Revision ulnar neuroplasty

Revision ulnar neuroplasty should be performed in cases of recurrence or persistence of symptoms or signs of ulnar entrapment neuropathy at the elbow following cubital tunnel release, with or without previous epicondylectomy or anterior transposition. Most cases of recurrence or persistence of symptoms reported in the literature could be traced at reoperation to failure of the initial treating surgeon to decompress the nerve adequately at all potential sites of compression. Included in this assessment were those cases of unwarranted postoperative nerve tension in elbow flexion, the result of maintaining the neurolysed nerve in its retrocondylar position. The most probable sites of persistent compression include (1) the medial intermuscular septum, (2) the arcade of Struthers, (3) fibrous bands at the entrance or exit of the cubital tunnel, (4) persistence or kinking at Osborne's arcuate ligament, (5) fascial slings, and (6) incomplete anterior transposition. Severe perineural fibrous compromising intraneural microcirculation in an inadequate, poorly vascularized bed is also a frequent finding, particularly in cases in which patients have undergone submuscular transposition. When a revision ulnar neuroplasty is performed at the elbow, a formal neurolysis and epineurotomy should be performed under loupe magnification. Once all potentially compressing structures have been freed and the nerve completely relaxed, it should be placed within a muscle sleeve of the flexorpronator mass, created by a 5-mm trough deep to the anterior flexor-pronator fascia. The overlying fascia is repaired securely without any direct contact with the nerve.