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Single- and two-incision carpal tunnel release techniques appear equally efficacious

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Author Verified

Single- and two-incision carpal tunnel release techniques appear equally efficacious

Vol: 3| Issue: 5| Number:55| ISSN#: 2564-2537
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A

Prospective randomized comparison of single-incision and two-incision carpal tunnel release outcomes

Hand (N Y). 2014 Mar;9(1):36-42. doi: 10.1007/s11552-013-9572-z.

Contributing Authors:
TN Castillo J Yao

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OE EXCLUSIVE

Dr. J. Yao discusses a prospective randomized comparison of single-incision and two-incision carpal tunnel release

Synopsis

30 patients with carpal tunnel syndrome were randomized to undergo single- or two-incision carpal tunnel release to compare clinical and functional outcomes between surgical techniques. Upon analysis, results revealed no significant difference between groups with respect to the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, Brigham and Womens Carpal Tunnel Questionnaire (BWCTQ) for symptom severity and functional status, grip strength, pinch strength, scar tenderness, or radial and ulnar pillar pain. The single-incision group demonstrated improved Semmes-Weinstein monofilament scores in the second finger at 6 weeks and third finger at 6+ months postoperatively when compared to the two-incision group.

Publication Funding Details +
Funding:
Non-Industry funded
Sponsor:
Stanford School of Medicine Medical Scholars Research Fellowship Program and the Department of Orthopaedic Surgery
Conflicts:
Other

Risk of Bias

5.5/10

Reporting Criteria

17/20

Fragility Index

N/A

Was the allocation sequence adequately generated?

Was allocation adequately concealed?

Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?

Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?

Blinding Patients: Was knowledge of the allocated interventions adequately prevented?

Was loss to follow-up (missing outcome data) infrequent?

Are reports of the study free of suggestion of selective outcome reporting?

Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?

Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?

Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

3/4

Randomization

2/4

Outcome Measurements

4/4

Inclusion / Exclusion

4/4

Therapy Description

4/4

Statistics

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Carpal tunnel release (CTR) is one of the most common surgical procedures performed in the United States. During CTR, the complete division of the flexor retinaculum is standard clinical practice, but the optimal CTR technique itself remains arguable. Previously, the authors conducted a retrospective study that reported improved function and fewer postoperative symptoms in patients that received a two-incision approach compared to single-incision technique. This randomized control trial was needed to further prospectively evaluate qualitative and quantitative postoperative outcomes between single- and two-incision CTR.

What was the principal research question?

Is single or two-incision carpal tunnel release more efficacious for treating patients with carpal tunnel syndrome, assessed up to 6+ months postoperatively?

Study Characteristics -
Population:
30 patients with carpal tunnel syndrome, who were scheduled to undergo carpal tunnel release
Intervention:
Two-incision CTR Group: A 1cm transverse incision was made in the distal wrist flexion crease, followed by a small incision into the antebrachial fascia overlying the median nerve. Then, 80% of the TCL was incised in an antegrade fashion using a Beaver blade (Catalog # 379081; Becton, Dickinson and Company, Franklin Lakes, NJ, USA), and a 1cm longitudinal incision was made along the radial aspect of the fourth digit at Kaplan's cardinal line. The subcutaneous tissues were dissected to the palmar fascia, where the superficial palmar arch was then protected. The remaining 20% of the TCL was then resected in a retrograde fashion (Mean age: 62.00 +/- 14.14, n=14, 11 completed all follow-up appointments).
Comparison:
Single-incision CTR Group: A 2cm longitudinal incision limited by the distal wrist flexion crease and Kaplan's cardinal line along the radial aspect of the fourth ray was made. The subcutaneous tissues were dissected to the palmar fascia, which was then incised sharply, followed by incision of the TCL (Mean age: 62.94 +/- 17.17, n=16, 12 completed all follow-up appointments).
Outcomes:
Outcome measurements included Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ), a 5-point Likert scale, post-operative pillar pain (determined using a visual analog scale (VAS)), grip strength (determined using a hydraulic hand dynamometer), pinch strength (determined using a pinch gauge), and sensation (measured using a Semmes-Weinstein Monofilament (SWM) kit).
Methods:
RCT: Single-centered
Time:
Follow-up occurred 2 weeks, 6 weeks, and 6+ months postoperatively.

What were the important findings?

  • BWCTQ symptom severity scale (SSS), BWCTQ functional status scale (FSS), DASH scores, grip strength, and pinch strength did not differ significantly between the single- and two-incision groups at any follow-up time point (all p>0.05).
  • The two incision group reduced scar tenderness, radial pillar pain, and ulnar pillar pain, although this did not reach statistical significance at any time point when compared to the single-incision group (all p>0.05). At 6+ months follow-up, no patients in the two-incision group reported scar tenderness or pillar pain.
  • Semmes-Weinstein monofilament scores (measured thumb, second finger, third finger) demonstrated significantly more improvement in the single-incision group compared to the two-incision group in the second finger at 6 weeks (p=0.03) and third finger at 6 months postoperatively (p=0.04). No other statistically significant differences were observed in any finger at any other time point (p>0.05).
  • A statistically significant positive correlation was observed between pre-and post-operative FSS and DASH scores in both groups (p<0.0001). A statistically significant negative correlation was observed between pre-operative and 2 week postoperative grip and pinch strength and DASH scores but these findings lost statistical significance by 6 week and 6+ month time points, with the exception of grip and pinch strength ((R= -0.80, p <0.0001) and DASH scores (R= -0.83, p <0.0001) in the single-incision group at 6+ months postoperative.

What should I remember most?

The single-incision and two-incision techniques for carpal tunnel release were similar at 2 weeks, 6 weeks, and 6+ months postoperative with respect to Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ) for symptom severity and functional status, grip strength, and pinch strength. Less scar tenderness, and radial and ulnar pillar pain was reported in the two-incision group, although this finding did not reach statistical significance. Improved Semmes-Weinstein monofilament scores were observed in the single-incision group in the second finger at 6 weeks and third finger at 6+ months postoperative.

How will this affect the care of my patients?

Based on the results of this study, both the single- and two-incision carpel tunnel release techniques may be offered as equally efficacious treatments for patients with carpel tunnel syndrome. Future studies with larger cohorts and less patient drop-out should compare the aforementioned findings between surgical techniques. It may also be advantageous to conduct a cost-comparison between treatment groups.

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