Comparison of Knifelight Surgery versus Conventional Open Surgery in the Treatment of Carpal Tunnel Syndrome

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.

Short incision versus minimally invasive surgery with tool-kit for carpal tunnel syndrome release: a prospective randomized control trial to evaluate the anterior wrist pain and time to return to work or activities

Trial design

The prospective randomized controlled trial.

Background

This study compares outcomes in terms of early postoperative anterior wrist pain and time to return to work or activities of daily living of patients who underwent carpal tunnel syndrome (CTS) release with short incision and those who had minimally invasive surgery (MIS) with CTS kits.

Methods

A total of 24 patients diagnosed with primary CTS confirmed with electrodiagnosis at an academic university hospital were randomly assigned into one of two groups of 12 patients each: a short incision group and an MIS with tool-kit group using computer-generated block randomization (block of four). Sequentially numbered, opaque, sealed envelopes were used in the allocation concealment process. In the short incision group, skin was incised longitudinally from Kaplan’s line to the area distal to transverse wrist crease (2.5–4.0 cm) while in the tool-kit group, an incision of less than 2.5 cm. was made using special MIS-CTS kits. Primary outcomes evaluated include visual analogue scale (VAS) measurement of pain intensity in the anterior carpal area both while at rest and while conducting daily activities at the 2nd week postoperatively as well as the time to return to activities of daily living and work. Improvement in the Michigan hand questionnaire (MHQ) score, a secondary outcome, was also measured at the 2nd week postoperatively. Patients, allocator and outcome assessor were blinded.

Results

Demographic data, including preoperative electrodiagnostic severity and occupation, were similar in the two groups. There were no significant differences in terms of VAS of the early postoperative anterior carpal area at rest (p > 0.99), while conducting daily activities (p = 0.89) and time to return to activities of daily living (p = 0.46) and work (p = 0.24). The MHQ score improvement at the 2nd week postoperatively showed no significant difference between the groups (p = 0.95). The MIS wound length in the tool-kit group was significantly shorter than in the short incision group (1.95 vs 2.92 cm, p < 0.01).

Conclusions

There is no difference in early postoperative anterior wrist pain, time to return to work or to activities of daily living between the surgical techniques. Short incision is recommended for benefit in term of cost-effectiveness, while MIS with tool-kit could be preferred in patients who concerned in cosmetic appearance between the surgical techniques.

Trial registration

www.clinicaltrials.in.th (TCTR20200530003). Registered 30 May 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05663-5.

Effectiveness and safety of surgical treatment of carpal tunnel syndrome via a mini-transverse incision and a bush hook versus a mid-palmar small longitudinal incision

Background

Minimally invasive surgery for carpal tunnel syndrome has been consistently the mainstay of treatment. In this study, we developed a novel bush hook via a mini-transverse incision at proximal wrist crease to surgically treat carpal tunnel syndrome and our aim was to compare the results with those of mid-palmar small longitudinal incision in carpal tunnel release.

Methods

This is a retrospective study on patients who received a mini-transverse incision and a novel bush hook or a mid-palmar small longitudinal incision for treatment of carpal tunnel syndrome. The decision to receive either technique was made mainly based on patients' choice. The clinical results were evaluated at 1 week, 1 month, 3 and 6 months postoperatively and compared.

Results

In total, 58 patients in mini-transverse incision group and 74 in mid-palmar longitudinal incision group were include. The follow-up period was 6.8 ± 1.6 months. The mini-transverse incision group had a significantly smaller incision (4.3 ± 0.4 mm vs. 26.2 ± 1.6 mm), shorter surgical time (7.8 ± 2.6 min vs. 19.7 ± 2.8 min), but not for hospital stay (3.2 ± 1.9 vs. 3.6 ± 2.2 days). Both groups showed significant improvement from baseline level at any time points postoperatively (all P < 0.001). At 1 month and 3 months, the mini-transverse incision group showed a significantly better improvement of VAS, SSS and FSS score (P < 0.05). At 6 months, the differences were no longer significant (P > 0.05). In addition, the mini-transverse incision group showed a significantly reduced time to return to the work and activities, tendency to higher rate of excellence and good outcomes and fewer complications.

Conclusions

This novel technique via a mini-transverse incision and bush hook showed better clinical effectiveness and safety, and can be considered as an alternative for wrist tunnel release after the results are validated by higher-level evidence studies.

Evidence level: III.

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-transverse incision using a novel bush-hook versus conventional open incision for treatment of carpal tunnel syndrome: a prospective study

Purpose

This study aimed to investigate the outcomes of a mini-transverse incision with a bush-hook versus a conventional open incision for carpal tunnel release (CTR).

Methods

This was a prospective study. The decision to receive either technique (mini-transverse incision with a bush-hook or conventional open incision) was primarily based on patients’ choice. Patients’ symptom severity, functional status, and symptomatic pain were measured at pre-operation, 1 month, and 3 and 6 months postoperatively, and any relevant complications were recorded. Kelly’s scale was used to evaluate the overall clinical efficacy.

Results

Eighty-nine patients were included in the open CTR group and 85 patients in the mini-transverse incision group. The mini-transverse incision group had a significantly smaller incision (4.4±0.6 vs 44.8±3.7 mm), shorter surgical time (7.8±1.9 vs 21.2±3.4 min), and shorter hospital stay (3.7±1.6 vs 5.9±2.0 days) than did the open CTR group. Both groups showed significant improvements from baseline levels (all P<0.001). At postoperative 1 month and 3 months, the transverse incision group showed a significantly better VAS, SSS, and FSS (all P<0.05), but the difference was non-significant at 6 months except for FSS (P=0.022). Also, mini-transverse incision showed a significantly reduced time to return to work and activities, trend to a higher rate of excellence, and good and fewer complications than did the open CTR.

Conclusions

The mini-transverse incision exhibited better performance in surgery-related measures, symptomatic remission, functional recovery, and postoperative morbidity, thus could be considered a promising technique alternative.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02608-x.

Minimally invasive carpal tunnel decompression using the KnifeLight: How I Do It

BACKGROUND

Carpal tunnel decompression is commonly performed open or endoscopically. Carpal tunnel release using the KnifeLight instrument (Stryker, Kalamazoo, MI) is an alternative method established in 2000.

METHOD

The instrument has a cutting blade placed between two blunt flat tips with an integrated light source which helps to locate the tool blade by transillumination through the tissues. The instrument is inserted into an opening made in the wrist crease and transverse carpal ligament and used to divide the ligament.

CONCLUSION

This is a simple, efficient, and reproducible alternative for carpal tunnel decompression.

Minimally Invasive Carpal Tunnel Release (CTR) Using the Wongsiri Technique with MiniSURE

INTRODUCTION

The standard open technique for carpal tunnel surgery has wound problems and complications significantly more than minimally invasive surgery using the Wongsiri technique with MiniSURE Kit® (Surgical Innovation Healthcare Co., Ltd, Bangkok, Thailand) and in particular, the open technique surgery requires a longer time for return to work. CTR surgery with endoscopic devices improves the results with fewer wound problems when compared with the commonly used open technique; however, nerve complications and injury are more prevalent with endoscopic surgery than with the open technique. The Wongsiri technique produces good results with new medical devices such as the MiniSURE View, for improved vision and line-of-sight, and the MiniSURE Cut for improved and complete cutting via the supraretinacular technique that may reduce the nerve problems associated with endoscopic tooling in the carpal tunnel.

PURPOSE

To evaluate the results of the operation and postoperative outcomes of the Wongsiri technique with a MiniSURE Kit®.

METHODS

20 patients underwent carpal tunnel release using the Wongsiri technique and a MiniSURE Kit® with a five-step surgery: MIS starts when the surgeon makes a 1.5-1.8 cm incision, creates a working space, inserts the visual tube of MiniSURE View, inserts the freer, and then cuts the transverse carpal ligament by using the MiniSURE Cut.

RESULTS

All 20 successes of the Wongsiri technique and MiniSURE Kit® surgery occurred within 6.8 minutes operative time and a 12 mm wound size. A single outlier, in one case (6.7%), the patient experienced pillar pain which abated within one month. Patients can return to work in 7.3 days.

CONCLUSIONS

The Wongsiri technique with the MiniSURE Kit® demonstrated good outcomes similar to the endoscope. By contrast with the endoscopic surgery, the Wongsiri technique with the MiniSURE Kit® reduced preop, operating, and postop time, many resources, and significant costs and resulted in no nerve problems or complications.

The comparison of limited-incision versus standard-incision in treatment of carpal tunnel syndrome: A meta-analysis of randomized controlled trials

BACKGROUND

Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. Compared with standard release, the efficacy, safety, and postoperative complications of limited carpal tunnel release remain controversial. The purpose of this study was to compare the effects of the 2 treatments.

METHODS

The English-language literature was searched using MEDLINE, Web of Science, and Embase. Randomized controlled trials that compared standard and limited incision for carpal tunnel release were included in the meta-analysis. Strength, interval to return to activities, the rate of adverse events, effectiveness, and operative time were compared.

RESULTS

Thirteen randomized controlled trials (RCTs) containing 1020 patients were included. Limited incision treated patients showed better early recovery of grip strength (mean difference [MD], 4.25 [0.86-7.65]; P = .01) and pinch strength (MD, 1.37 [0.24-2.51]; P = .02) but no advantage after more than 6 months. Patients treated with limited incision showed an earlier return to activities (MD,-8.80 [-9.21 to -8.39]; P < .01) and reduced operative time (standardized mean difference [SMD], -1.68 [-3.24 to-0.12]; P = .04). The rate of adverse event was significantly higher in standard group compared with that in limited group (risk ratio [RR] 0.61, 95% CI 0.38-0.96, P = .03).

CONCLUSIONS

Limited incision release allows us to return to activities early, reduces operative time, decreases rate of adverse events, and improves strength during the early postoperative period. Results at 6 months or longer are similar according to current data. However, the results of this meta-analysis should be interpreted with caution due to heterogeneity amongst the included studies.

Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review

OBJECTIVE

To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found.

CONCLUSIONS

Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.

A Randomized Comparison of Double Small, Standard, and Endoscopic Approaches for Carpal Tunnel Release

BACKGROUND

The purpose of this study was to introduce a new surgical technique of carpal tunnel release through double small incisions, and to compare the technique with the standard open release and endoscopic release.

METHODS

Two hundred and seven patients were allocated randomly into group A (n = 73), B (n = 65), or C (n = 69). Patients in group A were treated with carpal tunnel release by means of double small incisions. Patients in group B were treated by means of the standard incision. Patients in group C had endoscopic release.

RESULTS

Preoperatively, the mean severity of symptoms of groups A, B, and C was 3.7 ± 0.58, 3.8 ± 0.62, and 3.7 ± 0.52, respectively; and the mean functional status was 3.2 ± 0.71, 3.2 ± 0.71, and 3.5 ± 0.64, respectively. At the final follow-up of 3 years, the mean severity of symptoms of the groups was 1.2 ± 0.45, 1.2 ± 0.31, and 1.5 ± 0.36, respectively; and the mean functional status was 1.2 ± 0.38, 1.2 ± 0.41, and 1.5 ± 0.42, respectively. Patient satisfaction was 95 ± 4.2, 90 ± 5.8, and 93 ± 4.4, respectively. There were no significant differences between groups regarding symptom severity or function status (p > 0.05). For scar appearance, there were significant differences between groups A and B and between B and C, but not between A and C; for patient satisfaction, there were significant differences in all comparisons.

CONCLUSIONS

Carpal tunnel release by means of double small incisions is a minimally invasive and less technically challenging procedure with good nerve visualization, resulting in good appearance of scars.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial

This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.

Factors affecting symptoms and functionality of patients with carpal tunnel syndrome: a retrospective study

[Purpose] The aim of this retrospective study was to determine the associations between clinical, physical, and neurophysiological outcomes and self-reported symptoms and functions of patients after surgical carpal tunnel release. [Subjects and Methods] Among 261 patients who had undergone open surgical carpal tunnel release within the last three years, 83 (mean age 50.27 ± 11.13 years) participated in this study. Their socio-demographics and comorbidities were recorded. The intensity of pain, paresthesia, and fatigue symptoms in the hand were assessed by means of a Visual Analogue Scale, the Semmes-Weinstein Monofilaments test of light touch pressure sensation, and Jamar dynamometry for measurement of grip and pinch strengths. The Boston Carpal Tunnel Questionnaire evaluated the severity of symptoms and hand functional status, and the variables were analyzed by multivariate linear regression. [Results] The severity of the symptoms and functional status of release surgery patients was associated with diabetes mellitus, migraine, night pain, paresthesia and fatigue symptoms, impaired light touch pressure, and lack of medical treatment. [Conclusion] Appropriate post-surgery treatment programs for these factors should be taken into consideration to help patients obtain optimal functionality and health in their daily lives.