Revision Carpal Tunnel Release Research Articles

Revision Endoscopic Carpal Tunnel Release: An Update on Technique and Outcomes.

Carpal tunnel release is among the most frequently conducted upper extremity procedures. While it typically provides patients with improved sensation, decreased pain, and improved function, a small percentage of cases require revision due to failed initial surgery. Consequently, adoption of endoscopic techniques for carpal tunnel revision procedures is beginning to be explored. A retrospective analysis was conducted of postoperative clinical visits and patient-reported outcome measures for four patients who had undergone five endoscopic revision carpal tunnel release procedures (one patient had bilateral disease). All five cases had symptoms consistent with recurrent carpal tunnel syndrome. One hundred percent (5 of 5) of cases resulted in patients reporting symptom improvement. Postoperative clinical visits and improved patient-reported outcome measures (QuickDash, PROMIS Upper Extremity, VAS Pain, PSEQ, PHQ, and Surgery Satisfaction) scores from baseline to 6 weeks demonstrated successful postoperative function and symptom resolution. Five of five cases resulted in patients resuming normal activities without restrictions within 1-5 weeks, with an average of 3.4 weeks. Preliminary findings suggest the endoscopic revision procedure may be safe and effective for patients with recurrent carpal tunnel syndrome, extending the indications to include scars proximal to the wrist crease. Moreover, this minimally invasive procedure facilitates a transition back to normal activities and avoids incisions on weight-bearing surfaces of the palm. Adopting endoscopic revision may reduce the need for prolonged postoperative care and physical therapy. However, due to the limited sample size of five patients, further investigation with larger cohorts is warranted to confirm these observations.

Carpal tunnel release in the dialysis-dependent population: Incidence and outcomes

Level of evidenceLevel III, retrospective case-control study. BackgroundThe association between dialysis and carpal tunnel syndrome is well-established. As the number of patients living with dialysis-dependent end-stage renal disease (ESRD) increases, it is important that we understand outcomes after carpal tunnel release in this population. PurposeTo investigate (1) the prevalence of carpal tunnel syndrome (CTS) in dialysis-dependent patients, (2) the incidence of carpal tunnel release (CTR), and (3) the differences in complications after CTR between hemodialysis patients, peritoneal dialysis patients, and matched controls. Patients and methodsQuerying the PearlDiver database, we determined prevalence of CTS and incidence of CTR in dialysis-dependent and control patients. We compared peritoneal dialysis (PD) patients to matched populations of hemodialysis (HD) patients and non-dialysis-dependent controls. Complications were identified, including hospital admission, emergency department visits, infection, revision surgery, and postoperative chronic regional pain syndrome (CRPS). ResultsThe rates of CTS and CTR in dialysis patients were significantly increased relative to controls. Dialysis-dependent patients had increased rates of hospital admission within 30 days postoperatively (OR 4.13, P ​< ​.0001 for PD; OR 4.42, P ​< ​.0001 for HD), infection within 6 months postoperatively (OR 2.32, P ​= ​.013 for PD; OR 3.20, P ​< ​.0001 for HD), and need for revision CTR (OR 2.04, P ​= ​.009 for PD; OR 1.62, P ​= ​.037 for HD). Emergency department presentation within 30 days postoperatively was less common in PD vs HD (OR 0.63, P ​= ​.038). ConclusionsWhen compared to the control population, patients undergoing dialysis are more likely to be diagnosed with carpal tunnel syndrome, undergo carpal tunnel release, and are at significantly increased risk for perioperative complications.

Use of Nerve Wraps in the Upper Extremity

Objectives Nerve wraps have been used to potentially decrease perineural scarring and to create a local environment conducive to nerve healing, but no consensus exists on the indications for their use. The primary purpose of this study is to assess the operative indications for using the porcine extracellular matrix (PEM) nerve wrap in the upper extremities at a single center. Methods A retrospective review of all patients that underwent PEM nerve wrapping over eight years by hand and upper extremity surgeons at a single orthopaedic practice yielded 104 procedures in 102 patients for analysis. Results The most common indication for surgery was for nerve wrapping of acute traumatic nerve injuries in 57 patients (55%), most frequently involving lacerations of the hand and forearm. Neurolysis and nerve wrapping for cases of chronic nerve compression with perineural scarring and fibrosis was the second most common indication, involving 41 patients (39%), most frequently for revision carpal and cubital tunnel release surgery. Six patients (5.8%) underwent mass removal or contracture release involving neurolysis with nerve wrapping. Three patients (2.9%) required reoperation, two in the acute group and one in the chronic group. However, there were no cases of nerve wrap rejection or extrusion. Conclusion PEM nerve wrapping was used for various nerve injuries, from acute lacerations to recalcitrant chronic compression and mass excision. Further studies are necessary to determine whether patient outcomes are improved with the PEM nerve wrap. Level of Evidence Level 4

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.

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.

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.

Patient-Reported Outcomes Improve after Hypothenar Fat Flap for the Treatment of Recurrent Carpal Tunnel Syndrome.

Background: Recalcitrant carpal tunnel syndrome (CTS) can present with persistent or recurrent symptoms after carpal tunnel release (CTR). A common aetiology for recurrent CTS is the development of perineural adhesions due to excess scarring. The hypothenar fat pad flap (HFPF) has been described to decrease the amount of scarring formed after revision CTR. Herein, we present a prospective evaluation of these patients. Methods: A prospective series of consecutive patients by a single surgeon with recurrent CTS was conducted. All patients had at least 3 months follow-up. Patients received a revision open CTR with HFPF. The primary outcome was the Boston Carpal Tunnel Questionnaire (BCTQ). Secondary outcomes included pain and satisfaction on visual analogue scale, range of motion, grip strength, patient-reported outcomes and complications. Clinical outcomes were compared between preoperative and postoperative intervals using paired t-tests, with significance defined as p < 0.05. Results: Fifteen wrists (14 patients) were recruited for the study. Patients were predominantly male (n=9; 66%). Revision open CTR with HFPF was performed a median of 42 months (range: 4-300 months) post primary CTR. Patients demonstrated improved patient-reported outcomes with significantly improved BCTQ pain score (p<0.01), Patient-Rated Wrist and Hand Evaluation (p<0.01) and QuickDASH (p<0.001). Two patients in the series reported postoperative complications; however, there was no incidence of donor site morbidity recorded. Conclusions: Revision open CTR with hypothenar fat pad flap is associated with decreased pain, high patient satisfaction and improved functional measures compared to pre-operative status. Level of Evidence: Level IV (Therapeutic).

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.

Persistent Pain as an Early Indicator for Operative Carpal Tunnel Revision after Primary Release: A Retrospective Analysis of Recurrent and Persistent Carpal Tunnel Syndrome.

Prolonged symptoms of carpal tunnel syndrome (CTS) after primary carpal tunnel release (CTR) can reduce the quality of life and lead to multiple referrals across specialties. The following study aimed to identify differences in symptoms, signs, and intraoperative findings between recurrent and persistent CTS cases to avoid undesired outcomes after primary CTR. A retrospective analysis was conducted on revision CTRs performed between 2005 and 2015 using literature-based definitions for recurrent (a relapse of symptoms occurs following a symptom-free period of ≥3 months) and persistent (symptoms persisting longer than three months after surgical release) CTS. The parameters assessed were symptoms, clinical signs, and intraoperative findings. Out of 53 cases, 85% (n = 45) were external referrals, whereby our own revision rate was 0.67% (n = 8/1199). Paresthesia and numbness were frequent in both groups; however, abnormal postoperative pain was reported more often in persistent cases (86%; n = 30/35) in comparison to recurrent cases (50%; n = 9/18; p = 0.009). Scarring around the median nerve was observed in almost all recurrent cases (94%; n = 17/18) and in 40% (n = 14/35) of persistent cases (p < 0.001). Incomplete division of the palmar ligament was the primary cause for revision in the persistent cohort (49%; n = 17/35). For patients experiencing symptoms for more than three months after CTR, primarily presenting as pain, it is advisable to consider referring the patient to a certified hand clinic for additional evaluation.

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.

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.

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis.

The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR. The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire. A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery. Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

Early Revision Rate Following Primary Carpal Tunnel Release

The published revision rates after carpal tunnel release (CTR) vary from 0.3% to 7%. The explanation for this variation may not be fully apparent. The purpose of this study was to determine the rate of surgical revision within 1-5 years following primary CTR at a single academic institution, compare it with rates reported in the literature, and attempt to provide explanations for these differences. We identified all patients who underwent primary CTR at a single orthopedic practice by 18 fellowship-trained orthopedic hand surgeons from October 1, 2015, through October 1, 2020, using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD), 10th Revision, codes. Patients who underwent CTR because of a diagnosis other than primary carpal tunnel syndrome were excluded. Patients who required revision CTR were identified using a practice-wide database query using a combination of CPT and ICD-10 codes. Operative reports and outpatient clinic notes were reviewed to determine the cause of revision. Data on patient demographics, surgical technique (open vs single-portal endoscopic), and medical comorbidities were collected. A total of 11,847 primary CTR procedures were performed during the 5-year period on 9,310 patients. We found 24 revision CTR procedures among 23 patients, resulting in a revision rate of 0.2%. Of 9,422 open primary CTRs performed, 22 cases (0.23%) went on to undergo revision. Endoscopic CTR was performed in 2,425 cases, with 2 cases (0.08%) ultimately undergoing revision. The average length of time from primary CTR to revision was 436 days (range, 11-1,647 days). We noted a substantially lower rate of revision CTR within 1-5 years of primary release (0.2%) in our practice than that noted in previously published studies, although we accept that this does not account for out-of-area migration. There was no significant difference in the revision rates between open and single-portal endoscopic primary CTR. Therapeutic III.

Revision Carpal Tunnel Release With Umbilical Cord Allograft: A Four-Year Retrospective Cohort Study

Background: Refractory symptoms of carpal tunnel syndrome can persist or reoccur after carpal tunnel release (CTR) surgery in 1% to 25% of patients, with up to 12% of patients requiring secondary surgery. If revision surgery is required, the results are much less successful compared to primary surgery. In this study, we investigated whether cryopreserved human umbilical cord allograft placement during CTR revision surgery improved short- and long-term surgical outcomes. Methods: We conducted a single-center cohort analysis of patients between January 2015 and July 2018 who underwent secondary open revision CTR with umbilical cord allograft for recurrent or persistent compression neuropathy of the median nerve. Surgical outcomes of patients in the study group-reduction of pain, paresthesia, and weakness; complications; and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores-were compared to the outcomes of controls without umbilical cord allograft use who were operated on by the same surgeon between December 2011 and September 2015. Results: A total of 37 patients underwent CTR with (n=26) and without (n=11) umbilical cord allograft (mean follow-up of 4 years). Following surgery, preoperative symptoms of pain (96% vs 73%, P=0.048) and paresthesia (100% vs 73%, P=0.014) were significantly improved in the patients who received umbilical cord allograft. Mean QuickDASH scores (19.0 vs 23.7, P=0.58) and preoperative weakness (90% vs 67%, P=0.14) were improved in the patients who received umbilical cord allograft but were nonsignificant. Short- and long-term complications were similar between groups (P=0.56, P=0.51, respectively). Conclusion: This study suggests that human umbilical cord allograft placement during open revision CTR is safe and effective for improving long-term symptoms of compressive neuropathy in patients with recurrent carpal tunnel syndrome.

Is the outcome of a revision carpal tunnel release as good as those of a primary release? A matched cohort study.

This study aimed to compare primary and revision carpal tunnel release outcomes in all patients with carpal tunnel syndrome and when corrected for baseline severity and demographics. A total of 903 hands of primary and 132 hands of revision patients underwent carpal tunnel release and patients completed online questionnaires on demographics, clinical severity, and satisfaction. The primary outcome measure, the Boston Carpal Tunnel Questionnaire (BCTQ), was administered at intake and six months after surgery. The BCTQ total score at six months was better in primary (1.55±0.58) than revision patients (1.94±0.73, p=<0.001), and primary patients improved more on the BCTQ total score (1.10±0.71 vs. 0.90±0.72, p=0.003). In patients matched on similar baseline characteristics using propensity score matching, the BCTQ total score at six months was also better in primary patients (1.65±0.63) than in revision patients (1.92±0.73, p=0.002), and primary patients still had more improvement in BCTQ total score (1.18±0.73 vs. 0.89±0.73, p=0.004). This study shows that the outcome after revision carpal tunnel release is only 16% worse compared to primary carpal tunnel release. Preoperative symptom severity, functional status, and demographics may play a role since correcting for these factors reduces the difference in outcome between primary and revision CTR.

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.

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects

Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor. Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW. Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW. In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not. Therapeutic III.

Exoscope for Upper Extremity Peripheral Nerve Surgery: Revision Carpal Tunnel Release With Epineurolysis and Hypothenar Fat Flap

The exoscope is a high-resolution three-dimensional external microscope that allows the surgeon to perform delicate dissection in multiple regions of the body. The exoscope was originally used for intracranial and spine surgery. In this article, we describe its novel use in upper extremity peripheral nerve decompression surgery after recurrent carpal tunnel syndrome. This surgery is typically performed under the microscope, which allows precise microsurgical dissection to distinguish scar tissue from healthy nerve fascicles. Our case report highlights a 70-year-old man with recurrent carpal tunnel syndrome who underwent revision carpal tunnel surgery with epineurolysis and hypothenar fat flap. The ergonomic benefits of using the exoscope for microsurgery are described, along with intraoperative photos. Adequate symptom resolution was achieved.

A Comparison of Histologic and Intraoperative Visual Assessments of Transverse Carpal Ligament During Revision Carpal Tunnel Release

We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR. All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist's assessment of the flexor retinaculum specimen was categorized as either "ligamentous" if a previously undivided TCL was identified or "nonligamentous" if scar or any other tissue was identified. The surgeon's intraoperative assessment served as the reference standard when comparing the histologic assessment. A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon's intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time. Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases. Diagnostic III.

The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period

To establish the incidence of revision carpal tunnel surgery within a 1-year postoperative period using a national administrative database. This information has been unknown until this point because of the absence of laterality-specific coding with the International Classification of Diseases, Ninth Edition and earlier coding systems. Data were collected from the Humana insurance database using PearlDiver patient records from 2015 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes related to carpal tunnel diagnosis and release. Codes were used to identify patients who underwent carpal tunnel release (CTR) and had revision CTR within a 1-year follow-up period. Patient demographic characteristics, including age, sex, medical comorbidities, and smoking status, were collected. In addition, multivariable analysis of the risk of a revision procedure within 1 postoperative year was performed to determine independent risk factors, including the surgical approach, associated with revision CTR. Among 4,549 patients who underwent a primary CTR during the study period, 207 patients (4.8%) underwent a revision CTR within 1 year. The average time from the primary CTR to the revision CTR was 135 days (standard deviation, 99.1 days; range, 21-365 days). Primary endoscopic CTR was associated with an increased rate of revision CTR (odds ratio, 1.3; 95% confidence interval, 1.2-1.6). Patient factors associated with a higher likelihood of requiring revision CTR included diabetes mellitus, tobacco use, psychiatric condition, cervical disease, and history of cubital tunnel release. This study identified a rate of revision CTR of 4.8% within the first postoperative year. Both the surgical technique and patient-specific risk factors influence the likelihood of requiring revision surgery. Notably, an endoscopic approach is associated with a higher risk of revision surgery. Prognostic II.