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Original Research|Articles in Press

Early Revision Rate Following Primary Carpal Tunnel Release

Open AccessPublished:February 20, 2023DOI:https://doi.org/10.1016/j.jhsg.2023.01.010

      Purpose

      The published revision rates after carpal tunnel release (CTR) vary from 0.3% to 7%. The explanation for this variation may not be fully apparent. The purpose of this study was to determine the rate of surgical revision within 1–5 years following primary CTR at a single academic institution, compare it with rates reported in the literature, and attempt to provide explanations for these differences.

      Methods

      We identified all patients who underwent primary CTR at a single orthopedic practice by 18 fellowship-trained orthopedic hand surgeons from October 1, 2015, through October 1, 2020, using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD), 10th Revision, codes. Patients who underwent CTR because of a diagnosis other than primary carpal tunnel syndrome were excluded. Patients who required revision CTR were identified using a practice-wide database query using a combination of CPT and ICD-10 codes. Operative reports and outpatient clinic notes were reviewed to determine the cause of revision. Data on patient demographics, surgical technique (open vs single-portal endoscopic), and medical comorbidities were collected.

      Results

      A total of 11,847 primary CTR procedures were performed during the 5-year period on 9,310 patients. We found 24 revision CTR procedures among 23 patients, resulting in a revision rate of 0.2%. Of 9,422 open primary CTRs performed, 22 cases (0.23%) went on to undergo revision. Endoscopic CTR was performed in 2,425 cases, with 2 cases (0.08%) ultimately undergoing revision. The average length of time from primary CTR to revision was 436 days (range, 11–1,647 days).

      Conclusions

      We noted a substantially lower rate of revision CTR within 1–5 years of primary release (0.2%) in our practice than that noted in previously published studies, although we accept that this does not account for out-of-area migration. There was no significant difference in the revision rates between open and single-portal endoscopic primary CTR.

      Type of study/level of evidence

      Therapeutic III.

      Key words

      Carpal tunnel syndrome (CTS) is the most common compressive neuropathy diagnosed in the upper extremities, with a prevalence of 3.7% in the general population in the United States.
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      Long-term trends in carpal tunnel syndrome.
      reported an estimated annual incidence of 424 diagnoses per 100,000 person-years. Consequently, carpal tunnel release (CTR) is one of the most commonly performed upper-extremity procedures, with an estimated 400,000–600,000 annual surgical cases.
      • Fajardo M.
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      Incidence of carpal tunnel release: trends and implications within the United States ambulatory care setting.
      ,
      • Palmer D.H.
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      Although the majority of CTR surgeries are effective, unsuccessful CTR can lead to patient dissatisfaction and morbidity.
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      Evaluation and management of unsuccessful carpal tunnel release.
      This is most often attributed to incomplete release of the transverse carpal ligament; recurrence, with perineural scarring and/or circumferential fibrosis of the median nerve; or other related complications.
      • Zhang D.
      • Earp B.E.
      • Blazar P.
      Evaluation and management of unsuccessful carpal tunnel release.
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      • Gohritz A.
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      • Lanz U.
      Revision surgery after carpal tunnel release—analysis of the pathology in 200 cases during a 2 year period.
      • Zieske L.
      • Ebersole G.C.
      • Davidge K.
      • Fox I.
      • Mackinnon S.E.
      Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes.
      • Jones N.F.
      • Ahn H.C.
      • Eo S.
      Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release.
      • Tung T.H.
      • Mackinnon S.E.
      Secondary carpal tunnel surgery.
      Revision surgery may be indicated in cases of persistent or recurrent CTS symptoms after other potential etiologies have been ruled out (ie, cervical radiculopathy, brachial plexopathy, and generalized peripheral polyneuropathy).
      • Zhang D.
      • Earp B.E.
      • Blazar P.
      Evaluation and management of unsuccessful carpal tunnel release.
      ,
      • Zieske L.
      • Ebersole G.C.
      • Davidge K.
      • Fox I.
      • Mackinnon S.E.
      Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes.
      Currently, the true revision rate after primary CTR is unclear, with the revision rates in the literature ranging from 0.3% to 7%.
      • Concannon M.J.
      • Brownfield M.L.
      • Puckett C.L.
      The incidence of recurrence after endoscopic carpal tunnel release.
      • Nancollas M.P.
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      • Wheeler D.R.
      • Sherwin F.S.
      Long-term results of carpal tunnel release.
      • Cobb T.K.
      • Amadio P.C.
      Reoperation for carpal tunnel syndrome.
      • Trumble T.E.
      • Diao E.
      • Abrams R.A.
      • Gilbert-Anderson M.M.
      Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial.
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      • Ranstam J.
      Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.
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      • Peimer C.A.
      Endoscopic release of the carpal tunnel: a randomized prospective multicenter study.
      • Eichhorn J.D.
      • Dieterich K.
      Open versus endoscopic carpal tunnel release. Results of a prospective study.
      • Macdermid J.C.
      • Robert S.
      • Richards R.S.
      • Roth J.H.
      • Ross D.C.
      • King G.J.
      Endoscopic versus open carpal tunnel release: a randomized trial.
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      • Hankins C.L.
      • Brown M.G.
      • Lopez R.A.
      • Lee A.K.
      • Dang J.
      • Harper R.D.
      A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
      In fact, 2 recent large retrospective studies noted overall CTR revision rates of 4.8% and 1.5%.
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      ,
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      Therefore, the purpose of the present study was to determine the early revision rate following primary CTR at a single, academic orthopedic hand surgery practice. “Early” was defined as revision surgery within 1–5 years of primary CTR. We hypothesized that the rate of revision CTR would be lower than other recently reported rates, with comparable follow-up (median, 1 year and 4.79 years, respectively).
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      ,
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.

      Methods

      Institutional review board approval was obtained, including a waiver of informed consent per institutional protocol, and we adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. We performed a search of a database of patients at a single academic orthopedic practice from October 1, 2015, through October 1, 2020. This search collected data on all patients who underwent CTR surgery during this time, determined based on the presence of the Current Procedural Terminology (CPT) codes 64721 (open CTR), 29848 (endoscopic CTR), or 64708 (open neuroplasty of peripheral nerve), performed by 1 of 18 board-certified, fellowship-trained, orthopedic hand surgeons. The CPT code 64708 was included to potentially identify revision surgeries; only cases with the CPT codes 64721 or 29848 were considered primary CTR. Only procedures with the corresponding laterality-specific International Classification of Diseases, 10th Revision (ICD-10) codes of G56.01, G56.02, or G56.03 (CTS of the right, left, or bilateral upper limbs) were included. Patients who underwent CTR secondary to acute trauma (radius fracture, perilunate dislocation, etc) were excluded. The remaining group of patients represented our cohort of primary CTR cases.
      Patients who required revision CTR were identified in a stepwise fashion using a practice-wide electronic medical record data query. This process is outlined in the Figure. All patients had a minimum of 1 year and a maximum of 5 years of chart follow-up, which was used as the working definition of the “early” postoperative period. In cases in which the query identified potential revisions, a complete review of the patient’s electronic medical records (including operative reports) was performed.
      Data on patient demographics were collected, including age, sex, race, smoking status, and medical history. The specific comorbidities recorded included history of diabetes mellitus (type I or II), thyroid disease, psychiatric conditions (defined as diagnoses of anxiety, depression, or “other mental illness”), and rheumatoid arthritis (RA) because all these represent potential risk factors for CTS.
      • Solmaz V.
      • Yavuz S.
      • İnanr A.
      • et al.
      Investigation of nerve conduction studies of carpal tunnel syndrome cases with different risk factors: an electrodiagnostic study.
      • Shiri R.
      Arthritis as a risk factor for carpal tunnel syndrome: a meta-analysis.
      • Pourmemari M.H.
      • Shiri R.
      Diabetes as a risk factor for carpal tunnel syndrome: a systematic review and meta-analysis.
      • Palumbo C.F.
      • Szabo R.M.
      • Olmsted S.L.
      The effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndrome.
      • Shin Y.H.
      • Yoon J.O.
      • Kim Y.K.
      • Kim J.K.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      Additionally, we performed a query of patients who underwent CTR for a history of cervical spine disease, ulnar neuropathy, or other median neuropathy based on their ICD-10 codes. The surgical technique used in each CTR was determined based on the CPT code associated with the procedure, 64721 for open surgery and 29848 for endoscopic surgery. All endoscopic CTR surgeries were performed using the single-portal technique.
      In the overall cohort, continuous data were compared using 2-sample t tests, and categorical data were compared using chi-square tests. Multivariate logistic regression was planned to determine the potential associations of risk factors with revision. Additionally, patients who did not undergo revision were demographically matched with those who underwent revision at a ratio of 4:1. Propensity score matching based on age, sex, and body mass index was chosen in order to control for potentially confounding variables when analyzing risk factors for undergoing revision CTR. The 4:1 ratio to control for patients who underwent revision was chosen because the size of the control cohort allowed it, and a greater ratio would not provide additional statistical power. Odds ratios were calculated, with significance set at P <.05. All statistical analyses were performed using R Studio (version 3.6.3).

      Results

      Study cohort

      From October 1, 2015, to October 1, 2020, 11,847 primary CTR operations were performed on 9,310 unique patients. Of these patients, 41% were men and 59% were women. The average patient age at the time of surgery was 65 years (range, 21–103 years). There were 9,422 open primary CTRs among 7,486 patients (79.5% of the total cases and 80.4% of the total patients) and 2,425 endoscopic primary CTRs among 1,824 patients (20.5% of the cases and 19.6% of the total patients). Additional demographic and comorbidity data are presented in Table 1.
      Table 1Patient Demographics and Risk Factors in Overall Cohort
      CTR Data Per PatientPrimary CTR Without RevisionPrimary CTR With Revision CTR
      Total Patientsn = 9,287n = 23
      Variablen%n%
      Sex
       Male3,81741.11356.5
       Female5,47058.91043.5
      Age
       Average64.8-59.1-
       Range21–103-33–80-
      BMI, kg/m2
       <251,63617.6626.1
       25–29.92,92631.5313.0
       >29.94,34546.81043.5
      Surgical approach
       Open7,46580.42191.3
       Endoscopic1,82219.628.7
      Tobacco use
       Current1,31014.1730.4
       Former1,92920.814.3
       Nonsmoker3,73040.2834.8
      Comorbidities
       DM (type 1 or 2)1,42415.3521.7
       Thyroid disease1,23913.3313.0
       Psychiatric conditions2,04622.01043.5
       Rheumatoid arthritis8929.6417.4
       Cervical disease3043.328.7
       Ulnar neuropathy7408.0417.4
       Other median neuropathy300.314.3
      BMI, body mass index; DM, diabetes mellitus.

      Revision CTR rate and cohort characteristics

      The overall revision rate for all primary CTR surgeries was 0.2% (24/11,847). The revision rate for primary open CTR was 0.23% (22/9,422) compared with 0.08% (2/2,425) for primary endoscopic CTR (P = .14). All 24 revision CTR operations were performed using an open technique. The mean time to revision was 436 days (range, 11–1,647 days), with a median of 293.5 days. Thirteen revisions (54%) were performed within 1 year of primary CTR. One patient underwent bilateral revision surgeries following bilateral primary CTRs. Twenty-two patients (96%) had their revision surgery performed by the same surgeon as that who performed the primary CTR, and the other patient underwent revision performed by a different surgeon within the same practice.
      Of the 23 patients who went on to undergo revision, 14 (61%) had recurrent CTS symptoms, 7 (30%) had persistent symptoms, and 2 (9%) had worsening symptoms with associated pain immediately following their primary surgery.
      The indication for revision in each of the 24 cases is described in Table 2. The intraoperative findings from 21 of the 24 cases are detailed in Table 2. The operative reports for the remaining 3 cases were unavailable, and data were gathered from office notes primarily. During their revision surgery, 7 patients (29%) underwent a concomitant soft-tissue flap procedure, 5 patients required flexor tendon tenosynovectomy (20.8%), and 4 patients (16.7%) underwent a median nerve wrap for prevention of recurrent perineural scarring and adhesion formation. The decision to perform 1 or more of these additional procedures was made during surgery on a case-by-case basis because of the degree of perineural scarring, adhesions, transverse carpal ligament reformation, and flexor tenosynovial hypertrophy. Depending on surgeon preference, it may be reasonable to have nerve wraps available during revision CTR cases.
      Table 2Patient Demographics and Risk Factors in Matched Cohort
      CTR Data Per PatientPrimary CTR Without RevisionPrimary CTR With Revision CTROdds Ratio (95% Confidence Interval)P Value
      Total Patientsn = 92n = 23
      Variablen%n%
      Sex1 (0.39–2.54)1
       Male4056.51356.5
       Female5243.51043.5
      Age1 (0.97–1.03)1
       Average60.1-60.1-
      BMI1.01 (0.94–1.08)1
       Average30.8-31.2-
      Surgical approach1.89 (0.57–9.0).397
       Open7177.22191.3
       Endoscopic2122.828.7
      Tobacco use.094
       Current1621.9741.21.79 (0.54–5.76)
       Former2027.415.90.23 (0.01–1.41)
       Nonsmoker3750.7952.9
      Comorbidities
       DM (type 1 or 2)1920.7521.71.08 (0.32–3.18)1
       Thyroid disease1010.93131.26 (0.25–4.70).72
       Psychiatric conditions1920.71043.52.93 (1.09–7.81).047
       RA39.8417.41.96 (0.47–6.89).289
       Cervical disease55.428.71.71 (0.21–8.99).626
       Ulnar neuropathy1112521.72.06 (0.56–6.55).309
       Other median neuropathy0014.4-.2
      BMI, body mass index; DM, diabetes mellitus.
      Prior to primary CTR, each of these patients underwent electromyography (EMG) and nerve conduction study (NCS) testing and met the American Association of Electrodiagnostic Medicine’s diagnostic criteria for CTS.
      American Association of Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation
      Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: summary statement.
      ,
      • Lew H.L.
      • Wang L.
      • Robinson L.R.
      Test-retest reliability of combined sensory index: implications for diagnosing carpal tunnel syndrome.
      Sixteen patients (67%) underwent repeat prerevision EMG and NCS. Of these patients, 12 (75%) had equivalent results compared with the results of their original preoperative testing, whereas 3 (19%) had more severe findings, and 1 patient (6%) was noted to have mildly improved EMG and NCS measurements. The decision to repeat EMG and NCS testing was made by the treating surgeon.
      Overall, the revision group was predominantly comprised of men (57% compared with 41% of the patients in the overall cohort) and had a greater proportion of active smokers (30% vs 14%, respectively) as well as patients with psychiatric conditions (44% vs 22%, respectively), diabetes mellitus (22% vs 15%, respectively), RA (17% vs 10%, respectively), cervical spine disease (9% vs 3%, respectively), and other median neuropathy (4.3% vs 0.3%, respectively). Unfortunately, the small size of the revision cohort (n = 23) precluded the use of multivariate analysis to describe the effect of surgical technique and comorbidities on the revision rate. The results of the analysis of the 4:1 matched revision versus nonrevision cohort are presented in Table 2. Following the matching calculation, no significant differences were present in age, sex, or body mass index between the control and revision cohorts, and significantly greater odds of progression to revision CTR existed only for patients with a history of psychiatric conditions (43.5% vs 20.7%; odds ratio, 2.93 [95% confidence interval, 1.09–7.81]; P = .047).

      Discussion

      Primary CTR is typically successful; however, unfortunately, complications can occur that necessitate revision surgery.
      • Zhang D.
      • Earp B.E.
      • Blazar P.
      Evaluation and management of unsuccessful carpal tunnel release.
      • Stütz N.
      • Gohritz A.
      • Van Schoonhoven J.
      • Lanz U.
      Revision surgery after carpal tunnel release—analysis of the pathology in 200 cases during a 2 year period.
      • Zieske L.
      • Ebersole G.C.
      • Davidge K.
      • Fox I.
      • Mackinnon S.E.
      Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes.
      • Jones N.F.
      • Ahn H.C.
      • Eo S.
      Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release.
      • Tung T.H.
      • Mackinnon S.E.
      Secondary carpal tunnel surgery.
      The impetus for our study was the meaningful discrepancy in revision rates between the 2 most contemporary, retrospective studies to date (Wessel et al
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      4.8% vs Westenberg et al
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      1.3%). Additionally, we sought to compare the revision rates between open and endoscopic CTR in our own study cohort. Overall, the revision rate in our cohort (n = 11,847) was 0.2%, which is substantially lower than those recently reported in the literature. Additionally, no statistically significant difference in revision rate was noted between open (0.23%) and endoscopic (0.08%) primary CTR.
      A number of studies have sought to clarify the revision rate following CTR (Table 3). Over a 14-year period (2002–2015), Westenberg et al
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      conducted a large retrospective review of 9,417 primary open and endoscopic CTR surgeries in 7,464 patients. Their overall revision rate was 1.3%, performed at a median of 1.23 years after primary CTR. In contrast to our results, their rate of revision CTR was greater after endoscopic CTR (2.8%) compared with that after open CTR (1.4%), and they reported this as a risk factor. However, only 425 patients (6% of the cases) underwent endoscopic release in this group. Given that this only amounts to an average of 30 endoscopic CTR cases per year over a 14-year period, the relatively low volume could have potentially contributed to the higher revision rate for the endoscopic technique.
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      In contrast, our study included 2,425 endoscopic CTRs over 5 years which averages to 485 per year.
      Table 3Details of Patients Who Underwent Revision CTR
      Patient IDLateralityDays to RevisionPreop EMG/NCSPreop EMG/NCS GradePrerevision EMG ResultSame Surgeon?Primary ApproachRevision ApproachReason for RevisionRevision Surgery Intraop FindingsConcomitant Procedures
      1Right421YesModerate-to-severeEquivalent (moderate-to-severe)NoOpenOpenRecurrent symptoms1. Incomplete release of TCL

      2. Median n. severely compressed, w/ hourglass appearance
      N/a
      2Left43YesSevereN/aYesOpenOpenWorsening symptoms with pain1. Median n. compressed under distal forearm fascia

      2. Flexor tenosynovial hypertrophy
      Forearm flexor tenosynovectomy
      3Right1647YesModerateEquivalent (moderate)YesOpenOpenRecurrent symptoms1. Reformation and thickening of TCL

      2. Median n. flattened and atrophied
      CuTR, Ulnar nerve release at wrist, flexor pronator lengthening
      4Left840YesSevereEquivalent (severe)YesOpenOpenRecurrent symptoms1. Perineural scarring w/ adhesions and tethering causing compressionPedicled synovial flap
      5Right434YesSevereEquivalent (severe)YesOpenOpenRecurrent symptoms1. Reformation and thickening of TCL

      2. Flexor tenosynovial hypertrophy
      Hypothenar fat flap, Forearm flexor tenosynovectomy
      6Right112YesModerateN/aYesEndoscopicOpenRecurrent symptomsFull operative report unavailableN/a
      7Right805YesSevereEquivalent (severe)YesOpenOpenPersistent symptoms1. Perineural scarring w/ adhesions and tethering causing compressionNerve wrap
      8Right175YesSevereEquivalent (severe)YesEndoscopicOpenPersistent symptoms1. Thin, scarred in portion of TCL causing compressionHypothenar fat flap, CuTR
      9Left1125YesSevereMild improvement in conduction (moderate)YesOpenOpenRecurrent symptoms1. Thin, scarred in portion of TCL causing compressionLong TFR, Revision Ulnar n. transposition
      10Right134YesSevereEquivalent (severe)YesOpenOpenPersistent symptoms1. Flexor tenosynovial hypertrophyForearm flexor tenosynovectomy
      11Right302YesModerate-to-severeMore severe (severe)YesOpenOpenPersistent symptoms1. Reformation and thickening of TCL

      2. Perineural scarring w/ adhesions

      3. Median n. severely compressed w/ hourglass appearance
      Hypothenar fat flap
      12Right425YesModerate-to-severeEquivalent (moderate-to-severe)YesOpenOpenPersistent symptoms1. Flexor tenosynovial hypertrophyForearm flexor tenosynovectomy, Median nerve neurolysis at elbow, Lacertus release
      13Right168YesSevereEquivalent (severe)YesOpenOpenPersistent symptoms1. Perineural scarring w/ adhesions

      2. Flexor tenosynovial hypertrophy
      Nerve wrap, Forearm flexor tenosynovectomy
      14Left90YesModerateMore severe (severe)YesOpenOpenRecurrent symptoms1. Thin, scarred in portion of TCL causing compression

      2. Median n. severely compressed w/ hourglass appearance
      Hypothenar fat flap
      15Left427YesModerateN/aYesOpenOpenRecurrent symptomsFull operative report unavailableN/a
      16Left131YesModerateMore severe (moderate-to-severe)YesOpenOpenRecurrent symptoms1. Thin, scarred in portion of TCL causing compression

      2. Perineural scarring w/ adhesions
      Pedicled synovial flap
      17Left11YesModerate-to-severeN/aYesOpenOpenWorsening symptoms with pain1. Compressive superficial band of distal forearm fascial tissueN/a
      18Right245YesModerateEquivalent (Moderate)YesOpenOpenPersistent symptoms1. Perineural scarring w/ adhesions and tethering causing compressionNerve wrap
      19Right90YesModerateN/aYesOpenOpenRecurrent symptoms1. Perineural scarring w/ adhesions and tethering causing compressionNerve wrap
      20 LeftLeft285YesModerateN/aYesOpenOpenRecurrent symptoms1. Thin, scarred in portion of TCL causing compression

      2. Perineural scarring w/ adhesions
      N/a
      20 RightRight273YesModerateN/aYesOpenOpenRecurrent symptoms1. Perineural scarring w/ adhesionsN/a
      21Left1113YesSevereEquivalent (Severe)YesOpenOpenRecurrent symptomsFull operative report unavailableHypothenar fat flap
      22Left651YesSevereN/aYesOpenOpenRecurrent symptoms1. Perineural scarring w/ adhesionsRing TFR, Revision CuTR
      23Right524YesSevereEquivalent (Severe)YesOpenOpenRecurrent symptoms1. Reformation and thickening of TCL

      2. Perineural scarring w/ adhesions
      N/a
      CuTR, cubital tunnel release; intraop, intraoperative; N/a, not available; preop, preoperative; TCL, transverse carpal ligament; TFR, trigger finger release.
      In 2021, Wessel et al
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      performed a retrospective review of an insurance database, including 4,549 patients, over a 3-year period (2015–2017), with a focus on revision CTR rate within 1 year of the index procedure. They reported an overall 1-year revision rate of 4.8%. The open and endoscopic CTR subgroups had revision rates of 4.4% and 6.5%, respectively. These rates are substantially higher than those found in our study and other studies in the literature.
      • Nancollas M.P.
      • Peimer C.A.
      • Wheeler D.R.
      • Sherwin F.S.
      Long-term results of carpal tunnel release.
      ,
      • Trumble T.E.
      • Diao E.
      • Abrams R.A.
      • Gilbert-Anderson M.M.
      Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial.
      • Atroshi I.
      • Larsson G.
      • Ornstein E.
      • Hofer M.
      • Johnsson R.
      • Ranstam J.
      Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.
      • Agee J.M.
      • McCarroll Jr., H.R.
      • Tortosa R.D.
      • Berry D.A.
      • Szabo R.M.
      • Peimer C.A.
      Endoscopic release of the carpal tunnel: a randomized prospective multicenter study.
      • Eichhorn J.D.
      • Dieterich K.
      Open versus endoscopic carpal tunnel release. Results of a prospective study.
      ,
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      ,
      • Hankins C.L.
      • Brown M.G.
      • Lopez R.A.
      • Lee A.K.
      • Dang J.
      • Harper R.D.
      A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
      ,
      • Zhang D.
      • Blazar P.
      • Earp B.E.
      Rates of complications and secondary surgeries of mini-open carpal tunnel release.
      ,
      • Lane J.C.
      • Craig R.S.
      • Rees J.L.
      • et al.
      Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis.
      Because of complete reliance on accurate coding and the inability to manually review individual patient charts and operative reports, it is likely that these results overestimated the true revision rate within 1 year of CTR.
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      Using England’s National Health Service database, Lane et al
      • Lane J.C.
      • Craig R.S.
      • Rees J.L.
      • et al.
      Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis.
      analyzed all CTR cases performed over a 19-year period (1998–2017) using a combination of Office of Population Censuses and Surveys Classification of Interventions and Procedures codes and ICD codes. A total of 855,832 cases were included, with a median follow-up duration of 7.5 years. However, no distinction between open or endoscopic CTR techniques was made, and patient charts and/or operative reports were not reviewed. Despite this, the authors identified 17,956 presumed paired primary and revision surgeries, resulting in a revision rate of 2.1%. The median time to reoperation was 331 days.
      • Lane J.C.
      • Craig R.S.
      • Rees J.L.
      • et al.
      Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis.
      Apart from these 3 large studies, other smaller prospective and retrospective studies have described varying rates of revision surgery following primary CTR, as detailed in Table 4.
      • Trumble T.E.
      • Diao E.
      • Abrams R.A.
      • Gilbert-Anderson M.M.
      Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial.
      • Atroshi I.
      • Larsson G.
      • Ornstein E.
      • Hofer M.
      • Johnsson R.
      • Ranstam J.
      Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.
      • Agee J.M.
      • McCarroll Jr., H.R.
      • Tortosa R.D.
      • Berry D.A.
      • Szabo R.M.
      • Peimer C.A.
      Endoscopic release of the carpal tunnel: a randomized prospective multicenter study.
      ,
      • Hankins C.L.
      • Brown M.G.
      • Lopez R.A.
      • Lee A.K.
      • Dang J.
      • Harper R.D.
      A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
      ,
      • Zhang D.
      • Blazar P.
      • Earp B.E.
      Rates of complications and secondary surgeries of mini-open carpal tunnel release.
      ,
      • Brown M.G.
      • Keyser B.
      • Rothenberg E.S.
      Endoscopic carpal tunnel release.
      • Brown M.G.
      • Rothenberg E.S.
      • Keyser B.
      • Woloszyn T.T.
      • Wolford A.
      Results of 1236 endoscopic carpal tunnel release procedures using the Brown technique.
      • Chow J.C.
      Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome.
      Table 4Review of Current Literature
      Authors (Reference)JournalYear PublishedData Collection PeriodApproachResults and Revision RateFollow-upComments and Notes
      Wessel et al
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      J Hand Surg Am20212015–2017Open, endo (portal data not provided)Combined: 217/4,549 = 4.8%

      Open: 170/3,829 = 4.4%

      Endo: 47/720 = 6.5%
      1-y chart review follow-upRR, insurance database, no direct chart/operative report review
      Westenberg et al
      • Hankins C.L.
      • Brown M.G.
      • Lopez R.A.
      • Lee A.K.
      • Dang J.
      • Harper R.D.
      A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
      Plast Reconstr Surg20202002–2015Open, 1-portal Endo, 2-portal endoCombined: 118/9,417 = 1.3% (per release)

      Open: 101/7,039 = 1.4% (per patient)

      Endo: 12/425 = 2.8% (per patient)
      Median 4.8 yRR, number of 1-portal vs 2-portal endo CTR not reported
      Lane et al
      • Alsharif A.
      • Al Habbal A.
      • Daaboul Y.
      • Al Hawat L.
      • Al Habbal O.
      • Kakaje A.
      Is psychological distress associated with carpal tunnel syndrome symptoms and nerve conduction study findings? A case-control study from Syria.
      Lancet Rheumatol20201998–2017Open, endo (portal data not provided)Combined: 17,956/8,55832 = 2.1%Median 7.5 yRR, National Health Service database (United Kingdom), open described as “primary technique,” no direct chart/operative report review
      Zhang et al
      • Concannon M.J.
      • Brownfield M.L.
      • Puckett C.L.
      The incidence of recurrence after endoscopic carpal tunnel release.
      Hand20192008–2013OpenTotal: 11/1,144 = 1.0%Min 1 mo,

      Median 9 mo
      RR, “Mini-Open” 1.5–2 cm incision
      Hankins et al
      • Solmaz V.
      • Yavuz S.
      • İnanr A.
      • et al.
      Investigation of nerve conduction studies of carpal tunnel syndrome cases with different risk factors: an electrodiagnostic study.
      Plast Reconstr Surg20071993–20052-portal endoTotal: 403/14,722 = 2.7%

      Nonwork Comp: 322/12,494 = 2.6%

      Work comp: 81/2,228 = 3.6%
      3 mo per protocol; subset 2,163 patients followed for 10 yRR
      Atroshi et al
      • Agee J.M.
      • McCarroll Jr., H.R.
      • Tortosa R.D.
      • Berry D.A.
      • Szabo R.M.
      • Peimer C.A.
      Endoscopic release of the carpal tunnel: a randomized prospective multicenter study.
      BMJ20061998–2002Open, 2-portal endoCombined: 3/128 = 2.3%

      Open: 1/65 = 1.5%

      Endo: 2/63 = 3.2%
      Min 3 mo Office visit; Questionnaire at 12 moRCT
      MacDermid et al
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      J Hand Surg Am2003N/aOpen, 2-portal endoCombined: 5/123 = 4.1%

      Open: 0/32 = 0.0%

      Endo: 5/91 = 5.5%
      Clinic: 12 wk;

      Phone call: mean 3.2 y postop
      RCT, unbalanced enrollment 3:1 (endo:open)
      Eichhorn et al
      • Macdermid J.C.
      • Robert S.
      • Richards R.S.
      • Roth J.H.
      • Ross D.C.
      • King G.J.
      Endoscopic versus open carpal tunnel release: a randomized trial.
      Chirurgische Praxis2003N/aOpen, endoCombined: 4/124 = 3.2%

      Open: 3/60 = 5%

      Endo: 1/64 = 1.6%
      N/aAbstract only
      Trumble et al
      • Atroshi I.
      • Larsson G.
      • Ornstein E.
      • Hofer M.
      • Johnsson R.
      • Ranstam J.
      Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.
      J Bone Joint Surg Am2002N/aOpen, 1-portal endoCombined: 1/192 = 0.5%

      Open: 1/95 = 1.1%

      Endo: 0/97 = 0.0%
      1 yRCT
      Concannon et al
      • Nancollas M.P.
      • Peimer C.A.
      • Wheeler D.R.
      • Sherwin F.S.
      Long-term results of carpal tunnel release.
      Plast Reconstr Surg20001986–1996Open, 2-portal endoCombined: 6/191 = 3.1%

      Open: 0/103 = 0.0%

      Endo: 6/88 = 6.8%
      Open: mean 29 mo.; Endo: mean 22 mo. (combination chart review and phone call)RR, open: 35% WC

      Endo: 54% WC
      Nancollas et al
      • Cobb T.K.
      • Amadio P.C.
      Reoperation for carpal tunnel syndrome.
      J Hand Surg Br19951980–1985OpenTotal: 1/60 = 1.7%Phone call questionnaire: mean 4.8 yRR
      Agee et al
      • Eichhorn J.D.
      • Dieterich K.
      Open versus endoscopic carpal tunnel release. Results of a prospective study.
      J Hand Surg Am1992N/aOpen, 1-portal endoCombined: 2/147 = 1.4%

      Open: 0/65 = 0%

      Endo: 2/82 = 2.4%
      26 wkRCT
      Endo, endoscopic; RR, retrospective review; RCT, randomized controlled trial; WC, Workers' Compensation patients.
      An additional goal of our study was to compare the rates of previously described risk factors for CTS in patients who underwent revision versus those in the remainder of the study cohort patients (those who did not undergo revision). Patients who required revision CTR were associated with higher percentages of the following risk factors: current smokers (30.4% vs 14.1%), diabetes mellitus (21.7% vs 15.3%), RA (17.4% vs 9.6%), cervical spine disease (8.7% vs 3.3%), psychiatric conditions (43.5% vs 22%), and other median neuropathy (4.4% vs 0.3%).
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      ,
      • Pourmemari M.H.
      • Shiri R.
      Diabetes as a risk factor for carpal tunnel syndrome: a systematic review and meta-analysis.
      • Palumbo C.F.
      • Szabo R.M.
      • Olmsted S.L.
      The effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndrome.
      • Shin Y.H.
      • Yoon J.O.
      • Kim Y.K.
      • Kim J.K.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      Demographic matching revealed significantly greater odds of requiring revision CTR only for patients with a history of psychiatric diagnosis, although all risk factors analyzed trended toward increased odds of requiring revision in the matched analysis. Unfortunately, we were unable to use multivariate analysis to describe the effect of these comorbidities on the revision rate because of the limited sample size, representing a distinct weakness. However, our results are grossly comparable with those of Westenberg et al,
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      who also reported higher rates of diabetes mellitus (29.2% vs 21.7%, respectively), RA (16.8% vs 7.7%, respectively), smoking (27.4% vs 12.5%, respectively), and cervical radiculopathy (23.9% vs 16.4%, respectively) in their revision group versus those in a matched case-control cohort of patients who underwent primary release only.
      Previous studies have demonstrated that psychological status and illness behavior can play a role in the severity of perceived preoperative CTS symptoms and diminished postoperative patient satisfaction following CTR.
      • Shin Y.H.
      • Yoon J.O.
      • Kim Y.K.
      • Kim J.K.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      ,
      • Alsharif A.
      • Al Habbal A.
      • Daaboul Y.
      • Al Hawat L.
      • Al Habbal O.
      • Kakaje A.
      Is psychological distress associated with carpal tunnel syndrome symptoms and nerve conduction study findings? A case-control study from Syria.
      • Sun P.O.
      • Walbeehm E.T.
      • Selles R.W.
      • et al.
      Influence of illness perceptions, psychological distress and pain catastrophizing on self-reported symptom severity and functional status in patients with carpal tunnel syndrome.
      • Nunez F.
      • Vranceanu A.M.
      • Ring D.
      Determinants of pain in patients with carpal tunnel syndrome.
      • Mosegaard S.B.
      • Stilling M.
      • Hansen T.B.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      A significant portion of our patients who underwent revision CTR carried a psychiatric diagnosis (43.5%). Although it is possible that patients with a psychiatric history were less likely to be satisfied with CTR and more likely to catastrophize recurrent or persistent symptoms, no definitive conclusions can be made from this retrospective study.
      Our study has a number of strengths. First, the use of the original ICD-10 implementation date (October 1, 2015) as the start date for our data collection period, in conjunction with the CPT code queries, allowed for more accurate filtering of all primary CTR data, particularly with regard to laterality.
      Centers for Disease Control and Prevention. International Classification of Diseases, (ICD-10-CM/PCS) Transition - Background.
      Despite this meticulous protocol, a substantial number of false positives were noted, as shown in the Figure. After careful manual review of available operative reports and clinical notes from 52 identified potential revision cases, only 24 represented true revisions. The majority of these false positives were due to inaccurately coded laterality; these patients were initially identified as having undergone 2 CTR procedures coded with the same laterality; however, they actually underwent a staged bilateral procedure. The ability to manually review all pertinent patient medical records represents a distinct advantage in terms of accuracy and validity when compared with insurance database studies.
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      ,
      • Lane J.C.
      • Craig R.S.
      • Rees J.L.
      • et al.
      Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis.
      Second, our query included nearly 12,000 consecutive primary CTR cases at a single institution over a relatively condensed time frame (5 years: 2015–2020). This total number is substantially larger than those in recent large, retrospective studies in the United States. Furthermore, we used a more condensed time frame (5 years; 2015–2020) compared with those in other large retrospective reviews, with access to individual patient charts, by Westenberg et al
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      (9,417 cases over 14 years; 2002–2015) and Hankins et al
      • Hankins C.L.
      • Brown M.G.
      • Lopez R.A.
      • Lee A.K.
      • Dang J.
      • Harper R.D.
      A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
      (14,722 patients over 13 years; 1993–2005). Our shorter time frame increased the likelihood that the experience level of the surgeons was similar. Moreover, the timing of our study ensured that our data reflect our current revision rate. Because of the learning curve for endoscopic CTR, studies that included this technique from the 1990s and early 2000s, when it was first described, may have had a higher revision rate. The 2-portal endoscopic technique is no longer frequently used.
      • Leinberry C.F.
      • Rivlin M.
      • Maltenfort M.
      • et al.
      Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective.
      In 2011, Leinberry et al
      • Leinberry C.F.
      • Rivlin M.
      • Maltenfort M.
      • et al.
      Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective.
      surveyed the members of the American Society for Surgery of the Hand regarding their current CTS management. Of the participating members who predominantly use an endoscopic technique (in more than two-thirds of their primary cases), a single-portal technique was preferred by 82% of surgeons. Our study included single-portal endoscopic CTR cases only, whereas other similar studies either included 2-portal techniques (Westenberg et al,
      • Westenberg R.F.
      • Oflazoglu K.
      • de Planque C.A.
      • Jupiter J.B.
      • Eberlin K.R.
      • Chen N.C.
      Revision carpal tunnel release: risk factors and rate of secondary surgery.
      Hankins et al,
      • Hankins C.L.
      • Brown M.G.
      • Lopez R.A.
      • Lee A.K.
      • Dang J.
      • Harper R.D.
      A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
      Atroshi et al,
      • Atroshi I.
      • Larsson G.
      • Ornstein E.
      • Hofer M.
      • Johnsson R.
      • Ranstam J.
      Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.
      and MacDermid
      • Macdermid J.C.
      • Robert S.
      • Richards R.S.
      • Roth J.H.
      • Ross D.C.
      • King G.J.
      Endoscopic versus open carpal tunnel release: a randomized trial.
      ) or did not describe the number of portals used during endoscopic CTR (Wessel et al
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      and Lane et al
      • Lane J.C.
      • Craig R.S.
      • Rees J.L.
      • et al.
      Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis.
      ).
      Our study also has several limitations. First, any database query of this size is susceptible to coding errors. To mitigate this, we performed a manual review of the patients’ records in potential revision cases to identify inaccuracies. Second, because the design and large cohort size of our retrospective study, we were unable to contact patients to determine whether they ultimately underwent revision CTR at an outside institution. It was deemed unfeasible to attempt to contact 9,310 patients. Consequently, we had to make the false assumption that if any further care was sought and/or revision was performed, it was done at our own institution. It is likely that, to some degree, this assumption led to underestimation of the true revision rate in our cohort. However, we are a large referral practice in the region, and, therefore, we believe that this would be relatively uncommon. Third, although the majority of revision CTR is performed within a year of primary release, our revision rate in patients outside that time frame would be expected to increase slightly as more time for follow-up passes. We suspect that this would primarily pertain to patients in the latter portion of the database query. Fourth, not all complete EMG or NCS reports were available for review, and in many cases, repeat testing was performed by a different physician. However, the study impression (moderate, moderate-to-severe, severe, etc) was available for all EMG or NCS tests and was included. Fifth, the willingness of our surgeons to offer revision surgery and the willingness of our patients to proceed with revision CTR may not mirror that of the general population. Finally, as mentioned previously, multivariate logistic regression to determine the potential associations between risk factors for CTS and revision surgery could not be performed because of the small size of our revision cohort.
      Overall, our study noted a substantially lower rate of early revision CTR (0.2% overall and 0.11% within 1 year) than previously published studies. Although the time elapsed from primary CTR to revision is variable, the overwhelming majority of revision surgeries are performed within 1–2 years of patients’ primary release. No statistically significant difference in the revision rate was noted between our open CTR cohort and our single-portal endoscopic CTR cohort. These findings will allow us to better counsel patients considering CTR surgery. Finally, it is possible that large database studies that do not include manual review of patient charts and operative notes unintentionally over-report revision rates following primary CTR because of potentially inaccurate coding.

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