Surgical Procedures

Revision Ulnar Nerve Transposition Following Failed Submuscular Ulnar Nerve Transposition

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Failed surgical management of cubital tunnel syndrome may warrant a revision ulnar nerve transposition. Revision surgery is associated with increased technical difficulty depending on the primary procedure. The senior author’s preferred technique for management of cubital tunnel syndrome is a transmuscular ulnar nerve transposition. The technique for revision surgery incorporates methods towards a transmuscular transposition. In this case, a 23-year-old patient presented with a three-year history of significant and continuous ulnar neuropathy two-years following an anterior submuscular ulnar nerve transposition. Examination revealed ulnar intrinsic atrophy and decreased ulnar nerve sensation with normal and intact medial antebrachial cutaneous nerve sensation. Electrodiagnostic studies include small ulnar CMAP amplitude with absent SNAP and fibrillations with motor unit potentials. The scratch collapse test with ethyl chloride hierarchy revealed positive provocations in the order of the cubital tunnel, Guyon’s canal, and Struthers’ ligament. Surgical management for this case includes revision ulnar nerve transposition, supercharge anterior interosseous to ulnar motor nerve transfer for motor recovery, side-to-side bridging nerve grafts with acellularized nerve allografts from median to ulnar sensory nerves for early sensory recovery, and a flexor digitorum profundus tenodesis. This video documents the revision transposition component of this patient’s surgical management.

Standard 160708

Extended 160708

POSITION

Supine.

INCISION

A proximal and distal extension of an incision along the course of the ulnar nerve behind the medial epicondyle. Release of Struthers’s ligament incorporates a proximal incision.

REFERENCES

  1. Dy CJ, Mackinnon SE. Ulnar neuropathy: evaluation and management. Curr Rev Musculoskelet Med. 2016 Jun;9(2):178-84. Review. PMID: 27080868.
  2. Davidge KM, Gontre G, Tang D, Boyd KU, Yee A, Damiano MS, Mackinnon SE. The “hierarchical” Scratch Collapse Test for identifying multilevel ulnar nerve compression. Hand (N Y). 2015 Sep;10(3):388-95. PMID: 26330768.
  3. Davidge KM, Yee A, Moore AM, Mackinnon SE. The Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer for Restoring Intrinsic Function: Clinical Experience. Plast Reconstr Surg. 2015 Sep;136(3):344e-352e. PMID: 26313839.
  4. Ebersole GC, Davidge K, Damiano M, Mackinnon SE. Validity and responsiveness of the DASH questionnaire as an outcome measure following ulnar nerve transposition for cubital tunnel syndrome. Plast Reconstr Surg. 2013 Jul;132(1):81e-90e. PMID: 23806957.
  5. González G, Mackinnon SE, Espinosa A, Barbour J. Cubital tunnel syndrome and the scratch test to determine the surgical procedure. Acta Ortop Mex. 2012 Nov-Dec;26(6):375-8. PMID: 24712205.
  6. Barbour J, Yee A, Kahn LC, Mackinnon SE. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation. J Hand Surg Am. 2012 Oct;37(10):2150-9. PMID: 23021177.
  7. Kale SS, Glaus SW, Yee A, Nicoson MC, Hunter DA, Mackinnon SE, Johnson PJ. Reverse end-to-side nerve transfer: from animal model to clinical use. J Hand Surg Am. 2011 Oct;36(10):1631-1639.e2. PMID: 21872405.
  8. Mackinnon SE. Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Am. 2009 Oct;34(8):1574-5; author reply 1575. PMID: 19801113.
  9. Brown JM, Mokhtee D, Evangelista MS, Mackinnon SE. Scratch Collapse Test Localizes Osborne’s Band as the Point of Maximal Nerve Compression in Cubital Tunnel Syndrome. Hand (N Y). 2010 Jun;5(2):141-7. PMID: 19774420.
  10. Colbert SH, Mackinnon SE. Nerve compressions in the upper extremity. Mo Med. 2008 Nov-Dec;105(6):527-35. Review. PMID: 19052017.
  11. Mackinnon SE, Novak CB. Operative findings in reoperation of patients with cubital tunnel syndrome. Hand (N Y). 2007 Sep;2(3):137-43. PMID: 18780075.
  12. Lowe JB 3rd, Maggi SP, Mackinnon SE. The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans. Plast Reconstr Surg. 2004 Sep 1;114(3):692-6. PMID: 15318047.
  13. Novak CB, Mackinnon SE, Stuebe AM. Patient self-reported outcome after ulnar nerve transposition. Ann Plast Surg. 2002 Mar;48(3):274-80. PMID: 11862032.
  14. Lowe JB 3rd, Novak CB, Mackinnon SE. Current approach to cubital tunnel syndrome. Neurosurg Clin N Am. 2001 Apr;12(2):267-84. PMID: 11525206.
  15. Watchmaker GP, Lee G, Mackinnon SE. Intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition. J Hand Surg Am. 1994 Nov;19(6):915-22. PMID: 7876489.
  16. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg Am. 1994 Sep;19(5):817-20. PMID: 7806810.
  17. Nath RK, Mackinnon SE, Weeks PM. Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release: a case report. J Hand Surg Am. 1993 Sep;18(5):896-8. PMID: 8228067.
  18. Dellon AL, Mackinnon SE. Human ulnar neuropathy at the elbow: clinical, electrical, and morphometric correlations. J Reconstr Microsurg. 1988 Apr;4(3):179-84. PMID: 3392696.
  19. Dellon AL, Schlegel RW, Mackinnon SE. Validity of nerve conduction velocity studies after anterior transposition of the ulnar nerve. J Hand Surg Am. 1987 Sep;12(5 Pt 1):700-3. PMID: 3655227.
  20. Dellon AL, MacKinnon SE, Hudson AR, Hunter DA. Effect of submuscular versus intramuscular placement of ulnar nerve: experimental model in the primate. J Hand Surg Br. 1986 Feb;11(1):117-9. PMID: 3958531.
  21. Dellon AL, MacKinnon SE. Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg Br. 1985 Feb;10(1):33-6. PMID: 3998599.

Disclosure: No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.

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