Nicholas Alan Johnson

Thumb carpometacarpal joint replacement (CMCJR) is gaining popularity for the surgical management of thumb base osteoarthritis. However, there is considerable variability in the literature regarding postoperative management, with limited information on timescales for return to normal function. This study aims to develop consensus-based guidance for postoperative best practice. A three-round modified Delphi process was undertaken with 16 experienced hand surgeons and hand therapists from the UK and mainland Europe. The initial survey was developed following a comprehensive review of the literature and consultation with a patient and public involvement group. The second round was an iteration of the first, including refinement of themes into statements. The third round presented the guidance for overall agreement and comment. Consensus throughout was defined as ≥ 70% agreement. In round one, consensus was reached on postoperative immediate protection duration of ten to 14 days and the need for a postoperative radiograph. In round two, agreement was achieved for seven out of ten statements that included the type of immediate postoperative protection to be a bulky bandage allowing restricted thumb movement, splinting practices, thumb full range of motion commencement, and a return to driving timescale of four weeks. Return to timescales of light (two weeks), moderate (four weeks), and heavy tasks (six to eight weeks) were further defined in round three and accepted by the panellists. This Delphi study established consensus-based guidance for best practice in the postoperative management of thumb CMCJR, with specific inclusion of timescales for return to normal function. This will be beneficial for clinics, particularly in the UK, which are newly adopting this technique. Recommendations regarding the timing and frequency of postoperative radiographs remain to be clearly defined.

Aims: The association between scaphoid fractures and ligament injuries is uncertain, and the clinical relevance is not well established. The aim of this study was to undertake a secondary analysis of data from the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) to evaluate the incidence of concurrent ligament injuries in patients with a scaphoid waist fracture displaced by ≤ 2 mm, explore the radiological changes between one and five years after the injury, and assess whether there is an association between the characteristics of the fracture and ligament injury. Methods: All 439 patients from the SWIFFT had baseline measurements available from plain radiographs and CT scans. Further follow-up measurements were undertaken from CT scans in 292 patients at 52 weeks and 239 patients at five years. A total of 345 patients had radiographs suitable for assessment of the scapholunate (SL) and lunotriquetral (LT) intervals at 52 weeks and/or five years. Results: Only 12 patients (2.8%) had widening of the SL gap by > 3 mm on initial imaging. There was no progression of these gaps at five years, and no patient had widening of the LT gap. Conclusion: Injury to the interosseous intercarpal ligaments causing diastasis of carpal bones is rare in patients with a scaphoid waist fracture displaced by ≤ 2 mm. Treatment of the fracture with a cast or surgical fixation, without additional imaging or intervention for a potential ligament injury, appears adequate for most fractures. If there are ligament injuries not identified with standard imaging, they do not seem to progress. Cite this article: Bone Joint J 2026;108-B(4):538–543.

Basal osteoarthritis of the thumb is extremely common and causes pain and difficulty with essential ‘pinching’ tasks such as writing and dressing. It has been shown, in high-quality studies, that physiotherapy can result in clinically important improvements in pain and function, but the delivery of nonoperative treatment currently varies considerably throughout the NHS in the UK. Trapeziectomy is an effective, simple, and low-cost procedure, and the most common of surgical treatment for basal osteoarthritis of the thumb in the UK. However, recovery can be lengthy and complications include subsidence of the thumb metacarpal, instability, and weakness. New designs of thumb carpometacarpal joint arthroplasty (CMCJA) show promising early results with low complication rates and a quick return to function, but the implants are expensive and high-quality evidence about the outcome is lacking. The Surgery versus Conservative OsteOarthritis of Thumb Trial (SCOOTT) is a multicentre, three-arm, randomized controlled trial which is currently being undertaken, comparing the clinical outcomes and cost-effectiveness of an enhanced package of non-surgical management, trapeziectomy, and thumb CMCJA. Cite this article: Bone Joint J 2026;108-B(1):4–8.

Distal radial fractures are common, but questions remain regarding their optimum management. We describe a simple three-step management algorithm based around assessment and treatment of articular step, alignment, and length.

Background: Thumb carpometacarpal osteoarthritis (CMC-1 OA) is a common and debilitating condition, particularly among older adults and women. With the aging population, the prevalence of CMC-1 OA is expected to rise, emphasizing the need to find effective nonoperative strategies. So far, for determining the most effective nonoperative interventions in CMC-1 OA, two network meta-analyses (NMAs) have been published. However, these NMAs were limited to specific intervention types: one comparing multiple splints and the other comparing different intraarticular injections. Therefore, an NMA that compared all nonoperative intervention types is urgently needed. Questions/purposes: This study aimed to assess and compare the effectiveness of available nonoperative interventions (both nonpharmacologic and pharmacologic) for CMC-1 OA to establish which nonoperative options are more effective than control in terms of (1) pain, (2) function, and (3) grip strength. Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) NMA guidelines (PROSPERO: CRD2021272247) and conducted a comprehensive search across Medline, Embase, CENTRAL, and CINAHL up to March 2023. We included randomized controlled trials (RCTs) and quasi-RCTs evaluating nonoperative interventions for symptomatic CMC-1 OA, excluding inflammatory or posttraumatic arthritis. Studies comparing ≥ 2 interventions or against a control, focusing on pain reduction, functional improvement, and grip strength, were selected. We assessed methodologic quality using the modified Coleman Methodology Score, including only studies scoring > 70. Risk of bias was evaluated with the Risk of Bias 2.0 tool, and evidence quality with Confidence in Network Meta-Analysis (CINeMA). Of 29 screened studies, 22 (21 RCTs and one quasi-RCT) were included, involving 1631 women and 331 men. We analyzed eight different nonoperative interventions, including splints, hand exercises, injections, and multimodal treatment (≥ 2 nonpharmacologic interventions or nonpharmacologic with a pharmacologic intervention). Six studies had a low risk of bias, eight had a high risk, and the remainder were moderate. We extracted mean and SD scores, and NMA and pairwise analyses were performed at short- (≤ 3 months) and medium-term (> 3 to ≤ 12 months) time points. Standardized mean differences were re-expressed into common units for interpretation, which were the VAS (range 0 to 10) for pain, the DASH test (range to 100) for function, and pounds for grip strength. Clinical recommendations were considered strong if the mean differences exceeded the minimum clinically important difference—1.4 points for VAS, 10 points for DASH, and 14 pounds for grip strength—and were supported by moderate or high confidence in the evidence, as assessed using CINeMA methodology. Results: Our NMA (based on moderate or high confidence) showed a clinically important reduction in pain at the short-term time point for multimodal treatment and hand exercises versus control (mean difference VAS score -5.3 [95% confidence interval (CI) -7.6 to -3.0] and -5.0 [95% CI -8.5 to -1.5]). At the medium-term time point, only the rigid carpometacarpal-metacarpophalangeal (CMC-MCP) splint was superior to control (mean difference VAS score -1.9 [95% CI -3.1 to -0.6]) and demonstrated clinical importance. For function, only the rigid CMC-MCP splint demonstrated a clinically important improvement at the medium-term time point versus control (mean difference DASH score -11 [95% CI -21 to -1]). Hand exercises resulted in a clinically important improvement in short-term grip strength versus control (mean difference 21 pounds [95% CI 11 to 31]). Conclusion: This systematic review and NMA show that multimodal treatment and hand exercises reduce short-term pain and improve grip strength, while a rigid CMC-MCP splint enhances medium-term function. Future research should evaluate long-term efficacy. Level of Evidence: Level I, therapeutic study.

Radial forearm free flaps (RFFF) are a versatile option for the reconstruction of a wide variety of soft tissue defects and are particularly common in head and neck surgery. Benefits of RFFF include a relatively short operating time, a long pedicle, and a thinner, more pliable flap. However, in addition to its role in reconstructive surgery, the radial artery may be utilized for a number of other procedures including coronary angiography and percutaneous coronary interventions. Concern has previously been raised that prior catheterization may deleteriously affect the function of the radial artery and in the field of cardiothoracic surgery, individuals are increasingly advising against its use as a graft for coronary artery bypass graft surgery in such circumstances. Despite this, little is known about the effect on RFFF. In this review article, we concisely consider the available evidence of the effect of previous transradial catheterization on the radial artery and discuss the implications for reconstructive surgery. We then summarize the key considerations regarding their use in current practice.

Assessing the risk of re-fracture related to the percentage of partial union in scaphoid waist fractures

Loss of anterior tilt after a distal radial fracture can lead to carpal malalignment, which may cause functional impairment. The aim of this study was to establish whether distal radial osteotomy for malunion, which primarily restores the dorsal tilt, will also improve carpal malalignment as measured by capitate shift. Radiographs of 67 patients who underwent osteotomy after malunion of a distal radial fracture were reviewed. Measurements of capitate shift and dorsal tilt were recorded. Linear regression modelling was used to assess the relationship between dorsal tilt and capitate shift. Change in capitate shift was strongly associated with change in dorsal tilt following osteotomy. This relationship was maintained on long-term radiographs. Capitate shift is strongly related to dorsal tilt following a distal radial fracture. Correcting the dorsal tilt during an osteotomy, therefore, will improve capitate shift and carpal malalignment. Capitate shift is unrelated to age, sex and is easy to visually assess. Level of evidence: IV

We investigated the effectiveness of cognitive behavioural therapy (CBT) for patients with psychological disorders thought to be influencing recovery from elective and traumatic hand conditions. Demographic data and psychological assessment scores (Primary Health Questionnaire 9 (PHQ9), General Anxiety Disorder Assessment (GAD7), Impact of Event Scale (IES)) were prospectively collected before and after CBT treatment. One hundred and fourteen patients underwent CBT with 81 completing treatment. Full data was available for 78 (68%) patients. Mean age was 43 (range 13–84) and 63% were women. Sixty-one per cent had sustained a traumatic hand injury. PHQ9, GAD7 and IES scores decreased significantly following treatment. Many patients with hand conditions have associated psychological problems that may influence outcome. CBT in a hand unit setting appears to be an effective treatment. Further research with a control group should investigate whether CBT improves psychological health or if this may occur as patients recover from their physical hand disorder regardless of CBT. Level of evidence: IV