This study was supported by a fund from the University-Industry Collaborative Education Program of the Ministry of Education in 2021 (project number: 202101312014) and a fund from the University-Industry Collaborative Education Program of the Ministry of Education in 2022 (project number: 220905634190447).

This study was approved by the ethics committee of our institution and all patients provided informed consent before participating in the study.
1. Preoperative steps
<ol>
	<li>Exclude patients with cervical radiculitis, brachial plexus lesion, pronator syndrome, and nerve tear before the operation.</li>
	<li>Define carpal tunnel syndrome based on persistent numbness, tingling, pain, and muscle weakness in the median nerve distribution area, positive physical examination (Tinel sign, wrist compression test, thenar muscle weakness or atrophy), and electromyography.</li>
</ol>
2. Initial surgical procedures
NOTE: Pay attention to the abnormal anatomy of nerves and blood vessels during the operation.
<ol>
	<li>Preoperative preparation
	<ol>
		<li>Position the patient in the supine position on the operating table with the affected limb and a tourniquet is tied to the proximal end of the upper arm. Prepare the distal end of the affected limb and wrap it in a routine aseptic manner under brachial plexus anesthesia or general anesthesia. Place the patient&#39;s palms upward on the table and properly fix them on a small square piece of cloth. 
		NOTE: During the operation, avoid damaging the visible palmar cutaneous branch of the median nerve and prolonging the use of the tourniquet.</li>
	</ol>
	</li>
	<li>Skin incision
	<ol>
		<li>Cut the skin longitudinally along the surgically marked incision in the palm and make a longitudinal incision 3 cm in length. Carefully dissect the subcutaneous fat layer (Figure 2C), taking care to protect the small branches of the palmar cutaneous nerve, which may traverse proximally through the incision.</li>
	</ol>
	</li>
	<li>Subcutaneous separation
	<ol>
		<li>Retract the subcutaneous tissue and protect the median nerve. Then, sharply separate and incise the palmar fascia. Use a smooth, curved vascular clamp to sharply separate the tissue below the transverse carpal ligament, and use curved, blunt-headed scissors to cut the proximal transverse carpal ligament or forearm fascia.</li>
	</ol>
	</li>
	<li>Release of the carpal canal
	<ol>
		<li>Locate the distal end of the transverse carpal ligament, where the ligament is relatively weak. Make a sharp incision of the transverse carpal ligament between the superficial palmar arch and the distal end of the transverse carpal ligament, under the guidance of accurate identification of the median nerve position to avoid median nerve injury due to any deviation in position.
		<ol>
			<li>Identify the tissue before cutting off any tissue structure, and avoid damaging the ulnar nerve, the median nerve (including the motor branch), and the palmar arch.</li>
		</ol>
		</li>
		<li>Perform the dissection below the transverse carpal ligament using smooth, curved vascular forceps. When separating along the ulnar side of the median nerve during the operation, avoid damaging its motor branch, which can be located below or across the ligament. 
		NOTE: Operating on the ulnar side of the median nerve avoids damage to the ulnar nerve that runs within Guyon&#39;s canal while allowing greater identification of the dorsal structures of the carpal tunnel.</li>
	</ol>
	</li>
	<li>Release of the transverse carpal ligament
	<ol>
		<li>Sharply separate and incise the transverse carpal ligament. Take care to pull the retractor up the incised transverse carpal ligament at this time to protect the median nerve below it and avoid damage to the communication branch between the median nerve and the ulnar nerve.</li>
		<li>Cut the transverse carpal ligament with scissors along the ulnar side of the median nerve under direct vision through the incision (Figure 3A). Keep the incision on the ulnar side of the long palmar muscle and cut along the ulnar edge of the transverse carpal ligament and the ulnar edge of the long palmar tendon to avoid damage to the superficial palmar arch, palmar cutaneous nerve, and the recurrent branch of the median nerve.</li>
		<li>Fully stop the bleeding when the incision is exposed. Before releasing the transverse carpal ligament during the operation, take care to distinguish the superficial palmar arch, Guyon canal (wrist ulnar nerve canal), and carpal tunnel.</li>
		<li>Use a retractor to pull up the skin near the incision and release the transverse carpal ligament to the level of the far flexion carpal crease&#160;(Figure 3B). Under direct vision, use blunt-tip scissors to incise the proximal forearm fascia 2-3 cm to allow a finger to pass through the fascia (Figure 3C). Then, use a retractor to pull the skin distal to the incision, and loosen the transverse carpal ligament and palmar fascia to the level of the median nerve branch.</li>
		<li>During the operation, take care to check whether there is any lesion or injury at the bottom of the carpal canal so that the median nerve can be completely released and vital structures are not damaged (Figure 3D). If residual local compression is still present, consider additional release procedures to release the epineurium.</li>
	</ol>
	</li>
	<li>Closed incision
	<ol>
		<li>After the incision completely stops bleeding, loosen the tourniquet, rinse the surgical incision with normal saline, check the incision again for bleeding, and use bipolar electrocoagulation to stop bleeding if there is any bleeding. Be familiar with the course of the ulnar finger nerve in the middle finger and ring finger. Finally, fold the edge of the skin without tension.</li>
		<li>Anesthetize the skin margin of the incision with lidocaine and close it intermittently with 5-0 sutures. Cover the incision with loose, thick gauze so that the fingers can move freely (Figure 2D). Encourage finger movement and mild finger use immediately after the operation.</li>
	</ol>
	</li>
</ol>
3. Postoperative care
<ol>
	<li>Choose thick gauze to cover the wound; to ensure that the fingers can move freely, choose a palmar brace to fix for 3-4 weeks.</li>
	<li>After 3-4 weeks, remove the palmar brace and continue the treatment. 
	NOTE: In general, it takes 6-9 months for the patient for the symptoms to disappear completely.</li>
	<li>Ensure that the patient moves the fingers immediately after the operation and provide the patient with appropriate painkillers.</li>
	<li>Raise the affected limb and ice it for 48-72 h after the operation.</li>
	<li>Change the dressing 3-5 days after the operation. Guide postoperative wound care. Remove the stitches 10-14 days after the operation. Develop a reasonable plan for hand treatment and return to work.</li>
	<li>Encourage the patient to move the wrist freely at 2-3 months after the operation and at full intensity at 6-12 months after the operation. Evaluate the relief of postoperative numbness and tingling symptoms and changes in sensation, thenar atrophy, and muscle strength after the operation.</li>
</ol>

<ol>
	<li>Malakootian, M., Soveizi, M., Gholipour, A., Oveisee, M. Pathophysiology, diagnosis, treatment, and genetics of carpal tunnel syndrome: a review. Cellular and Molecular Neurobiology. 43 (5), 1817-1831 (2023).</li>
	<li>Sobeeh, M. G., Ghozy, S., Elshazli, R. M., Landry, M. Pain mechanisms in carpal tunnel syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes. Pain. 163 (10): E1054-E1094 (2022).</li>
	<li>Aydin, K., Cokluk, C., Cengiz, N., Bilgici, A. Microsurgical open mini uniskin incision technique in the surgical treatment of carpal tunnel syndrome. Neurology India. 54 (1), 64-67 (2006).</li>
	<li>Aydin, K., Cokluk, C., Piskin, A., Kocabicak, E. Ultrasonographically checking the sectioning of the transverse carpal ligament during carpal tunnel surgery with limited uniskin incisions. Turkish Neurosurgery. 17 (3), 219-223 (2007).</li>
	<li>Huisstede, B. M. et al. Carpal tunnel syndrome. Part 2. Effectiveness of surgical treatments. A systematic review. Archives of Physical Medicine and Rehabilitation. 91 (7), 1005-1024 (2010).</li>
	<li>Osiak, K., Elnazir, P., Walocha, J. A., Pasternak, A. Carpal tunnel syndrome: state-of-the-art review. Folia Morphologica. 81 (4), 851-862 (2022).</li>
	<li>Aroori, S., Spence, R. A. Carpal tunnel syndrome.The Ulster medical journal. 77(1),6-17 (2008).</li>
	<li>Lida, J., Hirabayashi, H., Nakase, H., Sakaki, T. Carpal tunnel syndrome: electrophysiological grading and surgical results by minimum incision open carpal tunnel release.&#160;Neurologia Medico-chirurgica.&#160;48&#160;(12), 554-559 (2008).</li>
	<li>Phalen, G. S. The carpal-tunnel syndrome: seventeen years&#39; experience in diagnosis and treatment of six hundred fifty-four hands. The Journal of Bone and Joint Surgery. American Volume.&#160;48&#160;(2), 211-228 (1966).</li>
	<li>Abdullah, A. F., Wolber, P. H., Ditto, E. W. Sequelae of carpal tunnel surgery: rationale for design of a surgical approach.&#160;Neurosurgery.&#160;37&#160;(5), 931-936 (1995).</li>
	<li>Dawson, D. M. Entrapment neuropathies of the upper extremities.&#160;The New England Journal of Medicine.&#160;329&#160;(27), 2013-2018 (1993).</li>
	<li>Hybbinette, C. H., Mannerfelt, L. The carpal tunnel syndrome: a retrospective study of 400 operated patients. Acta Orthopaedica Scandinavica. 46 (4), 610-620 (1975).</li>
	<li>Malla, M. A., Bhat, A. A., Samiullah, M., Farooq, M. Mini-open carpal tunnel release in carpal tunnel syndrome. Integrative Journal of Orthopaedics and Traumatology. 5 (2), 1-6 (2022).</li>
	<li>Harris, C. M., Tanner, E., Goldstein, M. N., Pettee, D. S. The surgical treatment of the carpal tunnel syndrome correlated with preoperative nerve conduction studies. The Journal of Bone and Joint Surgery. American Volume. 61 (1), 93-98 (1979).</li>
	<li>Hidayati, H. B., Subadi, I., Fidiana., Puspamaniar, V. A. Current diagnosis and management of carpal tunnel syndrome: A review. Anaesthesia Pain &#38; Intensive Care. 26 (3), 394-404 (2022).</li>
	<li>Carmo, J. D. &#39;INSIGHT-PRECISION&#39;: a new, mini-invasive technique for the surgical treatment of carpal tunnel syndrome. Journal of International Medical Research. 48 (1), 0300060519878082 (2020).</li>
	<li>Atthakomol, P. et al. Short incision versus minimally invasive surgery with tool-kit for carpal tunnel syndrome release: a prospective randomized control trial to evaluate the anterior wrist pain and time to return to work or activities. BMC Musculoskeletal Disorders. 23 (1), 708 (2022).</li>
	<li>Vetrano, I., Devigili, G., Nazzi, V. Minimally invasive carpal tunnel release: a technical note and a 20-year retrospective series. Cureus Journal of Medical Science. 14 (1), e21426 (2022).</li>
	<li>Lowry, W. E., Follender, A. B. Interfascicular neurolysis in the severe carpal tunnel syndrome. A prospective, randomized, double-blind, controlled study. Clinical Orthopaedics and Related Research. 227, 251-254 (1988).</li>
	<li>Franzini, A., Broggi, G., Servello, D., Dones, I., Pluchino, M. G. Transillumination in minimally invasive surgery for carpal tunnel release. Technical note. Journal of Neurosurgery. 85 (6), 1184-1186 (1996).</li>
	<li>Agee, J. M., McCarroll, H. R., North, E. R. Endoscopic carpal tunnel release using the single proximal incision technique. Hand Clinics. 10 (4), 647-659 (1994).</li>
	<li>Chow, J. C. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy: The Journal of Arthroscopic &#38; Related Surgery. 5 (1), 19-24 (1989).</li>
	<li>Okada, M., Tsubata, O., Yasumoto, S., Toda, N., Matsumoto, T. Clinical study of surgical treatment of carpal tunnel syndrome: open versus endoscopic technique. Journal of Orthopaedic Surgery. 8 (2), 19-25 (2000).</li>
	<li>Teh, K. K., Ng, E. S., Choon, D. S. K. Mini open carpal tunnel release using knifelight: evaluation of the safety and effectiveness of using a single wrist incision (cadaveric study). The Journal of Hand Surgery, European Volume. 34 (4), 506-510 (2009).</li>
	<li>Trumble, T. E., Diao, E., Abrams, R. A., Gilbert-Anderson, M. M. Single-portal endoscopic carpal tunnel release compared with open release: a prospective randomized trial. The Journal of Bone and Joint Surgery. American Volume. 84 (7), 1107-1115 (2002).</li>
	<li>Wongsiri, S., Suwanno, P., Tangtrakulwanich, B., Yuenyongviwat, V., Wongsiri, E. A new tool for mini open carpal tunnel release-the PSU retractor. BMC Musculoskeletal Disorders. 9, 126 (2008).</li>
	<li>Nazzi, V., Franzini, A., Messina, G., Broggi, G. Carpal tunnel syndrome: matching minimally invasive surgical techniques, technical note. Journal of Neurosurgery. 108 (5), 1033-1036 (2008).</li>
	<li>Martinez-Catasus, A. et al. Comparison between single portal endoscopic and 1-cm open carpal tunnel release. Hand Surgery and Rehabilitation. 38 (3), 202-206 (2019).</li>
	<li>Lam, K. H. S. et al. Ultrasound-guided interventions for carpal tunnel syndrome: a systematic review and meta-analyses. Diagnostics. 13 (6), 1138 (2023).</li>
	<li>Kamel, S. I., Freid, B., Pomeranz, C., Halpern, E. J., Nazarian, L. N. Minimally invasive ultrasound-guided carpal tunnel release improves long-term clinical outcomes in carpal tunnel syndrome. AJR American Journal of Roentgenology. 217 (2), 460-468 (2021).</li>
	<li>Chang, K. V. Ultrasound diagnosis and guided intervention of musculoskeletal/neuromuscular pathology 2022. Diagnostics. 13 (11), 1945 (2023).</li>
	<li>Peters, S., Page, M. J., Coppieters, M. W., Ross, M., Johnston, V. Rehabilitation following carpal tunnel release. The Cochrane Database of Systematic Reviews. 17 (2), CD004158 (2016).</li>
	<li>Bai, J. et al. Carpal tunnel release with a new mini-incision approach versus a conventional approach, a retrospective cohort study. International Journal of Surgery. 52, 105-109 (2018).</li>
	<li>Eberlin, K. R. et al. Multicenter randomized trial of carpal tunnel release with ultrasound guidance versus mini-open technique. Expert Review of Medical Devices. 20 (7), 597-605 (2023).</li>
	<li>Lee, Y. S., Youn, H., Shin, S. H., Chung, Y. G. Minimally invasive carpal tunnel release using a hook knife through a small transverse carpal incision: technique and outcome. Clinics In Orthopedic Surgery. 15 (2), 318-326 (2023).</li>
</ol>

The authors have no conflicts of interest to disclose.

Carpal tunnel surgical decompression combined with transection of the transverse carpal ligament has been a very successful operation for the treatment of CTS11,12,13,14,15,16. Over the years, the carpal tunnel decompression procedure has been developed to reduce complications and side effects associated with the operation. All previously described surgical techniques11,12,13,14,15,16,17,18 have proven successful in relieving symptoms such as CTS numbness, but each technique has its advantages and disadvantages.
Until now, for many orthopedic surgeons, the standard long-curve incision technique has been considered the optimal treatment for surgical carpal tunnel decompression. The greatest advantage of this technique is that it allows visualization of all structures and lesions in the carpal tunnel19, but it can have technical complications associated with the procedure itself6,7. Because the procedure is performed under direct vision7,19, early complications are usually rare. However, the incidence of late complications is relatively high. These late complications include hypertrophic postoperative scarring, tenderness in the surgical scarring area, loss of grip strength, and localized sympathetic dystrophy, which may delay the recovery time and cause emotional distress3,7,19,20.
To reduce these complications, various improved surgical techniques21,22,23,24,25,26 have emerged, such as limited incision or endoscopic techniques. In particular, endoscopic techniques have been accepted and widely used by surgeons. However, the endoscopic technique has its limitations, such as the large size of the endoscope and the rather long learning curve27. However, the most common technical complications of these approaches are injury to the median nerve and its branches, tendon tears, and arterial injury, which is an undesirable outcome4,7,24,28.
Recently, a new method called ultrasound-guided needle release with corticosteroid injection has been developed for treating carpal tunnel syndrome29,30,31. This method provides several advantages over traditional open surgery. First, it requires a smaller incision, which means less damage to the surrounding tissues and faster recovery. Second, it is less costly than traditional surgery because it does not require expensive equipment or a large operating room. Finally, the procedure is faster and simpler to perform, which reduces the overall treatment time and improves patient satisfaction.
The advantages of ultrasound-guided ultra-minimally invasive surgery may be no incision and rapid recovery, but the recurrence rate may be higher30. There is no prospective study to compare various ultrasound-guided techniques. Compared with traditional open surgery, ultrasound-guided needle release with corticosteroid injection is a more suitable option for CTS patients who are concerned about cosmetic results and recovery time. This method is also suitable for patients who are not suitable for general anesthesia.
In this study, the MSICTR technique is safe and effective in visualizing the structure and lesions of the carpal tunnel during surgery. As a result, potential technical complications and the risk of nerve, artery, or tendon injury were minimized. Transverse carpal ligament transection and carpal tunnel surgical decompression are more easily performed under direct vision. The only surgical signs are small scars left by the procedure and less scar tenderness. In these surgical patients, there were no complications of nerve, vascular, or tendon injuries associated with surgical intervention. Therefore, our patients generally do not require physical therapy or anti-inflammatory medication, and after 6 months of follow-up, their symptoms have improved significantly. The procedure shortens the recovery time of patients and reduces social and medical costs.
The small metacarpal incision technique typically does not require physiotherapy. However, there is limited information available on the effectiveness of postoperative rehabilitation interventions in individuals who have undergone carpal tunnel surgery32. However, given the potential benefits, individuals who undergo carpal tunnel surgery may wish to consult with a physiotherapist to determine if postoperative physiotherapy is appropriate for them.
The differences between the metacarpal small incision technique described herein, the limited incision technique, and the mini-incision technique for carpal tunnel surgery mainly lie in the incision length and surgical approach13,16,17,18,20,24,26,27,28,33,35. Regarding the incision length, the metacarpal small incision technique requires a slightly longer incision, generally 3 cm in length, which is longer than that of the limited incision technique and mini-incision technique. The limited incision technique has an incision length of 2-2.5 cm, while the mini-incision technique has an incision length of 1.5-2.0 cm33. The specific incision length for each technique depends on the size of the patient&#39;s hand.
In terms of the surgical approach, the metacarpal small incision technique is performed entirely under direct visualization, which ensures a precise release of the transverse carpal ligament and avoids nerve damage. This is in contrast to the limited incision and mini-incision techniques, which may require more precision and caution to avoid damage to the surrounding nerves and tissues as they involve smaller incisions. Therefore, surgeons performing these techniques must possess a high level of expertise and experience to ensure successful outcomes.
Overall, the differences between these three techniques are relatively small but crucial in ensuring a successful surgical outcome with minimal risk of complications. The choice of which technique to use depends on the surgeon&#39;s preference and expertise as well as the patient&#39;s specific condition and needs. In our opinion, MSICTR median nerve release is a safe, low-cost procedure with a low-grade learning curve and short operative time, which can be accomplished with conventional surgical instruments. The tolerance of the patients is reasonably high, and the procedure is in line with the current trend toward minimally invasive surgery.

Carpal tunnel syndrome (CTS) is a common peripheral nerve entrapment disorder caused by the compression of the median nerve in the wrist region, especially in the carpal canal. The clinical manifestations of CTS are diverse and may include pain, numbness, weakness, and hand muscle atrophy1,2, which can significantly impact the quality of life of patients. The diagnosis of CTS is typically based on clinical manifestations and physical examination, supported by electrophysiological studies such as electrodiagnostic testing3,4. For patients with mild symptoms, conservative treatment may be sufficient, but for those with moderate to severe symptoms, surgical intervention is often necessary5.
Many surgical techniques6,7,8,9,10,11,12,13,14,15,16,17, 
18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35 have been developed for the treatment of CTS, each with its advantages and disadvantages6,7,8. Open carpal tunnel decompression with a standard long palmar curved incision is a commonly used technique; however, it is associated with various complications such as scar tenderness, cosmetic dissatisfaction, and loss of hand grip and pinch strength3,7,9,10. Therefore, there is a need for a surgical technique that is effective in treating CTS but is also minimally invasive and associated with fewer complications.
The purpose of this study is to introduce a metacarpal small incision for carpal tunnel release (MSICTR) technique in the treatment of CTS and summarize our experience. This technique utilizes a small incision made at the base of the palm, over the carpal tunnel, allowing direct visualization of the median nerve and carpal tunnel contents (Figure 1). The advantages of MSICTR include shorter operation time, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional open carpal tunnel decompression techniques3.
Previous studies have shown that MSICTR is an effective and safe surgical technique for the treatment of CTS13,16,17,18,20,24,26,27,28. MSICTR has been associated with low rates of postoperative complications such as scar tenderness, infection, and median nerve damage17. Additionally, MSICTR can provide direct visualization of the median nerve and carpal tunnel contents, ensuring the complete release of the carpal tunnel and reducing the risk of residual compression18. The MSICTR technique is suitable for patients with CTS who have failed conservative management and are suitable for surgery. It can be used in patients with mild to severe symptoms of CTS and is particularly suitable for those who are concerned about cosmetic results and postoperative recovery time. However, MSICTR should not be used in patients with coagulation disorders or those who are not suitable for general anesthesia.
In summary, MSICTR is a safe and effective surgical technique for the treatment of CTS that has advantages over traditional open carpal tunnel decompression techniques. It is associated with shorter operation time, less postoperative pain, faster recovery, and improved cosmetic results. However, further randomized controlled trials are needed to compare MSICTR with other surgical techniques for CTS to establish its true efficacy and safety.

<table><tbody><tr><td>Absorbable suture</td><td>Shandong Boda Medical supplies Co., Ltd.</td><td>01-1517-8817-2</td><td>Absorbable suture in surgical suture, after implantation into human tissue, can be degraded and absorbed by the human body, and does not need to remove stitches, but to avoid the pain of suture removal of a new type of suture material.</td></tr><tr><td>Disposable aseptic surgical blade</td><td>Huaiyin Medical equipment Co., Ltd.</td><td>yuxiezhuzhun20192150063</td><td>It is used to cut soft tissue during surgery.</td></tr><tr><td>Disposable aseptic surgical membrane</td><td>Zhejiang Chun&#039;an Renhe Medical products Industry and Trade Co., Ltd.</td><td>zhechunxiebei20180017hao</td><td>It can be used to cover and protect the organs of surgical patients from bacterial infection in hospital operations. at the same time, it can be used for CT, nuclear magnetic resonance, organ B-ultrasound and other inspection imaging examination.</td></tr><tr><td>Disposable infusion device</td><td>Shandong Weigao Group Medical Polymer products Co., Ltd.</td><td>1401275143736</td><td>Clinical intravenous infusion</td></tr><tr><td>Disposable sterilized rubber surgical gloves</td><td>Shanghai Huaxin Medical Materials Co., Ltd.</td><td>huxiezhuzhun20172660706</td><td>It is used in surgical procedures to protect patients and users, to avoid cross-infection, and is not suitable for examination gloves or procedural gloves.</td></tr><tr><td>Hemostatic forceps</td><td>Hunan Kefu Medical Technology Development Co., Ltd.</td><td>xiangxiezhuzhun20192150038</td><td>Hemostatic forceps is a kind of surgical instrument which can block blood by clamping blood vessels.</td></tr><tr><td>LM bipolar drop hydrocoagulation forceps (hemostatic ablation electrode during surgery)</td><td>Jiangsu Yibo Leiming Medical Technology Co., Ltd.</td><td>20222068536P</td><td>LM bipolar drop hydrocoagulation forceps (hemostatic ablation electrode during surgery) for electrocoagulation of tissue</td></tr><tr><td>Medical forceps</td><td>Yangzhou Euro Science and Technology Development Co., Ltd.</td><td>6803</td><td>Medical forceps are used to hold human tissue.</td></tr><tr><td>Medical gauze piece</td><td>Steady medical supplies co., Ltd.</td><td>59400869174</td><td>Medical gauze is a disposable item used in surgery and wound care.</td></tr><tr><td>Medical surgical towel</td><td>Xuchang Zhende Medical dressing Co., Ltd.</td><td>yushiyaojianxiezhunzi2006di2640197hao</td><td>It is used for hemostasis and isolation in all kinds of operations. at the same time, it can be used to observe and protect the important parts of patients in bedside photography and fluoroscopic surgery.</td></tr><tr><td>Needle holder</td><td>Shanghai Youqun Medical equipment Co., Ltd.</td><td>91310113758584951A</td><td>The needle holder is mainly used to hold stitches and suture various tissues.</td></tr><tr><td>Single-use suction connecting pipe</td><td>Suzhou Jingle Polymer Medical equipment Co., Ltd.</td><td>huxiezhuzhun20183100062</td><td>It is used to attract, aspirate blood, lavage, and rinse during the operation and play an auxiliary role in the operation.</td></tr><tr><td>Surgical hilt</td><td>Zhejiang Suichang Shuangjian Medical equipment Co., Ltd.</td><td>zhexiezhuzhun2020207162234</td><td>The scalpel is divided into a blade and a handle. The blade is disposable, the handle is not. Other instruments are not disposable, but they are autoclaved each time they are used.</td></tr><tr><td>Surgical scissors</td><td>Maichuang Medical Technology (Suzhou) Co., Ltd.</td><td>91320509MA1MMLGX80</td><td>For cutting dressings, human epidermis or soft tissue. Tissue scissors: used for cutting tissue.</td></tr></tbody></table>

metacarpal small incision for carpal tunnel syndrome

Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally effective as traditional open carpal tunnel release (OCTR) techniques in relieving pain and numbness. However, patients who undergo OCTR are more likely to experience scar tenderness and pillar pain and take longer to return to work.
We present here a method of metacarpal small incision for carpal tunnel release (MSICTR) as a safe, reliable, cost-effective alternative surgical decompression of the median nerve of the wrist. This technique utilizes a metacarpal small incision and direct visualization of the median nerve and carpal tunnel contents, reducing the risk of permanent injury and neurasthenia when compared to traditional OCTR. MSICTR is also suitable for the examination of the median nerve, surrounding tendon sheath, or space-occupying lesions.
MSICTR is associated with shorter operation times, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional OCTR. Therefore, MSICTR is an effective surgical decompression of the median nerve for the treatment of carpal tunnel syndrome.

It is important to discuss the recovery time with the patient before the operation to make the patient's expectation of the outcome of the operation realistic. The surgical marker simplifies the identification of surgical incisions (Figure 2A).
When the surgical approach is performed in accordance with the above steps, all the diseased sites of the transverse carpal ligament and adjacent metacarpal fascia can be touched without any problem (Figure 3A-D).
We have conducted a retrospective study comparing the outcomes of the MSICTR technique with those of traditional open carpal tunnel decompression in 100 patients with CTS. Additionally, MSICTR patients had shorter recovery times and lower rates of postoperative complications such as scar tenderness and infection.
The data were collected prospectively for all patients who underwent MSICTR or traditional open carpal tunnel decompression between 2018 and 2021. Patients were evaluated presurgery and at 6 months post surgery using the visual analog scale (VAS) for pain score, a dynamometer for grip and kneading strength, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire for functional outcome.
The results of the study are summarized in Table 1, which shows the mean changes in pain score, grip, and kneading strength, and the DASH score at 6 months post surgery for patients who underwent MSICTR and traditional open carpal tunnel decompression. It can be seen that patients who underwent MSICTR had significant improvement in all parameters compared to patients who underwent traditional open carpal tunnel decompression.
Additionally, MSICTR patients had shorter recovery times and lower rates of postoperative complications such as scar tenderness and infection. We believe that the MSICTR technique is a valuable option for the treatment of CTS and is superior to traditional open carpal tunnel decompression in several aspects.
<img alt="Hand anatomy diagram with Kaplan's cardinal line, incision area, and hook of hamate for surgery." class="xfigimg" src="/files/ftp_upload/65808/65808fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Landmarks for the incision for carpel tunnel release. The green area is the area of the surgical incision. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65808/65808fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Hand surgery procedure, incision and suture, surgery setup for medical study, surgical instruments use." class="xfigimg" src="/files/ftp_upload/65808/65808fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: The surgical approach. (A) The incision is on the palmar side, ~3 cm. (B) The sutured incision is on the palmar side of the hand, ~ 3 cm. (C) Surgical separation of the subcutaneous fat layer. (D) Closed incision: covering the incision with loose, thick gauze. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65808/65808fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure on the wrist showing incision, tool use, and tissue handling in four stages." class="xfigimg" src="/files/ftp_upload/65808/65808fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Metacarpal small incision carpal tunnel release in the treatment of carpal tunnel syndrome. (A-D) Release of the transverse carpal ligament. (A) Cutting the transverse carpal ligament with scissors along the ulnar side of the median nerve under direct vision through the incision. (B) Using a retractor to pull up the skin proximal to the incision and release the transverse carpal ligament to the level of the far flexion carpal crease. (C) Using fingers to check whether the median nerve is completely released. (D) The median nerve was not damaged; it was completely released. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65808/65808fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Outcome</td>
			<td>MSICTR (n = 50)</td>
			<td>Open Decompression (n = 50)</td>
		</tr>
		<tr>
			<td>Pain Score (VAS)</td>
			<td>-2.8±1.1*</td>
			<td>-2.0±1.3</td>
		</tr>
		<tr>
			<td>Grip Strength (%)</td>
			<td>81±19*</td>
			<td>67±23</td>
		</tr>
		<tr>
			<td>Kneading Strength (%)</td>
			<td>75±21*</td>
			<td>61±24</td>
		</tr>
		<tr>
			<td>DASH Score (%)</td>
			<td>68±24*</td>
			<td>79±29</td>
		</tr>
	</tbody>
</table>
Table 1: Summary of outcomes at 6 months post surgery. *Statistically significant improvement compared to preoperative values (p &lt; 0.05).

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Metacarpal Small Incision for Carpal Tunnel Syndrome

Carpal tunnel decompression with transverse carpal ligament transection is a very successful treatment of carpal tunnel syndrome. The standard long-curved incision technique has become the best treatment for median nerve entrapment decompression. Here we introduce the metacarpal small incision carpal tunnel release (MSICTR) in the treatment of carpal tunnel syndrome (CTS).

Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally ...

metacarpal-small-incision-for-carpal-tunnel-syndrome

Nanyang Technological University

Research

JoVE Journal

Medicine

373 Views.  Zhejiang University. Plaats om te beginnen de patiënt op de operatietafel in rugligging met het aangedane ledemaat op zijn plaats en zet het proximale uiteinde van de bovenarm vast met een tourniquet. Onder brachiale plexus of algemene anesthesie, bereidt u het distale uiteinde van de aangedane ledematen voor en wikkelt u het in na een aseptische procedure. Leg de handpalmen van de patiënt naar boven op de tafel en bevestig ze aan een klein vierkant stukje doek.Maak een incisie van drie centimeter in de ...

Video: Metacarpal Small Incision for Carpal Tunnel Syndrome

Implantation of a Carotid Cuff for Triggering Shear-stress Induced Atherosclerosis in Mice

It is widely accepted that alterations in vascular shear stress trigger the expression of inflammatory genes in endothelial cells and thereby induce atherosclerosis (reviewed in 1 and 2). The role of shear stress has been extensively studied in vitro investigating the influence of flow dynamics on cultured endothelial cells 1,3,4 and in vivo in larger animals and humans 1,5,6,7,8. However, highly reproducible small animal models allowing systematic investigation of the influence of shear stress on plaque development are rare. Recently, Nam et al. 9 introduced a mouse model in which the ligation of branches of the carotid artery creates a region of low and oscillatory flow. Although this model causes endothelial dysfunction and rapid formation of atherosclerotic lesions in hyperlipidemic mice, it cannot be excluded that the observed inflammatory response is, at least in part, a consequence of endothelial and/or vessel damage due to ligation.
In order to avoid such limitations, a shear stress modifying cuff has been developed based upon calculated fluid dynamics, whose cone shaped inner lumen was selected to create defined regions of low, high and oscillatory shear stress within the common carotid artery 10. By applying this model in Apolipoprotein E (ApoE) knockout mice fed a high cholesterol western type diet, vascular lesions develop upstream and downstream from the cuff. Their phenotype is correlated with the regional flow dynamics 11 as confirmed by in vivo Magnetic Resonance Imaging (MRI) 12: Low and laminar shear stress upstream of the cuff causes the formation of extensive plaques of a more vulnerable phenotype, whereas oscillatory shear stress downstream of the cuff induces stable atherosclerotic lesions 11. In those regions of high shear stress and high laminar flow within the cuff, typically no atherosclerotic plaques are observed.
 
In conclusion, the shear stress-modifying cuff procedure is a reliable surgical approach to produce phenotypically different atherosclerotic lesions in ApoE-deficient mice.

The constricting cuff presented in this article is designed to induce atherosclerosis in the murine common carotid artery. Due to the conical shape of its inner lumen the implanted cuff generates well-defined regions of low, high and oscillatory shear stress triggering the development of atherosclerotic lesions of different inflammatory phenotypes.

It is widely accepted that alterations in vascular shear stress trigger the expression of inflammatory genes in endothelial cells and thereby induce ...

Common Carotid Artery Repair After Injection in a Mouse Model 

Facilitating Repeat Intracarotid Injections in Mouse Models by a Novel Injection Site Repair Technique

Given recent advances in the delivery of novel antitumor therapeutics using endovascular selective intraarterial delivery methods in neuro-oncology, there is an urgent need to develop methods for intracarotid injections in mouse models, including methods to repair the carotid artery in mice after injection to allow for subsequent injections. We developed a method of intracarotid injection in a mouse model to deliver therapeutics into the internal carotid artery (ICA) with two alternative procedures. 
During injection, the needle is inserted into the common carotid artery (CCA) after tying a suture around the external carotid artery (ECA) and injected therapeutics are delivered into the ICA. Following injection, the common carotid artery (CCA) can be ligated, which limits the number of intracarotid injections to one. The alternative procedure described in this article includes a modification where intracarotid artery injection is followed by injection site repair of the CCA, which restores blood flow within the CCA and avoids the complication of cerebral ischemia seen in some mouse models. 
We also compared the delivery of bone marrow-derived human mesenchymal stem cells (BM-hMSCs) to intracranial tumors when delivered through intracarotid injection with and without injection site repair following the injection. Delivery of BM-hMSCs does not differ significantly between the methods. Our results demonstrate that injection site repair of the CCA allows for repeat injections through the same artery and does not impair the delivery and distribution of injected material, thus providing a model with greater flexibility that more closely emulates intracarotid injection in humans.

Author Spotlight: Advancing Glioblastoma Treatment Through Intraarterial Delivery Strategies for Oncolytic Viruses and MicroRNAs

Repair of the intracarotid artery in a mouse model after injection returns blood flow to the artery without negatively impacting the distribution of the injected material. Injection site repair facilitates subsequent injections through the same artery and prevents cerebral ischemia in mouse strains that lack a complete Circle of Willis.

Given recent advances in the delivery of novel antitumor therapeutics using endovascular selective intraarterial delivery methods in neuro-oncology, there ...

Cancer Research

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures.

Minimally invasive surgical (MIS) procedures rely on anatomical references to localize structures not directly visible to the surgeon. This manuscript describes a combined method of plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to locate the structures at risk during MIS procedures.

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional ...

Screening of Axonal Degeneration in Carpal Tunnel Syndrome Using Ultrasonography and Nerve Conduction Studies

Axonal degeneration, indicative of surgical decompression, may coexist in carpal tunnel syndrome (CTS) as the disease progresses. However, the current diagnostic and severity gradation system cannot clearly indicate its coexistence, resulting in&#160;confusion of appropriate treatment prescription. There are also constraints in conventional methods for&#160;differentiation as well. This study aims at introducing an innovative, efficient, and quick screening protocol to differentiate axonal degeneration associated with CTS, using ultrasound and nerve conduction studies (NCS). It starts by using NCS to perform orthodromic stimulation at the wrist, to obtain the sensory conduction of the median and the ulnar nerves respectively. Meanwhile, the motor conduction&#160;of the median nerve is collected by stimulating the palm, wrist, and elbow, followed by the stimulation of the ulnar nerve at the wrist,&#160;below and above the elbow. Then, an ultrasound assessment is performed, using a linear array transducer, with cross-sectional area (CSA) and perimeter (P) at the wrist and at the one-third distal forearm calipered. Ratios (R-CSA, R-P) and changes from wrist to one-third distal forearm (&#916;CSA and &#916;P) are calculated according to a standard format. Potential axonal degeneration coexisting in CTS will be screened according to the criteria of NCS and cut-off values of ultrasound measurements established in a previous study. In terms of its noninvasiveness, low cost, convenience, and efficiency, it is easy to apply ultrasound complimentarily in clinical practice to prescreen patients with potential coexisting axonal degeneration. Nevertheless, the ultrasonographic imaging cannot directly reflect axonal degeneration. It still relies on conventional but invasive methods&#160;such as electromyography (EMG) and biopsy&#160;for confirmation if needed.

Here we present a protocol using nerve conduction studies and ultrasound to screen potential axonal degeneration associated with carpal tunnel syndrome. The criteria for differentiation are established. Compared to conventional approaches, this method is noninvasive, convenient, and efficient, with an overall satisfactory accuracy, sensitivity, and specificity.

Axonal degeneration, indicative of surgical decompression, may coexist in carpal tunnel syndrome (CTS) as the disease progresses. However, the current ...

Neuroscience

Transvenous Embolization of Carotid Cavernous Fistula through Inferior Petrosal Sinus with Detachable Coils and Ethylene Vinyl Alcohol Copolymer

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal branches of the external carotid artery (indirect fistula) and the cavernous sinus (CS). Trauma is the most common cause of CCF. The clinical presentation of CCF is closely related to the venous drainage pattern. Orbital and neuro-ophthalmological symptoms are the most common clinical presentation of CCF with drainage through the superior ophthalmic vein (SOV). Endovascular embolization by arterial or venous approaches is the most common management of CCF. Transvenous embolization using detachable coils and ethylene-vinyl alcohol copolymer (EVOH) is an alternative method for the treatment of CCF. Endovascular embolization offers different options to treat CCF by minimally invasive approach decreasing morbidity and residual fistulas. The purpose of this article is to report our treatment experiences via the inferior petrosal sinus (IPS), and immediate-term outcomes of endovascular embolization of CCF by using detachable coils and EVOH.

The purpose of the article is to present our experience in endovascular treatment via the inferior petrosal sinus of the carotid cavernous fistula with detachable coils and ethylene-vinyl alcohol copolymer.

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal ...

Functional and Physiological Methods of Evaluating Median Nerve Regeneration in the Rat

The main goal of this investigation is to show how to create and repair different types of median nerve (MN) lesions in the rat. Moreover, different methods of simulating postoperative physiotherapy are presented. Multiple standardized strategies are used to assess motor and sensory recovery using an MN model of peripheral nerve lesion and repair, thus permitting easy comparison of the results. Several options are included for providing a postoperative physiotherapy-like environment to rats that have undergone MN injuries. Finally, the paper provides a method to evaluate the recovery of the MN using several noninvasive tests (i.e., grasping test, pin prick test, ladder rung walking test, rope climbing test, and walking track analysis), and physiological measurements (infrared thermography, electroneuromyography, flexion strength evaluation, and flexor carpi radialis muscle weight determination). Hence, this model seems particularly appropriate to replicate a clinical scenario, facilitating extrapolation of results to the human species.
Although the sciatic nerve is the most studied nerve in peripheral nerve research, analysis of the rat MN presents various advantages. For example, there is a reduced incidence of joint contractures and automutilation of the affected limb in MN lesion studies. Furthermore, the MN is not covered by muscle masses, making its dissection easier than that of the sciatic nerve. In addition, MN recovery is observed sooner, because the MN is shorter than the sciatic nerve. Also, the MN has a parallel path to the ulnar nerve in the arm. Hence, the ulnar nerve can be easily used as the nerve graft for repairing MN injuries. Finally, the MN in rats is located in the forelimb, akin to the human upper limb; in humans, the upper limb is the site of most peripheral nerve lesions.

Presented is a protocol to produce different types of median nerve (MN) lesions and repair in the rat. Additionally, the protocol shows how to evaluate the functional recovery of the nerve using several noninvasive behavioral tests and physiological measurements.

The main goal of this investigation is to show how to create and repair different types of median nerve (MN) lesions in the rat. Moreover, different ...

Ultrasound-Guided Needle Release Combined with Corticosteroid Injection

Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome

The two main branches of the radial nerve (RN) are the deep branch (DBRN) and the superficial branch (SBRN). The RN splits into two main branches at the elbow. The DBRN runs between the deep and shallow layers of the supinator. The DBRN can be easily compressed at the arcade of Frohse (AF) due to its anatomical features. This work focuses on a 42-year-old male patient who had injured his left forearm 1 month prior. Multiple muscles of the forearm (extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris) were sutured in another hospital. After that, he had dorsiflexion limitations in his left ring and little fingers. The patient was reluctant to undergo another operation because he had undergone suture surgeries for multiple muscles 1 month prior. Ultrasound revealed that the deep branch of the radial nerve (DBRN) had edema and was thickened. The exit point of the DBRN had deeply adhered to the surrounding tissue. To relieve this, ultrasound-guided needle release plus a corticosteroid injection were performed on the DBRN. Nearly 3 months later, the dorsal extension in the patient's ring and little fingers was significantly improved (ring finger: &#8722;10&#176;, little finger: &#8722;15&#176;). Then, the same treatment was done for the second time. Nearly 1 month after that, the dorsal extension of the ring and the little finger was normal when the joints of the fingers were fully straightened. Ultrasound could evaluate the condition of the DBRN and its relationship with the surrounding tissues. Ultrasound-guided needle release combined with corticosteroid injection is an effective and safe treatment for DBRN adhesion.

Author Spotlight: Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome  

The deep branch of the radial nerve can easily be compressed at the arcade of Frohse due to its anatomical features. Ultrasound-guided needle release combined with corticosteroid injection is an effective and safe treatment for deep branch radial nerve adhesion.

The two main branches of the radial nerve (RN) are the deep branch (DBRN) and the superficial branch (SBRN). The RN splits into two main branches at the ...

Neuromuscular Ultrasound of the Median Nerve at the Carpal Tunnel

The use of neuromuscular ultrasound greatly enhances the evaluation of carpal tunnel syndrome as an adjunct diagnostic tool as it provides dynamic and structural information about the median nerve and its surrounding anatomy.&#8239;Neuromuscular ultrasound aids in diagnostic accuracy (when used with electrodiagnostic testing) and offers etiologic information as a non-invasive, painless, cost-effective, and radiation-free imaging technology that can be easily carried out at the bedside for immediate interpretation. Neuromuscular ultrasound has the limitation of subjectivity, and the need for training and experience will affect the interpretation of results. This article describes a basic practical guide to visualizing the median nerve using neuromuscular ultrasound in a step-by-step manner to aid in the evaluation of carpal tunnel syndrome. Even though the use of ultrasound in the assessment of median nerve entrapment has been long established, there has been no recognized standard protocol. The present protocol aims to provide clear and concise instructions to describe a standard technique to visualize the median nerve through diagnostic ultrasound.

The present protocol describes a technique for the standardization of median nerve ultrasound in cases of suspected carpal tunnel syndrome.

The use of neuromuscular ultrasound greatly enhances the evaluation of carpal tunnel syndrome as an adjunct diagnostic tool as it provides dynamic and ...

A1 Pulley Reconstruction for Severe Trigger Finger

The aim of this study was to evaluate the effectiveness of A1 pulley reconstruction in treating severe trigger fingers and to compare its outcomes with those of the traditional A1 pulley release technique. A total of 43 patients participated in the study, divided into two groups: 22 patients underwent A1 pulley reconstruction, while the remaining 21 patients received the standard A1 pulley release procedure. The outcomes were assessed using the Michigan Hand Outcomes Questionnaire (MHQ) 1 month post-surgery. The results demonstrated that patients who received the A1 pulley reconstruction reported significantly better outcomes. These included enhanced hand function and quality of life, reduced levels of pain, improved aesthetic appearances, and higher overall satisfaction when compared to the traditional release group. The findings suggest that A1 pulley reconstruction offers superior benefits over the standard release procedure for individuals suffering from severe trigger fingers, highlighting its potential as a more effective surgical intervention.

Here, we present a protocol to compare A1 pulley reconstruction with traditional release surgery in treating a trigger finger, revealing enhanced outcomes and patient satisfaction through the Michigan Hand Outcomes Questionnaire.

The aim of this study was to evaluate the effectiveness of A1 pulley reconstruction in treating severe trigger fingers and to compare its outcomes with ...

Wrist and Hand Examination

Source: <a href="https://www-jove-com.remotexs.ntu.edu.sg/author/Robert+E._Sallis">Robert E. Sallis</a>, MD. Kaiser Permanente, Fontana, California, USA
The wrist is a complex joint made up of 8 carpal bones and their numerous articulations and ligaments. Overlying the wrist are the tendons and muscles of the hand and fingers. The hand is made up of 5 metacarpal bones, and the tendons that run to the hand overlie these bones. Finally, the fingers consist of 14 phalanges with their articulations held together by collateral ligaments and volar plates. Common mechanisms of both acute and chronic wrist injury include impact, weight bearing (which can occur in gymnastics), twisting, and throwing. Osteoarthritis of the hand commonly affects distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints, while rheumatoid arthritis (RA) is seen in the metacarpophalangeal (MCP) and PIP joints.
It is important to compare the injured wrist or hand to the uninvolved side. Key aspects of the wrist and hand exam include inspection, palpation for tenderness or deformity, testing the range of motion (ROM) and strength, neurovascular assessment, ligaments and tendon testing, and the special tests.

Wrist and Hand: Motor, Sensory, Ligament and Tendon Testing

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA
The wrist is a complex joint made up of 8 carpal bones and their numerous ...

Metacarpal Small Incision for Carpal Tunnel Syndrome

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