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Revision Carpal Tunnel Release Following Endoscopic Compared to Open Decompression: Incidence and Operative Findings in a National Cohort
Peter C Ferrin, MD1, Bergen K Sather, B.S.2, Kelsi Krakauer, BS1, Timothy P Schweitzer, M.D., M.B.A.3, Angelo B Lipira, M.D., M.A.4 and Ravi F Sood, MD, MS5, (1)Oregon Health and Science University, Portland, OR, (2)Oregon Health & Science University, Portland, OR, (3)American Lake VA Medical Center, Tacoma, WA, (4)Plastic Surgery, Oregon Health & Science University, Portland, OR, (5)University of California Davis, Sacramento, CA

Introduction: Prior studies of revision CTR following endoscopic (ECTR) compared to open (OCTR) release have been limited by small sample size and limited follow-up. We sought to estimate the risk of revision CTR after endoscopic versus open CTR, the indications for revision, and the operative findings at the time of reoperation in the largest integrated healthcare system in the U.S.
Materials and Methods: We performed a retrospective cohort study of all adults undergoing ≥1 CTR for CTS from 2000-2021 in the Veterans Health Administration (VHA). We estimated the cumulative incidence of revision CTR using competing-risks methodology to account for differential follow-up and death during the study period. Operative reports and clinic notes for revision cases were manually reviewed for surgical indications and findings at re-operation.
Results: Among 134,851 wrists from 103,455 patients (89% male, 78% white, median age 62 years) undergoing ≥1 CTR, 1,809 underwent ≥1 revision in the VHA during the study period at a median of 2.5 (IQR 1.0-3.8) years. In competing-risks analysis, the cumulative incidence of revision was 1.06% (95% CI: 0.99-1.12%) at 5 years and 1.59% (95% CI: 1.51-1.67%) at 10 years (Figure, left). In both unadjusted and adjusted analyses, ECTR was associated with increased hazard of revision CTR compared to OCTR (HRadj 1.56, 95% CI: 1.34–1.81, p=8.5´10-9). The risk difference for revision CTR associated with ECTR compared to OCTR was 0.57% (95% CI: 0.31–0.84%) at 5 years (number needed to harm [NNH] 176) and 0.72% (95% CI: 0.36–1.07%) at 10 years (NNH 139; see Figure, right). Regardless of index CTR technique, the most common indication for revision was symptom recurrence (1,062 wrists, 59%) followed by symptom persistence (718 wrists, 40%; see Table). Incomplete release of the transverse carpal ligament was observed in 251 (14%) revision CTR cases overall and was significantly more common following ECTR (OR 1.62, 95% CI: 1.11–2.37, p=0.013).
Conclusions: Although ECTR is associated with increased risk of revision compared to OCTR, the absolute risk remains low regardless of technique.

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