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a a
a a b b
a b

c

c d c
Figure 4: Failed superficial nerve transposition. (a) The nerve is c d
taut over the epitrochlear bone (*) and kinks at the deep septum Figure 5: Failed superficial nerve transposition. (a and b) Arcade of
(zone 5) for an insufficient transposition; (b) nerve decompression by Struthers (*) was not released during the first surgery, causing nerve
the release of the flexor carpi ulnaris and deep septum. The circled kinking and compression. At the epitrochlear level, the nerve appears
area shows the region of ischemic injury to the nerve secondary to to lie within good tissue without tension (>); (c) following debridement,
compression; (c) after external neurolysishasbeen performed, the the nerve lies in a soft and vascular tissue bed without tension. An
nerve is prepared for anterior submuscular transposition; (d) following adipofascial flap is harvested (*); (d) anterior submuscular transposition
transposition, the nerve lies in a soft and vascular tissue bed without with muscular Z‑lengthening is performed. The adipofascial flap protects
tension the nerve in the proximal epitrochlear region

to be entrapped by fibrotic tissue in the new muscular obtained after primary surgery, particularly in patients
[44]
channel and neurolysis in necessary. When neurolysis over the age of 50 years, when conduction studies show
alone is insufficient for the release of the nerve or when muscle denervation, or when there is a history of multiple
[15]
the muscular channel has become fibrotic and does surgeries. To avoid the misinterpretation that the
not provide adequate vascularization of the nerve, the partial resolution of preoperative symptoms is a failure of
muscular bridge is opened, and the nerve is transferred treatment, it is mandatory that the patient be completely
[16]
superficially. [34] informed prior to surgery. Chronic axonal degeneration
is frequently associated with marginal improvement
POSTOPERATIVE TREATMENT of neuropathic pain, tenderness in the compression
area, and hand dysesthesias, [14,16] without a high rate of
A brachial‑metacarpal plaster cast is applied for 20 days, complete restoration of sensitivity and muscle strength.
with the elbow at 100°‑120° of extension. By the Nonetheless, the clinical advantages remain relevant
3rd postoperative day, the patient is allowed to temporarily provided that an expert surgeon performs the revision
remove the plaster to perform careful active elbow flexion surgery.
and extension movements. From the 7th day, the patient
begins active careful supination with the elbow at 60°‑90° REFERENCES
of flexion. From the 15th day, supination with the elbow
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20 days postoperatively, and the patient is then placed Boston: Little Brown; 1983. p. 88.
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Surg Radiol Anat 1986;8:155‑61.
3. Mackinnon SE, Novak CB. Operative Findings in reoperation of patients with
FUTURE DIRECTIONS cubitaltunnel syndrome. Hand (N Y) 2007;2:137‑43.
4. Dellon AL. Musculotendinousvariation about the median humeral epicondyle.
J Hand Surg Br 1986;11:175‑81.
Ulnar nerve anatomy at the elbow region and 5. O’Driscoll SW, Horii E, Carmichael SW, Morrey BF. The cubital tunnel and
pathophysiology of the compression syndrome are ulnar neuropathy. J Bone Jiont Surg Br 1991;73B: 613‑7.
well‑recognized. Nonetheless, failure following nerve 6. Childress HM. Recurrent ulnar‑nerve dislocation at the elbow.
decompression alone or with associated anterior nerve Clin Orthop Relat Res 1975;108:168‑73.
transposition still occurs. The failure to recognize dynamic 7. Osborne GV. The surgical treatment of tardy ulnar neuropathy.
J Bone Joint Surg Br 1957;39B:782.
ulnar nerve instability, idiopathic or induced after in situ 8. King T, Morgan FP. Late results of removing the medial humeral epicondyle
nerve decompression, represents the most frequent for traumatic neuritis. J Bone Joint Surg Br 1959;41B:51‑5.
procedural error leading to surgical failure. A thorough 9. Curtiss BF. Traumatic ulnar neuritis: transposition of the nerve.
understanding of the mechanisms causing ulnar nerve J Nerv Ment Dis 1898;25:480‑4.
compression and injury would reduce the rate of recurrence. 10. Adson AW. The surgical treatment of progressive ulnar paralysis. Minn Med
1918;1:455‑60.
11. Learmont JR. A technique for transplanting the ulnar nerve. Surg Gynecol Obstetr
CONCLUSION 1942;75:792‑3.
12. Panas J. Upon a rare case of ulnar nerve palsy. Arch Gen Med 1878;2:5‑22.
(in French)
The results of revision surgery following recalcitrant ulnar 13. Novak BC, Mackinnon SE. Selection of operative procedures for cubital
nerve compression at the elbow are inferior to those tunnel syndrome. Hand (N Y) 2009;4:50‑4.
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