Surgical decompression for de Quervain disease is effective, but two technical questions remain unresolved: whether the first dorsal compartment retinaculum should be repaired or reconstructed after release, and whether accessory abductor pollicis longus tendon slips should be excised. This narrative review critically examines the historical development and current evidence for these two controversies.

PubMed/MEDLINE, Embase, Scopus, Web of Science Core Collection, and Cochrane CENTRAL were searched through 3 October 2026 using two prespecified concept searches, supplemented by backward citation tracking. Historical reports, anatomical and biomechanical studies, comparative cohorts, randomized trials, and systematic reviews directly relevant to either question were included and interpreted according to study design and methodological limitations.

Clinically important tendon subluxation after release has been documented, and retinacular reconstruction can reduce tendon displacement. However, symptomatic instability is uncommon and comparative studies have not shown superior patient-reported or functional outcomes with routine reconstruction. Multiple abductor pollicis longus slips are common anatomical variants. Selective slip excision has been reported as a feasible decompression strategy, but no controlled study supports routine excision.

Current evidence supports adequate decompression and recognition of anatomical variation rather than a single mandatory technique. The available evidence does not justify routine retinacular reconstruction or routine accessory tendon excision in all patients; both may be considered selectively according to intraoperative findings.

Level V, narrative review.