Carpal Tunnel Syndrome

SECULAR TRENDS IN THE INCIDENCE OF MALPRACTICE CLAIMS FOR IATROGENIC INJURY DURING CARPAL TUNNEL RELEASE



Carpal tunnel release is perhaps the most common operative procedure performed on the hand and wrist in this country. In general, open decompression as introduced by Learmonth in 1933 and popularized by Phalen in the1950's is considered a safe procedure which provides predictable relief of symptoms with a low incidence of reported complications (1). Endoscopic techniques were introduced in 1989 in an attempt to reduce postoperative morbidity such as pillar pain and to accelerate patients return to work.(2,3,4). Prospective studies comparing endoscopic and open carpal tunnel release have shown that both achieve similar relief of preoperative symptoms (5).

I performed a retrospective review of malpractice claims made each calendar year for iatrogenic injury during carpal tunnel release surgery performed for the diagnosis of carpal tunnel syndrome (ICD-9 354.0) over a 13 year period from January, 1985 through December, 1997 recorded in the data bank of an association of mutual insurers, Physicians Insurance Association of America (source: PIAA data sharing project). The data bank contains report on malpractice claims from approximately 25 of the member companies covering approximately 80,000 physicians (approximately 20% of the private practice physicians in the United States). The data bank does not identify individual physicians or patients or include geographic information. The data was broken down for nerve, artery, and tendon injury.

There was a significant increase in the reported malpractice claims for iatrogenic injury during carpal tunnel release in the years following the initial introduction of endoscopic carpal tunnel release in the United States. In 1991 there were 11 claims, in 1992 12 claims and in 1993 nine claims compared to the previous six years which averaged four claims (Table). Since 1994, the number of malpractice claims for iatrogenic injury has returned to its baseline. Assuming the rate of complications and related malpractice claims with open release is relatively constant, this initial increase and subsequent decrease in claims seen from 1990-1994 could reflect advances along the learning curve of endoscopic carpal tunnel release or a decrease in the number of endoscopic carpal tunnel procedures being performed. Although the information in the PIAA data bank does not allow us to absolutely determine that the increased claims relate to endoscopic methods of carpal tunnel release, the chronological correlation of the claims data and the introduction of endoscopic techniques strongly suggest this.





REFERENCES:

1. Phalen GS, Gardner W, Laloude A. Neuropathy of the median nerve due to compression beneath the transverse carpal ligament. J Bone Joint Surg 32A:109-112, 1950.

2. Okutsu I, Ninomiya S, Takatori Y, et al: Endoscopic management of carpal tunnel syndrome. Arthroscopy;5:11-18. 1989

3 Chow, JC.: Endoscopic release of the carpal ligament for carpal tunnel syndrome: 22-month clinical result. Arthroscopy,6: 288-296,
1990.

4. Agee JM, McCarroll HR, Jr., Tortosa RD, Berry DA, Szabo RM, Peimer CA.: Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J. Hand Surg., 17A:987-995, 1992.

5. Brown RA, Gelberman RH, Seiler JG, III, Abrahamsson SO, Weiland AJ, Urbaniak JR, Schoenfeld DA, and Furcolo D. Carpal tunnel release: a prospective, randomized assessment of open and endoscopic methods. J Bone Joint Surg., 75A(9):1265-1275, 1993.