Endoscopic Versus Open Carpal Tunnel Surgery: Risk Factors and Rates of Revision Surgery.

PURPOSE: The purpose of our study was to compare the 1-year revision surgery rates and outcomes of open versus endoscopic carpal tunnel release. Our hypothesis was that, compared to open release, endoscopic carpal tunnel release was an independent risk factor for revision surgery within 1-year. METHODS: This was a retrospective cohort study of 4338 patients undergoing isolated endoscopic or open carpal tunnel release. Demographic data, medical comorbidities, surgical approach, need for revision surgery, hand dominance, history of prior injection, and Patient Reported Outcomes Measurement Information System upper extremity (UE), pain interference (PI) and physical function scores were analyzed. Multivariable analysis was used to identify the risk factors for revision surgery within one year of the index procedure. RESULTS: In total, 3280 patients (76%) underwent open and 1058 (24%) underwent endoscopic carpal tunnel release. Within one year of the index procedure, 45 patients required revision carpal tunnel release. The average time to revision was 143 days. The rate of revision carpal tunnel release in the open group was 0.71% compared to 2.08% in the endoscopic group. Multivariable analysis demonstrated that endoscopic surgery, male sex, cubital tunnel syndrome, tobacco use, and diabetes were associated independently with revision surgery. CONCLUSIONS: In this study, we found that endoscopic carpal tunnel release was associated independently with a 2.96 times greater likelihood of requiring revision carpal tunnel release within one year, compared to open carpal tunnel release. Male sex, concurrent cubital tunnel syndrome, tobacco use, and diabetes also were associated independently with greater risk of needing revision carpal tunnel release within one year. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Transversus Abdominis Plane Block With Liposomal Bupivacaine Versus Thoracic Epidural for Postoperative Analgesia After Deep Inferior Epigastric Artery Perforator Flap-Based Breast Reconstruction.

PURPOSE: Autologous breast reconstruction with abdominally based free flaps has traditionally been associated with a longer hospital stay and higher initial cost relative to other reconstructive methods. One important component of this course is postoperative pain control. Thoracic epidural anesthesia is considered among the most effective methods for pain control in the immediate postoperative period following these procedures. Recently, our institution began using 4 quadrant transversus abdominis plane (TAP) blocks with liposomal bupivacaine. Encouraging trends were observed with utilization of TAP blocks; however, we sought to quantify this effect compared with that of thoracic epidural anesthesia. This study would contribute to a growing body of evidence supporting an enhanced recovery pathway for microvascular breast reconstruction. METHOD: Thirty patients who underwent deep inferior epigastric artery perforator flap-based breast reconstruction from January 2016 to April 2017 were evaluated. Fifteen patients received thoracic epidural anesthesia, and 15 received 4 quadrant TAP blocks with liposomal bupivacaine. Opioid consumption was evaluated and compared for the first 3 days postoperatively. All opioids were converted to oral morphine equivalents (OMEs) for standardization. Day of discharge, day of Foley removal, and several traditionally opioid-related adverse effects were also recorded and compared. RESULT: On postoperative days 0, 1, 2, and 3, opioid consumption among those given epidural anesthesia compared with those who received TAP blocks with liposomal bupivacaine was 34.9 versus 32.6 OMEs (P = 0.81), 98.9 versus 92.4 OMEs (P = 0.78), 59.7 versus 56.0 OMEs (P = 0.79), and 59.6 versus 24.5 OMEs (P = 0.005*), respectively. Total opioid consumption for the epidural group was 253.1 versus 205.4 OMEs for the TAP block group (P = 0.2743). Time until removal of Foley was 2.7 days for patients with an epidural and 2.1 days for those receiving TAP blocks (P = 0.0056*). Length of stay for those receiving epidural was 4.33 days compared with 3.53 days for those receiving TAP blocks (P = 0.0002*). CONCLUSION: When using TAP blocks with liposomal bupivacaine, a statistically significant effect on postoperative day 3 and decreased opioid utilization overall were observed. Patients also had their Foley removed sooner and were discharged from the hospital earlier.