Use of the transverse carpal ligament for soft tissue reconstruction of a Mannerfelt lesion

Abstract

In 1969, Mannerfelt described the “critical corner” where the flexor pollicis longus (FPL) tendon tends to rupture from abrasion against osteophytes from the scaphotrapezial joint in patients with rheumatoid arthritis [2]. He further suggested that removal “of the spur and covering of the floor…may have saved these tendons from later attritional rupture.” Since then, it has been recognized that debridement of osteophytes and soft tissue reconstruction, to separate the arthritic wrist joint from the carpal canal, are important to avoid recurrent rupture following tendon reconstruction. The currently accepted method of soft tissue reconstruction uses the adjacent capsulo-ligamentous transposition flap to cover the exposed bone (Fig. 1) [1]. Although the transposition flap appears simple in illustration, we have found this approach to be difficult. The flap is limited in size and does not transpose easily, the donor site is difficult to close, and the soft tissue tends to be of poor quality. In the case of a large defect, a local transposition flap is inadequate to reline the carpal canal. Fig. 1 The recommended reconstruction for Mannerfelt lesions from Green's Operative Hand Surgery (reproduced with permission from Wolfe SW, Hotchkiss RN, Pederson WC, et al., editors, Green's Operative Hand Surgery, 6th edition We have utilized an alternative to the traditional approach of a local transposition flap. A large, radially based flap of the transverse carpal ligament can be used to resurface and reconstruct the volar soft tissues of the wrist along the carpal canal. Given the technical ease of this alternative approach, we report a case and revisit the management of the Mannerfelt lesion.