Name:
10.3171/2022.9.FOCVID2282_vid
Description:
10.3171/2022.9.FOCVID2282_vid
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/11979410-e6cf-4069-8ded-55d100bb2d76/videoscrubberimages/Scrubber_333.jpg
Duration:
T00H08M08S
Embed URL:
https://stream.cadmore.media/player/11979410-e6cf-4069-8ded-55d100bb2d76
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/11979410-e6cf-4069-8ded-55d100bb2d76/22-82.mp4?sv=2019-02-02&sr=c&sig=EzbSZlpTwOoZ3%2F4pYKbXlKBS%2FgpxzhjQrJ%2BeUqn47x0%3D&st=2025-01-21T09%3A59%3A51Z&se=2025-01-21T12%3A04%3A51Z&sp=r
Upload Date:
2022-11-10T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
RAJIV MIDHA: This is Dr. Rajiv Midha, and I'm pleased to present a case of a distal anterior interosseous nerve transfer in this patient with severe traumatic ulnar neuropathy at the elbow. This patient's physical exam, as you'll see in a moment, showed complete loss of hand intrinsic motor function of the ulnar nerve along with dense sensory involvement and only a flicker of movement at the flexor digitorum to the little finger.
RAJIV MIDHA: Have you bend your wrist and straighten it out. Now, try to open and close your fingers. Try to bring this finger over toward me. And just bend the tip of this finger down, just a flicker. And just now try to bring the fingers apart and together.
RAJIV MIDHA: OK, that's great. Thank you. In most patients who have ulnar nerve pathology at the elbow, such as compression with motor dysfunction, we would normally do a simple in situ decompression. In this patient who had significant trauma, both in the soft tissue and the joint and bones, we chose to do a ulnar nerve transposition in the subcutaneous position for the reasons identified in the slide.
RAJIV MIDHA: As you'll see in the subsequent videos, we did a very thorough decompression and neurolysis of the ulnar nerve from well above the elbow joint to well below the elbow joint through the two heads of the flexor carpi ulnaris. The patient was positioned supine under general anesthesia with the arm on a plastics armboard and prepped and draped from distal axilla down to hand. The incision at the elbow was curvilinear, centered at the medial epicondyle and just posterior to it.
RAJIV MIDHA: There was significant scarring and adhesions around the ulnar nerve, which were dissected using sharp techniques. With the ulnar nerve mobilized with external neurolysis, first above the elbow, and then sequentially at the elbow joint, and then distally. We identified and preserved a large branch from the medial antebrachial cutaneous nerve, and we use further sharp dissection to expose and unroof the distal ulnar nerve as it went into the two heads of the flexor carpi ulnaris muscle and deep to them.
RAJIV MIDHA: We identified both an articular branch, which we subsequently sacrificed, and an important branch to the FDP and FCU more distal, which was preserved in continuity along with the main trunk of the ulnar nerve. This allowed a generous length of the ulnar nerve. We stimulated the ulnar nerve at the elbow and found that there was no contraction of the muscles of the intrinsic hand, but there was some contraction of the FDP to the little finger.
RAJIV MIDHA: We then resected the medial intermuscular septum so that we could transpose the ulnar nerve in the subcutaneous plane. To do this, we lifted off a large amount of subcutaneous tissue of the flexor-pronator mass, place the ulnar nerve deep to subcutaneous tissue, and sutured the subcutaneous tissue onto the flexor-pronator mass to keep it completely in a lax position.
RAJIV MIDHA: With the distal exposure, we did an approximately 8-cm incision that exposed the distal forearm and to just proximal to the wrist crease. We identified the flexor carpi ulnaris muscle as a landmark and retracted it medially to expose the ulnar neurovascular bundle. We then went lateral to this and retracted the flexor muscles and tendons to expose the pronator quadratus muscle and the anterior interosseous nerve, along with its vessels.
RAJIV MIDHA: We next identified the ulnar nerve dorsal sensory branch, and this allowed it to be a landmark to expose the sensory aspect of the ulnar nerve, most medially going to the dorsal cutaneous branch, the main trunk of the sensory nerve most laterally, with the motor branch in the middle. We then performed an internal neurolysis, doing an epineurotomy, and then separating-- first without the microscope, and then with the microscope-- the sensory
RAJIV MIDHA: dorsal cutaneous branch, which is seen lowermost in this video. The middle part being the motor branch, and then the main trunk of the sensory being most lateral. And that's the one that's closest to the anterior interosseous nerve, as you can see there. We have gained length on the anterior interosseous nerve distally by taking down some of the pronator quadratus muscle, which we built with Bovie, as well as coagulation, and the incision of the muscle.
RAJIV MIDHA: This allowed us to gain great length of the pronator quadratus branch so that we could-- when we cut it distally, we could bring it up without tension to the ulnar nerve motor branch. When you stimulate the AIN, we can see that there is robust contraction of the pronator quadratus. When we stimulate the ulnar nerve motor branch, we see there is no contraction of hand intrinsics.
RAJIV MIDHA: Under the operating microscope, we then used a sharp technique to create a perineural window overlying the ulnar motor branch. We then brought the distal AIN in approximation to this. We used an 8-0 monofilament suture for the end-to-side repair of the distal AIN within the perineural window to the side of the ulnar motor branch. Usually, two to three sutures are sufficient for this, and these are done so that the repair is under no tension.
RAJIV MIDHA: We then used Tisseel fibrin glue to reinforce the repair. And then applied a generous amount of fibrin glue to reinforce the entire incision.
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