BACKGROUND:Carpometacarpal (CMC) joint instability can arise from multiple factors, including rheumatoid arthritis, congenital abnormalities, connective tissue disorders, and acute or cumulative trauma. Early detection is crucial, as ligamentous laxity leads to joint incongruence, which, if left untreated, may progress to osteoarthritis(45) First-line treatment consists of immobilization with a splint combined with physical therapy. However, when conservative management fails, surgical stabilization of the CMC-1 joint becomes necessary. Traditional open techniques typically require bone tunnels and tendon harvesting. Technique: We present a novel arthroscopic technique that is less invasive and reinforces the dorsal capsule and dorsal ligaments complex. This approach, inspired by the Birman open procedure, is based on the concept that the dorsal ligament complex is the primary stabilizer of the CMC-1 joint. Results: Seven cases were followed for an average of 24 months. The mean visual analog scale (VAS) pain score was 0. The Kapandji score was 10. Grip strength reached 95% and pinch strength 92.5% of the contralateral hand. One complication was observed: transient irritation of the dorsal radial nerve. CONCLUSION:Arthroscopy is a viable option for capsuloplasty of the dorsal carpometacarpal ligament of the CMC-1 joint. It offers a minimally invasive alternative with fewer risks and less tissue damage while providing improved visualization of the joint, bone, and soft tissues and avoiding the need for complex joint reconstructions.
Reconstruction of large shoulder defects may not be possible with standard pedicled flap designs. Here, we describe a technique for coverage of a wide shoulder defect using the “Kiss” latissimus dorsi pedicled flap. This concept utilizes 2 or more skin paddles in series and combines these in parallel to permit coverage of a wider shoulder defect while permitting primary closure of the back donor site.
Silicone arthroplasty of the proximal interphalangeal joint is traditionally performed through a dorsal approach, which requires violation of the extensor mechanism and may contribute to postoperative stiffness and extension lag. Volar approaches preserve the extensor apparatus and permit earlier active mobilization; however, previously described techniques differ in flexor sheath entry, volar plate management, and collateral ligament handling, limiting reproducibility. We describe a standardized volar technique that emphasizes controlled neurovascular mobilization; elevation of the A3 pulley as a laterally based flap (preserving A2 and A4); proximal disinsertion of the volar plate while maintaining its distal attachment; and bilateral complete proximal detachment of the proper collateral ligaments to achieve symmetric "shotgun" exposure. This collateral release corrects asymmetric ligament elongation or contracture in arthritic and post-traumatic deformities, restores coronal balance, and facilitates centered implant placement. Flexor tendons are retracted without division. After canal preparation and implant insertion, axial alignment and coronal and sagittal stability are assessed throughout the flexion-extension arc. The volar plate and collateral ligaments are not routinely repaired. Postoperative stability relies on implant-centered alignment and progressive peri-implant capsular fibrosis, with support from temporary buddy taping. This technique provides reproducible exposure while also serving as a structured soft-tissue rebalancing strategy. Clinical application should be limited to cases in which soft tissue balance can be restored and implant-centered stability achieved intraoperatively.
Thumb carpometacarpal (CMC) osteoarthritis in advanced stages is frequently associated with metacarpophalangeal (MCP) hyperextension, resulting in the characteristic Z-deformity and reduced pinch stability. Standard basal joint reconstruction may fail to correct MCP hyperextension, contributing to persistent functional impairment. Prosthetic trapeziometacarpal arthroplasty may partially correct Z-deformity but becomes unreliable when MCP hyperextension exceeds 30 degrees. This article describes a reproducible surgical technique combining trapeziectomy, APL suspension arthroplasty, and EPB reinsertion onto the dorsal aspect of the first metacarpal head to restore sagittal balance of the MCP joint. In this configuration, the EPB is intentionally converted from an active extensor into a passive dorsal stabilizer, providing a tenodesis-like restraint against hyperextension while preserving flexion arc. In 10 consecutive patients with Eaton-Littler stage III-IV disease and MCP hyperextension ≥30 degrees, mean hyperextension improved from 38.6 degrees preoperatively to 5.4 degrees at 12-month follow-up, with preservation of MCP flexion and improvement of key pinch strength and QuickDASH scores. This approach provides stable correction of MCP hyperextension while maintaining MCP motion, offering a motion-preserving alternative to capsulodesis or arthrodesis.
Recurrent anterior shoulder instability associated with glenoid bone loss poses a significant surgical challenge. The open Latarjet procedure with screw fixation remains a reliable option. However, screw-related complications, such as hardware irritation and graft fracture, have prompted the exploration of alternative fixation systems. This article describes a guided open Latarjet technique using dual suture-button constructs for coracoid fixation and reports early clinical and radiographic outcomes. Five male patients (median age, 27.5 y) with recurrent anterior instability and glenoid bone loss exceeding 15% or failed previous stabilization underwent this procedure. Functional outcomes, as assessed by the American Shoulder and Elbow Surgeons (ASES) score, pain levels quantified by the visual analog scale (VAS), and graft consolidation, were evaluated at 6, 12, and 24 months postoperatively. The mean ASES score improved from 46.5 preoperatively to 98 at 24 months, while median pain levels decreased from 7.5 to 0. Serial postoperative radiographs suggested graft consolidation in 4 of 5 patients within 6 months, with acceptable graft positioning in most cases. No redislocations, subjective instability, or hardware complications occurred. In this small single-center preliminary series, the guided open Latarjet with suture-button fixation appeared technically feasible and was associated with encouraging early clinical and radiographic findings. These results should be interpreted cautiously as descriptive and exploratory rather than definitive evidence of reproducibility or effectiveness.
Circumferential degloving injuries of the digits are common but continue to be a challenge to achieve stable coverage. Many techniques have been used to tackle these, ranging from skin grafts to multiple free flaps. This article describes a straightforward technique of using 2 pedicled flaps from the abdominal region to simultaneously cover both the volar and dorsal aspects of the digit. The dimensions, design, and method of using the technique are explained in detail with illustrative case examples. This "sandwich" flap design is simple, reliable, does not require a delay stage and minimises the need for later debulking procedures.
Distal radius fractures are common upper extremity injuries. Some intra-articular fracture patterns may benefit from a dorsal approach to assist in optimizing joint congruency by direct visualization and reduction of the articular surface. Dorsal plating can be associated with extensor tendon irritation and possible risk of attritional rupture. However, in combination with newer-generation thinner dorsal plates or fragment-specific dorsal plating, the risk of extensor tendon complications can be minimized with the use of extensor retinacular flaps for plate coverage. This paper summarizes a technique that utilizes an interdigitating flap design that can be done to optimize dorsal plate coverage in the treatment of certain intra-articular distal radius fractures.
Metacarpal and phalangeal nonunion is rare; however, surgery is required if these fractures result in instability or persistent pain. Revision of nonunion following plate fixation is challenging, as it demands bone grafting at the nonunion site and stable fixation. Here, we present a surgical technique for managing metacarpal and phalangeal nonunion after failed plate fixation using an intramedullary strut bone peg reinforced with intramedullary K-wires. This technique achieves a high union rate by increasing the intramedullary contact surface, promoting bone healing. Moreover, intramedullary K-wires bypass previous screw holes and help maintain fracture apposition and alignment at the nonunion sites.
Ruptures of the distal head of the biceps are quite common and are a consequence of eccentric load. Chronic lesions are defined as treated after 4 weeks from injury. Treatment of chronic lesions is challenging and typically requires a tendon graft due to proximal stump retraction and degeneration. We propose a new reconstruction technique using a Flexor Carpi Radialis (FCR) autograft reinforced with a Palmaris Longus (PL) autograft and fixed to the radial tuberosity with an Endobutton. We applied this technique in 6 patients with excellent functional outcomes. No major complications were observed and no morbidity or functional limitations were noticed at the harvest sites.
Two patients, a 65-year-old male and a 61-year-old female, presented with 5-digit partial hand amputations following pressor-induced necrosis and an industrial accident, respectively. Both patients had thumb metacarpophalangeal disarticulations with healthy interossei. These patients underwent combined Starfish procedures and thumb on-top-plasty utilizing the necessarily resected distal index metacarpals. Both patients went on to bony union, functional opposition, and use of their myoelectric prostheses. For patients with 5-digit partial hand amputations, the use of the resected distal 3 cm of index metacarpal to lengthen the remnant thumb can be done safely while performing a Starfish reconstruction.
Gartland type IV supracondylar humerus fractures in children are characterized by complete periosteal disruption and multidirectional instability, frequently resulting in failure of standard closed reduction maneuvers. Persistent rotational instability is the primary factor leading to loss of reduction and the subsequent need for open reduction. Although open reduction is effective, it is associated with increased soft-tissue dissection, longer operative times, and a higher risk of postoperative stiffness and neurovascular complications. We describe a temporary lateral cortical pin-assisted closed reduction technique that facilitates controlled rotational correction while preserving lateral cortical alignment. After restoration of lateral cortical continuity under fluoroscopic guidance, a temporary lateral Kirschner wire is inserted to act as a hinge, stabilizing the reduction and allowing precise rotational adjustment of the distal fragment before definitive fixation. Definitive stabilization is then achieved with standard percutaneous pinning, most commonly using a lateral-only configuration. This technique is simple, reproducible, and may expand the indications for successful closed reduction, thereby reducing the need for open reduction in selected Gartland type IV supracondylar humerus fractures.
Fractures of the metacarpals account for 18% to 44% of all hand fractures, with malunion being the most common complication. Sagittal plane malunion may result in extensor lag, bone shortening, loss of knuckle contour, and prominent dorsal or palmar bony deformity. In this paper, we describe a novel crescentic osteotomy technique of the border metacarpals stabilized with intramedullary screw fixation for the correction of extra-articular malunions. We report 3 cases of border metacarpal malunion treated with this method. At a median follow-up of 9 months (mean: 12.3 mo), patients achieved excellent outcomes, with a mean QuickDASH score of 1.5. This technique provides a safe, effective, and reproducible option for the correction of metacarpal malunions.
There is currently no consensus on which existing treatment for chronic Boutonniere deformity is most effective. We describe a method of central slip reconstruction with an autologous "V" shaped tendon graft folded on itself through a bone tunnel for the treatment of Boutonniere deformity. All 3 patients healed well with an average active range of motion of the distal interphalangeal joint 10 to 70 degrees, proximal interphalangeal joint 15 to 90 degrees, and metacarpophalangeal joint 0 to 90 degrees with a follow-up duration between 4 years and 5 years. This is a straightforward technique that can be performed in patients with chronic, post-traumatic and flexible Boutonniere deformity.
Isolated management of metacarpophalangeal (MCP) joint injuries or sagittal band disruptions often leads to incomplete symptom resolution and suboptimal functional outcomes, particularly in complex trauma. We present a combined surgical technique integrating MCP joint arthroscopy with open sagittal hood repair for traumatic extensor mechanism instability and intra-articular pathology. This paper describes a stepwise approach to address both intra-articular and soft tissue components of MCP joint injuries. Arthroscopy facilitates direct visualization, synovectomy, debridement, and capsular shrinkage, while open sagittal band repair allows for tendon centralization, repair of a hood rupture, and occasional definitive realignment. This dual approach provides a comprehensive treatment option, ensuring the stabilization of both the joint capsule and the extensor mechanism. An illustrative case demonstrates restored tendon alignment and joint stability with no intraoperative complications, highlighting how this combined technique enhances diagnostic precision and therapeutic outcomes in complex MCP joint injuries.
Technical note-2 illustrative cases. Suturing delicate structures risks iatrogenic damage from excessive exposure. Traditional methods, such as incisions and tissue retraction, can lead to adhesion, scarring, and impairment. We describe the reverse exposure-limiting suture (RELS) as a suture-burying maneuver facilitating controlled approximation while minimizing tissue exposure. RELS was applied to a proximal nail-bed laceration and a Zone 2 flexor tendon injury. The needle is first passed through the defect, then reversed beneath the overlying structure with the swage leading, allowing approximation without elevating protective tissues (such as eponychium) or releasing pulleys. As reversing the needle via the swage may theoretically increase tissue trauma, the technique should be applied cautiously in delicate regions. Both cases healed uneventfully: normal nail regrowth at 6 weeks (case 1) and excellent early function without pulley compromise at 3 months (case 2). Initial experience suggests that RELS is feasible in anatomically constrained regions; further study is needed to define its efficacy and stiffness, which may potentially compromise indications, safety, and outcomes.
Fifth metacarpal neck and distal diaphyseal fractures with severe angulation, displacement, or malrotation may benefit from surgery. Fixation approaches include antegrade and retrograde intramedullary fixation, transmetacarpal Kirschner wires (K-wire), and plate fixation. K-wires are a particularly promising option due to their simple, non-invasive, and cost-efficient nature. This study describes a novel K-wire technique for fracture fixation and presents early outcomes and complications. 21 patients with fifth metacarpal neck or distal shaft fractures were retrospectively reviewed after treatment with an antegrade intramedullary K-wire with a "T-handle" bend proximally, a gentle bend distally, and a transosseous wire transfixing the fourth and fifth metacarpal heads to control rotation. Patient characteristics, radiographic data, and postoperative outcomes were collected. Patients were immobilized in a cast or splint for an average of 5 weeks (range: 3.7 to 9.3 weeks). Mean follow-up was 8.4 weeks (range: 3.7 to 27.7 weeks). Mean preoperative angulation was 49.7 degrees (SD: 13.7 degrees, range: 19 to 71 degrees) and mean postoperative angulation was 17.5 degrees (SD: 4.2 degrees, range: 11 to 26 degrees). The operative small finger metacarpal phalangeal joint achieved an average flexion of 72.1 degrees compared with 89.6 degrees on the nonoperative side ( P =0.001). Four patients developed cellulitis around a K-wire and were successfully treated with pin removal and oral antibiotics. Two patients developed numbness over the dorsal small finger. There were no nonunions. In conclusion, severely angulated, displaced, or malrotated fifth metacarpal neck and distal shaft fractures can be effectively treated with this novel, simple, inexpensive, and minimally invasive K-wire technique.
