Complications of ECTR vs. OCTR Page

Complications of Endoscopic and Open Carpal Tunnel Release

Andrew K. Palmer, MD
David A. Toivonen, MD
Syracuse, NY

Abstract

Separate questionnaires regarding surgically treated complications of endoscopic and open carpal tunnel release over a 5-year period were sent to members of the American Society for Surgery of the Hand to assess and compare major complications of the 2 procedures. Four hundred fifty-five major complications from endoscopic carpal tunnel release were treated by the 708 respondents. This included 100 median nerve lacerations, 88 ulnar nerve lacerations, 77 digital nerve lacerations, 121 vessel lacerations, and 69 tendon lacerations. There were 283 major complications from open carpal tunnel release treated by 616 respondents, including 147 median nerve lacerations, 29 ulnar nerve lacerations, 54 digital nerve lacerations, 34 vessel lacerations, and 19 tendon lacerations. Although this is a retrospective voluntary study with resultant methodologic flaws, the data support the conclusion that carpal tunnel release, be it endoscopic or open, is not a safe and simple procedure. Major, if not devastating, complications can and do occur with both procedures, of which surgeons should be ever cautious. (Journal of Hand Surgery 1999;24A:561–565.)

Introduction

In 1950, at the 99th Annual Meeting of the American Medical Association, George S. Phalen, MD, reported on 11 patients with a relatively unknown condition: carpal tunnel syndrome. Although median nerve compression at the wrist after a fracture of the distal radius was first described by Sir James Paget in 1854,1 before Dr Phalen's address only 12 patients had been reported to have had operative release of the transverse carpal ligament for idiopathic carpal tunnel syndrome. Since then, carpal tunnel syndrome has become the most frequently diagnosed compression neuropathy and carpal tunnel release has become one of the most frequently performed operative procedures in this country. Open carpal tunnel release (OCTR), first described by Sir James Learmonth in 1933,2 is a time-honored procedure for the treatment of carpal tunnel syndrome with uniformly excellent results and very few reported complications. Some investigators, however, feel that OCTR is associated with enough postoperative discomfort, scar tenderness, and weakness that the patients' return to work is delayed significantly. To decrease this morbidity and to hasten patients' return to work, endoscopic carpal tunnel release (ECTR) was popularized. 3–12

Endoscopic carpal tunnel release instrumentation became commercially available in 1990. Since then, there has been a deluge of literature related to carpal tunnel syndrome, including not only reports regarding ECTR, but also regarding the anatomy of the carpal canal, the technique of OCTR and ECTR, and the etiology, pathogenesis, and pathomechanics of carpal tunnel syndrome. Although there have been reports in the recent literature of major neurovascular and tendon injury associated with both ECTR and OCTR, most of these are case reports or include small series. 13–15 Alarmed by a number of major complications resulting from ECTR that we have seen referred for consultation and treatment, we undertook this study to determine the frequency and types of complications resulting from ECTR that were treated by members of the American Society for Surgery of the Hand between 1990 and 1995. For comparison, we sampled the same individuals (ie, all members of that society) for complications resulting from OCTR that they treated during the same time period.

Materials and methods

Questionnaires were sent to 1,253 members of the American Society for Surgery of the Hand asking for information on complications resulting from OCTR and ECTR treated surgically between 1990 and 1995. (Two identical questionnaires were sent out 1 month apart, the first dealing with complications of ECTR and the second with complications of OCTR.) Respondents were specifically instructed to report only on complications that they had themselves treated surgically. Cases seen in consultation in which surgery was not performed or in which surgery was pending were not to be considered.

Respondents were asked how many nerve injuries (median, ulnar, and digital), arterial lacerations (ulnar, radial, and superficial arch), tendon lacerations, and other incidental complications they had seen during the 5-year time span and how these injuries were treated. They were asked whether these complications were their own or referred for treatment and whether they, themselves, perform (or previously performed) ECTR and/or OCTR. Respondents were asked to review their office and surgical records to accurately obtain these data, as opposed to simply responding from memory.

The questionnaires did not differentiate between the different techniques of ECTR (ie, 1- or 2-portal), the instrumentation (company name) used for performing ECTR, the technique of OCTR (ie, palmar incision vs palmar incision with proximal extension vs transverse distal forearm incision vs mini incision), the number of carpal tunnel releases performed compared with the number of complications seen (ie, an indication of the incidence of complications), or postoperative immobilization or return to work data. Rather, this study was undertaken simply to assess the frequency and types of complications treated surgically following OCTR and ECTR between 1990 and 1995.

Results

Of the 1,253 individuals questioned, there were 708 responses (57%) regarding ECTR and 616 responses (49%) regarding OCTR. Two hundred seventy-nine (39%) of the ECTR respondents reported that they performed ECTR and 587 (95%) of the OCTR respondents reported that they performed OCTR. One hundred seventy-five (63%) of the surgeons performing ECTR reported that they, themselves, had never had a major complication (major nerve, vessel, or tendon laceration), while 532 (91%) of the surgeons performing OCTR reported never having had a major complication. Forty-three respondents stated that they had stopped performing ECTR due to complications or fear of complications. Thirty-one respondents had stopped performing OCTR; 26 had stopped performing carpal tunnel release completely and 6 had converted from OCTR to ECTR due to perceived improved results. Four hundred fifty-five major complications (nerve, artery, and/or tendon lacerations) from ECTR and 283 from OCTR were reported to have been treated (Table 1).

Nerve injuries

Nerve lacerations

Median nerve injuries were reported with both ECTR and OCTR (Table 2).

Lacerations were reported as partial or complete, motor branch only, or unspecified. In addition, there were many palmar cutaneous branch injuries reported. Injury to the palmar cutaneous branch was far more prevalent with OCTR than with ECTR. Ulnar nerve lacerations were also seen with both ECTR and OCTR, although far more were reported in the ECTR group (Table 3).

Twelve of the ulnar nerve lacerations in the ECTR group involved cannulation of Guyon's canal. Digital nerve lacerations were reported in both groups (Table 4).

The common digital nerve to the third web space was the most frequently reported (7 of the 11 in which location was reported). Nerve injuries were treated with direct repair, nerve graft, or neurolysis with or without tendon transfer (Tables 2 –4 ).

Vessel lacerations

Respondents treated lacerations to the superficial arch, the ulnar artery, and radial artery in both groups with direct repair, grafting, ligation, and/or observation only (Table 5).

Tendon lacerations

Of the major complications reported, tendon lacerations were the least common. There were far more tendon lacerations in the ECTR group than in the OCTR group (Table 6).

Tendons of the small and ring fingers were the most frequently injured (Table 7).

Discussion

Since its introduction, ECTR has generated considerable interest on the part of surgeons and patients as well as considerable controversy. It is generally considered to be a more difficult procedure with greater potential for serious complications than OCTR. Based on the literature, it appears that complications are not common with either procedure. 3–12,16–22 We undertook this study to try to validate our clinical experience that there have been more complications associated with ECTR than are reported in the literature. For comparison, we also surveyed the same population of surgeons for complications associated with OCTR.

There is no way to ascertain the accuracy of the data collected. Did surgeons diligently search their operative records or computer files to determine the number of, location, and severity of complications treated or did they simply respond from memory? Did respondents overreport some complications to prove a point? As most respondents reported not only the number of complications but specifics regarding the complications, such as partial or complete, the exact location (ie, at the wrist, palm, or digit), and the exact form of treatment (ie, graft vs neurolysis vs direct repair or combination thereof), we feel that many, although most likely not all, respondents diligently collected accurate data.

We report a number of major complications following both OCTR and ECTR, yet we do not report or even guess at the incidence of complications. To do this, one must know the denominator, ie, the number of CTRs performed by the surgeons who inflicted (not treated) the complications. As many of the complications reported here are not those of the treating physician, the denominator was not obtainable.

We also made no attempt to determine which technique (ie, 1-portal, 2-portal, limited open, open, or extended open) or which manufacturer's equipment was preferred. We did not feel that such data would be reported objectively enough to draw conclusions that we could report, realizing that such information would inevitably be used commercially to promote or condemn one product or procedure over another.

Median, ulnar, and digital nerve lacerations have been reported in the literature with both procedures in the past; however, these reports have been merely anecdotal with the exception of laceration of the palmar cutaneous branch of the median nerve, which is considered, at least by Louis et al,23 to be the most frequent complication of OCTR. 11,13,15,20,23–25 Respondents in our survey reported large numbers of major nerve lacerations in both ECTR and OCTR cases as well as large numbers of palmar cutaneous branch lacerations. In addition to these lacerations, many respondents reported seeing neuropraxia of median, ulnar, and digital nerves following ECTR, but because the study did not specifically ask respondents to comment on this problem and because it deals only with surgically treated lesions, such data are not included in this report.

Although vascular injuries also have been reported from both ECTR and OCTR, these are felt to be rare. 13,24,29,34,36,37 It appears from our study, in which 121 vessel lacerations were noted in the ECTR group and 34 were noted in the OCTR group, that these injuries are not rare, especially lacerations of the palmar arch. We expect that there are even more vessel injuries than implied by our data, as many vessel injuries cause only ecchymosis of the palm, fingers, and forearm with no functional deficit. Because no treatment is undertaken other than observation, such data would not have been reported to us.

Few investigators have described tendon injuries in conjunction with CTR, especially OCTR, yet our respondents reported 69 tendon lacerations in the ECTR group and 19 in the OCTR group. 32,37,38

Accepting the limitations of a retrospective voluntary questionnaire study such as ours, valuable information can be gleaned by reviewing the data obtained. Nerve lacerations occur in alarming numbers in conjunction with both ECTR and OCTR. We had expected, based on our clinical experience, that some median and ulnar nerve lacerations and many digital nerve lacerations would have been reported in the ECTR group. We were, however, surprised at the large numbers that were reported (100 median and 88 ulnar nerve lacerations) in the ECTR group and we were even more surprised at the number of median, ulnar, and digital nerve lacerations reported in the OCTR group (147 median, 29 ulnar, and 54 digital nerve lacerations).

The data gathered by the respondents to our questionnaire revealed surprisingly high numbers of complications associated with both ECTR and OCTR. As these data are in conflict with existing literature and we had no way to establish the accuracy of the data submitted by the respondents to our questionnaire, we caution physicians not to read too much into what we are reporting. We feel, however, as this was a voluntary questionnaire with very specific guidelines as to how physicians gather and report information from their surgically treated cases, that we can state with certainty that neurovascular and tendinous complications are commonly associated with both ECTR and OCTR. We therefore recommend that surgeons performing either ECTR or OCTR be ever mindful of structures that lie within the carpal tunnel that may be injured.

References

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A 27 Year History of Malpractice Lawsuits for Surgical Treatment of Carpal TunnelSyndrome at the Nation’s Largest Medical Malpractice Insurance Company

Carter B. Lipton, MD, New York, NY
Benton E. Heyworth, MD, New York, NY
Andrew H. Patterson, MD, New York, NY
Melvin P. Rosenwasser, MD, New York, NY

presented at the American Society for Surgery of the Hand Annual Meeting, 2003

Objectives The frequency of major surgical complications in the treatment of carpal tunnel syndrome (CTS) is generally considered low. The purpose of this study is to examine the frequency and cause of malpractice lawsuits associated with treatment of CTS over the past twenty-seven years in the state of New York and examine the importance of surgical technique (open vs. endoscopic) , surgeon’s training, surgeon’s experience and patient demographics.

Methods The legal records of closed cases in New York from Medical Liability and Mutual Insurance Company (MLMIC), the U.S.’s largest medical malpractice insurance company, were reviewed for claims related to CTS between 1975 and 2002. The following data were gathered: patient information, procedure details, surgeon’s training, and claim outcome. Additionally, all cases with the ICD-9 code for CTS from inpatient and outpatient surgery between the years 1984–2002 from the New York Department of Health Statewide Planning and Research Cooperative System (SPARCS) data were analyzed.

Results 73 lawsuit claims were identified related to surgical management of CTS. 291,239 CTS procedures were identified in New York from SPARCS data. 67% of the CTS legal claims resulted in indemnity payments to the plaintiff, with a mean payment of $166,000. Mean indemnity payment for male plaintiffs was $217,000 vs. $143,000 for female plaintiffs. Plaintiffs were significantly younger than all New York CTS patients, 47 vs. 53 years old (p<.001). The most common causes for claims included: laceration of a nerve (49%), development or exacerbation of reflex sympathetic dystrophy (RSD) (12%), wrong operation or wrong operative side (7%), incorrect diagnosis (5%), and failure to obtain proper informed consent (3%). Development or exacerbation of RSD resulted in the highest mean indemnity payments ($410,000). 86% of claims involving laceration of a nerve resulted in indemnity payments. Since 1992, 15% of CTS procedures in New York were performed endoscopically, but 46% of nerve laceration claims were endoscopic cases. Endoscopic procedures have a higher frequency of claims involving nerve lacerations than open procedures (p<.01). Mean indemnity payments for endoscopic cases were $252,000 vs. $157,000 for open cases over this time. Five of the six claims involving complete transection of the median nerve were endoscopicprocedures.

Conclusions Surgical treatment of CTS is associated with a relatively large number of malpractice lawsuits in New York. These result in high payments to the plaintiff. In cases involving nerve injuries, endoscopic technique has resulted in significantly more lawsuits than open technique.

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