HAND

Painful digital neuromas are disorganized nerve proliferations that develop following traumatic or iatrogenic digital nerve injury, often resulting in debilitating allodynia, hypersensitivity, and impaired hand function. While conservative therapies such as desensitization, splinting, and pharmacological agents may offer temporary relief, over 50% of patients ultimately require surgical intervention. However, surgical strategies remain highly heterogeneous, and no consensus exists regarding the most effective operative technique.

A comprehensive search of 4 databases through May 2025 identified 30 studies encompassing over 600 adult patients who underwent surgical treatment for digital neuromas. Techniques assessed included neuroma excision with nerve stump transposition, direct end-to-end neurorrhaphy, nerve capping, regenerative peripheral nerve interface (RPNI) surgery, and targeted muscle reinnervation (TMR) surgery.

Excision with transposition relieved pain in up to 80% of cases but demonstrated inconsistent sensory recovery. Neurorrhaphy was associated with superior functional outcomes and a reduced recurrence rate. Nerve capping and polyglycolic acid-collagen conduits significantly improved pain scores and protective sensation. RPNI and TMR surgery, though reported in small series, provided over 80% pain relief with minimal complications. Meta-analysis was precluded by outcome heterogeneity.

Surgical treatment of painful digital neuromas provides meaningful pain relief and functional improvement, particularly when techniques restore physiologic targets for regenerating axons rather than relying on excision alone. Continuity-restoring and reinnervation-based approaches, including neurorrhaphy, nerve capping, RPNI, and TMR, demonstrate favourable outcomes with lower recurrence rates, although comparative evidence remains limited. Standardised outcome measures and higher-quality comparative studies are required to guide optimal, patient-specific surgical decision-making.

Although ulnar nerve cross-sectional area (CSA) can be used to diagnose cubital tunnel syndrome, the predictive value of preoperative CSA for postoperative outcomes remains uncertain. This study’s primary aim was to assess the relationship between preoperative ulnar nerve CSA and postoperative changes in Patient-Reported Outcomes Measurement Information System (PROMIS) scores in the early postoperative period.

A retrospective review was conducted of all cubital tunnel surgeries performed by the senior authors from January 2015 to May 2023. Demographics, preoperative study results, and PROMIS scores were obtained from patient charts. Bivariate and multivariable statistical testing was used to determine statistical significance. After a threshold effect of CSA was observed at 12 weeks post-operation, a Youden analysis was performed to determine the threshold value.

At 12 weeks post-operation, patients with preoperative CSA > 16 mm² had an average change in PROMIS physical function (PF) score of −0.95, which was significantly lower than the 3.41-point improvement experienced by patients with a CSA ≤ 16 mm². Preoperative CSA and postoperative PROMIS scores did not demonstrate a significant linear relationship, either before or after accounting for advanced patient age and type II diabetes mellitus diagnosis.

A preoperative ulnar nerve CSA > 16 mm² was predictive of significantly less improvement in PF at 12 weeks post-operation compared to the progress experienced by patients with smaller ulnar nerve CSA. These findings may aid in preoperative counseling regarding expectations for improvement in hand function during the early postoperative period.

Ultrasound measurement of median nerve cross-sectional area (CSA) is widely used in carpal tunnel syndrome (CTS) diagnosis. This study compared 3 common measurement methods: A-B, Ellipse, and Trace to evaluate their reliability and accuracy.

Two observers (experienced hand surgeon and orthopedic surgery resident) measured median nerve CSA in 10 patients with suspected CTS. Each method was applied in standard and zoom-enhanced views: A-B method (measuring major/minor axes), Ellipse method (fitting ellipse to nerve boundaries), and Trace method (manually tracing nerve boundary). Measurements were compared to ImageJ software analysis as reference standard. Reliability and accuracy were assessed using intraclass correlation coefficients (ICCs), Bland-Altman analysis, and standard detectable difference (SDD).

All methods showed high reliability (ICC: 0.940-0.994) but consistently underestimated CSA compared to ImageJ (12.15 ± 5.13 mm²). The Trace method showed smallest mean difference from ImageJ (−1.26 mm²), followed by A-B (−1.46 mm²) and Ellipse (−1.96 mm²). The Trace method demonstrated highest accuracy without zoom (85.5%) and lowest SDD (1.57 mm²). Interrater reliability was significantly higher in zoom condition for all methods, with Trace method showing highest interrater reliability in both zoom and nonzoom conditions.

All 3 ultrasound methods demonstrated high reliability in measuring median nerve CSA, with Trace method showing modest advantages in accuracy and precision. Zoom enhanced views improved interrater reliability but reduced measurement accuracy. Based on our findings, we recommend nonzoom Trace method for consistent longitudinal measurements, though maintaining proficiency in one selected method is more important. Further validation with larger studies is warranted.

Level 2

Lateral antebrachial cutaneous nerve neuropathy (LABCN) is a known complication following distal biceps tendon repair; however, potential risk factors leading to this are not well described. This retrospective study of distal biceps repairs seeks to determine associations between patient demographics, surgical technique, and injury characteristics associated with postoperative LABCN.

A retrospective chart review was performed on 275 patients with partial- or full-thickness biceps tendon ruptures who underwent operative repair. Patient characteristics were recorded including utilization of tobacco, alcohol, age, and body mass index, along with surgical factors including tourniquet time, approach, prior shoulder surgery, and tendon repair techniques. Lateral antebrachial cutaneous nerve neuropathy was identified by description of “numbness, tingling, burning, or decreased sensation” at postoperative visits. Chi-square and t tests were used to analyze differences in LABCN development rate for the listed variables.

Sixty-three of 275 (22.9%) patients were identified as having some form of LABCN postoperatively. Age, body mass index, and tourniquet time were not correlated with LABCN (P > .05). The 2-incision technique and the use of corkscrew anchor fixation correlated with lower LABCN rates (P < .05). Chronic biceps rupture, partial thickness tear, and history of prior ipsilateral shoulder surgery correlated with higher LABCN rates (P > .05).

Multiple factors affect the risk of LABCN after distal biceps repair. Patient-related factors do not appear to be associated with increased risk, except in cases where patients have a history of shoulder surgery or chronic distal biceps rupture. Surgical factors such as approach and method of tendon fixation demonstrate differences in the rate of postoperative LABCN.

Thumb carpometacarpal (CMC) joint osteoarthritis is a debilitating degenerative condition that primarily afflicts older adults. Traditional surgical interventions are effective but require prolonged recovery and potential loss of strength. Carpometacarpal joint denervation has emerged as an alternative due to its minimal recovery time and low morbidity. However, its conversion rate to arthroplasty and ideal patient selection criteria remain unclear.

We retrospectively reviewed patients undergoing thumb CMC joint denervation from January 2019 to November 2023, excluding those with concurrent procedures or follow-up shorter than 6 months. We collected and analyzed demographic and clinical data, with primary functional outcomes assessed via Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. Statistical analyses included Wilcoxon signed-rank tests for preoperative and postoperative comparisons and assessments of factors associated with achieving minimal clinically important difference (MCID).

Among 37 patients (mean age 56.4 ± 11.3 years, 70.3% female), 20 had complete preoperative and postoperative QuickDASH data. The median follow-up was 1.1 years. Although median QuickDASH scores improved from 39.8 to 14.8, the difference was not statistically significant (P = .073). Younger age (52.9 vs 63.8 years, P = .015) and dominant hand surgery (80% vs 20%, P = .023) were significantly associated with achieving MCID. Common complications included transient paresthesia (21.6%) and conversion to arthroplasty (13.5%).

Thumb CMC joint denervation provides greater benefit for younger patients and those undergoing surgery on their dominant hand. The favorable complication profile and low conversion to arthroplasty support the role of denervation in the treatment algorithm for first CMC osteoarthritis.

We hypothesized that hyperextension metacarpophalangeal (MP) thumb deformity may be caused by trapeziectomy alone due to telescoping of the first metacarpal without trapezial support.

To explore the relationship of trapeziectomy with hyperextension thumb MP joint deformity and contribute novel data on the underlying pathomechanics.

This basic anatomical research study examined thumb MP joint kinematics at 6 surgical stages in 10 cadaveric specimens: stage 1, baseline; 2, volar plate of the thumb MP joint division; 3, trapeziectomy; 4, Weilby’s ligament reconstruction and tendon interposition (LRTI); 5, extensor pollicis brevis (EPB) tenotomy; and 6, MP volar plate reconstruction by tenodesis with EPB. Six infrared cameras were used in a motion capture system to determine three-dimensional angles of the first MP joint during 10 cycles of thumb flexion-extension, measuring angles in maximum flexion and extension and the complete flexion-extension arc.

In comparison to baseline, the angle in extension and MP-ROM were significantly increased after stages 3 (trapezium extraction), 4 (LRTI), and 5 (EPB tenotomy). In comparison to values after stages 3, 4, and 5, the hyperextension was significantly corrected after stage 6 (tenodesis).

In a cadaveric model of trapeziectomy, secondary thumb column shortening favors an MP joint hyperextension deformity that is not corrected by LRTI or EPB tenotomy and requires a stabilization procedure.

Trapeziectomy with suture button suspensionplasty (SBS) is a common treatment for thumb carpometacarpal (CMC) osteoarthritis. This study aimed to evaluate the effect of bone tunnel configuration and suture count on the construct stability.

Twelve matched specimens underwent trapeziectomy and randomization to either a 2-strand 1-tunnel (single SBS) or divergent 4-strand 2-tunnel suture button (crossed dual SBS) construct. Mechanical stiffness was measured using material testing machine with a semiconstrained axial load over 5-mm displacement. Trapezial space was measured under no load and in a light and heavy physiologic pinch grip models. Subsequently, specimens were randomized to undergo single SBS or divergent 2-strand 2-tunnel suture (crossed suture) constructs, and loaded pinch testing was performed. Primary outcomes were analyzed using matched-pair t-tests.

The crossed dual SBS construct showed significantly higher stiffness compared to the single SBS construct in elastic deformation (19.9 vs 15.5 N/mm, P = .010) and maintained trapezial height better in both light (82% vs 71%, P = .021) and heavy (73% vs 46%, p = .004) pinch grips. The crossed suture technique also preserved trapezial height better than the single SBS construct in light (79% vs 64%, P = 0.021) and heavy (60% vs 44%, P = 0.039) pinch grips.

In the immediate postoperative period, a crossed dual SBS construct was stiffer to axial load and more stable in pinch grip compared to a single SBS construct. The novel crossed suture construct better preserved trapezial height then the singe SBS, suggesting that the crossed configuration may be more relevant than suture count in postoperative stability.

Traditional surgical management of trapeziometacarpal (TMC) joint destruction in rheumatoid arthritis involves trapezial resection with tendon interposition. The poly-l-d-lactide RegJoint (Scaffdex, Tampere, Finland) implant offers an alternative with promising short-term results in rheumatoid patients.

This study reports long-term outcomes from a randomized controlled trial comparing partial trapeziectomy with the RegJoint versus tendon interposition TMC arthroplasties in patients with inflammatory arthritis, including seropositive and juvenile rheumatoid arthritis, as well as a few cases of other inflammatory arthritis. A total of 13 patients with the RegJoint implant and 8 with tendon interposition completed a mean follow-up of 14.9 years.

At final follow-up, no significant differences were found between the groups in pain, function (measured by visual analog scores), strength, or overall functional ability. However, both groups experienced a significant decrease in grip strength compared with preoperative and 2-year follow-up data, with the RegJoint group also reporting increased pain.

Both RegJoint implant and tendon interposition provided comparable long-term outcomes for TMC arthroplasty in this small cohort of patients with inflammatory arthritis. Further studies are needed to confirm these findings.

Carpometacarpal (CMC) arthroplasty can provide symptomatic relief and improvement in function in patients with CMC osteoarthritis. The study purpose was to identify demographic, 30-day outcome, and reimbursement trends in CMC arthroplasty between 2012 and 2021.

This was a retrospective cohort study of adult patients undergoing CMC arthroplasty from January 1, 2012, to December 31, 2021, using the National Surgical Quality Improvement Program database. Patients were stratified based on year of index surgery: 2012-2015, 2016-2018, and 2019-2021. Baseline characteristics were collected and compared using the appropriate statistical test. Multivariable logistic regressions controlling for age and sex were performed to identify independent risk factors for 30-day morbidity, readmissions, and reoperations. Economic analyses assessed changes in reimbursement rates over the span of 10 years.

A total of 9046 patients were included in the analysis with mean age of 62.7 ± 9.2 and women comprising 74.9% of the total population. Between 2012 and 2021, the annual volume increased from 433 to 1043. The average body mass index (BMI) and proportion of patients with congestive heart failure (CHF) increased in 2019-2021. Increasing age, BMI, smoking, and length of stay ≥ 1 day were independent risk factors for 30-day readmissions. The Medicare reimbursement fee decreased by an average of 1.15% annually, for a total of 9.90% across 10 years.

The volume of CMC arthroplasty has risen from 2012 to 2021. However, conditions such as obesity and CHF have become more prevalent. Despite the growing patient complexity, Medicare reimbursement fees have markedly decreased.

Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common source of hand pain with limited nonoperative treatment options. Pulsed electromagnetic field (PEMF) therapy has been recently shown in studies to be effective in providing sustained pain relief in knee osteoarthritis. This study aimed to assess the efficacy of PEMF therapy for treating thumb CMC OA pain.

This single-center, double-blind, randomized controlled trial included adults with radiographically and/or clinically diagnosed CMC OA who reported an average Numeric Pain Rating Scale (NPRS) score between 3 and 8. Participants were randomized to either a PEMF device or an identical sham device that was used for 8 hours each night for 4 weeks. The primary outcome measure was the change in average daily NPRS from baseline to 4 weeks. Secondary outcome measures included Patient-Rated Wrist/Hand Evaluation (PRWHE) and Single Assessment Numeric Evaluation at 4 and 6 weeks.

Sixty-one participants were recruited, and 51 participants completed the study at 4 weeks. Both the PEMF therapy and sham device groups showed improvements in average NPRS and PRWHE at 4 weeks, but there was not a significant improvement between groups. At 6 weeks, there was a significantly greater change in average NPRS from baseline in the PEMF therapy group compared with the sham device group (P = .02).

Pulsed electromagnetic field therapy may improve thumb CMC OA pain with sustained relief beyond the treatment period. Future studies will need to assess if adjusting treatment duration or other factors can enhance its efficacy.

Two of the most prevalent techniques for tendon transfer are Pulvertaft weave (PTW) and side-to-side (STS) constructs. Our purpose was to compare pooled results from reported biomechanical properties of these approaches by a meta-analysis. Our null hypothesis was there are no significant differences in load to failure (LTF), initial construct stiffness, or cross-sectional area (CSA) between these techniques.

We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify candidate studies. We included studies with direct LTF comparisons of PTW and STS constructs. We performed a meta-analysis of pooled data comparing the 2 techniques for initial construct LTF (N), stiffness (N/mm), and CSA (mm²).

Eight studies with a total of 235 tested human or porcine tendon reconstruction constructs (107 PTW, 128 STS) met our inclusion criteria. Eight studies reported initial construct LTF, with weighted mean values of 103 (±36) and 198 (±61) N for the PTW and STS groups, respectively (P < .05). Four studies reported initial construct stiffness, with weighted mean values of 16 (±4) and 34 (±16) N/mm for the PTW and STS groups, respectively (P < .05). Five studies evaluated initial transfer bulk as measured by CSA, with weighted mean values of 28 (±14) and 29 (±13) mm² for the PTW and STS groups, respectively (P > .05).

Our meta-analysis demonstrated significant increased initial construct LTF and stiffness with STS tendon coaptation as compared with PTW. We found no difference for initial CSA between the 2 techniques.

The flexor digitorum superficialis of the little finger (FDS-small) exhibits anatomical variation, with absence reported in 2% to 30% of individuals. As FDS is the only flexor of the proximal interphalangeal joint (PIPJ), its absence may affect finger dexterity, particularly in professional musicians who depend on precise finger control. This study evaluates the impact of FDS-small presence or absence on the technical abilities of pianists and string musicians using novel dynamic assessment tools.

Thirty-one Bachelor of Music students (21 string players, 10 pianists) were assessed for FDS-small function and classified as “independent,” “common,” or “absent.” Tests included grip strength, static gap, and stretch tests, and a novel assessment method comprising custom-composed double-stop trill etudes for piano and strings. Technical performance was evaluated by 2 professional musicians using predefined criteria. Statistical analyses were conducted using Fisher’s exact tests, t tests, analysis of variance, and nonparametric equivalents.

Ten participants had absent FDS-small function in at least 1 hand. Pianists with bilateral absent FDS-small demonstrated superior coordination and regularity compared with those with FDS-small presence, while FDS-small absence did not significantly affect string players. Female pianists excelled in dynamic tests despite male musicians’ higher grip strength and trill speed.

Absence of FDS-small does not impair, and may even enhance, fine motor performance in pianists. For string musicians, FDS-small status does not influence technique. These findings may contribute to evaluating the risk versus benefits of FDS-small surgical repair and have implications for instrument selection and pedagogy.

The use of large language models (LLMs) such as ChatGPT and Gemini in clinical settings has surged, presenting potential benefits in reducing administrative workload and enhancing patient communication. However, concerns about the clinical accuracy of these tools persist. This study evaluated the concordance of ChatGPT and Gemini’s recommendations with American Academy of Orthopedic Surgeons (AAOS) clinical practice guidelines (CPGs) for carpal tunnel syndrome, distal radius fractures, and glenohumeral joint osteoarthritis.

ChatGPT (version 4o) and Gemini (version 1.5 Flash) were queried using structured text-based prompts aligned with AAOS CPGs. The LLMs’ outputs were analyzed by blinded reviewers to determine concordance with the guidelines. Concordance rates were compared across models, topics, and guideline strength using descriptive statistics and McNemar’s test. The transparency of responses, including source citation, was also assessed.

A total of 174 recommendations were generated, with an overall concordance rate of 62.1%. When comparing concordance rates between LLMs, there was no statistically significant difference between ChatGPT and Gemini (66.7% vs 57.5%, P = .131). Concordance varied by topic and guideline strength, with ChatGPT performing best for moderately supported guidelines. Both models demonstrated low citation transparency. Gemini provided sources for 39.1% of recommendations, significantly more than ChatGPT’s 3.5% (P < .0001).

Despite modest concordance rates, both models exhibited significant limitations, including variability across topics and guideline strengths, as well as insufficient citation transparency. These findings highlight the challenges in integrating LLMs into clinical practice and emphasize the need for further refinement and evaluation before adoption in hand surgery.

Presently, there is no consensus within the field of orthopedics on whether irrigation prior to wound closure in routine upper-extremity surgery reduces wound complications. Therefore, preclosure wound irrigation could provide time and cost savings. The aim of this study was to evaluate the effectiveness of wound irrigation in routine upper-extremity procedures.

We conducted a retrospective review of adult patients undergoing routine upper-extremity surgery at a single institution from 2013 to 2022. Patients were included if they underwent soft tissue upper extremity surgery. Patients were excluded for having concomitant lacerations, penetrating injuries, open fractures, or unknown irrigation technique. Our primary outcome was comparison of the rate of wound complications based on whether irrigation was used. Multivariable logistic regression was additionally used to determine whether irrigation prior to closure was associated with a lower incidence of postoperative wound complications independent of potential confounders.

We included 1425 patients. The mean age was 55.2 ± 16 years and 65% were female. The incision was irrigated prior to closure in 65% of surgeries. Wound complications occurred in 2.9% of patients (n = 41). On bivariable analysis, irrigation prior to closure was not associated with a decreased incidence of wound complications (3.5% vs 1.8%, P = .070). When adjusting for age, sex, BMI, operative time, history of prior surgery, diabetes, tobacco use, corticosteroid use, and immunosuppressant use, the employment of irrigation prior to wound closure was not associated with lower odds of wound complications in either bivariable (OR: 1.99, 95% CI 0.94-4.19, P = .07) or multivariable (OR: 1.88, 95% CI 0.88-4.04, P = .08) analysis.

Use of irrigation prior to wound closure was not associated with a difference in the odds of postoperative wound complications. Surgeons should consider forgoing irrigation prior to closure to increase operating room efficiency and provide cost savings to the patients and payers.

Upper limb orthopedic surgery has no standardized complication classification system. The adaptations in the Clavien-Dindo classification system have only been validated through the creation of scenarios. We hypothesized that the modified Clavien-Dindo-Sink (CDS) classification of hand and upper extremity surgery complications has good intraobserver and interobserver reliability in real-world scenarios. This study assessed the accuracy of the modified CDS classification in real-world scenarios and the absolute incidence of 30-day complications.

The sample size calculation was based on the modified CDS classification. A kappa value of 0.84, accompanied by a 95% confidence interval (CI) of 0.1 and involving 6 observers, indicated the inclusion of 111 events. To achieve the anticipated sample size of 111 complications, 1850 postoperative procedures will be necessary, given the expected 6% incidence of complications. Six evaluators, each with varying levels of expertise in the field, classified the cases according to the modified CDS classification in 2 rounds.

The incidence of early complications was 7.05% (95% CI = 6%-8%) in a tertiary care university hospital. Intraobserver agreement was moderate to almost perfect; however, interobserver agreement was moderate. The less experienced surgeons presented a better interobserver correlation than the more experienced ones.

In a real-world scenario of early postoperative complications of upper extremity surgery, the modified CDS classification presented a lower interobserver correlation than reported in the literature. The surgeon’s experience could influence its applicability.

Upper extremity (UE) injuries, ranging from the clavicle to the fingertips, are prevalent in ice hockey. Despite hockey’s growing popularity, comprehensive epidemiological data on UE injuries are limited. This study analyzes patterns of acute hockey-related UE injuries among young players in the United States, focusing on age-specific and sex-specific injury distributions.

The National Electronic Injury Surveillance System was analyzed for ice hockey–related injuries among patients aged 5 to 24 years from 2006 to 2023. Injuries were classified by patient demographics and anatomical region. Logistic regression models analyzed the association between injury patterns and predictive variables of interest (P < .05).

Of 258 302 estimated ice hockey–related injuries, 91 889 (35.57%) involved the UE. The shoulder (clavicle, scapula, proximal humerus) was the most common site of UE injuries (40.73%), followed by the wrist (19.55%) and then digits (11.23%). Fractures were the predominant injury type (35.85%). Youth players (5-13 years) had higher odds of fractures (odds ratio [OR] = 1.78) compared with other age groups. College-aged players (19-24 years) were more prone to dislocations (OR = 3.52). Males had higher odds of shoulder dislocations (OR = 6.55) and shoulder injuries overall (OR = 1.70), whereas females had higher odds of wrist injuries (OR = 1.92) and wrist strains or sprains (OR = 2.92).

This comprehensive analysis of UE injuries in ice hockey athletes highlights the significant burden of these injuries and identifies important patterns related to injury types, anatomical locations, and demographic factors. These findings provide a foundation for developing targeted injury prevention strategies and improving player safety in ice hockey.

Hand surgeons are increasingly asked to assign American Society of Anesthesiologists (ASA) physical status classifications for local anesthesia–only procedures despite minimal training. Artificial intelligence (AI) is a powerful tool that could assist in ASA class assignment. We evaluated the concordance/agreement between surgeon-rated and AI-rated ASA class.

Local anesthesia–only hand surgical episodes (n = 236) performed by 4 fellowship-trained hand surgeons at ambulatory surgery centers were included. We used ChatGPT to estimate ASA class–based patient medical history. Interrater agreement between surgeon and AI ratings were compared with the weighted Cohen κ. The most recent anesthesia-rated ASA class from another anesthesia event was also recorded (if present) and compared. We used multivariable logistic regression models to evaluate whether patient factors were associated with concordance. We also recorded 30-day postoperative emergency department visits and hospitalizations.

Overall concordance between surgeon and AI ratings was 56%. In 72% of discordant cases, surgeon-rated ASA class was lower than the AI rating. Surgeon-rated ASA class exhibited fair agreement with the AI rating (κ = 0.38). Artificial intelligence–rated ASA class exhibited moderate agreement with prior anesthesia-rated ASA class (κ = 0.44). In the multivariable model, age, sex, and presence of a prior anesthesia-rated ASA class were not associated with concordance between surgeon and AI ratings. Postoperative emergency department visits or hospitalization occurred in 7 (3%) patients, for which surgeon-rated ASA class was lower than AI rating in 4 cases.

Generative AI could be used as a tool to support ASA class assignment for local anesthesia–only hand surgeries.