Pyogenic flexor tenosynovitis (PFT) remains one of the most challenging hand infections, capable of causing undesired subsequent events including severe functional loss and amputation. While Kanavel cardinal signs have historically guided diagnosis, recent evidence suggests they lack the specificity required for modern clinical decision-making. This review evaluates the current landscape of PFT management, comparing the efficacy of conservative antibiotic therapy against surgical intervention. We analyse large-scale data regarding prognosis, highlighting that treatment delays - often driven by cognitive biases such as loss aversion - significantly worsen outcomes. We propose an updated treatment algorithm that incorporates diagnostic aspiration to rule out mimics and mandates a strict 12- to 24-hour limit for conservative trials. Furthermore, we discuss the evolution of surgical techniques from open drainage to closed catheter irrigation and Continuous Local Antibiotic Perfusion (CLAP) for severe cases. Surgeons must view PFT not merely as an infection, but as a 'compartment syndrome' of the tendon sheath requiring urgent decompression to prevent irreversible sequelae. Level of Evidence: Level V (Therapeutic).

Conventional techniques for planning perforator flaps rely on anatomical landmarks and handheld Doppler. Handheld Doppler can be unreliable in localising perforators, with false positive signals from the axial vessel or perforators that terminate in the muscle. Additionally, the loudness of the audible signal on Doppler does not correlate with the presence or size of the perforator. Advanced imaging modalities offer a more accurate tool for preoperative perforator mapping. These include ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Colour Doppler ultrasound (CDU) is available in most operating rooms, with the advantages of no added cost, lack of radiation and no requirement for intravenous contrast. Location and characteristics of perforators can be accurately mapped preoperatively, allowing for rapid and efficient flap harvest. Additionally, accurate preoperative perforator localisation with CDU allows elevation of thin and superthin flaps, which allow a better 'like-for-like' reconstruction in the hand and upper extremity. In this article, the technique of CDU for flap planning is discussed together with illustrative cases. Level of Evidence: Level V (Therapeutic).

Background: Distal scaphoid resection (DSR) with suspensionplasty using the Mini-TightRope™ has not previously been reported for isolated scaphotrapeziotrapezoid (STT) osteoarthritis. The aim of this study is to report outcomes of DSR using the Mini-TightRope™ for STT arthritis. Methods: We retrospectively evaluated four female patients (four wrists; mean age: 71 years) who underwent this procedure between 2018 and 2020, with a mean follow-up of 72 months. Clinical and radiographic outcomes, including pain (visual analogue scale [VAS]), grip strength, DASH-JSSH scores, trapezial subsidence and dorsal intercalated segment instability (DISI), were assessed. Results: The mean VAS improved from 6.0 to 1.0 and the DASH-JSSH score from 59.0 to 19.5. Grip strength was 13.9 kg (97% of the contralateral side), and the trapezial height was well maintained with minimal subsidence. DISI developed in all patients (mean radiolunate angle: 9.3°-32.7°) but remained asymptomatic, and no complications or revisions occurred. Conclusions: This simple, tissue-preserving technique provided satisfactory outcomes for isolated STT osteoarthritis. Level of Evidence: Level IV (Therapeutic).

Background: To describe and validate a novel mixed-reality (MR) navigation system for cup positioning in trapeziometacarpal arthroplasty and to assess its accuracy and reproducibility compared with the conventional freehand technique. Methods: A trackerless holographic navigation software for Microsoft HoloLens 2 was developed to provide real-time holographic feedback of anteversion and inclination during guidewire insertion. Two in vitro studies were performed. First, geometric trapezoidal models (n = 80) were used, in which an orthopaedic resident and an expert hand surgeon inserted Kirschner wires freehand and with navigation. Second, anatomical trapezium bio-models (n = 20) were used, with an expert surgeon performing freehand (n = 10) and navigated (n = 10) insertions. Postoperative CT quantified angular deviation from planned targets. Results were analysed using Student's t-test and Bartlett's test. Results: In geometric models, the pooled total mean absolute error was 6.99° (SD = 4.92°, 95% CI 3.47-10.52) for the freehand technique and 0.65° (SD = 0.26°, 95% CI 0.47-0.84) for MR guidance, with a mean paired difference of 6.34° favouring navigation (p = 0.002). Anteversion and inclination errors were significantly lower, and variability was reduced (Bartlett p < 0.01). No significant differences were observed between operators under MR guidance. In anatomical bio-models, MR guidance significantly reduced the overall mean angular error from 9.10° to 0.68° (p = 0.0004), while both anteversion and inclination errors were also significantly lower than with the conventional freehand technique. Conclusions: In this in vitro study, MR navigation substantially improves the accuracy and reproducibility of guidewire placement for trapeziometacarpal cup positioning compared with the freehand technique, while reducing variability and operator dependence. Clinical studies are required to determine its impact on intraoperative workflow and patient outcomes.

Background: Distal radioulnar joint (DRUJ) instability associated with forearm bone deformity is difficult to treat because residual osseous malalignment may impair forearm rotation even after triangular fibrocartilage complex (TFCC) reconstruction. This study evaluated the clinical usefulness of preoperative three-dimensional (3D) computer simulation and patient-matched instruments (PMIs) for corrective osteotomy in deformity-related DRUJ instability. Methods: Three patients with chronic DRUJ instability associated with forearm bone deformity underwent corrective osteotomy based on 3D computer simulation and PMI-assisted surgery. Preoperative simulation was used to determine osteotomy planes, correction angles, and postoperative forearm rotation. Patient-matched surgical guides and plates were manufactured according to the simulation. Corrective osteotomy was combined with TFCC repair or reconstruction. Clinical outcomes were evaluated based on pain, range of motion, grip strength, redislocation and Modified Mayo Wrist Score (MMWS). Results: Bone union was achieved in all patients within 6 months. Postoperative radiographs demonstrated correction of osseous deformity and reduction of the DRUJ. Forearm rotational limitation improved in all cases with fixed dislocation, and dynamic instability resolved in the remaining case. Wrist pain disappeared in all patients, and grip strength and MMWS improved without major complications. Conclusions: Preoperative 3D computer simulation and PMI-assisted corrective osteotomy enabled accurate restoration of osseous alignment and forearm rotation in deformity-related DRUJ instability. Combining corrective osteotomy with TFCC repair or reconstruction may provide stable and functional outcomes. Level of Evidence: Level IV (Therapeutic).

Wrist arthroscopy is increasingly used for the diagnosis and treatment of wrist pathology. However, the limited joint space and small arthroscopic portals make repeated insertion of instruments challenging and may result in soft-tissue trauma or creation of a false passage. Commercially available cannulas are generally unsuitable for wrist arthroscopy. We describe a simple technique using a segment of tubing from a disposable intravenous infusion set. A longitudinal slot is created in the tube, which is passed through the wrist joint to form a ring-shaped guide between two arthroscopic portals. The slotted design facilitates repeated instrument passage while allowing instruments to disengage from the guide for unrestricted intra-articular manipulation. This is a simple, inexpensive technique that requires no specialised equipment and may facilitate instrument passage during wrist arthroscopy. Level of Evidence: Level V (Therapeutic).

Background: Pulp pinch is the most frequently used grasping pattern amongst two-finger pinches; however, normative data on pulp pinch strength based on a large Japanese population have not been reported. The utility of such normative data would be enhanced by presenting five-grade classifications in addition to the mean and standard deviation (SD). Therefore, the objective of this study was to present normative data and establish sex-specific five-grade classifications for pulp pinch strength in healthy Japanese adults. Methods: A total of 514 healthy Japanese adults (337 men and 177 women) participated in this study. Maximal voluntary pulp pinch strength between the thumb and index finger of both the dominant and nondominant hands, as well as between the thumb and middle finger of the dominant hand, was measured using a muscle strength tester equipped with a pinch force sensor. Based on the deviation score [= 50 + ((measured value - mean) / SD) × 10], pinch strength was classified into five grades as follows: grade 5, deviation score ≥ 65; grade 4, deviation score ≥ 55 and < 65; grade 3, deviation score ≥ 45 and < 55; grade 2, deviation score ≥ 35 and < 45 and grade 1, deviation score < 35. Results: As normative data for pinch strength in healthy Japanese adults, the mean ± SD values of pulp pinch strength for each condition were calculated separately for men and women. Five-grade classifications were established for each pinch condition in men and women. Conclusions: Normative data and sex-specific five-grade classifications for pulp pinch strength in healthy Japanese adults were successfully developed and may serve as normative reference values for assessing patients with hand pathologies and evaluating pinch strength recovery. Level of Evidence: Level III (Diagnostic).

A minimally invasive Oberlin transfer was performed using the da Vinci Xi robot in four patients with upper brachial plexus injury. This technical note describes the technique, detailing patient selection, robotic setup, anaesthesia considerations, port placement and key intraoperative steps. In three of four patients, the procedure was completed in a minimally invasive fashion; one patient required conversion to an open approach due to impaired visualisation from diffuse oozing in a scarred surgical field. Postoperative recovery was uneventful in all patients with no complications or donor morbidity. Although outcome analysis was beyond the scope of this technical note, all patients demonstrated recovery of biceps (Medical Research Council (MRC) grade ≥ 4) at 12-month follow-up. Patients in whom the minimally invasive procedure was completed had shorter scars. Level of Evidence: Level V (Therapeutic).

Background: Large language models (LLMs) like ChatGPT show their potential use in healthcare. However, limited research has been conducted on how effective these models are in hand surgery. Therefore, the purpose of this study is to compare ChatGPT-4, ChatGPT-4o and ChatGPT-o1 across patient education, billing and diagnostic coding in hand surgery. Methods: LLMs were tested using standardised prompts for five common hand conditions: distal radius fractures, trigger finger, carpal tunnel syndrome, cubital tunnel syndrome and ganglion cysts. Three tasks were evaluated: (1) patient education (15 frequently asked questions), (2) CPT code prediction and recognition of a supplied correct CPT code from de-identified operative notes, and (3) ICD-10 code prediction from clinical vignettes (HPI, physical exam and imaging). Readability was assessed using the SMOG Index, Flesch-Kincaid Grade Level and Flesch Reading Ease. Accuracy for billing and diagnostic tasks was measured using F1 scores. Repeated-measures and group-level statistical analyses were performed using Friedman, Wilcoxon signed-rank, Kruskal-Wallis and Dunn tests with Holm-corrected post hoc comparisons, as appropriate. Results: ChatGPT-o1 generated significantly more complex responses than ChatGPT-4 and ChatGPT-4o (adjusted p < 0.001), while responses to surgical questions were significantly more difficult to read than diagnostic questions (SMOG: adjusted p = 0.001; FRE: adjusted p = 0.024). All models achieved near-perfect accuracy in detecting CPT codes. At the three-character ICD category level, ChatGPT-o1 outperformed ChatGPT-4o (adjusted p = 0.001). At the four-character ICD subcategory level, ChatGPT-o1 outperformed both ChatGPT-4 and ChatGPT-4o (adjusted p < 0.001 for both). For exact ICD-10 code prediction, ChatGPT-4o and ChatGPT-o1 both outperformed ChatGPT-4 (adjusted p < 0.001), while ChatGPT-4o and ChatGPT-o1 did not significantly differ (adjusted p = 0.995). Diagnostic accuracy improved with the addition of physical examination and imaging information. Conclusions: Even though LLMs struggled with predicting billing codes and exact ICD-10 codes, they performed better at recognizing supplied correct billing codes and identifying broader diagnostic groupings. All models produced educational content above the recommended reading level. These findings highlight both the promise and limitations of LLMs in hand surgery. Level of Evidence: Level V (Diagnostic).

Background: Ulnar-sided wrist pain (USWP) is a frequent complaint, and triangular fibrocartilage complex (TFCC) injuries are amongst its most common aetiologies. Nonsurgical management of USWP is heterogeneous with variable periods of immobilisation. This study describes the outcome of a structured multiphase, conservative program for USWP that was clinically diagnosed as TFCC injuries in a single centre. Methods: Thirty-two individuals with USWP, foveal tenderness ± distal radio-ulnar joint (DRUJ) laxity diagnosed as TFCC injuries participated in the structured multiphase therapy program from 2020 to 2023 and were followed up prospectively. Assessments included numeric pain rating scale (NPRS), wrist range-of-motion, grip strength, weight-bearing ability, Modified Mayo Wrist Score (MMWS) and Patient-Specific Functional Scale (PSFS). The program comprised 4 weeks of splint immobilisation, 3-4 weeks of dynamic DRUJ stabiliser strengthening and 4 weeks of neuromuscular retraining. Outcomes were reassessed at 3 months and 1 year. Results: Twenty-nine patients were evaluated; 14 completed therapy, 15 defaulted and 21 were reviewed at 1 year. Amongst these 21 patients, mean NPRS decreased by 4 points and PSFS improved significantly. Completers also showed significant improvement in weight-bearing ability and were more likely to achieve excellent/good MMWS at 3 months than defaulters. All completers returned to regular work/activities at 1 year, compared with 9 of 10 contactable defaulters. None required surgery within 1 year. Conclusions: A structured multiphase therapy program for USWP clinically diagnosed as TFCC injury improved pain, function and weight-bearing ability. Completers were more likely to achieve excellent/good MMWS at 3 months, and no patient required surgery within 1 year. Level of Evidence: Level IV (Therapeutic).

In cases of failure of trapeziometacarpal total joint replacements, we have chosen a different strategy than trapeziectomy for high-demand patients (or patients dissatisfied with a contralateral previous trapeziectomy), performing a trapeziometacarpal arthrodesis with an interposed corticocancellous iliac crest graft. This article aims to describe the technique and report our results in three patients. Median age at revision arthrodesis was 60 years. The stems were removed with a dorsal bone-lid, leaving a defect into which the bone graft was fitted and fixed with cortical screws before impaction of the graft into the trapezial remnant with K-wire fixation proximally. Cast immobilisation was used for 8 weeks. At final follow-up, all fusions had healed, and patients were satisfied according to strength measurements and PROMs. While further validation in a larger cohort with longer follow-up is required, we believe the technique may be of value, particularly in high-demand patients. Level of Evidence: Level V (Therapeutic).

Amyloidosis is a disorder characterised by progressive extracellular deposition of misfolded proteins, which can result in significant cardiac and neurologic morbidity. Traditionally, haematologists and cardiologists have served as primary diagnosticians for this disease when patients present with symptomatic systemic disease. However, musculoskeletal manifestations of the disease, such as carpal tunnel syndrome, trigger finger, spontaneous distal biceps tendon rupture and rotator cuff disease, are now recognised to frequently precede cardiac or neurologic involvement by several years. With the recent development of effective disease-modifying therapies, orthopaedic surgeons and hand surgeons in particular may play an increasingly important role in early diagnosis of amyloidosis. Recognition of these associated musculoskeletal conditions presents hand surgeons with a unique opportunity to perform targeted biopsies, allowing for earlier referrals, initiation of disease-modifying therapies and thus potentially stalling a devastating multiorgan disease. Level of Evidence: Level V (Therapeutic).

This technical note describes a reproducible technique for intraoperative assessment and optimisation of Zone II flexor tendon repairs using the Wide-Awake Local Anaesthesia No Tourniquet (WALANT) approach combined with intraoperative Total Active Movement examination (iTAMe). The aim is to provide surgeons with a systematic protocol to evaluate tendon glide, detect gapping and address pulley obstruction in real time, thereby improving repair integrity. The technique involves WALANT solution administration, tendon exposure via Bruner incision, four-strand core suture repair and iTAMe testing. Key steps include troubleshooting algorithms for gapping (suture reinforcement or re-repair) and triggering (pulley venting), complemented by intraoperative patient education (iPE) to enhance compliance. The principal conclusion is that integrating iTAMe into WALANT procedures enables immediate correction of repair flaws, reduces postoperative complications and empowers patients through direct engagement. This method offers a practical framework for surgeons adopting wide-awake tendon repair. Level of Evidence: Level V (Therapeutic).