[Special aspects of fractures of the distal forearm]. / Spezielle Aspekte der Frakturen am distalen Unterarm.

BACKGROUND: Fractures of the distal forearm, especially fractures of the distal radius which are the most common fracture in humans, are of increasing socioeconomic relevance due to the increasing incidence and the increasing costs that are associated with the popularity of palmar plating. OBJECTIVES: Radiological imaging for diagnosis and follow-up are presented with special focus on new biomechanical fracture concepts such as the four-corner concept. MATERIALS AND METHODS: The basic literature and expert opinions are evaluated and discussed. RESULTS: In intra-articular fractures of the distal radius, plain radiographs must be supplemented by computed tomography (CT). Direct CT arthrography allows not only analysis of the fracture pattern, but also detection of accompanying injuries of the carpus, especially the scapholunate ligament, and the ulnocarpal complex. The plain radiographs should also be analyzed for accompanying injuries. Therefore, both acquisition of the imaging data and their morphometrical analysis have to be standardized. CONCLUSIONS: In addition to diagnosis and follow-up, radiological imaging plays a decisive role in the treatment of distal forearm fractures. CT and direct CT arthrography have become important tools in intra-articular distal radius fractures.

[Distal radius fractures : Update on imaging]. / Distale Radiusfrakturen : Update zur Bildgebung.

Distal radius fractures are associated with high individual and socioeconomic relevance. Optimized radiography and computed tomography (CT) imaging are essential for individualized therapy planning. Plain CT imaging with 3D reconstruction and digital removal of the carpus and ulna is helpful for choosing the surgical approach in the presence of intra-articular radius fractures. If the fracture line leads towards the scapholunate compartment, ligamentous injury requiring treatment can be detected or ruled out before surgery with the help of direct CT arthrography (CTA). Acquisition of imaging data and morphometrical analysis must be standardized and reproducible. In the diagnostics of distal radius fractures it is necessary for radiologists and surgeons to use a unified fracture classification.

Injuries of the scapholunate and lunotriquetral ligaments as well as the TFCC in intra-articular distal radius fractures. Prevalence assessed with MDCT arthrography.

OBJECTIVES: To evaluate the prevalence of injuries of the scapholunate and lunotriquetral interosseous ligaments (SLIL, LTIL) as well as the triangular fibrocartilage complex (TFCC) in intra-articular distal radius fractures (iaDRF). METHODS: Two hundred and thirty-three patients with acute iaDRF underwent MDCT arthrography. The SLIL and LTIL were described as normal, partially or completely ruptured. Major injuries of the SLIL were defined as completely ruptured dorsal segments, those of the LTIL as completely ruptured palmar segments. The TFCC was judged as normal or injured. Interobserver variability was calculated. Injury findings were correlated with the types of iaDRF (AO classification). RESULTS: In 159 patients (68.2 %), no SLIL injuries were seen. Minor SLIL injuries were detected in 54 patients (23.2%), major injuries in 20 patients (8.6%). No correlation was found between the presence of SLIL lesions and the types of iaDRF. Minor LTIL injuries were seen in 23 patients (9.9%), major injuries in only 5 patients (2.2%). The TFCC was altered in 141 patients (60.5%). Interobserver variability was high for MDCT arthrography in assessing SLIL and TFC lesions, and fair for LTIL lesions. CONCLUSION: In iaDRF, prevalence of major injuries of the most relevant SLIL is about 9% as evaluated with CT arthrography. KEY POINTS: The C-shaped SLIL is built of dorsal, middle and palmar segments. In iaDRF, major SLIL injuries are associated in 8.6% of the cases. In iaDRF, the SLIL remains intact in 68.3% of the cases. IaDRF and SLIL ruptures can comprehensively be depicted with MDCT arthrography. A three-compartment approach is recommended to assess intrinsic ligaments and the TFCC.

[Hand injuries in mountain sports]. / Handverletzungen beim Bergsport.

BACKGROUND: Apart from clean cut finger amputations, every kind of hand injury can be seen in mountain and winter sports but only skier's thumb and injuries of the pulley system in sport climbers are seen in a greater number of cases. Nevertheless, these two common injuries as well as the rare frostbite of the fingers are often underdiagnosed or overdiagnosed as well as undertreated or overtreated. PURPOSE: This paper describes the diagnostics and treatment of skier's thumb, injuries of the pulley system in sport climbers and frostbite of the fingers. RESULTS: Before checking the metacarpophalangeal (MP) joint of the thumb for stability, radiographs should be taken to exclude a bony avulsion of the ulnar collateral ligament in skier's thumb. If there is no bony ligament avulsion further diagnostic procedures, e.g. ultrasound, are recommended to prove or exclude a Stener lesion, which is an absolute indication for operative treatment together with a dislocated bony ligament avulsion. To quantify the severity of a lesion of the pulley system ultrasound and magnetic resonance imaging (MRI) are needed. Most lesions of the pulley system can be treated conservatively. Only multiple pulley ruptures or isolated ruptures associated with a lesion of the lumbrical muscles or collateral ligaments require operative treatment. As long as there is no infection amputation should be done as late as possible in frostbite of the fingers because the extent of the frostbite can rarely be correctly estimated. CONCLUSION: Most cases of skier's thumb as well as lesions of the pulley system can be treated non-operatively but precise diagnostics are needed.

[Instability of the distal radioulnar joint: Treatment options for ulnar lesions of the triangular fibrocartilage complex]. / Instabilität des distalen Radioulnargelenks: Möglichkeiten der Behandlung ulnarer Läsionen des triangulären fibrokartilaginären Komplexes.

Injuries of the triangular fibrocartilage complex (TFCC) may be fatal to the distal radioulnar joint (DRUJ). This structure is one of the crucial stabilizers and guarantees unrestricted pronosupination of the forearm. A systematic examination is mandatory to diagnose DRUJ instability reliably. A clinical examination in comparison to the contralateral side is obligatory. Plain radiographs are required to exclude osseous lesions or deformities. Computed tomography of both wrists in neutral, pronation and supination is necessary to verify DRUJ instability in ambiguous situations. Based on a systematic examination wrist and DRUJ arthroscopy identify lesions clearly. Injuries of the radioulnar ligaments which entail DRUJ instability, should be reconstructed preferably anatomically. Ulnar-sided TFCC lesions may often cause DRUJ instability. Osseous ligament avulsions are mostly treated osteosynthetically. Ligament tears may be refixated using anchor or transosseous sutures. Tendon transplants are necessary for an anatomical reconstruction in cases of irreparable ruptures.

Grip force monitoring on the hand: Manugraphy system versus Jamar dynamometer.

INTRODUCTION: For clinical grip force assessment, the Jamar dynamometer is a wide accepted tool. Users have to be aware that this method does not represent all grip efforts applied. The Manugraphy system is a tool that measure total grip force as well as identify load distribution patterns of the hand while gripping cylinders wrapped with calibrated capacitive matrix sensor mats. The aim of this study was to validate an assessment setting of the Manugraphy system for clinical use. Further, the relationship and difference between the Manugraphy system and the Jamar dynamometer were investigated. MATERIALS AND METHODS: At two study centers, 152 healthy volunteers performed grip force tests with a digital Jamar dynamometer using handle positions 3 and 4 and the novel(®) Manugraphy system using two cylinders with circumferences of 150 and 200 mm. The subjects performed grip force testing with both devices on three different days. The intra- and inter-day variability for both methods was evaluated. To compare the values of both systems, the Spearman correlation coefficient was calculated. RESULTS: The force values, as measured by the sensor matrix, were higher than those of the Jamar dynamometer. Analyses showed significant positive correlations between values obtained by the two measurement methods (p < 0.001). There was no significant inter-day variation for the 200-mm cylinder of the Manugraphy system. For the 150-mm cylinder, a significant variation was observed at center B, but not at A. Nevertheless, the fluctuation of the grip force values obtained with the Manugraphy system was equal or better than those obtained with the Jamar dynamometer. CONCLUSIONS: The force values, obtained using the two systems, have a high correlation but are not directly comparable. Both systems allow valid and constant grip force measurement. As the sensor mat detects all forces applied perpendicularly to the cylinder surface, it characterizes grip force better than the Jamar dynamometer. In addition, information about load distribution of the hand is gained.

[Injuries of the proximal interphalangeal joint]. / Verletzungen der Mittelgelenke.

BACKGROUND: Injuries of the proximal interphalangeal joint (PIP joint) are common. They are frequently underestimated by patients and initial treating physicians, leading to unfavorable outcomes. Basic treatment includes meticulous clinical and radiological diagnosis as well as anatomical and biomechanical knowledge of the PIP joint. TREATMENT: In avulsions of the collateral ligaments and the palmar plate with or without involvement of bone, nonoperative treatment is preferred. Operative stabilization is reserved for large displaced bony fragments or complex instabilities. In central slip avulsion or rupture, osseous refixation, suture, or reconstruction is common and nonoperative treatment is limited to special situations like minimally displaced avulsions. In basal fractures of the middle phalanx, elimination of joint subluxation and restoration of joint stability are priority. If the fragments are too small for fixation with standard implants, therapeutic alternatives include refixation of the palmar plate, dynamic distraction fixation, percutaneous stuffing, or replacement by a hemihamate autograft. Early motion is initiated regardless of the treatment regime. Undertreatment leads to persistent swelling, instability, and limited range of motion, which are difficult to treat. Contributing factors are unnecessary immobilization, immobilization in more than 20° flexion or transfixation by K-wires. For residual limitations, nonoperative treatment with physiotherapists and splinting is first choice. Operative treatment is reserved for persistent flexion/extension contractures persisting for more than 6 months, as well as reconstructions in boutonniere and swan neck deformity and salvage procedures for destroyed joints.

[Scapholunate lesions]. / Die skapholunäre Bandverletzung.

Injuries to the scapholunate ligament are the most frequent cause of carpal instability. Therefore, if a scapholunate lesion is not diagnosed, it may result in a severe dysfunction of the wrist. This review describes the anatomy, and the kinematics of the wrist with an intact as well as a disrupted scapholunate ligament. The diagnostic of an isolated ligament lesion and a ligament injury associated with a fracture of the distal radius is presented. Finally, an algorithm for treatment based on the stage of injury is proposed.

Posterior interosseus nerve vs. medial cutaneous nerve of the forearm: differences in digital nerve reconstruction.

Digital nerve defects are common in hand trauma and for primary or secondary nerve reconstruction, the autologous nerve graft remains the gold standard. This study compares the regeneration results and donor side morbidity of either the posterior interosseus nerve (PIN) graft or the medial antebrachial cutaneous nerve (MACN) graft. 16 patients (group A, age 43 ± 13 years) with digital nerve defects were treated with a PIN graft and 12 patients (group B, age 40 ± 15 years) received a MACN graft. The average nerve gap was 22 mm in each group. After a follow-up of 15 ± 8 months in group A, S4-sensibility were measured in 9 cases, S3+ in 5 cases and in 1 case S2 and S0. Up to an inconspicuously scar in projection of the fourth extensor-tendon compartment, there was no significant donor side morbidity. In group B, a S4-senibility has been obtained in 4 cases, S3+ in 5 cases, S3, S2 and S0 in each 1 case after a follow-up of 16 ± 11 months. Regarding the donor side morbidity, almost all patients complained about a disturbing scar formation and unpleasant paresthesia at the forearm down to the rascetta. Neuroma-associated pain has been detected in 4 cases. Although there has been no significant difference in terms of nerve regeneration, we recommend the use of the PIN graft for digital nerve reconstruction, since harvesting this nerve is fast and easy and without any donor side morbidity compared to the MACN graft.

[Complex fragmentation of the distal radial articular surface. Reconstruction with subchondral Kirschner wires and bone grafts]. / Komplexe Fragmentation der distalen Radiusgelenkfläche. Rekonstruktion durch subchondrale Kirschner-Drähte und Knochentransplantate.

BACKGROUND: Complex fragmentation of the distal radial articular surface often results in three major problems: some fragments are too small for stabilisation by standard plates or screws; in addition, substantial loss of articular surfaces and metaphyseal/subchondral bony defects frequently occur. MATERIAL AND METHODS: To solve these problems the following strategy was developed: the fixation of small articular fragments was performed by small K-wires that were placed subchondrally and countersunk in the bone. In case of lost articular surfaces a silicone foil was inserted intra-articularly to induce a cartilage-like tissue. Bony defects were replaced by iliac crest bone grafts. Additional stability was achieved by dorsal and volar plate fixation or bridge plating. RESULTS: An average of 53° of extension, 44° of flexion, 74° of pronation, and 66° of supination were achieved. The grip strength was an average of 61% of that in the contralateral limb. The average radiographic measurements were -5° of palmar inclination, 21° of ulnar inclination, and 0 mm of positive ulnar variance. A good or excellent functional result was achieved for five of seven wrists according to the rating system of Gartland and Werley. According to the modified Mayo Wrist Score four of five wrists achieved a good and one a fair result.The DASH Score averaged 19 (6-59) points. CONCLUSIONS: The applied treatment resulted in stable, mobile wrists with reasonable alignment and nearly even articular surfaces. The functional results were similar to those reported by other authors for less complex distal radius fractures. This strategy seems to be a rational approach to the reconstruction of severely comminuted intra-articular fractures of the distal radius.

[Risk of injury to children's fingers in power-operated motor vehicle windows]. / Verletzungsrisiko von Kinderfingern in automatischen Scheibenschliessanlagen von Kraftfahrzeugen.

BACKGROUND: This study examines the dimensions of children's fingers and the risk of jam injuries in a 4-mm gap between glass and gasket of power-operated motor vehicle windows. MATERIAL AND METHODS: The diameter of the proximal, middle, and distal phalanx and of the proximal and distal interphalangeal joint of each finger of the right hand of 160 children was measured in a cross-sectional investigation. Six different drawings in cross section of gaskets and glass window panes of current motor vehicle side door windows at a vertical gap of 4 mm were drawn in correct proportion. The larger actual width of the oblique gap between window glass and gasket was measured and related to the diameters of children's fingers. RESULTS: Almost all fingers and joints fit in the largest actual gap of 18 mm between glass and gasket of one seal design. CONCLUSION: The European guideline 74/60/EWG specifications currently pertaining to closing force restriction do not eliminate the risk of potentially serious injury to children's fingers in motor vehicle power windows.

[Collateral ligament injuries of the metacarpophalangeal joints]. / Kollateralbandverletzungen der Fingergrundgelenke.

Collateral ligament injuries of the metacarpal joints of the fingers are rare conditions. The injury should be diagnosed by clinical investigation and standard radiographs. Leading symptoms are local tenderness and joint instability. Instability is verified by clinical stress testing of the metacarpophalangeal joint in 90° of flexion. In Grade I injuries stability is preserved due to ligament attenuation or small partial tears. Grade II injuries show laxity with firm endpoint according to incomplete tear. In Grade III injuries instability without endpoint can be found as a result of complete tears. Radiographs may show avulsed bone fragments.In Grade I and II tears or non- displaced avulsion fragments treatment is conservative with buddy taping for 6 weeks. In case of persistent instability or grade III tears suturing or refixation of the ligament are performed. Small avulsion fragments are removed and the ligament is fixed to the bone. Greater avulsion fragments are fixed by suitable small implants. Adequate treatment will lead to reliable good results. Even in chronic tears reconstruction with local material or tendon transplants is usually successful.

[Long-term results following denervation of the wrist]. / Langzeitergebnisse nach Handgelenkdenervation.

BACKGROUND: This retrospective study examines long-term follow-up results after complete denervation of the wrist. PATIENTS AND METHODS: Between 1994 and 2000 a total of 61 complete wrist denervations of 59 patients (median age at operation 46 years) were performed. In 2009 29 patients with 30 complete wrist denervations took part in a follow-up examination after an average of 10 years. The mobility of the wrist and the grip force were examined. Pain and satisfaction with the operation were determined by means of a visual analogue scale (VAS) (0-100). The patients were asked about pain reduction and how long it lasted. Further the DASH and the Mayo Wrist Score were evaluated. Radiographs of the denervated wrist were performed and the degree of the degenerative osteoarthritis was determined according to Knirk and Jupiter. RESULTS: In 7 of the 36 patients examined, a partial or total wrist arthrodesis was performed. These patients were excluded from the study. Pain was improved in 28 of the 30 denervated wrists examined, in 22 the improvement lasted until the follow-up examination, whereas in 6 the pain increased after a median of 90 months. The median pain intensity was 10 at rest and 50 with activity; the satisfaction was 90. The median of the extension/flexion was 81% and the grip force 82% in comparison to the opposite hand. The DASH Score was 25 and the Mayo Wrist Score 73. CONCLUSION: Complete denervation of the wrist according to Wilhelm is a treatment option for the chronically painful wrist and can lead to good grip force, mobility, sufficient pain reduction and satisfaction in the long term.

[Neurological complications of elbow stiffness]. / Neurologische Komplikationen bei Ellenbogensteife.

Although complications following release of elbow contracture are rare, among these the neurological complications are the most common. Fortunately the majority of complications are transient, however, major complications including complete nerve transection at the level of the elbow have been reported especially after arthroscopic release. The ulnar nerve is mostly involved, rarely the radial nerve and very rarely the median nerve. This article describes the risk of nerve lesions in contracture release of the elbow and provides guidelines on how to avoid them.

[Algorithms for treatment of complex hand injuries]. / Algorithmen zur Versorgung komplexer Handverletzungen.

BACKGROUND: The primary treatment strongly influences the course and prognosis of hand injuries. Complex injuries which compromise functional recovery are especially challenging. Despite an apparently unlimited number of injury patterns it is possible to develop strategies which facilitate a standardized approach to operative treatment. In this situation algorithms can be important guidelines for a rational approach. MATERIAL AND METHODS: The following algorithms have been proven in the treatment of complex injuries of the hand by our own experience. They were modified according to the current literature and refer to prehospital care, emergency room management, basic strategy in general and reconstruction of bone and joints, vessels, nerves, tendons and soft tissue coverage in detail. CONCLUSIONS: Algorithms facilitate the treatment of severe hand injuries. Applying simple yes/no decisions complex injury patterns are split into distinct partial problems which can be managed step by step.

[Treatment of carpal fractures. Recommendations of the Hand Surgery Group of the German Trauma Society]. / Behandlung von Handwurzelfrakturen. Empfehlungen der Sektion Handchirurgie der Deutschen Gesellschaft für Unfallchirurgie.

The primary goal in the treatment of carpal fractures is the preservation of a painless wrist function. Scaphoid fractures are the most common carpal fractures and when such a fracture is clinically suspected CT or MRI scans are usually advisable. Only stable and non-displaced scaphoid fractures can be treated conservatively, all other fractures require internal fixation with restoration of normal anatomy. Second most common are fractures of the triquetrum which can occur as chip avulsions of the dorsal rim and are usually treated symptomatically. Fractures of the body of the triquetrum should be treated according to the degree of instability and displacement. This is virtually true for all carpal bones. Perilunate fracture dislocations of the carpus deserve special attention. In these severe injuries a fracture line can run through all carpal bones but the scaphoid is mostly affected. Accurate reduction and internal fixation by screws and K-wires are indicated not only in these cases, but also in carpometacarpal fracture dislocations.

[Experiences with the "short arc motion" protocol for rehabilitation of extensor tendon injuries in zones E and F according to Wilhelm]. / Erfahrungen mit dem Short Arc Motion (SAM)-Schema in der Nachbehandlung isolierter Strecksehnenverletzungen der Zonen E und F nach Wilhelm.

Rehabilitation of extensor tendon injuries in zones E and F (according to Wilhelm) is difficult because of the broad bone-tendon interface favouring adhesions. Therefore RB Evans developed the so called "short arc motion" protocol to improve the results of extensor tendon injuries in zones E and F. This protocol consists of immobilisation of the PIP and DIP joints of the injured finger interrupted by regularly performed limited active motion exercises according to the principle of "minimal active tension". Evans demonstrated superior results using this protocol compared to pure immobilisation. In this study we retrospectively evaluated our results using the "short arc motion" regime in isolated extensor tendon injuries since 2000. 10 patients could be examined with a mean follow-up of 2 years and 5 months after operative treatment of fresh extensor tendon injuries as well as one patient with an old extensor tendon lesion. According to the Strickland-Glogovac formula our patients with fresh extensor tendon lesions had 70.3 % on average which is a good result. Using the Geldmacher score these patients had a mean result of 20.7 points indicating a good result too. With regard to the PIP joint, the mean extension deficit was 8.5 degrees. So our results are good, but not as good as those from Evans. Being aware of the limitations of a retrospective study lacking a control group of patients with traditional aftercare, we will continue to use the SAM protocol in our hospital.

[Comparison of the results between reconstruction of the extensor pollicis longus tendon using a free interposition tendon graft and extensor indicis transposition]. / Vergleich der Ergebnisse nach Rekonstruktion der Sehne des Musculus extensor pollicis longus durch freies Sehneninterponat gegenüber dem motorischen Ersatz durch eine Extensor indicis-Transposition.

QUESTION: Is there a difference in the results of free tendon grafting or transfer of the extensor indicis tendon for the reconstruction of the extensor pollicis longus tendon? PATIENTS AND METHODS: Two groups of patients, who underwent surgery between 1992 and 1998, were compared. From 58 patients with tendon grafts 48 were re-examined. For reconstruction, a graft harvested from the palmaris longus tendon was applied that was woven into the proximal and distal stump of the extensor pollicis tendon according to the technique of Pulvertaft. From 56 patients with transfer of the extensor indicis tendon, 40 were re-examined. The extensor indicis transfer was performed by the standard technique. Extension and flexion of the metacarpophalangeal and interphalangeal joints of the thumb, retroposition, abduction and opposition were examined. In addition, the span of the hand, grip strength and pinch strength were measured. A summarising assessment was performed according to the Geldmacher score, the subjective impairment was assessed by the DASH score. RESULTS: Both groups were comparable according to demographic data and aetiology of the rupture. The range of motion was nearly identical after both surgical techniques. Range of motion of the joints of the thumb, abduction and opposition reached normal values but both methods restored only 60 % of the normal retroposition. According to the Geldmacher score, both methods showed good and excellent results. The DASH score resulted in low values with 10 and, respectively, 14 points. After extensor indicis transfer all patients demonstrated isolated extension of the index. CONCLUSIONS: Both methods establish equally good results. Free tendon grafting is technically more demanding but preserves a more powerful isolated extension of the index finger and should, therefore, be preferred in patients with special demands on this function (e.g., musicians). The transfer of the extensor indicis tendon is technically less demanding, requires retraining and may impair the isolated function of the index finger.

[The dorsal flag flap for alternative skin coverage for defects of the thumb tip: case reports]. / Der dorsale fähnchenlappen zur alternativen defektdeckung an der daumenkuppe: fallberichte.

PURPOSE: This case report describes the use of the dorsal flag flap in contrast to its standard indication (dorsal and palmar defects of the proximal finger phalanx) for defect coverage of the thumb tip in three patients. PATIENTS AND METHOD: In 2006, defects of the thump tip were covered with a dorsal flag flap in three male cases. After 6 - 9 months a clinical evaluation was performed with special focus on pain, aesthetic aspect, sensibility and function. RESULTS: Primary wound healing without complications was observed in all cases. No functional impairments or pain have been reported, the aesthetic aspect was satisfying for the patients. All flaps showed an intact protection sensibility (in terms of pressure and pain perception). The subjective shortcoming of the sensitivity like numbness was not distracting to any of the patients. CONCLUSION: The dorsal flag flap is a good alternative for covering tissue defects at the thumb tip compared to local flap grafts or neurovascular long-distance flaps with satisfying results.

[Results after revision surgery for carpal tunnel release]. / Ergebnisse von Karpaltunnel-Revisionseingriffen.

PURPOSE: The aim of this study was to assess the clinical results of revision surgery due to persistent neurological disturbances after carpal tunnel release. PATIENTS AND METHOD: In a previous study we showed the reasons for persisting neurological symptoms after carpal tunnel release on the basis of the intraoperative findings in 200 patients who underwent revision surgery in the years 2001 - 2003. We classified them into four groups (1: incomplete release of the retinaculum flexorum, 2: traction neuropathy, 3: real recurrent carpal tunnel syndrome, and 4: nerve lesions). 122 of these patients have been investigated regarding the clinical results using two questionnaires in the year 2004. We used the DASH questionnaire as well as an additional self-assessment questionnaire asking about remaining symptoms of median nerve irritation and the subjective results of revision surgery. The completely filled-out forms were assigned to the four groups, analysed and the results compared with each other. RESULTS: Within group 1 (incomplete release), 78 % reported only one persistent neurological symptom, 89 % described a benefit from revision surgery and 84 % were satisfied with a median DASH score of 11. Within group 2 83 % complained about at least one persistent neurological problem and only 60 % reported on an improvement following revision surgery. The DASH score within group 2 averaged 30. 87 % of group 3 patients reported of an improvement following the revision operation (DASH score 24), whereas this was the case for only 55 % (DASH score 37) of group 4 patients. CONCLUSION: The incomplete release of the flexor retinaculum is the most common reason for revision surgery. In most of these patients the clinical symptoms can be resolved with revision surgery leading to a very high satisfaction of the patients. A similarly high satisfaction can be expected following revision surgery of a true recurrent carpal tunnel syndrome although in most patients a significant degree of functional deficit will remain. Revision surgery due to fibrotic adhesions of the median nerve, leading to a traction neuropathy, or iatrogenic nerve lesions during the primary surgery will definitely lead to unsatisfactory overall results.