| Cubital tunnel syndrome(CUTS),also known as delayed ulnar neuritis,elbow ulnar nerve entrapment syndrome and traumatic ulnar neuritis,is one of the common peripheral nerve entrapment syndromes in clinic,The incidence rate of Cubial tunnel syndrome is only lower than carpal tunnel syndrome,is about 25/10 million,and the incidence of male patients is about two times that of women.The typical clinical manifestation of cubital tunnel syndrome is abnormal palmar and dorsal sensation of one and a half fingers on the ulnar side.Mild patients may only have hand numbness,moderate and severe patients may have a history of night numbness,hand weakness,weakening of interosseous muscle and abductor digitorum minor,atrophy of thenar minor and interosseous muscle,atrophy of ulnar muscle in the upper part of forearm,weakening of deep flexor of ring little finger and flexor carpi ulnaris,etc.The five common entrapment sites around the elbow joint during the walking of the ulnar nerve in the upper limb are:Struthers ligment,medial muscle septum,medial epicondyle of humerus,Osborne ligament and deep fascia penetration point of the ulnar nerve.The literature shows that 60%～80%of the entrapment occurs in the cubital tunnel area,The decrease of cubital tunnel volume caused by elbow degeneration is the most common factor causing cubital tunnel syndrome.For the treatment of cubital tunnel syndrome,mild patients can adopt conservative treatment methods such as night brace,nutritional nerve drugs and nerve slip training.For moderate and severe patients with symptoms such as interosseous muscle atrophy and hand weakness,surgery is needed.The choice of surgical methods for cubital tunnel syndrome is still controversial.More and more scholars prefer neurolysis in situ,which can not only preserve the blood supply and anatomical position of ulnar nerve to a greater extent,but also reduce complications due to small incision.Cubital tunnel syndrome caused by degenerative lesions of elbow joint is due to the formation of osteophyte on the dorsal edge of elbow joint,especially ulnohumeral joint,which protrudes into the ulnar nerve groove,reducing the cubital tunnel volume,while the Osborne ligament is tough and inelastic,resulting in the traction and friction of ulnar nerve.Only neurolysis in situ can prolong the Osborne ligament.However,due to the increase of the bottom of the cubital canal behind the medial epicondyle of the humerus and the untreated osteophyte,The ulnar nerve will still be pulled when the patient bends the elbow,and it will cause complications such as anterior ulnar nerve slippage or subluxation.Excision of the hyperplastic osteophyte at the ulnar nerve groove and the lip edge of the humeral ulnar joint,deepening and widening of the ulnar nerve groove combined with in situ release of the ulnar nerve is a surgical method for the treatment of ulnar nerve compression caused by elbow osteoarthritis,but the extent to which it is increased is not quantified.In this study,color Doppler ultrasound diagnostic instrument was used to measure the ulnar nerve sulcus of 200 normal adults,measure the depth and width of the cross section of the cubital tunnel,and calculate the ratio of depth/width,which is the cubital tunnel index.The 1:1 model of elbow joint was printed according to the CT scanning image before operation,The cubital tunnel index was used to calculate the amount of bone to be removed when the cubital tunnel was expanded to the standard size,and the personalized "trial model" of bone removal was designed;During the operation,the Osborne ligament was cut in a Z-shape.After the ulnar nerve was exposed and released,the soft tissue at the bottom of the cubital tunnel and part of the joint capsule were separated and lifted under the periosteum.The hyperplastic osteophyte was removed with a high-speed grinding drill to deepen and widen the ulnar nerve groove.The "test model" was used to verify the degree of expansion.After the expanded bone wound was coated with bone wax for hemostasis,and the lifted soft tissue at the bottom of the cubital tunnel and joint capsule were sutured back to the original place,The ulnar nerve was returned to the ulnar nerve sulcus,and the Osborne ligament was extended by Z-shaped suture.It not only retains the blood supply and normal anatomical structure of the ulnar nerve,but also reduces the disadvantages of insufficient expansion of the cubital tunnel and incomplete neurolysis.For the severity of ulnar nerve entrapment,the literature at home and abroad is a subjective comparison of the thickening and thinning of the nerve,but there is a lack of reference data.In this subject,the nerve cross-sectional area was measured by color Doppler ultrasound diagnostic instrument at five parts near the elbow joint in 200 healthy volunteers with normal clinical examination,The ultrasonic images and neural CSA of each measurement point were obtained.Each measurement point was measured three times to obtain the average value,so as to provide clinical reference for cuts.The findings of this study are as follows:1 Using the trial model under the guidance of 3D printing,the ulnar nerve sulcus was deepened and widened,the internal environment of the cubital tunnel was improved,the physical compression of the ulnar nerve was reduced,the accompanying vessels of the ulnar nerve were not damaged,and the normal anatomical structure and walking position were retained.The clinical effect was satisfactory.2 The cubital tunnel index was measured and calculated by color Doppler ultrasound diagnostic instrument to quantify the formation of ulnar nerve sulcus,so as to avoid the problem of too much resection leading to the fracture of medial epicondyle of humerus and too little decompression.3 Through the measurement of normal CSA at five common entrapment sites of ulnar nerve by high-frequency ultrasound,it is found that the CSA values of ulnar nerve are different at different measurement points,and there are differences in CSA values between age and gender,which provides clinical reference data for further diagnosis of the degree of entrapment of ulnar nerve.In this project,the trial mold under the guidance of 3D printing is used to form the ulnar nerve sulcus.Combined with the in-situ release of the ulnar nerve,the Osborne ligament is extended without changing the normal anatomical structure and course of the ulnar nerve,which solves the problem of compression and traction of the ulnar nerve due to the change of cubital tunnel volume during elbow flexion and extension,and does not damage the accompanying vessels and normal structure of the ulnar nerve.The clinical effect is good,It has broad application prospects.Part one Ulnar nerve groove plasty guided by 3D printing technique for moderate to severe cubital tunnel syndromeObjective:This study aims to introduce a surgical method for deepening and widening the ulnar nerve groove.According to the concept of cubital tunnel index of healthy adults detected and calculated by high-frequency ultrasound,combined with the accurate cubital tunnel expansion under the guidance of advanced medical 3D printing technology,a personalized surgical scheme is created.After the ulnar nerve canal composed of the internal and posterior bone ligaments of the original elbow joint is scanned and calculated by CT,Under the guidance of computer-aided measurement,the bone drill is standardized to polish the hyperplastic osteophyte and expand the cubital tunnel.At the same time,it is covered with soft tissue.After the release of the ulnar nerve,it is re incorporated into the expanded cubital tunnel,which completely follows the physiological walking of the ulnar nerve without anterior transposition.The defects of scar compression and irritability after operation are avoided to the greatest extent,which ensures that the nerve is accompanied by vascular nutrition in situ and does not affect the range of motion of the joint.Methods:according to Gu Yudong’s classification,this study collected 40 patients with moderate and severe cubital tunnel syndrome caused by elbow osteoarthritis from Cangzhou Hospital of integrated traditional Chinese and Western medicine in Hebei Province.Before operation,a personalized surgical guide was designed according to 3D printing technology,and a "test model" for the amount of bone removed was designed according to the cubital tunnel index.During the operation,hyperplastic osteophytes and lip edges were removed,and the "test model" was used to verify the degree of deepening and widening.After the cubital tunnel was formed,the joint capsule and soft tissue were sutured back,and the original position of the nerve was released and returned,so as to prolong the repair of the arcuate ligament.The patients were followed up for 12 months.The grip strength,three finger pinch force,lateral pinch force,two-point discrimination of ring little finger,nerve conduction velocity,VAS score and DASH score were compared before and after operation.Results:all patients did not have medial instability of elbow joint,elbow joint pain and flexor weakness,wound infection and nerve dislocation.The preoperative and postoperative comparison showed that the grip strength,three finger pinch force,lateral pinch force,two-point discrimination of ring little finger,nerve conduction velocity,VAS score and DASH score were significantly improved(P<0.05).Summary:the precise cubital tunnel plasty under the guidance of 3D printing combined with ulnar nerve release is effective in the treatment of moderate and severe cubital tunnel syndrome caused by elbow osteoarthritis,which does not affect the normal anatomical structure and walking position of ulnar nerve.It is suitable for clinical application.Part Two Precise shaping of ulnar nerve sulcus under the guidance of"cubital tunnel index" measured by color Doppler ultrasound diagnostic instrumentObjective:cubital tunnel plasty is an effective method for the treatment of moderate and severe cubital tunnel syndrome caused by elbow osteoarthritis.The purpose of this study is to measure the width and depth of the cubital tunnel of normal adult healthy volunteers by high-frequency ultrasound,and obtain the ratio of cubital tunnel index:depth/width,so as to guide the clinical accurate expansion of the ulnar nerve sulcus.Methods:200 normal adult healthy volunteers with an average age of 27.8 years(22-54 years)were recruited in this study,including 102 males and 98 females.The body mass index was in the normal range(BMI 18.5-28).The depth and width of the bony structure of the cubital tunnel covered by the arcuate ligament and the volume of the bony cubital tunnel were measured by the color Doppler ultrasound diagnostic instrument(acusons3000 Siemens),a senior technician in the ultrasonic imaging department of our hospital.The data are measured three times,and the average value is taken to calculate the elbow tube index,that is,the ratio of depth/width.The data collection personnel shall summarize and enter into the database,and the professional statisticians shall conduct data statistical analysis.result:From July 2021 to February 2022,with the consent of the ethics committee of Cangzhou Hospital of integrated traditional Chinese and Western medicine in Hebei Province,200 normal adult healthy volunteers were recruited,with an average age of 27.8 years(22-54 years),including 102 males and 98 females,and their body mass index was in the normal range(BMI 18.5-28).By measuring the depth and width of ulnar nerve sulcus in 200 healthy adults,the depth of cubital tunnel was(3.82±1.23)mm,the width of cubital tunnel was(14.21±1.72)mm,and the average cubital tunnel index was 0.27±0.07.There was no significant difference in the cubital tunnel index measured by gender factors and left and right limb factors,P>0.05.Summary:Among the five common compression around the elbow of the ulnar nerve,the cubital tunnel is the most common site of ulnar nerve entrapment.For patients with degenerative lesions of the elbow joint,osteophytes proliferating at the lip edge of the humeral ulnar joint of the medial olecranon muscle of the ulna protrude into the cubital tunnel,reducing the cubital tunnel volume and causing entrapment of the ulnar nerve on the way,At the same time,uneven and smooth bone bed will also cause friction and traction of ulnar nerve.Cubital tunnel augmentation plasty is to expand and deepen the proliferative narrow and shallow ulnar nerve groove,and then return the ulnar nerve to it,without damaging the blood supply of the ulnar nerve and changing the physiological structure and position of the ulnar nerve.However,the range of bone cutting is only based on feeling and lacks quantitative standards.In this study,color Doppler ultrasound was used to calculate the average cubital tunnel index by measuring the width and depth of the cubital tunnel of 200 healthy adult volunteers,which provided a quantitative standard for the expansion of elbow arthroplasty,and avoided the risk of instability of elbow joint,iatrogenic fracture and insufficient decompression caused by too much osteotomy.Part Three Data acquisition of cubital tunnel in normal adults by color Doppler ultrasound diagnostic instrumentObjective:There are differences in the cross-sectional area of each part of the ulnar nerve during the walking of the upper limb.At present,there is no corresponding reference value in China.The purpose of this study is to obtain the normal value of the cross-sectional area of the ulnar nerve by using color Doppler ultrasound diagnostic instrument,so as to provide reference for clinical practice.Methods:200 normal adult healthy volunteers with an average age of 27.8 years(22-54 years)were recruited in this study,including 102 males and 98 females.The body mass index was in the normal range(BMI 18.5-28).The color Doppler ultrasound diagnostic instrument(acusons3000 Siemens),a senior technician in the ultrasonic imaging department of our hospital,was used to measure the cross-sectional area of the ulnar nerve at the proximal end of the medial epicondyle of the humerus,the entrance of the cubital tunnel,the apex of the medial epicondyle of the humerus,the exit of the cubital tunnel and the muscle entry point of the ulnar nerve in the elbow extension position and extreme flexion position The number of ulnar nerve bundles and the volume change of cubital tunnel in these two postures.The data collection personnel shall summarize and enter into the database,and the professional statisticians shall conduct data statistical analysis.Results:When the elbow joint is straightened,all the ulnar nerves are in the ulnar nerve groove and pass through the superficial layer of the posterior medial collateral ligament of elbow pMCL.Under ultrasound,pMCL was shown as a fibrous bundle structure from the radial side of the bottom of the posterior condylar sulcus of the medial epicondyle of the humerus to the ulnar edge of the olecranon of the ulna.When the elbow joint was straightened,pMCL relaxed and spread on the bottom layer of ulnar nerve groove;When the elbow is flexing,the ligament is tense,which makes the ulnar nerve groove shallow.With the increase of elbow flexion,the ulnar nerve is farther and farther away from the base of elbow joint.Under ultrasound,the cross-sectional area of ulnar nerve showed sieve mesh hypoechoic image,the cross-sectional area was quasi circular,the cubital tunnel was quasi circular when the elbow joint was straightened,and the CSA of ulnar nerve accounted for 19.57%of the cubital tunnel volume;The cubital tunnel flattened when the elbow was bent extremely,and the CSA of ulnar nerve accounted for 36.0%of the cubital tunnel volume.When measuring the CSA of ulnar nerve at five common sites of ulnar nerve compression,it was found that the CSA of ulnar nerve when elbow joint was straightened were 0.09(0.03)cm2,0.09(0.03)cm2,0.08(0.02)cm2,0.05(0.00)cm2 and 0.08(0.03)cm2 respectively.Cubital tube volume:0.44(0.15)cm2.The CSA of ulnar nerve during extreme flexion of elbow joint were 0.09(0.03)cm2,0.09(0.03)cm2,0.07(0.03)cm2,0.06(0.02)cm2 and 0.08(0.03)cm2 respectively.Cubital tube volume:0.24(0.15)cm2.There was no difference in CSA of ulnar nerve(P>0.05),but there was significant difference in cubital tunnel volume(P<0.05).There was no significant difference in CSA of ulnar nerve between left and right limbs(P>0.05).Gender had no effect on CSA of ulnar nerve(P>0.05).The cubital tunnel retinaculum(CTR)starts from the medial side of the top of the medial epicondyle of the humerus and ends at the posterior medial side of the olecranon of the ulna.Its starting point and ending point are in the shallow layer of the starting and ending point of pmcl.When extending the elbow,the ligament is relaxed,and the maximum cubital tunnel volume is 0.44(0.15)cm2.When flexing,both ligaments are tense,and the minimum cubital tunnel volume is 0.24(0.15)cm2.This study found that 57/200 of the ulnar nerve had complete dislocation of the ulnar nerve in the cubital tunnel and subluxation of the ulnar nerve in 26 cases.The dislocation(subluxation)rate was 28.5%.In 31 volunteers with ulnar nerve dislocation,the presence of cubital tennel retinaculum(Osborne ligament)was not found by ultrasound,while it was unclear in patients with subluxation.When the elbow joint flexed,the ulnar nerve moved to the superficial layer due to the tension of pmcl.Without the cubital tunnel support belt,the ulnar nerve slipped to the surface of the anterior flexor tendon of the medial epicondyle of the humerus.However,there was no significant change in CSA before and after ulnar nerve dislocation.12 patients had the presence of epitrochleoanconeus muscle.Summary:1 The ulnar nerve can be touched near the elbow joint.There is a slight difference in nerve CSA at the five common compression sites,but there is no difference with limb side and gender.2 Posterior bundle of medial collateral ligament(pMCL)and cubital tunnel retinaculum(CTR)play a decisive role in the stability of ulnar nerve in cubital tunnel.When flexing the elbow,the two ligaments are tense and the ulnar nerve becomes flat,which may be the direct cause of ulnar nerve compression.3 The absence of CTR will cause dynamic subluxation or dislocation of the ulnar nerve.Due to the tension of pMCL during elbow flexion,the ulnar nerve is far away from the bottom of the cubital tunnel,and the absence of CTR restraint in the superficial layer of the ulnar nerve will cause the dislocation of the ulnar nerve.Ulnar nerve dislocation is not the direct cause of cubital tunnel syndrome,but repeated stimulation of the dislocated nerve by the medial epicondyle of humerus will cause cubital tunnel syndrome.4 The epitrochleoanconeus muscle exists in healthy people(6%),CTR is the residual part of the epitrochleoanconeus muscle,and the existence of the epitrochleoanconeus muscle will not affect the stability of the ulnar nerve.There is no statistical difference in the CSA comparison of the ulnar nerve between healthy volunteers with the superior trochlear elbow muscle and normal CTR structure(P>0.05). |
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