Reconstructive Strategies for Chronic Extensor Pollicis Longus Ruptures: A Systematic Review and Descriptive Pooled Analysis

BACKGROUND: Chronic extensor pollicis longus (EPL) rupture causes loss of active thumb extension and functional impairment. Although extensor indicis proprius transfer remains the most commonly reported reconstructive procedure, alternative techniques include extensor pollicis brevis (EPB) transfer, tendon grafting, local tendon-flap reconstruction, and dual-tendon augmentation. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was performed using PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library from inception through May 31, 2026. Clinical studies reporting outcomes after reconstruction of chronic or irreparable EPL rupture were included. Extracted outcomes included thumb motion, Disabilities of the Arm, Shoulder, and Hand/shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) scores, strength, complications, and return to work. RESULTS: Twenty-four studies comprising 478 reconstructed thumbs/cases were included, predominantly Level IV evidence. Extensor indicis proprius transfer was the most frequently reported technique, accounting for approximately 343 reconstructions. Total active motion generally recovered to 88% to 93% of the contralateral side, with low reported QuickDASH scores. Local tendon-flap reconstruction achieved 89% total active motion and a 97% return-to-work rate in 1 larger series. Extensor pollicis brevis transfer and tendon grafting demonstrated favorable outcomes in selected patients, whereas dual-tendon augmentation showed encouraging early results but remains supported by limited evidence. No randomized trials and few comparative studies were identified. CONCLUSIONS: Reconstruction of chronic EPL rupture reliably restores thumb extension and function across multiple techniques. Extensor indicis proprius transfer remains the most established option, although tendon grafting, EPB transfer, local tendon-flap reconstruction, and emerging augmentation strategies also demonstrate favorable outcomes in selected patients. Higher-quality prospective studies are required to define optimal indications and comparative outcomes.