Palmaris Longus Tendon Research Articles

Fiber type composition of contiguous palmaris longus and abductor pollicis brevis muscles: Morphological evidence of a functional synergy.

The palmaris longus (PL) tendon is used in surgical opponensplasty to restore functional hand movements in thenar paralysis. Although successful PL autologous tendon transfer has been attributed to an established synergistic relationship between the PL and abductor pollicis brevis (APB) muscles in vivo, this functional relationship may be dependent on the quality of their spatial relationship and properties of their constituent muscle fibers. The purpose was to compare the proportion of type I and type II muscle fibers in the APB based on its contiguous morphological relationship with the PL tendon for indirect insight into their functional synergy, contractile capacity, and digastric arrangement. Twenty-four contiguous PL and APB specimens were harvested from the upper limbs (12 right and 12 left) of twelve formalin-embalmed cadavers (mean age: 74±10years). The fiber type composition of these muscles was determined by labeling serial cross sections with myosin heavy chain (MyHC) type I and type II monoclonal antibodies. The PL consisted of a relatively heterogeneous fiber type composition irrespective of the presence of a discrete (type I: 41±11%; type II: 55±12%; hybrid: 4±3%) or rudimentary (type I: 49±10%; type II: 45±9%; hybrid: 6±4%) tendinous connection with the APB. The APB fascicles arranged contiguously with the PL through a discrete tendon had significantly greater proportions of type II fibers (41±19%) compared to those with rudimentary PL connections (type II: 15±8%). Therefore, the APB fascicles arranged in a digastric relationship with the PL may have the capacity to produce more powerful contractions than those with rudimentary PL tendons based on the known contractile properties of type II muscle fibers. Knowledge of the spatial relationship between the PL and thenar musculature prior to PL autologous tendon transfer may be a useful indicator of the quality of established synergy in vivo.

The Palmaris Longus and Its Association with Carpal Tunnel Syndrome.

Background The palmaris tendon inserts into the palmar fascia and is positioned in close association with the transverse carpal ligament. Loading of this tendon has been demonstrated to increase carpal tunnel pressures. Purpose The purpose of this study was to determine if a relationship exists between the palmaris tendon, carpal tunnel syndrome (CTS), and handedness. The sensitivity, specificity, positive predictive value, and negative predictive value for Schaeffer's test were calculated. Methods A retrospective review of patient charts undergoing endoscopic carpal tunnel release was performed. Rates of palmaris longus agenesis (PLA) were compared to a population matched data set. Statistical analysis was performed using a one-proportion z -test. Schaeffer's test for the palmaris longus tendon was performed on all patients and compared to intraoperative confirmation. Results A total of 520 carpal tunnel releases were performed in 389 consecutive patients. The frequency of PLA in this surgical cohort was significantly lower compared to the population matched dataset. No correlation between handedness and laterality of CTS or PLA was found. Schaeffer's test was evaluated to yield sensitivity (93.6%), specificity (100%), positive predictive value (100%), and negative predictive value (50.8%). Conclusion The palmaris tendon was more prevalent in a population of patients undergoing carpal tunnel release. These findings can be used to provide further insight into the pathophysiology of CTS. While Schaeffer's test was accurate in detecting the palmaris longus tendon, a negative test was frequently incorrect. Further imaging is recommended in patients with a negative Schaeffer's test when the palmaris longus is desired for surgical utilization. Level of Evidence This is a Level III, prognostic study.

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability of the Elbow: A Systematic Review.

Background: Posterolateral rotatory instability (PLRI) is a common form of recurrent elbow instability. The aim of this systematic review is to present the outcomes and complications of lateral ulnar collateral ligament (LUCL) reconstruction surgery for PLRI. Methods: A literature search of LUCL reconstructions was performed, identifying 99 potential papers; 11 of which met inclusion/exclusion criteria, accounting for 148 patients. Papers were included if they reviewed cases of PLRI from 1976 to 2016 with reported outcome measures. Data were pooled and analyzed focusing on patient demographics as well as subjective and objective patient outcomes and complications. Results: The average age of patients was 34 years with a mean follow-up time of 49.8 months. The most common mechanism of injury was a traumatic elbow dislocation (66%), followed by cubitus varus deformity (7%), and unknown mechanisms (7%). Overall, 90% of patients achieved elbow stability and 2.7% experienced a failed reconstruction that necessitated an additional surgery. Furthermore, 93% were satisfied with the outcome of the reconstruction, and 83% reported good to excellent outcomes with 11% reporting moderate to severe persistent pain. Nearly half (45%) of reconstructions were done using a palmaris longus tendon graft, 24% with a triceps tendon graft, and 7% with a synthetic graft. Conclusions: Outcomes following LUCL reconstruction for PLRI are excellent and revision rates are low. LUCL reconstruction is a safe and reliable procedure.Level of Evidence: IV Therapeutic.

Our Experience in Oral Commissure Reconstruction After Surgical Excision of Stage 3 and Stage 4 Oral Cavity Malignancy

The upper and lower lips represent the most important functional and aesthetic anatomical structures of the lower segment of the face. The reconstructive aims are to restore the oral lining, oral competence and function (i.e. articulation, speech and mastication). Functional and aesthetic restoration of lip and oral commissure defects can be achieved using the composite radial free forearm flap (RFFF) with Palmaris longus tendon. To present the technique, we have used our experience with this form of reconstruction in 30 consecutive patients with lip and oral commissure defects who were surgically treated between 2012 and 2018. Reconstruction of the lip defect was done with RFFF with Palmaris longus tendon. The ends of the Palmaris longus tendon were passed intraorally and anchored to the remnant orbicularis oris muscle of the upper lip to provide adequate tension so that oral competency could be achieved and sagging of the commissure could be prevented, and in cases, where adequate orbicularis oris was not present, the tendon was sutured to the zygomatic prominence. The patients were followed for 1 year. In our study of 30 cases of stage 3 and stage 4 oral cavity squamous cell carcinoma, we did RFFF with Palmaris longus and found that the graft uptake was excellent, i.e. 93.33%. Flap failure occurred in only 2 out of the total 30 cases. Re-exploration of the flap was done, and venous congestion was the cause of flap failure. Re-anastomosis of the vessels was done, but still the flap could not be salvaged. Donor site healed satisfactorily without any complications except for scarring. All patients had excellent oral competence during rest, speaking and eating. Good sphincteric function was obtained in early post-operative days. Drooling or air leakage was seen only in 6 out of 30 cases after 1 year of follow-up. The patients’ articulation was near-normal. The aesthetic results were accepted by 24 patients. All patients were able to resume regular diet. No complications were observed such as dehiscence, fistula formation or abscess formation. The mouth opening was also adequate (2–3 finger width) in 24 out of 30 patients of oral commissure reconstruction. The RFFF with Palmaris longus has excellent viability. It is a secure and reliable reconstructive option which produced satisfactory aesthetic and functional results.

Extensor indicis transfer versus palmaris longus transplantation in reconstruction of extensor pollicis longus tendon: a protocol for a systematic review

This review will provide an overview of published data comparing transposition of the extensor indicis pollicis (EIP) tendon and palmaris longus (PL) tendon grafting in thumb extension reconstruction following loss of the extensor pollicis longus (EPL) tendon function. We will consider all studies comparing EIP and PL utilized to reconstruct thumb extension after injury/rupture of the EPL tendon. Only studies published in the English and German literature will be included. A systematic literature research will be performed across relevant health databases including the Cochrane Library, MEDLINE, and Google Scholar using the following keywords: ((extensor pollicis longus) OR EPL) AND ((extensor indicis) OR EIP OR (tendon transposition)) AND ((palmaris longus) OR (free tendon graft) OR (tendon transplantation)). Central tendencies will be reported in terms of means and standard deviations where necessary. If not reported, the standard deviation will be calculated from the standard error of the mean. Risk ratios will be calculated where possible. All calculations will be performed with a 95% confidence interval. Statistical significance will be set at P < 0.05. Adjusted effect estimates will be analyzed in preference to the unadjusted estimates, using inverse-variance weighted average. Pooled estimates will only be presented after consideration of both clinical and methodological heterogeneity of included studies. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.Systematic review registrationThe protocol was registered on PROSPERO CRD42019135735: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=135735

Reconstruction totale de la lèvre inférieure : technique de suspension labiale par double haubanage nasogénien et revue de la littérature

Total lower lip defect is rare and its reconstruction difficult. The challenges are both aesthetic and functional. Suspension of the lower lip is essential for restoring oral competence. We report an original and simple technique of suspension by double nasolabial rigging. Two upper base orbitonasolabial flaps, extended over several centimeters below the lip commissures are raised. The epidermis is completely removed. Then, the flaps are tunneled under the skin and fixed to the reconstructed lower lip in order to provide it with effective suspension to the maxillary. In our experience, we used the nasolabial rigging associated with a total reconstruction of the lower lip for three patients. Lip continence is effective in the long term. The review of literature shows that the use of conventional locoregional flaps restores a good labial competence but is limited to subtotal lower lip defect. Distant pedicled flaps or free flaps made without suspension of the lower lip don't restore the labial competence. Several procedures to suspend the lower lip with strips of fascia lata or tendon of palmaris longus, associated or not with a free flap, seem to provide satisfactory oral competence. All these techniques are poorly standardized and technically difficult. The technique of the double nasolabial rigging that we describe seems to be an effective and interesting alternative by its simplicity, its reproducibility and its adaptability. It allows to obtain a perfectly fixed posterior plane, able to receive any reconstruction of the lower lip.

Flexor tendon grafts for pulley reconstruction – Morphological aspects

BackgroundPulleys are crucial to convert flexor tendon excursion into angular motion at the metacarpophalangeal and interphalangeal joints. Loss of pulley function can lead to significant impairment of hand function and may require surgical reconstruction. This reconstruction can be achieved using different flexor tendons grafts, such as the intrasynovial flexor digitorum superficialis (FDS) or the extrasynovial palmaris longus (PL). However, there is limited knowledge on the micromorphology of human pulleys and the suitability of flexor tendon grafts for their reconstruction remains elusive. MethodsIn the present cadaver study A2 and A4 pulleys were compared with FDS and PL tendons by means of scanning electron microscopy (SEM), histology and immunohistochemistry. Surface morphology, core structure and vascularization of the specimens were analyzed. ResultsSEM imaging of the gliding surfaces revealed morphological differences between tendons and pulleys. Moreover, the core structure of FDS samples was characterized by bundles of individual collagen fibrils whereas PL tendons exhibited a less hierarchical microstructure. In contrast, pulleys consisted of lamellar sheets of densely packed collagen fibrils. Finally, immunohistochemical analyses revealed that the flexor tendons and pulleys contain similar numbers of CD31+ microvessels, indicating a comparable tissue vascularization. ConclusionThis study provides novel SEM and immunohistochemical insights into the micromorphology of human pulleys and flexor tendon grafts. Intrasynovial flexor tendons may be particularly suitable for pulley reconstruction and preserving the paratenon may be crucial for graft revascularization.

Ten Years' Follow-Up after Microsurgical Reconstruction of the Lip Using Forearm Flap Combined with Gracilis Muscle Transfer.

Dynamic reconstruction of the face by muscle transplantation using microsurgery may cause problems with muscle atrophy and synkinesia. Therefore, it is necessary to observe the patient on a long-term basis. In 2006, we reported a case of functional reconstruction using a radial forearm flap combined with an innervated gracilis muscle flap for total reconstruction of the lower lip.1 We applied the same method to reconstruct both the upper and lower lips and the commissure.2 The aim of this report is to describe the 10-year postoperative result in the latter case. The details of the case and surgical technique were reported.2 Briefly, the patient underwent a resection of two-fifths of his upper lip and one-third of his lower lip including the left commissure because of arteriovenous malformation. His left forearm flap was transferred and the radial artery and vein were anastomosed to the left facial artery and vein. Then, the gracilis muscle was transferred and the cut ends of the muscle were sutured to the orbicularis oris muscle, after which the motor nerve of the muscle was sutured to the buccal branch of the facial nerve. In addition, skin and mucosal defects were covered by a forearm flap and a sensory nerve of the forearm flap was sutured to the mental nerve. After 5 months, the skin of the forearm flap on the face was resected and replaced using a local flap. After 10 years, there is no recurrence of arteriovenous malformation. The patient has not required any additional treatment in the past 10 years. The lip sphincter function is maintained (Fig. 1). Facial expression and lip movement are achieved independently and no facial synkinesia is recognized. [See Video (online), which displays 10-year follow-up of the case. Oral sphincter function is maintained by the combination of the innervated gracilis muscle and the sensate forearm flap.] The depth of oral vestibule space and the length of lower lip are maintained and no salivation is observed. The patients can eat a normal diet. The result of Semmes-Weinstein monofilament test on the forearm flap in the oral cavity was 2.44. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video displays 10-year follow-up of the case. Oral sphincter function is maintained by the combination of the innervated gracilis muscle and the sensate forearm flap.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_1himk65z"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: (Left) Ten years after the reconstruction. (Right) Oral sphincter function is maintained and no facial synkinesia is recognized.The most important consideration in lip function is maintenance of the sphincter function by the orbicularis oris muscle. Ninkovic et al. reported a similar method using a gracilis muscle free flap.3 The difference from our method is the technique of covering the muscle. A graft or local flap covered the muscle in that report. The forearm flap provides a long pedicle and better sensation. Sensation of the lip and depth of vestibular space are important to reduce the saliva and support speech and eating. To achieve muscle sphincter function, the palmaris longus tendon can be attached to the forearm flap to suspend the lip by suturing it to the orbicularis oris muscle.4 However, postoperative loosening of the tendon and drooping of the flap may occur, and additional surgical treatment may be required.5 Our 10-year follow-up of this patient shows that combining the innervated gracilis muscle, which did not exhibit any dyssynergia and synkinesia, with the sensate forearm flap allows for a successful and sustainable lip reconstruction and contributes to maintenance of the patient’s quality of life, even in the long term. PATIENT CONSENT The patient provided written consent for the use of his images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

A Study on The Effects of the Absence of Palmaris Longus Tendon on Handgrip Strength of Athletes

The study aims to find out the incidence of the absence of palmaris longus tendon and to study the effects of the case on handgrip strength of athletes. We studied whether 190 athletes (male n= 80, mean age: 18.9� 2.2; female n= 110, mean age: 18.5� 1.2) included in our study had palmaris longus tendon or not. Then, the handgrip strength values of the athletes were obtained by using a Jamar dynamometer, according to the recommendations of the American Association of Hand Therapists. Total number of participants having no palmaris longus tendon was 59 (31.05%) and it was observed that 37(19.47%) of these individuals didn�t have the tendon in both hands. The number of participants with unilateral tendon absence was 22 (11.5%). The tendon was absent in right hand of 10 individuals (5.26%) and in left hand of 12 individuals (6.31%). After controlling age, height, body weight and body mass index variables of the groups, it was observed that the presence or the absence of palmaris longus tendon in both hands of male athletes didn�t cause any statistical effects on handgrip strength of the athletes. However, left handgrip strength of female athletes with palmaris longus tendon in left hand was found to be higher than left handgrip strength of female athletes with no palmaris longus tendon (p[.01). According to the findings of the study, we might state that the presence or the absence of palmaris longus tendon does not cause a significant effect on handgrip strength of both hands of male athletes (p].05) and that its presence causes a significant effect on left handgrip strength of female athletes (p[.01).

Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair Stabilization

Background: Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques. Hypothesis: Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament. Study Design: Controlled laboratory study. Methods: We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min). Results: Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness (P < .001) and residual torque (P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair (P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair (P = .766). Conclusion: Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow. Clinical Relevance: We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.

Primary Repair of Ulnar Collateral Ligament Injuries of the Elbow

Injuries to the medial ulnar collateral ligament (MUCL can be devastating in overhead and throwing athletes. Prior to 1986 injury to this ligament was considered to be career ending. In that year, Dr. Frank Jobe reported on his initial experiences with reconstruction of the MUCL. His first case was pitcher Tommy John, who underwent what at that point was considered an experimental surgery to reconstruct the ligament using the palmaris longus tendon. The success of the classic “Tommy John” surgery in professional athletes has led most of these injuries to be managed by the same reconstructive technique. However, the injuries in young athletes do not appear to be the same as those sustained by professionals; one of the issues that led Dr. Jobe to utilize a reconstruction rather than a repair was the “wear and tear” of repetitive micro-trauma rather than a discrete area of injury. Fortunately in young, active athletes, the initial injury often is isolated to a single area, increasing the chance of both nonoperative and direct repair each being successful in allowing a return to sport. Unfortunately, there has been little focus on alternative treatment options in these young, nonprofessional athletes who continue to have instability despite conservative treatment and who wish to continue in sports. Many of these young athletes may have MUCL injuries isolated to one area in the proximal or distal end of the ligament that would seemingly allow a repair rather than reconstruction. Rather than extrapolate the data from professional athletes that the classic “Tommy John” operation is necessary for all of these young athletes to return to sports, we developed a protocol of repair in these players in which the ligament had a single area of injury on either the proximal end, distal end, or both in an attempt to minimize morbidity and loss of time and allow a more rapid return to sports. The indications for repair include a repairable injury (i.e., an injury to the ligament confined to the proximal or distal end of the ligament with or without a small fragment of bone) and a patient who desires to continue his throwing activity. In our initial study, 93 % (56 of 60) of these young (age range 13–23, avg. 16) athletes in the study returned to sports within 6 months (range 4–11.7 months) postoperatively at the same or higher level of competition.

Ulnar artery: A case report of high origin and superficial course

Blood vessel variety of the upper appendage are normal and these can be of impressive enthusiasm to orthopedic surgeons, radiologists and anatomists. During routine dissection for college understudies of the right upper limb in a male cadaver, a variation starting point of ulnar artery from brachial artery was taken note. The brachial artery ending in the cubital fossa by partitioning into radial and ulnar or interosseous supply routes. The outspread artery had taken typical course and branches. Different divisions was the basic interosseous artery, anterior and posterior ulnar recurrent arteries demonstrated ordinary course.The irregular high source of ulnar artery route from the brachial artery was seen which was taking root from medial side of the brachial artery higher than the radial artery, running on the shallow muscles and going underneath the Palmaris longus tendon and intersection the tendon from lateral to medial side. At that point its running shallow to the muscles which were taking cause from the regular flexor source from the humerus and it was secured by the profound belt of the forearm arm, at that point it crosses the flexor retinaculum and partook in the formation of the superficial palmar arch. During its course, supply route didn't give any branch.

Biomechanical assessment of lateral ulnar collateral ligament repair and reconstruction with or without internal brace augmentation

BackgroundSurgical treatment of posterolateral rotatory instability (PLRI) using primary repair or reconstruction of the lateral collateral ligament complex have proven inconsistent. This study aimed to test the hypothesis that augmentation of LUCL repair or palmaris longus tendon reconstruction using a suture tape augmentation would be associated with less rotational displacement and greater torque load to failure (LTF) compared with nonaugmented constructs.MethodsCadaveric elbows (n = 12 matched pairs) were used. Baseline stiffness and displacement values were obtained. The LUCL was transected followed by repair alone, repair with augmentation, reconstruction with palmaris longus graft, or reconstruction with augmentation. Specimens were retested including torque LTF. Paired t tests were performed to assess the biomechanical effects of augmentation.ResultsAugmentation was associated with higher LTF than repair and reconstruction alone (P = .008 and .047, respectively). Displacement was less with augmentation in reconstruction groups (P = .048) but not in repair groups. Suture tape augmentation maintained rotational stiffness better than repair alone (P = .01). Although reconstruction with augmentation maintained rotational stiffness better than nonaugmented reconstruction, the differences were not statistically significant (P = .057). Mode of failure for repair alone was predominantly suture pulling through repaired ligament. Augmented repairs primarily failed at the anchor-bone interface. Modes of failure for both reconstruction groups were similar, including graft tearing and/or slipping at the anchor.ConclusionWhen positioned in neutral forearm rotation and 90o of flexion to simulate postoperative conditions, augmentation of LUCL repair or tendon reconstruction using suture tape is associated with better resistance to rotational loads compared with nonaugmented repair or reconstruction, while maintaining near-native rotational stiffness.

Clinical Assessment of Existence of Palmaris Longus Muscle among South Indian Population.

Background: Palmaris longus tendon is often used as a donor tendon by surgeons in tendon grafts. It is one of the flexor muscles of the forearm and documented well for its variations in both morphology and number of tendons. Prevalence of absence of this muscle varies among the individuals of same population and individuals of various ethnic groups. The aim of this study was to assess the existence of Palmaris longus muscle within a group of students and its association with side of the limb and gender of the individual. Methods: Three hundred medical students of 150 males and 150 females with age group of 18-21 years were clinically assessed. The standard Schaffer's test was used for the assessment of PL tendon. If the tendon was not found in this test, the confirmation was done by other four tests. Results: Results of this study shows that an overall absence of palmaris longus muscle in both sexes was found to be 32%, out of which 21% absence was found in males and 43% absence found in females. Among the males, the unilateral agenesis was seen in 16% and bilateral agenesis in 4% and in females the unilateral agenesis was seen in 29% and bilateral agenesis seen in 14%. Conclusions: To conclude; in the present study, prevalence of Palmaris longus muscle agenesis was found to be more in female subjects on their left side. Surgeons who plan for tendon reconstructive procedures should know variations of Palmaris longus muscle and its clinical assessment.

Fiber Type Composition of Contiguous Palmaris Longus and Abductor Pollicis Brevis Muscles: Morphological Evidence of a Functional Synergy

IntroductionThe palmaris longus (PL) tendon can be transferred to the thumb for use in surgical opponensplasty to restore functional hand movements in patients with thenar paralysis. Successful opponensplasty outcomes using the PL tendon have been attributed to an intrinsic synergy of the PL with the abductor pollicis brevis (APB) such that no specific muscular retraining is needed upon tendon transfer. This synergy has been demonstrated electromyographically in which synchronous EMG signals were recorded from the PL and APB during functional thenar movements in healthy young individuals, in vivo. Thus, although an established synergistic relationship between these muscles has been demonstrated, this functional relationship may depend on their spatial relationship and properties of their constituent muscle fibers. The purpose of this study was to compare the proportions of type I and type II muscle fibers in the APB from cadaveric muscle based on its contiguous morphological relationship with the PL tendon for further insight into their functional synergy, contractile capacity and digastric arrangement.MethodsTwenty‐four contiguous PL and APB specimens were harvested from the upper limbs (12 right, 12 left) of twelve formalin‐embalmed cadavers (mean age: 74 ± 10 years). The 24 limbs were classified into two groups based on the following morphological criteria: (1) APB with discrete PL tendon connections, or (2) APB with non‐discrete, or rudimentary, PL tendon connections. Cadaveric specimens were obtained from the body bequeathal program at the University of Western Ontario and approved for research use by the Committee for Cadaver Use in Research (REF#21092016). The fiber type composition of the APB and PL muscles was determined by labeling serial cross‐sections with myosin heavy chain type I and type II monoclonal antibodies.ResultsThe APB fascicles from 11 hands (46%) were classified as discrete based on their continuity with the PL tendon. Conversely, the APB fascicles from 13 hands (54%) were classified as non‐discrete due to rudimentary or minimal connections with the PL tendon. The PL consisted of a relatively heterogeneous fiber type composition irrespective of the presence of a discrete (type I: 41 ± 11%, type II: 55 ± 12%, hybrid: 4 ± 3%), or rudimentary (type I: 49 ± 10%,type II: 45 ± 9%, hybrid: 6 ± 4%), tendinous connection with APB musculature. The APB fascicles arranged in a digastric manner with the PL tendon had significantly greater proportions of type II fibers (41 ± 19%) compared to those with rudimentary PL connections (type II: 15 ± 8%).ConclusionThe APB fascicles arranged in a digastric relationship with the PL may have the capacity to produce more powerful contractions than those with rudimentary PL tendons based on the known contractile properties of type II muscle fibers. Knowledge of the spatial relationship between the PL and thenar musculature prior to PL autologous tendon transfer may be a useful indicator of the quality of established synergy in vivo.Support or Funding InformationSupported by NSERC

Repairing dorsal complex tissue defect of finger with flaps based on superficial palmar branch of radial artery with palmaris longus tendon

Objective To explore the clinical effects in repairing dorsal complex tissue defect of finger with the flap based on superficial palmar branch of radial artery (SPBRA) with palmaris longus tendon. Methods From May, 2011 to October, 2017, dorsal complex tissue defects of 15 fingers and thumbs in 15 patients were treated by the flaps which were based on SPBRA with palmaris longus tendon. There were 10 males and 5 females, in an average of 35.8 (19-51) years. All the defects (3 thumbs, 5 index, 2 middle and 5 ring fingers) were dorsal complex tissue defects and all had extensor tendon defects. The areas of soft tissue defect measured 2.0 cm×1.5 cm to 4.0 cm×2.0 cm. The lengths of tendon defect measured 2.0-4.0 cm. All patients received emergency surgery. The time before the surgery was 1.5-3.0 hours. The surgery time was 3.0-4.5 hours, 3.6 hours in an average. Postoperative regular follow-up. Results All of the wounds healed in stage I and all flaps survived. Texture of the flaps was soft with rosy color. No obvious swelling occurred. All the donor sites healed in stage I. The patients were followed-up for 4-18 months, 8 months in an average. The appearance and function of the repaired fingers and thumbs were satisfactory. The pain, temperature and touch sensations were good. The color of flaps was similar to the normal finger without swelling. The wear resistance of the flaps was good. Thin-line scars were in the wrist donor sites without contracture. The range of motion of active palmar flexion of the wrist was from 0° to 80° and active hyperextension was from 0° to 70°. No obvious limitation was found. Conclusion It is able to achieve a satisfactory clinical effects by using the flap that is based on SPBRA with palmaris longus tendon in repairing the dorsal complex tissue defect of hand. The advantages of the technique are that the donor site is concealed. The wound is small, and the flap is easy to be harvested and anastomosed. Key words: Superficial palmar branch of radial artery flaps; Complex tissue flaps; Palmaris longus tendons; Finger; Repair

Palmaris Longus Tendon Absence in Pre-Clinical Medical Students of Universiti Malaysia Sabah

Palmaris longus (PL) tendon is regularly used in reconstructive surgeries as a donor tendon because it is observed as an accessory muscle and has little practical use to the human hands. It is only found in mammals. For example, the orangutan has PL but it is absent variable in the higher class of apes such as gorillas and chimpanzees. The absence of PL in humans appears to be hereditary, but the genetic transmission is unclear. The main objective of this study is to determine the prevalence of PL tendon absence in pre-clinical medical students of UMS and to compare the lack between gender and ethnic groups. By using standard Schaffer’s test, we examined the presence or absence of PL tendon among the first and second-year medical students of UMS. Four additional tests, Thompson’s test, Mishra’s test I, and II, Pushpakumar’s tests were used to determine whether PL present or not. A total of 134 volunteers were examined, and 91.8% were right-handed, and 8.2% were left-handed. The overall absence (bilateral and unilateral) of PL tendon was 23.9%, whereas unilateral absent was 17.9%, and bilateral absent was 6.0%. The high prevalence of absence of PL tendon among females 25.5% compared to males 20.0%. Chinese and Indian have a higher incidence of PL tendon absence followed by Kadazandusun and Malay. In this study, there were different figures for each ethnic group. The prevalence of absence of PL varies depending on the populations.

The Outcome of the Reconstruction Surgery to Manage the Chronic Collateral Ligament Injury of the Thumb Metacarpophalangeal Joint

Background: Management of chronic collateral ligament injury of the Metacarpophalangeal (MCP) joint, either its Ulnar Collateral Ligament (UCL) or Radial Collateral Ligament (RCL), is challenging. Objectives: In this study, we report the outcome of ligament reconstruction procedure in the treatment of such injuries. Methods: In a retrospective study, the outcomes of static reconstruction surgery of the symptomatic chronic collateral ligament injury of the thumb MCP joint (five RCL and three UCL) were evaluated. We used palmaris longus tendon in four surgeries and flexor carpi radialis tendon in the remaining. The outcome measures included the thumb range of motion, the disabilities of the arm, shoulder, and hand (QuickDASH) questionnaire, pinch and grip strength, visual analog scale, and Kapandji opposition score. Results: Eight patients (6 males and 2 females) with the mean±SD age of 32±7.1 years were included in this study. The Mean±SD duration from the injury to surgery was 66.7±99.5 weeks. The Mean±SD follow-up of the patients was 4.88±1.35 years. The mean pinch and grip strength of the involved hand averaged 98.9% and 100% of the other hand, respectively. Postoperative pain was only noticed in two patients. The Mean±SD postoperative Kapandji opposition score was 9.4±0.7 (range: 8-10). The Mean±SD QuickDASH score was 12.9±1.9 (range: 11-17). The thumb range of motion was similar to the contralateral hand in all but one patient. All the operated joints were stable. A case of mild degenerative joint disease was the only observed postoperative complication. Conclusion: Static reconstruction of chronic collateral ligament injury of the thumb MCP joint provides acceptable results, regardless of the time interval between the injury and surgery.

Physeal sparing distal radio-ulnar joint ligament reconstruction in children.

Distal radio-ulnar joint (DRUJ) injuries are under-reported in the paediatric population. No single study has discussed methods of DRUJ reconstruction in immature patients with chronic instability. We present a physeal sparing ligamentoplasty for chronic DRUJ instability and describe the outcomes in two patients. Two consecutive children with chronic DRUJ instability were treated using physeal sparing ligamentoplasy. After the failure of triangular fibrocartilage complex repair, reconstruction was done using palmaris longus tendon graft that was tunnelled through the distal radius epiphysis and wrapped subperiosteally around the ulnar neck. Graft was tied in a neutral forearm position. DRUJ stability was achieved in both patients. Grip strength averaged 90% of the healthy side. Prono-supination range of motion (ROM) averaged 88 and 86%, respectively, of the healthy side, without intraoperative nor postoperative complications. Our novel technique was effective in the regain of DRUJ stability with minor effect on the prono-supination ROM. Further studies are planned to experiment the biomechanical effectiveness of our technique. Level of evidence: Therapeutic IV.

An Intraoperative Dilemma: Absent PL with Abnormal Insertion of FCR

Little known variations in hand anatomy may pose an operative challenge to a hand surgeon. Palmaris longus tendon is commonly known to be absent in the forearm. Abnormality in the insertion of flexor carpi radialis (FCR) tendon is scarcely documented. We present a previously operated case of flexor pollicis tendon repair that was preoperatively planned for an ipsilateral palmaris longus (PL) tendon graft. Intraoperatively the palmaris longus tendon was absent with an abnormal attachment of the Flexor carpi radialis tendon, mimicking the palmaris longus. Pre-planned procedure to use a tendon graft was abandoned and the flexor digitorum superficialis was rerouted to the distal phalanx of the thumb. Even with the known and documented variations in hand anatomy high level of suspicion is required intraoperatively, to prevent untoward complications.