Carpal arch alteration and related clinical status after endoscopic carpal tunnel release One hundred eight endoscopic carpal tunnel releases were performed by a modification of the technique described by Chow. Eighty-seven of the 108 cases were evaluated for quantitative postoperative widening of the transverse carpal arch. The average postoperative widening of the transverse carpal arch was 0.17 em (7%), with a range of 0 to 0.5 em. Seventy percent of the patients showed 0% to 10% widening, 26% showed 10% to 20% widening, and 4% showed more than 20% widening of the transverse carpal arch. Preliminary findings show that 3 weeks after endoscopic carpal tunnel release, pinch strength was at 102% and grip strength at 86% of preoperative values. Six weeks after surgery, pinch strength was 106% and grip strength was 121 % of preoperative values. The complication rate in this series was 3%. The transverse dimension of the carpal arch generally widens after endoscopic carpal tunnel release but to a lesser degree than has been reported for open carpal tunnel release. The rate of improvement of pinch and grip strength after endoscopic release is faster than that reported in the literature after open release. (J HAND SURG 1992;17A:I012-6.)
Steven F. Viegas, MD, Allan Pollard MD, and Karin Kaminksi, OT, Galveston, Texas
Division of the transverse carpal ligament to restore median nerve function by decompressing the carpal canal has been the standard of care almost since Phalen I began directing the attention of physicians to carpal tunnel syndrome in 1951. Recently several new techniques for endoscopic release of the transverse carpal ligament have been described.i" Fewer soft tissue structures are released in endoscopic carpal tunnel surgery than in open carpal tunnel surgery. However, there has not been any quantification of the effect of endoscopic release of the transverse carpal ligament on the carpal arch. Radiographic changes in the carpal arch after endoscopic carpal tunnel release (ECTR) by a modification of the Chow technique" were studied and
From the University of Texas Medical Branch, Galveston, Texas. Received for publication Nov. 18, 1991; accepted in revised form Feb. 7, 1992. One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Steven F. Viegas, MD, Associate Professor, Department of Surgery and Department of Anatomy and Neurosciences, Division of Orthopaedic Surgery, Rm 6.136 (G-92), McCullough Building, University of Texas Medical Branch, Galveston, TX 77551.
3/1/37382
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THE JOURNAL OF HAND SURGERY
compared with the changes previously reported by Gartsman et al." after open carpal tunnel release (OCTR). These findings, along with preliminary results in the first 108 cases of endoscopic carpal tunnel release, are reported.
Materials and methods One hundred eight endoscopic carpal tunnel releases were performed by a modification of the technique described by Chow.' Eighty-seven cases were included in the radiographic study. There were 54 female and 17 male patients. There were 55 right hands and 32 left hands that underwent ECTR. Fifteen patients had bilateral ECTR. The patients' ages ranged from 23 to 79 years, with an average of 48 years. All patients had a history of weakness or clumsiness of the involved hand and hypesthesia or paresthesia in the median nerve distribution. All of the patients who underwent an endoscopic carpal tunnel release had prolonged motor andlor sensory conduction latency across the carpal tunnel. All patients who underwent surgery had previously had at least I month of splinting and treatment with a nonsteroidal anti-inflammatory medication without relief. Eighty-seven wrists were assessed for a change in carpal arch diameter by means of standardized carpal tunnel views as described by Gartsman et al. 5 These
Vol. 17A. No.6 November 1992
Carpal arch alteration
1013
Fig. 1. X-ray film demonstrating earpal tunnel view obtained with wrist positioned in 50-degree extension splint. The distance is measured between the tip of the trapezial ridge and the tip of the hook of the hamate (white circles).
films were taken with the wrist held in 50 degrees of extension in a dorsal splint, the anterior surface of the forearm flat on the x-ray cassette, and a tube-to-table distance of 76.2 em. In 61 cases, both preoperative and postoperative x-ray films were obtained. Postoperative films were generally obtained 10 days after surgery. Twenty-six cases were evaluated by means of postoperative x-ray films that compared the treated and nontreated sides. The distance between the palmar ridge of the trapezium and the hook of the hamate was measured on each film (Fig. 1). The same instrumentation and basic technique as described by Chow} were used, except that the path of blunt dissection and subsequent placement of the slotted cannula and endoscope was superficial to the flexor tendons, tenosynovium, and median nerve and immediately dorsal to the transverse carpal ligament. The plane of dissection follows that described by Agee et al. in their report on endoscopic carpal tunnel release." The other modification in the technique was that an oblique rather than a transverse incision was used distally. This more closely followed the conventional incision for open carpal tunnel release and facilitated conversion from endoscopic to open carpal tunnel surgery should the need arise. The use of local, regional, or general anesthesia was based on a combination of the patient's preference and his or her medical status. An upper arm tourniquet was always placed on the patient but was not required in any of the endoscopic procedures.
The postoperative regimen included a soft dressing, which was replaced by Band-Aid adhesive bandages on the third postoperative day. Sutures were removed 1 week after the surgery. Light duty was advised for the first 2 postoperative weeks. Grip strength was obtained preoperatively and was monitored each week postoperatively with the Jamar dynamometer. Pinch strength was also followed, as was sensation as determined by two-point discrimination. General anesthesia was used in 34 cases, regional anesthesia in 39 cases, and local anesthesia in 14 cases. The operative time ranged from 11 to 40 minutes and averaged 25 minutes.
Results Eighty-seven cases were assessed for a change in the carpal arch diameter by means of standardized carpal tunnel views. The average change in the carpal arch, as measured from the apex of the palmar ridge of the trapezium to the apex of the hook of the hamate on the standardized carpal tunnel view, was an increase of 0.17 ern and ranged from 0.0 to 0.5 em. This was an average increase of 7% in the carpal tunnel diameter (range, 0 to 25%). The breakdown of the cases showed that 70% had an increase of 0% to 10% in carpal arch diameter, 26% of the cases had an increase of 10% to 20%, and 4% of the cases had an increase of 20% or more. Grip strength averaged 37% of the preoperative level I week after surgery. At 3 weeks grip strength had
1014
The Journal of HAND SURGERY
Viegas et al.
80
•
70
-?ft.
0
60
aCTR ECTR
50
til
r::::
40
CIl
:;:::
as
/l.
30 20 10 0 0-10
10·20
20+
Change In Arch (%) Fig. 2. Gartsman et aI.' reported that 40% of their cases (black bars) had a 0% to 10% increase in carpal arch width compared to our 70% (white bars). Twenty-eight percent of their cases had a 10% to 20% increase, whereas the present study found 26% in this range. Gartsman et al. reported that 32% of their cases had an increase of 20% or more (up to 52%), while in the endoscopically released carpal tunnels only 4% of the cases had an increase of more than 20% carpal arch diameter, with a maximum increase of 25%.
improved to 86% of the preoperative baseline, and by 6 weeks it averaged 121% of the preoperative level. Pinch strength averaged 70% of the preoperative level 1 week after surgery. At 3 weeks it had improved to 102% of the preoperative baseline, and by 6 weeks pinch strength averaged 106% of the preoperative level. The two-point discrimination was noted to be 6 mm or more in 63 patients and less than 6 mm in 17 patients. Seventy-one percent of the patients with preoperative two-point discrimination greater than 6 mID improved to level of 6 mm or less; 29% remained at greater than 6 mm. Of those in whom two-point discrimination remained at a level of greater than 6 mm, 41% showed improvement. Maximum improvement in two-point discrimination was reached at an average of 2 weeks postoperatively (range, 1 to 5 weeks). There were two postoperative complications-a transient neuropraxia of the common digital nerve to the second web space and a transient neuropraxia of the median nerve. One case was converted to an open carpal tunnel. This translates into a 3% complication rate. Discussion
No previous reports in the literature describe the effects of endoscopic division of the transverse carpal ligament on the carpal arch. Gartsman et a1.5 reported an average increase of 0.29 em in the carpal arch width
(range, 0.0 to 0.85 ern). This was a 13% average increase in the carpal arch width (range, 0% to 52%). This average increase and the upper range are greater than the 0.17 ern average distance and the 0.0 to 0.5 em range that were found in our series of endoscopic carpal tunnel releases. The breakdown of their cases is also different. Gartsman et a1.5 had a fairly equal distribution of cases that had increases of 0 to 10 degrees, 10 to 20 degrees, and 20 degrees or more in carpal arch width, while the majority of cases in our series had increases of 0 to 10 degrees, and very few had increases of 20 degrees or more in carpal arch width (Fig. 2). This may be of particular significance since Gartsman et al. also reported that patients with an increase of more than 20% in carpal arch width had a significantly decreased grip strength even 20 months after surgery. The change in the carpal arch width after endoscopic carpal tunnel release appears to be less than that reported for open carpal tunnel release. It remains unclear, however, whether this is advantageous. Clinically, the preliminary results of endoscopic carpal tunnel release are good. The differences in the arch dimensions following OCTR and ECTR may be only transient, since Richman et al., 6 using magnetic resonance imaging, demonstrated an average increase of 1.5 mm in the carpal tunnel diameter 6 weeks after surgery but later, at 8 months, found no significant difference in the preoperative and postoperative values. They did, however,
Vol. 17A, No.6 November 1992
Carpal arch alteration
1015
140
•
120
0
~ 100 e....
-
aCTA ECTR
..c
Cl l: ell
80
en
60
....
Q,
.;:
e
40 20 0
3
6
Post Op (weeks) Fig. 3. Gellman et at .' reported that 3 weeks after open carpal tunnel release (black bars) the average grip strength was 28% of the preoperative baseline . At 3 weeks after endoscopic carpal tunnel release (white bars) average grip strength was 86% of preoperative level. At 6 weeks after surgery the OCTR group had regained 73% of their preoperative grip strength while the patients in the present study who had an endoscopic release of the carpal tunnel had attained 121% of their preoperative grip strength . The patients that Gellman et aI.' reported on who had undergone open carpal tunnel release reached 99% of their preoperative grip strength 3 months after surgery.
120
--0~
..c
100
• 0
aCTR ECTR
80
Cl
e ell ....
-
60
en
s: u l: ii:
40 20 0 3
6
Post Op (weeks) Fig. 4. Gellman et aI.' found that 3 weeks after open carpal tunnel release their patients (black bars) had 74% of their preoperative pinch strength . This compares to 102% of the preoperative pinch strength that was mea sured in this study group 3 weeks after endoscopic carpal tunnel release (white bars). At 6 weeks the patients reported by Gellman et al. had regained 96% of their preoperative grip strength, compared with 106% in thc present study.
find a lasting increase in the carpal tunnel volume, which cannot be assessed on x-ray films. Gellman et a1. 7 reported on pinch and grip strength and two-point discrimination after open carpal tunnel
release. When their findings are compared with those in our study it appears that the return of grip strength is faster in the patients who have had an endoscopic release of the carpal tunnel (Fig . 3). The pinch strength
1016
The Journal of HAND SURGERY
Viegas et al.
also improved faster in the ECTR patients than in the patients reported by Gellman et al.? (Fig. 4). Gellman et al. 7 reported that of their patients who originally had greater than 6 rom two-point discrimination, 75% were found to have two-point discrimination of 6 mm or less after open carpal tunnel release. Seventeen percent of their patients were improved but did not have 6 mm or less two-point discrimination, and 8% of their patients had no change in their twopoint discrimination. In the patients reported here who originally had greater than 6 mm two-point discrimination, 71 % were found to have two point discrimination of 6 rom or less after ECTR. Twelve percent were improved but did not have 6 mm or less two-point discrimination, and 18% had no change in two-point discrimination. Since these findings are preliminary, it is unclear whether the percent of patients who had no change in two-point discrimination after ECTR would have a further decrease with time. The authors thank Drs. Bennett and Crouch for their encouragement and support.
REFERENCES 1. Phalen GS. Spontaneous compression of the median nerve at the wrist. JAMA 1951;145:1128-33. 2. Okutsu I, Ninomiya S, Takatori Y, Ugawa Y. Endoscopic management of carpal tunnel syndrome. Arthroscopy 1989;5:11-18. 3. Chow JCY. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy 1989;5:19-24. 4. North ER. Endoscopic carpal tunnel release. In: Gelberman RH. Operative nerve repair and reconstruction. vol. II. Philadelphia: JB Lippincott, 1991:913-20. 5. Gartsman G, Kovach J, Crouch C, Noble P, Bennett 1. Carpal arch alter carpal tunnel release. J HAND SURG 1986;1IA:372-4. 6. Richman JA, Gelberman RH, Rydevik BL, Hajek PC, Braun RM, Gylys-Morin VM, Berthoty D. Carpal tunnel syndrome: morphologic changes after release of the transverse carpal ligament. J HAND SURG 1989;14A:852-7. 7. Gellman H, Kan D, Gee V, Kuschner SH, Botte MJ. Analysis of pinch and grip strength after carpal tunnel release. J HAND SURG 1989;14A:863-4.
Bound volumes available to subscribers Bound volumes of the JOURNAL OF HAND SURGERY are available to subscribers (only) for the 1992 issues from the Publisher, at a cost of $42.00 for domestic, $51.00 for international, and $53.94 for Canadian subscribers for Vol. 17A (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone (800)325-4177, ext. 4351, or (314)453-4351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
Steven F. Viegas, MD, Allan Pollard MD, and Karin Kaminksi, OT, Galveston, Texas
Division of the transverse carpal ligament to restore median nerve function by decompressing the carpal canal has been the standard of care almost since Phalen I began directing the attention of physicians to carpal tunnel syndrome in 1951. Recently several new techniques for endoscopic release of the transverse carpal ligament have been described.i" Fewer soft tissue structures are released in endoscopic carpal tunnel surgery than in open carpal tunnel surgery. However, there has not been any quantification of the effect of endoscopic release of the transverse carpal ligament on the carpal arch. Radiographic changes in the carpal arch after endoscopic carpal tunnel release (ECTR) by a modification of the Chow technique" were studied and
From the University of Texas Medical Branch, Galveston, Texas. Received for publication Nov. 18, 1991; accepted in revised form Feb. 7, 1992. One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Steven F. Viegas, MD, Associate Professor, Department of Surgery and Department of Anatomy and Neurosciences, Division of Orthopaedic Surgery, Rm 6.136 (G-92), McCullough Building, University of Texas Medical Branch, Galveston, TX 77551.
3/1/37382
1012
THE JOURNAL OF HAND SURGERY
compared with the changes previously reported by Gartsman et al." after open carpal tunnel release (OCTR). These findings, along with preliminary results in the first 108 cases of endoscopic carpal tunnel release, are reported.
Materials and methods One hundred eight endoscopic carpal tunnel releases were performed by a modification of the technique described by Chow.' Eighty-seven cases were included in the radiographic study. There were 54 female and 17 male patients. There were 55 right hands and 32 left hands that underwent ECTR. Fifteen patients had bilateral ECTR. The patients' ages ranged from 23 to 79 years, with an average of 48 years. All patients had a history of weakness or clumsiness of the involved hand and hypesthesia or paresthesia in the median nerve distribution. All of the patients who underwent an endoscopic carpal tunnel release had prolonged motor andlor sensory conduction latency across the carpal tunnel. All patients who underwent surgery had previously had at least I month of splinting and treatment with a nonsteroidal anti-inflammatory medication without relief. Eighty-seven wrists were assessed for a change in carpal arch diameter by means of standardized carpal tunnel views as described by Gartsman et al. 5 These
Vol. 17A. No.6 November 1992
Carpal arch alteration
1013
Fig. 1. X-ray film demonstrating earpal tunnel view obtained with wrist positioned in 50-degree extension splint. The distance is measured between the tip of the trapezial ridge and the tip of the hook of the hamate (white circles).
films were taken with the wrist held in 50 degrees of extension in a dorsal splint, the anterior surface of the forearm flat on the x-ray cassette, and a tube-to-table distance of 76.2 em. In 61 cases, both preoperative and postoperative x-ray films were obtained. Postoperative films were generally obtained 10 days after surgery. Twenty-six cases were evaluated by means of postoperative x-ray films that compared the treated and nontreated sides. The distance between the palmar ridge of the trapezium and the hook of the hamate was measured on each film (Fig. 1). The same instrumentation and basic technique as described by Chow} were used, except that the path of blunt dissection and subsequent placement of the slotted cannula and endoscope was superficial to the flexor tendons, tenosynovium, and median nerve and immediately dorsal to the transverse carpal ligament. The plane of dissection follows that described by Agee et al. in their report on endoscopic carpal tunnel release." The other modification in the technique was that an oblique rather than a transverse incision was used distally. This more closely followed the conventional incision for open carpal tunnel release and facilitated conversion from endoscopic to open carpal tunnel surgery should the need arise. The use of local, regional, or general anesthesia was based on a combination of the patient's preference and his or her medical status. An upper arm tourniquet was always placed on the patient but was not required in any of the endoscopic procedures.
The postoperative regimen included a soft dressing, which was replaced by Band-Aid adhesive bandages on the third postoperative day. Sutures were removed 1 week after the surgery. Light duty was advised for the first 2 postoperative weeks. Grip strength was obtained preoperatively and was monitored each week postoperatively with the Jamar dynamometer. Pinch strength was also followed, as was sensation as determined by two-point discrimination. General anesthesia was used in 34 cases, regional anesthesia in 39 cases, and local anesthesia in 14 cases. The operative time ranged from 11 to 40 minutes and averaged 25 minutes.
Results Eighty-seven cases were assessed for a change in the carpal arch diameter by means of standardized carpal tunnel views. The average change in the carpal arch, as measured from the apex of the palmar ridge of the trapezium to the apex of the hook of the hamate on the standardized carpal tunnel view, was an increase of 0.17 ern and ranged from 0.0 to 0.5 em. This was an average increase of 7% in the carpal tunnel diameter (range, 0 to 25%). The breakdown of the cases showed that 70% had an increase of 0% to 10% in carpal arch diameter, 26% of the cases had an increase of 10% to 20%, and 4% of the cases had an increase of 20% or more. Grip strength averaged 37% of the preoperative level I week after surgery. At 3 weeks grip strength had
1014
The Journal of HAND SURGERY
Viegas et al.
80
•
70
-?ft.
0
60
aCTR ECTR
50
til
r::::
40
CIl
:;:::
as
/l.
30 20 10 0 0-10
10·20
20+
Change In Arch (%) Fig. 2. Gartsman et aI.' reported that 40% of their cases (black bars) had a 0% to 10% increase in carpal arch width compared to our 70% (white bars). Twenty-eight percent of their cases had a 10% to 20% increase, whereas the present study found 26% in this range. Gartsman et al. reported that 32% of their cases had an increase of 20% or more (up to 52%), while in the endoscopically released carpal tunnels only 4% of the cases had an increase of more than 20% carpal arch diameter, with a maximum increase of 25%.
improved to 86% of the preoperative baseline, and by 6 weeks it averaged 121% of the preoperative level. Pinch strength averaged 70% of the preoperative level 1 week after surgery. At 3 weeks it had improved to 102% of the preoperative baseline, and by 6 weeks pinch strength averaged 106% of the preoperative level. The two-point discrimination was noted to be 6 mm or more in 63 patients and less than 6 mm in 17 patients. Seventy-one percent of the patients with preoperative two-point discrimination greater than 6 mID improved to level of 6 mm or less; 29% remained at greater than 6 mm. Of those in whom two-point discrimination remained at a level of greater than 6 mm, 41% showed improvement. Maximum improvement in two-point discrimination was reached at an average of 2 weeks postoperatively (range, 1 to 5 weeks). There were two postoperative complications-a transient neuropraxia of the common digital nerve to the second web space and a transient neuropraxia of the median nerve. One case was converted to an open carpal tunnel. This translates into a 3% complication rate. Discussion
No previous reports in the literature describe the effects of endoscopic division of the transverse carpal ligament on the carpal arch. Gartsman et a1.5 reported an average increase of 0.29 em in the carpal arch width
(range, 0.0 to 0.85 ern). This was a 13% average increase in the carpal arch width (range, 0% to 52%). This average increase and the upper range are greater than the 0.17 ern average distance and the 0.0 to 0.5 em range that were found in our series of endoscopic carpal tunnel releases. The breakdown of their cases is also different. Gartsman et a1.5 had a fairly equal distribution of cases that had increases of 0 to 10 degrees, 10 to 20 degrees, and 20 degrees or more in carpal arch width, while the majority of cases in our series had increases of 0 to 10 degrees, and very few had increases of 20 degrees or more in carpal arch width (Fig. 2). This may be of particular significance since Gartsman et al. also reported that patients with an increase of more than 20% in carpal arch width had a significantly decreased grip strength even 20 months after surgery. The change in the carpal arch width after endoscopic carpal tunnel release appears to be less than that reported for open carpal tunnel release. It remains unclear, however, whether this is advantageous. Clinically, the preliminary results of endoscopic carpal tunnel release are good. The differences in the arch dimensions following OCTR and ECTR may be only transient, since Richman et al., 6 using magnetic resonance imaging, demonstrated an average increase of 1.5 mm in the carpal tunnel diameter 6 weeks after surgery but later, at 8 months, found no significant difference in the preoperative and postoperative values. They did, however,
Vol. 17A, No.6 November 1992
Carpal arch alteration
1015
140
•
120
0
~ 100 e....
-
aCTA ECTR
..c
Cl l: ell
80
en
60
....
Q,
.;:
e
40 20 0
3
6
Post Op (weeks) Fig. 3. Gellman et at .' reported that 3 weeks after open carpal tunnel release (black bars) the average grip strength was 28% of the preoperative baseline . At 3 weeks after endoscopic carpal tunnel release (white bars) average grip strength was 86% of preoperative level. At 6 weeks after surgery the OCTR group had regained 73% of their preoperative grip strength while the patients in the present study who had an endoscopic release of the carpal tunnel had attained 121% of their preoperative grip strength . The patients that Gellman et aI.' reported on who had undergone open carpal tunnel release reached 99% of their preoperative grip strength 3 months after surgery.
120
--0~
..c
100
• 0
aCTR ECTR
80
Cl
e ell ....
-
60
en
s: u l: ii:
40 20 0 3
6
Post Op (weeks) Fig. 4. Gellman et aI.' found that 3 weeks after open carpal tunnel release their patients (black bars) had 74% of their preoperative pinch strength . This compares to 102% of the preoperative pinch strength that was mea sured in this study group 3 weeks after endoscopic carpal tunnel release (white bars). At 6 weeks the patients reported by Gellman et al. had regained 96% of their preoperative grip strength, compared with 106% in thc present study.
find a lasting increase in the carpal tunnel volume, which cannot be assessed on x-ray films. Gellman et a1. 7 reported on pinch and grip strength and two-point discrimination after open carpal tunnel
release. When their findings are compared with those in our study it appears that the return of grip strength is faster in the patients who have had an endoscopic release of the carpal tunnel (Fig . 3). The pinch strength
1016
The Journal of HAND SURGERY
Viegas et al.
also improved faster in the ECTR patients than in the patients reported by Gellman et al.? (Fig. 4). Gellman et al. 7 reported that of their patients who originally had greater than 6 rom two-point discrimination, 75% were found to have two-point discrimination of 6 mm or less after open carpal tunnel release. Seventeen percent of their patients were improved but did not have 6 mm or less two-point discrimination, and 8% of their patients had no change in their twopoint discrimination. In the patients reported here who originally had greater than 6 mm two-point discrimination, 71 % were found to have two point discrimination of 6 rom or less after ECTR. Twelve percent were improved but did not have 6 mm or less two-point discrimination, and 18% had no change in two-point discrimination. Since these findings are preliminary, it is unclear whether the percent of patients who had no change in two-point discrimination after ECTR would have a further decrease with time. The authors thank Drs. Bennett and Crouch for their encouragement and support.
REFERENCES 1. Phalen GS. Spontaneous compression of the median nerve at the wrist. JAMA 1951;145:1128-33. 2. Okutsu I, Ninomiya S, Takatori Y, Ugawa Y. Endoscopic management of carpal tunnel syndrome. Arthroscopy 1989;5:11-18. 3. Chow JCY. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy 1989;5:19-24. 4. North ER. Endoscopic carpal tunnel release. In: Gelberman RH. Operative nerve repair and reconstruction. vol. II. Philadelphia: JB Lippincott, 1991:913-20. 5. Gartsman G, Kovach J, Crouch C, Noble P, Bennett 1. Carpal arch alter carpal tunnel release. J HAND SURG 1986;1IA:372-4. 6. Richman JA, Gelberman RH, Rydevik BL, Hajek PC, Braun RM, Gylys-Morin VM, Berthoty D. Carpal tunnel syndrome: morphologic changes after release of the transverse carpal ligament. J HAND SURG 1989;14A:852-7. 7. Gellman H, Kan D, Gee V, Kuschner SH, Botte MJ. Analysis of pinch and grip strength after carpal tunnel release. J HAND SURG 1989;14A:863-4.
Bound volumes available to subscribers Bound volumes of the JOURNAL OF HAND SURGERY are available to subscribers (only) for the 1992 issues from the Publisher, at a cost of $42.00 for domestic, $51.00 for international, and $53.94 for Canadian subscribers for Vol. 17A (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone (800)325-4177, ext. 4351, or (314)453-4351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
