Endoscopic Carpal Tunnel Release associated with increased risk of revision when compared with Open procedure: JAMA

Carpal tunnel release (CTR) is among the most common operations performed in orthopedics and is generally safe and effective. Controversy persists regarding the risks and benefits of Endoscopic Carpal tunnel release (ECTR) vs Open Carpal Tunnel Release (OCTR), with one concern being the potential for incomplete release of the transverse carpal ligament (TCL) during ECTR. Revision surgeries have been estimated to occur in 1% to 5% of patients.

Peter C. Ferrin et al conducted a study to estimate the incidence of revision CTR following ECTR compared with OCTR.

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. 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.

The key findings of the study were:

• 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).

The authors concluded that – “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.”

Further reading:

Revision Carpal Tunnel Release Following Endoscopic Compared With Open Decompression Peter C. Ferrin et al JAMA Network Open. 2024;7(1):e2352660. doi:10.1001/jamanetworkopen.2023.52660