Great Evidence to Guide Shared Decision-making About Endoscopic CTR

Two studies, one new and one a couple years old, provide practical guidance for a common office conversation

Smart Practice: “Increased odds” of reoperation after endoscopic CTR doesn’t mean “don’t do it,” but it does mean talk it over with your patients — they may still choose it, because the overall chance of a reoperation is still so low.

What’s the Claim?

A large, single-center retrospective, comparative study found that endoscopic carpal tunnel release was independently associated with a nearly threefold increase in the odds of reoperation (95% CI 1.7 to 5.3) compared to open CTR. The overall percentage of patients having a reoperation in both groups was low, though — 2.1% in the endoscopic group and 0.7% in the open CTR group.

How’s It Stack Up?

The best comparator study to this one came from a large insurance database, and it found that 6.5% of patients treated endoscopically underwent revision decompression within one year, compared with 4.4% of patients who had an open CTR. A difference, yes, but a much smaller one — after controlling for confounding variables, that odds ratio is only 1.3 (95% CI 1.1 to 1.5), not something approaching three. Of the two studies, we tend to trust the older one from the insurance database more, for two reasons:

  • It was less likely to have suffered from loss to follow-up (over such a short span, few patients were likely to have changed insurance coverage, and so all reoperations likely were captured)
  • It represents the efforts of many more surgeons, rather than a select few academicians, and so probably is more generalizable

Both studies found slight increases in odds associated with smoking, diabetes, and concomitant cubital tunnel syndrome.

What’s Our Take?