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Tsuchiya T, Takai K. Relationships between the global symptom score and electrophysiological findings after surgical release for carpal tunnel syndrome: Indications and outcomes. Acta Neurochir (Wien) 2024; 166:228. [PMID: 38780808 DOI: 10.1007/s00701-024-06092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Regarding surgical indications for carpal tunnel syndrome (CTS), the hypothesis that the recovery processes of subjective symptoms differ among pain, sensory, and motor symptoms and correlate with recovery in objective nerve conduction studies was examined in the present study. METHODS The global symptom score (GSS) is a method used to assess clinical outcomes and covers subjective symptoms, including pain (pain and nocturnal awakening), sensory (numbness and paresthesia), and motor (weakness/clumsiness) symptoms. The relationships between long-term changes in GSS and recovery in nerve conduction studies were investigated. RESULTS Forty patients (40 hands) were included (mean age 65 years; 80% female; 68% with moderate CTS: sensory nerve conduction velocity < 45 m/s and motor nerve distal latency > 4.5 ms). Pain and nocturnal awakening rapidly subsided within 1 month after surgery and did not recur in the long term (median 5.6 years). Paresthesia significantly decreased 3 months after surgery and in the long term thereafter. Weakness/clumsiness significantly decreased at 1 year. Sensory nerve distal latency, conduction velocity, and amplitude significantly improved 3 months and 1 year after surgery, and correlated with nocturnal awakening in the short term (3 months) in moderate CTS cases. The patient satisfaction rate was 91%. CONCLUSION Rapid recovery was observed in pain and nocturnal awakening, of which nocturnal awakening correlated with the recovery of sensory nerve conduction velocity. Patients with pain symptoms due to moderate CTS may benefit from surgical release.
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Affiliation(s)
- Takahiro Tsuchiya
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
| | - Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan.
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von Bergen TN, Reid R, Delarosa M, Gaul J, Chadderdon C. Surgeons' Recommendations for Return to Work After Carpal Tunnel Release. Hand (N Y) 2023; 18:100S-105S. [PMID: 35765861 PMCID: PMC9896273 DOI: 10.1177/15589447221085700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - John Gaul
- OrthoCarolina Hand Center, Charlotte,
NC, USA
| | - Christopher Chadderdon
- OrthoCarolina Hand Center, Charlotte,
NC, USA
- Atrium Health, Charlotte, NC, USA
- OrthoCarolina Research Institute,
Charlotte, NC, USA
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Poitevin L, Ferraguti MS. Anestesia local con epinefrina, sin manguito hemostático, para la liberación del túnel carpiano. Estudio comparativo de dos variantes técnicas en 89 casos. REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.6.1466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objetivo: Evaluar la eficacia intra- y posoperatoria, y la comodidad para el paciente de dos variantes de la anestesia en dos grupos con síndrome del túnel carpiano.
Materiales y Métodos: Estudio descriptivo, comparativo, retrospectivo, observacional mediante un cuestionario telefónico de 12 ítems sobre la anestesia local sin manguito. Se incorporó a pacientes con síndrome del túnel carpiano operados entre 2008 y 2019, mediante un miniabordaje abierto. Se dividió en: grupo 1: lidocaína al 2% más bupivacaína al 0,5% más epinefrina 1:200.000 más sedación ligera (n = 32) y grupo 2: lidocaína al 2% más epinefrina 1:200.000 (n = 57).
Resultados: Se evaluó a 89 pacientes (media de edad 66.9 años). Todos se mostraron satisfechos, confirmaron que volverían a elegir este procedimiento. No hubo diferencias significativas en la comodidad o el posible desarrollo de síntomas intra- o posoperatorios entre ambos grupos. La permanencia posoperatoria fue de 1-3 h, sin hospitalización. El sangrado fue mínimo.
Conclusiones: La liberación del túnel carpiano bajo anestesia local más epinefrina, sin manguito hemostático, resultó segura y sin complicaciones. Los pacientes no refirieron dolor local intraoperatorio ni posoperatorio inmediato, ni en el sitio del torniquete. La permanencia en el centro asistencial fue breve. La estancia corta y la menor cantidad de elementos empleados (anestésicos, manguito) implican una reducción de los costos del procedimiento. Si bien es recomendable la presencia de un anestesiólogo, puede llegar a realizarse en ámbitos adecuados sin él. No se recomienda su empleo sin estudios prequirúrgicos ni fuera del quirófano.Nivel de Evidencia: III
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Hein RE, Hollins AW, Fletcher AN, Ruch DS, Richard MJ, Mithani SK. Return to Activities After Simultaneous Bilateral Endoscopic Carpal Tunnel Release. Hand (N Y) 2022; 17:646-651. [PMID: 32940056 PMCID: PMC9274870 DOI: 10.1177/1558944720940061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Approximately 56% of patients diagnosed with carpal tunnel syndrome present with bilateral symptoms; however, few studies have investigated bilateral simultaneous endoscopic carpal tunnel release (ECTR) and postoperative effect on return to activity. The purpose of this study was to evaluate the length of recovery in patients who received bilateral simultaneous ECTR, including pain medication requirements, return to activities of daily living, return to work, and return to recreational activities. METHODS A retrospective analysis was performed on patients who underwent bilateral ECTR by a single hand fellowship-trained surgeon from 2013 to 2019. Demographic, operative, and clinical outcomes were collected via chart review and a telephone interview. Student t tests and χ2 tests were conducted for analysis. RESULTS Eighty patients were included in the study; 40 were successfully contacted for telephone interview follow-up. Patients reported an average of 2 days of use of postoperative narcotic pain medication and an average of 5, 7, and 19 days of return to activities of daily living, work, and recreational activities, respectively. Female patients reported more days of narcotic pain medications (1 day vs 3 days, P = .0483) and an average of longer return to work than men (9 days vs 5 days, P = .0477). Manual laborers reported longer return to work (9 days vs 5 days, P = .0500). Older patients (aged >65 years) reported longer return to recreational activities (39 days vs 11 days, P = .0189). CONCLUSIONS Simultaneous bilateral ECTR is a successful procedure with shorter recovery times than reported previously. Female patients, manual laborers, and older patients experience a longer recovery and should be counseled appropriately.
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Affiliation(s)
- Rachel E. Hein
- Duke University Medical Center, Durham, NC, USA,Rachel E. Hein, Department of Orthopaedic Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.
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Jones M, Evans J, Fullilove S, Doyle E, Gozzard C. The SToICAL trial: study protocol for the soft tissue injection of corticosteroid and local anaesthetic trial-a single site, non-inferiority randomised control trial evaluating pain after soft tissue corticosteroid injections with and without local anaesthetic. Trials 2021; 22:662. [PMID: 34583762 PMCID: PMC8479928 DOI: 10.1186/s13063-021-05627-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Corticosteroid injections are used in the treatment of hand and wrist conditions. The co-administration of a local anaesthetic and corticosteroid aims to reduce pain after the injection, although no studies have directly compared this with using corticosteroid alone. The aim is to determine whether pain experienced during the 24 h after a corticosteroid injection to the hand and wrist is no worse than (not inferior to) the pain experienced after a corticosteroid and local anaesthetic injection. METHODS A single-site, patient- and assessor-blinded, non-inferiority randomised control trial recording pain visual analogue scale (VAS) scores in patients with a clinical diagnosis of trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome, treated with a 1-ml triamcinolone (40 mg/1 ml) injection co-administered with or without 1 ml of 1% lidocaine. The primary aim is to investigate a difference in pain VAS scores at 1 h after the injection using a mean change score. A 95% power calculation was made using a minimally clinical important difference of 20 mm as the clinically admissible margin of non-inferiority and an assumed standard deviation of 25 mm, from previous studies. Including a 20% fall out rate, 100 patients are required. DISCUSSION Patients with a clinical diagnosis of trigger finger, de Quervains and carpal tunnel syndrome, are over the age 18 years old and who are able to give written informed consent will be included. Patients will be excluded if they have had previous surgery or corticosteroid injection for the condition being treated at the site considered for injection. Patients will be electronically randomised and injections delivered during their clinic appointment. Pain is assessed using a 100-mm VAS score taken, before and at the time of injection and at 5 min, 1 h, 2 h, 3 h and 24 h after the injection. The secondary outcomes are to determine a difference in pain VAS score at the time of injection and during the 24 h after. TRIAL REGISTRATION This study is registered on the IRAS (259336) on November 11, 2019, and EudraCT database on October 31, 2019 (2019-003742-32). REC/HRA approval was given in January 2020, and Clinical Trial Authorisation from the MHRA was given in December 2019. The study is registered on ClinicalTrials.gov ( NCT04253457 ) on February 5, 2020.
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Affiliation(s)
- M Jones
- Trauma and Orthopaedic Department, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK
| | - J Evans
- Health Services and Policy Research Group, University of Exeter, St Lukes Campus, 79 Heavitree Road, Exeter, EX1 1TX, UK.
| | - S Fullilove
- Trauma and Orthopaedic Department, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK
| | - E Doyle
- Trauma and Orthopaedic Department, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK
| | - C Gozzard
- Trauma and Orthopaedic Department, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK
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Kortlever JTP, Zhuang T, Ring D, Reichel LM, Vagner GA, Kamal RN. Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial. Hand (N Y) 2021; 16:439-446. [PMID: 31517517 PMCID: PMC8283107 DOI: 10.1177/1558944719873399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.
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Affiliation(s)
| | | | - David Ring
- The University of Texas at Austin, Austin, USA
| | | | | | - Robin N. Kamal
- Stanford University, Redwood City, CA, USA,Robin N. Kamal, VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, MC 6342, Redwood City, CA 94603, USA.
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Billig JI, Lu YT, Hayward RA, Sears ED. Surgical Timing for Carpal Tunnel Syndrome: A Comparison of Health Care Delivery in the Veterans Administration and Private Sector. J Hand Surg Am 2021; 46:544-551. [PMID: 33867201 PMCID: PMC8260449 DOI: 10.1016/j.jhsa.2021.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 12/10/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The U.S. Department of Veterans Affairs (VA) health care system monitors time from referral to specialist visit. We compared wait times for carpal tunnel release (CTR) at a VA hospital and its academic affiliate. METHODS We selected patients who underwent CTR at a VA hospital and its academic affiliate (AA) (2010-2015). We analyzed time from primary care physician (PCP) referral to CTR, which was subdivided into PCP referral to surgical consultation and surgical consultation to CTR. Electrodiagnostic testing (EDS) was categorized in relation to surgical consultation (prereferral vs postreferral). Multivariable Cox proportional hazard models were used to examine associations between clinical variables and surgical location. RESULTS Between 2010 and 2015, VA patients had a shorter median time from PCP referral to CTR (VA: 168 days; AA: 410 days), shorter time from PCP referral to surgical consultation (VA: 43 days; AA: 191 days), but longer time from surgical consultation to CTR (VA: 98 days; AA: 55 days). Using multivariable models, the VA was associated with a 35% shorter time to CTR (AA hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.52-0.82) and 75% shorter time to surgical consultation (AA HR, 0.25; 95% CI, 0.20-0.03). Receiving both prereferral and postreferral EDS was associated with almost a 2-fold prolonged time to CTR (AA HR, 0.49; 95% CI, 0.36-0.67). CONCLUSIONS The VA was associated with shorter overall time to CTR compared with its AA. However, the VA policy of prioritizing time from referral to surgical consultation may not optimally incentivize time to surgery. Repeat EDS was associated with longer wait times in both systems. CLINICAL RELEVANCE Given differences in where delays occur in each health care system, initiatives to improve efficiency will require targeting the appropriate sources of preoperative delay. Judicious use of EDS may be one avenue to decrease wait times in both systems.
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Affiliation(s)
- Jessica I Billig
- VA/National Clinician Scholars Program, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, MI; Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI
| | - Yu-Ting Lu
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI
| | - Rodney A Hayward
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Institute of Health Policy and Innovation, Michigan Medicine, Ann Arbor, MI
| | - Erika D Sears
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Institute of Health Policy and Innovation, Michigan Medicine, Ann Arbor, MI.
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Comparing Minor Hand Procedures Performed with or without the Use of a Tourniquet: A Randomized Controlled Trial. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3513. [PMID: 33854860 PMCID: PMC8032361 DOI: 10.1097/gox.0000000000003513] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/26/2022]
Abstract
Background Carpal tunnel syndrome and trigger finger are two of the most common conditions treated by the hand surgeon. During these procedures, a tourniquet is often used to minimize bleeding and improve visualization of the operative field. However, it may be associated with pain and discomfort. To date, there are few prospective studies investigating the safety and patient-centered outcomes of tourniquet-free minor hand procedures. Methods This is a randomized controlled trial comparing patients undergoing open carpal tunnel or trigger finger release with or without the use of a tourniquet. Perioperative subjective patient experience was investigated for both techniques. This was measured based on a numerical rating scale for pain, anxiety, and overall satisfaction. In addition, this was an equivalence trial in terms of operative time, bleeding scores, and perioperative complication rates. Results A total of 67 patients were recruited. Both groups were similar with respect to distribution of age, sex, handedness, anti-platelet use, and tobacco use. Median scores for operative time, anxiety, and overall satisfaction were comparable between the 2 groups. With regard to patient discomfort, median scores were significantly higher in the tourniquet group when compared with the no tourniquet group (3.58 versus 1.68, respectively, P = 0.02). Bleeding scores for the tourniquet group were significantly lower than for the no tourniquet group (1.14 versus 1.90, respectively, P = 0.001). Conclusions The application of wide awake local anesthesia no tourniquet (WALANT) in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort, improving perioperative patient experience. Additionally, it demonstrated the noninferiority of the tourniquet-free technique with respect to operative time and the rate of perioperative complications.
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Affiliation(s)
- Thomas R. Hales
- Medical Epidemiologist, NIOSH, Denver, CO, formerly Acting Director, OSHA Office of Occupational Medicine
| | - Patricia K. Bertsche
- Health Science Specialist, U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), Washington, D.C
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Abstract
Objectives
This study aims to analyze the nationwide trends in carpal tunnel surgery by surgeons practicing in Turkey according to experience in years, training received (plastic surgery or orthopedics), and working location (Turkey or abroad) by slightly modifying Munns’ survey. Materials and methods
A printed and online survey consisting of 11 questions was sent to Turkish and international surgeons. The surgeon’s province of practice, years in practice, type of education received as a resident, preferred operation room, preferred surgical approach, type of anesthesia used, use of postoperative orthosis and therapy were assessed in the survey. Results
The survey was completed by 198 surgeons (a 25% response rate). The majority of surgeons practicing in Turkey (87%) and 67% of surgeons practicing abroad demanded electromyography (EMG) and nerve conduction studies. Sixty- one percent of respondents from Turkey and 76% of respondents practicing abroad did not administer antibiotics preoperatively. While the most common anesthetic technique used by international surgeons was subcutaneous local anesthesia (42%), Turkish surgeons preferred wrist block (18%). Surgeons practicing in Turkey with fewer than five years of experience were more likely to administer antibiotics preoperatively, use EMG/nerve conduction studies, utilize a mini-open approach and apply an orthosis postoperatively (p<0.05). Conclusion There are comparable differences between Turkish and international surgeons regarding pre- and postoperative management of carpal tunnel surgery. Province of practice, years in practice, and type of education received as a resident have influence over the management of carpal tunnel syndrome.
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Halvorson AJ, Sechriest VF, Gravely A, DeVries AS. Risk of surgical site infection after carpal tunnel release performed in an operating room versus a clinic-based procedure room within a Veterans Affairs medical center. Am J Infect Control 2020; 48:173-177. [PMID: 31627986 DOI: 10.1016/j.ajic.2019.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/02/2019] [Accepted: 08/03/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Carpal tunnel release (CTR) is increasingly performed in a clinic-based procedure room (PR) environment, which is less restrictive than traditional operating rooms (ORs). It is unknown if there is an impact on surgical site infection (SSI) rates. METHODS Records of patients who underwent clean, elective CTR from October 2014 to April 2017 at a single site were identified using Current Procedural Terminology codes and charts reviewed using National Healthcare Safety Network SSI criteria. Procedure type and patient characteristics were assessed with multivariate logistic regression and costs compared using administrative data. RESULTS A total of 312 procedures were included: 221 in OR and 91 in PR. SSI rate, including revisions, was 2.88% (nonrevision rate was 2.30%). Unadjusted SSI rate was 3.2% in OR and 2.2% in PR (P = .64). After adjusting for underlying risk factors, procedure setting was not associated with risk of SSI (P = .53; odds ratio, 0.43; 95% confidence interval, 0.03-5.94). Revision CTR was a predictor of SSI (P = .02; odds ratio, 28.21; 95% confidence interval, 1.84-434.57). The mean total cost of CTR in the OR was $4,254.21 and PR was $416.93. CONCLUSIONS There was no significant difference in SSI rates for CTR performed in OR and PR environments. CTRs performed in a PR led to a 10-fold cost savings. Based on our findings of PRs as both safe and cost-effective, we recommend that more facilities explore the use of PRs for CTR.
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Affiliation(s)
- Amanda J Halvorson
- Infectious Disease, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
| | - V Franklin Sechriest
- Orthopaedic Surgery, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
| | - Amy Gravely
- Research Services, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
| | - Aaron S DeVries
- Infectious Disease, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN.
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Sears ED, Meerwijk EL, Schmidt EM, Kerr EA, Chung KC, Kamal RN, Harris AHS. Variation in Nonsurgical Services for Carpal Tunnel Syndrome Across a Large Integrated Health Care System. J Hand Surg Am 2019; 44:85-92.e1. [PMID: 30579690 PMCID: PMC6400455 DOI: 10.1016/j.jhsa.2018.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 09/19/2018] [Accepted: 11/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate facility-level variation in the use of services for patients with carpal tunnel syndrome (CTS) receiving care in the Veterans Health Administration (VHA). METHODS A national cohort of VHA patients diagnosed with CTS during fiscal year 2013 was divided into nonsurgical and operative treatment groups for comparison. We assessed the use of 5 types of CTS-related services (electrodiagnostic studies [EDS], imaging, steroid injection, oral steroids, and therapeutic modalities) in the prediagnosis and postdiagnosis periods before any operative intervention at the patient and facility levels. RESULTS Among 72,599 patients newly diagnosed with CTS, 5,666 (7.8%) received carpal tunnel release within 12 months. The remaining 66,933 (92.2%) were in the nonsurgical group. Therapeutic modalities and EDS were the most commonly employed services after the index diagnosis and had large facility-level variation in use. At the facility level, the use of therapeutic modalities ranged from 0% to 93% in the operative group (mean, 32%) compared with 1% to 67% (mean, 30%) in the nonsurgical group. The use of EDS in the postdiagnosis period ranged from 0% to 100% (mean, 59%) in the operative treatment group and 0% to 55% (mean, 26%) in the nonsurgical group at the facility level. CONCLUSIONS There is wide facility variation in the use of services for CTS among patients receiving operative and nonsurgical treatment. Care delivered by facilities with the highest and lowest rates of service use may suggest overuse and underuse, respectively, of nonsurgical CTS services and a lack of consideration of individual patient factors in making health care decisions regarding use. CLINICAL RELEVANCE Surgeons must understand the degree of treatment variability for CTS, comprehend the ramifications of large variation in reimbursement and waste in the health care system, and become involved in devising strategies to optimize hand care across all phases of care.
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Affiliation(s)
- Erika D. Sears
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI,Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Esther L. Meerwijk
- Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
| | - Eric M. Schmidt
- Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
| | - Eve A. Kerr
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI,Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Kevin C. Chung
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Alex H. S. Harris
- Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA,Department of Surgery, Stanford University, Palo Alto, CA
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Canadian Trends in Carpal Tunnel Surgery. J Hand Surg Am 2018; 43:1035.e1-1035.e8. [PMID: 29559326 DOI: 10.1016/j.jhsa.2018.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 01/03/2018] [Accepted: 02/09/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Treatment patterns of carpal tunnel surgery by members of the American Society of Surgery of the Hand (ASSH) have recently been published. The majority of cases in this study were performed in the general operating room with intravenous (IV) sedation or a Bier block. Patients were most commonly prescribed hydrocodone for postoperative pain. The majority of carpal tunnel releases at our center are performed under local anesthesia alone, with plain acetaminophen (Tylenol) or codeine prescribed for postoperative pain. The authors were interested in determining whether these differences were specific to our center or whether there were nationwide differences among the Canadian Society of Plastic Surgery (CSPS) members compared to the ASSH members. We aimed to conduct a similar study to assess current trends across members of the CSPS to assess similarities and differences compared with current practices by members of the ASSH. METHODS A 10-question survey, modeled after a previously published study, was sent electronically to Canadian plastic surgeons (n = 400). A description and a link to the survey was sent via e-mail and data were anonymously submitted and analyzed using descriptive statistics. RESULTS The online survey was completed by 183 surgeons (46%). The local procedure room is used by 161 (surgeons 88%), whereas 15 surgeons (8%) used the general operating room. Subcutaneous local anesthetic is used by 98 surgeons (54%), a median nerve block by 68 (7%), a full wrist block used by 6 (3%), local anesthesia with IV sedation used by 6 (3%), a Bier block used by 3 (2%), and a general anesthetic used by 1 (0.5%). After surgery, 70 surgeons (38%) prescribed codeine, 49 (27%) prescribed plain paracetamol, 24 (13%) prescribed nonsteroidal anti-inflammatories, 21 (12%) prescribed tramadol, and 21 (12%) prescribed a narcotic stronger than codeine. CONCLUSIONS Compared with data obtained from ASSH members, differences in practice by Canadian plastic surgeons responding to this survey appear to be related to type of anesthetic used and postoperative analgesia provided. The majority of procedures in this study were performed in a local procedure room under local anesthetic alone and the majority of patients are discharged with codeine or paracetamol. CLINICAL RELEVANCE This study draws comparisons between Canadian plastic surgeons and members of the ASSH with respect to carpal tunnel surgery and adherence to the American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Diagnosis and Treatment of Carpal Tunnel Syndrome.
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Logli AL, Bear BJ, Schwartz EG, Korcek KJ, Foster BJ. A Prospective, Randomized Trial of Splinting After Minicarpal Tunnel Release. J Hand Surg Am 2018; 43:775.e1-775.e8. [PMID: 29482955 DOI: 10.1016/j.jhsa.2018.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 12/23/2017] [Accepted: 01/22/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if any significant differences exist in patient-reported or clinical outcomes among 3 different postoperative orthotic regimens: no orthosis, removable orthosis, and plaster nonremovable orthosis-following miniopen carpal tunnel release (CTR) surgery for symptomatic isolated carpal tunnel syndrome. METHODS A total of 249 patients received a miniopen CTR and were subsequently randomized into 1 of 3 orthotic regimens: 80, no orthosis; 83, removable orthosis; and 86, nonremovable orthosis-to be removed at the first postoperative visit 10 to 14 days later. Patient-reported outcomes included the quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) surveys, Levine-Katz Symptom Severity and Functional Status Scales, and Pain at Rest and in Action using the Numerical Pain Rating Scale. Clinical outcomes included wrist range of motion, grip, and lateral pinch strengths. All outcomes were evaluated bilaterally at 10 to 14 days, 6 weeks, and 3, 6, and 12 months after surgery by evaluators blinded to the assigned regimen. Demographic information was obtained before surgery, and complications were recorded throughout the study. RESULTS There were no statistically significant differences in any patient-reported or clinical outcomes at any follow-up period except at 6 and 12 months: the lateral pinch strength of the nonremovable orthosis group with CTR in the dominant hand was weaker than both of the other groups. Patient demographic characteristics did not significantly influence the outcomes at any time. Scar tenderness was the most commonly observed complication followed by stiffness. There were 2 cases each of complex regional pain syndrome and superficial wound dehiscence and 1 case of wound infection that resolved with oral antibiotics. CONCLUSIONS The postoperative orthotic regimen does not change any patient-reported outcome up to at least 12 months following miniopen CTR. Lateral pinch strength was weaker in the nonremovable orthosis group at 6 and 12 months. Our data do not support the use of any postoperative orthosis following routine miniopen CTR. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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Affiliation(s)
- Anthony L Logli
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Brian J Bear
- Hand, Wrist & Elbow Service, OrthoIllinois, Inc., Rockford, IL; University of Illinois, College of Medicine at Rockford, Rockford, IL.
| | - Edric G Schwartz
- Hand, Wrist & Elbow Service, OrthoIllinois, Inc., Rockford, IL; University of Illinois, College of Medicine at Rockford, Rockford, IL
| | - Kenneth J Korcek
- Hand, Wrist & Elbow Service, OrthoIllinois, Inc., Rockford, IL; University of Illinois, College of Medicine at Rockford, Rockford, IL
| | - Brian J Foster
- Hand, Wrist & Elbow Service, OrthoIllinois, Inc., Rockford, IL; University of Illinois, College of Medicine at Rockford, Rockford, IL
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Öztürk İA, Engin MÇ, Köse A, Topal M, İpteç M. KARPAL TÜNEL SENDROMU OLAN BİR HASTADA STEROİD ENJEKSİYONUNUN KOMPLİKASYONU OLARAK "PERİTENDİNÖZ FİBROZİS". MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2017. [DOI: 10.17944/mkutfd.369203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Huisstede BM, van den Brink J, Randsdorp MS, Geelen SJ, Koes BW. Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review. Arch Phys Med Rehabil 2017; 99:1660-1680.e21. [PMID: 28577858 DOI: 10.1016/j.apmr.2017.04.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 04/17/2017] [Accepted: 04/27/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016. STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found. CONCLUSIONS Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.
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Affiliation(s)
- Bionka M Huisstede
- University Medical Center Utrecht, Rudolf Magnus Institute of Neurosciences, Department of Rehabilitation, Physical Therapy Science & Sports, Utrecht, The Netherlands; Erasmus MC, Department of General Practice, Rotterdam, The Netherlands.
| | - Janneke van den Brink
- University Medical Center Utrecht, Rudolf Magnus Institute of Neurosciences, Department of Rehabilitation, Physical Therapy Science & Sports, Utrecht, The Netherlands
| | - Manon S Randsdorp
- Erasmus MC, Department of General Practice, Rotterdam, The Netherlands
| | - Sven J Geelen
- University Medical Center Utrecht, Rudolf Magnus Institute of Neurosciences, Department of Rehabilitation, Physical Therapy Science & Sports, Utrecht, The Netherlands
| | - Bart W Koes
- Erasmus MC, Department of General Practice, Rotterdam, The Netherlands
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Foucher G, Van Overstraeten L, Braga da Silva J, Nolens D. Changes in grip strength in a randomized study of carpal tunnel release by three different techniques. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 6:185-189. [DOI: 10.1007/bf03380111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/1996] [Accepted: 05/15/1996] [Indexed: 11/24/2022]
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Golriz B, Ahmadi Bani M, Arazpour M, Bahramizadeh M, Curran S, Madani SP, Hutchins SW. Comparison of the efficacy of a neutral wrist splint and a wrist splint incorporating a lumbrical unit for the treatment of patients with carpal tunnel syndrome. Prosthet Orthot Int 2016. [PMID: 26195619 DOI: 10.1177/0309364615592695] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Different types of splints have been used as a conservative intervention to improve symptoms in patients with Carpal tunnel syndrome (CTS). Although a number of studies have been undertaken to compare different splints, information and understanding of the influence of these interventions are lacking. OBJECTIVES The purpose of this study was to compare the effect of a classic thermoplastic wrist splint or a wrist splint with an additional metacarpophalangeal unit on pain, function, grip strength, and pinch strength in patients with mild-to-moderate carpal tunnel syndrome. STUDY DESIGN Quasi experimental design. METHODS A total of 24 patients received conservative treatment using either the classic wrist splint or the wrist splint with the metacarpophalangeal unit for a period of 6 weeks. Primary outcome measures were pain, function, grip strength, and pinch strength. Data were collected immediately before and after using the two types of splints at baseline (0 weeks) and 6 weeks. Statistical analysis was performed using the paired t-test and an independent t-test. RESULTS Compared to baseline, both the classic thermoplastic wrist splint and the wrist splint with a metacarpophalangeal unit significantly decreased pain and increased function, pinch strength, and grip strength. Comparisons of the two types of splints for grip strength (P = 0.675) and pinch strength (P = 0.650) revealed that there were no significant differences between the two after 6 weeks of wear. However, there were significant differences in pain levels (P = 0.022) and the Disability of the Arm, Shoulder, and Hand score (P = 0.027) between the two types of splints from baseline to 6 weeks. CONCLUSION The wrist splint with a metacarpophalangeal unit was more effective than the classic thermoplastic wrist splint in pain reduction and improvement of function. CLINICAL RELEVANCE A wrist splint with a metacarpophalangeal unit may be an appropriate conservative treatment in the rehabilitation of patients with mild-to-moderate carpal tunnel syndrome.
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Affiliation(s)
- Batol Golriz
- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
| | - Monireh Ahmadi Bani
- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
| | - Mokhtar Arazpour
- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mahmood Bahramizadeh
- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
| | - Sarah Curran
- Cardiff School of Health Sciences, University of Wales Institute, Cardiff, UK
| | | | - Stephen W Hutchins
- Institute of Health & Social Care Research (IHSCR), Faculty of Health & Social Care, University of Salford, Manchester, Salford, UK
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Chen PC, Chuang CH, Tu YK, Bai CH, Chen CF, Liaw MY. A Bayesian network meta-analysis: Comparing the clinical effectiveness of local corticosteroid injections using different treatment strategies for carpal tunnel syndrome. BMC Musculoskelet Disord 2015; 16:363. [PMID: 26585378 PMCID: PMC4653918 DOI: 10.1186/s12891-015-0815-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/12/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Local corticosteroid injections are commonly used to improve the short-term symptomatic severity and the functional status of the hands affected by carpal tunnel syndrome. We conducted a systematic review and Bayesian network-meta-analysis to compare the clinical effectiveness of local corticosteroid injections using different injection approaches. METHODS Electronic literature in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and other sources were searched to identify clinical studies comparing different injection approaches with each other or placebo for carpal tunnel syndrome. Two review authors conducted selection of studies, data extraction, and assessment of risk of bias independently. Random-effects models were used to conduct the pairwise meta-analysis and the Bayesian network meta-analysis. RESULTS Overall, 10 studies with 633 patients were included in the systematic review. Among the injection approaches, local corticosteroid injections using the ultrasound-guided in-plane injection (Ulnar-I) approach was the best treatment strategy for clinical response (median OR versus placebo 128.30, 95% CrI 9.76 to 2299.00), change in symptom severity scale (median MD versus placebo -1.16, 95% CrI -1.95 to -0.38) , and change in functional status scale (median MD versus placebo -0.74, 95% CrI -2.00 to 0.52) at short-term follow-up period in the network meta-analysis. Local corticosteroid injections using other injection approaches were better than placebo for clinical response (for the PI approach, median OR versus placebo 8.85, 95% CrI 3.00 to 33.15; for the DI approach, median OR versus placebo 7.00, 95% CrI 0.53 to 118.80) , change in symptom severity scale (for the Ulnar-O approach, median MD versus placebo -0.78, 95% CrI -1.43 to -0.16; for the PI approach, median MD versus placebo -0.58, 95% CrI -0.95 to -0.22), and change in functional status scale (for the Ulnar-O approach, median MD versus placebo -0.63, 95% CrI -1.67 to 0.43; for the PI approach, median MD versus placebo -0.46, 95% CrI -1.11 to 0.21) at short-term follow-up period. The quality of studies is good. CONCLUSIONS According to our analyses, the ultrasound-guided in-plane injection (Ulnar-I) approach was the most effective treatment among the injection approaches for carpal tunnel syndrome.
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Affiliation(s)
- Po-Cheng Chen
- Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Ching-Hui Chuang
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Road, Niaosong District, Kaohsiung, 83301, Taiwan.
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Chyi-Huey Bai
- School of Public Health, Taipei Medical University, Taipei, Taiwan.
| | - Chieh-Feng Chen
- School of Public Health, Taipei Medical University, Taipei, Taiwan.
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
| | - Mei- Yun Liaw
- Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Vanni D, Sirabella FS, Galzio R, Salini V, Magliani V. The double tunnels technique: an alternative minimally invasive approach for carpal tunnel syndrome. J Neurosurg 2015; 123:1230-7. [DOI: 10.3171/2014.11.jns14901] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT
The purpose of this study was to assess the effectiveness and safety of an alternative minimally invasive technique for the treatment of carpal tunnel syndrome (CTS).
METHODS
This was designed as a prospective, randomized, open-label, blinded end point evaluation (PROBE) study. The active comparison was double tunnels technique (DTT) (Group A, 110 patients) versus standard open decompression of the median nerve (control [Group B], 110 patients). Patient recruitment started in January 2011. The primary outcomes were the functional Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) scores and visual analog scale (VAS) scores for pain (pVAS) at Weeks 2 and 4, and at Months 3, 6, and 12. The secondary outcome was the aesthetics (aVAS) score at Weeks 2 and 4, and at Months 3, 6, and 12.
RESULTS
The Student t-test and ANOVA were used, and the results were considered statistically significant if the p value was ≤ 0.05 for continuous variables. The DTT is a tissue-sparing approach that allows the surgeon to limit the length of the incision (0.6 ± 0.05 cm) and to respect the palmar fascia and the subcutaneous tissue. Recovery from wrist pain, night pain, numbness, stiffness, and weakness was achieved more effectively and quickly compared with the standard approach. Better BCTSQ, pVAS, and aVAS scores were observed in Group A.
CONCLUSIONS
The DTT is a safe and effective approach for the treatment of CTS. This technique entails faster recovery times, better aesthetic outcomes, and lower risks of complications.
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Affiliation(s)
- Daniele Vanni
- 1Orthopaedic and Traumatology Department, “G. D’Annunzio” University, Chieti
| | | | - Renato Galzio
- 2Neurosurgery Department, “L’Aquila” University, L’Aquila; and
| | - Vincenzo Salini
- 1Orthopaedic and Traumatology Department, “G. D’Annunzio” University, Chieti
| | - Vincenzo Magliani
- 3Neurotraumatology and Vertebro-Medullary Surgery, “Renzetti” Hospital, Lanciano, Italy
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Gümüştaş SA, Ekmekçi B, Tosun HB, Orak MM, Bekler Hİ. Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1253-60. [PMID: 26319124 DOI: 10.1007/s00590-015-1696-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 08/21/2015] [Indexed: 12/31/2022]
Abstract
This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.
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Affiliation(s)
- Seyit Ali Gümüştaş
- Department of Orthopaedics and Traumatology, Yavuz Selim Bone Disease and Rehabilitation Hospital, Trabzon, Turkey.
| | - Burcu Ekmekçi
- Department of Neurology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey.
| | - Haci Bayram Tosun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey.
| | - Mehmet Müfit Orak
- Department of Orthopaedics and Traumatology, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey.
| | - Halil İbrahim Bekler
- Department of Orthopaedics and Traumatology, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey.
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Shalimar A, Nor-Hazla MH, Arifaizad A, Jamari S. Splinting after Carpal Tunnel Release: Does it really Matter? Malays Orthop J 2015; 9:41-46. [PMID: 28435609 PMCID: PMC5333668 DOI: 10.5704/moj.1507.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Splinting of the wrist after carpal tunnel release (CTR) has been practised by many surgeons especially in North America. The main reason was to prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR have had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). The aim of our study was to compare the effects of post-operative splinting for a duration of one week with no splinting. Methods: All 30 of our patients underwent a standardized limited open CTR by a designated surgeon. Post operatively, they were randomized into a splinted (n=16) and a nonsplinted (n=14) group. The splint was kept for a week. Patients were reviewed at regular intervals of one week, two months and six months. At each follow up, these patients were clinically assessed for the following outcome measures: VAS (visual analogue score), 2PD (two-point discrimination), pinch grip, grip, Abductor Pollicis Brevis (APB)) power and completion of the Boston questionnaire. Results: All patients presented with significant improvement in the postoperative evaluation in the analyzed parameters within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up. Conclusion: We conclude that wrist splinting in the immediate post-operative period has no advantage when compared with the unsplinted wrist after a limited open carpal tunnel release.
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Affiliation(s)
- A Shalimar
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - M H Nor-Hazla
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - A Arifaizad
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - S Jamari
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
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Commentary on "Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand". J Hand Surg Am 2015; 40:772. [PMID: 25813922 DOI: 10.1016/j.jhsa.2015.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 01/06/2015] [Indexed: 02/02/2023]
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Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand. J Hand Surg Am 2015; 40:767-71.e2. [PMID: 25747738 DOI: 10.1016/j.jhsa.2014.12.046] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 12/04/2014] [Accepted: 12/04/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. METHODS An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N = 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. RESULTS 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). CONCLUSIONS When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and decision analysis V.
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Murthy PG, Goljan P, Mendez G, Jacoby SM, Shin EK, Osterman AL. Mini-open versus extended open release for severe carpal tunnel syndrome. Hand (N Y) 2015; 10:34-9. [PMID: 25767419 PMCID: PMC4349839 DOI: 10.1007/s11552-014-9650-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release. METHODS The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ). RESULTS Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision. CONCLUSION No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.
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Affiliation(s)
- Praveen G. Murthy
- The Philadelphia Hand Center, P.C., Thomas Jefferson University, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107 USA
| | - Peter Goljan
- The Philadelphia Hand Center, P.C., Thomas Jefferson University, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107 USA
| | - Gregory Mendez
- The Philadelphia Hand Center, P.C., Thomas Jefferson University, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107 USA
| | - Sidney M. Jacoby
- The Philadelphia Hand Center, P.C., Thomas Jefferson University, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107 USA
| | - Eon K. Shin
- The Philadelphia Hand Center, P.C., Thomas Jefferson University, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107 USA
| | - Arthur Lee Osterman
- The Philadelphia Hand Center, P.C., Thomas Jefferson University, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107 USA
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The usefulness of terminal latency index of median nerve and f-wave difference between median and ulnar nerves in assessing the severity of carpal tunnel syndrome. J Clin Neurophysiol 2014; 31:162-8. [PMID: 24691235 DOI: 10.1097/wnp.0000000000000041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The calculated electrophysiological parameters, such as terminal latency index (TLI), residual latency, modified F ratio, and F-wave inversion, have been investigated as a diagnostic tool for detection of early stage of carpal tunnel syndrome (CTS) in the literature. However, the correlation of these calculated electrophysiological parameters with the clinical severity of CTS has not been reported. The aim of this study was to determine the correlation of the calculated electrophysiological parameters and clinical severity in patients with CTS. A retrospective study was performed with 212 hands of 106 CTS patients. The CTS hands were classified as asymptomatic, mild, moderate, and severe according to the clinical severity. The distal motor latency and distal motor conduction velocity of median nerve, minimal F-wave latency of median and ulnar nerves, and sensory nerve conduction velocity in the finger-wrist and palm-wrist segment of median nerve (SNCV f-w and SNCV p-w) were obtained in a conventional nerve conduction study. The TLI, residual latency, and modified F ratio of the median nerve and the difference of minimal F-wave latencies between the median and ulnar nerves (F-diff M-U) were calculated. The distal motor latency, residual latency, and F-diff M-U were significantly increased according to the clinical severity of CTS. The motor conduction velocity, SNCV p-w, SNCV f-w, TLI, and modified F ratio were significantly decreased according to the clinical severity of CTS. In analyses of variance and Kruskal-Wallis test, we used the Scheffe test as a post-hoc comparison analysis. The TLI, F-diff M-U, and SNCV f-w showed a significant difference among all groups of each CTS severity. The sensitivity, specificity, and cut-off value of TLI, F-diff M-U, and SNCV f-w between asymptomatic and mild, mild and moderate, and moderate and severe CTS groups were calculated by using receiver operating characteristic curve analysis. The cut-off values of TLI, F-diff M-U, and SNCV f-w between the asymptomatic and mild CTS groups were, respectively, 0.33 millisecond, 0.3 millisecond, and 40 cm/second. The cut-off values of TLI, F-diff M-U, and SNCV f-w between mild and moderate were, respectively, 0.27 millisecond, 2.3 milliseconds, and 34.8 cm/second. The cut-off values of TLI, F-diff M-U, and SNCV f-w between moderate and severe CTS groups were, respectively, 0.20 millisecond, 4.2 milliseconds, and 26.4 cm/second. We found that calculated electrophysiological parameters of conventional nerve conduction study could be a good indicator to determine the severity of CTS.
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Abstract
Evidence-based medicine empowers physicians to systematically analyze published data so as to quickly formulate treatment plans that deliver safe, robust, and cost-effective patient care. In this article, we sample some areas in hand and upper extremity surgery where the evidence base is strong enough that it has or should have unified treatment strategies; we identify some problems where good evidence has failed to unify treatment, and discuss problems for which evidence is still lacking but needed because treatment remains controversial. We also discuss circumstances in which level 4 evidence is more likely than randomized trials to guide treatment.
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Affiliation(s)
- Brian Zafonte
- Department of Orthopaedic Surgery, University of California, 4860 Y Street, Suite 3800, Davis, Sacramento, CA 95817, USA
| | - Robert M Szabo
- Department of Orthopaedic Surgery, University of California, 4860 Y Street, Suite 3800, Davis, Sacramento, CA 95817, USA.
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Chen L, Duan X, Huang X, Lv J, Peng K, Xiang Z. Effectiveness and safety of endoscopic versus open carpal tunnel decompression. Arch Orthop Trauma Surg 2014; 134:585-93. [PMID: 24414237 DOI: 10.1007/s00402-013-1898-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the effectiveness and safety of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) using a meta-analysis of data from randomized controlled trials. MATERIALS AND METHODS Electronic searches of the Cochrane Register of Controlled Trials (CENTRAL, Issue 11 of 12, Nov 2012), PUBMED (1980 to Dec 2012), and EMBASE (1980 to Dec 2012) were used to identify randomized controlled trials that evaluated endoscopic vs open methods for treatment of carpal tunnel syndrome. Studies to be used were independently identified by two researchers. The methodological quality of the studies was assessed by the Cochrane Collaboration tool for assessing risk of bias. RESULTS Fifteen randomized controlled trials involving 1,596 hands were included. Based on the Cochrane Collaboration tool for assessing risk of bias, four studies were rated as high quality, five studies were rated as moderate quality, and six were rated as low quality. Our meta-analysis indicated that ECTR resulted in better recovery of pinch strength, earlier time of return to work, but a higher rate of reversible nerve problems (including neurapraxia and numbness) than OCTR. ECTR also resulted in a lower rate of irreversible nerve damage (P > 0.05), wound problems (including wound infection, wound hematoma and wound dehiscence) and reflex sympathetic dystrophy (P > 0.05) compared with OCTR. Our meta-analysis revealed no obvious statistical differences in relief of symptoms (pain and paraesthesia), recovery of grip strength and reoperation rate. CONCLUSION Our meta-analysis of available randomized controlled trials demonstrated that ECTR and OCTR were similar in relief of symptoms, but ECTR resulted in better recovery of function and earlier return to work and was safer than OCTR.
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Affiliation(s)
- Long Chen
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37, Guoxue Xiang, Chengdu, 610041, Sichuan, China
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Wiesman IM, Novak CB, Mackinnon SE, Winograd JM. Sensitivity and specificity of clinical testing for carpal tunnel syndrome. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2013; 11:70-2. [PMID: 24222987 DOI: 10.1177/229255030301100205] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The present study evaluated the sensitivity, specificity and predictive values of six clinical tests in the diagnosis of carpal tunnel syndrome (CTS). METHODS There were 29 carpal tunnel syndrome (CTS) subjects (mean age 48 years) and 30 control subjects (mean age 45 years). The six clinical tests included Tinel's sign, wrist flexion with fingers extended, wrist flexion with fingers flexed, wrist extension, combined wrist extension/median nerve pressure and combined wrist flexion/median nerve pressure. RESULTS The highest sensitivity and highest negative predictive value was found with wrist flexion with pressure (96%) and wrist extension with pressure (94%) at 60 s. The highest specificity was found with wrist flexion with fingers flexed for 30 s (95%). The highest positive predictive values were found with the wrist flexion with fingers flexed test for 30 s (91%) and the wrist extension test for 30 s (90%). CONCLUSION No one test possesses all the qualities necessary to be the ideal clinical test for the detection of carpal tunnel syndrome.
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Affiliation(s)
- Irvin M Wiesman
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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30
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Abstract
The number of citations that a published article has received reflects the importance that paper has on that area of practice. In hand surgery, it is unknown which journal articles are cited most frequently. The purpose of this study was to identify and analyze the characteristics of the top 100 papers in the field of hand surgery. The 100 most cited papers were identified in the following journals; the Journal of Hand Surgery (American volume), the Journal of Hand Surgery (European volume), the Journal of Hand Surgery (British and European volume), The Scandinavian Journal of Plastic and Reconstructive and Hand Surgery, Hand Clinics, and the Journal of Plastic Surgery and Hand Surgery. The articles were ranked in order of the number of citations received. These classic 100 papers were analyzed for article type, their journal distribution, as well as geographic and institutional origin.
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Affiliation(s)
- C W Joyce
- Department of Plastic and Reconstructive Surgery, University Hospital Galway , Galway , Ireland
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Povlsen B, Bashir M, Wong F. Long-term result and patient reported outcome of wrist splint treatment for carpal tunnel syndrome. J Plast Surg Hand Surg 2013; 48:175-8. [PMID: 24032598 DOI: 10.3109/2000656x.2013.837392] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Carpal tunnel syndrome (CTS) is the commonest peripheral neuropathy presenting to specialist hand and wrist clinics. This study investigated the long-term outcome of carpal tunnel syndrome treated with isolated night wrist splint and the factors determining the likelihood of success of this intervention. Seventy-five patients referred to a specialist hand clinic with CTS were given night wrist splint treatment for 3 months as per a previous study protocol. Fifty-two patients from this cohort did not wish to have surgery after wrist splint treatment and were followed for a further 33-month period. Baseline pain and numbness levels were recorded on a Visual Analogue Scale (VAS) using a questionnaire upon first presentation. A further questionnaire at 36 months reassessed pain and numbness levels, patients' satisfaction with the treatment, and whether they had subsequent surgical decompression. Of the patients who completed the follow-up questionnaire 33 months after their period of conservative management, 43% were successfully treated with splint treatment alone. There was no difference in the VAS for pain or numbness at the baseline and at 36 months between successful and failed treatment groups. Patients successfully treated with wrist splinting alone reported a higher level of satisfaction with their treatment compared to patients who failed wrist splint treatment or had surgical decompression. The results reinforce the previous recommendation on wrist splinting as a first-line treatment in the Primary Care setting. Referral to specialist hand and wrist clinics should be reserved for patients with symptoms refractory to this initial measure.
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Affiliation(s)
- Bo Povlsen
- Department of Orthopaedic Surgery, Guy's & St. Thomas' Hospital NHS Trust , London , UK
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Daniel ES, Paul S. A comparison study of the volar wrist cock-up splint and ulnar gutter splint in carpal tunnel syndrome. Occup Ther Health Care 2013; 12:79-93. [PMID: 23931649 DOI: 10.1080/j003v12n04_06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The objective of the study was to compare the effects of the volar wrist cock-up splint and the ulnar gutter splint on three dependent measures: level of comfort, pain relief and hand function, in clients with early symptoms of carpal tunnel syndrome. Four clients with initial onset of carpal tunnel syndrome symptoms participated in a study with alternating treatment design that compared the effects of the two splints. Comfort and pain were measured with perceived analogue scales and hand function was assessed using six sub-tests of the Jebsen Hand Function test. Evaluations were done every 2 weeks concurrent with the alternation of the splints for a period of 8 weeks. Descriptive analysis was used to identify differences in the dependent measures. Three participants showed improved performance in hand function tests with reduced time taken in tests following use of splints. Three participants showed reduced pain after splint use. One participant did not show changes with time taken in hand function tests or with level of pain. The study showed clinical evidence that both the splints contributed to alleviation of carpal tunnel syndrome symptoms. It is imperative that more efficacy studies be done to gain more confidence with the results of this study.
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Affiliation(s)
- E S Daniel
- 65 Atlantic Avenue, Apt-11, Brooklyn, NY, 11201
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Postoperative care and rehabilitation after open carpal tunnel surgery. Eur Surg 2013. [DOI: 10.1007/s10353-013-0210-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is the most common compressive neuropathy affecting the upper extremity, yet evidence-based guidelines for its diagnosis and treatment are lacking. We set out to expose any potential discrepancies in CTS practice attitudes based on surgeon's academic background, residency training, clinical experience, and other factors. METHODS This was an online survey-based study. Members of the American Association for Hand Surgery (AAHS) were sent an electronic mail request (n = 817). The online questionnaire consisted of 12 questions that queried surgeons' approaches to the diagnosis as well as operative and non-operative management of carpal tunnel syndrome. RESULTS One hundred twenty-three surgeons responded to the survey (15.1 %). The locations of surgical practices varied within the United States and beyond. Most respondents were either orthopedic or plastic surgeons. With respect to practice duration, 15.4 % had been in practice for 5 years or less, 30.9 % of the respondents had been in practice between 6 and 15 years, 30.9 % had been in practice between 16 and 25 years, and 26.8 % had been in practice for more than 25 years. The most notable interspecialty differences were related to the use of operative antibiotics and the surgical approach. Plastic surgeons were less likely to recommend antibiotic use during surgery and more likely to utilize an open extensile approach during surgical release. Younger surgeons were more likely to employ a mini-open approach for carpal tunnel release. CONCLUSIONS We conclude that background training and generational differences contribute to the varied approaches observed in the diagnosis and management of CTS.
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Leinberry CF, Rivlin M, Maltenfort M, Beredjiklian P, Matzon JL, Ilyas AM, Hutchinson DT. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective. J Hand Surg Am 2012; 37:1997-2003.e3. [PMID: 23021173 DOI: 10.1016/j.jhsa.2012.07.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 07/14/2012] [Accepted: 07/17/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE In 1987, Duncan et al.(1) reported on a survey of the members of the American Society for the Surgery of the Hand (ASSH) about their practices in treating carpal tunnel syndrome (CTS). To better understand changes in the treatment of CTS over the past 25 years, we repeated the survey while incorporating present-day controversies. METHODS With the approval of the ASSH, an Internet-based survey was e-mailed to all members of the Society. This included 33 primary questions focusing on 4 areas of study: surgeon demographic information, nonoperative treatment, surgical technique, and postoperative care. A total of 1,463 surveys were delivered and 707 surveys were completed and returned, for a response rate of 48%. Responses were compared with the responses from Duncan et al. published 25 years ago.(1) RESULTS In contrast to the practice patterns identified 25 years ago, this survey identified several changes in current clinical practices including the following statistically significant findings: Preoperatively, surgeons have increased the use of splints and corticosteroid injections, treat nonoperatively longer, and have narrowed their surgical indications. Regarding surgical technique, surgeons now are using tourniquets less, infiltrate the carpal tunnel with corticosteroids less, and place deep sutures less often. Furthermore, performing concomitant procedures along with release of the transverse carpal ligament has decreased. Orthotic use and duration postoperatively also decreased. CONCLUSIONS Although significant differences are evident between management of CTS between 1987 and 2011, no consensus has emerged.
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Abstract
Nerve conduction velocity (NCV) testing for the median nerve is the gold standard for diagnosing carpal tunnel syndrome (CTS), which affects about 6% of the general population. However, NCV equipment is relatively expensive and not always available at outpatient clinics. This study investigated the effects of different sampling rates and electrode placements on the NCV values of the median nerve to establish the practical significance of those specifications. The NCV of the median nerve at the wrist was measured in 30 healthy subjects with sampling rates of 2 kHz or 10 kHz and wide or narrow spacing of the electrode; Paired t-tests were used to compare the NCV values acquired by the different testing protocols. We found that the sampling rate had a statistically significant effect on the NCV values (P < 0.01), while the electrode placements did not significantly affect the NCV values (P > 0.05). The findings of this study have implications for improving the cost-effectiveness and technical applicability of NCV instruments.
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The effect of epineurotomy on the median nerve volume after the carpal tunnel release: a prospective randomised double-blind controlled trial. INTERNATIONAL ORTHOPAEDICS 2012; 36:1885-92. [PMID: 22588692 DOI: 10.1007/s00264-012-1565-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/23/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effects of epineurotomy on the post-surgical median nerve volume and clinical outcomes in carpal tunnel syndrome (CTS) patients with a prominent nerve narrowing. METHODS This was a prospective, randomised, double-blind controlled trial. Patients (n = 50) were randomised (1:1) to open-field surgical carpal tunnel release followed by a longitudinal epineurotomy of the nerve (test), or to open-field release without epineurotomy (control). RESULTS The nerve volume was slightly larger in the test group 90 days post-surgery (by 10.5 %, p = 0.157) but not 180 days post-surgery. No relevant electropyhsiological or clinical difference between groups and no effect of the nerve volume was observed. The subjective pain reduction was slightly more prominent in the control group at 180 days. Larger post-surgical nerve volume was associated with lower pain, but only in the control group. CONCLUSIONS Even in selected CTS patients, longitudinal epineurotomy confers no benefit regarding the nerve volume or clinical outcomes over a simple carpal tunnel release.
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Aslani HR, Alizadeh K, Eajazi A, Karimi A, Karimi MH, Zaferani Z, Hosseini Khameneh SM. Comparison of carpal tunnel release with three different techniques. Clin Neurol Neurosurg 2012; 114:965-8. [PMID: 22421246 DOI: 10.1016/j.clineuro.2012.02.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/26/2011] [Accepted: 02/12/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Carpal tunnel syndrome is one of the most common compression neuropathies in the upper limbs and requires surgery if conservative treatment fails. This article compares the result of regular open incision, mid-palmar mini incision and endoscopic technique in carpal tunnel release. METHODS This is a clinical trial study on 105 patients (10 males, 95 females) within one year, who were surgical candidates. The surgery was done with regular open incision or with mid-palmar small incision. The clinical outcomes were evaluated one week, 4 weeks and 4 months post-surgery. RESULTS Relief and satisfaction were better in the first month in the endoscopic and mid-palmar mini incision group. All 3 techniques had similar outcomes after 4 months. In the 4-month follow-up, night pain relief, followed by parasthesia relief had the best improvement. Weakness was the symptom with the least improvement. Longer incision cases were associated with more delay to return to work. CONCLUSION Carpal tunnel release with endoscopic and mini incision techniques have better early satisfaction rates compared to regular open incision, but no difference is seen between the two groups after four months.
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Affiliation(s)
- Hamid Reza Aslani
- Akhtar Orthopaedic Hospital, Shahid Beheshti Medical University, Tehran, Iran
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Strickland JW, Gozani SN. Accuracy of in-office nerve conduction studies for median neuropathy: a meta-analysis. J Hand Surg Am 2011; 36:52-60. [PMID: 21131139 DOI: 10.1016/j.jhsa.2010.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 09/09/2010] [Accepted: 09/13/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Carpal tunnel syndrome is the most common focal neuropathy. It is typically diagnosed clinically and confirmed by abnormal median nerve conduction across the wrist (median neuropathy [MN]). In-office nerve conduction testing devices facilitate performance of nerve conduction studies (NCS) and are used by hand surgeons in the evaluation of patients with upper extremity symptoms. The purpose of this meta-analysis was to determine the diagnostic accuracy of this testing method for MN in symptomatic patients. METHODS We searched the MEDLINE database for prospective cohort studies that evaluated the diagnostic accuracy of in-office NCS for MN in symptomatic patients with traditional electrodiagnostic laboratories as reference standards. We assessed included studies for quality and heterogeneity in diagnostic performance and determined pooled statistical outcome measures when appropriate. RESULTS We identified 5 studies with a total of 448 symptomatic hands. The pooled sensitivity and specificity were 0.88 (95% confidence interval [CI], 0.83-0.91) and 0.93 (95% CI, 0.88-0.96), respectively. Specificities exhibited heterogeneity. The diagnostic odds ratios were homogeneous, with a pooled value of 62.0 (95% CI, 30.1-127). CONCLUSIONS This meta-analysis showed that in-office NCS detects MN with clinically relevant accuracy. Performance was similar to interexaminer agreement for MN within a traditional electrodiagnostic laboratory. There was some variation in diagnostic operating characteristics. Therefore, physicians using this technology should interpret test results within a clinical context and with attention to the pretest probability of MN, rather than in absolute terms.
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Huisstede BM, Randsdorp MS, Coert JH, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part II: effectiveness of surgical treatments--a systematic review. Arch Phys Med Rehabil 2010; 91:1005-24. [PMID: 20599039 DOI: 10.1016/j.apmr.2010.03.023] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 03/16/2010] [Accepted: 03/25/2010] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions to treat carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 25 RCTs were included. Moderate evidence was found in favor of surgical treatment compared with splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term, and for the effectiveness of corticosteroid irrigation of the median nerve before skin closure as additive to carpal tunnel release in the short term. Limited evidence was found in favor of a double-incision technique compared with the standard incision technique. Also, limited evidence was found in favor of a mini-open technique assisted by a Knifelight instrument compared with a standard open release at 19 months of follow-up. However, in the short term and at 30 months of follow-up, no significant differences were found between the mini-open technique assisted by a Knifelight instrument compared with a standard open release. Many studies compared different surgical interventions, but no evidence was found in favor of any one of them. No RCTs explored the optimal timing strategy for surgery. No evidence was found for the efficacy of various presurgical or postsurgical treatment programs, including splinting. CONCLUSIONS Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS. However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. More research is needed to study conservative to surgical treatment in which also should be taken into account the optimal timing of surgery. Future research should also concentrate on optimal presurgical and postsurgical treatment programs.
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Affiliation(s)
- Bionka M Huisstede
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
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Isaac SM, Okoro T, Danial I, Wildin C. Does wrist immobilization following open carpal tunnel release improve functional outcome? A literature review. Curr Rev Musculoskelet Med 2010; 3:11-7. [PMID: 21063494 PMCID: PMC2941580 DOI: 10.1007/s12178-010-9060-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Carpal Tunnel Syndrome (CTS) is a compressive neuropathy of the median nerve in the carpal tunnel. It is the most common peripheral entrapment neuropathy. The surgical management includes dividing the flexor retinaculum to decompress the median nerve. Post-operative mobilization of the wrist is controversial. Some surgeons splint the wrist for 2-4 weeks whilst others encourage early mobilization. The literature has been inconclusive as to which method is most beneficial. The purpose of this study is to review the literature regarding the effectiveness of wrist immobilization following open carpal tunnel decompression. We reviewed all published clinical trials claiming to evaluate the mobility status following open carpal tunnel release. Studies not in the English language as well as those with small number of patients (n < 30) were excluded. There were five studies that fulfilled the eligibility criteria and were included in this review. We conclude that there is no beneficial effect from post-operative immobilization after open carpal tunnel decompression when compared to early mobilization.
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Affiliation(s)
- S M Isaac
- Trauma and Orthopaedics, University Hospitals of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP UK.
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Abstract
The purpose of this study was to determine if letting down the tourniquet prior to closure after carpal tunnel release decreases the amount of post-operative ecchymosis and subsequent post-operative pain. We prospectively studied 18 consecutive patients who were undergoing bilateral open carpal tunnel releases. The side done first was randomized and the tourniquet was released to obtain hemostasis prior to closure on this side only. The second side was completed, closed, and dressed prior to letting the tourniquet down. The patients' pre-operative and post-operative pain scores were recorded, as was an ecchymosis score at the 10-day follow-up visit. The results showed no significant difference between the two groups in either pain or ecchymosis. We conclude that the added surgical time required for letting the tourniquet down and obtaining hemostasis prior to closure in a carpal tunnel is unnecessary.
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Cellocco P, Rossi C, El Boustany S, Di Tanna GL, Costanzo G. Minimally invasive carpal tunnel release. Orthop Clin North Am 2009; 40:441-8, vii. [PMID: 19773048 DOI: 10.1016/j.ocl.2009.06.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We prospectively compared the safety and effectiveness of mini-incision (group A) and a limited open technique (group B) for carpal tunnel release (CTR) in 185 consecutive patients operated between November 1999 and May 2001, with a 5-year minimum follow-up. Patients in Group A had a minimally invasive approach (<2 cm incision), performed using the KnifeLight (Stryker, Kalamazoo, Michigan) instrument. Patients in Group B had a limited longitudinal incision (3-4 cm). Patient status was evaluated with an Italian modified version of the Boston Carpal Tunnel questionnaire, administered preoperatively and at 19, 30, and 60 postoperative months. Mini-incision CTR showed advantages over standard technique in early recovery, pillar pain, and recurrence rate. The recovery period after mini-incision is shorter than after standard procedure.
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Affiliation(s)
- Paolo Cellocco
- Department of Orthopedics, University of Roma La Sapienza - Polo Pontino, Istituto Chirurgico Ortopedico Traumatologico, via Franco Faggiana 1668, 04100 Latina, Italy.
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Assessing the accuracy of a combination of clinical tests for identifying carpal tunnel syndrome. J Clin Neurosci 2009; 16:929-33. [PMID: 19328695 DOI: 10.1016/j.jocn.2008.09.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 09/01/2008] [Accepted: 09/15/2008] [Indexed: 11/22/2022]
Abstract
The aim of the study was to investigate whether a combination of selected provocative manoeuvres and sensory testing could improve the accuracy of clinical diagnosis of carpal tunnel syndrome (CTS). Prospective studies were undertaken in 43 of 296 consecutive patients who were referred with suspected CTS and had undergone nerve conduction studies (NCS). Responses to Phalen's test, a modified carpal compression test (MCCT), and sensory testing over the thenar eminence were assessed for each patient. For each test (Phalen's; MCCT), sensitivity (0.64; 0.14), specificity (0.75; 0.96), positive likelihood ratio (PLR) (2.54; 3.64) and negative likelihood ratio (NLR) (0.49; 0.89) were calculated. The inclusion of sensory testing did not improve sensitivity (0.55; 0.13), specificity (0.75; 0.96), PLR (2.22; 3.29) or NLR (0.60; 0.91). These data indicate that assessment of thenar sensation does not improve the diagnostic accuracy of CTS. However, a positive Phalen's test is more likely to be associated with NCS changes that are consistent with CTS.
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Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2008; 90:2587-93. [PMID: 19047703 DOI: 10.2106/jbjs.g.01362] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no clear-cut consensus on the best diagnostic criteria for carpal tunnel syndrome. The objective of this study was to compare the probability of carpal tunnel syndrome being present following electrodiagnostic testing with the probability of it being present after the diagnosis was established on the basis of a clinical evaluation alone. METHODS The study sample included patients with any peripheral nerve diagnosis who had been referred to the electrodiagnostic laboratory of an academic health-care center. The probability of carpal tunnel syndrome before electrodiagnostic testing (pretest probability) was estimated with use of the CTS-6, a validated clinical diagnostic aid that is used to estimate the probability of carpal tunnel syndrome on the basis of the presence or absence of six clinical findings recorded as part of the history or noted on physical examination. All patients then underwent a standard electrodiagnostic assessment of the median nerve by a neurologist blinded to the result of the CTS-6 evaluation. Sensory nerve conduction velocity was used to classify the result of the electrodiagnostic testing as either positive or negative for carpal tunnel syndrome with use of two different criteria (one stringent and one lax) derived from the literature. The main outcome measure was the difference between the pretest and posttest probabilities of carpal tunnel syndrome. RESULTS One hundred and forty-three patients were studied. The pretest probability of carpal tunnel syndrome ranged between 0.10 and 0.99 (mean [and standard deviation], 0.81 +/- 0.22). Seventy-three percent of the patients had a pretest probability of at least 0.80. The average change in probability for these patients was -0.02 when the stringent electrodiagnostic criterion was used and -0.06 when the lax criterion was used. With either electrodiagnostic criterion, the majority of the large changes in probability were for patients for whom the pretest probability was < or =0.50. The probability of carpal tunnel syndrome was lowered after the electrodiagnostic testing in most of these cases. CONCLUSIONS For the majority of patients who are considered to have carpal tunnel syndrome on the basis of their history and physical examination alone, electrodiagnostic tests do not change the probability of diagnosing this condition to an extent that is clinically relevant.
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Affiliation(s)
- Brent Graham
- Hand Program, Toronto Western Hospital, 399 Bathurst Street, East Wing 2-425, Toronto, ON M5T 2S8, Canada.
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Splinting after Carpal Tunnel Release: Current Practice, Scientific Evidence, and Trends. Plast Reconstr Surg 2008; 122:1095-1099. [DOI: 10.1097/prs.0b013e31818459f4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
This article describes the condition known as carpal tunnel syndrome and reviews a carpal tunnel service that was started in Leicester in 1999. We look at how the service has developed to meet patient needs, and how we now aim to return patients back to function and employment as quickly as possible after surgery.
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Brininger TL, Rogers JC, Holm MB, Baker NA, Li ZM, Goitz RJ. Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial. Arch Phys Med Rehabil 2007; 88:1429-35. [PMID: 17964883 DOI: 10.1016/j.apmr.2007.07.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 07/03/2007] [Accepted: 07/03/2007] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare the effects of a neutral wrist and metacarpophalangeal (MCP) splint with a wrist cock-up splint, with and without exercises, for the treatment of carpal tunnel syndrome (CTS). DESIGN A 2x2x3 randomized factorial design with 3 main factors: splint (neutral wrist and MCP and wrist cock-up), exercise (exercises, no exercise), and time (baseline, 4wk, 8wk). SETTING Subjects were evaluated in an outpatient hand therapy clinic. PARTICIPANTS Sixty-one subjects with mild to moderate CTS; 51 subjects completed the study. INTERVENTIONS There were 4 groups: the neutral wrist and MCP group and the neutral wrist and MCP-exercise group received fabricated customized splints that supported the wrist and MCP joints; the wrist cock-up group and the wrist cock-up-exercise group received wrist cock-up splints. The neutral wrist and MCP-exercise and wrist cock-up-exercise groups also received tendon and nerve gliding exercises and were instructed to perform exercises 3 times a day. All subjects were instructed to wear the assigned splint every night for 4 weeks. MAIN OUTCOME MEASURES We used the CTS Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) to assess CTS symptoms and functional status. RESULTS Analysis of variance showed a significant main effect for splint and time on the SSS (P<.001, P=.014) and FSS (P<.001, P=.029), respectively. There were no interaction effects. CONCLUSIONS Our results validate the use of wrist splints for the treatment of CTS, and suggest that a splint that supports the wrist and MCP joints in neutral may be more effective than a wrist cock-up splint.
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Affiliation(s)
- Teresa L Brininger
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
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Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada. Hand (N Y) 2007; 2:173-8. [PMID: 18780048 PMCID: PMC2527229 DOI: 10.1007/s11552-007-9043-5] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 04/05/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. METHOD A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. RESULTS In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. CONCLUSION The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.
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Affiliation(s)
- Martin R. Leblanc
- Department of Plastic Surgery, Dalhousie University, Halifax, NS Canada
| | - Janice Lalonde
- Department of Plastic Surgery, Dalhousie University, Atlantic Health Sciences Corporation, Hilyard Place, Suite A280, 560 Main St., Saint John, NB E2K 1J5 Canada
| | - Donald H. Lalonde
- Department of Plastic Surgery, Dalhousie University, Atlantic Health Sciences Corporation, Hilyard Place, Suite A280, 560 Main St., Saint John, NB E2K 1J5 Canada
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