Reconstruction of the transverse carpal ligament to restore median nerve gliding. The rationale of a new technique for revision of recurrent median nerve neuropathy.

Two clinical and four surgical steps can be taken to return gliding and nutritional balance to the median nerve after revision surgery for a recurrent median nerve neuropathy: Step One (Clinical): An accurate diagnosis of the median nerve traction neuropathy. Consider brachial plexopathy and terminal neuropathies. Step Two (Surgical): Comprehensive exploration and meso-epineurolysis of the median nerve from the radial remnants of the divided TCL and fibrosed radial and ulnar bursae by resection of the bursae and flexor tenosynovectomy. Step Three (Surgical): Fasciotomy of the volar carpal ligament to lengthen the ulnar leaf of the TCL; permits visualization of the ulnar artery and neurolysis of the ulnar motor nerve. Step Four (Surgical): Mobilize the previously released radical leaf TCL and motor median nerve from the origin of the thenar muscles. Step Five (Surgical): Restore the inner gliding surface and strength of the flexor retinaculum of the hand and wrist by reconstruction of the TCL and the forearm antebrachial fascia. Step Six (Clinical): An immediate postoperative hand therapy program to restore gliding to the median nerve and flexor tendons. Protocols for upper extremity nerve gliding should be carried out under supervision at selected daily intervals. A prevailing brachial plexopathy requires positive supervised therapy for nerve gliding and posture control.