Iain, Whitaker

Iain Whitaker

Cronfa at Swansea University

 Cronfa -  Swansea University Open Access Repository   _____________________________________________________________   This is an author produced version of a paper published in :Plastic and Reconstructive Surgery                                              Cronfa URL for this paper:http://cronfa.swan.ac.uk/Record/cronfa18885_____________________________________________________________ Paper:Whitaker, I., Cairns, S. & Josty, I. (2008).  The Palmaris Longus Tendon Weave: A Novel Method of Reconstructingthe Transverse Carpal Ligament. Plastic and Reconstructive Surgery, 122(6), 227e-228e.http://dx.doi.org/10.1097/PRS.0b013e31818d230d        _____________________________________________________________  This article is brought to you by Swansea University. Any person downloading material is agreeing to abide by theterms of the repository licence. Authors are personally responsible for adhering to publisher restrictions or conditions.When uploading content they are required to comply with their publisher agreement and the SHERPA RoMEOdatabase to judge whether or not it is copyright safe to add this version of the paper to this repository. http://www.swansea.ac.uk/iss/researchsupport/cronfa-support/  Correspondence to Dr. KimDivision of Plastic and Reconstructive SurgeryNorthwestern UniversityFeinberg School of Medicine675 North St. Clair Street, Suite 19-250Chicago, Ill. 60611jokim@nmh.orgDISCLOSUREThe authors have no conflict of interest regardingthis research.REFERENCES1. Gordon, R. J., Quagliarello, B., and Lowy, F. D. Ventricularassist device-related infections. Lancet Infect. Dis. 6: 426, 2006.2. Rose, E. A., Gelijns, A. C., Moskowitz, A. J., et al. Long-termmechanical left ventricular assistance for end-stage heart fail-ure. N. Engl. J. Med. 345: 1435, 2001.3. Heerdt, P. M., Holmes, J. W., Cai, B., et al. Chronic unloadingby left ventricular assist device reverses contractile dysfunctionand alters gene expression in end-stage heart failure. Circu-lation 102: 2713, 2000.4. Hutchinson, O. Z., Oz, M. C., and Ascherman, J. A. The useof muscle flaps to treat left ventricular assist device infections.Plast. Reconstr. Surg. 107: 364, 2001.5. Sajjadian, A., Valeria, I. L., Acurturk, O., et al. Omental trans-position flap for salvage of ventricular assist devices. Plast.Reconstr. Surg. 118: 919, 2006.The Palmaris Longus Tendon Weave: A NovelMethod of Reconstructing the TransverseCarpal LigamentA good thing is right, when it tends to preserve the integrity,stability and beauty of the biologic community. It is wrong whenit tends otherwise.—Aldo Leopold, A Sand Country Almanac, 19441Sir:The ultimate goals of upper extremity reconstruc-tion are to provide (1) adequate soft-tissue protec-tion of vital structures and (2) optimal functional andaesthetic outcomes. Soft-tissue reconstruction of theupper extremity, when there is exposed bone or ten-don, particularly in the hand and fingers, requires thin,pliable tissue. When there is significant disruption ofthe transverse carpal ligament, reconstruction shouldbe considered to help stabilize the transverse carpalarch, prevent bowstringing of the flexor tendons, at-tempt to increase postoperative grip strength, and pro-tect the median nerve.2,3 We present the case of an18-year-old, right-handed, male, heavy manual workerwith a high-flow arteriovenous malformation affectingthe right little finger and hypothenar eminence, re-sulting in dorsal ulceration, bleeding, and pain. Ourreconstruction of choice following complete excisionconsisted of an innervated free lateral arm flap in com-bination with a palmaris longus tendon weave to re-construct the transverse carpal ligament. The long-term cosmetic and functional outcome was excellent,and the patient returned to heavy manual work within4 months postoperatively.Resection of the vascular malformation required rayamputation of the fifth metacarpal, ulnar palmar skin,and ulnar half of the transverse carpal ligament (Fig. 1).The palmaris longus tendon insertion into the transversecarpal ligament was preserved, and tenotomy at the mus-culotendinous junctions was performed. The tendon waswoven through the remaining transverse carpal ligamentin a zigzag manner and secured using 4-0 polydioxanonesuture (Fig. 2). An innervated free lateral arm flap com-pleted the soft-tissue reconstruction. There were no post-operative complications, and digital mobilization wascommenced on day 10. Review at 4 months revealed a soft,nonbulky flap with evidence of early sensory reinnerva-tion and normal tendon excursion. The patient was de-lighted and had returned to heavy manual work.Lateral arm flaps were first described in 1982, andtheir popularity for covering midsize defects of theupper extremity is increasing because of their matchingrecipient skin color, texture, and thickness, althoughFig. 1. Hand after resection of the vascular malformation, in-cluding a ray amputation of the fifth metacarpal, ulnar palmarskin, and ulnar half of the transverse carpal ligament.Fig. 2. The palmaris longus tendon is woven through the re-maining transverse carpal ligament in a zigzag manner and se-cured using 4-0 polydioxanone suture.Volume 122, Number 6 • Viewpoints227ethey may require a thinning procedure at a later date.Although as hand surgeons we often operate on thetransverse carpal ligament, our knowledge of the mor-phologic properties of the ligament is scarce. Researchunits from throughout the world are at present study-ing these properties in living subjects and cadavers,using magnetic resonance imaging and three-dimen-sional computer reconstruction. Several authors advo-cate reconstruction of the transverse carpal ligamentwith a variety of techniques following carpal tunnelrelease to avoid a decrease in postoperative gripstrength, particularly in young patients.2–5 A variety ofreasons have been postulated to explain this postop-erative weakness, including widening of the carpal archand volar migration of the median nerve and flexortendons, suggesting an element of bowstringing. Toour knowledge, the use of a palmaris longus tendonweave to reconstruct the transverse carpal ligament hasnot been described in the literature. When it is neces-sary to reconstruct the transverse carpal ligament fol-lowing significant disruption, we believe this offers apossible solution. The previously described techniquesfor reconstruction such as Z lengthening and the useof local transposition flaps would not have been pos-sible in this case. We believe that with limited indica-tions, this could be a useful technique for use by thehand surgeon.DOI: 10.1097/PRS.0b013e31818d230dIain Whitaker, M.A.(Cantab.), M.R.C.S.Scott Cairns, B.M., M.R.C.S.Ian Josty, B.Sc., F.R.C.S.Welsh Centre for Burns and Plastic SurgeryMorriston HospitalSwansea, United KingdomCorrespondence to Dr. WhitakerWelsh Centre for Burns and Plastic SurgeryMorriston HospitalSwansea, United KingdomREFERENCES1. Hunter, J. M., Read, R. L., and Gray, R. Carpal tunnel neu-ropathy caused by injury: Reconstruction of the transversecarpal ligament for the complex carpal tunnel syndromes.J. Hand Ther. 6: 145, 1993.2. Netscher, D., Mosharrafa, A., Lee, M., et al. Transverse carpalligament: Its effect on flexor tendon excursion, morphologicchanges of the carpal canal, and on pinch and grip strengthsafter open carpal tunnel release. Plast. Reconstr. Surg. 100: 636,1997.3. Zingale, A., and Albanese, V. Transverse carpal ligament re-construction with polyesterurethane patch for prevention ofrecurrence in therapy of failed primary carpal tunnel surgery.J. Neurosurg. Sci. 47: 111, 2003.4. Netscher, D. T. The benefit of transverse carpal ligamentreconstruction following open carpal tunnel release. Plast.Reconstr. Surg. 111: 2020, 2003.5. Netscher, D., Steadman, A. K., Thornby, J., and Cohen, V.Temporal changes in grip and pinch strength after opencarpal tunnel release and the effect of ligament reconstruc-tion. J. Hand Surg. (Am.) 23: 48, 1998.Intraperitoneal Bladder Rupture afterAbdominal LiposuctionSir:A 42-year-old woman underwent an outpatient lipo-suction procedure at a community hospital. Usinga flat suction cannula directed through bilateral stabincisions just above the hips, the surgeon removed over5100 cc of fat from the abdomen, hips, and waist. Thepatient was discharged to home from the recoveryroom in stable condition.While at home, the patient noted progressive voidingdifficulty. On postoperative day 3, she presented to herlocal emergency department in mild distress with uri-nary retention, diffuse abdominal discomfort, disten-tion, nausea, and vomiting. She was tachycardic withouthypotension or fever and demonstrated acute perito-neal signs. Her medical history included a remote ce-sarean section and an abdominal hysterectomy for be-nign disease. She denied any prior voiding difficulties.In the emergency department, a urinary catheter waseasily placed and drained a low volume of bloody urine.Laboratory tests revealed a serum creatinine level of 6.0mg/dl and a white blood cell count of 17,000 cells permicroliter. An abdominal computed tomographic scandemonstrated an intraperitoneal position of the uri-nary catheter, gross ascites, and free air (Fig. 1). Be-cause of the limited urologic resources of the referringhospital, the patient was transferred to our facility fordefinitive care.Broad-spectrum antibiotics were initiated and thepatient was brought to the operating room for an ex-ploratory laparotomy through a low midline incision.After draining a large volume of cloudy ascitic fluid, theurinary catheter balloon was visualized exiting the blad-der through a single 3-cm perforation in the posterioraspect of the dome. No other injuries were identified.There was notable chronic scarring of the prevesicalspace. Debridement and two-layer cystorrhaphy wereperformed, leaving a 20-French catheter for gravitydrainage through the urethra.Fig. 1. Computed tomographic scan of the abdomen/pelvisshowing an intraperitoneal urinary catheter balloon with mod-erate ascites, consistent with an intraperitoneal bladder injury.Plastic and Reconstructive Surgery • December 2008228e

The Palmaris Longus Tendon Weave: A Novel Method of Reconstructing the Transverse Carpal Ligament

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