Expert Review of Medical Devices

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Determinants of return to activity and work after

carpal tunnel release: a systematic review and
meta-analysis

Larry E. Miller & Kevin C. Chung

To cite this article: Larry E. Miller & Kevin C. Chung (2023) Determinants of return to activity
and work after carpal tunnel release: a systematic review and meta-analysis, Expert Review of
Medical Devices, 20:5, 417-425, DOI: 10.1080/17434440.2023.2195549

To link to this article: https://doi.org/10.1080/17434440.2023.2195549

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EXPERT REVIEW OF MEDICAL DEVICES
2023, VOL. 20, NO. 5, 417–425
https://doi.org/10.1080/17434440.2023.2195549

META-ANALYSIS

Determinants of return to activity and work after carpal tunnel release: a systematic
review and meta-analysis
Larry E. Millera and Kevin C. Chungb
a
Department of Biostatistics, Miller Scientific, Johnson City, TN, USA; bMichigan Medicine, University of Michigan Comprehensive Hand Center, Ann
Arbor, MI, USA

ABSTRACT ARTICLE HISTORY

Introduction: The determinants of time to return to activity (RTA) and return to work (RTW) after carpal Received 21 February 2023
tunnel release (CTR) remain unclear. Accepted 22 March 2023
Methods: We performed a systematic review of studies published from January 2000 to November 2022 KEYWORDS
involving patients treated with open (OCTR), mini-open (mOCTR), or endoscopic (ECTR) CTR and reporting RTA Carpal tunnel release; carpal
or RTW. The time to RTA and RTW were estimated using a random-effects meta-analysis model. Subgroup tunnel syndrome; meta-
analysis and multivariable meta-regression explored sources of heterogeneity in outcomes. analysis; return to activity;
Results: A total of 7386 patients in 48 studies (63 groups) were included, with 24 groups (4541 patients) return to work; systematic
treated with OCTR, 16 groups (1085 patients) treated with mOCTR, and 23 groups (1760 patients) review
treated with ECTR. Among 15 studies (20 groups) reporting RTA, the mean was 13.1 days (95% CI, 9.9–
16.3; I2>99%). Shorter duration of postoperative activity restriction guidance was associated with faster
RTA. Among 43 studies (58 groups) reporting RTW, the mean was 23.4 days (95% CI, 21.4–25.3; I2>99%).
Procedure type (mOCTR and ECTR compared to OCTR), prospective study design, and smaller propor­
tion of patients receiving disability benefit were associated with faster RTW.
Conclusions: The time to RTA and RTW after CTR are highly variable and influenced by study-, patient-,
and physician-specific factors.

1. Introduction
Carpal tunnel syndrome (CTS) is a major cause of disability and
a leading contributor to prolonged work absence [1]. Initial treat­
ment typically includes activity modification, physical therapy,
splinting, nonsteroidal anti-inflammatory drugs, or corticosteroid
injections [2]. Carpal tunnel release (CTR), which involves transec­
tion of the transverse carpal ligament, may be indicated if CTS
symptoms are severe or nonresponsive to conservative manage­
ment. Carpal tunnel release is among the most common hand and
wrist procedures, with an estimated lifetime prevalence of approxi­
mately 3% [3]. Strong evidence supports that CTR provides
a greater treatment benefit compared to nonsurgical treatment,
regardless of whether surgical access is gained via open (OCTR),
mini-open (mOCTR), or endoscopic (ECTR) approaches [4]. Among
the considerations for patients contemplating CTR are post-
surgical recovery time and duration of work absence. The time to
return to activity (RTA) and return to work (RTW) after CTR varies
considerably and may be influenced by factors such as surgical
technique, physician recommendations, employment physical
demands, household income, and litigatory factors [5].
Several meta-analyses have reported RTA and RTW in rando­
mized trials comparing CTR techniques, yet the number of studies
evaluated in these reviews ranged from 2 to 13 [6–10], which is
insufficient to evaluate statistically the association of additional
moderator variables with these outcomes. Most data regarding
RTA and RTW after CTR were derived from observational studies
and excluded from prior meta-analyses. Consequently, a review
that includes both randomized trials and observational studies of
CTR provides the opportunity to assess potential moderators of
RTA and RTW, including CTR technique, within a single analysis.
Thus, the objectives of this systematic review and meta-analysis
were to characterize RTA and RTW after CTR and explore factors
associated with these outcomes.
2. Methods
We prospectively registered the systematic review protocol in
December 2022 at www.researchregistry.com (reviewregis­
try1499). The systematic review and meta-analysis methodol­
ogy and reporting were in accordance with the statement on
the Preferred Reporting Items for Systematic Reviews and
Meta-analyses (PRISMA) [11].
2.1. Study eligibility criteria
Randomized trials and observational studies of CTR pub­
lished between January 2000 and November 2022 were
included in this review to provide results derived from
contemporary studies. The surgical techniques included in
this review were OCTR, mOCTR, and ECTR because they are
the most commonly performed types of surgery for CTS

CONTACT Larry E. Miller larry@millerscientific.com Miller Scientific, 3101 Browns Mill Road, Ste 6, #311, Johnson City, TN, 37604, USA
Supplemental data for this article can be accessed online at https://doi.org/10.1080/17434440.2023.2195549.
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
418 L. E. MILLER AND K. C. CHUNG

[12]. Classification of CTR technique was based on the 2.5. Statistical methods
description provided by study authors, regardless of inci­
The mean and 95% confidence interval (CI) were calculated for
sion length or location. The study-wide exclusion criteria
each outcome in individual studies and the overall pooled
included studies reporting mixed or unclear CTR techni­
estimate. The pooled RTA and RTW estimates were calculated
ques, studies with a sample size less than 10 patients,
using the DerSimonian and Laird method for random-effects
studies with concomitant surgical procedures, studies pub­
meta-analysis to account for anticipated inter-study heteroge­
lished only as abstracts, subgroup and special population
neity and visually depicted with forest plots. For studies where
studies, duplicate publications, and studies that did not
a variance measure (e.g. standard deviation) or the percentage
report analyzable RTA or RTW data.
of employed patients were not reported, we imputed these
missing data in accordance with Cochrane recommendations
2.2. Search strategy and study selection process [14]. Potential publication bias was assessed by visual exam­
ination of funnel plot symmetry, Egger tests [15], and the trim-
We systematically searched Medline, Embase, and the Cochrane
and-fill method to estimate the number of studies missing
Central Register of Controlled Trials for potentially eligible studies.
from the meta-analysis due to publication bias [16]. The influ­
The search strategies included combinations of diagnosis-, proce­
ence of missing data imputation and single-study effects on
dure-, and outcome-specific keywords. The Medline search strat­
outcomes were assessed in sensitivity analyses.
egy is provided in Supplementary Table S1; search strategies for
We estimated heterogeneity among studies with the I2 sta­
other databases were adapted as necessary. Additional manual
tistic where a value of 0% represented no heterogeneity and
searches were performed in the Directory of Open Access Journals
larger values represented increasing heterogeneity [17]. We first
and Google Scholar. We also manually searched the reference lists
explored potential sources of heterogeneity in RTA and RTW
of included papers and relevant review articles. Two researchers (L.
using subgroup analysis with a pre-defined list of patient- and
M. and D.F.) with expertise in systematic reviews independently
study-specific variables. The variables of interest included study
screened articles for eligibility. Full-text manuscripts were
design, geographic location of study, sample size, type of CTR
obtained for all potentially relevant studies. Disagreements related
procedure (OCTR, mOCTR, ECTR), median year of treatment,
to study eligibility were resolved by discussion and consensus. The
mean (preferentially) or median incision length (<2, 2.0–2.9,
final search was performed in December 2022.
≥3 cm), mean (preferentially) or median symptom duration
(<12 vs.≥12 months), mean (preferentially) or median age (≤50
2.3. Data extraction vs.>50 years), proportion of female patients, proportion of simul­
taneous bilateral cases, proportion of cases involving the domi­
The researchers independently extracted data from eligible stu­
nant hand, and reported duration of physician-recommended
dies using standardized data collection forms that were pilot
postoperative activity restriction. For the RTW subgroup analysis,
tested a priori. The data included study characteristics, patient
we additionally included the proportion of manual laborers and
characteristics, procedural data, RTA, and RTW. In studies with
the proportion of patients receiving disability benefit or workers
multiple eligible treatment groups, data were extracted for each
compensation. Variables that loaded into the univariable sub­
group separately. Data extraction discrepancies between the
group analysis at P < .1 were included in a multivariable meta-
two researchers were resolved by discussion.
regression model. A pseudo R2 statistic was calculated to deter­
mine the percentage of total between-study variance explained
2.4. Outcomes by the final meta-regression model [18]. Statistical analyses were
performed by a biostatistician using Stata v16.1 (Stata Corp,
The primary outcomes used to characterize patient recovery
College Station, TX, United States).
after CTR were the number of days to RTA and RTW. Return to
activities was characterized as the number of days after CTR
that patients returned to their activities of daily living, exclud­
3. Results
ing work. For studies that reported the time to return to
individual activities of daily living, we extracted data for the 3.1. Study selection
activity with the longest duration. Return to work was char­
Among 504 papers identified in the literature search, 63 CTR
acterized as the number of days after CTR that patients
treatment groups reported in 48 studies with 7386 patients
returned to work in any capacity. The mean number of days
were included in the systematic review [19–66]. Among the
for RTA and RTW was preferentially reported in each study; the
full-text papers that were reviewed, 78 were excluded, with
median was reported if the mean values were unavailable.
non-reporting of RTA or RTW being the most common reason
Given the lack of standardized definitions for RTA and RTW
for exclusion (Supplementary Figure S1).
and the potential for associated bias, we listed the outcome
definitions reported in each study. The methodological quality
of eligible studies was evaluated with The National Institutes
3.2. Study characteristics
of Health assessment tool for before-after studies, with studies
rated on 12 attributes related to adequacy of described objec­ A total of 24 groups with 4541 patients were treated with
tive, eligibility criteria, sample size justification, intervention OCTR, 16 groups with 1085 patients were treated with mOCTR,
description, follow-up completeness, and statistical analysis and 23 groups with 1760 patients were treated with ECTR. The
elements [13]. overall cohort represented 7386 patients from 20 different
 EXPERT REVIEW OF MEDICAL DEVICES 419

countries treated with CTR between 1990 to 2021 (Table 1). prior to surgery ranged from 1 to 84 months (median 17
The reported percentage of female patients among studies months). The reported percentage of employed patients ran­
ranged from 17% to 94% (median 71%), age ranged from 43 ged from 15% to 100% (median 79%), percentage of manual
to 65 years (median 52 years), and duration of CTS symptoms laborers ranged from 28% to 100% (median 53%), and the

Table 1. Characteristics of studies reporting return to activity or return to work after carpal tunnel release.
Prospective Treatment
Study design dates Country Patients Hands
OCTR
Acharya [2005] [19] Yes — United Kingdom 75 112
Asserson [2022] [20] No 2018–2020 United States 17 —
Atroshi [2006] [21] Yes 1998–2002 Sweden 65 65
Atroshi [2015] [22] No 2004–2010 Sweden 2821 —
Bekkelund [2001] [25] No 1996–1998 Norway 106 —
de la Fuente [2021] [28] Yes 2010–2013 Spain 42 42a
Dickson [2014] [30] No — United Kingdom 30 60
Gurpinar [2019] [37] Yes 2016–2018 Turkey 50 50
Hajibarati [2022] [38] No 2018–2020 Iran 23 23
Jansen [2021] [41] Yes 2017–2019 Netherlands 615 615
Jugovac [2002] [42] Yes 1997–2001 Croatia 36 36
Ketchum [2004] [43] No 1990–1998 United States 68 68
Khoshnevis [2020] [44] Yes 2015–2016 Iran 45 —
Kiymaz [2002] [45] No 1997–2000 Turkey 20 —
Larsen [2013] [46] Yes — Denmark 30 30
Ma [2021] [48] Yes 2017–2020 China 89 89
Malhotra [2007] [49] Yes 2003–2005 India 30 31
Mujadzic [2021] [50] No — United States 53 53
Ratzon [2006] [55] No — Israel 50 50
Saw [2003] [57] Yes 1998–2001 United Kingdom 76 76
Tarallo [2014] [59] Yes 2009–2011 Italy 60 60
Teng [2019] [60] No 2017–2017 China 38 —
Tian [2007] [61] Yes 2000–2004 China 30 36
Trumble [2002] [62] Yes — United States 72 95
mOCTR
Atthakomol [2022] [23] Yes 2020–2021 Thailand 12 12
Becker [2012] [24] Yes 2005–2010 United States 66 73
Cellocco [2009] [26] Yes 1999–2001 Italy 103 123
Duché [2010] [31] No 2003–2007 France 400 440
Fazil [2022a] [33] Yes 2017–2019 India 64 64
Fazil [2022b] [33] Yes 2017–2019 India 58 58
Gaba [2017] [35] No 2013–2014 India 27 33
Gil [2020a] [36] Yes — United States 22 —
Gil [2020b] [36] Yes — United States 19 —
Gil [2020c] [36] Yes — United States 26 —
Jugovac [2002] [42] Yes 1997–2001 Croatia 36 36
Khoshnevis [2020] [44] Yes 2015–2016 Iran 30 —
Larsen [2013] [46] Yes — Denmark 30 30
Tarallo [2014] [59] Yes 2009–2011 Italy 60 60
Teng [2019] [60] No 2017–2017 China 40 —
Weber [2005] [66] No — United States 92 184
ECTR
Atroshi [2006] [21] Yes 1998–2002 Sweden 63 63
Chalidis [2013] [27] Yes 2006–2010 Greece 85 170
Degeorge [2018] [29] No 2013–2015 France 30 60
Eisenhardt [2010] [32] No 1995–2002 Germany 170 192
Gurpinar [2019] [37] Yes 2016–2018 Turkey 54 54
Hajibarati [2022] [38] No 2018–2020 Iran 23 24
Hansen [2009] [39] Yes — Denmark 75 75
Hein [2022] [40] No 2013–2019 United States 80 160
Kiymaz [2002] [45] No 1997–2000 Turkey 30 —
Larsen [2013] [46] Yes — Denmark 30 30
Malhotra [2007] [49] Yes 2003–2005 India 30 30
Nazerani [2014] [51] Yes 2007–2012 Iran 176 —
Nesbitt [2006] [52] Yes 2001–2003 United States 12 24
Nguyen [2022] [53] Yes 2019–2020 Vietnam 77 77
Okada [2000] [54] No 1996–1999 Japan 26 30
Sabesan [2012] [56] No 1990–2006 United States 139 155
Saw [2003] [57] Yes 1998–2001 United Kingdom 74 74
Serra [2003] [58] No 1996–2000 Italy 164 200
Tian [2007] [61] Yes 2000–2004 China 32 34
Trumble [2002] [62] Yes — United States 75 97
Tuzuner [2004] [63] Yes 1994–2001 Turkey 191 227
van Rooij [2022] [64] Yes 2015–2019 Netherlands 81 162
Vogt [2002] [65] Yes — Germany 43 50
Abbreviations: ECTR, endoscopic carpal tunnel release, mOCTR, mini-open carpal tunnel release, OCTR, open carpal tunnel release.
a
An unknown number of bilateral cases was performed, but only the first wrist operated on was included in the analysis.
420 L. E. MILLER AND K. C. CHUNG
percentage receiving disability benefit ranged from 0% to 59%
(median 3%). Patient employment details were reported infre­
quently (Supplementary Table S2). Palm incision length ran­
ged from 2.0 to 8.8 cm (median 3.5 cm) for OCTR, 1.7 to 3.5 cm
(median 2.0 cm) for mOCTR, and 1.0 to 1.5 cm (median 1.0 cm)
at the wrist for ECTR. The percentage of surgeries involving
the dominant hand ranged from 57% to 100% (median 65%)
and the percentage of patients receiving simultaneous bilat­
eral CTR ranged from 0% to 100% (median 0%)
(Supplementary Table S3).
In general, RTA was defined as the number of days to
return to normal daily activities after CTR. Only 3 of 20 studies
provided guidance on the exact activities included within the
RTA definition [19,29,40]. The definition of RTW varied among
studies, but was generally defined as the number of days from
CTR until RTW in any capacity, although some studies speci­
fied return to regular duty [20,23,43,63]. Given the known
relationship between postoperative physician recommenda­
tions and duration of sick leave absence [55], we also
extracted the physician-prescribed activity limitations as
described in each study, which varied considerably
(Supplementary Table S4). Methodological study quality was
rated good for 42 (67%) groups, fair for 20 (32%) groups, and
poor for 1 (2%) group (Supplementary Table S5).
Figure 1. Forest plot of days to return to activity after carpal tunnel release. The mean and 95% confidence interval for return to activity (RTA) are plotted for each
study. The size of the square is proportional to the weight of the study. The pooled mean is denoted by the diamond apex and 95% confidence interval denoted by
the diamond width. The pooled time to return to activity was 13.1 days. I2 = 99%, where 0% represents no heterogeneity among studies and 100% represents
maximum heterogeneity among studies.
3.3. Return to activity after carpal tunnel release
Among 20 treatment groups in 15 studies that reported RTA after
CTR, the time to RTA in individual studies ranged from 4.9 days [64]
to 28.0 days [45]. The pooled mean RTA after CTR was 13.1 days
(95% CI: 9.9–16.3 days) among all studies (Figure 1), which was
largely unchanged in all sensitivity analyses (Supplementary Table
S6). Although results of the Egger test were not statistically sig­
nificant (z = 1.59, P = .11), visual inspection of the funnel plot
revealed substantial asymmetry. Results of the trim-and-fill analysis
indicated that four studies were missing from the upper right
quadrant of the funnel plot (Supplementary Figure S2). After
adjusting for this potential publication bias, the pooled mean
RTA after CTR was 15.1 days (95% CI: 11.5–18.8 days).
Significant heterogeneity in RTA was observed among stu­
dies (I2>99%, P < .001). In a subgroup analysis, studies with
shorter duration postoperative activity restriction guidance
and with a higher percentage of dominant hands treated
with CTR were associated with faster RTA. No other patient-
or study-specific covariate including CTR procedure type was
associated with RTA after CTR (Table 2). In a multivariable
meta-regression model, shorter duration of postoperative
activity restriction guidance was the only variable that was
associated with faster RTA after CTR (Supplementary Table S7).
 EXPERT REVIEW OF MEDICAL DEVICES 421

Table 2. Subgroup analysis of the association of study-level factors with days to return to activity after
carpal tunnel release.
Pooled
Variable Groups Mean 95% CI P
OVERALL 20 13.1 9.9, 16.3
Postoperative restrictions .03
No specific restrictions 2 9.3 2.9, 15.7
Restriction<2 weeks 5 10.0 7.3, 12.8
Restriction≥2 weeks 5 16.0 12.3, 19.7
Dominant hand treated .04
≥70% of patients 3 10.5 2.8, 18.1
<70% of patients 3 20.2 14.7, 25.7
Symptom duration (mo) .11
≥12 5 11.5 7.2, 15.8
<12 5 15.8 12.8, 18.7
Median treatment year .14
2010 and after 9 10.6 7.6, 13.6
2009 and before 11 15.1 9.9, 20.3
CTR procedure .19
Mini-open 5 10.9 6.3, 15.5
Endoscopic 10 12.3 7.4, 17.2
Open 5 16.8 12.1, 21.5
Simultaneous bilateral cases .19
≥20% of patients 6 9.5 6.2, 12.9
<20% of patients 12 13.3 8.8, 17.8
Median age (yr) .22
>50 11 10.6 5.5, 15.7
≤50 7 14.5 10.9, 18.0
Incision length (cm) .35
<2 6 10.8 8.2, 13.4
2.0 to 2.9 4 10.7 4.6, 16.9
≥3.0 3 14.3 10.2, 18.4
Geographic location .41
North America 1 5.0 4.1, 5.9
Europe 7 11.6 4.1, 19.1
Asia 12 14.5 11.8, 17.2
Number of patients .44
<50 10 12.8 10.0, 15.7
50–99 7 11.2 7.7, 14.8
≥100 3 17.2 8.5, 26.0
Study design .48
Prospective 12 12.0 9.3, 14.8
Retrospective 8 14.5 8.2, 20.8
Female sex .73
≥70% of patients 9 11.5 8.8, 14.2
<70% of patients 9 12.7 6.4, 19.0
Abbreviations: CI, confidence interval; CTR, carpal tunnel release.

3.4. Return to work after carpal tunnel release
Among 58 treatment groups in 43 studies that reported RTW
after CTR, the time to RTW in individual studies ranged from
7.0 days [40,46] to 74.9 days [43]. The pooled mean RTW after
CTR was 23.4 days (95% CI: 21.4–25.3 days) among all studies
(Figure 2), which was largely unchanged in all sensitivity ana­
lyses (Supplementary Table S6). Visual inspection of the funnel
plot revealed substantial asymmetry and results of the Egger
test were statistically significant (z = 5.33, P < .001), suggesting
possible publication bias. Results of the trim-and-fill analysis
indicated that seven studies were missing from the upper
right quadrant of the funnel plot (Supplementary Figure S3).
After adjusting for this potential publication bias, the pooled
mean RTW after CTR was 25.6 days (95% CI: 23.3–27.9 days).
Significant heterogeneity in RTW was observed among stu­
dies (I2>99%, P < .001). In a subgroup analysis, seven variables
were associated with faster RTW including CTR procedure type,
shorter incision length, higher percentage of female patients,
prospective study design, older age, smaller proportion of
patients receiving disability benefit, and longer duration of CTS
symptoms (Table 3). In a multivariable meta-regression model,
CTR procedure type (mOCTR and ECTR compared to OCTR),
prospective study design, and smaller proportion of patients
receiving disability benefit were independently associated with
faster RTW after CTR (Supplementary Table S8).
4. Discussion
We performed the first known meta-analysis of determinants
of RTA and RTW after CTR. In this analysis of 48 studies
comprising 7386 patients treated with CTR, there were several
major findings. First, the mean time to RTA and RTW in the
published CTR literature was 13.1 and 23.4 days, respectively.
Second, the variability in these outcomes among studies was
high (I2>99% for both). Third, patients tended to RTA in accor­
dance with the recovery duration recommended by the treat­
ing physician. Fourth, RTW after CTR was independently
associated with CTR procedure type, study design, and receipt
of disability benefits. Finally, the factors associated with RTA
and RTW after CTR identified in this meta-analysis explained
422 L. E. MILLER AND K. C. CHUNG
Figure 2. Forest plot of days to return to work after carpal tunnel release. The
mean and 95% confidence interval for return to work (RTW) are plotted for each
study. The size of the square is proportional to the weight of the study. The
pooled mean is denoted by the diamond apex and 95% confidence interval
denoted by the diamond width. The pooled time to return to work was 23.4
days. I2 = 99%, where 0% represents no heterogeneity among studies and 100%
represents maximum heterogeneity among studies.
some of the variability among studies, but results were likely
influenced by publication bias and unmeasured confounding.
It is important to place the results of the current meta-
analysis within the context of previous reviews. The systematic
review of Peters et al [5] identified 93 socio-demographic,
clinical, psychosocial, work-related, economic, and legal fac­
tors reported to influence RTW; however, quantitative synth­
esis of these data was not performed. Several meta-analyses of
randomized trials have compared outcomes between CTR
procedure types [6–10]. In the only previous meta-analysis
evaluating RTA after CTR in six randomized trials, Li et al [7]
reported that mOCTR was associated with a 9-day faster RTA
than with OCTR. In regards to RTW, meta-analysis results have
been mixed where studies evaluating ECTR alone [8] or ECTR
and mOCTR collectively [6] were associated with a 7-day faster
RTW compared to OCTR, although one meta-analysis [10]
reported no difference between ECTR and OCTR. Finally, in
a meta-analysis of 13 randomized trials by Vasiliadis et al [9],
ECTR was associated with a 10-day faster return to activity/
work than with OCTR. Importantly, none of these meta-
analyses attempted to evaluate the association of additional
moderator variables on RTA and RTW after CTR. Collectively,
these reviews suggest that smaller incision CTR techniques
may facilitate faster RTA and RTW; however, the results of
this meta-analysis suggest that additional factors may also
influence patient recovery.
Patients treated with CTR may be uncertain about the
appropriate time to RTA and RTW because 80% are not
provided with postoperative RTW recommendations [67].
Among patients who receive RTW advice, physician recom­
mendations range from 1 to 36 days [55]. A proposal for
future research is to develop a nomogram to inform phy­
sicians, patients, and payors about expected time to RTA
and RTW after CTR. Such nomograms have been developed
for primary health [68], low back pain [69], and cervical
spine surgery [70]. The data used in this model would
ideally be collected in a large cohort study in which can­
didate variables such as patient demographics, CTR proce­
dure type, and work physical demands, among others,
were collected. These results could ideally be utilized to
inform and refine the widely disparate current physician
recommendations and work policies regarding recovery
time after CTR.
There were several limitations pertaining to the quality of
the studies included in this review that warrant discussion.
While the high observed heterogeneity in RTA and RTW after
CTR afforded the opportunity to explore factors associated
with these outcomes, the results of the meta-analysis should
be interpreted cautiously. First, there was possible publica­
tion bias in the results although the overall RTA and RTW
estimates were not substantially different in the publication
bias-adjusted analysis. Second, meta-regression is inherently
an exploratory analysis that is considered hypothesis-
generating only. Third, meta-regression analysis is subject to
risks pertaining to ecological fallacy since inference about
individuals is attempted using only study-level information.
Consequently, readers are cautioned against drawing causal
inference from the results of this study. Fourth, there are
numerous factors that likely influenced RTA and RTW that
were not included in this meta-analysis due to infrequent
reporting in the literature such as psychological factors
[41,71], preoperative distal motor latency [39], household
income [5], and workplace disability policy [5], among others.
 EXPERT REVIEW OF MEDICAL DEVICES 423

Table 3. Subgroup analysis of the association of study-level factors with days to return to work after carpal tunnel
release.
Variable Groups Pooled Mean 95% CI P
OVERALL 58 23.4 21.4, 25.3
CTR procedure <.001
Endoscopic 20 17.6 14.7, 20.6
Mini-open 16 21.1 18.2, 24.0
Open 22 31.4 26.2, 36.5
Incision length (cm) <.001
<2 16 17.5 14.9, 20.2
2.0 to 2.9 10 24.1 19.3, 28.9
≥3.0 15 29.9 25.9, 33.9
Female sex <.001
≥70% of patients 35 20.5 17.7, 23.2
<70% of patients 23 28.4 24.9, 31.9
Study design .003
Prospective 38 20.4 18.5, 22.4
Retrospective 20 29.6 23.8, 35.4
Median age (yr) .01
>50 35 20.9 18.6, 23.2
≤50 23 27.5 22.7, 32.3
Disability benefit/WC .02
<10% of patients 10 21.2 12.7, 29.7
≥10% of patients 6 40.0 26.0, 54.0
Symptom duration (mo) .04
≥12 19 19.6 16.4, 22.9
<12 9 25.7 20.9, 30.5
Geographic location .13
Asia 20 20.1 16.0, 24.3
Europe 25 24.6 21.9, 27.2
North America 13 27.1 19.9, 34.4
Number of patients .25
<50 25 21.7 16.3, 27.0
50–99 23 24.0 21.1, 26.8
≥100 10 27.0 22.1, 26.2
Manual labor work .46
≥50% of patients 11 24.8 19.1, 30.5
<50% of patients 8 28.9 19.5, 38.3
Median treatment year .46
2010 and after 25 23.2 19.9, 26.4
2009 and before 29 24.7 22.2, 27.2
Dominant hand treated .53
<70% of patients 11 22.6 18.7, 26.4
≥70% of patients 8 25.6 17.0, 34.2
Postoperative restrictions .81
Restriction≥2 weeks 7 23.1 19.3, 26.9
Restriction<2 weeks 16 23.2 17.9, 28.6
No specific restrictions 11 24.9 20.5, 29.3
Simultaneous bilateral cases >.99
<20% of patients 33 22.6 20.2, 25.0
≥20% of patients 14 22.6 17.2, 28.0
Note: Abbreviations: CI, confidence interval; CTR, carpal tunnel release; WC, workers compensation.

Fifth, it is plausible that the definitions of mOCTR and OCTR Acknowledgments

were inconsistently applied given the partial overlapping
The authors thank David Fay, PhD for assistance with the systematic
incision length between these groups. Finally, we noted review.
variability in RTA and RTW definitions among studies and
inconsistent reporting of occupational factors known to influ­
ence RTW, which is a finding that has been reported by
others [72].
Funding
This study was supported by Sonex Health, Inc. (Eagan, MN, United States).

5. Conclusions
The time to RTA and RTW after CTR are highly variable and
strongly influenced by study-, patient-, and physician-specific
factors. These results highlight the need for quantitative mod­
els to assist physicians in providing RTA and RTW recommen­
dations on an individual basis.
Declaration of interest
Dr. Miller and Dr. Chung reported receiving funds from Sonex Health, Inc.
during the conduct of the study. The authors have no other relevant affiliations
or financial involvement with any organization or entity with a financial interest
in or financial conflict with the subject matter or materials discussed in the
manuscript apart from those disclosed.
424 L. E. MILLER AND K. C. CHUNG
Reviewers disclosure
Peer reviewers on this manuscript have no relevant financial relationships
or otherwise to disclose.
Author contributions
Concept and design: Miller.
Acquisition, analysis, or interpretation of data: Miller, Chung.
Drafting of the manuscript: Miller.
Critical revision of the manuscript for important intellectual content: Miller,
Chung.
Statistical analysis: Miller.
Administrative, technical, or material support: Miller, Chung.
Supervision: Miller, Chung.
Data availability statement
Supporting data from this research will not be made available.
References
Papers of special note have been highlighted as: • of interest •• of
considerable interest
1. U.S. Bureau of Labor Statistics. Survey of occupational injuries and
illnesses data. [cited 2022 December 17]. Available from: https://
www.bls.gov/iif/nonfatal-injuries-and-illnesses-tables.htm#dafw.
2. American Academy of Orthopaedic Surgeons. Management of carpal
tunnel syndrome evidence-based clinical practice guideline. [cited 2022
Dec 15]. Available from: https://www.aaos.org/globalassets/quality-and
-practice-resources/carpal-tunnel/cts_cpg_4-25-19.pdf.
•• American Academy of Orthopedic Surgeons clinical practice guide­
lines for the management of carpal tunnel syndrome.
3. Pourmemari MH, Heliovaara M, Viikari-Juntura E, et al. Carpal tun­
nel release: lifetime prevalence, annual incidence, and risk factors.
Muscle Nerve. 2018;58(4):497–502.
4. Keith MW, Masear V, Amadio PC, et al. Treatment of carpal tunnel
syndrome. J Am Acad Orthop Surg. 2009;17(6):397–405. DOI:10.
5435/00124635-200906000-00008
5. Peters S, Johnston V, Hines S, et al. Prognostic factors for return-to-
work following surgery for carpal tunnel syndrome: a systematic
review. JBI Database System Rev Implement Rep. 2016;14
(9):135–216. 10.11124/JBISRIR-2016-003099
•• A systematic review of 11 studies investigating 93 prognostic
factors for delayed return to work and 27 prognostic factors
for work role functioning.
6. Sanati KA, Mansouri M, Macdonald D, et al. Surgical techniques and
return to work following carpal tunnel release: a systematic review
and meta-analysis. J Occup Rehabil. 2011;21(4):474–481. 10.1007/
s10926-011-9310-8
•• A meta-analysis of surgical techniques and return to work that
reported remarkable inconsistencies in how return to work was
examined in different randomized trials.
7. Li G, Kong L, Kou N, et al. The comparison of limited-incision versus
standard-incision in treatment of carpal tunnel syndrome: a
meta-analysis of randomized controlled trials. Medicine (Baltimore).
2019;98(18):e15372. DOI:10.1097/MD.0000000000015372
8. Li Y, Luo W, Wu G, et al. Open versus endoscopic carpal tunnel
release: a systematic review and meta-analysis of randomized con­
trolled trials. BMC Musculoskelet Disord. 2020;21(1):272.
9. Vasiliadis HS, Nikolakopoulou A, Shrier I, et al. Endoscopic and
open release similarly safe for the treatment of carpal tunnel
syndrome. a systematic review and meta-analysis. PLoS ONE.
2015;10(12):e0143683. DOI:10.1371/journal.pone.0143683
10. Zuo D, Zhou Z, Wang H, et al. Endoscopic versus open carpal
tunnel release for idiopathic carpal tunnel syndrome: a
meta-analysis of randomized controlled trials. J Orthop Surg Res.
2015;10:12.
11. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for
reporting systematic reviews and meta-analyses of studies that
evaluate health care interventions: explanation and elaboration.
Ann Intern Med. 2009;151(4):W65–94. DOI:10.7326/0003-4819-151-
4-200908180-00136
12. Munns JJ, Awan HM. Trends in carpal tunnel surgery: an online
survey of members of the American society for surgery of the hand.
J Hand Surg Am. 2015;40(4):767–771 e762.
13. National Institute of Health. Quality assessment tool for
before-after (pre-post) studies with no control group. [cited 2022
Dec 15].Available from: https://www.nhlbi.nih.gov/health-topics
/study-quality-assessment-tools.
14. Cochrane. Cochrane handbook for systematic reviews of
interventions. [cited 2022 Dec 17]. Available from: https://training.
cochrane.org/handbook/current/chapter-10#section-10-12.
15. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis
detected by a simple, graphical test. BMJ. 1997;315(7109):629–634.
16. Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based
method of testing and adjusting for publication bias in
meta-analysis. Biometrics. 2000;56(2):455–463.
17. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency
in meta-analyses. BMJ. 2003;327(7414):557–560.
18. Borenstein M, Higgins JP. Meta-analysis and subgroups. Prev Sci.
2013;14(2):134–143.
19. Acharya AD, Auchincloss JM. Return to functional hand use and work
following open carpal tunnel surgery. J Hand Surg Br. 2005;30
(6):607–610.
20. Asserson DB, North TJ, Rhee PC, et al. Return to work following ultra­
sound guided thread carpal tunnel release versus open carpal tunnel
release: a comparative study. J Hand Surg Eur Vol. 2022;47(4):359–363.
21. Atroshi I, Larsson GU, Ornstein E, et al. Outcomes of endoscopic
surgery compared with open surgery for carpal tunnel syndrome
among employed patients: randomised controlled trial. BMJ.
2006;332(7556):1473.
22. Atroshi I, Zhou C, Joud A, et al. Sickness absence from work among
persons with new physician-diagnosed carpal tunnel syndrome: a
population-based matched-cohort study. PLoS ONE. 2015;10(3):
e0119795.
23. Atthakomol P, Kaensuk S, Manosroi W, et al. Short incision versus
minimally invasive surgery with tool-kit for carpal tunnel syndrome
release: a prospective randomized control trial to evaluate the
anterior wrist pain and time to return to work or activities. BMC
Musculoskelet Disord. 2022;23(1):708.
24. Becker SJ, Makanji HS, Ring D. Expected and actual improvement of
symptoms with carpal tunnel release. J Hand Surg Am. 2012;37
(7):1324–1329.
25. Bekkelund SI, Pierre-Jerome C, Torbergsen T, et al. Impact of occu­
pational variables in carpal tunnel syndrome. Acta Neurol Scand.
2001;103(3):193–197.
26. Cellocco P, Rossi C, El Boustany S, et al. Minimally invasive carpal
tunnel release. Orthop Clin North Am. 2009;40(4):441–448, vii.
27. Chalidis BE, Dimitriou CG. One portal simultaneous bilateral endo­
scopic carpal tunnel release under local anaesthesia. Do the results
justify the effort? Int Orthop. 2013;37(8):1501–1505.
28. de la Fuente J, Aramendi JF, Ibanez JM, et al. Minimally invasive
ultrasound-guided vs open release for carpal tunnel syndrome in
working population: a randomized controlled trial. J Clin
Ultrasound. 2021;49(7):693–703. DOI:10.1002/jcu.23019
29. Degeorge B, Coulomb R, Kouyoumdjian P, et al. Bilateral simultaneous
endoscopic carpal tunnel release: mean time to resume activities of
daily living and return to work. Hand Surg Rehabil. 2018;37(3):175–179.
30. Dickson DR, Boddice T, Collier AM. A comparison of the functional
difficulties in staged and simultaneous open carpal tunnel
decompression. J Hand Surg Eur Vol. 2014;39(6):627–631.
31. Duche R, Trabelsi A. The Canaletto implant for reconstructing transverse
carpal ligament in carpal tunnel surgery. Surgical technique and cohort
prospective study about 400 Canaletto cases versus 400 cases with
open carpal tunnel surgery. Chir Main. 2010;29(6):352–359.
32. Eisenhardt SU, Mathonia C, Stark GB, et al. Retrospective analysis of
242 patients whose carpal tunnels were released using a one-port

endoscopic procedure: superior results of early intervention. J Plast
Surg Hand Surg. 2010;44(6):311–317.
33. Muhammed FV, Surendran S, Karuppal R, et al. Mini-open transverse
flexor crease incision versus limited longitudinal palmar incision carpal
tunnel release: a short term outcome study. J Orthop. 2022;29:15–21.
34. Fowler JR, Chung KC, Miller LE. Multicenter pragmatic study of
carpal tunnel release with ultrasound guidance. Expert Rev Med
Devices. 2022;19(3):273–280.
35. Gaba S, Bhogesha S, Singh O. Limited incision carpal tunnel release.
Indian J Orthop. 2017;51(2):192–198.
36. Gil JA, Weiss B, Kleiner J, et al. A prospective evaluation of the
effect of supervised hand therapy after carpal tunnel surgery. Hand
(N Y). 2020;15(3):315–321.
37. Gurpinar T, Polat B, Polat AE, et al. Comparison of open and
endoscopic carpal tunnel surgery regarding clinical outcomes,
complication and return to daily life: a prospective comparative
study. Pak J Med Sci. 2019;35(6):1532–1537.
38. Hajibarati B, Molaei H, Hasanzadeh A, et al. Carpal tunnel syn­
drome: open or endoscopic release surgery method? Arch Bone
Jt Surg. 2022;10(8):677–682.
39. Hansen TB, Dalsgaard J, Meldgaard A, et al. A prospective study of
prognostic factors for duration of sick leave after endoscopic carpal
tunnel release. BMC Musculoskelet Disord. 2009;10:144.
40. Hein RE, Hollins AW, Fletcher AN, et al. Return to activities after
simultaneous bilateral endoscopic carpal tunnel release. Hand
(N Y). 2022;17(4):646–651. doi:10.1177/1558944720940061.
41. Jansen MC, van der Oest MJW, de Haas NP, et al. The influence of
illness perception and mental health on return to work after carpal
tunnel release surgery. J Hand Surg Am. 2021;46(9):748–757.
42. Jugovac I, Burgic N, Micovic V, et al. Carpal tunnel release by
limited palmar incision vs traditional open technique: randomized
controlled trial. Croat Med J. 2002;43(1):33–36.
43. Ketchum LD. A comparison of flexor tenosynovectomy, open carpal
tunnel release, and open carpal tunnel release with flexor tenosy­
novectomy in the treatment of carpal tunnel syndrome. Plast
Reconstr Surg. 2004;113(7):2020–2029.
44. Khoshnevis J, Layegh H, Yavari N, et al. Comparing open conven­
tional carpal tunnel release with mini-incision technique in the
treatment of carpal tunnel syndrome: a non-randomized clinical
trial. Ann Med Surg (Lond). 2020;55:119–123.
45. Kiymaz N, Cirak B, Tuncay I, et al. Comparing open surgery with
endoscopic releasing in the treatment of carpal tunnel syndrome.
Minim Invasive Neurosurg. 2002;45(4):228–230.
46. Larsen MB, Sorensen AI, Crone KL, et al. Carpal tunnel release:
a randomized comparison of three surgical methods. J Hand Surg
Eur Vol. 2013;38(6):646–650.
47. Lecoq B, Hanouz N, Morello R, et al. Ultrasound-assisted surgical
release of carpal tunnel syndrome: results of a pilot open-label
uncontrolled trial conducted outside the operating theatre. Joint
Bone Spine. 2015;82(6):442–445. DOI:10.1016/j.jbspin.2015.01.024
48. Ma T, Wang D, Hu Y, et al. Mini-transverse incision using a novel
bush-hook versus conventional open incision for treatment of
carpal tunnel syndrome: a prospective study. J Orthop Surg Res.
2021;16(1):462.
49. Malhotra R, Kiran EK, Dua A, et al. Endoscopic versus open carpal
tunnel release: a short-term comparative study. Indian J Orthop.
2007;41(1):57–61.
50. Mujadzic T, Friedman HI, Mujadzic MM, et al. Modified carpal tunnel
release: a new approach to minimizing pillar pain. Ann Plast Surg.
2021;86(6S Suppl 5):S503–509. DOI:10.1097/SAP.0000000000002885
51. Nazerani S, Kalantar Motamedi MH, Nazerani T, et al. Endoscopic carpal
tunnel release: a 5-year experience. Trauma Mon. 2014;19(4):e18058.
52. Nesbitt KS, Innis PC, Dubin NH, et al. Staged versus simultaneous
bilateral endoscopic carpal tunnel release: an outcome study. Plast
Reconstr Surg. 2006;118(1):139–145. 10.1097/01.prs.0000221073.
99662.39. discussion 146-137.
53. Nguyen TT, Duong K, Tran SQ, et al. Two-port endoscopic surgery
for carpal tunnel syndrome - a prospective cohort study. Malays
Orthop J. 2022;16(2):55–62.
EXPERT REVIEW OF MEDICAL DEVICES 425
54. Okada M, Tsubata O, Yasumoto S, et al. Clinical study of surgical
treatment of carpal tunnel syndrome: open versus endoscopic
technique. J Orthop Surg (Hong Kong). 2000;8(2):19–25.
55. Ratzon N, Schejter-Margalit T, Froom P. Time to return to work and
surgeons’ recommendations after carpal tunnel release. Occup
Med (Lond). 2006;56(1):46–50.
56. Sabesan VJ, Pedrotty D, Urbaniak JR, et al. An evidence-based
review of a single surgeon’s experience with endoscopic carpal
tunnel release. J Surg Orthop Adv. 2012;21(3):117–121.
57. Saw NL, Jones S, Shepstone L, et al. Early outcome and
cost-effectiveness of endoscopic versus open carpal tunnel release:
a randomized prospective trial. J Hand Surg Br. 2003;28(5):444–449.
58. Serra L, Panagiotopoulos K, Bucciero A, et al. Endoscopic release in
carpal tunnel syndrome: analysis of clinical results in 200 cases. Minim
Invasive Neurosurg. 2003;46(1):11–15. DOI:10.1055/s-2003-37966
59. Tarallo M, Fino P, Sorvillo V, et al. Comparative analysis between
minimal access versus traditional accesses in carpal tunnel syn­
drome: a perspective randomised study. J Plast Reconstr Aesthet
Surg. 2014;67(2):237–243.
60. Teng X, Xu J, Yuan H, et al. Comparison of wrist arthroscopy, small
incision surgery, and conventional surgery for the treatment of
carpal tunnel syndrome: a retrospective study at a single center.
Med Sci Monit. 2019;25:4122–4129.
61. Tian Y, Zhao H, Wang T. Prospective comparison of endoscopic and
open surgical methods for carpal tunnel syndrome. Chin Med Sci J.
2007;22(2):104–107.
62. Trumble TE, Diao E, Abrams RA, et al. Single-portal endoscopic
carpal tunnel release compared with open release: a prospective,
randomized trial. J Bone Joint Surg Am. 2002;84(7):1107–1115.
63. Tuzuner S, Sherman GM, Ozkaynak S, et al. Endoscopic carpal
tunnel release: modification of Menon’s technique and data from
191 cases. Arthroscopy: The Journal of Arthroscopic & Related
Surgery. 2004;20(7):721–727.
64. van Rooij JAF, Fechner MR, van Tits H, et al. Self-reliance and
postoperative hand recovery after simultaneous, bilateral endo­
scopic carpal tunnel release: a prospective study. J Hand Surg
Am. 2022;47(5):e471–477.
65. Vogt T, Scholz J. Clinical outcome and predictive value of electro­
diagnostics in endoscopic carpal tunnel surgery. Neurosurg Rev.
2002;25(4):218–221.
66. Weber RA, Boyer KM. Consecutive versus simultaneous bilateral
carpal tunnel release. Ann Plast Surg. 2005;54(1):15–19.
67. von Bergen TN, Reid R, Delarosa M, et al. Surgeons’ recommenda­
tions for return to work after carpal tunnel release. Hand (N Y).
2022;18:15589447221085700.
68. von Celsing AS, Svardsudd K, Wallman T. Predicting return to work
among sickness-certified patients in general practice: properties of
two assessment tools. Ups J Med Sci. 2014;119(3):268–277.
69. Nordeman L, Gunnarsson R, Mannerkorpi K. Prognostic factors for
work ability in women with chronic low back pain consulting
primary health care: a 2-year prospective longitudinal cohort
study. Clin J Pain. 2014;30(5):391–398.
70. Devin CJ, Bydon M, Alvi MA, et al. A predictive model and nomo­
gram for predicting return to work at 3 months after cervical spine
surgery: an analysis from the Quality Outcomes Database.
Neurosurg Focus. 2018;45(5):E9. DOI:10.3171/2018.8.FOCUS18326
71. Cowan J, Makanji H, Mudgal C, et al. Determinants of return to
work after carpal tunnel release. J Hand Surg Am. 2012;37(1):18–27.
10.1016/j.jhsa.2011.10.033
• A prospective cohort study that reported job type and psycho­
logical factors such as patient expectations, catastrophic think­
ing, and anxiety in response to pain as potential contributing
factors to return to work after carpal tunnel release.
72. Newington L, Stevens M, Warwick D, et al. Sickness absence after
carpal tunnel release: a systematic review of the literature. Scand
J Work Environ Health. 2018;44(6):557–567. 10.5271/sjweh.3762
•• A systematic review of return to work after carpal tunnel
release in which the authors conclude that a standardized
definition of return to work is needed, as well as an agreed
method of collecting and reporting related data.