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Anatomical Study as a Basis for Endoscopic Cubital Tunnel Release
Ather Mirza, MD1; Brian Lee, BS2; Daniel Lorenzana, BA2; (1)Ather Mirza, MD, (2)M. Ather Mirza, MD
Private Practice, Smithtown, NY, USA

Introduction:

This is an anatomical study in fresh frozen cadavers of the ulnar nerve, as related to endoscopic release of the cubital tunnel. We also present a retrospective review of patients treated with decompression via endoscopic visualization.

Materials and Methods:

To further our understanding of relevant anatomy, we dissected eighteen cadaver arms. We paid special attention to fascial membranes as potential sites of constriction, as well as the position of nerves, vessels, and aberrant anatomy of interest. These findings facilitated our understanding of the extent of release endoscopically in fifty-eight patients with cubital tunnel syndrome. The ulnar nerve was identified through a 3 cm curved incision between the medial epicondyle and olecranon. We performed endoscopic simple decompression using a scope mounted sleeve knife assembly and a clear cannula. Diagnosis was made with patient history and neurological testing. Outcome measures included (1) DASH score (2) Gabel and Amadio score and (3) Grip and pinch strength.

Results:

We noted a fascial band proximal to the medial epicondyle in only 6 of 18 cadaver specimens. We observed a high degree of variability in the anatomy of the flexor pronator aponeurosis distal to the medial epicondyle, including 4 specimens without prominent fascial bands. Where present (n=11), medial antebrachial cutaneous nerve branches crossed the ulnar nerve at an average distance of 3.10 cm, range: (2 - 4.45). Aberrant structures were noted in 9 of the 18 specimens, including: the anconeus epitrochlearis muscle in 2 specimens, the basilic vein crossing the ulnar nerve in 3 specimens, and the so-called ‘Arcade of Struthers’ in 1 specimen. The average preoperative DASH score was 51.4 (n=30), postoperative was 24.5 (n=50). The Gabel and Amadio outcome scores were 15 excellent, 28 good, 7 fair and 8 poor (n=58). Average follow-up ranged from 3 months to 2 years. There were no nerve injuries or recurrences. Postoperatively two patients had hematomas that resolved without sequela.

Conclusions:

Cadaveric dissections shed light on vulnerable anatomy during release, including branches of the MACN, UN, brachial artery, and the basilic vein. The high degree of anatomical variability in this study highlights the advantage of endoscopic visualization in allowing surgeons to minimize operative trauma. 58 patients with ulnar nerve compression were treated with endoscopic decompression using a scope-mounted blade. There were no injuries to major nerve branches or blood vessels, and minimal complications. This technique is facile and minimally invasive.


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