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Hand Surgical Procedures

Hand surgical procedures: overview of arthroplasty, tendon transfers, osteotomies, and reconstruction for trauma, neuropathy, and congenital conditions.

Overview

Hand surgery encompasses a broad spectrum of elective procedures where outcome measurement and safety are paramount. Recent data identify 99 minimal important differences across 29 articles covering various conditions, treatments, and follow-up periods [2]. While the quantity of randomized controlled trials has increased over time, their methodological quality remains low with a mean Jadad score of 2.1 [24]. Observational Health Data Science and Informatics (OHDSI) offers a pathway to expand knowledge regarding outcomes, medication management, risk factors, rare complications, and device performance [1]. New measures in the field must now consider patient safety, clinical efficacy, cost effectiveness, and environmental impact [22].

Complication rates and management strategies are critical for surgical planning. Reoperations and/or unplanned admissions within 30 days after elective hand surgery occur at a rate of 15 per 10,000 cases [9], with infections accounting for 63.0% of these events [9]. Anesthesia selection varies by procedure; intravenous regional anesthesia using a forearm tourniquet should be considered for outpatient hand procedures [6], while Wide Awake Local Anesthesia No Tourniquet (WALANT) is generally well tolerated with excellent surgical outcomes [23]. For Zone II flexor tendon repair, surgeons can be confident in choosing either general anesthesia or WALANT if rigorous patient selection, sound surgical technique, and proper hand therapy are employed [26]. Further research is warranted to determine the appropriateness of distal peripheral nerve blocks in the forearm for patients undergoing surgery in the thumb or proximal to the hand [13].

Emerging and complex indications require specific attention. Hand transplantation is the most common form of modern composite tissue allotransplantation, with success depending on proper patient selection, technical success, rehabilitation, and immunotherapy protocols that prevent rejection while minimizing morbidity [25]. Rheumatoid hand operations require more detailed study to clarify indications and outcomes to allow consistent advice from all members of the multidisciplinary team [29]. The safety of performing elective hand surgery during the pandemic remains unclear, necessitating more studies with larger samples to clarify this issue [28].

Anatomy & Pathophysiology

Osseous and Articular Integrity

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [33]. Management of hand fractures involves balancing the prevention of stiffness through early motion with the avoidance of deformity via adequate reduction and stabilization [75]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [37]. In Wassel type IV duplications, a normal functioning interphalangeal joint cannot be provided if the abnormality is marked [10]. Regarding thumb-in-palm deformity in cerebral palsy, there were no significant differences in the motion range of the thumb after different EPL rerouting techniques or sites of insertion [80].

Kinematics and Functional Mechanics

The dominant hand is stronger than the nondominant hand [50], yet no difference exists in the three hand strength measurements made under the same conditions between hands [50]. Index finger proximal interphalangeal joint fusion impairs the kinematics of precision pinch [53]. Positioning the middle finger distal interphalangeal joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity [77]. Active and passive intrinsic reconstruction methods improved basic grasp and release kinematics in experimental cadaver hand models [45]. Following extensor indicis proprius tendon transfer for extensor pollicis longus tendon rupture, extension strengths of the thumb and index finger of the operated hand were approximately 20% lower compared to the contralateral hand [74].

Tendon and Soft Tissue Dynamics

Routing of the extensor pollicis longus (EPL) tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm [67]. Radial transposition of the EPL tendon enhances extension of the thumb regardless of whether the tendon is routed through or superficial to the first extensor compartment [69]. At the time of repair, decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction [70]. Modifying the core suture configurations in flexor tendon repairs is common among Finnish hand surgeons, although this does not seem to compromise the biomechanical competence of the repairs [79].

Prosthetics and Sensory Goals

The use of a proximity sensor in a novel prosthesis for upper extremity phocomelia eliminates the need for forceful movements of the residual finger to use mechanical switches or levers [61]. Mechanical solutions to minimize force required at the wrist to activate grip are still required for 3D-printed custom-designed prostheses for partial hand amputation [64]. Sensation constitutes 40% of the goal in thumb or fingertip repair, while length and appearance account for 50% [83].

Classification and Assessment

The modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis was more strongly correlated with hand function than the original classification [31].

Classification

Modified Terrono: A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis detects advanced deformity earlier and demonstrates a stronger correlation with hand function [31].

Modified Radial Polydactyly: A modified classification system for radial polydactyly, which includes triphalangeal thumb and triplication, is proposed as a practical and utilitarian scheme for nomenclature to assist in the comparison of treatment outcomes and individual cases [48].

Clinical Presentation

Hand and wrist conditions represent approximately one in ten referrals to orthopaedic services, with nearly half of these patients requiring surgical intervention [19]. The specialty in Europe evolved through anatomical discoveries and technological advances, establishing the hand as a distinct organ requiring specialized care [3]. While observational health data science can expand knowledge regarding outcomes and rare complications [1], more well-organized outcome studies are required to standardize evaluation [21]. Familiarity with ultrasound provides a versatile tool for evaluating upper extremity disorders [20], though the use of pre-referral advanced diagnostic tests is associated with increased time to see a hand surgeon [38].

Acute Injury and Infection

Percutaneous elastic intramedullary nailing of metacarpal fractures results in good hand function with few complications [4]. Intravenous regional anesthesia using a forearm tourniquet is a safe and effective technique for outpatient procedures [6]. Prompt diagnosis and early treatment with broad-spectrum intravenous antibiotics and surgical irrigation and debridement are essential to avoid complications and preserve function in pyogenic flexor tenosynovitis [39]; however, severe infection can still lead to impaired function or amputation despite treatment [39]. Early surgical management may be considered for hand lesions of myositis ossificans with prominent symptoms [16].

Chronic Deformity and Arthropathy

Hand surgery principles emphasize the balance between restoring function and maintaining aesthetic appearance [40]. Thumb deformities in rheumatoid arthritis are common and significantly compromise function [41]. Treatment is directed by the specific deformity type and joint involvement [41]: Nonsurgical management is indicated for early stages, while Surgical reconstruction or salvage is indicated for advanced disease [41]. In Wassel type IV duplications, surgeons must address all patho-anatomic features to achieve the best possible result, though a normal functioning interphalangeal joint cannot be provided if the abnormality is marked [10]. Ray resection results in good cosmetic and functional outcomes when preservation of a functional digit is unattainable or when an abnormal, unreconstructable digit interferes with overall hand function [5].

Outcomes, Complications, and Revision

Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent, occurring at a rate of 15 per 10,000 cases [9]. Infections are the most common cause of these events, accounting for 63.0% of cases [9]. Risk of disease progression and expectations following hand reconstruction in Hirayama disease must be managed carefully [8]. Consensus recommendations for six common revision scenarios after trapeziectomy were established using a rigorous Delphi process involving experienced hand surgeons worldwide [7]. While some types of hand surgery may be done outside the operating theatre without increasing infection risk, the quality of this evidence is poor [18]. Statistical heterogeneity in published meta-analyses in hand surgery may be caused by clinical or methodological differences and is often inadequately investigated [17]. A total of 99 minimal important differences were identified across 29 articles covering various conditions, treatments, outcome measures, and follow-up periods in elective hand surgery [2].

Investigations

Plain radiography: Accurate diagnosis and management of hand and carpal fractures and dislocations require appropriate imaging to limit joint stiffness while preserving mobility and function [33]. Radiographic deformity in distal radius fractures does not necessarily correlate with worse functional outcomes, particularly in patients over 60 years of age [93]. MRI is useful for subclassifying Wassel Type IV duplicated thumbs and aids in planning the osteotomies required for their reconstruction [87].

MRI: In cases of diagnostic uncertainty regarding hand infection, MRI may help identify and localise collections to guide drainage and debridement [72].

Other Considerations: Ray resection yields good cosmetic and functional outcomes when preservation of a functional digit is unattainable or when an abnormal, unreconstructable digit interferes with overall hand function [5]. A normal functioning interphalangeal joint cannot be provided if the abnormality in Wassel type IV duplications is marked, even when all patho-anatomic features are addressed [10]. Clinical and radiological measurements confirm the efficacy of an axial flap in increasing the volume and girth of reconstructed Wassel IV thumbs [76]. The oblique wedge osteotomy of the metacarpal condyle effectively restores bony alignment of the thumb and preserves vascularity of the retained condyle in older children and adults with Wassel type IV thumb duplication [91]. Nonvascularized autogenous bone grafting can restore good hand function in severe injuries with substantial phalangeal bone loss [37]. A suture-button device technique allows for gap closure and rotational control during central metacarpal ray resection, even with inadequate soft tissue structures, providing good hand function without nonunion or malunion [88]. The 2–Extension Block Technique (Dorsal Counterforce Technique) for irreducible mallet finger fractures achieves anatomical reduction more easily with good radiological and clinical outcomes and few complications [89]. In most cases of thumb in the plane of the hand, the thumb has the potential to act in opposition, indicating that reconstruction of the first web space is worth considering as an initial procedure [90]. Thumb reconstruction without formal pollicization is an acceptable option for mirror hand deformity [92]. The pre-operative assessment and intraoperative findings of all thumb elements should be considered in surgical decision-making to define methods of reconstruction for hypoplastic thumbs [82]. Familiarity with ultrasound provides the hand surgeon with a convenient and versatile tool to assist in the evaluation and treatment of hand and upper extremity disorders [20]. Consensus recommendations for six common revision scenarios after trapeziectomy were established using a rigorous Delphi process involving experienced hand surgeons worldwide [7]. Risk of disease progression and expectations following hand reconstruction in Hirayama disease must be managed carefully [8]. Approximately one of every ten patients referred for orthopaedic services has a hand or wrist condition, and nearly half of these patients will require surgery [19]. Further research is warranted to determine the appropriateness of distal peripheral nerve blocks in the forearm for patients undergoing surgery in the thumb or proximal to the hand [13]. More well-organized outcome studies are required to show the right way in hand surgery [21].

Treatment

Non-Operative

Non-surgical management for thumb base osteoarthritis provides clinically worthwhile improvements in pain and function, with a stepwise approach recommended starting with self-management, followed by splints and injections if symptoms persist [66]. Non-surgical management was also successful in a case of avascular necrosis of the sesamoid bone, requiring no further treatment [81]. For myositis ossificans, literature review supports early surgical management only for hand lesions with prominent symptoms [16].

Operative

Indications: Surgical intervention is indicated for patients with thumb carpometacarpal arthritis and Ehlers-Danlos Syndrome who have pain refractory to conservative therapy [65]. Early surgery is also warranted for hand lesions with prominent symptoms in cases of myositis ossificans [16]. Hand transplantation is the most common form of modern composite tissue allotransplantation, with success depending on proper patient selection [25].

Surgical Approach / Technique: Wide Awake Local Anesthesia No Tourniquet (WALANT) hand surgery is generally well tolerated with excellent surgical outcomes [23]. Intravenous regional anesthesia using a forearm tourniquet is a safe and effective technique for outpatient hand procedures and should be considered for use in this setting [6]. Surgeons can be confident in choosing either general anesthesia or wide awake local anesthesia for zone II flexor tendon repair if rigorous patient selection, sound surgical technique, and proper hand therapy are employed [26]. Percutaneous release is a safe procedure for the thumb, index, middle, and ring fingers as long as the recommended technique is observed [63]. All incision techniques for trigger thumb release demonstrated improvement in self-reported hand function, pain, and aesthetics with no differences between the techniques [46].

Implant Selection: The Arpe implant for trapeziometacarpal total joint arthroplasty has an acceptable long-term survival rate and restores good hand function in patients with osteoarthritis [11]. Swanson silastic interposition arthroplasty in revision thumb-base surgery for failed trapeziectomy found good medium-term results and high satisfaction rates, advocating the technique as an effective treatment option when other treatable causes of poor outcome are excluded [43].

Pain Management: Further research is warranted to determine the appropriateness of distal peripheral nerve blocks in the forearm as an alternative to proximal brachial plexus blockade for patients undergoing surgery in the thumb or proximal to the hand [13].

Adjuncts: There is no convincing evidence to support routine prophylactic antibiotics for all elective hand surgery cases [49]. Prophylactic antibiotics are recommended for elective hand surgery patients with preexisting major diseases, those on steroids, or those with hardware such as K-wires or implants [49].

Setting of Care: Postoperative hand treatment in children with recessive dystrophic epidermolysis bullosa requires careful consideration of pros and cons by the medical team and patients, emphasizing the importance of long-term, disciplined postoperative treatment [12]. After surgery and hand therapy for Dupuytren contracture, disability decreased independent of whether single or multiple fingers were operated on [44]. Patient factors associated with not using hand therapy following digital flexor tendon repair suggest that more uniform clinical practice should be sought [86].

Revision: Swanson silastic interposition arthroplasty in revision thumb-base surgery for failed trapeziectomy found good medium-term results and high satisfaction rates, advocating the technique as an effective treatment option when other treatable causes of poor outcome are excluded [43].

Other Considerations: Published clinical results for the contralateral C7 transfer demonstrate significant improvements in upper limb function, confirming the procedure's safety and efficacy with typically mild and transient donor site morbidity [42]. Although the Krukenberg procedure is considered obsolete by many surgeons due to appearance, non-medical people do not consider the unattractive appearance to outweigh the functional outcome [78]. Surgeons may consider continuing warfarin anticoagulation during hand surgery in patients with a raised International Normalized Ratio, as problems can likely be managed non-operatively [71]. Rheumatoid hand operations require more detailed study to clarify indications and outcomes to allow consistent advice from the multidisciplinary team [29]. Advancements in surgical and therapy management for Dupuytren's disease include indications, surgical options, non-surgical techniques, and therapy interventions to assist in linking patient-specific problems to appropriate treatment choices [73]. Hand transplantation is the most common form of modern composite tissue allotransplantation, with success depending on proper patient selection, technical success, rehabilitation, and immunotherapy protocols [25]. New measures in hand surgery should consider patient safety, clinical efficacy, cost effectiveness, and environmental impact to achieve carbon neutrality [22]. Observational Health Data Science and Informatics (OHDSI) can expand knowledge regarding outcomes, medication management, risk factors, rare complications, and device performance in hand surgery [1]. A total of 99 minimal important differences were identified across 29 articles covering various conditions, treatments, outcome measures, and follow-up periods in elective hand surgery [2]. The quantity of randomized controlled trials in hand surgery has increased over time, but methodological quality has remained low with a mean Jadad score of 2.1 [24]. Hand surgery randomized controlled trials demonstrate fragility in non-significant findings, where a small number of event changes can potentially alter conclusions [27].

Complications

Infection: Infections represent the predominant cause of adverse events following elective hand surgery, accounting for 63.0% of all reoperations and unplanned admissions within 30 days [9]. While the overall rate of reoperations or unplanned admissions is infrequent at 15 per 10,000 cases [9], the safety of performing elective hand surgery during a pandemic remains unclear, necessitating further studies with larger sample sizes to clarify this risk [28].

Wound complications: Procedures performed in the procedure room setting using wide-awake local anesthesia without a tourniquet demonstrate a low complication rate of 2.7% [47]. In pediatric populations with recessive dystrophic epidermolysis bullosa, wound management requires careful consideration of all pros and cons by both the medical team and patients, with an emphasis on long-term, disciplined postoperative treatment [12].

Other Considerations: Percutaneous elastic intramedullary nailing of metacarpal fractures is associated with good hand function and few complications [4]. Immunocompetent pediatric hand transplantation remains ethically impermissible outside of rigorously designed and transparent clinical trials due to the immediate and long-term morbid consequences of immunosuppression and uncertain long-term outcomes [51]. Furthermore, hand surgery randomized controlled trials demonstrate fragility in non-significant findings, where a small number of event changes can potentially alter conclusions [27].

Recovery

Light activity (weeks): Evidence does not specify a distinct week range for light activity or driving; however, patients undergoing percutaneous elastic intramedullary nailing for metacarpal fractures achieve good hand function with few complications [4], and those with recessive dystrophic epidermolysis bullosa require long-term, disciplined postoperative treatment to manage the pros and cons of surgery [12].

Full activity (months): Functional recovery timelines vary by procedure; patients treated with electrothermal therapy for thumb basal joint instability demonstrated satisfactory subjective and functional stability at a minimum of 2 years' follow-up [62], while those receiving microsurgical free lateral great toe flaps for Wassel-Flatt IV-D thumb duplication were followed for 8–12 months with satisfactory appearance [59]. Additionally, a patient with an ectopic nail on a hidden thumb duplication regained full range of movement of the hand at 2 years postoperatively [94].

Complete recovery / outcome plateau (months): Long-term results after surgical reconstruction for radial polydactyly were excellent, though the revision rate trended upward over time despite maintenance of favorable scores on objective outcome measures [55]. The Arpe implant for trapeziometacarpal total joint arthroplasty demonstrates an acceptable long-term survival rate and restores good hand function [11], while ray resection yields good cosmetic and functional outcomes when preservation of a functional digit is unattainable [5].

Rehabilitation protocol: For recessive dystrophic epidermolysis bullosa, the medical team and patients must emphasize the importance of long-term, disciplined postoperative treatment [12]. Despite recurrent scarring and contracture in the short and mid term, surgical release can provide significant improvements in hand function for this population [52].

Functional milestones: A total of 99 minimal important differences were identified in 29 articles covering various conditions, treatments, outcome measures, and follow-up periods in elective hand surgery [2].

Other Considerations: Risk of disease progression and expectations following hand reconstruction must be managed carefully in Hirayama disease [8]. All flaps survived in the cohort of patients followed for 8–12 months with satisfactory appearance of the reconstructed thumbs in revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap [59].

Key Evidence

  • [L5] For hand surgery, OHDSI can expand what is currently known about outcomes, medication management, risk factors, rare complications, device performance, and more. (10.1016/j.jhsa.2024.09.009)
  • [L2] A total of 99 minimal important differences were identified in 29 articles covering various conditions, treatments, outcome measures, and follow-up periods in elective hand surgery. (10.1177/1753193414553908)
  • [L5] The paper outlines the historical development of hand surgery in Europe, highlighting key figures, anatomical discoveries, and technological advances that established the specialty, culminating in the formation of national and international federations and the recognition of the hand as a distinct organ requiring specialized care. (10.1054/jhsb.2000.0395)
  • [L4] The general outcome was good hand function with few complications. (10.1186/1749-799x-6-37)
  • [L5] Ray resection results in good cosmetic and functional outcomes when preservation of a functional digit is unattainable or when the presence of an abnormal, unreconstructable digit interferes with the overall hand function. (10.5435/jaaos-d-14-00056)
  • [L4] It should be considered for use in outpatient hand procedures. (10.1177/1558944718812190)
  • [L5] The study established consensus recommendations for six common revision scenarios using a rigorous Delphi process involving experienced hand surgeons worldwide. (10.1177/17531934241227386)
  • [L4] Risk of disease progression and expectations following hand reconstruction must be managed carefully. (10.1016/j.jhsa.2024.06.010)
  • [L4] Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent (15 per 10,000 cases) and are most commonly related to infections (63.0%). (10.1016/j.jhsa.2017.10.015)
  • [Commentary] The hand surgeon should address all patho-anatomic features to achieve the best possible result, though a normal functioning interphalangeal joint cannot be provided if the abnormality is marked. (10.1177/1753193414538149)
  • [L2] The Arpe implant has an acceptable long-term survival rate and restores good hand function. (10.1177/1753193419871660)
  • [L4] Both the medical team and patients should carefully consider all pros and cons for hand surgery, emphasizing the importance of long-term, disciplined postoperative treatment. (10.1197/j.jht.2007.10.001)
  • [L2] Further research is warranted to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand. (10.1016/j.jhsa.2016.07.092)
  • [Case_report] Their review of the literature supports the idea that early surgical management may be considered for hand lesions with prominent symptoms. (10.1016/j.jhsa.2017.03.007)
  • [L5] Understanding heterogeneity in published meta-analyses would help in the understanding of the available evidence in Hand Surgery, as statistical heterogeneity may be caused by clinical or methodological differences and is often inadequately investigated. (10.1177/17531934251317837)
  • [L4] Although the current evidence is of poor quality, it suggests that some types of hand surgery may be done outside the operating theatre without increasing the risk of infection. (10.1177/1753193416676408)
  • [L3] Approximately one of every ten patients who are referred for orthopaedic services has a hand or wrist condition, and nearly half will require surgery. (10.2106/00004623-200401000-00009)
  • [L4] Familiarity with ultrasound can provide the hand surgeon with a convenient and versatile tool to assist in the evaluation and treatment of hand and upper extremity disorders. (10.1016/j.jhsa.2014.08.017)
  • [L5] Ring's attitude is needed, more well-organized outcome studies are required to show the right way in hand surgery. (10.1177/1753193414562691)
  • [L5] New measures in hand surgery should consider patient safety, clinical efficacy, cost effectiveness, and the environmental impact. (10.1177/15589447211054134)
  • [L4] WALANT hand surgery was generally well tolerated with excellent surgical outcomes. (10.1177/15589447211058838)
  • [L1] The quantity of randomized controlled trials in hand surgery has increased over time, but methodological quality has remained low with a mean Jadad score of 2.1, indicating a need to improve the quality of trials in hand surgery literature. (10.1177/1753193418780184)
  • [L4] Hand transplantation is the most common form of modern composite tissue allotransplantation, with success depending on proper patient selection, technical success, rehabilitation, and immunotherapy protocols that prevent rejection while minimizing morbidity. (10.1016/j.jhsa.2011.09.001)
  • [L1] Surgeons can be confident in choosing either technique if rigorous patient selection, sound surgical technique, and proper hand therapy are employed. (10.1016/j.jhsa.2024.06.008)
  • [L2] Hand surgery RCTs demonstrate fragility in non-significant findings, with a small number of event changes potentially altering conclusions. (10.1177/17531934251327880)
  • [L4] The safety of performing elective hand surgery during the pandemic remains unclear, and more studies with larger samples are needed to clarify this question. (10.1177/15589447211064360)
  • [L4] Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team. (10.1177/1753193411409830)
  • [L3] The modified classification could detect advanced deformity earlier and was more strongly correlated with hand function. (10.1177/1753193419886719)
  • [Case_report] The technique is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss. (10.1016/j.jhsa.2008.04.025)
  • [L3] Use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions. (10.1016/j.jhsa.2019.09.009)
  • [L5] Prompt diagnosis and early treatment with broad-spectrum intravenous antibiotics and surgical irrigation and debridement are essential to avoid complications and preserve hand function, though severe infection can still lead to impaired function or amputation. (10.1016/j.jhsa.2019.04.011)
  • [L5] Thumb deformities in rheumatoid arthritis are common and significantly compromise function; treatment is directed by the specific deformity type and joint involvement, with nonsurgical management for early stages and surgical reconstruction or salvage for advanced disease. (10.5435/00124635-200702000-00006)
  • [L5] Published clinical results have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient. (10.1177/17531934251314640)
  • [L4] The study found good medium-term results and high satisfaction rates, advocating the technique as an effective treatment option for revision thumb-base surgery provided other treatable causes of poor outcome are excluded. (10.1177/1753193412447496)
  • [L4] After surgery and hand therapy, disability decreased independent of single or multiple operated fingers. (10.1016/j.jhsa.2014.04.029)
  • [L5] Active and passive intrinsic reconstruction methods improved basic grasp and release kinematics in experimental cadaver hand models. (10.1016/j.jhsa.2014.09.031)
  • [L3] All groups demonstrated improvement in self-reported hand function, pain, and aesthetics with no differences between incision techniques. (10.1177/17531934241232341)
  • [L4] The study demonstrated a complication rate of 2.7% for hand surgery procedures performed in the procedure room setting. (10.1016/j.jhsa.2024.10.017)
  • [L2] We propose a modified classification that is a practical and utilitarian scheme for nomenclature of radial polydactyly and that may assist comparison of treatment outcomes and individual cases. (10.1016/j.jhsa.2007.12.012)
  • [L4] The review concludes that there is no convincing evidence to support routine prophylactic antibiotics for all elective hand surgery cases, but recommends their use for patients with preexisting major diseases, those on steroids, or those with hardware such as K-wires or implants. (10.1016/j.jhsa.2007.12.017)
  • [L5] Immunocompetent pediatric hand transplantation remains ethically impermissible outside of rigorously designed and transparent clinical trials due to the immediate and long-term morbid consequences of immunosuppression and uncertain long-term outcomes. (10.1016/j.jhsa.2026.02.008)
  • [L4] Despite recurrent scarring and contracture in the short and mid term, surgical release can provide significant improvements in hand function. (10.1177/17531934251313989)
  • [L1] This study reports impairment in the kinematics of precision pinch associated with index finger PIP joint fusion. (10.1016/j.jhsa.2011.09.010)
  • [L4] Long-term results after surgical reconstruction for radial polydactyly were excellent but the revision rate trended upward over time despite maintenance of favorable scores on the objective outcome measures used. (10.1016/j.jhsa.2014.05.006)
  • [L4] All flaps survived and patients were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs. (10.1177/17531934231222400)
  • [L4] The use of a proximity sensor eliminates the need for forceful movements of the residual finger to use mechanical switches or levers and makes the operation more intuitive and easier to understand. (10.1177/17531934231209645)
  • [L4] Of 17 thumbs, 16 had satisfactory subjective and functional stability at a minimum 2 years' follow-up. (10.1016/j.arthro.2008.10.001)
  • [L4] It is a safe procedure for the thumb, index, middle, and ring fingers as long as the recommended technique is observed. (10.1016/j.jhsa.2010.06.006)
  • [L4] Mechanical solutions to minimize force required at the wrist to activate grip are still required. (10.1016/j.jht.2020.04.005)
  • [L4] Patients with pain refractory to conservative therapy may benefit from relief and increased hand strength following surgical intervention. (10.1177/1753193418785825)
  • [L1] Non-surgical treatment provides clinically worthwhile improvements in pain and function, with a stepwise approach recommended starting with self-management, followed by splints and injections if symptoms persist. (10.1177/17531934241313206)
  • [L4] Routing of the EPL tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm. (10.1016/j.jhsa.2015.01.018)
  • [L5] This biomechanical model demonstrates that radial transposition of the EPL tendon enhances extension of the thumb regardless of whether the tendon is routed through, or superficial to, the first extensor compartment. (10.1016/j.jhsa.2018.01.015)
  • [L5] At the time of repair, decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction. (10.1016/j.jhsa.2013.08.092)
  • [L3] Surgeons may consider continuing warfarin anticoagulation during hand surgery, as problems can likely be managed non-operatively. (10.1177/1753193417711652)
  • [L4] In the presence of diagnostic uncertainty in hand infection, imaging by sonography or MRI may help to identify and localise collections, then guide drainage and debridement. (10.1177/1753193408087113)
  • [L5] The article highlights advancements in surgical and therapy management for Dupuytren's disease, reviewing indications, surgical options, non-surgical techniques, and therapy interventions to assist in linking patient-specific problems to appropriate treatment choices. (10.1016/j.jht.2013.10.006)
  • [L4] Extension strengths of the thumb and index finger of the operated hand were approximately 20% lower compared to the contralateral hand, yet clinical functional scores and range of motion were favourable. (10.1177/17531934241226949)
  • [L5] Management of hand fractures involves balancing the prevention of stiffness through early motion with the avoidance of deformity via adequate reduction and stabilization. (10.1016/j.jhsa.2016.03.007)
  • [L4] Clinical and radiological measurements showed the efficacy of this reconstruction in increasing the volume and girth of the reconstructed thumb. (10.1016/j.jhsa.2015.02.032)
  • [L2] Positioning the middle finger DIP joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity, allowing other considerations such as appearance to be prioritized. (10.1016/j.jhsa.2014.06.021)
  • [L4] Although considered obsolete by many surgeons due to appearance, non-medical people do not consider the unattractive appearance to outweigh the functional outcome. (10.1177/1753193411406479)
  • [L5] Modifying the core suture configurations in flexor tendon repairs is common among Finnish hand surgeons, although this does not seem to compromise the biomechanical competence of the repairs. (10.1177/1753193416641624)
  • [L5] We were unable to find significant differences in the motion range of the thumb after these rerouting techniques or sites of insertion. (10.1177/1753193419857067)
  • [L4] Non-surgical management was successful in this case of avascular necrosis of the sesamoid bone, with no further treatment necessary. (10.1177/1753193408094153)
  • [L5] The pre-operative assessment and intraoperative findings of all thumb elements should be considered in surgical decision-making to define the methods of reconstruction. (10.1177/1753193418793579)
  • [L5] Sensation is the most important factor in thumb or fingertip repair, constituting 40% of the goal, while length and appearance account for 50%. (10.1177/17531934211051303)
  • [L3] Patient factors associated with not using hand therapy suggest that more uniform clinical practice should be sought. (10.1016/j.jht.2024.07.002)
  • [L4] MRI proved useful in subclassifying Wassel Type IV duplicated thumbs and may aid in planning the osteotomies needed for their reconstruction. (10.1177/1753193420983213)
  • [L4] The described technique allows for gap closure and rotational control during central ray resection, even in the face of inadequate soft tissue structures, providing good hand function without nonunion or malunion. (10.1016/j.jhsa.2016.05.005)
  • [L4] Using this additional method, anatomical reduction was achieved more easily with good radiological and clinical outcomes and few complications. (10.1016/j.jhsa.2018.09.016)
  • [L4] In most cases of thumb in the plane of the hand, the thumb has the potential to act in opposition, indicating that reconstruction of the first web space is worth considering as an initial procedure. (10.1177/1753193411417230)
  • [L4] This technique effectively restores bony alignment of the thumb and preserves vascularity of the retained condyle. (10.1177/1753193410373686)
  • [L4] The technique of thumb reconstruction used in the current series is an acceptable option. (10.1177/1753193412475129)
  • [L4] Radiographic deformity and nonsurgical treatment do not necessarily correlate with worse functional outcomes, particularly in patients over 60 years of age. (10.1016/j.jhsa.2012.04.006)
  • [L4] Two years postoperatively, the patient remains free of local and distant disease with well-healed flaps and regained full range of movement of the hand. (10.1177/1753193408101859)

See Also

References

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[2] Minimal important changes and differences in elective hand surgery. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414553908

[3] The History of Hand Surgery in Europe. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0395

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[5] Ray Resections of the Fingers. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00056

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[8] Hirayama Disease: Surgical Restoration of Hand Function. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.06.010

[9] Thirty-Day Reoperation and/or Admission After Elective Hand Surgery in Adults: A 10-Year Review. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.015

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[12] Postoperative Hand Treatment in Children with Recessive Dystrophic Epidermolysis Bullosa. Journal of Hand Therapy. 2008. DOI: 10.1197/j.jht.2007.10.001

[13] Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.092

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[18] Surgical site infection after hand surgery outside the operating theatre: a systematic review. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416676408

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[22] How Can We Make Hand Surgery Carbon Neutral?. HAND. 2021. DOI: 10.1177/15589447211054134

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[25] The Current State of Hand Transplantation. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.09.001

[26] Outcomes of Zone II Flexor Tendon Repair Under General Versus Wide Awake Local Anesthesia: A Randomized Controlled Trial. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.06.008

[27] The application of the reverse fragility index to randomized controlled trials in hand surgery. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251327880

[28] Evaluation of the COVID-19 Infection Rate in the Perioperative Period of Elective Surgeries of the Hand and Microsurgery. HAND. 2021. DOI: 10.1177/15589447211064360

[29] Rheumatoid hand surgery: differing perceptions amongst surgeons, rheumatologists and therapists in the UK. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411409830

[31] A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis: a cross-sectional analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419886719

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[37] Nonvascularized Autogenous Bone Graft for Extensive Phalangeal Bone Loss: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.04.025

[38] The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.09.009

[39] Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.04.011

[40] 9. Hand Surgery. 2013.

[41] Reconstruction of the Rheumatoid Thumb. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200702000-00006

[42] Harnessing the uninjured hemisphere for treatment of the stroke or brain-injured patient – evolution of the contralateral C7 transfer. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251314640

[43] The use of Swanson silastic interposition arthroplasty in revision thumb-base surgery for failed trapeziectomy; a case series of 10 patients. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412447496

[44] Hand Function and Quality of Life Before and After Fasciectomy for Dupuytren Contracture. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.029

[45] The Effect of Intrinsic Loading and Reconstruction Upon Grip Capacity and Finger Extension Kinematics. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.031

[46] Incision techniques for trigger thumb release: a comparison of outcomes of four types of skin incision. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241232341

[47] The Use of the Procedure Room for Wide-Awake Local Anesthesia, No Tourniquet Hand Surgery in “High-Risk” Patients. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.10.017

[48] A Classification System of Radial Polydactyly: Inclusion of Triphalangeal Thumb and Triplication. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.12.012

[49] The Role of Prophylactic Antibiotics in Elective Hand Surgery. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.12.017

[50] Qualitative_Research_Exchange_Interfacing_Practice_and_Research_S0894113008001245. n.d..

[51] Current Ethics of Hand Transplants in Non-Immunocompromised Children. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.02.008

[52] Clinical and functional outcomes of hand surgery for recessive dystrophic epidermolysis bullosa. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251313989

[53] Influence of Index Finger Proximal Interphalangeal Joint Arthrodesis on Precision Pinch Kinematics. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.09.010

[55] Long-Term Outcomes Following Radial Polydactyly Reconstruction. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.006

[59] Revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231222400

[61] Novel prosthesis with proximity sensor for upper extremity phocomelia. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231209645

[62] Electrothermal Treatment of Thumb Basal Joint Instability. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.10.001

[63] Anatomic Outcome of Percutaneous Release Among Patients With Trigger Finger. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.006

[64] 3D-printed custom-designed prostheses for partial hand amputation: Mechanical challenges still exist. Journal of Hand Therapy. 2021. DOI: 10.1016/j.jht.2020.04.005

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[66] Guideline on managing thumb base osteoarthritis: The British Society for Surgery of the Hand Evidence for Surgical Treatment (BEST) findings and recommendations. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934241313206

[67] Rerouting Extensor Pollicis Longus Tendon Transfer. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.01.018

[69] Intracompartmental Versus Extracompartmental Transposition of the Extensor Pollicis Longus for Treating Thumb-in-Palm Deformity: A Biomechanical Comparison. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.015

[70] Decellularized Human Tendon–Bone Grafts for Composite Flexor Tendon Reconstruction: A Cadaveric Model of Initial Mechanical Properties. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.092

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[72] Re: Safe, tension-free stabilisation of retrieved flexor tendon ends. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087113

[73] Surgical and therapy update on the management of Dupuytren's disease. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.10.006

[74] Clinical outcomes of extensor indicis proprius tendon transfer for extensor pollicis longus tendon rupture. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241226949

[75] Hand Fractures: Indications, the Tried and True and New Innovations. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.03.007

[76] Use of an Axial Flap to Increase the Girth of Wassel IV Thumb Reconstructions. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.02.032

[77] Simulated Distal Interphalangeal Joint Fusion of the Index and Middle Fingers in 0° and 20° of Flexion: A Comparison of Grip Strength and Dexterity. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.021

[78] The Krukenberg procedure revisited. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411406479

[79] Suture configurations and biomechanical properties of flexor tendon repairs by 16 hand surgeons in Finland. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416641624

[80] Extensor pollicis longus rerouting for thumb-in-palm deformity in cerebral palsy: a biomechanical analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419857067

[81] Re: The search for the optimal placement of percutaneous K-wires in the digits of the hand. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408094153

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[83] Soft and tissue repair of the hand and digital reconstruction. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211051303

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[92] Thumb reconstruction without formal pollicization in mirror hand deformity: a series of four cases. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193412475129

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