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Rapid Responses: Rapid Responses published:
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Endoscopic surgery for Carpal Tunnel Syndrome
- Sam Al-Jafari (27 June 2006)
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Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among emplyed patients: randomised controlled trial
- Jeremy A Read, Paul Hamilton and Neil Ferguson (27 June 2006)
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Carpal Tunnel Surgery
- Adeyinka G. Molajo, Deborah Livesey, Rosemary Swerdlow, and Philip Wykes. (6 July 2006)
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Which Surgery for Carpal Tunnel Syndrome?
- Michael Schenker (7 July 2006)
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Sam Al-Jafari, Senior House Officer in Orthopaedics North Manchester General Hospital, Delaunays Road, Manchester M8 5RB
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Atroshi et al. showed that endoscopic surgery for Carpal Tunnel Syndrome was associated with less postoperative pain than open surgery. They stated that no previous randomised studies comparing open carpal tunnel release have specifically assess postoperative hand pain with a patient reported outcome measure. In fact, Rab et al. (Rab et al. Intra- individual comparison between open and 2-portal endoscopic release in clinically matched bilateral carpal syndrome. J Plastic, reconstructive & Aesthetic Surgery 2006; 59 730-6) conducted a randomised intra- individual comparison between open and endoscopic release in bilateral carpal tunnel syndrome. They used Visual Analogue Pain score to assess pain at 2, 4, 6, 12, 26 and 52 weeks and showed no significant difference between the two methods. This study supports Atroshi's conclusion that the cost effectiveness of endoscopic is brought into question. Competing interests: None declared |
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Jeremy A Read, SpR Orthopaedics Princess Royal Hospital, RH16 4EX, Paul Hamilton and Neil Ferguson
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EDITOR – We would like to congratulate Atroshi et al1 on a well designed and conducted investigation into outcome differences between open and arthroscopic carpal tunnel surgery. We note their conclusion that the stated benefits of endoscopic decompression, being reduced palm pain and earlier return to work, are uncertain and would like to make the following points. (i) They do not indicate the level of experience of the operating surgeons in this procedure, but as their stated times for endoscopic surgery are shorter than for open1 which is in contrast to earlier work2 one would assume they have a significant level of experience in this technique. Would this marginal benefit be achievable by all surgeons and is the learning curve going to limit its uptake by newer trainees in a time pressured environment? Which brings us to point (ii) in the era of ISTC’s and surgical practitioners, where time and cost are ever more important and training opportunities are limited, it seems unlikely that a technique with higher costs and similar outcomes to both standard open3 and mini-open procedures4 will be embraced enthusiastically. Reference List 1. Atroshi I, Larsson GU, 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. BMJ 2006;332:1473. 2. Ferdinand RD. Endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome: A PROSPECTIVE, RANDOMISED, BLINDED ASSESSMENT. Journal of Bone & Joint Surgery - British Volume 2002;84- B:375-9. 3. Gerritsen AAM. Systematic review of randomized clinical trials of surgical treatment for carpal tunnel syndrome. British Journal of Surgery 2001;88:1285-95. 4. Klein RDM. Open Carpal Tunnel Release Using a 1-Centimeter Incision: Technique and Outcomes for 104 Patients. Plastic & Reconstructive Surgery 2003;111:1616-22. Competing interests: None declared |
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Adeyinka G. Molajo, Senior House Officer in Orthopaedics and Trauma Royal Bolton Hospital, Bolton, Lancashire. BL4 0JR, Deborah Livesey, Rosemary Swerdlow, and Philip Wykes.
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EDITOR- I read Atroshi’s research comparing open versus endoscopic carpal tunnel repair with great interest. It showed that there was little long term benefit from endoscopic surgery, compared with open surgery I note that patients in the study did not receive any post operative physiotherapy or occupational therapy support. In the department I currently operate, we have adopted a standard operating technique regardless of surgeon grade (local anaesthetic, NO tourniquet) and early mobilisation and follow up by the hand therapists in a dedicated clinic at 2 and 6 weeks. Recent audit yielded encouraging results with regards to scar pain and relief of symptoms at 6 weeks. Scar pain was reported in 37% of patients. (compared with 52% and 82% endoscopic vs open at 3 months in the published study) I wonder whether the surgical method used is less important than post operative therapy in determining outcome of carpal tunnel decompression? Competing interests: None declared |
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Michael Schenker, Consultant Plastic and Hand Surgeon Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP
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EDITOR – Atroshi et al (1) show a small difference in scar pain after endoscopic carpal tunnel release in comparison to the open technique with no effect on the patients’ time off-sick. In line with the results of previous studies (2) they rightly question the cost effectiveness of endoscopic carpal tunnel surgery. As a Plastic Surgeon who routinely performs open carpal tunnel release I would have found it very useful to have known more about the technique of open carpal tunnel release used in this paper. Especially, no reference was made to a potential injury to the palmar branch of the median nerve, which is relevant for post-operative scar tenderness. Most surgeons would place the skin incision for open carpal tunnel release in order to avoid this nerve, but a nerve branch often runs across the incision and is inevitably divided by the standard open technique. A “paper that changed my practice” demonstrated that careful preservation of this branch results in significantly less scar discomfort after open carpal tunnel release (3). There may well be no difference at all in scar pain between open and endoscopic carpal tunnel release. 1 Atroshi I, Larsson G-U, 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. BMJ 2006;332:1473-6 2 Thoma A, Veltri K, Haines T, Duku E. A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression. Plast Reconstr Surg 2004;114:1137-46 3 Ahcan U, Arnez ZM, Bajrovic F, Zorman P. Surgical technique to reduce scar discomfort after carpal tunnel surgery. J Hand Surg 2002;27[Am]:821-7 Competing interests: None declared |
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