Fascial Epicondylar Augmentation in Cases of Cubital Tunnel Syndrome with Ulnar Nerve Instability

Cubital tunnel syndrome (CubTS) is one of the most common compression-traction neuropathy in the upper extremity. The gold standard is simple in situ decompression with revision of potential compression sites through skin incision as small as rationally possible. Properly conducted conservative treatment is more effective in CubTS as opposed to carpal tunnel syndrome. At the same time, optimal management of CubTS remains controversial. Nevertheless, there is a subclass of patients with symptoms of CubTS that have ulnar nerve instability (UNI) with subluxation of the nerve over the medial epicondyle where conservative treatment would not be successful. UNI can be diagnosed by ultrasound preoperatively, but there are situations where the ulnar nerve becomes unstable with elbow flexion already on the operating table. Currently the most popular surgical reconstruction for clinically relevant UNI is anterior transposition of the nerve. With the proposed technique the nerve stays in orthotopic position, and the segmental vascularity is preserved, innervation to the flexor carpi ulnaris muscle is not jeopardized and ulnar nerve glide-floss exercises are possible as opposed to the standard subcutaneous transposition technique. No subfascial transposition, slings or blocking flaps are used for nerve stabilization which we consider contradiction to the surgery of nerve release.