Annals of Surgical Education ISSN: 2692-7926

Research Article

Are Orthopedic Hand Surgery Fellows Learning the

Endoscopic Carpal Tunnel Technique?
Nicholas A. Beck, Ericka A. Lawler and Joseph A. Buckwalter V*
Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, USA

Abstract
Purpose: To investigate the current training patterns of orthopedic hand surgery fellows in Carpal Tunnel Release (CTR) by endoscopic and open techniques.
Methods: A survey study was conducted of orthopedic hand surgery fellowships by requesting the number of cases logged by the previous year’s fellows (2016-
2017) for Open Carpal Tunnel Release (OCTR) and Endoscopic (ECTR). This data was obtained by having the program director query the Accreditation Council
for Graduate Medical Education (ACGME) Accreditation Data System. In addition, the ACGME was contacted and asked to provide aggregate data for the cases
logged by fellows for OCTR and ECTR from academic year 2016-2017. Basic statistical analysis was performed for the survey data. Polynomial regression analysis
was performed on aggregate data.
Results: A survey was completed by 11 fellowship directors, representing 17% of hand fellowships and providing data on 23% of hand fellows. Most fellowship
programs that responded primarily teach open technique. Fellows performed an average of 106 total carpal tunnel releases: 18 ECTR and 88 OCTR. The aggregate
data from the ACGME included mean, standard deviation, minimum, maximum, and fellow percentiles for ECTR and OCTR for all fellows from academic year
2016-2017. The standard deviation of ECTR (30) was greater than the average (24), indicating a large variability in training patterns. Thirty percent of fellows
performed ≤ 1 ECTR, whereas the most recorded were 147 ECTR. Over half of the fellows performed >10 ECTR. Nearly all fellows recorded at least 36 OCTR.
Conclusion: Orthopedic hand fellowships have large variability in training of ECTR and OCTR. Most fellowships teach primarily the open technique, but many
fellows do get adequate training of ECTR based on previously published standards to safely perform the technique independently.
Keywords: Endoscopic versus open carpal tunnel release; Hand fellowship; Surgical education; Technique training

Introduction nerve and vascular injury [4,11,12]. Improvements in the equipment

and technique have yielded similar rates of complications and patient
Carpal tunnel syndrome is the most common compression
satisfaction to open carpal tunnel release [6,13].
neuropathy treated by hand surgeons, and carpal tunnel release is
one of the most often performed procedures. An estimated 576,924 For other high-volume orthopedic procedures, increased surgeon
carpal tunnel releases were performed in 2006 with current numbers case volume has been associated with better outcomes [14,15]. No
likely higher [1,2]. Release of the transverse carpal ligament is an such studies have shown clear recommendations for the number of
effective treatment for patients with carpal tunnel syndrome and can cases needed to traverse the learning curve for endoscopic carpal
be performed as an Open Carpal Tunnel Release (OCTR) through tunnel release. The Accreditation Council for Graduate Medical
a standard open or mini-open approach or via a single incision [3] Education (ACGME) has minimums for orthopedic surgery residents
or double incision [4] endoscopic technique. Endoscopic Carpal for 15 categories which require at least 10 carpal tunnel releases [16]
Tunnel Release (ECTR) has been shown to be a safe and reliable through either open or endoscopic technique. No such minimums are
alternative to open or mini-open carpal tunnel techniques [5-7] published for orthopedic hand surgery fellows.
and may offer benefits of less immediate post-operative pain and a
The purpose of this study was to determine the current training
quicker return to work [6,8-10]. However, ECTR requires specialized
patterns of orthopedic hand surgery fellows in open and endoscopic
equipment that increases cost and there remains a concern about the
carpal tunnel release techniques. A secondary aim was to estimate
significant learning curve for the technique. Early clinical studies
the number of fellows that are trained to independently perform the
on endoscopic technique show higher complication rates, including
endoscopic technique during their fellowship year.
Materials and Methods
Citation: Beck NA, Lawler EA, Joseph A. Buckwalter V. Are Ortho-
A survey study was designed by creating a three question form to
pedic Hand Surgery Fellows Learning the Endoscopic Carpal Tunnel
obtain the following previous academic year’s data (2016-2017) from
Technique? Ann Surg Edu. 2021;2(1):1013.
program directors: the number of fellows in the program, the total
Copyright: © 2021 Nicholas A. Beck number of cases logged with Current Procedural Terminology (CPT)
Publisher Name: Medtext Publications LLC code 29848 (Endoscopy, wrist, surgical, with release of transverse
carpal ligament) for ECTR, and the total number of cases logged with
Manuscript compiled: Mar 25th, 2021
CPT code 64721 (Neuroplasty and/or transposition; median nerve
*Corresponding author: Joseph A. Buckwalter V, Department of Or- at carpal tunnel) for OCTR. The survey allowed free form answers
thopedic Surgery and Rehabilitation, University of Iowa Hospitals and using Google Forms online customizable template. The survey was
Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA, Tel: 319-356- emailed to all orthopedic hand surgery fellowships program directors
7160; Fax: 319-353-6754; Email: [email protected] and their program coordinators, along with detailed instructions on

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 Annals of Surgical Education

how to obtain the data from the ACGME Accreditation Data System. Table 1: Results of Survey Study of Orthopedic Hand Surgery Fellowship
The email and link to the form were sent twice to increase response Program Directors.
rate, with an interval of one month. Survey Study Results
  Endoscopic CTR Open CTR Total CTR
The ACGME was contacted and a formal request was made for Mean 18 88 106
case log data for orthopedic hand surgery fellows. The request was Standard Deviation 23 34 29
denied as they currently do not provide case log data reported at the Minimum 0 28 39
individual trainee level to external researchers. We were, however, Maximum 108 137 137
able to obtain aggregate data on the CPT codes for endoscopic and Table 2: Aggregate data for orthopedic hand surgery fellows. This data
open carpal tunnel releases from fellows during the academic year represents 146 fellows trained in 64 programs in the United States.
2016-2017 from the ACGME. ACGME Aggregate Data
  Endoscopic CTR Open CTR
Basic statistical analysis to obtain mean and standard deviation Mean 24 86
was performed for survey data. Regression analysis was performed Standard Deviation 31 50
on the reported fellow percentiles from ACGME aggregate data Minimum 0 3
to estimate the percentage of trainees that performed at least 10 Maximum 147 303
endoscopic carpal tunnel releases. Table 3: Orthopedic hand surgery fellow case percentiles for endoscopic and
open carpal tunnel releases.
Results
Orthopedic Hand Fellow Percentiles
We received 11 responses from program directors out of a total   10% 30% 50% 70% 90%
of 64 orthopedic hand surgery fellowship programs, representing a Endoscopic CTR 0 1 13 34 70
response rate of 17%. The data we obtained comprised 23% of the Open CTR 36 54 75 100 151
fellows in the nation. This data is summarized in Table 1.
2007-2014 showed 14% of carpal tunnel releases were performed
Fellows from programs that responded to our survey performed endoscopically, although the use of endoscopic release grew 1.6x
an average of 106 total carpal tunnel release surgeries. Most orthopedic faster than open releases over that time period [17]. We were unable
hand surgery fellowship programs teach primarily the open technique. to discern from the ACGME aggregate data how many programs
The average number of OCTR was 88, versus 18 ECTR. This ratio primarily teach endoscopic technique, but our survey data indicated
of nearly 5 OCTR to one ECTR was consistent across the programs that only 1 fellowship (9% of responders) reported more ECTR cases
that responded, with only one program (9%) reporting more ECTR than OCTR cases. This was somewhat lower than expected, as recent
cases than OCTR. The range of reported cases was 0 to 108 cases for survey studies of active and candidate ASSH members showed 26% to
ECTR and 28 to 137 cases for OCTR. The variability of ECTR cases 36% of surgeons use endoscopic CTR a majority of the time [18,19].
was high as the standard deviation (23 cases) was greater than then
The February 2016 AAOS clinical practice guidelines for
average number of cases reported (18 cases). OCTR also showed high
management of carpal tunnel syndrome give a strong recommendation
variability with a standard deviation of 34 cases.
for surgical release of the transverse carpal ligament regardless of
Aggregate data obtained from the ACGME included the technique, with limited evidence suggesting endoscopic technique
experience of fellows participating in the 64 accredited programs in based on the possible short-term benefits [20]. Published benefits
the 2016-2017 academic year. We were provided basic statistics which of endoscopic technique over open include less short term post-
included average, standard deviation, minimum, and maximum operative pain [6,8,9], faster return to work [6,9,10], better short term
of ECTR and OCTR which is summarized in Table 2. We were also grip and pinch strength [6,9,10], and patients who have had both
provided the fellow percentiles for ECTR and OCTR summarized in performed on them preferred the endoscopic technique [21]. One
Table 3. possible reason for fellowships primarily teaching open technique is
that recent Meta analyses [6,10,22,23] have questioned the real benefit
The ACGME aggregate data showed similar trends to the survey
of ECTR over OCTR as they result in similar long-term outcomes.
data. Fellows performed far more OCTR than ECTR on average. The
means were 86 OCTR cases and 24 ECTR cases. Again, the standard Fellowship programs may be less inclined to teach endoscopic
deviation was high for both. The range of reported cases was 0 to 147 carpal tunnel release due to the well-established learning curve for
cases for ECTR and 3 to 303 cases for OCTR. the technique. The technique is learned either from appropriate
supervision by an experienced surgeon, or by attending a training
The fellow percentiles give a better idea of the variability of fellow
course. Multiple authors have reported the complications observed
experience with ECTR and OCTR techniques. The 50% percentile
from cadaver specimens used to teach the techniques. Rowland and
represents the mode, which was 74 for OCTR cases and 13 for ECTR
Kleinert found incomplete releases in 38% of specimens, lacerations
cases. The 30th percentile for ECTR cases was 1 case, indicating nearly
of an ulnar artery and median nerve, a partial flexor tendon laceration,
one-third of fellows logged ≤ 1 ECTR cases. A regression analysis
and a fracture of the hook of the hamate while teaching a 2-portal
performed on the ECTR percentile data estimated 53 percent of
endoscopic technique [24]. A similar study by Makowiec et al. [25]
fellows logged ≥ 10 ECTR cases.
showed 33% incomplete release of the transverse carpal ligament and
Discussion 3% rate of nerve or vascular injury. Another study by Van Heest et
We found that the vast majority of fellowship programs primarily al. [26] on cadavers with single portal ECTR found 56% incomplete
teach the open technique for carpal tunnel release. The fellow averages release of the transverse carpal ligament and vascular injuries in 2 of
from both the survey data and the ACGME’s aggregate data indicate the 43 specimens (4.6%). A retrospective review of a single surgeon’s
that fellows perform nearly 5 OCTR cases for every 1 ECTR case. first 2 years of practice reported a conversion to open in 11% of
This is in line with current national trends. Pearl Diver data from cases performed in the first 6 months compared to just 1.4% the

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 Annals of Surgical Education

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Cost is another important factor for fellowship programs to Fellowship Training on Rates of Endoscopic and Open Carpal Tunnel Release. J Hand
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18. Leinberry CF, Rivlin M, Maltenfort M, Beredjiklian P, Matzon JL, Ilya AM, et al.
Our study has several limitations. Survey studies have inherent
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