Carpal Tunnel Release With Wide Awake Local Anesthesia and No Tourniquet: With Versus Without Epinephrine

Background: Wide awake local anesthesia and no tourniquet (WALANT) relies on epinephrine to create a relatively bloodless field. This study evaluated the effect of epinephrine on carpal tunnel release (CTR) surgical time and bleeding, including the need for use of a tourniquet or electrocautery. The hypothesis was that wide awake anesthesia without epinephrine is a viable option for CTR but increases operative time. Methods: Records of all patients who underwent CTR under wide awake anesthesia between October 2017 and September 2018 were reviewed. The injection consisted of either 10 cc of 1% lidocaine with 1:100,000 epinephrine mixed with 1 cc of sodium bicarbonate (8.4%) (WALANT group) or 10 cc of 1% lidocaine (wide awake local anesthesia, no tourniquet and no epinephrine [WALANE] group). The time between skin incision and skin closure was calculated. Tourniquet and electrocautery use as well as operative complications were documented. Results: Thirty-two patients underwent 43 CTRs; 22 CTRs were done under WALANT, and 21 CTRs were done under WALANE. The skin-skin time was 12.8 minute (6-25 minute; standard deviation [SD] = 4.7) for WALANT and 17.4 minute (9-30 minute; SD = 5.8) for WALANE. There was a significant statistical difference (36%) in skin-skin time between the 2 groups. None of the patients required electrocautery or a tourniquet. There were no operative complications. Conclusion: Operative time increased by 36% when epinephrine was not used. Epinephrine is not an absolute necessity to perform wide awake anesthesia but, at the same time, has the added value of decreasing surgical time. Level of evidence: IV     

Morphologic Analysis of the Carpal Tunnel and Median Nerve Following Open and Endoscopic Carpal Tunnel Release

Background: Endoscopic carpal tunnel release (ECTR) has purported advantages over open release such as reduced intraoperative dissection and trauma and more rapid recovery. Endoscopic carpal tunnel release has been shown to have comparable outcomes to open release, but open release is considered easier and safer to perform. Previous studies have demonstrated an increase in carpal tunnel volume, regardless of the technique used. However, the mechanism by which this volumetric increase occurs has been debated. Our study will determine through magnetic resonance imaging (MRI) analysis the morphologic changes that occur in both open carpal tunnel release (OCTR) and ECTR, thereby clarifying any morphologic differences that occur as a result of the 2 operative techniques. We hypothesize that there will be no morphologic differences between the 2 techniques. Methods: This was a prospective study to compare the postoperative anatomy of both techniques with MRI. Nineteen patients with clinical and nerve conduction study–confirmed carpal tunnel syndrome underwent either open or endoscopic release. Magnetic resonance imaging was performed preoperatively and 6 months postoperatively in all patients to examine the volume of the carpal tunnel, transverse distance, anteroposterior (AP) distance, divergence of tendons, and Guyon’s canal transverse and AP distance. Results: There was no significant difference in the postoperative morphology of the carpal tunnel and median nerve between OCTR and ECTR at 6-month follow-up on MRI. Conclusion: We conclude that there are no morphologic differences in OCTR and ECTR. It is an increase in the AP dimension that appears to be responsible for the increase in the volume of the carpal tunnel.     

内镜下腕管松解术与常规腕管切开松解术治疗腕管综合征的Meta分析

目的对内镜下腕管松解术（endoscopic carpal tunnel release,ECTR）和常规腕管切开松解术（open carpal tunnelrelease,OCTR）治疗腕管综合征的疗效进行系统评价。方法按照Cohrane系统评价的方法,计算机检索MEDLINE（1966年~2010年3月）、EMBASE（1966年~2010年3月）、Cochrane图书馆（2010年1月）及中国生物医学文献数据库（1979年~2009年12月）,并手工检索相关的中英文骨科杂志。收集所有相关的随机对照试验,并评价纳入研究的方法学质量,采用Cochrane协作网提供的软件Revman4.2.2进行Meta分析,以获得ECTR与OCTR治疗腕管综合征的疗效及其安全性是否有差异的相关证据。结果共纳入8个随机对照试验进行评价,Meta分析显示,ECTR组与OCTR组的术后并发症发生率、主观满意率、手术时间及术后手握力和捏力功能恢复差异无统计学意义（P〉0.05）;ECTR组术后疼痛发生率和恢复工作时间显著低于OCTR组（P〈0.05）。结论与OCTR相比,ECTR可降低腕管综合征的术后疼痛发生率,缩短恢复工作时间;2种手术方式术后并发症发生率、主观满意度、手术时间、术后握力与捏力无统计学差异。因研究质量及样本的局限性,2种手术方法与手术时间和手功能的关系有待于进一步研究。