Name:
Revision Cubital Tunnel Decompression and Submuscular Transposition
Description:
Revision Cubital Tunnel Decompression and Submuscular Transposition
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Duration:
T00H14M02S
Embed URL:
https://stream.cadmore.media/player/e2526f22-25ff-4dd3-bc31-a7c02435b1f8
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e2526f22-25ff-4dd3-bc31-a7c02435b1f8/v-005859.mp4?sv=2019-02-02&sr=c&sig=CXVDqknOpoOHdixQMrnL1iKQYPTp6t8Zjdsn9%2Fr1wM8%3D&st=2024-11-21T17%3A25%3A53Z&se=2024-11-21T19%3A30%3A53Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
MUSTAFA CHOPAN: Welcome, everyone. I'm Dr. Chopan. Alongside with me is Dr. Harvey Chim. And today we'll be talking about the interesting topic of Revisional Cubital Tunnel Surgery. These can be difficult and challenging cases and something you will encounter in clinical practice, and so it's important to have a good foundation here.
HARVEY CHIM: Our disclosures are listed here. Along with running through some of the clinical basics of the syndrome itself, it's important to walk away from this conversation with a good understanding of the challenges inherent in revisional surgery and learning some of the key steps of a powerful operative technique used during these challenging cases. As we all know, cubital tunnel syndrome is second to only carpal tunnel syndrome with regard to incidences of upper extremity entrapment neuropathies.
HARVEY CHIM: Its classical presentation we're all familiar with in some form, way or another, these either direct compression of the nerve or ischemia of the nerve and the causes of this can be multiple, variable and often difficult to identify. Obtaining a thorough history and physical is critical in your evaluation. The exam typically starts from a distal to proximal approach, evaluating both motor and sensory components.
HARVEY CHIM: Common things that you may find upon your inspection is wasting of the first dorsal interosseous space or the hypothenar eminence. You can potentially see a Duchenne sign or a Wartenberg sign. You're also testing and evaluating the strength of the ulnar innervated muscles and sometimes the involvement of the dorsal cutaneous ulnar nerve branch can help distinguish between a proximal and distal compression with cubital and Guyon's canal.
HARVEY CHIM: The exam is further complemented with the use of provocative testing either direct compression or elbow flexion can be fairly sensitive and specific when used in commination, and the hierarchical scratch collapse test can be quite useful in a difficult and challenging patient population. Important to also remember that cubital tunnel syndrome is a clinical diagnosis, and so the use of electroconductive study tests is a useful adjunct but not necessary for the diagnosis.
HARVEY CHIM: The management of cubital tunnel syndrome is typically dichotomized into conservative and operative approaches. The treatment is typically tailored to the severity of the disease, but operative interventions are considered for those folks who fail conservative measures or those with evidence of advanced motor involvement.
MUSTAFA CHOPAN: Surgical options come in a variety of flavors, ranging from the inside to decompression or endoscopic techniques to a medial epicondylectomy and more so the tried and true methods of anterior transposition.
MUSTAFA CHOPAN: Now, in theory, the transposition methods tackle the etiology of this entrapment neuropathy via two distinct mechanisms one; changing the position of the nerve to somewhere less superficial so that there is an avoidance of direct compression on the nerve, and two; rerouting the nerve such that with elbow flexion there is diminished tension put on the ulnar nerve.
MUSTAFA CHOPAN: Failed decompressions unfortunately happen more often following cubital tunnel surgery than carpal tunnel release and has been reported as high as 25%. Failed decompression can be roughly categorized into three different groups.
MUSTAFA CHOPAN: One: a persistence of symptoms. This is often attributable to not releasing all sites of compression within the cubital tunnel or not appreciating additional points of compression, either proximally or distally. The second group is characterized by patients who experience initial improvement, but then their symptoms recur.
MUSTAFA CHOPAN: This is thought to be attributable to perineural scarring and then the last group of patients who experience a new onset of symptoms more often than not, this is due to a technical reason.
HARVEY CHIM: As such, the indications for revisional surgery are listed here.
MUSTAFA CHOPAN: Revisions in any surgical circumstance are obviously different than primary surgery for a variety of reasons.
MUSTAFA CHOPAN: The most important one being that somebody else was there and so the scarring that takes place afterwards makes the dissection difficult. In previous transposition methods, the anatomical structures have been altered and so the surface topography that you normally relied on for surgical landmarks can no longer be trusted. Now, for these reasons, that's why the incision is oftentimes extended more proximal and distal finding virginal territory and then working through the prior operative field is the usual game plan for these revisional cases.
MUSTAFA CHOPAN: To highlight some of the key steps in a submuscular transposition, ee will be presenting one of our revisional cases in the setting of a previous subcutaneous anterior transposition.
HARVEY CHIM: To orient the viewer in this video, proximal is located superiorly. You can notice the previous incision with the dotted line. It is located between the medial epicondyle and the olecranon process.
HARVEY CHIM: For our purposes, the incision is extended. The skin is sharply incised and blunt dissection is carried down to the nerve.
HARVEY CHIM: Here the nerve is finally visualized in a dense field of scar.
HARVEY CHIM: As the nerve is dissected free, you begin to appreciate an hourglass transition in to the nerve proximally. This resembles a neuroma in continuity and as mentioned in the setting of an anterior transposition subcutaneously, this likely is secondary to inadequate decompression of the nerve along its length.
MUSTAFA CHOPAN: For adequate release, all points of compression should be addressed. Here you can visualize distally the FCU fascia being incised after a fascicle to the FCU had been identified and preserved.
HARVEY CHIM: The intermuscular septum of the triceps is similarly addressed proximally.
HARVEY CHIM: A segment of the septum is excised to prevent kinking of the ulnar nerve following transposition.
MUSTAFA CHOPAN: The flexor-pronator mass is then dissected free from its overlying subcutaneous tissue and being visualized here along its medial edge.
MUSTAFA CHOPAN: Here the flexor-pronator mass is sharply incised and released from its origin at the epicondyle. The nerve is gently suspended and protected in a vessiloop.
HARVEY CHIM: It's fascial origins are carefully dissected out medially and incised.
MUSTAFA CHOPAN: The remaining muscular attachments are similarly released.
HARVEY CHIM: This is typically performed to the extent that the origin of the flexor-pronator mass can be mobilized. A good landmark for this is until the median nerve is visualized upon mobilization. The ulnar nerve is wrapped with a nerve protector and transposed underneath the muscle next to the median nerve. The lack of any additional compressive points is confirmed.
MUSTAFA CHOPAN: The medial epicondyle is then marked at various points for resuspension anchoring of the flexor-pronator mass. Adequate positioning of the nerve is confirmed again. The resuspension of the origin of the flexor-pronator mass is performed with suture anchors.
MUSTAFA CHOPAN: The suture anchors are tied down with the elbow and wrist flexed. Any remaining fascial edges of the flexor-pronator mass is further secured to any nearby fascia.
MUSTAFA CHOPAN: In some respect, this is a recreation of Osborn's ligament, albeit with a nerve that has been fully transposed and away from the site.
HARVEY CHIM: The skin is then closed in a layered fashion. The tourniquet is released and a padded elbow splint is placed. Rigid splinting is discontinued at our two week follow up appointment, followed by four weeks of a hinged elbow brace and further care and coordination with our occupational therapist.
HARVEY CHIM: The video has depicted our technique of a submuscular transposition, which is quite useful in the setting of a recurrent cubital tunnel syndrome. We hope you enjoyed this video and gained the know how to add this technique to your repertoire.
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