Recalcitrant cubital tunnel syndrome

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1 Topi: Peripherl Nerve Repir nd Regenertion Relitrnt uitl tunnel syndrome Adolfo Vigsio, Ignzio Mroio, Eleonor Morndini Hnd Surgery nd Orthopedi Mirosurgery Unit, Istituto Clinio Città di Bresi Gruppo Sn Donto, Bresi, Itly. Address for orrespondene: Dr. Ignzio Mroio, Hnd Surgery nd Orthopedi Mirosurgery Unit, Istituto Clinio Città di Bresi Gruppo Sn Donto, Bresi, Itly. E mil: info@ignziomroio.it ABSTRACT Ulnr nerve neuropthy t the elow represents the seond most frequent ompression neuropthy of the upper extremity. Of the five different ntomil res responsile for ulnr nerve ompression t the elow region, the epitrohler olernon hnnel nd Osorne s rde re the most ommon. An dditionl use of nerve dmge is dynmi proess in whih the ulnr nerve dislotes nteriorly t the epitrohler olernon level during elow flexion, prtilly or ompletely, using nerve frition nd onstrition leding to hroni neuropthi pin. Filure fter primry surgery is generlly seondry to proedurl errors or tehnil omissions, frequently represented y inomplete nerve deompression, filure to reognize nerve instility fter nerve deompression, loosening of the nerve nhor fter superfiil nerve trnsposition with onsequent spontneous nerve relotion in the epitrohler olernon hnnel, perineurl firosis nd neurodesis, whih retes new nerve ompression. In ssoition with the linil evlution, eletromyogrphy studies, mgneti resonne imging nd ultrsound re useful tools tht my id in the deision mking proess when onsidering revision surgery. Superfiil nterior trnsposition is the most ommonly employed tehnique ut lso hs high filure rte, s opposed to nterior deep trnsposition tht is the method of hoie for mny surgeons despite eing more tehnilly demnding. The results of revision surgery following relitrnt ulnr nerve ompression t the elow re inferior to those otined fter primry surgery. Nonetheless, the linil dvntges remin relevnt provided tht the revision surgery is performed y n expert surgeon. To void misinterprettion, the ptient is ompletely informed of the qulity of results. Key words: Cuitl tunnel syndrome, filed nerve deompression, nerve trnsposition, relitrnt nerve ompression, ulnr nerve INTRODUCTION Ulnr nerve neuropthy t the elow represents the seond most frequent ompression neuropthy of the upper extremity. [1] The ulnr nerve my e ompressed t the elow region in the following five different ntomil res, [2] listed from proximl to distl: (1) rde of Struthers, (2) the proximl epitrohler region, (3) the epitrohler olernon hnnel, (4) the firous rh etween the humerl nd ulnr portions of the flexor rpi ulnris (FCU), etter Quik Response Code: Aess this rtile online Wesite: DOI: / known s Osorne s rde, nd (5) the vertil firous septum tht origintes from the uln nd seprtes the ulnr nerve nd the ulnr prt of the FCU from the prontor flexor musles innervted y the medin nerve [3] [Figure 1 nd ]. The epitrohler olernon hnnel nd Osorne s rde or ligment re the most frequent res of ompression. An dditionl use of nerve dmge t the epitrohler olernon level is nerve instility. This is dynmi proess in whih the ulnr nerve dislotes nteriorly during elow flexion, rehing the epiondylr rest (suluxtion) or pssing over it ompletely (luxtion). Ligmentous lxity or the sene of stiliztion mehnisms [4,5] uses ontinuous snpping of the nerve over the epitrohle, nd in the se of omplete nterior dislotion, the nerve kinks t the Osorne rde, using nerve frition nd onstrition leding to hroni neuropthi pin. [6] Vrious surgil proedures hve een desried for the tretment of uitl tunnel syndrome, inluding in situ 176 Plst Aesthet Res Vol 2 Issue 4 Jul 15, 2015

2 deompressions, [7] medil epiondyletomy, [8] suutneous trnsposition, [9] intrmusulr trnsposition, [10] nd sumusulr trnsposition. [11] However, s reported in the first desription of this neuropthy y Pns [12] in 1878, surgil tretment frequently yields poor results nd my worsen the initil linil ondition. In reent study onduted y the Amerin Assoition of Hnd Surgery, [13] 61% of surgeons reported inferior results following surgil ulnr nerve deompression t the elow ompred with the results otined following deompression fter rpl tunnel relese (44% stisftory results vs. 88%, respetively). Aording to the literture, no surgil tehnique my e defined s superior to the others. [14 16] The persistene of preopertive symptoms fter surgery is defined s filure, wheres the repperne of symptoms fter period of relief is defined s reurrene, nd surgil revision is indited in oth ses. [15] Preopertive ftors tht my e ssoited with poor results fter surgery depend on multiple elements, inluding n inorret dignosis, [17] dvned neuropthy with neurologil lesion nd musulr trophy, [18] oexisting pthologies suh s doule rush syndrome, [16] ervil spine rdiulopthies, [19] thori outlet syndrome, [20] ulnr ompression syndromes t the wrist, endorine disorders suh s dietes mellitus or thyroid disese, nd polyneuropthies, prtiulrly if they re ssoited with musulr trophy or deresed senstion. [13] Some of Figure 1: () There re five possile res of ulnr nerve ompression t the elow level. (1): Arde of Struthers; (2): proximl epitrohler region; (3): epitrohler-olernon hnnel; nd (4): firous rh etween the humerl nd ulnr prts of the flexor rpi ulnris (FCU), etter known s Osorne s rde; () the figure shows the opening of Osorne s rde (4) with the relese of the septum etween the ulnr prt of the FCU nd the flexor-prontor group (5). (1), (2) nd (3) indite the relese of the other res of deompression these onditions my mimi ulnr nerve syndrome t the wrist, whih, in ddition to the different symptoms noted y ptients, my render reognition of ulnr neuropthy t the elow diffiult. CAUSES OF FAILURE AFTER PRIMARY SURGERY Filure fter surgery is minly due to proedurl errors or tehnil omissions, frequently represented y inomplete nerve deompression, filure to reognize nerve instility fter the nerve hs een deompressed, loosening of the nerve nhor fter superfiil nerve trnsposition with onsequent spontneous nerve relotion in the epitrohler olernon hnnel, perineurl firosis nd neurodesis tht retes new site of nerve ompression in res different from those ffeted y the originl ompression, unintended injury to one or more sensory regionl nerves or to the ulnr nerve itself, rtiulr elow instility due to unintended injury to the ulnr ollterl ligment, or elow stiffening in the flexed position. It is widely epted tht when primry nerve deompression is performed, only one of the five possile sites of ompression is generlly found to tully e responsile for the nerve impingement, [2] nd these sites re usully the epitrohler olernon hnnel or the Osorne firous rde. The surgeon s experiene will generlly determine the deision to proeed with wide nerve deompression or to perform limited proedure. [15] The retion of new nerve ompression site my e relized when the nteriorly trnsposed nerve hs not een widely relesed efore the trnsposition. In ft, regrdless of the method employed, when the nerve is nteriorly trnsposed, new nd nonntomil pth is reted. It is therefore mndtory tht the nerve lies in soft nd loose tissue ed suh tht no ompression is endured y the nerve, whih n our when the medil intrmusulr septum is not relesed or when the nerve kinks etween the ulnr prt of the FCU nd the flexor nd prontor musle groups. [13,14,16,21] To void suh ompression, when trnsposition is performed, it is dvisle to widely relese the nerve y opening the uitl hnnel nd Osorne s rde, removing the medil musulr septum, nd opening oth the rde of Struthers nd the septum etween the ulnr stump of the FCU nd the flexor prontors. [13] When in situ nerve deompression is ompleted, dynmi nerve instility during elow flexion my our (nerve suluxtion or luxtion), nd the omission of nerve stility evlution is onsidered to e tehnil error. Aording to the literture, [22] more thn 50% of filures fter simple deompression re due to the misdignosis of nerve instility. In ses of nerve instility, nterior nerve trnsposition, either deep or superfiil, should e onsidered. Notly, nontrumti nerve deridement nd relese, inluding tht for long trt (10 15 m), does not dmge the nerve or use its devsulriztion, s ws previously elieved. [13,15,23] Plst Aesthet Res Vol 2 Issue 4 Jul 15,

3 Perineurl firosis prevents the nerve from gliding during elow exursion nd my e relted to ptient predisposition or to improper intropertive mnipultion of the nerve. [14] Firosis following simple deompression n use dherene of the nerve to the epitrohler olernon hnnel nd n dditionlly use the hnnel s losure due to the srring t Osorne s ligment. Firosis fter nterior trnsposition my our independently of the tehnique employed nd usully ours t the site of tehnil error or omission. Following superfiil nerve trnspositions, in prtiulr, firosis preferentilly lolizes to the nterior soft tissue re nd the epitrohler region. Aording to the literture, superfiil trnsposition presents the highest perentge of filure, suggesting tht this tehnique hs some intrinsi limittions represented y the position of the nerve under the skin, in reltively hypovsulr tissue suseptile to trum. [13,15] During nterior trnsposition, unintended injury to the suutneous nterhil nerves my our, leding to the formtion of pinful neuroms. During hrvest of the ulnr nerve, in 61% of ses, 1 to 3 sensory nerves n e found proximl to the epiondyle (t men level of 1.8 m from the epiondyle) or distlly in 100% of ses (t men level of 3.1 m from the epiondyle). [24,13] An unintended nerve lesion my produe one or more pinful neuroms, reting hyperlgesi or hyperestheti re in the medil prt of the elow, jeoprdizing hieving stisftory results from the deompression. Clinil studies hve reported nerve lesion rte of up to 90%, whih is thought to our seondry to the diffiulty in loting nd proteting these nerves during dissetion. [25,26] In ontrst, lesions of the min trunk of the ulnr nerve re rre. To llow nterior nerve trnsposition, it is generlly neessry to srifie the first motor fsile to the FCU, whih does not impir musulr funtion. [27] Medil elow instility is quite unommon ut my our following dmge to the ollterl ulnr ligment, prtiulrly during medil epiondyletomy, or s onsequene of n exessively ggressive nterior sumusulr trnsposition. [28] The ulnr ollterl ligment is loted just elow the flexor prontor group nd origintes, ording to O Drisoll et l., [28] from the medil epiondyle. Elow stiffness presents s flexion ontrture due to prolonged immoiliztion, inpproprite postopertive rehilittion, or exessive firosis formtion in the soft tissues. The extension lg is generlly from 5 to 30. [1,29,30] Stiffness ours fter deep trnsposition in 5 10% of ses [14,15,31] nd is generlly due to prolonged immoiliztion. Following primry deep trnsposition, the uthors permit the ptient to remove the orthesis from the 3rd to 7th dy postopertively, for 1 2 h/dy to perform tive motion. The orthesis is definitively removed 20 dys fter surgery. In ses of persistent stiffness, dequte rehilittion, nd medil therpy re typilly required. CLINICAL EVALUATION After otining thorough linil history, it is mndtory to verify the sene of neurologil disorders originting from the upper extremities nd ervil spine. The evlution my then proeed to the elow with the evlution of the position nd extent of the surgil sr, s well s plption of the ulnr nerve long its ourse, whih my e inside the epitrohler olernon hnnel or medil to the epiondyle if nerve trnsposition ws performed. Ares of tenderness nd nerve instility during elow rtiulr motion re refully investigted. In ses of ulnr neuropthy t the elow, plption long the ourse of the nerve my trigger Tinel s sign with the hrteristi spred of presthesis long the re innervted y the nerve up to the 4th nd 5th fingers or, in the se of nterhil sensory nerve neuropthies, to the medil prt of the elow nd the medil proximl third of the forerm. An importnt provotive test is the pressure flexion test [32] in whih pressure is exerted on the ulnr nerve for 1 min while the elow is flexed. Sensitivity testing of the utneous territories of the ulnr nd medin nerves of the hnd should e performed. [14] The linil evlution is ompleted y motor testing. Advned neuropthy is indited y musulr hypotrophy or trophy of the intrinsi musles innervted y the ulnr nerve. Typilly, trophy initilly involves the first dorsl interosseous musle nd then extends to the hypothenr musles. Assessment for the griffe deformity t the 4th nd 5th fingers (hyperextension of the metrpophlngel joint nd flexion of the interphlngel joint), the Froment nd Wrtenerg signs (dution of the 5th finger) nd the inility to ross the long fingers (rossed finger test) omplete the motor testing. When present, musle impirment represents negtive prognosti ftor. In generl, the neurologil signs re less severe, with no ltertions in musle tone, nd identifition is sed solely on the linil evlution of stheni nd/or diminished strength of the intrinsi musles innervted y the ulnr nerve. INSTRUMENTAL EVALUATION Eletromyogrphy (EMG) is useful in the differentil dignosis to exlude rdiulopthies, thori outlet syndrome, nd medin or ulnr nerve ompression t the wrist. However, it fils to revel neuropthies of the smll sensory nerves in the elow re. When preopertive EMG is performed, the results re prtiulrly useful when ssessing postopertive symptoms. In ses of reurrene, the neurologil symptoms worsen, whih orreltes well with the ondution vlues, onfirming the indition for surgil revision. Conversely, when worsening of the linil ondition is not onfirmed y ondution studies, the indition for revision surgery should e ditted y the severity nd persistene of symptoms. Notly, in ses of hroni xonl lesions, the ondution study results my e unhnged from the preopertive vlues while there is slight improvement in the linil ondition. [14] Therefore, when fed with worsening symptoms nd unhnged ondution studies, it is diffiult to determine whether it is more useful to se the tretment deision on the symptoms, whih would suggest surgery, or on the ondution studies, 178 Plst Aesthet Res Vol 2 Issue 4 Jul 15, 2015

4 whih would suggest wthful witing pproh in the hopes of n eventul lte reovery. Among 30 surgil revisions for the relitrnt uil tunnel, Gel nd Amdio [15] performed surgery in 9 ptients who hd norml EMGs, onluding tht norml ondution vlues were not suffiient to exlude surgil revision. Ultrsound (US) exmintion my lso id surgeons in the deision mking proess. In ft, the dynmi nd stti evlution of the ulnr nerve my revel morphologil ltertions to the nerve trunk nd to the surrounding soft tissues. In the uthors experiene, mgneti resonne imging (MRI) offers less informtion thn well performed US. In ssoition with the linil evlution, these 2 dignosti tools my ssist in the deision mking proess. When surgery is postponed, nd symptoms do not improve in short period, revision surgery should e reonsidered. In onlusion, in some ses, prtiulrly in those of primry nerve instility, the pre nd postopertive ondution studies my e negtive even in the presene of severe neuropthi symptoms. In these ses, US exmintion nd MRI my id in identifying res of mehnil nerve injury tht my indite the need for surgery. Inditions for revision surgery The persistene or worsening of neuropthi pin, derese in utneous sensitivity with presthesis long the territory of the ulnr nerve in the hnd, nd musle defiits despite onservtive medil tretment re inditions for revision surgery, [14,33] espeilly if they re ssoited with signifint worsening of the ondution study results. Tehniques in revision surgery The literture [14 16] regrding surgil revision of filed ulnr nerve deompression t the elow is limited to few retrospetive studies nd se reports. [26,29,34] Aording to these reports, superfiil nterior trnsposition is the most ommonly employed tehnique for primry surgery nd presents filure rte of 60 80%. [35,36] The gol of revision surgery is essentilly to deride the nerve of its surrounding firosis tht is using the ompression nd kinking. Neurolysis hs n importnt role in the revision of filed surgery of the ulnr nerve t the elow. However, neurolysis nnot e used s n isolted tehnique euse simple sr exision tivtes firoti retion tht, within rief time intervl, will ompress the nerve gin, leding to filure. [15] The removl of externl perineurl firosis is the primry indition for neurolysis. [37 39] When the firosis extends within the nerve, mong the fsiles, internl neurolysis should e onsidered. However, in suh ses, dmge to the vsulr supply of the internl nerve my our, nd severe nerve srring my develop, jeoprdizing the ttinment of good result even in ses of nterior nerve trnsposition. [15] Medil epiondyletomy is not onsidered stisftory hoie for revision surgery, s demonstrted y poor results in ll of the ses treted y Golderg et l. [40] These results my e due to the firoti nd hypovsulr tissue in whih the nerve remins following the proedure. [19] Anterior nerve trnsposition (suutneous, intrmusulr, nd sumusulr) is the most ommonly used revision tehnique fter filed nerve deompression, [14,19] in ses of nerve instility (nerve suluxtion or luxtion), fter medil epiondyletomy, nd following filed nterior trnsposition. Among nerve trnspositions, suutneous trnsposition yields unpreditle results when used in revision surgery, nd, for this reson, it is rrely used y surgeons. If the nerve is moved from the uitl hnnel to redue mehnil stress, it is trnsposed to reltively hypovsulr re [13,15] where it is more exposed to diret trum. [19] Gel nd Amdio [15] noted 12 poor results in 17 ses, wheres Cputo nd Wtson [34] reported 50% rte of poor results using this tehnique. Intrmusulr trnsposition is rrely used in revision surgery, with only two ses desried in the literture, oth of whih yielded unstisftory results. [15,18] Sumusulr trnsposition is widely used in revision surgery. [41 43] With this tehnique, good results my e hieved following filed simple deompressions, medil epiondyletomy, nd filed superfiil trnspositions. [14 16] If performed using the proper tehnique, the results of nterior sumusulr trnsposition re superior to those otined with other tehniques. In ontrst, if this tehnique is employed for the tretment of filed sumusulr trnsposition, the results re not stisftory. [15] In suh ses, division of the epitrohler musulr ridge nd superfiil trnsposition of the nerve with ssoited externl neurolysis yields good results. [34,44] The following tehniques re not effetive nd re rrely used: (1) the relotion of the nerve in the uitl tunnel hs rrely een used y surgeons, s it is n ineffetive method of treting relitrnt ulnr nerve ompression; [14,22,33] (2) the results of nerve isoltion with syntheti mteril, suh s silion or polymeri sustnes, re unstisftory; [32,41] nd (3) wrpping the ulnr nerve with utologous sphenous vein hs een desried with good results. [45,46] Additionl studies re needed prior to delring this tehnique s n effetive method for the tretment of filed ulnr nerve deompression. The uthors prefer nerve isoltion y mens of musle flps or ft tissue [16,47] integrted with nterior sumusulr trnsposition in ses of extensive perineurl nd soft tissue firoti retions. Tehnique preferred y the uthors Anterior deep trnsposition is the method of hoie for mny surgeons when revision ulnr nerve surgery is neessry. When pprohing revision surgery for relitrnt ulnr nerve ompression, it n e diffiult to lote the re of nerve ompromise. For this reson, thorough explortion of ll of the possile res of ompression is neessry, strting from the proximl rde of Struthers to the deep septum etween the FCU nd the flexor prontor group. [3,14,15] The skin inision in revision Plst Aesthet Res Vol 2 Issue 4 Jul 15,

5 ses is generlly longer thn the initil inision, oth in the proximl nd distl diretions. In the suutneous tissue, the identifition of smll regionl sensory nerves my e diffiult euse they re frequently inorported in the sr tissue from previous surgeries. It is not unommon to find tht one or more of these nerves hve een severed. Possile neuroms must e removed, [3,14,19] nd proximl nerve stumps must e uterized nd positioned in good qulity soft tissue, suh s the trieps musle. [3,14,19] In ses in whih the ulnr nerve is entrpped in firm, firous sr tissue, it is dvisle to egin the explortion proximl to the region of the previous inision to identify the nerve in helthy re. Progressing distlly, the nerve is then relesed from the sr. Depending on the tehnique used during the first surgery, the following three different situtions my e enountered: (1) the nerve hs een deompressed nd is still in the epitrohler olernon hnnel; (2) the nerve is outside of the epitrohler olernon hnnel euse dynmi nerve instility hs ourred with reurrent nterior suluxtion during elow flexion, or euse it hs een trnsposed nteriorly in the suutneous tissue; or (3) the nerve is outside of the epitrohler olernon hnnel euse it hs een trnsposed nteriorly under the flexor prontor musles. Regrdless of where the nerve is loted, the presene of sr tissue is onsistent pttern, whih inreses oth the diffiulty of the dissetion nd the risk of nerve dmge. In these ses, identifition of the nerve distl to the uitl hnnel t the FCU musle entrne is reommended. From there, dissetion proeeds in distl to proximl diretion. One the nerve nd potentil ompression res hve een relesed, the following different ntomil situtions my e enountered: (1) the ulnr nerve ws previously deompressed only nd is still loted in the epitrohler olernon hnnel. Proeed with nterior sumusulr trnsposition with myotomy of the epitrohler musles using the Z lengthening tehnique. [16] It is of prmount importne tht exision of the medil intermusulr septum nd omplete opening of the distl septum etween the FCU nd the flexor prontor musle group re performed. If the trnsposition hs een omplished properly, the nerve will lie in its new lotion without res of ompression or kinking; (2) the ulnr nerve ws previously trnsposed nteriorly nd superfiilly, ut there is urrently severe firosis tht renders nerve deridement diffiult. If the intermusulr septum ws not relesed during the previous surgery, the nerve psses over the septum, whih dislotes the nerve from eneth, reting ompression. In other ses, the nerve my e found top the epitrohler one s onsequene of n erroneous trnsposition or of filure of the soft tissue nhorge. This sitution retes tension long the nerve, resulting in ute ngultion nd kinking of the nerve t Osorne s rde or t the deep distl septum t the level of the FCU. Externl neurolysis nd sumusulr trnsposition re performed s desried in setion A [Figures 2-5]; nd (3) the ulnr nerve ws previously lredy trnsposed. Surgery then ommenes with identifition of the nerve proximl nd distl to the srred re, isoltion of the nerve from the point of firosis up to the entrne in the epitrohler musles, nd deompression of the rde of Struthers, the intermusulr septum proximlly, nd the deep flexor prontor septum distlly. Relese of the nerve t the entrne, exits, nd eneth the musulr hnnel is then performed. The nerve is generlly found Figure 2: When deompression is insuffiient, the nerve kinks t Osorne s rde nd is ompressed y the intermusulr septum when trnsposed nteriorly. () The ptient underwent two surgeries for simple nerve deompression. The nerve is disloted nterior to the epitrohler one, presenting with pseudoneurom ulging (*) proximl to the ompression re t Osorne s rde level (>) whih hd not een previously relesed (<); () following deompression t zones 4 nd 5 (refer to Figure 1) (<) nd externl neurolysis (*), nerve trnsposition my e performed; () nterior sumusulr trnsposition using musle Z-lengthening proedure d Figure 3: Filed nerve deompression treted with superfiil nterior trnsposition. () The ulnr nerve (*) is firoti (<>), swollen, nd hrd to plption; () the intermusulr septum (white rrows) nd the distl deep septum in zone 5 (lk rrows) were not relesed during the initil surgery 180 Plst Aesthet Res Vol 2 Issue 4 Jul 15, 2015

6 d Figure 4: Filed superfiil nerve trnsposition. () The nerve is tut over the epitrohler one (*) nd kinks t the deep septum (zone 5) for n insuffiient trnsposition; () nerve deompression y the relese of the flexor rpi ulnris nd deep septum. The irled re shows the region of ishemi injury to the nerve seondry to ompression; () fter externl neurolysishseen performed, the nerve is prepred for nterior sumusulr trnsposition; (d) following trnsposition, the nerve lies in soft nd vsulr tissue ed without tension to e entrpped y firoti tissue[44] in the new musulr hnnel nd neurolysis in neessry. When neurolysis lone is insuffiient for the relese of the nerve or when the musulr hnnel hs eome firoti nd does not provide dequte vsulriztion of the nerve, the musulr ridge is opened, nd the nerve is trnsferred superfiilly.[34] POSTOPERATIVE TREATMENT A rhil metrpl plster st is pplied for 20 dys, with the elow t of extension. By the 3rd postopertive dy, the ptient is llowed to temporrily remove the plster to perform reful tive elow flexion nd extension movements. From the 7th dy, the ptient egins tive reful supintion with the elow t of flexion. From the 15th dy, supintion with the elow extended is permitted. The plster is definitively removed 20 dys postopertively, nd the ptient is then pled under the re of therpist. FUTURE DIRECTIONS Ulnr nerve ntomy t the elow region nd pthophysiology of the ompression syndrome re well reognized. Nonetheless, filure following nerve deompression lone or with ssoited nterior nerve trnsposition still ours. The filure to reognize dynmi ulnr nerve instility, idiopthi or indued fter in situ nerve deompression, represents the most frequent proedurl error leding to surgil filure. A thorough understnding of the mehnisms using ulnr nerve ompression nd injury would redue the rte of reurrene. CONCLUSION The results of revision surgery following relitrnt ulnr nerve ompression t the elow re inferior to those Plst Aesthet Res Vol 2 Issue 4 Jul 15, 2015 d Figure 5: Filed superfiil nerve trnsposition. ( nd ) Arde of Struthers (*) ws not relesed during the first surgery, using nerve kinking nd ompression. At the epitrohler level, the nerve ppers to lie within good tissue without tension (>); () following deridement, the nerve lies in soft nd vsulr tissue ed without tension. An dipofsil flp is hrvested (*); (d) nterior sumusulr trnsposition with musulr Z-lengthening is performed. The dipofsil flp protets the nerve in the proximl epitrohler region otined fter primry surgery, prtiulrly in ptients over the ge of 50 yers, when ondution studies show musle denervtion, or when there is history of multiple surgeries.[15] To void the misinterprettion tht the prtil resolution of preopertive symptoms is filure of tretment, it is mndtory tht the ptient e ompletely informed prior to surgery.[16] Chroni xonl degenertion is frequently ssoited with mrginl improvement of neuropthi pin, tenderness in the ompression re, nd hnd dysesthesis,[14,16] without high rte of omplete restortion of sensitivity nd musle strength. Nonetheless, the linil dvntges remin relevnt provided tht n expert surgeon performs the revision surgery. REFERENCES Dwson DM, Hllett M, Millender LH. Entrpment Neuropthies. 1st ed. Boston: Little Brown; p. 88. Amdio PC. Antomil sis for tehnique of ulnr nerve trnsposition. Surg Rdiol Ant 1986;8: Mkinnon SE, Novk CB. Opertive Findings in reopertion of ptients with uitltunnel syndrome. Hnd (N Y) 2007;2: Dellon AL. Musulotendinousvrition out the medin humerl epiondyle. J Hnd Surg Br 1986;11: O Drisoll SW, Horii E, Crmihel SW, Morrey BF. The uitl tunnel nd ulnr neuropthy. J Bone Jiont Surg Br 1991;73B: Childress HM. Reurrent ulnr nerve dislotion t the elow. Clin Orthop Relt Res 1975;108: Osorne GV. The surgil tretment of trdy ulnr neuropthy. J Bone Joint Surg Br 1957;39B:782. King T, Morgn FP. Lte results of removing the medil humerl epiondyle for trumti neuritis. J Bone Joint Surg Br 1959;41B:51 5. Curtiss BF. Trumti ulnr neuritis: trnsposition of the nerve. J Nerv Ment Dis 1898;25: Adson AW. The surgil tretment of progressive ulnr prlysis. Minn Med 1918;1: Lermont JR. A tehnique for trnsplnting the ulnr nerve. Surg Gyneol Ostetr 1942;75: Pns J. Upon rre se of ulnr nerve plsy. Arh Gen Med 1878;2:5 22. (in Frenh) Novk BC, Mkinnon SE. Seletion of opertive proedures for uitl tunnel syndrome. Hnd (N Y) 2009;4:

7 14. Ruhelsmn DE, Lee SK, Posner MA. Filed surgery for ulnr nerve ompression t the elow. Hnd Clin 2007;23: Gel GT, Amdio PC. Reopertion for filed deompression of the ulnr nerve in the region of the elow. J Bone Joint Surg Am 1990;72A: Vogel BR, Nossmn BC, Ryn GM. Revision nterior sumusulr trnsposition of the ulnr nerve for filed suutneous trnsposition. Br J Plst Surg 2004;57: Pukett BN, Gston RG, Lourie GM. A novel tehnique for the tretment of reurrent uitl tunnel syndrome: ulnr nerve wrpping with tissue engineered io sffold. J Hnd Surg Eur Vol 2011;36: Gy JR, Love JG. Dignosis nd tretment of trdy prlysis of the ulnr nerve: sed on study of 100 ses. J Bone Joint Surg Am 1947;29: Jkson LC, Hothkiss RN. Cuitl tunnel surgery, omplitions nd tretment of filures. Hnd Clin 1996;12: Ryn GM. Thori outlet syndrome. J Shoulder Elow Surg 1998;7: Spinner M. Nerve deompression. In: Morrey BF, editor. Mster Tehniques in Orthopedi Surgery: The Elow. New York: Rven Press; p Antonidis G, Rihter HP. Pin fter surgery for ulnr neuropthy t the elow: ontinuing hllenge. Neurosurgery 1997;41: Heithoff SJ. Cuitltunnel syndrome does not require trnsposition of the ulnr nerve. J Hnd Surg Am 1999;24A: Lowe JB 3rd, Mggi SP, Mkinnon SE. The position of rossing rnhes of the medil nte rhil utneous nerve during uitl tunnel surgery in humns. Plst Reonstr Surg 2004;114: Mkinnon SE, Dellon AL, Hudson AR, Hunter DA. A primte model for hroni nerve ompression. J Reonstr Mirosurg 1985;1: Rogers MR, Bergfield TG, Auliino PL. The filed ulnr nerve trnsposition. Etiology nd tretment. Clin Orthop Relt Res 1991;269: Wthmker GP, Lee G, Mkinnon SE. Intrneurltopogrphy of the ulnr nerve in the uitl tunnel filittes nterior trnsposition. J Hnd Surg Am 1994;19: O Drisoll SW, Jloszynski R, Morrey BF, An KN. Origin of the medil ulnr ollterl ligment. J Hnd Surg Am 1992;17; Broudy AS, Leffert RD, Smith RJ. Tehnil prolems with ulnr nerve trnsposition t the elow: findings nd results of reopertion. J Hnd Surg Am 1978;3: Leffert RD. Anterior sumusulrtrnsposition of the ulnr nerves y Ler month tehnique. J Hnd Surg Am 1982;7: Jnes PC, Mnn RJ, Frmworth TK. Sumusulr trnsposition of the ulnr nerve. Clin Orthop Relt Res 1989;238: Novk CB, Lee GW, Mkinnon SE, Ly L. Provotive testing for uitl tunnel syndrome. J Hnd Surg Am 1994;19: Filippi R, Chrlmpki P, Reish R, Koh D, Grunert P. Reurrent uitl tunnel syndrome. Etiology nd tretment. Minim Invsive Neurosurg 2001;44: Cputo AE, Wtson HK. Suutneous nterior trnsposition of the ulnr nerve for filed deompression of uitl tunnel syndrome. J Hnd Surg Am 2000;25: Mowlvi A, Andrews K, Lille S, Verhulst S, Zook EG, Milner S. The mngement of uitl tunnel syndrome: met nlysis of linil studies. Plst Reonstr Surg 2000;106: Dellon AL. Review of tretment results for ulnr nerve entrpment t the elow. J Hnd Surg Am 1989;14A: Goth D. Animl experiment studies of neurolysis of peripherl nerves. Hndhir Mikrohir Plst Chir 1987;19: Grf P, Hewe W, Biemer E. Vsulr supply of the ulnr nerve following neurolysis in the re of the elow. Hndhir Mikrohir Plst Chir 1986;18: Rydevik B, Lundorg G, Nordorg C. Intrneurltissue retions indued y internl neurolysis. An experimentl study on the lood nerve rrier, onnetive tissues nd nerve fires of rit tiil nerve. Snd J Plst Reonstr Surg 1976;10: Golderg BJ, Light TR, Blir SJ. Ulnr neuropthy t the elow: results of medil epiondiletomy. J Hnd Surg Am 1989;14: Posner MA. Compressive ulnr neuropthies t the elow: II. Tretment. J Am Ad Orthop Surg 1998;6: Siegel DB. Sumusulr trnsposition of the ulnr nerve. Hnd Clin 1996;12: Kleinmn WB. Revision ulnr neuroplsty. Hnd Clin 1994;10: Dgregorio G, Sint Cst Y. Simple neurolysis for filed nterior sumusulr trnsposition of the ulnr nerve t the elow. Int Orthop 2004;28: Vrdks DG, Vritimidis SE, Soterenos DG. Findings of explortion of vein wrpped ulnr nerve; report of Cse. J Hnd Surg Am 2001;26: Vritimidis SE, Rino F, Soterenos DG. Relitrnt post surgil neuropthy of the ulnr nerve t the elow: tretment with utogenous sphenous vein wrpping. J Reonstr Mirosurg 2000;16: Godette GA, Ryn GM. Medil trieps flp overge for n ulnr neurom. Orthop Rev 1993;22: How to ite this rtile: Vigsio A, Mroio I, Morndini E. Relitrnt uitl tunnel syndrome. Plst Aesthet Res 2015;2: Soure of Support: Nil, Conflit of Interest: None delred. Reeived: ; Aepted: Plst Aesthet Res Vol 2 Issue 4 Jul 15, 2015