Left Elbow Exploration and Hardware Removal with Ulnar Nerve Decompression, Cubital Tunnel Release, and Anterior Subcutaneous Transposition of the Ulnar Nerve

CHAPTER 1

My name is Kiran Agarwal-Harding. I'm an orthopaedic trauma surgeon here at Beth Israel Deaconess Medical Center at Harvard. So today's case is a late 60's gentleman, 60-year-old gentleman, who had a fall and sustained an intra-articular distal humerus fracture about eight months ago. So he had open reduction internal fixation done with an olecranon osteotomy by one of my partners, and healed up very nicely, excellent range of motion, but did develop numbness and tingling in the fourth and fifth fingers, consistent with an ulnar neuropathy. So likely related to scarring and compression of the ulnar nerve at the elbow. Motor function was completely intact. So I elected to, basically, I offered to take him to the operating room to do an ulnar nerve exploration, decompression at the elbow, and anterior transposition to basically get it outta that bed of scar and into some virgin territory to keep it free and unkinked. Hopefully, that would make his symptoms a lot better. He also had a very large medial column plate with an additional extra screw on the medial side. So we discussed also removing that plate as well, just so that there wouldn't be so much hardware and scar on that side of the elbow that could potentially cause a recurrence of the ulnar neuropathy. So the steps of the procedure, you know, he had a prior posterior incision on the posterior aspect of the elbow. Rather than open up that same incision and dissect all the way across the soft tissues and create a very large soft tissue skin flap, I will take an approach that's medial to the elbow with an incision centered on the medial epicondyle, or just posterior to it. So we'll make that incision, this will all be done under tourniquet. We'll make an incision and start the dissection proximally dissecting down to identify the ulnar nerve. This is where it's much less likely to have a lot of scar tissue up proximally. Most of the dissection was done distally around the distal humerus. So that will be a place where we can reliably identify the nerve. We'll find it there at the medial aspect of the triceps tendon, and then we'll dissect it, taking care to protect the blood supply and the epineural, you know, tissue around the nerve. We'll dissect it distally, and, of course, we're gonna probably encounter quite a lot of scar around the elbow, but we'll continue through the cubital tunnel where from the prior operative note, I know that the nerve was just placed back there. It was in C2 decompression for the purposes of the distal humerus fracture. So we'll dissect it past the cubital tunnel and then all the way to the two heads of the flexor carpi ulnaris. There are usually two little motor branches coming off the nerve there, that is the furthest extent that we'll take the dissection. Mobilizing the nerve completely, that should allow us to transpose it anteriorly. We'll at that point take out the hardware. And then one method that I learned from one of my mentors, Melvin Rosenwasser at Columbia, was to create this adipofascial flap in the anterior subcutaneous tissues. And you basically take the fat directly off of the flexor pronator musculature and between that and the subcutaneous fat of the skin and you create a nice fold of tissue that you can then wrap around the nerve and keeping it in that subcutaneous position and nicely embedvded in fat so that it can glide smoothly and be protected and hopefully won't scar down again. So that's the procedure that we'll plan to do today.

CHAPTER 2

So usually, you have to go about eight centimeters above to get to the medial epicondyle - to the intermuscular septum. That's as high as up you need to go. Yeah. And then typically, four, eight, all the way up to here is usually is the furthest extent you would need to go. Yep. So if we straighten the arm out. You want 45, 45? Let's do it 15, 15. Okay. So just behind the medial epicondyle, so it's not like sitting right on the toughness of the sharp edge of the bone. Sorry for my multiple marks. I'll do that. So I chose not to use his old incision, you know, 'cause otherwise, we'll have to raise a really large skin flap. And all of our work is on this side, and if we're gonna anteriorly transpose it, it's an even bigger skin flap, you know? So that's why I chose to do it like this. May need to extend depending on how much scar we find here. It's quite a lot of scar actually. You can feel how much scar there is. Is this patient going home after this? Yes. Okay, tourniquet up please. All right. 250 for 60 minutes, inflating. All right, knife please.

CHAPTER 3

Thank you. Can you extend the elbow for me just a hair? Thank you. Oh. Guys, he's reacting a little bit to that. Better? Seems like it. Yeah. Great. Let's take a 15 blade next. Ohh, with the, Adsons yeah, thanks.

CHAPTER 4

Thank you. Dissecting scissors. Very little skin here. The nerve could be anywhere, you know? One second on that. Got two Senns? Sharp ones, please. Thank you. Maybe you can help us. Do you mind holding that? It's gonna be hard for Miles to do everything himself. All right, you got the scissors? Think I can feel the nerve there. You wanna feel that? Yeah, you feel it? You can probably get a self-retainer now. Come off this. So it's just already dense scar here. Can I get some Adsons that actually come together? These are a little bit bent. I think the nerve is gonna be right here somewhere. Knife, please. Let me see what we... Yeah, I'm not going to. I'm just gonna be ready. Yeah, because I don't wanna get a low number. You got a Jake? Thank you. See the nerve there? Right there. We got vessel loops? Look at this. See how tendonous it is there? Yeah. Kind of incredible, huh? Is..? That's the nerve right here, right? Yeah. And then that's the intermuscular septum. Kind of incredible, huh? Yeah. Do you want the blue vessel loops? Blue's fine, yeah. Any color really. As long as it's not yellow. That's usually hard to tell with the fat. This is fine what you gave me fine. Yeah, this is fine. Yeah. We'll take a few minutes before we take that. All right, let's turn like this. Knife, please. So I see the nerve there. It's safe to come through this stuff here. Just leave that there for me. Another thing we're gonna try to do is avoid stripping the blood supply from the nerve. And you can see I'm just being careful here to see if there's any of those little blood supply branching vessels in there. Knife down. And you see that beautiful vessel in there, right? Beautiful. I'll just take that up higher there.

CHAPTER 5

Knife back, please. Very stuck down here. So that's why you always start up here rather than trying to find it here, right? Yeah. 'Cause you're coming down here, like MABCN, you're just watching for it as you come? Yeah, I think generally, it's gonna be up here, you know? Yeah, that's why I'm just trying to dissect through these soft tissues as we go. Okay. You know? But I haven't seen any branches of it really. Yeah. But yeah, that's a really good point. Don't wanna cause a neuroma as you're trying to dissect out a nerve, you know? I like Jake 'cause it's got such a fine point, so you can kinda like really spread very precisely. Knife to Miles. Thank you. Great. Just hang on to that. Blood sugars are doing better now? It's 80. Yeah. Okay, that's great. Go ahead and cut that. Don't pass point. Can get that with the Bovie 'cause that's gonna bleed. Can I take the knife? Thanks. This is not a very glorious case to do as an assistant. Do you think you're gonna end up doing stuff like this? I'd say unlikely, but... Most I'll do on this side probably be like a mini open to, I used to do... Well, you'll do medial epicondyle fractures, yeah. A medial pen where... Yeah, for supracondylars. Yeah. Are you really good at supracondylars? Nah, I wouldn't say I'm really good at anything. Knife to Miles. Let someone else do it. Oh, come on. You're really good at a lot of stuff. Don't pass point, nerve's right underneath you. Good, good. Excellent. Nice. Now we're getting around the corner. I'm happy to hold. Yeah, actually, if you don't mind, that'll free up Miles's other hand. Let me know if I need to move, or... I think you're doing great. That's perfect. I'll let you know. Let's get a sharper 15 blade ready. And extend the elbow for us. There we go. That's it, perfect. We can dissect this soft tissue for the time being. Make sure we don't hit your MABCN. Kiran, you're doing something? So is he responding to that? He's responding to this, yes. Okay. Deeper. Was he moving or was that you moving? Yeah. No, he's moving a lot. He's moving a lot. Okay. So we're gonna just stop operating until he's more under anesthesia. I guess so, yeah. Just to stop him from wiggling? Yeah. Yeah, I guess so. There we go. There's a branch here I may be seeing. Yeah. I'm saying it for the camera 'cause I know you know. Tiny little branch there. We'll see if we can save it. All right. Well, we're getting there slowly. So what I'm gonna do here is just visualize a plate just so we know where that is. Nerve's down there obviously. All right, so we got plate there. You can take that knife back for a sec. All right. So we'll dissect there in a minute. You know, it's so interesting when I was in the UK when I did my traveling fellowship, like cubital tunnel releases is something, it's like a case that they give to a junior resident. Yeah. The attending just walks outta the room, and is like, "Okay, do the cubital tunnel release. I'll be back." I always thought that's so interesting 'cause when I was a resident here, like I never really did a cubital tunnel release without the attending nearby. UK though, like the definitions and years are very different too. Yeah, I guess so. Senior resident's like a PGY10 sometimes. Yeah. No kidding. It's kinda crazy, huh? Nice. Let's use scissors for this. Watch that nerve, yeah? Thanks, that's great. So now, we're through the worst of it there. Some pretty dense scar here. Yeah. Hmm. Hmm. Quite a bit of scar right there. There we go. Two heads of FCU now. Yeah, I see. We'll keep taking that. You got a little Senn? Just protect that nerve for me. Work on the other side of you. Yeah, good, thanks. What's our tourniquet time? 26 minutes. All right, great. Thank you. And these fibers usually just spread in line between the two heads. Don't need to cut anything. Don't wanna cause too much bleeding. Remember, we wanna come all the way out to here with the release so we can get a good transposition. You can come outta there, switch you. Oops, sorry. Switch you to over here, and just 'cause he's so - the fascia is so dense here, you know, I'm just gonna release it a little bit further. Worst thing you wanna do is create another point of compression, huh? Yeah. And usually, you'll see like a little branch of FCU somewhere. Yeah, you can relax there. That's a branch. This is where his compression is. Right here, you see how hyperemic it is? See that? Yeah. I wonder if any of this is gonna come up on the camera 'cause it's so tiny. There it is. Okay, now that's free. All right, now we gotta start moving it. So similar to how we did before. We'll start from the proximal and then start mobilizing it up towards the distal. I think we probably have to release this. You got a knife, please? Just gonna take another hair more incision up here.

CHAPTER 6

It's kinda crazy, huh? Army-Navy? Yeah, Army-Navy will be better. Can I have you hold this? Yes. Can I adjust here one sec? Yeah, that's it. There we go. So that feels more free now. Still a little band there. Reach in there. Feel that little band. Feel that? Yeah. So I think we'll need to take a little bit more skin. Knife, please. It's probably not affecting us much, but before I expose it, I just wanna get a little bit better skin exposure too. Yeah, I think that should be okay. All right, you got the vessel loops available, right? If we need them. Excellent. All right, I'll take one vessel loop. And we tie these, never snap them. Take a look at this. See that? It's blood supply running with a nerve. So we'll try to mobilize that with it. Got into it a little bit there. This to me seems like nothing. That's a nice-looking vein there. Let's trace this distally. Can we rotate the arm just a hair? There it is. Yep, thanks. That's the point of most compression right there. Obviously, right along here where all the scar is. You got a little Freer. Do I have it up? I do, thanks. And this may be foolish, but I think that it's worthwhile to try to mobilize this venae comitantes with a, you know, I think I see this little, you see that? It's like you can see this branching vessel coming off of this vein. Yeah. Onto here and giving blood supply. So I think it's worthwhile trying to mobilize this vein outta the cubital tunnel as well and just preserve that. It just is a little tedious 'cause they're very, very small. Very, very small here. There we go. Now we're starting to get our plane. All right, we will take another vessel loop in just a second. You know, what we can probably do is reuse this guy. Can I hand that back to you? Are you doing okay up there? Yeah. Yeah. Yeah, blood sugars are back up to normal. Okay, that's good. Quite hard to find a hypoglycemia protocol for like unless you search for something specific. But anyway, once it's up above 70, it then says to wait two hours before checking again, so... Okay. It should be in the clear. Okay, great. And he seems to be okay. He's tolerating everything? Yeah, I mean he needs a little bit of pheno now and again. Huh. Okay. Yeah. That's just the anesthetic... Look at this. You see this? A little branching thing to the triceps. Yeah. So if we do mobilize that, we'll have to take that branch. So let's get a little vessel loop around here. Vessel loop. Big vessels here, huh? It's got a lot of big veins. Got another vessel loop ready to go? Right here. Awesome. Okay, vessel loop. Can you extend the elbow a little bit for me? Thank you. So we will be taking hardware out. Okay. You wanna send it? No, no. No need to send anything. Okay. Unless there's a protocol for it or something, then I'm happy to, but I don't think so. No. I think that's the end of our plate there, huh? So the reason I'm doing this is just to find a plane so I can dissect distally, I mean posteriorly. I think this is the right medical plate. What's our tourniquet time? 55 minutes. Got another vessel loop? Go ahead, tie that, Miles. All right, we got a knife? All right, extend the elbow for me. Can you just hold that for me, Miles? Just like that. Yep, great. Just scar, scar, scar. All this is just scar. You see this? This white scar I'm just cutting? Can you add another 30 minutes of the tourniquet for us? Hold that for me too. Is this a fresh knife or no? It's the fresh one, but... It is? It might need to be refreshened. Yeah, probably. Huh? Yeah, this is super dull. Hold that one too. Thank you. You can let go of this one. Oh yeah, you can let go of this one now. A fresh 15. Thank you. Ah, so much better. Still kinked over here. We can let go of this guy. This thing. I think that's tendon. That's tendon, huh? Seems like it. Yeah. Yeah. Is that you wiggling or is that him? Okay. Yes. I apologize. No apology necessary. It's all good. Just wanna make sure I'm not getting him. Knife down for a second. Can you hold this for me, Miles? Just gently. And we'll see the sharp knife back again. Oh, thanks. We are so close. Almost free. Hold that for me again, Miles. A little lumen here. This is no regular cubital tunnel case, huh? This is. Yeah. Post-traumatic and postoperative, you know? I think we may have a little branch there, huh? Yeah. Feeding into... Yeah, probably into one of the heads of the FCU, yeah. Let's see if we can avoid it. Scar. Some more scar. So this is what it looks like when we don't transpose, huh? Yeah. Its kinda dramatic, huh? Yeah. Relax on there. Okay. I think we can probably just come through all this now. Do you mind just gently holding that for me, Miles? Thank you. There we go. All right, we're getting there slowly but surely. I was trying to protect this vein, but this vein just goes right into scar here, you know? Yeah. I don't think I'm gonna be able to get it. But I see little branches here, so I'm gonna try to preserve those and maybe just take the vein here. Flip part of it up over. Yeah, I think so. I'll try my best. I mean I think that we've preserved a nice blood supply to the nerve here, so I think it'll be okay. So I'm just gonna have to come through this unfortunately. And this one too. Just gently. Gently, yep, good. All right. We got the stuff for hardware removal up on the table, right? Yes. We believe it's gonna be this guy. Excellent. Gonna take that in just a minute. I think we may need to take this little guy here. Can you hold that again for me, Miles? Thank you. I'm just gonna take these down here. So that's nice and mobile now. We'll get that into a nice transposition. So let's get this plate out.

CHAPTER 7

How many screws we got to take out? There's four or five. Can you wiggle the screen again? Well five, I guess if we're taking out... Do you mind wiggling the camera? That's a good long screw. Yeah. Nice little Driscoll principle there. Yeah, exactly. What's our tourniquet time? 75. All right, we're gonna come down once we hit 90, okay? So this is a free screw. How many do we have distal? So including the free screw, there are four distal. Okay, so this is the third one, the one that's like way in the joint. And then how many do we have on the shaft? Two. Just two on the shaft. That's fourth. That should be the fourth one. We're gonna take 3-0 Monocryl and 4-0 Nylons. All right, let's get to the rest of the plate here. Army-Navy. Can I put you here? Got some little venous bleeder here. I think there's another screw in there. You think we're gonna get another screw there? Here is where I think they're gonna be. Right there. This one? Yep. That's our most distal one probably. Yeah, I think just the hole right above is probably... Screw driver. Got it. Show that to me. There she blows. How much more plate do we have to dissect out before we can mobilize it, do you think? It's up there, but maybe we'll just put a Freer under it. I don't know the amount of scar tissue this guy's forming, I'm worried. You can let the arm go. That's okay. We're done with the screwdrivers. This is coming... Is it coming? Oh yeah, it is. Here, let me just dissect this stuff off of the top. Can you get around it? Yeah. Nice. A little stuck on there pretty good. Some tissue on the back side of it. Yeah. There we go.

CHAPTER 8

All right, let's put the tourniquet down, please. Okay. So let's hold some pressure. Deflating tourniquet. Thank you. All right, 9:35. Thanks. What was our total tourniquet time? 83, I think. Okay, not bad. Let's hand some of these instruments back to you. So we'll just hold pressure for a minute or two. Not bad. Nerve looks great. Okay, I think we had a little bleeder here somewhere.

CHAPTER 9

So now, we're just gonna create the little pocket. Dissecting scissors. So he doesn't have like a huge amount of fat. Yeah. He's a pretty skinny guy. So we'll have to kinda just do a subcutaneous transposition with like a little bit of a sling. I'll try my best to put a little sling on it. You see any overt bleeders that we can get maybe over here somewhere? Yep, right there. Senn please, sharp Senn. All right, hold that there for me. Yep, like that. Thanks. So we'll try to see if we can preserve this MABCN branch that goes into this guy here, you know, and we'll just try to go underneath that. So just elevate this off of a scar here. I think we should probably excise some of this stuff too. This is that band, the intermuscular septum. So I think if we, let me adjust you. Thank you. Nerve is well behind me. So I think we should just excise this thing. There we go. That'll be much better. Create more of a pocket here. One more Senn. Thanks, and I'll take a sharp knife. You got that guy? Yeah. So I'm just trying to create a plane here, Miles, just above the scar. Got a little bleeder here somewhere. We are up and over the top now. That's actually quite a nice muscular layer, I mean a fatty layer. So let's see. I think we're good there too. There we go. That's nice. Yeah, so there we are. There it is. Okay, so that's released now. So I think we can probably resect a little bit more of this intermuscular septum so it doesn't cause any issues. Oh, we got some bleeder here. Fresh towel, please. All right, what do you think? Should we take a little bit more of this out? So are you going to..? Otherwise, you're gonna get in that pocket and... Yeah. Yeah, I'm just taking out some of this so it doesn't cause any issue in the future. Just intermuscular septum. Yeah. So this will come very nicely here, I think. You agree? Yep. All right. And then I think what we can do probably is elevate just a small subcutaneous little pocket here. Ah, but you wouldn't put it up just right in here. We'll wrap it in this fat. Oh, okay. Nerves like fat. So I think giving it like a little sling here with some fat will be good. Hold that up like that. Yep, you got it. So that's preserved blood supply to that, right? Then we can bring that as sort of like a little sling to protect it. That's the idea. Have you ever seen that before? Yeah, I think I've only seen one transposition in quite some time. This is a little bit of a different technique than we typically do. I learned this when I was in fellowship. So where's our little MABCN branch? There it is. Relax a little bit. We'll try to preserve that guy. So you sort of take, you need to stay, you need to leave enough fat subcutaneously so you don't devascularize it. We got a nice little vessel there that we don't wanna mess up. No branching vessels there. Good, okay. All right, relax there. Let's see what we can do with this thing now. I wonder if we've mobilized it enough. Probably not. Cool, all right, so we got plenty of blood supply still to the skin there. We got a nice little pocket of fat here that we can use, and then we can bring this up and over, and that'll create a nice little pocket. You see that? Let me see if we can just free that up a little bit more. Is that him kicking? Yeah. Yeah. Is he doing okay? Yeah. He's not moving on you? Nope. Starting to react a little bit? All right, relax. Relax, come outta those. Yep. Good. So that'll create a nice little pocket there. And then if he's fully extended, which he is there, no kinking, and then if he fully flexes, he's resisting me a little bit, no kinking there at all. Good. So that'll be it. All right, so let's take some irrigation. Let's get whatever little bleeding is going on here. Let's get a little basin, and we can cut these things out now, I think. More irrigation, please. A little bit more. Just keep it coming. I think we're good after this one. Should we hold a little bit more pressure? Yeah. I have one, two, three, four, five... This still seems a little kinked here, huh? Except for that one spot, I think it's really nicely freed. Wasn't there like a little branch of..? Yeah. The nerve somewhere there? We thought the branch was coming off. This just seems like a bunch of scar. Like it's so much there. Yeah. I mean usually, if you need to sacrifice one branch... Yeah. Without losing function. That's just scar, that's no branch. Can you dab there? I think we need to free that up just a hair more. You got that knife back? Yeah, that was good. Yeah. All right. All right, and fully extended. That seems okay. And that's nice and free up there. That's really nice. Okay, so we'll bring that up here and then we'll just pin that there. No compression there at all. Nice big pocket. All right, Monocryl. Thank you. No, it doesn't seem like it. Okay. For dressing, what would you like? For dressing? We'll do four-by-four Xeroform and ABD. All right. Do we got scissors? And I'll hand this snap back to you. All right, Miles, you wanna just run your pinky in there and just feel the nerve and make sure it's fine all the way? Yeah. Feels good? Oh, there we go. That was a bit aggressive. Does that feel good? Yeah, I mean that was good work. That's good. That's all I'm asking for. We have plenty of room there. Plenty of room. The nerve is free all the way up. Great. Excellent. I think that's very nice. So that'll hold it there. And then let's see if we can just do another stitch here maybe. Are you gonna need a sling? Yeah. And an eight? Yeah. Cool. But no splint. Okay. Hmm, I don't like that stitch. Let's get rid of that one. I think that's otherwise fine. Good. All right.

CHAPTER 10

One more splash irrigation. See any obvious bleeders, Miles? I don't think so. I think it's quite dry. No. All right. So we're closing now. Okay, thank you. Yeah. Yeah, of course. The other thing I'd like to do with the closure, you know, by putting the nerve up there, it's sort of away from your incision as well. So it's a little bit protected if ever there's any need to come back, which hopefully, there never will be. For the hand, are we using the mini C? Yeah. Okay. A little bit more Monocryl for me please. So you can feel that, Miles, like nice pocket of tissue there. Yeah. Nerve's protected. Yeah. All right. Nylons next, please. What do you think? Anything we could have done different? I don't think so. It was a 4-0? Yes. Do you have a little daintier needle driver? I don't. Really? Really. They don't have it in the normal... I'm looking at this guy's skin. These sutures are too small. Let's switch to a 3-0, please. Ah, this is just too tiny. It's just a little blood, huh? Like what, a hundred? Maybe 50, I'd say. Yeah. Do you wanna start sewing on one side too? Yep. Just, you know, don't take like huge scooping bites 'cause the nerve's pretty close, huh? Ooh, that was super short. You see how short you cut that? Yeah. Sorry. You're being careful not to go too deep and hit the nerve. Okay, thank you. You got another nylon? Yeah, we can call blood loss 100. I think that might be a little excessive, but... Yeah. You okay? Mm-hmm. We got three more stitches to throw and then we're all done. Okay. Any local in there? No local? Okay. No, we'll give him a block post-op once we check his nerve. Wet and a dry, please. Let's get something clean underneath the arm maybe. Some people do very small incisions. I don't know, I feel like it's better to get a good exposure, you know? We'll take a Kerlix as well. You got scissors maybe? We are all done with the case. Can you hold that for me? All right, we got that Kerlix? Yeah. Have you seen me do this before? Yeah. I just think that it makes it less likely to be cinched too tight. It's another trick I learned in fellowship. I think Flex-Master would be better. Miles, can you get this thing off too? Or here, you don't have the angle. Can you roll this up for me? Sure. Where's that black scissors? Great, thanks.

CHAPTER 11

All right, well, so the procedure went well, very much as expected, although a few anatomical variants that I think are noteworthy. So I started marking the medial epicondyle and then marked eight centimeters in both directions, sort of, as a rough template for what the extent of our dissection would be. We incised the skin and dissected through the subcutaneous tissues. We did identify a small branching nerve of the medial antebrachial cutaneous nerve, which we protected throughout the entire case. We began our deep dissection here proximally right at the edge of the triceps. We incised the fascia and immediately identified the nerve there in virgin territory without any scar tissue at all, dissected up so that it was nice and free in that medial arm tissue. The patient's intermuscular septum was actually really robust, very tendonous. So that was, I think, very noteworthy. But we continued, as described, the antegrade dissection of the nerve. Quite a lot of scar tissue here, but a really nice venae comitantes that we were able to preserve, giving some blood supply and with a nice epineurial tissue around the nerve so that we could see all the little branching vessels, knowing that the blood supply to the nerve was preserved. We were able to mobilize it through the very dense scar here and all the way to the two heads of the FCU. We did identify two separate motor branches to the two heads of the FCU there, and split the fascia so that we could get a nice mobilization of the nerve to bring it anteriorly along with that venae comitantes so that it could be mobilized with its blood supply preserved. That very, very tight band of intermuscular septum, we actually excised that taking out a whole section so that there wouldn't be a secondary point of compression. And then, of course, now we can totally mobilize our medial column. So, you know, we dissected the plate out and then took out the screws in the plate. So once that was all done, then we released the tourniquet. We dealt with all of our small bleeders, making sure that we have a clean hemostatic wound bed, and then we created that adipofascial flap in the front. So just, you know, preserving the fascia of the flexor pronator wad, we elevated the fat off of that, and then created a plane leaving enough subcutaneous fat to preserve the skin flap and preserving all the little branches of blood vessels that go into this nice adipofascial flap, nice thick flap. It's a pedicled flap essentially that we then can wrap around the nerve and then suture to that anterior skin flap in order to create a little pocket into which the nerve is sitting. We made sure with the elbow in full extension and with full flexion that there was no kinking of that nerve. It was gliding smoothly, I could insert my finger into that little tunnel we'd created and it was very free inside there. So once we sutured that flap down and made sure that the nerve was protected, then we washed out the wound and closed the skin and that was our procedure. Patient went into a soft dressing just with a very loosely placed ACE wrap, and he can continue to range his elbow so that he doesn't get stiff, especially after his prior injury.