Motor Branch Of Pronator Quadratus Transfer For Treatment Of Severe Cubital Tunnel Syndrome

Objective: Recently， with the development of basis research andtreatment of the cubital tunnel syndrome，the excellent rate of postoperativeoutcome improve to75%-90%.However, postoperative functional recovery inpatients with hand intrinsic muscle atrophy and motor nerve conductionvelocity of ulnar nerve less than30m/s still limited. So,we focus on how toimprove the hand intrinsic muscle function enhance the quality of their. Inrecent years,many successful study of end-to-side nerve transfer has beenreported. Contrast to end-to-end nerve coaptation, there has many advantagesof end-to-side nerve transfer, such as less affection of the donor side, neuralsources,early nerve recovery and higher nerve regeneration rate.Baesd on theprevious study,we designed the branch of pronator quadratus transfer to motorbranch of ulnar nerve for treatment of severe cubital tunnel syndrome,in orderto shorten the time of recovery,reserve more intrinsic muscle,and improve thefunctional recovery of intrinsic muscle.Method:1Patients:40patients (43sides) diagnosed with severe cubital tunnelsyndrome were included in our study,include31men,12women; age from33to68years old(average age40years).The bilateral patients occupy3patients.Left side in16patients and right side in27patients.The medicalhistory was from3months to5years(average16months).11patients werecarpentry,8patients were brick layer,5patients were farmer,10patients werecivil servants,3patients were public officials,3patients were freelance.29patients show the intrinsic muscle atrophy,25patients show claw hand.15patients had an old trauma,9patients had an elbow osteoarthritis,6patients hadtumor,13patients have no reason.The Tinel sign of all the patients are positive.All patients divide into two groups: the ulnar nerve anterior transposition group:23cases; The ulnar nerve anterior transposition and nerve to pronatorquadratus of median nerve end to side transfer group:20cases. The standard ofchoice of the cases according to the requirement of the research:(1)Age:between33to57years old;(2)No other central and peripheral nervous systemdisease;(3)No other systemic disease;(4)All patients are voluntary;(5)Allpatients are diagnosed severe cubital tunnel syndrome;(6)All patientsexamined the EMG X-ray B ultrasound and MRI。2Operation method:(1) The ulnar nerve anterior transposition: An8cmlong curved skin incision was made posterior to the medial epicondyle of thehumerus to expose the elbow tube. The cubital tunnel retinaculum, or arcuateligament was released. If present, Struther’s arcade was also released. Thiswas followed by widening of the entrance tothe cubital tunnel between the twoheads of the flexor carpi ulnaris muscle. Finally, after ensuring that there wasno further compression of the nerve. The subcutaneous tissues were thendissected anterior to the medial epicondyle to form a subcutaneous ‘‘bed’’ forthe nerve.The nerve was transposed, and then retained in the subcutaneous bedwith a fascial sling raised from the underlying muscle fascia, which wassutured from below to the dermis using non-absorbable sutures. Then close theskin.Flexion the elbow with plaster cats for4weeks.(2) The same procedurewas followed initially. The ulnar nerve anterior transposition and nerve topronator quadratus of median nerve end to side transfer: Mark the incisionulnar to the thenar crease to expose the Guyon canal, Open the Guyon canal toexpose the proximal tendinous edge. The deep motor branch is just below thisedge. Follow the ulnar nerve proximally into the forearm and identify branchpoint of the dorsal cutaneous branch of the ulnar nerve; usually10cmproximal to the wrist. Divide the anterior interosseous nerve distally at themidportion within the pronator quadratus muscle and transpose the nervetoward the ulnar nerve to determine the location of the superchargedend-to-side coaptation. Always,the radial nerve is sensory group,the ulnar sideis dorsal cutaneous branch,middle is motor group.Cut the nerve to pronatorquadratus muscle,make a wide perineural window (2mm), determine the tension-free,using interrupted8–0nylon epineurial sutures. Flexion theelbow with plaster cats for4weeks.3Postoperative management:Flexion the elbow with plaster cats for4weeks.Instruction the patients to functional exercise,include individual fingerand thumb abduction/adduction with the hand in pronation,foream pronationand supination,elbow flexion and extending,wrist flexion and extending. Allpatients take EMG examination during the follow-up at1,2,3,6,12monthsafter operation.4Analyze the data by SPSS13.0statistical software and the results ofmeasurement data are expressed as the x s.Results:The ulnar nerve anterior transposition group: excellent7,good5,acceptable7,disappointing4. The excellent rate52.17%.The ulnar nerveanterior transposition and nerve to pronator quadratus of median nerve end toside transfer group: excellent9,good8,acceptable1,disappointing2. Theexcellent rate85%. And there was significant difference between2groups:P＜0.05.The forearm pronation angle was no significant difference before andafter operation.Conclusion: Nerve to pronator quadratus of median nerve end to sidetransfer to ulnar deep branch to treat severe cubital tunnel syndrome can gainexcellent clinical results also can delay the hand intrinsic muscle atrophy.