The Transverse Carpal Ligament As A Vascularized Ligamentous Flap In Scapholunate Ligament Injury
Lacey R. Pflibsen, MD1; Lauren DeBusk, MD Candidate 20232; Danielle Thornburg, MD3; Nellie Movtchan, MD1; Anthony A. Smith, MD4; Shelley S. Noland, MD5; Erwin A Kruger, MD3; Edward M. Reece, MD,6
1Mayo Clinic Arizona, Phoenix, AZ; 2Mayo Clinic Alix School of Medicine, Scottsdale, AZ; 3Mayo Clinic, Phoenix, AZ; 4Plastic Surgery, Mayo Clinic, Phoenix, AZ; 5Department of Orthopaedics and Sports Medicine, Mayo Clinic, Phoenix, AZ; 6Baylor College of Medicine, Houston, TX
Introduction: Scapholunate ligament (SL) injury has been widely discussed in the literature and a variety of techniques proposed for repair and reconstruction. Many methods focus on repair of the dorsal aspect of the SL ligament with either primary repair or reconstruction. All techniques of repair and reconstruction have potential drawbacks of attenuation, failure, and eventual scapholunate advanced collapse. The purpose of this study was to evaluate the transverse carpal ligament (TCL) vascular anatomy for radially and ulnarly based ligamentous flaps, and to evaluate SL ligament repair or reconstruction from the volar aspect.
Methods: Cadaveric dissection of three patients (six hands) was performed. Careful dissection was done to identify possible perforating vessels to the transverse carpal ligament on both the radial and ulnar aspects. Measurements from the scaphoid tubercle and pisiform were taken. The TCL was dissected radially (TCLr) or ulnarly (TCLu) to evaluate flap length, reach, and ability to be used at the SL ligament.
Results: Through our cadaveric dissection, we identified radial and ulnar TCL perforator vessels which were approximately 1 cm proximal to the scaphoid tubercle and pisiform respectively (Figure 1). Skeletonization provided approximately 1 cm in length from their origin. Maneuvering of the flaps revealed several promising applications due to their ability to cover a wide range of bone and soft tissue defects. Both TCLr and TCLu flaps were capable of reaching the SL ligament without interference from other important structures (Figure 2). The radially based flap can be extended by incorporating the pisohamate ligament.
Conclusion: The transverse carpal ligament has reliable vascular anatomy in our small cohort to make radially or ulnarly based vascularized ligamentous flaps. We propose its possible use in SL repair or reconstruction as it can provide vascularized ligamentous tissue to a challenging injury.
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