A Comparison of Histologic and Intraoperative Visual Assessments of Transverse Carpal Ligament During Revision Carpal Tunnel Release

Purpose 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. Methods 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. Results 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. Conclusions 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.