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The results of this study suggest that a decreased vascularization of the median nerve after releasing the carpal tunnel predicts an inferior clinical improvement assessed by the Boston Carpal Tunnel Questionnaire., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We present a case of a 29-year-old woman with diffuse, unilateral wrist pain and carpal tunnel syndrome secondary to an interosseous ganglion of the lunate and aim to highlight uncommon aetiologies when assessing patients with atypical carpal tunnel symptoms., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Transthyretin amyloidosis is a frequent cause of heart failure, resulting from an accumulation of abnormal proteins in the myocardium. Recent research has highlighted the importance of early diagnosis to enhance the effectiveness of specific treatments. Extra-cardiac symptoms may precede several years before cardiac complications, with carpal tunnel syndrome often considered a red flag. The aim of this prospective, observational cohort study was to determine the incidence rate of positive synovial biopsies for transthyretin amyloidosis in patients aged 60-80 years undergoing carpal tunnel decompression, and to identify risk factors. The diagnosis of transthyretin amyloidosis was confirmed through the analysis of synovial tissue biopsies using Congo Red and immunohistochemical staining. The study included 254 patients, with an 18.5% prevalence of transthyretin amyloidosis. Risk factors for positive test results were identified as male sex, trigger finger, hearing disorders and valve disease. A predictive analysis using logistic regression yielded a probability model for individuals belonging to the positive group. Level of evidence III., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Level of Evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Although surgical release of upper extremity nerve compression syndromes is highly effective, persistence or recurrence of symptoms and signs may occur. Thorough investigation is necessary in this situation before treatment is recommended. If the symptoms cannot be explained by other pathology than compression of the affected nerve and if conservative management has not provided improvement, reoperation may be considered. This review provides an overview of the diagnostic and surgical considerations in the revision of carpal tunnel syndrome, cubital tunnel syndrome and thoracic outlet syndrome. Level of evidence: V., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of this single-centre retrospective study was to evaluate the outcomes of carpal tunnel release surgery in patients with hereditary neuropathy with pressure palsies (HNPP). The secondary aims were to identify prognostic factors for the outcome of carpal tunnel release and to assess the outcome of cubital tunnel release. Our primary hypothesis was postoperative improvement. In total, 18 patients (26 carpal tunnel releases) with at least one symptomatic carpal tunnel syndrome were included. At a median follow-up of 8.5 years, more than 73% of the patients were satisfied with the results. The visual analogue scale (0 to 10) for discomfort decreased by 2.2 points ( p <  0.001). The Boston Carpal Tunnel Questionnaire symptom severity scale decreased by 1.3 points ( p  < 0.001). The decrease in the Functional Status Scale was not significant. No significant prognostic factor for outcome was identified. A total of 12 patients also underwent cubital tunnel release, and three patients underwent just this procedure (23 procedures). Despite the lack of preoperative data, cubital tunnel release provided encouraging results.  Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications. Level of evidence: V., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Shin: (1) Editor in Chief, Techniques in Hand and Upper Extremity; (2) Royalties: Trimed orthopedics/Mayo medical ventures. Dr Pulos and Dr Townsley have no conflicting interests for this article.

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future. Level of evidence: V., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The primary aim of our study was to assess the environmental impact of moving from a standard to a lean and green model for a carpal tunnel decompression. We objectively measured the clinical waste generated, the number of single use items and the number of sterile instruments required for a standard procedure, and then moved to smaller instrument trays, smaller drapes and fewer disposables. These two models were compared for waste generation, financial costs and carbon footprint. Information prospectively collected on seven patients in the standard model and 103 patients in the lean and green model in two hospitals over a 15-month period, demonstrated a reduction in CO 2 emissions of 80%, clinical waste reduction of 65%, and an average aggregate cost saving of 66%. The lean and green model can deliver a safe, efficient, cost-effective and sustainable service for patients undergoing carpal tunnel decompression. Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of this study was to compare the symptomatic, functional and satisfaction outcomes of patients with different temperaments undergoing carpal tunnel surgery by a single surgeon. Dominant temperaments of 171 patients with carpal tunnel syndrome were determined using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A). Patients were divided into six temperament groups, and the impact of their respective group measured against preoperative and postoperative symptom severity and functional capacity using the Boston Carpal Tunnel Questionnaire (BCTQ] and satisfaction using the Patient Evaluation Measure (PEM). Patients in the depressive group had the largest improvement in symptoms (BCTQ score change, -2.2) as well as a significant improvement in function (BCTQ score change, -2.1), yet had the lowest postoperative satisfaction (mean PEM score 9). Determination of patient temperament before surgery for carpal tunnel syndrome (CTS) may be useful as an ancillary technique to help predict postoperative satisfaction, which may in turn help guide preoperative communication and expectation setting. Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This review article examines the use of nerve conduction studies in the management of carpal tunnel syndrome. These studies should be understood not as a test that determines the diagnosis but as a measure of impaired nerve function. They are sensitive indicators of local demyelination and axonal loss that can detect and quantify these changes before the appearance of clinical signs, providing information that cannot be obtained with the unaided senses of the physician, nor by any other investigation. They are the best available indicator of overall disease severity, correlating with symptoms and anatomical change in the median nerve. They have some prognostic value for surgical outcome and are sufficiently sensitive to change for the evaluation of treatment response. When surgery does not yield the expected improvement in symptoms, they can help to establish whether decompression has been achieved provided preoperative results are available for comparison., Competing Interests: Declaration of conflicting interestsThe author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Controversy remains regarding the optimal technique and suture type for wound closure after carpal tunnel surgery. Adult patients undergoing open carpal tunnel release were prospectively randomized to receive either interrupted, buried Monocryl sutures or traditional nylon horizontal mattress sutures for their wound closures. At the 2-week and 6-week postoperative visits, Patient and Observer Scar Assessment Scale questionnaires were completed. At 2 weeks, patients and observers had a significantly better opinion of incisions closed with Monocryl. By 6 weeks, neither patients nor observers found a difference between suture types in any category. Scars of wounds closed with Monocryl did not change appreciably in appearance between 2 and 6 weeks. However, patients and observers noted significant improvement in scar appearance in the nylon group over time. Monocryl suture represents an effective method for carpal tunnel closure that leads to improved patient- and observer-reported outcome scores in the early postoperative period compared with nylon. Level of evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This single-centre retrospective study reports our management of carpal tunnel syndrome in 52 children (103 hands) with mucopolysaccharidoses and mucolipidoses. All except one were bilateral. The median age at surgery was 4 years (range 1.5 to 12). The diagnosis of carpal tunnel syndrome was confirmed by an electromyogram (EMG) in all patients; 38% of these presented without any clinical signs. Surgical neurolysis was performed in all hands, combined with epineurotomy in 52 hands (50%) and flexor tenosynovectomy in 75 hands (73%). Surgery was bilateral in 98% of children (102 hands). The mean follow-up was 12 years (range 1 to 19) and the EMG was normalized in 78% of hands. Ten patients suffered recurrence, eight of whom required further surgery. Screening for carpal tunnel syndrome is essential for the management of children mucopolysaccharidoses and mucolipidoses. Surgical treatment should be carried out early with follow-up by EMG to detect recurrence. Level of evidence: IV.

In this prospective cohort study, the health-related quality of life (HRQoL) from a societal perspective of carpal tunnel syndrome (CTS) patients was determined and compared with other diseases. In addition, the effect of carpal tunnel release (CTR) was analysed 6 weeks postoperatively with regard to mean EQ-5D index value improvement, side-effects of surgery and cost per quality adjusted life year (QALY) gained. We found a baseline mean EQ-5D index value of 0.75 (SD: 0.23), comparable with values seen in other disease like breast cancer, diabetes and asthma. Furthermore, we found that CTR improved HRQoL substantially 6 weeks postoperatively (mean + 0.12, SD: 0.22) and significantly reduced symptom reporting (mean -52%, SD: 53) with a cost per QALY gained of €396.05. In conclusion, CTS has a comparable impact on quality of life as compared with other diseases, and CTR has the potential to substantially improve patient's HRQoL at a fairly modest cost. Level of evidence: III.

We used high-resolution ultrasound to examine 35 median nerves (35 patients) with failed carpal tunnel decompression to identify the cause of failure. The carpal tunnel was examined before revision surgery, and the results were correlated with surgical findings. The cross-sectional area was measured, and nerve morphology was analysed at the sites of compression. We found persistent median nerve compression in 30 out of 35 patients. In 20 patients, the compression was caused by a residual transverse carpal ligament, in four by perineural fibrosis, in five by both of these causes and in one by tenosynovitis. In four patients, evidence of median nerve injury with an epineural/fascicular lesion was detected; and in one, no abnormalities were found. Surgical findings were consistent with the ultrasound findings except in one patient where tenosynovitis was associated with a giant cell tumour, which was missed by ultrasound. High-resolution ultrasound can provide helpful information in preoperative diagnosis of failed carpal tunnel decompression with good correlation between the ultrasound and surgical findings. Level of evidence: IV.

A retrospective review of hospital employees at a single employer institution who underwent ultrasound guided thread carpal tunnel release (TCTR) or open carpal tunnel release (OCTR) between January 2018 and August 2020 was performed to ascertain differences in return-to-work status. Patient age, sex, occupation, handedness, severity of carpal tunnel syndrome, prior treatments and surgical outcomes were reviewed. A total of 18 patients underwent TCTR and 17 patients underwent OCTR. The TCTR group averaged 12 days to return to work without restrictions, as opposed to 33 days for the OCTR group. Resolution of symptoms was afforded in all patients without any complications regardless of surgical technique. While both TCTR and OCTR were effective, our data indicates that TCTR resulted in a shorter return to work. Level of evidence: III.

The aim of this study was to assess the clinical results after extensor indicis proprius opponensplasty in patients with carpal tunnel syndrome and severe thenar muscle atrophy. Forty patients who underwent this procedure during open carpal tunnel releases. The mean follow-up period was 17 months (range 10 to 36). Kapandji scores significantly improved from 5.5 before surgery to 9.6 at final follow-up. Thumb pronation angle also significantly improved from 111° before surgery to 149°. Side and pulp pinch strength significantly improved postoperatively, as well as DASH scores at final follow-up. In conclusion, the extensor indicis proprius tendon transfer technique represents a reliable opponensplasty procedure to achieve consistent results in patients with severe carpal tunnel syndrome. Level of evidence: IV.

We performed a systematic review on the success of different surgical techniques for the management of recurrent and persistent carpal tunnel syndrome. Twenty studies met the inclusion criteria and were grouped by the type of revision carpal tunnel release, which were simple open release, open release with flap coverage or open release with implant coverage. Meta-analysis showed no difference, and pooled success proportions were 0.89, 0.89 and 0.85 for simple open carpal tunnel release, additional flap coverage and implant groups, respectively. No added value for coverage of the nerve was seen. Our review indicates that simple carpal tunnel release without additional coverage of the median nerve seems preferable as it is less invasive and without additional donor site morbidity. We found that the included studies were of low quality with moderate risk of bias and did not differentiate between persistent and recurrent carpal tunnel syndrome.

Sensory changes are common manifestations of nerve complications of carpal tunnel surgery. Division or contusion of a superficial communicating branch between the median nerve and the ulnar nerve, the communicating branch of Berrettini, can explain these symptoms. The aim of this study was to describe the potential value of high-resolution sonography to examine this branch. We conducted a study on eight fresh cadaver hands. An ultrasound assessment of the communicating branch of Berrettini, accompanied by an injection of methylene blue, was performed by a senior radiologist. Subsequent dissections confirmed that the eight guided ultrasound injections allowed the methylene blue to be placed around the origin and termination of the communicating branch of Berrettini. This study extends the limits of ultrasound both in the postoperative diagnosis of potential nerve complications and its possible use in ultrasound-guided carpal tunnel release.

This study quantified recovery of thumb motion in patients with carpal tunnel syndrome after carpal tunnel release using three-dimensional motion analysis with a retroreflective surface-based marker method. Eighteen hands from 14 patients who underwent carpal tunnel release for idiopathic carpal tunnel syndrome were included. The angular movements of the three joints of the thumb, the path length of the thumb tip and the area enclosed by the perimeter path of the thumb tip were measured during circumduction. The range of joint movement, including abduction/adduction of the trapeziometacarpal joint, and flexion/extension of the interphalangeal and metacarpophalangeal joints and the path length of the thumb tips, improved significantly 1 year after surgery. The quantification of thumb kinematics helps to better understand motor dysfunction in carpal tunnel syndrome, assess the severity of the condition and decide on treatment. Level of evidence: IV.

We sought to establish whether carpal and cubital tunnel syndrome requiring surgery is associated with deprivation in England. Data from 10,496 adult patients who were treated in our hand unit over a 20-year period were reviewed. The Index of Multiple Deprivation was used to measure deprivation from the patients' postcode. The mean age at surgery in the most deprived three quintiles was significantly lower than in the least deprived two quintiles for carpal tunnel release (55 vs 59 years, respectively) and cubital tunnel release (52 vs 57 years, respectively). The incidence rate was significantly lower for the three least deprived quintiles when compared with the most deprived quintile for both conditions. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for carpal tunnel release was 0.70 for men and 0.76 for women. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for cubital tunnel release was 0.79 for men and 0.49 for women. Carpal tunnel and cubital tunnel syndrome requiring surgery is more common in deprived patients and occurs at an earlier age. Level of evidence: IV.

The relationship between surgery for cubital tunnel and carpal tunnel syndrome was examined in this retrospective study. Between 1997 and 2018, data from consecutive patients who underwent carpal tunnel release (8352 patients), cubital tunnel release (1681 patients) or both procedures (692 patients) were analysed. The relative risk of undergoing cubital tunnel release in the population who had carpal tunnel release compared with those with no carpal tunnel release was 15.3 (male 20.3; female 12.5). The relative risk of undergoing carpal tunnel release in the population who had cubital tunnel release compared with those who did not undergo carpal tunnel release was 11.5 (male 16.5; female 9.1). Our study showed that men and women who undergo carpal tunnel release are over 20 times and 10 times more likely to have cubital tunnel release than those who did not undergo carpal tunnel release, respectively. These findings suggest that the two conditions may share a similar aetiology. Level of evidence: IV.

We systematically reviewed prospective studies for five hand procedures to analyse postoperative follow-up time, clinical or radiographic plateau, and whether the authors provide justification for times used. Demographic data, outcomes and mean follow-up were analysed. A total of 188 articles met our inclusion criteria. The mean postoperative follow-up time among these studies were carpal tunnel release, 21 months (range 1.5-111); cubital tunnel release, 27 months (2.5-46); open reduction and internal fixation for the distal radius fracture, 24 months (3-120); thumb carpometacarpal joint arthroplasty, 64 months (8.5-228); and flexor tendon repair, 25 months (3-59). Authors provided justification for follow-up intervals in 10% of these reports. We conclude that most prospective clinical studies in hand surgery do not properly justify follow-up length. Clinically unnecessary follow-up is costly without much benefit. In prospective research, we believe justified postoperative follow-up is essential, based on expected time to detect clinical plateau, capture complications and determine the need for secondary surgery. Level of evidence: III.

This prospective single-centre study describes the functional outcomes, satisfaction and health-related quality of life after open revision carpal tunnel decompression for recurrent carpal tunnel syndrome. The QuickDASH, patient satisfaction and EuroQol-5 dimensions questionnaires were collected preoperatively and postoperatively over a 5-year period (2013-2018). The median time to revision was 13.3 years (range 3.9-35.4 years; interquartile range 7.2-15.9 years). Outcomes were available for 14 hands in 13 patients at a mean of 20 months after revision surgery. The mean preoperative and postoperative QuickDASH scores were 55 and 29, respectively, and the mean improvement in QuickDASH was 26. The mean improvement in EuroQol-5 dimensions score was 0.1, and 13 of the 14 patients were satisfied. The net promoter score was 85. This study confirms that patients undergoing revision open carpal tunnel decompression for recurrent carpal tunnel syndrome experience a significant improvement in function and health-related quality of life. Level of evidence: IV.

The aim of this study was to investigate the incidence rates and operations for carpal tunnel syndrome and ulnar and radial neuropathies in specialist care in Finland. Patients diagnosed with entrapment neuropathies of the upper extremity were identified from the Care Register for Health Care, 2007-2016. There were 81,911 cases in 54,095,070 person-years. The total crude incidence rates per 100,000 person-years among women and men were 197 and 105 for carpal tunnel syndrome, 26 and 36 for ulnar neuropathies, and 5.7 and 8.5 for radial neuropathies, respectively. Of these, carpal tunnel syndrome was operated on in 63% of women and 61% of men, ulnar neuropathy in 43% of women and 47% of men, and radial neuropathy in 11% of women and 8% of men. Incidence of carpal tunnel syndrome and ulnar neuropathies increased up to late middle age, while radial neuropathies were less common. Level of evidence: III.

Arm sling elevation is widely used after hand surgery to prevent swelling and pain. This prospective cohort study investigated whether arm sling elevation has any value after carpal tunnel release surgery. Patients were assigned to one of two groups after carpal tunnel release: with or without arm sling elevation. The primary outcome was postoperative swelling. Secondary outcomes were pain and symptom relief and functional outcome. Volumetric analysis showed no significant difference between the sling and non-sling group. Pain scores and improvement of symptom severity and functional status scores were similar for both groups. Thirty-eight per cent found the sling uncomfortable. These results do not support routine use of arm sling elevation after carpal tunnel release. Level of evidence: III.

Some patients present with typical clinical features of carpal tunnel syndrome despite normal nerve conduction studies. This study compared the preoperative and 1-year postoperative QuickDASH scores in patients with normal and abnormal nerve conduction studies, who underwent carpal tunnel decompression. Of the 637 patients included in the study, 19 had clinical features of carpal tunnel syndrome but normal nerve conduction studies, and underwent decompression after failure of conservative management. Preoperative QuickDASH scores were comparable in both groups (58 vs 54.8). However, there were significant differences between the normal and abnormal nerve conduction study groups in the QuickDASH at 1 year (34.9 vs 21.5) and change in QuickDASH postoperatively (23.1 vs 33.4). Patients with normal nerve conduction studies had comparable preoperative disability scores compared with those with abnormal studies. Although they had a significant improvement in QuickDASH at 1 year, this was significantly less than those with abnormal nerve conduction studies. Level of evidence: III.

We studied whether mental health status is significantly correlated to patient reported functional outcomes and satisfaction after carpal tunnel release. Over a 7-year period, 809 patients completed Short Form-12 (SF-12) questionnaires which allowed calculation of the SF-12 mental component summary 1 year postoperatively, 780 (96%) completed a satisfaction questionnaire and 777 (96%) completed a QuickDisabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Median QuickDASH score was 55 preoperatively (interquartile range [IQR] 28) and 14 postoperatively (IQR 32). A total of 674 patients were satisfied. Patients with mental disability had worse QuickDASH scores (median 34, IQR 41) and a higher incidence of dissatisfaction (52/245, 21%) than those without mental disability (n = 9, IQR 20, 10%, both p  < 0.001). Regression analyses indicated scores in the SF-12 mental component summary were significantly related to postoperative QuickDASH score ( p  < 0.001) and satisfaction ( p  = 0.02). We concluded that patients with mental disability report poorer outcomes and lower satisfaction rates; however, the majority still exhibit significant improvements and are satisfied. Level of evidence: II.

The utility of routine preoperative electrodiagnostic studies for carpal tunnel syndrome is controversial. One argument in support of routine preoperative electrodiagnostic study is the acquisition of an objective baseline for comparison in cases of postoperative symptom persistence or recurrence. We identified 1141 patients who underwent carpal tunnel release in 1383 limbs at a tertiary care referral centre from July 2008 to June 2013. The prevalence of preoperative electrodiagnostic study acquisition was 88%. Postoperative studies were acquired in 129 out of 1383 limbs that underwent carpal tunnel release (9.3%) at a median 24.3 months after surgery. Assessment of the median nerve for persistent or recurrent carpal tunnel syndrome was part of the rationale for obtaining electrodiagnostic studies in 81% of cases in which postoperative electrodiagnostic studies were acquired. Younger age, lower body mass index, Hispanic race and education level of eighth grade or less were associated with postoperative electrodiagnostic study acquisition. Level of evidence: IV.

Sleep disturbance is a frequent symptom of carpal tunnel syndrome. The aim of this study was to investigate the effect of median nerve decompression on sleep quality of patients with this condition. The study sample consisted of 41 patients with severe carpal tunnel syndrome who were admitted to our clinic and treated with open median nerve decompression. Sensation and functional recovery of the patients were followed using the Boston Function Questionnaire, the Semmes-Weinstein monofilament test and the two-point discrimination test. Symptomatic recovery of the patients was followed by the Boston Symptom Questionnaire. The tests were used before surgery and at three and six months afterwards. Sensory, functional and symptomatic recovery from the third month to the sixth month following surgery also affected sleep parameters and improved the sleep quality of patients with carpal tunnel syndrome. Level of evidence: IV.

The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from -100 to 100. Positive scores indicate good performance. This study quantifies the scores in 810 patients at a mean of 14 months following four common procedures. The score was 83 for trigger finger release ( n = 103), 68 for carpal tunnel decompression ( n = 467), 62 for surgery for Dupuytren's disease ( n = 224) and 44 for ganglia excision ( n = 16). Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction. Level of evidence: II.

No consensus exists about the minimal clinically important difference for the Boston Carpal Tunnel Questionnaire, which hampers its clinical application. This study assessed the minimal clinically important difference of this questionnaire. The Boston Carpal Tunnel Questionnaire was completed by 180 patients, with clinically defined carpal tunnel syndrome, preoperatively and at about 8 months follow-up after carpal tunnel release, together with a six-point scale for perceived improvement. Receiver operator characteristics curves showed that relative changes in Symptom Severity Scale and Functional Status Scale scores correspond better to a clinically relevant improvement than absolute changes. The minimal clinically important difference should be individually calculated from baseline Symptom Severity Scale and Functional Status Scale scores, as patients experiencing more symptoms require more improvement to notice a clinically important difference. By taking this into account, the Boston Carpal Tunnel Questionnaire is more meaningful as an outcome measure in research and clinical practice.

We conducted a prospective randomized controlled trial to investigate carpal tunnel decompression under local anaesthesia. Carpal tunnel decompression was performed in 37 wrists using local anaesthesia and an arm tourniquet and 36 without tourniquet but with a local anaesthetic mixture containing adrenaline. Patients who underwent carpal tunnel decompression using a tourniquet experienced a significantly greater degree of pain when compared with those who did not have a tourniquet. Pain and hand function improved to a similar degree in both groups. We conclude that carpal tunnel decompression performed with a tourniquet causes patients unnecessary pain with no additional benefit as compared with the wide-awake carpal tunnel decompression without use of a tourniquet., Level of Evidence: I.

There is a limited evidence base from which to derive recommendations for safe and effective return to different types of occupation after carpal tunnel release surgery. The current practice of members of the British Society for Surgery of the Hand and the British Association of Hand Therapists was investigated with a questionnaire. In total, 173 surgeons and 137 therapists responded from an estimated sample of 1959. Median recommended return-to-work times were 7 days for desk-based duties, 15 days for repetitive light manual duties and 30 days for heavy manual duties. However, the responses were wide-ranging: 0-30 days for desk-based; 1-56 days for repetitive light manual; and 1-90 days for heavy manual. Variation in the recommended timescales for return to work and other functional activities after carpal tunnel release suggests that patients are receiving different and possibly even conflicting advice., Level of Evidence: V.

Studies suggest that low vitamin D levels are associated with carpal tunnel syndrome. We aimed to evaluate whether level of vitamin D receptor expression in the endothelial cells of the subsynovial connective tissue is associated with clinical features of carpal tunnel syndrome. We obtained the subsynovial connective tissue from 52 women with carpal tunnel syndrome during surgery and performed immunohistochemical analysis of vitamin D receptors in the endothelial cells of the subsynovial connective tissue. We explored correlation of vitamin D receptor expression with clinical features of carpal tunnel syndrome, such as age, symptom duration, symptom severity and electrophysiological severity. Diverse range of vitamin D receptor expression was observed. Vitamin D receptor expression was independently associated with distal motor latency. This suggests that vitamin D receptor expression may be associated with disease progression, as prolonged distal motor latency reflects severity of the disease. Further studies are necessary to explore the role of vitamin D and vitamin D receptors in patients with carpal tunnel syndrome., Level of Evidence: IV.