Impact of age and donor sites on bioactivities of tendon cells in autologous tenocyte implantation (OrthoATI™) for treatment of chronic tendinopathy.

OBJECTIVES: Autologous tenocyte implantation (OrthoATI™) therapy has demonstrated efficacy in treating patients with tendinopathy at various anatomical sites. This study evaluates the effect of patient age, gender, and tendon biopsy site on morphology, growth, and gene expression of autologous tendon cells used to treat chronic tendinopathy. METHODS: Patients undergoing OrthoATI™ for tendinopathies between 2020 and 2022 were initially treated by biopsies taken from patella tendon (PT) or palmaris longus tendon (PL). The biopsies were sent to a Good Manufacturing Practice (GMP) cell laboratory where tendon cells were isolated, cultured, and expanded for four to six weeks. Cell morphology was assessed using phase contrast microscopy. Droplet digital PCR (ddPCR) was utilized for gene expression analysis. Dichotomous results were compared between groups using x2 or Fisher's exact tests with no adjustment for multiple comparisons. The nonparametric Mann-Whitney U and Kruskal-Wallis tests were utilized for the sex and age (<35y, 35-44y, 45-54y, >55y) analyses, respectively. All analyses were performed using IBM SPSS v27, and a two-tailed P-value of <0.05 was considered statistically significant. RESULTS: 149 patients were included in the analysis. The PT was biopsied in 63 patients, and PL in 86 patients. There were no observer effects for age and gender between the PT and PL groups. There was no statistical significance between the PT and PL tendons for cell morphology, average cell population doubling time (PDT) (PT 83.9 vs PL 82.7 â€‹h, p â€‹= â€‹0.482), cellular yield (PT 16.2 vs PL 15.2 â€‹× â€‹106, p â€‹= â€‹0.099), and cell viability (PT 98.7 vs PL 99.0%, p â€‹= â€‹0.277). Additionally, ddPCR analyses showed no statistical significance found in tenogenic gene expression, including collagen type I (COL1, p â€‹= â€‹0.86), tenomodulin (TNMD, p â€‹= â€‹0.837) and scleraxis (SCX, p â€‹= â€‹0.331) between PT- and PL-derived tendon cells. An age stratification analysis found no effect on growth and gene expression. COL1 was found to be higher in males when compared to females (P â€‹< â€‹0.001), but otherwise no difference was seen in growth and gene expression in the gender analysis. No postbiopsy clinical complications were reported for either group. CONCLUSION: This study has shown that the growth and bioactivities of tendon cells from tendon biopsies for OrthoATI™ are not affected by tendon donor site and age. LEVEL OF EVIDENCE: IV.

Three in one - unusual palmaris longus muscle anatomical variation.

The palmaris longus muscle (PLM) is one of the most variable muscles in human body, pre-senting a wide range of morphological variants such as reversed course, biventer muscle, bi-furcated tendon or total agenesis. Their clinical impact is particularly important in diagnosis and treatment of carpal tunnel syndrome and reconstructive surgery. We present a case of PLM including a previously undescribed combination of variations. A routine dissection of male cadaver aged approximately 60 demonstrated a biventer muscle, with superior and inferior belly being interrupted by a long tendon. The inferior belly passed deep to the flexor retinaculum and its terminal tendon connected to flexor digitorum superfi-cialis tendon for 5th finger. The clinical importance of variations found have been described separately, including unsuita-bility of biventer muscles for tendon reconstruction and increased risk for developing carpal tunnel syndrome in patients with PLM tendon passing deep to the flexor retinaculum. In conclusion, as another variation of PLM is described, it is crucial to bear in mind the poten-tial morphological types of the muscle in diagnosis and treatment of patients, especially in surgery of the hand and forearm.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction Between Palmaris Longus Autograft and Knee Medial Collateral Ligament Allograft.

Background: Medial ulnar collateral ligament (mUCL) injury can cause significant pain and alter throwing mechanics. Common autograft options for mUCL reconstruction (UCLR) include the palmaris longus (PL) and hamstring tendons. Allograft use may reduce donor site morbidity and decrease function related to PL autografts. Purpose: To compare varus stability and load to failure between a novel allograft for UCLR-knee medial collateral ligament (kMCL)-and a PL autograft in human donor elbow specimens. Study Design: Controlled laboratory study. Methods: A total of 24 fresh-frozen human elbows were dissected to expose the mUCL. Medial elbow stability was tested with the mUCL intact (native), deficient, and reconstructed utilizing the humeral single-docking technique with either a (1) kMCL allograft (n = 12) or (2) a PL autograft (n = 12). A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion tracking cameras. The elbow was cycled through a full range of motion 5 times. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion, and failure modes were recorded. Results: The mUCL-deficient elbows demonstrated significantly greater valgus rotation compared with the intact and reconstructed elbows at every flexion angle tested (10°-120°) (P <.001). Both kMCL- and PL-reconstructed elbows exhibited significantly higher mean valgus rotation compared with the intact state between 10° and 40° of flexion (P < .01). There were no significant differences in valgus rotation at any flexion angle between the kMCL and PL graft groups. When loaded to failure, elbows reconstructed with both kMCL and PL grafts failed at similar torque values (18.6 ± 4 and 18.1 ± 3.4 N·m, respectively; P = .765). Conclusion: Fresh-frozen and aseptically processed kMCL allografts demonstrated similar kinematic and failure properties to PL tendon autografts in UCL-reconstructed elbows, although neither graft fully restored kinematics between 10° and 40°. Clinical Relevance: Prepared kMCL ligament allografts may provide a viable graft material when reconstructing elbow ligaments while avoiding the potential complications related to PL autografts- including donor site morbidity.

A very rare case of the accessory palmaris longus muscle and clinical significance.

The palmaris longus muscle is located in the forearm region. It morphological variability was noted during standard anatomical dissection of the upper limb. The muscle was characterized by a normal course, i.e. originating from the medial humeral epicondyle and inserting to the palmaris aponeurosis, but a small additional tendon attached to the flexor retinaculum was observed in its distal part. An accessory palmaris longus muscle was also observed nearby. Interestingly, this accessory muscle was reversed, and the first part was not muscular, but tendinous, represented by two tendons originating from the common muscular mass attached to the medial epicondyle of the humerus; these later connected together, creating one muscle belly distally attached to the flexor retinaculum. This additional structure was innervated by a neural branch from the median nerve and the ulnar artery was responsible for blood supply. The course of the median nerve is also clinically important, because before entering the carpal tunnel, it was located directly under the accessory palmaris longus muscle. In turn, the ulnar artery passed through a special hole created by the flexor digiti minimi brevis and flexor retinaculum, before passing under the palmaris brevis muscle.

Ligament reconstruction with modified suture anchor fixation technique for chronic distal radioulnar joint instability: A case report and literature review.

INTRODUCTION: The chronic instability of the DRUJ should be appropriately treated. Ligament reconstruction in the original technique needs an adequate length of the graft, which needs to be modified in such a case. CASE PRESENTATION: A 27-year-old male presented with right wrist pain accompanied by limited movement that has been felt for the last two months. There was an obvious deformity with tenderness. Palpation revealed a positive ballottement and piano-key sign test. An X-ray examination revealed a union fracture one-third distally on the right radius bone with dorsal dislocation of the right distal radioulnar joint. The result of an MRI confirmed a triangular fibrocartilage complex tear. The patient was diagnosed with chronic DRUJ instability. DISCUSSION: We performed a chronic DRUJ reconstruction using the harvesting palmaris longus tendon. However, the length of the graft is too short. Further, we performed a modified technique with suture anchor fixation for this patient. This technique could be a helpful alternative if the length of the graft is insufficient. As a result, there was an improvement in the DASH score and EQ5D questionnaires. CONCLUSION: Chronic DRUJ instability could be treated by ligament reconstruction with modified suture anchors fixation in the inadequate length of the graft situation.

A Cadaveric Case of Palmaris Longus Agenesis and Reversal.

The palmaris longus frequently exhibits anatomical variations with palmaris longus agenesis and reversal being the most prevalent. These variations are relevant clinically, as the muscle is often used during plastic surgeries for grafting tendons. They are also relevant in pathology, as hypertrophy of the reversed muscle is related to median nerve compression. In this report, we describe an unusual case in which a male cadaver-donor exhibited a right-sided palmaris longus reversal and left-sided palmaris longus agenesis. Review of the literature documents no previous co-occurrence of these anomalies. Since the muscle has relevance in a variety of contexts within medicine and surgery, reporting on a variation like this carries significant educational and clinical value.

Assessing the Accuracy of Common Clinical Tests for Detecting Palmaris Longus: A Prospective Study in a Tertiary Center.

Background Palmaris longus (PL) is a short-bellied muscle with a long tendon that merges with the palmar aponeurosis. It is supplied by the median nerve and acts as a tensor of the palmar aponeurosis and flexes the wrist. This tendon is commonly used for tendon transfers and as a donor for tendon graft. There are numerous clinical tests to detect the presence of PL like Schaeffer's test, Thompson's test, Mishra's test I, Mishra's test II, Pushpakumar's "two-finger sign" method, and AIIMS test. The principle of all these tests is to make the tendon prominent by eliciting its flexor action and then its identification by inspection and palpation. Objectives The tests that are consistently easy to perform with good understandability would be easy to explain to the general population (patients). The aim of our study is to find out the accuracy and easy comprehensibility of various tests using compulsive postures for detecting PL tendon clinically. Materials and Methods This is a prospective study on 137 participants. All the patients were subjected to six clinical tests to detect the presence or absence of PL tendon. The results were recorded for both hands by a single observer. Results Of the 137 participants, 75 were males (54.74%) and 62 were females (45.26%). The mean age was 21 years. The AIIMS test showed the maximum number of tendons, that is, 113 (82.4%) in the right hand and 108 (78.8%) in the left hand. In view of the ability to comprehend the tests, 119 (86.9%) subjects understood Schaeffer's test very easily. Conclusion According to this study, the AIIMS test best demonstrates the PL tendon, and Schaeffer's test was the test most easily understood by the subjects.

A Novel Technique to Convert Static Sling into a Dynamic Sling in Reconstruction of Total Lower Lip Defects Using Palmaris Longus Tendon with Free Radial Forearm Flap and Case Series.

Lower lip reconstruction has been a major challenge for the reconstructive surgeons since time immemorial. Various types of reconstruction had been described for the reconstruction of lower lip ranging from local flaps to free tissue transfer to free functioning muscle transfer. For complete lower lip defects, the free radial forearm flap with palmaris longus tendon has been the standard of reconstruction for many years. Literatures suggests various techniques for utilizing palmaris longus tendon sling as a static as well as dynamic structure. The limitation with static reconstruction is the loss of sling support with time leading to eversion and drooping of the reconstructed lower lip and drooling of saliva. In this article we describe a simpler and novel technique which converts static reconstruction into a dynamic one with a series of 5 patients. Aim of this prospective study was to evaluate the post operative functional and aesthetic outcome of our technique of total lower lip reconstruction using free radial forearm flap with palmaris longus sling reconstruction. The medical records included were demographics, including age, gender, and reason for the acquired defect, lip reconstructed, reconstructive method, flap survival, and outcomes. At 6 months follow up, all patients had satisfactory outcome and were able to take oral diets and none of the patients complained of drooling, an inability to eat in a public setting, or microstomia. This technique which is a simpler modification can be helpful in converting the traditional static sling reconstruction of lower lip into a dynamic one resulting in good aesthetic and functional outcomes.

Dorsal Scapholunate Ligament Reconstruction by Using Palmaris Longus Tendon Graft in Chronic Static Scapholunate Dissociations: Does It Yield Favorable Radiographic and Functional Results?

Background Scapholunate (SL) instability is the most common dissociative carpal instability, and the most frequent cause of wrist osteoarthritis (OA), termed as scapholunate advanced collapse (SLAC). The aim of this study was to present the mid-term clinical and radiographic results of dorsal SL ligament reconstruction by utilizing free palmaris longus tendon graft in patients with symptomatic, chronic, static SL dissociation; while assessing the safety and efficacy of this technique, Materials and Methods In total, 42 patients with a mean age of 44.1 (range 26-53) and mean follow-up duration of 69.4 months (range 60-72) with a diagnosis of chronic, static, and reducible SL instabilities with no chondral damage were enrolled. They all underwent dorsal SL ligament reconstruction with the exam same technique. Results At the last follow-up, patients' mean preoperative SL gap improved from 4.7 (range 4-6) to 2.1 (range 2-3), as did SLA from 84 degrees (range 67-101 degrees) to 66 degrees (range 49-72 degrees)( p <0.001 for both). Preoperative mean VAS (visual analog score), DASH (Disabilities of the Arm, Shoulder and Hand), Mayo wrist scores and SF-36 scores showed significant improvements in the last follow-up visit ( p <0.001, for all). No major complications were acquired in either of the patients. Conclusion Dorsal SL ligament reconstruction by using free PL tendon graft was detected to provide successful restoration of the normal carpal alignment together with SL joint stability. This procedure, by significantly reducing pain and improving grip strength was detected to yield significantly improved clinical and functional outcomes, together with high patient satisfaction indicated by improved health-related quality of life (HRQOL) scores. Level of Evidence IV.

Opponensplasty for Severe Carpal Tunnel Syndrome with the Transfer of the Palmaris Longus Tendon to the Rerouted Extensor Pollicis Brevis Tendon.

The authors describe a novel opponensplasty for severe carpal tunnel syndrome that uses the palmaris longus (PL) tendon transferred to the rerouted extensor pollicis brevis (EPB) tendon with pulley reconstruction using a portion of the PL tendon simultaneously with the carpal tunnel release. Like the Camitz opponensplasty, this technique utilises the PL as the motor source, does not require special postoperative treatment and enables fast functional recovery even in older patients. Compared with the Camitz procedure, this technique can easily acquire thumb rotation without tendon bowstringing. Furthermore, because the function of the EPB tendon is preserved, the tendency of flexion in the thumb metacarpophalangeal (MP) joint is not observed after surgery, and improvement can be expected in patients with preoperative MP joint extension lag. This technique is a useful alternative to the Camitz procedure, as it overcomes the disadvantages of the Camitz procedure while preserving the advantages. Level of Evidence: Level V (Therapeutic).

Persistent Median Artery, Bifid Median Nerve, and Reversed Palmaris Longus Encountered During Cadaveric Dissection: The First Reported Case.

The median artery is a transient embryological structure that normally disappears with the development of the radial and ulnar arteries. In rare instances, though, it persists as the persistent median artery (PMA). The superficial and deep palmar arches are formed through the anastomoses of the radial and ulnar arteries, giving hand and digits their main blood supply. This complex network of vessels and their anastomoses are prone to anatomical variations based on how the anastomosis occurs and which arteries contribute to this anastomosis. While it normally forms through the anastomosis of the radial and ulnar arteries, the superficial palmar arch (SPA) may also form differently, as in our case here, where the median artery persisted and branched off the radial artery, anastomosing with the ulnar artery to give rise to the SPA. This may also interfere with the normal compartmental architecture within the hand, possibly contributing to various clinical pathologies like carpal tunnel syndrome (CTS). Notably, in addition to the persistent median artery, our findings revealed a reversed palmaris longus and a bifid median nerve. These two additional variations can potentially exacerbate the risk of CTS. Alone, the coexistence of the PMA and the reversed palmaris longus is deemed a rare anomaly, only reported once in the literature. The addition of a third variation to the existing ones, like the bifid median nerve, is first reported by us and calls for more investigation for a possible genetic mutation. In this case, we report a persistent median artery, reversed palmaris longus muscle, and bifid median nerve in the forearm of a male cadaver found during a routine anatomy teaching session.

Results after open lunate excision alone or in combination with palmaris longus tendon ball arthroplasty for the treatment of Kienböck's disease.

PURPOSE: This study aims to compare results after open lunate excision alone and in combination with palmaris longus tendon ball arthroplasty for the treatment of late-staged Kienböck's disease (KD). METHODS: This is a retrospective study using the prospectively collected data, and patients who had a discharge diagnosis of KD (stage IIIB based on Lichtman staging criteria) and underwent surgical treatment by lunate excision alone or in combination with palmaris longus tendon ball arthroplasty between January 2011 and December 2020 were included in this study. Variables of interest involved demographics, disease condition, operative procedure, and the outcomes evaluated at the last follow-up. Within and between comparisons were performed. RESULTS: Thirty-five patients underwent lunate excision alone, and 40 patients underwent the combination procedure. At the final follow-up, patients in both groups exhibited significant improvements compared to pre-operation, such as wrist flexion, wrist extension, carpal height ratio, PRWE score, Cooney score, and grip strength (all P < 0.05). Compared to the excision group, combination procedure group had significantly longer surgical time (P < 0.001), more blood loss (P < 0.001) and exhibited better wrist flexion (P = 0.001), PRWE score (P = 0.001), Cooney score (P = 0.0034), and grip strength (P = 0.017). The excellent or good rate based on Cooney wrist score was not significantly different (87.5% vs 71.4%, P = 0.083). CONCLUSION: Lunate excision in combination with palmaris longus tendon ball arthroplasty is a better option than lunate excision alone for the treatment of stage III KD and can be considered as an operative option.

Bilateral Bifid Tendon of Palmaris Longus - Advantageous in Tendon Transfer?

Background: Variable insertions of Palmaris longus (PL) muscle tendon is described by various authors. Presence of extra PL tendon is also described in literature. As autologus tendon grafting is a blooming arena of clinical research at present time, an additional tendinous slip of PL has promising scope for use as an autograft. Case Report: We report here bilateral bitendinous distal attachment of PL muscle encountered during routine cadaveric dissection. The additional PL tendon in a multitendinous insertion pattern with optimum length and thickness is indeed an additional advantage from the point of view of autograft harvesting. This has also importance in understanding the unusual, altered symptomatology in compressive conditions. Conclusion: Although relatively common, surgeons should be well aware of the various possible aversion of distal attachment of PL which might have significant impact in alteration of symptomatology of neurovascular compressions in the forearm and hand and while choosing an appropriate tendon autograft.

Reversed Palmaris Longus: A Rare Anatomical Phenomenon Discovered.

The palmaris longus (PL) muscle is considered by many to be a vestigial muscle due to it having little to no functional significance on the upper limb. This, however, made it highly valuable in surgical procedures, especially as a graft in plastic and reconstructive cases. Variations in the muscle's morphology were discussed in the literature, but some are more rare than others. Those variations may have clinical implications on different pathologies such as Guyon's syndrome or Carpal tunnel syndrome based on the nerves and vessels surrounding it, and thus demand a proper understanding of the variation's anatomy. Here, we report a case of one of the rarer variations, a unilaterally reversed palmaris longus muscle in the left forearm of a 55-year-old male cadaver, discovered in a routine teaching session. Throughout the case, we will discuss the normal anatomy, the variation, and the clinical implications this variation may have.

Effects of the 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 Izzet 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.

Clinical assessment of absence of palmaris longus muscle and its association with ethnicity.

OBJECTIVE: To compare two clinical tests used for assessment of absence of palmaris longus, and to determine the prevalence of the absence of palmaris longus among ethnic groups in a cosmopolitan setting. Methods: The cross-sectional descriptive study was conducted at the Bahria University Health Sciences, Karachi, from April 2021 to May 2022, during which forearms belonging to Sindhi, Punjabi and Urdu-speaking ethnic groups were tested. Assessment of presence or absence of palmaris longus was performed using Schaeffer's and Thompson's tests. Agenesis and association of ethnicity and agenesis were compared. Data was analysed using SPSS 23. RESULTS: Of the 250 subjects, 152(60.8%) were females and 98(39.2%) were males. The overall mean age was 20.4±2.23 years (range: 18-23 years). In terms of ethnicity, 100(40%) subjects each were Punjabis and Urdu-speaking, while 50(20%) were Sindhis. The total forearms assessed were 500. The overall agenesis was 186(37.2%). When the two assessment tests were compared, highly significant differences were noted (p<0.000). Overall agenesis was highest among Sindhis 40%, followed by 38% in Punjabis, and 35% in Urdu-speaking. Significant differences were observed when one-sided palmaris longus absence was compared with two-sided absence (p<0.037). Conclusion: Schaeffer's test had more accuracy compared to the Thompson's test in the determination of palmaris longus agenesis. There were variations in terms of agenesis among the ethnic groups.

A Unique Three-Tendinous Head Reverse Palmaris Longus: A Case Report.

The Palmaris longus (PL) is a fusiform muscle that is part of the superficial flexors on the anterior compartment of the forearm. It originates from the common flexor tendon at the medial epicondyle of the humerus and inserts at the flexor retinaculum. The Palmaris longus has been reported to present in multiple variations. Some of these variations include agenesis, reversal, and multiple bellies of the muscle. The Palmaris longus is clinically significant as a landmark for carpal tunnel syndrome steroid injection, hand anesthesia, and used as a surgical graft. Medical students at the University of Medicine and Health Sciences, St. Kitts and Nevis, encountered a unique variation of the PL during cadaver dissection. This article explores the exclusiveness of a three-tendinous head reverse PL and what makes it unique compared to similar findings in other reports.

Biomechanical Properties of Knee Medial Collateral Ligament Compared to Palmaris Longus for Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament reconstruction (UCLR) is frequently performed among injured overhead-throwing athletes. One of the most common graft choices when performing a UCLR is the ipsilateral palmaris longus tendon (PL). The purpose of this study was to investigate the material properties of aseptically processed cadaveric knee collateral ligaments (kMCL) as a potential graft source for UCLR and compare them to the gold standard PL autograft. Each PL and kMCL cadaveric sample was subjected to cyclic preconditioning, stress relaxation, and load-to-failure testing, and the mechanical properties were recorded. PL samples exhibited a greater average decrease in stress compared to the kMCL samples during the stress-relaxation test (p < 0.0001). PL samples also demonstrated a greater average Young's modulus in the linear region of the stress-strain curve compared to the kMCL samples (p < 0.01). The average yield strain and maximum strain of kMCL samples were significantly greater than the PL, p = 0.03 and 0.02, respectively. Both graft materials had comparable maximum toughness and demonstrated a similar ability to deform plastically without rupture. The clinical significance of our result is that prepared knee medial collateral ligament allografts may provide a viable graft material for use in the reconstruction of elbow ligaments.

The incidence of palmaris longus in the heterogeneous Israeli population.

We evaluated the frequency of absence of the palmaris longus tendon in the heterogeneous Israeli population. Nine hundred and fifty wrists were evaluated using a modified Mishra/Schaeffer technique (thumb/little-finger opposition with resisted wrist flexion), which was validated by ultrasound scanning. The geographical and ethnic origin of volunteers was documented. When physical examination was equivocal, any vague, superficial structure was subsequently identified as the median nerve by ultrasound. Physical examination reliably identified palmaris longus only when a structure was clinically obvious (visually or by palpation). There was bilateral absence of the palmaris longus in 21% and unilateral absence in 15% of participants. Frequency of bilateral absence varied between 4.5% and 30%, depending on geographical origin (p = 0.0007). The incidence of palmaris longus tendon varied significantly by geographical, but not by ethnic origin.Level of evidence: II.