Carpal tunnel release with a new mini-incision approach versus a conventional approach, a retrospective cohort study

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.

Is Carpal Tunnel Release Necessary in High-Energy Distal Fractures of the Radius?

Purpose This study aimed to compare the clinical outcomes of patients who underwent volar plate osteosynthesis for high-energy distal radius fracture (DRFx) and carpal tunnel release (CTR) for acute or subacute carpal tunnel syndrome (CTS) with patients who did not undergo CTR. Methods This study is a retrospective evaluation of all high-energy DRFx treated with volar plate osteosynthesis in a regional hospital between January 2021 and January 2023. All adult patients (≥18 years) who underwent open reduction and internal fixation were included in the study after obtaining approval from the internal review board of our institution. Only patients who underwent plate osteosynthesis of the volar aspect through a modified Henry incision and patients who underwent CTR through a classic separate incision were included in the study. Clinical results include hand dynamometry, visual analog scale (VAS) scores, and physical examination findings of patients who underwent volar plate osteosynthesis because of high-energy DRFx and CTR due to CTS in the acute and subacute periods were retrospectively examined. Results Among the patients who underwent volar plate osteosynthesis because of high-energy DRFx, no statistically significant difference was detected between the hand grip strength and VAS scores of patients who underwent CTR because of acute CTS and subacute CTS at the sixth postoperative week (p>0.05). Conclusion Prophylactic CTR may be performed in the same session in selected cases, such as DRFx caused by a high-energy injury, to establish a scale for DRFx at a high risk of CTS and avoid delays in treatment. CTR for transient CTS detected in the subacute period during outpatient follow-up does not improve clinical outcomes.

The Mini-Incision Technique Versus Conventional Open Approach for Carpal Tunnel Release: A Retrospective, Comparative Cohort Study

Background and objective Open carpal tunnel release (OCTR) is the gold standard technique for treating carpal tunnel syndrome (CTS). While mini-incision carpal tunnel release (MCTR) has been introduced as an alternative approach, there have been some concerns over its effectiveness and risks. In light of this, the aim of the study was to compare the long-standing clinical outcomes after MCTR with those following OCTR. Methods We employed a retrospective cohort design for this study. Patients were classified into two surgery groups, followed up for two years, and compared in terms of the following variables: duration of symptoms; pinch strength; grip strength; 2-point discrimination; visual analog scale (VAS) score; Levine symptom score; Levine function score; quick disabilities of the arm, shoulder, and hand (QuickDASH) score; wound pain; and pillar pain. Results The study included data regarding 120 patients, 71.66% of whom were females. The MCTR and OCTR groups were similar in terms of age, sex, duration of symptoms, and certain other aspects at baseline. The operation duration (15.15 ±2.20 vs. 25.01 ±2.15 minutes, p<0.01) and incision length (11.425 ±1.56 vs. 20.35 ±2.43 mm, p<0.01) were significantly shorter in the MCTR group compared to the OCTR group. Wound pain and pillar pain were not documented in the MCTR group at three and six months. The OCTR group had pillar pain in 25% of the patients till two years postoperatively. Conclusion Based on our findings, we propose that MCTR is superior to OCTR. The mini-incision technique has the advantages of small incision and scar, low pain, and faster recovery. Moreover, the technique was also found to be safe with no major complications or recurrence of symptoms. Further randomized control trials may help to re-evaluate the technique and validate our findings.

The Isolated Motor Branch of the Ulnar Nerve Injury During Open Carpal Tunnel Release

A 76-year-old woman underwent open carpal tunnel release (OCTR). She had sudden sharp shooting pain in her hand, in the mid-palmar area, during the operation. She was then unable to abduct or adduct her thumb and fingers after surgery. She had no sensation impairment of the ulnar digit. The nerve conduction study confirmed a complete transection of the motor branch of the ulnar nerve (MUN). The MUN was repaired, and the patient recovered her intrinsic hand muscle function two years after the operation. The mechanism of injury, related anatomy and potentially dangerous area, clinical findings, management, and prevention are discussed.

Delayed Surgical Treatment in Patients with Chronic Carpal Tunnel Syndrome Is Still Effective in the Improvement of Hand Function

Background and Objectives: Severe carpal tunnel syndrome (CTS) is the most common compression neuropathy in the upper extremities treated conservatively; later, when advanced, CTS is treated mostly surgically. The most prevalent symptoms comprise numbness, as well as sensation loss in the thumb, index, and middle finger, and thenar muscle strength loss, resulting in impaired daily functioning for patients. Data on the results of CTS treatment in patients with delayed surgical intervention are scarce. The aim of this study was to determine the postoperative results of chronic carpal tunnel syndrome treatment in patients with symptoms lasting for at least 5 years. Materials and Methods: A total of 86 patients (69 females, 17 males) with a mean age of 58 years reporting symptoms of CTS for at least 5 years (mean: 8.5 years) were prospectively studied. The average follow-up time was 33 months. All patients underwent the surgical open decompression of the median nerve at the wrist. A preoperative observation was composed of an interview and a clinical examination. The subjects completed the DASH (the Disabilities of the Arm, Shoulder, and Hand), PRWE (Patient-Rated Wrist Evaluation), and self-report questionnaires. Global grip strength, sensory discrimination, characteristic symptoms of CTS, and thenar muscle atrophy were examined. Postoperatively, clinical and functional examinations were repeated, and patients expressed their opinions by completing a BCTQ (Boston Carpal Tunnel Syndrome Questionnaire). Results: We found improvements in daily activities and hand function postoperatively. Overall, 88% of patients were satisfied with the outcome of surgery. DASH scores decreased after surgery from 44.82 to 14.12 at p < 0.001. PRWE questionnaire scores decreased from 53.34 to 15.19 at p < 0.001. The mean score of the BCTQ on the scale regarding the severity of symptoms was 1.48 and 1.62 on the scale regarding function after surgery. No significant differences were found in the scores between the male and female groups or between age groups (p > 0.05). A significant increase in global grip strength from 16.61 kg to 21.91 kg was observed postoperatively at p < 0.001. No significant difference was detected in the measurement of sensory discrimination (6.02 vs. 5.44). In most of the examined patients, night numbness and wrist pain subsided after surgery at p < 0.001. Thenar muscle atrophy diminished after surgery at p < 0.001. Conclusions: Most patients were satisfied with the results of CTS surgery regarding the open decompression of the median nerve even after 5 years of ineffective conservative treatment. Significant improvement of the hand function was confirmed in the functional studies.

Anatomic Study of the Motor Branch of the Ulnar Nerve Regarding Carpal Tunnel Surgery: A Cadaveric Study

Background: Motor branch of the ulnar nerve (MUN) injury during carpal tunnel surgery is rare and it should never be injured during carpal tunnel release (CTR). However, an iatrogenic injury of the MUN can cause catastrophic physical and mental suffering. The aim of our study is to understand the anatomy of the MUN in relation to carpal tunnel in order to prevent iatrogenic injury during CTR. Methods: We dissected 34 fresh cadaver hands and located the MUN in relation to the anatomical axis used for carpal tunnel surgery. Possible mechanisms of injury and the vulnerable area of the MUN were determined along the dissection. Results: The MUN turned towards the thumb distal to hook of hamate. It then travelled on the floor of the carpal tunnel which was formed by intrinsic hand muscles under flexor tendons. The nerve located at 29.39 ± 7.41, 35.01 ± 3.14 and 38.79 ± 4.03 mm (Mean ± SD) in the central axis of ring finger, the vertical axis of the third web-space and the central axis of middle finger respectively. The nerve's turning point, 10.9 ± 2.63 mm distal to the centre of hook of hamate where it lies just below the level of the transverse carpal ligament. Conclusions: Surgeons should be aware of the nerve's location. Surgical dissection or passing of any surgical instruments around the hook of hamate should be done with care. Level of Evidence: Level IV (Therapeutic).

Update on surgical procedures for carpal tunnel syndrome: What is the current evidence and practice? What are the future research directions?

Carpal tunnel syndrome (CTS) is a multifactorial compression neuropathy. It is reported to be very common and rising globally. CTS’s treatment varies from conservative measures to surgical treatments. Surgery has shown to be an effective method for more severe cases. However few unclear aspects and room for further research and improvements still remains. We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS. The simple algorithm of leaving the choice of the surgical method to surgeons’ preference and experience (together with consideration of patients’ related factors) seem to be the best available option, which is supported by the most recent metanalysis and systematic reviews. We suggest that surgeons (unless in presence of precise indications towards endoscopic release) should tend to perform a minimally invasive open approach release, favoring the advantage of a better neurovascular structures visualization (and a consequent higher chance to perform a complete release with long term relief of symptoms) instead of favoring an early reduction (in the first postoperative days) of immobilization and pain. Research towards a universally accepted standardization should be aimed for by the researchers, who have failed to date to sufficiently limit bias and limitations.

Amyloidosis and Carpal Tunnel Syndrome: Surgical Technique for Extended Carpal Tunnel Release with Tenosynovium and Transverse Carpal Ligament Biopsies

Carpal tunnel syndrome (CTS) is common in patients with transthyretin amyloidosis (ATTR), and many experience residual symptoms and/or develop recurrent disease following routine carpal tunnel release (CTR). An extended CTR with median nerve neurolysis is recommended for thorough nerve decompression. Tissue confirmation of amyloidosis can be performed at the time of CTR with biopsies of the transverse carpal ligament and/or tenosynovium.

METHODS

We describe a retrospective, single-center experience performing an extended CTR technique including unilateral and bilateral cases for 13 consecutive patients (18 wrists) with ATTR and symptomatic median neuropathy at the wrist.

RESULTS

The mean patient age was 83 (range 67-90) years and 11 (85%) were men. Notable intraoperative findings in all cases included thickened tenosynovium and median nerve epineurium, and adherence of the median nerve to the deep surface of transverse carpal ligament. Pathology findings were positive for amyloidosis from both the transverse carpal ligament and the tenosynovium biopsies in all patients.

CONCLUSIONS

Extended CTR with simultaneous wrist tissue biopsy can be safely performed for ATTR patients with CTS. Characteristic intraoperative findings should increase clinical suspicion for undiagnosed ATTR and prompt performance of biopsy for diagnostic confirmation. Volar wrist tenosynovial biopsy is our preferred tissue for confirmation of ATTR, for patients with and without CTS, given its safety profile and 100% pathological yield in our series.

A Retrospective Clinical Study of Endoscopic Treatment of Carpal Tunnel Syndrome using the Modified Soft Tissue Release kit

OBJECTIVE

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy, and endoscopic carpal tunnel release (ECTR) is one of the minimally invasive procedures for the treatment of CTS. Based on the shortcomings of ECTR, we designed the "Modified Soft Tissue Release Kit" to assist the endoscopic operation. This study aimed to evaluate the effectiveness and safety of endoscopic treatment of CTS using this kit.

METHODS

This retrospective review included 57 patients (86 wrists) who underwent ECTR using the "Modified Soft Tissue Release Kit" at our department between January 2017 and August 2019. Three scale scores (i.e., Quick-Disabilities of the Arm, Shoulder, and Hand [QDASH]; Boston Carpal Tunnel Syndrome Questionnaire [BCTSQ]: symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS]) were recorded to assess hand function and symptoms preoperatively, 1 month postoperatively, 3 months postoperatively, and at the last follow-up. We also asked patients to answer a satisfaction question during follow-up. Pre- and post-operation scores were compared using paired Wilcoxon signed-rank test. Spearman's rank-order correlation was used to evaluate the relationship between scale scores and patient satisfaction.

RESULTS

A total of 55 patients (83 wrists) were followed up, with an average follow-up of 27.2 ± 9.3 months. The median preoperative QDASH score was 45.5; the scores at 1 month postoperatively, 3 months postoperatively, and the last follow-up were 4.5, 0, and 0, respectively, with a significant decrease noted compared with the preoperative scores (P < 0.001). The median preoperative BCTSQ-SS and BCTSQ-FS scores were 3.3 and 2.8, respectively; the scores at 1 month postoperatively, 3 months postoperatively, and the last follow-up were 1.2, 1.0, and 1.0, and 1.1, 1.0, and 1.0, respectively, all of which decreased significantly compared with the preoperative scores (P < 0.001). The incidence of nerve injury was 0. The incidence of pillar pain was 0 at the last follow-up. One patient showed no improvement in hand symptoms and function postoperatively, and two patients showed long-term recurrence despite postoperative symptom remission. Approximately 94.5% (52/55) of the patients were satisfied or very satisfied with the outcome.

CONCLUSIONS

ECTR with the "Modified Soft Tissue Release Kit" can significantly relieve symptoms and improve function in patients with CTS, with significant short- and mid-term efficacy and high safety.

Prospective Comparative Analysis Study of Minimally Invasive Surgical Decompressions versus Traditional Surgical Decompression of Carpal Tunnel Syndrome

Objective: Carpal tunnel syndrome (CTS) occurs when there is compression on the median nerve within the carpal tunnel in the wrist joint. It commonly affects those who make frequent, repetitive hand movements, with women being more affected than men. The present study was aimed at comparing minimally invasive and classical surgical decompression techniques for carpal tunnel syndrome. Materials and Methods: One hundred and four patients with CTS who were scheduled for carpal tunnel decompression were chosen at random. The patients were divided into two groups. Group A had standard classical long incision decompression, whereas Group B had minimally invasive decompression. The patients were evaluated with the Boston Functional Score Scale. Between the two groups, a comparison of visit reports was made at 3, 6, and 12 months after surgery. Results: There was no significant difference in patient age (Group A was 38 years old and Group B was 36 years old) and availability of bilateral CTS status (A was 34 and B was 31). The female-male ratios in groups A and B were 3.6 to 0.2 and 3.1 to 0.3, respectively, with a p-value of p<0.05 indicating significant difference. Comparing both groups, the minimally invasive decompression technique showed a high rate of functional hand grip and a low rate of complications including early wound healing, rapid resumption of palmar strength grip, and rapid return to daily activities. Conclusion: The findings indicate that patients who underwent the minimally invasive surgical decompression one-stitch technique showed significant improvement over the traditional method.

A prospective cohort study: platelet-rich plasma combined with carpal tunnel release treating carpal tunnel syndrome

Background

PRP injection was proved to promote the health condition of individuals with mild to moderate Carpal Tunnel Syndrome (CTS). However, carpal tunnel release (CTR) was still a necessary treatment for individuals with moderate and severe CTS.

Methods

To explore whether adjuvant PRP treatment would improve the prognosis while using CTR, we included 82 patients in this study. Preoperative and postoperative visual analog scale (VAS), Boston carpal tunnel syndrome questionnaire-symptom severity scale (BCTQ-SSS), Boston carpal tunnel syndrome questionnaire-functional status scale (BCTQ-FSS), and grip strength were used to examine the patient's symptoms and function.

Results

CTR combined with PRP treatment improved the VAS (1.9 ± 0.5 versus 1.4 ± 0.4, P < .05), BCTQ-SSS (1.8 ± 0.4versus 1.5 ± 0.3, P < .05) and BCTQ-FSS (1.8 ± 0.5 versus 1.4 ± 0.6, P < .05) in patients with moderate symptoms within one month after surgery. At the same time, it does not show any advantages in treating individuals with severe carpal tunnel syndrome.

Conclusions

PRP does not affect long-term prognosis while increasing the surgery cost. To conclude, PRP as an adjuvant treatment of CTR has limited effect. Considering the additional financial burden on patients, CTR combined with PRP should be cautious in CTS treatment.

Mini-open carpal tunnel release: technique, feasibility and clinical outcome compared to the conventional procedure in a long-term follow-up

We sought to evaluate the findings of our anatomically landmarks based mini-open procedure (MCTR) through a palmar approach and to compare its outcome and practicability to the conventional method (OCTR). The study consisted of 100 matched patients (n = 50 MCTR, n = 50 OCTR) with a minimum follow-up of three years. The outcome was characterized via the Disabilities of Arm, Shoulder and Hand Score (DASH), Symptom Severity Scale (SSS), Functional Status Scale (FSC), and Visual Analogue Scale (VAS). All adverse events were observed. An alpha of 0.05 and a confidence level of 95% were set for statistical analyses. Both techniques showed comparable functional results in a long-term period (mean follow-up MCTR: 60 months and OCTR: 54 months). MCTR versus OCTR at mean: DASH: 4.6/8.3 (p = 0.398), SSS: 1.3/1.2 (p = 0.534), FSC: 1.3/1.2 (p = 0.617), VAS: 0.4/0.7 (p = 0.246). The MCTR convinced through a lower rate of scar sensibility (MCTR: 0% vs. OCTR: 12%, 0/50 vs. 6/50; p = 0.007) and pillar pain, as well as a shortened recovery period and surgical time relative to the OCTR. Low complication rates were observed in both groups, no recurrences had to be documented. The MCTR procedure revealed a similar good clinical outcome as the conventional technique. MCTR is a minimally-invasive, reliable, fast and simple procedure with an obvious benefit regarding scar sensibility.

Grip Strength Measurement for Outcome Assessment in Common Hand Surgeries

Grip strength has been used to evaluate the upper extremity functional status and clinical outcomes following upper extremity trauma or surgery. Understanding general recovery patterns of grip strengthening can be helpful in assessing the patients’ recovery status and in assisting in preoperative consultations regarding expectations for recovery. We summarize related studies on grip strength measurement and recovery patterns in common hand conditions, including carpal tunnel syndrome, cubital tunnel syndrome, triangular fibrocartilage complex injury, and distal radius fractures.

A mini-incision carpal tunnel release technique to prevent pillar pain: A technical note

Pillar pain represents one of the most common complications of classic open carpal tunnel release (CTR). This complication causes a sense of discomfort worse than the compression syndrome itself. We, herein, introduce a new treatment method for CTR through a mini-incision, which allows subcutaneously cutting the transverse carpal ligament (TCL) and releasing the median nerve without neurovascular complications. This mini-incision approach can allow the direct visualization and preservation of the thenar motor branch in those rare cases where it has an aberrant origin. For the past 10 years, we have consecutively performed this technique in the surgical treatment of 318 patients with the diagnosis of primary CTS, without developing any neurovascular and tendon injuries as well as pillar pain.