- Discussion:
- motivation: w/ maximal elbow flexion, high extraneural pressures occur at the medial epicondyle;
- hence the medial epicondyle is a major impinging structure which forces the ulnar nerve to make a sharp turn
whenever the elbow is maximally flexed;
- medial epicondylectomy allows some anterior displacement of the ulnar nerve and removes the epicondyle as the
as an impinging structure during flexion;
-
advantages:
- avoids nerve devascularization;
- avoids iatrogenic compression of the nerve which can occur w/ transposition;
- relieves compression of the nerve which occurs in flexion, by removing one origin of the
FCU;
- nerve is allowed to seek its own path of least resistance;
- preserves small proximal nerve branches to the elbow joint;
- blood supply to the nerve is preserved;
-
disadvantages:
- potential weakness and elbow instability due to iatrogenic injury to the flexor-pronator origin and
MCL, respectively;
- protective prominence of the epicondyle is lost;
- postoperative tenderness at the osteotomy site;
-
outcomes:
- in the study by Masatoshi Amako et al, the authors compared minimal medial epicondylectomy (18 patients) for cubital tunnel syndrome w/
decompression of cubital tunnel and preservation of the anterior medial collateral ligament and partial medial epicondylectomy (14 patients);
- both groups had significant improvement in their Yasutake scores following medial epicondylectomy;
- there was no significant difference in improvement of either the Yasutake scores or the motor conduction velocity between the 2 groups;
- valgus instability of the elbow was significantly greater in the partial epicondylectomy group;
- the authors concluded that minimal medial epicondylectomy combined with ulnar nerve decompression is an effective treatment
for cubital tunnel syndrome and that a larger excision of the medial epicondyle should be avoided;
- Comparison between partial and minimal medial epicondylectomy combined with decompression for the treatment of cubital tunnel syndrome
J Hand Surg 2000;25A:1043-1050
- Anatomy & Sites of Compression of Cubital Tunnel:
- Technique:
- includes exploration of the ulnar nerve proximally & distally relieving medial ntermuscular septum and
releasing arcade of Struthers and the aponeurosis between humeral and ulnar origins of the FCU;
-
skin incision:
- gentle curved incision just anterior to the medial epicondyle;
- look for posterior branches of the
medial antebrachial nerve, which tend to cross just proximal to the epicondyle;
-
deep exposure:
- identify the ulnar nerve proximal to the epicondyle and tag it;
- origin of the flexor pronator mass is identified over medial epicondyle;
-
identification of proximal and distal compression:
- see:
anatomy and sites of compression;
-
osteotomy:
- ensure that the ulnar nerve is retracted out of the way prior to performing the osteotomy;
- flex the elbow to 90 deg;
- longitudinally incise thru the flexor pronator origin, directly over the center of the epicondyle;
- incise directly down to bone and subperiosteally elevate the origin on both sides of the epicondyle;
- once the epicondyle is exposed, mark the proposed osteotomy site with cautery;
- common mistake is to perform an inadequate bone resection, usually atleast 6-7 mm of resection is needed;
- the osteotomy should be made parallel to the course of the nerve w/ the elbow flexed;
- it is advantagous to include a portion of the supracondylar ridge, inorder to ensure that
the attached medial intermuscular septum is also decompressed;
- overly aggressive resection of the epicondyle, however, may disrupt the anterior fibers of the
MCL;
- use a rongeur to remove sharp edges of the osteotomy;
- once the osteotomy is completed, flex and extend the elbow to observe free anterior translation of the ulnar nerve;
- following closure, both leaves of the flexor pronator origin are closed;
- Post Operative Care:
- in the study by Seradge 1997, the effects of early and late mobilization following medial epicondylectomy was
evaluated in a randomized prospective study;
- flexion contracture of more than 5 deg was seen in 5% of the early mobilization group vs 52% of the late group;
- patients with flexion contractures had more pain than those without contractures;
- patients in the early ROM group returned to work earlier than the late group;
Newest Knowledge of Rheumatoid Arthritis--General Orthopaedics: Elbow: Ulnar Nerve Decompression With Medial Epicondylectomy for Neuropathy at the Elbow.
Medial Epicondylectomy for subluxing ulnar nerve.
D Gore, S Larson.
Am. J. Surg. Vol 111. 1966, p 851-853.
Cubital tunnel syndrome. Treatment by medial epicondylectomy.
Medial Epicondylectomy for the Treatment of Ulnar Nerve Compression at the Elbow.
SJ Heithoff, LH Millender.
J. Hand Surg. 15-A. 1990, p 22-29.
Medial epicondylectomy for ulnar nerve compression syndrome at the elbow.
RE Jones, C Gauntt.
CORR Vol 139, 1979, p 174-178.
Cubital tunnel release and medial epicondylectomy: effect of timing of mobilization.
Cubital tunnel release with medial epicondylectomy factors influencing the outcome.
H Seradge et al.
J. Hand Surg. Vol 23-A. No 3. May 1998. p 483.
A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy;
FA Kaempffe et al.
J. hand. Surg. Vol 23-A. No 3. May 1998. p 492.
Cubital tunnel release and medial epicondylectomy: effect of timing of mobilization.
H Seradge.
J. Hand Surg. Vol 22-A. 1997. 863-866.
