Grandizio Louis C, Choe Lisa J, Klena Joel C
Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
J Hand Surg Am. 2022 Sep;47(9):900.e1-900.e5. doi: 10.1016/j.jhsa.2021.07.030. Epub 2021 Sep 20.
We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR.
All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist's assessment of the flexor retinaculum specimen was categorized as either "ligamentous" if a previously undivided TCL was identified or "nonligamentous" if scar or any other tissue was identified. The surgeon's intraoperative assessment served as the reference standard when comparing the histologic assessment.
A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon's intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time.
Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases.
TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.
我们试图确定在翻修腕管松解术（CTR）期间，外科医生与病理学家在区分先前未分开的腕横韧带（TCL）和瘢痕方面的一致性。此外，我们旨在描述翻修CTR期间TCL和屈肌腱滑膜的组织学发现。
纳入2013年至2019年间由同一位外科医生为持续性或复发性腕管综合征（CTS）进行翻修CTR的所有患者。外科医生在术中评估是否存在瘢痕与先前未分开的TCL。送检两份病理标本（一份由屈肌支持带组成，一份由腱滑膜组成）进行苏木精-伊红染色的组织病理学分析。如果识别出先前未分开的TCL，病理学家对屈肌支持带标本的评估分类为“韧带样”；如果识别出瘢痕或任何其他组织，则分类为“非韧带样”。在比较组织学评估时，以外科医生的术中评估作为参考标准。
共有40例患者接受了46次翻修CTR。在46例病例中的30例（65%）中，组织学评估与外科医生对先前未分开的TCL与瘢痕的术中评估一致。在46例翻修病例中的12例（26%）中，外科医生确定存在先前未分开的TCL。在这12例病例中，病理学家仅17%的时间识别出韧带。
在翻修CTR的情况下，外科医生与病理学家在确定先前未分开的TCL与非韧带组织方面的一致性较低。本研究结果表明，病理学家（临床信息有限）在使用常规苏木精-伊红染色时，难以确认持续性CTS伴先前未松解TCL的临床诊断。翻修CTR期间对TCL进行常规活检的临床效用可能有限，因为它不会改变这些病例的诊断或治疗。
研究类型/证据水平：诊断性III级。
