Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis

A comparative analysis of short-term results in range of motion following arthroscopic arthrolysis with vs. without peripheral nerve block in cases of elbow stiffness

Background

This study aimed to investigate the clinical short-term results in patients with elbow stiffness, particularly focusing on the range of motion (ROM) following arthroscopic arthrolysis. Our objective was to assess potential differences in postoperative outcomes between patients who received an additional peripheral nerve block with postoperative nerve block catheter, and those who exclusively underwent general anesthesia at 6 weeks, 3 months, and 6 months after surgery.

Methods

A single-center study was performed on patients undergoing arthroscopic elbow arthrolysis due to persistent elbow stiffness between 2014 and 2018. The participants were divided into 2 cohorts: One underwent arthroscopic elbow arthrolysis with an additional peripheral nerve block, combined with a postoperative nerve block catheter (group 1), while the other received the procedure without peripheral nerve block (group 2). Standardized assessments of ROM and the Disabilities of the Arm, Shoulder, and Hand score were conducted and analyzed preoperatively and at the 6-week, 3-month, and 6-month follow-up.

Results

A total of 32 patients were included in this study. In group 1 (18 patients), ROM in extension/flexion improved significantly from 95° (±27.17) to 124.4° (±12.7°; P = .000012) after 6 months. Similarly, a significant improvement from 150° (±29.1) to 170.6° (±13°; P = .0013) was observed after 6 months for ROM in pronation/supination. In contrast, group 2 (14 patients) demonstrated an improvement in elbow motion after 6 months, compared to preoperative values, although this increase did not reach statistical significance after 6 months (ROM extension/flexion, P = .6016; ROM pronation/supination, P = .2461). Furthermore, a significant difference (P = .0199) in the delta values of ROM arc for extension/flexion before surgery and after 6 months was identified when comparing both groups, favoring the patient group with additional regional anesthesia (group 1).

Conclusion

Additional peripheral nerve block combined with a postoperative nerve block catheter in arthroscopic arthrolysis in cases of elbow stiffness may be an opportunity to enhance postoperative outcomes by achieving better functional ROM, perhaps through reduced postoperative pain.

Higher Revision Rates With In Situ Decompression as Compared to Ulnar Nerve Transposition for Cubital Tunnel Syndrome: A Meta-Regression Analysis

The purpose of this study was to examine the effect of follow-up time on revision rates of in situ decompression and ulnar nerve transposition for the surgical treatment of cubital tunnel syndrome. A comprehensive literature search was performed to identify prospective and retrospective primary comparison studies assessing the revision rates of in situ decompression and ulnar nerve transposition for the treatment of cubital tunnel syndrome. Meta-regression analyses were used to assess the effect of average study follow-up on the revision rates of both cubital tunnel syndrome treatments. Modeling results were then used to estimate revision rates between decompression and transposition at increasing follow-up times. Sixteen studies including 2,225 patients were included. Average study follow-up time was a statistically significant moderator of revision rates. Model predictions show that in situ decompression operations had an increased risk for revision as compared to ulnar transposition after 48 months of follow-up. In studies with follow-up time ≥48 months, revision rates for in situ decompression (11.9%) were significantly greater than in ulnar transposition (3.2%). In situ decompression for cubital tunnel syndrome is associated with an increased risk of revision surgery as compared to ulnar nerve transposition, particularly when assessed at longer follow-up intervals. The effect of follow-up duration on revision rates demonstrates the need for additional studies to compare outcomes of these operative approaches at follow-up times ≥48 months. This study provides evidence that ulnar nerve transposition may ultimately lead to lower revision rates and demonstrates the need for prospective, randomized trials to corroborate this effect.

Ulnar nerve anteposition with adipofascial flap, an alternative treatment for severe cubital syndrome

BACKGROUND

Ulnar nerve entrapment at the elbow is the second most common cause of nerve entrapment in the upper limb. Surgical techniques mainly include simple decompression, decompression with anterior transposition and medial epicondylectomy.

METHODS

We performed decompression with anterior transposition and protected ulnar nerve by adipofascial flap (a random flap with radial based vascularization, harvested through the avascular plane of Scarpa's fascia. We analyzed patients who underwent ulnar nerve ante-position from 2015 to 2022 according to inclusion and exclusion criteria for a total of 57 patients. All patients included were graded on the McGowan's classification Messina criteria and the British Medical Research Council modified by Mackinnon and Dellon.

RESULTS

The average McGowan's score was 2.4 (± 0.6), Messina's criteria 91.2% indicated a satisfactory or excellent result, sensibility at 6 months was 98.5% S3 or more. A preferential technique has not yet been defined.

CONCLUSIONS

The adipofascial flap offers numerous advantages in providing a pliable, vascular fat envelope, which mimics the natural fatty environment of peripheral nerves and creates favorable micro-environmental conditions to contribute to neural regeneration via axon outgrowth.

Neurolysis versus anterior transposition of the ulnar nerve in cubital tunnel syndrome: a 12 years single secondary specialist centre experience

BACKGROUND

Various conservative treatments and surgical techniques have been reported in the literature as efficient and feasible measures to treat the cubital tunnel syndrome. However, there has been no consensus on the best management of the syndrome, and uniform standardised guidelines have not yet been accepted or introduced. With our study, we present our experience on the clinical efficacies and outcomes of the surgical techniques of neurolysis alone and neurolysis associated with ulnar nerve anterior transposition at the elbow joint in patients with neuropathic symptoms due to cubital tunnel syndrome.

MATERIALS AND METHODS

A total of 107 patients with cubital tunnel syndrome were retrospectively enrolled, surgically treated and followed up in our study. The cohort was divided into two groups: 41 patients treated only with neurolysis of the ulnar nerve (Group 1), and 66 patients treated with neurolysis and anterior transposition (Group 2). Of the participants, 35 were women and 72 were men. The average age was 54 years. Significant comorbidities were preoperatively diagnosed in 26 patients. Conservative measures had been considered, followed by surgical management if appropriate. A pre-op electromyography was performed for all patients. All surgical procedures were performed by the same surgical team. A post-operative follow-up was carried out, and the findings were recorded. The "McGowan" and "Wilson and Krout" classifications and the DASH score were used. A satisfaction questionnaire was administered to all patients post-operatively at 2 weeks).

RESULTS

Ulnar nerve neurolysis and anterior transposition surgery were all successfully performed. Overall complications were post-operative haematoma (8%) and wound problems (5%). In 6% there was recurrence of symptoms. In 11% there was no improvement of symptoms. Pre-op McGowan classifications for groups 1 and 2 were 0% and 0% (grade 0), 21% and 24% (grade 1), 46% and 44% (grade 2), and 33% and 34% (grade 3), respectively. The post-op McGowan classifications were 34% and 37% (grade 0), 39% and 40% (grade 1), 23% and 20% (grade 2), and 4% and 3% (grade 3), respectively. The post-op Wilson and Krout classifications were 45% and 46% (excellent), 26% and 28% (good), 19% and 15% (fair), and 10% and 11% (poor), respectively. The DASH score means for groups 1 and 2 were 14.8 and 15.2, respectively. A negative Froment's sign was present in 73.2% and 71.2%, respectively. In Group 1, the post-op satisfaction questionnaire scores were 0 for one patient, 1 for four patients, 2 for seven patients, 3 for ten patients, 4 for twelve patients and 5 for seven patients. In Group 2, the post-op satisfaction questionnaire scores were 0 for three patients, 1 for nine patients, 2 for twelve patients, 3 for fifteen patients, 4 for eighteen patients and 5 for nine patients.

CONCLUSIONS

In our experience, the surgical technique to treat the cubital tunnel syndrome most efficiently and feasibly has not yet been established in terms of indications and outcomes. This is supported by the data present in the international literature. Good and similar results were obtained with neurolysis alone and neurolysis associated with anterior transposition of the ulnar nerve (in line with the international data). In conclusion, more high-quality studies of greater statistical power are needed to provide a consensus on the surgical indications and techniques to treat the cubital tunnel syndrome and to establish internationally standardised guidelines.

Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis

IMPORTANCE

Cubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications.

OBJECTIVE

To evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure.

DATA SOURCES

PubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies.

STUDY SELECTION

Experimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact.

MAIN OUTCOMES AND MEASURES

The primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence.

RESULTS

A total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates.

CONCLUSIONS AND RELEVANCE

In this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.

Rates of Revision Surgery following In Situ Decompression versus Anterior Transposition for the Treatment of Idiopathic Cubital Tunnel Syndrome

Objective  The current understanding of revision rates following surgery for the primary surgical treatment of idiopathic cubital tunnel syndrome (CuTS) remains unclear. The purpose of this study was to describe and compare the rate of revision surgery following in situ decompression (SD) versus anterior transposition (AT) after the surgical treatment of idiopathic CuTS and examine possible predicting variables for revision. Materials and Methods  A retrospective cohort study was performed at a single institution by querying records for all CuTS surgeries performed between January 2010 and December 2015. The initial query resulted in 1,967 cases. Exclusion criteria included acute trauma, concurrent unrelated primary elbow procedure, revision surgery, incomplete records, and age younger than 18 or older than 89 years. A total of 1,384 surgeries met criteria for study inclusion. A case-control study was then performed with 39 cases of revision and a group of 76 control cases that did not undergo revision surgery. Bivariate analysis followed by multivariate logistic regression was performed to evaluate predictors of revision. Results  Of the 1,384 procedures, 979 were SDs (70.7%) and 405 were ATs (29.3%). Among the 1,384 total procedures, there were 39 primary cubital tunnel surgeries resulting in a revision surgery (2.8%). The revision rate for SD was 3.1% and the revision rate for AT was 2.2%. Predictors of revision were younger age, increased nerve conduction velocity, and decreased duration of symptoms. Conclusion  In the surgical treatment of idiopathic CuTS, the overall revision rate is low (2.8%). This study found no significant difference in revision rate between SD and AT, but that risk for revision surgery overall was associated with younger age, increased nerve conduction velocity, and decreased duration of symptoms. Level of Evidence  This is a therapeutic, level III study.

Reporting Outcomes and Outcome Measures in Cubital Tunnel Syndrome: A Systematic Review

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.

Ulnar Nerve In Situ Decompression versus Transposition for Idiopathic Cubital Tunnel Syndrome: An Updated Meta-Analysis

Purpose Evidence for the superiority of in situ simple decompression (SD) versus ulnar nerve transposition (UNT) for cubital tunnel syndrome remains controversial. The purpose of this study was to compare the clinical improvement, complication rate, and revision rate of SD versus UNT using the available evidence. Materials and Methods We performed a literature search of relevant publications using PubMed, SCOPUS, Cochrane Library, and Springer Link. Inclusion criteria included (1) adult patients >18 years of age, (2) idiopathic cubital tunnel syndrome, (3) primary comparison studies including both SD versus UNT with discrete data for each procedure, (4) average follow-up of at least 2 months, and (5) a full English language manuscript available. Odds ratios of improvement, complications, and revision surgery after SD compared with UNT were calculated. Data were analyzed using both fixed and random effects models, and studies were assessed for publication bias and heterogeneity. Results A total of 1,511 articles from 1970 to 2017 were identified before inclusion, and exclusion criteria were applied. Ultimately 17 studies met the inclusion criteria and included 2,154 procedures. Of these, 1,040 were SD, and 1,114 were UNT procedures. Study heterogeneity was low. Odds ratios of clinical improvement and revision surgery with SD versus UNT were not significantly different. The odds ratio of complications with SD versus UNT was 0.449 (95% confidence interval [CI] of 0.290-0.695) and 0.469 (95% CI of 0.297-0.738) for fixed and random effect models, respectively. The difference in complications between SD versus UNT was significant ( P < 0.001). Conclusion There is no statistically significant difference in clinical outcomes or rate of revision surgery between SD versus UNT. However, there were significantly more complications with UNT. The current body of evidence regarding cubital tunnel syndrome lacks prospective, randomized, controlled trials, uniform reporting of indications, and standardized outcome scoring.

Ulnar nerve entrapment at the elbow. A surgical series and a systematic review of the literature

Chronic compression of the ulnar nerve at the elbow is the second most common entrapment neuropathy. Various surgical options have been described. Timing of surgery is also debated. In this study we report the long-term results of a consecutive surgical series of anterior subcutaneous transpositions and review the pertinent literature. Sixty consecutive patients underwent anterior subcutaneous transposition at our Institution to treat ulnar nerve compression at the elbow. McGowan scale was used in the neurological exam before surgery. Bishop rating system was used to assess outcome. Seventy-eight% of patients scored good-excellent. None of the patients worsened. No complications and no recurrences were reported. Young age and good pre-operative neurological status (McGowan grade 1) were predictive of favorable outcome both at univariate and at multivariate analysis. No differences in outcome were observed between patients with intermediate (McGowan grade 2) and severe (McGowan grade 3) neuropathy. Thirty-four studies assessing outcome of different surgical techniques were reviewed. Anterior subcutaneous transposition had the lowest recurrence rate with an excellent effectiveness and safety profile. The favorable predictive role for outcome of preoperative neurological status was confirmed. The good long-term clinical results of the present series and the results of literature analysis confirm the value of anterior subcutaneous transposition of the ulnar nerve at the elbow. This technique has a particular effectiveness in most severe compressions, where outcomes are comparable with intermediate neuropathy cases. Moreover, our results suggest an aggressive attitude towards ulnar nerve compression at the elbow, particularly in younger patients.

A minimally invasive approach for cubital tunnel release and ulnar nerve transposition

OBJECTIVES

The aim of the study is to introduce a new minimally invasive technique for ulnar nerve release and transposition.

METHODS

From January 2010 to May 2011, 51 patients with cubital tunnel syndrome were treated through a 1.5 to 2 cm incision. Limb functional recovery, scar esthetics, sensitivity of scar, numbness of the operating area, and patient satisfaction were assessed.

RESULTS

No wound hematoma nor infection was observed in the group. The time of operation was 36 ± 17.2 minutes. At the final follow-up of 63 ± 7.3 months, 2-point discrimination of the small finger was improved from 6.3 ± 2.2 mm to 5.2 ± 2.4 mm. Grip and pinch strength of the hand were improved from 14.2 ± 7.7 kg and 3.7 ± 2.4 kg to 35.2 ± 12.7 kg and 4.1 ± 2.8 kg, respectively. The motor nerve conduction velocity was improved from 36.5 ± 11.2 to 44.6 ± 6.7 (m/sec). The Disabilities of the Shoulder, Arm, and Hand questionnaire score was improved from 37.2 ± 23.8 to 10.5 ± 9.6. No patients reported scar pain, sensitivity of scar, or numbness of the operating area. No revision surgery was needed. Michigan Hand Outcome score for aesthetics was 94.6%±5.1 and satisfaction was 92 ± 8, respectively. We obtained 33 excellent, 12 good, 5 fair, and 1 poor result.

CONCLUSION

Ulnar nerve decompression with anterior transposition can be safely and effectively accomplished through the small incision. It can be an alternative technique producing good appearance.

Autogenous Vein Wrapping versus In Situ Decompression for Management of Secondary Cubital Tunnel Syndrome after Surgical Fixation of Elbow Fractures: Short-Term Functional and Neurophysiological Outcome

PURPOSE

The aim of this study was to compare the functional and neurophysiological outcome of in situ decompression versus in situ decompression augmented with autogenous vein wrapping in management of secondary cubital tunnel syndrome at the elbow following fixation of elbow fractures.

METHODS

A prospective comparative randomized study was performed on 29 patients who were divided into two groups: group I (in situ decompression) and group II (in situ decompression augmented with autogenous vein wrapping). We measured the patients' demographics, subjective reports of symptoms, and objective evaluation of the functional and neurophysiological outcomes of both groups.

RESULTS

Group II patients achieved statistically better results in both neurophysiological scoring and clinical sensory rating but not in all other parameters.

CONCLUSION

Autogenous vein wrapping for secondary cubital tunnel syndrome after elbow fracture fixation only provides a better sensory outcome.

LEVEL OF EVIDENCE

Level II, therapeutic prospective comparative study.