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Procedures and Practice

Hand surgery: overview of common procedures for trauma, degeneration, congenital issues, and tumors—evidence-based & surgeon-dependent decision-making.

Overview

Patient satisfaction following hand surgery is driven more strongly by the experience of care delivery than by treatment outcomes or patient characteristics [1]. To ensure methodologic rigor and meaningful assessment of treatment durability, orthopaedic and sports medicine studies generally prefer a minimum 2-year follow-up period [2]. Shorter durations are acceptable only when clinical outcomes plateau earlier, provided the research question, diagnosis, treatment, and primary outcome measure justify the deviation [2].

Integrating evidence-based practice with patient-centeredness allows clinicians to optimize decision-making by valuing experience while recognizing its limitations [5]. This approach lets patients’ values and preferences guide the customization of evidence to achieve the best possible outcomes [5]. The minimal clinically important difference (MCID) and clinically important difference (CID) serve as useful tools for defining guidelines on whether a treatment produces clinically meaningful effects [6]. However, pitfalls associated with these metrics require a detailed understanding of their calculation methods and context of use [6].

Understanding the current evidence and appropriate indications for emerging technologies in orthopaedic trauma is critical for their utilization [10]. Surgeons should heed recommendations from pragmatic randomized controlled trials while carefully considering applicability to individual patients [17]. There is a need for more evidence-based practice guidelines regarding pain management for pediatric ACL reconstruction [4]. Additionally, universal opioid-prescribing protocols are needed to reduce the amount of opioids available for diversion without negatively impacting patient-important outcomes after orthopaedic surgery [37].

In surgical education, accurate metrics and precisely defined outcome measures are key to valid and reliable assessment [39]. Precise definition of assessment tools, such as checklists and global rating scales (GRS), is advocated for in studies measuring surgical skills in simulation-based training [39]. The level of expertise of surgeons performing procedures should be reported in published articles to ensure valid comparisons and interpretation of results [41]. Finally, successful clinical audit depends on adherence to method, supportive culture, user involvement, and addressing barriers such as lack of time, funding, and skills [40].

Anatomy & Pathophysiology

General Principles

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging [49]. These measures are utilized to limit joint stiffness while preserving mobility and function [49]. The comprehensive overview of hand anatomy, diagnosis, and treatment principles emphasizes the balance between restoring function and maintaining aesthetic appearance [89].

Congenital Anomalies

Surgical treatment for congenital failure of formation of the upper limb is directed primarily at correcting radial angulation and flexed position to improve hand function and appearance [72]. Centralization and soft tissue distraction are key concepts for severe cases [72].

Functional Anatomy

The dominant hand is stronger than the nondominant hand [42]. No difference exists in three hand strength measurements made under the same conditions [42].

Thumb CMC Dislocations

For thumb CMC dislocations, the literature lacks consensus on optimal management due to the rarity of the condition [91]. This lack of consensus relies on case reports and retrospective studies [91].

Educational Resources

The paper provides examination questions and answers regarding hand surgery anatomy and management [91].

Classification

Standardized Terminology: Standardized terminology for the trochanteric fossa or piriform fossa of the femur is recommended due to confusing and recurrent terminology errors in the literature regarding the entry point [13].

Rotterdam Classification: A modified Rotterdam classification is helpful for characterizing rare conditions of thumb triplication and tetraplication for use in patient management and communication between surgeons [50].

Other Considerations: Current classification systems for triangular fibrocartilage complex tears are largely considered unhelpful by wrist surgeons [30].

Clinical Presentation

The foundation of clinical evaluation lies in an organized, patient-centric physical examination, which is vital for developing a solid attending-patient relationship and serves as the key part of the treatment pipeline that guides the content and timing of treatment [33]. This approach integrates evidence-based practice with patient-centeredness, allowing clinicians to make decisions that optimize outcomes by valuing experience while recognizing its limitations and letting patients' values and preferences guide the customization of evidence [5]. The routine use of patient-reported outcome measures (PROMs) reflects a growing recognition of the importance of patient perspectives in improving treatments [3], and patient-reported experiences (PREMs) are expected to play a greater role in research, strategies, and clinical practice [3].

History and Patient Experience: Patient recommendations for a hand surgery clinic after surgery are more strongly driven by patients' experience with care delivery than by treatment outcome and patient characteristics [1]. Surgical patients are markedly more likely to reference clinical aspects of care, such as complications or misdiagnosis, in negative online reviews compared with nonsurgical patients, who more commonly reference nonclinical aspects [34].

Inspection and Physical Examination: Recognition of pseudo-obstruction of the colon by thorough physical examination and early abdominal radiographs is essential to avoid operative intervention [12]. For pelvic fractures with urogenital injuries, diagnosis relies on a combination of physical examination, urinalysis, and imaging [9]. Evaluation and workup of hamstring injuries, along with nonoperative treatment options and surgical decision-making, are based on patient presentation and injury patterns [14]. Terminology regarding the trochanteric fossa or piriform fossa of the femur is confusing due to recurrent errors and requires standardization [13].

Special Tests and Diagnostic Accuracy: Prospective studies are needed to establish the diagnostic accuracy of identifying red flags in patients with elbow pain [8]. Retrograde urethrogram and cystography serve as benchmarks for diagnosing pelvic fractures with urogenital injuries [9]. Key aspects of study design and analysis must be considered when evaluating available evidence supporting the diagnosis and treatment of upper-extremity conditions [11].

Red-Flag Patterns and Complex Presentations: Front-line providers must manage patients with complex regional pain syndrome en route to pain specialists to ensure timely diagnosis and treatment [35]. Early diagnosis of congenital dislocation of the hip associated with central core disease is valuable as it may reduce soft-tissue tightness and improve outcomes [36]. There is a need for more evidence-based practice guidelines regarding pain management in pediatric ACL reconstruction [4].

Outcome Metrics and Management Guidelines: The minimal clinically important difference (MCID) and clinically important difference (CID) are useful tools to define general guidelines for determining whether a treatment produces clinically meaningful effects [6]. Pitfalls associated with MCID and CID metrics require a detailed understanding of the methods to calculate them and their context of use [6]. Guidelines recommend a 'patient blood management' approach to diagnose and treat anaemia, minimize blood loss, and optimize the patient's physiological response in orthopaedic surgery [31]. Early recognition, objective documentation, and timely intervention are essential to optimize outcomes for both the trainee and the program in the management of a struggling fellow [16].

Investigations

Plain radiography: Radiographic measurements contain inherent errors and are not an exact science; clinical decisions should not be based on radiographic measurements alone but rather on the total clinical evaluation of the patient [80]. Roentgenograms can demonstrate fracture union and absence of avascular necrosis in severe hip injuries, such as fracture-dislocations of the femoral head [108]. A standardized fluoroscopy language protocol improves intraoperative communication between orthopaedic surgeons and radiology technologists, decreases confusion, and reduces the need for repeat radiographs [86].

MRI: Ultrasonography is an effective alternative to MRI for diagnosing musculoskeletal pathology, offering real-time imaging, excellent soft-tissue contrast, and high spatial resolution without radiation exposure [38]. The utility of ultrasonography in orthopaedic surgery remains underutilized compared to other diagnostic modalities [38]. Reproducible scales are essential for the valid evaluation of cartilage repair, whether through histology or noninvasive MRI techniques [83].

CT: Computerized tomography is a valuable technical advance for diagnosing orthopaedic conditions, although its clinical efficacy and cost-effectiveness in trauma and other applications require further bulk studies to determine optimal use [76]. O-ARM CT-guided navigation for percutaneous iliosacral screw fixation in unstable pelvic ring lesions minimizes X-ray dose, invasiveness, and morbidity [92].

Bone scan: Technetium scans can demonstrate fracture union and absence of avascular necrosis in severe hip injuries, such as fracture-dislocations of the femoral head [108].

Other Considerations: Prospective studies are needed to establish the diagnostic accuracy of identifying red flags in patients with elbow pain [8]. Recognition of pseudo-obstruction of the colon in orthopaedic patients requires thorough physical examination and early abdominal radiographs to avoid operative intervention [12]. Optimal function of Computer Aided Orthopaedic Surgery (CAOS) systems and surgeon familiarity are critical to avoid errors and ensure patient safety [24]. A technique for accurate localization of vertebrae at surgery is rapid, simple, and offers unparalleled accuracy in identifying the involved vertebral area without introducing a substance that cannot be readily removed [101]. A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up in central ray deficiency cleft reconstruction [110]. More than two-thirds of clinical management questions on the Orthopaedic In-Training Examination were supported by studies with a level of evidence of IV or lower [81]. All subpectoral, suprapectoral, and top-of-groove biceps tenodesis techniques resulted in excellent clinical improvement based on patient-reported outcome measures from a global registry [95]. A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for the evaluation and management of acetabular fractures [105].

Treatment

Non-Operative

Conservative management is often the primary approach for several conditions. Nonsurgical management of adhesive capsulitis of the hip is frequently successful, though it requires patient compliance and can be protracted [26]. For deep gluteal pain, nonsurgical management represents the mainstay of treatment [82]. Voluntary habitual dislocation of the hip should also be treated conservatively via immobilization or even without it, as the prognosis is good and the condition resolves spontaneously [79]. In pediatric cases, moderate nonprogressive coxa vara often does not require surgery [77]. Similarly, conservative management is indicated for spinal fractures and dislocations complicating ankylosing spondylitis in patients without neural involvement [61]. A patient with an osteochondritis dissecans lesion of the trochlear groove was successfully managed nonoperatively with a locked knee brace, returning to full activity in 5 months without complication [66].

Operative

Indications: Surgical intervention is indicated for coxa vara in childhood when there is progressive, painful, unilateral deformity or leg-length discrepancy [77]. For spinal fractures and dislocations complicating ankylosing spondylitis, immediate exploration followed by fusion is indicated in patients with progressive neural involvement or instability [61]. In non-elite patients, persistent grade 2 or 3 medial collateral ligament (MCL) laxity beyond 12 weeks in the setting of anterior cruciate ligament (ACL) rupture should prompt combined ACL reconstruction with MCL repair and reconstruction [74]. For advanced Dupuytren disease, dermofasciectomy is effective and durable, particularly with appropriate postoperative care [20]. Contralateral C7 transfer is indicated for stroke or brain-injured patients to improve upper limb function [21]. Open and endoscopic surgical approaches are indicated for deep gluteal pain in refractory cases [82].

Surgical Approach / Technique: Surgical decision-making for hamstring injuries is based on patient presentation and injury patterns, alongside evaluation, workup, and nonoperative treatment options [14]. The team physician should advocate for a balance between surgical and nonoperative management [73].

Adjuncts: Quality improvement methods were effective in altering long-term opioid prescribing behavior by physicians in hand surgery [7]. Evidence-based practice guidelines for pain management in pediatric ACL reconstruction are needed [4].

Other Considerations: Integrating evidence-based practice with patient-centeredness allows clinicians to optimize decision-making, value experience while recognizing its limitations, and let patients' values and preferences guide the customization of evidence to achieve the best possible outcomes [5]. Surgeons should heed recommendations from pragmatic randomized controlled trials while carefully considering their applicability to individual patients [17]. Understanding the current evidence and appropriate indications for emerging technologies is critical for their utilization in orthopaedic trauma [10]. Experience in the orthopaedic management of Schwartz syndrome is scanty as reported patients were not followed beyond the age of twelve years [63].

Complications

Other Considerations: Quality improvement methods effectively alter physician opioid prescribing behavior in the long term [7]. Overlapping surgery appears safe and noninferior to nonoverlapping surgery regarding postoperative complications, reoperation, readmission, morbidity, and mortality [48]. The incidence of early complications in volar plating of distal radius fractures decreases significantly with increased surgeon experience [65]. Surgical disciplines in hand surgery face challenges regarding complication rates and cost-effectiveness [87]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity over time in Autologous Matrix-Induced Chondrogenesis for focal cartilage defects [19]. Long-term outcomes for pelvic ring injuries are complicated by posterior pelvic pain and are largely multifactorial [23].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return. However, patient recommendations for hand surgery clinics are driven more strongly by the experience with care delivery than by treatment outcome or patient characteristics [1].

Full activity (months): Evidence does not provide specific month ranges for full activity, manual work, or sport return. For adhesive capsulitis of the hip, nonsurgical management is often successful but requires a protracted amount of time and strict patient compliance [26]. In contrast, dermofasciectomy for advanced Dupuytren disease is efficacious and durable with appropriate postoperative care [20].

Complete recovery / outcome plateau (months): A 2-year minimum follow-up period is generally preferred to ensure methodologic rigor and meaningful assessment of treatment durability, although shorter durations may be justified when clinical outcomes plateau earlier depending on the research question, diagnosis, treatment, and primary outcome measure [2]. Long-term outcomes for pelvic fractures are dependent on the pelvic ring injury and associated injuries, complicated by posterior pelvic pain but largely multifactorial [23]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity over time following autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [19].

Rehabilitation protocol: Functional results for endoprosthetic replacement of the humerus combined with trapezius and latissimus dorsi transfer do not justify two separate approaches and a prolonged operation time [96]. Contralateral C7 transfer harnessing the uninjured hemisphere demonstrates significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient [21].

Functional milestones: The routine use of patient-reported outcome measures (PROMs) reflects a growing recognition of the importance of patient perspectives in improving treatments [3]. Patient-reported experiences (PREMs) are expected to play a greater role in research, strategies, and clinical practice [3]. The Musculoskeletal Function Assessment Questionnaire was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [94].

Other Considerations: Quality improvement methods were effective in altering opioid prescribing behavior by physicians in the long term [7]. Diagnosis of pelvic fractures with urogenital injuries relies on a combination of physical examination, urinalysis, and imaging, with retrograde urethrogram and cystography serving as benchmarks [9]. Early recognition, objective documentation, and timely intervention are essential to optimize outcomes for both the trainee and the program in the management of a struggling fellow [16]. Much of the literature from fifty and 100 years ago remains relevant to the practice of orthopaedic surgery today [22]. Using fragility indices, especially when considering patient loss to follow-up, can improve the reliability of findings in randomized controlled trials [25]. Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [114].

Key Evidence

  • [L3] Patient recommendations are more strongly driven by patients' experience with care delivery than by treatment outcome and patient characteristics. (10.1016/j.jhsa.2023.11.010)
  • [L5] While a 2-year minimum follow-up period is generally preferred to ensure methodologic rigor and meaningful assessment of treatment durability, the authors encourage authors to justify shorter durations when clinical outcomes plateau earlier, depending on the research question, diagnosis, treatment, and primary outcome measure. (10.1016/j.arthro.2025.08.019)
  • [L5] The routine use of PROMs reflects a growing recognition of the importance of patient perspectives in improving treatments, and it will only be a matter of time before patient-reported experiences (PREMs) play a greater role in research, strategies, and clinical practice. (10.1302/0301-620x.97b7.36546)
  • [L4] There is a need for more evidence-based practice guidelines regarding pain management. (10.1177/2325967121s00449)
  • [L5] Integrating the principles and processes from evidence-based practice with those of patient-centeredness allows clinicians to make decisions that help achieve the best possible outcomes by optimizing decision making, valuing experience while recognizing its limitations, and letting patients' values and preferences guide the customization of evidence. (10.1016/j.jht.2009.09.002)
  • [L5] The MCID and CID are useful tools to define general guidelines to determine whether a treatment produces clinically meaningful effects, but the many pitfalls associated with these metrics require a detailed understanding of the methods to calculate them and their context of use. (10.1186/s13018-014-0144-x)
  • [L4] Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. (10.2106/jbjs.19.01052)
  • [L4] Prospective studies are needed to establish diagnostic accuracy. (10.1016/j.jht.2026.02.009)
  • [L5] Diagnosis relies on a combination of physical examination, urinalysis, and imaging, with retrograde urethrogram and cystography serving as benchmarks. (10.5435/jaaos-d-25-01053)
  • [L5] It is important to consider the key aspects of study design and analysis when considering the available evidence supporting the diagnosis and treatment of upper-extremity conditions. (10.1016/j.jhsa.2023.04.002)
  • [L4] Recognition by thorough physical examination and early abdominal radiographs is essential if operative intervention is to be avoided. (10.2106/00004623-198365060-00030)
  • [Paper] The recommended entry point in literature is confusing due to recurrent terminology errors and requires standardisation. (10.1016/j.injury.2012.08.049)
  • [L5] This current concepts review highlights the evaluation and workup of hamstring injuries, nonoperative treatment options, and surgical decision-making based on patient presentation and injury patterns. (10.1177/03635465231164931)
  • [Paper] Consequently, no specific clinical conclusions regarding patient outcomes or interventions are stated. (10.2106/00004623-196143060-00017)
  • [L5] Early recognition, objective documentation, and timely intervention are essential to optimize outcomes for both the trainee and the program. (10.2106/jbjs.25.01198)
  • [L5] Surgeons should heed recommendations from pragmatic RCTs while carefully considering applicability to individual patients. (10.1302/0301-620x.101b2.bjj-2018-1352.r1)
  • [L4] Universal guidelines and recommendations for applicants and PDs would improve the utility of preference signaling. (10.5435/jaaos-d-23-00220)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L3] These findings underscore the efficacy and durability of dermofasciectomy in managing advanced cases, particularly with appropriate postoperative care. (10.1016/j.jhsa.2025.02.007)
  • [L5] Published clinical results have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient. (10.1177/17531934251314640)
  • [L5] Much of what is in the literature fifty and 100 years ago remains relevant to the practice of orthopaedic surgery today. (10.2106/00004623-199173090-00001)
  • [L5] This collection of abstracts introduces fundamental principles, potential pitfalls, and various modalities of Computer Aided Orthopaedic Surgery (CAOS), highlighting that while clinical benefits are recognized, optimal system function and surgeon familiarity are critical to avoid errors and ensure patient safety. (10.1016/j.injury.2004.05.022)
  • [L1] Using these indices, especially when considering patient loss to follow-up, can improve the reliability of findings. (10.5435/jaaos-d-24-00691)
  • [L5] Nonsurgical management is often successful but can take a protracted amount of time and requires patient compliance. (10.5435/00124635-201312000-00005)
  • [L5] Current classification systems are largely considered to be unhelpful. (10.1177/1753193419826459)
  • [L5] The guidelines recommend a 'patient blood management' approach to diagnose and treat anaemia, minimize blood loss, and optimize the patient's physiological response. (10.1302/0301-620x.105b8.bjj-2022-1290.r1)
  • [L4] An ideal app should include home program media, evidence-based practice, postoperative protocols, and functional outcome measures related to reported diagnoses encountered in the clinic. (10.1016/j.jht.2016.11.010)
  • [L5] An organized, patient-centric physical examination is vital for developing a solid attending-patient relationship and serves as the key part of the treatment pipeline that guides the content and timing of treatment. (10.1016/j.arthro.2017.10.001)
  • [L4] Surgical patients were markedly more likely to reference a clinical aspect of care, such as complications or misdiagnosis compared with nonsurgical patients, who more commonly referenced nonclinical aspects of care. (10.5435/jaaos-d-22-00631)
  • [L5] The authors assert that pain specialists are the rightful owners of complex regional pain syndrome care, but front-line providers must manage patients en route to specialists to ensure timely diagnosis and treatment. (10.1016/j.injury.2010.11.019)
  • [L4] Early diagnosis is valuable as it may reduce soft-tissue tightness and improve outcomes. (10.2106/00004623-197557050-00011)
  • [L5] There is a need for more universal opioid-prescribing protocols to reduce the amount of opioids available for diversion without a negative impact on patient-important outcomes. (10.2106/jbjs.17.01480)
  • [L5] Ultrasonography is an effective alternative to MRI for diagnosing musculoskeletal pathology, offering real-time imaging, excellent soft-tissue contrast, and high spatial resolution without radiation exposure, though its utility remains underutilized in orthopaedic surgery compared to other modalities. (10.5435/jaaos-d-16-00221)
  • [L5] The authors advocate for precise definition of assessment tools (checklists and GRS) in any study and emphasize that accurate metrics and precisely defined outcome measures are key to valid and reliable assessment in surgical education. (10.5435/jaaos-d-17-00875)
  • [L5] The paper reviews guidelines for clinical audit, emphasizing that successful audit depends on adherence to method, supportive culture, user involvement, and addressing barriers such as lack of time, funding, and skills. (10.1177/175899830300800105)
  • [L5] The level of expertise of surgeons performing procedures should be reported in published articles to ensure valid comparisons and interpretation of results, and the Journal has adopted specific criteria to standardize this reporting. (10.1177/1753193416641590)
  • [L5] Success stories inspire us, but failures teach us, and both need to be heard to ensure that well-designed studies with negative or poor outcomes are published and valued. (10.1002/ksa.70164)
  • [L5] Pilot and feasibility studies focus on the processes of the study and not efficacy, with statistical analyses often greatly underpowered due to small sample sizes. (10.1258/ht.2012.012012)
  • [L4] Despite the existence of national guidelines, they are not fully implemented across all localities. (10.1177/1753193420974244)
  • [L5] The commentary concludes that overlapping surgery appears safe and noninferior to nonoverlapping surgery regarding postoperative complications, reoperation, readmission, morbidity, and mortality, and that institutional policies and peer-review processes are necessary to ensure patient safety and efficiency. (10.2106/jbjs.19.01507)
  • [L4] The modified classification may be helpful for characterizing the rare conditions of thumb triplication and tetraplication for use in patient management and communication between surgeons. (10.1177/17531934231173111)
  • [L4] Conservative management is indicated for patients without neural involvement, while immediate exploration followed by fusion is indicated for those with progressive neural involvement or instability. (10.2106/00004623-196749020-00012)
  • [L4] Experience in orthopaedic management is scanty as none of the reported patients were followed beyond the age of twelve years. (10.2106/00004623-197557040-00018)
  • [L4] The incidence of complications decreased significantly with increased surgeon experience, suggesting that many early complications are avoidable. (10.1007/s11552-010-9313-5)
  • [Case_report] The patient was successfully managed nonoperatively with a locked knee brace and returned to full activity in 5 months without complication. (10.1155/2021/9776362)
  • [L5] Surgical treatment is directed primarily at correcting radial angulation and flexed position to improve hand function and appearance, with centralization and soft tissue distraction being key concepts for severe cases. (10.1016/j.hcl.2008.10.005)
  • [L5] The author emphasizes that the role of the team physician is evolving, requiring availability, trust, and the ability to navigate complex return-to-play decisions amidst external pressures, while advocating for a balance between surgical and nonoperative management. (10.1177/0363546512468428)
  • [L5] In non-elite patients, persistent grade 2 or 3 laxity beyond 12 weeks should prompt combined anterior cruciate ligament reconstruction with MCL repair and reconstruction. (10.1002/arj.70105)
  • [L5] While computerized tomography is a valuable technical advance for diagnosing orthopaedic conditions, the question of how to make the best use of this tool, particularly regarding clinical efficacy and cost-effectiveness in trauma and other applications, remains to be answered through bulk studies. (10.2106/00004623-197860080-00013)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [Case_report] The condition should be treated conservatively by immobilization or even without it, as the prognosis is good and the condition resolves spontaneously. (10.2106/00004623-198466070-00025)
  • [L5] Radiographic measurements are not an exact science and contain inherent errors; clinical decisions should not be based on measurements alone but rather on the total clinical evaluation of the patient. (10.2106/00004623-199072030-00001)
  • [L4] More than two-thirds of clinical management questions on the Orthopaedic In-Training Examination were supported by studies whose level of evidence was IV or lower, reflecting the state of the art of the orthopaedic literature rather than a deficiency in the examination itself. (10.2106/jbjs.i.00530)
  • [L5] Although nonsurgical management represents the mainstay of treatment, open and endoscopic surgical approaches have yielded encouraging success rates in refractory cases. (10.5435/jaaos-d-21-00707)
  • [L5] Reproducible scales are essential for valid evaluation of cartilage repair, whether through histology or noninvasive MRI techniques. (10.1177/0363546510369651)
  • [L3] A standardized fluoroscopy language protocol improves intraoperative communication between orthopaedic surgeons and radiology technologists, decreases confusion, and reduces the need for repeat radiographs. (10.5435/jaaos-d-20-00314)
  • [L5] Surgical disciplines in hand surgery have seen evolutionary developments in Dupuytren disease treatment, nerve reconstruction, and hand transplantation that have substantially modified practice, though challenges remain regarding complication rates and cost-effectiveness. (10.5435/jaaos-21-04-202)
  • [L5] The paper provides examination questions and answers regarding hand surgery anatomy and management, noting that for thumb CMC dislocations, the literature lacks consensus on optimal management due to the rarity of the condition and reliance on case reports and retrospective studies. (10.1177/17531934231186529)
  • [Paper] It meets the basic principles of computer-assisted surgery, minimizing X-ray dose, invasiveness and morbidity. (10.1016/j.otsr.2013.03.002)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L3] All techniques resulted in excellent clinical improvement based upon PROMs from a global registry. (10.1016/j.arthro.2023.01.038)
  • [L5] Therefore, the functional results do not justify two separate approaches and a prolonged operation time. (10.1007/s00402-004-0713-2)
  • [L4] The technique is rapid, simple, and offers unparalleled accuracy in identifying the involved vertebral area without introducing a substance that cannot be readily removed. (10.2106/00004623-195739030-00022)
  • [Case_report] Despite the severity of the injury to the hip, roentgenograms and a technetium scan showed the fracture to be united, with no evidence of avascular necrosis. (10.2106/00004623-197961080-00018)
  • [L4] A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up. (10.1016/j.jhsa.2008.05.010)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)

See Also

References

[1] Driving Factors of Recommending a Hand Surgery Clinic After Surgery. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.11.010

[2] Rethinking Standards for Minimum Short-Term Follow-Up Duration for Clinical Outcome in Orthopaedic and Sports Medicine Studies. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2025.08.019

[3] What are the key drivers that change practice?. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b7.36546

[4] Variability Exists in Pain Management Practices for Pediatric ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00449

[5] ASHT President's Lecture: Making Decisions Using Values, Experience, and Evidence. Journal of Hand Therapy. 2010. DOI: 10.1016/j.jht.2009.09.002

[6] Determining the clinical importance of treatment benefits for interventions for painful orthopedic conditions. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-014-0144-x

[7] Evaluation of Quality Improvement Methods for Altering Opioid Prescribing Behavior in Hand Surgery. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01052

[8] The importance of identifying red flags in patients with elbow pain: A systematic review. Journal of Hand Therapy. 2026. DOI: 10.1016/j.jht.2026.02.009

[9] Management of Pelvic Fractures With Urogenital Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-25-01053

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

[11] Study Design and Analysis in Hand Surgery Research: Tips for Success. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.04.002

[12] Pseudo-obstruction of the colon. A postoperative complication in orthopaedic patients.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365060-00030

[13] Trochanteric fossa or piriform fossa of the femur: Time for standardised terminology?. Injury. 2013. DOI: 10.1016/j.injury.2012.08.049

[14] Hamstring Injuries: A Current Concepts Review: Evaluation, Nonoperative Treatment, and Surgical Decision Making. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231164931

[15] News Notes. The Journal of Bone & Joint Surgery. 1961. DOI: 10.2106/00004623-196143060-00017

[16] Fellowship Directors Forum: Strategies for the Management of a Struggling Fellow. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.25.01198

[17] The challenges of translating the results of randomized controlled trials in orthopaedic surgery into clinical practice. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b2.bjj-2018-1352.r1

[18] Perceptions of Preference Signaling in Orthopaedic Surgery: A Survey of Applicants and Program Directors. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00220

[19] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[20] A Longitudinal Analysis of 281 Cases of Dermofasciectomy Efficacy in Advanced Dupuytren Disease Cases: A 20-Year Perspective. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.02.007

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

[22] A sense of history.. The Journal of Bone & Joint Surgery. 1991. DOI: 10.2106/00004623-199173090-00001

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

[24] Abstracts. Injury. 2004. DOI: 10.1016/j.injury.2004.05.022

[25] Beyond the Usual Significance: Fragility Indices of Randomized Controlled Trials in Top General Orthopaedic Journals. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00691

[26] Adhesive Capsulitis of the Hip: A Review. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201312000-00005

[30] Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419826459

[31] The importance of anaemia in orthopaedic surgery. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b8.bjj-2022-1290.r1

[32] Exploring the needs of certified hand therapists regarding electronic applications. Journal of Hand Therapy. 2018. DOI: 10.1016/j.jht.2016.11.010

[33] Principles That Will Improve Your Physical Examination. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.10.001

[34] Characterizing Single-star Negative Online Reviews of Orthopaedic Trauma Association Members. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00631

[35] Complex regional pain syndrome after musculoskeletal trauma: Who owns the monkey?. Injury. 2011. DOI: 10.1016/j.injury.2010.11.019

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[38] Ultrasonography as a Diagnostic, Therapeutic, and Research Tool in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00221

[39] Measuring Surgical Skills in Simulation-based Training. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00875

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[48] Overlapping Surgeries: Where to Draw the Line?. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01507

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[50] Triplication and tetraplication of the thumb: a modification of the Rotterdam classification. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231173111

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[82] Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-21-00707

[83] Interpretive Skills. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510369651

[86] Use of Standardized Language for C-arm Fluoroscopy Improves Intraoperative Communication and Efficiency. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00314

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