July 25, 2024

Patients’ post-op perceptions suggest a need for better pre-op education.

MISMATCHED EXPECTATIONS Surgeons and patients have different ideas about how long it takes to fully recover from successful carpal tunnel release surgery.

Surgeons often laud the speedy recoveries from carpal tunnel release (CTR) surgery, but some patients may beg to differ.

That’s one of the main takeaways from "Patient Perceived Time to Recovery After Carpal Tunnel Release," a prospective study that was presented at the poster exhibition at the 2024 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in San Francisco.

The study surveyed 51 patients who underwent isolated CTR surgery preoperatively, and then at multiple timepoints postoperatively until they reported full recovery. Patients completed a 0-10 Likert scale for pain, the QuickDASH, the Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) and Functional Status Scale (FSS). The patients were also asked if they felt fully recovered at four weeks, six weeks, three months, six months, nine months and 12 months.

The findings were eye-opening. Average time to self-reported full recovery was 5.5 months. What’s more, even at 12 months, six of 51 patients (11.8%) didn’t feel fully recovered.

In terms of outcome-based measurements, the mean Likert pain score, QuickDASH, BCTQ-SSS and BCTQ-FSS significantly improved from preoperative to full recovery, and the mean differences in these four measures exceeded minimal clinically important differences (MCID). Specifically, postoperative scores surpassed preoperative scores for the four metrics above by eight, 11, 14 and 15 weeks, respectively. Finally, the study found that higher preoperative scores on those metrics were all associated with failure to fully recover by 12 months postoperatively.

The authors point out that despite CTR surgery being one of the most common procedures in the U.S., there is limited research on patients’ perceptions of postoperative recovery.

Perhaps there should be. When a disparity exists between when a surgeon believes a patient is fully recovered and when the patient feels fully healed, there’s probably room for improved communication and patient education to set expectations.

As the study authors put it, "The time until patient-reported full recovery after surgery after isolated CTR is substantial and surprising. Patients and surgeons may assess different parameters when measuring recovery. Surgeons should be aware of this discrepancy when discussing expected recovery after surgery."

A massive study of veterans suggests it does — but the difference is minimal, as are the occurrences.

SLIGHT WRIST RISK? Patients who receive endoscopic carpal tunnel release as opposed to the open compression technique are at higher risk for revision surgery, but revision cases remain rare overall, according to a recent study.

Endoscopic carpal tunnel release (ECTR) surgeries were associated with a higher risk for revision procedures compared to cases in which the open compression (OCTR) technique was used, according to a study of more than 100,000 cases in the Veterans Health Administration.

However, the research, which appeared early this year on JAMA Network Open, found that the absolute risk of revision surgery remained low no matter which technique surgeons used.

The researchers spent two years examining cases that occurred between 1999 to 2021 involving 134,851 wrists from 103,455 patients. Regardless of technique, slightly more than 1% of patients required revision surgery five years after their original surgeries, while nearly 1.6% needed revisions after 10 years. The risk difference for revision CTR was 0.57% higher with ECTR than OCTR after five years and 0.72% after 10 years.

The most commonly cited reason for revision surgeries involving each technique was a recurrence of original symptoms. A reconstituted transverse carpal ligament was more common after ECTR than with OCTR, while scarring of overlying tissues and of the median nerve itself were more common following OCTR. Incomplete transverse-carpal-ligament (TCL) release was observed in nearly 14% of the wrists that underwent revision surgeries and was more common among patients who originally underwent ECTR.

"Controversy persists regarding the risks and benefits of ECTR vs OCTR, with one concern being the potential for incomplete release of the TCL during ECTR," notes the study.

The study, performed by doctors who practice in California, Washington and Oregon, notes that OCTR remains more prevalent than ECTR, even as ECTR has steadily gained popularity over the last three decades.

Patients who undergo revision surgery often report they’re unsatisfied with their results, stating that symptoms and pain persist.

"Although revision CTR is uncommon, delineating its incidence and risk factors is important for public health, considering that CTR is among the most common operations in the U.S. and that outcomes of revision CTR are suboptimal," notes the study.

Instruments are an important part of the carpal tunnel syndrome surgery process as more patients head to ambulatory surgery facilities for these procedures.

Hand Biomechanics Lab

The number of people afflicted with carpal tunnel syndrome continues to rise each year and so does the volume of surgery procedures in outpatient settings to solve the problem. Repetitive stress activities as well as jobs and hobbies that require continuous motion by the hand, such as lengthy time of the computer keyboard, are among the culprits for this syndrome. Family history, rheumatoid arthritis and even emotion stress also are among the risk factors to increase the likelihood of getting this condition. Additionally, diabetes, obesity and hypothyroidism all increase the risk.

The diagnosis by a physician is the first step to recovery. Carpal tunnel syndrome can be misdiagnosed as tendonitis or thoracic outlet syndrome, so it’s important to get it right for long-term effectiveness. Once diagnosed, surgeons can offer a solution by relieving pressure on the nerve through endoscopic surgery. Many surgeons rely on the endoscopic surgery method, as opposed to the open release method, because it offers less trauma and faster recovery. Recovery times averages about two weeks for the endoscopic procedure, which allows people to get back to normal life quickly.

Hand Biomechanics Lab has been a leader in developing instruments that support surgeons who use the endoscopic surgery method – and by offering state-of-the-art instruments outpatient facilities are able to increase their caseload while continuing to adhere to the highest safety standards. The proper equipment is key to successful outcomes, so keeping the latest innovations and advances in mind when outfitting an OR and updating equipment is critical.

Cost also plays an important role when considering the best solutions for this growing market, especially in the cost-conscious ambulatory surgery center community. Hand Biomechanics Lab brings value with its unique equipment. For example, the drop-in replacement disposable blade assembly – for use with the 3M Agee Inside Job or MicroAire SmartRelease systems – is up to 60% less in cost than the price of the current standard blade. This blade assembly is available in a six-pack and is distributed exclusively by Brasseler USA Surgical. Keeping ahead of the surgical trends is the goal of any OR leader as hand surgeries continue to grow in the outpatient setting.