Treatment of ulnar neuropathy at the elbow: cost-utility analysis

Direct Economic Burden of Cubital Tunnel Surgery in the United States: Total Payments and Components of Cost

PURPOSE

Despite its widespread prevalence, the cost of cubital tunnel syndrome (CuTS) in the United States to patients and insurers is not well understood. The purpose of this study was to quantify the direct payments associated with operative treatment of CuTS. We hypothesized that CuTS represents a substantial cost to the payer in facility fees, surgeon fees and other expenses.

METHODS

Utilizing the MarketScan database of insured patients (commercial and Medicaid), we identified a cohort of 41,777 patients aged 18-64 years with surgically treated CuTS from 2006 to 2018. We estimated the median 90-day payments from encounters associated with cubital tunnel release (CuTR) and/or ulnar nerve transposition surgery by summing all payments for claims within 90 days after the index surgery. Published estimates of the annual number of cubital tunnel surgeries were used to calculate the annual expenditure.

RESULTS

Of 41,777 patients, the median (interquartile range [IQR]) values of total direct payments were $5,522 [$3,426, $9,541]. With an estimated 94,645 cases/year, this leads to an annual payment of more than $522 million. Index facility payments (median[IQR] $2,555 [$1,359, $4,708] were the highest, followed by index provider payments ($1,691 [$1,328, $2,217]). The median index surgeon payment (median[IQR] $905 [$707, $1,184]) represented just over half of the provider payments. Post-operative care had a median [IQR] payment of $377 ($424, $1,987). Limitations of claims databases prevented assessment of other indirect costs associated with cubital tunnel surgery.

CONCLUSIONS

Payments for the surgical treatment of CuTS from the index surgery to 90 days post-operatively have an estimated median of $5,522 per patient, totaling $52 million annually. Index facility fees are responsible for more than 46% of payments, while index payments to surgeons represent approximately 16%. Defining this data is critical to understanding one component of the economic impact of CuTS.

LEVEL OF EVIDENCE

Level IV.

Ulnar neuropathy

Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.

Cost of surgical treatment for ulnar nerve entrapment in Finland, 2011-2015: a registry-based cost description study

OBJECTIVES

The aim of this study was to evaluate the cost of surgical treatment for primary ulnar nerve entrapment (UNE) borne by the public sector in Finland.

DESIGN

Registry-based cost description study.

SETTING

Primary and secondary care throughout Finland.

PARTICIPANTS

We identified all the patients diagnosed with primary UNE in the whole population of Finland from 2011 to 2015 from the Care Register for Health Care. From these patients, we identified those who had undergone ulnar nerve release during the year they were diagnosed or the following year.

INTERVENTIONS

Open ulnar nerve release.

OUTCOME MEASURES

The primary outcome measure was cost borne by the public sector in 2015 euros. The cost of surgery was based on the diagnosis-related group prices. We calculated the cost of a single visit to a primary care physician, an electroneuromyography examination, a preoperative visit to a hand surgeon and a follow-up appointment by telephone in specialised care for each patient. These unit costs were provided by the Finnish Institute for Health and Welfare and the same costs were used for each patient. We obtained the number of reimbursed sick days and the total amount reimbursed to each patient in euros within the 2 years after diagnosis from the Social Insurance Institution of Finland.

RESULTS

During our study period, approximately 1786 primary UNE diagnoses were made yearly, and on average, 876 (49%) of patients received surgical treatment annually. The surgery-related cost per patient averaged at EUR 1341 (43%) and reimbursed sick leaves at EUR 952 (30%) during this period. The annual cost of surgical treatment for UNE borne by the public sector in Finland varied between EUR 3082 and EUR 3213 per patient.

CONCLUSIONS

The average cost of surgical treatment for UNE in Finland was EUR 3140 per patient between 2011 and 2015.

Understanding Health Economics in Hand Surgery

Rising health care costs in the United States, besides evolving payment models that place emphasis on value instead of volume, have led to an increasing number of studies evaluating hand surgery from an economic perspective. To better understand such economics-based studies, this review provides a foundational understanding of what value entails by defining its features of quality and cost. Principles of evaluating value through cost-benefit, cost-effectiveness, and cost-utility analyses are discussed. Models of discounting and clinical decision analyses are also discussed. Understanding such concepts and their evaluation in economic analyses will provide greater insight into the economic landscape of hand surgery and improving patient care.

Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve

PURPOSE

Patients with severe ulnar neuropathy at the elbow frequently experience suboptimal surgical outcomes. Clinical symptoms alone may not accurately represent the severity of underlying nerve injury, calling for objective assessment tools, such as electrodiagnostic studies. The goal of our study was to determine whether specific electrodiagnostic parameters can be used to predict the outcomes after in situ decompression of the ulnar nerve.

METHODS

This prospective study enrolled consecutive patients aged ≥18 years diagnosed with ulnar neuropathy at the elbow. Patients completed a baseline battery of motor, sensory, functional, and electrodiagnostic tests before undergoing in situ decompression of the ulnar nerve. They were reassessed at 6 weeks, 3 months, 6 months, and 12 months after surgery. Forty-two patients completed at least 2 follow-up assessments and were included in the study.

RESULTS

When controlling for other electrodiagnostic measurements and demographic factors, none of the electrodiagnostic parameters were predictive of outcomes at 12 months after surgery. Patients with decreased compound muscle action potential amplitudes demonstrated slower trends of recovery in grip strength, pinch strength, and overall scores on the Michigan Hand Outcomes Questionnaire as well as its function, work, and activities of daily living subscales, Disabilities of the Arm, Shoulder, and Hand questionnaire, and the Carpal Tunnel Questionnaire. Decreased motor nerve conduction velocity was predictive of slower recovery of 2-point discrimination and pinch strength.

CONCLUSIONS

Compound muscle action potential amplitude, but not other conventional electrodiagnostic parameters, was predictive of functional outcomes after in situ decompression of the ulnar nerve. This parameter should play a role in determining the timing and prognosis of treatment for ulnar neuropathy at the elbow.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A Systematic Review of Health State Utility Values in the Plastic Surgery Literature

Cost-utility analyses assess health gains acquired by interventions by incorporating weighted health state utility values (HSUVs). HSUVs are important in plastic and reconstructive surgery (PRS) because they include qualitative metrics when comparing operative techniques or interventions. We systematically reviewed the literature to identify the extent and quality of existing original utilities research within PRS.

Methods

A systematic review of articles with original PRS utility data was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis guidelines. Subspecialty, survey sample size, and respondent characteristics were extracted. For each HSUV, the utility measure [direct (standard gamble, time trade off, visual analog scale) and/or indirect], mean utility score, and measure of variance were recorded. Similar HSUVs were pooled into weighted averages based on sample size if they were derived from the same utility measure.

Results

In total, 348 HSUVs for 194 disease states were derived from 56 studies within seven PRS subspecialties. Utility studies were most common in breast (n = 17, 30.4%) and hand/upper extremity (n = 15, 26.8%), and direct measurements were most frequent [visual analog scale (55.4%), standard gamble (46.4%), time trade off (57.1%)]. Studies surveying the general public had more respondents (n = 165, IQR 103-299) than those that surveyed patients (n = 61, IQR 48-79) or healthcare professionals (n = 42, IQR 10-109). HSUVs for 18 health states were aggregated.

Conclusions

The HSUV literature within PRS is scant and heterogeneous. Researchers should become familiar with these outcomes, as integrating utility and cost data will help illustrate that the impact of certain interventions are cost-effective when we consider patient quality of life.

Long-term Reoperation Rate for Cubital Tunnel Syndrome: Subcutaneous Transposition Versus In Situ Decompression

Background: The purpose of this study was to compare the long-term revision rate of in situ ulnar nerve decompression with anterior subcutaneous transposition surgery for idiopathic cubital tunnel syndrome. Methods: This retrospective, multicenter, cohort study compared patients who underwent ulnar nerve surgery with a minimum 5 years of follow-up. The primary outcome studied was the need for revision cubital tunnel surgery. In total, there were 132 cases corresponding to 119 patients. The cohorts were matched for age and comorbidity. Results: The long-term reoperation rate for in situ decompression was 25% compared with 12% for anterior subcutaneous transposition. Seventy-eight percent of revisions of in situ decompression were performed within the first 3 years. Younger age and female sex were identified as independent predictors of need for revision. Conclusions: In the long-term follow-up, in situ decompression is seen to have a statistically significant higher reoperation rate compared with subcutaneous transposition.

A Cost-Effectiveness Analysis of Corticosteroid Injections and Open Surgical Release for Trigger Finger

PURPOSE

To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger.

METHODS

Using a US health care payer perspective, we created a decision tree model to estimate the costs and outcomes associated with 4 treatment strategies for trigger finger: offering up to 3 steroid injections before to surgery or immediate open surgical release. Costs were obtained from a large administrative claims database. We calculated expected quality-adjusted life-years for each treatment strategy, which were compared using incremental cost-effectiveness ratios. Separate analyses were performed for commercially insured and Medicare Advantage patients. We performed a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations that simultaneously sampled from the uncertainty distributions of all model inputs.

RESULTS

Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively.

CONCLUSIONS

Multiple treatment strategies exist for treating trigger finger, and our cost-effectiveness analysis helps define the relative value of different approaches. From a health care payer perspective, offering 3 steroid injections before surgery is a cost-effective strategy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analyses II.

Cubital tunnel syndrome: a surgical modification to in situ decompression to improve results

BACKGROUND

The gold standard for surgical treatment of cubital tunnel syndrome is in situ decompression. However, this procedure does not come without complications. Subluxation of the ulnar nerve and ulnar nerve neuritis from adhesion formation remain 2 potential complications after this procedure. It has been shown in the literature that young, active, male patients are most likely to have these complications postoperatively. We have developed a modification to in situ decompression by developing a fascial turnover flap and using a porcine submucosa extracellular matrix (Axogen) to help reduce both ulnar nerve subluxation and adhesion formation postoperatively.

METHODS

Thirteen patients underwent cubital tunnel surgery by the highlighted technique to prevent postoperative ulnar nerve subluxation and adhesion formation. Patient outcomes including elbow range of motion, functional status, paresthesia, and grip strength were recorded.

RESULTS

Of the 13 patients, 10 had excellent results, 1 had a good result, and 2 required revision with anterior transposition of the nerve. The mean Mayo Elbow Performance Score of the 11 patients not needing revision was 92.7.

CONCLUSION

The described surgical technique provides surgeons with the ability to directly decompress the ulnar nerve while decreasing postoperative complications such as instability and adhesion formation.

Features of the Ulnar Nerve Predicting Postoperative Prognosis in Idiopathic Cubital Tunnel Syndrome: Three Distinct Features of the Ulnar Nerve

PURPOSE

This retrospective case-control study was performed to determine the relationships between features of the ulnar nerve and postoperative outcomes following in situ decompression in idiopathic cubital tunnel syndrome (CuTS).

METHODS

The study population consisted of 86 patients who had undergone surgery for CuTS. We evaluated demographic factors, hand dominance, symptom onset time, time from diagnosis to surgery, findings of electrodiagnosis (nerve conduction velocity/electromyography), and preoperative clinical status. Intraoperatively, the ulnar nerve was defined as a definitively compressed, abnormally enlarged, or inflammatory lesion. Clinical improvements were evaluated at least 2 years after surgery.

RESULTS

Fifty-four patients showed improvement after surgery in terms of the modified McGowan grade and were designated as group 1. Meanwhile, 32 patients with unchanged or aggravated status were classified as group 2. Preoperative status, as determined by the modified McGowan grade, Boston Symptom Severity Scale score, severity of electrodiagnosis, and predominant symptoms were similar between the groups (all, P > 0.05). On regression analysis, only the classification of nerve lesions and the time from diagnosis to surgery had an impact on postoperative outcome (all, P < 0.05). Especially, enlarged ulnar lesion predicted poor prognosis (P = 0.003).

CONCLUSIONS

Ulnar nerve enlargement, grossly detected intraoperatively, and long interval between diagnosis and surgery were independently associated with poor prognosis of CuTS. Among the anatomic structures involved in the generation of CuTS, the medial epicondyle showed a strong association with enlarged nerve lesions.

Cost-Effectiveness Analysis of Combined Dual Motor Nerve Transfers versus Alternative Surgical and Nonsurgical Management Strategies to Restore Shoulder Function Following Upper Brachial Plexus Injury

BACKGROUND

Restoration of shoulder function is an important treatment goal in upper brachial plexus injury (UBPI). Combined dual motor nerve transfer (CDNT) of spinal accessory to suprascapular and radial to axillary nerves demonstrates good functional recovery with minimal risk of perioperative complications.

OBJECTIVE

To evaluate the cost-effectiveness of CDNT vs alternative operative and nonoperative treatments for UBPI.

METHODS

A decision model was constructed to evaluate costs ($, third-party payer) and effectiveness (quality-adjusted life years [QALYs]) of CDNT compared to glenohumeral arthrodesis (GA), conservative management, and nontreatment strategies. Estimates for branch probabilities, costs, and QALYs were derived from published studies. Incremental cost-effectiveness ratios (ICER, $/QALY) were calculated to compare the competing strategies. One-way, 2-way, and probabilistic sensitivity analyses with 100 000 iterations were performed to account for effects of uncertainty in model inputs.

RESULTS

Base case model demonstrated CDNT effectiveness, yielding an expected 21.04 lifetime QALYs, compared to 20.89 QALYs with GA, 19.68 QALYs with conservative management, and 19.15 QALYs with no treatment. The ICERs for CDNT, GA, and conservative management vs nontreatment were $5776.73/QALY, $10 483.52/QALY, and $882.47/QALY, respectively. Adjusting for potential income associated with increased likelihood of returning to work after clinical recovery demonstrated CDNT as the dominant strategy, with ICER = -$56 459.54/QALY relative to nontreatment. Probabilistic sensitivity analysis showed CDNT cost-effectiveness at a willingness-to-pay threshold of $50 000/QALY in 78.47% and 81.97% of trials with and without income adjustment, respectively. Conservative management dominated in <1% of iterations.

CONCLUSION

CDNT and GA are cost-effective interventions to restore shoulder function in patients with UBPI.

The Triceps Traction Test: A Decision Tool for the Choice of Stabilizing Flap After In Situ Decompression of the Ulnar Nerve

PURPOSE

Recent evidence demonstrates that in situ decompression has comparable outcomes to other surgical techniques for cubital tunnel syndrome. However, this technique does not address the instability of the ulnar nerve, a common indication to transpose the ulnar nerve. Transposition of the ulnar nerve can potentially devascularize the ulnar nerve, stabilizing flaps block subluxation of the ulnar nerve and thereby negate the need for transposition. Flaps originating from the triceps and the flexor-pronator fascia could be used to stabilize the ulnar nerve. Herein, we present a novel intraoperative test, the "triceps traction test" and our algorithm for choosing a stabilizing flap when ulnar nerve instability is encountered after in situ decompression.

Comparison of Surgical Encounter Direct Costs for Three Methods of Cubital Tunnel Decompression

BACKGROUND

In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors' null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition.

METHODS

Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution's information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression.

RESULTS

In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider.

CONCLUSIONS

Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.

Cost-Effective Management of Stenosing Tenosynovitis

PURPOSE

Stenosing tenosynovitis (STS) is a common condition treated by hand surgeons. Limited evidence exists to support the nonsurgical management of STS. The purpose of this study was to prospectively evaluate a cohort of patients with STS, and to determine the strategy for treating patients with this condition that is most cost effective in terms of dollars reimbursed by payers.

METHODS

Prospective data were collected on patients diagnosed with STS between March 2014 and September 2014. All patients were initially treated with a corticosteroid injection. Patients with persistent symptoms were given the option of injection or surgery. A maximum of 3 injections were offered. All patients were evaluated every 6 months through office appointments or phone calls. A cost analysis was performed in our cohort using actual reimbursement rates for injections, initial and established patient visits, and facility and physician fees for surgery, using the reimbursement rates from the 6 payers covering this patient cohort. Cost savings were calculated based on offering 1, 2, and 3 injections.

RESULTS

Eighty-eight digits in 82 patients were followed for an average of 21.9 months (range, 18.7-22.7 mo) after an initial corticosteroid injection. Thirty-five digits went on to surgical release, whereas 53 digits were treated nonsurgically. Had all patients initially undergone surgery, the cost would have totaled $169,088.98 ($1,921 per digit). Offering up to 3 injections yielded a potential savings of $72,730 ($826 per digit) or 43% of the total cost. For the 33 patients who underwent more than 1 injection, offering a second injection yielded potential savings of $15,956 ($484 per digit, 22.7%), and for the 7 patients presenting a third time, a third injection saved $1,986 ($283 per digit, 14.5%).

CONCLUSIONS

Based on the data from our cohort, the efficient way to treat STS in terms of health care dollars spent is to offer up to 3 injections before surgical release. The first injection had the highest component of cost savings, at $826 per digit.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

Cost-utility studies in upper limb orthopaedic surgery: a systematic review of published literature

AIMS

The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery.

MATERIALS AND METHODS

We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale.

RESULTS

The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding.

CONCLUSION

It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416-23.

Predictors of surgical outcomes after in situ ulnar nerve decompression for cubital tunnel syndrome

Background

In the treatment of cubital tunnel syndrome (CuTS), in situ ulnar nerve decompression is commonly used. This study aims to investigate predictive factors for poor recovery and ulnar nerve instability following this procedure.

Methods

We enrolled 235 patients who underwent in situ ulnar nerve decompression for the treatment of CuTS from January 2010 to December 2014. All patients underwent >2 years' follow-up. The primary outcome was postoperative recovery, which was assessed by Messina's criteria, and the secondary outcome was postoperative ulnar nerve instability. Potential risk factors were collected from demographic data and electrodiagnostic test, which included age, gender, body mass index, history of tobacco or alcohol use, history of major medical comorbidities, disease duration, preoperative severity, motor conduction velocity, and sensory conduction velocity.

Results

A total of 208 patients (88.5%) had satisfactory outcomes, while the other 27 patients (11.5%) had not. There were 25 patients (10.6%) showing postoperative ulnar nerve instability during follow-up. The multivariate analysis showed that only severe preoperative symptom (odds ratio [OR], 3.06; 95% confidence interval [CI], 2.16-4.32) was associated with unsatisfactory postoperative outcomes in patients with CuTS (P<0.001). In the model investigating independent factors associated with postoperative ulnar nerve instability, we found that young age (OR, 2.41; 95% CI, 1.63-3.58) was associated with the incidence of postoperative ulnar nerve instability (P<0.001).

Conclusion

We found that severe preoperative symptom was associated with unsatisfactory postoperative outcomes, and young age was a risk factor for the incidence of postoperative ulnar nerve instability. Patients with these risk factors should be informed of the possibility of worse surgical outcomes.

A systematic review of medial epicondylectomy as a surgical treatment for cubital tunnel syndrome

The aim of this study was to review the literature of decompression of the cubital tunnel with medial epicondylectomy and to assess outcomes and complications. Twenty-one case series reported on 886 medial epicondylectomies. The mean percentage of patients obtaining improvement of one or more McGowan grade was 79%. The mean percentage obtaining a good/excellent Wilson Krout grade of outcome was 83%. Of six comparative studies, two showed no significant differences in outcomes between medial epicondylectomy and transposition procedures, and three reported better outcomes with medial epicondylectomy. One reported similar outcomes with medial epicondylectomy and simple decompression. The existing literature on medial epicondylectomy is of limited methodological quality and does not allow for firm conclusions to be drawn regarding its efficacy compared with other surgical techniques. Further studies should aim for high methodological quality, randomized comparison with simple decompression or anterior transposition and should utilize standardized outcome measures.

LEVEL OF EVIDENCE

II.

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion

OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurological function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with the authors' most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness-to-pay threshold of $50,000/QALY gained. CONCLUSIONS The authors' model demonstrates that ulnar and median nerve transfers for upper brachial plexus injury improves QALY in a cost-effective manner.

Treatment for ulnar neuropathy at the elbow

BACKGROUND

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical, but optimal management remains controversial. This is an update of a review first published in 2010 and previously updated in 2012.

OBJECTIVES

To determine the effectiveness and safety of conservative and surgical treatment in ulnar neuropathy at the elbow (UNE). We intended to test whether:- surgical treatment is effective in reducing symptoms and signs and in increasing nerve function;- conservative treatment is effective in reducing symptoms and signs and in increasing nerve function;- it is possible to identify the best treatment on the basis of clinical, neurophysiological, or nerve imaging assessment.

SEARCH METHODS

On 31 May 2016 we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL Plus, and LILACS. We also searched PEDro (14 October 2016), and the papers cited in relevant reviews. On 4 July 2016 we searched trials registries for ongoing or unpublished trials.

SELECTION CRITERIA

The review included only randomised controlled clinical trials (RCTs) or quasi-RCTs evaluating people with clinical symptoms suggesting the presence of UNE. We included trials evaluating all forms of surgical and conservative treatments. We considered studies regarding therapy of UNE with or without neurophysiological evidence of entrapment.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The review authors independently extracted data from included trials and assessed trial quality. We contacted trial investigators for any missing information.

MAIN RESULTS

We identified nine RCTs (587 participants) for inclusion in the review, of which three studies were found at this update. The sequence generation was inadequate in one study and not described in three studies. We performed two meta-analyses to evaluate the clinical (3 trials, 261 participants) and neurophysiological (2 trials, 101 participants) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition; four trials in total examined this comparison.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08; moderate-quality evidence) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). The number of participants to clinically improve was 91 out of 131 in the simple decompression group and 97 out of 130 in the transposition group. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85; moderate-quality evidence).In one trial (47 participants), the authors compared medial epicondylectomy with anterior transposition and found no difference in clinical and neurophysiological outcomes.In one trial (48 participants), the investigators compared subcutaneous transposition with submuscular transposition and found no difference in clinical outcomes.In one trial (54 participants for 56 nerves treated), the authors found no difference between endoscopic and open decompression in improving clinical function.One trial (51 participants) assessed conservative treatment in clinically mild or moderate UNE. Based on low-quality evidence, the trial authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to information provision did not result in further improvement.One trial (55 participants) assessed the effectiveness of corticosteroid injection and found no difference versus placebo in improving symptoms at three months' follow-up.

AUTHORS' CONCLUSIONS

We found only two studies of treatment of ulnar neuropathy using conservative treatment as the comparator. The available comparative treatment evidence is not sufficient to support a multiple treatment meta-analysis to identify the best treatment for idiopathic UNE on the basis of clinical, neurophysiological, and imaging characteristics. We do not know when to treat a person with this condition conservatively or surgically. Moderate-quality evidence indicates that simple decompression and decompression with transposition are equally effective in idiopathic UNE, including when the nerve impairment is severe. Decompression with transposition is associated with more deep and superficial wound infections than simple decompression, also based on moderate-quality evidence. People undergoing endoscopic surgery were more likely to have a haematoma. Evidence from one small RCT of conservative treatment showed that in mild cases, information on movements or positions to avoid may reduce subjective discomfort.

Simultaneous Bilateral Versus Staged Bilateral Carpal Tunnel Release: A Cost-effectiveness Analysis

The purpose of this study was to determine if simultaneous bilateral carpal tunnel release (CTR) is a cost-effective strategy compared with bilateral staged CTR for the treatment of bilateral carpal tunnel syndrome.

METHODS

A decision analytic model was created to compare the cost effectiveness of three strategies (ie, bilateral simultaneous CTR, bilateral staged CTR, and no treatment). Direct medical costs were estimated from 2013 Medicare reimbursement rates and wholesale drug costs in US dollars. Indirect costs were derived from consecutive patients undergoing unilateral or simultaneous bilateral CTR at our institution and from national average wages for 2013. Health state utility values were derived from a general population of volunteers using the Short Form-6 dimensions (SF-6D) health questionnaire.

RESULTS

Both surgical strategies were cost effective compared with the no-treatment strategy. Bilateral simultaneous CTR had lower total costs and higher total effectiveness than bilateral staged CTR, and had an incremental cost-effectiveness ratio of $921 per quality-adjusted life year compared with the no-treatment strategy. The conclusions of the analysis remained unchanged though all sensitivity analyses, displaying robustness against parameter uncertainty.

CONCLUSIONS

Surgical management is cost effective for the treatment of bilateral carpal tunnel syndrome. Bilateral simultaneous CTR, however, has lower total costs and higher total effectiveness compared with bilateral staged CTR.

LEVEL OF EVIDENCE

Economic and Decision Analysis I.

Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome

BACKGROUND

Medial epicondylectomy (ME) is one of several accepted surgical options for the treatment of cubital tunnel syndrome (CuTS). Although reported outcomes after ME are generally favorable, few data exist regarding which patients are prone to poorer outcomes requiring revision surgery. The goal of this study was to identify risk factors predicting the need for revision surgery after ME for the treatment of CuTS.

METHODS

We conducted a retrospective chart review of all patients treated at our institution with ME for CuTS from 2006 through 2011. We identified patients who underwent additional operations for recurrent or persistent ulnar nerve symptoms as the revision cohort. We performed bivariate analysis to determine which variables had a significant influence on the need for revision surgery. We examined qualitative factors associated with revision, including the degree of bony resection performed during the index ME, and intraoperative findings at the time of revision surgery.

RESULTS

Revision surgery was required in 13.3% of cases (11 of 83). On bivariate analysis, younger age, associated workers' compensation claims, lesser disease severity, and preoperative opioid use were all significant predictors of the need for revision surgery. Perineural scarring and heterotopic bone formation about the elbow were the 2 most common findings at the time of revision.

CONCLUSIONS

For patients with CuTS, the risk of revision surgery after ME is higher in younger patients, patients with less severe disease, patients taking opioid medications preoperatively, and patients with associated workers' compensation claims.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Predicting Revision Following In Situ Ulnar Nerve Decompression for Patients With Idiopathic Cubital Tunnel Syndrome

PURPOSE

To determine the incidence of revision and potential risk factors for needing revision surgery following in situ ulnar nerve decompression for patients with idiopathic cubital tunnel syndrome (CTS).

METHODS

We conducted a retrospective chart review of all patients treated at 1 specialty hand center with an open in situ ulnar nerve decompression for idiopathic CTS from January 2006 through December 2010. Revision incidence was determined by identifying patients who underwent additional surgeries for recurrent or persistent ulnar nerve symptoms. Bivariate analysis was performed to determine which variables had a significant influence on the need for revision surgery.

RESULTS

Revision surgery was required in 3.2% (7 of 216) of all cases. Age younger than 50 years at the time of index decompression was the lone significant predictor of need for revision surgery. Other patient factors, including gender, diabetes, smoking history, and workers' compensation status were not predictive of the need for revision surgery. Disease-specific variables including nerve conduction velocities, McGowan grading, and predominant symptom type were also not predictive of revision.

CONCLUSIONS

For patients with idiopathic CTS, the risk of revision surgery following in situ ulnar nerve decompression is low. However, this risk was increased in patients who were younger than 50 years at the time of the index procedure. The findings of this study suggest that, in the absence of underlying elbow arthritis or prior elbow trauma, in situ ulnar nerve decompression is an effective, minimal-risk option for the initial surgical treatment of CTS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Risk Factors for Ulnar Nerve Instability Resulting in Transposition in Patients With Cubital Tunnel Syndrome

PURPOSE

To assess the incidence of ulnar nerve instability in patients undergoing in situ decompression and to identify preoperative risk factors to predict the need for transposition.

METHODS

Using our surgical database, we retrospectively identified 363 patients who were candidates for in situ ulnar nerve decompression for the treatment of cubital tunnel syndrome over a 5-year period. During this time, the 3 participating surgeons considered ulnar nerve instability to be a contraindication for in situ ulnar nerve decompression. We collected demographic data including sex, age, weight, height, and body mass index. We recorded the number of patients who underwent ulnar nerve transposition owing to ulnar nerve instability and evaluated whether ulnar nerve instability was diagnosed before, during, or after surgery.

RESULTS

Of the 363 patients who were considered for in situ ulnar nerve decompression, 76 patients (21%) underwent ulnar nerve transposition secondary to ulnar nerve instability. Twenty-nine patients (8%) were identified with instability before surgery, and 44 patients (12%) were identified with instability during surgery following in situ decompression. Three patients (1%) were not diagnosed with instability until after surgery and subsequently underwent secondary transposition. Patients who underwent transposition owing to instability were more likely to be male and to be younger.

CONCLUSIONS

A notable percentage of patients with a stable nerve before surgery will have ulnar nerve instability following decompression. Identification of factors correlating to instability and the potential need for transposition can aid surgeons and patients in preoperative planning.

Predictors of surgical revision after in situ decompression of the ulnar nerve

BACKGROUND

This study was performed to identify factors associated with the need for revision surgery after in situ decompression of the ulnar nerve for cubital tunnel syndrome.

METHODS

This case-control investigation examined all patients treated at one institution with open in situ decompression for cubital tunnel syndrome between 2006 and 2011. The case patients were 44 failed decompressions that required revision, and the controls were 79 randomly selected patients treated with a single operation. Demographic data and disease-specific data were extracted from the medical records. The rate of revision surgery after in situ decompression was determined from our 5-year experience. A multivariate logistic regression model was used based on univariate testing to determine predictors of revision cubital tunnel surgery.

RESULTS

Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period. Predictors of revision surgery included a history of elbow fracture or dislocation (odds ratio [OR], 7.1) and McGowan stage I disease (OR, 3.2). Concurrent surgery with in situ decompression was protective against revision surgery (OR, 0.19).

DISCUSSION

The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery.

Setting expectations following endoscopic cubital tunnel release

BACKGROUND

The objective was to evaluate recovery characteristics of patients undergoing endoscopic cubital tunnel release (ECuTR) by determining the following: (1) return to work (RTW) times following ECuTR compared with RTW times of patients that underwent anterior transposition of the ulnar nerve (ATUN), (2) satisfaction rates and factors affecting satisfaction, (3) resolution rates of common preoperative complaints and findings, and (4) effect of preoperative ulnar nerve subluxation on postoperative outcomes.

METHODS

A total of 172 cases in 148 patients undergoing ECuTR were prospectively enrolled including 56 women and 92 men. Kaplan-Meier analyses were performed to determine RTW time for ECuTR patients and for a cohort of 15 patients that underwent ATUN. Patients were evaluated for subjective and objective complaints preoperatively and postoperatively. Cases were grouped by Dellon's classification preoperatively and modified by Bishop's postoperatively.

RESULTS

Half of ECuTR patients returned to normal work within 8 days postoperatively versus 71 days following ATUN. Variables significantly negatively affecting RTW were male sex, manual labor, and worker's compensation status. Dellon's was the best predictor of postoperative satisfaction. Complete resolution of symptoms occurred in 86 % of patients for weakness, 81 % for pain, 79 % for numbness and tingling (N/T), 78 % for atrophy, 76 % for abnormal two-point discrimination, and 65 % for Wartenberg's. Preoperative ulnar nerve subluxation had no effect on outcome.

CONCLUSIONS

Improved RTW time following ECuTR versus ATUN indicates potential and substantial cost-saving implications with respect to reduced worker productivity loss. Patients with more severe preoperative Dellon's classification can expect less optimal results regarding postoperative satisfaction and resolution rates of N/T and pain.

Quality assessment in hand surgery

Measuring quality assessment in hand surgery remains an underexplored area. However, measuring quality is becoming increasingly transparent and important. Patients now have direct access to hospital and physician metrics and large payers have linked financial incentives to quality metrics. It is critical for hand surgeons to understand the essential elements of quality and its assessment. This article reviews several areas of hand surgery quality assessments including safety, outcomes, satisfaction, and cost.

Minimal-incision in situ ulnar nerve decompression at the elbow

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.