Background Thumb carpometacarpal joint osteoarthritis (CMC OA) is common, affecting mainly individuals in their 50s and 60s. Operative options are numerous, including ligament reconstruction and tendon interposition (LRTI), suspensionplasty, arthroplasty, or arthrodesis. This review sought to summarize and compare these surgical treatments for thumb CMC OA. Methods Systematic review and meta-analysis were performed per PRISMA guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane were queried for articles on thumb CMC OA since 2005. Patients under 18 years of age, revision surgery, concomitant non-thumb surgeries, and studies with less than 12-month follow-up were excluded. Demographics, strength, outcome scores, and complications were evaluated. Results 177 articles were included, evaluating 13,332 thumbs, average age 61 years and 81% female. Of included thumbs, 38% received CMC arthroplasty (5088 thumbs), 36% LRTI (4751 thumbs), suspensionplasty (1932 thumbs), CMC arthrodesis (870 thumbs), and trapeziectomy alone (691 thumbs). Postoperative grip strength, DASH, and VAS pain score were similar across included techniques. QuickDASH was significantly lower in suspensionplasty and Kapandji score was significantly higher in trapeziectomy alone. CMC arthroplasty demonstrated a revision rate of 6% compared to 4% in CMC arthrodesis and 1% in trapeziectomy, suspensionplasty, and LRTI each. Fastest return to work was 8 weeks for trapeziectomy alone. Conclusions Thumb CMC OA is a common problem affecting an aging population. Multiple operative options exist and are described, with all demonstrating reasonable outcomes. While complication rates are relatively low across modalities, CMC arthroplasty and arthrodesis may present with a different complication profile compared to other treatments. Although, available literature is mostly observational and heterogenous, and newer CMC arthroplasty are being approved. Level of Evidence IV
Introduction:Chronic static scapholunate dissociation remains a therapeutic challenge, and the long-term ability of ligamentoplasty procedures to maintain carpal correction is uncertain. Our hypothesis was that SLIC 2 ligamentoplasty may provide sustained clinical improvement despite partial loss of radiological correction over time. We report the minimum 5-year outcomes of this technique in patients with reducible chronic static scapholunate dissociation. Methods:This retrospective case series included seven patients who underwent SLIC 2 ligamentoplasty between April 2014 and June 2019 for Garcia-Elias stage 4 reducible chronic static scapholunate dissociation. All patients were reassessed after a minimum follow-up of 5 years. Preoperative and 1-year clinical and radiological data were collected from medical records, and final outcomes were assessed during standardized long-term reassessment. Radiological assessment included the scapholunate gap, scapholunate angle, capitolunate angle, posterior scaphoid subluxation, and posterior radioscaphoid angle. Clinical assessment included pain, grip strength, range of motion, QuickDASH, PRWE, and Mayo Wrist Score. Results:At a median follow-up of 72 months (IQR, 69.5-78), the initial radiological correction was progressively lost. Compared with immediate postoperative values, the median scapholunate gap increased from 2.0 mm (IQR, 1.8-2.1) to 4.2 mm (IQR, 4.0-4.4) (p = 0.016), and the scapholunate angle increased from 50° (IQR, 49-64.5) to 80° (IQR, 76-86) (p = 0.016). Despite this radiological recurrence, clinical outcomes remained improved. Pain during effort decreased from 5.5 (IQR, 3.8-7.2) to 2 (IQR, 1-3) (p = 0.031), PRWE improved from 49.5 (IQR, 35.8-52.3) to 16 (IQR, 11.3-23.8) (p = 0.031), and Mayo Wrist Score improved from 70 (IQR, 67.5-77.5) to 80 (IQR, 72.5-82.5) (p = 0.016). One patient developed progressive SLAC arthritis. Conclusion:SLIC 2 ligamentoplasty provided sustained clinical improvement at more than 5 years despite progressive loss of the initial radiological correction. These findings should be interpreted cautiously given the small and highly selected cohort, but suggest that SLIC 2 may remain an option in selected patients with reducible chronic static scapholunate dissociation. Level of evidence:IV.
Purpose:Extensor pollicis longus (EPL) tendon ruptures are a rare but recognized complication following distal radius fractures (DRFs) with several proposed mechanisms for their pathophysiology. Existing literature on the incidence of EPL ruptures has largely been limited to small, single-center studies. The purpose of this study was to define the incidence of EPL ruptures following operatively and non-operatively treated DRFs using a large, multicenter database. Methods:A retrospective cohort analysis was performed using the TriNetX database. Patients aged 18 to 90 years who sustained a distal radius fracture between January 1, 2005, and September 1, 2025 were identified using ICD-10 and CPT codes. Patients were stratified into operative and non-operative treatment cohorts. EPL ruptures occurring between two weeks and three years following the index fracture were recorded. Cohorts were matched based on age and demographic characteristics to minimize potential confounding variables. Odds ratios with 95% confidence intervals were calculated, with statistical significance defined as p < 0.05. Results:A total of 1,206,837 distal radius fractures were analyzed, including 1,093,856 nonoperatively treated fractures and 112,981 operatively treated fractures. In the nonoperative cohort, 1087 EPL ruptures were identified, corresponding to an incidence of 0.1%. In the operative cohort, 411 EPL ruptures were reported, yielding an incidence of 0.36%, nearly three times higher than that observed in nonoperative management. Matched analysis revealed no significant demographic or clinical confounding factors in either cohort. Conclusions:The incidence of EPL rupture following distal radius fractures were lower than previously reported in smaller clinical series. Operatively treated fractures were associated with a higher incidence of EPL rupture, likely reflecting previously described etiologies, such as hardware-related mechanical irritation, dorsal screw penetration, increased fracture severity, surgical exposure, and disruption of tendon vascularity or gliding mechanics. These findings provide important data for patient counseling regarding treatment risks and underscore the importance of heightened clinical vigilance for early detection of EPL tendon injury following both operative and non-operative DRF management.
Reconstruction of the interosseous membrane of the forearm has gained popularity over recent decades and several surgical techniques have been described to treat the longitudinal instability of the forearm after an Essex-Lopresti injury (ELI). We propose a synthetic reconstruction of the interosseous ligament (IOL) with double Arthrex FiberTape® and present data from cadaveric specimens used to test the reconstruction. After reconstruction, proximal migratory forces were applied to the radius to assess the radioulnar displacement at wrist level. Safety of the technique was also assessed by measuring the distance between the fixation system and the posterior interosseous nerve (PIN). These experiments provide preliminary biomechanical data to support further evaluation of this technique for potential clinical application.
Purpose Literature on digital replantation has historically prioritized primary outcomes such as viability rates, return-to-work timelines, and restoration of range of motion and grip strength. Psychological and psychosocial sequelae, including post-traumatic stress disorder (PTSD), depression, anxiety, sleep disturbance, adjustment disorder, and body image disruption, are reported inconsistently, infrequently, or not at all. This narrative review examines the scope and quality of psychological outcome reporting in the digital replantation and revascularization literature from 2015 to 2025. Methods A literature search of PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, and the Cochrane Library was conducted for English-language studies published between January 2015 and December 2025, using combinations of terms including “replantation,” “revascularization”, “digit amputation”, “PTSD”, “anxiety”, “depression”, “adjustment disorder”, “body image”, and “psychosocial outcomes”. Studies reporting at least one psychological or psychiatric outcome following digital or upper extremity replantation, revascularization, or upper extremity amputation were included. Adult or mixed adult-pediatric cohorts were included. Given study heterogeneity, findings were synthesized narratively, to broadly characterize the available literature, by outcome domain. Results Nineteen studies met inclusion criteria. Depression was the most frequently reported discrete outcome (10/19 studies, 52%), followed by anxiety (8/19 studies, 42%) and PTSD (7/19 studies, 36%). PTSD prevalence ranged from 46% to 69%, and depression and anxiety prevalence ranged from 7% to 71% across studies using validated instruments. Adjustment disorder was identified in two studies, including one large retrospective analysis (n = 1986) demonstrating significantly higher prevalence following replantation failure (2.7% vs <1%). Pre-injury anxiety was identified as an independent predictor of replantation failure in one prospective cohort. No included study reported formal psychiatric or behavioral health referral rates. Conclusions There is a pervasive gap in the reporting of psychological and psychosocial outcomes following digital replantation and revascularization. Existing evidence demonstrates that psychiatric morbidity is more common than is currently reflected in traditional surgical outcome reporting. Standardized, validated psychological screening instruments should be incorporated into replantation outcome reporting, and multidisciplinary care models inclusive of behavioral health are warranted.
Background:The volar plate (VP) of the proximal interphalangeal joint (PIPj) is a key stabilizer against postero-anterior stresses. Traumatic VP disruption typically results from PIPj hyperextension combined with variable degrees of lateral deviation or torsional forces. Missed diagnoses and inadequate early management, particularly in patients with rheumatic conditions, may lead to chronic lesions and progressive PIPj hyperextension deformities. This study describes a novel surgical technique for chronic volar plate reconstruction and evaluates its long-term clinical outcomes. Materials and methods:The technique consists of creating a check-rein mechanism over the PIPj using two distally based tendon slips of the flexor digitorum superficialis (FDS). These slips are crossed over the joint and secured with two mini bone anchors implanted in the proximal phalanx metaphysis. Twelve digits with chronic traumatic VP disruption were treated at two institutions and retrospectively reviewed. The mean follow-up period was 7 years. Outcomes were assessed using Catalano's criteria (excellent, good, fair, poor). Range of motion (ROM) of the PIPj and DIPj was recorded preoperatively and at final evaluation. Patients completed the DASH questionnaire, and pain was assessed using a numeric rating scale (NRS). Results:At the latest follow-up, outcomes were classified as excellent in 8 cases, good in 3 cases, and fair in 1 case, the latter due to postoperative PIPj contracture. No failures of the reconstruction and no recurrence of the initial deformity were observed. Eleven of twelve patients returned to their previous occupational activities, including those requiring high functional demands such as competitive sports. Conclusion:This technique provides a straightforward surgical option for correcting chronic PIPj hyperextension deformities, with durable and satisfactory outcomes at long-term follow-up. Larger samples and comparative studies are required to further validate its effectiveness and potential advantages over existing reconstructive methods.
Acute boutonniere deformity is a heterogeneous clinical entity that has traditionally been attributed to rupture of the central slip of the extensor mechanism, with secondary palmar migration of the lateral bands. The temporal relationship between central slip detachment and lateral band displacement remains incompletely defined. We report a clinical case in which a patient presented with an immediate, actively irreducible boutonniere deformity caused by an uncommon injury pattern, characterized by longitudinal disruption of a single lateral band and rupture of the ipsilateral collateral ligament, with the central slip largely intact. The deformity could not be reduced by closed means and required surgical treatment.Motivated by this observation, we performed an exploratory anatomical study on 16 cadaveric fingers. Isolated lesions of the central slip or of a single lateral band did not, in this model, produce an actively irreducible boutonniere deformity. By contrast, combined injuries consisting of a longitudinal lesion of one lateral band and rupture of the ipsilateral collateral ligament consistently resulted in immediate palmar displacement of the lateral band below the axis of the proximal interphalangeal (PIP) joint, irrespective of central slip integrity.These exploratory findings suggest that, alongside the classical mechanism of central slip rupture, an under-recognized injury pattern combining longitudinal lateral band disruption and ipsilateral collateral ligament failure may produce an immediate, actively irreducible boutonniere deformity, with potential implications for early diagnosis and treatment. Further clinical validation is required. Level of evidence:IV.
Purpose:Outpatient hand clinic non-attendance is a pervasive issue, and identifying risk factors for clinic non-attendance can help inform strategies for addressing this problem. No study has evaluated risk factors for hand clinic non-attendance among emergency department (ED) patients at urban safety-net community hospitals, which are a common source of referrals for many hand providers. Methods:We conducted a one-year retrospective chart review of all ED patients at an urban safety-net community hospital for whom hand surgery consults were ordered in 2023. For patients who were deemed to require follow-up in hand clinic, bivariable and multivariable analyses were performed to identify demographic and consult-related factors associated with hand clinic non-attendance. P < 0.05 was considered significant for all analyses. Results:Of the 200 patients who required follow-up in our hand clinic, 129 (64.5%) attended their hand clinic appointment and 71 (35.5%) did not. On multivariable analysis, factors significantly associated with decreased likelihood of hand clinic attendance were being marginally housed (adjusted odds ratio (aOR) = 0.27, 95% confidence interval (CI): 0.11-0.63) and not having a primary care provider (aOR = 0.38, CI: 0.19-0.78). Factors significantly associated with increased likelihood of attendance included having a bone injury (aOR = 2.28, CI: 1.12-4.63), having a tendon injury (aOR = 7.83, CI: 1.64-37.48), or having undergone a nailbed repair (aOR = 6.24, CI: 1.28-30.38). Conclusions:Among patients referred to an urban safety-net community-based hand clinic after presentation to the ED, hand clinic non-attendance is common. Various unique factors are significantly associated with increased or decreased likelihood of clinic attendance in this setting. These factors could be used to develop strategies for improving clinic attendance for similar practices moving forward.
Introduction:Whether the operating microscope provides superior functional outcomes compared with surgical loupes for peripheral nerve repair remains debated. No randomized controlled trial has addressed this question. We critically appraised all studies directly comparing these two magnification modalities for upper limb nerve repair. Methods:A narrative review following SANRA guidelines was conducted across four databases (1980-2026). Only studies with a direct microscope versus loupes comparison or testing magnification as a predictive variable were included. Experimental models (nerve and vascular, animal and synthetic), cadaveric studies, and clinical series were eligible. Results:Eleven studies met inclusion criteria: four experimental, one cadaveric with practice survey, five clinical series, and one individual-patient-data meta-analysis. Experimental and cadaveric evidence consistently demonstrated microscope superiority for structures below 1.5 mm. None of the five clinical comparisons, totaling 2610 patients with follow-up from 2 to 20 years, demonstrated any significant functional difference. The largest propensity score-matched cohort study (2416 patients) and the largest meta-analysis (623 cases) confirmed that age, delay, and nerve type are the dominant prognostic determinants. Conclusion:No currently available clinical study has demonstrated a detectable functional superiority of microscope-assisted repair over loupe-assisted repair, explained by the modest amplitude of the precision difference, caliber-dependent saturation above 1.5 mm, and the dominance of biological factors. High-quality loupes (≥×4.5) may be reasonable in selected emergency and resource-limited settings, but formal non-inferiority to the microscope remains unproven. A standardized in vivo experimental study with histological endpoints is the essential next step before considering a multicenter clinical trial. Level of evidence:IV (narrative review of predominantly Level IV studies).
Wide Awake Local Anesthesia No Tourniquet (WALANT) is often introduced as an anesthetic technique that avoids general anesthesia, regional blocks, sedation, and tourniquet discomfort. This description is accurate, but incomplete. The deeper significance of WALANT is that it restores living physiology to the operating theatre. For more than a century, reconstructive surgeons repaired tendons, transferred nerves, corrected deformities, balanced muscles, and reconstructed movement in patients whose physiology was temporarily silent. Tendon tension was estimated, nerve function was predicted, muscle balance was assumed, and the final judgment of success was delayed until rehabilitation revealed the truth. WALANT challenges this old paradigm by allowing movement, tension, balance, spasticity, sensory response, and patient-specific biomechanics to be observed during surgery itself. Its expanding role in tendon transfer, thumb reconstruction, peripheral nerve surgery, brachial plexus reconstruction, spasticity surgery, and ambulatory microsurgery suggests that its greatest contribution may not be anesthetic freedom, but the birth of physiology-guided reconstruction. This editorial argues that WALANT has moved beyond tendons and beyond anesthesia. It has become a new way of thinking about reconstructive surgery.
Purpose:Despite the frequent occurrence of thumb ulnar collateral ligament injury, evidence supporting current diagnostic and treatment recommendations remains limited. To identify areas where comparative research is needed to support future evidence-based guidelines and potential challenges to their subsequent implementation, this study aimed to characterize international practice patterns, identifying consensus and variation. Methods:A web-based international survey was distributed between May and December 2024 through professional societies for hand surgery and associated clinical networks. The questionnaire comprised twenty-five items covering clinician characteristics, diagnostic strategies, and treatment preferences. Responses were analyzed descriptively and stratified by geographic region and years of clinical experience. Results:Of 293 returned questionnaires, 262 were eligible for analysis. Respondents had practiced for a median of thirteen years, and most were based in Europe. Physical examination was considered sufficient to diagnose a complete ligament tear by most respondents (78%), whereas far fewer regarded it sufficient to detect a Stener lesion (27%). Radiographs were routinely used by 69%, ultrasound by 51%, and MRI by 40%. There was consensus for operative treatment of Stener lesions (95%) and displaced avulsion fractures (79%). Considerable variation existed for complete tears without Stener lesion: 59% preferred surgery, 52% would also attempt nonoperative treatment, and 25% reported they would never consider conservative management for any full-thickness tear. Conclusion:These findings identify areas of variation in which comparative evidence may be most relevant, while also showing where existing practice patterns may influence future guideline implementation. Level of evidence:Not applicable.
Background:Pyogenic flexor tenosynovitis (PFT) is a common hand infection associated with significant morbidity. Management varies due to lack of evidence-based guidelines, typically involving surgery and antibiotics. We conducted a cohort study, comparing outcomes between different surgical methods to see if one is optimal. Methods:Retrospective data collection of patients who underwent surgery for PFT in a single tertiary plastic surgery unit between 21 August 2013 and 4 October 2023 was undertaken. Demographics, injury mechanism, operative details and antibiotic use were recorded. Cases involving cellulitis or osteomyelitis were excluded. Outcomes included length of stay, length of follow-up and post-operative complications. Multivariable regression analyses were performed, adjusting for age, diabetes and smoking status. Results:A total of 174 patients (mean age 47.2 years [SD 18.7]) were included. PFT most commonly resulted from animal bites (23.7% of cases). There was wide variation in antibiotic prescribing practice. Open surgery was performed in 121 cases, whilst 53 underwent minimally invasive procedures. No statistically significant differences in outcomes were observed between techniques in unadjusted or adjusted analyses. Diabetes was associated with an increased likelihood of requiring further procedures on multivariable analysis. Conclusion:There is no evidence of differing outcomes for open or minimally invasive techniques. Diabetes may be associated with a requirement for further procedures. However, these results should be interpreted in the context of the retrospective design, missing data and potential for confounding by indication. Standardised, evidence-based management guidelines are required, with prospective multi-centre studies needed to better define optimal treatment strategies.
Upper extremity burns comprise a significant proportion of severe burn injuries. Their effective management necessitates a multidisciplinary approach, with early integration of hand surgery specialists. This is a narrative review article of current treatment modalities, prioritizing strategies to minimize acute-phase complications and optimize long-term outcomes. We cover initial management principles including resuscitation, thorough secondary assessment, and prompt debridement; elaborate on reconstructive surgical interventions such as skin grafting and flap techniques, paying close attention to strategies that preserve key anatomic locations for good functional outcomes; and outline common complications such as infection, heterotopic ossification, scar contractures, edema, and compartment syndrome, providing evidence-based prevention and treatment strategies. Although the management of upper extremity burn patients can be complex, utilizing a standardized and meticulous approach to the management of these devastating injuries can result in significantly improved functionality of the upper extremity.
Purpose:Wide excisions of the extensor tendons at the level of the proximal phalanx (P1) may be required during oncologic resections. We present an original, single-stage reconstructive technique of the extensor apparatus of the hand used after wide resection for Lipofibromatosis (LPF), a rare pediatric soft tissue tumor. Methods:A 9-year-old girl presented to our institution with a mass on the dorsum of the left hand at the Metacarpophalangeal (MCP) joint of the third digit: following biopsy, the lesion was diagnosed as LPF. Wide surgical excision was performed, requiring complete resection of the extensor apparatus, including the central slip and lateral bands. Reconstruction was performed using a hemisection of the Extensor Digitorum Communis(EDC) tendon to reconstruct the central slip, combined with a Palmaris Longus (PL) autograft to reconstruct the sagittal and lateral bands sutured to the intrinsic muscles. Results:At 2-year follow-up, the patient demonstrated near-complete active extension, full flexion, and no evidence of recurrence. A residual extension lag of 10° at the Proximal Interphalangeal (PIP) joint was observed. Grip strength was comparable to the contralateral side. Conclusion:This technique allows functional restoration of the extensor mechanism in a single stage and may represent an alternative in complex reconstructions. The good clinical outcome prompted us to report this technique, which, to our knowledge, has not been previously described. At a current follow-up of two years, the result remains stable, with no evidence of local recurrence.
Purpose:Trapeziometacarpal joint replacement is an effective treatment for trapeziometacarpal osteoarthritis, but postoperative de Quervain tenosynovitis remains a concern, with reported incidences of 4-17%. Thumb lengthening has been suggested as contributory. This study evaluated the association between postoperative thumb lengthening and de Quervain tenosynovitis using the M1-M2 arch described by Duché and Trabelsi. Methods:A retrospective cohort study included 49 patients (53 procedures) who underwent primary trapeziometacarpal joint replacement with a dual-mobility ball-and-socket implant. Thumb lengthening was quantified radiographically with the M1-M2 arch on thumb abduction and Kapandji frontal views. De Quervain tenosynovitis was diagnosed clinically and using ultrasound. An association between thumb lengthening and de Quervain tenosynovitis was assessed using point-biserial correlation analysis. Results:De Quervain tenosynovitis occurred in 14 of 53 wrists (26.4%), with a mean onset of 8.2 weeks. Patients with de Quervain tenosynovitis demonstrated greater thumb lengthening than those without, on both the abduction view (2.46 ± 1.46 mm vs. 0.75 ± 1.00 mm) and Kapandji frontal view (2.37 ± 1.39 mm vs. 0.34 ± 0.74 mm). Strong correlation was found between de Quervain tenosynovitis and thumb lengthening on the Kapandji frontal view and moderate correlation was found on the abduction view. Inter-observer reliability for the M1-M2 arch measurement was good, with an ICC of 0.88 for the Kapandji view and 0.84 for the thumb abduction view. Conclusion:Greater postoperative thumb lengthening was associated with de Quervain tenosynovitis following trapeziometacarpal joint replacement. These findings suggest that attention to restoration of thumb column length may be relevant in reducing the risk of postoperative de Quervain tenosynovitis. Prospective studies with large cohorts and standardized imaging protocols are warranted to clarify this relationship. Level of evidence:III.
Reconstruction of hand soft tissue defects relies on accurate perforator localization, yet conventional planning with computed tomography angiography or handheld Doppler requires mental three-dimensional (3D) translation, and is associated with mapping errors or intraoperative adjustments. This article evaluates the use of an innovative patient-specific, surface-conforming 3D-printed guides that convert segmented preoperative magnetic resonance imaging (MRI) data into tangible templates to project dorsal metacarpal artery (DMA) perforator emergence points onto the skin with reproducible accuracy.In an illustrative case, a 66-year-old man underwent wide local excision of a digital porocarcinoma followed by propeller flap reconstruction. The third and fourth DMA perforators were identified from MRI, with a 2 mm-thick dorsal hand shell designed with 1 cm fenestrations corresponding to perforator emergence points. The perforators were marked onto the skin through the custom guide preoperatively, with skin markings cross verified with handheld Doppler. Reconstruction proceeded using a fourth DMA perforator-based propeller flap rotated to achieve tension-free coverage, with complete flap survival and restoration of full digital motion and satisfactory aesthetics.The 3D-printed guide reduced cognitive load, accelerated perforator localization, and minimized unnecessary dissection, supporting shorter tourniquet duration and safer elevation. The hand’s distinct bony landmarks and stable contours enable reliable registration of rigid surface guides. As costs and workflows for imaging-to-print continue to decrease, patient-specific 3D-printed guides represent a practical, scalable adjunct that improved accuracy, efficiency, and reproducibility in perforator-based hand reconstruction.
