Determination of congenital absence of palmaris longus tendon with clinical examination and ultrasonography

Ultrasound identification of hand and wrist anatomical structures by hand surgeons new to ultrasonographic techniques

PURPOSE

Ultrasound is becoming an essential tool for hand surgeons, but most of them are trained on the job, without any diploma or dedicated training. The aim of this study was to assess the ability of hand surgeons new to ultrasound to identify hand and wrist anatomical structures.

METHODS

A monocentric study was conducted from January 2022 to April 2022. Ten residents and five attending hand surgeons, ultrasound novices, were involved in this study. The participants underwent two tests, wherein they were required to identify 17 anatomical structures using ultrasound, on the same subject. The second test was similar and carried out 2 to 6 weeks later by all participants. The number of structures successfully identified and if it was the case, the detection time per structure, were recorded. The correlations between participants age, years of surgical experience, surgical background (orthopedic or plastic) and the ability to perform immediately during the first test or to progress between the two tests were also assessed.

RESULTS

The average number of structures identified during the first test (T1) was 14.1+/-2.1 (82.9%), versus 16.2+/-0.8 (95.3%) structures during the second test (T2) (p = 0.001). The mean detection time per structure was 53.4 +/- 18.9 s during T1 versus 27.7 +/- 7.2 s during T2 (p < 0.0001). A moderate negative correlation between the progression in the number of anatomical structures identified between the two tests and the years of surgical experience (ρ=-0.56; p = 0.029) was found. The other parameters were neither correlated with the ability to perform at the first test nor with the progression between the two tests.

CONCLUSION

Hand surgeons new to ultrasound are most of the time able to identify hand and wrist anatomical structures. Comparison of their first and second tests showed significant potential for improvement in anatomical structure identification and detection time of those, especially in surgeons with limited surgical experience.

Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis

BACKGROUND

Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique.

RESULTS

Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003).

CONCLUSIONS

Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.

Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review

PURPOSE

To perform a systematic review evaluating clinical outcomes in patients undergoing medial ulnar collateral ligament reconstruction (MUCLR) with soft-tissue allograft.

METHODS

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes evaluated were patient-reported outcome scores, return to play (RTP) rates, incidence of postoperative complications, and rates of graft rupture or mechanical failure.

RESULTS

The literature search identified 395 articles, and 5 studies met final inclusion criteria after full-text review. A total of 274 patients were analyzed in the included studies and follow-up ranged from 3.0 to 7.6 years. Two studies (number of patients = 141) reported outcomes exclusively of MUCLR with allograft, whereas 3 studies (number of patients = 133) reported outcomes in patients undergoing MUCLR with either allograft or autograft. Allograft sources included gracilis, semitendinosus, plantaris, peroneus longus, and palmaris longus. Level of patient athletic competition ranged from recreational athletes to the professional level; however, nonathletes in the setting of trauma were also included. The RTP rate after MUCLR with soft-tissue allograft was 95.3%, and 89.3% of patients returned to a similar or greater level of play postoperatively. The Timmerman-Andrews score was reported in 2 studies, and the means postoperatively ranged from 94.55 to 97. Postoperative complication rates were low (range, 0% to 20%), and there were no reported incidences of allograft rupture or mechanical failure.

CONCLUSIONS

Based on the available data, soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of RTP, and low rates of postoperative complications and graft failure at short-term follow-up. There remains a lack of high-quality evidence directly comparing autograft versus allograft outcomes in elite overhead-throwing athletes to support allograft as an acceptable alternative for MUCLR in this patient population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Prediction Of Palmaris Longus Tendon Length And Thickness Through Simple Anthropometric Measurements

OBJECTIVE

This study aimed to test whether palmaris longus tendon (PLT) length and thickness can be predicted from simple anthropometric measurements.

MATERIALS AND METHODS

120 healthy volunteers with bilateral PL muscles were enrolled in this prospective study. PLT length and thickness were measured by ultrasonographic examination. Anthropometric measurements included body height, weight, forearm length, and wrist circumference. Correlation, linear regression, and Bland-Altman plot were used for analysis.

RESULTS

The mean PLT length and thickness were 10.8±1.4 cm and 4.0±0.9 mm, respectively. Body height and PLT length had a moderate positive correlation (r:0.407, p:0.001), and forearm length and PLT thickness had a weak positive correlation (r:0.229, p:0.001). The regression analysis showed that body height was the best predictor for PLT length, and forearm length was the best predictor for PLT thickness. The regression equations were as follows: PLT length=0.276+(0.062×height) (r2=0.165, p<0.001) and PLT thickness=1.373+(0.108×forearm length) (r2=0.052, p<0.001). The predicted PLT lengths and thicknesses were calculated using these regression formulas and compared with the actual thicknesses and lengths using the Bland-Altman plot. The upper and lower limits of agreement (95% CI) ranged from -2.54 cm to 2.51 cm for actual PLT length and predicted PLT length and from -1.76 mm to 1.74 mm for actual PLT thickness and predicted PLT thickness in the Bland-Altman plot with a weak agreement and proportional bias.

CONCLUSIONS

These findings indicate that height and forearm length have limited accuracy in predicting PLT length and thickness. The preoperative ultrasonographic examination can provide valuable assistance, particularly in cases that require grafts with precise length and thickness requirements.

Alternate Graft Options for Staged Flexor Tendon Reconstruction: A Cadaveric Study of Hamstring Autografts Compared to Conventional Autografts

PURPOSE

To compare the semitendinosus and gracilis tendon lengths and diameters to the palmaris longus, plantaris, flexor digitorum profundus, and flexor pollicis longus (FPL) tendons in a cadaveric model to evaluate the feasibility of hamstring autograft use for staged flexor tendon reconstruction.

METHODS

Fifteen fresh cadavers were evaluated for surgical incisions about the knee, forearm, and hand. All flexor digitorum profundus (FDP), FPL, palmaris longus, plantaris, semitendinosus, and gracilis tendons were harvested from each specimen. Diameter and length were recorded and means with SDs were calculated. The mean diameters of the gracilis and semitendinosus were compared to the mean diameters of the FDP and FPL tendons. The hamstring tendon lengths were then compared in terms of percentage of the palmaris longus and plantaris tendon lengths.

RESULTS

The gracilis (18.0 cm) and semitendinosus (19.9 cm) means were notably longer than the palmaris longus (16.0 cm) and shorter than the plantaris (30.0 cm). The average gracilis tendon diameter (3.8 mm) was smaller than the flexor tendon diameters except for the little finger FDP (3.8 mm). The semitendinosus tendon diameter (4.8 mm) was larger than all flexor tendons with the exception of the middle finger FDP (4.6 mm). Average gracilis and semitendinosus tendon diameters were 3.7 mm and 4.5 mm in males, and 3.8 mm and 4.8 mm in females.

CONCLUSIONS

This study showed the gracilis tendon to have adequate length and diameter for potential autograft use in staged flexor tendon reconstruction in all digits but the little finger. The semitendinosus is larger in diameter than the native flexor tendons, making it a poor autograft option in cases with an intact pulley system.

CLINICAL RELEVANCE

Common tendon autograft options for flexor tendon reconstruction are variably present, and the use of gracilis and semitendinosus autograft present potential graft options.

Effects of Presence Rate of the Palmaris Longus Tendon on Wrist Proprioception and Grip Strength

INTRODUCTION

The palmaris longus muscle displays a great variation in terms of incidence and shape. This study has documented the incidence ratio of this muscle among the students at Bolu Abant İzzet Baysal University, Faculty of Medicine, and has revealed the effects of its presence on wrist proprioception and grip strength.

METHODS

A total of 101 students between the ages of 18 and 25 were included in the study. Age, height, weight, body mass index (BMI), and dominant upper extremity of the individuals were recorded. After the presence of palmaris longus tendon (PLT) was determined by using the Schaeffer's test, wrist proprioception was evaluated by using a digital inclinometer, and grip strength was evaluated by using a hand dynamometer.

RESULTS

PLT absence rates were evaluated separately as right and left, and it was found as 16.8% and 17.8%. No correlation was found between the dominant upper extremity and BMI and the presence of PLT. The presence or absence of PLT has no effect on grip strength and wrist proprioception.  Conclusion: PLT is used in many clinical areas, such as reconstructive and cosmetic surgery, graft applications, tendon repairs, ptosis correction operations, and ligament stabilization. We think there will be no significant loss in the sense of proprioception and grip strength in the absence of PLT.

Tendon repair with intercalated partial extensor carpi radialis longus tendon graft for chronic extensor pollicis longus tendon rupture

BACKGROUND

The main treatment choices for chronic extensor pollicis longus (EPL) tendon rupture consists of tendon transfer and tendon repair with tendon graft. Tendon transfer with extensor indicis proprius (EIP) is currently considered the gold standard treatment which yields predictable and satisfactory results, but potentially compromises the strength of independent extension of the index finger. We propose our method of using a partial extensor carpi radialis longus (ECRL) tendon graft to repair chronic EPL tendon tears.

METHODS

The distal stump of the EPL was located through an incision at the basal joint level. The proximal stump was located through a curved incision at the dorsoradial wrist where the partial ECRL tendon graft was harvested. The tendon graft was subcutaneously transposed, sutured at both ends, and tensioned at full thumb extension with a neutral wrist position.

RESULTS

From March 2016 to June 2019, 23 patients (mean age: 59.7 years; mean follow-up: 29.6 months) were retrospectively reviewed. All the patients were followed for a minimum of 12 months. The final total active motion was 93.2% of the contralateral thumb. The mean Quick Disabilities of the Arm, Shoulder and Hand score was 6.0. There was one complication possibly due to poor EPL muscle quality, and the patient was subsequently treated with EIP tendon transfer.

CONCLUSION

Our study showed that using a partial ECRL tendon graft to repair chronic EPL tendon rupture results in satisfactory functional outcomes. The advantages of this method include preservation of EIP function and using the same incision for graft harvesting and tendon repair. This method can be considered an alternative to EIP tendon transfer in patients with high demand for their index finger function.