Patient-reported outcomes after acute carpal tunnel release in patients with distal radius open reduction internal fixation

Background

Acute carpal tunnel syndrome (CTS) is a complication that can develop after distal radius fractures. Our hypothesis tested whether patient-reported outcomes after acute carpal tunnel release (CTR) performed in combination with distal radius fracture open reduction internal fixation (ORIF) are worse than patient-reported outcomes with only elective CTR as measured by the symptom severity and functional status scales of the Boston carpal tunnel questionnaire (BCTQ).

Methods

A retrospective assessment identified 26 patients treated with acute CTR at the same time as distal radius ORIF, no history of pre-existing CTS or CTR, no other injuries, and >12 months follow-up. Sixteen of these patients (Group A) could be contacted and answered the BCTQ. Group A was age- and sex-matched to control patients (Group B) treated with only elective CTR. A case–control study was performed comparing outcomes of both groups.

Results

The average age of patients was 51 ± 15 years, with an average follow-up of Group A at 49 ± 21 months versus Group B at 55 ± 20 months. The mean symptom severity scale score for Group A was 1.4 ± 0.4 and for Group B was 1.4 ± 0.4. The mean functional status scale score for Group A was 1.4 ± 0.5 and for Group B was 1.3 ± 0.4. The mean total BCTQ score for Group A was 26.5 ± 7.5 and for Group B was 24.9 ± 7.5. There were no statistical or clinically significant differences between Group A and Group B for symptom severity, functional status, and total BCTQ scores.

Conclusions

Patients with acute CTR performed at the same time with distal radius ORIF do as well in the long-term as those patients with only elective CTR as measured by the BCTQ. Patients should expect similar recovery of subjective nerve function from acute median nerve dysfunction when CTR is performed with distal radius ORIF as patients with only elective CTR.     

Median Nerve Compression in the Forearm: A Clinical Diagnosis

Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.     

Flexor Tenosynovectomy for Recurrent Carpal Tunnel Syndrome: A Retrospective Case Series of 108 Hands

Background: The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery. Fibrosis and hypertrophy have been identified in the flexor tenosynovium in these patients. The authors use flexor tenosynovectomy (FTS) for recurrent CTS after primary carpal tunnel release and present a review of these patients. Methods: A retrospective chart review was performed of 108 cases of FTS for recurrent CTS from 1995 to 2015 by 4 attending surgeons at one institution. Demographic information, symptoms, and outcomes were among the data recorded. A phone survey was conducted on available patients where the shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and satisfaction were assessed. Results: Average office follow-up was 12 months. Average age was 57.5 years. A total of 104 (96%) reported symptom improvement and 48 (44%) reported complete symptom resolution. Forty patients were available for long-term follow-up at an average 6.75 years postoperatively via phone interview. Average QuickDASH score was 31.2 in these patients. Thirty-six (90%) of 40 patients were initially satisfied at last office visit, and 31 (78%) of 40 were satisfied at average 6.9 years, a maintenance of satisfaction of 86%. Satisfied patients were older (58 years) than unsatisfied patients (51 years). Conclusion: Both long-term satisfaction and QuickDASH scores in our cohort are consistent with or better than published results from nerve-shielding procedures. The authors believe a decrease in both carpal tunnel volume and potential adhesions of fibrotic or inflammatory synovium contributes to the benefits of this procedure. This remains our procedure of choice for recurrent CTS.     

RESULTS OF OPEN CARPAL TUNNEL RELEASE: A COMPREHENSIVE,RETROSPECTIVE STUDY OF 188 HANDS

Background : Many recent reports of the results of decompression of the median nerve in the carpal tunnel have concentrated on only one aspect of recovery (numbness, grip etc.), and there are no reports of a comprehensive study of outcome. The aim of the present study was to review comprehensively the results of the direct visualization method of decompression of the carpal tunnel and to compare them with the published results of endoscopic release. Methods : Patients' perceptions of the severity of pain, numbness and paraesthesiae due to carpal tunnel syndrome (CTS), before and after open carpal tunnel release (CTR) in 188 hands were reviewed retrospectively at a minimum time of follow-up of 18 months. Motor and sensory testing, provocation testing and measurement of scar tenderness in 135 hands were performed at a clinical review. Results : Subjective results showed that 70% experienced a reduction in the severity of pain after CTR, 78% of hands experienced a reduction in the severity of paraesthesiae and 77% experienced a reduction in the severity of numbness. A total of 49% had improvements in all three symptoms after CTR. At the clinical review, sensory testing revealed that 59% of hands had normal or slightly diminished light touch, 35% had normal static two-point discrimination and 61% had normal dynamic two-point discrimination. Results for Tinel's test, Phalen's test and pressure provocation testing were positive in 10% of hands. There was no scar tenderness in 38%, no persisting thenar atrophy in 90%. Normal grip strength was found in 93% and 91% had normal pinch strength. Conclusions : It was concluded that open carpal tunnel release remains a safe and reliable treatment for carpal tunnel syndrome. The very low incidence of serious complications from the open technique of CTR, when compared with endoscopic CTR as published by different authors in the literature, and the comparable clinical results, appears to make the open technique a safer and preferable option. However, a properly controlled trial of both techniques is necessary to compare them.     

Functional sensibility assessment. part II: Effects of sensory improvement on precise pinch force modulation after transverse carpal tunnel release

Patients with median nerve compression at the carpal tunnel often have poor sensory afferents. Without adequate sensory modulation control, these patients frequently exhibit clumsy performance and excessive force output in the affected hand. We analyzed precision grip function after the sensory recovery of patients with carpal tunnel syndrome (CTS) who underwent carpal tunnel release (CTR). Thirteen CTS patients were evaluated using a custom‐designed pinch device and conventional sensory tools before and after CTR to measure sensibility, maximum pinch strength, and anticipated pinch force adjustments to movement‐induced load fluctuations in a pinch‐holding‐up activity. Based on these tests, five force‐related parameters and sensory measurements were used to determine improvements in pinch performance after sensory recovery. The force ratio between the exerted pinch force and maximum load force of the lifting object was used to determine pinch force coordination and to prove that CTR enabled precision motor output. The magnitude of peak pinch force indicated an economic force output during manipulations following CTR. The peak pinch force, force ratio, and percentage of maximum pinch force also demonstrated a moderate correlation with the Semmes–Weinstein test. Analysis of these tests revealed that improved sensory function helped restore patients' performance in precise pinch force control evaluations. These results suggest that sensory information plays an important role in adjusting balanced force output in dexterous manipulation. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:1534–1539, 2009     

Ultrasound assessment of the effectiveness of carpal tunnel release on median nerve deformation

To assess the biomechanical effect of carpal tunnel release (CTR), we evaluated the deformation and displacement patterns of the median nerve before and after CTR in carpal tunnel syndrome (CTS) patients. Sixteen wrists of 14 idiopathic CTS patients who had open CTR and 26 wrists of 13 asymptomatic volunteers were evaluated by ultrasound. Cross‐sectional images of the carpal tunnel during motion from full finger extension to flexion were recorded. The area, perimeter, aspect ratio of a minimum enclosing rectangle, and circularity of the median nerve were measured in finger extension and flexion positions. Deformation indices, determined by the flexion–extension ratio for each parameter, were compared before and after CTR. After CTR, the deformation indices of perimeter and circularity became significantly larger and the aspect ratio became significantly smaller than those before CTR (p < 0.05). Those differences were more obvious when comparing the values between the patients before CTR and the controls. Since the deformation indices after CTR are similar to the patterns of normal subjects, the surrounding structures and environment of the median nerve may be normalized upon CTR. This may be a way to tell how the median nerves recover after CTR. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:726–730, 2015.     

Opioid Versus Nonopioid Analgesia After Carpal Tunnel Release: A Randomized,Prospective Study

Background: The purpose of this investigation was to compare pain control and patient satisfaction for conventional postoperative opioid analgesia and nonopioid multimodal analgesia after elective open or endoscopic carpal tunnel release (CTR). Methods: As part of a randomized, prospective study, patients undergoing primary, elective CTR were randomized to receive either postoperative opioids or nonopioid medications as part of a multimodal pain control strategy. Patients currently taking opioids were excluded. Patients completed a postoperative pain journal and completed the shortened version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), Boston Carpal Tunnel Questionnaire, Numeric Pain Rating Scale (NPRS), and satisfaction ratings at their 2-week visit. Results: A total of 68 patients were included. Preoperatively, there were no statistically significant differences between the 2 groups with respect to pain scores, coping skills, or carpal tunnel symptoms. At 2 weeks postoperatively, patients in the nonopioid group had lower average NPRS and QuickDASH scores. Patients who took opioids consumed an average of 5 pills. No patient randomized to the nonopioid group required any opioids. Patients in the nonopioid group demonstrated lower early postoperative NPRS scores. Patient satisfaction with their pain control regimen and outcome was not significantly different between the 2 groups at any time point. Conclusions: Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes. Considering the risks associated with the use of opioid analgesics, we recommend against prescribing opioids after CTR, particularly in patients not currently taking narcotic medications.     

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.     

Platelet-rich plasma versus corticosteroid injections for carpal tunnel syndrome

Background: Platelet-rich plasma therapy has the potential to promote peripheral nerve regeneration through the autologous supply of growth factors. Therefore, this study aimed to compare the effects of platelet-rich plasma injections with the effects of corticosteroid injections in the treatment of carpal tunnel syndrome.

Methods: In total, 40 patients with mild carpal tunnel syndrome were equally divided into two groups. Nerve conduction studies were carried out, and the Boston Carpal Tunnel Questionnaire was administered to both groups before treatment. One group of patients received platelet-rich plasma injections, and the patients in the other group received corticosteroid injections into the carpal tunnel. The patients were followed for 6 months. After 3 and 6 months, the nerve conduction studies and the Boston Carpal Tunnel Questionnaire were repeated.

Results: Although distal motor latencies did not change in either of the groups during the follow-up period, improvements in sensory nerve conduction were recorded after 3 months in both groups. However, there was no significant difference between the groups in the nerve conduction studies. In the Boston Carpal Tunnel Questionnaire, both the symptom severity score and the functional capacity score of the platelet-rich plasma group were significantly better than those of the corticosteroid group after 3 months, although there were no significant differences after 6 months.

Conclusions: Platelet-rich plasma injections may be considered for the temporary symptomatic relief of mild carpal tunnel syndrome.     

Effect of radial shock wave therapy for carpal tunnel syndrome: A prospective randomized,double‐blind,placebo‐controlled trial

Three recent studies demonstrated the positive effect of extracorporeal shock wave therapy (ESWT) for treating carpal tunnel syndrome (CTS). However, none have entirely proved the effects of ESWT on CTS because all studies had a small sample size and lacked a placebo‐controlled design. Moreover, radial ESWT (rESWT) has not been used to treat CTS. We conducted a prospective randomized, controlled, double‐blinded study to assess the effect of rESWT for treating CTS. Thirty‐four enrolled patients (40 wrists) were randomized into intervention and control groups (20 wrists in each). Participants in the intervention group underwent three sessions of rESWT with nightly splinting, whereas those in the control group underwent sham rESWT with nightly splinting. The primary outcome was visual analog scale (VAS), whereas the secondary outcomes included the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), cross‐sectional area (CSA) of the median nerve, sensory nerve conduction velocity of the median nerve, and finger pinch strength. Evaluations were performed before treatment and at 1, 4, 8, and 12 weeks after the third rESWT session. A significantly greater improvement in the VAS, BCTQ scores, and CSA of the median nerve was noted in the intervention group throughout the study as compared to the control group (except for BCTQ severity at week 12 and CSA at weeks 1 and 4) (p < 0.05). This is the first study to assess rESWT in a randomized placebo‐controlled trial and demonstrate that rESWT is a safe and effective method for relieving pain and disability in patients with CTS. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:977–984, 2016.     

Patient satisfaction after open carpal tunnel release correlates with depression

PURPOSE: To test the null hypothesis that depression does not correlate with patient satisfaction after open release of electrodiagnostically confirmed carpal tunnel syndrome when controlling for other demographic, disease-related, and psychosocial factors. METHODS: Eighty-two survey respondents who had recovered (minimum 2 years after surgery) from a limited incision open carpal tunnel release completed measures of satisfaction, perceived disability, depression, pain catastrophizing, and pain anxiety. Univariate and multivariate analyses sought predictors of satisfaction and perceived disability from among demographic, disease related, and psychological factors. RESULTS: The average satisfaction score was 8 points (range, 0-10) and the average Disabilities of the Arm, Shoulder, and Hand score was 13 points (range, 0-76). Predictors of greater dissatisfaction included greater depression and the categorical electrophysiologic test rating. Predictors of perceived disability included depression, pain catastrophizing, and static numbness. Depression was the dominant predictor of both satisfaction and perceived disability. CONCLUSIONS: Dissatisfaction and perceived disability after limited open carpal tunnel release for electrodiagnostically confirmed idiopathic carpal tunnel syndrome is predicted primarily by depression and ineffective coping skills and to a lesser degree by clinical or electrophysiologic evidence of advanced nerve damage. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.     

ASSOCIATION OF OBESITY,GENDER, AGE AND OCCUPATION WITH CARPAL TUNNEL SYNDROME

Background : The present study determines the association of obesity, gender, age and occupation in patients with carpal tunnel syndrome (CTS) in a New Zealand population. Methods : Analysis of questionnaires and clinical review of patients who had undergone surgical decompression of the median nerve in the carpal tunnel. Results : The age and gender distribution of 655 hands (512 patients) that had undergone carpal tunnel release (CTR) were compared with the age and gender distribution of the New Zealand population. The results indicate that the 3-year-period prevalence of CTS in females is more than double that in males. Proportionally there were more patients over age 55 than in the general population. The findings also indicate that, proportionally, six times the number of females who worked in moderate manual work underwent CTR compared with the general female population and proportionally twice the number of males who worked in heavy office/clerical work underwent CTR compared with the general male population. It was also found that CTR patients are twice as likely to be overweight (body mass index [BMI] > 25) than the general population and female patients are twice as likely to be obese (BMI > 30) than the general population. Conclusions : Carpal tunnel syndrome is more than twice as common in females as it is in males, and patients aged more than 55 years are more likely to suffer from CTS. Females with CTS are more likely to work in moderate manual work and males with CTS are more likely to work in heavy office/clerical work. Obesity and CTS are related statistically.     

Endoscopic versus open carpal tunnel release: A short-term comparative study

Objective:

To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS).

Materials and Methods:

Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient''s symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months.

Results:

During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months.

Conclusion:

Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.     

Results of treatment of carpal tunnel syndrome with associated hourglass deformity of the median nerve

Two hundred twenty-seven successive cases of carpal tunnel syndrome confirmed by abnormal electrodiagnostic studies were reviewed. All cases underwent open carpal tunnel release by a single surgeon over a 3-year period. Thirty-two hands (14% of all cases) in 29 patients demonstrated an hourglass deformity at the time of surgery. Electrodiagnostic tests revealed no evidence of any other type of peripheral neuropathy in any patient. Postoperative electrodiagnostic studies were obtained in all cases on completion of therapy. The length of the follow-up period averaged 11 months (range, 3-35 months). The duration of preoperative symptoms ranged from 2 years to more than 10 years. Twenty-eight of the 32 hands (88%) with hourglass deformities demonstrated subjective clinical improvement or complete resolution of symptoms. Chronicity of symptoms and electrophysiologic severity did not correlate with the presence of the hourglass deformity. Presence of hourglass compression of the median nerve in carpal tunnel syndrome is therefore not a negative prognostic indicator.     

Long-term outcomes following single-portal endoscopic carpal tunnel release

Background

There is limited published information about long-term outcomes and recurrence rates following single-portal endoscopic carpal tunnel release.

Methods

We reviewed symptom and function outcomes from a prospectively collected database of patients who underwent single-portal endoscopic carpal tunnel release at a minimum of 8 years follow-up. Out of 207 patients in the original database, we were able to confirm correct current contact information for 106 patients. Of these, 91 patients with 115 single-portal endoscopic carpal tunnel releases agreed to participate. All of these patients were eligible for this long-term follow-up study based on documented preoperative and 6-month postoperative Levine-Katz questionnaire scores. Patients then completed a current update of the Levine-Katz questionnaires to assess function and symptom outcomes at latest follow-up.

Results

The average 6-month postoperative scores were significantly lower compared with the average preoperative scores and were maintained at long-term follow-up. There were no significant differences in average change in scores at long-term follow-up compared to 6-months postoperative.

Conclusions

Single-portal endoscopic carpal tunnel release is an effective surgical treatment for carpal tunnel syndrome. Low recurrence rates and maintenance of low symptom and function scores can be expected at 8 to 10 years following this technique.     

Mini-open versus extended open release for severe carpal tunnel syndrome

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.     

Electromyographic evaluation after endoscopic carpal tunnel release in idiopathic carpal tunnel syndrome

The purpose of this study was to electromyographically evaluate results in patients with carpal tunnel syndrome (CTS) who underwent endoscopic carpal tunnel release (ECTR). The subjects were 26 patients with idiopathic CTS (37 hands) who were followed for at least 6 months after ECTR. To compare results informatively, hands were classified into four groups: those with normal distal motor latency (DML) and sensory conduction velocity (SCV) were classified as group A, those with normal DML and abnormal SCV as group B, those with an abnormal DML and normal SCV as group C, and those with abnormal DML and SCV as group D. All but one of the hands were classified as group D on the basis of preoperative electromyographic evaluation, while one was classified as group C. The mean preoperative obtainable DML and SCV values were 7.2 m and 27.3 m/s, respectively. Postoperatively, 12 hands were in group A, 8 hands in group B, 2 hands in group C, and 15 hands in group D. The mean DML and SCV values at final follow-up were 4.3 ms and 40.8 m/s, respectively. Of the 25 hands with muscle atrophy before surgery, 6 hands were in group A, 5 hands were in group B, 1 hand was in group C, and 13 hands were in group D at final follow-up. Thenar muscle atrophy and denervation potentials were present before surgery in 13 of the 15 hands classified as group D at the final follow-up. Received for publication on June 23, 1998; accepted on Oct. 30, 1998     

Carpal arch and median nerve changes during radioulnar wrist compression in carpal tunnel syndrome patients

The purpose of this study was to investigate the morphological changes of the carpal arch and median nerve during the application of radiounlarly directed compressive force across the wrist in patients with carpal tunnel syndrome. Radioulnar compressive forces of 10 N and 20 N were applied at the distal level of the carpal tunnel in 10 female patients diagnosed with carpal tunnel syndrome. Immediately prior to force application and after 3 min of application, ultrasound images of the distal carpal tunnel were obtained. It was found that applying force across the wrist decreased the carpal arch width (p < 0.001) and resulted in increased carpal arch height (p < 0.01), increased carpal arch curvature (p < 0.001), and increased radial distribution of the carpal arch area (p < 0.05). It was also shown that wrist compression reduced the flattening of the median nerve, as indicated by changes in the nerve's circularity and flattening ratio (p < 0.001). This study demonstrated that the carpal arch can be non‐invasively augmented by applying compressive force across the wrist, and that this strategy may decompress the median nerve providing symptom relief to patients with carpal tunnel syndrome. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1234–1240, 2016.     

Histopathological,clinical, and electrophysiological features influencing postoperative outcomes in carpal tunnel syndrome

Data on the outcome predictors of surgical result of carpal tunnel syndrome (CTS) is sparse and often conflicting. The purpose of this prospective comparative study was to evaluate the neurophysiologic findings and histological characteristics of the flexor tenosynovium in patients with CTS, assessing possible associations between these findings and preoperative patient status or surgical outcome. We evaluated 30 consecutive patients with a diagnosis of idiopathic CTS who were referred for surgery. Demographic data, subjective and objective data, and responses on an expanded assessment set, were collected before and 6 months after surgery. All patients underwent diagnostic neurophysiological testing prior to surgery, and histological analysis of tenosynovium specimens that were removed during surgery. Ten fresh‐frozen cadavers served as controls. There was significant improvement in most of the disease specific (Boston questionnaire and Hi‐Ob scale) and health generic (SF‐36 questionnaire) evaluation tools used in the study at the 6‐month follow‐up. Vascular changes were noted in the tenosynovium of the flexor tendon of patients with CTS when compared with controls. Greater synovial vascularization was negative predictor of the SF‐36's physical summary score before surgery. Bilateral presentation of symptoms and low nerve conduction velocity were negative predictors of the quality of life of patients after surgery for CTS. These findings have to be considered when discussing with patients as for the expected and desired outcomes of CTS surgery. The increased vascularization of flexor tenosynovium is associated with patients' functional status. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1298–1304, 2011     

Pressure–morphology relationship of a released carpal tunnel

We investigated morphological changes of a released carpal tunnel in response to variations of carpal tunnel pressure. Pressure within the carpal tunnel is known to be elevated in patients with carpal tunnel syndrome and dependent on wrist posture. Previously, increased carpal tunnel pressure was shown to affect the morphology of the carpal tunnel with an intact transverse carpal ligament (TCL). However, the pressure–morphology relationship of the carpal tunnel after release of the TCL has not been investigated. Carpal tunnel release (CTR) was performed endoscopically on cadaveric hands and the carpal tunnel pressure was dynamically increased from 10 to 120 mmHg. Simultaneously, carpal tunnel cross‐sectional images were captured by an ultrasound system, and pressure measurements were recorded by a pressure transducer. Carpal tunnel pressure significantly affected carpal arch area (p < 0.001), with an increase of >62 mm² at 120 mmHg. Carpal arch height, length, and width also significantly changed with carpal tunnel pressure (p < 0.05). As carpal tunnel pressure increased, carpal arch height and length increased, but the carpal arch width decreased. Analyses of the pressure–morphology relationship for a released carpal tunnel revealed a nine times greater compliance than that previously reported for a carpal tunnel with an intact TCL. This change of structural properties as a result of transecting the TCL helps explain the reduction of carpal tunnel pressure and relief of symptoms for patients after CTR surgery. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 616–620, 2013