Surgical Management

Lunotriquetral stability can be restored by ligament repair, reconstruction, or arthrodesis. Additional procedures may be necessary if significant ulnar variance or arthrosis is present.

Ligament repair is a technically demanding procedure. A dorsal approach between the fourth and fifth compartments and a transverse capsulotomy distal to the TFCC exposes the LT articulation. The remaining LT ligament is typically adherent to the lunate. The radial border of the triquetrum is freshened and three or four parallel drill holes are placed in an ulnar to radial direction. Nonabsorbable suture is passed through the drill holes, anchored to the LT remnant, and passed back through the holes. The joint is reduced and fixed with Kirschner wires (K wires). Proper alignment is confirmed radiographically before the sutures are tied. The sutures are then tightened. The dorsal radiotriquetral ligament may be advanced and tightened during closure for augmentation. Eight weeks of cast immobilization and 4 weeks of splint immobilization is recommended postoperatively.

Reconstruction can be performed when insufficient LT ligament is available for primary repair (Fig. 64-3). A distally based strip of ECU or flexor carpi ulnaris (FCU) is harvested. Static deformity should be reduced and provisionally fixed before preparation for the lunate and triquetrum tunnels. A K wire is drilled from the dorsal ulnar corner of the triquetrum to the volar radial corner of the LT joint. A second K wire is placed in the lunate from its mid-dorsal radial border to exit at the same place in the LT joint. After radiographic confirmation, the holes are serially enlarged with awls. The tendon graft is then passed through the triquetrum and the lunate. The LT joint is percutaneously pinned and again confirmed radiographically

Triquetrum

Figure 64—3. Illustration of lunotriquetral (LT) reconstruction.

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