Endoscopic Carpal Tunnel Release Research Articles

Direct Variable Cost Comparison of Endoscopic Versus Open Carpal Tunnel Release: A Time-Driven Activity-Based Costing Analysis.

To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR). We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs. Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case. Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted. Economic and Decision Analysis Level II.

Metacarpal Small Incision for Carpal Tunnel Syndrome.

Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally effective as traditional open carpal tunnel release (OCTR) techniques in relieving pain and numbness. However, patients who undergo OCTR are more likely to experience scar tenderness and pillar pain and take longer to return to work. We present here a method of metacarpal small incision for carpal tunnel release (MSICTR) as a safe, reliable, cost-effective alternative surgical decompression of the median nerve of the wrist. This technique utilizes a metacarpal small incision and direct visualization of the median nerve and carpal tunnel contents, reducing the risk of permanent injury and neurasthenia when compared to traditional OCTR. MSICTR is also suitable for the examination of the median nerve, surrounding tendon sheath, or space-occupying lesions. MSICTR is associated with shorter operation times, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional OCTR. Therefore, MSICTR is an effective surgical decompression of the median nerve for the treatment of carpal tunnel syndrome.

458 Endoscopic Versus Open Carpal Tunnel Release: An Umbrella Review and a Meta-Analysis

INTRODUCTION: Whether open carpal tunnel release (OCTR) versus endoscopic carpal tunnel release (ECTR) has super outcomes remains a controversial topic. METHODS: A PubMed, Scopus and Cochrane databases was conducted for all meta-analyses comparing OCTR and ECTR performed between 2000-2022 in accordance to PRISMA and Joanna Briggs Institute guidance of umbrella reviews. The primary outcomes were: 1) functional ability: symptoms severity, grip strength, pinch strength, two-point discrimination, and pain, 2) operative outcomes: operation time, total complications, nerve injury, scar formation, and 3) time to return to work. Pooled analysis was performed to compare outcomes using Review Manager Version 5.2.11. RESULTS: 9 meta-analyses were included, 5 were of high quality and 4 were moderate quality on the Assessment of Multiple Systematic Reviews (AMSTAR) scale. Functional ability: OCTR was associated with better pinch strength after 3-months (0.70, 95% CI = 0.00, 1.40, p = 0.05) and after 6-months (0.77, 95% CI = 0.14, 1.40, p = 0.02, I2 = 84%). Operative outcomes: OCTR was associated with less nerve injury (3.26, 95% CI = 1.20, 8.86, p = 0.02, I2 = 0%) and more risk of scars formation (0.40, 95% CI = 0.24, 0.66, p = 0.0003, I2 = 41). Return to work: OCTR was associated with longer return to work (-10.89, 95% CI = -15.14, -6.64, p < 0.00001, I2 = 83%). There were no significant differences between OCTR and ECTR in the hand function, symptom severity, grip strength, pain, operation time and total complications. CONCLUSIONS: In an umbrella review and meta-analysis of OCTR vs. ECTR, we found that while OCTR demonstrated higher pinch strength and lower nerve injury risk, ECTR was associated with less scar formation and a shorter time to return to work.

Comparison of early clinical outcome in carpal tunnel release - mini-open technique with palmar incision vs. endoscopic technique with wrist crease incision-

BackgroundThe purpose of this study was to examine two techniques for Carpal Tunnel Syndrome, mini-Open Carpal Tunnel Release (mini-OCTR) and Endoscopic Carpal Tunnel Release (ECTR), to compare their therapeutic efficacy.MethodsSixteen patients who underwent mini-OCTR in palmar incision and 17 patients who underwent ECTR in the wrist crease incision were included in the study. All patients presented preoperatively and at 1, 3, and 6 months postoperatively and were assessed with the Visual Analogue Scale (VAS) and the Disabilities of Arm, Shoulder and Hand Score (DASH). We also assessed the pain and cosmetic VAS of the entire affected hand or surgical wound, and the patient’s satisfaction with the surgery.ResultsIn the objective evaluation, both surgical techniques showed improvement at 6 months postoperatively. The DASH score was significantly lower in the ECTR group (average = 3 months: 13.6, 6 months: 11.9) than in the mini-OCTR group (average = 3 months: 27.3, 6 months: 20.6) at 3 and 6 months postoperatively. Also, the pain VAS score was significantly lower in the ECTR group (average = 17.1) than in the mini-OCTR group (average = 36.6) at 3 months postoperatively. The cosmetic VAS was significantly lower in the ECTR group (average = 1 month: 15.3, 3 months: 12.2, 6 months: 5.41) than in the mini-OCTR group (average = 1 month: 33.3, 3 months: 31.2, 6 months: 24.8) at all time points postoperatively. Patient satisfaction scores tended to be higher in the ECTR group (average = 3.3) compared to the mini-OCTR group (average = 2.7).ConclusionsECTR in wrist increase incision resulted in better pain and cosmetic recovery in an early postoperative phase compared with mini-OCTR in palmar incision. Our findings suggest that ECTR is an effective technique for patient satisfaction.

A Modified Endoscopic Carpal Tunnel Release Surgery

In this study, a modified version of the endoscopic carpal tunnel release surgery was introduced, which is safe and easy to handle. Moreover, the requirement for surgical instruments is low. Six patients with carpal tunnel syndrome underwent the modified procedure. No neurovascular injuries occurred in these patients. According to the one-year follow-up data, all the patients were satisfied with the outcomes. The modified endoscopic carpal tunnel release technique has been proven to be safe with satisfactory outcomes in six patients in this study.

A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release

Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR. We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases. A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%). Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous. Prognostic II.

State of the art review. Complications after carpal tunnel release.

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Wrist & Hand

The February 2024 Wrist & Hand Roundup360 looks at: Occupational therapy for thumb carpometacarpal osteoarthritis?; Age and patient-reported benefits from operative management of intra-articular distal radius fractures: a meta-regression analysis; Long-term outcomes of nonsurgical treatment of thumb carpometacarpal osteoarthritis: a cohort study; Semi-occlusive dressing versus surgery in fingertip injuries: a randomized controlled trial; Re-fracture in partial union of the scaphoid waist?; The WALANT distal radius fracture: a systematic review; Endoscopic carpal tunnel release with or without hand therapy?; Ten-year trends in the level of evidence in hand surgery.

Revision Carpal Tunnel Release Following Endoscopic Compared With Open Decompression

Carpal tunnel release (CTR) technique may influence the likelihood of revision surgery. Prior studies of revision CTR following endoscopic CTR (ECTR) compared with open CTR (OCTR) have been limited by sample size and duration of follow-up. To estimate the incidence of revision CTR following ECTR compared with OCTR in a national cohort. This retrospective cohort study used data from the US Veterans Health Administration. Participants included all adults (age ≥18 years) undergoing at least 1 outpatient CTR from October 1, 1999, to May 20, 2021. Data were analyzed from May 21, 2021, to November 27, 2023. Index CTR technique. The primary outcome was time to revision CTR, defined as repeat ipsilateral CTR during the study period. Secondary outcomes were indications for revision, findings during revision, and additional procedures performed during revision. Among 134 851 wrists from 103 455 patients (92 510 [89.4%] male; median [IQR] age, 62 [53-70] years) undergoing at least 1 CTR, 1809 wrists underwent at least 1 revision at a median (IQR) of 2.5 (1.0-3.8) years. In competing-risks analysis, the cumulative incidence of revision was 1.06% (95% CI, 0.99%-1.12%) at 5 years and 1.59% (95% CI, 1.51%-1.67%) at 10 years. ECTR was associated with increased hazard of revision CTR compared with OCTR (adjusted hazard ratio [aHR], 1.56; 95% CI, 1.34-1.81; P < .001). The risk difference for revision CTR associated with ECTR compared with OCTR was 0.57% (95% CI, 0.31%-0.84%) at 5 years (number needed to harm, 176) and 0.72% (95% CI, 0.36%-1.07%) at 10 years (number needed to harm, 139). Regardless of index CTR technique, the most common indication for revision was symptom recurrence (1062 wrists [58.7%]). A reconstituted transverse carpal ligament (TCL) was more common after ECTR compared with OCTR, whereas scarring of the overlying tissues and of the median nerve itself were more common following OCTR. Incomplete transverse-carpal-ligament release was observed in 251 of the wrists undergoing revision CTR (13.94%) and was more common among revisions following ECTR (odds ratio, 1.62; 95% CI, 1.11-2.37; P = .01). In this cohort study of revision CTR in the Veterans Health Administration, ECTR was associated with increased risk of revision compared with OCTR, but the absolute risk was low regardless of technique. Intraoperative findings at revision varied significantly according to index CTR technique.

A Comparison of Early Complication Rates of Endoscopic Carpal Tunnel Release With and Without Resident Involvement

The purpose of this study was to compare the complication rates of endoscopic carpal tunnel release (ECTR) relative to orthopedic resident trainee involvement in the procedure. All patients undergoing isolated, elective ECTR by two attending surgeons within a 59-month period were analyzed. Cases were categorized as the following according to the degree of resident involvement: ECTR performed by attending with either no resident or a resident as an assistant (group 1), resident performing a portion of the procedure (group 2), and resident performing the entire procedure (group 3). Early postoperative complications and/or intraoperative conversion to an open procedure were the outcomes of interest. We used a noninferiority design, hypothesizing that resident involvement would not be associated with inferior outcomes compared with cases without resident involvement. Multiple logistic regression models, adjusted for patient demographic and surgical characteristics, were fit to assess the relationship between resident involvement groups and complication/conversion outcomes. A total of 1,167 ECTR cases (895 patients) were performed and returned for postoperative follow-up for at least 2 weeks after surgery. Operative time was significantly shorter for group 1 cases versus group 2 and 3 cases. The early postoperative complication and conversion rates were 1.7% and 1.0%, respectively. Superficial infection (1.2%), deep infection (0.3%), and transient neuropraxia (0.3%) occurred infrequently and did not differ relative to resident involvement. No differences in the odds of complication and/or conversion relative to resident involvement were observed. The results of ECTR performed entirely or in part by attending-supervised resident trainees were not inferior to ECTR performed by an attending surgeon regarding the odds of experiencing complications or conversion to an open procedure. With appropriate supervision, ECTR can be performed safely by orthopedic and plastic surgery residents. Therapeutic II.

Causes of Iatrogenic Median Nerve Injury after Endoscopic Carpal Tunnel Release.

Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon's experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated. Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes-Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively. Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side. Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel. Level of Evidence: Level IV (Therapeutic).

Comparative analysis of open versus endoscopic carpal tunnel release in a comprehensive national database

PurposeCarpal tunnel syndrome is the most common compressive neuropathy. There is limited evidence to support endoscopic compared to open carpal tunnel release according to the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on carpal tunnel syndrome. The purpose of the present study was to assess differences between the two procedures by comparing 30- and 90-day complications and mean hospital costs in a large patient population. MethodsUsing the national Mariner15 Database by PearlDiver Technologies, we retrospectively studied 27,192 carpal tunnel syndrome patients who received carpal tunnel release using an endoscopic or open surgical approach from 2010 to 2019. Patients who met the inclusion criteria were grouped and case-matched at a 1:1 ratio through the corresponding International Classification of Diseases codes (n = 13,596) and assessed for 30- and 90-day complications such as median nerve injury, superficial palmar arch injury, and revision carpal tunnel release surgery. Univariate analysis was used to compare outcomes and a multivariate regression was performed to identify risk factors associated with each outcome. ResultsEndoscopic carpal tunnel release was associated with a higher rate of median nerve injury than open release at 30 days (0.3% vs. 0.1% odds ratio, 2.21; 95% confidence interval, 1.29–3.81; p < 0.05) and 90 days (0.4% vs. 0.3%; odds ratio, 1.77; 95% confidence interval, 1.16–2.70; p < 0.05). Endoscopic release was also associated with a higher rate of superficial palmar arch injury (0.1% vs. 0%; odds ratio, 25.02; 95% confidence interval, 1.48–423.0; p < 0.05). ConclusionsIn the present study, risk of median nerve injury and vascular injury was higher after endoscopic than open carpal tunnel release. At 90 days, all-cause revision rates were similar between techniques. Surgeons should understand these differences, to optimize surgical decision-making. Level of evidenceTherapeutic, IIIa.

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.

Best-Evidence Systematic Review and Meta-Analysis of Endoscopic Carpal Tunnel Release Outcomes

The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of endoscopic carpal tunnel release (ECTR) using best-evidence synthesis methods. A systematic search of multiple databases was conducted for prospective contemporary studies published between January 2013 and January 2023 with at least 50 ECTR cases. Outcomes included the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) measured on a 0-100 scale, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS) on a 1-5 scale, pain visual analog scale on a 0-10 scale, conversion to open carpal tunnel release (CTR), complications, and reoperations. Outcomes were analyzed using a random-effects meta-analysis model. Metaregression was used to determine the association of patient- and study-level factors with ECTR outcomes. A total of 17 studies with 1,632 patients treated with ECTR were included. Median follow-up durations ranged from 4 to 7 months depending on the outcome. Statistically significant and clinically important improvements were noted after ECTR for Q-DASH, BCTQ-SSS, BCTQ-FSS, and pain visual analog scale scores, with mean differences from baseline of-28.8,-1.8,-1.5, and-5.1, respectively (P < .001 for all). In metaregression, the strongest predictor of improvement in Q-DASH, BCTQ-SSS, and BCTQ-FSS was a greater preoperative score for that variable (all P ≤ .005), indicating that patients with worse symptoms improved the most. The risks of conversion to open CTR, complications, and revision CTR were 0.7%, 0.7%, and 0.5%, respectively. In a best-evidence synthesis of contemporary studies, ECTR resulted in significant improvements in function and pain, with a low risk of conversion to open surgery, complications, and reoperations over short-term follow-up. Patients treated with ECTR can expect generally favorable clinical outcomes over the short term. However, long-term outcomes after ECTR are not well characterized.

Patient Experiences With Hand Surgery in the Office Versus Ambulatory Surgery Center.

Background In hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method.This study investigates the degree of patient satisfaction, out-of-pocket costs, peri- and postoperative pain, convenience, and comfort experienced with in-office hand procedures compared to ambulatory surgery center (ASC) procedures. Methods A 10-question survey consisting of a 10-point Likert scale of agreement and numerical questions was administered to patients treated with minor hand operations in the office and ASC settings in Florida, USA. The surgical procedures included are bony reconstruction, percutaneous pinning, open reduction internal fixation, closed fracture reduction, mass removal, endoscopic carpal tunnel release, Dupuytren's release/tendon repair, and trigger finger release. Procedures and patient demographics were assessed via chart review. Independent samples t-test was used to determine statistical associations with significance defined as p < 0.05. Results Patients reported a strong level of agreement in response to questions 1-3 and 6-8, indicating a high degree of convenience, comfort, and overall satisfaction with both in-office and ASC procedures. Positive metrics gauged in questions 1-3 and 6-8 averaged 9.64 ± 0.14 in the office setting and 9.62 ± 0.16 in the ASC setting.Questions 4 and 5 averaged 2.74 ± 0.29 in the office setting and 2.84 ± 4.12 in the ASC setting, indicating mild disagreement that the surgery or recovery period was painful. In-office patients reported taking 0.91 ± 2.80 days off work and ASC patients reported taking 12.43 ± 22.51 days off work following surgery (p = 0.0039). Respondents reported an out-of-pocket cost averaging $348 ± $943 in the office setting and $574 ± $1262 in the ASC setting, depending on insurance coverage (p = 0.3019). Conclusions Though costs and time off of work differed between the two groups due to the different procedures in either setting, patient satisfaction metrics were comparable. While patient satisfaction depends on the operating physician, these results demonstrate that patients treated in-office and in an ASC have similar levels of approval with their hand surgery care.

Proximity of the Ulnar Neurovascular Structures in Endoscopic Carpal Tunnel Release Surgery: A Cadaveric Study

To evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR). Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade's proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible. The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4-20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0-15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1-7.8) and to the median nerve was 3.3 mm (range, 0-6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures. There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR. These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device.

Understanding the Learning Curve of Carpal Tunnel Release With Ultrasound Guidance: A Review.

Carpal tunnel syndrome (CTS) is the most common compressive neuropathyand can be treated through carpal tunnel release (CTR) if nonoperative treatments fail. CTR can be performed through a variety of techniques, including traditional open, mini-open, endoscopic, and CTR with ultrasound guidance (CTR-US). The evidence on endoscopic CTR is mixed, due to a higher potential for nerve injury with endoscopic CTR compared to traditional open CTR. CTR-US offers the potential advantage of allowing the visualization of all key anatomical structures, combined with a very small incision and minimal soft tissue insult. As with any ultrasonographic technique or procedure, the learning curve needs to be considered for any provider considering adopting CTR-US. However, literature on ultrasound use around the wrist, including early evidence on the learning curve of CTR-US specifically, demonstrates this skill can be learned relatively quickly by providers with a wide range of prior experience in ultrasound and CTR. Overall, there is a need for high-quality studies comparing different CTR techniques, particularly CTR-US, as it offers the potential for considerable cost savings.

Poster 176: Distal Mononeuropathy and Nerve Release after Arthroscopic Shoulder Surgery: A Matched Cohort Analysis

Objectives: Following arthroscopic shoulder procedures such as total shoulder arthroplasties, reverse total shoulder arthroplasties, and rotator cuff repairs, select patients have presented with symptomatic distal mononeuropathy (DMN) that require follow-up nerve release procedure(s). This occurrence may be secondary to operative complications such as limb traction, surgical dissection, hematoma formation, or interscalene block placement. Separately, many patients presenting for impending shoulder procedures have been found to have preexisting DMN that similarly require nerve release for management. This retrospective cohort study aims to compare the clinical outcomes of a cohort of patients who underwent peripheral nerve release (cubital/carpal tunnel) for DMN following recent shoulder surgery to a cohort with no prior history of a shoulder procedure before DMN presentation. Methods: From 2010 to 2020, CPT codes were used to identify a cohort of patients over the age of 18 who underwent a shoulder procedure (rotator cuff repair, total shoulder arthroplasty, reverse total shoulder arthroplasty, and shoulder stabilization) and had an ensuing nerve release procedure for DMN (open or endoscopic cubital or carpal tunnel release) within 2 years of that surgery. A second cohort of patients who underwent a nerve release procedure for DMN presentation (open or endoscopic cubital or carpal tunnel release) with no prior history of shoulder surgery were identified using CPT codes and subsequently matched to the first cohort by age, sex, and BMI in a 3:1 (control: case) ratio. Following this, chart review and Redcap surveys were used to collect: demographics, surgical history, electromyography/nerve conduction velocity (EMG/NCV) results, post-operative symptoms (numbness, weakness, pain), and patient-reported outcomes (ASES, SANE, DASH). EMG/NCV results were categorized as Mild/Moderate/Severe based on standard practices. T-tests and Mann-Whitney tests were used for statistical analysis between the two groups with significance set at P &lt; .05. Results: 120 patients are included in this analysis (28 case, 92 control). There was no statistical difference between the groups for mean age at surgery, sex, or BMI . Patients with prior shoulder surgery before DMN presentation had a nerve release at an average of 0.81 ± 0.61 years after shoulder surgery. Mean follow-up time after nerve release for all patients in both cohorts was 4.91 ± 2.11 years. The most common nerve release for DMN across both cohorts was open carpal tunnel release (n=86), followed by endoscopic carpal tunnel release (n=22), open cubital tunnel release (n=16), and endoscopic cubital tunnel release (n=2). There was no statistical difference in preoperative EMG/NCV results between patients in the case group (39.3% mild, 32.1% moderate, 28.6% severe) compared to patients in the control group (29.3% mild, 47.8% moderate, 22.8% Severe) (P=0.125). There was no difference between groups for preoperative ASES, SANE, and DASH (P≥0.188), or for postoperative ASES, SANE, and DASH (P≥0.170). Following nerve release, patients in the case group were found to have significantly more post-operative numbness/tingling (42.9%) than patients in the control group (18.5%) (P=0.017). There was no difference between groups in postoperative pain (P=0.075) or weakness (P=0.156) [Figure 1]. Residual post-operative numbness following nerve release, was more likely to occur in the forearm for patients in the case group (21.4%) than patients in the control group (6.52% of patients) (P=0.032) [Figure 2]. Although not significant, 65.2% of patients in the case group reported complete resolution of symptoms following nerve release procedure compared to 50% of patients in the control group (P=.219). Conclusions: Patients with a history of shoulder surgery prior to presentation of DMN are more likely to experience persistent numbness or tingling after nerve release surgery than patients without a history of shoulder surgery. These patients are also more likely to experience symptoms located in the forearm. However, patient-reported outcomes between patients undergoing nerve release surgery with a history of shoulder surgery and those without are similar. Surgeons should be aware of these findings for improved patient education regarding post-operative prognosis.

Endoscopic Versus Open Carpal Tunnel Surgery: Risk Factors and Rates of Revision Surgery

The purpose of our study was to compare the 1-year revision surgery rates and outcomes of open versus endoscopic carpal tunnel release. Our hypothesis was that, compared to open release, endoscopic carpal tunnel release was an independent risk factor for revision surgery within 1-year. This was a retrospective cohort study of 4338 patients undergoing isolated endoscopic or open carpal tunnel release. Demographic data, medical comorbidities, surgical approach, need for revision surgery, hand dominance, history of prior injection, and Patient Reported Outcomes Measurement Information System upper extremity (UE), pain interference (PI) and physical function scores were analyzed. Multivariable analysis was used to identify the risk factors for revision surgery within one year of the index procedure. In total, 3280 patients (76%) underwent open and 1058 (24%) underwent endoscopic carpal tunnel release. Within one year of the index procedure, 45 patients required revision carpal tunnel release. The average time to revision was 143 days. The rate of revision carpal tunnel release in the open group was 0.71% compared to 2.08% in the endoscopic group. Multivariable analysis demonstrated that endoscopic surgery, male sex, cubital tunnel syndrome, tobacco use, and diabetes were associated independently with revision surgery. In this study, we found that endoscopic carpal tunnel release was associated independently with a 2.96 times greater likelihood of requiring revision carpal tunnel release within one year, compared to open carpal tunnel release. Male sex, concurrent cubital tunnel syndrome, tobacco use, and diabetes also were associated independently with greater risk of needing revision carpal tunnel release within one year. Prognostic II.

Carpal tunnel syndrome with thenar muscle atrophy: Camitz procedure + OCTR versus FDS4 opponensplasty + ECTR

People with severe carpal tunnel syndrome with thenar muscle atrophy suffer from loss of dexterity of the affected hand, which hinders their daily lives. There are different options for opponensplasty. The more traditional option is Camitz operation combined with open carpal tunnel release (OCTR). Another option is to use the flexor digitorum superficialis of the ring finger (FDS4) for opponensplasty and to combine it with endoscopic carpal tunnel release (ECTR). In this study, we prospectively compared the surgical outcomes of these two methods. A total of 27 cases were recruited (13 Camitz + OCTR; 14 FDS 4 + ECTR). Both groups showed good improvement in numbness, pulp-pinch strength, Kapandji score, thumb dexterity and hand function. The technique of FDS4 + ECTR had additional benefits of earlier restoration of thumb opposition and dexterity. In addition, FDS4 + ECTR was demonstrated to restore stronger pulp-pinch strength.