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decompressions, medial epicondylectomy, subcutaneous these conditions may mimic ulnar nerve syndrome at the
[8]
[7]
transposition, [9] intramuscular transposition, [10] and wrist, which, in addition to the different symptoms noted
[11]
submuscular transposition. However, as reported in the by patients, may render recognition of ulnar neuropathy
first description of this neuropathy by Panas in 1878, at the elbow difficult.
[12]
surgical treatment frequently yields poor results and may
worsen the initial clinical condition. In a recent study CAUSES OF FAILURE AFTER PRIMARY
conducted by the American Association of Hand Surgery, SURGERY
[13]
61% of surgeons reported inferior results following surgical
ulnar nerve decompression at the elbow compared with Failure after surgery is mainly due to procedural errors or
the results obtained following decompression after technical omissions, frequently represented by incomplete
carpal tunnel release (44% satisfactory results vs. 88%, nerve decompression, failure to recognize nerve instability
respectively). after the nerve has been decompressed, loosening of
According to the literature, no surgical technique may be the nerve anchor after superficial nerve transposition
defined as superior to the others. [14‑16] The persistence with consequent spontaneous nerve relocation in the
of preoperative symptoms after surgery is defined as epitrochlear‑olecranon channel, perineural fibrosis and
failure, whereas the reappearance of symptoms after neurodesis that creates a new site of nerve compression
a period of relief is defined as recurrence, and surgical in areas different from those affected by the original
revision is indicated in both cases. Preoperative compression, unintended injury to one or more sensory
[15]
factors that may be associated with poor results after regional nerves or to the ulnar nerve itself, articular elbow
surgery depend on multiple elements, including an instability due to unintended injury to the ulnar collateral
incorrect diagnosis, advanced neuropathy with a ligament, or elbow stiffening in the flexed position.
[17]
neurological lesion and muscular atrophy, coexisting It is widely accepted that when primary nerve
[18]
pathologies such as double crush syndrome, cervical decompression is performed, only one of the five possible
[16]
spine radiculopathies, thoracic outlet syndrome, sites of compression is generally found to actually be
[19]
[20]
ulnar compression syndromes at the wrist, endocrine responsible for the nerve impingement, and these sites
[2]
disorders such as diabetes mellitus or thyroid disease, are usually the epitrochlear‑olecranon channel or the
and polyneuropathies, particularly if they are associated Osborne fibrous arcade. The surgeon’s experience will
[13]
with muscular atrophy or decreased sensation. Some of
generally determine the decision to proceed with a wide
nerve decompression or to perform a limited procedure. [15]
The creation of a new nerve compression site may be
realized when the anteriorly transposed nerve has not
been widely released before the transposition. In fact,
regardless of the method employed, when the nerve is
anteriorly transposed, a new and nonanatomical path is
created. It is therefore mandatory that the nerve lies in
a soft and loose tissue bed such that no compression
is endured by the nerve, which can occur when the
medial intramuscular septum is not released or when
a
the nerve kinks between the ulnar part of the FCU and
the flexor and pronator muscle groups. [13,14,16,21] To avoid
such compression, when transposition is performed,
it is advisable to widely release the nerve by opening
the cubital channel and Osborne’s arcade, removing the
medial muscular septum, and opening both the arcade
of Struthers and the septum between the ulnar stump of
the FCU and the flexor‑pronators. When in situ nerve
[13]
decompression is completed, dynamic nerve instability
during elbow flexion may occur (nerve subluxation or
luxation), and the omission of nerve stability evaluation
is considered to be a technical error. According to the
literature, more than 50% of failures after simple
[22]
b decompression are due to the misdiagnosis of nerve
Figure 1: (a) There are five possible areas of ulnar nerve compression instability. In cases of nerve instability, anterior nerve
at the elbow level. (1): Arcade of Struthers; (2): proximal epitrochlear transposition, either deep or superficial, should be
region; (3): epitrochlear‑olecranon channel; and (4): fibrous arch
between the humeral and ulnar parts of the flexor carpi ulnaris (FCU), considered. Notably, nontraumatic nerve debridement and
better known as Osborne’s arcade; (b) the figure shows the opening of release, including that for a long tract (10‑15 cm), does
Osborne’s arcade (4) with the release of the septum between the ulnar not damage the nerve or cause its devascularization, as
part of the FCU and the flexor‑pronator group (5). (1), (2) and (3) indicate
the release of the other areas of decompression was previously believed. [13,15,23]

Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015 177