BACKGROUND:The Lisfranc joint comprises the articulations between the cuneiforms and bases of the metatarsals and is susceptible to a variety of complex injuries which are frequently missed or diagnosed late. This can result in morbidity with poor outcomes, and renders it challenging to standardise management and allow prognostication. Existing classification systems, including the Myerson-Hardcastle (MHC) and Nunley & Vertullo classifications, do not consider the propagation of force through the midfoot, which is key to identifying structures which may require stabilization. They also demonstrate poor clinical utility due to poor correlation with outcomes. This study aimed to develop a new classification system for Lisfranc injuries using data from a large single-surgeon case series from a tertiary level trauma hospital in Australia. The primary outcome measures for this study were inter- and intra-observer reliability. METHODS:The Suthersan classification was developed to address shortfalls in current classification systems. Patient records were manually searched for Lisfranc injuries. Direct 'crush' Lisfranc injuries were excluded due to unpredictable injury patterns. Indirect Lisfranc injuries were included in analysis. Two orthopaedics foot and ankle surgeons and one hand surgeon reviewed patient radiographs and classified them using the MHC and Suthersan classification. Inter- and intra-observer reliability for both classification systems was assessed using Cohen's Kappa statistic. RESULTS:176 indirect Lisfranc injuries with accessible CT scans were identified. Mean patient age was 41.6 y and 45.5% were female sex. Suthersan Grade 1a injuries were most common and grade 4 injuries were least common. 19 CT scans were not classifiable using the MHC. Combined inter-rater reliability was 0.95 (Z = 42.3) for Suthersan classification and 0.65 (Z = 21.7) for MHC. Mean intra-rater agreement was 97.7% for Suthersan classification and 87.9% for MHC. CONCLUSION:The Suthersan classification demonstrates excellent inter- and intra-rater agreement compared to the MHC. By considering propagation of force, the Suthersan classification may allow for prognostication and the development of management algorithms following prospective clinical observational studies correlating categories with outcomes.

Background: The development of the International Consortium for Health Outcomes Measurement (ICHOM) standard sets reflects an increasing awareness of the need for systematic, standardised data collection on patient outcomes. Objective: To describe the implementation of the ICHOM standardised set for hand and wrist conditions in the Department of Hand and Peripheral Nerve Surgery at a large, referral hospital in Sydney, Australia. Method: Patient outcomes were collected according to ICHOM-defined clinical pathways for three common procedures: carpal tunnel release, trigger digit release, and distal radius fixation. Response rates were recorded at preoperative and condition-specific follow-up time points over two 3-month periods before and after the employment of a dedicated research officer. Results: Sixty-three patients were treated prior to the implementation of a research officer and 87 patients after. Pre-operative data completion improved from 35% to 93%; 3-month patient reported outcome measures from 25% to 64%; and 3-month clinician reported outcome measures from 0% to 40%. Conclusion: The ICHOM standard set was successfully implemented in an Australian public hospital, aided significantly by the employment of a research officer. Implications for health information management practice: Standardised outcome measurement can be embedded in existing clinical workflows utilising a framework including dedicated personnel, robust information technology infrastructure, and patient engagement strategies. This template is broadly applicable across institutions and facilitates a shift towards value-based healthcare metrics.

Background: Fibro-osseous pseudotumour of the digit (FOPD) is a rare, benign soft-tissue lesion that mimics infection and malignancy due to its rapid growth, pain, and radiological features. Misdiagnosis can result in inappropriate treatment, including unnecessary ablative surgery. Methods: A narrative literature review was conducted using PubMed and Embase, supplemented by reference screening. Case reports and case series of FOPD involving the digits of the hands or feet were included. Data were synthesised to identify clinical, histopathological, radiological, and management patterns. In addition, we report a recurrent case of FOPD misdiagnosed as tenosynovitis. Results: Twenty-two case reports published between 2015 and 2025 and four large case series prior to 2015 yielded a total of 134 patients. Fibro-osseous pseudotumor of the digit typically affects young to middle-aged adults (mean age, 36 years) with a slight female predominance. Lesions presented as rapidly enlarging painful nodules, occasionally associated with prior trauma, and were frequently mistaken for infection or extraskeletal osteosarcoma. Complete surgical excision was the definitive treatment, with recurrence reported rarely and almost exclusively following incomplete excision. Our case demonstrated recurrence after initial debridement, with subsequent definitive excision leading to functional recovery, although residual stiffness and sensory disturbance persisted. Conclusions: Fibro-osseous pseudotumor of the digit should be considered in the differential diagnosis of rapidly enlarging digital lesions. Complete surgical excision is curative in most cases, while molecular markers such as ubiquitin-specific peptidase 6 may refine the diagnosis in morphologically ambiguous presentations. Future research should prioritise the development of standardised diagnostic criteria, prognostic markers, and long-term outcome reporting.

INTRODUCTION:Distal radius fractures are common injuries with a substantial burden of disease. Although volar locking plate fixation is commonly used, the relationship between preoperative factors and early- to medium-term patient-reported outcomes remains poorly delineated. This study examined whether patient characteristics, injury features and routine prereduction radiographic measurements were associated with 3-month Patient-Rated Wrist and Hand Evaluation (PRWHE) scores after volar locking plate fixation. METHODS:A retrospective cohort study at a tertiary trauma centre was conducted. Adults who underwent volar locking plate fixation were identified from a prospectively maintained registry. Demographics, comorbidities, injury details and prereduction radiographs were reviewed. The primary outcome was the PRWHE score at 3 months postoperative. Grip strength and range of motion were also assessed, where available. Multivariable linear regression analysis evaluated associations between preoperative factors and PRWHE scores. Sensitivity analysis utilised complete-case analysis, and paired testing was used to assess temporal associations. RESULTS:Amongst prereduction radiographic factors, greater sagittal translation and ulnar styloid fracture were associated with poorer patient-reported outcomes. Older age was associated with worse function, and female sex was associated with better outcomes. When considering clinician-measured outcomes, greater grip strength and ulnar deviation were associated with superior patient-reported outcomes. Analysis of the small paired 3- to 6-month cohort revealed improvement in pain, grip strength and wrist range of motion. CONCLUSION:Certain prereduction radiographic features, male sex and older age are associated with poorer patient-reported outcomes following volar locking plate fixation of distal radius fractures. These findings may assist in preoperative counselling, prognostication and identification of patients at risk. LEVEL OF EVIDENCE:III.

BACKGROUND:Olecranon fractures are a common fragility injury in elderly patients, typically resulting from low-energy mechanisms. While evidence supporting nonoperative management in this population has increased, rates and long-term trends in operative fixation of olecranon fractures in elderly Australians remain poorly characterised. This study evaluated national trends in operative management of olecranon fractures in Australians aged 75 years and older from 2000 to 2024. METHODS:A retrospective analysis of Medicare Benefits Schedule data was performed from 2000 to 2024. Olecranon fracture fixations were identified using item number 47399 (treatment of olecranon fracture by open reduction). Patients aged 75 years and older were included. Annual case volumes and per-capita rates were stratified by year and sex. Temporal trends were assessed using linear regression and correlation analysis. RESULTS:A total of 3,644 olecranon fixation procedures were performed in patients aged 75 years and older. Annual volumes increased over time, reaching 193 procedures in 2024, with a mean annual increase of 3.9 cases (p < 0.001). Female patients accounted for 82.7% of all procedures, though their proportional representation declined 0.45% per year (p < 0.001). Male per-capita fixation rates increased 2.2-fold (r = 0.57; p < 0.01), while female rates remained stable. CONCLUSION:Operative fixation of olecranon fractures in Australians aged 75 years and older increased over the 25-year study period, despite growing evidence supporting nonoperative management in this population. Although female patients accounted for the majority of procedures, their per-capita fixation rates remained stable, while male rates doubled. These findings reflect evolving surgical practice and support further research into patient selection, clinical outcomes and economic implications.

Background: Suture-button suspension is commonly used post trapeziectomy, stabilising the first metacarpal base to its adjacent counterpart. It has more recently been used in the setting of carpometacarpal instability, avoiding the morbidity of tendon harvest and large tunnels required in traditional stabilisation techniques. Evidence for its use in this setting remains limited. Methods: A retrospective review of 13 consecutive patients, including 4 adolescents, with CMC1 instability treated with suture-button stabilisation by 2 fellowship-trained hand surgeons between 2018 and 2024 was performed. Mean follow-up was 11.8 months (3-24). Ten patients had chronic instability; 3 had acute traumatic dislocation with persistent instability. Outcomes included visual analog scale (VAS) pain scores, Kapandji scores, key pinch strength, complications, radiographic reduction, and return to work or sport. Results: Seven chronic instability patients had paired quantitative data. Mean VAS decreased by 4.43 points ( P < .001), and mean Kapandji improved by 1.57 points ( P = .042). The remaining 3 chronic instability patients reported improved pain, motion, and function; and achieved full opposition and stability at final follow-up. All acute dislocation patients regained stability, maintained reduction, and achieved full opposition with pain resolution by 12 weeks. Complications included 1 periprosthetic fracture, 1 corticosteroid injection for pain, and an elective button removal. All patients returned to work or sport by 12 weeks, with no fixation failures or recurrent subluxations. Conclusions: Suture-button stabilisation provided reliable restoration of stability, pain relief, and early functional recovery. It may be considered an alternative to ligament reconstruction or Kirschner wire stabilisation in select patients.

Purpose Thumb phalangeal and metacarpal fractures are undergoing surgical intervention more frequently and can be stabilized using a range of modalities. Intramedullary screw (IMS) fixation has become more common in the management of these fractures. Violation of the articular cartilage and the extensor tendon is a concern when IMS fixation is used. The aim of this study was to assess the cartilaginous and soft tissue footprint resulting from retrograde IMS insertion in the proximal phalanx and metacarpal of the thumb. Methods Ten cadaveric thumbs underwent radiographic guided insertion of 2.8, 3.6, and 4.1 mm diameter headless compression screws. The width of the extensor tendon lesion was measured using a ruler, and the surface area of the defect within the articular cartilage using digital processing software. Results The mean footprint in the proximal phalanx following insertion of a 2.8 mm screw involved 15.58% of the extensor tendon width and 2.45% of the articular surface, increasing to 16.19% and 3.73%, respectively, when a 3.6 mm screw was inserted. The mean lesion in the metacarpal when a 3.6 mm screw was used was 14.79% of the extensor tendon width and 2.35% of the articular surface, with 9.29% tendon width and 4.10% articular surface disruption observed with the insertion of a 4.1 mm screw. Conclusions The use of retrograde intramedullary screw fixation in the proximal phalanx and metacarpal of the thumb results in violation of the articular cartilage and terminal extensor tendon that is comparable to prior reports assessing the lesser digits. Clinical relevance This study quantifies the disruption of the articular cartilage and terminal extensor tendon when intramedullary screws are inserted into thumb proximal phalanges and metacarpals in a retrograde fashion and finds comparable results to prior reports assessing the lesser digits. Quantification of articular and extensor tendon defects can be used with clinical outcomes to examine the benefits and detriments of intramedullary fixation of the thumb metacarpal and proximal phalanx.

BACKGROUND:Scaphoid nonunion is a rare but challenging condition in the pediatric population. While acute scaphoid fractures in children typically heal well with cast immobilization, nonunion can result in persistent pain and functional impairment. The medial femoral condyle (MFC) flap offers potential advantages for reconstruction by providing a robust blood supply and structural support. However, its application in skeletally immature patients is limited by concerns over damaging the open distal femoral physis. METHODS:We present 2 cases of skeletally immature patients with scaphoid nonunion treated using modified physeal-sparing MFC osseous flaps. The flap was harvested using a pedicle based on the transverse branch of the descending genicular artery to avoid injury to the distal femoral physis. Intraoperative fluoroscopy guided harvest site selection. The flaps were inset to reconstruct the scaphoid defect and secured with cannulated screw fixation. Postoperative immobilization was followed by staged rehabilitation. Long-term clinical and radiologic outcomes were assessed, including patient-reported outcome measures. RESULTS:Both patients achieved radiologic union confirmed on computed tomography within 3 months postoperatively. Functional outcome scores improved, with QuickDASH scores improving from 31.9 and 36.4 preoperatively to 0 at long-term follow-up of 8.4 and 8.5 years. Both patients returned to pain-free, near-normal wrist function and activities, although heterotopic ossification along the pedicle was noted to limit wrist flexion and radial deviation. No clinical or radiographic evidence of distal femoral physeal arrest or growth disturbance was noted, with preserved knee function on follow-up. CONCLUSION:This series demonstrates the feasibility of a physeal-sparing modified MFC osseous flap based on the transverse branch of the descending genicular artery for select skeletally immature patients with complex scaphoid nonunion. In these 2 cases, the technique avoided distal femoral physeal injury and was associated with union and good long-term wrist and knee function. However, heterotopic ossification, possible hardware-related impingement, and the need for secondary surgery in 1 patient highlight the importance of cautious patient selection and appropriate counseling. LEVELS OF EVIDENCE:Level IV.

BACKGROUND:Bony and soft tissue hand injuries are common and their ensuing management can result in adhesions between tendons and the surrounding bone, soft tissues or inserted hardware. Knowledge of the patterns of motion restriction imparted by different adhesions has implications for rehabilitation protocols following injury or surgery. The aim of this study was to quantify the degree and pattern of digital motion loss due to adhesions at various levels of the flexor apparatus in a cadaveric model. METHODS:Ten cadaveric limbs underwent range of motion assessment of the digits in a standardized fashion. Simulated adhesions were performed by applying suture anchors at the level of the middle phalanx, before subsequently being excised and further adhesions performed at the level of the proximal phalanx. The range of motion of the metacarpophalangeal (MCPJ), proximal (PIPJ) and distal interphalangeal joints (DIPJ) were recorded for each measurement. RESULTS:Following the placement of a simulated adhesion between the flexor digitorum superficialis and FDP tendons at the level of the proximal phalanx, median total flexion reduced by 32.6°, predominantly occurring at the level of the DIPJ. Extension decreased by 9.2°. When a simulated adhesion was placed between the FDP tendon and middle phalanx, median total flexion reduced by 14.4°, predominantly occurring at the DIPJ. Extension decreased by 8.6°. CONCLUSION:Adhesions in the flexor apparatus led to restrictions in both flexion and extension range, with DIPJ flexion being disproportionately affected. Interestingly, adhesions at different locations yielded similar patterns of motion loss, likely secondary to the FDPs substantial role in digital flexion. These findings may inform hypothesis for clinical practice and may assist in the future management of flexor tendon injuries, though must be taken in the context of a cadaveric, FDP dominant model.

Background: Mallet fingers are common injuries with management often being guided by presence of fracture, joint subluxation, chronicity and patient requirements and surgeon preferences. The purpose of this study was to understand current trends of management of mallet finger injuries. Methods: This study surveyed an international group of English-speaking hand surgeons (n = 244) with different types of mallet finger injury patterns to assess current trends and identify any regional variations in practice. Results: Nonoperative management with extension splinting was the preferred treatment for soft tissue (93%) and congruent bony (87%) mallet finger injuries amongst surgeons from all regions. Similarly, most surgeons (76%) preferred operative treatment for incongruent bony injuries. The management of subtle joint subluxation was contentious with 36% recommending splinting and the rest opting for closed reduction and wiring or open reduction. Conclusions: While there is no consensus on treatment, surgeons seem to prefer nonoperative treatment for most soft tissue mallet injuries. Surgeon preference seems to dictate the management of bony mallet injuries especially with incongruent joints. Prospective randomised studies would be beneficial in providing evidence-based guidelines for management of this common injury. Level of Evidence: Level V (Therapeutic).

Wrist arthroplasty is becoming increasingly popular. Metal-on-metal (MOM) articulations have been offered to diminish wear and increase range of motion. This systematic review aims to survey the literature for reports of MOM disease in the setting of wrist arthroplasty, identify patient characteristics that may predispose to its incidence and offer an algorithm for management of such patients. An electronic database search of PubMed, Ovid Medline, Embase and CENTRAL was performed. Studies were included if they were published in English; reported original data following the implantation of a wrist replacement device; and commented on the presence of either intra-capsular metallosis or raised systemic metal ion levels. Studies were graded by the QUADAS-2 tool. Nine studies with 124 patients were identified for inclusion. The mean age was 63 years (range 29–87). Complications included neurological symptoms, wrist pain, loss of range of motion and swelling. Time to revision surgery ranged from 12.5 to 72 months. The arc range of motion ranged from 112 to 140 degrees. MOM disease is seen in patients with a retained arc of motion, particularly in females. A MOM articulation is not recommended when implanting a wrist arthroplasty. Close surveillance utilizing regular clinical, haematological and radiological review should be performed in patients who have previously undergone wrist arthroplasty with MOM articulation. Level of Evidence: V

There is increasing recognition that intimate partner violence (IPV) is a global public health issue (1). In Australia, one in 6 women and one in 17 men experience IPV (2, 3). Musculoskeletal injuries are the second most common pathology suffered due to IPV, and previous studies have reported that as many as 1 in 50 patients present to orthopaedic outpatient clinics as a direct result of IPV (4, 5). Thus, this setting provides a unique opportunity to recognise patients at risk and facilitate intervention. To investigate the perceptions and experiences of Australian orthopaedic clinicians regarding IPV injuries in outpatient clinics, and to identify barriers that prevent the detection of IPV in this setting. Orthopaedic surgeons and registrars were surveyed using a secure online platform distributed via the Australian Orthopaedic Association (AOA) from December 2023 to February 2024. Responses were analysed using Chi-square, Mann-Whitney U and Kruskal-Wallis tests with a 5

Background The emergence of generative artificial intelligence, such as ChatGPT (OpenAI, San Francisco, CA, USA), offers significant potential for improving the delivery of patient information and aiding in clinical decision-making. The aim of this study was to investigate the accuracy and consistency of ChatGPT in providing patient information and answering orthopaedic clinical questions regarding Achilles tendon ruptures. Methods Eight questions regarding Achilles tendon rupture management were presented to ChatGPT twice, resulting in 16 responses. References were requested for all responses. Each response was evaluated for accuracy and consistency, utilising a grading scale ranging from I (comprehensive) to IV (completely incorrect). Final grading was determined through consensus discussions among two orthopaedic registrars and two senior orthopaedic surgeons. Descriptive statistics were performed. Results All of the responses produced by ChatGPT were graded as containing both correct and incorrect information (grade III). Consistency was observed in six out of eight (75%) questions when comparing the two responses for each question. ChatGPT provided 47 references, with 16 out of 47 (34%) correct, 19 out of 47 (40%) incorrect, and 12 out of 47 (26%) fabricated. Conclusion ChatGPT lacks accuracy and consistency in providing information on the management of Achilles tendon ruptures. All patient information and orthopaedic clinical decision-making recommendations contained inaccurate or fabricated information.

BACKGROUND:The financial and resource burden of management of olecranon fractures in the elderly is likely to increase with an aging population. There is limited evidence guiding treatment choice in this cohort. This study aimed to determine whether operative treatment of displaced olecranon fractures in elderly patients provides superior 12-month functional outcomes compared to nonoperative treatment. METHODS:A multicenter pragmatic randomized controlled trial was conducted across 24 hospitals in Australia and New Zealand. Patients aged ≥75 years presenting with an acute (within 14 days), displaced, closed, isolated olecranon fracture were included. Operative treatment involved reduction and stabilization using tension band wiring or plate fixation. Nonoperative treatment consisted of a sling for comfort and early movement as tolerated. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes were the DASH score at 3 months and pain, quality of life, Mayo Elbow Performance Score (MEPS), active elbow range of motion, and complication rate at 3 and 12 months. Data were analyzed based on an intention-to-treat principle, with sensitivity analyses using as-treated groups. RESULTS:Sixty participants were randomized, 27 to the operative group (mean age and standard deviation [SD], 83 ± 5.8 years; 22 [81%] females) and 33 to the nonoperative group (mean age, 82 ± 4.5 years; 23 [70%] females), with no significant difference in baseline characteristics. There was no significant difference (mean difference, -6.6; 95% confidence interval [CI] = -14.9 to 1.8; p = 0.12) in the mean DASH scores at 12 months (the primary outcome) between the operative (12.3 ± 14) and nonoperative (18.9 ± 18) groups. Although active elbow extension was significantly superior in the operative group at 12 months, no other secondary outcome differed significantly between groups at 12 months. CONCLUSIONS:The study found no significant difference in DASH scores at 12 months between the operative and nonoperative groups. This supports nonoperative treatment as a reasonable option for displaced stable olecranon fractures in elderly patients. LEVEL OF EVIDENCE:Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Purpose Clavicular nonunion is an uncommon complication with a significant impact on quality of life and can be difficult to manage. In recalcitrant cases, or situations unfavorable for take of nonvascularized grafts, vascularized osseous reconstruction may be utilized. Several donor sites for such flaps have been described, with each associated with unique benefits and drawbacks. Methods A systematic review utilizing MEDLINE and Embase databases was performed for cases of vascularized bone reconstruction for clavicle nonunion. Results Twenty-six papers met inclusion, comprising 67 patients. Mean age was 43.1 years, across 32 male and 35 female patients. Mean period of nonunion was 43.2 months in the fibular group, 42.0 months in the medial femoral condyle (MFC), and 12 months in the rib flap group. Patients had undergone a mean of 2.67 prior operations at the time of vascularized osseous flap; a proportion of patients had undergone prior locoregional radiotherapy (9/26) or been complicated by infection (12/22). Radiological union was achieved in 95.2% (20/21) of fibular flaps, 95.6% (25/27) of MFC flaps, and 66.7% (2/3) of rib flaps. Mean time to union was 10.6 months for the fibular group, 7.8 months for the MFCs, and 4.0 months for the rib flaps. Complications occurred in 55.6% (20/36) of patients having fibular flaps, 26.1% (6/23) of MFC flaps, and 50% (2/4) of rib flaps. Conclusions All osseous flaps yielded similar and consistent rates of union when used to reconstruct defects of the clavicle. Higher complication rates, particularly donor site morbidity, were noted with fibula and rib flaps when compared to the MFC.

Surgical wound management consisting of careful debridement remains a key principle in the management of open fractures. There remains limited recent literature regarding outcomes of debridement within 24 h compared to within six hours. This study evaluates implementation of the British Association of Plastic and Reconstructive and Aesthetic Surgery/British Orthopaedic Association (BAPRAS/BOA) guidelines on time to debridement of open lower limb fractures and assesses the impact on patient outcomes. Single centre retrospective cohort study evaluating operative management of adult patients with open tibial fractures at a level one trauma centre. Seventy-one patients with 72 open diaphyseal tibial fractures were included. Surgery occurred within six hours in 52.1

We present a case of a femoral head lag screw ‘cold welded’ to an intramedullary nail (IMN) in a female in her 20s during exchange femoral nailing of a subtrochanteric femoral osteotomy non-union. We subsequently developed a reverse spiral-fluted bolt extraction socket, designed to engage the outer wall of a bolt or screw. The lag screw was removed from the Smith and Nephew Meta-Tan IMN, 1 week later, and exchange nailing was successfully completed. This case report describes a technically challenging situation of a cold-welded femoral head lag screw during a complex revision. This report introduces a novel removal device and technique for such cases.

PURPOSE:Phalangeal fractures are undergoing surgical intervention more frequently and can be stabilized via a range of modalities. Intramedullary screw (IMS) fixation has become popular in the management of metacarpal and phalangeal fractures, with promising short- to medium-term results. Violation of articular cartilage and the terminal extensor tendon is a concern when IMS fixation is used in the middle phalanx. The aim of this study was to assess the cartilaginous and soft tissue footprint resulting from retrograde IMS insertion in the middle phalanx. METHODS:Ten cadaveric hands underwent radiographic guided insertion of 1.7 and 2.2 mm diameter headless compression screws. The width of the extensor tendon lesion and the surface area of the surface defect within the articular cartilage were both measured using digital processing software. RESULTS:Using the 1.7 mm screw, the mean lesion involved 12.1% of the width of the extensor tendon and 1.8% of the total articular surface. Using the 2.2 mm screw, the mean lesion involved 20.4% of the width of the extensor tendon and 3.5% of the total articular surface. CONCLUSIONS:The use of retrograde intramedullary screw fixation in the middle phalanx results in minimal violation of the articular cartilage and terminal extensor tendon. CLINICAL RELEVANCE:This study finds minimal disruption of the articular cartilage and terminal extensor tendon when intramedullary screws are inserted into middle phalanges in a retrograde fashion. When combined with promising early- to mid-term clinical outcomes, these findings render intramedullary screw fixation a suitable therapeutic option in this cohort.

Background Arthroscopic dorsal capsuloligamentous reconstruction (ADCLR) has gained popularity in addressing symptomatic scapholunate instability without radiographic malalignment (European Wrist Arthroscopy Society [EWAS] grade IIIB/IIIC/IV).Case Description A midcarpal ultra-wide version of the ADCLR is described, wherein suture needles are directly inserted into the midcarpal joint without prior entry into the radiocarpal joint. A wide "bite" is taken to plicate the dorsal radiocarpal (DRC), dorsal intercarpal (DIC), and dorsal scapholunotriquetral (DSLT) ligaments. An incision is then performed to allow direct visualization suture passage beneath the extensor tendons. A total of 68 consecutive patients received a midcarpal ultra-wide scapholunotriquetral capsulo-ligamentoplasty (MUSCL) between July 2020 and November 2023. Mean follow-up was 8 months (range 2-24 months). The mean pre- and postoperative range of dorsiflexion was 64.54 and 68.32 degrees, respectively ( p = 0.14). The mean preoperative and postoperative range of palmarflexion was 71.89 and 67.18 degrees, respectively ( p = 0.18). A significant improvement of 35.19 points was noted in mean QuickDASH score post-surgery ( p < 0.001).Literature Review Several modifications of the ADCLR exist, including those that take a wider bite incorporating capsule from the mid-carpal joint as well as augmentations with capsuloligamentous imbrications and suture anchor repairs. These approaches yield good pain relief, improved range of motion, and enhanced grip strength when compared with open techniques.Clinical Relevance This technique eliminates the challenging maneuver of passing needles from the radiocarpal joint into the midcarpal joint, offering both procedural simplicity and efficacy, with promising short-term outcomes. Long-term follow-up is necessary.