Endoscopic release of the carpal tunnel: a randomized prospective multicenter study

Endoscopic Versus Open Carpal Tunnel Release: An Umbrella Review and a Meta-analysis

INTRODUCTION

Whether endoscopic carpal tunnel release (ECTR) versus open carpal tunnel release (OCTR) has superior outcomes remains a controversial topic. Therefore, we sought to perform an umbrella review and meta-analysis to compare ECTR and OCTR with regards to (1) postoperative functional ability, (2) operative outcomes, and (3) time to return to work.

METHODS

A PubMed, Scopus, and Cochrane database search was conducted for all meta-analyses comparing ECTR and OCTR performed between 2000 and 2022 in accordance to PRISMA and Joanna Briggs Institute guidance for umbrella reviews. The primary outcomes were as follows: (1) functional ability-symptoms severity, postoperative grip strength, postoperative pinch strength, 2-point discrimination, and pain; (2) operative outcomes-operation time, total complications, nerve injury, and scar-related complication; and (3) time to return to work. Quality was assessed using the Assessment of Multiple Systematic Reviews. Pooled analysis was performed to compare several clinical outcome measures between groups, depending on the availability of data using Review Manager Version 5.2.11.

RESULTS

A total of 9 meta-analyses were included, 5 were of high quality and 4 were moderate quality. For functional ability, ECTR was associated with better pinch strength after 3 months (0.70, 95% confidence interval [CI] = 0.00, 1.40, P = 0.05) and 6 months (0.77, 95% CI = 0.14, 1.40, P = 0.02, I2 = 84%). For return to work, OCTR was associated with longer return to work compared with ECTR (-10.89, 95% CI = -15.14, -6.64, P < 0.00001, I2= 83%). There were no significant differences between OCTR and ECTR in the hand function, symptom severity, grip strength, pain, operation time, and total complications.

CONCLUSIONS

In an umbrella review and meta-analysis of ECTR versus OCTR, ECTR was associated with a higher pinch strength, and a shorter time to return to work. Differences in major complications, such as nerve injury, were unclear due to statistical inconsistency and bias.

Surgical Interventions for the Management of Carpal Tunnel Syndrome: A Narrative Review

Carpal tunnel syndrome (CTS) is a severe condition that affects the hand, causing pain, numbness, paresthesia, and autonomic dysfunction caused by increased pressure, damage, and demyelination of the median nerve in the carpal tunnel. The most effective treatment for CTS is carpal tunnel release (CTR) via transverse carpal ligament (TCL) transect. We can apply decompression through endoscopic procedures; standard open techniques and minimally invasive wrist incisions can all be used to accomplish decompression. Superior outcomes have been reported in many studies, including patient satisfaction, symptom relief, improvements in multiple assessment modality results, and fewer complications. Soreness at the incision site, tenderness around the site of ligament release, transitory loss of motor or sensory function, and the need for a repeat operation are all postoperative consequences. There is minimal and low-quality evidence to support the effectiveness of postoperative rehabilitation, such as wrist orthoses, dressings, exercise, and ice therapy, which have benefited patients anecdotally.

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.

Revision Carpal Tunnel Release Following Endoscopic Compared With Open Decompression

Importance

Carpal tunnel release (CTR) technique may influence the likelihood of revision surgery. Prior studies of revision CTR following endoscopic CTR (ECTR) compared with open CTR (OCTR) have been limited by sample size and duration of follow-up.

Objective

To estimate the incidence of revision CTR following ECTR compared with OCTR in a national cohort.

Design, Setting, and Participants

This retrospective cohort study used data from the US Veterans Health Administration. Participants included all adults (age ≥18 years) undergoing at least 1 outpatient CTR from October 1, 1999, to May 20, 2021. Data were analyzed from May 21, 2021, to November 27, 2023.

Exposure

Index CTR technique.

Main Outcomes and Measures

The primary outcome was time to revision CTR, defined as repeat ipsilateral CTR during the study period. Secondary outcomes were indications for revision, findings during revision, and additional procedures performed during revision.

Results

Among 134 851 wrists from 103 455 patients (92 510 [89.4%] male; median [IQR] age, 62 [53-70] years) undergoing at least 1 CTR, 1809 wrists underwent at least 1 revision at a median (IQR) of 2.5 (1.0-3.8) years. In competing-risks analysis, the cumulative incidence of revision was 1.06% (95% CI, 0.99%-1.12%) at 5 years and 1.59% (95% CI, 1.51%-1.67%) at 10 years. ECTR was associated with increased hazard of revision CTR compared with OCTR (adjusted hazard ratio [aHR], 1.56; 95% CI, 1.34-1.81; P < .001). The risk difference for revision CTR associated with ECTR compared with OCTR was 0.57% (95% CI, 0.31%-0.84%) at 5 years (number needed to harm, 176) and 0.72% (95% CI, 0.36%-1.07%) at 10 years (number needed to harm, 139). Regardless of index CTR technique, the most common indication for revision was symptom recurrence (1062 wrists [58.7%]). A reconstituted transverse carpal ligament (TCL) was more common after ECTR compared with OCTR, whereas scarring of the overlying tissues and of the median nerve itself were more common following OCTR. Incomplete transverse-carpal-ligament release was observed in 251 of the wrists undergoing revision CTR (13.94%) and was more common among revisions following ECTR (odds ratio, 1.62; 95% CI, 1.11-2.37; P = .01).

Conclusions and Relevance

In this cohort study of revision CTR in the Veterans Health Administration, ECTR was associated with increased risk of revision compared with OCTR, but the absolute risk was low regardless of technique. Intraoperative findings at revision varied significantly according to index CTR technique.

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis

BACKGROUND

Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS.

METHODS

Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed.

RESULTS

From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63.

CONCLUSIONS

PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.

Carpal tunnel syndrome

Median neuropathy at the wrist, commonly referred to as carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. It is caused by chronic compression of the median nerve at the wrist within the space-limited carpal tunnel. Risk factors that contribute to the etiology of compression include female gender, obesity, work-related factors, and underlying medical conditions, such as hypothyroidism, pregnancy, and amyloidosis. The diagnosis is made on clinical grounds, although these can be confounded by anatomical variations. Electrodiagnostic studies, which are specific and sensitive in diagnosing CTS, support the diagnosis; however, a subgroup may present with normal results. The advent of imaging techniques, including ultrasound and MRI, further assists the diagnostic process. The management of CTS is divided into the nonsurgical approaches that include hand therapy, splinting and corticosteroid injection, and surgical decompression of the carpal tunnel. Although several surgical techniques have been developed, no one method is more effective than the other. Each of these management approaches are effective at providing symptom relief and are utilized at different severities of the condition. There is, however, a lack of consensus on standardized diagnostic criteria, as well as when and to whom to refer patients for surgery.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release

BACKGROUND

The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR.

METHODS

We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year.

RESULTS

Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR.

CONCLUSIONS

The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

Multi-investigator collaboration in orthopedic surgery research compared to other medical fields: Update comparing 2021-2009

The purpose of this study was to assess the prevalence of multicenter studies in the orthopedic literature compared to general medicine and other surgical subspecialty studies as an update to a previous study. The number of multicenter research studies across three orthopedic surgery journals was higher in 2021 compared to 2009 (7.2% [95% CI: 5.1%-9.4%, χ2  [df = 1 = 43.8]], p < 0.0001), as was the number of authors and institutions listed on clinical research studies. While these trends in multicenter research publishing are encouraging, orthopedic surgery still lags behind the general medicine and other surgical subspecialty literature bases. Of the 934 orthopedic surgery studies published, 92 (9.9%) were multicenter studies compared to 64.4% of the general medicine and 26.9% of the other surgical subspecialty studies (χ2  [df = 2] = 472.6, p < 0.001). Multicenter trials conducted in orthopedics have fundamentally changed musculoskeletal care, affecting the lives of millions of patients. Participation in multicenter research should be encouraged and prioritized through continued advocacy, funding, support, and direction from orthopedic governing bodies, journals, and subspecialty groups.

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.

[Endoscopic release of the carpal tunnel using the Agee technique modified by Neumann]

OBJECTIVE

Decompression of the median nerve by complete endoscopic release of the transverse carpal ligament (TCL) and the distal antebrachial fascia. Minimization of surgical trauma results in decreased postoperative morbidity and earlier return to work and daily activities.

INDICATIONS

Symptomatic carpal tunnel syndrome.

CONTRAINDICATIONS

Revision surgery after open or endoscopic procedure, rheumatic diseases.

SURGICAL TECHNIQUE

Small transverse incision at the ulnar border of the palmaris longus tendon, and proximal to the distal wrist flexion crease. Exposure and incision of the antebrachial fascia, dilatation of the carpal tunnel and dissection of synovial tissue from the undersurface of the TCL. With the wrist in extension, the endoscopic blade assembly with integrated camera is inserted into the canal. Exposure of TCL and short incision in the middle portion. Gradually, dissection of the distal portion of the TCL then completion by retraction of the blade distally to proximally.

POSTOPERATIVE MANAGEMENT

Slightly compressive dressing, selfcare on day 1 after procedure.

RESULTS

More than 25 years of experience, more than 8000 treated patients, and 3 documented cases with intraoperative lesions of the median nerve requiring revision. High acceptance and patient satisfaction in AQS1 patient-reported surveillance.

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.

The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images

Iatrogenic injury of the median nerve has been reported after endoscopic carpal tunnel release and corticoid injection. In 784 MR images of the wrist, the position of the median nerve in relation to the palmaris longus tendon was analysed. The ulnar edge of the median nerve was found medial to the palmaris longus tendon in 14% and 36% of patients at the proximal wrist crease and entrance of the carpal tunnel, respectively, compared with 23% and 40% of patients with carpal tunnel syndrome (88 patients). The position of the median nerve in relation to the palmaris longus tendon varies widely. It is suggested that the palmaris longus tendon may not be considered a safe landmark to locate the position of the median nerve and care should be taken when introducing an endoscopic instrument or during steroid injection for carpal tunnel syndrome.Level of evidence: IV.

Research advances and trends in the surgical treatment of carpal tunnel syndrome from 2003 to 2022: A CiteSpace-based bibliometric analysis

Background

Carpal Tunnel Syndrome (CTS) is one of the most common peripheral neuropathies. The typical symptoms are tingling and numbness in the median nerve distribution of the hand. Current treatment for CTS includes general conservative treatment and surgical treatment. Surgical treatment plays a crucial role in the management of CTS, but little bibliometric analysis has been conducted on it. Therefore, this study aimed to map the literature co-citation network using CiteSpace (6.1 R4) software. Research frontiers and trends were identified by retrieving subject headings with significant changing word frequency trends, which can be used to predict future research advances in the surgical treatment of CTS.

Methods

Publications on the surgical treatment of CTS in the Web of Science database were collected between 2003 and 2022. CiteSpace software was applied to visualize and analyze publications, countries, institutions, journals, authors, references, and keywords.

Results

A total of 336 articles were collected, with the USA being the major publishing power in all countries/regions. JOURNAL OF HAND SURGERY AMERICAN VOLUME was the journal with the most published and co-cited articles. Based on keyword and reference co-citation analysis, keywords such as CTS, surgery, release, median nerve, and diagnosis were the focus of the study.

Conclusion

The results of this bibliometric study provide clinical research advances and trends in the surgical treatment of patients with CTS over the past 20 years, which may help researchers to identify hot topics and explore new directions for future research in the field.

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.

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.

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.

Improving the Science in Plastic Surgery

SUMMARY

In 1906, George Bernard Shaw criticized the medical profession for its lack of science and compassion. Since then, advances in both medical and surgical subspecialties have improved quality of patient care. Unfortunately, the reporting of these advances is variable and is frequently biased. Such limitations lead to false claims, wasted research dollars, and inability to synthesize and apply evidence to practice. It was hoped that the introduction of evidence-based medicine would improve the quality of health care and decrease health dollar waste. For this to occur, however, credible "best evidence"-one of the components of evidence-based medicine-is required. This article provides a framework for credible research evidence in plastic surgery, as follows: (1) stating the clinical research question, (2) selecting the proper study design, (3) measuring critical (important) outcomes, (4) using the correct scale(s) to measure the outcomes, (5) including economic evaluations with clinical (effectiveness) studies, and (6) reporting a study's results using the Enhancing the Quality and Transparency of Health Research, or EQUATOR, guidelines. Surgeon investigators are encouraged to continue improving the science in plastic surgery by applying the framework outlined in this article. Improving surgical clinical research should decrease resource waste and provide patients with improved evidence-based care.

Endoscopic Carpal Tunnel Release: Techniques, Controversies, and Comparison to Open Techniques

Endoscopic carpal tunnel release (ECTR) continues to rise in popularity as a treatment option for carpal tunnel syndrome. Numerous variations in technique and instrumentation currently exist, broadly classified into two-portal and single-portal techniques with antegrade and retrograde designs. ECTR is equally effective as open carpal tunnel release for alleviating symptoms of carpal tunnel syndrome with no differences in long-term outcomes. ECTR has an increased risk of transient nerve injury, whereas open carpal tunnel release has an increased risk of wound and scar complications. ECTR has higher direct costs but is associated with earlier return to work. ECTR is a safe and effective approach to carpal tunnel release in the hands of experienced surgeons.

History of Wrist Arthroscopy

Wrist arthroscopy has a rich history, drawing on contributions from around the world. Its foundation was laid in Japan with Kenji Takagi and Masaki Watanabe, who developed the arthroscope and the techniques for arthroscopy. Across several decades they advanced the optic and lighting technology, allowing the miniaturization which made wrist arthroscopy technologically feasible. A safe and standardized technique for wrist arthroscopy was evolved by Terry Whipple, Gary Poehling, and James Roth in the 1980s, and they shared this with their fellow surgeons through courses and publications. The techniques then spread across the world, leading to widespread uptake and exploration of new therapeutic possibilities. The worldwide spread of wrist arthroscopy was accelerated by the European Wrist Arthroscopy Society (EWAS), founded in 2005 by Christophe Mathoulin. The Asia Pacific Wrist Association (APWA), founded by PC Ho in 2015, also extended the progression of wrist arthroscopy. This article brings together this history and tells the global story of its development through the recollections of those involved. The manuscript includes some amazing videos of the early historical arthroscopy. There are also videos of Gary and Terry describing some of their special memories of the early politics, developments, and evolution of wrist arthroscopy.

Our 15-year experience of complications of Chow's technique for endoscopic carpal tunnel releasing

PURPOSE

Our objective in this study was to summarize our 15-year experience treating carpal tunnel syndrome released with Chow technique, focusing on the complications and how to avoid them.

METHOD

We systematically evaluated the postoperative complications in 211 patients who underwent endoscopic carpal tunnel release (ECTR) with Chow technique. We recorded the incidence of complex regional pain syndrome type I (CRPS I), median nerve and digital nerve injury, superficial palmar arch injury, and tendon injury.

RESULT

The overall incidence of complications was 5.6%, and involved 10 cases of CRPS I, 1 case of median nerve trunk injury, and 1 case of superficial palmar arch injury. No other complication occurred. We used oral pregabalin and neurotropin to relieve CRPS I symptoms, and performed second operations for the other two complications.

CONCLUSIONS

Our study revealed that ECTR could reduce structural and cutaneous complications, but increase the incidence of nerve injury. we speculated that the incidence of CRPS I may be higher in the Asian population.

Liberação endoscópica do túnel cubital na neurite hansênica do nervo ulnar

Objetivos Os objetivos deste estudo foram caracterizar melhor o papel da liberação endoscópica do túnel cubital na neurite hansênica e determinar se há melhora da dor, sensibilidade e força com esta técnica minimamente invasiva.

Métodos Um total de 44 procedimentos endoscópicos para descompressão do nervo ulnar no cotovelo foram realizados em pacientes previamente diagnosticados com neurite por hanseníase. Os critérios de inclusão foram indicação cirúrgica para liberação do nervo ulnar e insucesso do tratamento clínico por 4 semanas em pacientes com síndrome do túnel cubital que sofreram deterioração progressiva da função motora ou sensitiva do nervo ulnar apesar do tratamento de 1 mg/kg/dia de prednisona e fisioterapia. A liberação endoscópica foi realizada com CTS Relief Kit (Linvatec. Largo, FL, EUA) e um artroscópio padrão de 4 mm e 30°.

Resultados O estudo incluiu 39 pacientes, sendo 29 (74,4%) homens e 10 (25,6%) mulheres. A idade dos pacientes variou de 12 a 64 anos (33 ± 14,97). Cinco pacientes foram submetidos à liberação bilateral. A liberação provocou melhora estatisticamente significativa de dor (p = 0,002), sensibilidade (p <0,001) e força (p <0,001). Os melhores resultados foram obtidos quando a liberação ulnar foi realizada em menos de 6 meses após a indicação da cirurgia. Nenhum procedimento foi convertido de endoscópico para aberto. Não foram relatadas complicações maiores (infecção, lesão vascular e lesão nervosa). Um paciente apresentou subluxação do nervo ulnar.

Conclusão A liberação endoscópica do nervo ulnar no cotovelo na neurite hansênica traz benefícios verdadeiros e seguros para o paciente, como melhora da dor, sensibilidade e força.

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.

Suprafascial plane endoscopy versus open carpal tunnel release for idiopathic carpal tunnel syndrome: Use of the Accordion Severity Grading System

This study aimed to assess the safety and effectiveness of modified endoscopic technique with a single portal from an external carpal tunnel approach for surgical operations in a suprafascial plane superficial to the transverse carpal ligament. Reversible nerve injury risk is threefold greater with a conventional endoscopic method than with open carpal tunnel release (OCTR), and this suprafascial plane endoscopic release (SPER) should circumvent the problem of hardware in the carpal tunnel encountered with the conventional endoscopic method and liable to cause iatrogenic damage to the median nerve. However, the surgical consequences of the new technique have not been studied. To fill this gap, a retrospective therapeutic study was conducted to compare negative outcomes versus open surgery. The Accordion Severity Grading System was used to grade complications from 0 to 3 according to necessity of treatment. Sequela and failure rates were also compared between the SPER and OCTR groups. Eighty-eight cases in 72 patients with idiopathic carpal tunnel syndrome (ICTS) met the inclusion criteria. SPER was performed in 28 hands in 27 patients, and OCTR in 60 hands in 49 patients. The results showed no significant difference in complication, sequela, or failure rates between groups (p > 0.05). Suprafascial plane endoscopic release, has certain advantages over the open method and was validated as a safe and effective method of treating ICTS.

French trends in carpal tunnel surgery: An online survey of members of the French Society for Surgery of the Hand

Several surgical and anesthesia techniques are used in carpal tunnel surgery. The practices of members of the American Society for Surgery of the Hand and the Canadian Society of Plastic Surgery were recently published and compared. Because of the great difference in these practices, we investigated the practices of the members of the French Society for Surgery of the Hand and how they would change. An online survey including 14 systematic and 12 conditional questions was sent by email to all 685 surgeons who were members of the French Society for Surgery of the Hand in July 2019. Data were analyzed using descriptive statistics. The survey was completed by 129 members (19%). The open approach was used by 56% of the surgeons (8% by traditional open technique, 48% by minimally invasive open technique), endoscopic techniques by 40% and ultrasound-guided techniques by 4%. Most surgeons used regional anesthesia (69%) or local anesthesia (25%). Half of the surgeons (50%) would consider changing their surgical technique. Sixty-one percent were interested in ultrasound-guided techniques and 34% in endoscopic techniques. Almost half the surgeons (48%) would consider changing their anesthesia technique and 97% were interested in local anesthesia. Our study showed that the open approach and regional anesthesia were the most frequently used techniques but that an increase in endoscopic and ultrasound-guided techniques as well as local anesthesia techniques was likely. LEVEL OF EVIDENCE: Economic and decision analysis V.

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.

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.

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.

Onset of Trigger Finger after Carpal Tunnel Syndrome Surgery: Assessment of Open and Endoscopic Techniques

Objective  The present study aimed to determine the frequency of trigger finger (TF) onset after surgery for carpal tunnel syndrome (CTS) using an open (OT) or an endoscopic technique (ET). As a secondary endpoint, the present study also compared paresthesia remission and residual pain rates in patients submitted to both techniques.

Methods  Trigger finger onset and remission rates of paresthesia and pain at the median nerve territory was verified prospectively in a series of adult patients submitted to an OT procedure ( n  = 34). These findings were compared with a retrospective cohort submitted to ET ( n  = 33) by the same surgical team. Patients were evaluated with a structured questionnaire in a return visit at least 6 months after surgery.

Results  Sixty-seven patients were evaluated. There was no difference regarding trigger finger onset (OT, 26.5% versus ET, 27.3%; p  = 0.94) and pain (OT, 76.5% versus ET, 84.8%; p  = 0.38). Patients submitted to OT had fewer paresthesia complaints compared with those operated using ET (OT, 5.9% versus ET, 24.2%; p  = 0.03).

Conclusions  In our series, the surgical technique did not influence trigger finger onset and residual pain rates. Patients submitted to OT had less complaints of residual postoperative paresthesia.

Supraretinacular endoscopic carpal tunnel release: A safe alternative method for treatment of carpal tunnel syndrome

PURPOSE

Supraretinacular endoscopic carpal tunnel release (SRECTR) is a technique in which an endoscope is inserted superficial to the flexor retinaculum through a subcutaneous tunnel. The benefits of this method include a clear view for the surgeon and absence of median nerve compression. Surgeons can operate with a familiar view of the flexor retinaculum and median nerve downward, similar to open surgery. This study aimed to investigate the learning curve for SRECTR, an alternate method for carpal tunnel release, and evaluate its complications and the functional outcomes using a disposable commercial kit.

METHODS

We examined the open conversion rates and complications associated with SRECTR in 200 consecutive patients performed by two surgeons. We compared the operative time operated by a single surgeon. We evaluated outcomes in 191 patients according to Kelly's grading system. Patients' mean follow-up period was 12.7 months.

RESULTS

Nine patients required conversion to open surgery. There were no injuries to the nerves and tendons and no hematoma or incomplete dissection of the flexor retinaculum. The operative times varied between 11 and 34 minutes. We obtained the following results based on Kelly's grading of outcomes: excellent in 116, good in 59, fair in 13, and poor in 3 patients.

CONCLUSIONS

We found no patients with neurapraxia, major nerve injury, flexor tendon injury, superficial palmar arch injury, and hematoma. Although there was a learning curve associated with SRECTR, we performed 200 consecutive cases without neurovascular complications. This method may be a safe alternative to minimally invasive carpal tunnel surgery.

Endoscopic Carpal Tunnel Release Without Invading the Tunnel: A New Transretinacular Technique

Established endoscopic carpal tunnel release (ECTR) techniques carry a not entirely eludible risk of iatrogenic complications, mainly because of incomplete view of the cutting blade and intraoperative pressure increase inside the carpal tunnel (CT). We describe a novel single-portal ECTR method, conceived to reduce these risks, by optimizing visual control and avoiding dilatation of the CT. After incising the well exposed proximal third of the transverse carpal ligament (TCL), transection of the remainder is completed using a pediatric urethrotome. This small caliber instrument is moved in the plane of the TCL, without invading the tunnel, and provides detailed view of the TCL and any crossing anatomical structures at any given moment. We present the technique and the results of a retrospective case series of 33 patients with CT syndrome who underwent the procedure, after failing to respond to conservative treatment. Because of improved view and the avoidance of intraoperative pressure trauma to structures passing through the CT, the described approach may contribute to prevent iatrogenic complications and represent a valid improvement over conventional ECTR procedures.

Endoscopic carpal tunnel release with or without suture: Does it make a difference? A case-control study

A case-control study was conducted to compare wound healing with or without skin suture after endoscopic carpal tunnel release. The primary endpoint was esthetics on the Manchester Scar Scale (MSS). Patients were recruited between April 2016 and April 2017. Inclusion criteria comprised carpal tunnel syndrome with clinical and electromyographic confirmation on the Canterbury NCS (nerve conduction studies) Severity Scale. Age, gender, occupation, handedness, smoking status, and operated side were noted. In the first group (64 patients) the skin was not sutured. In the second group (44 patients) the skin was closed Ethilon™ 5-0 intradermal running suture. All 108 patients had 3 months' follow-up. Since data were not normally distributed, analysis was performed with the Mann-Whitney U test (MWU) for independent samples. There were no significant differences in age (p = 0,416), gender (p = 0.670) or occupation (p = 0.725) between groups. MSS score did not significantly differ between groups (MWU test; p = 0.529): sutureless, 6.64 ± 1.21; sutured, 6.45 + 1.09. Thus, sutureless wound closure can be a useful option in treating carpal tunnel syndrome by a single-portal endoscopic technique. That the wound remains open enables easy evacuation of any hematoma, avoiding pain due increased intra-tissular pressure.

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.

Initial Outcomes of a Novel High-Visibility Endoscopic Carpal Tunnel Release Technique

Background  A large variety of endoscopic carpal tunnel release methods have been described in efforts to shorten recovery time, reduce scar discomfort, and allow earlier return to work. The majority of existing techniques are the modifications of the Agee, Chow, and Menon techniques, all of which require dedicated equipment that can increase facility and surgical fees for the patient and institution. We present a novel high-visibility endoscopic carpal tunnel release technique that uses common hand surgery instruments available in all surgical units, without requiring disposable or custom devices. Description of Technique  The cases were performed under local anesthesia using routine reusable instruments and a conventional 2.5-mm 30-degree small joint arthroscope. Following proximal dissection, a clear, colorless, plastic shield was created from a standard syringe that offered a 360-degree vision of the carpal tunnel and protection of the median nerve. Release of the transverse carpal ligament was performed under full arthroscopic vision using Metzenbaum dissection scissors. Methods  This pilot study analyses the first nine cases in eight patients who were operated on using this technique, with a minimum of 6 months of follow-up. Results  No peri- or postoperative complications were encountered. All patients demonstrated significant improvements in the Disabilities of the Arm, Shoulder, and Hand score, the Boston Carpal Tunnel Questionnaire score, and a visual analog score for pain. Conclusion  The high-visibility endoscopic carpal tunnel release technique is safe and effective, and offers a viable cost-reducing alternative to the existing endoscopic methods for carpal tunnel syndrome. Future comparative trials are required to validate these findings in a larger series. Level of Evidence  This is a Level IV study.

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.

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.

A Prospective, Randomized Trial Comparing Open and Endoscopic Carpal Tunnel Release Within the Same Patient

Background: Surgical management of carpal tunnel syndrome includes performing an endoscopic (ECTR) or open (OCTR) carpal tunnel release. Several studies have shown less postoperative pain and improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine outcomes, patient satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient. Methods: This was a prospective study in which patients with bilateral carpal tunnel syndrome underwent surgical release with both techniques, with initial operative approach randomized in the more symptomatic hand. Demographic data and functional outcomes were recorded, including the pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score, and overall satisfaction. Results: Thirty patients completed the study; there were no significant differences in any measure at any of the postoperative time points. Symptom severity and functional status scores were not significantly different between groups at any evaluation. Subjectively, 24 of 30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason, although pain scores were not significantly different. Differences in overall satisfaction were also not significant. Conclusions: Both techniques are well tolerated with no differences in outcomes. With the added cost and equipment associated with ECTR, and no added benefit, the usefulness of ECTR is questionable.

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.

Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia

Purpose

We report on patient and surgeon experience after single-port endoscopic carpal tunnel release (CTR) using wide-awake local anesthesia no tourniquet (WALANT) technique.

Methods

From July to November 2018, patients undergoing endoscopic CTR with WALANT were prospectively included. Follow-up was 3 months. Patient ratings before, during, and after the operation were collected. We recorded the surgeon’s experience during surgery compared with the endoscopic CTR under local anesthesia with exsanguination and tourniquet. Complications were defined as nerve injury, infection, or the need for revision surgery.

Results

The cohort consisted of 20 patients (24 wrists). All patients except one reported a complete or substantial decrease of symptoms. The 2 surgeons involved judged the procedure to be technically more demanding owing to impaired visualization (33%) caused by increased bleeding and edema in the operative field. There was one conversion from endoscopic to open surgery.

Conclusions

We recommend starting single-port endoscopic CTR using WALANT with a noninflated tourniquet in place for use when necessary.

Type of study/level of evidence

Therapeutic IV.

Outcomes of Endoscopic Carpal Tunnel Release With Ring Finger Flexor Digitorum Superficialis Opponensplasty in Severe Carpal Tunnel Syndrome

PURPOSE

To evaluate the outcomes of endoscopic CTR with ring finger flexor digitorum superficialis (FDS) opponensplasty for the treatment of patients with severe carpal tunnel syndrome (CTS).

METHODS

We prospectively studied 52 patients who were graded as having severe CTS by physical examination and electrodiagnostic studies and who underwent endoscopic CTR-ring finger FDS opponensplasty. Preoperative and postoperative data were collected for active perpendicular thumb abduction; Kapandji score for thumb opposition; grip, key, and tip pinch strength; Medical Research Council score on sensory and motor recovery; Semmes-Weinstein monofilament testing; thenar muscle bulk recovery; and work status.

RESULTS

Follow-up was 17.5 months on average (range, 7-34 months). Thumb abduction improved significantly from 13.2° (±4.6°) before surgery to 61.7° (±6.4°) afterward. Mean thumb opposition (as measured by Kapandji score) improved significantly from grade 1.5 to 8.7. Tip pinch strength significantly improved from 38.9% to 72.9% of the contralateral side. Medical Research Council scores improved to S3+ and S4 in 85% of patients and to M4 and M5 in 96% of patients. Sensory threshold recovery to 3.61 and 4.31 monofilament occurred in 85% of patients. We observed thenar muscle bulk recovery in 51.9% of patients. Time to return to work was 5 weeks after surgery, on average. Two patients reported scar pain, 2 reported pillar pain, and we found ring finger proximal interphalangeal joint contracture in 3.

CONCLUSIONS

Endoscopic CTR with FDS opponensplasty provides satisfactory outcomes of improved thumb abduction and opposition, sensory and motor recovery, and early return to work in patients with severe CTS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

'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.

Comparison of open and endoscopic carpal tunnel surgery regarding clinical outcomes, complication and return to daily life: A prospective comparative study

Objective

This study aimed to compare the clinical results and complications as well as patient satisfaction in patients with carpal tunnel syndrome operated with open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR) techniques.

Methods

This study conducted in Istanbul Training and Research Hospital between August 2016 and January 2018. A total of 54 patients were operated with the ECTR technique and 50 patients were operated with the OCTR technique after failing nonsurgical treatment. Patients functional scores are assessed with the carpal tunnel syndrome-functional status score (CTS-FSS) and carpal tunnel syndrome-symptom severity score (CTS-SSS). Operation time, incision length and complications of the two techniques were noted and compared.

Results

The age, sex distribution, distribution of sides, and complaint period were not significant (p > 0.05) between the groups. The preoperative or postoperative CTS-SSS and CTS-FSS values did not differ significantly (p > 0.05). Incision length, time to return to work and return to daily life in the OCTR group was significantly higher than the ECTR group (p < 0.05).

Conclusion

ECTR has similar results in terms of symptom relief, severity, functional status, pillar pain and complication rates compared to OCTR. However, it has the advantages of early return to daily life, early return to work and less incision length.

Sleep disturbance and response to surgical decompression in patients with carpal tunnel syndrome: a prospective randomized pilot comparison of open versus endoscopic release

BACKGROUND

Sleep disturbance is a common complaint of patients with carpal tunnel syndrome (CTS). While carpal tunnel release (CTR) surgery has been shown to relieve subjective sleep-related complaints, data is lacking on the global effect on sleep using validated sleep measures. Additionally, it is not known if open (OCTR) or endoscopic release (ECTR) produce differing degrees of sleep-symptom relief.

METHODS

Sixty patients were randomly allocated to undergo either OCTR (n=30) or ECTR (n=30) surgery. Forty-three (71.7%) of the patients were female, and mean age of all patients was 49.4 years (range, 35-78). Prior to surgery, patients were administered three baseline self-reported outcome measures: the Pittsburgh Sleep Quality Index (PQSI), the Insomnia Severity Scale (ISI) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, which were subsequently administered at three postoperative time points: 1-2 weeks, 4-6 weeks and 6-12 months.

RESULTS

All 60 patients experienced significant improvements in the three outcome scores by their first postoperative visit compared to preoperatively. ECTR provided superior improvement to OCTR at the first postoperative visit for ISI (P=0.006) and PSQI (P=0.016), and at the second visit for PSQI (P=0.0038). There were no significant differences between the two groups for the QuickDASH at any time points, or for the ISI/PSQI at the final follow-up.

CONCLUSION

Endoscopic and open CTR both improve sleep symptoms postoperatively in the short-term which is sustained for 6-12 months, although endoscopic CTR does so more rapidly.