• Tourniquet

• Blunt and sharp tendon strippers (if a gracilis autograft is needed)

• Metzenbaum scissors

• Sharp dissection scissors

• Bovie electrocautery

• Bipolar electrocautery

• Right-angle retractors

• Baby Hohmann retractors

• Vessel loops

• Key elevator

• One-fourth-in osteotome and/or small burr (if posteromedial olecranon osteophytes are present)

• Drills—3.5 mm (for palmaris autograft) and 4.0 mm (for gracilis autograft)

• Curettes—no. 1 and no. 2 curved and straight

• Mineral oil

• Hewson suture passer (Smith & Nephew)

• The patient is positioned supine on a standard operating table.

• The operative arm is placed on a hand table.

• A nonsterile tourniquet is placed as proximal on the operative extremity as possible.

• If a palmaris longus tendon autograft is to be harvested, we recommend marking out the course of the tendon preoperatively while the patient is able to perform active wrist flexion and opposition of the thumb and small finger.

• The elbow is flexed to 30-45 degrees while operating on the medial elbow.

• Surgical towels placed under the elbow and wrist permit an optimal degree of elevation for hand placement during dissection and drilling.

• If need for a gracilis autograft is anticipated, the contralateral lower extremity is prepared and draped.

• A large bump or triangle placed under the foot allows necessary flexion, external rotation, and abduction of the leg to perform dissection at popliteal fossa.

• Autograft Harvest

• The ipsilateral palmaris longus tendon is harvested using a three-incision technique (Fig. 23-1).¹,²

▪ Three separate 1-cm transverse incisions are made over the volar forearm: one just proximal to the wrist crease, a second 3-5 cm proximal to the first, and a third ˜15 cm proximal to the first.

▪ A hemostat is used to bluntly free up the tendon at each incision.

▪ A hemostat is placed deep to the tendon at each incision to ensure that the correct structure is being harvested, while the nearby flexor tendons and median nerve are protected.

▪ The wrist is flexed by an assistant while the tendon is transected at the distal incision.

▪ The hemostat is used to deliver the transected tendon out of the second incision.

▪ The end of the tendon is whipstitched using a size 0 absorbable braided suture.

▪ In-line traction is placed on the tendon, and its course proximally is confirmed with palpation.

• If there is any doubt regarding the location of the tendon proximally, the most proximal incision can be delayed until this time.

▪ The tendon is drawn out of the most proximal incision. Traction can be placed on the tendon, and muscle can be bluntly or sharply removed if additional tendon length is required.

• A minimal length of 15 cm is recommended.

▪ The tendon is transected at the proximal incision and taken to the back table, where the proximal end is whipstitched with size 0 absorbable braided suture.

• When necessary, the contralateral gracilis tendon is harvested through a minimally invasive posteromedial knee incision.³,⁴,⁵

▪ A 2- to 3-cm transverse incision is made at the medial aspect of the popliteal fossa, directly over the gracilis tendon.

▪ Dissection with Metzenbaum scissors is performed to identify and isolate the gracilis tendon.

▪ A loop of suture is placed around the gracilis tendon to enable traction and further local dissection of the tendon.

▪ An atraumatic tendon stripper is used proximally to bluntly separate the tendon from the muscle.

▪ A sharp tendon stripper is then passed over the tendon distally to free the tendon from its insertion at the pes anserinus.

▪ The tendon is taken to the back table for further preparation.

• Superficial Dissection

• A slight V-shaped, two-armed incision is made at the medial elbow, centered directly over the medial epicondyle and extending 3 cm proximal and 6 cm distal to the medial epicondyle (Fig. 23-2).

• The branches of the medial antebrachial cutaneous nerve (MABCN), which are variable in their course about the medial elbow⁶ (Fig. 23-3) are identified, mobilized, and protected.

▪ The most constant branch of the MABCN is often found in the distal aspect of the incision ˜3 cm distal to the medial epicondyle.

• Dissection of the branches of the MABCN must be carried as far proximal as the incision allows to ensure necessary mobility throughout the procedure.

• A vessel loop is placed around each branch of the MABCN to allow gentle mobilization throughout the procedure.

• Ulnar Nerve Release

• The ulnar nerve is released along its course from the arcade of Struthers proximally to its path between the two heads of the flexor carpi ulnaris (FCU) distally.

• It is safest to begin the dissection proximal to the Osborne ligament, where the nerve is more easily identified and mobilized.

• A vessel loop is placed around the nerve to allow gentle mobilization during further dissection.

• Care must be taken to identify and protect the first two branches of the ulnar nerve.⁷,⁸

▪ The first (posterior) branch typically arises just distal to the medial epicondyle.

▪ The second (anterior) branch typically arises where the nerve courses between the two heads of the FCU.

▪ Dissection along the medial, more superficial side of the ulnar nerve usually is safest and will help avoid iatrogenic injury to these branches.

▪ Thorough dissection of these branches is required to ensure safe mobilization of the ulnar nerve throughout the procedure.

• Distally, the ulnar nerve is released by splitting the superficial fascia of the FCU in line with its muscular fibers.

• A key elevator is used to split the flexor carpal ulnaris (FCU) muscle in line with its fibers, preferably along the raphe between the humeral and ulnar heads of the muscle.

• The deep FCU aponeurosis is a common site of unrecognized or residual nerve compression and should be completely released, distally, well under the muscle.

• The small vessels that travel with the nerve and course along the floor of the cubital tunnel are carefully cauterized to maintain hemostasis.

• Ulnar Nerve Transposition Sling

• With the ulnar nerve mobilized and retracted posteriorly, the medial intermuscular septum is easily identified.

• The medial intermuscular septum is bluntly separated from the triceps muscle and sharply divided at the most proximal aspect of the incision for a length of 4-5 cm.

• A no. 15 scalpel is used to separate a 3-5 mm wide strip of the distal intermuscular septum from the humerus (Fig. 23-4).

• The distal insertion into the superior aspect of the medial epicondyle is left intact.

▪ If the distal insertion is disrupted, it may be sutured back to the periosteum or fascia overlying the flexor-pronator mass.

• Several small vessels run along the septum and often require use of electrocautery for hemostasis.