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Materials and Equipment

Surgical barrier integrity, glove selection (latex, nitrile, double-gloving), and equipment considerations for hand surgery infection control.

102 citationsUpdated Sep 2026

Overview

Advancements in technology, materials, and smart autonomous systems continue to optimize clinical results for lower extremity external fixation, even as complication rates decrease [1]. In the realm of arthroplasty, biomaterial innovations have expanded design options for the proximal interphalangeal joint [2], while the clinical success of non-cemented or biologically stabilized implants must be judged against contemporary cementing techniques rather than early 1970s procedures [7]. For small joint arthroplasty, the literature remains unclear regarding which implant type provides the most reliable results [36]. Silicone implants have demonstrated long-term reliability but carry risks of fracture and stiffness [36], whereas newer designs such as pyrocarbon present unique challenges including dislocations and loosening [36]. Although many recently available trapezium implants show short-term success, determining medium- to long-term outcomes requires further study [3].

Emerging technologies, including 3D design and printing, are anticipated to become easier and more efficient, leading to mainstream utilization in clinics and hospitals [28]. However, high-level evidence is still needed to determine whether 3-dimensional printed models improve clinical outcomes in hand surgery [5], and understanding the current evidence and appropriate indications for these emerging technologies in orthopaedic trauma is of critical importance [4]. Intraoperative practices also reflect evolving standards; two pairs of gloves should be worn when performing a major orthopaedic procedure [19], and the 'one size fits all' philosophy for digital tourniquets is questioned due to the difficulty in defining safe limits for application time and surface pressures [20].

Wound management and biological materials offer specific advantages, such as Integra providing durable functional skin coverage with decreased donor site morbidity [62]. Tissue engineered tendon constructs may provide considerable clinical benefit given the lack of adequate intrasynovial tendon graft sources and the propensity for current repair methods to cause adhesion formation [38]. Furthermore, the development of a functional, durable, and biocompatible scaffold for these constructs requires careful consideration of key aspects [38].

Anatomy & Pathophysiology

Skeletal Architecture

The hand and wrist skeleton comprises 27 bones, 19 of which are long bones [48]. The hand is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [48]. The thumb ray is the shortest, consisting of a metacarpal and two phalanges, and exhibits greater mobility than the other rays [48]. In terms of length, the index metacarpal is the longest, while the thumb metacarpal is the shortest [48]. The proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [48]. The transverse palmar axis is oblique, forming an acute angle of approximately 75 degrees with the longitudinal axis [48]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [48]. The wrist possesses three axes of movement, permitting the hand to be positioned in any spatial configuration for grasping [48].

The metacarpophalangeal joints serve as the keystones of the longitudinal arches of the hand [90]. Volar plates prevent hyperextension at these joints [90]. The fifth metacarpal has a range of flexion–extension of approximately 20 degrees [90], while the ring metacarpal has about 10 degrees of mobility in flexion and extension [90].

Musculotendinous Anatomy

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [47]. Extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [47]. The compartment contents are as follows: * First compartment: Abductor pollicis longus and extensor pollicis brevis [47]. * Second compartment: Extensor carpi radialis longus and extensor carpi radialis brevis [47]. * Third compartment: Extensor pollicis longus, which turns abruptly radialward about Lister tubercle [47]. * Fourth compartment: Extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis [47]. * Fifth compartment: Extensor digiti quinti [47]. * Sixth compartment: Extensor carpi ulnaris tendon [47].

Sagittal bands stabilize the digital extensor tendons over the midline of the metacarpophalangeal joint [47]. Rupture or attenuation of the sagittal band fibers can cause the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head [47]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [47]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [98]. This tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [98]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [98]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [98].

There are seven interosseous muscles, four dorsal and three volar [86]. The dorsal interossei are abductors, while the volar interossei are adductors [86]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [86]. The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei [86].

Soft Tissue and Vascular Anatomy

The dorsal skin is thin, possesses a normal pilosebaceous system, and has loose connections with deeper planes allowing free gliding [100]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [100]. The palmar skin forms a cutaneous unit extending from the distal transverse crease of the wrist up to the transverse crease at the base of the digits [84]. The superficial palmar fascia covers a triangular area of the central palm, with four central bands extending distally toward each finger [101]. Digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers, with dorsal fibers called Cleland ligament and palmar fibers called Grayson ligament [101].

The "princeps pollicis" artery is the terminal branch of the radial artery that crosses the first intermetacarpal space [93]. Only 15% of anatomical dissections of the palmar arteries of the thumb fall into the classical "typical" category [93]. The function of the palmaris brevis is believed to be to protect the ulnar nerve and artery from overlying pressure [187].

Biomechanics and Material Properties

The mechanical performance of an orthopaedic device depends on strength, strain, and fatigue [16]. Stress is defined as force applied over a unit of area, with the SI unit being Pascals (Pa) [16]. Strain is the deformation of a material by a force acting on it, calculated as change in length divided by original length [16]. Biomaterials used in orthopaedics must be biocompatible, resistant to corrosion and degradation, and have adequate mechanical and wear properties [82].

Ceramics are strong, brittle, and corrosion-resistant materials consisting of elements linked by covalent or ionic bonds [82]. Polymers are materials made of atoms covalently bound to form monomers, which are bound to one another to form chains or sheets [82]. Material properties, surface geometry, and local chemistry affect host response and incorporation or failure of the material [81]. Properties of surfaces important to biomaterials include roughness, morphology, wettability, surface mobility, chemical composition, electrical charge, crystallinity, and modulus [81].

The clinical success of non-cemented or biologically stabilized implants must be judged in comparison with contemporary cementing techniques [7]. Advances in biomaterials have improved and expanded arthroplasty design [2]. The production of surgical instruments, devices, and implants requires the processing and manufacturing of biomaterials including metals, polymers, and ceramics [23]. Material composition, structure, and manufacture determine the mechanical properties of the material and its biocompatibility [23].

Classification

Medical Device Regulation (MDR): Under the MDR, device classification is determined by the associated risk [67]. Most classical hand surgical plates and screws fall under MDR class IIa [67], while joint implants are generally classified as MDR class III [67]. Negotiating classifications with regulatory authorities is essential for new implants in hand surgery [67].

Clinical Presentation

Patients often struggle to accurately describe symptoms and may incorrectly attribute pathology to a perceived deficit [24]. A careful physical examination is essential to direct care and future testing if indicated [24]. Given the density of structures in a small space, a systematic method for approaching the hand and wrist examination is essential [24]. A careful history suggests the correct diagnosis in approximately 90% of patients with hand problems [108].

History Taking The chief complaint as perceived by the patient should be summarized in one or two sentences [108]. The patient’s hand dominance, age, gender, occupation, and hobbies requiring hand dexterity or strength should be noted [108]. The approximate date of onset of symptoms and, if injury is the cause, the exact date and mechanism of injury should be recorded [108]. The patient should be questioned about prior treatment and their perception of its effectiveness [108]. The nature of pain (sharp, aching, dull, or burning), presence of night symptoms, aggravating and relieving factors, and timing relative to work or sleep should be detailed [108]. Symptoms of numbness or tingling should be assessed to indicate a neurologic problem rather than a mechanical one [108]. Specific motor difficulties, such as difficulty in writing or unscrewing jar tops, should be noted [108]. If the patient complains principally of unilateral symptoms, the examiner should ask whether similar symptoms are occurring on the opposite side [108]. The impact of altered appearance on the patient should be discussed because the hand is an exposed area of the body [108]. The medical history should include prior hand injuries and systemic diseases such as rheumatoid arthritis, diabetes, endocrine disorders, renal disease, or vascular disease [108].

Inspection Examination of the hand should begin with observation of vascular condition by noting the color of the fingers [108]. Nerve function can be assessed by observing sudomotor function as revealed by sweatiness of the finger pulps [108]. The extent and timing of injury are suggested by the degree of swelling and ecchymosis [108]. The posture of the digits and the wrist may signal tendon or bone disruption [108]. A diagram of the hand is often helpful in documenting abnormalities such as lumps, laceration sites, previous scars, amputated fingers, and areas of decreased sensation [108].

Palpation The hand, wrist, and forearm are gently palpated to note temperature and moisture of the fingers [108]. Circulation is assessed by capillary refill, where circulation should return within 3 seconds when the skin is blanched in the paronychial region [108]. Areas of tenderness on palpation are carefully noted [108].

Range of Motion and Muscle Integrity The passive and active range of motion of the shoulder, elbow, forearm, wrist, and hand are evaluated [108]. In documenting range of motion, active extension is recorded to the left and active flexion to the right [108]. When the range of passive extension and flexion differs from active motion, the passive range of motion values are noted in parentheses next to the corresponding active range of motion values [108]. The integrity of individual muscles should be documented [108]. The flexor digitorum profundus to each finger is tested by stabilizing the middle phalanx and asking the patient to flex the distal interphalangeal joint [108]. The flexor digitorum superficialis of each finger is tested by keeping all fingers except the one being tested in full extension and asking the patient to flex the finger at the proximal interphalangeal joint [108]. The function of the flexor pollicis longus is tested by asking the patient to flex the interphalangeal joint of the thumb [108]. The function of the extrinsic extensors is tested by asking the patient to extend the metacarpophalangeal joints of the fingers [108]. Health professionals are encouraged to measure key pinch to detect difficulties in opening packages [110].

Investigations

Imaging and Diagnostic Modalities

Plain radiography: Plain radiographs serve as an excellent starting point for most bone tumors [121]. They are also the primary modality for assessing osseous integration of implanted spongy hydroxyapatite, where standard X-rays demonstrated integration in all patients at five-year follow-up [30]. In central ray deficiency, a new technique quantifying the radiographic divergence of border rays demonstrates improved alignment at long-term follow-up [149]. For proximal interphalangeal joint arthroplasty, radiologic evidence of loosening was significantly more frequent in the uncemented group compared to the cemented group (p < .001) [59]. In total hip arthroplasty using the Trabecular Metal Monoblock Acetabular Cup System, postoperative polar gaps were observed in 13 hips (25%), with eight gaps measuring less than 1 mm and the remaining ranging from 1.8 to 3.5 mm [11]. All observed polar gaps disappeared up to 6 months postoperatively, and no periacetabular osteolysis was observed in the 3 DeLee-Charnley zones during the follow-up period [11]. All implants were considered radiologically fully incorporated at 2 years, and the cup with the largest total migration of 2.69 mm was considered stable without clinical or radiologic signs of loosening [11]. The inclination of the initial cup position ranged from 29.8° to 51.2° (mean, 41.0°; SD, 4.7°; SE, 0.7°) [11]. Heterotopic ossification was observed in 10 hips (20%), classified as grade I in 7 cases and grade II in 3 cases according to the Brooker classification [11]. For pyrolytic carbon implants, clinical outcomes and radiographic signs of loosening suggest that the surrounding bone does not form a stable interface [27].

MRI: MRI is often helpful for soft-tissue tumors, bone masses with a soft-tissue component, and any malignant tumor [121]. In Dupuytren’s disease, MRI assessment is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [114]. However, MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [114]. It may also provide a quantitative noninvasive measure of cellularity in affected areas, which serves as an index of biologic activity [114]. For autologous osteochondral mosaicplasty, follow-up assessment includes MRI evaluation to assess the quality of the donor site repair, which is semiquantitatively assessed according to the scoring system of Henderson et al [52]. The radiologist reviewing the MRI for donor site repair is masked to clinical results [52].

Fluoroscopy and Doppler: The mini C-arm is recommended for hand surgical procedures due to its improved image quality and overall practicality compared to the standard C-arm [79]. Surgeons' hands receive the most radiation exposure during distal radial plate fixation under fluoroscopy [163]. An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, though false-negatives are possible [114]. Doppler imaging is a promising improvement for identifying palmar structures, but higher resolution imaging technology is needed [114].

Radionuclide Imaging: Technetium-99m radionuclide imaging showed identical uptake at the site of the implanted spongy hydroxyapatite and in the contralateral side during the perfusion phase in 16 of 17 patients [30]. In 15 of 17 patients, there was no activity during the soft tissue phase, indicating that there was no inflammatory reaction around the implant [30]. In the bone phase, 15 patients had increased uptake, suggesting either persisting osteoclastic and osteoblastic activity or osseous integration of the ceramic [30].

Other Considerations: 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 [70]. Diagnostic tests such as imaging and serum laboratory studies are useful in determining hand pathology but can be expensive, time consuming, and often nonspecific [24]. Despite radiological findings of progressive collapse, the poly-ld-lactic acid scaffold can be considered a good alternative to traditional trapeziectomy with tendon interposition and suspensionplasty, with long-lasting satisfactory clinical results [42].

Clinical Examination and Functional Assessment

A careful physical examination is essential to direct care and future testing if indicated for the injured or dysfunctional hand and wrist [24]. Clinical evaluation requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [24]. Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit, whether real or imagined [24]. A systematic method to approaching the physical examination of the hand is essential due to the number of structures in a small space [24]. The GripAble is a reliable tool for measuring grip strength [17].

The hand is both an organ designed to obtain information and an organ of execution [44]. It functions efficiently only if the proximal joints of the limb are stable and yet mobile [44]. The wrist is usually in flexion when close to the trunk and in extension when placed at a distance for gripping [44]. Forearm rotation (pronation–supination) plays an important role, particularly for bringing food to the mouth [44]. The open hand, with fingers extended and in contact, forms a balanced graceful oval in its longitudinal axis [44]. The back of the hand is the surface that is usually visible and is therefore aesthetically important, while the palmar surface is the functional surface [44]. The posterior or dorsal aspect of the hand is convex, and the anterior, palmar or volar aspect is concave [44]. The digits converge in closing—that is, they flex and adduct—and diverge in opening—that is, they extend and abduct [44]. When the fingers are extended and separated, the tips of the fingers lie on the circumference of a circle whose center is the head of the third metacarpal [44].

The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand, and about the same number of tendons activated by the forearm muscles [44]. The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [48]. The radioulno-carpal articulation has two axes of movement to which is added a third—pronation and supination from the forearm [48]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [48]. The radial ray or first ray is the shortest, made up of only three bones—a metacarpal and two phalanges [48]. The trapezium is clearly angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [48]. The thumb metacarpal is the shortest, the index finger metacarpal is the longest, and the others decrease in length from the third to the fifth digits [48]. The proximal and particularly the middle phalanges of the middle and ring fingers are longer than those of the index finger [48]. The more ulnar the digit, the more obliquely it must deviate as it approaches the palm [48]. The two ulnar metacarpals, especially the fifth, have slightly more mobility in flexion–rotation, compensating for their lack of length [48].

The skeleton of the hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [48]. When the thumb spreads to grasp an object, the cup becomes a gutter whose major oblique axis follows the thumb crease [48]. The transverse axis of the palm, which corresponds to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis [48]. The transverse axis is oblique, more distal at the metacarpophalangeal joint of the index finger and more proximal at the fifth metacarpophalangeal joint [48]. The transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [48]. It is necessary to take the obliquity of the transverse palmar axis into account when applying plaster casts or splints and also in the positioning of crutch and cane handles [48]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [48].

Extrinsic muscles have their origin outside of the hand and their insertion on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [47]. The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [47]. The first (most radial) compartment contains the abductor pollicis longus and the extensor pollicis brevis [47]. The abductor pollicis longus has multiple slips that insert at the base of the thumb metacarpal and radially abducts the thumb [47]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the proximal phalanx of the thumb and actively extends the metacarpophalangeal joint of the thumb [47]. The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexes and radially deviates the wrist [47]. The extensor carpi radialis brevis inserts into the base of the middle metacarpal, providing balanced wrist dorsiflexion [47]. The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm through the third compartment and turns abruptly radialward about Lister tubercle [47]. The extensor pollicis longus provides forceful extension of the thumb interphalangeal joint [47]. The oblique course of the extensor pollicis longus tendon provides a substantial adduction component to the pull of the extensor pollicis longus [47].

The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [47]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [47]. Distal interphalangeal joint extension is achieved through the conjoined lateral bands that are composed of tendinous slips from the extrinsic and intrinsic tendons [47]. The extensor indicis proprius inserts on the index finger ulnar to the extensor digitorum communis [47]. The extensor digitorum communis inserts on the index, middle, ring, and, in some cases, little fingers [47]. The extensor digiti quinti tendon inserts on the little finger ulnar to the extensor digitorum communis insertion [47]. The extensor carpi ulnaris tendon runs through the sixth compartment and inserts at the base of the little finger metacarpal [47]. The extensor carpi ulnaris provides wrist extension and ulnar deviation [47]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [47]. The extensor indicis proprius tendon may be recognized at the wrist level as possessing the most distal muscle belly of any of the digital extensor tendons [47].

The digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by their attachment to sagittal band fibers [47]. The sagittal band fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [47]. The sagittal band fibers form a sling that allows proximal extrinsic extensor tension to be transmitted to the proximal phalanx, permitting metacarpophalangeal joint extension without a tendinous insertion onto the proximal phalanx [47]. By holding the extrinsic extensor tendon balanced over the prominence of the metacarpal head, the sagittal bands normally keep the extrinsic extensor as far as possible away from the center of rotation of the metacarpophalangeal joint, thereby giving it the greatest mechanical efficiency [47]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [47]. The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [47]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [47]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [47].

Biomechanical and Material Testing

The PW technique displayed greater stiffness and ultimate load compared with the TL for proximal tendon-prosthesis junctions [77]. For 3 cm of cortical contact, successful initial fixation can be achieved in most cases with both taper angle designs for titanium tapered splined stems [31]. All devices showed burnishing to some degree, a not uncommon finding for tibial bearings [29]. 57% of devices showed noticeable scratching and pitting [29]. The degree of pitting ranged from mild to severe [29]. In the severe case, oxidation is implicated as the geometry of the pits was indicative of a fatigue mechanism [29]. The relatively high pressures generated by a simple digital tourniquet are not expected to have detrimental effects on neurovascular structures for short surgical procedures [41]. This method of defatting skin flaps using arthroscopic instruments provided an effective treatment for patients and did not require the purchase of specialised equipment [9].

While many recently available implants have been shown to have short-term success, determining the medium- to long-term outcomes require further study [3]. Further clinical studies will be needed to determine the effectiveness of the Dynamic Tendon Grip (DTG) device compared to traditional techniques for zone two flexor tendon injury [12]. Tissue engineering will undoubtedly play a key role in reconstructive hand surgery in the not too distant future [78]. Understanding the current evidence and appropriate indications of emerging technologies is of critical importance for their utilization in orthopaedic trauma [4]. It highlights that while complication rates have decreased, clinical results can still be optimized through advancements in technology, materials, and smart autonomous systems for external fixation of the lower extremities [1]. This article highlights the basic dimensions of commonly used headless screws, stand-alone lag screws, non-locking and locking screws for plating, and biocomposite screws to codify their dimensions into a readily available reference chart for the treatment of bone of varying dimensions [21]. The authors provide guidelines for camera selection, standard views, and image formatting to ensure accurate and precise presentation in hand surgery photography [25]. During the 35 years from 1886 to 1921, operative treatment witnessed an unprecedented revolution where radiology became integral and all types of osteosynthesis were introduced into clinical

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions for the conditions described.

Operative

Indications: Replantation is indicated for severed thumbs or multiple digits, transmetacarpal hand amputations, wrist- or distal forearm-level amputations, and amputations of almost any body part in a child [92]. Contraindications include severely crushed or mangled parts, multilevel amputation, amputations in patients with arteriosclerotic vessels, amputations in patients with other serious injuries or diseases, and amputations with prolonged warm ischemic times [92]. In adults, replantation of a single finger proximal to the insertion of the flexor digitorum superficialis is usually contraindicated because of the poor functional outcome due to stiffness [92]. The clinical success of non-cemented or biologically stabilized implants must be judged in comparison with the results obtained using the most contemporary cementing techniques [7].

Surgical Approach / Technique: The surgical sequence of replantation begins with a wide surgical exposure that allows identification and isolation of arteries, veins, and nerves [92]. The bone is shortened and securely internally fixed with sufficient stability to allow institution of early postoperative motion [92]. The extensor tendons are repaired first and then the flexor tendons [92]. Anastomosis of one or preferably two arteries is performed, followed by repair of the nerves and anastomosis of the veins [92]. Two veins should be repaired for each artery repaired [92]. In replantations proximal to the distal forearm, fasciotomies of all muscle compartments should be performed at the time of replantation [92]. The patient undergoing proximal replantation should be returned to the operating room in 48–72 hours, so the wound may be reevaluated and any additional necrotic tissue debrided [92]. For skeletal infection, treatment should be initiated with broad-spectrum antimicrobial coverage and narrowed down once cultures and sensitivities of specimens from the affected site are obtained [43]. Adequate débridement remains a crucial step in the surgical treatment of skeletal infection [43]. In the management of septic nonunions, the initial phase utilizes hardware removal, wide debridement, soft tissue coverage as needed, culture-specific local and IV antibiotics, and bony stabilization that minimized foreign material at the site of infection [91]. The second phase is dedicated to culture-specific antibiotic treatment, ending when clinical, laboratory, and radiographic signs of infection are absent, usually after 6 weeks of therapy [91].

Implant Selection: Material composition, structure, and manufacture determine the mechanical properties and biocompatibility of orthopaedic biomaterials [23]. The field of orthopaedic biomaterials is continually changing, with materials used for years being modified and updated to optimize performance [23]. An electron beam melting (EBM) printed Ti-6Al-4V LCP plate is advantageous for clinical implants because it can be customized with great potential for improvement [33]. The Trabecular Metal Monoblock Acetabular Cup System showed no periacetabular osteolysis in all hips for the whole follow-up period in the 3 DeLee-Charnley zones [11]. All Trabecular Metal Monoblock Acetabular Cup System implants were considered radiologically fully incorporated at 2 years after the operation [11]. The cup with the largest observed total migration of 2.69 mm in the Trabecular Metal Monoblock Acetabular Cup System study was considered stable without any clinical or radiologic signs of loosening [11]. Postoperative polar gap was observed in 13 THAs (25%) in the Trabecular Metal Monoblock Acetabular Cup System study, with all gaps disappearing up to 6 months [11]. Heterotopic ossification was observed in 10 THAs (20%) in the Trabecular Metal Monoblock Acetabular Cup System study, consisting of 7 THAs with grade I and 3 with grade II according to Brooker classification [11]. The poly-ld-lactic acid scaffold can be considered a good alternative to traditional trapeziectomy with tendon interposition and suspensionplasty, with long-lasting satisfactory clinical results despite radiological findings of progressive collapse [42]. MatOrtho proximal interphalangeal joint arthroplasty achieves good pain relief, improvement in functional scores, and may improve range of motion, though caution is advised for stiff joints or those with significant deformity/instability [37]. Cellulose implants in Dupuytren’s surgery result in improved finger extension and high satisfaction, with the implant being well-tolerated and facilitating rehabilitation [35]. Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template (Integra) for the treatment of donor site defects after pedicle flaps in hand surgery [32]. The use of Integra Artificial Dermis to reduce donor site morbidity after pedicle flaps in hand surgery resulted in favorable cosmetic and functional outcomes [32].

Adjuncts: The wire-washer set acts like a bolt with washers and nuts but is more versatile in application for drawing bone fragments together and securing them [13]. The wire-washer set uses a wire tightener to assure that a precise and reproducible amount of compressive force is always employed [13]. The square washers in the wire-washer set are made with corners bent over slightly to form points which will bite into bone cortex [13]. Thinner bone cortex requires a larger washer in the wire-washer set in order that the pressure may be distributed [13]. A forceps for grasping and holding bone plates facilitates the non-touch technique and reduces the danger of dropping the plate [169]. A semirigid tendon retriever and flexor sheath dilator can be made intraoperatively and is useful in both acute and delayed flexor tendon repairs/reconstructions [168]. The semirigid tendon retriever and flexor sheath dilator has an extremely low cost [168]. A self-turning sling device enables patients in large body casts or hip spica casts to turn themselves easily and without help, maintaining a secure and comfortable position [51]. A fracture table for the accident room provides a strong, steady, yet mobile table for fracture treatment in the emergency room with no trouble from undesirable motion during manipulations [158]. Percutaneous release of the A1 pulley using a #15 blade was associated with good efficacy and an acceptable margin of safety [117]. The Dynamic Tendon Grip (DTG) novel knot array requires further clinical studies to determine its effectiveness compared to traditional techniques for zone two flexor tendon injury [12]. No significant differences in functional outcomes were observed between a polymer-assisted peripheral nerve repair device and microsutures [14]. Suture material had no effect on the work of flexion related to flexor digitorum profundus and flexor digitorum superficialis tendon repair in Zone II [120]. Wound care required significantly more time when non-absorbable sutures were used for wound closure after fasciectomy for Dupuytren’s contracture [134]. When the thickness is 5 mm, sufficient durability is achieved in ring orthosis design and production by rapid prototyping, providing advantages in aesthetics, time, and cost [65]. A removable, short opponens orthosis is fabricated from low temperature plastic by the hand therapist for basal joint arthroplasty rehabilitation [172]. The orthotic device for basal joint arthroplasty is worn at all times excluding hygiene and exercises [172]. Patients continue to wear an orthosis during hours of sleep through 10 weeks post-basal joint arthroplasty [172]. Unrestricted activities are allowed at 12 weeks post-basal joint arthroplasty [172]. A customised splint is fitted at 2 weeks after trapeziectomy with porcine collagen interposition, and gentle mobilisation out of the splint is started during the day at 4 weeks [148]. The splint is not worn after 6 weeks post-trapeziectomy with porcine collagen interposition, except when performing heavier tasks [148].

Pain Management: The preferred method of anesthesia for replantation is axillary or supraclavicular block because this technique provides a sympathetic block resulting in vasodilation [92]. Intravenous regional anesthesia using a forearm tourniquet should be considered for use in outpatient hand procedures [129]. One-per-mil tumescent technique proved safe and effective for a wide range of indications in upper extremity surgeries [63].

Other Considerations: An overview of the latest applications of 3D printing in hand surgery and practical experience of implementing them into daily clinical routine has been provided [6]. The incorporation of point of care ultrasound into the routine practice of the hand surgeon has the potential to improve preoperative planning, increase the accuracy of diagnosis, and reduce operative times and morbidity [26]. CT-generated radiographs are diagnostically beneficial for less experienced surgeons and at least as good as conventional plain radiographs for experienced surgeons in classifying pelvic ring injuries [22]. Very few highly ranked smartphone applications are available specifically related to orthopaedic surgery, and none are available specifically for hand surgeons [165]. During the 35 years from 1886 to 1921, operative treatment witnessed an unprecedented revolution where radiology became integral and all types of osteosynthesis were introduced into clinical practice [10]. Lane's efforts to encourage internal fixation were a failure and the treatment fell into disrepute, largely because surgeons were very late in realizing that developments in metallurgy could help them [75]. Inflammation may destroy the integrity of orthopaedic hardware, which may be evident on physical, radiographic, or intraoperative examination [43]. Some clinicians have incorporated local antibiotic delivery with products such as antibiotic beads, powder, or cement into their practice for skeletal infection [43]. Biodegradable antibiotic delivery devices release most of their incorporated antibiotic content after degradation and can carry a wider range of antibiotic agents [83]. Biodegradable antibiotic delivery devices leave no substratum for bacterial colonization and are easy to use [83]. Biodegradable antibiotic delivery devices are associated with an increased risk of antibiotic resistance and persistent drainage from wounds and seromas [83]. Some biodegradable antibiotic delivery devices release acidic degradation products limiting the volume that can be used [83]. Bioactive glass has antimicrobial, osteoconductive, and angiogenic properties and integrates with bone and soft tissue [83]. Good soft tissue coverage is required for the use of bioactive glass [83]. Local flaps provide well-vascularized, healthy tissue that covers the defect improving bone and wound healing [83]. Pedicle length limits the distance a local flap can be transferred to, and donor site morbidity is a disadvantage [83]. Vascularized free flaps provide well-vascularized, healthy tissue that covers the defect improving bone and wound healing [83]. Vascularized free flaps require microsurgical anastomoses and carry a high risk of complications and failure of graft [83]. Vascularized free flaps involve prolonged operating time and are contraindicated in peripheral arterial disease [83]. Primary bone grafting is a single-stage procedure with superior osteoconductive, osteoinductive, and osteogenic properties of the graft [85]. Primary bone grafting is associated with donor site morbidity, limited availability, risk of early resorption, and risk of relapse of infection [85]. Graft incorporation in primary bone grafting is slow and unreliable [85]. Bone graft substitutes have no donor site morbidity and allow antibiotics to be added for local release [85]. Bone graft substitutes are associated with persistent drainage from wounds and seromas, and the release of antibiotics is usually uncontrolled [85]. The induced membrane (Masquelet) technique combines the advantages of antibiotic-impregnated cement spacers with those of delayed bone grafting [85]. The induced membrane in the Masquelet technique is highly vascularized and rich in growth and osteoinductive factors [85]. The Masquelet technique is a two-stage procedure associated with an increased risk of antibiotic resistance and limited availability of bone graft [85]. The Masquelet technique can be associated with prolonged healing and recovery time [85]. Local antibiotic delivery in septic nonunions is typically with antibiotic beads between serial debridements and with antibiotic PMMA spacers or antibiotic rods after definitive wound closure [91]. Stabilization in the initial phase of septic nonunion management is with an antibiotic rod when applicable, otherwise with external fixation [91]. Repeat exposure to mesh-glue dressing is associated with allergic contact dermatitis, and clinicians should weigh the benefits of repeat use given this risk [157]. Symptoms of allergic contact dermatitis from mesh-glue dressing uniformly resolved with treatment [157]. The authors highly recommend wearing cotton gloves over latex inner gloves during orthopaedic operations [124]. The relatively high pressures generated by a simple and fail-safe digital tourniquet are not expected to have detrimental effects on neurovascular structures for short surgical procedures [41]. The initial treating physician should place the amputated part in a sponge soaked with either normal saline or Ringer’s lactate solution [92]. The wrapped amputated part should be placed into a plastic bag, which is sealed and immersed in an ice-water solution [92]. Under no circumstances should the amputated part be placed directly into ice water or exposed to dry ice [92]. A tourniquet is usually not required to control bleeding in replantation cases, and a compressive dressing should be applied to the amputation stump [92]. No attempt should be made to ligate bleeding vessels because it might compromise subsequent neurovascular repair [92]. If the amputated part is not cooled, ischemia is poorly tolerated and successful revascularization is unlikely after 6 hours [92]. Cooled parts may be replanted up to 12 hours after injury [92]. Postoperatively, the hand is protected in a loose, bulky dressing [92]. Anticoagulation should be given in the perioperative period to diminish the likelihood of anastomosis thrombosis [92]. Low-molecular-weight dextran for 5–7 days and aspirin are among the recommended regimens for anticoagulation after replantation [92]. Vasospastic agents such as nicotine, caffeine, theophylline, and theobromine should be restricted for the first few weeks after replantation or revascularization [92]. The patient should be placed on a broad-spectrum antibiotic for 5–7 days after replantation [92]. Clinical monitoring of the replanted or revascularized part may be supplemented with a pulse oximeter, laser Doppler, or temperature probe [92]. If no improvement is seen after 4–6 hours of impending failure in a replanted part, the patient may be returned to the operating room for exploration of the anastomoses [92]. Vascular revision is most successful when carried out within 48 hours of injury [92]. If failure appears secondary to poor venous outflow, the intermittent application of leeches (Hirudo species) for 1–5 days may provide transient venous drainage while adequate venous drainage is reestablished [92]. Approximately 85% of replanted parts remain viable [92]. Sensory recovery with two-point discrimination of 10 mm or less occurs in approximately 50% of adults with viable replanted parts [92]. Patients with viable replanted or revascularized parts often complain of cold intolerance during the first 2 or 3 years after replantation [92]. Amputations are a significant source of decreased function, pain, and psychosocial morbidity [87]. Despite recent advances in limb salvage techniques, rates of amputation after severe trauma have remained essentially stable [87]. Recovery from amputation requires diligent attention to appropriate surgical techniques for limb-length preservation, nerve and muscle management, and a robust, healthy terminal residuum to optimize the surgical outcome and prevent complications [87].

Complications

Implant Failure and Loosening: Silicone implants for small joint arthroplasty carry risks of fracture and stiffness [36]. Pyrocarbon implants present unique problems such as dislocations and loosening [36]. The surrounding bone does not form a stable interface with pyrolytic carbon implants, as suggested by clinical outcomes and radiographic signs of loosening [27]. In thumb carpometacarpal joint hemiresection interposition arthroplasty, revision surgery rates due to persistent pain and instability were higher with the use of implants [73].

Degenerative Changes and Instability: Major primary complications and a high incidence of radiographic signs of degenerative changes were observed after 8.8 years following bipolar radial head arthroplasty [18]. Despite these findings, mainly good clinical results were achieved with Judet's bipolar prosthesis after 8.8 years [18].

Radiographic Findings and Heterotopic Ossification: Postoperative polar gap was observed in 13 total hip arthroplasties (25%) using the Trabecular Metal Monoblock Acetabular Cup System [11]. All postoperative polar gaps observed in this study disappeared up to 6 months [11]. No periacetabular osteolysis was observed in all hips for the whole follow-up period [11]. Heterotopic ossification was observed in 10 total hip arthroplasties (20%) [11]. Seven total hip arthroplasties with heterotopic ossification were classified as grade I and three as grade II according to Brooker classification [11]. No complications and no revision of any part of the arthroplasty were reported in the 2-year follow-up [11].

Infection: The risk of superficial wound infections is 1.2% in the context of flail chest injuries [113]. The risk of serious infections with surgical fixation is 3% in the context of flail chest injuries [113]. Pneumonia and sepsis are the two most common causes of mortality in patients with flail chest injuries [113].

Fixation Failure and Hardware Issues: A study of 650 operative cases for flail chest reported a 1.2% fixation failure rate [113]. A study of 650 operative cases for flail chest reported a 1.4% plate removal rate due to discomfort and chest stiffness [113]. The use of smooth intramedullary wires for flail chest fixation should be avoided due to the risk of migration into adjacent organs [113]. The use of absorbable plates for flail chest fixation may be associated with foreign body reaction and fluid accumulation [113].

Other Considerations: Safe limits for application time and surface pressures for digital tourniquets are difficult to define [20]. The 'one size fits all' philosophy for digital tourniquets is questioned [20]. The relatively high pressures generated by a simple digital tourniquet method are not expected to have detrimental effects on neurovascular structures for short surgical procedures [41]. Glove tears during arthroscopic shoulder surgery using solid-core suture can be minimized by frequent glove changes or use of more durable, less penetrable gloves [34]. Mechanical solutions to minimize force required at the wrist to activate grip in 3D-printed custom-designed prostheses for partial hand amputation are still required [69]. Development of extension gloves for children with recessive dystrophic epidermolysis bullosa faces challenges including limited long-term use due to material and usability issues [139].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The wire-washer set functions like a bolt with washers and nuts but offers greater versatility in application, using a wire tightener to assure a precise and reproducible amount of compressive force [13]. For cellulose implants in Dupuytren's surgery, the implant is well-tolerated and facilitates rehabilitation [35]. Prompt, complete removal of hairs or strands of material causing constriction is usually sufficient to salvage the digit [50].

Functional milestones: Clinical results for external fixation of the lower extremities can be optimized through advancements in technology, materials, and smart autonomous systems [1]. Determining the medium- to long-term outcomes of recently available trapezium implants requires further study [3]. The clinical success of any non-cemented or biologically stabilized implant must be judged in comparison with the results obtained using the most contemporary cementing techniques [7]. No significant differences in functional outcomes were observed between the polymer-assisted peripheral nerve repair device and microsutures [14]. The utility attachment for cineplastic artificial arms permits the performance of work requiring heavier physical demands and allows for rapid grasp and release [15]. A lock device on the utility attachment for cineplastic artificial arms enables long-continued holding without fatigue [15]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [18]. In 15 of 17 patients, technetium-99m radionuclide imaging showed no activity during the soft tissue phase, indicating no inflammatory reaction around the implanted spongy hydroxyapatite [30]. For 3 cm of cortical contact, successful initial fixation can be achieved in most cases with both taper angle designs of titanium tapered splined stems [31]. Favorable cosmetic and functional outcomes were obtained using Integra artificial dermis for the treatment of donor site defects after pedicle flaps in hand surgery [32]. Finger extension is improved and satisfaction is high with cellulose implants in Dupuytren's surgery [35]. MatOrtho proximal interphalangeal joint arthroplasty achieves good pain relief, improvement in functional scores, and may improve range of motion, though caution is advised for stiff joints or those with significant deformity or instability [37]. The poly-ld-lactic acid scaffold for CMC arthroplasty can be considered a good alternative to traditional trapeziectomy with tendon interposition and suspensionplasty, with long-lasting satisfactory clinical results despite radiological findings of progressive collapse [42]. When the thickness is 5 mm, sufficient durability is achieved for ring orthosis design and production by rapid prototyping, providing advantages in aesthetics, time, and cost [65]. Resin-plaster bandage is a convenient and useful material for many casts, particularly for long-term wear, casts exposed to moisture, and situations requiring lightness and strength [72]. The implanted upper-extremity neuroprosthesis stimulator has proved to be safe and reliable, with seven years as the longest time in situ at the time of writing [74]. Current evidence demonstrates efficacy and safety for medical cannabis in chronic musculoskeletal and neuropathic pain, but definitive conclusions regarding efficacy in hand and upper extremity conditions require continued investigation [159]. Histology was consistent for autograft and PLLA grafts, ascribed to the PLLA resembling autograft in early load bearing, gradual resorption, and consequent load transfer to newly formed tissue [174]. Kaplan's cardinal line represents a consistent surface marker for a safe zone proximal to the superficial palmar arch [176]. Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the deltoid muscle contracture [191].

Other Considerations: No additional recovery-relevant content is present in the evidence base that does not fit the labels above.

Key Evidence

• [L5] It highlights that while complication rates have decreased, clinical results can still be optimized through advancements in technology, materials, and smart autonomous systems. [1] (10.1016/j.injury.2019.03.041)
• [L5] Advances in biomaterials have improved and expanded arthroplasty design. [2] (10.1016/j.hcl.2017.12.008)
• [Paper] While many recently available implants have been shown to have short-term success, determining the medium- to long-term outcomes require further study. [3] (10.1016/j.hcl.2012.08.020)
• [L5] There remains a need for high-level evidence regarding whether the use of 3-dimensional printed models can improve clinical outcomes. [5] (10.1016/j.jhsa.2021.05.028)
• [L5] This article provides an overview of the latest applications of 3D printing in hand surgery and practical experience of implementing them into daily clinical routine. [6] (10.1155/2021/4650245)
• [L5] The clinical success of any non-cemented or biologically stabilized implant must be judged in comparison with the results that are obtained using the most contemporary cementing techniques, not with the results of procedures that were performed using the cementing techniques of the early 1970's. [7] (10.2106/00004623-198769090-00026)
• [L5] The orthosis must be fabricated with specific positioning and material considerations to manage various hand conditions effectively. [8] (10.1016/j.jht.2022.12.004)
• [L4] This method provided an effective treatment for our patients and did not require the purchase of specialised equipment. [9] (10.1054/jhsb.2000.0390)
• [L5] During the 35 years from 1886 to 1921, operative treatment witnessed an unprecedented revolution where radiology became integral and all types of osteosynthesis were introduced into clinical practice. [10] (10.1007/s00402-010-1082-7)
• [L4] [11] (10.1016/j.arth.2008.09.027)
• [L5] Further clinical studies will be needed to determine the effectiveness of this device compared to traditional techniques. [12] (10.1186/s12891-022-05279-9)
• [L5] [13] (10.2106/00004623-195840020-00009)
• [L5] No significant differences in functional outcomes were observed between the polymer-assisted system and microsutures. [14] (10.1016/j.jhsg.2025.100812)
• [L5] The utility attachment permits the patient with a cineplastic prosthesis to perform work requiring heavier physical demands and allows for rapid grasp and release, while a lock device enables long-continued holding without fatigue. [15] (10.2106/00004623-194830010-00028)
• [L3] The GripAble is a reliable tool for measuring grip strength. [17] (10.1186/s12891-022-05026-0)
• [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. [18] (10.1016/j.jse.2010.05.022)
• [L1] Based on the current evidence, two pairs of gloves should be worn when performing a major orthopaedic procedure. [19] (10.1016/j.arth.2025.10.110)
• [L5] Safe limits for application time and surface pressures are difficult to define, and the 'one size fits all' philosophy is questioned. [20] (10.1177/1753193413492059)
• [L5] This article highlights the basic dimensions of commonly used headless screws, stand-alone lag screws, non-locking and locking screws for plating, and biocomposite screws to codify their dimensions into a readily available reference chart for the treatment of bone of varying dimensions. [21] (10.1016/j.jhsa.2014.11.012)
• [L5] The authors provide guidelines for camera selection, standard views, and image formatting to ensure accurate and precise presentation. [25] (10.1016/j.jhsa.2013.03.038)
• [L5] Its incorporation into the routine practice of the hand surgeon has the potential to improve preoperative planning, increase the accuracy of diagnosis, and reduce operative times and morbidity. [26] (10.1016/j.jhsa.2021.02.004)
• [L5] The clinical outcomes and radiographic signs of loosening suggest that the surrounding bone does not form a stable interface with pyrolytic carbon implants. [27] (10.2106/jbjs.k.00527)
• [L5] It is anticipated that 3D design and printing will become easier and more efficient, leading to mainstream utilization in clinics and hospitals. [28] (10.1016/j.jht.2019.12.018)
• [L4] [29] (10.1016/j.arth.2015.04.027)
• [L4] [30] (10.1054/jhsb.2001.0686)
• [L5] For 3 cm of cortical contact, successful initial fixation can be achieved in most cases with both taper angle designs. [31] (10.1016/j.arth.2021.04.013)
• [L4] Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. [32] (10.1016/j.jhsa.2014.08.014)
• [L5] An EBM plate is advantageous for clinical implants because it can be customized with great potential for improvement. [33] (10.1186/s13018-014-0106-3)
• [L3] Risk can potentially be minimized by frequent glove changes or use of more durable, less penetrable gloves. [34] (10.1016/j.arthro.2006.10.012)
• [Textbook] Finger extension is improved and satisfaction is high, with the implant being well-tolerated and facilitating rehabilitation. [35] (10.1007/978-3-642-22697-7_25)
• [L5] The literature is not clear as to which type of implant provides the most reliable results, though silicone implants have been reliable for many years with risks of fracture and stiffness, while newer designs like pyrocarbon present unique problems such as dislocations and loosening. [36] (10.1016/j.hcl.2010.01.003)
• [L4] Patients can be advised that the procedure achieves good pain relief, improvement in functional scores and may improve range of motion, though caution is advised for stiff joints or those with significant deformity/instability. [37] (10.1177/1753193415614251)
• [L5] Generating tissue engineered tendon constructs can be of considerable clinical benefit given the lack of adequate intrasynovial tendon graft sources, donor site morbidity, and the propensity for current methods of repair to cause adhesion formation, though this requires careful consideration of key aspects of developing a functional, durable, and biocompatible scaffold. [38] (10.1177/1753193413512432)
• [L4] The relatively high pressures generated are not expected to have detrimental effects on neurovascular structures for short surgical procedures. [41] (10.1054/jhsb.2002.0781)
• [L4] Despite radiological findings of progressive collapse, the poly-ld-lactic acid scaffold can be considered a good alternative to traditional trapeziectomy with tendon interposition and suspensionplasty, with long-lasting satisfactory clinical results. [42] (10.1177/1558944720918366)
• [Case_report] Prompt, complete removal of the hairs or strands of material is usually sufficient to salvage the digit. [50] (10.2106/00004623-199406000-00024)
• [L5] The described device enables patients in large body casts or hip spica casts to turn themselves easily and without help, maintaining a secure and comfortable position. [51] (10.2106/00004623-194830010-00035)
• [L4] [52] (10.1177/0363546507306465)
• [L3] There were significantly more cases with radiologic evidence of loosening in the uncemented group (p < .001). [59] (10.1016/j.jhsa.2008.01.030)
• [L5] Integra is an appropriate treatment for providing wound coverage and for skin defects, offering advantages such as ease of use, decreased donor site morbidity, and durable functional skin coverage. [62] (10.1016/j.jhsa.2011.11.007)
• [L4] It proved safe and effective for a wide range of indications. [63] (10.1016/j.jhsa.2013.09.034)
• [L4] When the thickness is 5 mm, sufficient durability is achieved, providing advantages in aesthetics, time, and cost. [65] (10.1016/j.jht.2019.02.003)
• [L5] [67] (10.1177/17531934251323855)
• [L4] The authors found no significant advantages of using expensive commercially produced vancomycin-impregnated cement and recommend the addition of vancomycin powder by hand in the operating theatre. [68] (10.1302/0301-620x.99b1.bjj-2016-0566.r1)
• [L4] Mechanical solutions to minimize force required at the wrist to activate grip are still required. [69] (10.1016/j.jht.2020.04.005)
• [L2] Revision surgery rates due to persistent pain and instability were higher with the use of implants. [73] (10.1177/1558944720974124)
• [L4] The implanted stimulator has proved to be safe and reliable, with seven years as the longest time in situ at the time of writing. [74] (10.2106/00004623-199704000-00008)
• [Paper] Lane's efforts to encourage internal fixation were a failure and the treatment fell into disrepute, largely because surgeons were very late in realizing that developments in metallurgy could help them. [75] (10.1016/s0020-1383(70)80246-7)
• [L5] The PW technique displayed greater stiffness and ultimate load compared with the TL. [77] (10.1016/j.jhsa.2014.10.034)
• [L5] Tissue engineering will undoubtedly play a key role in reconstructive hand surgery in the not too distant future. [78] (10.1016/j.jhsa.2017.06.014)
• [L5] Due to its improved image quality and overall practicality, the mini C-arm is recommended for hand surgical procedures. [79] (10.1177/1558944718770210)
• [L4] Health professionals are encouraged to measure key pinch to detect difficulties in opening packages. [110] (10.1016/j.jht.2012.04.003)
• [L5] Percutaneous release of the A1 pulley using a #15 blade was associated with good efficacy and an acceptable margin of safety in this series. [117] (10.1016/j.jhsa.2012.08.019)
• [L5] Suture material had no effect on this interaction. [120] (10.1016/j.jhsa.2008.12.003)
• [L5] The device converts a free electric saw into a bench saw with an adjustable table, allowing one man to cut bone grafts safely and has given complete satisfaction at the Hospital for Special Surgery over six months of use. [123] (10.2106/00004623-195032040-00030)
• [L1] The authors highly recommend wearing cotton gloves over latex inner gloves during orthopaedic operations. [124] (10.2106/00004623-199072060-00019)
• [L4] It should be considered for use in outpatient hand procedures. [129] (10.1177/1558944718812190)
• [L1] Wound care required significantly more time when non-absorbable sutures were used. [134] (10.1177/1753193409105728)
• [Case_report] This case report highlights challenges in developing extension gloves for children with recessive dystrophic epidermolysis bullosa, including limited long-term use due to material and usability issues. [139] (10.1016/j.jht.2026.01.002)
• [L1] [148] (10.1054/jhsb.2001.0554)
• [L4] A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up. [149] (10.1016/j.jhsa.2008.05.010)
• [L2] Although symptoms uniformly resolved with treatment, clinicians should weigh the benefits of repeat use of this dressing given the risk of ACD. [157] (10.1016/j.arth.2025.05.001)
• [L5] The apparatus provides a strong, steady, yet mobile table for fracture treatment in the emergency room with no trouble from undesirable motion during manipulations. [158] (10.2106/00004623-196547070-00017)
• [L4] Current evidence demonstrates efficacy and safety for chronic musculoskeletal and neuropathic pain, but definitive conclusions regarding efficacy in hand and upper extremity conditions require continued investigation. [159] (10.1016/j.jhsa.2022.11.008)
• [L5] Surgeons' hands receive the most radiation exposure during distal radial plate fixation under fluoroscopy. [163] (10.2106/jbjs.n.00839)
• [L4] However, very few highly ranked applications are available specifically related to orthopaedic surgery, and none are available specifically for hand surgeons. [165] (10.1016/s0363-5023(11)60052-x)
• [L4] [168] (10.1016/j.jhsa.2006.11.013)
• [L5] The forceps has proved helpful as a simple and secure method of handling a bone plate for fixation of a fracture, facilitating the non-touch technique and reducing the danger of dropping the plate. [169] (10.2106/00004623-194931030-00029)
• [L5] [172] (10.1016/j.jht.2013.10.004)
• [L5] Histology was consistent for autograft and PLLA grafts, ascribed to the PLLA resembling autograft in early load bearing, gradual resorption, and consequent load transfer to newly formed tissue. [174] (10.1177/2325967115s00033)
• [L4] The original description of Kaplan's cardinal line represents a consistent surface marker for a safe zone proximal to the superficial palmar arch. [176] (10.1007/s11552-009-9229-0)
• [L5] The function of the palmaris brevis is believed to be to protect the ulnar nerve and artery from overlying pressure, rather than to improve palmar grasp. [187] (10.2106/00004623-197254020-00012)
• [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. [191] (10.2106/00004623-199802000-00010)

See Also

• Dislocations
• Tumors
• Trapeziectomy

References

[1] External fixation of the lower extremities: Biomechanical perspective and recent innovations. Injury. 2019. DOI: 10.1016/j.injury.2019.03.041

[2] Advances in Proximal Interphalangeal Joint Arthroplasty. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.12.008

[3] Trapezium Prosthetic Arthroplasty (Silicone, Artelon, Metal, and Pyrocarbon). Hand Clinics. 2013. DOI: 10.1016/j.hcl.2012.08.020

[4] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[5] Three-Dimensional Printing in Hand Surgery. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.05.028

[6] Overview of In‐Hospital 3D Printing and Practical Applications in Hand Surgery. BioMed Research International. 2021. DOI: 10.1155/2021/4650245

[7] Biological fixation of porous-coated implants. The Journal of Bone & Joint Surgery. 1987. DOI: 10.2106/00004623-198769090-00026

[8] Relative motion orthoses: fabrication tips. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2022.12.004

[9] Defatting of Skin Flaps Using Arthroscopic Instruments – an Effective Alternative. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0390

[10] Early history of operative treatment of fractures. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1082-7

[11] Migration of the Trabecular Metal Monoblock Acetabular Cup System. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2008.09.027

[12] Dynamic Tendon Grip (DTG™) novel knot array compared to traditional sutures for zone two flexor tendon injury – a biomechanical feasibility study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05279-9

[13] Instruments for Use with Flexible Steel Wire in Bone Surgery. The Journal of Bone & Joint Surgery. 1958. DOI: 10.2106/00004623-195840020-00009

[14] A Novel Atraumatic Polymer-Assisted Peripheral Nerve Repair Device Compared With Microsurgical Neurorrhaphy. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100812

[15] A UTILITY ATTACHMENT FOR CINEPLASTIC ARTIFICIAL ARMS. The Journal of Bone & Joint Surgery. 1948. DOI: 10.2106/00004623-194830010-00028

[16] Chapter 58 Biomaterials. 2019.

[17] Modernising grip dynamometry: Inter-instrument reliability between GripAble and Jamar. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05026-0

[18] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[19] 2025 ICM: Gloves. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.110

[20] Variability in local pressures under digital tourniquets. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413492059

[21] Nuts and Bolts: Dimensions of Commonly Utilized Screws in Upper Extremity Surgery. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.11.012

[22] Chapter 32 Pelvic Fractures: Definitive Treatment and Outcomes. 2021.

[23] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Summary.

[24] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[25] The Art and Science of Photography in Hand Surgery. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.03.038

[26] The Use of Point of Care Ultrasound in Hand Surgery. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.02.004

[27] Questions about Implant-Bone Interface with Pyrolytic Carbon. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.k.00527

[28] A current snapshot of the state of 3D printing in hand rehabilitation. Journal of Hand Therapy. 2020. DOI: 10.1016/j.jht.2019.12.018

[29] Oxidation_of_Second_Generation_Sequentially_Irradiated_and_Annealed_Highly_Cross_S0883540315003174. The Journal of Arthroplasty. 2015. DOI: 10.1016/j.arth.2015.04.027

[30] Spongy Hydroxyapatite in Hand Surgery – A Five Year Follow-Up. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2001.0686

[31] How Does Contact Length Impact Titanium Tapered Splined Stem Stability: A Biomechanical Matched Pair Cadaveric Study. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.04.013

[32] Use of Integra Artificial Dermis to Reduce Donor Site Morbidity After Pedicle Flaps in Hand Surgery. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.08.014

[33] A study on the mechanical characteristics of the EBM-printed Ti-6Al-4V LCP plates in vitro. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/s13018-014-0106-3

[34] Glove Tears During Arthroscopic Shoulder Surgery Using Solid‐Core Suture. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.10.012

[35] 25. Cellulose Implants in Dupuytren’s Surgery. Dupuytren’s Disease and Related Hyperproliferative Disorders. 2012. DOI: 10.1007/978-3-642-22697-7_25

[36] Complications of Small Joint Arthroplasty. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.01.003

[37] MatOrtho proximal interphalangeal joint arthroplasty: minimum 2-year follow-up. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415614251

[38] Tissue engineering in flexor tendon surgery: current state and future advances. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413512432

[41] A Simple and Fail Safe Method for Digital Tourniquet. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0781

[42] Retrospective Review of Long-term Outcomes of Patients Undergoing CMC Arthroplasty With Interposition Scaffold. HAND. 2020. DOI: 10.1177/1558944720918366

[43] Orthopaedic Basic Science Fifth Edition Print Ebook. Venous Thromboembolic Disease and Fat Embolism Syndrome > Summary.

[44] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[47] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[48] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[50] Hair and thread constriction of the digits in infants. A case report.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199406000-00024

[51] A SELF-TURNING SLING DEVICE. The Journal of Bone & Joint Surgery. 1948. DOI: 10.2106/00004623-194830010-00035

[52] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[59] Cemented Versus Uncemented Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint With a Mean 5-Year Follow-Up. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.01.030

[62] The Use of Integra in Hand and Upper Extremity Surgery. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.007

[63] One-per-Mil Tumescent Technique for Upper Extremity Surgeries: Broadening the Indication. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.09.034

[65] Ring orthosis design and production by rapid prototyping approach. Journal of Hand Therapy. 2020. DOI: 10.1016/j.jht.2019.02.003

[67] From concept to market: The development journey of a new implant in hand surgery. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251323855

[68] Comparison of the elution properties of commercially available gentamicin and bone cement containing vancomycin with ‘home-made’ preparations. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b1.bjj-2016-0566.r1

[69] 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

[70] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[72] Biomaterials, Artificial Cells, and Immobilization Biotechnology. 1991.

[73] Systematic Review of Thumb Carpometacarpal Joint Hemiresection Interposition Arthroplasty Materials. HAND. 2020. DOI: 10.1177/1558944720974124

[74] An Implanted Upper-Extremity Neuroprosthesis. Follow-up of Five Patients. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199704000-00008

[75] The influence of arbuthnot lane on fracture treatment. Injury. 1970. DOI: 10.1016/s0020-1383(70)80246-7

[77] Proximal Tendon-Prosthesis Junction for Active Tendon Implants of the Hand: A Biomechanical Comparison of 2 Techniques. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.10.034

[78] Tissue Engineering in Hand Surgery: A Technology Update. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.014

[79] A Comparison of Image Quality and Radiation Exposure Between the Mini C-Arm and the Standard C-Arm. HAND. 2018. DOI: 10.1177/1558944718770210

[81] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Surface Properties.

[82] Aaos Comprehensive Orthopaedic Review 3. Biomaterials > General Information.

[83] Rockwood And Green S Fractures In Adults. 21: Psychosocial Aspects of Recovery After Trauma > Dead Space Management.

[84] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.

[85] Rockwood And Green S Fractures In Adults. 21: Psychosocial Aspects of Recovery After Trauma > Management of Bone Defects.

[86] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[87] Orthopaedic Knowledge Update Trauma. Amputations in Patients With Trauma > Summary.

[90] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[91] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Operative Treatment of Nonunion.

[92] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > 1. Replantation.

[93] Exam Of The Hand Wrist 2Ed. Techniques of investigation of the arterial supply by J P Melki > Vascularization of the thumb > Palmar aspect.

[98] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[100] Exam Of The Hand Wrist 2Ed. The dorsal skin.

[101] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[108] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > DIAGNOSIS OF DISORDERS OF THE HAND.

[110] Packaging—A Problem for Patients with Hand Disorders? A Cross-sectional Study on the Forces Applied to Packaging Tear Tabs. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2012.04.003

[113] Rockwood And Green S Fractures In Adults. Signs and Symptoms of Chest Wall Injuries > Management of Expected Adverse Outcomes and Unexpected Complications Related to Flail Chest Injuries.

[114] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

[117] Percutaneous Release of the A1 Pulley: A Cadaver Study. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.08.019

[120] Work of Flexion Related to Different Suture Materials After Flexor Digitorum Profundus and Flexor Digitorum Superficialis Tendon Repair in Zone II: A Biomechanical Study. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.12.003

[121] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Evaluation and Treatment of Musculoskeletal Tumors > Summary.

[123] A TABLE ATTACHMENT FOR THE ELECTRIC SAW. The Journal of Bone & Joint Surgery. 1950. DOI: 10.2106/00004623-195032040-00030

[124] Outer gloves in orthopaedic procedures. Cloth compared with latex.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072060-00019

[129] Intravenous Regional Anesthesia Using a Forearm Tourniquet: A Safe and Effective Technique for Outpatient Hand Procedures. HAND. 2018. DOI: 10.1177/1558944718812190

[134] A prospective randomised trial of absorbable versus non-absorbable sutures for wound closure after fasciectomy for Dupuytren’s contracture. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409105728

[139] Development and evaluation of extension gloves for children with recessive dystrophic epidermolysis bullosa: A case report. Journal of Hand Therapy. 2026. DOI: 10.1016/j.jht.2026.01.002

[148] Adverse Effect of Porcine Collagen Interposition after Trapeziectomy a Comparative Study. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0554

[149] Central Ray Deficiency: Subjective and Objective Outcome of Cleft Reconstruction. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.05.010

[157] Repeat Exposure to Mesh-Glue Dressing Is Associated With Allergic Contact Dermatitis: A Prospective Cohort Study. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.001

[158] A Successful Fracture Table for the Accident Room. The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547070-00017

[159] Medical Cannabis in Hand Surgery: A Review of the Current Evidence. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.11.008

[163] Fluoroscopic Radiation Exposure. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.00839

[165] The Use of Smartphone “Apps” among Orthopaedic Surgeons. The Journal of Hand Surgery. 2011. DOI: 10.1016/s0363-5023(11)60052-x

[168] A Simple, Semirigid, and Surgeon-Friendly Tendon Retriever and Flexor Sheath Dilator. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.11.013

[169] FORCEPS FOR GRASPING AND HOLDING BONE PLATES. The Journal of Bone & Joint Surgery. 1949. DOI: 10.2106/00004623-194931030-00029

[172] Evolution of basal joint arthroplasty and technology in hand surgery. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.10.004

[174] Long-term In-vivo Evaluation Of A Resorbable PLLA Scaffold For Regeneration Of The ACL. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00033

[176] The Clinical Application of Kaplan's Cardinal Line as a Surface Marker for the Superficial Palmar Arch. HAND. 2009. DOI: 10.1007/s11552-009-9229-0

[187] The Palmaris Brevis-A Reconsideration of Its Anatomy and Possible Function. The Journal of Bone & Joint Surgery. 1972. DOI: 10.2106/00004623-197254020-00012

[191] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010