Open versus Endoscopic Carpal Tunnel Release: A Meta-analysis of Randomized Controlled Trials

Background

Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial.

Questions/purposes

The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time.

Methods

The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included.

Results

Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08–5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33–1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35–0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08–7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, −8.73 days [−12.82 to −4.65]; p < 0.001); and reduced operative time (MD, −4.81 minutes [−9.23 to −0.39]; p = 0.03).

Conclusions

High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety.     

Effect of clopidogrel pretreatment on angiographic and clinical outcomes in patients undergoing primary percutaneous coronary intervention for ST-elevation acute myocardial infarction

Pretreatment with clopidogrel before elective primary percutaneous coronary intervention (PCI) has been shown to reduce ischemic complications. There are limited data about the value of clopidogrel pretreatment in the setting of PCI for ST-elevation myocardial infarction (STEMI). We aimed to examine the effect of clopidogrel preloading on angiographic and clinical outcomes in patients with STEMI who were treated with PCI. We conducted a prospective registry of all patients treated with primary PCI for STEMI from March 2003 to June 2006. Excluded were patients with cardiogenic shock. For the current analysis, patients (n = 292) were allocated into 2 groups. One group received clopidogrel loading dose before PCI (in the emergency department or coronary care unit, n = 165); the other,immediately after PCI (n = 127). TIMI myocardial perfusion (TMP) grade at the end of PCI and 30-day and 6-month clinical outcomes were assessed. Clinical characteristics were similar among the groups. However, patients pretreated with clopidogrel were more likely to receive aspirin and beta blockers before the current admission. TMP grade 3 occurred in a higher proportion of patients in the clopidogrel pretreatment group than in the no-pretreatment group (85% vs 71%, p = 0.01). Multivariate logistic regression analysis showed that clopidogrel pretreatment was associated with an odds ratio of 2.2 for TMP grade 3 (1.2 to 3.9, p = 0.01). Furthermore, the incidence of reinfarction at 30 days was lower in the pretreatment group (0% vs 3.2%, respectively, p = 0.04). In conclusion, these findings support the early use of clopidogrel in patients with STEMI who are treated with primary PCI.     

Center or side: biases in selecting grasp points on small bars

Choosing appropriate grasp points is necessary for successfully interacting with objects in our environment. We brought two possible determinants of grasp point selection into conflict: the attempt to grasp an object near its center of mass to minimize torque and ensure stability and the attempt to minimize movement distance. We let our participants grasp two elongated objects of different mass and surface friction that were approached from different distances to both sides of the object. Maximizing stability predicts grasp points close to the object’s center, while minimizing movement costs predicts a bias of the grasp axis toward the side at which the movement started. We found smaller deviations from the center of mass for the smooth and heavy object, presumably because the larger torques and more slippery surface for the heavy object increase the chance of unwanted object rotation. However, our right-handed participants tended to grasp the objects to the right of the center of mass, irrespective of where the movement started. The rightward bias persisted when vision was removed once the hand was half way to the object. It was reduced when the required precision was increased. Starting the movement above the object eliminated the bias. Grasping with the left hand, participants tended to grasp the object to the left of its center. Thus, the selected grasp points seem to reflect a compromise between maximizing stability by grasping near the center of mass and grasping on the side of the acting hand, perhaps to increase visibility of the object.     

The influence of target object shape on maximum grip aperture in human grasping movements

The shape of a target object could influence maximum grip aperture in human grasping movements in several different ways. Maximum grip aperture could be influenced by the required precision of digit placement, by the aim to avoid colliding with the wrong parts of the target objects, by the mass of the target objects, or by (mis)judging the width or the volume of the target objects. To examine the influence of these five factors, we asked subjects to grasp five differently shaped target objects with the same maximal width, height and depth and compared their maximum grip aperture with what one would expect for each of the five factors. The five target objects, a cube, a three-dimensional plus sign, a rectangular block, a cylinder and a sphere, were all grasped with the same final grip aperture. The experimentally observed maximum grip apertures correlated poorly with the maximum grip apertures that were expected on the basis of the required precision, the actual mass, the perceived width and the perceived volume. They correlated much better with the maximum grip apertures that were expected on the basis of avoiding unintended collisions with the target object. We propose that the influence of target object shape on maximum grip aperture might primarily be the result of the need to avoid colliding with the wrong parts of the target object.     

Effect of intensive glycemic control on platelet reactivity in patients with long-standing uncontrolled diabetes

Background

It has been previously shown that platelets of patients with diabetes are more reactive and less responsive to anti-platelet drugs compared with platelets from subjects without diabetes. Studies examining the effect of glycemic control on platelet reactivity have yielded conflicting data. Thus, in this study, we sought to explore the effect of tight glycemic control on platelet reactivity in patients with long standing uncontrolled diabetes.

Methods

The study included 30 patients with long-standing treated diabetes and a baseline HbA1c level of ≥ 8.5%. All patients were treated with aspirin and statins. Patients were tested at baseline and after 3 months of intensive glycemic and metabolic control. The treatment goal was to achieve a HbA1c level of ≤ 7%. Platelet reactivity was assessed by light transmission aggregation in response to 5 and 10 μM ADP and to 0.5 mg/ml arachidonic acid (AA). Additonally, platelet activation was assessed by plasma levels of soluble P-selectin using an enzyme-linked immunosorbent assay.

Results

The mean duration of diabetes from the time of diagnosis was 20.46 ± 9.31 years. Baseline HbA1c was 9.4 ± 0.8%. Following the intensive glycemic control period, the HbA1C level decreased to 8.1 ± 0.8% (P < 0.0001). Other laboratory parameters did not change significantly except for triglyceride levels, which decreased. None of the platelet aggregation studies nor P-selectin levels differed between baseline and after 3 months of intensive glycemic control.

Conclusions

Intensive glycemic control in patients with longstanding uncontrolled diabetes does not seem to result in a reduction in platelet reactivity.     

Clinical picture of cardiogenic shock as primary manifestation of sepsis originating in the knee joint

This is a case report of a male with infection in the right knee joint progressing to sepsis. However, the patient initially complained mainly of dysarthria and breathlessness. He rapidly developed respiratory insufficiency with the loss of consciousness. Echocardiography revealed severe dysfunction of the left ventricle, suggesting acute failure of the chronically failing heart. The patient was referred to a coronary care unit. Only the further course of the disease, particularly progression of the local finding on the right leg and development of fever, together with significantly elevated inflammatory parameters in laboratory findings, resulted in the diagnosis of sepsis which also included myocardial dysfunction and brain hypoperfusion manifested as dysarthria.     

Etiology of Anemia Among Infants, School-Aged Children, and Young Non-Pregnant Women in Different Settings of South-Central Cote d'Ivoire

Anemia affects one-quarter of the world''s population, but its etiology remains poorly understood. We determined the prevalence of anemia and studied underlying risk factors in infants (6–23 months), young school-aged children (6–8 years), and young non-pregnant women (15–25 years) in south-central Côte d''Ivoire. Blood, stool, and urine samples were subjected to standardized, quality-controlled methods. We found high prevalence of anemia, malaria, inflammation, and deficiencies of iron, riboflavin, and vitamin A but low prevalence and intensities of soil-transmitted helminth and schistosome infections. Multivariate regression analysis revealed significant associations between anemia and Plasmodium falciparum for infants, inflammation for school-aged children, and cellular iron deficiency for both school-aged children and non-pregnant women. Women with riboflavin deficiency had significantly lower odds of anemia. Our findings call for interventions to protect infants from malaria, improved intake of dietary iron, better access to health care, and health education.