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Ulnar nerve transposition using a mini-invasive approach: Case series of 30 patients
Abstract
The treatment of ulnar nerve compression at the elbow remains controversial. No single technique has yet proven its superiority. We describe a technique combining the advantages of the mini-invasive approach with those of transposition. We present the results of 30 patients, of mean age 52 years, who underwent anterior subcutaneous transposition of the ulnar nerve using a mini-invasive approach with a follow-up of more than six months. The incision measures 3 cm. The results were evaluated by measuring pain intensity, quick disabilities of the arm shoulder and hand (DASH), grip strength and pinch, and McGowan score, pre- and post-operatively. All parameters were improved post-operative. The mean pain score went from 5.5 to 4, the quick DASH from 48 to 38, mean grip strength from 28 to 31 kg, and mean pinch strength from 4.7 to 6.4 kg. The McGowan score was also improved; pre-operatively, there were 16 patients at stage III, seven patients stage II, seven patients stage I, and post-operatively there was one patient stage III, three patients stage II, 16 patients stage I, and 10 patients stage 0. Analysis of our series shows that a 3 cm incision without endoscopy allows subcutanous transposition, with results at least as good as those with other techniques. The advantages of our technique are that it is easy, has a limited approach, preserves blood supply, allows placement of the nerve in a favourable environment, and decreases nerve stretching during elbow flexion.
... Both 6-and 9-month postoperative pain scores were significantly lower in our cohort than those reported in the literature for similar procedures (Table 2). [62][63][64] In addition, Welch's t-tests revealed that our 6-and 9-month SF-36 pain scores were significantly improved compared to similar injury patterns that did not undergo surgical intervention (Table 6). 25 Sensory recovery in our cohort compared favorably with a 2007 study that included eight partially transected median nerves. ...
... The mean 9-month DASH score in our cohort was 22.9 (n = 8, range: 5.0-62.5). While it is difficult to match cohort demographics with published reports, our final scores and mean improvement compared favorably to similar nerve procedures in the literature [62][63][64]67 (Tables 5 and 6). Novak et al. 25 also reported DASH scores and found a mean score of 52 ± 22 in untreated injuries, which was 29.1 points higher (p-value: 0.002) than 9-month QuickDASH scores in our cohort ( Table 6). ...
Background
Treatment of patients with traumatic axonotmesis presents challenges. Processed human umbilical cord membrane has been recently developed with improved handling and resorption time compared to other amniotic membrane wraps, and may be beneficial in nerve reconstruction. This study evaluates postoperative outcomes after traumatic peripheral nerve injury after placement of commercially available processed human umbilical cord membrane.
Methods
We performed a prospective, single-center pilot study of patients undergoing multi-level surgical reconstruction for exposed, non-transected peripheral nerve. Functional outcomes including pain, range of motion, pinch and grip strength, and the QuickDASH and SF-36 patient-reported outcome measures were recorded, when possible, at the 1-week and 3, 6, and 9 months postop visit. One-tailed paired t-tests were performed to evaluate outcome improvement at final follow-up.
Results
Twenty patients had processed human umbilical cord membrane placement without surgical complications. Mean follow-up was 7.5 months (range: 3–10 months) and mean age was 39 years (range: 15–65). Twelve (67%) patients were male, and the majority of placement sites were in the upper extremity (85%). Mean preoperative visual analog scale pain score was significantly reduced at most recent follow-up, as were QuickDASH scores. All patients had improved functional outcomes at the 9-month follow-up, and SF-36 outcomes at 9 months showed improvement across all dimensions.
Conclusion
This study indicates that processed human umbilical cord membrane may be a useful adjunct in nerve surgery with noted improvements in postoperative function, pain, and patient-reported outcome measures. Future studies are needed to assess long-term outcomes after traumatic nerve injury treated with processed human umbilical cord membrane.
... This is in agreement with the results given by Thomsen et al. [29] and Vanderpool et al. [30]. On the other hand, few similar studies have reported a male predominance [31]. ...
... However at 6 months interval, the NCVs improved in 70% of cases in the group A and 60% of cases in group B. This relation was found to have no statistically significant difference between both modalities. This is in accordance with several series which found a significant improvement in the postoperative transelbow NCVs studies compared to the preoperative values; however there was no significant difference between both types of surgery [25,31]. They concluded that electrophysiological values help predict the functional outcome of surgery. ...
... Подкожную транспозицию локтевого нерва на переднюю поверхность локтевого сустава выполняют при оперативных вмешательствах по поводу синдрома кубитального канала и его рецидива, при рецидивирующем вывихе-подвывихе локтевого нерва, для ликвидации диастаза локтевого нерва при его сшивании [1,2,3,4,5]. Для того, чтобы локтевой нерв после подкожной передней транспозиции не вывихивался в область локтевой борозды, его фиксируют различными способами [6,7]. Нами предложен и используется способ фиксации локтевого нерва, который заключается в создании кожно-подкожно-фасциального блока-рубца [8]. ...
... Этот же способ используют также при лечении рецидивирующего вывиха-подвывиха локтевого нерва и для устранения значительного диастаза при сшивании поврежденного локтевого нерва. С целью предупреждения вывихивания после передней подкожной транспозиции локтевой нерв фиксируют в перемещенном положении адипозными, фасциальными лоскутами-блоками [3,7,9]. Мы разработали и используем способ фиксации перемещенного нерва [8]. ...
Objectives. To confirm the absence of dislocation of the ulnar nerve after its anterior subcutaneous transposition. Methods. Diagnostic ultrasonographic examination of the ulnar nerve after subcutaneous anterior transposition in patients (n=9) had been carried out. There were 4 females and 5 males in the studied group; the average age was 42 years (ranging 25-59 years). The transposition of the ulnar nerve was performed on one right and on eight left upper extremities: in 8 patients with cubital tunnel syndrome and in 1 with old injury of the ulnar nerve. Ultrasonography was performed in all patients after 16 months in average (from 6 to 25) after surgery. For prevention of dislocation of the ulnar nerve after its subcutaneous transposition the method of fixation of the ulnar nerve had been worked out. The longitudinal undulating incision with length of 12-14 cm was performed. The top of one of the "waves" section should be turned laterally and placed 1,5-2 cm laterally from the apex of the medial epicondyle of the humerus. After transposition of the nerve in the forearm fascia in the longitudinal direction C-shaped incision that form and location coincides with the peak of the "waves" of skin incision was carried out. In the area of the top "waves" 3-4 vertical mattress skin-subcutaneous-fascial sutures had been imposed. Diagnostic ultrasonographic examination was performed on an ultrasound diagnostic apparatus Philips HD7 (Austria) with the using of a L 12-3 MHz linear array transducer. Results. The analysis of transverse and longitudinal ultrasound scannings in all operated patients (n=9) in extension, flexion and upon attempt of forcible displacement of the ulnar nerve the skin-subcutaneous-fascial block scar reliably held the ulnar nerve in the anterior subcutaneous transposition. Conclusion. Ultrasonographic examination permits to confirm objectively the absence of dislocation of the ulnar nerve after anterior subcutaneous transposition.
... The incision length is comparable to the traditional open in situ decompression procedure, although some centers perform nerve transposition surgery with a minimally invasive approach (incision length of about 3 cm). Studies on a limited number of patients did not show a significant difference in the outcomes of procedures performed using the minimally invasive technique compared to the traditional access [34]. After making an incision in the skin, dissecting the underlying tissues, cutting the roof of the cubital tunnel, and exposing the ulnar nerve, it is completely separated from its base, allowing for its relocation. ...
Cubital tunnel syndrome (CuTS) is one of the most common neuropathies of the upper extremity. This condition, if left untreated, can significantly impact patients' everyday functioning and quality of life. Diagnosis of CuTS is mostly based on clinical evaluation but can be supplemented by electrodiagnostic studies, and various imaging techniques. Conservative treatments such as physical therapy, splinting, and anti-inflammatory medications are often first-line interventions. However, surgical approach may become necessary when conservative measures fail to provide relief or in cases of severe compression. There are numerous surgical approaches to treating CuTS and there is no clear consensus on one best method. Simple decompression of the ulnar nerve and its subcutaneous transposition are the most popular surgical techniques employed. Each method has its advantages and drawbacks, with varying implications for nerve recovery and postoperative complications. This review aims to provide a comprehensive overview of CuTS, while focusing on available surgical treatment approaches, their popularity and outcomes. Further research is warranted to refine surgical techniques and develop more effective interventions for this debilitating condition.
... Page 2 of 7 Sprangers and van der Heijden BMC Musculoskeletal Disorders (2023) 24:137 as to what constitutes the superior surgical approach [3][4][5]. ...
Background
Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Surgical decompression of the ulnar nerve aims to improve complaints and prevent permanent damage to the nerve. Open and endoscopic release of the cubital tunnel are both used in common practice, but none has proven to be superior. This study assesses patient reported outcome and experience measures (PROMs and PREMs respectively), in addition to objective outcomes of both techniques.
Methods
A prospective single-center open randomized non-inferiority trial will take place at the Plastic Surgery Department in the Jeroen Bosch Hospital, the Netherlands. 160 patients with cubital tunnel syndrome will be included. Patients are allocated to endoscopic or open cubital tunnel release by randomization. The surgeon and patients are not blinded for treatment allocation. The follow-up time will take 18 months.
Discussion
Currently, the choice for one of the methods is based on surgeon’s preferences and degree of familiarity with a particular technique. It is assumed that the open technique is easier, faster and cheaper. The endoscopic release, however, has better exposure of the nerve and reduces the chance of damaging the nerve and might decrease scar discomfort. PROMs and PREMs have proven potential to improve the quality of care. Better health care experiences are associated with better clinical outcome in self-reported post-surgical questionnaires. Combining subjective measures with objective outcomes, efficacy, patient treatment experience and safety profile could help differentiating between open and endoscopic cubital tunnel release. This could aid clinicians in evidence based choices towards the best surgical approach in patients with cubital tunnel syndrome.
Trial registration
This study is registered prospectively with the Dutch Trial Registration under NL9556. Universal Trial Number (WHO-UTN) U1111-1267–3059. Registration date 26–06-2021. The URL: https://www.trialregister.nl/trial/9556
... [16][17][18][19] Peripheral nerve injuries are known to result in poor sensory and/ or motor function if left untreated. 8,20 Significant declines in postoperative function and chronic pain may lead to long-term disabilities for patients who do not receive timely operative treatment [21][22][23][24][25][26] (Table 5). This could impact more than patient outcomes, as both proximal and distal nerve injuries may contribute to high costs, lost work or medical disabilities, increased pharmacologic dependencies and expenses, and substantial lost function. ...
Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.
... ulnar nerve anterior subcutaneous transposition, anterior submuscular, and intramuscular transposition [8][9][10]. Interestingly, decreasing the incision length to 3 cm still bears the risk of medial antebrachial cutaneous nerve (MACN) injury [11] even though some authors have advocate the safety of mini-invasive incision [12]. ...
Introduction
Medial skin incision is obligatory for ulnar nerve transposition in cubital tunnel syndrome. However, inadvertent surgical damage to the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) has been a concern in the current surgical approach.
Hypothesis
We hypothesized a modified curved skin incision to avoid the damage to the medial cutaneous nerve.
Materials and methods
The numbers and locations of MACN and MBCN terminal branches were investigated; also, the location of the posterior branch of MACN in ten fresh frozen cadaveric upper extremities. Using modified incision which is more anterior than classic approach and includes antegrade dissection of the cutaneous branches, same measurement was performed in clinical cases. We described the techniques.
Results
The average number of MACN posterior terminal branches was 2.6 ± 1.6 and 4.4 ± 2.4 branches in the cadaveric specimens and clinical cases, respectively. The average number of MBCN terminal branches was 2.1 ± 0.87 branches. The MACN posterior terminal branches were located at an average of 19 mm proximal and 45 mm distal from the medial epicondyle. In clinical cases, we could preserve all MBCN terminal branches and posterior terminal branches of MACN using the indexed skin incision.
Discussion
Our modified medial skin incision technique with antegrade subcutaneous dissection exposed all the terminal branches of MACN and thus, could reduce the risk of inadvertent injury. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN.
Level of proof
IV, Cadaveric and Therapeutic study.
... The mini-invasive approach has becoming a trend in the aim to preserve blood supply therefore preventing the perineural fibrosis. A case series of 30 patients with mini-invasive ulnar nerve transposition resulted in excellent outcome for primary cubital tunnel syndrome surgery [22]. ...
Background:
Indications for revision surgery are unclear in refractory cubital tunnel syndrome patients, and the optimal surgical method has not been determined. The systematic review evaluates the evidence of functional outcome for revision surgery in refractory cubital tunnel syndrome patients.
Hypothesis:
We hypothesize that functional outcome of revision surgery in refractory cubital tunnel syndrome will be favorable.
Methods:
We searched PubMed, Ovid/MEDLINE, Cochrane, Google Scholar, and EMBASE databases using the keywords "cubital tunnel syndrome" or "recurrent cubital tunnel syndrome" and "revision surgery" according to the MeSH index for English-language studies. We performed a systematic review using PRISMA guidelines. The review was registered in PROSPERO (CRD42018096622).
Results:
Based on the Oxford Centre for Evidence-Based Medicine criteria, one level 3b study and nine level 4 studies were identified, including 195 elbows of 192 patients aged 15-75 years. The remission period for recurrent cubital tunnel syndrome was 6-21 months, and the follow-up period was 6-113 months. Transposition surgery was the primary surgery in 99 (51%) of 178 elbows. The most common intraoperative finding at revision surgery was perineural scarring (79%), with the most frequent entrapment site being the medial intermuscular septum (33%). The most common revision surgery was submuscular transposition of the ulnar nerve (75%). Most studies reported favorable outcomes, although outcomes varied widely among studies.
Conclusion:
This is the first study to summarize the functional outcomes of revision surgery for refractory cubital tunnel syndrome which showed to be favorable. Functional outcomes were averagely reported and varied widely. A consensus regarding the functional outcomes parameter after surgery for cubital tunnel syndrome is urgently needed.
Level of evidence:
III, systematic review.
... The handling of the nerve and surrounding tissue dissection is kept to a minimum (Karthik et al., 2012). Recent articles by Lequint et al. (2013) and Konishiike et al. (2011) describe the advantages of a minimal invasive open approach without and with endoscopic assistance, respectively. In their studies they also transpose the nerve, which we believe unnecessarily reduces blood supply to the nerve (however they claim not to) and creates a larger wound surface. ...
Both open and endoscopic methods for ulnar nerve decompression have been described. The purpose of this study is to compare the 6-month results of a minimal invasive open technique with an endoscopic technique. We treated 60 patients with unilateral ulnar neuropathy at the elbow, employing both techniques. Six months postoperative we found no differences in treatment effect on pain and disability scores between both groups, but both techniques resulted in an early postoperative relief of symptoms and good patient satisfaction.
Wide-Awake Local Anesthesia No Tourniquet (WALANT) has expanded its applications over the past decade from common hand procedures to a broader range of more complex surgeries. However, despite its frequent use, there is limited literature on WALANT for cubital tunnel syndrome. We have adapted the endoscopic technique reported by other colleagues to a mini-open approach. This approach is characterized by a smaller incision while preserving its blood supply. Our objective is to describe this two-stage local anesthetic injection method that has enabled us to safely and successfully treat 16 patients without complications.
We conducted a retrospective cohort study. Sixteen patients meeting specific inclusion criteria underwent ulnar nerve decompression under WALANT. Patients were preoperatively classified according to Dellon’s classification. Surgical technique included a staged local anesthetic solution infiltration and careful dissection to preserve nerve stability.
Preoperative classification revealed six mild, six moderate, and four severe cases. Intraoperative discomfort was reported by four patients before incorporating a second stage of distal local anesthetic infiltration. All patients exhibited stable intraoperative ulnar nerve positioning and were discharged independently 20 min post-surgery. Follow-up at an average of 12 weeks (range 10 -18 weeks) showed symptom resolution in all patients. No complications, including iatrogenic injury to medial antebrachial cutaneous nerve branches, were reported.
This study demonstrates the feasibility and effectiveness of the WALANT technique for ulnar nerve decompression at the elbow. Incorporating a staged local anesthetic infiltration enhances patient comfort.
Hypothesis:
Outcomes reporting for the surgical release of ulnar nerve cubital tunnel entrapment have variability in subjective, objective, and validated measures. The aim of this study is to review the literature to reassess the measures used to report surgical outcomes for ulnar neurolysis at the elbow.
Methods:
This study was conducted in accordance with the PRISMA guidelines on systematic reviews. Six electronic databases were queried from the past 10 years using specific search terms and Boolean operators. Two independent reviewers assessed 4290 unique titles and abstracts that were screened for inclusion criteria. Sixty-eight full text articles were included for analysis.
Results:
Statistical significance was noted in the number of outcome measures reported between studies from journals of impact factor within the first and third quartiles (P = 0.0086) and first and fourth quartiles (P = 0.0247), although no significance exists in the number of cubital tunnel-specific measures based on impact factor (P = 0.0783). Seventy-nine percent (n = 54) of the included studies report subjective measures; 54% (n = 37) included objective measures. Seventy percent (n = 48) of the studies report disease-specific outcome measures.
Conclusion:
There exists a discordance within the literature regarding the most appropriate, descriptive, and translational measures for reporting surgical outcomes of cubital tunnel syndrome. We recommend journal editors implement a requirement that authors reporting outcomes of ulnar nerve decompression must use a standard, validated measure to make comparisons across the literature universal. Furthermore, a minimum of at least 1 subjective and 1 objective measure should be standard.
Purpose
Comparison between studies assessing outcomes after surgical treatment of cubital tunnel syndrome (CuTS) has proven to be difficult owing to variations in outcome reporting. This study aimed to identify outcomes and outcome measures used to evaluate postoperative results for CuTS.
Methods
We performed computerized database searches of MEDLINE and EMBASE. Studies with 20 or more patients aged 18 and older who were undergoing medial epicondylectomy, endoscopic decompression, open simple decompression, or decompression with subcutaneous, submuscular, or intramuscular transposition for ulnar neuropathy at the elbow were included. Outcomes and outcome measures were extracted and tabulated.
Results
Of the 101 studies included, 45 unique outcomes and 31 postoperative outcome measures were identified. These included 7 condition-specific, clinician-reported instruments; 4 condition-specific, clinician-reported instruments; 8 patient-reported, generic instruments; 11 clinician-generated instruments; and one utility measure. Outcome measures were divided into 6 unique domains. Overall, 60% of studies used condition-specific outcome measures. The frequency of any condition-specific outcome measure ranged from 1% to 37% of included studies.
Conclusions
There is marked heterogeneity in outcomes and outcome measures used to assess CuTS. A standardized core outcome set is needed to compare results of various techniques of cubital tunnel decompression.
Clinical relevance
This study builds on the existing literature to support the notion that there is marked heterogeneity in outcomes and outcome measures used to assess CuTS. The authors believe that a future standardized set of core outcomes is needed to limit heterogeneity among studies assessing postoperative outcomes in CuTS to compare these interventions more easily and pool results in the form of systematic reviews and meta-analyses.
Background:
Cubital tunnel syndrome is the second most common peripheral entrapment syndrome. To date, there is no true consensus on the ideal surgical management. A minimally invasive, endoscopic approach has gained popularity but has not been adequately compared to the more traditional, open approach.
Methods:
With compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies published between 1990 and 2016 that compared the efficacy of endoscopic cubital tunnel release to open cubital tunnel release. A meta-analysis was then performed through a random-effects model with inverse variance weighting to calculate I values for heterogeneity analysis. Forest plots were constructed for each analysis group.
Results:
Five studies involving 655 patients (endoscopic cubital tunnel release, n = 226; open cubital tunnel release, n = 429) were included. Meta-analysis revealed no significant superiority of open release in achieving an "excellent" or "good" Bishop score (OR, 1.27; 95 percent CI, 0.59 to 2.75; p = 0.54) and reduction in visual analogue scale score (mean difference, -0.41; 95 percent CI, -1.49 to 0.67; p = 0.46). However, in the endoscopic release cohort, lower rates of new-onset scar tenderness/elbow pain were found (OR, 0.19; 95 percent CI, 0.07 to 0.53; p = 0.002), but there was a higher incidence of postoperative hematomas (OR, 5.70; 95 percent CI, 1.20 to 27.03; p = 0.03). The reoperation rate in the endoscopic and open release groups was 4.9 and 4.1 percent, respectively (p = 0.90).
Conclusions:
The authors demonstrated equivalent overall clinical improvement between endoscopic and open cubital tunnel release in terms of Bishop score and visual analogue scale score reduction. Because of the low power of most studies, further investigations with a larger patient population and longer follow-up are needed to better characterize the role of endoscopic cubital tunnel release.
Neuropathies of the elbow
are a common cause of pain and disability. When conservative treatment fails, surgical treatments have been designed to alleviate compression, decrease tension, or both. Traditional surgical approaches provide extensile exposure to provide access to constricting anatomy, while preventing injury to vulnerable anatomy. Minimally invasive techniques attempt to provide the same efficacy while minimizing complications, pain, and surgical trauma to the nerve and expediting recovery through smaller skin incisions [1]. The ulnar nerve is the most commonly affected nerve at the elbow; to a lesser degree the radial nerve can be impacted. For most ulnar pathology, an in situ decompression may be adequate to treat the patient’s symptoms. If there is an associated instability of the nerve, or if the decompression leads to instability, the surgeon may opt to transpose the nerve. Furthermore, in cases of capsular releases with large gains in motion, it may be beneficial to either decompress or transpose the nerve to avoid an ulnar nerve palsy. Multiple techniques have been described to treat these conditions; what is paramount is a careful understanding of the anatomy in question.
Importance
Cubital tunnel syndrome is the second most common peripheral nerve compression syndrome in the USA. There is controversy in the literature regarding the best surgical option.
Objective
The purpose of this investigation was to perform a systematic review to determine if there is a difference in clinical outcomes or complications between open and endoscopic cubital tunnel release in patients with compression of the ulnar nerve in the cubital tunnel.
Evidence review
A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS and Cochrane Central Register of Controlled Trials databases were searched for level I–IV therapeutic comparative studies of open versus endoscopic cubital tunnel decompression in adult human patients. The levels of evidence were then assigned based on the Oxford Centre for Evidence-Based Medicine. Study methodological quality was analysed using the Modified Coleman Methodology Score. Only the outcome measurements that 3 or more studies used were included in our data synthesis. Postoperative patient satisfaction, Bishop score, recurrence and complication rates were compared between the endoscopic and open groups using the χ² test using p<0.05.
Findings
Six articles (507 patients, mean age of 48.2 years, with 28.8 months average follow-up) were analysed. 76.1% of patients were satisfied in the endoscopic group, and 73.8% were satisfied in the open group (p=0.7023). 87.4% of endoscopic patients and 81.2% of open patients had a Bishop score of excellent or good (p=0.236). The endoscopic group had a recurrence rate of 1.1%, and the open group had a 3.5% recurrence rate (p=0.0872). There were significantly fewer complications in the endoscopic group (7.9%) compared to the open group (12.9%) (p<0.01).
Conclusions and relevance
Equivalent clinical outcomes, patient satisfaction and recurrence rates were observed between open and endoscopic techniques. However, a significantly lower complication rate was observed with the endoscopic technique.
Level of evidence
Level IV, systematic review of level I–IV studies.
Neuropathies of the elbow
are a common cause of pain and disability. When conservative treatment fails, surgical treatments have been designed to alleviate compression, decrease tension, or both. Traditional surgical approaches provide extensile exposure to provide access to constricting anatomy, while preventing injury to vulnerable anatomy. Minimally invasive techniques attempt to provide the same efficacy while minimizing complications, pain, and surgical trauma to the nerve and expediting recovery through smaller skin incisions [1]. The ulnar nerve is the most commonly affected nerve at the elbow; to a lesser degree the radial nerve can be impacted. For most ulnar pathology, an in situ decompression may be adequate to treat the patient’s symptoms. If there is an associated instability of the nerve, or if the decompression leads to instability, the surgeon may opt to transpose the nerve. Furthermore, in cases of capsular releases with large gains in motion, it may be beneficial to either decompress or transpose the nerve to avoid an ulnar nerve palsy. Multiple techniques have been described to treat these conditions; what is paramount is a careful understanding of the anatomy in question.
Purpose
To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.
Methods
A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included “DASH” and “hand” and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.
Results
Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29–93) and scapholunate advance collapse (range, 17–89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.
Conclusions
Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.
Type of study/level of evidence
Therapeutic III.
This review discusses key diagnostic points and treatment guidelines for compression neuropathies of the wrist, forearm, and elbow. Recent treatment progress is reviewed, controversies are highlighted, and consensus is summarized. Limited or mini-open releases and endoscopic carpal tunnel releases are considered equally safe and efficient. Both methods are currently mainstays of surgical treatment.
The carpal tunnel syndrome is the most common entrapment syndrome of the upper limb. Compression of the median nerve is most often idiopathic and typically occurs in women aged 50. The diagnosis is clinical and must look for signs of gravity (hypoesthesia, thenar atrophy). The electromyogram is not required but recommended for surgical indication, It assesses the severity of the disease and identifies other injury. Conservative treatment is available in the beginner to moderate forms. In case of failure of this treatment or with severe objective signs, treatment is surgical. The ulnar nerve at the elbow comes in the second position of the upper limb entrapment syndromes. Clinical examination looks for signs of serious problems with objectives symptoms. Treatment is usually surgical.
Simple decompression of the ulnar nerve at the elbow has not been shown to reduce nerve strain in cadavers. In this study, ulnar nerve strain at the elbow was measured intraoperatively in 11 patients with cubital tunnel syndrome, before and after simple decompression. Statistical analysis was performed using a paired Student's t-test. Mean ulnar nerve strain before and after simple decompression was 30.5% (range 9% to 69%) and 5.5% (range -2% to 11%), respectively; this difference was statistically significant (p < 0.01) with a statistical power of 96%. Simple decompression reduced ulnar nerve strain in all patients by an average of 24.5%. Our results suggest that the pathophysiology of cubital tunnel syndrome may be multifactorial, being neither a simple compression neuropathy nor a simple traction neuropathy, and simple decompression may be a favourable surgical procedure for cubital tunnel syndrome in terms of decompression and reduction of strain in the ulnar nerve.
The application of telerobotics in the biomedical field has grown rapidly and is showing very promising results. Robotically
assisted microsurgery and nerve manipulation are some of its latest innovations. The purpose of this article is to update
the community of shoulder and elbow surgeons on that field. Simple anterior subcutaneous translocation of the ulnar nerve
was first experimented in two cadavers, and then performed in one live patient who presented with cubital tunnel syndrome.
This procedure is the first reported case using the robot in elbow surgery. In this paper we attempt to analyze various aspects
related to human versus robotically assisted surgery.
KeywordsTelesurgery–Robotic surgery–Cubital tunnel–Ulnar nerve
We report on a technique of endoscopic release of the cubital tunnel, which is a modification of Bruno and Tsai's technique. This article covers the history, complications, indications, and postoperative management of ulnar nerve entrapments treated endoscopically, with a special focus on our technique. This minimally invasive alternative to transposition requires no mobilization of the ulnar nerve, which could potentially reduce iatrogenic trauma to the nerve and its vascularity. (J Hand Surg 2011;36A:147-151. Copyright (C) 2011 by the American Society for Surgery of the Hand. All rights reserved.)
The purpose of this study was to assess subjective and objective outcomes in treating recurrent cubital tunnel at secondary neurolysis by nerve wrapping with a tissue engineered three-dimensional biomatrix. Five patients with a mean age of 44.1 years and an average follow-up of 13.3 months were included in the study. All patients had improvement in visual analogue scales. Four patients that had preoperative intrinsic atrophy with clawing had no clawing or intrinsic atrophy at final follow-up. Postoperatively, four of the five patients had two-point discrimination of 5 mm. Grip strength on average increased 90%. Three patients had an excellent outcome, one patient had a good outcome, and one patient had a fair outcome. All five patients said they would have surgery again.
We treated 20 patients with cubital tunnel syndrome by anterior transposition of the ulnar nerve with endoscopic assistance. Five elbows were classified preoperatively as McGowan's stage 1, 11 as stage 2 and four as stage 3. Excellent outcomes were obtained in nine and good in eight patients. Three patients had fair results. Improvement of symptoms occurred in all patients. There were no serious complications. All ulnar nerves remained anteriorly transposed.
The optimal surgical treatment for cubital tunnel syndrome remains unclear. We aim to evaluate the long-term outcome of surgical treatment by comparing the results of the different methods proposed.
We retrospectively reviewed 113 patients in whom 3 different surgical methods were used for cubital tunnel syndrome treatment. In situ decompression, partial epicondylectomy, and anterior subcutaneous transposition were performed from 1997 to 2007.
Results were graded as excellent in 51 patients (45%), good in 34 (30%), fair in 8 (7%), and poor in 20 (18%). When we compared the results among the different surgical procedures, good and excellent results were achieved in 26 of 31 patients (84%) treated with in situ decompression, 36 of 45 (80%) treated with release and partial medial epicondylectomy, and 23 of 37 (62%) treated with release and anterior subcutaneous transposition of the nerve.
Our results indicate that in situ decompression and partial epicondylectomy both represent efficient and safe methods for cubital tunnel syndrome management. In patients in whom anterior subcutaneous transposition was performed, although they had a significant improvement of their clinical signs and symptoms, they had an inferior outcome when compared with patients treated with the other 2 methods.
The primary objective of this systematic review was to identify and analyze the outcomes measures that have been used to evaluate postoperative results following surgery for cubital tunnel syndrome. The secondary objective was to compare the postoperative results among patients evaluated using patient-satisfaction instruments to those evaluated using surgeon-reported scales.
Computerized database searches of MEDLINE, EMBASE, and MEDLINE In-Process were performed. Studies involving adults with cubital tunnel syndrome in whom the surgical intervention was simple decompression, anterior transposition (subcutaneous, submuscular or intramuscular), endoscopic decompression, or medial epicondylectomy were included. A systematic review was performed that included randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series.
This systematic review of the literature identified 42 studies that satisfied the inclusion criteria. The authors identified 21 health outcomes measures used in cubital tunnel studies. These consisted of 2 generic instruments; 10 symptom-specific, author-reported instruments; 3 symptom-specific, patient-reported instruments; and 6 patient questionnaires. No measure demonstrated adequate development or validation for use in its target population. Available data revealed a consistently high level of patient satisfaction following simple decompression or submuscular transposition (65% to 92%). The results of the author-reported, symptom-specific scales varied widely and showed no obvious association with patient satisfaction. The variation in reporting of results prevented statistical comparisons between author-reported results and patient-reported results.
To the best of our knowledge, this is the first systematic review to delineate the outcomes measures used to evaluate the treatment of cubital tunnel syndrome. Our results show that reliable, reproducible, and valid outcomes measures are lacking from the surgical literature. A standardized assessment protocol for ulnar neuropathy is required for future comparison trials.
Therapeutic III.
In order to assess their late benefits we present the long-term results of a comparison of treating cubital tunnel syndrome with anterior submuscular transposition or simple decompression.
Of 40 patients initially recruited to this study 33 were available for long term follow-up. Sixteen patients underwent anterior submuscular transposition (group A); simple decompression was performed in 17 of the patients (group B). The indications for inclusion were a typical clinical presentation confirmed by abnormal nerve conduction studies. The mean duration of the symptoms before operation was 13 months (range 2 to 84 months) in group A and 8.4 months (range 1.5 to 36 months) in group B. All patients were seen 2 months after surgery and at least 3 years later. The mean duration of follow-up was 63.1 month in the first group and 52 months in the second group.
No complications were seen in either group. In the group treated by anterior transposition, ten of 16 patients were completely free of signs and symptoms; slight residual hypesthesia or paresthesia was observed in two patients. Paresis and atrophy was observed in only one person. In the simple decompression group, 11 of 17 patients were completely free of signs and symptoms. In five patients slight residual symptoms were observed; no paresis or atrophy was reported in any of this group.
These long-term results show that both surgical techniques have a good outcome. Thus, the less invasive simple decompression should be preferred.
Optimal surgical management of cubital tunnel syndrome remains uncertain despite the publication of numerous case series, observational studies, systematic reviews, and, in recent years, randomized controlled studies. The purpose of this meta-analysis was to compare simple decompression to anterior transposition of the ulnar nerve for the treatment of this condition, using comparative trials and randomized controlled trials.
Computerized database searches of MEDLINE, EMBASE, Cochrane Central, and all relevant surgical archives were performed. Studies involving adults with cubital tunnel syndrome in whom surgical intervention was simple decompression or anterior transposition (subcutaneous or submuscular) were included. Analysis was limited to randomized controlled trials and comparative observational studies. Included studies were assessed for quality, heterogeneity, and publication bias. Odds ratios of clinical improvement comparing simple decompression to anterior transposition (submuscular or subcutaneous) were calculated for each study.
Ten studies involving a total of 449 simple decompressions, 342 subcutaneous transpositions, and 115 submuscular transpositions were included. There was little evidence of publication bias or statistical study heterogeneity. Odds of improvement with simple decompression versus anterior transposition were 0.751, 95% confidence interval (0.542, 1.040). Subanalyses on the basis of transposition technique (subcutaneous or submuscular) and study quality did not render a statistically significant result.
This report represents the best cumulative evidence to date examining the surgical management of cubital tunnel syndrome. In this study, we found no statistically significant difference, but rather a trend toward an improved clinical outcome with transposition of the ulnar nerve as opposed to simple decompression. Additional prospective, randomized studies that use reproducible preoperative and postoperative objective measures might add statistical power to this finding.
Surgical treatment for cubital ulnar nerve compression includes medial epicondylectomy, simple decompression, or anterior transposition (subcutaneous, intramuscular, or submuscular). There is a dearth of prospective randomized studies on which to base guidelines for choosing one operative treatment over another. The authors review the literature on this subject and present their findings.
The authors reviewed the literature from January 1970 to July 1997. Two authors decided independently whether an article should be included for review based on previously formulated inclusion and exclusion criteria. In addition to demographic information, data concerning preoperative status and outcome were extracted. For statistical analyses chi-square and Kruskal-Wallis tests were performed. Irrespective of their preoperative status, patients with simple decompression had the best outcome, whereas those with anterior subcutaneous and submuscular transposition had the worst. If outcome was related to the patient's preoperative status, a significant difference was not found among the various groups for those patients with a preoperative McGowan Grade 2. However, for those with McGowan Grade 3 (severe) symptoms, patients with anterior intramuscular transposition had the best outcome followed by those with simple decompression and anterior submuscular transposition. Statistical analysis was not possible for patients with McGowan Grade 1 because of the small numbers of patients in several treatment modality groups.
Formulating a uniform guideline for operative treatment is not possible based on the results of this study. However, the authors believe that support is given to their policy, which is primarily to perform a simple decompression. Its surgical simplicity with preservation of the anatomy, especially the vascularization, and the possibility of rapid postoperative rehabilitation are also taken into consideration. If subluxation is found intraoperatively, anterior transposition is proposed.
Despite extensive clinical experience in treating cubital tunnel syndrome, optimal surgical management remains controversial. A meta-analysis of 30 studies with accurate preoperative and postoperative staging was undertaken. Patients were staged preoperatively into minimum, moderate, and severe groups on the basis of clinical presentation. Treatment modalities included nonoperative management, surgical decompression, medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition. Statistical analysis using a standard SAS database with analysis of variance and chi-square tests was used to assess the efficacy of each therapeutic modality. For minimum-staged patients, all modalities produced similar degrees of satisfaction. However, total relief occurred most after medial epicondylectomy and least after anterior subcutaneous transposition. Patients treated nonoperatively had the highest rate of recurrence. For moderate-staged patients, submuscular transposition was most efficacious, whereas patients with nonoperative management fared the worst. Finally, for severe-staged patients, current therapeutic modalities were not consistently effective, with medial epicondylectomy producing the poorest operative result. This article reveals statistically significant differences in outcomes among therapeutic modalities, which may assist in treatment planning; it introduces standardized methods to aid in determining, analyzing, and communicating treatment outcomes.
The operation has the advantage of simplicity, and it avoids the slight danger of secondary cicatricial contracture of the nerve when it is transplanted anteriorly and implanted in muscle. There is a slight hazard from external injuries because the nerve is unprotected by the epicondyle.
1. The progress of recovery after transposition of the ulnar nerve has been studied in forty-six patients with ulnar neuritis of traumatic or mechanical origin.
2. In assessing the results, the lesions were divided into three grades according to the severity of the neurological signs: Grade I, minimal lesions with no detectable motor weakness; Grade II, intermediate lesions; Grade III, severe lesions with paralysis of one or more of the ulnar intrinsic muscles.
3. The earliest and most constant result after operation was the relief of discomfort and ulnar paraesthesiae.
4. The degree of motor recovery varied according to the severity of the lesion at the time of the operation. In Grades I and II cases, all the muscles (with one exception) were acting against gravity and resistance at the final examination. In Grade III cases, the recovery was usually far from complete. Recovery of sensibility was uniformly good.
5. In a further six patients with persistent symptoms after transposition, relief was obtained by free mobilisation and placing the nerve deep to the flexor origin.
The main objective of this study was to compare the clinical outcome of participants treated by simple decompression (SD) of the ulnar nerve versus anterior subcutaneous transposition (AST).
A prospective randomized controlled study was performed. Three hundred forty participants were referred to our institution between March 1999 and July 2002. One hundred fifty-two patients met the inclusion criteria and were randomized into two surgical groups: 75 were assigned to SD, and 77 were assigned to AST. Participants were followed for 1 year after surgery. The main outcome measure was clinical outcome 1 year after surgery.
An excellent or good result was obtained in 49 of 75 participants who underwent SD and in 54 of 77 participants undergoing AST. The difference was not statistically significant. However, the complication rate was statistically lower in the SD group (9.6%) compared with the AST group (31.1%) (risk ratio, 0.32; 95% confidence interval, 0.14-0.69). Duration of symptoms, (sub)luxation of the ulnar nerve, and severity of the complaints did not influence outcome.
Surgery for ulnar neuropathy at the elbow is effective. The outcomes of SD and AST are equivalent, except for the complication rate. Because the intervention is simpler and associated with fewer complications, SD is advised, even in the presence of (sub)luxation.
The purpose of this prospective randomised study was to evaluate which operative technique for treatment of cubital tunnel syndrome is preferable: subcutaneous anterior transposition or nerve decompression without transposition. This study included 66 patients suffering from pain and/or neurological deficits with clinically and electromyographically proven cubital tunnel syndrome. Thirty-two patients underwent nerve decompression without transposition and 34 underwent subcutaneous transposition of the nerve. Follow-up examinations evaluating pain, motor and sensory deficits as well as motor nerve conduction velocities, were performed 3 and 9 months postoperatively. There were no significant differences between the outcomes of the two groups at either postoperative follow-up examination. We recommend simple decompression of the nerve in cases without deformity of the elbow, as this is the less invasive operative procedure.
Anterior, subcutaneous ulnar nerve transposition decompresses the ulnar nerve and, by transposing anterior to the medial epicondyle, eliminates longitudinal traction forces applied to the nerve during elbow flexion. This article reviews the indications and contraindications of the technique and describes the surgical technique in detail.
There is currently no consensus on the optimal operative treatment for cubital tunnel syndrome. The objective of this meta-analysis of randomized, controlled trials was to evaluate the efficacy of simple decompression compared with that of anterior transposition of the ulnar nerve in the treatment of this condition.
Multiple databases were searched for randomized, controlled trials on the outcome of operative treatment of cubital tunnel syndrome in patients who had not previously sustained trauma or undergone a surgical procedure involving the elbow. Two reviewers abstracted baseline characteristics, clinical scores, and motor nerve-conduction velocities independently. Data were pooled across studies, standard mean differences in effect sizes weighted by study sample size were calculated, and heterogeneity across studies was assessed.
We identified four randomized, controlled trials comparing simple decompression with anterior ulnar nerve transposition (two submuscular and two subcutaneous). In three studies that included a total of 261 patients, a clinical scoring system was used as the primary clinical outcome. There were no significant differences between simple decompression and anterior transposition in terms of the clinical scores in those studies (standard mean difference in effect size = -0.04 [95% confidence interval = -0.36 to 0.28], p = 0.81). We did not find significant heterogeneity across these studies (I(2) = 34.2%, p = 0.22). Two reports, on a total of 100 patients, presented postoperative motor nerve-conduction velocities; they showed no significant differences between the procedures (standard mean difference in effect size = 0.24 [95% confidence interval -0.15 to 0.63] in favor of simple decompression, p = 0.23; I(2) = 0%, p = 0.9).
The results of this meta-analysis suggest that there is no difference in motor nerve-conduction velocities or clinical outcome scores between simple decompression and ulnar nerve transposition for the treatment of ulnar nerve compression at the elbow in patients with no prior traumatic injuries or surgical procedures involving the affected elbow. Confidence intervals around the points of estimate were narrow, which probably exclude the possibility of clinically meaningful differences. These data suggest that simple decompression of the ulnar nerve is a reasonable alternative to anterior transposition for the surgical management of ulnar nerve compression at the elbow.