What’s New in Hand and Wrist Surgery

This Guest Editorial provides an overview of the latest articles in the hand and wrist literature from 2023 to 2024, mostly from The Journal of Hand Surgery, The Journal of Hand Surgery (European Volume), HAND, Plastic and Reconstructive Surgery, and The Journal of Bone & Joint Surgery. The intent is to provide an update for the practicing general orthopaedic surgeon regarding the latest findings and innovations in the hand and wrist literature. Carpus Scaphoid Nonunion In the treatment of scaphoid nonunions, there continues to be controversy on various types of surgical interventions and methods to augment healing1,2. In recent years, there has been much attention to key surgical factors that contribute to improved healing rates. Carpal malalignment as the result of scaphoid nonunion involving a humpback flexed deformity with dorsal intercalated segment instability3 has been traditionally thought to be the key instability to correct during nonunion surgery4. However, little is known regarding whether various bone-grafting techniques can correct carpal malignment or if nonunion healing is dependent on the correction of the carpal alignment. In a study of 59 scaphoid waist nonunions treated volarly with a tricortical nonvascularized autograft, sustained correction of carpal alignment only occurred in 54% of patients5. Furthermore, in the 73% of fractures that united at a mean of 4.4 months, the correction of carpal alignment did not correlate with union. This highlights that our understanding of scaphoid nonunion healing and of the contribution of mechanical alignment is still in its infancy. Low-intensity pulsed ultrasound (LIPUS) was traditionally thought to be a useful and noninvasive adjunct to improve bone healing6,7. In scaphoid nonunions, it was even shown to potentially shorten the time to union after surgical treatment in an underpowered prospective trial8. White et al. performed a randomized controlled trial (RCT) of 142 patients treated surgically for scaphoid nonunions comparing LIPUS with a sham intervention3. There ultimately were no differences in the time to union, total union rate, patient-reported outcome measures, or wrist function, with the authors concluding that this intervention is not indicated for scaphoid nonunions. Reconstruction of Nonsalvageable Osteonecrosis Osteonecrosis of the carpal bones represents very challenging pathologies treated by hand surgeons. Nonunions of the proximal pole of the scaphoid are particularly problematic, given their compromised vascularity, limited bone stock, and biomechanical issues2. When deemed nonsalvageable, surgical options include rib9 or proximal hamate10 nonvascularized autografts as well as medial femoral trochlea vascularized autografts11. When attempting to treat patients with unsalvageable proximal pole nonunions, there remains controversy on the optimal technique or evidence-based algorithm. The proximal hamate as a nonvascularized option continues to have more evidence to support its use, with a study of 14 patients showing a 100% union rate and promising restoration of wrist function and patient-reported outcome measures12. Alternatively, the same international collaboration that popularized the medial femoral trochlea procedure described 17 patients who underwent a lateral femoral trochlea vascularized osteochondral flap, who had a high healing rate and predictable restoration of wrist function13. In a similar study of patients with nonsalvageable lunates with coronal split fractures from Kienböck disease, the medial femoral trochlea osteochondral flap demonstrated promise in 33 patients, yielding a >90% union rate14. These studies highlight the ongoing need to better elucidate an algorithm for these challenging fractures. Scapholunate Ligament Chronic scapholunate ligament injuries remain one of the most challenging pathologies faced by hand surgeons, without evidence-based algorithms guiding their treatment. There are many types of scapholunate ligament reconstructions, each attempting to reconstruct both the intrinsic and extrinsic stabilizers of the scapholunate ligament articulation. An excellent example of the controversy is highlighted in a study of 3 common reconstruction techniques15, including dorsal capsulodesis16,17 with a mean follow-up of 11.8 years, tri-ligament Brunelli tenodesis18 with a mean follow-up of 5.9 years, and bone-ligament-bone reconstruction19 with a mean follow-up of 8.9 years. Over the long-term follow-up, every technique showed radiographic deterioration that did not correlate with functional outcomes15. There also were no difference in clinical outcomes between the 3 techniques. Another example of an emerging technique is anatomical front-and-back reconstruction, targeting an open reconstruction of many of the critical extrinsic ligaments associated with the scaphoid and the lunate20. In a study of 21 anatomical front-and-back reconstructions with a minimum 1-year follow-up, both clinical and radiographic outcomes improved, with 2 reoperations21. In another study by the same group, anatomical front-and-back reconstruction appeared to yield better radiographic correction at 1 year compared with Brunelli tri-ligament tenodesis22. However, as with the previously mentioned techniques, it remains to be seen if long-term outcomes of this or any other emerging scapholunate ligament reconstruction technique will hold up. Compressive Neuropathy Carpal Tunnel Syndrome One of the major innovations in recent years has been the use of ultrasound to diagnose carpal tunnel syndrome23,24. It has yielded superior results when used in place of nerve conduction studies23 and to complement the CTS-6 (6-item Carpal Tunnel Syndrome) diagnostic criteria25. For example, ultrasound has been shown to predict the more symptomatic side in bilateral carpal tunnel syndrome26. However, the ability of either ultrasound or nerve conduction studies to predict the response to surgery remains unclear. In a study comparing patients with "clear" and "borderline" diagnoses of carpal tunnel syndrome on nerve conduction studies or ultrasound, it was found that these did not correlate with overall surgical improvement26. However, the cross-sectional area of the nerve on ultrasound does initially decrease after the surgical procedure and appears to remain smaller across longitudinal follow-up in the short term27. The optimal type of carpal tunnel release has been a matter of debate for the last 2 decades, particularly comparing open and endoscopic techniques. Although there were higher rates of complications early in the learning curve for endoscopic techniques28, no major differences between endoscopic and open techniques remained when surgeon experience was equivalent29. This was further reinforced by Schroeder et al., who examined 634 endoscopic releases compared with 491 open releases, finding no differences in terms of pain medications, patient phone calls, or therapy referrals30. There was a lower likelihood of needing therapy with the endoscopic approach. Furthermore, the rate of intraoperative conversion to open release was 1% in a retrospective review of 892 cases and 0.62% in a systematic review of 40,351 cases31. Also, the risks of conversion to open release or of complications do not appear to be associated with resident involvement31. Taken together, this explains the exponential increase in endoscopic carpal tunnel releases being performed, from 9.1% of total carpal tunnel releases in 2012 to 25.2% in 2020. The association with carpal tunnel syndrome and amyloidosis remains an emerging area of investigation, as the formation of amyloid deposits in musculoskeletal tissues is likely to be present 5 to 10 years prior to cardiac disease32. As a result of many recent reviews, the criteria for biopsy during carpal tunnel release include bilateral symptoms and age of ≥60 years for women and ≥50 for men32,33. In a recent study, the addition of patients with spinal stenosis and cardiac disease satisfying the prior 2 screening questions increased the percentage of positive biopsies to 22.5%34. Furthermore, another recent study demonstrated that a single biopsy specimen source, either the tenosynovium or the transverse carpal ligament, is adequate35. Diagnosis of carpal tunnel syndrome using the CTS-6 screening test has been established as a reliable method that can be administered by therapists and medical students and via telemedicine36,37. A recent study from the same group demonstrated high sensitivity and specificity when administered by medical assistants as well as by therapists35, setting the foundation for its use as a screening program and in conjunction with future artificial intelligence (AI) applications. Cubital Tunnel Syndrome Failure of a cubital tunnel surgery due to recurrent symptoms can be a complicated problem to treat, given its multiple possible etiologies. Many surgeons prefer to perform a transposition, either subcutaneous or submuscular, in this setting. In a recent meta-analysis, these 2 techniques were compared across 20 studies and 471 patients, demonstrating more reliable improvement in those who underwent a submuscular transposition38. Distal Radius Osteotomy Distal radial malunions can lead to poor clinical outcomes due to malalignment of the carpus or distal radioulnar joint malalignment. Surgical correction is often necessary in younger, more active patients39, with controversy regarding whether the optimal treatment approach involves a volar or dorsal osteotomy. A recent meta-analysis of 403 patients comparing these 2 approaches showed fewer complications and reoperations with the volar approach40. Although the approach should be tailored to the patient's specific malunion, this highlights what underlies the recent shift toward the volar approach for many of these malunions. When performing the volar approach, studies have demonstrated that, as long as there is cortical contact volarly, there is no need for a bone graft41,42. A recent study took this a step further, showing that cortical contact might not even be necessary when using volar osteotomy43. These are important steps to developing an algorithmic approach to these challenging pathologies. Age and Radiographic Factors Guidelines for the treatment of acute distal radial fractures, dependent on many fracture and patient factors, continue to evolve44. Despite poor radiographic alignment being associated with poor clinical outcomes45, there still remains a lack of consensus on the critical radiographic outcomes for acceptable alignment. In a retrospective study of 1,319 women treated nonoperatively or operatively for distal radial fractures, exceeding radiographic thresholds of a volar tilt of 25°, dorsal tilt of 10°, or ulnar variance of 7 mm was correlated with worsening post-treatment outcomes46. In a recent study of 366 patients, dorsal tilt of >5° was found to be the strongest factor that correlated with worsening clinical outcomes in most patients47. It should be noted that the exception was for patients >75 years of age, in whom it was not until dorsal tilt was >20° that a clinical difference was experienced. Another recent study supported the tolerance of malunions by these older patients, showing worse clinical outcomes at 3 months but no difference in clinical outcomes at 1 year after the injury48. Another recent study reinforced the diminishing benefit of surgery for patients >80 years of age, showing that they will likely not achieve a clinically meaningful benefit from surgical treatment49. This and other factors can be utilized to develop and improve patient decision aids for patients with distal radial fractures, as a recent study showed the importance of these aids in improving the patient decision-making process50. When treating distal radial fractures surgically, a recent study showed a low overall complication rate of 12.3%, including a 2.7% implant removal rate and a 1.9% rate of carpal tunnel surgery51. As highlighted by the studies above, optimizing the restoration of volar tilt remains a critical aspect of the surgical outcome. Not only is this critical to optimize wrist function47, but failure to do so puts increased pressure on the flexor pollicis longus tendon52. Such pressure is particularly concerning given that the plate is placed distal to the watershed line. Ultimately, adequately performed surgical correction does appear to maintain functional outcomes over a long-term follow-up period, even in spite of a 6% risk of osteoarthritis47. Finger and Thumb Arthritis Proximal Interphalangeal (PIP) Joint Arthroplasty PIP joint arthroplasty remains controversial with regard to indications, patient factors, and implant choice53. There remain evolving considerations regarding controversial indications for PIP joint arthroplasty, including border digits54 and young age55, but patients' ability to return to heavy labor or regular work appears to be predictable in a recent study56. With regard to patient choice, silicone arthroplasty has remained the gold standard for many patients. The type of silicone implant chosen appears not to matter, as demonstrated by a recent comparative study57. However, in carefully selected patients, promising outcomes can be achieved with alternative implants, such as pyrocarbon total PIP joint arthroplasty58. A trend in PIP joint arthroplasty has been to utilize a pyrocarbon implant in a hemiarthroplasty59, with a recent long-term follow-up showing a 72% 10-year survival rate and predictable clinical outcomes60. In a recent study, surface replacement arthroplasty with a metal-plastic articulation has also shown promising short-term outcomes without traditional signs of loosening that plagued prior implant designs61. Metacarpophalangeal (MCP) Joint Arthroplasty MCP joint arthroplasty remains the preferred procedure for patients with MCP joint arthritis53. Silicone implants remain the preference for many surgeons treating patients with rheumatoid arthritis. However, in patients with osteoarthritis, Claxton et al. demonstrated that pyrocarbon implants were associated with predictable clinical outcomes at >5 years of follow-up, with 7% revision and 20% complication rates62. Thumb Basal Joint Arthritis The Patient-Specific Functional Scale was recently found to be useful for measuring the status of individuals with thumb arthritis63, but consensus with regard to trapeziometacarpal arthritis management remains elusive given the wide breadth of clinical presentations and variable treatment algorithms. Initial nonoperative treatment options include activity modification, bracing, hand therapy, and intra-articular injections. The longevity of the results of nonoperative management (e.g., orthosis and exercise therapy) was supported by a recent study that found no worsening of pain or of limitations in activities of daily living at 1 year after nonoperative modalities were initiated64. Additionally, multiple studies examining various intra-articular injections showed positive results in terms of pain reduction with autologous fat and platelet-rich plasma compared with saline solution injections65, as well as equivalent pain reduction and functional outcomes between corticosteroid, hyaluronic acid, and platelet-rich plasma administration in the trapeziometacarpal joint66. When nonoperative interventions fail, various surgical options such as denervation67, suspensionplasty68, and implant replacement are used. Although various suspensionplasty techniques have been reported, a recent RCT comparing trapeziectomy with ligament reconstruction plus tendon interposition versus suture tape suspensionplasty found comparable postoperative patient-reported outcome measures and objective clinical measurements, although patients with ligament reconstruction and tendon interposition had faster return to work and fewer complications68. Interestingly, recent biomechanical studies found greater metacarpal subsidence with ligament reconstruction and tendon interposition compared with suture suspensionplasty68,69 and abductor pollicis longus suspensionplasty69, supporting the potential use of the latter techniques, particularly in the setting of concurrent proximal row carpectomy and trapeziectomy, given the increased risk of thumb metacarpal subsidence in this situation70. Implant arthroplasty has been growing in popularity worldwide because of its theoretical advantages of maintaining thumb length, improving pinch, and providing quicker postoperative recovery. Single-mobility71 implants have shown promise compared with dual-mobility72 implants, with a recent report of the ARPE single-mobility prosthesis demonstrating a 5-year survival of 83% and a 30-year survival of 50%71. Although concern for implant dislocation persists, dual-mobility prostheses have been reported to have had less risk of this postoperative complication73. Furthermore, capsular resection was found to have equivalent clinical outcomes and complications compared with capsular repair in dual-mobility implants, raising its possible advantage of improved visualization for implant positioning without compromising postoperative results74. Wrist Arthroscopy One of the biggest evolutions in wrist surgery in the last decade has involved innovations in wrist arthroscopy. As Mak and Ho reviewed, comprehensive management of triangular fibrocartilage complex tears, from acute anatomic repairs to graft reconstruction of chronic triangular fibrocartilage complex tears, can be performed arthroscopically75. Arthroscopic innovations are well incorporated into many surgeons' practices around the world; however, as more hand surgeons in North America adopt these techniques, novel training methodologies will be required. In a recent study, 2 low-fidelity arthroscopy models for basic and advanced skill sets showed promise in arthroscopic training76. A major advance in wrist arthroscopy has come with performing wrist arthritis treatment, including 4-corner arthrodesis, using arthroscopy77. Many recent studies have shown potential advantages of arthroscopic 4-corner arthrodesis over the open approach, with improved time to union and wrist functional outcomes78,79. A recent study demonstrated the ability to perform this technique with only 2 percutaneous compression screws, with reliable fusion and improvements in clinical outcomes80. Nevertheless, it will be critical to perform comparative studies assessing the efficacy of arthroscopic advances such as these, as well as ones involving intercarpal ligament injuries81. Opioid-Free Multimodal Analgesia A tremendous amount of attention has been given in the last decade to combatting the opioid crisis and limiting the number of opioids prescribed in hand surgery. This is particularly important given the dose-dependent association of opioids with complications, as well as with prolonged opioid usage82,83. This has been demonstrated in a recent study showing that chronic preoperative opioid usage was associated with an increased risk of prolonged postoperative usage84. Furthermore, the initial prescription size was directly correlated with prolonged postoperative usage85,86. Unfortunately, a recent systematic review demonstrated that there is routinely excessive opioid prescription relative to consumption, with the mean percentage of opioids consumed being between 11% and 77% of the initial prescription87. Multimodal regimens, an effort to combat the risks of prolonged usage, have been shown to reduce the amounts of opioids consumed88; their tactics include education89, standardized institutional regimens90, and anti-inflammatory medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs)91 and systematic glucocorticoids92,93. These regimens have all been moving toward opioid-free protocols in upper-extremity surgery. In a recent prospective RCT, opioid-free analgesia for carpometacarpal (CMC) arthroplasty resulted in equivalent pain scores and satisfaction94. In a recent systematic review, opioid-free multimodal pain regimens in a total of 1,480 patients appeared to provide adequate pain relief after various hand surgeries, but did require increased use of rescue analgesia95. This highlights that the move toward limiting opioids prescribed in hand surgery is promising, but still has work to be done on optimizing the protocols. AI Interest in the deployment of AI in hand surgery continues to gain traction as a topic of interest. In particular, the utilization of deep learning in detecting often-missed radiographic abnormalities is promising. A recent deep learning algorithm was reported to have a sensitivity of 93.8%, a specificity of 93.3%, and an accuracy of 93.4% in the detection of lunate and perilunate injuries on lateral radiographs96. Favorable results for the use of AI in the identification of hand pathologies on radiographs were echoed by several authors97,98. Another major area of AI interest is ChatGPT (Chat Generative Pre-Trained Transformer; OpenAI), a language learning model chatbot platform. Its utilization in improving health literacy was shown to be efficient99, and its ability to provide generally appropriate answers to common hand-surgery clinical questions was confirmed100,101. However, its test-retest reliability was poor, with an intraclass correlation efficient of 0.12, and higher-order thinking skill questions (Bloom level 4) were not as well answered as lower-order thinking skill questions (Bloom level 1 to 3)101. Lastly, AI has been examined within hand surgery to potentially provide clinical prediction models, such as predicting continued opioid use after hand surgery or utilizing grip-and-release test videos to predict carpal tunnel syndrome presence and severity102,103. Unfortunately, neither proved ready for widespread clinical use. Peripheral Nerves Tendon transfers, nerve grafts, and nerve transfers continue to be the mainstay of nerve-injury management, as none have demonstrated superiority in all situations. Consequently, technique selection is dependent on the degree of injury and specific neurologic deficits. In isolated radial nerve injury, tendon transfers were found to demonstrate the highest percentage of good outcomes (82%) with the lowest percentage of poor outcomes (9%) in 754 patients when compared with nerve grafts and transfers104. Interestingly, Adidharma et al. found that utilization of the various options for nerve gap reconstruction changed after the introduction of the allograft Current Procedural Terminology (CPT) code in 2018, with utilization of autologous nerve grafts, particularly for gaps of <4 cm, and of conduit declining, whereas allograft utilization markedly increased105. However, autograft utilization for gaps of ≥4 cm did not decrease105. Lastly, variable clinical outcomes have been reported for nerve transfers, with inconsistent reliability of supercharging of the ulnar nerve105 and sensory nerve transfers106 but promising outcomes for distal nerve transfers107 and targeted muscle reinnervation for amputees108–111. In particular, utilization of targeted muscle reinnervation for the prevention and management of phantom limb pain and residual limb pain, and improved myoelectric prosthesis control, has shown notable promise and positive clinical outcome results to support its continued investigation and application108–111. Tendinopathies De Quervain tenosynovitis is one of the most common wrist tendinopathies, with recent risk factors reported in the literature, including the presence of tendon subcompartments112, first pregnancy, and pregnancy duration of >40 weeks113. Although it is a common clinical entity, continued controversy exists as to its optimal treatment. A recent comprehensive network meta-analysis examining nonoperative interventions concluded that corticosteroid injection plus a short term of immobilization was the most effective treatment in improving visual analog scale (VAS) pain scores and the Disabilities of the Arm, Shoulder or Hand (DASH) or QuickDASH (abbreviated version of the DASH) outcomes in the short and medium terms compared with placebo, extracorporeal shockwave therapy, isolated corticosteroid injection, laser therapy, casting alone, and platelet-rich plasma injection114. For those patients who underwent failed nonoperative management, all of the surgical interventions showed excellent improvement in the VAS pain score, but risk factors for continued pain after first extensor compartment release included smoking, younger age, concomitant surgery, longer duration of symptoms, and higher preoperative VAS pain115. Similarly, trigger finger is one of the most common hand tendinopathies that is often managed initially with corticosteroid injection. A recent prospective cohort study of 114 patients treated with repeated injections and followed for 12 months found that Quinnell grade-III or IV trigger fingers, body mass index of ≥25 kg/m2, and <6 months of symptom relief from a previous injection were strong predictors of symptom recurrence, with the presence of all 3 risk factors being associated with an 11.8% success rate at 1 year116. Additionally, they found that overall success rates from repeated injections decreased from 97.4% at 1 month to 49.1% at 12 months116. In situations with injection failure, surgical intervention is warranted, with open and percutaneous release of the A1 pulley demonstrating no difference with respect to revision procedures, complications, or postoperative pain117. Furthermore, in those patients with concomitant PIP joint contracture, simple A1 pulley release with and without ulnar superficialis slip resection had equivalent postoperative PIP joint contracture measurements and clinical scores, supporting simple A1 pulley release even in the setting of joint contracture118. Wrist Arthritis Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) remain the most common reasons for posttraumatic degenerative wrist arthritis. Historically, notable controversy existed as to the clinical superiority of proximal row carpectomy compared with 4-corner arthrodesis as motion-preserving options. However, a recent systematic review and meta-analysis examined 61 studies with 3,174 wrists, of which 54% were treated with proximal row carpectomy and the remainder were treated with 4-corner arthrodesis119. They found that proximal row carpectomy demonstrated significantly greater postoperative improvement in wrist extension, flexion, ulnar deviation, and VAS scores, and no differences in grip strength, compared with 4-corner arthrodesis. Moreover, only 5.2% of patients with proximal row carpectomy required arthrodesis compared with 11% with 4-corner arthrodesis, and complications related to nonunion and implants were only present with 4-corner arthrodesis. Although proximal row carpectomy and 4-corner arthrodesis are the most common procedures reported, partial (lunocapitate120 and radiolunate121) wrist arthrodeses have also been reported as having good clinical outcomes. For those patients who are ineligible for partial wrist arthrodesis but still desire wrist motion, total wrist arthroplasty is a viable option with high patient satisfaction, preserved wrist range of motion, and improved DASH or QuickDASH and VAS scores in patients with either inflammatory or non-inflammatory arthritis122,123. However, there is continued concern regarding radiolucency, lack of implant osseointegration, osseous impingement, implant impingement-related osteolysis, and issues surrounding soft-tissue balancing resulting in limited long-term survival rates123–126. Although annual surveillance radiographs for implant assessment have been advocated, an investigation into periprosthetic radiolucency found that the size of the lucency did not correlate with clinical outcomes and, thus, revision surgery was not advocated to be undertaken in the setting of radiographs showing radiolucency in asymptomatic patients126. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 7 other articles relevant to hand and wrist surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Barrett PC, Hackley DT, Yu-Shan AA, Shumate TG, Larson KG, Deneault CR, Bravo CJ, Peterman NJ, Apel PJ. Provision of a home-based video-assisted therapy program is noninferior to in-person hand therapy after thumb carpometacarpal arthroplasty. J Bone Joint Surg Am. 2024 Apr 17;106(8):674-80. In this single-center RCT of patients undergoing a primary thumb CMC arthroplasty, video-based therapy was compared with standardized treatment with a hand therapist. Overall, there were no differences between the treatment group (n = 27) and the control group (n = 27) with regard to the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score at 12 weeks or 1 year postoperatively. The video-based group saved a mean of 201.3 mi (324 km) in travel overall. This is a very well-done prospective trial comparing traditional therapy with a novel video-based program, showing the benefits of such a virtual program after CMC arthroplasty. This is very similar to other studies in the shoulder and elbow showing the benefits of such virtual programs in postoperative rehabilitation. However, just like other thumb CMC studies, this study is hurt by the lack of a specific patient-reported outcome measure for the thumb. This makes any comparative trials investigating thumb CMC arthroplasty difficult, as a nonspecific patient-reported outcome measure for the upper extremity will not capture potential differences in thumb function. Challoumas D, Ramasubbu R, Rooney E, Seymour-Jackson E, Putti A, Millar NL. Management of de Quervain tenosynovitis: a systematic review and network meta-analysis. JAMA Netw Open. 2023 Oct 2;6(10):e2337001. This is a very well-done systematic review and network meta-analysis comparing the treatment options for de Quervain tenosynovitis. A total of 30 studies were included, and comparisons were performed using pairwise meta-analyses. A corticosteroid injection followed by 3 to 4 weeks of immobilization had the best outcomes in the short and intermediate terms. Furthermore, ultrasound guidance had the best pain outcomes. This study helps to create an evidence-based algorithm for the nonoperative treatment of de Quervain tenosynovitis, using some of the best available evidence. It is rare that these types of studies produce such a convincing treatment recommendation, which highlights the value of such a study. Ma H, Ruan B, Li J, Zhang J, Wu C, Tian H, Zhao Y, Feng D, Yan W, Xi X. Topology-optimized splints vs casts for distal radius fractures: a randomized clinical trial. JAMA Netw Open. 2024 Feb 5;7(2):e2354359. This is an RCT comparing the treatment of distal radial fractures with topology-optimized splints made for the patients compared with casts following closed reduction. Assessment of the clinical and radiographic parameters showed improved outcomes for the topology-optimized splints at 6 weeks and lower complications, but no difference in overall outcomes at 12 weeks. This is a well-designed trial to support a growing body of evidence favoring a move away from using casts in adults with distal radial fractures. Using these splints has many clear advantages for patients and providers. However, the maintenance of reduction is something that is not as clear and will require more similar high-quality trials in the future. Pérez-Úbeda MJ, Arribas P, Gimeno García-Andrade MD, Garvín L, Rodríguez A, Ponz V, Ballester S, Fernández S, Fuentes-Ferrer M, Ascaso A, Portolés-Pérez A, Marco F. Adjuvant arthroscopy does not improve the functional outcome of volar locking plate for distal radius fractures: a randomized clinical trial. Arthroscopy. 2024 Feb;40(2):305-17. This is an RCT of 180 patients undergoing a surgical procedure for distal radial fractures, comparing treatment with and without arthroscopic assistance; 82% of fractures were intra-articular. There were no differences in patient-reported outcomes at 1 year postoperatively. The postoperative computed tomographic (CT) scans did show a difference in joint step-off. This is an interesting study that continues to try to answer the question about the need for arthroscopic-assisted joint reduction. However, it falls short in answering many of the important questions. To start, 18% of patients in the study did not have an intra-articular fracture, and many others who did have an intra-articular fracture did not require any interventions, making the postoperative CT comparison less useful. Ideally, one would randomize only intra-articular fractures with clear incongruity to this type of study. Furthermore, the primary reason to perform arthroscopy is to align the joint and prevent or possibly slow the progression of future arthritis, given that the rates of arthritis in the studies that have >10 years of follow-up is >80%. This study is not only underpowered but falls short of the longevity needed to assess this question. Räisänen MP, Leppänen OV, Soikkeli J, Reito A, Malmivaara A, Buchbinder R, Kautiainen H, Kaivorinne A, Stjernberg-Salmela S, Lappalainen M, Luokkala T, Pönkkö A, Taskinen HS, Pääkkönen M, Jaatinen K, Juurakko J, Karjalainen VL, Karjalainen T. Surgery, needle fasciotomy, or collagenase injection for Dupuytren contracture: a randomized controlled trial. Ann Intern Med. 2024 Mar;177(3):280-90. A multicenter RCT compared surgery (n = 101), needle fasciotomy (n = 101), and collagenase (n = 100) in the treatment of Dupuytren contracture. Success was determined by a >50% reduction in the contracture and the patient reaching an acceptable symptom state. Success was 71% at 3 months and 78% at 2 years for surgery; 73% at 3 months and 50% at 2 years for needle fasciotomy; and 73% at 3 months and 65% at 2 years for collagenase. This is a great contribution to the growing literature comparing these treatments, with surgery seeming to continually prevail over longer-term follow-up. However, with the move toward procedural rooms, there are other important considerations including cost, risks with surgery, and patient preferences with regard to surgical or nonoperative interventions. Thus, these decisions should be customized by informed patients for what works best for their specific situation. van Delft EAK, van Bruggen SGJ, van Stralen KJ, Bloemers FW, Sosef NL, Schep NWL, Vermeulen J. 4 weeks versus 6 weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial. Bone Joint J. 2023 Sep 1;105-B(9):993-9. This study is an RCT comparing patients with distal radial fractures treated for either 4 or 6 weeks in a cast following closed reduction. Assessments using patient-reported outcome measures, radiographic outcomes, and wrist range of motion for the 93 enrolled patients showed no major differences between the 2 groups at 1 year postoperatively. This study shows that, in the properly selected patient, 4 weeks of immobilization are appropriate and safe. However, this study did not stratify by fracture severity, so these results might not be applicable to patients with more severe fractures or worse bone stock (e.g., elderly patients). Yin W, Liu X, Wang K, Shen L, Li Y, Cai Q, Chen S, Chen J, Liu S. Ultrasound-guided hydrogel injection provides better therapeutic effects after hand tendon surgery than intraoperative injection: a randomized controlled trial. Clin Orthop Relat Res. 2024 Nov 1;482(11):2017-27. In this RCT of patients undergoing tendon repairs, the authors compared injecting hydrogels during the surgical procedure and ultrasound-guided postoperative injections. The primary goal was to assess tendon adhesions by assessing overall hand function. Ultimately, the ultrasound-guided group appeared to have less pain by 3 weeks and better hand function at 6 weeks and at 1 year postoperatively, with all other outcomes assessed being similar. This is an important study to challenge how surgeons typically approach injections meant to augment a surgical procedure. This study introduces the safety and potential efficacy of performing injections postoperatively using ultrasound guidance, with potential benefits of modulating the inflammatory cascade at more ideal time points and avoiding losing whatever is being injected as a result of the immediate postoperative recovery response.