Endoscopic release of the carpal tunnel: A randomized prospective multicenter study
A 10-center randomized prospective multicenter study of endoscopic release of the carpal tunnel was carried out. Surgery was performed with a new device for transecting the transverse carpal ligament while control hands were treated with conventional open surgery. There were 122 patients in the study; 25 had carpal tunnel surgery on both hands and 97 had surgery on one hand. Of the surgical procedures, 65 were in the control group and 82 were in the device group. The endoscopic device was coupled to a fiberoptic light and a video camera. A trigger-activated blade was used to incise the transverse carpal ligament. After surgery, the best predictors of return to work and to activities of daily living were strength and tenderness variables. For patients in the device group with one affected hand, the median time for return to work was 21½ days less than that for the control group. Two patients treated with the endoscopic device required reoperation by open surgical decompression; only one of these had incomplete release with the device. Two patients in the device group experienced transient ulnar neurapraxia.
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Cited by (466)
Comparison of the Short-Term Clinical Effectiveness of 5% Dextrose Water, Platelet-rich Plasma and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials
2023, Archives of Physical Medicine and RehabilitationTo compare the short-term effectiveness of corticosteroids, 5% dextrose (D5W), and platelet-rich plasma (PRP) injections for treating carpal tunnel syndrome (CTS).
Four databases (MEDLINE [PubMed], Embase, the Cochrane Controlled Trials Register, and Web of Science [WOS]) were researched from inception to the first of April 2022.
Two authors independently screened the literature to identify the RCTs meeting the included criteria, which involved comparing corticosteroid, 5% dextrose water (D5W), and PRP injection with each other or placebo-controlled for treating CTS.
The 2 reviewers independently conducted information extraction, the utcomes included were the changes in Symptom Severity Scale, Functional Status Scale, and Visual Analog Scale at short-term follow-up after drug injection treatment and any adverse events reported.
Twelve randomized controlled trials with 749 patients (817 hands) were included. The results of this study suggested that PRP injection was the most likely to relieve symptoms, improve functions, and alleviate pain, with the surface under the cumulative ranking curve being 91.5%, 92.7%, and 80.8%, respectively, after D5W injection (74.4%, 72.2%, 72.1%), and corticosteroid injection (33.7%, 31.9%, 46.2%). The injection of 3 drugs was significantly better than that of a placebo.
From the results of the network meta-analysis, PRP injection is the most recommended treatment among the injection of corticosteroid, D5W, and PRP.
Early Revision Rate Following Primary Carpal Tunnel Release
2023, Journal of Hand Surgery Global OnlineThe published revision rates after carpal tunnel release (CTR) vary from 0.3% to 7%. The explanation for this variation may not be fully apparent. The purpose of this study was to determine the rate of surgical revision within 1–5 years following primary CTR at a single academic institution, compare it with rates reported in the literature, and attempt to provide explanations for these differences.
We identified all patients who underwent primary CTR at a single orthopedic practice by 18 fellowship-trained orthopedic hand surgeons from October 1, 2015, through October 1, 2020, using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD), 10th Revision, codes. Patients who underwent CTR because of a diagnosis other than primary carpal tunnel syndrome were excluded. Patients who required revision CTR were identified using a practice-wide database query using a combination of CPT and ICD-10 codes. Operative reports and outpatient clinic notes were reviewed to determine the cause of revision. Data on patient demographics, surgical technique (open vs single-portal endoscopic), and medical comorbidities were collected.
A total of 11,847 primary CTR procedures were performed during the 5-year period on 9,310 patients. We found 24 revision CTR procedures among 23 patients, resulting in a revision rate of 0.2%. Of 9,422 open primary CTRs performed, 22 cases (0.23%) went on to undergo revision. Endoscopic CTR was performed in 2,425 cases, with 2 cases (0.08%) ultimately undergoing revision. The average length of time from primary CTR to revision was 436 days (range, 11–1,647 days).
We noted a substantially lower rate of revision CTR within 1–5 years of primary release (0.2%) in our practice than that noted in previously published studies, although we accept that this does not account for out-of-area migration. There was no significant difference in the revision rates between open and single-portal endoscopic primary CTR.
Therapeutic III.
Proximity of the Ulnar Neurovascular Structures in Endoscopic Carpal Tunnel Release Surgery: A Cadaveric Study
2023, Journal of Hand SurgeryTo evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR).
Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade’s proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible.
The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4–20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0–15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1–7.8) and to the median nerve was 3.3 mm (range, 0–6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures.
There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR.
These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device.
Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects
2022, Journal of Hand SurgeryMost randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study’s primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor.
Using the Ohio Bureau of Workers’ Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW.
Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker’s compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW.
In a large statewide worker’s compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not.
Therapeutic III.
Suprafascial plane endoscopy versus open carpal tunnel release for idiopathic carpal tunnel syndrome: Use of the Accordion Severity Grading System
2022, Hand Surgery and RehabilitationThis study aimed to assess the safety and effectiveness of modified endoscopic technique with a single portal from an external carpal tunnel approach for surgical operations in a suprafascial plane superficial to the transverse carpal ligament. Reversible nerve injury risk is threefold greater with a conventional endoscopic method than with open carpal tunnel release (OCTR), and this suprafascial plane endoscopic release (SPER) should circumvent the problem of hardware in the carpal tunnel encountered with the conventional endoscopic method and liable to cause iatrogenic damage to the median nerve. However, the surgical consequences of the new technique have not been studied. To fill this gap, a retrospective therapeutic study was conducted to compare negative outcomes versus open surgery. The Accordion Severity Grading System was used to grade complications from 0 to 3 according to necessity of treatment. Sequela and failure rates were also compared between the SPER and OCTR groups. Eighty-eight cases in 72 patients with idiopathic carpal tunnel syndrome (ICTS) met the inclusion criteria. SPER was performed in 28 hands in 27 patients, and OCTR in 60 hands in 49 patients. The results showed no significant difference in complication, sequela, or failure rates between groups (p > 0.05). Suprafascial plane endoscopic release, has certain advantages over the open method and was validated as a safe and effective method of treating ICTS.
Cette étude visait à évaluer la sûreté et l’efficacité de la technique endoscopique modifiée à simple portail à partir d’un abord externe du canal carpien pour exécuter des opérations chirurgicales dans un plan suprafascial, superficiel au ligament transverse du carpe. Il existe une vulnérabilité particulière aux lésions nerveuses réversibles qui sont trois fois plus susceptibles de se produire avec la méthode endoscopique conventionnelle qu’avec la libération du canal carpien à ciel ouvert (OCTR). Théoriquement, la libération endoscopique suprafasciale (SPER) contourne le problème de la présence de matériel dans le canal carpien de la méthode endoscopique conventionnelle, qui peut causer des dommages iatrogènes au nerf médian, mais les conséquences chirurgicales de la nouvelle technique n’ont pas été étudiées. Pour combler cette lacune, une étude thérapeutique rétrospective a été menée pour étudier ses résultats négatifs par rapport à ceux de la technique à ciel ouvert. Une échelle de classement (connue sous le nom de système d’évaluation de la gravité "Accordéon") a été utilisée pour noter les complications. Les grades de complication variaient de 0 à 3 selon la mesure dans laquelle leur traitement avait été nécessaire. En outre, les conséquences et les taux d’échec ont également été comparés entre les groupes SPER et OCTR. Quatre-vingt-huit cas chez 72 patients présentant un syndrome idiopathique du canal carpien (SICC) ont été identifiés en accord avec nos critères d’inclusion. La SPER a été exécuté sur 28 mains chez 27 patients, et la technique à ciel ouvert a été exécutée sur 60 mains chez 49 patients. Les résultats ont montré qu’il n’y avait aucune différence statistiquement significative concernant les complications, les séquelles, et les taux d’échec entre les groupes endoscopique et ouvert (p > 0,05). La libération endoscopique du canal carpien de plan suprafascial, qui présente certains avantages par rapport à la technique à ciel ouvert, est validée comme une méthode sûre et efficace de traitement du SICC.
French trends in carpal tunnel surgery: An online survey of members of the French Society for Surgery of the Hand
2022, Hand Surgery and RehabilitationSeveral surgical and anesthesia techniques are used in carpal tunnel surgery. The practices of members of the American Society for Surgery of the Hand and the Canadian Society of Plastic Surgery were recently published and compared. Because of the great difference in these practices, we investigated the practices of the members of the French Society for Surgery of the Hand and how they would change. An online survey including 14 systematic and 12 conditional questions was sent by email to all 685 surgeons who were members of the French Society for Surgery of the Hand in July 2019. Data were analyzed using descriptive statistics. The survey was completed by 129 members (19%). The open approach was used by 56% of the surgeons (8% by traditional open technique, 48% by minimally invasive open technique), endoscopic techniques by 40% and ultrasound-guided techniques by 4%. Most surgeons used regional anesthesia (69%) or local anesthesia (25%). Half of the surgeons (50%) would consider changing their surgical technique. Sixty-one percent were interested in ultrasound-guided techniques and 34% in endoscopic techniques. Almost half the surgeons (48%) would consider changing their anesthesia technique and 97% were interested in local anesthesia. Our study showed that the open approach and regional anesthesia were the most frequently used techniques but that an increase in endoscopic and ultrasound-guided techniques as well as local anesthesia techniques was likely.
Economic and decision analysis V.
Plusieurs techniques chirurgicales et anesthésiques permettent la libération du nerf médian au canal carpien. Les pratiques des membres de l’American Society for Surgery of the Hand et de la Canadian Society of Plastic Surgery ont récemment été publiées et comparées. Devant la grande différence de ces pratiques, nous nous sommes intéressés à celles des chirurgiens membres de la Société Française de Chirurgie de la Main ainsi qu’à leur évolution. Un questionnaire en ligne comportant 14 questions systématiques et 12 conditionnelles a été envoyé par email en juillet 2019 aux 685 chirurgiens membres de la Société Française de Chirurgie de la Main. Les données ont été analysées en utilisant des statistiques descriptives. Le questionnaire a été complété par 129 membres (19 %). La voie d’abord à ciel ouvert était utilisée par 56 % des chirurgiens (8 % par abord classique, 48 % par mini-abord), 40 % utilisaient les techniques endoscopiques et 4 % les techniques échoguidées. La majorité des chirurgiens utilisaient l’anesthésie locorégionale (69 %), suivie par l’anesthésie locale (25 %). La moitié des chirurgiens (50 %) pouvait envisager de changer de technique chirurgicale. Parmi eux, 61 % s’intéressaient aux techniques échoguidées et 34 % aux techniques endoscopiques. Près de la moitié des chirurgiens (48 %) pouvait envisager de changer de technique d’anesthésie et 97 % d’entre eux s’intéressaient à l’anesthésie locale. Notre étude a montré que la voie d’abord à ciel ouvert et l’anesthésie locorégionale étaient les techniques les plus fréquemment utilisées mais qu’une progression des techniques endoscopiques et échoguidées ainsi que des techniques d’anesthésie locale était probable.
analyse économique et décisionnelle V.