Background: Depression and pain catastrophizing are aspects of the patient’s mindset that have been shown to be important in relation to the outcome of carpal tunnel release. However, other factors of the patient’s mindset have been understudied, such as treatment expectations and illness perceptions. The aim of the present study was to investigate the influence of these mindset aspects on outcome of carpal tunnel release, in addition to psychological distress and pain catastrophizing. Methods: A total of 307 patients with carpal tunnel syndrome who visited outpatient hand surgery clinics and who completed online questionnaires regarding demographic and psychosocial characteristics and carpal tunnel syndrome severity were included. The patient mindset was measured with the Patient Health Questionnaire-4, the Pain Catastrophizing Scale, the Credibility Expectancy Questionnaire, and the Brief Illness Perception Questionnaire. Hierarchical linear regression models were used to examine the relation between self-reported severity 6 months after carpal tunnel release, as measured with the Boston Carpal Tunnel Questionnaire, and psychosocial aspects of mindset, adjusting for preoperative Boston Carpal Tunnel Questionnaire score, patient characteristics, and comorbidities. Results: Independent associations with better self-reported outcome were found for higher treatment expectations (β = −0.202; p < 0.001) and illness comprehensibility (β = −0.223; p < 0.001). The additional explained variance in Boston Carpal Tunnel Questionnaire scores by the patient’s mindset was 13.2 percent (psychological distress and pain catastrophizing together, 2.1 percent; treatment expectations and illness perceptions together, 11.1 percent). Conclusion: Treatment outcome expectations and comprehensibility of illness are both independently associated with the outcome of carpal tunnel release, showing the importance of these aspects of the patient’s mindset for the outcome of carpal tunnel release. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

OBJECTIVEThe aim of this study was to evaluate the self-reported outcome of revision surgery in patients with recurrent and persistent carpal tunnel syndrome (CTS) and to identify predictors of clinical outcome of revision surgery.METHODSA total of 114 hands in 112 patients were surgically treated for recurrent and persistent CTS in one of 10 specialized hand clinics. As part of routine care, patients were asked to complete online questionnaires regarding demographic data, comorbidities, and clinical severity measures. The Boston Carpal Tunnel Questionnaire (BCTQ) was administered at intake and at 6 months postoperatively to evaluate clinical outcome. The BCTQ comprises the subscales Symptom Severity Scale (SSS) and Functional Status Scale (FSS), and the individual scores were also assessed. Using multivariable regression models, the authors identified factors predictive of the outcome as measured by the BCTQ FSS, SSS, and total score at 6 months.RESULTSRevision surgery significantly improved symptoms and function. Longer total duration of symptoms, a higher BCTQ total score at intake, and diagnosis of complex regional pain syndrome (CRPS) along with CTS were associated with worse outcome after revision surgery at 6 months postoperatively. The multivariable prediction models could explain 33%, 23%, and 30% of the variance in outcome as measured by the FSS, SSS, and BCTQ total scores, respectively, at 6 months. Although patients with higher BCTQ scores at intake have worse outcomes, they generally have the most improvement in symptoms and function.CONCLUSIONSThis study identified total duration of symptoms, BCTQ total score at intake, and diagnosis of CRPS along with CTS as predictors of clinical outcome and confirmed that revision surgery significantly improves self-reported symptoms and function in patients with recurrent and persistent CTS. Patients with more severe CTS symptoms have greater improvement in symptoms at 6 months postoperatively than patients with less severe CTS, but 80% of patients still had residual symptoms 6 months postoperatively. These results can be used to inform both patient and surgeon to manage expectations on improvement of symptoms.

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Background Ulna shortening osteotomy (USO) for ulnar impaction syndrome (UIS) aims to improve pain and function by unloading the ulnar carpus. Previous studies often lack validated patient-reported outcomes or have small sample sizes. The primary objective of this study was to investigate patient-reported pain and hand function at 12 months after USO for UIS. Secondary objectives were to investigate the active range of motion, grip strength, complications, and whether outcomes differed based on etiology. Materials and methods We report on 106 patients with UIS who received USO between 2012 and 2019. In 44 of these patients, USO was performed secondary to distal radius fracture. Pain and function were measured with the Patient Rated Wrist/Hand Evaluation (PRWHE) before surgery and at 3 and 12 months after surgery. Active range of motion and grip strength were measured before surgery and at 3 and 12 months after surgery. Complications were scored using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions (ICHAW) tool. Results The PRWHE total score improved from a mean of 64 (SD = 18) before surgery to 40 (22) at 3 months and 32 (23) at 12 months after surgery (P  < 0.001; effect size Cohen’s d = −1.4). There was no difference in the improvement in PRWHE total score (P = 0.99) based on etiology. Also, no clinically relevant changes in the active range of motion were measured. Independent of etiology, mean grip strength improved from 24 (11) before surgery to 30 (12) at 12 months (P  = 0.001). Sixty-four percent of patients experienced at least one complication, ranging from minor to severe. Of the 80 complications in total, 50 patients (47%) had complaints of hardware irritation, of which 34 (32%) had their hardware removed. Six patients (6%) needed refixation because of nonunion. Conclusion We found beneficial outcomes in patients with UIS that underwent USO, although there was a large variance in the outcome and a relatively high number of complications (which includes plate removals). Results of this study may be used in preoperative counseling and shared decision-making when considering USO. Level of evidence Therapeutic III.

Objective: To describe outcomes of nonsurgical treatment for symptomatic thumb carpometacarpal joint (CMC-1) instability. Secondary, to evaluate the conversion rate to surgical treatment. Design: Prospective cohort study. Setting: A total of 20 outpatient clinics for hand surgery and hand therapy in the Netherlands. Participants: A consecutive sample of patients with symptomatic CMC-1 instability (NZ431). Intervention: Nonsurgical treatment including exercise therapy and an orthosis. Main Outcome Measures: Pain (visual analog scale [VAS], 0-100) and hand function (Michigan Hand Outcomes Questionnaire [MHQ], 0-100) at baseline, 6 weeks, and 3 months. Conversion to surgery was recorded for all patients with a median follow-up of 2.8 years (range, 0.8-6.7y). Results: VAS scores for pain during the last week, at rest, and during physical load improved with a mean difference at 3 months of 17 (97.5% CI, 9-25), 13 (97.5% CI, 9-18), and 19 (97.5% CI, 12-27), respectively (P<.001). No difference was present at 3 months for MHQ total score, but the subscales activities of daily living, work, pain, and satisfaction improved by 7 (97.5% CI, 1-14), 10 (97.5% CI, 4-16), 5 (97.5% CI, 2-9), and 12 (97.5% CI, 2-22) points, respectively (P<.001-.007). After median follow-up of 2.8 years, only 59 participants (14%) were surgically treated. Both in the subgroups that did and did not convert to surgery, VAS pain scores decreased at 3 months compared with baseline (P<.001-.010), whereas MHQ total score did not improve in both subgroups. However, VAS and MHQ scores remained worse for patients who eventually converted to surgery (P<.001). Conclusions: In this large sample of patients with symptomatic CMC-1 instability, nonsurgical treatment demonstrated clinically relevant improvements in pain and aspects of hand function. Furthermore, after 2.8 years, only 14% of all patients were surgically treated, indicating that nonsurgical treatment is a successful treatment of choice.