Bilateral Carpal Tunnel Release Research Articles

Comparison of WALANT versus locoregional nerve block in staged bilateral endoscopic carpal tunnel release.

Carpal tunnel release can be performed as open or endoscopic surgery. In WALANT (wide awake local anesthesia no tourniquet) a tourniquet is not used, ensuring less discomfort for the patient. In locoregional distal nerve block, on the other hand, a tourniquet is needed and can be painful. This raises the question as to which method of anesthesia is actually preferred for the patient and the surgeon. Patients undergoing staged bilateral carpal tunnel release present a unique opportunity to study this question. Fifteen patients were included in this prospective study. The primary endpoint was the preference for anesthesia type in patients and surgeons. Surgeon preference was based on the visibility and fluency of the procedure. Secondary endpoints for patients comprised pain scores for performing surgery and anesthesia and pain caused by the tourniquet. Baseline demographic and clinical information was collected. There was no significant difference in pain for performing local anesthesia or surgery. Surgeons may find that performing endoscopic release under WALANT is more challenging, as visibility tends to be significantly poorer. The mean pain caused by the tourniquet used during the wrist block procedure was rated as 3.6. In both surgeries, 77% (10/13) of the patients preferred the WALANT anesthesia. In general, endoscopic carpal tunnel release was better tolerated under WALANT than locoregional distal nerve block. Although statistical analysis showed no significant difference in visibility and fluency for the surgeon between the two anesthesia techniques, we do not recommend endoscopic release under WALANT due to the consistent report of reduced visibility in the surgical field. This limitation, likely related to the presence of anesthetic fluid, may have failed to reach statistical significance due to small sample size, but is nevertheless a considerable challenge in practice. 1B.

P.059 Weill-Marchesani Syndrome – a rare etiology for bilateral carpal tunnel syndrome in children

Background: Carpal tunnel syndrome (CTS) is less common in children but can be associated with significant disability. Pediatric CTS can be associated with an underlying disorder most commonly storage disorders including mucopolysaccharidoses (MPS). We report a patient with bilateral severe CTS secondary to Weill-Marchesani Syndrome (WMS). Methods: A retrospective chart review was completed. Results: A five-year-old female presented with a three-year history of bilateral thumb weakness and insensate digits two and three. Nerve conduction studies (NCS) revealed severe bilateral CTS. She underwent bilateral carpal tunnel release (CTR). Unfortunately, post-operative NCS was unchanged. Ultrasound showed significant median nerve compression with flexor tendon thickening. Metabolic investigations showed no evidence of a storage disorder. Trio whole exome sequencing showed two de novo likely pathogenic variants in ADAMTS10: c.1174delC, p.H392TfsX9 and a deletion of exons 3-8. Her exam was also noted to show bilateral camptodactyly and brachydactyly, and bilateral cataracts characteristic of WMS. Conclusions: Identifying the etiology of CTS is important for management and prognosis. WMS is a genetic connective tissue disorder that can cause brachydactyly and abnormal tendon thickening, which can have implications on surgical outcomes. Awareness of this diagnosis prior to surgery would allow for better patient counseling and management decisions.

Simultaneous versus staged bilateral carpal tunnel release via open and endoscopic surgeries: a retrospective propensity score-matched patient comorbidity analysis.

Carpal tunnel syndrome (CTS) presents bilaterally in nearly 60%-70% of affected patients. Bilateral carpal tunnel release (CTR) can be performed in a staged or simultaneous fashion. There remains a limited understanding of the optimal preoperative factors to use for patient selection when determining simultaneous versus staged bilateral CTR. Moreover, it is unclear how these factors influence postoperative outcomes. In this study, the authors aimed to identify and compare preoperative comorbidities and postoperative outcomes in patients who had undergone simultaneous versus staged open and endoscopic bilateral CTR. The authors performed a retrospective analysis of data collected from the TriNetX database. Patients with bilateral CTS who had been treated from February 1, 2002, to February 1, 2022, were dichotomized by their bilateral release approach: simultaneous or staged within 3 months. The resulting groups were analyzed separately by open versus endoscopic techniques. Next, cohorts were analyzed for preoperative comorbidities to identify possible factors for surgical determination. Then, they were propensity score matched on demographics and comorbidities. Postoperative outcomes within 6 months of surgery were measured with and without matching. After matching, 9286 and 3709 patients remained in the open and endoscopic groups, respectively. Those who had undergone staged surgeries via an open or endoscopic approach had more preoperative comorbidities. After matching, staged open release was associated with significantly higher rates of postprocedural care, hand/joint pain, limb pain, trigger finger, and upper respiratory tract infections. Simultaneous open release was associated with higher rates of emergency room visits. Staged endoscopic release was associated with significantly higher rates of postprocedural care, limb pain, and trigger finger. No significant outcomes were favored in the simultaneous endoscopic group. Before matching, patients who had undergone staged CTR had significantly higher rates of preoperative medical comorbidities compared with patients in the simultaneous CTR group. Moreover, staged CTR was significantly associated with higher rates of postoperative complications. After matching on demographics and comorbidities, staged CTR was still associated with higher rates of postoperative complications, suggesting that preoperative comorbidities do not influence postoperative outcome. Further prospective studies could be used to validate these results and provide new findings for the management and treatment of these groups.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release.

The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR. We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year. Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR. The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

Characteristics of Carpal Tunnel Syndrome in Wild-Type Transthyretin Amyloidosis.

Carpal tunnel syndrome (CTS) is one of the most common extra-cardiac manifestations of wild-type transthyretin amyloidosis (wtATTR); however, the characteristics of CTS in this population remain poorly understood. This retrospective cohort study reports findings from a single-centre experience of comprehensive neurological screening at the time of wtATTR diagnosis by nerve conduction studies (NCS) and neurologist assessment. Seventy-nine patients underwent neurological screening, 73 (92%) males, mean age 79.2 ± 7.5 years. Seventy-four (94%) had electrodiagnostic findings of median neuropathy at the wrist (MNW), 37 (50%) of which had a prior diagnosis of CTS and 37 (50%) had a new diagnosis of MNW. Over half of wtATTR patients (42, 53%) had bilateral MNW on screening. Most with pre-existing CTS had bilateral disease (28, 76%) and underwent bilateral carpal tunnel release (CTR) (23, 62%) prior to screening. Twenty-one (19%) wrists had mild MNW, 43 (38%) moderateand 49 (43%) severe. Twenty-one (28%) wtATTR patients with MNW were asymptomatic, 10 of which (48%) had moderate disease. Nineteen (36%) wtATTR patients with symptomatic MNW had recurrent disease despite previous CTR. As a result of screening, 36 (68%) patients with symptomatic MNW were referred for CTR. MNW is exceptionally common at the time of wtATTR diagnosis, affecting 94% of our patients. Most had severe, bilateral MNW on NCS. Some were asymptomatic, despite having moderate disease. The rate of recurrence following CTR was observed to be higher in wtATTR patients than the general population.

115. Does Autoimmune Rheumatic Disease Influence Outcomes of Carpal Tunnel Release? A Retrospective Review

BACKGROUND: Few studies have investigated the outcomes of carpal tunnel release (CTR) in patients with rheumatic disease. The aim of this study was to determine the predictive factors associated with increased complication and reoperation rates in this population. METHODS: Between 2018 and 2020, 1694 patients underwent CTR at our institution. After manually reviewing the medical records, the authors identified 128 patients with autoimmune rheumatic disease who underwent CTR. Univariate regression analysis was performed to study association with demographics (age, sex, race), comorbities (smoking, diabetes, hypothyroidism, cervical radiculopathy, obesity), unilateral or bilateral treated wrist(s), type of surgery (open or endoscopic), and preoperative severity as determined by electromyography studies. RESULTS: One hundred twenty eight of 1694 patients (7.6%) had autoimmune rheumatic disease including rheumatoid arthritis (n = 68, 53.1%), Sjogren’s syndrome (n = 13, 10.2%), psoriasis (n = 38, 29.7%), vasculitis (n = 22, 17.2%), dermatomyositis (n = 2, 1.6%), inflammatory bowel disease (n = 13, 10.2%), lupus (n = 9, 7%), systemic scleroderma (n = 2, 1.6%). Three patients received CTR revision (2.3%). There were 24 total complications (18.8%) including prolonged postoperative pain and paresthesia (n = 20, 83.3%), surgical site infection (n = 3, 12.5%), wound dehiscence (n = 1, 4.2%), and surgical reoperation (n = 1, 4.2%). Univariate analysis demonstrated no demographic factors, comorbidities, or open versus endoscopic surgery were predictive of increased complication rate or revision CTR rates in the rheumatic disease population. CONCLUSION: Autoimmune rheumatic disease is associated with higher rates of CTR revision than the general population. As compared to factors significant for higher risk of revision surgery in the normal population, older age, male sex, bilateral CTR, and endoscopic CTR were not associated with higher odds for revision surgery.

Open Versus Endoscopic Carpal Tunnel Release: A Comparison of Opioid Prescription Patterns and Occupational Therapy Referrals.

Endoscopic and open carpal tunnel releases (ECTR and OCTR) are safe and effective operations. We compared the approaches in terms of postoperative opioid refills and occupational therapy (OT) referrals. We conducted a retrospective study of patients with carpal tunnel syndrome (CTS) treated with ECTR or OCTR. Patients with isolated idiopathic CTS were included; patients undergoing simultaneous bilateral carpal tunnel release (CTR), revision CTR, and additional procedures at time of CTR were excluded. Outcomes included number of patients requiring an opioid refill and/or an OT referral within 6 months of surgery. A total of 1125 patients met inclusion criteria. Endoscopic release was performed in 634 (56%) cases and open release in 491 (44%). Unadjusted analysis revealed no difference in number of patients requiring refills (6.0% vs 7.1%, P = .44), mean number of refills among those requiring one (1.29 vs 1.23, P = .69), total oral morphine equivalents (45.1 vs 44.7, P = .84), number of patients calling regarding pain (12.8% vs 14.7%, P = .36), OT referrals (12.1% vs 11.4%, P = .71), or average number of OT visits (4.5 vs 4.2, P = .74) for endoscopic and open techniques, respectively. Adjusted analysis revealed lower age, lower body mass index, and history of muscle relaxant as predictors of opioid refills, and in contrast to the unadjusted analysis, operating surgeon and surgical technique were predictors of referral to OT. Endoscopic CTR and OCTR did not differ in terms of unadjusted postoperative patient calls for pain, number of opioid refills, or OT referrals. After correcting for individual surgeon practice, endoscopic was associated with decreased odds of requiring postoperative OT.

A Prospective Evaluation of the Prevalence of Persistent Median Artery in Patients with Carpal Tunnel Syndrome.

The median artery is an embryonic structure that typically regresses during gestation. Occasionally, the artery remains and is then termed a persistent median artery (PMA). A PMA can be associated with other anatomic anomalies, and has been known to contribute to carpal tunnel syndrome (CTS). Recent literature has observed an increase in PMA prevalence, speculated to indicate microevolutionary change. We performed a prospective observational study to investigate the current prevalence rate of PMA in patients undergoing carpal tunnel release (CTR). Institutional review board approval was obtained. From October 2020 to January 2021, patients ≥18 years old undergoing open CTR by 9 orthopaedic hand surgeons were included in analysis. Patients undergoing endoscopic CTR were excluded. Intraoperatively, the carpal tunnel was evaluated for the presence of a PMA, median nerve anomalies, or any other anatomic anomalies. If a patient underwent bilateral CTR during the study, only one side was included in analysis as determined randomly. Three hundred and sixty open CTRs in 327 patients were performed during the study. Twenty-seven PMAs were identified, for an overall prevalence rate of 8.3%. The average age of patients with a PMA was 63.6 years (SD 13.3 years), consisting of 15 men and 12 women. There were no statistical differences in age, gender, or laterality between patients that did and did not have a PMA. Thirty-three patients underwent bilateral CTR during the study, with 3 being found to have a PMA unilaterally, and zero having a PMA bilaterally. Two bifid median nerves (0.6%) were also identified. This study represents the highest prevalence rate of PMA directly observed in CTR patients reported to date (8.3%). A PMA is not a rare finding, and it should be recognized and protected during CTR. Occasionally, a PMA can be the cause of an acute presentation of CTS.

P.045 Biopsies of the transverse carpal ligament and tenosynovium for tissue confirmation of transthyretin amyloidosis

Background: Transthyretin Amyloidosis (ATTR) is a common cause of both cardiomyopathy and carpal tunnel syndrome, with many patients needing carpal tunnel release (CTR). Although tafamidis is now an approved treatment of ATTR cardiomyopathy, insurers in most provinces require biopsy confirmation of amyloidosis. Endomyocardial biopsy is often the chosen approach due to optimal sensitivity, albeit with risk of serious adverse events such as stroke, cardiac tamponade, and arrhythmias. CTR may present an ideal opportunity for obtaining amyloidosis biopsy confirmation. Methods: ATTR patients undergoing CTR had biopsy of their transverse carpal ligament (TCL) and/or flexor tenosynovium to assess the sensitivity of both sites for biopsy confirmation of amyloidosis. Results: Twelve patients consecutively underwent biopsies during CTR, with 4 (33%) having bilateral CTR and biopsy. Among 16 TCL biopsies and 14 tenosynovium biopsies, 100% demonstrated amyloid deposition. Another patient had isolated tenosynovium biopsy without CTR and also demonstrated amyloidosis. There were no serious adverse events, and 1/13 (8%) had wound dehiscence requiring repeat suturing. Conclusions: Biopsy of the TCL and/or tenosynovium during CTR is safe, cost-effective, and sensitive, and may represent an alternative to endomyocardial biopsy in patients requiring tissue confirmation for tafamidis approval. ATTR patients eligible for tafamidis may benefit from early neurology assessment.

142 Simultaneous Versus Staged Bilateral Carpal Tunnel Release Surgeries: A Retrospective Propensity-Matched Patient Comorbidity Analysis

INTRODUCTION: Carpal Tunnel Entrapment is the most common peripheral neuropathy, accounting for ∼ 90% of all neuropathies and frequently, occurs bilaterally. While thousands of carpal tunnel releases are performed each year bilaterally, the current understanding of pre-operative factors and postoperative outcomes in simultaneous and staged bilateral carpal tunnel release remain poor. METHODS: We performed a retrospective database analysis of the TriNetX database, consisting of 92 health care networks throughout the United States. Patients were divided into two cohorts: individuals with simultaneous bilateral carpal tunnel release and individuals with staged carpal tunnel releases within 3 months of each other. Numerous pre-operative comorbidities were evaluated for surgical determination and then, matched via propensity score matching. Post-operative outcomes were measured within 180 of surgery with and without propensity score matching. Statistical analysis was done through TriNetX software, which utilizes JAVA, R, and Python programming languages. RESULTS: The two cohorts result in 17,513 patients for staged carpal tunnel releases and 9,649 for simultaneous bilateral carpal tunnel release surgery. After propensity score matching, 9,289 patients were used in the analysis. Overall, those that underwent staged surgeries had more pre-operative co-morbidities (Hypertension, obesity, chronic kidney disease, arthritis, etc.). Upon matching, patients with staged releases had significantly higher postprocedural aftercare (OR 2.023; 1.813, 2.258), hand/ joint pain (OR 1.876; 1.212-2.905), pain in the extremity (OR 1.161; 1.055, 1.277), trigger finger (OR 1.608; 1.387-1.865), and an upper respiratory tract infection (OR 1.366; 1.206-1.546). Patients with simultaneous bilateral carpal tunnel release had more emergency room visits (OR .835; .766-.91). Non-significant outcomes pulmonary or venous embolism, intraoperative complications, hematomas, surgical site infection, and rehospitalizations. CONCLUSION: These findings demonstrate selection variance between simultaneous and staged carpal tunnel releases. Even after matching, simultaneous bilateral carpal tunnel releases provide fewer post-operative complications while only showing a mild increase in emergency room visits. Further prospective studies could be used to validate these results as well as provide new findings to the management and treatment of these groups.

Evaluation of Patient Expectations before Carpal Tunnel Release.

Background:Carpal tunnel release (CTR) is common, yet patient treatment expectations remain unclear. The primary purpose was to describe patient expectations before CTR. Secondarily, we aimed to identify factors influencing expectations.Methods:Included patients underwent unilateral or bilateral CTR between 2015 and 2017 at a single academic center. Expectations regarding the level of relief/improvement were queried. Area deprivation index (ADI) was used to measure social deprivation. Univariate and multivariable logistic regression identified factors associated with expecting great relief/improvement.Results:Of 307 included patients, mean age was 54 ± 16 years and 63% were women. Patients most commonly expected great (58%) or some (23%) relief/improvement. Few patients expected little (3%) or no (4%) relief/improvement, and 13% had no expectations. In the multivariable analysis, male sex, lower social deprivation, and lower BMI were associated with expecting great relief/improvement. Age, surgical technique (open versus endoscopic), use of the operating room versus procedure room, and preoperative factors (constant numbness, weakness/atrophy, duration of symptoms, and QuickDASH) were not associated with expectations.Conclusions:Most patients expect some to great improvement after CTR. This was independent of several factors with a known association with worse outcomes (advanced age, atrophy/weakness, and constant numbness). Male sex was associated with the expectation of great improvement, in which superior outcomes relative to females have not been borne out in the literature. These findings highlight patient counseling opportunities. The observed association between social deprivation and expectations warrants further investigation, as the socioeconomically disadvantaged experience worse healthcare outcomes in general.

Self-Reliance and Postoperative Hand Recovery After Simultaneous, Bilateral Endoscopic Carpal Tunnel Release: A Prospective Study

Outcomes and recovery of endoscopic carpal tunnel release (ECTR) have been broadly examined in studies. The total recovery time can potentially be reduced by performing simultaneous, bilateral ECTR. In this study we prospectively investigated days to self-reliance. As secondary outcomes, we investigated direct postoperative recovery of hand function and pre and postoperative symptom severity after simultaneous, bilateral ECTR. In this single-center prospective case series, we included all patients willing to participate after undergoing bilateral ECTR between December 2015 and July 2019. Every patient recorded days to self-reliance (when a patient could perform basic activities of daily living without the need for assistance from another person) and completed a preoperative and postoperative Boston Carpal Tunnel Questionnaire (BCTQ) evaluating postoperative hand function and pre and postoperative symptom severity. In total, 81 patients received simultaneous, bilateral ECTR. Median days until self-reliance was 4; mean number of days was 4.9. Concerning BCTQ scores, postoperative functional status increased significantly each day, and mean BCTQ score decreased gradually from intense difficulty to little difficulty in daily tasks over a period of 7 days. Preoperative BCTQ symptom severity showed significant improvement compared to postoperative symptoms, evolving from medium to slight symptoms. Simultaneous, bilateral ECTR offers recovery to self-reliance in 4 to 5 days with a gradual and significant increase of hand function in the following postoperative days. Therapeutic II.

Long-term Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance.

The purpose of this study was to determine the long-term safety and efficacy of carpal tunnel release (CTR) using ultrasound guidance in a group of patients treated by a single physician. The study group consisted of 76 consecutive CTRs performed on 47 patients between June 2017 and April 2019 for whom 1-year follow-up was available. All procedures were performed by the same operator using a single CTR technique. Outcomes included complications; Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scores; and a 5-point global satisfaction score (4 = satisfied, 5 = very satisfied). The 47 patients included 27 females and 20 males (ages 31-91 years). Twenty-five patients (50 hands) had simultaneous bilateral CTRs, 4 patients (8 hands) had staged bilateral CTRs, and 18 patients had unilateral CTRs. No complications occurred. Statistically and clinically significant reductions in BCTQ-SSS, BCTQ-FSS, and QDASH scores occurred by 1 to 2 weeks post-CTR and persisted at 1-year (mean 1-year changes vs. pre-CTR -2.11, -1.70, and -44.99, respectively; P < .001 for all). The mean global satisfaction score at 1-year was 4.63. CTR using ultrasound (US) guidance is a safe and effective procedure that produces statistically and clinically significant improvements within 1 to 2 weeks postprocedure that persist to 1 year. Furthermore, simultaneous bilateral CTRs using US guidance are feasible and may be advantageous for patients who are candidates for bilateral CTR.

A Comparison of Open Carpal Tunnel Release Outcomes Between Procedure Room and Operating Room Settings

PurposeCarpal tunnel release (CTR) surgical costs are minimized when performed in the procedure room (PR) setting, compared with the operating room. However, it remains unclear whether outcomes differ between surgical settings. Our purpose was to compare outcomes at 1 year or greater follow-up after open CTR between patients treated in PR versus operating room settings using the Boston Carpal Tunnel Questionnaire (BCTQ).MethodsA change in clinical care protocols at our institution occurred in 2014. Before this, all CTRs were performed in the operating room; thereafter, these were transitioned to the PR. Adult patients who underwent isolated unilateral or bilateral open CTR in either surgical setting were considered for inclusion, in which procedures were conducted between January 2014 and October 2018 for the PR group and January 2009 and March 2014 for the operating room group. The Functional Status Scale (FSS) and the Symptom Severity Scale (SSS) components of the BCTQ were collected for all eligible patients at a minimum of 1 year after surgery. We used univariate and multivariable linear regression to determine whether postoperative BCTQ scores were equivalent between PR and operating room groups within a threshold of one-fourth of the lowest estimates of the minimal clinically important difference.ResultsNo differences in demographics, comorbidities, or insurance type were observed between the 104 PR and 112 operating room patients. Survey response rate was 25% and 25% for the PR and operating room patients, respectively. At a mean follow-up of 3 ± 1 years, FSS and SSS scores were equivalent between PR and operating room groups on bivariate analysis. The multivariable equivalence test also demonstrated equivalent FSS and SSS scores between PR and operating room groups within a one-fourth minimal clinically important difference threshold while controlling for age, sex, presence of diabetes or thyroid disease, unilateral versus bilateral CTR, and surgeon.ConclusionsClinical outcomes did not differ between PR and operating room settings after open CTR.Type of study/level of evidenceTherapeutic III.

The Clinical Spectrum of T60a Variant Hereditary Transthyretin Amyloidosis In Ireland

Introduction Hereditary transthyretin amyloidosis (hATTR) is a progressive multisystem disorder with a wide clinical spectrum. In the Irish population, the T60A variant is the most common genotype. We aimed to describe the spectrum of patients with T60A hATTR attending an Irish national amyloid clinic. Methods The medical, laboratory and radiological records of all patients attending our cardiac amyloidosis referral clinic with a confirmed diagnosis of T60A variant hATTR were reviewed. Results The T60A mutation accounted for 94% of our hATTR population (15 patients; 60% male; median age at diagnosis of 65 years [IQR = 63,67], median follow up 10 months [IQR 4,60]). The majority (80%) were symptomatic at presentation with the remainder referred for family screening. Ten patients (66%) had a family history suggestive of amyloidosis; six of these had a first degree relative with a T60A mutation. Neurological manifestations predated cardiac manifestations and were present in 93% of patients at the time of diagnosis (peripheral neuropathy in 80% and autonomic neuropathy in 95%). Five patients (33%) had undergone a bilateral carpal tunnel release procedure at a median of 11 years (IQR 9, 13) pre-diagnosis. Symptoms of heart failure were present in 53% during follow up (New York Heart Association class II 40%; class III 13%; the remainder remained asymptomatic) while 33% had a heart failure hospitalisation over the past year. All patients had cardiac involvement at presentation by Technitium-99m, 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy (Perugini Grade 2 in 40%; Grade 3 in 60%). Only those with symptoms had ventricular hypertrophy on echocardiography (median left ventricular wall thickness 2cm (IQR 1.5, 2.5); median right ventricular (RV) wall thickness 0.8cm [IQR 0.68, 0.92]). Due to abnormalities on haematological testing, 9 patients (60%) required tissue confirmation of ATTR (RV endomyocardial biopsy in 5; rectal, bladder or fat pad in 3; bone marrow aspirate in 1). All patients were heterozygous for the T60A variant. All patients received disease modifying treatment at some point during follow-up (diflunisal 80%; doxycycline 7%; patisiran 33% and tafamidis 7%). All patients with Perugini grade 2 on initial Tc-DPD imaging progressed to grade 3 on repeat imaging at a median interval of 18 months (IQR 6.75, 36). Conclusions T60A variant hATTR presents with a mixed phenotype of polyneuropathy and heart failure. Neurological manifestations are more prevalent at an earlier stage while cardiac involvement by TC-DPD is already at an advanced stage at the time of diagnosis irrespective of symptoms and progressed over short term follow-up in our cohort.

Return to Activities After Simultaneous Bilateral Endoscopic Carpal Tunnel Release.

Approximately 56% of patients diagnosed with carpal tunnel syndrome present with bilateral symptoms; however, few studies have investigated bilateral simultaneous endoscopic carpal tunnel release (ECTR) and postoperative effect on return to activity. The purpose of this study was to evaluate the length of recovery in patients who received bilateral simultaneous ECTR, including pain medication requirements, return to activities of daily living, return to work, and return to recreational activities. A retrospective analysis was performed on patients who underwent bilateral ECTR by a single hand fellowship-trained surgeon from 2013 to 2019. Demographic, operative, and clinical outcomes were collected via chart review and a telephone interview. Student t tests and χ2 tests were conducted for analysis. Eighty patients were included in the study; 40 were successfully contacted for telephone interview follow-up. Patients reported an average of 2 days of use of postoperative narcotic pain medication and an average of 5, 7, and 19 days of return to activities of daily living, work, and recreational activities, respectively. Female patients reported more days of narcotic pain medications (1 day vs 3 days, P = .0483) and an average of longer return to work than men (9 days vs 5 days, P = .0477). Manual laborers reported longer return to work (9 days vs 5 days, P = .0500). Older patients (aged >65 years) reported longer return to recreational activities (39 days vs 11 days, P = .0189). Simultaneous bilateral ECTR is a successful procedure with shorter recovery times than reported previously. Female patients, manual laborers, and older patients experience a longer recovery and should be counseled appropriately.

Revision Carpal Tunnel Release: Risk Factors and Rate of Secondary Surgery.

The first aim of this study was to determine the rate of revision carpal tunnel release in five urban hospitals over a period of 14 years. The secondary aim was to assess what demographic, condition-related, and treatment-related factors are associated with revision carpal tunnel release. Between 2002 and 2015, 7464 patients underwent carpal tunnel release. After manually reviewing the medical records, the authors identified 113 patients who underwent revision surgery. Multivariable logistic regression analysis was performed to study association with demographics (age, sex, and race), unilateral or bilateral treated wrist(s) (including carpal tunnel release performed simultaneously and separately), and type of surgery (open or endoscopic). To gain further insight into these factors, a matched case-control analysis in a 1:3 ratio was performed. One hundred thirteen of 7464 patients (1.5 percent) underwent revision carpal tunnel surgery. The median (interquartile range) time to revision surgery was 1.23 years (0.47 to 3.89 years). In multivariable logistic regression analysis, older age, male sex, bilateral carpal tunnel release, and endoscopic carpal tunnel release were independently associated with higher odds for revision surgery. Multivariable conditional logistic regression of the matched case-control cohort showed that smoking and rheumatoid arthritis were independently associated with revision carpal tunnel release. Splint treatment before the initial surgery was independently associated with single carpal tunnel release. Endoscopic release, male sex, smoking, rheumatoid arthritis, and undergoing staged or simultaneous bilateral carpal tunnel release are risk factors for revision surgery. Risk, III.

Analysis of surgical options for patients with bilateral carpal tunnel syndrome

BackgroundBilateral endoscopic carpal tunnel release is a modality offered for the treatment of the median nerve compression neuropathy. This retrospective study compares outcomes for patients undergoing open carpal tunnel release versus bilateral endoscopic carpal tunnel release. We hypothesized that there is no significant difference in postoperative complication rates between unilateral open and bilateral endoscopic carpal tunnel release surgery. MethodsThe authors identified all patients who underwent open carpal tunnel release, unilateral endoscopic carpal tunnel release and bilateral endoscopic carpal tunnel release at a university hospital from 2012 to 2014. Cases were identified using CPT billing codes and the data was assessed using an analysis of variance (ANOVA). All endoscopic carpal tunnel releases were done by the same surgeon (AP), and greater than 90% of open procedures were done by a different same surgeon (DF). ResultsThe total combined complication rate was 24.7% with no significant difference (p > .05) between techniques. There were no major complications necessitating a return to the operating room. Variables that had a statistically significant difference between groups (p < .05) included mean tourniquet time, mean total procedure time, and return to work as determined from the number of follow-up appointments. ConclusionsThe study demonstrates equivocal complication profiles and decreased cost associated with bilateral endoscopic tunnel release as compared to sequential open carpal tunnel release. Endoscopic bilateral carpal tunnel release for patients with bilateral carpal tunnel syndrome offers a safe and effective alternative to open carpal tunnel release.

Palmar Digital Neuropathy With Anatomical Variation of Median Nerve: Usefulness of Orthodromic Technique: A Case Report

Anatomic variation of palmar digital nerve pathways were reported in several cases. Selective exploration of palmar digital nerves with a nerve conduction study has been challenging, because of technical issues. We report a patient who received bilateral carpal tunnel release operation, complaining of a tingling sensation, and hypoesthesia on the middle and ring fingers. An electrodiagnostic study revealed a sensory neuropathy of palmar digital nerve of the left median nerve, supplying the ulnar side of the middle finger, and radial side of the ring finger. She underwent re-operation of open left carpal tunnel release, and a branching site of common digital nerves of the median nerve was identified not at the palm, but at a far proximal site around the distal wrist crease. Usefulness of an orthodromic sensory conduction study was clarified to eliminate volume conducted response or co-activation of nearby nerves in the patient with selective involvement of palmar digital nerve.

Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release: A Randomized Trial

Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.