Complications of endoscopic and open carpal tunnel release.

Separate questionnaires regarding surgically treated complications of endoscopic and open carpal tunnel release over a 5-year period were sent to members of the American Society for Surgery of the Hand to assess and compare major complications of the 2 procedures. Four hundred fifty-five major complications from endoscopic carpal tunnel release were treated by the 708 respondents. This included 100 median nerve lacerations, 88 ulnar nerve lacerations, 77 digital nerve lacerations, 121 vessel lacerations, and 69 tendon lacerations. There were 283 major complications from open carpal tunnel release treated by 616 respondents, including 147 median nerve lacerations, 29 ulnar nerve lacerations, 54 digital nerve lacerations, 34 vessel lacerations, and 19 tendon lacerations. Although this is a retrospective voluntary study with resultant methodologic flaws, the data support the conclusion that carpal tunnel release, be it endoscopic or open, is not a safe and simple procedure. Major, if not devastating, complications can and do occur with both procedures, of which surgeons should be ever cautious.     

Endoscopic carpal tunnel release for recurrent carpal tunnel syndrome after previous open release.

Recurrent carpal tunnel syndrome from various causes has been shown to occur in up to 19% of patients. Endoscopic carpal tunnel release has been used to decompress the median nerve in carpal tunnel syndrome for many years. However, endoscopic release for recurrent carpal tunnel syndrome after previous surgical release has not been reported. Nine hands in six patients had recurrent carpal tunnel syndrome five to 20 years after previous open carpal tunnel release. All the cases were successfully treated with endoscopic release.     

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     

A cost-utility analysis of open and endoscopic carpal tunnel release

BACKGROUND

Open carpal tunnel release (OCTR) is the standard procedure for the surgical treatment of carpal tunnel syndrome. With the advent of minimally invasive surgery, endoscopic carpal tunnel release (ECTR) was introduced.

OBJECTIVE

To use a decision analytical model to compare ECTR with OCTR in an economic evaluation.

METHODS

Direct medical costs were obtained from a Canadian university hospital. Utility values obtained from experts, presented with carpal tunnel syndrome outcome health states, were transformed into quality-adjusted life years (QALYs). The probabilities of the health states associated with both techniques were obtained from the literature.

RESULTS

The incremental cost-utility ratio (ICUR) was $124,311.32/QALY gained, providing strong evidence to reject ECTR when ECTR is performed in the main operating room and OCTR is performed in the day surgery unit. A one-way sensitivity analysis in the present study demonstrated that when both OCTR and ECTR are performed in day surgery unit, the ICUR falls in the ‘win-win’ quadrant, making ECTR both more effective and less costly than OCTR. If the scar tenderness probability is decreased in the ECTR group in a second one-way sensitivity analysis, the ICUR decreases to $100,621.91/QALY gained, providing evidence to reject ECTR. If the reflex sympathetic dystrophy probability is increased in the ECTR group in a third one-way sensitivity analysis, the ICUR increases to $202,657.88/QALY gained, providing strong evidence to reject ECTR.

CONCLUSIONS

There is still uncertainty associated with the costs and effectiveness of ECTR and OCTR. To obtain a definitive answer as to whether the ECTR is more effective than the OCTR, it is necessary to perform a large, randomized, controlled trial in which the utilities and resource use are measured prospectively.     

Mini open carpal tunnel release

Release of the flexor retinaculum to decompress the median nerve is the most common surgical procedure in the hand, and the numbers continue to rise. The surgical intent is simple: cut the retinaculum only. Like most procedures so designed, the results are generally thought to be excellent. However, with the rising incidence of this problem in the workforce and the postoperative time loss, great effort has been directed to defining a less invasive surgery that would satisfactorily decompress the nerve but allow a speedier recovery and return to work. Thus, there have evolved various offshoot types of carpal tunnel releases: endoscopic and mini open. Each method has proponents and variations and generally yields very satisfactory results. However, without care, there may be more surgical complications, and we may not have effectively shortened the return to work time. Caution is the key. With careful attention to detail during the procedure, however, mini open carpal tunnel releases can provide a safe, effective, and minimally invasive method for accomplishing this frequent task. Copyright © 2001 by the American Society for Surgery of the Hand     

Outcomes of open and endoscopic carpal tunnel release: a meta-analysis

Background

Currently, there are two genres of surgical treatment of carpal tunnel syndrome, open versus endoscopic. The goal of our study is to analyze published data by comparing outcomes of surgical treatment for carpal tunnel syndrome and determine if one approach is superior to the other (open versus endoscopic).

Methods

A meta-analysis of retrospective series of Carpal tunnel release including >20 patients, with results measuring outcomes based on at least six of the following nine parameters (paresthesia relief, scar tenderness, two-point discrimination, thenar muscle weakness, Semmes–Weinstein/SW monofilament testing, return to work time, grip and pinch strength, and complications).

Results

Endoscopic carpal tunnel approach showed statistically superior outcomes in eight of the nine categories investigated. Only in the category of complications (mean occurrence of 1.2 % in the open release versus 2.2 % in the endoscopic release group) was the endoscopic group inferior.

Conclusion

This suggests that the endoscopic release is superior to the open release, particularly in experienced hands.     

Early outcome and cost-effectiveness of endoscopic versus open carpal tunnel release: a randomized prospective trial

Proponents of endoscopic carpal tunnel release have been advocating the technique for more than 10 years but there is still debate about its efficacy, safety and cost-effectiveness. We have performed a randomized, prospective, blind trial to compare early outcome after single portal endoscopic or open carpal tunnel surgery and to assess the cost-effectiveness of the procedures. There were no significant differences in symptom and functional activity scores, grip strength or anterior carpal pain in the first 3 months. For those in employment, we found a statistically significant difference between the two treatment groups with the endoscopic group returning to work, on average, 8 (95% CI, 2-13 days) days sooner than the open group. This translates into a cost saving to industry. There were no major neurovascular complications in either group. On the basis of these findings, we recommend that endoscopic carpal tunnel release should be considered in the employed as a cost-effective procedure, but perhaps not in the general population as a whole.     

Anthropometry and endoscopic carpal tunnel release

A prospective study was performed in 100 consecutive endoscopic carpal tunnel releases (ECTR) to assess the effect of a number of anthropometric measures on the ease of introduction of the ECTR system into the carpal tunnel. Ease of access to the carpal tunnel correlated with the wrist circumference, height and age of patients. Surgeons should be aware that ECTR is likely to be more difficult in small patients with small wrists and should have a higher threshold for conversion to the open technique to avoid neurological complications.     

Double incision open technique for carpal tunnel release: An alternative to endoscopic release

I prospectively evaluated the results of 30 consecutive patients with bilateral carpal tunnel release using two techniques. The first release was performed with a standard incision while the opposite hand underwent release by a double incision open technique. Postoperatively, subjective complaints of pain, grip strength, pinch strength, and pillar tenderness were evaluated at 1, 2, 4, 6, and 10 weeks. All patients expressed complete relief of preoperative numbness in both hands. The improvement in pinch and grip strength and lack of pillar tenderness in the hands that underwent the double incision open technique closely matched the reported results of endoscopic carpal tunnel release. There were no complications with either technique.     

Failed endoscopic carpal tunnel release. Operative findings and results of open revision surgery.

From 1994 to 1997, 22 patients (24 wrists) underwent open revision carpal tunnel release for persistent carpal tunnel syndrome after a primary endoscopic release. The age range was from 21 to 77 years. At the time of revision surgery, 22 wrists had an incomplete release of the flexor retinaculum and two patients had median nerve transection (one partial and one complete). One patient had release of Guyon's canal and not the carpal tunnel. After the open revision carpal tunnel release, 20 patients returned to work with five patients returning to jobs of lighter duty. In addition, these 20 patients had significant improvement in symptoms. The remaining two patients had sustained a median nerve injury and did not return to work. One of these patients developed a painful neuroma in continuity of the median nerve which required vein wrapping with a saphenous vein graft. This study indicates that endoscopic release of the flexor retinaculum holds the same risks and complications as open release. Based on our study we believe that patients with persistent carpal tunnel syndrome after failed endoscopic flexor retinaculum release can be successfully treated with open release.     

内窥镜与常规开放手术治疗腕管综合征的疗效比较

目的对比研究内窥镜视下腕管松解术（endoscopic carpal tunnel release,ECTR）与常规腕管切开术（open carpal tunnel release,OCTR）治疗腕管综合征的临床疗效。方法对44例腕管综合征的患者，根据手术不同分为两组：ECTR组14例，OCTR组30例。观察术后患手创面愈合、瘢痕生长情况，“柱状”痛并发症的发生率，恢复工作时间和电生理检测等情况。结果术后随访时间为8～214个月，平均15．5个月。两组患者均未出现伤口感染及肌腱、神经、血管损伤等并发症。术后半年两组夜间疼痛症状全部消失，ECTR组和OCTR组手指麻木消失率分别为93．75％和91．18％，拇短展肌萎缩恢复率分别为57．14％和58．82％；“柱状”痛发生率分别为0％和23．53％，满意率分别为93．75％和67．65％，两组差异有统计学意义（P〈0．05）；术后1、3、6、12个月握力恢复率，ECTR组较OCTR组明显提高，差异有统计学意义（P〈0．05）；正中神经电生理检测两组差异无统计学意义。ECTR组在手术时间、恢复工作和住院时间均较OCTR组缩短。结论术后ECTR组在切口愈合较常规切开者美观、无“柱状”痛、握力恢复、缩短手术时间、平均住院日及恢复工作时间等方面优于OCTR组。     

Comparison of postoperative pain after open and endoscopic carpal tunnel release: A randomized controlled study

Background:

Results of open and endoscopic carpal tunnel surgery were compared with many studies done previously. To the best of our knowledge, difference in pain after endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) has not been objectively documented in literature. The aim of the study was to compare the pain intensity in the early postoperative period in patients undergoing OCTR versus those undergoing ECTR.

Materials and Methods:

Fifty patients diagnosed with carpal tunnel syndrome were randomized into two groups using “random number generator” software (Research Randomizer, version 3.0); endoscopic surgery group [(21 female, 1 male; mean age 49 years (range 31–64 years)] and open surgery group [(25 female, 3 male; mean age 45.1 years (range 29–68 years)] and received carpal tunnel release. Surgery was performed under regional intravenous anesthesia. The patients’ pain level was assessed at the 1^st, 2^nd, 4^th, and 24^th postoperative hours using a visual analog scale (VAS) score.

Results:

Mean age, gender and duration of symptoms were found similar for both groups. Boston functional scores were improved for both groups (P < 0.001, P < 0.001). Pain assessment at the postoperative 1^st, 2^nd, 4^th and 24^th hours revealed significantly low VAS scores in the endoscopic surgery group (P = 0.003, P < 0.001, P < 0.001, P < 0.001). Need for analgesic medication was significantly lower in the endoscopic surgery group (P < 0.001).

Conclusion:

Endoscopic carpal tunnel surgery is an effective treatment method in carpal tunnel release vis-a-vis postoperative pain relief.     

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.     

A potential complication of endoscopic carpal tunnel release.

Complications of carpal tunnel release have been well documented in the literature. Recently, a procedure for endoscopic release of the transverse carpal ligament has been described. This case report demonstrates a potential complication of endoscopic carpal tunnel release, in which the flexor digitorum superficialis tendon to the ring finger was nearly cut when the arthroscopic trocar passed beneath it. The procedure was converted to an open carpal tunnel release when the transverse fibers of the carpal ligament were not seen after several passes of the trocar. This complication was related to the inability to fully extend the wrist and metacarpophalangeal joints because of arthritic contractures. This case underscores the need for accurate identification of endoscopic anatomy prior to release of the carpal tunnel. The surgeon should not hesitate to convert to open technique if it becomes necessary.