State of the art review. Complications after carpal tunnel release.

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Protocol for Endoscopic Versus Open Cubital tunnel release (EVOCU): an open randomized controlled trial : EVOCU trial: Endoscopic Versus Open Cubital tunnel release.

BACKGROUND: Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Surgical decompression of the ulnar nerve aims to improve complaints and prevent permanent damage to the nerve. Open and endoscopic release of the cubital tunnel are both used in common practice, but none has proven to be superior. This study assesses patient reported outcome and experience measures (PROMs and PREMs respectively), in addition to objective outcomes of both techniques. METHODS: A prospective single-center open randomized non-inferiority trial will take place at the Plastic Surgery Department in the Jeroen Bosch Hospital, the Netherlands. 160 patients with cubital tunnel syndrome will be included. Patients are allocated to endoscopic or open cubital tunnel release by randomization. The surgeon and patients are not blinded for treatment allocation. The follow-up time will take 18 months. DISCUSSION: Currently, the choice for one of the methods is based on surgeon's preferences and degree of familiarity with a particular technique. It is assumed that the open technique is easier, faster and cheaper. The endoscopic release, however, has better exposure of the nerve and reduces the chance of damaging the nerve and might decrease scar discomfort. PROMs and PREMs have proven potential to improve the quality of care. Better health care experiences are associated with better clinical outcome in self-reported post-surgical questionnaires. Combining subjective measures with objective outcomes, efficacy, patient treatment experience and safety profile could help differentiating between open and endoscopic cubital tunnel release. This could aid clinicians in evidence based choices towards the best surgical approach in patients with cubital tunnel syndrome. TRIAL REGISTRATION: This study is registered prospectively with the Dutch Trial Registration under NL9556. Universal Trial Number (WHO-UTN) U1111-1267-3059. Registration date 26-06-2021. The URL: https://www.trialregister.nl/trial/9556.

Systematic review and meta-analysis of surgical options for recurrent or persistent carpal tunnel syndrome: simple decompression versus coverage of the median nerve.

We performed a systematic review on the success of different surgical techniques for the management of recurrent and persistent carpal tunnel syndrome. Twenty studies met the inclusion criteria and were grouped by the type of revision carpal tunnel release, which were simple open release, open release with flap coverage or open release with implant coverage. Meta-analysis showed no difference, and pooled success proportions were 0.89, 0.89 and 0.85 for simple open carpal tunnel release, additional flap coverage and implant groups, respectively. No added value for coverage of the nerve was seen. Our review indicates that simple carpal tunnel release without additional coverage of the median nerve seems preferable as it is less invasive and without additional donor site morbidity. We found that the included studies were of low quality with moderate risk of bias and did not differentiate between persistent and recurrent carpal tunnel syndrome.

Peri-operative care for patients undergoing lymphaticovenular anastomosis: A systematic review.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that involves the anastomosis of a functional lymphatic channel to a venule. Although peri-operative care might be an important contributor to the success of this technique, evidence about optimal peri-operative care seems limited. This review aims to summarize the peri-operative methods used by authors reporting on LVA. METHODS: A systematic search of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peri-operative care used by authors was summarized and listed in a pre-defined form. Studies were also graded on quality of evidence by the GRADE system and a lymphedema surgery-specific system. RESULTS: In total, 22 studies were identified describing peri-operative measures. Although most authors were sparse in their description of peri-operative management, most recommended initiation of conventional compression therapy at 1-4 weeks after surgery. Prophylactic antibiotics, elevation of the affected limb, bandaging, low-molecular-weight heparin, prostaglandin E1, and manual pressure therapy were also described. The quality of evidence of the included studies was low on average. CONCLUSION: Although supermicrosurgical LVAs are gaining in popularity, there are no high-quality prospective trials evaluating these new techniques and the description of peri-operative management is scarce. Of the available studies, a peri-operative management consisting of prophylactic antibiotics, elevation of the affected limb during night and hospital stay, and compression therapy 4 weeks post-surgery for 6 months seems to be preferred. Future studies should describe a detailed peri-operative protocol to allow for a better comparison between study results and to determine optimal peri-operative recommendations.