Endoscopic versus open carpal tunnel release: A randomized trial.

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.

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. 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. 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 12weeks. DASH scores improved significantly from a median of 67.5 to 16 (p = 0.002), grip strengths improved from 42 to 55.0lbs (p = 0.30), chuck pinch strengths improved significantly from 11 to 15.5lbs (p = 0.02), and key pinch strengths increased significantly from 13 to 18lbs (p = 0.003). Average static two-point discrimination decreased from 5.9 to 4.8mm. 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. 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.

Consequent to persistent debate over endoscopic versus open carpal tunnel release,a minimally invasive technique was developed which combines the reduced tissue trauma and postoperative morbidity of endoscopic release with the simplicity and safety of the traditional open technique.After Chow described an endoscopic technique of carpal tunnel release in 1989, several modifications of his approach were developed including the use of video equipment for visualization ofthetransversecarpalligamentandspeciallydesigned instruments [1, 2, 3, 4, 5, 6, 7, 8].The clinical efficacy of the endoscopic release was found to be equivalent to that of open carpal tunnel release [4, 9,10].Proponents of endoscopic release claim a reduction in postoperative morbidity as less tissue is surgically violated [11, 12]. A multicenter randomized prospective study comparing open and endoscopic carpal tunnel releases showed greater grip and pinch strength and less scar and pillar tenderness at various early postoperative period in patients who underwent endoscopic release [4 ].In addition,endoscopic patients were found to have earlier return to activities of daily living (median 5 days versus 13 days)and to work (16.5 days versus 45.5 days) [4]. Another multicenter randomized prospective study corroborated the findings of less scar tenderness and reduced time out of work (median time of 14 days versus 28 days)in patients following the endoscopic procedure [9].Additionally,the advantages of both one and two-portal endoscopic releases compared with open release in postoperative parameters of tenderness,grip and pinch strength,as well as return to normal activities were demonstrated in another study [10]

Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice

Carpal tunnel release (CTR) can be performed using either an open or endoscopic approach. The patient recovery trajectories remain poorly understood. This study aimed to define and compare patient-reported recovery following unilateral open and endoscopic CTR. A PRISMA-compliant, preregistered (CRD42023427718) systematic review was conducted, searching PubMed, Embase, and Cochrane databases on 4 July 2023 and 21 August 2024. Studies were included if they reported recovery data (patient-reported outcome measures (PROMs)) at predefined time points for adults undergoing unilateral CTR. Boston Carpal Tunnel Questionnaire and Quick Disabilities of Arm, Shoulder, and Hand scores were extracted. Standardized mean change (SMC) scores from baseline were pooled using random-effects meta-analysis. An innovative modification of the National Institutes of Health quality assessment tools was used to evaluate the risk of bias. In all, 49 studies were included (4546 participants included in the analysis; 3137 open CTR, 1409 endoscopic CTR). Both approaches improved PROM scores over 12 weeks, with early (4-week) outcomes strongly correlating (>0.89) with later (12-week) outcomes. Symptoms continued improving up to 104 weeks. At 1 week, open CTR showed symptomatic deterioration (SMC 10.29; 95% confidence interval (c.i.) 6.35 and 14.21 respectively), comparatively, endoscopic CTR demonstrated an improvement (SMC -2.83; 95% c.i. -7.80 and 2.14 respectively). By 2 weeks, symptom severity remained slightly worse in open CTR, but confidence intervals overlapped from week 3 and thereafter open CTR showed greater symptomatic improvement. Most studies had a high risk of bias and measured outcomes too infrequently for a granular comparison. Patient-reported recovery trajectories for CTR can inform patient counselling and future research. Endoscopic CTR may result in fewer symptoms in the first 2 weeks, but open CTR may offer comparable or potentially greater improvement thereafter. Future trials with high-frequency PROM capture should prioritize early (first 3 weeks) and long-term (≥24 weeks) outcomes.

Comparison of morphologic consequences of open and endoscopic carpal tunnel release

BackgroundThe symptoms in carpal tunnel syndrome (CTS) can be ameliorated by open and endoscopic release of the transverse carpal ligament. It is unknown whether a mini-incision or endoscopic carpal tunnel release more effectively reverses the pathological changes that are observed in the median nerve in patients with CTS and these morphologic changes correlates with the subjective outcomes after carpal tunnel release. We hypothesized that (1) at 24 weeks after surgery, the subjective outcomes of mini-incision release and endoscopic release would not differ in patients with CTS; and (2) the ultrasonographic (US) morphology of the median nerve reverses similarly after mini-incision and endoscopic release; (3) the subjective outcomes correlates with these morphologic changes.MethodsBetween November 2011 and January 2013, 67 patients with CTS in their dominant wrist were randomized to either mini-incision (n = 32) or endoscopic (n = 35) release. Each patient was assessed by both the Boston Carpal Tunnel Questionnaire (BCTQ) and the Disabilities of the Arm, Shoulder, and Hand (DASH) pre-operatively and 24 weeks’ post-operation. An US examination was conducted at both time points to measure the cross-sectional area (CSA) at the inlet, middle, and outlet (CSA-I, CSA-M and CSA-O) and the flattening ratio (FR) at the middle and outlet (FR-M and FR-O) of the median nerve.ResultsThe post-operative mean BCTQ and DASH scores were improved significantly from the pre-operative scores in both groups (p < 0.001). The mean CSA-I decreased and CSA-M and CSA-O increased similarly in both groups (by 3.3, 3.0, and 3.8 mm2 in the mini-incision group and 2.9, 3.1. and 2.7 mm2 in the endoscopic group. The mean FR-M/FR-O decreased similarly from 3.6/4.2 to 3.2/3.0 in the mini-incision group and 3.8/4.3 to 3.2/2.9 in the endoscopic group. There were no significant differences in the subjective outcome scores or median nerve measures between the two groups. Improvement in the BCTQ-S only was significantly correlated with changes in the CSA at the inlet.ConclusionsMini-incision and endoscopic release both similarly relieved subjective symptoms and functions along with the pathological changes in the median nerve morphology along the carpal tunnel in patients with idiopathic CTS. Symptom relief after surgical decompression seems to correlate with reduced nerve swelling at carpal inlet and reversed nerve flattening inside carpal tunnel.Trial registrationThis study was retrospectively registered in “ClinicalTrials.gov” at Oct 18th, 2013, and the registration number was NCT01972165.

Purpose: The purpose of this study was to report trends, complications, and costs associated with endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR). Methods: Using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes, patients who had open versus endoscopic carpal tunnel release (CTR) were identified retrospectively in the PearlDiver database from both the Medicare and Humana (a private payer health insurance) populations from 2005 to 2014. These groups were then evaluated for postoperative complications, including wound infection within 90 days, wound dehiscence within 90 days, and intraoperative median nerve injury. We also used the data output for each group to compare the cost of the 2 procedure types. Data were analyzed via the Student t test. Statistical significance was set at P < .05. Results: A significantly lower percentage of patients in the endoscopic CTR group had a postoperative infection (5.21 vs 7.97 per 1000 patients per year, P < .001; 7.36 vs 11.23 per 1000 patients per year, P < .001) and wound dehiscence (1.58 vs 2.87 per 1000 patients per year, P < .001; 2.14 vs 3.73 per 1000 patients per year, P < .05) than open CTR group in the Medicare and Humana populations, respectively. Median nerve injury occurred 0.59/1000 ECTRs versus 1.69/1000 OCTRs (Medicare) and 1.96/1000 ECTRs versus 3.72/1000 OCTRs (Humana). Endoscopic CTR cost was more than open CTR for both the Medicare population ($1643 vs $1015 per procedure, P < .001) and Humana population ($1928 vs $1191 per procedure, P < .001). Conclusions: In both the Medicare and private insurance patient populations, endoscopic CTR is associated with fewer postoperative complications than open CTR, but is associated with greater expenses.

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.

Trends in open and endoscopic carpal tunnel release utilization in the Medicare patient population

Background: Surgical management of carpal tunnel syndrome includes performing an endoscopic (ECTR) or open (OCTR) carpal tunnel release. Several studies have shown less postoperative pain and improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine outcomes, patient satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient. Methods: This was a prospective study in which patients with bilateral carpal tunnel syndrome underwent surgical release with both techniques, with initial operative approach randomized in the more symptomatic hand. Demographic data and functional outcomes were recorded, including the pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score, and overall satisfaction. Results: Thirty patients completed the study; there were no significant differences in any measure at any of the postoperative time points. Symptom severity and functional status scores were not significantly different between groups at any evaluation. Subjectively, 24 of 30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason, although pain scores were not significantly different. Differences in overall satisfaction were also not significant. Conclusions: Both techniques are well tolerated with no differences in outcomes. With the added cost and equipment associated with ECTR, and no added benefit, the usefulness of ECTR is questionable.

The purpose of this study was to evaluate changes in open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR) utilization, reimbursement, and patient demographics in the Medicare population from 2013 to 2021 at national and regional levels. The Medicare Physician & Other Practitioners database from 2013 to 2021 was queried to extract all instances of OCTR and ECTR. Utilization per 10,000 beneficiaries, inflation-adjusted reimbursement, and patient characteristics were extracted for OCTR and ECTR each year. Data were stratified by region based on US Census guidelines. Kruskal-Wallis tests and multivariable linear regressions were performed. From 2013 to 2021, national utilization per 10,000 beneficiaries increased by 6% for OCTR and by 50% for ECTR. In 2021, the Midwest had the greatest utilization of OCTR (29 of 10,000) and the lowest utilization of ECTR (7 of 10,000). Inflation-adjusted reimbursement declined for both OCTR and ECTR during the study period (10.3% and 11.8%, respectively), with the South having the lowest reimbursement for both procedures. The severity of patient comorbidity profiles and dual Medicare-Medicaid enrollees decreased for both procedures as well. Both OCTR and ECTR utilization have increased, while inflation-adjusted reimbursement has decreased. Patient populations encompassed fewer dual Medicare-Medicaid enrollees, indicating surgeons may be more selective in operative indications. These findings should be addressed to ensure the economic sustainability of carpal tunnel release procedures and equitable access to quality hand care for all patients with Medicare. [Orthopedics. 2025;48(1):e45-e51.].

Background:This study compared trends in use, predictive factors, and reimbursement of endoscopic carpal tunnel release (ECTR) withthose of open carpal tunnel release (OCTR) from 2010 to 2021 using a national administrative database.Methods:ECTR and OCTR patients were identified in the PearlDiver M151Ortho data set. Numeric and proportional utilization of these procedures was characterized for each year of study. Multivariate analysis was conducted to identify predictive factors for having ECTR performed. The average 90-day reimbursement of ECTR and OCTR was determined.Results:From 2010 through 2021, 441,023 ECTR and 1,767,820 OCTR procedures were identified. The proportional use of ECTR compared with OCTR rose from 2010 (15.7% of procedures) to 2021 (26.1%). Independent predictors of having ECTR performed rather than OCTR included geographic variation (compared with having surgery in the Midwest, Northeast odds ratio [OR], 1.53; West OR, 1.62; and South OR, 1.66), having Medicare or commercial insurance (compared with commercial, Medicare OR, 0.94, and Medicaid OR, 0.69), female sex, and fewer comorbidities. The average 90-day reimbursement for ECTR was $3,114.82, compared with $3,087.62 for OCTR.Discussion:As of 2021, over one-fourth of carpal tunnel releases are done endoscopically. Several factors independently predict whether patients receive ECTR or OCTR.

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

To evaluate the usefulness of endoscopic carpal tunnel release (ECTR) on patients with idiopathic carpal tunnel syndrome, multiple aspects of the results of 44 hands (42 patients) treated by ECTR and 40 hands (40 patients) treated by open carpal tunnel release (OCTR) were compared. Results of ECTR were compared with those of OCTR to study not only recovery rate and surgical safety but also cost-effectiveness. Although ECTR was much less invasive than OCTR, recovery of median nerve palsy in the ECTR group was not as good as that in the OCTR group one month after the surgery. Three months after surgery, the palsy of patients treated by ECTR had improved to almost the same extent as in those treated by OCTR. There were no major surgical complications in both ECTR and OCTR groups. The cost and time needed for ECTR treatment was 1/3 of those needed for OCTR. ECTR reduced both cost and treatment time, which is beneficial for both doctors and patients.