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American Association for Hand Surgery

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Risk of revision surgery after endoscopic carpal tunnel release in the Veterans Health Administration
Ravi F. Sood, M.D., M.S.1, Bergen K. Sather, B.S.2, Mai N. Le, B.S.2, Kelsi Krakauer, B.S.2, Timothy P. Schweitzer, M.D., M.B.A.3 and Angelo B. Lipira, M.D., M.A.4, (1)University of Washington, Seattle, WA, (2)Oregon Health & Science University, Portland, OR, (3)VA Portland Medical Center, Portland, OR, (4)Plastic Surgery, Oregon Health & Science University, Portland, OR

Introduction: In choosing between endoscopic or open technique for carpal tunnel release (CTR), the risks of nerve injury, incomplete decompression, and recurrent carpal tunnel syndrome (CTS) requiring revision surgery must be considered. However, large studies focused on recurrence are lacking. We sought to estimate the risk of revision CTR after endoscopic as compared to open CTR in a nationwide cohort.

Materials and Methods: We performed a retrospective cohort study of all adults undergoing at least one CTR for CTS from 2000-2021 in the Veterans Health Administration (VHA). The exposure of interest was surgical approach (endoscopic or open), identified by CPT code. The primary outcome was revision CTR, defined as a repeat ipsilateral CTR performed any time after the index CTR. We estimated the cumulative incidence of revision CTR using competing-risks methodology to account for differential follow-up and death during the study period. Association testing was based on multivariable Fine-Gray regression to control for potential confounders and account for correlated outcomes between wrists from patients undergoing bilateral CTRs.

Results: Among 96,200 patients undergoing at least one CTR in our study period, the majority (89%) were men, with median age of 62 years, and 29% underwent bilateral CTR. Of 124,106 wrists operated on at least once, the index CTR was performed via endoscopic technique in 9,578 (7.7%) of cases. In the overall cohort, revision CTR was performed in 2,045 (1.6%) wrists at a median interval of 1.7 years, corresponding to a cumulative incidence of 2.0% (95% CI: 1.9-2.1) at 10 years. In unadjusted analysis (see Figure), the cumulative incidence of revision CTR was higher in the endoscopic group (2.4% at 10 years, 95% CI: 2.1-2.8%) compared to the open group (1.9% at 10 years, 95% CI: 1.8-2.0%). After adjusting for age, sex, race, and whether CTS was bilateral, as well as history of amyloidosis, diabetes mellitus, obesity, rheumatoid arthritis, and smoking, endoscopic release was independently associated with a higher hazard of re-operation (hazard ratio 1.34, 95% CI: 1.15-1.55, p = 0.00014).

Conclusions: Revision CTR is significantly more common after endoscopic compared to open release. However, the absolute risk is low regardless of technique. Understanding the indications for re-operation will provide further information to guide surgeons and patients in selecting CTR technique.


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