Flexor tendon reconstruction in zone 2 remains a challenging procedure. The palmaris longus tendon is commonly used as a graft; however, alternative options such as the toe extensor digitorum longus tendon are required when the palmaris longus is absent. Clinical evidence comparing functional outcomes between these grafts is limited.

This retrospective cohort study included patients who underwent flexor tendon reconstruction using either palmaris longus or extensor digitorum longus tendon grafts. Reconstructions were performed as single-stage or two-stage procedures depending on injury severity and associated trauma. Functional outcomes were assessed using the Strickland score at a minimum follow-up of twelve months. Twenty-seven patients were included, with seventeen treated using palmaris longus and ten using extensor digitorum longus graft.

Single-stage reconstruction resulted in better functional outcomes compared with two-stage procedures. When graft types were compared regardless of reconstruction stage, no meaningful difference in functional outcomes was observed. In the single-stage subgroup, extensor digitorum longus graft demonstrated higher Strickland scores compared with palmaris longus grafts. No association was found between functional outcomes and patient age, sex, dominant hand, mechanism of injury, or treated finger.

The extensor digitorum longus tendon is a reliable alternative to the palmaris longus for zone 2 flexor tendon reconstruction, providing comparable overall functional outcomes. This exploratory finding of higher scores with extensor digitorum longus tendon in single-stage procedures requires prospective validation and should not be interpreted as evidence of superiority.