Prevalence and Subtypes of Tenosynovial Amyloid in Patients Undergoing Carpal Tunnel Release

J Hand Surg Am. 2022 Jun;47(6):540-543. doi: 10.1016/j.jhsa.2022.02.013. Epub 2022 Apr 22.

Abstract

Purpose: The purpose of this study was to determine the prevalence and subtypes of amyloid in tenosynovial biopsies of patients undergoing carpal tunnel release (CTR).

Methods: A retrospective review was performed involving patients who underwent CTR from June 2020 to July 2021. Prior to this period, a protocol had been established to obtain routine intraoperative tenosynovial biopsies. Tenosynovium was preserved in formalin and stained with Congo red for amyloid. Positive specimens were sent to an external laboratory for confirmation and subtyping by mass spectrometry. Men 50 years or older and women 60 or older were included for analysis. Acute, traumatic, and revision cases were excluded.

Results: Of 185 patients who underwent CTR with tenosynovial biopsy, 54 (29%) demonstrated positive Congo red stain, confirmed by the external laboratory. A subtype analysis revealed wild-type transthyretin (TTR) in 44 patients (80%), mixed wild-type TTR with κ light chains in 1 patient, and hereditary TTR in 1 patient. Patients with positive specimens were significantly older than those who tested negative (77 vs 68 years, respectively), and positivity increased by decade for both sexes. Male sex, atrial fibrillation, and spinal stenosis were significantly more prevalent among positive cases. There were no complications from the biopsies.

Conclusions: We confirmed evidence of amyloidosis in the tenosynovium of 29% of men 50 years or older and women 60 or older who underwent CTR. The majority demonstrated wild-type TTR. As these patients are at risk of developing cardiomyopathy, there is an opportunity for early detection, monitoring, and interventions known to improve outcomes. Considering the low cost of Congo red staining and the potential value of subtyping with regard to treatment of cardiomyopathy, our findings support routine tenosynovial biopsy during CTR in patients who meet the age criteria.

Type of study/level of evidence: Differential diagnosis or symptom prevalence study II.

Keywords: Amyloid; biopsy; carpal tunnel release; tenosynovium.

MeSH terms

  • Amyloidosis* / epidemiology
  • Amyloidosis* / surgery
  • Cardiomyopathies* / complications
  • Carpal Tunnel Syndrome* / epidemiology
  • Carpal Tunnel Syndrome* / etiology
  • Carpal Tunnel Syndrome* / surgery
  • Congo Red
  • Female
  • Humans
  • Male
  • Prevalence

Substances

  • Congo Red