Long Term Re-Operation Rate After Open Versus Endoscopic Release Of Carpal Tunnel Syndrome

Size: px

Start display at page:

Download "Long Term Re-Operation Rate After Open Versus Endoscopic Release Of Carpal Tunnel Syndrome"

Alicia Rice
6 years ago
Views:

1 ISPUB.COM The Internet Journal of Orthopedic Surgery Volume 24 Number 1 Long Term Re-Operation Rate After Open Versus Endoscopic Release Of Carpal Tunnel Syndrome D Ip, N Fu Citation D Ip, N Fu. Long Term Re-Operation Rate After Open Versus Endoscopic Release Of Carpal Tunnel Syndrome. The Internet Journal of Orthopedic Surgery Volume 24 Number 1. DOI: /IJOS Abstract Objective: The current randomized prospective cohort study assess the long-term mean 7 years follow up of patients with bilateral carpal tunnel syndrome with one side receiving open release while the other hand received endoscopic release Materials and Methods: The patient cohort consisted of 50 consecutive unselected patients with bilateral carpal tunnel confirmed with nerve conduction testing, and randomized to receive either open or endoscopic release for either hand by the drawing of envelopes. The proportion of hands with recurrence of symptoms which required re-operation was charted over the years to assess the rate of success of either procedure, as there is little dispute that re-operation represents surgical failure Results: Upon completion of the study, among the 50 hands that received endoscopic carpal tunnel release, the rate of reoperation at 7 years was 30%; while among the 50 hands that received open release, the rate of operation at 7 years was 4%; the difference reached statistical significance (p < 0.05) by Chi Square testing Conclusion: We conclude that open carpal tunnel release have less re-operation rate relative to endoscopic carpal tunnel release on the long-term and this piece of important information need to be conveyed to patients before signing consent for any endoscopic procedure INTRODUCTION The prospective study was designed following the not uncommon recurrence of relapse of clinical symptoms requiring re-operation noticed by the senior author for hands receiving endoscopic carpal tunnel release. The reason in the majority of cases were found during the time of re-operation to be due to re-growth of transverse carpal ligament compressing on the median nerve contributed sometimes by incomplete release; and the current medical literature also contain reports that the endoscopic method can give rise to other complications including traumatic neuroma, flexor tendon injury, and vascular injury as well. On the other hand, one good point about open release is that one can trim back of the edges of the divided transverse carpal ligament to ensure the likelihood of re-growth of the divided ligament is minimized, and the other advantage is there is a direct visual of the median nerve and any concomitant pathology such as ganglion nearby or underneath can be surgically tackled during the same operative procedure. Many proponents of endoscopic carpal tunnel release report excellent short-term clinical result, but it is the long-term clinical result which is important for the patient, as patients should be made aware of the long-term rate of re-operation of the closed versus the open procedures before deciding which option to choose. In fact, a recent meta-analysis of randomized controlled trials found no difference in the overall complication rate, subjective patient satisfaction, operative time, and hand grip strength [1]. However, a closer look at the studies they analyzed were all short-term studies and thus cannot reflect the long-term re-operation rate. MATERIALS AND METHODS The study population consisted of a series of consecutive unselected 50 patients with a mean age of 46 (range 35 to 56) presenting DOI: /IJOS of 5

2 with clinical bilateral carpal tunnel syndrome and confirmed by nerve conduction studies. All affected hands had the clinical sign previously reported by the senior author in the medical literature which showed very early evidence of muscle wasting which warranted surgical operation otherwise known by the name on-profile sign of carpal tunnel syndrome [2]. Exclusion criteria included previous history of hand surgery, and patients with unilateral involvement. The study lasted from 2007 to The study represented a prospective randomized cohort study where either one of the symptomatic hands was being assigned at random to receive either open release or endoscopic release by the drawing of envelopes. During the initial visit, the pros and cons of the open versus the closed procedure was told to the patient and consent was obtained for operation, and for study entry. The endoscopic release followed Chow s 2 portal method and an intra-operative image of the release was shown to the patient as in Figure 1. All surgical operations were done by the author who had performed in excess of one hundred open as well as endoscopic procedures before the study and thus had evolved past the usual learning curve. Table 1 shows the nerve conduction study results of all subjects in the study who required reoperation. Although the end point of the current study was to assess the re-operation rate during long-term clinical follow up; we also serially assessed the degree of overall satisfaction of the patient with the procedure by a score where 0 represents total dissatisfaction with the procedure, and 10 represented total satisfaction to be filled by the patient at the end of the first year of the study and again at the 7 year mark. In this study, the patients all had bilateral involvement and thus acted as his or her own control. As for the scoring of the degree of satisfaction, patients were offered brief guidelines of aspects they can take into consideration including: the ability of the procedure for symptom control, the power and use of the hand, the degree of post-operative pain, the quality and appearance of the surgical scar, and the severity of any resurgence of symptoms if any. The patients gave an overall score at the 1 year follow up mark, and at the end of the study at the 7 year mark. At early follow up at the 1 year mark the mean score of satisfaction for open release was 8 out of 10 and the mean score for the endoscopic release group was 9 out of 10. At the 7 year mark, while the mean score of open release was still 8 out of 10, the mean score of the endoscopic release group deteriorated to only 5 out of 10. The mean time for re-operation of the 15 hands initially operated using the endoscopic procedure was 2.5 years relative to the time of the index operation; the mean time for re-operation of the 2 hands initially operated using the open release relative to the time of the index operation was 4.5 years. The difference in re-operation rate in the two groups was 30% re-operation rate in the endoscopic group versus only 4% re-operation rate in the open release group. The result when subjected to statistical analysis was found to reach statistical significance (p < 0.05) on analysis using the Chi Square test. The mean clinical follow up of this cohort was seven years, a significantly long follow-up is required to reveal the actual long-term recurrence rate or surgical failure of the open versus the endoscopic procedure. RESULTS The male:female ratio among the study population was 1:4 in this study. The mean time from symptom occurrence to operation was 9 months as there was a trial period of conservative treatment using conventional physical therapy and the use of night splint before surgery. All 50 subjects in the study population completed the treatment regimen with good compliance, there was no defaults. In total 100 symptomatic hands were operated on. No major operative complications was recorded apart from 2 hands with superficial post-operative infection which promptly responded to a course of antibiotics. 2 of 5

recurrence rate with the endoscopic procedure [7-8].

3 Table 1 Nerve Conduction Results after Index operation and before re-operation tendon [5], as well as vascular [5] injury. In addition, incomplete release [6] is not uncommon, and it is not surprising therefore that even short-term follow up studies comparing open versus endoscopic release already showed a higher recurrence rate with the endoscopic procedure [7-8]. A group from University of Missouri plastic surgeons reported for instance a very much higher incidence of recurrence with carpal tunnel release done by the endoscopic method. The author is not aware of any long-term clinical follow up studies in excess of five years to assess and compare the re-operation rate of the open versus the endoscopic procedure; which in the current study revealed a statistically significant downside with respect to the endoscopic procedure. This study also showed when followed up for long enough, the overall degree of patient satisfaction went downhill with the endoscopic procedure whereas the satisfaction rate was maintained with open release procedures that involved trimming back of the divided ends of the transverse carpal ligament as in this study. Figure 1 Last, but not the least important, it is imperative to point out that the open release procedure allow the operative surgeon to have a clear vision of the status of the compressed median nerve and any neurolysis can at the same time be performed, as well as one can tackle any concomitant pathology in the same operation, such as clearing away protuberant synovial overgrowth in the carpal tunnel as in patients with rheumatoid arthritis. CONCLUSION DISCUSSION Proponents of endoscopic carpal tunnel release are abundant and high-light the smaller wound size and the earlier recovery of grip strength. However, as pointed out in newly published meta-analysis of the literature, there exists no superiority of the clinical outcome of endoscopic over open release [1], in addition, there existed reports in the medical literature of the not infrequent technical difficulties during introduction of the cannula assembly into the carpal tunnel as well as pulling it out of the exit portal [3]. To add to this, the endoscopic procedure can give rise to nerve [4], The current prospective study of a patient cohort of 50 patients with bilateral documented carpal tunnel syndrome with one hand receiving open release while the contralateral side had endoscopic release revealed a much higher recurrence rate and re-operation rate when followed on the long-term in the endoscopic release group. This important piece of information should be made known to patients prior to deciding on which surgical procedure to choose. References 1. Zuo D, Zhou Z, Wang H, Liao Y, Zheng L, Hua Y (2015) Endoscopic versus open carpal tunnel release for idiopathic carpal tunnel syndrome: a meta-analysis of randomized controlled trials J Orthop Surg Res Jan 28:10:12 2. Ip D (2007) Orthopedic Rehabilitation, Asessment, and Enablement Springer-Verlag, Germany Chapter 5, page Uchiyama S, Nakamura K, Itsubo T, Murakami H, Hayashi M, Imaeda T (2013) Technical difficulties and their prediction in 2-portal endoscopic carpal tunnel release for idiopathic carpal tunnel syndrome Arthroscopy 29(5): Chen L, Duan X, Huang X, Lv J, Peng K, Xiang Z (2014) 3 of 5

4 Effectiveness and safety of endoscopic versus open carpal tunnel decompression Arch Orthop Trauma Surg 134(4): Benson LS, Bare AA, Nagle DJ, Harder VS, Williams CS, Visotsky JL (2006) Complications of endoscopic and open carpal tunnel release Arthroscopy 22(9): Jones NF, Ahn HC, Eo S (2012) Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release Plast Reconstr Surg 129(3): Concannon MJ, Brownfield ML, Puckett CL (2000) The incidence of recurrence after endoscopic carpal tunnel release Plastic Reconstr Surg 105(5): Forman DL, Kirk H, Caulfield KA, Shenko J, Caputo AE, Ashmead D (1998) 9. Persistent or recurrent carpal tunnel syndrome following prior endoscopic carpal tunnel release J Hand Surg 23(6): of 5

5 Author Information David Ip, MBBS FRCS(Edin)Orth FHKCOS FHKCOS(Rehab) FHKAM(Ortho Surg) Asia Medical Pain Centre Hong Kong SAR China Nga-Yue Fu, B Sc Asia Medical Pain Centre Hong Kong SAR China 5 of 5

Use Of Low-Level Laser Therapy In Conservative Treatment Of Delayed Union Of Human Upper And Lower Limb Fractures

ISPUB.COM The Internet Journal of Orthopedic Surgery Volume 25 Number 1 Use Of Low-Level Laser Therapy In Conservative Treatment Of Delayed Union Of Human Upper And Lower Limb Fractures D Ip Citation D