Sood Ravi F, Kamenko Srdjan, McCreary Eleanor, Sather Bergen K, Schmitt Michael, Peterson Steven L, Lipira Angelo B
Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon.
J Bone Joint Surg Am. 2021 Jul 21;103(14):1284-1294. doi: 10.2106/JBJS.20.02093.
As carpal tunnel syndrome often precedes other signs of systemic amyloidosis, tenosynovial biopsy at the time of carpal tunnel release may facilitate early diagnosis and treatment. However, evidence-based guidelines for amyloidosis screening during carpal tunnel release have not been established. We sought to develop a predictive model for amyloidosis after carpal tunnel release to inform screening efforts.
We performed a retrospective cohort study of adults without known amyloidosis undergoing at least 1 carpal tunnel release from 2000 to 2019 with use of the national Veterans Health Administration database. After estimating the cumulative incidence of amyloidosis after carpal tunnel release, we identified risk factors, constructed a predictive nomogram based on a multivariable subdistribution-hazard competing-risks model, and performed cross-validation.
Among 89,981 patients undergoing at least 1 carpal tunnel release, 310 were subsequently diagnosed with amyloidosis at a median interval of 4.5 years, corresponding to a cumulative incidence of 0.55% (95% confidence interval [CI]: 0.47% to 0.63%) at 10 years. Amyloidosis diagnosis following carpal tunnel release was associated with an increased hazard of heart failure (hazard ratio [HR], 4.68; 95% CI: 4.26 to 5.55) and death (HR, 1.27; 95% CI: 1.07 to 1.51) after adjustment for potential confounders. Age, male sex, Black race, monoclonal gammopathy of undetermined significance or multiple myeloma, rheumatoid arthritis, atrial fibrillation, spinal stenosis, and bilateral carpal tunnel syndrome were independently associated with increased risk of amyloidosis diagnosis and were included in the risk nomogram.
Amyloidosis diagnosis after carpal tunnel release is rare but is associated with poor outcomes. We present an amyloidosis-risk nomogram to help guide tenosynovial biopsy at time of carpal tunnel release.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
由于腕管综合征常先于系统性淀粉样变性的其他体征出现，在进行腕管松解术时进行腱鞘活检可能有助于早期诊断和治疗。然而，尚未建立基于证据的腕管松解术期间淀粉样变性筛查指南。我们试图开发一种腕管松解术后淀粉样变性的预测模型，以为筛查工作提供参考。
我们利用国家退伍军人健康管理局数据库，对2000年至2019年期间至少接受过1次腕管松解术且无已知淀粉样变性的成年人进行了一项回顾性队列研究。在估计腕管松解术后淀粉样变性的累积发病率后，我们确定了风险因素，基于多变量亚分布风险竞争风险模型构建了预测列线图，并进行了交叉验证。
在89981例至少接受过1次腕管松解术的患者中，310例随后被诊断为淀粉样变性，中位间隔时间为4.5年，10年时的累积发病率为0.55%（95%置信区间[CI]：0.47%至0.63%）。在调整潜在混杂因素后，腕管松解术后淀粉样变性的诊断与心力衰竭风险增加（风险比[HR]，4.68；95%CI：4.26至5.55）和死亡风险增加（HR，1.27；95%CI：1.07至1.51）相关。年龄、男性、黑人种族、意义未明的单克隆丙种球蛋白病或多发性骨髓瘤、类风湿性关节炎、心房颤动、椎管狭窄和双侧腕管综合征与淀粉样变性诊断风险增加独立相关，并被纳入风险列线图。
腕管松解术后淀粉样变性的诊断很少见，但与不良预后相关。我们提出了一种淀粉样变性风险列线图，以帮助指导腕管松解术时的腱鞘活检。
预后IV级。有关证据水平的完整描述，请参阅作者须知。
