Flexor tendon injuries are a common result of trauma to the hand. The mechanisms of injury often result in open wounds with contamination and infection. The complications associated with infected wounds pose challenges to flexor tendon repair. Management entails adequate eradication of infection and tissue healing prior to tendon repair. Whilst guidelines exist for the management of flexor tendon injuries of the hand, the literature puts little emphasis on the management of these cases with the presence of concomitant infection. Creating clear outlines to adequately manage such cases would aid future management for optimal outcomes. A comprehensive search of literature was conducted. Articles published in English within the last 20 years were used. Wounds with macroscopic wound contamination should receive empiric antibiotics. There is little evidence supporting prophylactic antibiotics. Pyogenic flexor tenosynovitis should be immediately taken to theatre. If possible, primary tendon repair is the ideal method of repair, however this is often limited by infection. The choice of secondary reconstruction depends on timing and extent of injury. If there is loss of nerve function, a tendon transfer is required. Tendon grafts are used in cases of loss of tendon length. A damaged tendon sheath requires two-stage tendon reconstruction. Infected wounds are a common complicating presenting factor in flexor tendon injuries. Empiric antibiotics in complex and contaminated wounds is essential. Primary tendon repairs have the best outcomes, however repair should be withheld until granulation tissue develops. Secondary repair options should be looked at on a case-specific basis.

To identify and summarize all primary studies addressing clinical results of patients undergoing denervation surgery for hand and wrist conditions. We searched seven electronic databases, including MEDLINE (Ovid MEDLINE ALL, 1946 to present), Embase (OVID, 1974 to present), and the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We included any primary study addressing clinical outcomes of patients undergoing denervation surgery of the hand and wrist, regardless of their design or language. Two independent authors screened the studies. Three reviewers extracted the data, and two assessed the risk of bias using the MINORS score. 72 studies were included in this review, 65 already published, and seven ongoing studies. Most studies are of low level of evidence, and the majority (66%) were performed in Europe. Forty-three studies (60%) reported outcomes on wrist denervation surgery, 16 on first carpometacarpal denervation surgery, and nine on digit joints denervation. Overall, hand and wrist denervation surgery seems to be a safe, pain-relieving, and motion-preserving treatment option for painful arthropathy. Nevertheless, surgeons must advise patients that revision surgery could be needed. High-quality, prospective, comparative studies are missing for wrist and hand denervation to provide strong evidence-based recommendations.

Anatomic total shoulder arthroplasty (TSA) has advanced considerably in recent decades, with the glenoid component recognized as a pivotal determinant of patient outcomes. This review integrates current literature and biomechanical insights surrounding contemporary glenoid implant designs, including all-polyethylene, hybrid, metal-backed, augmented, and inlay options. It examines key considerations such as the balance between conforming and nonconforming articulations, differences between keeled and pegged fixation, and how implant characteristics affect micromotion, radiolucency, and loosening risks. Additionally, innovative technologies like patient-specific instrumentation, computer-assisted surgery, and artificial intelligence are discussed in relation to improving implant positioning and surgical precision. By collating available evidence and implant strategies for glenoid replacement in anatomic TSA, this article aims to assist orthopaedic surgeons in making informed, patient-specific implant choices based on individual anatomy and functional requirements.

Varus-posteromedial rotatory instability (VPMRI) of the elbow is a relatively uncommon yet significant injury that can often present with subtle clinical symptoms, such as mild joint misalignment. These initial symptoms may be easily overlooked or misdiagnosed, especially in the absence of overt signs of instability. As a result, the injury is frequently missed in early stages, leading to improper or delayed treatment. If left untreated, VPMRI can result in severe long-term complications, including rapid joint degeneration, traumatic arthritis, heterotopic ossification, elbow stiffness, and ulnar nerve entrapment. The progressive nature of these issues can lead to permanent functional impairment and reduced quality of life. A comprehensive literature review was performed to investigate the study objective. By examining both conservative and surgical interventions, the review provides a comprehensive understanding of this injury, emphasizing the importance of early diagnosis and appropriate management. Understanding the specific forces involved, such as axial loading, varus stress, and forearm pronation, is crucial for developing effective treatment strategies. Early intervention can prevent long-term complications and improve functional outcomes, making timely and accurate diagnosis essential for optimal care.

Surgical and technological advancements have revolutionized myoelectric prosthetic options for patients with upper extremity amputations, but partial hand amputations have remained a challenge. The Starfish procedure is a novel surgical technique that involves transferring intrinsic hand muscles to a subcutaneous location to allow immediate signal detection and independent digital control of a myoelectric prosthesis. We report the outcomes of our cohort of patients treated with this procedure. Twenty-one patients underwent the Starfish procedure between 2015 and 2021. All patients had a postoperative evaluation with an Ottobock Myoboy to determine if they had viable signals from interossei transfers. All patients completed a specialized survey for amputees, depression, and PTSD surveys. All patients had recordable myoelectric signals at each muscle transfer. Three patients were lost to follow-up and three patients were multi-extremity amputees and therefore their DASH scores were not included given the confounding associated injuries thus 15 patients were available for outcomes data. 14 out of 15 remaining patients (93%) obtained a myoelectric prosthesis. Patients reported using their prosthesis an average of 5.5h per day and 5.5 days per week. The average DASH score prior to surgery was 67.9 and after surgery was 40.5 (p=0.014). VAS Pain scores were 3.8 for residual limb pain and 2.7 for phantom pain. Mean follow-up was 2.1 years. 71% of patients reported being "extremely" or "very" satisfied with the overall function of their prosthesis. The most common functional activities that the prosthesis allowed patients to perform include dressing, housework, meal preparation and eating. 73% of previously working patients were able to return to employment. The Starfish procedure provides immediately detectable superficial myoelectric signals that allow intuitive and independent finger control. At 2-year follow up, patients have a high satisfaction rate, consistent myoelectric prosthetic use, improved DASH scores, and a high rate of return to work.

To review the utility of the Superficial Circumflex Iliac Artery Perforator (SCIP) flap for a wide range of defect reconstructions, emphasizing the groin's vascular anatomy, relevant anatomical variations, and recent advancements overcoming traditional groin flap limitations. Based on a literature review, anatomical knowledge, and clinical experience, this article summarizes the variations of the superficial circumflex iliac artery (SCIA), surgical techniques for SCIP flap harvesting, and the role of preoperative color Doppler ultrasound mapping for safe and efficient flap elevation. The SCIA displays significant anatomical variations, necessitating thorough preoperative assessment for successful flap harvest. The perforator flap concept and supermicrosurgery have addressed the challenges of the traditional groin flap's short, small pedicle, making the SCIP flap a more reliable option. The SCIP flap offers remarkable versatility by potentially including multiple tissues-skin, fat, lymphatic vessels, lymph nodes, deep fascia, sartorius muscle, lateral femoral cutaneous nerve, and iliac bone-allowing its use as a chimeric flap for a broad spectrum of defects, ranging from simple to complex. With a comprehensive understanding of groin vascular anatomy and appropriate preoperative evaluation, including color Doppler ultrasound, the SCIP flap is a reliable and highly versatile reconstructive tool. Its ability to incorporate various tissues and minimal donor site morbidity, with scars concealable under clothing, make it an excellent choice for various reconstructive challenges.

In upper brachial plexus (C5-C6) avulsion injuries, deltoid reinnervation via radial-to-axillary nerve transfer is standard. However, fracture-dislocations around the shoulder complicate surgical exposure due to fibrosis and distorted anatomy. Fifteen male patients (mean age: 26.1 years) with C5-C6 avulsion injuries and concomitant shoulder fractures were treated between October 2019 and April 2022 using a modified posterior approach. The "teres major first" technique utilized the inferior border of the teres major muscle as a consistent landmark to identify and mobilize the long head triceps branch and anterior axillary nerve. A vertical slit in the teres major tendon improved access and allowed tension-free coaptation. All patients also received spinal accessory to suprascapular nerve transfers, and partial ulnar and/or median nerve transfers for elbow flexion restoration. All patients had fibrous adhesions in the quadrangular space, and 3 had distal axillary nerve injuries. The teres major landmark enabled safe dissection in all cases. Twelve of 15 patients achieved deltoid reinnervation with active shoulder abduction between 110° and 170° (mean 156°; MRC grade III-IV). Three patients (2 with proximal humerus fractures and 1 with lateral clavicle fracture with coracoclavicular disruption) showed limited recovery (70°-80° abduction). Triceps donor site weakness (MRC grade ≥3 in 14/15) was tolerated well, and full elbow flexion was restored in all patients. EMG evidence of reinnervation appeared by week 21 (deltoid) and week 23 (infraspinatus), with improvement in active shoulder abduction from week 27 onward. The "teres major first" approach enables rapid and safe identification of target nerves in brachial plexus injuries complicated by shoulder fractures and dislocations. This technique minimizes dissection in fibrotic areas, ensures tension-free repair, and achieves reliable functional outcomes. However this study is limited by the relatively small sample size and a reduced statistical power.

Open fractures of the distal phalanx are common injuries with the potential for significant complications, yet standardized treatment guidelines remain lacking. Surgical debridement and antibiotic administration are crucial steps in the management of open fractures, but the optimal timing and combination of these interventions remain uncertain. This systematic review evaluates the impact of surgical debridement timing and antibiotic administration on complications, including infections, malunion and non-union, physeal closure disturbances, and nail deformities, with a focus on differences between adult and pediatric population. Following PRISMA 2020 guidelines, a comprehensive literature search of Medline, Embase, and Cochrane Library was conducted. Studies examining open distal phalanx fractures treated with surgical debridement, with or without antibiotics, were included. Pediatric (<18 years) and adult (≥18 years) populations were analyzed separately, and subgroup analyses were performed based on treatment timing. Statistical comparisons utilized chi-squared tests with significance set at p<0.05. A total of 24 studies, including 915 fractures, were analyzed. The average patient age was 16.48 years, with males comprising 78.1%. Early debridement (<24h) was performed in 91.0% of cases. Pediatric patients had significantly higher complication rates than adults, particularly for infections and malunion/non-union. Infections rates were lowest when debridement occurred within 8h and increased significantly with delays beyond 24h (p<0.00001). Antibiotic administration with surgical debridement was associated with lower infection rates, particularly in pediatric patients. Among pediatric fractures treated with delayed debridement (>24h), those receiving antibiotics alone had significantly lower infection rates than those receiving both debridement and antibiotics (p=0.009), suggesting potential preselection bias. Malunion/non-union was more frequent in pediatric patients and strongly associated with delayed intervention (>24h). Nail deformities were most commonly seen in debrided fractures, emphasizing the importance of meticulous surgical technique. Early surgical debridement (<8h) as the preferred management strategy for open distal phalanx fractures, minimizing infection and complication rates. Delayed debridement (>24h) significantly worsened outcomes, particularly in pediatric patients. Antibiotic administration reduced infection rates but was not a substitute for timely debridement. These findings highlight the need for standardized treatment protocols and further comparative studies to optimize management strategies across different age groups.

Exploratory study, level of evidence IV.