Use of a hard cast after surgery
I'm scheduling surgery for fairly sever CTS, here in the States. The surgeon I'm considering has all his patients in a rigid cast for a full 15 days following surgery. The cast extends to the base of the fingers. After that time both the cast and the sutures are removed in a single visit. I know that this is contrary to the more common practice today, where an immobilizing bandage is usually worn for just 2 to 5 days, followed by the use of a lighter bandage to protect the stitches. Can this practice - the use of a hard cast that covers most of the palm - possibly promote better healing and/or possibly offer better long term outcomes ? Or does the restrictive cast pose problems with regaining good (full) range of motion. Could it possibly actually limit long term recovery in some other regard ? My main concern isn't discomfort from the cast, or a shorter term delay in returning to activities. It's regarding having a good long term outcome by avoiding scaring and recurrent CTS. But a cast may only be an additional encumbrance. I'd really appreciate a perspective on this matter.
Thank you for the reply. I understand what you are saying.
I would much appreciate it if you could share your own personal opinion.
Of the two surgeons local to me for whom I know the details of their post-operative regimes, one uses traditional sutures a bulky dressing for the first 48 hours, and encourages early mobilisation, the other uses an absorbable suture but keeps a pressure dressing on for a week to try and reduce bleeding and swelling at the operation site. We have studied the outcomes of the first surgeon extensively and they are excellent, on a par with the best results reported in the literature so I think it is safe to say that there is nothing fundamentally wrong with that post-operative regime, but no surgeon's results in CTS are perfect with 100% resolution of symptoms every time and it remains possible that even in that case some change in policy might yield even better results.
The only trial I am aware of was published in 1995 (Cook AC, Szabo RM, Birkholz, SW King EF "Early mobilization following carpal tunnel release. A prospective randomized study" J Hand Surg; 20B(2); 228-230). 25 patients were splinted after surgery and 25 mobilised immediately. They actually concluded that splinting was detrimental, finding that splinted patients were a bit slower to recover but there were no long-term differences and that trial was not really large enough to give a definitive answer. JB
When I meet with my prospective surgeon on Jan 15th we will discuss the matter a bit more, but I don't think I will sway him to a different view on the issue of splinting. Still, I am inclined to proceed under his care because we agree on a number of other matters.
This 2010 survey of the literature which also came to the conclusion that splinting does not offer a long term benefit...but they were at least guarded in ascribing any pronounced detrimental results (some were noted but they seemed to all be short term).
"Does wrist immobilization following open carpal tunnel release improve functional outcome? A literature review."
Current Reviews in Musculoskeletal Medicine
October 2010, Volume 3, Issue 1-4, pp 11-17
S. M. Isaac,T. Okoro, I. Danial, C. Wildin
Thanks for the reference - that's useful and I hadn't found that one. Three of the five papers they found are actually in my reference collection but unfortunately not indexed in a way that makes them easy to find (there are now about 4000 papers in my endnote database). It takes quite a bit to persuade most people to change an established policy but most doctors nowadays are open to argment based on evidence.JB
So far as I can see there is hardly any good quality evidence one way or the other and there is room for some large, well designed trials of different post-operative care regimens. It will not be possible to carry out blinded trials but much better work could be done than is available in the existing literature. Until such trials are carried out I am afraid you are at the mercy of the opinions and personal experience of your surgeon. JB