The April 2024 Wrist & Hand Roundup. 360. looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique

The October 2023 Wrist & Hand Roundup³⁶⁰ looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

Aims

Few studies have examined the long-term outcome of carpal tunnel release (CTR). The aim of this study was to evaluate the patient-reported long-term outcome of CTR for electrophysiologically severe carpal tunnel syndrome (CTS).

We report a new surgical technique of open carpal tunnel release with subneural reconstruction of the transverse carpal ligament and compare this with isolated open and endoscopic carpal tunnel release. Between December 2007 and October 2011, 213 patients with carpal tunnel syndrome (70 male, 143 female; mean age 45.6 years; 29 to 67) were recruited from three different centres and were randomly allocated to three groups: group A, open carpal tunnel release with subneural reconstruction of the transverse carpal ligament (n = 68); group B, isolated open carpal tunnel release (n = 92); and group C, endoscopic carpal tunnel release (n = 53). At a mean final follow-up of 24 months (22 to 26), we found no significant difference between the groups in terms of severity of symptoms or lateral grip strength. Compared with groups B and C, group A had significantly better functional status, cylindrical grip strength and pinch grip strength. There were significant differences in Michigan Hand Outcome scores between groups A and B, A and C, and B and C. Group A had the best functional status, cylindrical grip strength, pinch grip strength and Michigan Hand Outcome score. Subneural reconstruction of the transverse carpal ligament during carpal tunnel decompression maximises hand strength by stabilising the transverse carpal arch. Cite this article: Bone Joint J 2015;97-B:221–8

Background. It was hypothesised that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression. Methods. Patients consented to randomisation to treatment with either preservation of the parietal layer of the ulnar bursa beneath the flexor retinaculum at the time of open carpal tunnel decompression (57 patients) or division of this gliding layer as part of a standard open carpal tunnel decompression (61 patients). Grip strength was measured, scar pain was rated and the validated Patient Evaluation Measure questionnaire was used to assess symptoms and disability pre-operatively and at eight to nine weeks following surgery in seventy-seven women and thirty-four men; the remaining seven patients were lost to follow-up. Results. There was no difference between the groups with respect to age, sex, hand dominance or side of surgery. Grip strength, scar pain and Patient Evaluation Measure score were not significantly different between the two groups, although there was a trend towards poorer subjective outcome as demonstrated by the questionnaire in the group in which the ulnar bursa within the carpal tunnel had been preserved. Preserving the ulnar bursa within the carpal tunnel did however result in a lower prevalence of suspected wound infection or inflammation (p=0.04). Conclusions. In this group of patients, preservation of the ulnar bursa around the median nerve during open carpal tunnel release produced no significant difference in grip strength or self-rated symptoms. We recommend incision of the ulnar bursa during open carpal tunnel decompression to allow complete visualisation of the median nerve and carpal tunnel contents

This study compares the endoscopic carpal tunnel release with the conventional open technique with respect to short and long-term improvements of functional and clinical outcomes.

We assessed 72 outpatients diagnosed with carpal tunnel syndrome. Thirty-seven patients underwent the endoscopic method according to Chow and 35 were assigned to the open method. Improvement in symptoms, severity and functionality were evaluated shortly preoperatively (at two days, one week and two weeks) and one year after using the Symptom Severity Scale, Symptom Severity Status and DASH questionnaire. Changes in clinical outcomes (grip strength, key pinch and two-point discrimination test) were evaluated one year postoperatively. Complications were also assessed.

Both groups showed similar improvement in all but one outcome one year after the release; increase in grip strength was significantly higher for the endoscopic group. The endoscopic method was also associated with a significantly faster short-term improvement. Separate analysis of the questionnaire components referring to pain reveals that the delay of improvement in the open group is due to the persistence of pain for a longer period. Paresthesias and numbness decrease shortly after the operation with comparable rates for both groups.

The purposes of the present study were to assess the outcome of surgery for carpal tunnel syndrome (CTS), to evaluate histological findings of subsynovial connective tissue (SSCT) of patients with CTS in comparison with a control group, and to assess whether the histologic appearance of the flexor tenosynovium is correlated with clinical history, preoperative or postoperative physical examination, general health, symptoms and function as assessed by validated tools, or nerve conduction studies. Materials and Methods: We studied 30 consecutive patients who had idiopathic CTS and were referred to our institution for surgery. All patients had had diagnostic neurophysiological testing. A study specific questionnaire, a historical-objective scale (Hi-Ob), the Boston Carpal Tunnel Questionnaire (BCTQ), the SF-36 questionnaire were administered to the patients preoperatively and six months after surgery. A standard open carpal tunnel release was performed and 1 cm 3 of tickened synovium was removed from the flexor digitorum superficialis tendons. Specimens of SSCT from flexor tendon at wrist were also obtained from ten fresh-frozen cadavers witrh no history of CTS. Seriated hematoxylin and eosin stained sections were obtained and conventional light microscopy at a magnification of 20X was performed. The number of cells, the number of vessels, the surface of the lumen of the vessels, the total vascular surface, the thickness of the wall of vessels in each selected image were measured with an Autocad software. The results per specimen were averaged for statistical analysis. Results: Six months after surgery the SF-36 mental and physical summary scores (P< 0.001 and P=0.001, respectively), the Symptom severity score (P< 0.001) and the HI-Ob (P< 0.001) improved. In comparison with cadavers, the typical pathologic findings of SSCT of patients with CTS were vascular hypertrophy and vessel’s wall thickening. At multivariate linear regression analyses greater histopathological changes were important predictor of lower SF-36 scores following surgery. As for the electromyographic parameters, higher preoperative values of 3M SCV and MCV were positively associated with SF-36 BP and SF scores. The greater neurophysiological impairment of the median nerve was predictive of lower SF-36 VT at follow up. Older patients, females and patients who had had the higher number or severity of comorbidities preoperatively achieved the lower SF-36 scores following surgery. Conclusions: We demonstrated many variables to be associated with the CTS and its surgical treatments thus confirming data from previous reports and suggesting new important associations that have not been described previously. Physicians should consider these results when discussing with patients on the likely outcomes of carpal tunnel surgery

No studies have focused on the relationships between pathological changes in the subsynovial connective tissue and clinical or neurophysiological findings in patients suffering from carpal tunnel syndrome (CTS). Twenty-five consecutive patients (mean age 58.8±10 years; range 39–79) operated on for idiopathic CTS were evaluated before surgery and six month later. The indication for surgery was the presence of symptoms despite a three-month trial of conservative management. Mean duration of symptoms was 5.3±4.6 years (range 0.5–15). On admission, demographic and medical history data were recorded from all the patients. Subsequently, patients underwent preoperative physical examination and an outcome set including a mixed historic and objective scale (Hi-Ob), the Italian version of the Boston Carpal Tunnel Questionnaire (BCTQ) and the official Italian version of the SF-36 questionnaire was administered. The baseline diagnostic work-up included standard radiographs of the hand and wrist, blood examination and neurophysiological testing. Patients underwent open carpal tunnel release and thickened synovium from the flexor digitorum superficialis tendons was harvested. The number of cells, the number, diameter and density of the vessels, and the total surface of angiogenetic foci were measured. On the SF-36 questionnaire, the preoperative physical component summary (PCS) and mental component summary (MCS) scores averaged 36.5±4.2 and 40.8±5.7, respectively; at follow they averaged 47±10.2 and 46.8±7.3, respectively, with significant improvement for PCS. Preoperative and postoperative Hi-Ob scores measured 3.4±0.5 and 1.3±0.5, respectively. The BCTQ symptoms scale averaged 3.9±0.3 before surgery and 1.5±0.2 at follow up, whereas the BCQT functional status scale measured 3.4±0.5 at baseline and 1.4±0.3 six months after the operation. Univariate and multiple linear regression analysis were used to evaluate relationships between explanatory variables and outcomes. A high grade of preoperative neurophysiologic impairment was in direct relationship with the improvement in SF-36’s PCS score obtained with surgery (p=0.017). Conversely, no association was detected between neurophysiological grade and the postoperative improvement in Hi-Ob or BCQT scales. The univariate analysis showed a trend toward a direct association between number of vessels in the synovium and the improvement of BCTQ symptoms at follow-up (p=0.06). This trend was confirmed to a lesser extent at the multivariate analysis. With the numbers available, no other histological parameters were associated with the baseline neurophysiological findings or clinical outcomes. Although our results should be interpreted cautiously due to the small sample size, we conclude that the severity of pathological changes in the flexor synovium during CTS do not influence the baseline severity or outcome of this syndrome

Introduction: Carpal tunnel decompression is the most commonly performed procedure in hand surgery. This study was done to assess the effectiveness and acceptability by patients of open carpal tunnel release under local anaesthetic and compare our results with previous published work from our department following alterations to our operative techniques. Methods: 92 carpal tunnel releases were performed on 80 patients over a four year period, 2001 to 2004. 55 were females and 25 were males. A patient satisfaction survey was done by a postal questionnaire which addressed opinion regarding preference for LA over GA, pain due to LA infiltration, effectiveness of LA, patient comfort during surgery, outcome of surgery and overall satisfaction with the procedure. In this cohort of patients we did not use a tourniquet which caused severe pain in 29% of cases in the previous study. We also administered LA with adrenaline using a dental syringe to reduce pain which was previously reported as severe in 20% of cases. Results: 62 patients replied to the questionnaire, a response rate of 77.5%. Preference for LA over GA was 90% as compared to 70% in the previous study. Pain due to tourniquet use was previously reported as severe in 29% of cases but this did not apply in this subset of patients. Pain due to infiltration of LA with a dental syringe was severe in 9% of cases compared to 20% with a 25G needle. Effectiveness of LA, outcome of surgery and overall satisfaction with the procedure remained unchanged. Conclusion: Carpal tunnel decompression is a quick, convenient, inexpensive and safe method of treatment. We have demonstrated that injecting LA with adrenaline using a dental syringe obviates the need for tourniquet and improves patients’ acceptability and tolerance of this procedure

Introduction A randomised, double blind controlled study of the short term results of single portal endoscopic carpal tunnel release (ECTR) versus open carpal tunnel release (OCTR) is presented. Methods Twenty patients undergoing bilateral carpal tunnel release were inducted into the study. Each patient had one side performed as an ECTR and the other as an OCTR. The side that ECTR was performed on was randomised. Assessment was performed at one, two and six weeks post-operatively by the patient and a blinded hand therapist. The patient was blinded at the one week review. Assessment looked at pain, function and satisfaction, as well as objective strength and motion. Results All patients prefered the side of the endoscopic release at one, two and six weeks. ECTR was associated with less pain, greater ease of use, improved strength and better motion. Conclusions There is a significantly improved short term outcome, on both subjective and objective measures, with endoscopic carpal tunnel release compared to open carpal tunnel release

Endoscopic carpal tunnel release has the advantage over open release of reduced tissue trauma and postoperative morbidity. Limited open carpal tunnel release has also been shown to have comparable results, but is easier to perform and is safer. We have compared the results of both techniques in a prospective, randomised trial. Thirty patients with bilateral carpal tunnel syndrome had simultaneous bilateral release. The technique of release was randomly allocated to either two-portal endoscopic release (ECTR) or limited open release using the Strickland instrumentation (LOCTR). The results showed that the outcome was similar at follow-up of one year using both techniques. However, the LOCTR group had significantly less tenderness of the scar at the second and fourth postoperative week (p < 0.01). There was also less thenar and hypothenar (pillar) pain after LOCTR. Subjective evaluation showed a preference for LOCTR

To compare the results of standard open carpal tunnel release against minimal access release using the ‘Stryker Knifelight’ in the same patients. A prospective, randomised trial was carried out recruiting all patients with bilateral carpal tunnel syndrome. There were 26 patients (18 females and 8 males), with a mean age of 48 years. The patients were randomised to having the ‘Knifelight’ on one side and therefore acted as their own controls. They were assessed preoperatively, and at 2 and 6 weeks postop by questionnaire, and grip strength measurements. All sides were improved following release but those done by the open method were more likely to have complete resolution at 6 weeks. In contrast, the ‘Knife-light’ sides had better grip strength and allowed earlier return to work. In terms of preference, the patients were split equally between the 2 techniques. 2 patients had minor complications following minimal access release including one with numbness over the thenar eminence for 6 weeks. This study shows that open carpal tunnel release remains the ‘gold standard’ but the minimal access technique offers some advantages in terms of quicker recovery

The advantages and disadvantages of endoscopic compared with open carpal tunnelreleasearecontroversial. We have performed a prospective, randomised, blinded assessment in a district general hospital in order to determine if there was any demonstrable advantage in undertaking either technique. Twenty-five patients with confirmed bilateral idiopathic carpal tunnel syndrome were randomised to undergo endoscopic release by the single portal Agee technique to one hand and open release to the other.

Independent preoperative and postoperative assessment was undertaken by a hand therapist who was blinded to the type of treatment. Follow-up was for 12 months.

The operating time was two minutes shorter for the open technique (p < 0.005). At all stages of postoperative assessment, the endoscopic technique had no significant advantages in terms of return of muscle strength and assessment of hand function, grip strength, manual dexterity or sensation.

In comparison with open release, single-portal endoscopic carpal tunnel release has a similar incidence of complications and a similar return of hand function, but is a slightly slower technique to undertake.