So I want to focus a little bit on complications. In other words, we have kind of a standard approach, which is about a 10 centimeter incision the way I was taught. And why not continue doing that? Well, it's a pretty big incision, and there's a lot of soft tissue that needs to heal. Traditional treatment has, as the other speakers have said, about 80% good to excellent results, is generally what we quote in the literature. And there's a variety of papers, most of which are not level one type papers, about the different ways to approach this. So really, the question is, why would you change your approach? Well, I think you would if you think there's a better way. What about in situ release? There was traditional older literature that had a certain failure rate. Generally, if you look at all comers, it was a 75% up to about a 92% success in the older literature. And there were some more contemporary papers that suggest that there's a role for in situ release. And in in situ release, the areas of compression are decompressed, but the nerve is left within its original bed. And there have been some comparison studies with other treatments that inform us that there may be a role for that, as opposed to the more traditional anterior transpositions and or epicondylar releases or epicondylitis. So why consider an in situ release? Well, potential advantages, not necessarily proven, but inferred are that the ulnar nerve is not devascularized. It avoids a torturous course. Some of the more aggressive anterior transpositions build in two curves instead of one traction point. And those can be an area of problem. Or maybe you, as a clinician, have seen some problems with the other treatments, a submuscular that's not done well or a medial epicondylar bony resection which has had some scarring or heterotopic bone or a subcutaneous release that's still symptomatic. I mean, these may be your own cases, or they may be ones that you've inherited. When might simple decompression alone not be adequate? Well, we know that the nerve has a tendency to have a peak loading, both traction and compression, around the flexion point. So the nerve stretches in elbow flexion. The nerve may subluxate when the elbow is flexed, which is another problem. You may encounter local problems in the path of the nerve, scarring or osteophytes, or severe elbow deformity from previous trauma or something like a cubitus valgus. So there are a few studies that indicate these changes in pressure. This is one from Richard Gelberman and Ken Yamaguchi that looks at what happens during the flexion arc and that as the flexion goes beyond 90 degrees, that the pressures increase in the tunnel. And this is something that would validate something that we see clinically. So if you do an in situ decompression, what else can you add? Well, you can add a medial epicondylectomy so that in flexion the nerve translates anteriorly somewhat. And then you can also do a subcutaneous transposition, but create a fascial dermal sling. I trained with Richard Eaton and he taught me how to do a fascial dermal sling, which is what he routinely did with the standard open release. The medial epicondylectomy, Brent already alluded to, I don't personally do this because of the concerns about the raw bone and covering it. And I think that there are a little more reliable ways to handle those local problems. It's been mentioned that there are some comparison studies and as we go towards using the more rigorous studies to base our treatments, there are several that I would just review over the next couple of minutes. This first one, Neurosurgery 2005, was a prospective randomized clinical study. They graded severe carpal tunnels and they compared submusculars with a flexor pronator mass Z lengthening with a simple decompression. They saw no difference in the clinical or the electrophysiologic outcomes. The groups routinely had over 80% good to excellent results. Another piece of data that confirms that 80% rule. Naban and co-authors in the Journal of Hand Surgery British did a beta analysis of simple decompression versus traditional anterior transposition. No big differences between the groups. Bartles and neurosurgery, again, a prospective randomized controlled study of simple decompression of the nerve versus the anterior subcutaneous transposition. And all of their patients had pretty effective results. The outcomes they felt were equivalent except for the complication rate. And so that tipped the needle in favor of the more simple intervention. Again, in the neurosurgery literature, Biggs and co-authors in 2006 looked at 23 of neuralysis only or transposition 21. Again, pretty equivalent results but more wound complications in the transposition group. Therefore, the needle tipped in these studies towards that. So there are other studies that look at that. I looked at my own experience from 2008 to 2015. And I had 60 cases of primary cubital tunnel syndrome where I did not do the traditional 10 centimeter incision. And I used a variety of techniques. I was trying to focus on if I could do this with a mini open successfully. The majority were these in situ releases and the majority had a medial epicondylar release as well. Less than 10% had an anterior transposition. I used the endoscope to visualize. I used some of the release systems. And so this is a typical case with a relatively modest incision. Using retractors to visualize the nerve and do dissection proximally and distally all under direct vision or endoscopically assisted visualization. Here I'm using one of the endoscopic tools to do the cutting. And combined in this particular patient with a lateral epicondylar release and a radial tunnel release because there was pathology on both sides of the elbow, reasonable results. My more recent cases, I've not used the endoscopic systems and I did a lot of associated procedures. Again, medial epicondylar fascia release being the most common. 60% had lateral releases or olecranon tip or wrist or carpal tunnel. So I would do things in combination. And my main outcome measure, because this is retrospective, was what was my incidence of recurrence. And in this group it was zero. So that is pretty good evidence for me that I'm onto something reasonable. If you're used judiciously, things like Ragnell's, Army-Navy retractors, nasal specula, and you can do good visualization with a relatively limited incision. And so this is an example where I put, I find the nerve, I cut Osborne's ligament first, get a vessel loop around it, and then go forward. And this demonstrates how much distance I was able to go distally in the carpal tunnel space using this limited approach and the right retraction. And then I go up approximately and I do the same thing. Use the freer elevator, use a variety of traditional instruments. And again, show that I'm up pretty far. I have the equivalent of the 10 centimeter incision visualization here. When you do the medial epicondylar release, you have tissue to do the fascial dermal sling a la Eaton and others. And here you get that tissue if you harvest it somewhat carefully. And you may get that also when you release the fascia and try to lengthen the muscle tendon unit. So there's tissue for the sling and flexion is very important because if you're a subluxator, you want to do probably something else. And those include those approaches. So in conclusion, I think there is a role for in situ release, evaluating the flexion and doing some supplemental strategies if you see that.

complications

treatment

cubital tunnel syndrome

in situ release

minimally invasive techniques