Transverse Carpal Ligament Research Articles

Anatomic Relationship Between the Hook of the Hamate and the Distal Transverse Carpal Ligament: Implications for Ultrasound-Guided Carpal Tunnel Release.

During ultrasound-guided carpal tunnel release, osseous landmarks may supplement direct visualization of the distal transverse carpal ligament (dTCL) to ensure a complete release. The purpose of this study was to determine the relationship between the apex of the hook of the hamate (aHH) and the dTCL within the transverse safe zone (TSZ) of the carpal tunnel. Twenty unembalmed cadaveric specimens were dissected to determine the aHH-dTCL distance and the aHH-SPA distance (the distance between the aHH and the superficial palmar arch) at the ulnar and radial limits of the TSZ (the distance between the hook of the hamate or ulnar artery to the median nerve). The aHH-dTCL distance averaged 11-12 mm across the TSZ (maximum, 18.2 mm), whereas the aHH-SPA distance was significantly greater on the radial side of the TSZ compared with the ulnar side (22.6 ± 3.6 mm vs. 14.0 ± 4.0 mm). The dTCL lies approximately 11-12 mm distal to the aHH across the TSZ, with an upper limit of 18.2 mm. Along with direct sonographic visualization of the dTCL, the aHH can be used with other osseous landmarks to estimate the position of the dTCL during ultrasound-guided carpal tunnel release.

Correlation of musculoskeletal ultrasound and electrodiagnosis in patients with Carpal tunnel syndrome

The MSK USG provides a clear image of tendons and nerves at level of the carpal tunnel. However, there is no specific ultrasonographic standardized measure in Mexicans that supports diagnosis of STC. To establish ultrasound measurements of the median nerve in healthy people and their correlation with electrodiagnosis in patients with STC. Two phases were performed. In first, 48 hands in 24 healthy subjects were assessed with EMG study. By means of the musculoskeletal ultrasound, the Cross Sectional Area of the median nerve was measured in two points: 12 cm cephalic to the proximal crease of the carpus and the tunnel entrance. The index A is calculated with these two measurements and finally the thickness of the transverse carpal ligament was measured. In the second phase, 25 patients with a clinical and electromyographic diagnosis of CTS were evaluated, who underwent the same ultrasonographic measurements. We explored Kolmogorov-Smirnov distribution of quantitative series of sample, Student's T for variables of central tendency ( P < 0.05) Fisher's test for comparison groups and Momios OD coefficient to establish sensitivity and specificity of indicators. Index A and AST were found with greater difference in patients with CTS ( P ≤ 0.001) with respect to controls, having direct correlation with clinical stage. The predictive variables of CTS were age > 44 years, BMI > 26.381, and index A greater than 1.1. The MSK USG in CTS is useful for perform its diagnosis. Index A is a tool with high sensitivity and specificity as well as being essential in cases where median nerve in initial stages still has no increase in size of its thickness.

Computer-Aided Rehabilitation for the Carpal Tunnel Syndrome using Exergames

Carpal tunnel syndrome (CTS) has reached epidemic proportions as the surgical release of the transverse carpal ligament is included in the top ten most common operations, which significantly affects health care costs. Additional costs to consider include time off work, lost wages, and diminished workplace productivity. Non-surgical management of CTS such as splinting, non-steroidal anti-inflammatory medication, steroid injections and ergonomic modification of the work habits can help in early cases, but can be ineffective in more advanced cases, often leading to recommendation for surgical treatment. It is possible to attain meaningful physiotherapy results through interesting and engaging computer-based games which provide the motivation to continue therapy at home, even away from direct therapist supervision. Motivation and immersion in the game scenario also helps patients forget that they are performing exercises as a part of their therapy. Accordingly, we present a Unity3D Fly-A-Plane game, the scenario of which combines CTS-specific physiotherapy exercises in a natural game scenario to fly an airplane through a sequence of hoops in the sky. The game employs the Leap Motion sensor, whose detailed wrist and hand (including fingers) tracking abilities make it an excellent hardware platform for rehabilitation oriented exercises intended for patients suffering from CTS.

Finite element analysis for transverse carpal ligament tensile strain and carpal arch area

Mechanics of carpal tunnel soft tissue, such as fat, muscle and transverse carpal ligament (TCL), around the median nerve may render the median nerve vulnerable to compression neuropathy. The purpose of this study was to understand the roles of carpal tunnel soft tissue mechanical properties and intratunnel pressure on the TCL tensile strain and carpal arch area (CAA) using finite element analysis (FEA). Manual segmentation of the thenar muscles, skin, fat, TCL, hamate bone, and trapezium bone in the transverse plane at distal carpal tunnel were obtained from B-mode ultrasound images of one cadaveric hand. Sensitivity analyses were conducted to examine the dependence of TCL tensile strain and CAA on TCL elastic modulus (0.125–10 MPa volar-dorsally; 1.375–110 MPa transversely), skin-fat and thenar muscle initial shear modulus (1.6–160 kPa for skin-fat; 0.425–42.5 kPa for muscle), and intratunnel pressure (60–480 mmHg). Predictions of TCL tensile strain under different intratunnel pressures were validated with the experimental data obtained on the same cadaveric hand. Results showed that skin, fat and muscles had little effect on the TCL tensile strain and CAA changes. However, TCL tensile strain and CAA increased with decreased elastic modulus of TCL and increased intratunnel pressure. The TCL tensile strain and CAA increased linearly with increased pressure while increased exponentially with decreased elastic modulus of TCL. Softening the TCL by decreasing the elastic modulus may be an alternative clinical approach to carpal tunnel expansion to accommodate elevated intratunnel pressure and alleviate median nerve compression neuropathy.

Ultrasound-guided needle release of the transverse carpal ligament with and without corticosteroid injection for the treatment of carpal tunnel syndrome

BackgroundTo compare the clinical effectiveness of ultrasound-guided needle release of the transverse carpal ligament (TCL) with and without corticosteroid injection in carpal tunnel syndrome (CTS).MethodsFrom June 2016 to June 2017, 49 CTS patients (50 wrists) were included in this study. Twenty-five wrists were treated with ultrasound-guided needle release of the TCL plus corticosteroid injection (group A), and 25 wrists were treated with single ultrasound-guided needle release of the TCL (group B). The following parameters were assessed and compared including postprocedure results according to relief of symptoms, ultrasound parameters (cross-sectional area of the median nerve at the levels of pisiform, flattening ratio of median nerve at the levels of the hamate bone, and the thicknesses of TCL on the cross-section at the level of the hamate bone), and electrophysiological parameters (distal motor latency and sensory conduction velocity).ResultsGroup A had higher overall excellent and good rate 3 months after the procedure than group B (84 vs 52%, P < 0.05). There were significant differences regarding the above ultrasonic and electrophysiological parameters between the baseline and postprocedure values in both groups (all P < 0.05). There were significant differences regarding the postprocedure values of above ultrasonic and electrophysiological parameters between the two groups (all P < 0.05). No complications such as infection or tendon rupture were noted. No procedures were converted to the open release.ConclusionsBoth techniques are effective in treating CTS. Ultrasound-guided needle release of the TCL with corticosteroid injection had better treatment benefits than single ultrasound-guided needle release of the TCL in treating CTS.

Influence of the thickness of the transverse carpal ligament in carpal tunnel syndrome

ObjectiveTo determine if the thickness of the transverse carpal ligament measured by T2 axial magnetic resonance imaging actually influences the onset of carpal tunnel syndrome. Material and method94 patients between January 2015 and June 2016, of whom 28 had carpal tunnel syndrome, underwent magnetic resonance imaging, 37 with discomfort in different carpus regions without symptoms of carpal tunnel and 29 healthy subjects. Two observers performed 3 measurements in 3 different levels, and in the 3 groups of patients. ResultsNo statistically significant differences in transverse carpal ligament thickness measurements between the carpal tunnel syndrome group and the group without carpal tunnel involvement became apparent, but statistical differences between the control group and the carpal tunnel syndrome group, and between the control group and the group without involvement of the carpal tunnel were observed. In both these groups, the thickness of the transverse ligament was higher than in the control group. DiscussionAn increase in the thickness of the transverse ligament in was found in this study in subjects with involvement of carpal tunnel syndrome as evidenced by numerous studies in the literature. There is no certain causative factor, but rather a set of facts that make onset of the syndrome possible in a specific group of patients. ConclusionCarpal tunnel syndrome is multifactorial. The thickness of the transverse ligament does not directly affect the onset of symptoms.

Ultrasound‐Guided Microinvasive Carpal Tunnel Release Using a Novel Retractable Needle‐Mounted Blade: A Cadaveric Study

Ultrasound (US)-guided microinvasive procedures are defined as those performed via needles without notable scarring. Ten cadaver hands underwent US-guided microinvasive carpal tunnel release using a novel needle-based tool, the micro i-Blade (Summit Medical Products, Inc, Sandy, UT). A US-imaged landmark, the inflexion point of the ligaments distal to the hook of the hamate, was used to position the distal extent of the cut. The transverse carpal ligament was successfully released in all hands without damage to nerves or arteries. In 3 specimens, the fascia between the thenar and hypothenar muscles was partly preserved, whereas the palmar aponeurosis was partly cut in 1 specimen. The micro i-Blade with the cutting knife retracted was also useful as a probe palpated through the palm of the cadaver hand, to test the release of the transverse carpal ligament and to guide the procedure.

Retractor endoscopic techniques in the treatment of entrapment peripheral neuropathies

With increasing awareness for minimally invasive approaches, endoscopic techniques for peripheral nerve decompression are becoming increasingly popular. The first endoscopic approach to release a pinched nerve was for carpal tunnel release through a single entry port, whereby the compressed canal was dilated with bougies and an endoscope introduced into this canal to transect the transverse carpal ligament. Since most of the manipulations with the blunt bougie in this technique were done in a blind fashion, there was a lurking potential for iatrogenic nerve injury using the bougie technique. Thus the retractor-integrated endoscopic technique was developed. In this technique, the retractor bearing the endoscope is introduced into a plane above the compressing ligaments and the nerve proper and a bird’s eye perspective of the anatomical site is gained. Owing to the simplicity of the technique, the retractor-endoscope was used to decompress any nerve at any site in the body: furthermore it was employed for harvesting nerves, vessels and tendons for transplantation. In this paper, we describe the various endoscopic techniques used for decompression in peripheral nerve entrapment syndromes and provide a comprehensive and comparative metaanalysis of the techniques.

The effects of standardised cold and compression therapy on swelling, pain and functional outcome after division of the transverse carpal ligament in carpal tunnel syndrome

This prospective, randomised study examines the effect of standardised cold compression therapy on swelling, pain and functional outcome after division of the transverse carpal ligament in carpal tunnel syndrome in comparison to cooling alone. Fifty patients for division of the transverse carpal ligament were randomised into two groups. In group 1, postoperative conventional cooling therapy was performed. Group 2 was given standardised cooling and compression therapy with the Cryo/Cuff™-system (3 × 10 min twice daily). Follow-up examinations were performed on days 1, 8 and 21 after the operation. One patient in group 1 and 3 patients in group 2 could not be followed up. Test parameters were pain, swelling, mobility, strength, and the DASH and MHQ score. There were no significant differences between the two groups at any time point. In this study, no advantage could be demonstrated for standardised cooling and compression therapy with the Cryo/Cuff™-system in comparison with conventional cooling after division of the transverse carpal ligament.

Surgical Causes of Recurrent Carpal Tunnel Syndrome

The aim of this research is to characterize the most common causes of recurrent carpal tunnel syndrome. Cases that were included in this study subjected to a detailed history and examination. The diagnosis was confirmed by electrophysiological studies and intraoperative findings. This study demonstrates that, all patients were found to have fibrosis surrounding the median nerve, which was attached to the radial leaf of the transverse carpal ligament, except one patient whose median nerve was found to have an adhesion to the subcutaneous tissue and 6% of the cases were found to have the incomplete release of the flexor retinaculum.

Ultrasound Guided Transverse Carpal Ligament Fenestration for Carpal Tunnel Syndrome: A Case Series

Carpal tunnel syndrome is caused by compression of the median nerve under the transverse carpal ligament. We present a description of an ultrasound-guided (USG) percutaneous technique of the transcarpal tunnel and provide a discussion to the evidence in utilizing a minimally invasive technique as an alternative to open and endoscopic carpal tunnel release. USG percutaneous transverse carpal ligament fenestration is a quick, and relatively simple office based treatment for carpal tunnel syndrome. The use of ultrasound provides satisfactory visualization for the procedure and requires very little time and effort for setup. Here, in this case series, we detail the procedure and the results from our follow-up. This report details a case series of 2 patients with confirmed electrodiagnostic findings of mild to severe median neuropathy at the wrist in a university hospital outpatient pain management center. USG percutaneous fenestration of the transcarpal ligament was performed under local anesthesia. Patients were followed up from 4 to 20 weeks. It was found in patient 1, a greater than 60% reduction in pain at 20 weeks follow-up, and patient 2 had at least 50% reduction in pain at 8 weeks follow-up. Both patients had a minimum of 50% improvement in pain and sensory disturbance and without any adverse events. The main advantage of USG transverse carpal ligament fenestration is that it is an office based procedure, requiring local anesthesia only. Minimally invasive USG transcarpal ligament fenestration, in select patients, may be an appropriate tool and even prove to be a surgery-sparing modality. The limitations of this study includes no case-control, small sample size, and the short term follow-up. In conclusion, this case series presents an alternative to a more invasive and costlier procedure including open and endoscopic carpal tunnel release, usually performed in a surgical suite. USG percutaneous transverse carpal ligament fenestration is a quick, and relatively simple office based treatment for carpal tunnel syndrome. The use of ultrasound provides satisfactory visualization for the procedure and requires very little time and effort for setup. Key words: Ultrasound guided, transverse carpal ligament, fenestration, carpal tunnel syndrome

Anatomical Relationships between Muscles Overlying Distal Transverse Carpal Ligament and Thenar Motor Branch of the Median Nerve.

BackgroundThe purpose of the current study is to investigate anatomical relationships between the muscle overlying the distal transverse carpal ligament (TCL) and the thenar motor branch of the median nerve.MethodsOf the 192 wrists that underwent open carpal tunnel release, a muscle belly overlying the TCL was observed on the distal margin of TCL in 25 wrists and ligament exposure could not be achieved without transection of it. We recorded surgical findings of these 25 wrists. The origin of the recurrent motor branch arising from the major median nerve was marked on the axial and coronal section diagrams of the wrist.ResultsThe presence of muscle overlying the TCL was seen in 25 wrists (21 patients, 13%). The locations of origin were distributed not only on the radial side but anterior or ulnar side of the major median nerve. Abnormal branches originated from the unusual side in 14 cases (56% of those with a muscle overlying the TCL): central-anterior side in eight cases, ulnar-anterior side in five cases, and ulnar side in one case. These anomalous branches were frequently associated with the muscle belly overlying the TCL in our study regardless of the origin site. The branches were prone to cut if careless midline incision along the third web space was performed. Unusual origin and aberrant pathway of the recurrent thenar motor branch were associated with the presence of a muscle overlying the TCL.ConclusionsA thorough knowledge of the standard and variant anatomy of the muscle belly and recurrent motor branch in the carpal tunnel is fundamental to prevention of complications such as muscle wasting or atrophy by iatrogenic motor branch injury during carpal tunnel release.

Carpal Tunnel Release Experience with Minimal Wrist Incision

Objective: Carpal tunnel syndrome (CTS) is the most common peripheral trap neuropathy resulting from compression of the median nerve in the carpal tunnel of the wrist. Open release of the transverse carpal ligament is now the most commonly used method. New techniques are being developed to avoid complications of standard long curvilinear incision. Methods: Between March 2010 and January 2016, carpal tunnel release was performed by the same surgeon with 110 minimally invasive techniques in 96 patients due to CTS. Complaints and physical examination findings were compatible with CTS and mid- to severe-severity CTS cases supported by EMG were included in the study. Results: Complaints and examination findings were recorded at the post-operative 1st year outpatient clinics of the patients. Of the110 carpal tunnel release, in 50 patients (%45,5) total, in 45 patients (%40.9) significant, in 13 patients (%11,8) slight improvement were recorded, while no improvement was recorded in 2 patients (%1,8). They stated that 88% of the patients were satisfied with the operation and 12% were not satisfied. Visual Analog Scale (VAS) was used to evaluate pain complaints. The mean VAS score was 7,5 pre-operatively and 3,2 at post-operatively 1 year follow-up. Conclusion: In patients with CTS, median nerve decompression with minimal wrist incision is an effective and reliable surgical procedure.

MRI Assessment of Changes in Swelling of Wrist Structures Following OMT in Patients With Carpal Tunnel Syndrome

Abstract We treated patients with carpal tunnel syndrome using OMT. Treatments were focused on the upper thoracic spine, lower cervical spine, and tenderpoints in the forearm muscles. OMT was not applied to the wrist in an attempt to stretch the transverse carpal ligament. MRI images were used to assess changes in fluid content in both the carpal tunnel and median nerve after OMT treatment. MRI measurements of median nerve area, carpal tunnel area and length of the transverse carpal ligament were also obtained. These measurements were correlated with changes in nerve conduction velocities (NCVs), pain ratings, wrist motion measurements, and somatic dysfunction information. The numeric data were compared and contrasted using Hest statistics. Significance probabilities of P &amp;lt; 0.05 were computed. Statistically significant changes were noted in pain ratings, wrist motions and nerve conduction (sensory amplitude). Five patients responded with improvement in symptoms and one did not. The responder group demonstrated a decrease in the amount of swelling of both the median nerve and carpal tunnel. The nonresponder demonstrated increased swelling in both the median nerve and carpal tunnel. Changes in the swelling of both the median nerve and carpal tunnel appear to more closely parallel changes in hand symptoms than nerve conduction results.1 No statistically significant increases occurred in the length of the transverse carpal ligament or the carpal tunnel area. Minimal changes in both the length of the transverse carpal ligament and carpal tunnel area did occur despite no active attempts to stretch this region. All six patients had a predominance of acute changes in the upper thoracic spine and upper ribs. Most patients had tension in the flexor muscles of the forearm. Treatment of the upper thoracic spine, upper ribs, and forearms are all important in the management of carpal tunnel syndrome.

Influencia del espesor del ligamento transverso del carpo en el síndrome del túnel carpiano

ObjectiveTo determine if the thickness of the transverse carpal ligament measured by T2 axial magnetic resonance imaging actually influences the onset of carpal tunnel syndrome. Material and method94 patients between January 2015 and June 2016, of whom 28 had carpal tunnel syndrome, underwent magnetic resonance imaging, 37 with discomfort in different carpus regions without symptoms of carpal tunnel and 29 healthy subjects. Two observers performed 3 measurements in 3 different levels, and in the 3 groups of patients. ResultsNo statistically significant differences in transverse carpal ligament thickness measurements between the carpal tunnel syndrome group and the group without carpal tunnel involvement became apparent, but statistical differences between the control group and the carpal tunnel syndrome group, and between the control group and the group without involvement of the carpal tunnel were observed. In both these groups, the thickness of the transverse ligament was higher than in the control group. DiscussionAn increase in the thickness of the transverse ligament in was found in this study in subjects with involvement of carpal tunnel syndrome as evidenced by numerous studies in the literature. There is no certain causative factor, but rather a set of facts that make onset of the syndrome possible in a specific group of patients. ConclusionCarpal tunnel syndrome is multifactorial. The thickness of the transverse ligament does not directly affect the onset of symptoms.

Validation of the range of dry needling with the fascial winding technique in the carpal tunnel using ultrasound

ObjectivesTo use ultrasound imaging to show how the needles in dry needling applied in the carpal tunnel can reach the transverse carpal ligament, acting on it in the form of traction-stretching when the fascial winding technique is performed. The potential associated risks are also assessed. DesignValidation study. ParticipantsHealthy volunteers (n = 18). MethodsFour dry needling needles were applied to the carpal tunnel, only using anatomical references, according to the original approach known as “four-pole carpal dry needling”, and manipulating the needles following the so-called fascial winding technique according to the authors, in the form of unidirectional rotation. An ultrasound recording of the distance reached was then performed, and compared with the mechanical action achieved on the transverse carpal ligament. Results93.1% of the needles placed came into contact with the transverse carpal ligament with traction-stretching of the ligament observed when the needles were manipulated with the fascial winding technique in 80.6%. The mean distance from the tip of the needle to the median nerve was 3.75 mm, with CI95% [3.10, 4.41] and it was 7.78 mm with CI95% [6.64, 8.91] to the ulnar artery. Pain immediately after the technique concluded was of mild intensity, almost nil 10 min later, and non-existent after one week. ConclusionDry needling with fascial winding technique in the carpal tunnel using the four-pole carpal dry needling approach is valid for reaching and traction of the transverse carpal ligament, and may stretch it and relax it. It is also safe with regard to the median nerve and ulnar artery, with a very mild level of pain.

Carpal tunnel syndrome: is the local corticosteroid injection electrophysiologically effective?

Background: Carpal Tunnel Syndrome (CTS), compressive lesion of the median nerve at the wrist, is the most world widely prevalent entrapment neuropathy. There are current therapeutic tools available, including conservative measures (e.g. manual splints, local corticosteroids injections or systemic corticosteroid therapy, etc) and surgical intervention on carpal transverse ligament. Current scientific data regarding improvement related to conservative measures are still conflicted, despite several studies support clinical improvement on pain scales, more objective data regarding electrophysiologic parameter still lack on literature.

Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes?

ObjectiveThis case-control study was designed to test the hypothesis whether carpal tunnel release (CTR) during fixation of distal radius 23-C2 AO fractures improves outcomes. MethodsThirty-five consecutive patients who sustained distal radius fractures of the dominant hand participated in this study. Patients were allocated into two groups: (a) The ORIF + CTR (16 patients (11 males and 5 females)); (b) the ORIF and NOT CTR 19 patients (12 males and 7 females). Patient assessment included visual analogic scale of pain (VAS), the subjective Mayo Wrist Score (MWS), electromyograms (EMG) at 3 month and 6 months from the day of injury and complications. All patients had the same physiotherapy treatment algorithm following surgery. Patient follow up took place at 1 month, 3, 6, and 12 months. ResultsA the T12 month follow up point the VAS average was 0.8 (range 0–3) in ORIF + CTR group compared to 1.2 (range 0–3) in the ORIF and NOT CTR. The MWS average was 98.7 (range 95–100) in ORIF + CTR group versus 97.6 (range 95–100) in ORIF no CTR group. There was no statistical significance (p > 0.5) between the two groups during the follow up period. Patients in the sixth month of ORIF + CTR had no suffering of the median nerve, while 31.58% of patients in ORIF and no CTR found to have carpal tunnel syndrome. ConclusionsRoutine release of the transverse carpal ligament at the time of fracture fixation may reduce the incidence of postoperative median nerve dysfunction.

What Are the “Critical Portions” of Carpal Tunnel Release, Ulnar Nerve Transposition, and ORIF Distal Radius?

There is no financial information to disclose. Overlapping surgery is attracting increased scrutiny. The American College of Surgeons (ACS) states that the attending surgeon must be present for all “critical portions” of a surgery; however, critical portions of surgeries are not defined. We hypothesized a Delphi panel process would promote and measure consensus on the critical portion of 3 common hand surgeries. We used a 3-round Delphi process to achieve consensus on the “critical portions” in carpal tunnel release (CTR), ulnar nerve transposition (UNT; subcutaneous/submuscular), and ORIF distal radius. “Critical” was based on the ACS definition. Panelists were 10 hand surgeons (7 fellowship-trained surgeons and 3 fellows). Round 1 (in-person): panel reached consensus on steps of each procedure. Round 2 (online): panelists rated steps from 1 (not critical) to 9 (extremely critical) and provided open-ended comments. Round 3 (online): panelists received summary statistics and open-ended comments from round 2 and re-rated the steps. We operationalized consensus as ≥ 80% rated a step using the same range: 1-3 (not critical), 4-6 (somewhat critical), 7-9 (critical). From round 2 to round 3 the range of scores compressed, indicating greater agreement. Final round results are summarized in Figure 29-1. For CTR, panelists reached consensus that dividing the transverse carpal ligament was critical and wound closure and dressings were non-critical. There was no consensus on skin incision or division of subcutaneous tissue. For UNT, panelists reached consensus that mobilizing the ulnar nerve, preparing the transposition, transposing the nerve, and assessing the transposed nerve were critical and closure and splint/dressings were non-critical. There was no consensus on skin incision, preservation of MABC, and hemostasis. For ORIF distal radius, panelists reached consensus that fracture reduction, skeletal fixation, and fluoroscopic evaluation were critical; fracture exposure and assessment of joint stability was somewhat critical; and hemostasis, closure, and splint/dressings were non-critical. There was no consensus on whether skin incision was critical. •For all procedures, panelists reached a consensus rating for the majority of steps, but not for skin incision.•The project provides proof of concept that a Delphi process is useful in fostering and measuring consensus on the critical portions of surgery.•Further work is needed to address areas of disagreement and the implications of a consensus that a step is “somewhat critical.” A consensus is needed whether such areas should be eliminated through further rounds or leeway in surgical practice is appropriate.•Efforts are underway to repeat this process with additional and more diverse panelists.

Anatomic and clinical study of a new surgical procedure with volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome

Objective To investigate the anatomical basis and clinical effects of a new surgical procedure with volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome. Methods On 8 fresh adult upper limb specimens (16 sides), anatomical observation and measurement of carpal tunnel and palm structures were performed to determine the entry point, guide line and operative level of a new surgical procedure with volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome. According to the anatomical findings, the new operation was performed on 68 patients with moderate to severe carpal tunnel syndrome. Postoperative recovery of the patients was followed up and compared with that of 75 patients who received conventional open carpal tunnel release at the corresponding period. Results According to the results of anatomical study, the best entry point of the surgical procedure was determined as following. A line parallel and ulnar to the metacarpophalangeal joint was drawn when the thumb was at maximum radial abduction. Another line was drawn along the long axis between the index and middle fingers. A 1-cm long vertical incision was made at 45° and 1-cm ulnar to the intersection of these two lines. The surgical projection line was the line connecting the surgical incision and the intersection point between palmaris longus tendon and distal wrist crease. The dissection plane was the space between the superficial palmar fascia and the palmar aponeurosis. The 68 minimally invasive surgery treated cases were follow-up for 6 to 12 months, the average follow-up being 9.5 months. Based on the carpal tunnel syndrome postoperative functional assessment criteria proposed by Gu, the results were satisfactory. Postoperative pain symptoms, sensory examination, muscle atrophy, thumb opposition, pinching and grip strength were all significantly improved. There was very little postoperative scar pain. Compared with the conventional surgery the minimally invasive procedure has obvious advantages. Conclusion Volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome has sound anatomical basis. It can effectively reach and divide the transverse carpal ligament, decompress the median nerve. Therefore it is an effective minimally invasive approach in the treatment of carpal tunnel syndrome. Key words: Carpal tunnel syndrome; Surgical procedures, minimally invasive; Anatomy; Clinical study