Michael Shuler, MD, a hand and upper-extremity surgeon at Athens (Ga.) Orthopedic Clinic can perform an endoscopic carpal tunnel release in as little as five minutes.
The incision is about 1 centimeter long. Patients typically wear a soft dressing for three days. After that, he generally does not impose activity restrictions. The speed is striking. But Dr. Shuler believes the more important change happens after the patient leaves the operating room.
Traditional hand surgery has often required patients to accept a long recovery in exchange for relief: weeks in a cast, followed by stiffness, therapy and a gradual return to ordinary tasks.
Newer minimally invasive techniques are challenging that bargain. For Dr. Shuler, the goal is not simply to make the incision smaller. It is to remove unnecessary steps from the operation and unnecessary months from the patient’s recovery time. That philosophy connects two procedures that have reshaped his practice: endoscopic carpal tunnel release and a suture-based approach to thumb carpometacarpal arthroplasty.
One treats a compressed nerve. The other addresses an arthritic joint. Both reflect the same broader shift in outpatient orthopedics: the measure of innovation is increasingly not only whether surgery works, but how little recovery it demands.
When there is nothing to protect
Carpal tunnel release is mechanically straightforward. The surgeon divides the transverse carpal ligament to relieve pressure on the median nerve. Unlike an operation that repairs a tendon or reconstructs a ligament, there is no newly repaired tissue that must be shielded while it heals.
“All we’re doing is releasing a ligament that’s pushing on the nerve,” Dr. Shuler told Becker’s. “There’s nothing that we repair.” That distinction allows him to move patients more quickly. In a traditional open release, the incision sits in the palm, where the skin repeatedly expands and contracts as the hand grips, pushes and bears weight. Activity can place stress directly across the wound.
The endoscopic incision is positioned closer to the wrist crease, away from the highest-pressure portion of the palm. Through that small opening, the surgeon inserts a camera and releases the ligament while watching the blade pass beneath it. The location reduces one of the main postoperative concerns: the wound reopening during use.
Dr. Shuler’s confidence in the technique is personal as well as professional. He underwent the procedure himself about 17 years ago. The scars, he said, are still barely visible.
The camera was the barrier
Endoscopic carpal tunnel release is not new, but its adoption has been uneven. Dr. Shuler believes the greatest obstacle has been surgeon comfort with the camera and instrumentation. Early in the technique’s development, some physicians were concerned about injuring the median nerve, a potentially devastating complication in an operation intended to protect it. The perceived risk can make an open incision feel safer because it is more familiar. Dr. Shuler sees the visualization differently.
“Once you get used to the technique, I would argue it’s probably safer because you’re actually looking at exactly what you’re cutting through the camera,” he said. A surgeon attempting a smaller open release may pass scissors beneath the skin without seeing the full path of the instrument. Endoscopy replaces that limited view with a magnified image of the ligament.
The learning curve remains real, particularly for hand surgeons who may have less routine exposure to arthroscopy than sports medicine surgeons. Dr. Shuler has taught the technique to other orthopedic surgeons since 2015. Once physicians become comfortable with the equipment, he said, the procedure can become easier and more reproducible than trying to perform a conventional release through a very small incision.
The three-month problem in thumb arthritis
The recovery challenge is larger in surgery for arthritis at the base of the thumb. The carpometacarpal joint allows the thumb to oppose the fingers, grip objects and perform many of the fine movements that define hand function. When arthritis destroys the joint surface, even opening a jar or turning a key can become painful.
Surgery typically begins by removing the trapezium, the small arthritic bone at the base of the thumb. Removing the bone eliminates the grinding surface. It also leaves a space beneath the thumb metacarpal that must be managed.
Traditional ligament reconstruction and tendon interposition, known as LRTI, uses part or all of a functioning tendon to suspend and stabilize the thumb. The procedure may also require bone tunnels, tendon weaving and prolonged immobilization.
Patients are commonly placed in a cast for about six weeks. Once the cast comes off, they may spend several more weeks regaining motion. The result can be a recovery approaching three months. That timeline once created a high threshold for surgery, Dr. Shuler said. Patients had to be in enough pain to justify not only the operation but also the disruption that followed it.
“You can imagine, if you’re putting a cast on for six weeks, No. 1, you’re in a cast for six weeks,” he said. “Then, No. 2, you’re trying to get your motion back for probably another six weeks.”
Dr. Shuler began questioning whether that recovery was necessary while studying the evidence behind thumb CMC arthroplasty during fellowship. The essential therapeutic step was removing the arthritic bone. The remaining parts of the operation were intended to prevent the thumb metacarpal from collapsing into the empty space and contacting the scaphoid below.
Historically, surgeons tried temporary pinning. Later, tendon-based reconstructions became common. But the tendon being harvested often worked normally before surgery. Studies suggested that patients could tolerate losing a portion of it. Dr. Shuler still wondered why an otherwise healthy structure should be sacrificed if another method could provide the required stability.
The alternative was a high-strength suture bridge, sometimes described as a suture-button suspension construct. Instead of harvesting a tendon, the surgeon uses the suture to hold the thumb metacarpal in position after the trapezium is removed.
At first, Dr. Shuler followed the traditional recovery protocol and immobilized these patients for six weeks, as well. The outcomes did not look dramatically different. Then he reconsidered what the construct made possible. The suture had substantial tensile strength immediately after surgery. Unlike a tendon reconstruction, it did not need weeks to biologically heal into place before it could tolerate movement.
“We don’t really need to cast these people for six weeks,” he recalled thinking.
The recovery changed when the cast came off
Dr. Shuler began placing patients in a splint for two weeks, then allowing them to start moving the thumb. The difference, he said, was substantial. Pain improved sooner. Patients returned more quickly to golf and other activities. Therapy advanced faster because clinicians were less concerned that early motion would disrupt a delicate reconstruction.
The operation itself also became shorter. Dr. Shuler said a suture-bridge CMC arthroplasty generally takes him about 20 to 25 minutes in women and 25 to 30 minutes in men, whose bone is often more difficult to remove. For him, that is roughly half the time required for a traditional LRTI. The shorter operation eliminates tendon harvesting and weaving. The stronger initial construct reduces immobilization.
At two weeks, patients transition from the splint into a removable brace and begin therapy. They gradually discontinue the brace before or around six weeks, depending on their progress. Some patients who require surgery on both thumbs return within six to eight weeks, asking when the second side can be done. That question would have been much less common when the expected recovery lasted months.
What nine years of follow-up showed
A faster recovery matters only if the reconstruction remains durable. Dr. Shuler published long-term results from his first 242 suture-bridge CMC arthroplasties, with follow-up extending to nine years. At the time of that analysis, none of the constructs had failed because the suture spontaneously ruptured, he said.
The finding addressed a natural concern: whether a synthetic suspension strong enough to accelerate rehabilitation would eventually wear out. The longer-term experience suggested the technique was not merely trading durability for convenience.
Since that original series, Dr. Shuler estimates he has performed close to 2,000 of the procedures. He has encountered some failures, generally after a fall or another event that forcefully catches the thumb. Even then, he said, revision is relatively contained. The damaged suture can be removed and replaced without recreating the entire original operation.
No surgical complication is trivial to the patient who experiences it. But the failures have not resembled a widespread, time-dependent breakdown of the construct. The greater lesson, Dr. Shuler said, has been that strong initial stabilization can change the entire postoperative pathway.
A less burdensome recovery can also change when patients are willing to undergo an operation. Dr. Shuler is careful not to suggest that physicians should operate on people who do not need surgery. But when the traditional treatment requires six weeks in a cast and several additional weeks of rehabilitation, patients may defer care until pain becomes severe.
Reducing immobilization changes the calculation. The operation no longer demands the same prolonged loss of hand function. That can make surgery more practical for patients who work, care for family members or simply cannot place daily life on hold for three months.
The clinical indication may not change. The patient’s willingness to accept the treatment can.
Hand surgery’s natural home
Both procedures fit a setting Dr. Shuler believes is particularly well suited to his specialty.
“Hand surgery is designed for outpatient surgery,” he said. Unlike total joint replacement or complex spine surgery, hand procedures generally did not require years of clinical and operational redesign before they could migrate safely out of hospitals. Dr. Shuler said he now performs hospital-based cases mainly when a patient’s medical condition makes an ASC inappropriate or when Medicare reimbursement at the surgery center does not adequately cover the cost of an implant.
The limitations are often financial or medical rather than technical. Regional anesthesia, postoperative nerve blocks and minimally invasive techniques have made it possible to perform a wide range of upper-extremity procedures without hospital admission. Wide-awake surgery under local anesthesia is extending that trend further for some surgeons and selected cases.
Dr. Shuler does not believe every procedure or patient belongs in an office or ASC. But he sees little reason for the hospital to remain the default home for most hand surgery.
The next advance is time
Orthopedic innovation is often measured through new implants, robotics or increasingly complex procedures. Dr. Shuler’s approach points in a different direction.
The most meaningful innovation may be removing something the patient no longer needs. A large incision. A harvested tendon. Six weeks in a cast. An additional month rebuilding motion lost during immobilization. A hospital visit for an operation that can be performed safely in an outpatient center.
The procedures still require technical skill, careful selection and respect for complications. Faster is not inherently better, and smaller is not automatically safer. But when a surgeon can achieve a durable result with less disruption, recovery becomes part of the clinical outcome rather than an unavoidable price paid for it.
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