Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis

Jennifer C E Lane, Richard S Craig, Jonathan L Rees, Matthew D Gardiner, Jane Green, Daniel Prieto-Alhambra, Dominic Furniss, Jennifer C E Lane, Richard S Craig, Jonathan L Rees, Matthew D Gardiner, Jane Green, Daniel Prieto-Alhambra, Dominic Furniss

Abstract

Background: Carpal tunnel decompression surgery to treat carpal tunnel syndrome is a common procedure, yet data on safety and effectiveness of the operation in the general population remain scarce. We aimed to estimate the incidence of reoperation and serious postoperative complications (requiring admission to hospital or further surgery) following carpal tunnel decompression in routine clinical practice and to identify the patient factors associated with these adverse outcomes.

Methods: We did a nationwide cohort analysis including all carpal tunnel decompression surgeries in patients aged 18 years or older, done in the National Health Service in England between April 1, 1998, and March 31, 2017, using the Hospital Episode Statistics dataset linked to mortality records. Patients were followed-up until death or until the end of the study (March 31, 2017). Primary outcomes were the overall incidence of carpal tunnel decompression reoperation and serious postoperative complications (surgical site infection or dehiscence, or neurovascular or tendon injury, requiring admission to hospital or further surgery) within 30 days and 90 days after surgery. Multivariable Cox regression analysis was used to identify factors influencing complications and reoperation, and the Fine and Gray method was used to adjust for the competing risk of mortality. This study is registered with ClinicalTrials.gov, NCT03573765.

Findings: 855 832 carpal tunnel decompression surgeries were done between April 1, 1998, and March 31, 2017 (incidence rate 1·10 per 1000 person-years [95% CI 1·02-1·17]). 29 288 procedures (3·42%) led to carpal tunnel decompression reoperation (incidence rate 3·18 per 1000 person-years [95% CI 3·12-3·23]). Of the 855 832 initial surgeries, 620 procedures (0·070% [95% CI 0·067-0·078]) led to a serious complication within 30 days after surgery, and 698 procedures (0·082% [0·076-0·088]) within 90 days. Local complications within 90 days after surgery were associated with male sex (adjusted hazard ratio 2·32 [95% CI 1·74-3·09]) and age category 18-29 years (2·25 [1·10-4·62]). Male sex (adjusted subhazard ratio 1·09 [95% CI 1·06-1·13]), old age (>80 years vs 50-59 years: 1·09 [1·03-1·15]), and greater levels of comorbidity (Charlson score ≥5 vs 0: 1·25 [1·19-1·32]) and socioeconomic deprivation (most deprived 10% vs least deprived 10%: 1·18 [1·10-1·27]) were associated with increased reoperation risk.

Interpretation: To our knowledge, this is the largest national study on carpal tunnel decompression to date, providing strong evidence on serious postoperative complication and reoperation rates. Carpal tunnel decompression appears to be a safe operation in most patients, with an overall serious complication rate (requiring admission to hospital or further surgery) of less than 0·1%.

Funding: Versus Arthritis; Medical Research Council; Royal College of Surgeons of England and National Joint Registry research fellowship; University of Oxford; National Institute for Health Research; and National Institute for Health Research Biomedical Research Centre, Oxford.

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Figures

Figure 1
Figure 1
Study profile ICD-10=International Classification of Diseases 10. OPCS=Office of Population Censuses and Surveys Classification of Interventions and Procedures.
Figure 2
Figure 2
Incidence of primary carpal tunnel decompression by age and sex
Figure 3
Figure 3
Representative Kaplan-Meier analysis for reoperations within the first 10 years after primary surgery For visual clarity there is a break in the y-axis between 0% and 95%.

References

    1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282:153–158.
    1. Burton CL, Chen Y, Chesterton LS, van der Windt DA. Trends in the prevalence, incidence and surgical management of carpal tunnel syndrome between 1993 and 2013: an observational analysis of UK primary care records. BMJ Open. 2018;8
    1. US Department of Labor Bureau of Labor Statistics Nonfatal occupational injuries and illnesses requiring days away from work, 2015. 2016.
    1. Bland JD. Carpal tunnel syndrome. BMJ. 2007;335:343–346.
    1. Burton CL, Chesterton LS, Chen Y, van der Windt DA. Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care. Clin Epidemiol. 2018;10:739–748.
    1. Lawrence RC, Felson DT, Helmick CG. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58:26–35.
    1. Benson LS, Bare AA, Nagle DJ, Harder VS, Williams CS, Visotsky JL. Complications of endoscopic and open carpal tunnel release. Arthroscopy. 2006;22:919–924.
    1. Vasiliadis HS, Georgoulas P, Shrier I, Salanti G, Scholten RJ. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. 2014;1
    1. Scholten RJPM, Mink van der Molen A, Uitdehaag BMJ, Bouter LM, de Vet HCW. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;4
    1. Goodman AD, Gil JA, Starr AM, Akelman E, Weiss AC. Thirty-day reoperation and/or admission after elective hand surgery in adults: a 10-year review. J Hand Surg Am. 2018;43:383.e1–383.e7.
    1. Devana SK, Jensen AR, Yamaguchi KT. Trends and complications in open versus endoscopic carpal tunnel release in private payer and medicare patient populations. Hand (N Y) 2019;14:455–461.
    1. Palmer AK, Toivonen DA. Complications of endoscopic and open carpal tunnel release. J Hand Surg Am. 1999;24:561–565.
    1. Werner BC, Teran VA, Deal DN. Patient-related risk factors for infection following open carpal tunnel release: an analysis of over 450,000 medicare patients. J Hand Surg Am. 2018;43:214–219.
    1. Makady A, van Veelen A, Jonsson P. Using real-world data in health technology assessment (HTA) practice: a comparative study of five HTA agencies. Pharmacoeconomics. 2018;36:359–368.
    1. Hollingworth W, Rooshenas L, Busby J. National Institute for Health Research Journals Library; Southampton (UK): 2015. Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study.
    1. NHS Digital Hospital episode statistics. 2018.
    1. NHS Digital Linked HES-ONS mortality data. 2018.
    1. King's Fund . King's Fund; London: 2014. Commission on the future of health and social care in England: the UK private health market.
    1. Lane JCE, Schnier C, Green J, Lam WL, Furniss D, Sudlow CLM. Can we use routinely collected hospital and GP data for epidemiological study of common hand conditions? A UK Biobank based validation project. bioRxiv. 2018 doi: 10.1101/274167. published online March 2. (preprint).
    1. NHS Digital National clinical coding standards: OPCS-4 and ICD-10. 2017.
    1. WHO International Classification of Disease version 10. 2016.
    1. Padua L, Coraci D, Erra C. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15:1273–1284.
    1. Ministry of Housing, Communities, and Local Government English indices of deprivation. 2018.
    1. Quan H, Li B, Couris CM. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676–682.
    1. NHS Digital NHS outcomes framework. 2018.
    1. Office for National Statistics Population estimates for the UK, England and Wales, Scotland and Northern Ireland. 2018.
    1. Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc. 1999;94:496–509.
    1. de Krom MC, Knipschild PG, Kester AD, Thijs CT, Boekkooi PF, Spaans F. Carpal tunnel syndrome: prevalence in the general population. J Clin Epidemiol. 1992;45:373–376.
    1. Tadjerbashi K, Åkesson A, Atroshi I. Incidence of referred carpal tunnel syndrome and carpal tunnel release surgery in the general population: increase over time and regional variations. J Orthop Surg (Hong Kong) 2019;27
    1. Craig RS, Lane JCE, Carr AJ, Furniss D, Collins GS, Rees JL. Serious adverse events and lifetime risk of reoperation after elective shoulder replacement: population based cohort study using hospital episode statistics for England. BMJ. 2019;364
    1. Lübbeke A, Rees JL, Barea C, Combescure C, Carr AJ, Silman AJ. International variation in shoulder arthroplasty. Acta Orthop. 2017;88:592–599.
    1. Cobb TK, Amadio PC, Leatherwood DF, Schleck CD, Ilstrup DM. Outcome of reoperation for carpal tunnel syndrome. J Hand Surg Am. 1996;21:347–356.
    1. Office for National Statistics Migration statistics quarterly report: February 2020. 2020.
    1. NHS Digital National data opt-out, June 2020. 2020.
    1. NHS England Medical directorate and Strategy and Innovation directorate . NHS England, NHS Clinical Commissioners, the Academy of Medical Royal Colleges, NHS Improvement and the National Institute for Health and Care Excellence; London: 2018. Evidence-based interventions: consultation document.
    1. Sears ED, Swiatek PR, Hou H, Chung KC. The influence of insurance type on management of carpal tunnel syndrome: an analysis of nationwide practice trends. Plast Reconstr Surg. 2016;138:1041–1049.

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