Description of WALANT technique in open bone and ligament wrist surgery.

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

Efficacy of topical curcumin on mild to moderate carpal tunnel syndrome: a randomized double-blind, placebo-controlled clinical trial.

OBJECTIVES: Recently, there has been a renewed interest in traditional medicine for carpal tunnel syndrome (CTS). Curcumin has been reported as an agent with antioxidant, anti-inflammatory, analgesic, and neuroprotective attributes. This study is one of the first investigations to assess the effect of curcumin gel on CTS. METHODS: This study is a prospective, 8-week, randomized, placebo-controlled, parallel-group clinical trial. A total of 70 patients with CTS were analyzed. The intervention group (n = 35) received a topical curcumin gel and a night wrist splint and the control group (n = 35) received a placebo gel and a night wrist splint for 8 weeks. The primary outcome was the assessment of the symptom severity scale (SSS) and functional status scale (FSS) of the participants using the Boston Carpal Tunnel Questionnaire (BCTQ) after 8 weeks. In addition, all participants were evaluated by electrodiagnostic (EDX) test at baseline and after 8 weeks. RESULTS: The mean scores of SSS demonstrated a significant decrease in the curcumin group compared to the placebo group; P-value= 0.021. The mean change score of SSS after the intervention was 12.45 ± 8.18 in curcumin and 3.28 ± 7.06 in the placebo group; P-value = 0.0001 and the mean change score of FSS were 6.24 ± 4.91 and 2.31 ± 4.95 in curcumin and placebo groups, respectively; P-value = 0.002. However, the EDX study showed no significant changes in both groups. CONCLUSIONS: It seems that curcumin gel could be effective in the improvement of the symptom severity and daily activity of patients with CTS.

Additional contribution of phonophoresis and low-level laser therapy to exercise in the treatment of carpal tunnel syndrome: A clinical, electrophysiological, and ultrasonographic evaluation.

OBJECTIVES: Carpal Tunnel Syndrome (CTS) is the most common peripheral nerve compression syndrome. This study aims to evaluate the additive contribution of phonophoresis and low-level laser therapy (LLLT) to tendon and nerve gliding exercises electrophysiologically, ultrasonographically, and clinically in the treatment of moderate CTS. METHODS: The sample consisted of 45 patients with moderate CTS, randomized into three groups. Group 1 received phonophoresis and exercise, Group 2 received LLLT and exercise, and Group 3 received exercise alone. Participants were evaluated electrophysiologically, clinically, and ultrasonographically before treatment and at the 6th and 12th weeks after the treatment. RESULTS: An improvement was observed in clinical parameters (Boston Functional Status Scale, Boston Symptom Severity Scale, visual analog scale at rest, and visual analog scale during activity) for all groups at the 6th and 12th weeks after the treatment (p<0.05). An improvement was also noted in the ultrasonographic parameter (cross-sectional area) for all groups at the 12th week after the treatment (p=0.017). CONCLUSION: Phonophoresis and LLLT do not provide additional effects to exercise therapy. Exercise therapy alone may positively contribute to ultrasonographic and clinical outcomes in the treatment of moderate CTS.

The sono-elastography evaluation of the immediate effects of neurodynamic mobilization technique on median nerve stiffness in patients with carpal tunnel syndrome.

OBJECTIVES: The stiffness of median nerve increases in carpal tunnel syndrome (CTS) even at mild stage of syndrome which could be regarded as a diagnostic criterion. The aim of this study was to evaluate the immediate effects of neurodynamic technique on median nerve stiffness and cross-sectional area (CSA) at wrist and elbow in individuals with CTS. MATERIAL AND METHODS: It was a quasi-experimental study. Twenty patients were recruited for this study. They were included if aged 18-65 years and diagnosed with CTS based on electrodiagnostic and clinical findings. The exclusion criteria were previous surgeries at wrist or elbow. Patients were assessed by shear wave sono-elastography before and immediately after one session of neurodynamic mobilization technique (NDM). The primary outcome measure was the stiffness of the median nerve at wrist and the secondary outcomes were nerve stiffness at elbow and CSA of nerve at wrist and elbow. RESULTS: Median nerve stiffness and CSA decreased significantly at wrist immediately after a session of NDM. These parameters also decreased at elbow but were not statistically significant. CONCLUSION: One session of NDM reduced the stiffness and CSA of median nerve at wrist in patients with CTS as detected by sono-elastography verifying that sono-elastography is able to quickly detect the immediate biomechanical changes of the median nerve.

A prospective, comparative study of the analgesic effect between the WALANT technique and local anesthesia associated with sedation for hand surgery.

PURPOSE: The primary objective of this study was to compare the WALANT (wide awake, local anesthesia, no tourniquet) technique with local anesthesia associated with sedation in relation to pain intensity for minor hand surgical procedures. The secondary objective was to evaluate the need for analgesic complementation. METHODS: A prospective, randomized, comparative, and clinical study was carried out. The sample size in each group was determined after statistical evaluation of the results of a pilot project. The participants were allocated to one of two groups; those in group 1 were submitted to the WALANT technique, and those in group 2, to local anesthesia associated with sedation, for elective surgery. The surgical procedures were carpal tunnel syndrome, De Quervain's tenosynovitis, synovial cyst, finger cyst, and trigger finger. Pain intensity, need for complementation and evolution to complex regional pain syndrome were evaluated. RESULTS: There was no difference between groups in pain intensity after WALANT and need for intraoperative complementation. There was no significant difference in the amount of opioid applied postoperatively between the groups. There was no difference between groups regarding comfort during surgery. There was no difference in adverse effects and complications between the groups. Hematoma was the most frequent adverse event. No severe adverse events were observed. CONCLUSIONS: The WALANT technique promoted an analgesic effect similar to that of local anesthesia associated with sedation, without increasing adverse effects.

Clinical efficacy of electroacupuncture-like magnetic therapy compared to conventional transcutaneous electrical nerve stimulation in individuals with carpal tunnel syndrome.

This study aimed to evaluate the clinical efficacy of an electroacupuncture-like magnetic therapy (ELMT) and conventional transcutaneous electrical nerve stimulation (TENS) in patients with carpal tunnel syndrome (CTS). A prospective randomized controlled trial in single-centre was conducted. Thirty-four CTS patients confirmed by electrodiagnostic study were randomized into TENS or ELMT group and completed a six-week treatment program. TENS or ELMT treatment was applied on acupuncture point PC-6 (Neiguan) and one selected hand acupoint. Therapeutic exercises were also included after the electrophysical modality. Their physical signs, motor and sensory performances, Boston Carpal Tunnel Questionnaire (BCTQ) scores, and results of electrodiagnostic study were evaluated. After treatments, both groups demonstrated significantly decreased BCTQ scores and positive rate of Tinel's sign in the major symptomatic side, which indicated improvements in the symptom severity and physical functions. Significant increases in distal sensory amplitude and nerve conduction velocity of the median nerve were only found in the ELMT group. Our study found either conventional TENS or ELMT plus therapeutic exercises could improve the symptomatology and physical provocation sign of CTS. The ELMT has additional improvement in the nerve conduction in patients with CTS.

Safety and efficacy of a modified WALANT technique using undiluted adrenaline during open surgical carpal tunnel release: a prospective report of 308 procedures.

PURPOSE: The current study aimed to report on the safety and efficacy of utilizing a modified WALANT (mWALANT) technique during open surgical carpal tunnel release (CTR), where we used undiluted epinephrine compared to the originally described WALANT technique. METHODS: From January 2015 till the end of June 2021, 200 patients (175 (87.5%) were females) who presented with carpal tunnel syndrome, either bilateral (108 (54%) patients) or unilateral (92 (46%)) were included, formulating a total of 308 procedures. Open surgical CTR was performed as a daycare procedure by the same surgeon. The mWALANT injectable mixture was prepared by mixing 8 CC of 2% lidocaine HCl + 1 CC of 0.25 mg/1 ml epinephrine without dilution (2.5 times the concentration used in the original WALANT technique). The injection was performed before draping. RESULTS: The patients' average age at surgery was 42.88 ± 13.03 years old; they were followed up for an average of 31 ± 17.17 months. The average operative time was 9.5 ± 1.87 min. None (0.0%) of the patients needed top-up of local anesthesia or shift into general anesthesia, and no (0.0%) patients needed postoperative hospital stay. The average VAS during the surgical procedure was 2.5 ± 2.1, mainly reported during infiltration of the local anesthesia; no patients reported discomfort during the surgical procedure itself. 180 (90%) patients reported a full return to their usual preoperative ADL after an average of 4.7 ± 1.2 weeks. No (0.0%) postoperative fingers ischemic or temperature changes. Two (1%) patients experienced an adrenaline rush in the form of tachycardia that needed sedation and close monitoring by the anesthesiologist; they were discharged on the same day. One (0.5%) patient (who had uncontrolled diabetes mellitus) showed a superficial wound infection which resolved after conservative management. CONCLUSIONS: Using undiluted epinephrine during the mWALANT technique is safe and effective. There is no need to wait until the drugs fully function, and no epinephrine-related complications were encountered apart from occasional adrenaline rush symptoms.

Effects of high-intensity laser therapy on pain, functional status, hand grip strength, and median nerve cross-sectional area by ultrasonography in patients with carpal tunnel syndrome.

The aim of this study was to evaluate the effects of high intensity laser therapy (HILT) on pain, functional status, hand grip strength, and median nerve cross-sectional area by ultrasonography in patients with carpal tunnel syndrome. Sixty patients who were diagnosed with carpal tunnel syndrome were included in the study. The patients observed during the research were randomly divided into two groups with 30 patients in each group. Splint+ exercise and HILT (pulsed mode with a power of 8.0 W and energy density of 8 J/cm2 for 1.40 minutes for every 25 cm2, continuous mode with a power of 3.0 W and energy density of 80 J/cm2 for 11 minutes for each 25 cm2; total 10 sessions 5 days a week) were applied for 2 weeks for the first group, and splint+exercise and sham laser treatment were applied for 2 weeks for the second group. Randomization was undertaken with the assistance of a computer-generated random number table before beginning the treatment processes. The patients were evaluated with the determined scales before the treatment, at the end of the treatment, and at the 3rd month. Hydraulic hand dynamometer was used to measure hand grip strength, visual analog scale (VAS) for pain, Boston CTS Questionnaire to assess function, and ultrasonography to measure median nerve cross-sectional area. The impact of time on the change in VAS levels was found to be of statistical significance within each group of patients (p<0.001), but between-group comparisons did not yield significant results (p<0.454). The effects of time on variations in Boston CTS Questionnaire scores were found to have been of statistical significance for both groups (p<0.001), but significance was not subsequently observed when the results of the two groups were compared on a between-group basis (p=0.226 and p=0.973 for the FSS and SSS, respectively). While time had a statistically significant effect on the change in hand grip strength for both groups (p=0.000), between-group comparisons statistical significance finding in favor of HILT was found in the early period (p=0.012). The time-group association patterns of the groups showed significant difference (p=0.025). While time had a statistically significant effect on the changes in the median cross-sectional areas of the nerve for the patients of both treatment groups (p<0.001), between-group comparisons yielded no findings of statistical significance (p=0.438). The time-group relationship patterns of the groups were found to reflect statistical significance (p=0.001). In conclusion, the results of the research presented here have confirmed that hand grip strength may increase and the median nerve's cross-sectional area may decrease upon the application of high-intensity laser for individuals experiencing CTS. However, this effect was demonstrated here only in the short-term and the evidence was not maintained through the course of follow-up of a longer duration.

Protocol for a double-blinded randomised controlled trial investigating the use of adjunct bicarbonate in carpal tunnel release: a single-centre study.

INTRODUCTION: This study aims to compare the effectiveness of buffered and non-buffered long-acting local anaesthetics in pain relief during and after carpal tunnel release (CTR) surgery. Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. Surgical treatment of CTS, CTR, is the most common hand surgical operation. CTR is usually performed under local anaesthesia, the application of which is often the most painful event during the procedure. One important aspect of patient satisfaction is adequate pain management during and after CTR. Long-acting local anaesthetics provide good postoperative pain control. Adjunct bicarbonate has been shown to reduce pain during injection of local anaesthetic and to prolong its analgesic effect. To date, no published randomised controlled trial has compared buffered to non-buffered long-acting local anaesthetic during CTR. METHODS AND ANALYSIS: The study will randomly assign 116 patients with CTS to receive buffered or non-buffered mixtures of lidocaine and bupivacaine with epinephrine before CTR. The primary outcome is overall pain experienced during the injection of local anaesthetic, assessed with the Visual Analogue Scale. The secondary outcomes are pain intensity from the injection and during CTR, use of painkillers and pain intensity every 4 hours until third postoperative night, symptom severity and functional status preoperatively and at 3 months after surgery, and patient-rated outcome measures at 3 months after surgery. ETHICS AND DISSEMINATION: This protocol was approved by the Research Ethics Committee of the Northern Savo Hospital District (2311/2021). The study will be performed according to the principles of good clinical practice and the Declaration of Helsinki. The results are expected to be presented in an international hand surgical conference and the manuscript to be sent to a hand surgery-orientated peer-reviewed journal during 2024. TRIAL REGISTRATION NUMBER: This study is registered to clinicaltrials.gov, study ID NCT05328180.

The effectiveness of biophysical agents in the treatment of carpal tunnel syndrome- an umbrella review.

BACKGROUND: Our objective was to summarize, synthesize, and integrate the evidence evaluating the effectiveness of biophysical agents compared to other conservative treatments, for the management of carpal tunnel syndrome (CTS). METHODS: This was an overview of systematic reviews (SRs). We searched several online databases and obtained SRs relating to managing CTS using biophysical agents. Two independent researchers screened and appraised the quality of the SRs using the A MeaSurement Tool to Assess systematic Reviews-2 appraisal tool. We extracted information related to study characteristics as well as the effectiveness of biophysical agents for CTS, the effect sizes, and between-group significances. We categorized the information based on the type of biophysical agent. We also performed a citation mapping and calculated the corrected covered area index. RESULTS: We found 17 SRs addressing 12 different biophysical agents. The quality of the SRs was mainly critically low (n = 16) or low (n = 1). The evidence was inconclusive for the effectiveness of Low-level Laser therapy and favorable for the short-term efficacy of non-thermal ultrasound in improving symptom severity, function, pain, global rating of improvement, satisfaction with treatment, and other electrophysiological measures compared to manual therapy or placebo. Evidence was inconclusive for Extracorporeal Shockwave therapy, and favorable for the short-term effectiveness of Shortwave and Microwave Diathermy on pain and hand function. The corrected covered area index was lower than 35% indicating a low overlap of the SRs. CONCLUSIONS: The findings were based on low-quality primary studies, with an unclear or high risk of bias, small sample sizes, and short follow-ups. Therefore, no recommendations can be made for the long-term effectiveness of any biophysical agents. High-quality evidence is needed to support evidence-based recommendations on the use of biophysical agents in the management of CTS. PROSPERO REGISTRATION NUMBER: CRD42022319002, registered on 17/04/2022.

The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study.

STUDY DESIGN: Single-blinded, randomized controlled study. INTRODUCTION: Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders. PURPOSE OF THE STUDY: This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS. METHODS: A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome. RESULTS: We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group. DISCUSSION: This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients. CONCLUSIONS: MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.

Photobiomodulation Therapy in Carpal Tunnel Release: A Randomized Controlled Trial.

Background: Carpal tunnel release (CTR) is widely accepted as an effective treatment for carpal tunnel syndrome. However, the recovery is often delayed and incomplete. Photobiomodulation therapy (PBMT) produces a nonthermal effect on living tissues; it promotes healing, remodels and reduces inflammation of an injured nerve. The purpose of this study was to compare the outcome of CTR between patients who underwent postoperative PBMT and without PBMT. Materials and methods: We recruited 105 patients who had open CTR from January 2019 to January 2021. Fifty-six patients fulfilled the study criteria and were randomized into two groups: with PBMT (n = 28) and without PBMT (n = 28). Demographic and clinical data were obtained preoperatively. The PBMT group had ten 3-min sessions over 3 weeks using 808 nm, 50 mW PBMT to deliver 9 J per session to the CTR incision scar. Clinical outcomes were assessed at 1, 3, and 6 months postoperatively. Data analysis was performed with SPSS software. Results: There were significant improvements in the Functional Status Scale in the Boston Carpal Tunnel Questionnaire (p = 0.018) and pain (visual analogue scales) in the morning (p = 0.019) at 1 month postoperatively in the PBMT group compared with the non-PBMT group. Improvement of tip pinch strength at 3 months (p = 0.022) and 6 months (p = 0.024), lateral pinch strength at 1 month (p = 0.042) and 3 months (p = 0.05), and tripod pinch strength at 3 months (p = 0.005) was significantly better in the PBMT group. Thumb 2-point discrimination (2PD) at 3 months (p = 0.018) and 6 months (p = 0.016) and index finger 2PD at 3 months (p = 0.039) were also significantly improved in the PBMT group. There were no side effects of PBMT reported. Conclusions: Patients who underwent PBMT post-CTR had better outcomes. PBMT may be a valuable adjunct to post-CTR care.

Effectiveness of physiotherapy plus acupuncture compared with physiotherapy alone on pain, disability and grip strength in people with carpal tunnel syndrome: A randomized clinical trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome in the upper extremities. Acupuncture is often used as a treatment method in CTS and numerous studies consider it effective. However, no study has yet compared the efficacy of physical therapy including bone and neural mobilization, exercise and electrotherapy with and without acupuncture in CTS patients. PURPOSE: comparing the effect of physiotherapy plus acupuncture with physiotherapy alone on pain, disability and grip strength in CTS patients. METHOD: Forty patients with mild to moderate CTS were randomly divided into two equal groups. Both groups received exercise and manual techniques for 10 sessions. Patients in the physiotherapy plus acupuncture group also received 30 min of acupuncture in every session. The visual analog scale (VAS) score, the score on the Boston carpal tunnel questionnaire for functional status and symptom severity, shortened disability of arm, shoulder, hand (Quick-DASH) score and grip strength were evaluated at pre-test and post-test. RESULTS: According to ANOVA results, there is a significant interaction between group and time for VAS, BCTQ and Quick-DASH parameters. At the post-test, while the parameters of VAS, BCTQ and Quick-DASH in the physiotherapy plus acupuncture group had a statistically significant difference compared to the physiotherapy group, no significant difference was observed between the two groups in the pre-test. Moreover, there is no significant difference between groups in grip strength improvement. CONCLUSION: This study shows preliminary evidence that physiotherapy plus acupuncture, was more effective than physiotherapy alone in pain relief and improving disability of patients suffering from CTS.

Comparison of 4 weeks of cupping and Kinesio-taping on clinical and ultrasound outcomes of carpal tunnel syndrome during pregnancy.

OBJECTIVE: To explore effect of cupping and Kinesio-taping techniques on clinical and ultrasound outcomes of carpal tunnel syndrome (CTS) during pregnancy. METHODS: Thirty pregnant women suffering from CTS were randomly assigned into Kinesio-taping (n = 15) and cupping (n = 15) groups. In Kinesio-taping group, individuals underwent Kinesio-taping for three days, one day with no treatment, and three days with Kinesio-taping, continuing this procedure for four weeks. In cupping group, cupping was moved for 5 min with pressure of 50 mm-Hg on the carpal tunnel area. This procedure continued longitudinally in forearm area for 2 min. The therapeutic intervention of cupping group continued with eight sessions, two days a week for 4 weeks. Ultrasound outcomes including median nerve cross-sectional area through ultrasonography, and clinical outcomes including pain through visual analog scale and severity of symptoms and functional status through Boston questionnaire were measured in both groups before and after therapeutic program. RESULTS: In both groups, a significant reduction was observed in all variables after treatment compared to pre-treatment (P < 0.001). In inter-group comparison, a significant improvement was found in outcomes of Boston questionnaire and ultrasound results about median nerve cross-sectional area at pisiform and hook of hamate in cupping group compared to Kinesio-taping at end of four weeks (P < 0.001). CONCLUSION: Both cupping and Kinesio-taping improved clinical and ultrasound outcomes of CTS. However, efficacy of cupping compared to Kinesio-taping was better in improvement of median nerve cross-sectional area at hamate hook and pisiform levels, symptoms severity scale, and functional status scale, which makes the results clinically more applicable.

The Role of Vitamin D in Carpal Tunnel Syndrome Risk and Supplementation Outcomes: A Systematic Review.

BACKGROUND: Carpal tunnel syndrome (CTS) is a debilitating neuropathy that accompanies pain and other physical limitations and disrupts the normal functioning of the victims' lives. OBJECTIVE: We aimed to investigate Vitamin D's preventive and therapeutic effects on the occurrence and remission of CTS symptoms. METHODS: In this systematic review the PRISMA statement has been designed primarily. An extensive search was undertaken in various databases, including PubMed, Cochrane library, Web of Science, EMBASE, and Scopus. After considering the inclusion and exclusion criteria of the study, finally, 19 articles were retrieved. The raw data were extracted and entered into an Excel form, and the study outcomes were investigated. RESULTS: The main symptoms and tests, including functional score, nerve conduction, and pain, were improved after Vitamin D supplementation in CTS patients. However, they revealed worse scores in people with low Vitamin D levels. In addition, the scores of mentioned indices were worsened in people with lower serum Vitamin D levels. Nevertheless, some studies did not find a significant relationship between low serum 25(OH)D and more significant pain scores in CTS patients. In addition, Vitamin D inserts its effects on CTS by regulating cell proliferation, nerve growth factor, suppression of oxidative stress and inflammatory cytokines, and improvement in cartilage and microvascular damage. CONCLUSION: Vitamin D supplementation can improve the symptoms in CTS patients, and low serum 25(OH)D can aggravate the symptoms of the disease and could be a risk factor for its occurrence. However, more observational studies and clinical trials are needed.

Wide Awake Local Anesthesia No Tourniquet Surgery of Carpal Tunnel Syndrome: Patients' Experience and Recall Bias in a Day-Care Setting.

Background and Objective: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a technique of local anesthesia commonly used in the surgical treatment of a wide variety of conditions affecting the upper extremity, including Carpal Tunnel Syndrome (CTS). The recent retrospective studies investigated patient experiences in a wide variety of hand disorder-related cases. The aim of our study is to evaluate patient satisfaction regarding open surgical treatment for CTS using the WALANT technique. Material and Methods: we enrolled 82 patients with CTS without medical record of surgical treatment for CTS. For WALANT, a hand surgeon used a combination of 1:200,000 epinephrine, 1% lidocaine, and 1 mL 8.4% sodium bicarbonate solution without tourniquet application and sedating the patient. All patients were treated in a day-care setting. For assessment of patient experience, Lalonde's questionnaire was adapted. Participants completed survey twice: one month and six months after the surgical treatment was performed. Results: the median pre-operative pain score for all patients was 4 (range 0-8) after one month and 3 (range 1-8) after six months. The median intraoperative pain score for all patients was 1 (range 0-8) after one month and 1 (range 1-7) after six months. The median post-operative pain score for all patients was 3 (range 0-9) after one month and 1 (range 0-8) after six months. More than half (61% after one month and 73% after six months) of the patients responded by stating that their real experience of WALANT was better than their initial expectations. An absolute majority of patients (95% after one month and 90% after six months) would recommend WALANT treatment to their relatives. Conclusions: overall, patient satisfaction with treatment for CTS using WALANT is high. Furthermore, complications related to the performed treatment and persistent post-operative pain could be associated with more reliable patient recall of this healthcare intervention. A longer period of time between intervention and assessment of patient experience could possibly be a reason for recall bias.

Ultrasound-Guided WALANT Technique in Carpal Tunnel Decompression Surgery* / Técnica WALANT guiada por ultrassom na cirurgia de descompressão do túnel do carpo

Abstract Carpal tunnel syndrome (CTS) is the most common compressive neuropathy in the human body. Its symptoms result from compression of the median nerve in the carpus. The treatment can be conservative, with medications and/or infiltrations that alleviate the symptoms, or surgical, which is more effective, with decompression of the median nerve by surgical section of the flexor retinaculum of the carpus. The anesthetic technique varies according to the anesthesia method: sedation, venous locoregional anesthesia and, more recently, wide-awake local anesthesia no tourniquet (WALANT), which can be performed by the surgeons themselves. The WALANT technique uses local anesthesia with a vasoconstrictor, and does not require the use of a tourniquet on the upper limb nor sedation. The median nerve block in ultrasound-guided WALANT provides better accuracy to the technique, with greater patient safety; in the present article, its use in the performance of carpal tunnel decompression is described, and the literature is reviewed.

Resumo A síndrome do túnel do carpo (STC) é a neuropatía compressiva mais comum do corpo humano. Seus sintomas decorrem da compressão do nervo mediano no carpo. O tratamento pode ser incruento, com medicações e/ou infiltrações que amenizam os sintomas, ou cruento, mais eficaz, com a descompressão do nervo mediano pela seção cirúrgicadoretináculodos flexores do carpo. A técnica anestésica varia de acordo com o serviço de anestesia: sedação, anestesia locorregional venosa e, mais recentemente, a anestesia local com o paciente acordado e sem torniquete (wide-awake local anesthesia no tourniquet, WALANT), que pode ser realizada pelo próprio cirurgião. Por utilizar anestesia local com vasoconstritor, essa técnica dispensa o uso de torniquete no membro superior e a necessidade de sedação. O bloqueio do nervo mediano na WALANT guiada por ultrassonografiaconfere melhor precisão àtécnica,e mais segurança ao paciente, e, neste artigo seu uso na realização da descompressão do túnel do carpo é descrito, e a literatura, revisada.

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique improves the efficiency of distal nerve blocks for carpal tunnel release.

BACKGROUND: Axillary block is the standard for carpal tunnel release (CTR), providing effective anesthesia, and tolerance of tourniquet. Conversely, distal blocks are less used due to poor tolerance of tourniquet. Wide Awake Local Anesthesia No Tourniquet (WALANT), proposed for hand and wrist surgeries, avoids its use. This study assesses the benefits of the addition of WALANT to distal blocks during endoscopic CTR (eCTR). METHODS: This randomized, open-label, controlled trial prospectively enrolled 60 patients scheduled for eCTR. Patients were randomized to receive distal blocks at the wrist combined to either a high arm tourniquet (Distal block group) or a WALANT in the area of surgery (Distal + Walant group). The primary endpoint was the global pain score summing pain scores related to puncture, local anesthetic injection, pneumatic tourniquet, surgical procedure, tourniquet deflation, and residual sensitivity after surgery. RESULTS: Mean global pain score was significantly reduced in the Distal + Walant group (0.5 ± 1.4 vs. 2.2 ± 2.4; p < 0.001). No need for an additional anesthetic procedure was required in the Distal + Walant group. Even if the quality of visualization was high in both groups, it was better in the Distal block group (5 [5-5] vs. 4 [4-5]; p < 0.001). No rescue tourniquet was necessary for the Distal + Walant group. The rate of hematoma 15 days post-surgery was significantly reduced in the Distal + Walant group (20% vs. 57%; p < 0.01). CONCLUSIONS: The addition of WALANT to distal blocks is adapted for eCTR. This combined technique decreases perioperative pain scores, provides good surgery conditions, and reduces the risk of postoperative hematoma. CLINICAL TRIAL NUMBER AND REGISTRY URL: The trial was registered on ClinicalTrials.gov (NCT04494100) on July 31, 2020 https://clinicaltrials.gov/ct2/show/NCT04494100?term=CMC+ambroise+pare&cntry=FR&draw=4&rank=28.

Comparison of acupotomy release combined with glucocorticoid intrathecal injection versus isolated glucocorticoid intrathecal injection for carpal tunnel syndrome: A protocol for a meta-analysis of comparative studies.

BACKGROUND: Carpal tunnel syndrome (CTS) is more common in people who need to engage in repetitive wrist work. Once it has occurred, localized pain and numbness of the fingers will develop, in severe cases, muscle atrophy will even arise, and after rest and physical therapy, many patients will still be unable to relieve or recur. In this case, the patient can receive intrathecal glucocorticoid injections, but the hormone injections alone can only provide short-term relief, and because the mechanical factors of median nerve compression are not fundamentally removed. Therefore, combined acupotomy release can help to release the compression of the transverse carpal ligament on the nerve and increase the volume within the carpal tunnel to achieve more satisfactory long-term results. Hence, a meta-analysis is necessary to provide evidence whether there is a significant difference in the treatment of CTS with acupotomy release combined with glucocorticoid intrathecal injection (ARGI) compared with isolated glucocorticoid intrathecal injection (GI). METHODS: We will search, with no time restriction, without any restriction of language and status, the time from the establishment of the database to October 2022, on the following databases: PubMed, Cochrane central register of controlled trials, Web of Science, Chinese national knowledge infrastructure, Wanfang data, Chinese scientific journals database, Chinese databases SinoMed, and electronic databases. The electronic database search will be supplemented by a manual search of the reference lists of included articles. We will apply the risk-of-bias tool of the Cochrane collaboration for randomized controlled trials to assess the methodological quality. Risk-of-Bias Assessment Tool for nonrandomized studies was used to evaluate the quality of comparative studies. Statistical analysis will be conducted using RevMan 5.4 software. RESULTS: This systematic review will evaluate the difference in efficacy of ARGI versus isolated GI in the treatment of CTS. CONCLUSION: The conclusion of this study will provide evidence for judging whether ARGI is superior to GI for treatment of CTS.