Amy McGreane, DNP, ARNP-BC

Carpal tunnel release is one of the most common hand surgeries performed at the North Florida/South Georgia Veterans Health System (NFSGVHS). Depending on surgeon experience and comfort level, surgeries are performed through either the traditional open method or the endoscopic method, single or double port (Figures 1 and 2). The advantage of the endoscopic method is faster recovery and return to work; however, the endoscopic method requires more expensive equipment and a steeper learning curve for surgeons. Complications are uncommon but can create unsatisfactory patient experiences because of costly lost workdays and long travel distances to the medical facility.

The purpose of this study was to compare the endoscopic method with the open carpal tunnel release method to determine whether there was an increased complication risk. Researchers anticipated that this information would help surgeons better inform patients of operative risks and prompt changes in NFSGVHS treatment plans to improve the quality of veteran care.

Methods

An Institutional Review Board- approved (#647-2011) retrospective review was done of patients who had carpal tunnel surgery performed by the NFSGVHS plastic surgery service from January 1, 2005, to December 31, 2010. Surgeries included in the review took place at the Malcom Randall VAMC in Gainesville and at the Lake City VAMC, both in Florida. Most of the surgeries included in the study were performed by a resident or fellow under the supervision of an attending physician. Eight different attending surgeons staffed the operations. Seven were board-certified or board-eligible plastic surgeons, 2 had advanced hand fellowship training, and 1 was a general surgeon with hand fellowship training. All hand fellowship-trained surgeons were in their first year of practice at the time of the study.

Only primary carpal tunnel releases were included in the study. Exclusion criteria included patients who were operated on by a service section other than the plastic surgery service (orthopedics or neurosurgery) and hands on which other procedures were performed during the same operation. Charts were reviewed for up to 1 year post surgery. Complications that required intervention were recorded. Researchers did not include pillar tenderness or an increase in occupational therapy visits as complications, due to the wide variety of patient tolerance to postoperative pain and varying motivation to return to work and daily routine.

Methods of release were endoscopic, open, or endoscopic converted to open. All but 6 of the completed endoscopic surgeries were performed using the double port Chow technique. The other 6 endoscopic surgeries were performed using the single port Agee technique at the distal wrist crease. There were 3 endoscopic converted to open cases that were performed using a single port, proximally-based technique in the midpalm. This method was abandoned after 3 unsuccessful endoscopic attempts, 1 resulting in digital nerve injury despite interactive cadaver labs prior to operative experience.

Endoscopic surgeries converted to open were recorded as open surgeries, because the patients had the full invasive experience. Researchers used the chi-square test and P value < .05 to compare the different methods of carpal tunnel release with identified complications.

Results and Complications

A total of 584 hands belonging to 452 patients were included in the study. Patients included 395 men and 57 women aged from 33 to 91 years. There were 271 endoscopic releases, 228 open releases, and 85 endoscopic converted to open releases. The NFSGVHS conversion rate was 23.7%. Complications in the converted cases (n = 4) were included in the open release results.

There were 40 complications in 38 hands. The overall complication rate was 6.5%. Complications noted were tendonitis presenting as De Quervain disease or trigger finger (9 endoscopic surgeries; 6 open surgeries), infection (2 endoscopic surgeries; 6 open surgeries), wound dehiscence (5 open surgeries), nerve injury (1 open surgery), respiratory distress (1 endoscopic), complex regional pain syndrome (1 open surgery), and scheduled returns to the operating room (OR) for recurrent, ongoing, or worsening symptoms (5 endoscopic surgeries; 5 open surgeries). Complications with an n > 1 were evaluated for statistical significance with P value < .05 (Table 1).

The NFSGVHS study had 10 patients return to the OR for open exploration (Table 2). Nine of these patients went back to the OR based on symptoms consistent with nerve conduction studies that had deteriorated compared with their preoperative studies. One endoscopic case was brought back to the OR for a suspected nerve injury without nerve conduction studies. Findings during reoperation included scar adhesions, incomplete release of ligaments, digital nerve injury, and negative explorations.

Two hypothenar fat transfers were performed to prevent scar adhesions in cases that had originally been open releases.¹ Two of the open cases were endoscopic converted to open cases. One went back to the OR with a suspected nerve injury. Dense adhesions and an injured common digital nerve were identified and repaired. The second converted case that went back to the OR had a suspected, but unconfirmed, nerve injury to the motor branch. The diagnosis and treatment were delayed for more than a year due to the patient having other pressing medical and family concerns. An exploration found significant scar adhesions, and an opponensplasty was performed.

One patient had respiratory insufficiency secondary to chemical pneumonitis. The patient was sedated during an endoscopic carpal tunnel release, aspirated, and kept intubated in the intensive care unit until the morning after surgery.

An early complex regional pain syndrome diagnosis was made in a patient with underlying neuropathy and a preoperative “profound” median neuropathies diagnosis at the wrist with underlying peripheral neuropathy found on nerve conduction studies. The patient experienced an unusual amount of postoperative pain and edema after an uncomplicated open carpal tunnel release. This was treated with rapid intervention using anti- inflammatories and hand therapy. The patient also started a regimen of skin care, edema management, neuroreeducation, and contrast baths. Symptoms responded within a week.

There were 12 wound complications: 10 in open and 2 in endoscopic surgeries. Total wound complications were equally split between patients with and without diabetes. Infection and dehiscence were noted. Sutures were removed an average of 9.6 days after surgery in the patients whose wounds broke down. A statistically significant relationship was found only between the open method of release and wound dehiscence (P < .05).

There was no statistically significant difference in the overall complication rate in the NFSGVHS population when comparing endoscopic with open carpal tunnel release or when comparing the risk of postoperative tendonitis, wound infection, or return to the OR.

Discussion

Carpal tunnel syndrome was documented by James Paget in mid-19th century in reference to a distal radius fracture.² It is the most common peripheral nerve compression, with an incidence ranging from 1 to 3 cases per 1,000 subjects per year and a prevalence of 50 cases per 1,000 subjects per year.³ In an active-duty U.S. military population, the incidence of carpal tunnel syndrome is 3.98 per 1,000 person years.⁴

Related: Risk Factors for Postoperative Complications in Trigger Finger Release

The endoscopic method of release was first introduced in 1989 by Okutsu and colleagues.⁵ About 500,000 carpal tunnel releases are now performed in the U.S. every year, with 50,000 performed endoscopically.³ There were 185 carpal tunnel releases (56 endoscopic and 129 open) performed at the NFSGVHS in 2012.⁶ The minimally invasive procedure was designed to preserve the overlying skin and fascia, promoting an earlier return to work and daily activities. This is particularly relevant for manual workers who desire rapid return of grip strength. Multiple published reports have found more rapid recovery based on a reduction in scar tenderness, increase in grip strength, or return to work.^7-13 Patients seem to have equivalent results over the long term, ranging from 3 months to 1 year.^7,8,13-15 Return to work was not evaluated in this study, because many patients were either retired or not working steadily.

The endoscopic method was criticized after its introduction due to its potential increase in major structural injury to the median nerve, ulnar nerve, palmar arch, ulnar artery, or flexor tendons.¹⁶ A meta-analysis found improved outcomes but a statistically significant higher complication rate in endoscopic, compared with open release (2.2% in endoscopic vs 1.2% in open).¹⁶ Referral patterns have found iatrogenic nerve injury in patients referred by surgeons without formal hand fellowship training.¹⁷ There is a wide variety of background training for surgeons who may offer carpal tunnel release, including plastic surgery, orthopedics, general surgery, and neurosurgery.

Related: Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient With Rheumatoid Arthritis and Psoriasis

Major structural injuries were reported by hand surgeons using both open and endoscopic methods in a questionnaire sent to members of the American Society for Surgery of the Hand, indicating that either approach demands respect.¹⁸ A large review of the literature from 1966 to 2001 by Benson and colleagues found that the endoscopic approach was not more likely to produce injury to tendons, arteries, or nerves compared with the open approach and actually had a lower rate of structural damage (0.49% vs 0.19%).¹⁹ Researchers who conducted this study confirmed one common digital nerve injury in an endoscopic converted to open technique, using a distally-based port with the blade not being deployed via the endoscopic method. The endoscopic method has been found to have a higher rate of reversible nerve injury (neuropraxia) compared with the open technique.^7,10,19

The NFSGVHS results found a higher rate of wound dehiscence. More frequent wound site complications, particularly infection, hypertrophic scar, and scar tenderness have been noted using the open method.^3,8,20 This is probably due to the deeper and slightly larger incision used for the open method compared with the smaller and shallower incisions used for the endoscopic release.

There is the inevitable learning curve for the endoscopic release due to the more complicated nature of the procedure. The NFSGVHS conversion rate was 23.7% over the 5-year period from 2005 to 2010. All 3 fellowship- trained hand surgeons were in their first year of practice at the time of the study, so the authors anticipate a lower conversion rate in forthcoming studies. The NFSGVHS researchers did not consider converting to an open technique to be a complication and believe it is appropriate to teach plastic surgery residents and fellows to have a low threshold to convert when visualization is not optimal and the potential for significant injury exists. The learning curve and a higher conversion rate have been acknowledged by Beck and colleagues with no increase in morbidity.²¹

The authors anticipated finding an increased rate of tendonitis in the endoscopic method, as found by Goshtasby and colleagues, where trigger finger was found more frequently in the endoscopic patients.²² The NFSGVHS study found that the number of patients presenting for steroid injections to treat postoperative tendonitis in the hand and wrist was not statistically significant when comparing the 2 surgical methods of release (3.3% in endoscopic vs 1.9% in open; P = .28).

The NFSGVHS rate of return to the OR within a year of surgery was 1.7%. The researchers from NFSGHVS anticipated a higher rate of return to the OR for ongoing symptoms secondary to incomplete release of the transverse carpal ligament. Published studies have found an intact retinaculum to be a cause of persistent symptoms when smaller incisions are used.^23,24 Five endoscopic cases and 5 open cases eventually returned to the OR for carpal tunnel exploration. Two of the patients were classified as recurrent, because they had improvement of symptoms initially but presented > 6 months later with new symptoms. Eight of the patients were classified as persistent, because they did not have an extended period of relief of preoperative symptoms (Table 2).²⁵ There was no statistically significant difference in return to the OR in the 2 study groups. The NFSGVHS researchers did note a trend in more incomplete nerve releases in the endoscopic group and more scar adhesions as the etiology of symptoms in the open group who went back to surgery.

Published studies have found no difference in overall complication rates when comparing the open with the endoscopic method of release, which is consistent with NFSGVHS data.^8,11,12,26

A limitation of the current retrospective study is the large number of providers who both operated on the patients and documented their postoperative findings. The strength of the study is that VA patients tend to stay within the VISN for their health care so postoperative problems will be identified and routed to the plastic surgery service for evaluation and treatment.

Clinical implications for the NFSGVHS practice are that surgeons can confidently offer both the open and endoscopic surgeries without an overall risk of increased complications to patients. Patients who are identified as higher risk for wound dehiscence, such as those who place an unusual amount of pressure on their palms due to assisted walking devices or are at a higher risk of falling onto the surgical site, will be steered toward an endoscopic surgery. The NFSGVHS began a splinting protocol in the early postoperative period that was not previously used on those select patients who have open carpal tunnel releases.

Conclusion

Wound dehiscence was the only statistically significant complication found in the NFSGVHS veteran population when comparing open with endoscopic carpal tunnel release. This can potentially be prevented in future patients by delaying the removal of sutures and prolonging the use of a protective dressing in patients who undergo open release. There was not a statistically significant increase in overall complications when using the minimally invasive method of release, which is consistent with existing literature.

Acknowledgement
This material is the result of work supported with resources and the use of facilities at the Malcom Randall VAMC.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Carpal tunnel release is one of the most common hand surgeries performed at the North Florida/South Georgia Veterans Health System (NFSGVHS). Depending on surgeon experience and comfort level, surgeries are performed through either the traditional open method or the endoscopic method, single or double port (Figures 1 and 2). The advantage of the endoscopic method is faster recovery and return to work; however, the endoscopic method requires more expensive equipment and a steeper learning curve for surgeons. Complications are uncommon but can create unsatisfactory patient experiences because of costly lost workdays and long travel distances to the medical facility.

The purpose of this study was to compare the endoscopic method with the open carpal tunnel release method to determine whether there was an increased complication risk. Researchers anticipated that this information would help surgeons better inform patients of operative risks and prompt changes in NFSGVHS treatment plans to improve the quality of veteran care.

Methods

An Institutional Review Board- approved (#647-2011) retrospective review was done of patients who had carpal tunnel surgery performed by the NFSGVHS plastic surgery service from January 1, 2005, to December 31, 2010. Surgeries included in the review took place at the Malcom Randall VAMC in Gainesville and at the Lake City VAMC, both in Florida. Most of the surgeries included in the study were performed by a resident or fellow under the supervision of an attending physician. Eight different attending surgeons staffed the operations. Seven were board-certified or board-eligible plastic surgeons, 2 had advanced hand fellowship training, and 1 was a general surgeon with hand fellowship training. All hand fellowship-trained surgeons were in their first year of practice at the time of the study.

Only primary carpal tunnel releases were included in the study. Exclusion criteria included patients who were operated on by a service section other than the plastic surgery service (orthopedics or neurosurgery) and hands on which other procedures were performed during the same operation. Charts were reviewed for up to 1 year post surgery. Complications that required intervention were recorded. Researchers did not include pillar tenderness or an increase in occupational therapy visits as complications, due to the wide variety of patient tolerance to postoperative pain and varying motivation to return to work and daily routine.

Methods of release were endoscopic, open, or endoscopic converted to open. All but 6 of the completed endoscopic surgeries were performed using the double port Chow technique. The other 6 endoscopic surgeries were performed using the single port Agee technique at the distal wrist crease. There were 3 endoscopic converted to open cases that were performed using a single port, proximally-based technique in the midpalm. This method was abandoned after 3 unsuccessful endoscopic attempts, 1 resulting in digital nerve injury despite interactive cadaver labs prior to operative experience.

Endoscopic surgeries converted to open were recorded as open surgeries, because the patients had the full invasive experience. Researchers used the chi-square test and P value < .05 to compare the different methods of carpal tunnel release with identified complications.

Results and Complications

A total of 584 hands belonging to 452 patients were included in the study. Patients included 395 men and 57 women aged from 33 to 91 years. There were 271 endoscopic releases, 228 open releases, and 85 endoscopic converted to open releases. The NFSGVHS conversion rate was 23.7%. Complications in the converted cases (n = 4) were included in the open release results.

There were 40 complications in 38 hands. The overall complication rate was 6.5%. Complications noted were tendonitis presenting as De Quervain disease or trigger finger (9 endoscopic surgeries; 6 open surgeries), infection (2 endoscopic surgeries; 6 open surgeries), wound dehiscence (5 open surgeries), nerve injury (1 open surgery), respiratory distress (1 endoscopic), complex regional pain syndrome (1 open surgery), and scheduled returns to the operating room (OR) for recurrent, ongoing, or worsening symptoms (5 endoscopic surgeries; 5 open surgeries). Complications with an n > 1 were evaluated for statistical significance with P value < .05 (Table 1).

The NFSGVHS study had 10 patients return to the OR for open exploration (Table 2). Nine of these patients went back to the OR based on symptoms consistent with nerve conduction studies that had deteriorated compared with their preoperative studies. One endoscopic case was brought back to the OR for a suspected nerve injury without nerve conduction studies. Findings during reoperation included scar adhesions, incomplete release of ligaments, digital nerve injury, and negative explorations.

Two hypothenar fat transfers were performed to prevent scar adhesions in cases that had originally been open releases.¹ Two of the open cases were endoscopic converted to open cases. One went back to the OR with a suspected nerve injury. Dense adhesions and an injured common digital nerve were identified and repaired. The second converted case that went back to the OR had a suspected, but unconfirmed, nerve injury to the motor branch. The diagnosis and treatment were delayed for more than a year due to the patient having other pressing medical and family concerns. An exploration found significant scar adhesions, and an opponensplasty was performed.

One patient had respiratory insufficiency secondary to chemical pneumonitis. The patient was sedated during an endoscopic carpal tunnel release, aspirated, and kept intubated in the intensive care unit until the morning after surgery.

An early complex regional pain syndrome diagnosis was made in a patient with underlying neuropathy and a preoperative “profound” median neuropathies diagnosis at the wrist with underlying peripheral neuropathy found on nerve conduction studies. The patient experienced an unusual amount of postoperative pain and edema after an uncomplicated open carpal tunnel release. This was treated with rapid intervention using anti- inflammatories and hand therapy. The patient also started a regimen of skin care, edema management, neuroreeducation, and contrast baths. Symptoms responded within a week.

There were 12 wound complications: 10 in open and 2 in endoscopic surgeries. Total wound complications were equally split between patients with and without diabetes. Infection and dehiscence were noted. Sutures were removed an average of 9.6 days after surgery in the patients whose wounds broke down. A statistically significant relationship was found only between the open method of release and wound dehiscence (P < .05).

There was no statistically significant difference in the overall complication rate in the NFSGVHS population when comparing endoscopic with open carpal tunnel release or when comparing the risk of postoperative tendonitis, wound infection, or return to the OR.

Discussion

Carpal tunnel syndrome was documented by James Paget in mid-19th century in reference to a distal radius fracture.² It is the most common peripheral nerve compression, with an incidence ranging from 1 to 3 cases per 1,000 subjects per year and a prevalence of 50 cases per 1,000 subjects per year.³ In an active-duty U.S. military population, the incidence of carpal tunnel syndrome is 3.98 per 1,000 person years.⁴

Related: Risk Factors for Postoperative Complications in Trigger Finger Release

The endoscopic method of release was first introduced in 1989 by Okutsu and colleagues.⁵ About 500,000 carpal tunnel releases are now performed in the U.S. every year, with 50,000 performed endoscopically.³ There were 185 carpal tunnel releases (56 endoscopic and 129 open) performed at the NFSGVHS in 2012.⁶ The minimally invasive procedure was designed to preserve the overlying skin and fascia, promoting an earlier return to work and daily activities. This is particularly relevant for manual workers who desire rapid return of grip strength. Multiple published reports have found more rapid recovery based on a reduction in scar tenderness, increase in grip strength, or return to work.^7-13 Patients seem to have equivalent results over the long term, ranging from 3 months to 1 year.^7,8,13-15 Return to work was not evaluated in this study, because many patients were either retired or not working steadily.

The endoscopic method was criticized after its introduction due to its potential increase in major structural injury to the median nerve, ulnar nerve, palmar arch, ulnar artery, or flexor tendons.¹⁶ A meta-analysis found improved outcomes but a statistically significant higher complication rate in endoscopic, compared with open release (2.2% in endoscopic vs 1.2% in open).¹⁶ Referral patterns have found iatrogenic nerve injury in patients referred by surgeons without formal hand fellowship training.¹⁷ There is a wide variety of background training for surgeons who may offer carpal tunnel release, including plastic surgery, orthopedics, general surgery, and neurosurgery.

Related: Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient With Rheumatoid Arthritis and Psoriasis

Major structural injuries were reported by hand surgeons using both open and endoscopic methods in a questionnaire sent to members of the American Society for Surgery of the Hand, indicating that either approach demands respect.¹⁸ A large review of the literature from 1966 to 2001 by Benson and colleagues found that the endoscopic approach was not more likely to produce injury to tendons, arteries, or nerves compared with the open approach and actually had a lower rate of structural damage (0.49% vs 0.19%).¹⁹ Researchers who conducted this study confirmed one common digital nerve injury in an endoscopic converted to open technique, using a distally-based port with the blade not being deployed via the endoscopic method. The endoscopic method has been found to have a higher rate of reversible nerve injury (neuropraxia) compared with the open technique.^7,10,19

The NFSGVHS results found a higher rate of wound dehiscence. More frequent wound site complications, particularly infection, hypertrophic scar, and scar tenderness have been noted using the open method.^3,8,20 This is probably due to the deeper and slightly larger incision used for the open method compared with the smaller and shallower incisions used for the endoscopic release.

There is the inevitable learning curve for the endoscopic release due to the more complicated nature of the procedure. The NFSGVHS conversion rate was 23.7% over the 5-year period from 2005 to 2010. All 3 fellowship- trained hand surgeons were in their first year of practice at the time of the study, so the authors anticipate a lower conversion rate in forthcoming studies. The NFSGVHS researchers did not consider converting to an open technique to be a complication and believe it is appropriate to teach plastic surgery residents and fellows to have a low threshold to convert when visualization is not optimal and the potential for significant injury exists. The learning curve and a higher conversion rate have been acknowledged by Beck and colleagues with no increase in morbidity.²¹

The authors anticipated finding an increased rate of tendonitis in the endoscopic method, as found by Goshtasby and colleagues, where trigger finger was found more frequently in the endoscopic patients.²² The NFSGVHS study found that the number of patients presenting for steroid injections to treat postoperative tendonitis in the hand and wrist was not statistically significant when comparing the 2 surgical methods of release (3.3% in endoscopic vs 1.9% in open; P = .28).

The NFSGVHS rate of return to the OR within a year of surgery was 1.7%. The researchers from NFSGHVS anticipated a higher rate of return to the OR for ongoing symptoms secondary to incomplete release of the transverse carpal ligament. Published studies have found an intact retinaculum to be a cause of persistent symptoms when smaller incisions are used.^23,24 Five endoscopic cases and 5 open cases eventually returned to the OR for carpal tunnel exploration. Two of the patients were classified as recurrent, because they had improvement of symptoms initially but presented > 6 months later with new symptoms. Eight of the patients were classified as persistent, because they did not have an extended period of relief of preoperative symptoms (Table 2).²⁵ There was no statistically significant difference in return to the OR in the 2 study groups. The NFSGVHS researchers did note a trend in more incomplete nerve releases in the endoscopic group and more scar adhesions as the etiology of symptoms in the open group who went back to surgery.

Published studies have found no difference in overall complication rates when comparing the open with the endoscopic method of release, which is consistent with NFSGVHS data.^8,11,12,26

A limitation of the current retrospective study is the large number of providers who both operated on the patients and documented their postoperative findings. The strength of the study is that VA patients tend to stay within the VISN for their health care so postoperative problems will be identified and routed to the plastic surgery service for evaluation and treatment.

Clinical implications for the NFSGVHS practice are that surgeons can confidently offer both the open and endoscopic surgeries without an overall risk of increased complications to patients. Patients who are identified as higher risk for wound dehiscence, such as those who place an unusual amount of pressure on their palms due to assisted walking devices or are at a higher risk of falling onto the surgical site, will be steered toward an endoscopic surgery. The NFSGVHS began a splinting protocol in the early postoperative period that was not previously used on those select patients who have open carpal tunnel releases.

Conclusion

Wound dehiscence was the only statistically significant complication found in the NFSGVHS veteran population when comparing open with endoscopic carpal tunnel release. This can potentially be prevented in future patients by delaying the removal of sutures and prolonging the use of a protective dressing in patients who undergo open release. There was not a statistically significant increase in overall complications when using the minimally invasive method of release, which is consistent with existing literature.

Acknowledgement
This material is the result of work supported with resources and the use of facilities at the Malcom Randall VAMC.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Carpal tunnel release is one of the most common hand surgeries performed at the North Florida/South Georgia Veterans Health System (NFSGVHS). Depending on surgeon experience and comfort level, surgeries are performed through either the traditional open method or the endoscopic method, single or double port (Figures 1 and 2). The advantage of the endoscopic method is faster recovery and return to work; however, the endoscopic method requires more expensive equipment and a steeper learning curve for surgeons. Complications are uncommon but can create unsatisfactory patient experiences because of costly lost workdays and long travel distances to the medical facility.

The purpose of this study was to compare the endoscopic method with the open carpal tunnel release method to determine whether there was an increased complication risk. Researchers anticipated that this information would help surgeons better inform patients of operative risks and prompt changes in NFSGVHS treatment plans to improve the quality of veteran care.

Methods

An Institutional Review Board- approved (#647-2011) retrospective review was done of patients who had carpal tunnel surgery performed by the NFSGVHS plastic surgery service from January 1, 2005, to December 31, 2010. Surgeries included in the review took place at the Malcom Randall VAMC in Gainesville and at the Lake City VAMC, both in Florida. Most of the surgeries included in the study were performed by a resident or fellow under the supervision of an attending physician. Eight different attending surgeons staffed the operations. Seven were board-certified or board-eligible plastic surgeons, 2 had advanced hand fellowship training, and 1 was a general surgeon with hand fellowship training. All hand fellowship-trained surgeons were in their first year of practice at the time of the study.

Only primary carpal tunnel releases were included in the study. Exclusion criteria included patients who were operated on by a service section other than the plastic surgery service (orthopedics or neurosurgery) and hands on which other procedures were performed during the same operation. Charts were reviewed for up to 1 year post surgery. Complications that required intervention were recorded. Researchers did not include pillar tenderness or an increase in occupational therapy visits as complications, due to the wide variety of patient tolerance to postoperative pain and varying motivation to return to work and daily routine.

Methods of release were endoscopic, open, or endoscopic converted to open. All but 6 of the completed endoscopic surgeries were performed using the double port Chow technique. The other 6 endoscopic surgeries were performed using the single port Agee technique at the distal wrist crease. There were 3 endoscopic converted to open cases that were performed using a single port, proximally-based technique in the midpalm. This method was abandoned after 3 unsuccessful endoscopic attempts, 1 resulting in digital nerve injury despite interactive cadaver labs prior to operative experience.

Endoscopic surgeries converted to open were recorded as open surgeries, because the patients had the full invasive experience. Researchers used the chi-square test and P value < .05 to compare the different methods of carpal tunnel release with identified complications.

Results and Complications

A total of 584 hands belonging to 452 patients were included in the study. Patients included 395 men and 57 women aged from 33 to 91 years. There were 271 endoscopic releases, 228 open releases, and 85 endoscopic converted to open releases. The NFSGVHS conversion rate was 23.7%. Complications in the converted cases (n = 4) were included in the open release results.

There were 40 complications in 38 hands. The overall complication rate was 6.5%. Complications noted were tendonitis presenting as De Quervain disease or trigger finger (9 endoscopic surgeries; 6 open surgeries), infection (2 endoscopic surgeries; 6 open surgeries), wound dehiscence (5 open surgeries), nerve injury (1 open surgery), respiratory distress (1 endoscopic), complex regional pain syndrome (1 open surgery), and scheduled returns to the operating room (OR) for recurrent, ongoing, or worsening symptoms (5 endoscopic surgeries; 5 open surgeries). Complications with an n > 1 were evaluated for statistical significance with P value < .05 (Table 1).

The NFSGVHS study had 10 patients return to the OR for open exploration (Table 2). Nine of these patients went back to the OR based on symptoms consistent with nerve conduction studies that had deteriorated compared with their preoperative studies. One endoscopic case was brought back to the OR for a suspected nerve injury without nerve conduction studies. Findings during reoperation included scar adhesions, incomplete release of ligaments, digital nerve injury, and negative explorations.

Two hypothenar fat transfers were performed to prevent scar adhesions in cases that had originally been open releases.¹ Two of the open cases were endoscopic converted to open cases. One went back to the OR with a suspected nerve injury. Dense adhesions and an injured common digital nerve were identified and repaired. The second converted case that went back to the OR had a suspected, but unconfirmed, nerve injury to the motor branch. The diagnosis and treatment were delayed for more than a year due to the patient having other pressing medical and family concerns. An exploration found significant scar adhesions, and an opponensplasty was performed.

One patient had respiratory insufficiency secondary to chemical pneumonitis. The patient was sedated during an endoscopic carpal tunnel release, aspirated, and kept intubated in the intensive care unit until the morning after surgery.

An early complex regional pain syndrome diagnosis was made in a patient with underlying neuropathy and a preoperative “profound” median neuropathies diagnosis at the wrist with underlying peripheral neuropathy found on nerve conduction studies. The patient experienced an unusual amount of postoperative pain and edema after an uncomplicated open carpal tunnel release. This was treated with rapid intervention using anti- inflammatories and hand therapy. The patient also started a regimen of skin care, edema management, neuroreeducation, and contrast baths. Symptoms responded within a week.

There were 12 wound complications: 10 in open and 2 in endoscopic surgeries. Total wound complications were equally split between patients with and without diabetes. Infection and dehiscence were noted. Sutures were removed an average of 9.6 days after surgery in the patients whose wounds broke down. A statistically significant relationship was found only between the open method of release and wound dehiscence (P < .05).

There was no statistically significant difference in the overall complication rate in the NFSGVHS population when comparing endoscopic with open carpal tunnel release or when comparing the risk of postoperative tendonitis, wound infection, or return to the OR.

Discussion

Carpal tunnel syndrome was documented by James Paget in mid-19th century in reference to a distal radius fracture.² It is the most common peripheral nerve compression, with an incidence ranging from 1 to 3 cases per 1,000 subjects per year and a prevalence of 50 cases per 1,000 subjects per year.³ In an active-duty U.S. military population, the incidence of carpal tunnel syndrome is 3.98 per 1,000 person years.⁴

Related: Risk Factors for Postoperative Complications in Trigger Finger Release

The endoscopic method of release was first introduced in 1989 by Okutsu and colleagues.⁵ About 500,000 carpal tunnel releases are now performed in the U.S. every year, with 50,000 performed endoscopically.³ There were 185 carpal tunnel releases (56 endoscopic and 129 open) performed at the NFSGVHS in 2012.⁶ The minimally invasive procedure was designed to preserve the overlying skin and fascia, promoting an earlier return to work and daily activities. This is particularly relevant for manual workers who desire rapid return of grip strength. Multiple published reports have found more rapid recovery based on a reduction in scar tenderness, increase in grip strength, or return to work.^7-13 Patients seem to have equivalent results over the long term, ranging from 3 months to 1 year.^7,8,13-15 Return to work was not evaluated in this study, because many patients were either retired or not working steadily.

The endoscopic method was criticized after its introduction due to its potential increase in major structural injury to the median nerve, ulnar nerve, palmar arch, ulnar artery, or flexor tendons.¹⁶ A meta-analysis found improved outcomes but a statistically significant higher complication rate in endoscopic, compared with open release (2.2% in endoscopic vs 1.2% in open).¹⁶ Referral patterns have found iatrogenic nerve injury in patients referred by surgeons without formal hand fellowship training.¹⁷ There is a wide variety of background training for surgeons who may offer carpal tunnel release, including plastic surgery, orthopedics, general surgery, and neurosurgery.

Related: Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient With Rheumatoid Arthritis and Psoriasis

Major structural injuries were reported by hand surgeons using both open and endoscopic methods in a questionnaire sent to members of the American Society for Surgery of the Hand, indicating that either approach demands respect.¹⁸ A large review of the literature from 1966 to 2001 by Benson and colleagues found that the endoscopic approach was not more likely to produce injury to tendons, arteries, or nerves compared with the open approach and actually had a lower rate of structural damage (0.49% vs 0.19%).¹⁹ Researchers who conducted this study confirmed one common digital nerve injury in an endoscopic converted to open technique, using a distally-based port with the blade not being deployed via the endoscopic method. The endoscopic method has been found to have a higher rate of reversible nerve injury (neuropraxia) compared with the open technique.^7,10,19

The NFSGVHS results found a higher rate of wound dehiscence. More frequent wound site complications, particularly infection, hypertrophic scar, and scar tenderness have been noted using the open method.^3,8,20 This is probably due to the deeper and slightly larger incision used for the open method compared with the smaller and shallower incisions used for the endoscopic release.

There is the inevitable learning curve for the endoscopic release due to the more complicated nature of the procedure. The NFSGVHS conversion rate was 23.7% over the 5-year period from 2005 to 2010. All 3 fellowship- trained hand surgeons were in their first year of practice at the time of the study, so the authors anticipate a lower conversion rate in forthcoming studies. The NFSGVHS researchers did not consider converting to an open technique to be a complication and believe it is appropriate to teach plastic surgery residents and fellows to have a low threshold to convert when visualization is not optimal and the potential for significant injury exists. The learning curve and a higher conversion rate have been acknowledged by Beck and colleagues with no increase in morbidity.²¹

The authors anticipated finding an increased rate of tendonitis in the endoscopic method, as found by Goshtasby and colleagues, where trigger finger was found more frequently in the endoscopic patients.²² The NFSGVHS study found that the number of patients presenting for steroid injections to treat postoperative tendonitis in the hand and wrist was not statistically significant when comparing the 2 surgical methods of release (3.3% in endoscopic vs 1.9% in open; P = .28).

The NFSGVHS rate of return to the OR within a year of surgery was 1.7%. The researchers from NFSGHVS anticipated a higher rate of return to the OR for ongoing symptoms secondary to incomplete release of the transverse carpal ligament. Published studies have found an intact retinaculum to be a cause of persistent symptoms when smaller incisions are used.^23,24 Five endoscopic cases and 5 open cases eventually returned to the OR for carpal tunnel exploration. Two of the patients were classified as recurrent, because they had improvement of symptoms initially but presented > 6 months later with new symptoms. Eight of the patients were classified as persistent, because they did not have an extended period of relief of preoperative symptoms (Table 2).²⁵ There was no statistically significant difference in return to the OR in the 2 study groups. The NFSGVHS researchers did note a trend in more incomplete nerve releases in the endoscopic group and more scar adhesions as the etiology of symptoms in the open group who went back to surgery.

Published studies have found no difference in overall complication rates when comparing the open with the endoscopic method of release, which is consistent with NFSGVHS data.^8,11,12,26

A limitation of the current retrospective study is the large number of providers who both operated on the patients and documented their postoperative findings. The strength of the study is that VA patients tend to stay within the VISN for their health care so postoperative problems will be identified and routed to the plastic surgery service for evaluation and treatment.

Clinical implications for the NFSGVHS practice are that surgeons can confidently offer both the open and endoscopic surgeries without an overall risk of increased complications to patients. Patients who are identified as higher risk for wound dehiscence, such as those who place an unusual amount of pressure on their palms due to assisted walking devices or are at a higher risk of falling onto the surgical site, will be steered toward an endoscopic surgery. The NFSGVHS began a splinting protocol in the early postoperative period that was not previously used on those select patients who have open carpal tunnel releases.

Conclusion

Wound dehiscence was the only statistically significant complication found in the NFSGVHS veteran population when comparing open with endoscopic carpal tunnel release. This can potentially be prevented in future patients by delaying the removal of sutures and prolonging the use of a protective dressing in patients who undergo open release. There was not a statistically significant increase in overall complications when using the minimally invasive method of release, which is consistent with existing literature.

Acknowledgement
This material is the result of work supported with resources and the use of facilities at the Malcom Randall VAMC.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Stenosing tenosynovitis, or trigger finger, is a pathology commonly referred to the plastic and hand surgery service of the North Florida/South Georgia Veterans Health System (NFSGVHS). Patients usually present to their primary care provider with symptoms of the finger being temporarily locked or stuck in the flexed position. This can be a painful problem due to the size mismatch between the flexor tendon and the pulley under which it glides.

Patients are typically referred to surgery after failing ≥ 1 attempt at nonoperative management. The surgery is relatively quick and straightforward; however, postoperative complications can lead to an unexpected costly and lengthy recovery. The objective of this study was to identify potential risk factors that can predispose patients to postoperative complications so that those risk factors may be better anticipated and modified, if possible.

Methods

A retrospective chart review of trigger finger release surgery was performed on-site at the Malcom Randall VAMC in Gainesville, Florida, from January 2005 to December 2010 to identify risk factors associated with postoperative complications. The study was approved by both the NFSGVHS Internal Review Board and the University of Florida Institutional Review Board. Patients who underwent surgery exclusively for ≥ 1 trigger fingers by the plastic surgery service were included in the study.

The surgery involves making an incision over the affected A1 pulley in the hand (Figure 1) and sharply releasing it (Figure 2) under direct vision. Potential risk factors for postoperative complications were recorded. These risk factors included smoking status, diabetic status, type of incision, and number of digits released during the surgical procedure.

Results

Ninety-eight digits (on 81 hands) were identified as meeting inclusion criteria. Surgeries were performed using a longitudinal (43), transverse (48), oblique (5), or Brunner (2) incision. There were 10 complications: cellulitis (3), pyogenic flexor tenosynovitis (3), scar adhesion (1), delayed healing (2), and incomplete release (1). The overall complication rate was 10.2%. The authors compared risk factors with complications, using the chi square test and a determining of P < .05.

Related: Making the Case for Minimally Invasive Surgery

There was no link found between overall postoperative complications and diabetic status, incision type, or smoking status. There was a statistically significant link between diabetic patients and the incidence of postoperative infection (P = .002) and between 2 digits operated on during the same surgery and postoperative infection (P = .027)

Discussion

The routine practice of the NFSGVHS hand clinic is to offer a steroid injection as the initial treatment for trigger finger. Health care providers (HCPs) allow no more than 3 injections to the same digit to avoid the rare but potentially serious complication of a tendon rupture.¹ Due to the large NFSGVHS catchment area, wait time for elective trigger finger surgery is several months. This 3-injection plan has been well received by patients and referring providers due to these wait times. However, a recent article by Kerrigan and Stanwix concluded that the most cost-efficient treatment strategy is 2 steroid injections before surgery.²

More often than not, trigger finger release is a short, outpatient surgery with a quick recovery. To minimize the risk of stiffness and scar adhesions, the NFSGVHS practice is to refer all postoperative hand cases for ≥ 1 hand therapy appointment on the same day as their first postoperative visit.

Cost Estimates

When complications occur, they can be costly to patients due to both time spent away from home and work and additional expenses. When the current procedural terminology (CPT) codes are run through the VistA integrated billing system, based on the VHA Chief Business Office Reasonable Charges, a complication can more than double the charges associated with A1 pulley surgery.

A flexor sheath incision and drainage (I+D) (CPT 26020) charges $8,935.35 (facility charge, $6,911.95 plus professional fee, $2,023.40), compared with open trigger finger release (CPT 26055) at $8,365.66 (facility charge, $6,911.95 plus professional fee, $1,453.71). According to a conversation with the finance service officer at NFSGVHS (2/11/2014), the anesthesia bill ($490.56/15 min), anticipated level 3 emergency department visits (facility charge, $889.22 plus professional fee $493.40), and inpatient stays (daily floor bed $786.19) can make an infectious complication costly.

Trigger finger can also be released percutaneously. This is a reasonable option that avoids the operating room, but NFSGVHS surgeons prefer the open surgery due to concerns for tendon and nerve injury that can result from a blind sweep of the needle.^3,4 

Related: Prevention of Venous Thromboembolism After Total Joint Replacement

Existing studies found complications for trigger finger release ranging from 1% to 31%.^5,6 Wound complications and joint stiffness are known complications.^5-7 In this study, 60% of the complications were infections, and 80% of the complications were wound complications. Six of 8 patients with wound-healing complications received perioperative antibiotics. Three patients returned to the operating room for an I+D of the flexor sheath. The results showed a statistically significant link between > 1 digit treated at the same surgery and postoperative complications (P = .027). A PubMed search revealed no existing hand literature with this association.

Risk Factors

Diabetes, tobacco use, type of incision, and number of digits treated were assessed as risk factors for complications after trigger finger surgery. Nicotine is widely accepted as increasing the risk for wound complications.⁸ Almost 20% of the U.S. population smokes, compared with 22% of the VA population and 32% of active-duty military personnel.⁹ One in 4 veterans has been diagnosed with diabetes, a well-known predisposing factor in delayed wound healing and infection.^10,11 No prior studies were found comparing type of incision or multiple digits treated as complications risk factors.

There is also a well-known association between trigger finger and diabetes. Chronic hyperglycemia results in the accumulation of collagen within tendon sheaths due to impairment of collagen breakdown. Patients with diabetes tend to present with multiple digit involvement and respond less favorably to steroid injections compared with patients without diabetes.¹² Wound healing is also impaired in patients with diabetes. All 6 wound infections in this study were in patients with diabetes. Proposed etiologies for wound-healing complications include pathologic angiogenesis, impaired fibroblast proliferation and migration, impaired circulation, decreased oxygenation, and a defective immune response to the injured site.¹³

Trigger finger may develop in multiple digits. Once surgery has been planned for 1 digit, patients may request surgery on another digit on the same hand that has not had an attempt at nonoperative intervention. The NFSGVHS plastic surgeons have raised the threshold to offer multiple surgical procedures on the same hand at the same operative visit to minimize recovery time and number of visits, particularly when patients are travelling long distances. This may be less convenient; however, the overall cost to the patient and the health care system in the event of a complication is significant. Plastic surgery providers also run an alcohol prep pad over the incision site to prevent inoculation of the flexor sheath during suture removal.

Current recommendations to ameliorate the postoperative risks to the patient and costs to the system include endorsing a more conservative approach to treating trigger finger than was previously practiced at NFSGVHS. The known, less favorable response of patients with diabetes to steroid injections plus their elevated risk of postoperative infection create a catch-22 for the treatment plan. Given the low risk of a single steroid injection to the flexor sheath, this procedure is still recommended as a first-line treatment.

Related: Experience Tells in Hip Arthroplasty

During the 5-year study there was a lower threshold for surgical management and for treatment of multiple digits during the same surgery than the one currently practiced, with an overall consensus of the hospital’s HCPs. The authors recommend that all patients start with a steroid injection before committing to surgery. Patients with diabetes are informed that the injection will cause a temporary rise in their blood glucose.¹⁴ If they are resistant to the injection, high-dose oral nonsteroidal anti-inflammatory drugs and/or proximal interphalangeal joint splinting is ordered.

Verification of A_1C values showing better chronic management of blood sugar is a procedure HCPs from the NFSGVHS will begin to follow. Preoperative A_1C values between 6.5% and 8% in patients known to have diabetes has been recommended.¹⁵ A_1C values > 7% have been found to be an independent risk factor for stenosing tenosynovitis.¹⁶ The total number of trigger finger surgeries may drop with the benefit of improved utilization of resources.

Conclusion

The authors found a statistically significant association between postoperative infection and 2 patient populations: patients with diabetes (P = .002) and patients having > 1 digit released during the same surgery (P = .027). This outcome suggests using caution when offering A1 pulley release in select patient populations.

Acknowledgement
Justine Pierson, BS, research coordinator at University of Florida, for statistical analysis. Funding is through salary.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Stenosing tenosynovitis, or trigger finger, is a pathology commonly referred to the plastic and hand surgery service of the North Florida/South Georgia Veterans Health System (NFSGVHS). Patients usually present to their primary care provider with symptoms of the finger being temporarily locked or stuck in the flexed position. This can be a painful problem due to the size mismatch between the flexor tendon and the pulley under which it glides.

Patients are typically referred to surgery after failing ≥ 1 attempt at nonoperative management. The surgery is relatively quick and straightforward; however, postoperative complications can lead to an unexpected costly and lengthy recovery. The objective of this study was to identify potential risk factors that can predispose patients to postoperative complications so that those risk factors may be better anticipated and modified, if possible.

Methods

A retrospective chart review of trigger finger release surgery was performed on-site at the Malcom Randall VAMC in Gainesville, Florida, from January 2005 to December 2010 to identify risk factors associated with postoperative complications. The study was approved by both the NFSGVHS Internal Review Board and the University of Florida Institutional Review Board. Patients who underwent surgery exclusively for ≥ 1 trigger fingers by the plastic surgery service were included in the study.

The surgery involves making an incision over the affected A1 pulley in the hand (Figure 1) and sharply releasing it (Figure 2) under direct vision. Potential risk factors for postoperative complications were recorded. These risk factors included smoking status, diabetic status, type of incision, and number of digits released during the surgical procedure.

Results

Ninety-eight digits (on 81 hands) were identified as meeting inclusion criteria. Surgeries were performed using a longitudinal (43), transverse (48), oblique (5), or Brunner (2) incision. There were 10 complications: cellulitis (3), pyogenic flexor tenosynovitis (3), scar adhesion (1), delayed healing (2), and incomplete release (1). The overall complication rate was 10.2%. The authors compared risk factors with complications, using the chi square test and a determining of P < .05.

Related: Making the Case for Minimally Invasive Surgery

There was no link found between overall postoperative complications and diabetic status, incision type, or smoking status. There was a statistically significant link between diabetic patients and the incidence of postoperative infection (P = .002) and between 2 digits operated on during the same surgery and postoperative infection (P = .027)

Discussion

The routine practice of the NFSGVHS hand clinic is to offer a steroid injection as the initial treatment for trigger finger. Health care providers (HCPs) allow no more than 3 injections to the same digit to avoid the rare but potentially serious complication of a tendon rupture.¹ Due to the large NFSGVHS catchment area, wait time for elective trigger finger surgery is several months. This 3-injection plan has been well received by patients and referring providers due to these wait times. However, a recent article by Kerrigan and Stanwix concluded that the most cost-efficient treatment strategy is 2 steroid injections before surgery.²

More often than not, trigger finger release is a short, outpatient surgery with a quick recovery. To minimize the risk of stiffness and scar adhesions, the NFSGVHS practice is to refer all postoperative hand cases for ≥ 1 hand therapy appointment on the same day as their first postoperative visit.

Cost Estimates

When complications occur, they can be costly to patients due to both time spent away from home and work and additional expenses. When the current procedural terminology (CPT) codes are run through the VistA integrated billing system, based on the VHA Chief Business Office Reasonable Charges, a complication can more than double the charges associated with A1 pulley surgery.

A flexor sheath incision and drainage (I+D) (CPT 26020) charges $8,935.35 (facility charge, $6,911.95 plus professional fee, $2,023.40), compared with open trigger finger release (CPT 26055) at $8,365.66 (facility charge, $6,911.95 plus professional fee, $1,453.71). According to a conversation with the finance service officer at NFSGVHS (2/11/2014), the anesthesia bill ($490.56/15 min), anticipated level 3 emergency department visits (facility charge, $889.22 plus professional fee $493.40), and inpatient stays (daily floor bed $786.19) can make an infectious complication costly.

Trigger finger can also be released percutaneously. This is a reasonable option that avoids the operating room, but NFSGVHS surgeons prefer the open surgery due to concerns for tendon and nerve injury that can result from a blind sweep of the needle.^3,4 

Related: Prevention of Venous Thromboembolism After Total Joint Replacement

Existing studies found complications for trigger finger release ranging from 1% to 31%.^5,6 Wound complications and joint stiffness are known complications.^5-7 In this study, 60% of the complications were infections, and 80% of the complications were wound complications. Six of 8 patients with wound-healing complications received perioperative antibiotics. Three patients returned to the operating room for an I+D of the flexor sheath. The results showed a statistically significant link between > 1 digit treated at the same surgery and postoperative complications (P = .027). A PubMed search revealed no existing hand literature with this association.

Risk Factors

Diabetes, tobacco use, type of incision, and number of digits treated were assessed as risk factors for complications after trigger finger surgery. Nicotine is widely accepted as increasing the risk for wound complications.⁸ Almost 20% of the U.S. population smokes, compared with 22% of the VA population and 32% of active-duty military personnel.⁹ One in 4 veterans has been diagnosed with diabetes, a well-known predisposing factor in delayed wound healing and infection.^10,11 No prior studies were found comparing type of incision or multiple digits treated as complications risk factors.

There is also a well-known association between trigger finger and diabetes. Chronic hyperglycemia results in the accumulation of collagen within tendon sheaths due to impairment of collagen breakdown. Patients with diabetes tend to present with multiple digit involvement and respond less favorably to steroid injections compared with patients without diabetes.¹² Wound healing is also impaired in patients with diabetes. All 6 wound infections in this study were in patients with diabetes. Proposed etiologies for wound-healing complications include pathologic angiogenesis, impaired fibroblast proliferation and migration, impaired circulation, decreased oxygenation, and a defective immune response to the injured site.¹³

Trigger finger may develop in multiple digits. Once surgery has been planned for 1 digit, patients may request surgery on another digit on the same hand that has not had an attempt at nonoperative intervention. The NFSGVHS plastic surgeons have raised the threshold to offer multiple surgical procedures on the same hand at the same operative visit to minimize recovery time and number of visits, particularly when patients are travelling long distances. This may be less convenient; however, the overall cost to the patient and the health care system in the event of a complication is significant. Plastic surgery providers also run an alcohol prep pad over the incision site to prevent inoculation of the flexor sheath during suture removal.

Current recommendations to ameliorate the postoperative risks to the patient and costs to the system include endorsing a more conservative approach to treating trigger finger than was previously practiced at NFSGVHS. The known, less favorable response of patients with diabetes to steroid injections plus their elevated risk of postoperative infection create a catch-22 for the treatment plan. Given the low risk of a single steroid injection to the flexor sheath, this procedure is still recommended as a first-line treatment.

Related: Experience Tells in Hip Arthroplasty

During the 5-year study there was a lower threshold for surgical management and for treatment of multiple digits during the same surgery than the one currently practiced, with an overall consensus of the hospital’s HCPs. The authors recommend that all patients start with a steroid injection before committing to surgery. Patients with diabetes are informed that the injection will cause a temporary rise in their blood glucose.¹⁴ If they are resistant to the injection, high-dose oral nonsteroidal anti-inflammatory drugs and/or proximal interphalangeal joint splinting is ordered.

Verification of A_1C values showing better chronic management of blood sugar is a procedure HCPs from the NFSGVHS will begin to follow. Preoperative A_1C values between 6.5% and 8% in patients known to have diabetes has been recommended.¹⁵ A_1C values > 7% have been found to be an independent risk factor for stenosing tenosynovitis.¹⁶ The total number of trigger finger surgeries may drop with the benefit of improved utilization of resources.

Conclusion

The authors found a statistically significant association between postoperative infection and 2 patient populations: patients with diabetes (P = .002) and patients having > 1 digit released during the same surgery (P = .027). This outcome suggests using caution when offering A1 pulley release in select patient populations.

Acknowledgement
Justine Pierson, BS, research coordinator at University of Florida, for statistical analysis. Funding is through salary.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Stenosing tenosynovitis, or trigger finger, is a pathology commonly referred to the plastic and hand surgery service of the North Florida/South Georgia Veterans Health System (NFSGVHS). Patients usually present to their primary care provider with symptoms of the finger being temporarily locked or stuck in the flexed position. This can be a painful problem due to the size mismatch between the flexor tendon and the pulley under which it glides.

Patients are typically referred to surgery after failing ≥ 1 attempt at nonoperative management. The surgery is relatively quick and straightforward; however, postoperative complications can lead to an unexpected costly and lengthy recovery. The objective of this study was to identify potential risk factors that can predispose patients to postoperative complications so that those risk factors may be better anticipated and modified, if possible.

Methods

A retrospective chart review of trigger finger release surgery was performed on-site at the Malcom Randall VAMC in Gainesville, Florida, from January 2005 to December 2010 to identify risk factors associated with postoperative complications. The study was approved by both the NFSGVHS Internal Review Board and the University of Florida Institutional Review Board. Patients who underwent surgery exclusively for ≥ 1 trigger fingers by the plastic surgery service were included in the study.

The surgery involves making an incision over the affected A1 pulley in the hand (Figure 1) and sharply releasing it (Figure 2) under direct vision. Potential risk factors for postoperative complications were recorded. These risk factors included smoking status, diabetic status, type of incision, and number of digits released during the surgical procedure.

Results

Ninety-eight digits (on 81 hands) were identified as meeting inclusion criteria. Surgeries were performed using a longitudinal (43), transverse (48), oblique (5), or Brunner (2) incision. There were 10 complications: cellulitis (3), pyogenic flexor tenosynovitis (3), scar adhesion (1), delayed healing (2), and incomplete release (1). The overall complication rate was 10.2%. The authors compared risk factors with complications, using the chi square test and a determining of P < .05.

Related: Making the Case for Minimally Invasive Surgery

There was no link found between overall postoperative complications and diabetic status, incision type, or smoking status. There was a statistically significant link between diabetic patients and the incidence of postoperative infection (P = .002) and between 2 digits operated on during the same surgery and postoperative infection (P = .027)

Discussion

The routine practice of the NFSGVHS hand clinic is to offer a steroid injection as the initial treatment for trigger finger. Health care providers (HCPs) allow no more than 3 injections to the same digit to avoid the rare but potentially serious complication of a tendon rupture.¹ Due to the large NFSGVHS catchment area, wait time for elective trigger finger surgery is several months. This 3-injection plan has been well received by patients and referring providers due to these wait times. However, a recent article by Kerrigan and Stanwix concluded that the most cost-efficient treatment strategy is 2 steroid injections before surgery.²

More often than not, trigger finger release is a short, outpatient surgery with a quick recovery. To minimize the risk of stiffness and scar adhesions, the NFSGVHS practice is to refer all postoperative hand cases for ≥ 1 hand therapy appointment on the same day as their first postoperative visit.

Cost Estimates

When complications occur, they can be costly to patients due to both time spent away from home and work and additional expenses. When the current procedural terminology (CPT) codes are run through the VistA integrated billing system, based on the VHA Chief Business Office Reasonable Charges, a complication can more than double the charges associated with A1 pulley surgery.

A flexor sheath incision and drainage (I+D) (CPT 26020) charges $8,935.35 (facility charge, $6,911.95 plus professional fee, $2,023.40), compared with open trigger finger release (CPT 26055) at $8,365.66 (facility charge, $6,911.95 plus professional fee, $1,453.71). According to a conversation with the finance service officer at NFSGVHS (2/11/2014), the anesthesia bill ($490.56/15 min), anticipated level 3 emergency department visits (facility charge, $889.22 plus professional fee $493.40), and inpatient stays (daily floor bed $786.19) can make an infectious complication costly.

Trigger finger can also be released percutaneously. This is a reasonable option that avoids the operating room, but NFSGVHS surgeons prefer the open surgery due to concerns for tendon and nerve injury that can result from a blind sweep of the needle.^3,4 

Related: Prevention of Venous Thromboembolism After Total Joint Replacement

Existing studies found complications for trigger finger release ranging from 1% to 31%.^5,6 Wound complications and joint stiffness are known complications.^5-7 In this study, 60% of the complications were infections, and 80% of the complications were wound complications. Six of 8 patients with wound-healing complications received perioperative antibiotics. Three patients returned to the operating room for an I+D of the flexor sheath. The results showed a statistically significant link between > 1 digit treated at the same surgery and postoperative complications (P = .027). A PubMed search revealed no existing hand literature with this association.

Risk Factors

Diabetes, tobacco use, type of incision, and number of digits treated were assessed as risk factors for complications after trigger finger surgery. Nicotine is widely accepted as increasing the risk for wound complications.⁸ Almost 20% of the U.S. population smokes, compared with 22% of the VA population and 32% of active-duty military personnel.⁹ One in 4 veterans has been diagnosed with diabetes, a well-known predisposing factor in delayed wound healing and infection.^10,11 No prior studies were found comparing type of incision or multiple digits treated as complications risk factors.

There is also a well-known association between trigger finger and diabetes. Chronic hyperglycemia results in the accumulation of collagen within tendon sheaths due to impairment of collagen breakdown. Patients with diabetes tend to present with multiple digit involvement and respond less favorably to steroid injections compared with patients without diabetes.¹² Wound healing is also impaired in patients with diabetes. All 6 wound infections in this study were in patients with diabetes. Proposed etiologies for wound-healing complications include pathologic angiogenesis, impaired fibroblast proliferation and migration, impaired circulation, decreased oxygenation, and a defective immune response to the injured site.¹³

Trigger finger may develop in multiple digits. Once surgery has been planned for 1 digit, patients may request surgery on another digit on the same hand that has not had an attempt at nonoperative intervention. The NFSGVHS plastic surgeons have raised the threshold to offer multiple surgical procedures on the same hand at the same operative visit to minimize recovery time and number of visits, particularly when patients are travelling long distances. This may be less convenient; however, the overall cost to the patient and the health care system in the event of a complication is significant. Plastic surgery providers also run an alcohol prep pad over the incision site to prevent inoculation of the flexor sheath during suture removal.

Current recommendations to ameliorate the postoperative risks to the patient and costs to the system include endorsing a more conservative approach to treating trigger finger than was previously practiced at NFSGVHS. The known, less favorable response of patients with diabetes to steroid injections plus their elevated risk of postoperative infection create a catch-22 for the treatment plan. Given the low risk of a single steroid injection to the flexor sheath, this procedure is still recommended as a first-line treatment.

Related: Experience Tells in Hip Arthroplasty

During the 5-year study there was a lower threshold for surgical management and for treatment of multiple digits during the same surgery than the one currently practiced, with an overall consensus of the hospital’s HCPs. The authors recommend that all patients start with a steroid injection before committing to surgery. Patients with diabetes are informed that the injection will cause a temporary rise in their blood glucose.¹⁴ If they are resistant to the injection, high-dose oral nonsteroidal anti-inflammatory drugs and/or proximal interphalangeal joint splinting is ordered.

Verification of A_1C values showing better chronic management of blood sugar is a procedure HCPs from the NFSGVHS will begin to follow. Preoperative A_1C values between 6.5% and 8% in patients known to have diabetes has been recommended.¹⁵ A_1C values > 7% have been found to be an independent risk factor for stenosing tenosynovitis.¹⁶ The total number of trigger finger surgeries may drop with the benefit of improved utilization of resources.

Conclusion

The authors found a statistically significant association between postoperative infection and 2 patient populations: patients with diabetes (P = .002) and patients having > 1 digit released during the same surgery (P = .027). This outcome suggests using caution when offering A1 pulley release in select patient populations.

Acknowledgement
Justine Pierson, BS, research coordinator at University of Florida, for statistical analysis. Funding is through salary.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.