Comparison of palmaris longus and split flexor carpi radialis tendon grafts in two-stage flexor tendon reconstruction

Two-stage flexor tendon reconstruction continues to be an important option for delayed or missed Zone II flexor tendon injuries when direct repair is no longer feasible. Although the palmaris longus is commonly used as a donor tendon, it may be absent, unavailable, or unsuitable in some patients. In this retrospective comparative study, we evaluated the feasibility of split flexor carpi radialis tendon grafts as an alternative donor source and described their outcomes in relation to palmaris longus grafts. Thirty patients treated between December 2022 and February 2025 were included; 14 received split flexor carpi radialis grafts and 16 received palmaris longus grafts. Clinical assessment included graft length, fingertip-to-pulp distance, active interphalangeal flexion, extension lag, Strickland percentage and grade, grip strength, and QuickDASH score. Baseline characteristics were similar between the groups. No statistically significant differences were found in graft length, range of motion, Strickland percentage, original Strickland grade distribution, grip strength relative to the contralateral side, QuickDASH score, or complication profile. Dominance-corrected grip strength was higher in the palmaris longus group; however, the absolute difference was small. No infections, implant exposure, graft ruptures, or implant-related synovitis were reported. One patient in each group underwent tenolysis. In this series, split flexor carpi radialis grafting was technically feasible and yielded acceptable clinical and functional outcomes, indicating that it may be considered a feasible alternative donor source when the palmaris longus tendon is absent, unavailable, or unsuitable.