In this observational prospective cohort study, 152 patients with open carpal tunnel release surgery were investigated. Complete clinical examinations were performed and recorded before the surgery, two weeks after the surgery and 6 months after the surgery. The Boston Carpal Tunnel Questionnaire (BCTQ) were assessed on admission and at last follow-up visits to evaluate clinical outcomes. Patients’ satisfaction was determined by a 10-point verbal descriptor nominal scale (1 = very poor, 5 = fair and 10 = excellent) and recorded during the last follow -up visits.

Results

Among 152 patients who were investigated, there were 118 (77.6%) females and 34 (22.36%) males. Overall, surgery improved the outcomes based on Symptom Severity Scale (SSS) and Functional Status Scale (FSS) (P < 0.05). Most of the considered variables did not show significant effects on clinical outcomes and patients’ satisfaction. However, duration of symptoms and electrophysiological severity were the predictors of the change score in SSS(P < 0.05). As well as, age was the only predictor of the change score in FSS (P < 0.05). Finally, according to the linear regression model, the pre-operative grip strength and age were the independent predictors of post-operative satisfaction (P < 0.05).

Conclusions

Results of the present study revealed that there was a significant improvement in clinical outcomes after CTS surgery. Stronger pre-operative grip strength and younger age were independent predictors of higher post-operative satisfaction. These results can be used in pre-operative counseling and management of post-operative expectations.

Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study

Background

Carpal tunnel syndrome is a common upper-limb nerve compression disease. Carpal tunnel syndrome can lead to several symptoms such as tingling or numbness, pain in the hand or wrist, and reduced grip strength. Based on demographic characteristics, patient reported outcome measures, and with special attention to pain catastrophizing, the purpose of this study was to identify risk factors for low patient-reported satisfaction following surgical treatment of idiopathic carpal tunnel syndrome.

Methods

A total of 417 hands from 417 patients (64. 5% females) with a mean age of 58. 0 years were included in this 1-year prospective follow-up study. We collected preoperative data on disability using the Disability of the Arm, Shoulder and Hand questionnaire (DASH), quality of life using the EuroQol-5D (EQ-5D), pain catastrophizing using the Pain Catastrophizing Scale (PCS) and distal motor latency. Data on DASH score, EQ-5D, and patient satisfaction was collected 12 months postoperatively. Wilcoxon matched-pairs signed-rank test was used to test for difference in preoperative and postoperative DASH and EQ-5D score. Risk factors for low postoperative patient reported satisfaction was examined using stepwise multiple logistic regression analysis.

Results

We found a general improvement in patients’ DASH scores (12.29 [95% CI: 10.65–13.90], p < 0.001) and EQ-5D (0.14 [95% CI: 0.13–0.16], p < 0.001) from preoperative to 12 months postoperative. In the fully adjusted multiple regression analysis we found a statistically significant effect of preoperative PCS on patient reported satisfaction with OR = 1.05 (p = 0.022), for a one unit increase in preoperative PCS. There was no statistically significant predictive effect of preoperative EQ-5D (p = 0.869), DASH (p = 0.076), distal motor latency (p = 0.067), age (p = 0.505) or gender (p = 0.222).

Conclusions

Patients improved in both DASH and EQ-5D from preoperative to 12 months postoperative. Higher preoperative PCS seems to have a negative effect on postoperative patient reported satisfaction after carpal tunnel release.

'INSIGHT-PRECISION': a new, mini-invasive technique for the surgical treatment of carpal tunnel syndrome

Objective

To describe a new mini-invasive surgical technique for carpal tunnel release and to present clinical findings associated with using this technique.

Methods

Patients with idiopathic carpal tunnel syndrome without prior surgical treatment, who underwent a new minimally-invasive surgical technique using a specific surgical tool-kit developed by the author, were included. Prospective data were collected, including preoperative electrodiagnostic testing. The subjective condition of all patients was evaluated pre- and postoperatively with a five-level Likert-type scale (LS) and muscular strength was tested using a JAMAR dynamometer and pinch gauge.

Results

A total of 116 patients (157 hands/cases) underwent surgery performed by the author, and were followed for a mean of 40 months (range, 6 months–7 years). Of these, preoperative electrodiagnostic testing was performed in 112 patients (96.6%). No significant complications were reported. By three months, patients reported that they were satisfied or very satisfied in 147/149 cases (98.7%; LS grade I and II). Strength recovery at three months, based on the average of four measures, was 99.17% (range, 97.43–100.97%).

Conclusions

The described technique is minimally invasive, safe and simple to perform, and provides good results.

Minimally invasive modified Camitz opponensplasty for severe carpal tunnel syndrome

PURPOSE

We aimed to compare the clinical results and the complications between the minimally invasive modified Camitz opponensplasty and the conventional Camitz opponensplasty for severe carpal tunnel syndrome (CTS), and to evaluate the efficacy of the modified technique for CTS.

METHODS

Twenty-eight hands in 24 patients with severe CTS who had disorder of the thumb opposition with thenar muscle atrophy (group 1) were treated by minimally invasive modified Camitz opponensplasty, passing the transferred palmaris longus (PL) tendon under the abductor pollicis brevis (APB) fascia using only palm and thumb incision, and no incision to either wrist crease or forearm. Ten hands in 10 patients (group 2) were treated by the conventional Camitz opponensplasty. Clinical evaluation was made by comparing the results before and after surgery for the angle of the thumb palmar abduction, pinch power, and grip strength.

RESULTS

All clinical findings significantly improved after surgery compared with before surgery in all patients. In group 1, there were no complications including transferred tendon bowstring, painful wrist scar, or injury to the palmar cutaneous branch of the median nerve in all hands. Conversely, patients in group 2 had four painful wrist scars and nine bowstrings of the transferred tendon.

CONCLUSIONS

Several complications have been considered to attribute to the long incision and an extensive dissection crossing the wrist crease from the palm to the wrist in the conventional Camitz procedure. The current modified Camitz opponensplasty by minimally invasive incision without straddling the wrist crease is a simple and effective procedure that can decrease the risk of painful scar around the wrist crease in severe CTS patients with disorder of thumb opposition. Additionally, this technique, by passing the transferred PL tendon under the APB fascia, is useful in restoring the thumb opposition immediately, and in preventing the bowstringing of the transferred tendon.

Resultado clínico y electrodiagnóstico en pacientes con liberación quirúrgica del síndrome del túnel del carpo

Introducción. La cirugía de síndrome del túnel del carpo (STC) es efectiva, aunque algunos reportes muestran satisfacción de solo el 75% luego de los procedimientos. La escala funcional HiOb es la que mejor se correlaciona con el estado neurofisiológico del nervio mediano.Objetivo. Determinar los resultados clínicos, funcionales y electrofisiológicos luego de una liberación quirúrgica en pacientes con STC.Materiales y métodos. Estudio analítico y descriptivo de pacientes con STC operados entre 2013 y 2014. Todos los individuos tenían pruebas clínicas y electrofisiológicas pre y post quirúrgicas.Resultados. Se estudiaron 36 pacientes con edad promedio de 49 años; los signos clínicos prequirúrgicos más frecuentes fueron Phalen y elevación de manos (91%). El seguimiento mínimo fue 6 meses. Hubo mejoría del dolor; de los signos de Tinel, de Phalen y de elevación de manos; en la escala HiOb, y en el Cuestionario de Boston, tanto en la función como en los síntomas. Los resultados electrofisiológicos mostraron mejoría en latencia distal motora del nervio mediano, latencia distal sensitiva del nervio mediano y delta sensitivo.Conclusiones. La liberación quirúrgica del STC es un procedimiento eficaz en la mejoría del dolor, los síntomas, las escalas funcionales y los hallazgos electrofisiológicos. El signo de Tinel prequirúrgico se asocia a peores resultados en el cuestionario de Boston.

Upper extremity disability is associated with pain intensity and grip strength in women with bilateral idiopathic carpal tunnel syndrome

BACKGROUND

The upper extremity disability in patients with carpal tunnel syndrome (CTS) is related to dysfunction due to the median nerve damage. However, there is no report on which dysfunctions affect the upper extremity disability.

PURPOSE

This study aimed to investigate which clinical factors influence upper extremity disability in women with CTS.

METHODS

We analyzed 60 hands of women with bilateral idiopathic CTS. Upper extremity disability was assessed using Hand10, a validated and self-administered tool. Pain intensity was measured using the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-J). We performed nerve conduction studies, assessed physical and psychological parameters, and collected demographic data. Physical parameters comprised grip strength, pinch strength, tactile threshold, static 2-point discrimination sensation, and severity of numbness. Psychological parameters include depression, pain anxiety, and distress.

RESULTS

The bivariate analysis revealed that Hand10 was significantly correlated with age, symptom duration, SF-MPQ-J, grip strength, pain anxiety, and distress. Multiple regression analysis demonstrated that SF-MPQ-J and grip strength were related to Hand10 score.

CONCLUSIONS

Pain intensity and grip strength were dysfunctions affecting the upper extremity disability in women with bilateral idiopathic CTS. Rehabilitation approaches for CTS should be considered based on the adaptive activities of the neural networks.

Endoscopic carpal tunnel release surgery: a case study in Vietnam

Background

This study aims at investigating the outcome and electrophysiologic recovery of 150 carpal tunnel syndrome hands after single-portal endoscopic surgery.

Methods

Patients with the cross-sectional area of the median nerve being 13–15 mm² on ultrasound or abnormal sensory nerve conduction velocity on EMG are assigned to endoscopic surgery that cuts the decompressing transverse ligament to avoid the emergence of severe symptoms, such as muscular atrophy and loss of hand function.

Results

Single-portal endoscopic release is a safe and efficacious option for carpal tunnel release. The findings demonstrate encouraging results.

Conclusion

The endoscopic carpal tunnel release with the placement of a MicroAire system is a safe and effective method for treating carpal tunnel syndrome.

Sonographic morphometry of abductor pollicis brevis: can direct contact yield images comparable with those obtained by the water bath technique?

PURPOSE

This study sought to compare ultrasound-guided measurements of the abductor pollicis brevis (APB) using the water bath technique (WBT) and the direct contact method (DM) and investigate whether the DM can reproduce the measurements that would be obtained with a non-contact method, such as the WBT.

METHODS

The APB muscles of 80 hands (40 healthy adults) were measured. The WBT was performed in a plastic container filled with water. The probe was placed adjacent to the skin surface without contact. In the DM, sonographic images were obtained with the probe and skin separated by sufficient transmission gel. The muscle thickness and cross-sectional area (CSA) were calculated with both methods. All subjects were examined three times by two examiners to estimate the inter- and intra-observer reliability. Bland-Altman analysis was performed to examine the agreement between the methods.

RESULTS

No significant differences in the thickness or CSA of the APB were found. The interclass correlation coefficients for the WBT and DM showed almost perfect intra- and inter-observer reliability (range 0.87-0.94). There was no systematic bias between the techniques in the Bland-Altman analysis.

CONCLUSION

Similar to the WBT, the DM provides measurements of the APB thickness and CSA without causing morphometric changes.

Imaging of Microhemodynamics in Peripheral Nerves by Contact Endoscope

BACKGROUND

Entrapment neuropathies include a wide field of locations. In most cases, the microsurgical decompression is still the therapy of choice. However, the role of venous stasis and ischemia is still discussed controversially. Here the authors evaluated the visualization of microvessels and the microperfusion at peripheral nerves with a contact endoscope during the surgical decompression for the first time.

METHODS

Eight patients were subjected to endoscopic or endoscopically assisted peripheral nerve decompression. In 3 patients with nerve tumors, the tumor carrying nerve was inspected endoscopically proximal and distal to the tumor site before and after resection. Microcirculation was assessed by a contact endoscope, allowing a 150-fold magnification, at superficial areas proximal and distal to the compression site. The electronically stored records were analyzed retrospectively using image processing software. Vessel diameter, red blood cell velocity, and blood flow, before and after decompression, were extracted.

RESULTS

The contact endoscope was easy to handle intraoperatively without problems. All minimally invasive procedures were performed without complications. In the offline computer-assisted analysis, single arterioles and veins were visualized showing decreased red blood cell velocity prior to decompression. After surgical treatment, a statistically significant increase of blood flow was observed.

CONCLUSIONS

Basically, the application of a contact endoscope for visualization of peripheral nerves' microcirculation is feasible. The observed effect of increased blood flow after decompression should be compared with the clinical outcome in a further prospective randomized study.

Predicting Clinical Outcome After Surgical Treatment in Patients With Carpal Tunnel Syndrome

PURPOSE

Carpal tunnel release (CTR) is typically offered to symptomatic patients with electrophysiological abnormalities when night orthoses no longer prevent waking with numbness and preferably before there is any static numbness, weakness, or atrophy. The ability to predict the amount of symptom relief after CTR could be beneficial for managing patient expectations and, therefore, improve treatment satisfaction. Therefore, the aim of this study was to identify predictors for symptom relief after CTR and to determine their contribution to symptom relief at 6 months after surgery.

METHODS

A total of 1,049 patients who underwent CTR between 2011 and 2015 at 1 of 11 Xpert Clinics in the Netherlands were asked to complete online questionnaires at intake and 3 and 6 months after surgery. Patient demographics, comorbidities, and baseline scores were considered potential predictors for the amount of symptom relief on the Boston Carpal Tunnel Questionnaire (BCTQ) score, which was the primary outcome measure.

RESULTS

A low score on the BCTQ at intake, a codiagnosis of a trigger finger, ulnar nerve neuropathy, trapeziometacarpal joint arthrosis, and instability or arthrosis of the wrist were associated with a smaller improvement in the BCTQ domains after a CTR at 6 months after surgery and accounted for 35% to 42% of the variance on the BCTQ domains in our multivariable regression models.

CONCLUSIONS

In this study, we showed that clinical severity of carpal tunnel syndrome at intake is the most important factor in estimating symptom relief after surgical treatment. Furthermore, this study contributes to a more precise understanding of the capabilities of CTR in relieving symptoms for different subgroups of patients. Results of our study can be used to manage patient expectation on symptom relief from CTR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Hand Surgeons Performing More Open Carpal Tunnel Releases Do Not Show Better Patient Outcomes

BACKGROUND

Although previous studies have shown that more experienced surgeons have better patient outcomes following a variety of procedures, in hand surgery and carpal tunnel release in particular, this relation remains unproven. The authors assessed whether there is an association between surgeon volume and patient outcomes following open carpal tunnel release.

METHODS

Patients who underwent carpal tunnel release between 2011 and 2015 at outpatient hand surgery clinics in The Netherlands were included. Surgeon annual volume was defined as the average number of carpal tunnel releases performed per year per participating surgeon over the study period. Primary outcome measures were the Symptom Severity Scale and Functional Status Scale of the Boston Carpal Tunnel Questionnaire 6 months postoperatively. Multilevel random intercept linear regression analyses were performed to assess whether there was an association between surgeon annual volume and outcome measures, with adjustment for patient characteristics, concomitant procedures, and intake score on the Boston Carpal Tunnel Questionnaire.

RESULTS

A total of 1345 patients were included, operated on by 17 surgeons. Median annual surgeon volume was 75 (interquartile range, 50 to 149). Only 0.5 to 0.6 percent of the total variance in patient outcome on the Boston Carpal Tunnel Questionnaire could be explained by random differences between surgeons. The authors did not find an association between annual surgeon volume and outcome measures 6 months postoperatively (Symptom Severity Scale: β = 0.000; 95 percent CI, -0.001 to 0.001; and Functional Status Scale: β = 0.000; 95 percent CI, -0.001 to 0.001).

CONCLUSION

In the authors' sample of highly specialized hand surgeons operating in high-volume centers, they found no differences in outcome between high- and low-volume surgeons.

Preoperative predictors of patient satisfaction after carpal tunnel release

BACKGROUND

We investigated preoperative factors among demographic and clinical characteristics, as well as psychological factors that influence postoperative patient satisfaction, with the goal of assisting preoperative patient consultation for CTR.

MATERIALS AND METHODS

We included 92 hands from 60 patients diagnosed with idiopathic carpal tunnel syndrome. We selected the following factors as possible preoperative predictors for patient satisfaction: age, sex, duration of symptoms, static two-point discrimination, the Semmes-Weinstein monofilament test, grip strength, electrophysiological category and scores for the Boston Carpal Tunnel Questionnaire, the Pain Anxiety Symptoms scale and the Center for the Epidemiological Study of Depression scale. We used a cumulative logit model with generalized estimation equations to identify the predictors of patient satisfaction after CTR.

RESULTS

Univariate analyses demonstrated significant correlations of patient satisfaction with age, preoperative grip power and preoperative CES-D. Multivariate analyses showed that age and preoperative CES-D scores were significantly correlated with patient satisfaction.

CONCLUSION

Age and depression level were preoperative predictors influencing satisfaction after CTR.

LEVELS OF EVIDENCE

IV.