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

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

Carpal tunnel syndrome: associated abnormalities in ulnar nerve function and the effect of carpal tunnel release on these abnormalities

Twenty of 59 hands (34%) of patients with carpal tunnel syndrome had abnormalities in sensibility testing of both median and ulnar nerves by either two-point discrimination, Semmes-Weinstein monofilament testing, or both. Before surgery, 53% of patients complained of paresthesias and/or numbness in ulnar nerve distribution. Eighty percent of the hands had abnormal Semmes-Weinstein monofilament testing of the ulnar nerve. Thirty-five percent had abnormal two-point discrimination. Forty-one percent had abnormal electromyographic testing of the ulnar nerve. All hands had median nerve decompression alone. Guyon's canal was not released. After surgery, 89% of patients had improvement in paresthesias and/or numbness of the ulnar nerve. Ninety-four percent had improvement in Semmes-Weinstein monofilament testing. Eighty-six percent had improvement in two-point discrimination. Patients with a residual abnormality in ulnar nerve sensibility also had continued abnormality in median nerve sensibility. A significant percentage of patients with carpal tunnel syndrome also have signs and symptoms of ulnar nerve compression. Most improved with carpal tunnel release alone.     

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

Background

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

Methods

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

Results

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

Conclusion

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

Single-portal endoscopic carpal tunnel release compared with open release : a prospective,randomized trial

BACKGROUND: Carpal tunnel syndrome is a common condition causing hand pain and numbness. Endoscopic carpal tunnel release has been demonstrated to reduce recovery time, although previous studies have raised concerns about an increased rate of complications. The purpose of this prospective, randomized study was to compare open carpal tunnel release with single-portal endoscopic carpal tunnel release. METHODS: A prospective, randomized, multicenter center study was performed on 192 hands in 147 patients. The open method was performed in ninety-five hands in seventy-two patients, and the endoscopic method was performed in ninety-seven hands in seventy-five patients. All of the patients had clinical signs or symptoms and electrodiagnostic findings consistent with carpal tunnel syndrome and had not responded to, or had refused, nonoperative management. Follow-up evaluations with use of validated outcome instruments and quantitative measurements of grip strength, pinch strength, and hand dexterity were performed at two, four, eight, twelve, twenty-six, and fifty-two weeks after the surgery. Complications were identified. The cost of the procedures and the time until return to work were recorded and compared between the groups. RESULTS: During the first three months after surgery, the patients treated with the endoscopic method had better Carpal Tunnel Syndrome Symptom Severity Scores, better Carpal Tunnel Syndrome Functional Status Scores, and better subjective satisfaction scores. During the first three months after surgery, they also had significantly (p < 0.05) greater grip strength, pinch strength, and hand dexterity. The open technique resulted in greater scar tenderness during the first three months after surgery as well as a longer time until the patients could return to work (median, thirty-eight days compared with eighteen days after the endoscopic release). No technical problems with respect to nerve, tendon, or artery injuries were noted in either group. There was no significant difference in the rate of complications or the cost of surgery between the two groups. CONCLUSION: Good clinical outcomes and patient satisfaction are achieved more quickly when the endoscopic method of carpal tunnel release is used. Single-portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome.     

Sensibility testing in patients with carpal tunnel syndrome

We evaluated the sensibility of the hand preoperatively and at intervals postoperatively in twenty-three hands of twenty patients with idiopathic carpal-tunnel syndrome who underwent carpal tunnel release. Tests of sensibility included the threshold tests (vibrometry, 256-cycles-per-second vibration, and Semmes-Weinstein monofilaments) and one innervation-density test (two-point discrimination). In addition the wrist-flexion test, nerve-percussion test, and tourniquet test were performed preoperatively. Only five of the twenty-three hands had abnormal two-point discrimination and each of these also had markedly abnormal threshold-test values. Nineteen of twenty-three hands preoperatively had decreased sensibility detected by both Semmes-Weinstein monofilament testing and vibrometry. Six weeks after carpal tunnel release, all of the hands demonstrated improvement on threshold testing, and 65 per cent had normal values.     

Concomitant endoscopic carpal and cubital tunnel release: safety and efficacy

Background

When performed alone, endoscopic carpal tunnel release and endoscopic cubital tunnel release are safe and effective surgical options for the treatment of carpal and cubital tunnel syndromes, respectively. However, there is currently no literature that describes the performance of both procedures concomitantly. We describe the results of 17 cases in which dual endoscopic carpal and cubital tunnel releases were performed for the treatment of concurrent carpal and cubital tunnel syndromes.

Methods

A retrospective review of all patients in a single surgeon practice that presented with concomitant ipsilateral carpal and cubital tunnel syndromes was performed. Within an 8-month period, 17 patients had undergone 19 concomitant ipsilateral endoscopic carpal and cubital tunnel releases after failing conservative treatment. Pre- and postoperative measurements included subjective numbness/tingling; subjective pain; manual muscle testing of the abductor pollicis brevis (APB), intrinsics, and flexor digitorum profundus (FDP); static two-point discrimination; quick-DASH (Disabilities of the Arm, Shoulder and Hand) scores; grip strength; chuck pinch strength; and key pinch strength. Complete data are available for 15 patients and 17 total procedures.

Results

Thirteen male and four female patients (average age of 50.5) underwent dual endoscopic cubital and carpal tunnel release. Two patients were lost to follow-up and eliminated from data analysis. Pre- and postoperative comparisons were completed for median DASH scores, grip strength, chuck pinch strength, and key pinch strength at their preoperative visit and at 12 weeks. DASH scores improved significantly from a median of 67.5 to 16 (p?=?0.002), grip strengths improved from 42 to 55.0 lbs (p?=?0.30), chuck pinch strengths improved significantly from 11 to 15.5 lbs (p?=?0.02), and key pinch strengths increased significantly from 13 to 18 lbs (p?=?0.003). Average static two-point discrimination decreased from 5.9 to 4.8 mm. In terms of pain, 82 % of patients had complete resolution of pain, and the remaining 18 % experienced pain only with strenuous activity. In terms of numbness/tingling, 100 % of patients had complete resolution of median nerve symptoms; 88 % of patients had substantial improvement of numbness and tingling symptoms, and 12 % had residual ulnar nerve symptoms. In terms of muscle strength, 92 % of patients had improvement to 5/5 APB strength, while 100 % of patients had improvement to 5/5 intrinsic and FDP strengths. Two minor complications occurred, including one superficial hematoma and one superficial cellulitis.

Conclusions

Preliminary data demonstrate that dual endoscopic carpal and cubital tunnel release is a safe and effective treatment option for patients who present with concurrent cubital and carpal tunnel syndromes recalcitrant to non-surgical management. Postoperative results and complications are comparable to endoscopic carpal and cubital tunnel releases performed alone.     

Clinical outcomes of carpal tunnel release in patients 65 and older

PURPOSE: Some hand surgeons have encountered an attitude among referring physicians as well as patients that carpal tunnel release (CTR) is less effective and more morbid in older patients. The purpose of this study was to determine the efficacy of CTR in patients aged 65 and older. METHODS: Patients 65 years of age or older with carpal tunnel syndrome for whom release was indicated were studied prospectively. All patients had a limited palmar incision CTR and a standardized postoperative rehabilitation protocol. The patients' subjective and objective signs and symptoms were measured before surgery and at 6 months after surgery. Scar tenderness and patient satisfaction also were recorded. The Michigan Hand Outcome Questionnaire was used to determine overall hand function, activities of daily living, work performance, pain, aesthetics, and satisfaction with hand function. RESULTS: Seventy-five patients (105 hands) were enrolled; 6-month follow-up data were available on 92 hands on 66 patients. The mean age was 74 +/- 6 years. By patient report, paresthesias, numbness, day pain, night pain, and nocturnal numbness each decreased significantly from severe or very severe to mild or none. All but 2 of the Tinel's signs and one of the Phalen's signs became negative. The mean 2-point discrimination improved from 6.4 +/- 1.3 mm to 4.9 +/- 1.1 mm. Grip and pinch strength increased by 0.9 +/- 7.4 kgf and 0.6 +/- 2.5 kgf, respectively. The Michigan Hand Outcome Questionnaire confirmed a significant improvement in overall hand function, activities of daily living, pain, and satisfaction with hand function. Overall 83% of patients were either very or completely satisfied with their results. CONCLUSIONS: Patients 65 years of age or older objectively benefit and have improved clinical outcomes after CTR. Age alone should not be a contraindication to CTR.     

Endoscopic versus open carpal tunnel release: A short-term comparative study

Objective:

To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS).

Materials and Methods:

Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient''s symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months.

Results:

During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months.

Conclusion:

Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.     

经手掌近侧小切口的腕管切开松解减压术

目的 报告使用手掌近侧小切口的腕管切开松解减压术的疗效。方法 自大、小鱼际纹交界处向远侧腕横纹做纵行切口，长2～2．5cm，直视下切开屈肌支持带，解除正中神经卡压。术后随访并与同期采用传统长切口的病例比较，观察小切口的疗效。结果 随访病例19例30腕，其中小切口6例11腕，长切口13例19腕，它们在手指麻木、腕痛、握力及两点辨别觉改善等方面无明显差异，在切口长度、手术时间、恢复正常生活与工作时间以及术后瘢痕触痛、墩柱部疼痛等方面，前者优于后者。结论 经手掌近侧小切口实施腕管切开松解减压术，较传统方法有更多优点，是一种安全、有效的治疗方法。     

Early recovery after endoscopic vs. short-incision open carpal tunnel release

Endoscopic carpal tunnel release has been claimed to offer improvement in recovery time and postoperative discomfort over open carpal tunnel release. Short-incision open carpal tunnel release has been claimed to offer recoveries comparable with endoscopic techniques. Patients receiving carpal tunnel surgery were randomized to short-incision open release or single-portal endoscopic release. Preoperative and postoperative evaluation included grip and pinch strength measurements and patient completion of a questionnaire regarding symptoms and function. Thirty-six operated hands completed evaluation, including 22 endoscopic and 14 open releases. Early grip and pinch strength after endoscopic carpal tunnel release were improved significantly over short-incision open release (p < 0.05). Subjective evaluation indicated a trend toward improved symptoms and function with endoscopic over short-incision open carpal tunnel release. Endoscopic carpal tunnel release provides faster recovery of strength than short-incision open carpal tunnel release and improves early postoperative comfort and function to a small degree.     

Palmaris brevis turnover flap as an adjunct to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome

Thirteen hands in 11 patients with previous carpal tunnel releases were treated by microscopic internal neurolysis and palmaris brevis "turnover" flaps. All patients in the series had positive electrodiagnostic testing, dysesthetic wrist pain, and numbness in the median nerve distribution before operation. Average age was 41.9 years (range, 27 to 62 years). Ten were male and 3 were female. Range of follow-up after the procedure was from 1 to 1 1/2 years. All hands with abnormal preoperative two-point discriminations or Semmes-Weinstein measurements showed numerical improvement in their sensory parameters. Thenar strength and bulk improved at least one grade in all six cases of thenar atrophy. Mean grip strength was 15.2% greater than before operation. Key pinch increased 5.5% and pulp pinch 31.9%. Subjective assessment of improvement ranged from 25% to 100%. All patients returned to their former jobs or to vocational retaining except the oldest patient who is semiretired.     

Endoscopic carpal tunnel release in the elderly.

The present study is aimed to clarify the postoperative outcome of endoscopic carpal tunnel release in elderly patients with carpal tunnel syndrome. Endoscopic carpal tunnel release was performed on 37 hands of 27 patients (2 men, 25 women) who were aged 70 years or older and clinically and electrophysiologically diagnosed with carpal tunnel syndrome. Mean age at the time of surgery was 74.5 years (range: 70-85 years). Mean postoperative follow-up was 35.5 months (range: 12-114 months). Pain was present preoperatively in 20 hands, but quickly resolved postoperatively in all cases. Numbness completely disappeared in 13 of 37 hands (35.1%), but some degree of numbness remained in the remaining cases. Preoperative severity of thenar muscle atrophy was none in 4 hands, mild in 7 hands, moderate in 12 hands and severe in 14 hands. Postoperative severity of thenar muscle atrophy at final follow-up was none in 13 hands, mild in 16 hands, moderate in 2 hands and severe in 6 hands, confirming that thenar muscle atrophy improves even in elderly patients. However, moderate or severe thenar muscle atrophy remained in 8 hands (21.6%). Endoscopic carpal tunnel release should be considered in the elderly, even though clinical symptoms may not improve substantially in advanced cases.     

Endoscopic release of the carpal tunnel: A randomized prospective multicenter study

A 10-center randomized prospective multicenter study of endoscopic release of the carpal tunnel was carried out. Surgery was performed with a new device for transecting the transverse carpal ligament while control hands were treated with conventional open surgery. There were 122 patients in the study; 25 had carpal tunnel surgery on both hands and 97 had surgery on one hand. Of the surgical procedures, 65 were in the control group and 82 were in the device group. The endoscopic device was coupled to a fiberoptic light and a video camera. A trigger-activated blade was used to incise the transverse carpal ligament. After surgery, the best predictors of return to work and to activities of daily living were strength and tenderness variables. For patients in the device group with one affected hand, the median time for return to work was 21 1/2 days less than that for the control group. Two patients treated with the endoscopic device required reoperation by open surgical decompression; only one of these had incomplete release with the device. Two patients in the device group experienced transient ulnar neurapraxia.     

Factors associated with trigger digit following carpal tunnel release

BACKGROUND Trigger digit is a common disorder of the hand associated with carpal tunnel syndrome.Carpal tunnel release(CTR) surgery may be a risk factor for trigger digit development;however,the association between surgical approach to CTR and postoperative trigger digit is equivocal.AIM To investigate patient risk factors for trigger digit development following either open carpal tunnel release(OCTR) or endoscopic carpal tunnel release(ECTR).METHODS This retrospective chart analysis evaluated 967 CTR procedures from 694 patients for the development of postoperative trigger digit.Patients were stratified according to the technique utilized for their CTR,either open or endoscopic.The development of postoperative trigger digit was evaluated at three time points:within 6 mo following CTR,between 6 mo and 12 mo following CTR,and after 12 mo following CTR.Firth's penalized likelihood logistic regression was conducted to evaluate sociodemographic and patient comorbidities as potential independent risk factors for trigger digit.Secondary regression models were conducted within each surgical group to reveal any potential interaction effects between surgical approach and patient risk factors for the development of postoperative trigger digit.RESULTS A total of 47 hands developed postoperative trigger digit following 967 CTR procedures(4.9%).In total,64 digits experienced postoperative triggering.The long finger was most commonly affected.There was no significant difference between the open and endoscopic groups for trigger digit development at all three time points following CTR.Furthermore,there were no significant independent risk factors for postoperative trigger digit;however,within group analysis revealed a significant interaction effect between gender and surgical approach(P=0.008).Females were more likely to develop postoperative trigger digit than males after OCTR(OR=3.992),but were less likely to develop postoperative trigger digit than males after ECTR(OR=0.489).CONCLUSION Patient comorbidities do not influence the development of trigger digit following CTR.Markedly,gender differences for postoperative trigger digit may depend on surgical approach to CTR.     

Common risk factors seen in secondary carpal tunnel surgery

BACKGROUND: We hypothesized that there are several common risk factors associated with secondary carpal tunnel releases. Therefore, we chose to investigate these common factors by analyzing the charts of those patients requiring a second carpal tunnel release (CTR) procedure. METHODS: A retrospective chart review was performed, and patients were identified by searching hospital medical record databases using the Common Procedural Terminology. RESULTS: Between January 1, 2000, and March 31, 2004, 2357 patients had a primary CTR, and 48 of them were found to have had a secondary CTR (of these 48, 9 had diabetes mellitus, 11 had hypertension, and 6 had gastrointestinal-related illnesses). Seven percent of those who had an open release primarily required a second CTR, while only 0.2% of those who had an endoscopic release primarily required a second CTR. CONCLUSION: A greater number of secondary CTR procedures were required for those patients with symptoms of carpal tunnel syndrome in the group that had an open release primarily versus those that had an endoscopic release primarily. Diabetes mellitus and hypertension may also contribute to the need for secondary surgery.     

Entrapment neuropathy of the palmar cutaneous branch of the median nerve by the fascia of flexor digitorum superficialis

A case of thenar numbness, with concomitant carpal tunnel syndrome is presented. Physical findings and the result of injection of a local anesthetic into two different sites of tenderness suggested coexistence of entrapment and/or compression of the palmar cutaneous branch of the median nerve and the main trunk of the median nerve at the carpal tunnel. At operation, constriction of the palmar cutaneous branch of the median nerve by the fascia of seemingly normal flexor digitorum superficialis was observed beneath the site of maximum tenderness. After decompression of this nerve, combined with carpal tunnel release, the patient lost all pain and numbness; there was no recurrence at 5 months follow-up.     

Prospective randomized comparison of single-incision and two-incision carpal tunnel release outcomes

Background

This study analyzes both the subjective and objective symptom and functional outcomes of patients who underwent either traditional single-incision or two-incision carpal tunnel release (CTR).

Methods

From 2008 to 2009, patients with isolated carpal tunnel syndrome were randomized to undergo either single-incision or two-incision CTR by a single surgeon at a university medical center. Pre-operatively, participants completed a Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ), as well as grip and pinch strength and Semmes–Weinstein monofilament sensation testing. At 2 weeks, 6 weeks and at least 6 months post-operatively, these measurements were repeated along with assessment of scar tenderness and pillar pain. Data were analyzed using SPSS version 20 software to perform non-parametric tests and Pearson's correlations. Significance was set at p?=?0.05.

Results

There was no statistically significant difference between the single- and two-incision CTR groups with respect to pre- and post-operative DASH scores, BWCTQ scores, grip strength, pinch strength, scar tenderness, or pillar pain. The only statistically significant difference was improved sensation by Semmes–Weinstein in the single-incision group in the second finger at 6 weeks post-operatively and in the third finger at 6 months post-operatively.

Conclusions

The preservation of the superficial nerves and subcutaneous tissue between the thenar and hypothenar eminences may account for reports of less scar tenderness and pillar pain among recipients of two-incision CTR compared to single-incision CTR in the early post-operative period. However, there is similar post-operative recovery and improvement in grip and pinch strength and sensation after 6+ months post-operatively.     

A comparison of two limited open techniques for carpal tunnel release

Review of the literature shows the effectiveness of limited open carpal tunnel release to be comparable to that of endoscopic carpal tunnel release in respect of recovery of grip strength, time of return to work and complication rate. A randomised, controlled study was designed to compare the effectiveness of a single versus a double limited open technique of carpal tunnel release. Sixty-five patients (73 hands) with a mean age of 48 years were operated on, 40 hands by the single incision and 33 by the double incision method. Grip and pinch strengths, digital sensibility (Filament and 2PD tests) and Levine scores were evaluated throughout 12 months of follow-up. We found that the single incision method offers better results in respect of grip and pinch strengths: less weakness at 1 month after surgery and a faster improvement relative to pre-operative values which is statistically significant. This, however, did not translate directly into Levine functional and symptom scores which, at each assessment, did not differ significantly between the two methods.     

Evaluation of carpal tunnel release using the Knifelight instrument

We have performed a prospective randomized controlled trial to compare the results of open carpal tunnel release with those of carpal tunnel release using a Knifelight (Stryker, Kalamazoo, MI). This is a new knife with its own battery-powered light source which enables the operation to be performed through a small incision in the palm of the hand. There were 43 patients in the open operation group and 39 in the Knifelight group. We found no difference in discomfort reported during surgery, in the operative time, in the grip strength measured at 2 and 6 weeks post-operatively or in the proportion of patients cured of their pre-operative symptoms. Patients in the Knifelight group had a statistically significant improvement in the time to return to work and in scar tenderness at 6 weeks post-operatively.     

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

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