修订的尺神经转位术失败后的尺神经转位-标准

                               
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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.  

Table of Contents (Standard)
00:00 Introduction
00:32 Incision and Superficial Dissection
01:24 Proximal Superficial Dissection
01:47 Identifying the Ulnar Nerve Proximally and Remnant Medial Intermuscular Septum
02:22 Distal Superficial Dissection
02:32 Identifying a Branch of Medial Antebrachial Cutaneous Nerve
03:19 Identifying and Dissecting in the Interval between the Flexor Musculature
04:31 Identifying the Ulnar Nerve Distally and Distal Intermuscular Septum
05:48 Proximal Dissection through Scar Tissue
06:37 Elevating Superficial Fascia to Reveal the Pronator-Flexor Musculature
07:21 Identifying the Medial Antebrachial Cutaneous Nerve
07:51 Dissecting and Identifying the Proximal and Distal Extent of the Submuscular Transposition
08:21 Creating the Medial and Lateral Fascial Flaps
09:03 Proximal Dissection of Ulnar Nerve through Pronator-Flexor Musculature
10:02 Distal Dissection of Ulnar Nerve through Pronator-Flexor Musculature
12:10 Release of the Ulnar Nerve from Submuscular Transposition
12:26 Release of the Distal Intermuscular Septum
13:15 Creating the Transmuscular Bed
13:38 Elevating the Ulnar Nerve from Submuscular Transposition
13:52 Examining and Releasing the Medial Antebrachial Cutaneous Nerve
14:35 Neurolysis of the Ulnar Nerve and Neurolyzing the Flexor Carpi Ulnaris Branch Proximally
15:31 Resecting the Fascial Septum "T" between the Pronator-Flexor Musculature
16:02 Resecting Remnant Medial Intermuscular Septum
16:19 Elevating the Ulnar Nerve to the Transmuscular Bed
17:08 Additional Examining and Releasing the Medial Antebrachial Cutaneous Nerve
17:55 Suturing the Fascial Flaps for a Revision Transmuscular Transposition
18:22 Proximal Dissection and Release of Struthers' Ligament
19:33 Credits