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

Lo, I-Ninga,b; Yin, Cheng-Yua,b; Yu, Jin-Hueic; Huang, Hui-Kuanga,b,d,e; Huang, Yi-Chaoa,b; Wang, Jung-Pana,b,*

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Journal of the Chinese Medical Association: July 2021 - Volume 84 - Issue 7 - p 728-732
doi: 10.1097/JCMA.0000000000000551
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Extensor pollicis longus (EPL) tendon rupture poses substantial functional disability to the hand. The main etiologies for EPL tendon rupture include mechanical irritation, attrition, and compromised vascular supply secondary to hemorrhage and pressure,1,2 which are often caused by distal radius fracture, rheumatoid arthritis, synovitis, bony deformity, and certain occupational overuse.3 The chronic nature of most EPL tendon ruptures makes it more challenging to treat due to tendon retraction and gap formation.

The main treatment choices for EPL tendon ruptures consist of: (1) primary tendon repair, which is usually not possible in the chronic setting; (2) tendon transfer; and (3) repair with intercalated tendon graft.4,5 Tendon transfer with extensor indicis proprius (EIP) is considered the gold standard treatment, which has the advantages of a smaller surgical incision, and shorter surgical time with predictable functional results.1,5,6 However, some literature have shown that tendon transfer with EIP could potentially cause weakness in the independent extension strength of the index finger.7–9

In this study, we propose our technique of using a partial extensor carpi radialis longus (ECRL) tendon graft, which could be harvested from the same incision as exploration for the EPL stump, to repair chronic EPL tendon ruptures. Our hypothesis is that this technique can achieve satisfactory function, range of motion similar to the unaffected thumb, while preserving the independent extension of the index finger.


2.1. Patients

We retrospectively reviewed all of our patients treated with this method from March 2016 to June 2019. The medical records were reviewed for basic patient demographics, etiologies of tendon rupture, and the time delay from onset of symptoms to surgical repair. All the patients were followed for a minimum of 12 months. The indication for this procedure was chronic EPL tear with tendon retraction unable to be repaired by primary anastomosis. The contraindications for this procedure included: (1) poor EPL muscle quality; (2) poor ECRL tendon quality; and (3) poor quality of the proximal EPL tendon stump (shorter than 2 cm) inadequate for proper suture. All the operations were performed by a single surgeon in a single medical center. This retrospective study was approved by the Institutional Review Board.

2.2. Surgical Technique

All the operations were conducted under general anesthesia, in a supine position with the arm extended over an arm table and a tourniquet applied over the upper arm. A small incision was made at the base of the first metacarpal where the distal tendon stump of the EPL is usually located. A curve incision was then made over the dorsal radial wrist. The incision extended from the Lister’s tubercle proximally along the third extensor compartment as needed to locate the retracted proximal stump. The dorsal branch of the radial nerve was identified and carefully protected. After both ends of the EPL tendon were identified, the gap distance was measured with the wrist neutral and the thumb in full extension.

This incision allowed for complete visualization of the ECRL tendon. The tendon graft was harvested proximal to the extensor retinaculum, thus it was not necessary to open the second extensor compartment or the extensor retinaculum. We took approximately half the width of the ECRL tendon. The length of the graft was the measured gap plus four extra centimeters, with 2 cm at both ends for anastomosis. The distal anastomosis was performed with side-to-side sutures to avoid bulkiness. Three pairs of sutures were inserted on each side of the overlapping tendon graft and tendon stump. The sutures were performed with 3–0 prolene, and the knots were hidden between the overlapping tendons at intervals of 0.5 cm. The proximal anastomosis was performed with a Pulvertaft weave.10

The repaired tendon was rerouted, avoiding the Lister’s tubercle, and placed in the subcutaneous layer under the dorsal branch of the radial nerve. A plaster orthosis was applied after the operation, with the wrist at 30 degrees extension, the carpal–metacarpal joint in adduction, and the metacarpal-phalangeal joint (MCP) and interphalangeal joint (IP) joints in full extension. The method is shown in Fig. 1.

Fig. 1
Fig. 1:
The method for partial ECRL tendon graft for EPL tendon repair. A, The distal stump of the EPL was located through an incision made over the first metacarpal base. The black arrow points to the dorsal branch of the radial nerve, which is marked in purple, and was carefully protected. The proximal stump was located and the ECRL tendon was identified. B, The gap length was measured and a half-width ECRL tendon graft was harvested. C, The repaired tendon was placed over the subcutaneous layer and tensioned with the wrist neutral and thumb fully-extended. ECRL = extensor carpi radialis longus; EPL = extensor pollicis longus.

2.3. Postoperative Care

The patients were instructed to keep the orthosis for 6 weeks. The patients took off the orthosis three times per day for range of motion (ROM) exercise, which included stretching of the MCP and IP joints while the wrist was kept in extension. The orthosis was discarded at postoperative 6 weeks and the patient was allowed to move without restrictions.

2.4. Parameters for Evaluation

The patients were followed at postoperative 2, 4, 6, and 12 weeks, then at 6 and 12 months, and subsequently annually. Range of motion was evaluated with the total active motion (TAM) system which includes the motion arc of the carpometacarpal joint, the MCP and IP joints, presented as a percentage of the contralateral thumb.11–13 Pinch strength was also evaluated, as the EPL contributes to thumb adduction,4 and compared to the contralateral hand. The ability to extend the thumb to the palm level and the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score14 were also measured.


During the study period, 23 patients were included. There were 17 female and 6 male patients. The mean age was 59.7 (range: 33–76) years old. Fourteen patients had a prior distal radius fracture, two patients had rheumatoid arthritis, two patients had a previous cutting injury during which primary repair was not performed, two patients had a previous blunt injury, and three patients could not recall a specific traumatic event. The average time delay from symptom-onset to surgery was 9.1 weeks (range 2–54, median: 4 weeks). The mean follow-up time was 29.6 months (range: 12–51 months). There was one patient with a complication who required secondary surgery. The details will be described later.

At final follow-up, the mean TAM was 93.2% (SD 5.9) of the contralateral hand. The mean pinch strength was 95.4% (SD 10.5) of the contralateral hand. The mean Quick DASH score was 6.0 (SD 7.0). All patients, except for the patient with the complication, were able to elevate the operated thumb to palm level. The details of the patients are shown in Table 1. An example is presented in Fig. 2.

Table 1 - Details of the patients and their outcomes
Patient Age Sex Side of injury Cause of injury Time from injury to surgery (weeks) Operative procedure Follow-up time (months) TAM (% of contralateral hand) Pinch (% of contralateral hand) Quick DASH
1 57 F L DRF 4 TG 48 92 92 9.1
2 57 M L Blunt injury 1 TG 51 100 123 27.5
3 62 F R RA 52 TG 48 86 90 13.6
4 54 F R DRF 24 TG + ROI 48 92 110 0
5 33 F R RA 12 TG 43 95 98 0
6 54 F R unknown 8 TG 39 100 100 0
7 74 F R DRF 12 TG 36 92 95 4.5
8 59 M L DRF 2 TG 39 96 90 6.8
9 63 F R DRF 8 TG + radius lengthening 38 100 100 0
10 68 F L DRF 1 TG 36 90 95 4.5
11 59 M R DRF 12 TG + ROI 33 100 100 2.3
12 64 F R DRF 24 TG 33 88 92 6.8
13 65 F L DRF 8 TG 31 76 87 13.6
14 59 F R unknown 1 TG 27 94 100 4.5
15a 55 F R DRF 4 TG + radius corrective osteotomy 17 90 95 18.2
16 38 M R DRF 4 TG 17 100 100 0
17 64 F R DRF 4 TG + ROI 17 100 62 6.8
18 75 F R DRF 8 TG + radius lengthening 16 90 96 11.4
19 43 M L Cutting injury 4 TG 15 92 97 2.3
20 60 M L Blunt injury 4 TG 12 96 97 0
21 59 F L Cutting injury 4 TG 12 96 95 4.5
22 76 F L unknown 4 TG 12 86 88 2.3
23 76 F L DRF 4 TG 12 92 92 0
Mean 59.7 9.1 (Median: 4) 29.6 93.2 (SD 5.9) 95.4 (SD 10.5) 6.0 (SD 7.0)
Sex presented as F = female, M = male; side of injury presented as R = right, L = left; DRF = prior distal radius fracture; RA = rheumatoid arthritis; TG = partial ECRL intercalated tendon graft; ROI = removal of implant; TAM = total active motion (sum of ROM of CMCJ, MCPJ, and IPJ).
ECRL = extensor carpi radialis longus; EIP = extensor indicis proprius; MCP = metacarpal-phalangeal joint; Quick DASH = Quick Disabilities of the Arm, Shoulder and Hand; ROM = range of motion.
aPatient 15 is the case with the complication. The second surgery was performed at 5 months after the index surgery with EIP tendon transfer. The presented functional assessment was evaluated at the final follow-up (12 months after the second surgery).

Fig. 2
Fig. 2:
The follow-up image for case 11, a 59-year-old man who underwent volar plating for right distal radius fracture. Gradual weakness of thumb extension was noted 12 weeks prior to the surgery. Thirty-three months after EPL repair with partial ECRL tendon graft showed a TAM of 100%, the pinch strength 100% of the contralateral side, a Quick DASH score of 2.3, and the patient could elevate the thumb to palm level. ECRL = extensor carpi radialis longus; EPL = extensor pollicis longus; TAM = total active motion; Quick DASH = Quick Disabilities of the Arm, Shoulder and Hand.

There was one case with a complication. A 55-year-old woman who had a previous distal radius fracture treated by casting 5 months previously presented with wrist pain, limited ROM of the wrist and an inability to extend the IP joint of the thumb for 4 weeks. Intra-articular malunion of the distal radius fracture with EPL rupture was diagnosed. Intra-articular corrective osteotomy and EPL repair with intercalated partial ECRL tendon graft were performed simultaneously. However, weakness of the thumb and poor function were noted. Secondary surgery was performed at postoperative 5 months. Upon surgical exploration, the previous sutures were intact and no loosening was found. Thus, tendon adhesion and poor EPL muscle quality were suspected to be the cause of failure. EIP tendon transfer was performed. Subsequent follow-up at 12 months after the second surgery showed her TAM was 90%, and pinch strength was 95% of the contralateral hand. Her Quick DASH score was 18.2.


The use of intercalated partial ECRL tendon grafts to repair chronic EPL tears with tendon retraction showed satisfactory results in our case series of 23 patients. The procedure achieved a mean TAM of 93.2% of the contralateral thumb, 95.4% pinch strength of the contralateral hand, and a mean Quick DASH score of 6.0. While the concept of using an intercalated tendon graft to repair the retracted EPL tendon is not new, various choices for tendon grafts have been described in the literature. A case report illustrated a similar technique, which showed good functional results.15 We believe there are several advantages of this method. There is no need to sacrifice another muscle-tendon unit and the EPL muscle can be properly utilized. Since only a partial width of the ECRL tendon is harvested, the function of ECRL is preserved. With the original muscle, the rehabilitation process would be more intuitive.

The past literature has shown good functional outcomes using a free tendon graft to repair a chronic EPL tendon rupture,4,16,17 Also, a creative method of making a lengthening flap using the EPL tendon stump for direct repair, which did not need a free tendon graft, and with good results, has been described.3 Pillukat et al compared the surgical outcome of EIP tendon transfer and free interpositional tendon graft for the treatment of chronic EPL tendon rupture and reported comparable and satisfactory results for both groups.7 Chung et al also compared tendon transfer and tendon grafting in rheumatoid arthritic patients with extensor tendon ruptures and reported equally satisfying results for both methods.18 These findings are in line with the results of our patients. For the choice of potential tendon grafts, we chose a partial ECRL graft over the palmaris longus (PL) tendon for several reasons. The absence of the PL has been reported in approximately 15% of the population globally, with variations among different ethnic groups, while the presence of ECRL is more consistent.19 Also, another incision is needed to harvest the PL tendon. Finally, if spared, the PL muscle-tendon unit can serve as a donor for tendon transfer for radial nerve palsy in the future if the patient sustains certain injuries. Another possible candidate within proximity is a partial tendon graft from the extensor carpi radialis brevis (ECRB) tendon. Considering ECRB is the main wrist extensor while the ECRL is a mixture of wrist abductor and extensor, we decided to preserve the integrity of the ECRB tendon.20

The extension strength of the index finger is a frequently discussed issue with EIP tendon transfer. In the case series described by Pillukat et al, all patients were able to perform independent extension of the index finger after the tendon transfer.7 Other studies have shown that EIP tendon transfer resulted in approximately 50% loss of the extension strength of the index finger and a minimal extension lag. However, it was concluded that the loss in strength did not affect functional outcomes and was negligible in all cases.8,9 It is worth noting that EIP is absent in approximately 4% of the population and thus should be confirmed before making a surgical plan.21–23

In our method, we inserted the sutures for the tendon graft while keeping the wrist neutral and the thumb in full extension. Low et al performed a cadaver study and case series and concluded that EIP transfer tensioned with the wrist neutral and thumb in full extension provided better tensioning and resulted in good flexion and extension range for the thumb.24 In a comparative study, Jung et al reported that over-tensioning (wrist neutral, thumb full extension) was superior to standard tensioning (30 degrees flexion of the wrist, thumb full extension) in terms of better ROM, extension strength of the thumb, and less elevation deficit in EIP tendon transfer for EPL tendon rupture.25 In our series of partial ECRL tendon graft repair for EPL ruptures, the over-tensioning position also resulted in satisfactory ROM. No patient complained of tightness or flexion deficit.

As mentioned earlier, there were a few contraindications to our method. During the inclusion period of our study, two patients were excluded. One patient, who had a history of rheumatoid arthritis, had poor ECRL quality on exploration and was thus treated with a PL tendon allograft instead. The other patient had a very short proximal tendon stump of the retracted EPL and proper tendon suturing was not possible. EIP tendon transfer was performed instead. The muscle quality of the EPL is another concern. While the past pieces of literature have concluded that tendon grafting might be optimal up to 20 weeks postrupture,6 and a case report even described successful results with a repair performed up to 20 years after the injury,17 it is widely accepted that muscle atrophy, apoptosis, and fatty degeneration occur with tendon rupture and long-term disuse.26,27 Although we could not find clear guidelines in the literature defining whether a muscle is still viable for repair, we would routinely check the color and excitability of the muscle when stimulated by a nerve stimulator. In our series, three patients had a surgical delay of more than 6 months, the longest one being 13 months after injury. All three patients were successfully treated with this method. Since none of these contraindications can be properly evaluated before the surgery, it is crucial to have an alternative plan while performing the surgery.

There are certain limitations to this study. This was a retrospective case series and no control group was provided. Also, the most common cause for EPL tendon rupture in our series was a prior distal radius fracture, thus additional procedures were performed on some of our patients, including removal of a previous implant, corrective osteotomy for previous malunion, potentially complicating the treatment outcomes rather than a simple tendon repair.

In conclusion, we present our case series of chronic EPL tendon ruptures treated with an intercalated partial ECRL tendon graft. Our surgical outcomes at a minimum of 12-months follow-up showed satisfactory ROM of the thumb, pinch strength, and a low Quick DASH score. While certain contraindications to this procedure are to be noted, we believe this is a reliable alternative treatment to EIP tendon transfer, especially for patients who have high demands for the extension function of the index finger.


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Extensor carpi radialis longus; Extensor pollicis longus; Tendon graft

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