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Endoscopic Cubital Tunnel Release: Surgical Principles

This article explores the surgical principles of endoscopic cubital tunnel release, including the release of all compression sites, preservation of ulnar nerve vascularity, and early mobilization of the elbow. It discusses the evidence supporting the use of endoscopic techniques and provides insights into the potential complications and postoperative care.

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Endoscopic Cubital Tunnel Release: Surgical Principles

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  1. Mark Rekant M.D. Associate Professor, Department of Orthopaedic Surgery Philadelphia Hand to Shoulder Center Thomas Jefferson University Endoscopic CubitalTunnel Release

  2. SurgicalPrinciples • Release all possible compressionsites • Preserve the vascularity of the ulnarnerve • Allow early mobilization of theelbow

  3. MinimalInvasion…

  4. Minimally InvasiveSurgery • GoogleSearch • “Minimally InvasiveSurgery” • Over 20 millionresults • “Minimally Invasive Cubital tunnelsurgery” • Over 33,000results

  5. Where’s theevidence?

  6. Endoscopic Cubital Tunnelrelease • “It is a patient driven procedurethat is performedthrough a smaller incision, is less invasive, and results in faster recoverytime.” • Tyson K. Cobb,MD

  7. Is this the right thing todo?

  8. Points ofcompression

  9. 4 Prospectively Randomized controlledtrials • In-situ vs. anteriortransposition • Bartels et al, 2005 • Biggs et al, 2006 • Gervasio etal,2005 • Nabhan et al,2005 • No statistical difference clinicalresults • Higher complication rate withtransposition

  10. 2 meta-analyses in-situ vs.transposition • Including submusculartransposition • No differencein reported outcomes for transposition of anytype

  11. 3 Studies included in metaanalysis • 1461 papers reviewed, 6RCTs • 131 pts had in-situ decompression • 130hadtransposition in 3 includedstudies • 2 studies submuscular, 1 studysubcutaneous • No difference in NCV’s or clinical resolution between methods

  12. WhyEndoscopic? • Endoscopic allows for a extended in-situ release with smaller incision and potential quicker return to function • Concerns • Technically demanding • Have all points of compression been releasedadequately? • Possible injury to ulnar nerve, cutaneous sensory • branches, crossingvessels.

  13. Endoscopic CubitalTunnel Release • 2 different surgicalapproaches • Cannulated pushcut • Segway (Double barreldesign) • EndoRelease (Integra), Clear Cannula (AMSurgical) • Directdissection • Storz(Hoffman)

  14. Integra

  15. Storz

  16. Indications • Persistent symptoms despite appropriate course of non-operativemanagement

  17. Contraindications • Masses or space occupyinglesions • Severe elbow contractures requiringrelease • Symptomatic subluxation of the ulnarnerve • Prior ulnar nervesurgery • Priortransposition • Prior elbow trauma with scarred and adherentnerve • Limited external rotation of theshoulder

  18. Technique • Local or generalanesthesia • Incision 15-20 mm long epicondylar groove • Cubital tunnel retinaculum incisedallowing • direct visualization of the ulnarnerve

  19. Cu'bltal Tlmnel Cu'bltal Tunnel Subcutaneous Nerves /Tissue

  20. Leading edge ofOsborne’s Ligament

  21. Releasing Osborne’sLigament

  22. FCUFascia

  23. FCU Fasciareleased

  24. 1st fibrousarcade

  25. Distalrelease

  26. SurgicalPearls • Release of the submuscularmembrane • Thickened fibrous bands at 3, 5 and 7 cm distal tothe • retrocondylargroove • Avoid muscle branches toFCU • Place arm on bump toelevate • Use slightly larger incision for first fewcases • Use the hooded speculum as adissector

  27. SurgicalPearls • Adipose tissue(Proximally) • Makes visualizationdifficult • Avoid creating multiplelayers • Use 20 gauge Angiocath though skin placedadjacent to ulnar nerve to deliver Marcaine at end ofcase if general anesthesia used

  28. Theevidence • Tsai, et al JHS1999 • 76 patients (85elbows) • Hoffman, JHS Br2006 • 76 nerves in 75patients • Ahcan and Zorman, JHS2007 • 36patients

  29. 34patients • Retrospective, 12 month followup • Equivalentresults • Less pain and higher satisfaction with endoscopicgroup • Higher complication rate in open group (11% vs 40%)– • includes scar tenderness and numbness at theelbow

  30. Potentialcomplications • Injury to branches of the medialantebrachial • cutaneousnerve • Injury to the ulnarnerve • Hematoma (most common, Cobb JHS2010) • Keloidformation • Recurrent cubitaltunnel • Nerveinstability

  31. Post opcare • Soft dressing – tegadermor acewrap • Immediate range of motionallowed • Full motion expected by first post opvisit • Most patients feel ready for return tofull • activities between 4-6weeks.

  32. Endoscopic CubitalTunnel Release • Two different surgicalapproaches • Steep learningcurve • Potential for less post op pain andfaster recovery • Further prospective comparativestudies • needed.

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