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Anderson D, Woods B, Abubakar T, Koontz C, Li N, Hasoon J, Viswanath O, Kaye AD, Urits I. A Comprehensive Review of Cubital Tunnel Syndrome. Orthop Rev (Pavia) 2022; 14:38239. [PMID: 36128335 PMCID: PMC9476617 DOI: 10.52965/001c.38239] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Cubital Tunnel Syndrome (CuTS) is the compression of the ulnar nerve as it courses through the cubital tunnel near the elbow at the location colloquially referred to as the "funny bone". CuTS is the most commonly diagnosed mononeuropathy after carpal tunnel syndrome. Cubital tunnel syndrome can manifest as numbness, tingling, or pain in the ring/small fingers and dorsoulnar hand. Repetitive pressure, stretching, flexion, or trauma of the elbow joint are known causes of CuTS. Chronic ulnar nerve compression and CuTS, when left untreated, can lead to atrophy of the first dorsal interosseus muscle and affect one's quality of life to the point that they are no longer able to participate in daily activities involving fine motor function. It is estimated that up to 5.9% of the general population have had symptoms of CuTS. CuTS is underdiagnosed due to lack of seeking of treatment for symptoms. Compression or damage to the ulnar nerve is the main cause of symptoms experienced by an individual with CuTS. Repetitive elbow pressure or a history or elbow joint trauma or injury are additional known causes that can lead to CuTS. Common presentations of CuTS include paresthesia, clumsiness of the hand, hand atrophy and weakness. The earliest sign of CuTS is most commonly numbness and tingling of the ring and 5th finger. Older patients tend to present with motor symptoms of chronic onset; younger patients tend to have more acute symptoms. Pain and point tenderness at the medial elbow may also be seen. CuTS lacks universally agreed upon diagnostic and treatment algorithms. CuTS can be diagnosed by physical exam using Tinel's sign, flexion-compression tests, palpating the ulnar nerve for thickening presence of local tenderness along the nerve. Ultrasound and nerve conduction studies may be used in combination with physical exam for diagnosis. Conservative treatment for CuTS is almost always pursued before surgical treatment and includes elbow splints, braces, and night-gliding exercises. Surgical treatment may be pursued in severe CuTS refractory to conservative treatment. Surgical options include open and endoscopic in-situ decompression, medial epicondylectomy, and anterior transposition of the ulnar nerve. CuTS is a prevalent disease that, if left untreated, can significantly alter an individual's quality of life. Therefore, an accurate diagnosis and appropriate treatment is paramount in reducing further damage and preventing worsening or future symptoms.
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Affiliation(s)
| | - Bison Woods
- Medical School, Medical College of Wisconsin
| | - Tunde Abubakar
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Colby Koontz
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Nathan Li
- Medical School, Medical College of Wisconsin
| | - Jamal Hasoon
- Anesthesiology, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Omar Viswanath
- Anesthesiology, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Alan D Kaye
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Ivan Urits
- Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School
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Lucchina S, Fusetti C, Guidi M. Sonographic Follow-Up of Patients With Cubital Tunnel Syndrome Undergoing in Situ Open Neurolysis or Endoscopic Release: The SPECTRE Study. Hand (N Y) 2021; 16:385-390. [PMID: 31296044 PMCID: PMC8120578 DOI: 10.1177/1558944719857816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:The measurement of cross-sectional area (CSA) is a diagnostic tool to detect entrapments syndrome. The aim of this study was to compare the clinical outcome in elbows undergoing endoscopic and "in situ" open cubital tunnel release for cubital tunnel syndrome (CuTS) using ultrasound-related changes in the largest CSA of the ulnar nerve. The purpose is to determine the association between clinical outcome and CSA. Methods: From May 2011 to April 2016, 60 patients with CuTS were prospectively followed and not randomly divided in two groups: 30 patients undergoing an endoscopic release (ER) and 30 patients with "in situ" open neurolysis (OR). A sonographic examination was performed by the senior authors at baseline and 3, 6, and 12 months after surgical decompression. Results: CSA values were statistically significantly lower in the ER. Hand grip strength difference with Jamar test was not statistically significant a 12 months (39 kg vs 27 kg). Static-2 point discrimination test difference was only statistically significant lower in the endoscopic group at 3, 6 and 12 months but not clinically relevant (5 mm vs 6 mm). The American Shoulder and Elbow Surgeons-Elbow questionnaire (ASES-e) function score, ASES-e Pain score, and ASES-e Satisfaction score were not statistically significant different between the two groups at 3, 6, and 12 months post operatively. Conclusions: The study confirms that in spite of lower values of CSA in the ER, there is not a statistically significant difference between the two techniques in terms of subjective outcomes. Ultrasound (US) measurements seem to have a limited value in clinical results of patients treated for entrapment neuropathy of the ulnar nerve.Type of study/LOE: Prognostic Level III.
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Affiliation(s)
- Stefano Lucchina
- Locarno Hand Center, Switzerland,Regional Hospital La Carità, Locarno, Switzerland,Stefano Lucchina, Locarno Hand Center, Via Ramogna 16, 6600 Locarno, Switzerland.
| | | | - Marco Guidi
- Regional Hospital San Giovanni, Bellinzona, Switzerland
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Bilgin Badur N, Unlu Ozkan F, Aktas I. Efficacy of shortwave diathermy in ulnar nerve entrapment at the elbow: a double-blind randomized controlled clinical trial. Clin Rehabil 2020; 34:1048-1055. [PMID: 32567357 DOI: 10.1177/0269215520930062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To investigate the efficacy of shortwave diathermy in treatment of ulnar nerve entrapment at the elbow. DESIGN The study was a double blind, randomized controlled clinical trial. SETTING, PARTICIPANTS A total of 76 adult patients diagnosed with ulnar nerve entrapment at the elbow clinically and electrophysiologically, were randomly assigned into two groups. Patients were evaluated at baseline, after completing treatment and 1 and 3 months after treatment. Physical examination, quick-DASH (disabilities of arm, shoulder, hand) and SF-36 (short form) questionnaires for daily life activities, dynamometer for grip strength, and visual analog scale for pain were used. INTERVENTION A total of 10 sessions of shortwave diathermy were applied to patients in treatment group as five sessions/week, 2 weeks. Control group was given placebo shortwave diathermy. Both groups were given elbow splints and informed to avoid symptom provoking activities. MAIN OUTCOME MEASURES Visual analog scale, grip strength, SF-36, and quick-DASH results. RESULTS Out of 76 patients, 61 of them completed the study where n = 31 for treatment group and n = 30 for control group. Mean age was 46.18 ± 13.45 years. There were 32 (52.5%) women and 29 (47.5%) men. The p values between groups 3 months after intervention for visual analog scale, quick-DASH, SF-36 questionnaire, and dynamometer were 0.669, 0.277, 0.604, and 0.126, respectively (p > 0.05). CONCLUSION Application of shortwave diathermy to patients with ulnar nerve neuropathy at the elbow was not associated with any difference in outcome.
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Affiliation(s)
- Naciye Bilgin Badur
- Department of Physical Medicine and Rehabilitation, Sureyyapasa Chest Diseases and Thoracic Surgery Education and Training Hospital, Istanbul, Turkey
| | - Feyza Unlu Ozkan
- Department of Physical Medicine and Rehabilitation, Istanbul Fatih Sultan Mehmet Education and Training Hospital, Istanbul, Turkey
| | - Ilknur Aktas
- Department of Physical Medicine and Rehabilitation, Istanbul Fatih Sultan Mehmet Education and Training Hospital, Istanbul, Turkey
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Chen LC, Ho TY, Shen YP, Su YC, Li TY, Tsai CK, Wu YT. Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial. Arch Phys Med Rehabil 2020; 101:1296-1303. [PMID: 32325164 DOI: 10.1016/j.apmr.2020.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE). DESIGN Prospective, randomized, double-blind, controlled trial (6-month follow-up). SETTING Outpatients of local medical center settings. PARTICIPANTS Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis. INTERVENTIONS Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively. MAIN OUTCOME MEASURES The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection. RESULTS Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward. CONCLUSIONS We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.
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Affiliation(s)
- Liang-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Tsung-Yen Ho
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Department of Physical Medicine and Rehabilitation, Taichung Armed Forces General Hospital, Taichung City, Taiwan, Republic of China
| | - Yu-Ping Shen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yu-Chi Su
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Tsung-Ying Li
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chia-Kuang Tsai
- Department of Neurology, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Graduate Institute of Medical Science, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yung-Tsan Wu
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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Frantz LM, Adams JM, Granberry GS, Johnson SM, Hearon BF. Outcomes of ulnar nerve anterior transmuscular transposition and significance of ulnar nerve instability in cubital tunnel syndrome. J Shoulder Elbow Surg 2019; 28:1120-1129. [PMID: 30770314 DOI: 10.1016/j.jse.2018.11.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND We investigated the experience of a single surgeon with ulnar nerve anterior transmuscular transposition with the patient in the lateral decubitus position for cubital tunnel syndrome. METHODS The medical records of all patients who underwent primary or revision ulnar nerve anterior transmuscular transposition were screened to define a cohort of 156 patients (162 limbs) for further study of demographic and disease-specific data and retrospective assessment of short-term outcomes. Ulnar neuropathy severity was stratified by McGowan grade. A prospective cohort composed of 49 patients (51 limbs) with a minimum 2-year follow-up volunteered to complete patient outcome surveys, and some presented for an ulnar nerve-focused examination to assess long-term outcomes. RESULTS The overall patient satisfaction rate was 92%, with statistically significant improvements in ulnar sensation and intrinsic strength at short- and long-term follow-up. Outcomes were better for lower McGowan grades than for higher grades and better in primary cases than in revision cases. Ulnar nerve instability was observed in 69 of 162 cases (43%) in this series. A major complication occurred in 7 cases (4.3%), but all were mitigated by contributory patient-related factors. Reoperation for recurrent ulnar paresthesia was required in 4 cases (2.5%). No operations or outcomes were compromised by the lateral decubitus position. DISCUSSION AND CONCLUSION Ulnar nerve anterior transmuscular transposition in the lateral decubitus position is a good surgical option for primary or recurrent cubital tunnel syndrome and remains our preferred procedure. The high prevalence of ulnar nerve instability observed in this study is a factor worthy of consideration by surgeons and patients weighing the surgical options for ulnar neuropathy at the elbow.
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Affiliation(s)
- Lisa M Frantz
- University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | | | | | | | - Bernard F Hearon
- Advanced Orthopaedics Associates, PA, Wichita, KS, USA; Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA.
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Histological Evidence of Intrinsic Muscle Degeneration in Compression Ulnar Neuropathy. Ann Plast Surg 2019; 82:541-545. [PMID: 30950876 DOI: 10.1097/sap.0000000000001853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We investigated the histological characteristics of the tissues in the intrinsic hand muscles of patients with compressive ulnar neuropathy (CUN) to determine how the compromised nerve influences the target muscle. METHODS In total, 83 patients underwent surgery for CUN in our institution between March 2015 and August 2017. Of these, 45 patients who met our inclusion/exclusion criteria were initially included in this study. Basic demographic data including age, sex, hand dominance, duration of symptoms, bone mineral density, and clinical stage were evaluated. During the ulnar nerve decompression surgery, a biopsy of the ipsilateral adductor pollicis was performed. Using the biopsy samples, we analyzed the tissue composition and degree of degeneration, and investigated the association with demographic factors and clinical status. RESULTS The ratio of muscle/connective tissue/fat was 62.62 ± 8.27%/23.44 ± 4.10%/14.16 ± 6.68% in the affected muscle. The ratio was different than that of samples taken from control groups. In samples containing muscle fibers, although the total fat content remained low, fat was consistently concentrated at the fascicular borders, between fascicles (perifascicular fat, 62.3 ± 18.2% of fascicles), and within fascicles (intrafascicular fat, 35.6 ± 11.8% of fascicles). The proportion of centrally nucleated muscle fibers was also significantly elevated (5.58 ± 4.25%; P < 0.001) compared with that of both controls (1.09 ± 1.26%) and the clinical threshold for abnormal central nuclei (3%). Preoperative scores assessed using Gabel and Amadio criteria were positively correlated with the muscle composition (r = 0.89, P < 0.001). In addition, the clinical status was negatively correlated with the degree of fat accumulation and the proportion of centrally nucleated muscle fibers (r = -0.94, P < 0.001, r = -0.82, P < 0.001). CONCLUSIONS We demonstrated that target muscle in CUN underwent degeneration, which was potentially exacerbated by inflammation, and that the degree of degeneration was correlated with the patient's clinical status. Histologically, reversible recovery of the hand muscles may be possible if decompression of the ulnar nerve is performed at earlier stages.
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Mota PTD, Maio M, Sapage R, Branco C, Pintado C. Hereditary Neuropathy with Liability to Pressure Palsies: A Rare Condition That Presents with Common Symptoms: A Case Report. JBJS Case Connect 2018; 8:e95. [PMID: 30489379 DOI: 10.2106/jbjs.cc.18.00132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 13-year-old girl presented with paresthesia of the fourth and fifth fingers and the dorsal ulnar surface of the left hand that had started 3 months prior. Physical examination showed loss of sensation at the ulnar side of the fourth and fifth fingers and a positive Froment sign. Electromyography showed a severe motor conduction block in the ulnar nerve at the elbow. Eighteen months later, the patient had similar symptoms in the right hand. The diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP) was considered and confirmed with genetic testing. CONCLUSION HNPP is a rare disease that should be considered not only in patients with multiple compressive neuropathies, but also in patients with any unexpected or unexplained neuropathy, even if it is isolated.
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Affiliation(s)
| | - Marta Maio
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Rita Sapage
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Carlos Branco
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Carlos Pintado
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, Portugal
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Yahya A, Malarkey AR, Eschbaugh RL, Bamberger HB. Trends in the Surgical Treatment for Cubital Tunnel Syndrome: A Survey of Members of the American Society for Surgery of the Hand. Hand (N Y) 2018; 13:516-521. [PMID: 28832192 PMCID: PMC6109899 DOI: 10.1177/1558944717725377] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cubital tunnel syndrome is the second most common compression neuropathy affecting the upper extremity. The aim of this study was to determine the preferred surgical treatment for cubital tunnel syndrome by members of the American Society for Surgery of the Hand (ASSH). METHODS We invited members of the ASSH research mailing list to complete our online survey. They were presented with 6 hypothetical cases and asked to choose their preferred treatment from the following options: open in situ decompression, endoscopic decompression, submuscular transposition, subcutaneous transposition, medial epicondylectomy, and conservative management. This was assessed independently and anonymously through an online survey (SurveyMonkey). RESULTS 1069 responses were received. Seventy-three percent of the respondents preferred to continue conservative management when a patient presented with occasional paresthesias for greater than 6 months with a normal electromyogram (EMG) or nerve conduction velocity (NCV). Sixty-five percent picked open in situ decompression if paresthesias, weakness of intrinsics, and EMG/NCV reports of mild to moderate ulnar nerve entrapment was present. More than 50% of respondents picked open in situ decompression, as their preferred treatment when sensory loss of two-point discrimination of less than 5 or more than 10 was present in addition to the findings mentioned above. Seventy-nine percent of the respondents said their treatment algorithm would change if ulnar nerve subluxation was present. CONCLUSIONS Our survey results indicate that open in situ decompression is the preferred operative procedure, if there is no ulnar nerve subluxation, among hand surgeons for cubital tunnel syndrome.
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Affiliation(s)
- Ayesha Yahya
- Ohio University, Athens, USA,Ayesha Yahya, Department of Orthopaedic Surgery, WellSpan York Hospital, 1001 S George Street, York, PA 17403, USA.
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Reizner W, Rubin TA, Hausman MR. Cubital Tunnel Syndrome in the Athlete. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Camp CL, Tebo CC, Degen RM, Dines JS, Altchek DW, Werner BC. Patient-Related Risk Factors for Infection Following Ulnar Nerve Release at the Cubital Tunnel: An Analysis of 15,188 Cases. Orthop J Sports Med 2018; 6:2325967118772799. [PMID: 29796400 PMCID: PMC5956641 DOI: 10.1177/2325967118772799] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although cubital tunnel release is a commonly performed orthopaedic procedure, the overall incidence of and independent risk factors for infection largely remain undefined in the current literature. PURPOSE To establish the rate of postoperative infection after isolated cubital tunnel release and define relevant patient-related risk factors. STUDY DESIGN Case-control study; Level 3. METHODS All Medicare-insured patients undergoing ulnar nerve decompression at the cubital tunnel from 2010 through 2012 were identified. A multivariate binomial logistic regression analysis was utilized to evaluate the impact of patient-related risk factors for postoperative infection. RESULTS A total of 330 (2.17%) postoperative infections were identified in 15,188 cases. The majority (87%) were managed nonoperatively, while 13% required surgical debridement. The most significant risk factors for infection included hemodialysis use (odds ratio [OR], 2.47), chronic anemia (OR, 2.24), age <65 years (OR, 2.08), tobacco use (OR, 1.65), morbid obesity (OR, 1.53), inflammatory arthritis (OR, 1.43), depression (OR, 1.36), hyperlipidemia (OR, 1.33), male sex (OR, 1.32), and chronic lung disease (OR, 1.29). CONCLUSION The present study was adequately powered to determine numerous patient-related risk factors for infection following cubital tunnel release.
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Affiliation(s)
- Christopher L. Camp
- Sports Medicine Center, Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA
| | - Collin C. Tebo
- Weill-Cornell Medical School, Cornell University, New York, New York, USA
| | - Ryan M. Degen
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Joshua S. Dines
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - David W. Altchek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Eberlin KR, Marjoua Y, Jupiter JB. Compressive Neuropathy of the Ulnar Nerve: A Perspective on History and Current Controversies. J Hand Surg Am 2017; 42:464-469. [PMID: 28578769 DOI: 10.1016/j.jhsa.2017.03.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/21/2016] [Accepted: 03/21/2017] [Indexed: 02/02/2023]
Abstract
The untoward effects resulting from compression of the ulnar nerve have been recognized for almost 2 centuries. Initial treatment of cubital tunnel syndrome focused on complete transection of the nerve at the level of the elbow, resulting in initial alleviation of pain but significant functional morbidity. A number of subsequent techniques have been described including in situ decompression, subcutaneous transposition, submuscular transposition, and most recently, endoscopic release. This manuscript focuses on the historical aspects of each of these treatments and our current understanding of their efficacy.
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Affiliation(s)
- Kyle R Eberlin
- Hand Surgery Service, Massachusetts General Hospital, Boston, MA.
| | - Youssra Marjoua
- Hand Surgery Service, Massachusetts General Hospital, Boston, MA
| | - Jesse B Jupiter
- Hand Surgery Service, Massachusetts General Hospital, Boston, MA
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Roberts GL, Maclean AD, Logan AJ. Ulna Nerve Decompression at the Elbow in Patients with Normal Nerve Conduction Tests. ACTA ACUST UNITED AC 2016; 20:260-5. [PMID: 26051766 DOI: 10.1142/s0218810415500215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ulna nerve compression at the elbow is the second most common neuropathy of the upper limb. It has been suggested that nerve conduction tests are required to correctly make the diagnosis. The aim of this study was to assess whether patients with normal nerve conduction testing benefitted from surgical release of the ulna nerve. METHODS 56 patients with symptoms of ulna nerve compression at the elbow were evaluated prospectively. All patients underwent electrophysiology testing followed by ulna nerve decompression irrespective of the results of the electrophysiology testing. Functional scores using the QuickDASH and PEM score were collected up to 12 months post-surgery. RESULTS No difference was found between the group with normal and the group with abnormal electrophysiology studies. CONCLUSIONS We conclude that patients who clinically have ulna nerve compression still benefit from ulna nerve decompression despite normal nerve conduction tests.
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Affiliation(s)
- Gareth L Roberts
- 1 Department of Hand Surgery, University Hospital of Wales, Cardiff, UK
| | - Angus D Maclean
- 1 Department of Hand Surgery, University Hospital of Wales, Cardiff, UK
| | - Andrew J Logan
- 1 Department of Hand Surgery, University Hospital of Wales, Cardiff, UK
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Adkinson JM, Zhong L, Aliu O, Chung KC. Surgical Treatment of Cubital Tunnel Syndrome: Trends and the Influence of Patient and Surgeon Characteristics. J Hand Surg Am 2015; 40:1824-31. [PMID: 26142079 PMCID: PMC4819985 DOI: 10.1016/j.jhsa.2015.05.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine trends in and determinants of the use of different procedures for treatment of cubital tunnel syndrome. METHODS We performed a retrospective cross-sectional analysis of the Healthcare Cost and Utilization Project Florida State Ambulatory Surgery Database for 2005 to 2012. We selected all patients who underwent in situ decompression, transposition, or other surgical treatments for cubital tunnel syndrome. We tested trends in the use of these techniques and performed a multivariable analysis to examine associations among patient characteristics, surgeon case volume, and the use of different techniques. RESULTS Of the 26,164 patients who underwent surgery for cubital tunnel syndrome, 80% underwent in situ decompression, 16% underwent transposition, and 4% underwent other surgical treatment. Over the study period, there was a statistically significant increase in the use of in situ release and a decrease in the use of transposition. Women and patients treated by surgeons with a higher cubital tunnel surgery case volume underwent in situ release with a statistically higher incidence than other techniques. CONCLUSIONS In Florida, surgeon practice reflected the widespread adoption of in situ release as the primary treatment for cubital tunnel syndrome, and its relative incidence increased during the study period. Patient demographics and surgeon-level factors influenced procedure selection. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Joshua M Adkinson
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lin Zhong
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Oluseyi Aliu
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Kevin C Chung
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, MI.
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Ellegaard HR, Fuglsang-Frederiksen A, Hess A, Johnsen B, Qerama E. High-resolution ultrasound in ulnar neuropathy at the elbow: A prospective study. Muscle Nerve 2015; 52:759-66. [DOI: 10.1002/mus.24638] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Hanne R. Ellegaard
- Department of Clinical Neurophysiology; Aarhus University Hospital; Noerrebrogade 44, Building 10, Parterre 8000 Aarhus C Denmark
| | - Anders Fuglsang-Frederiksen
- Department of Clinical Neurophysiology; Aarhus University Hospital; Noerrebrogade 44, Building 10, Parterre 8000 Aarhus C Denmark
| | - Alexander Hess
- Department of Clinical Neurophysiology; Aarhus University Hospital; Noerrebrogade 44, Building 10, Parterre 8000 Aarhus C Denmark
| | - Birger Johnsen
- Department of Clinical Neurophysiology; Aarhus University Hospital; Noerrebrogade 44, Building 10, Parterre 8000 Aarhus C Denmark
| | - Erisela Qerama
- Department of Clinical Neurophysiology; Aarhus University Hospital; Noerrebrogade 44, Building 10, Parterre 8000 Aarhus C Denmark
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Robinson LR. How electrodiagnosis predicts clinical outcome of focal peripheral nerve lesions. Muscle Nerve 2015; 52:321-33. [DOI: 10.1002/mus.24709] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Lawrence R. Robinson
- Division of Physical Medicine and Rehabilitation; University of Toronto, Sunnybrook Health Sciences Centre; H391, 2075 Bayview Avenue Toronto Ontario M4N 3M5
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Carter GT, Weiss MD, Friedman AS, Allan CH, Robinson L. Diagnosis and Treatment of Work-Related Ulnar Neuropathy at the Elbow. Phys Med Rehabil Clin N Am 2015; 26:513-22. [PMID: 26231962 DOI: 10.1016/j.pmr.2015.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome and occurs most commonly at the elbow due to mechanical forces that produce traction or ischemia to the nerve. The primary symptom associated with UNE is diminished sensation or dysesthesias in the fourth or fifth digits, often coupled with pain in the proximal medial aspect of the elbow. Treatment may be conservative or surgical, but optimal management remains controversial. Surgery should include exploration of the ulnar nerve throughout its course around the elbow and release of all compressive structures.
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Affiliation(s)
- Gregory T Carter
- St Luke's Rehabilitation Institute, 711 South Cowley Avenue, Spokane, WA 99202, USA.
| | - Michael D Weiss
- Department of Neurology, University of Washington School of Medicine, 1959 NE, Pacific Avenue, Seattle, WA 98195, USA
| | - Andrew S Friedman
- Department of Physical Medicine and Rehabilitation, Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA 98101, USA
| | - Christopher H Allan
- Department of Orthopedic Surgery, Hand and Microsurgery Section, Harborview Medical Center, The University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Larry Robinson
- Rehabilitation Services, Physical Medicine and Rehabilitation, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario M4N 3M5, Canada
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Omejec G, Podnar S. What causes ulnar neuropathy at the elbow? Clin Neurophysiol 2015; 127:919-924. [PMID: 26093933 DOI: 10.1016/j.clinph.2015.05.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/02/2015] [Accepted: 05/26/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine what causes ulnar neuropathy at the elbow (UNE) by analyzing patients' clinical, electrodiagnostic (EDx) and ultrasonographic (US) findings. METHODS In prospectively recruited patients with definite UNE, four blinded examiners took a history and performed neurologic, EDx and US examinations. A multivariate logistic regression model was used to investigate the association between UNE location and patient variables. RESULTS We included 117 patients; 73% with lesions in the retroepicondylar (RTC) groove and 27% under the humeroulnar aponeurotic arcade (HUA). In our multivariate model, hard manual labor (OR=152; 95% CI 12-1847; p<0.001), dominant arm involvement (OR=4.12; 95% CI 1.01-16.72; p=0.048), and age (OR=1.10; 95% CI 1.03-1.18; p=0.004) were predictive of ulnar neuropathy at HUA. CONCLUSION Our data suggest that UNE at HUA is related to years of hard labor affecting mainly dominant hands, and is caused by work-related changes in the HUA. By contrast, UNE in the RTC groove affects mainly the non-dominant arms of younger administrative workers and is caused by external compression of the ulnar nerve. SIGNIFICANCE We believe that our findings will help to improve the diagnosis and treatment of UNE patients, hopefully leading to improved clinical outcomes.
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Affiliation(s)
- Gregor Omejec
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Center Ljubljana, Slovenia.
| | - Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Center Ljubljana, Slovenia.
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Assmus H, Antoniadis G, Bischoff C. Carpal and cubital tunnel and other, rarer nerve compression syndromes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:14-25; quiz 26. [PMID: 25613452 PMCID: PMC4318466 DOI: 10.3238/arztebl.2015.0014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 07/31/2014] [Accepted: 07/31/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND Carpal tunnel syndrome is by far the most common peripheral nerve compression syndrome, affecting approximately one in every six adults to a greater or lesser extent. Splitting the flexor retinaculum to treat carpal tunnel syndrome is the second most common specialized surgical procedure in Germany. Cubital tunnel syndrome is rarer by a factor of 13, and the other compression syndromes are rarer still. METHODS This review is based on publications retrieved by a selective literature search of PubMed and the Cochrane Library, along with current guidelines and the authors' clinical and scientific experience. RESULTS Randomized controlled trials have shown, with a high level of evidence, that the surgical treatment of carpal tunnel syndrome yields very good results regardless of the particular technique used, as long as the diagnosis and the indication for surgery are well established by the electrophysiologic and radiological findings and the operation is properly performed. The success rates of open surgery, and the single-portal and dual-portal endoscopic methods are 91.6%, 93.4% and 92.5%, respectively. When performed by experienced hands, all these procedures have complication rates below 1%. The surgical treatment of cubital tunnel syndrome has a comparably low complication rate, but worse results overall. Neuro-ultrasonography and magnetic resonance imaging (neuro-MRI) are increasingly being used to complement the diagnostic findings of electrophysiologic studies. CONCLUSION Evidence-based diagnostic methods and treatment recommendations are now available for the two most common peripheral nerve compression syndromes. Further controlled trials are needed for most of the rarer syndromes, especially the controversial ones.
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Affiliation(s)
- Hans Assmus
- (Former Practice of Peripheral Nerve Surgery in Dossenheim/Heidelberg)
| | - Gregor Antoniadis
- District Hospital of Günzburg (Neurosurgical Department of the University of Ulm)
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Smeraglia F, Del Buono A, Maffulli N. Endoscopic cubital tunnel release: a systematic review. Br Med Bull 2015; 116:155-63. [PMID: 26608457 DOI: 10.1093/bmb/ldv049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2015] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Theoretical advantages of endoscopic cubital tunnel release are the short incision, lower risk of nerve damage, reduced manipulation of the nerve and possible faster recovery. SOURCES OF DATA We systematically searched Medline (PubMed), Web of Science and Scopus databases using the following keywords: 'endoscopic ulnar nerve', 'endoscopic cubital nerve', 'endoscopic ulnar compression' and 'endoscopic ulnar neuropathy'. Twenty-one studies were included in this review. The quality of the studies was assessed using the Coleman Methodological Score. AREAS OF AGREEMENT Endoscopic release is effective for cubital tunnel entrapment and allows adequate visualization of the site of entrapment. There is a negative association between the severity of the compression and reported outcomes. Injury to the medial branch of the antebrachial cutaneous nerve is less frequent thanks to the limited dissection. The most frequent complication is the development of a hematoma. AREAS OF CONTROVERSY It is unclear whether ulnar nerve instability is a contraindication to simple decompression. GROWING POINTS The shorter time to return to work and the cosmetic appearance of the scar can be considered advantages of the endoscopic technique. AREAS TIMELY FOR DEVELOPING RESEARCH There is a need to perform randomized clinical trials with common and validated scoring system with a longer duration of follow-up. The literature pertinent to endoscopic cubital tunnel release is lacking in the evaluation of the learning curve. Further investigations are necessary to assess the role of ulnar nerve instability.
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Affiliation(s)
| | - Angelo Del Buono
- Department of Orthopaedic and Trauma Surgery, Ospedale Vaio Fidenza (PR), Fidenza, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Salerno 84081, Italy Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4 DG, UK
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20
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Sakamoto SM, Hausman MR. Ulnar Neuropathy About the Elbow. OPER TECHN SPORT MED 2014. [DOI: 10.1053/j.otsm.2014.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bacle G, Marteau E, Freslon M, Desmoineaux P, Saint-Cast Y, Lancigu R, Kerjean Y, Vernet E, Fournier J, Corcia P, Le Nen D, Rabarin F, Laulan J. Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months. Orthop Traumatol Surg Res 2014; 100:S205-8. [PMID: 24721248 DOI: 10.1016/j.otsr.2014.03.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cubital tunnel syndrome is the second most frequent entrapment syndrome. Physiopathology is mixed, and treatment options are multiple, none having yet proved superior efficacy. OBJECTIVES The present retrospective multicenter study compared results and rates of complications and recurrence between the 4 main cubital tunnel syndrome treatments, to identify trends and optimize outcome. MATERIALAND METHODS Patients presenting with primary clinical cubital tunnel syndrome diagnosed on electroneuromyography were included and operated on using 1 of the following 4 techniques: open or endoscopic in situ decompression, or subcutaneous or submuscular anterior transposition. Four specialized upper-limb surgery centers participated, each systematically performing 1 of the above procedures. Subjective and objective results and rates of complications and recurrence were compared at end of follow-up. RESULTS Five hundred and two patients were included and 375 followed up for a mean 92 months (range, 9-144 months); 103 were lost to follow-up and 24 died. Whichever the procedure, more than 90% of patients were cured or showed improvement. There was a single case of scar pain at end of follow-up, managed by endoscopic decompression; there were no other long-term complications. None of the 4 techniques aggravated symptoms. There were 6 recurrences by end of follow-up: 1 associated with open in situ decompression and 5 with submuscular transposition. CONCLUSION Surgery was effective in treating cubital tunnel syndrome. Submuscular anterior transposition was associated with recurrence. In contrast to literature reports, subcutaneous anterior transposition, which is a reliable and valid technique, was not associated with a higher complication rate than in situ decompression. LEVEL OF EVIDENCE Level IV. Multicenter retrospective.
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Affiliation(s)
- G Bacle
- Service de Chirurgie Orthopédique 1 et 2, Unité de Chirurgie de la Main, Hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France.
| | - E Marteau
- Service de Chirurgie Orthopédique 1 et 2, Unité de Chirurgie de la Main, Hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France
| | - M Freslon
- Service de Chirurgie Orthopédique, CHU de Poitiers, 2, rue de la Milèterie, 86021 Poitiers, France
| | - P Desmoineaux
- Service de Chirurgie Orthopédique, CH de Versailles, 78157 Le Chesnay cedex, France
| | - Y Saint-Cast
- Centre de la Main, Angers Assistance Main, 49100 Angers, France
| | - R Lancigu
- Centre de la Main, Angers Assistance Main, 49100 Angers, France
| | - Y Kerjean
- Clinique Jeanne-d'Arc, Nantes Assistance Main, 44000 Nantes, France
| | - E Vernet
- Clinique Jeanne-d'Arc, Nantes Assistance Main, 44000 Nantes, France
| | - J Fournier
- Service de Chirurgie Orthopédique 1 et 2, Unité de Chirurgie de la Main, Hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France
| | - P Corcia
- Service d'Électroneuromyographie, Hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France
| | - D Le Nen
- Service de Chirurgie Orthopédique, Hôpital de la Cavale-Blanche, CHU de Brest, 29200 Brest, France
| | - F Rabarin
- Centre de la Main, Angers Assistance Main, 49100 Angers, France
| | - J Laulan
- Service de Chirurgie Orthopédique 1 et 2, Unité de Chirurgie de la Main, Hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France
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Abstract
With initiatives to decrease operative morbidity, complications, and associated costs, minimalincision techniques have found an expanding role within multiple specialties. Minimal-incision in situ open techniques for ulnar nerve release at the elbow provide adequate exposure and reproducible, satisfactory outcomes. Furthermore, there is no need for endoscopic equipment and the resultant dependence on staff adequately trained to operate and troubleshoot equipment. More robust research with a focus on complications and standard outcome measures will be required to further define the role of minimal-incision techniques. This technical modification, however, augments the increasing armamentarium of the hand surgeon.
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Affiliation(s)
- Joshua M. Adkinson
- Division of Plastic Surgery, Department of Surgery, Lehigh Valley Health Network, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18103-4689, USA
| | - Kevin C. Chung
- Section of Plastic Surgery, University of Michigan Medical School, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA,Corresponding author.
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Current Evidence for Effectiveness of Interventions for Cubital Tunnel Syndrome, Radial Tunnel Syndrome, Instability, or Bursitis of the Elbow. Clin J Pain 2013; 29:1087-96. [DOI: 10.1097/ajp.0b013e31828b8e7d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
This article discusses an alternative approach to general anesthesia with the use of local anesthesia in minor operating procedure suites when performing in situ decompression of cubital tunnel syndrome for those patients who have mild to moderately severe symptoms and for those who fail to respond to conservative measures. Anterior transposition can easily be performed in the same setting if indicated all with local anesthesia.
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25
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Shah CM, Calfee RP, Gelberman RH, Goldfarb CA. Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome. J Hand Surg Am 2013; 38:1125-1130.e1. [PMID: 23647638 PMCID: PMC3989882 DOI: 10.1016/j.jhsa.2013.02.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 02/15/2013] [Accepted: 02/21/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To prospectively analyze, using validated outcome measures, symptom improvement in patients with mild to moderate cubital tunnel syndrome treated with rigid night splinting and activity modifications. METHODS Nineteen patients (25 extremities) were enrolled prospectively between August 2009 and January 2011 following a diagnosis of idiopathic cubital tunnel syndrome. Patients were treated with activity modifications as well as a 3-month course of rigid night splinting maintaining 45° of elbow flexion. Treatment failure was defined as progression to operative management. Outcome measures included patient-reported splinting compliance as well as the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short Form-12. Follow-up included a standardized physical examination. Subgroup analysis included an examination of the association between splinting success and ulnar nerve hypermobility. RESULTS Twenty-four of 25 extremities were available at mean follow-up of 2 years (range, 15-32 mo). Twenty-one of 24 (88%) extremities were successfully treated without surgery. We observed a high compliance rate with the splinting protocol during the 3-month treatment period. Quick Disabilities of the Arm, Shoulder, and Hand scores improved significantly from 29 to 11, Short Form-12 physical component summary score improved significantly from 45 to 54, and Short Form-12 mental component summary score improved significantly from 54 to 62. Average grip strength increased significantly from 32 kg to 35 kg, and ulnar nerve provocative testing resolved in 82% of patients available for follow-up examination. CONCLUSIONS Rigid night splinting when combined with activity modification appears to be a successful, well-tolerated, and durable treatment modality in the management of cubital tunnel syndrome. We recommend that patients presenting with mild to moderate symptoms consider initial treatment with activity modification and rigid night splinting for 3 months based on a high likelihood of avoiding surgical intervention. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Chirag M Shah
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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Karthik K, Nanda R, Storey S, Stothard J. Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression. J Hand Surg Eur Vol 2012; 37:115-22. [PMID: 21914694 DOI: 10.1177/1753193411416426] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26-87) years. Through incisions ≤4 cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop's score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p = 0.01) and pinch grip (p = 0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.
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Affiliation(s)
- K Karthik
- Department of Orthopaedic Surgery, Queen Elizabeth Hospital, Woolwich, London, UK.
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Collis J. Ulnar neuropathy at the elbow: a review and single case cadaveric study. HAND THERAPY 2011. [DOI: 10.1258/ht.2011.011007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Ulnar neuropathy at the elbow (UNE) causes sensory and motor dysfunction of the ulnar nerve and can lead to permanent loss of hand function. Hand therapists frequently encounter this pathology and are required to be cognisant of symptoms, diagnosis, therapeutic and surgical management. A detailed understanding of the anatomical structures will give the therapist greater expertise in managing this pathology. Methods A single case cadaveric study was undertaken to investigate known sites of ulnar nerve compression and observe the mechanisms by which compression occurs. A literature review reports on knowledge relating to the pathology, diagnosis, therapeutic and surgical management of UNE. Results Anatomic structures compressing the ulnar nerve are the Arcade of Struthers, the medial intermuscular septum, the cubital tunnel and the deep flexor aponeurosis. UNE is attributable to mechanical compression from fibrous and bony structures at these sites and to traction on the ulnar nerve from elbow flexion. Provocative tests are a useful tool in the diagnosis of UNE but should be used cautiously due to limitations in statistical accuracy. Conservative treatment approaches of splintage, ergonomic adaptations, education and neural mobilizations lack high-quality evidence but may have benefit primarily for early or mild to moderate disease. There is some evidence in support of conservative management in longer standing disease. Discussion Therapists play an important role in the diagnosis and management of UNE and should have a sound understanding of the relevant anatomy, pathology, diagnosis and treatment. Conservative treatment may be efficacious for UNE but lacks evidence from randomized, controlled trials. Further research is needed to verify current precepts and traditional approaches.
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Affiliation(s)
- Julie Collis
- Auckland University of Technology, Auckland, New Zealand
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Friedrich JM, Robinson LR. Prognostic indicators from electrodiagnostic studies for ulnar neuropathy at the elbow. Muscle Nerve 2011; 43:596-600. [PMID: 21319168 DOI: 10.1002/mus.21925] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2010] [Indexed: 11/09/2022]
Abstract
INTRODUCTION We examined the prognostic value of electrodiagnostic (EDX) studies for ulnar neuropathy at the elbow (UNE). METHODS In this retrospective study, EDX results were compared with subjective recovery (resolution of symptoms) and surgery in patients diagnosed with UNE. RESULTS Of the 193 patients, 59 with "definite" UNE were included in the analysis. The combination of conduction block across the elbow to the first dorsal interosseous (FDI) and normal distal compound muscle action potential (CMAP) amplitude from the abductor digiti minimi (ADM) was strongly associated with recovery: 86% of these subjects achieved full subjective recovery compared to only 7% without conduction block and with an abnormal CMAP. There were no EDX predictors of surgery. CONCLUSION EDX results contain useful prognostic information in UNE.
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Affiliation(s)
- Jason M Friedrich
- Department of Rehabilitation Medicine, University of Washington, Box 356380, 1959 NE Pacific Street, Seattle, Washington 98195, USA
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Toussaint CP, Perry EC, Pisansky MT, Anderson DE. What's new in the diagnosis and treatment of peripheral nerve entrapment neuropathies. Neurol Clin 2011; 28:979-1004. [PMID: 20816274 DOI: 10.1016/j.ncl.2010.03.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Entrapment neuropathies can be common conditions with the potential to cause significant disability. Correct diagnosis is essential for proper management. This article is a review of recent developments related to diagnosis and treatment of various common and uncommon nerve entrapment disorders. When combined with classical peripheral nerve examination techniques, innovations in imaging modalities have led to more reliable diagnoses. Moreover, innovations in conservative and surgical techniques have been controversial as to their effects on patient outcome, but randomized controlled trials have provided important information regarding common operative techniques. Treatment strategies for painful peripheral neuropathies are also reviewed.
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Affiliation(s)
- Charles P Toussaint
- Department of Neurological Surgery, Loyola University Medical Center, 2160 South 1st Avenue, Maywood, IL 60153, USA
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Abstract
Cubital tunnel syndrome is the second most common nerve entrapment in the upper extremity. There are no current publications concerning the recurrence rates after endoscopic cubital tunnel release. The purpose of this study is to evaluate the recurrence rate of endoscopic cubital tunnel release compared to published reports of recurrence following open cubital tunnel procedures. We reviewed 134 consecutive cases of endoscopic cubital tunnel release in 117 patients. There were 104 cases in 94 patients with greater than 3 months follow-up. The mean follow-up time was 736 days. They were grouped using Dellon's classification. Two literature control groups were used from published reports of recurrence rate following open cubital tunnel release. A recurrence was identified if the patient was symptom-free following surgery but had symptoms reappear 3 months or more after surgery as defined in the literature. Of the 104 cases, 92.31% had more than a 4-month follow-up. One case (0.96%) met the criteria for recurrence at 4 months postprocedure. Data were then compared to the literature control groups used from published reports of recurrence rates following open cubital tunnel release. Pooled, the combined controls had 22 of 180 cases (12.22%) with recurrences. The percentage of procedure recurrence varied significantly with p value equal to 0.0004. It is recognized that there is a lack of common classification and comparative analysis of these studies, but they do classify preoperative grading and recurrence similarly. We are 95% confident that our true recurrence rate is between 0.02% and 5.24% and that endoscopic cubital tunnel release has a recurrence rate, which is not higher than open cubital tunnel release literature controls.
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Affiliation(s)
- Tyson K. Cobb
- Orthopaedic Specialists, 3385 Dexter Ct. Suite 300, Davenport, Iowa 52807 USA
| | - Patrick T. Sterbank
- Division of Hand Surgery, 3385 Dexter Ct. Suite 300, Davenport, Iowa 52807 USA
| | - Jon H. Lemke
- Genesis Health System, Suite 490, Pavilion 1, Genesis Central Park, 1401 West Central Park, Davenport, Iowa 52804 USA
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Submuscular versus subcutaneous anterior ulnar nerve transposition: a rat histologic study. J Hand Surg Am 2009; 34:1811-4. [PMID: 19897324 DOI: 10.1016/j.jhsa.2009.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/12/2009] [Accepted: 08/13/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE The 2 most common methods of ulnar nerve anterior transposition are submuscular and subcutaneous. Controversy exists as to which technique yields superior results. The purpose of this study was to examine the histologic differences between the 2 methods in a rat model. METHODS Twenty forelimbs in 10 adult Sprague-Dawley rats had bilateral ulnar nerve transpositions; one side with the submuscular method, and the other side with the subcutaneous method. Animals were killed 6 weeks after the index surgery and the forelimbs were examined for histologic evidence of the health of the axons and perineural scar formation. RESULTS Nerve health was assessed using a 4-part classification in which 4 = normal nerve, 3 = abnormal axons in one-third cross-sectional area (CSA), 2 = abnormal axons in two-thirds CSA, and 1 = abnormal axons in 100% CSA. Perineural scar formation was assessed using a 3-part classification in which 3 = scar completely encasing nerve, 2 = scar formation partially surrounding nerve, and 1 = no scar. The submuscular method displayed healthier ulnar nerve axons. In addition, the submuscular method displayed less perineural scar tissue. CONCLUSIONS On this basis of this rat model, the submuscular method of ulnar nerve anterior transposition displayed histologically healthier axons and less perineural scar tissue when compared to the subcutaneous method.
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Patient Education for the Treatment of Ulnar Neuropathy at the Elbow. Arch Phys Med Rehabil 2009; 90:1839-45. [DOI: 10.1016/j.apmr.2009.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Accepted: 06/09/2009] [Indexed: 11/22/2022]
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Bibliography. Current world literature. Obesity and nutrition. Curr Opin Endocrinol Diabetes Obes 2008; 15:470-5. [PMID: 18769222 DOI: 10.1097/med.0b013e328311f3cb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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