213 patients with carpal tunnel syndrome were randomized to 1 of 3 groups: open carpal tunnel release (OCTR) with transverse carpal ligament (TCL) reconstruction, isolated OCTR, or endoscopic carpal tunnel release (ECTR). The purpose of this study was to evaluate whether OCTR with TCL reconstruction would lead to greater grip strength recovery compared to the other two techniques. Patients were followed for 2 years postoperatively. By final follow-up, the OCTR with TCL reconstruction group had significantly more favourable cylindrical grip strength recovery compared to the other two, although lateral grip strength was similar between groups. OCTR with TCL reconstruction was also associated with improved functional outcomes and lower incidence of flexor tendon bowstringing.