Changes in carpal tunnel compliance with incremental flexor retinaculum release

Background: Flexor retinaculum transection is a routine surgical treatment for carpal tunnel syndrome, yet the biomechanical and clinical sequelae of the procedure remain unclear. We investigated the effects of flexor retinaculum release on carpal tunnel structural compliance using cadaveric hands. Methods: The flexor retinaculum was incrementally and sequentially released with transections of 25, 50, 75, and 100% of the transverse carpal ligament, followed by the distal aponeurosis and then the antebrachial fascia. Paired outward 10N forces were applied to the insertion sites of the transverse carpal ligament at the distal (hamate-trapezium) and proximal (pisiform-scaphoid) levels of the carpal tunnel. Carpal tunnel compliance was defined as the change in carpal arch width normalized to the constant 10N force. Results: With the flexor retinaculum intact, carpal tunnel compliance at the proximal level, 0.696 ± 0.128mm/N, was 13.6 times greater than that at the distal level, 0.056 ± 0.020mm/N. Complete release of the transverse carpal ligament was required to achieve a significant gain in compliance at the distal level (p < 0.05). Subsequent release of the distal aponeurosis resulted in an appreciable additional increase in compliance (43.0%, p = 0.052) at the distal level, but a minimal increase (1.7%, p = 0.987) at the proximal level. Complete flexor retinaculum release provided a significant gain in compliance relative to transverse carpal ligament release alone at both proximal and distal levels (p < 0.05). Conclusions: Overall, complete flexor retinaculum release increased proximal compliance by 52% and distal compliance by 332%. The increase in carpal tunnel compliance with complete flexor retinaculum release helps explain the benefit of carpal tunnel release surgery for patients with carpal tunnel syndrome.