Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months

Revision surgery for recurrent ulnar nerve compression following failed subcutaneous transposition : Author list

BACKGROUND

Recurrent ulnar nerve compression after primary anterior subcutaneous transposition is relatively rare, and revision surgery is challenging. This study retrospectively evaluated the clinical outcomes of revision anterior subcutaneous transposition for recurrent ulnar nerve compression.

METHODS

Eight patients who underwent revision anterior subcutaneous transposition for recurrent ulnar nerve compression were enrolled in this study. The outcomes were based on preoperative and postoperative symptoms, physical examination findings, and electromyographic evaluation.

RESULTS

Ulnar nerve enlargement was preoperatively found in all patients with a mean cross sectional area of 0.15 cm2 (range, 0.14-0.18 cm2). Intraoperative findings showed that recurrent compression occurred in three areas, including the medial intermuscular septum (n = 5), the medial epicondyle (n = 6) and nerve entrance to forearm fascia (n = 1). Post-operation, significant improvements were observed in ring/little finger numbness (from severe to mild, p = 0.031), grip strength (from 48.00% to 80.38% of the intact side, p < 0.001) and McGowan grade (from Grade III to Grade I, p = 0.049). Postoperative electromyography test also showed significant improvement in motor nerve conduction at elbow (velocity, 23.30 ± 9.598 vs. 35.30 ± 9.367, p = 0.012; amplitude, 3.40 ± 3.703 vs. 5.65 ± 2.056, p = 0.007) and sensory nerve conduction at wrist (velocity, 27.04 ± 22.450 vs. 36.45 ± 18.099, p = 0.139; amplitude, 1.44 ± 1.600 vs. 4.00 ± 2.642, p = 0.011). Seven of the eight patients reported satisfaction with the postoperative results.

CONCLUSIONS

Revision anterior subcutaneous transposition was an effective treatment for recurrent ulnar nerve compression from prior failed procedures.

Morphological Characteristics of the Cubital Tunnel as Indication for Anterior Interosseous Nerve Supercharge End-to-Side Transfer in Treating Advanced Cubital Tunnel Syndrome

BACKGROUND

Cubital tunnel syndrome (CuTS) is a prevalent compressive neuropathy addressed through various treatments, including the anterior interosseous nerve (AIN) supercharge end-to-side (SETS) transfer for advanced CuTS. Decision to add AIN-SETS is based on various indicators and protocols, but deciding on the appropriate method for borderline cases can be challenging. Therefore, this study aims to non-invasively examine the cubital tunnel anatomy of patients using CT scans and compare the findings with existing indicators and measurements, to determine if they can serve as supplementary indicators to aid in treatment decisions.

HYPOTHESIS

The bony cubital tunnel volume is correlated to other traditional indicators and can be used as an additional indication for deciding whether to perform AIN-SETS in treating advanced CuTS.

PATIENTS AND METHODS

This is a single-center retrospective cohort study from South Korea, including 91 patients aged 20-70 years with CuTS. Participants were classified into Group A (n = 43), who underwent both cubital tunnel release (CuTR) and AIN-SETS, and Group B (n = 48), who underwent only CuTR. Preoperative elbow CT data were analyzed for cubital tunnel morphology analysis, with follow-up assessments such as grip strength and electromyography/ nerve conduction velocity (EMG/NCV) tests at 3,6, and 12 months postoperatively.

RESULTS

Group A and B showed no significant differences in demographic parameters, except for a longer disease duration in Group A (p = 0.032). Group A had a smaller cubital tunnel volume (CTV) compared to Group B (1150.6 ± 52.8 mm³ vs. 1173.5 ± 56.2 mm³, p = 0.014) and a smaller cross-sectional area (40.9 ± 10.2 mm² vs. 45.1 ± 11.7 mm², p = 0.033). Pearson correlation analysis revealed statistically significant positive correlations between CTV measurements and pre-operative grip strength, as well as EMG results, a key indicator for AIN-SETS (R² = 0.48, 0.23, p = 0.01).

DISCUSSION

Measuring the cubital tunnel anatomy using CT can aid in determining the treatment approach for advanced CuTS patients and assist in deciding whether to perform AIN-SETS surgery, serving as a supplementary indicator for cases at the borderline limits of other indicators. Future research may be necessary to establish control groups without symptoms and determine appropriate cut-off values.

LEVEL OF EVIDENCE

IV.

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

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

State of the art review. Upper extremity revision nerve compression surgery

Although surgical release of upper extremity nerve compression syndromes is highly effective, persistence or recurrence of symptoms and signs may occur. Thorough investigation is necessary in this situation before treatment is recommended. If the symptoms cannot be explained by other pathology than compression of the affected nerve and if conservative management has not provided improvement, reoperation may be considered. This review provides an overview of the diagnostic and surgical considerations in the revision of carpal tunnel syndrome, cubital tunnel syndrome and thoracic outlet syndrome.Level of evidence: V.

Endoscopic Versus Open In Situ Decompression for the Management of Cubital Tunnel Syndrome

This study compared the results of endoscopic cubital tunnel release (eCuTR) with those of open cubital tunnel release (oCuTR) for the management of cubital tunnel syndrome (CuTS). In this retrospective study, 35 patients underwent eCuTR or oCuTR. Group I and group II consisted of 16 patients undergoing eCuTR and 19 patients undergoing oCuTR, respectively. Patients were asked to report paresthesia and pain, and electromyography was performed. The Dellon and Bishop classifications were used. The Disabilities of the Arm, Shoulder and Hand (DASH) and visual analog scale (VAS) pain scores were recorded, as well as the key pinch strength and two-point discrimination. The incision length and operation duration were noted. The mean follow-up was 39 months. The mean operating time was longer in the endoscopy group (43 vs 22 minutes). Overall, 34.3% (n=12) of the cases were classified as Dellon grade II and 65.7% (n=23) were classified as Dellon grade III. According to the Bishop score, excellent or good results were obtained for 75% of the patients in the eCuTR group and 78.9% of the patients in the oCuTR group. In the eCuTR and oCuTR groups, all outcome measures improved after surgery: DASH score (preoperative, 37.7 vs 30.7; postoperative, 15.4 vs 20), VAS score (preoperative, 7.8 vs 7.3; postoperative, 4.3 vs 4.1), pinch strength (preoperative, 74 vs 66; postoperative, 93 vs 84), and two-point discrimination (preoperative, 5.6 vs 6.6; postoperative, 4.9 vs 4.5). No significant difference was apparent between the two techniques in outcomes. However, the endoscopic release had a higher reoperation rate and took twice as long to perform despite having a shorter incision. [Orthopedics. 2024;47(3):e119-e124.].

Recurrence of ulnar tunnel syndrome: Long-term clinical and functional results of surgical management using revision neurolysis and subcutaneous anterior transposition

OBJECTIVE

Recurrence after primary ulnar tunnel syndrome surgery is observed in 1.4%-25% of patients. However, the outcome of revision surgery is uncertain and limited. This study aimed to assess the clinical and functional outcomes of neurolysis combined with anterior subcutaneous transposition in cases of recurrence.

PATIENTS AND METHODS

This retrospective single-center study included patients who were operated on for iterative ulnar tunnel syndrome at the elbow between January 1996 and December 2020, with a minimum follow-up of 24 months. Demographic data, pre- and post-operative clinical evaluations, surgical details, and satisfaction levels were collected.

RESULTS

Twenty-eight patients were reviewed. Mean follow-up was 11.7 years (range, 2.1-26.4 years). The secondary procedure led to significant improvement in mean Quick-DASH score, from 25.3 (range, 11-50) to 20.0 (range, 11-49) (p = 0.023), with a satisfaction rate of 78.5%. Symptoms of pain (p = 0.033), amyotrophy (p = 0.013), hypoesthesia (p < 0.01), and paresthesia (p < 0.001) also showed significant improvement. There were 7 cases of failure (25.0%).

CONCLUSION

The combination of neurolysis and anterior subcutaneous transposition was a reliable technique, improving clinical outcome in recurrent ulnar tunnel syndrome after previous surgery.

LEVEL OF EVIDENCE

IV - retrospective study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors Associated With Severity of Cubital Tunnel Syndrome at Presentation

BACKGROUND

The outcomes of cubital tunnel syndrome surgery are affected by preoperative disease severity. The aim of this study was to identify factors associated with clinical and electrodiagnostic severity of cubital tunnel syndrome at presentation.

METHODS

We retrospectively identified 213 patients with electrodiagnostically confirmed cubital tunnel syndrome who underwent cubital tunnel surgery from July 2008 to June 2013. Our primary response variable was clinical cubital tunnel syndrome severity assessed by the McGowan grade. Our secondary response variables were sensory nerve action potential (SNAP) recordability, presence of fibrillations, and motor nerve conduction velocities (CVs) in the abductor digiti minimi (ADM) and first dorsal interosseous (FDI). Bivariate analysis was used to screen for factors associated with disease severity; significant variables were selected for multivariable regression analysis.

RESULTS

Older age was associated with higher McGowan grade and diabetes mellitus was associated with unrecordable SNAPs on bivariate analysis. No other variables met inclusion criteria for multivariable regression analysis for McGowan grade or unrecordable SNAPs. Multivariable regression analysis showed older age and higher Distressed Communities Index (DCI) to be associated with decreased motor nerve CVs in ADM. Multivariable regression analysis showed higher body mass index (BMI) and higher DCI to be associated with decreased motor nerve CVs in FDI. No variable was associated with the presence of fibrillations.

CONCLUSIONS

A subset of patients with cubital tunnel syndrome may benefit from earlier referral for hand surgery evaluation and earlier surgery. Older patients, with higher BMI, with diabetes mellitus, and with economic distress are at higher risk for presentation with more severe disease.

A complete analysis of the surgical treatment for cubital tunnel syndrome: an umbrella review

BACKGROUND

Numerous original studies have been presented regarding various surgical treatments for cubital tunnel syndrome (CubTS). The results of these analyses regarding the different surgical treatments for CubTS frequently differ and, in some cases, contradict each other, creating confusion. Therefore, our umbrella review aimed to summarize the evidence from meta-analyses and systematic reviews regarding the surgical treatments of CubTS, and along with the new, more detailed outcomes, provide an evidence-based tool for surgeons performing these procedures.

MATERIALS AND METHODS

To perform this umbrella review, a systematic search was conducted for meta-analyses investigating CubTS in PubMed, Scopus, Embase, Web of Science, Google Scholar, Cochrane Library, BIOSIS, and EBSCO medical databases.

RESULTS

Detailed comparison of surgical outcomes, such as clinical improvement, complications, or reoperation rates, of different treatment methods for CubTS was performed. New risk ratios in all categories were established based on all of the primary studies available in the literature.

DISCUSSION

The goal of the present umbrella review was to gather and summarize all data about the surgical treatments for CubTS in the available literature and provide new outcomes and an evidence-based tool for surgeons performing these procedures. Each comparison of the surgical techniques has been discussed, and the present study's results were compared with the outcomes of the previous studies.

Percutaneous ultrasound-guided ulnar nerve release technique compared to open technique: A cadaveric study

OBJECTIVES

To evaluate the outcomes of a novel percutaneous ultrasound-guided technique for release of ulnar nerve entrapment at the elbow when compared to standard open release Methods: One single surgeon performed an ultrasound-guided percutaneous release of the cubital tunnel on a group of five cadaveric elbows and open release on five others. All procedures were timed, and incision lengths were recorded. Meticulous anatomic dissection was then performed to assess the complete release of the carpal tunnel and iatrogenic injuries.

RESULTS

No significant difference was found between the two groups in terms of complete release and iatrogenic injury, whereas Operative time was significantly shorter for the US-guided technique. Incomplete releases of the nerve were found only during the first two trials in each group, while the third, fourth, and fifth trials showed a complete ulnar nerve release in both series, highlighting a fast learning curve for both techniques. All of this through a significantly smaller incision in the US-guided technique.

CONCLUSIONS

This study highlights the similar effects of these two techniques in terms of complete release of the ulnar nerve, with no clear superiority of one over the other in terms of morbidity rate. Both have a fast learning curve for an ultrasound-trained surgeon, with the US-guided technique being a less traumatic and quicker alternative procedure.

Intraneural or extraneural ganglion cysts as a cause of cubital tunnel syndrome: A retrospective observational study

Purpose

Cubital tunnel syndrome caused by ganglion cysts has rarely been reported. The purpose of this study was to evaluate the surgical treatment outcomes of a patient diagnosed with cubital tunnel syndrome caused by intraneural or extraneural cysts and to summarize our experience.

Method

In total, 34 patients were evaluated retrospectively from January 2011 to January 2020 with a follow-up of more than 24 months. Preoperative data, such as demographic data, clinical symptoms, physical examination findings, and laboratory tests, were all recorded and pre-operative and post-operative data were compared. The function was evaluated by the modified Bishop scoring system and the McGowan grade at the last follow-up.

Results

Improvement of interosseous muscle strength, the Visual Analog Scale (VAS), 2-point discrimination (2-PD), electromyogram (EMG) result, Wartenberg sign, claw hand, and weakness could be clearly observed in all patients. Extraneural cysts were completely removed and the pedicles of the cysts were ligated. Intraneural cysts were incised and drained, and part of their cyst walls were removed using a microsurgical technique. All patients underwent anterior subcutaneous transposition (AST). At the last follow-up, McGowan's (0-IIa) grade increased from seven patients (20.6%) preoperatively to 27 patients (79.4%); the excellent and good rate according to the modified Bishop scoring system was 82.4% (28 patients), and all patients had no symptoms of recurrence after surgery.

Conclusion

The treatment of cubital tunnel syndrome caused by intraneural or extraneural cysts achieved good long-term results through extraneural cyst resection or intraneural cyst incision and drainage combined with subcutaneous transposition. Early diagnosis and surgical treatment are essential for the patient's postoperative recovery.

Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters

BACKGROUND

Current classifications for cubital tunnel syndrome have not been shown to reliably predict postoperative outcomes. In this article, the authors introduce a new classification that incorporates clinical and electrodiagnostic parameters, including compound muscle action potential amplitude, to classify the preoperative severity of cubital tunnel syndrome. The authors compare this to established classifications and evaluate its association with patient-rated improvement.

METHODS

The authors reviewed 44 patients who were treated surgically for cubital tunnel syndrome. Patients were retrospectively classified using their proposed classification and the Akahori, McGowan-Goldberg, Dellon, and Gu classifications. Correlation of grades was assessed by Spearman coefficients and agreement was assessed by weighted kappa coefficients. Patient-reported impairment was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire before and after surgery.

RESULTS

The classifications tended to grade patients in a similar way, with Spearman coefficients of 0.60 to 0.85 ( p < 0.0001) and weighted kappa coefficients of 0.46 to 0.71 ( p < 0.0001). Preoperative Disabilities of the Arm, Shoulder, and Hand scores increased with severity grade for most classifications. In multivariable analysis, the authors' classification predicted postoperative Disabilities of the Arm, Shoulder, and Hand score improvement, whereas established classifications did not.

CONCLUSIONS

Established classifications are imperfect indicators of preoperative severity. The authors introduce a preoperative classification for cubital tunnel syndrome that incorporates electrodiagnostic findings in addition to classic signs and symptoms.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, III.

Endoscopic cubital tunnel decompression: state of the art

Cubital tunnel syndrome is a common compressive neuropathy of the upper limb. Surgical decompression is indicated for patients who failed conservative therapy. Decompression in situ has shown to achieve comparable outcomes as decompression with anterior transposition in idiopathic cubital tunnel syndrome. Endoscopic cubital tunnel decompression has gained popularity in recent years, as surgeons can attain decompression of the ulnar nerve along its course using a small incision. Results from randomised controlled studies and systematic reviews, comparing endoscopic with open decompression in situ, are promising. Cases in which anterior transposition of the ulnar nerve is needed, an endoscopic technique can still be used by creating an additional volar portal, for the mobilisation of ulnar nerve. Early short-term results are encouraging. Further adequately powered, prospective, preferably double-blinded, randomised study are needed.

Endoscopic cubital tunnel decompression - Review of the literature

Cubital tunnel syndrome is the second most common compressive neuropathy of the upper limb. Endoscopic cubital tunnel decompression has gained popularity in recent years as this enables surgeons to achieve decompression of the ulnar nerve along its course using a small incision. This article describes the technical peals in performing endoscopic cubital tunnel decompression. In conditions which anterior transposition of the ulnar nerve is needed, subcutaneous transposition can be performed under endoscopic guidance. In addition, current literature is reviewed, and outcomes are presented. While short term results are encouraging, further prospective randomized study with longer follow-up is recommended.

Ultrasound-Assisted Precise In Situ Decompression for Cubital Tunnel Syndrome

Objective

To explore the effect of locating the ulnar nerve compression sites and guiding the small incision so as to decompress the ulnar nerve in situ on the elbow by high‐frequency ultrasound before operation.

Methods

A retrospective analysis was conducted on 56 patients who underwent ultrasound‐assisted in situ decompression for cubital tunnel syndrome from May 2018 to August 2019. The patients' average age was 51.13 ± 7.35 years, mean duration of symptoms was 6.51 ± 1.96 months, and mean postoperative follow‐up was 6.07 ± 0.82 months. Nine patients had Dellon's stage mild, 39 had stage moderate, and eight had stage severe. Ultrasound and electromyography were completed in all patients before operation. The presence of ulnar nerve compressive lesion, the specific location, and the reason and extent of compression were determined by ultrasound. A small incision in situ surgery was given to decompress the ulnar nerve according to the pre‐defined compressive sites.

Results

All patients underwent in situ decompression. The compression sites around the elbow were as follows: two in the arcade of Struthers, one in the medial intermuscular septum, four in the anconeus epitrochlearis muscle, five beside the cyst of the proximal flexor carpi ulnaris (FCU), and the remaining 44 cases were all from the compression between Osborne's ligament to the two heads of the FCU. The compression localizations diagnosed by ultrasound were confirmed by operations. Preoperative ultrasound confirmed no ulnar nerve subluxation in all cases. The postoperative outcomes were satisfactory. There was no recurrence or aggravation of symptoms in this group of patients according to the modified Bishop scoring system; results showed that 43 cases were excellent, 10 were good, and three were fair.

Conclusions

High‐frequency ultrasound can accurately and comprehensively evaluate the ulnar nerve compression and the surrounding tissues, thus providing significant guidance for the precise minimally invasive treatment of ulnar nerve compression.

Risk factors and outcomes in 385 cases of ulnar nerve submuscular transposition

Submuscular transposition (SMT) for treatment of ulnar nerve entrapment is commonly performed, however published comparisons of surgical techniques exclude a high proportion of the at-risk population encountered in real world practice. To examine the influence of risk factors on the clinical outcome following SMT we performed a retrospective review of all patients who underwent SMT, including patient self-reported outcome and Louisiana State University Medical Centre ulnar nerve grading scale. A total of 403 ulnar nerves were operated, with follow-up data available for 385 cases (359 patients). Risk factors (including smoking, diabetes, previous elbow trauma/pathology, subluxation, workers' compensation) were reported in 266 of 385 surgeries (69.09%). SMT was the primary procedure in 339 nerves (88.05%), revision procedure in 46 nerves (11.95%). At last follow up 91.05% reported symptomatic improvement. Nerve grade improvement in 71.09% of primary and 67.39% revision surgery (p = 0.605). No significant difference in improvement was identified between demographic and risk categories, except for patient reported improvement in those without peripheral neuropathy (90.59% vs 73.33%, p = 0.027), and those not improved were on average older than those improved (62.94 vs. 55.68 years, p = 0.012). Superficial infection occurred in 2.6% and there were no deep infections. Application of published exclusion criteria would have resulted in exclusion of ½-⅔ of our cohort. SMT in patients with a history of elbow trauma, diabetes, workers compensation, smoking history, nerve subluxation or revision surgery have similar outcomes compared to those without these factors, whilst improved results were observed in younger patients and those without peripheral neuropathy.

Comparison of In Situ Versus Subcutaneous Versus Submuscular Transpositions in the Management of McGowan Stage III Cubital Tunnel Syndrome

Background: The objective of the study was to evaluate and compare the clinical outcomes of in situ decompression with subcutaneous and submuscular transpositions for surgical management of advanced (McGowan stage III) cubital tunnel syndrome (CuTS). Methods: A retrospective review of patients in our institution undergoing primary surgery for CuTS from February 1989 to May 2009 was performed. Patients with advanced CuTS with a minimum of 12 months of follow-up without any previous bony or soft tissue procedures around the elbow were included. Seventy-four patients underwent 80 primary ulnar nerve surgeries. Patients' demographics, presenting symptoms, physical examination, electrodiagnostic findings, and perioperative complications were recorded. Primary surgical techniques were compared and the risk factors for revision surgery were assessed. Results: Of the 80 surgical procedures, there were 17 decompressions (21%), 47 subcutaneous transpositions (59%), and 16 submuscular transpositions (20%). Fifty-two percent of patients had resolution of their symptoms after primary surgery. The overall complication rate after primary surgery was 12.5%. Nineteen patients (24%) had revision surgery at a median of 30 months after their primary procedure. Eight patients (42%) had symptomatic improvement after revision surgery. Patients with their dominant extremity affected, static 2-point discrimination (S2PD) greater than 10 mm, and age less than 50 years at presentation had a higher rate of revision surgery. Three patients had a second revision surgery and neurolysis for persistent symptoms. Conclusions: The overall revision rate in advanced CuTS was 24%. Forty-two percent of patients had reported subjective symptomatic improvement after revision surgery. Younger age at presentation and a greater S2PD were associated with a higher rate of revision surgery.

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

IMPORTANCE

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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

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

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

PURPOSE

Comparison between studies assessing outcomes after surgical treatment of cubital tunnel syndrome (CuTS) has proven to be difficult owing to variations in outcome reporting. This study aimed to identify outcomes and outcome measures used to evaluate postoperative results for CuTS.

METHODS

We performed computerized database searches of MEDLINE and EMBASE. Studies with 20 or more patients aged 18 and older who were undergoing medial epicondylectomy, endoscopic decompression, open simple decompression, or decompression with subcutaneous, submuscular, or intramuscular transposition for ulnar neuropathy at the elbow were included. Outcomes and outcome measures were extracted and tabulated.

RESULTS

Of the 101 studies included, 45 unique outcomes and 31 postoperative outcome measures were identified. These included 7 condition-specific, clinician-reported instruments; 4 condition-specific, clinician-reported instruments; 8 patient-reported, generic instruments; 11 clinician-generated instruments; and one utility measure. Outcome measures were divided into 6 unique domains. Overall, 60% of studies used condition-specific outcome measures. The frequency of any condition-specific outcome measure ranged from 1% to 37% of included studies.

CONCLUSIONS

There is marked heterogeneity in outcomes and outcome measures used to assess CuTS. A standardized core outcome set is needed to compare results of various techniques of cubital tunnel decompression.

CLINICAL RELEVANCE

This study builds on the existing literature to support the notion that there is marked heterogeneity in outcomes and outcome measures used to assess CuTS. The authors believe that a future standardized set of core outcomes is needed to limit heterogeneity among studies assessing postoperative outcomes in CuTS to compare these interventions more easily and pool results in the form of systematic reviews and meta-analyses.

Ulnar neuropathy at the elbow in 413 Japanese patients: An assessment of pathological elbow lesions and neurological severity

BACKGROUND

Various pathological elbow lesions are often complicated with ulnar neuropathy at the elbow (UNE), although the precise pathology, incidence, and clinical and neurological features of these lesions have not been identified. We therefore investigated elbow pathology and neurological severity in Japanese patients with UNE.

METHODS

The medical records of 457 Japanese UNE patients who were surgically treated among 6 hospitals were retrospectively examined. Eligible patients had UNE diagnosed by physical findings and nerve conduction studies according to the criteria of the American Association of Electrodiagnostic Medicine. The elbows were analyzed with regard to age, gender, occupation, pathology at the elbow, and severity of nerve palsy.

RESULTS

A total of 398 patients with 413 UNE elbows of a mean age of 63 years (range: 15-87) met the inclusion criteria. UNE elbows were predominantly in male patients (69.0%). Overall, 310 elbows (75.1%) had 1 or more elbow lesions: 238 elbows (76.8%) had a single lesion and 72 elbows (23.3%) had 2 or more lesions. The most common lesion was primary elbow osteoarthritis (EOA) occurring in 54.5% of elbows, followed next by medial elbow ganglion in 8.5% and cubitus valgus in 6.5%. Most elbows with medial elbow ganglion or cubitus valgus were associated with EOA. Entrapment sites were at the cubital tunnel in 84.5%-91.3% of UNE elbows, regardless of an association with elbow lesion. The incidence of McGowan grade III lesion was 50.8% in elbows with primary EOA, which was higher than the 35.0% in elbows with no lesion.

CONCLUSIONS

This study revealed that UNE had various isolated or combined elbow lesions. In Japanese UNE, primary or secondary EOA was found in 62.2% of cases and severe motor weakness was noted in 47.2%. The incidences of EOA and severe ulnar nerve palsy in the Japanese UNE are higher than those in Caucasians.

LEVEL OF EVIDENCE

Level IV; Prognostic-Investigating the effect of a patient characteristic on the outcome of a disease; Case series.

In idiopathic cubital tunnel syndrome, ulnar nerve excursion and instability can be reduced by repairing Osborne's ligament after simple decompression

Osborne's modified decompression involves repairing Osborne's ligament beneath the ulnar nerve after simple decompression for idiopathic cubital tunnel syndrome. In this retrospective interrupted time series, 31 patients underwent modified simple decompression and 20 patients underwent conventional simple decompression. In the modified simple decompression group, the ulnar nerve length was measured at operation in full elbow flexion and extension before and after repair of Osborne's ligament. Ulnar nerve instability during elbow motion was measured using ultrasonography before operation and at 12 months after operation. In patients treated by modified simple decompression, the ulnar nerve length in full elbow flexion reduced significantly after repair of Osborne's ligament. At 12 months after surgery, the grade of ulnar nerve instability was lower in the modified simple decompression group than in the conventional simple decompression group. The clinical outcomes did not differ significantly between the groups at 24 months after operation. Level of evidence: III.

A systematic review and meta-analysis comparing open versus endoscopic in situ decompression for the treatment of cubital tunnel syndrome

To examine whether endoscopic in situ decompression (EISD) or open in situ decompression (OISD) would have superior outcomes with lower morbidity in patients with idiopathic cubital tunnel syndrome, we reviewed all studies compared both surgical techniques with regard to postoperative outcomes and complication profile in a systematic review design with meta-analysis. Two independent reviewers conducted a PRISMA-compliant search of PubMed, EMBASE, and the Cochrane Library databases for relevant studies about clinical comparisons of OISD and EISD in cubital tunnel syndrome. We performed all meta-analyses with the Review Manager 5.3 software. For dichotomous variables, the risk ratio (RR) and 95% confidence intervals (CIs) were calculated. For continuous variables, the mean difference (MD) and 95% CIs were calculated. The level of significance was set as p < 0.05. Finally, 8 articles with 582 patients finally were included in this meta-analysis. Pooled analysis showed that the difference in Bishop score, visual analogue scale score reduction, postoperative satisfaction, postoperative hematoma rate and secondary surgical procedures were not statistically significant between the EISD group and the OISD group (p > 0.05). However, pooled results showed that patients who underwent EISD had a greater improvement in the scar tenderness/elbow pain than did those who underwent OISD with statistical significance (p < 0.0001). This meta-analysis demonstrated that EISD and OISD for surgical treating cubital tunnel syndrome had equivalent efficacy regarding postoperative clinical recovery, whereas the incidences of adverse events of EISD were also same as those with the OISD technique.

Management of cubital tunnel syndrome by anterior trans-muscular transposition of the ulnar nerve

Background

Various surgical options are used for the treatment of ulnar nerve entrapment at the elbow. In this study, anterior trans-muscular transposition of the ulnar nerve was used for the treatment of cubital tunnel syndrome.

Objectives

To evaluate the surgical results of anterior trans-muscular transposition technique for the treatment of cubital tunnel syndrome with particular emphasis on clinical outcome.

Methods

Forty patients with cubital tunnel syndrome were operated using anterior trans-muscular transposition technique. Patients were classified into post-operative clinical outcome grades according to the Wilson & Krout criteria, and they were followed up by visual analog scale (VAS), the Disability of Arm Shoulder and Hand (DASH) questionnaire, electrophysiological study, and post-operative clinical evaluation.

Results

Forty patients with cubital tunnel syndrome who underwent anterior trans-muscular transposition of the ulnar nerve show a significant clinical improvement at 24 months post-surgery regarding visual analog scale (VAS), the Disability of Arm Shoulder and Hand (DASH) questionnaire, electrophysiological study, and the Wilson & Krout grading as 87.5% of the patients recorded excellent and good outcome.

Conclusion

Anterior transmuscular transposition of the ulnar nerve is a safe and effective treatment for ulnar nerve entrapment at the elbow.

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

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

Novel minimally invasive technique in the treatment of cubital tunnel syndrome

Background

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity in the United States. Most cases are idiopathic and symptoms consist of a combination of weakness, pain, and sensory disturbances ranging from paresthesias and dysesthesias to numbness or complete anesthesia. The purpose of this study is to report results of a novel, minimally invasive surgical procedure for cubital tunnel syndrome with comparison to existing interventions including full open or endoscopic approaches.

Methods

A total of 41 consecutive patients underwent the procedure, their ages ranged from ages 36 to 81 with an average age of 60.52±12.18 years. The procedure consists of a 1.0-2.0-cm incision with decompression of the ulnar nerve under direct visualization proximally with Metzenbaum scissors as a dilator for distal decompression. Patients were evaluated for improvements in pain, numbness, paresthesias, weakness, and muscle atrophy and was measured utilizing the Gabel/Amadio scale.

Results

Fifty-three point two percent (n=25) of patients were found to have excellent outcomes, 36.2% (n=17) had good outcomes, 8.5% (n=4) had fair outcomes, and 2.1% (n=1) had poor outcomes as determined by the Gabel/Amadio scale. The greatest improvement in all patients was the reduction in sensory symptoms: pain, numbness, and paresthesia. There were no operative or postoperative complications.

Conclusions

This novel procedure provided symptom relief comparable to the most effective existing techniques without significant complications, and with rapid recovery and minimal scar formation. The authors assert that this technique demonstrates optimal results for patients with relative ease of adoption for surgeons.

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.

Comparing endoscopic and open decompression of the ulnar nerve in cubital tunnel syndrome: a prospective randomized study

BACKGROUND

Prospective randomized data is currently lacking which compares endoscopically assisted surgery with open surgical techniques in the treatment of cubital tunnel syndrome (CUTS). The aim of this study is to compare patient outcome in both techniques.

METHOD

This prospective study comprised of 45 patients who, between October 2014 and February 2017, were randomly assigned to undergo either endoscopic or open surgery (22 and 23 patients respectively) for decompression of the ulnar nerve. Patients were followed up at 3 and 12 months postoperation. McGowan classification was used to determine the severity of symptoms. Surgical outcome was evaluated by Bishop classification. Pain levels were monitored according to gender from 0 to 10 days postoperation. Other factors investigated were chronic scar pain, working status, operation duration, and patient satisfaction regarding postoperative scarring and the procedure itself.

RESULTS

Both methods are equally effective in the treatment of CUTS (Bishop score excellent or good 90% vs 96%). Postoperative pain is significant particularly in the first few days following surgery, but with no significant difference depending on procedure. In the open group, postoperative pain was significantly higher in women than in men; pain did not differ between the sexes in the endoscopic group. The tendency to lower levels of pain among endoscopically operated women in comparison with women in the open group was not statistically notable. Patients who underwent open decompression experienced notably higher levels of postoperative chronic scar pain. Although working status and satisfaction with the surgical outcome were the same in both groups, satisfaction with scarring was higher in the endoscopy group. Operation time was significantly longer by endoscopy.

CONCLUSIONS

Both studied methods produced equal satisfactory outcomes in the treatment of CUTS. Endoscopy has the potential to minimize chronic scar pain and improve scarring esthetics, at the expense of longer operating time.

CLINICAL TRIAL REGISTRATION NUMBER

Supported by Ministry of Health, Czech Republic-conceptual development of research organization (FNOs/2014, project number 20). Graphical abstract Median postoperative pain from 0 to 10 days by group.

Recurrent Cubital Tunnel Syndrome Caused by Ganglion: A Report of Nine Cases

BACKGROUND

Cubital tunnel syndrome (CuTS) is generally treated successfully by surgery and recurrent cases are rare. This study retrospectively investigated the clinical characteristics of recurrent CuTS caused by ganglion.

METHODS

We evaluated nine patients who were surgically treated for recurrent CuTS caused by ganglion. Age distribution at recurrence ranged from 43 to 79 years. The initial surgery for CuTS had been performed using various methods. The asymptomatic period from initial surgery to recurrence ranged from 22 to 252 months. Clinical, diagnostic imaging, and operative findings during the second surgery were analyzed. All patients were treated by anterior subcutaneous ulnar nerve transposition with ganglion resection and later examined directly within a mean of 71 months after the second surgery.

RESULTS

The interval from recurrence to consultation was shorter than two months for eight cases. Chief complaints included numbness with or without pain in the ring and little fingers in all patients and resting pain in the medial elbow in five patients. Elbow osteoarthritis was present in all cases. Although four of 10 ganglia were palpable, ultrasonography and magnetic resonance imaging could identify all ganglia preoperatively. The ulnar nerve typically had become entrapped by the ganglion posteriorly and by fascia, scar tissue, and/or muscle anteriorly. Chief complaints and ulnar nerve function were improved in all patients following revision surgery.

CONCLUSIONS

The acute onset of numbness with or without intolerable pain in the ring and little fingers after a long-term remission period following initial surgery for CuTS in patients with elbow osteoarthritis appears to be the characteristic clinical profile of recurrent CuTS caused by ganglion. As ganglia are often not palpable, ultrasonography and magnetic resonance imaging are recommended for accurate diagnosis.

Trends in the Surgical Treatment for Cubital Tunnel Syndrome: A Survey of Members of the American Society for Surgery of the Hand

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.

Endoscopic versus Open In Situ Cubital Tunnel Release: A Systematic Review of the Literature and Meta-Analysis of 655 Patients

BACKGROUND

Cubital tunnel syndrome is the second most common peripheral entrapment syndrome. To date, there is no true consensus on the ideal surgical management. A minimally invasive, endoscopic approach has gained popularity but has not been adequately compared to the more traditional, open approach.

METHODS

With compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies published between 1990 and 2016 that compared the efficacy of endoscopic cubital tunnel release to open cubital tunnel release. A meta-analysis was then performed through a random-effects model with inverse variance weighting to calculate I values for heterogeneity analysis. Forest plots were constructed for each analysis group.

RESULTS

Five studies involving 655 patients (endoscopic cubital tunnel release, n = 226; open cubital tunnel release, n = 429) were included. Meta-analysis revealed no significant superiority of open release in achieving an "excellent" or "good" Bishop score (OR, 1.27; 95 percent CI, 0.59 to 2.75; p = 0.54) and reduction in visual analogue scale score (mean difference, -0.41; 95 percent CI, -1.49 to 0.67; p = 0.46). However, in the endoscopic release cohort, lower rates of new-onset scar tenderness/elbow pain were found (OR, 0.19; 95 percent CI, 0.07 to 0.53; p = 0.002), but there was a higher incidence of postoperative hematomas (OR, 5.70; 95 percent CI, 1.20 to 27.03; p = 0.03). The reoperation rate in the endoscopic and open release groups was 4.9 and 4.1 percent, respectively (p = 0.90).

CONCLUSIONS

The authors demonstrated equivalent overall clinical improvement between endoscopic and open cubital tunnel release in terms of Bishop score and visual analogue scale score reduction. Because of the low power of most studies, further investigations with a larger patient population and longer follow-up are needed to better characterize the role of endoscopic cubital tunnel release.

Surgical Approaches and Their Outcomes in the Treatment of Cubital Tunnel Syndrome

Purpose: This review was undertaken in order to provide an updated summary of the current literature on outcomes for various surgical treatments for cubital tunnel syndrome.

Methods: Studies reporting outcomes for surgical treatment of cubital tunnel syndrome were collected through the PubMed database. Study structure, number of participants/procedures, mean follow-up times, scoring scales, and outcomes were collected according to the type of surgery: open decompression, endoscopic decompression, minimal incision, subcutaneous transposition, intramuscular transposition, and submuscular transposition.

Results: Our findings indicate varying but comparable levels of success among all surgical techniques reviewed. Many different scoring scales were utilized, limiting direct quantitative comparison between most studies.

Discussion: While some studies directly compared two or more techniques, there was rarely a statistically significant difference between groups. In comparisons that did reach statistically significant differences, there were others yet that found no difference in comparing the same techniques.

Conclusions: None of the techniques in this review has demonstrated universal superiority above all others, but all appear to be effective in the treatment of cubital tunnel syndrome. The only consensus seems to be that transposition is preferred where the ulnar nerve tends to subluxate either on preoperative or intraoperative examination.

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

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

Trends in Open and Endoscopic Cubital Tunnel Release in the Medicare Patient Population

BACKGROUND

Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release.

METHODS

We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated.

RESULTS

Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the <65 years age range.

CONCLUSIONS

Despite the unexpectedly lower reimbursement rate with endoscopic release, endoscopy utilization is growing faster than open releases in the Medicare population. Lower reimbursement is likely related to lack of a dedicated current procedural terminology code for endoscopic cubital tunnel release.

Can We Make Simple In Situ Decompression of the Ulnar Nerve at the Elbow Still Easier?

BACKGROUND

In situ decompression and transposition are equally effective in cubital tunnel syndrome treatment. Both are traditionally performed in the supine position.

OBJECTIVE

To validate our surgical technique for in situ decompression in the lateral decubitus position, comparing results with other techniques used in our institutions.

METHODS

A retrospective study was performed from January 2009 to February 2016, of 188 patients with cubital tunnel syndrome 115 males, 73 females; mean age, 53.44 ± 12.12 years standard deviation (range, 18-84 years) treated with in situ decompression in the lateral or supine positions or transposition (subcutaneous or submuscular). The lateral decubitus group received local anesthesia and the remainder received a brachial plexus block. Clinical and electrophysiologic results between these 4 groups were compared.

RESULTS

There were no statistically significant demographic differences between groups. Results were better in in situ decompression groups compared with transpositions. Mean follow-up was 1511.1 ± 770.57 days standard deviation (range, 310-4203 days). There were no recurrences or residual elbow pain/dysesthesia/anesthetic scar/hyperesthesia/neuroma in the lateral decubitus group. Complication and recurrence rates were in direct correlation to incision size. The worst results were seen in transpositions, particularly in the submuscular group. In situ decompression in the supine position had better results than transpositions but worse than those performed in lateral decubitus. Smaller surgical wound correlates with a reduction in operating time, costs, complication rates, and time out of work.

CONCLUSIONS

In situ decompression is equally as effective as ulnar nerve transpositions but with fewer complications and recurrences. In the lateral decubitus position, the retroepicondylar tunnel is more accessible, allowing smaller incisions and better results.

Differential expression of miRNAs in Osborne's ligament of cubital tunnel syndrome

Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression disease, however, the pathogenesis and pathology of CuTS remain to be fully elucidated. The aim of the present study was to compare the expression pattern of microRNAs (miRNAs) in pachyntic Osborne's ligament with that in control tendinous tissue, and select meaningful miRNAs for further investigation of the clinical pathological mechanism underlying CuTS. A microarray assay was performed to examine the expression profiles of miRNAs in the Osborne's ligament and control tendinous tissues. An online bioinformatics algorithms tool (miRWalk) was used to predict putative target genes for the deregulated miRNAs, and functional annotation was performed by Gene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. Finally, the results of microarray were partially validated using reverse transcription‑quantitative polymerase chain reaction analysis. The expression of total of 60 miRNAs were found to be significantly different between the pachyntic Osborne's ligament and control tendinous tissues. MiRWalk2.0 predicted 1,804 target genes for these miRNAs, and the GO functional analysis of the predicted genes suggested cellular mechanisms, including metabolic process, regulation of cell growth, cell cycle processes, cell division regulation, cellular metabolic process and signal transmission, were involved. Furthermore, KEGG pathway analysis revealed important pathways, including adherent junction, focal adhesion, lysine degradation, cell adhesion molecules and mitogen‑activated protein kinase. Compared with the heathy tissue, Osborne's ligament tissue from patients with CuTS showed a markedly different miRNA expression profile, which suggested that miRNAs may be involved in the pathogenesis of CuTS.

Endoscopic neurolysis of the ulnar nerve: retrospective evaluation of the first 60 cases

BACKGROUND

The aim of this study was to determine the clinical efficacy of minimally invasive endoscopic ulnar nerve release at midterm follow-up.

METHODS

This was a retrospective, consecutive, single-center study. The inclusion criterion was presentation of the patient with isolated and stable cubital tunnel syndrome. The surgical technique described by Hoffmann and Siemionow in 2006 was used for all patients. The cubital tunnel syndrome was graded by Dellon's classification and scored as described by MacDermid and Grewal in 2013.

RESULTS

Sixty patients underwent surgery (62 cubital tunnel operations). Fifty-three patients were included in the study. The mean follow-up was 17 months (6-34). In the preoperative period, according to Dellon's classification, 8 patients were grade 1, 29 patients were grade 2, and 16 patients were grade 3. After surgery, according to the MacDermid score, 45 patients (84.9%) had good or excellent results, 6 (11.3%) had moderate results, and 2 (3.8%) had poor results. The mean preoperative score was 103.1 (25-181), and the mean postoperative score was 26.3 (0-135). By comparison with standard surgical technique, the endoscopic technique appears to be reliable with a similar success rate and functional improvement. The advantages are the minimally invasive portion of the surgical technique. Endoscopic control allowed complete release of the ulnar nerve with few complications.

CONCLUSION

The endoscopic technique as described by Hoffman et al had similar efficacy to open surgical techniques with the advantage of being minimally invasive.

Open Versus Endoscopic Cubital Tunnel In Situ Decompression: A Systematic Review of Outcomes and Complications

BACKGROUND

Endoscopic cubital tunnel release has been proposed as an alternative to open in situ release. However, it is difficult to analyze outcomes after endoscopic release, as only a few small case series exist.

METHODS

The electronic databases of PubMed (1960-June 2014) were systematically screened for studies related to endoscopic cubital tunnel release or open in situ cubital tunnel release. Baseline characteristics, clinical scores, and complication rates were abstracted. The binary outcome was defined as rate of excellent/good response versus fair/poor. Complications were recorded into 3 categories: wound problems, persistent ulnar nerve symptoms, and other.

RESULTS

We included 8 articles that reported the clinical outcomes after surgical intervention including a total of 494 patients (344 endoscopic, 150 open in situ). The pooled rate of excellent/good was 92.0% (88.8%-95.2%) for endoscopic and 82.7% (76.15%-89.2%) for open. We identified 18 articles that detailed complications including a total of 1108 patients (691 endoscopic, 417 open). The 4 articles that listed complication rates for both endoscopic and open techniques were analyzed and showed a pooled odds ratio of 0.280 (95% confidence interval, 0.125-0.625), indicating that endoscopic patients have reduced odds of complications.

CONCLUSIONS

The results of this systematic review suggest that there is a difference in clinical outcomes between the open in situ and endoscopic cubital tunnel release, with the endoscopic technique being superior in regard to both complication rates along with patient satisfaction.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rates of Complications and Secondary Surgeries After In Situ Cubital Tunnel Release Compared With Ulnar Nerve Transposition: A Retrospective Review

PURPOSE

The purpose of this study was to contrast the rate and types of complications and secondary surgeries for in situ cubital tunnel release and ulnar nerve transposition.

METHODS

A retrospective cohort study was performed by query of hospital billing records for all patients who underwent cubital tunnel surgery from August 2008 to July 2013, yielding 421 patients. Exclusion criteria were acute trauma, revision surgery, neoplasm, age younger than 18 years, incomplete records, and postoperative follow-up less than 3 months. Of the remaining 234 patients, 147 patients underwent 157 in situ cubital tunnel releases and 87 patients underwent 90 ulnar nerve transpositions.

RESULTS

In 157 in situ cubital tunnel releases, there were 6 complications (3.8%), including 3 cases (1.9%) of ulnar nerve instability, 2 cases (1.3%) of postoperative infection, and 1 case (0.6%) of a postoperative seroma. In 90 ulnar nerve transpositions, there were 2 complications (2.2%), including 1 case (1.1%) of postoperative infection and 1 case (1.1%) of medial antebrachial cutaneous nerve injury. The secondary surgery rate was 5.7% overall, 2.5% for in situ cubital tunnel release, and 11.1% for ulnar nerve transposition. Chronic kidney disease was associated with complication after cubital tunnel surgery. Prior trauma to the elbow and ulnar nerve transposition were associated with secondary surgery.

CONCLUSIONS

The short-term complication rates of cubital tunnel surgery are low (3.2%), but higher for patients with chronic kidney disease. The secondary surgery rate after cubital tunnel surgery was 5.7% overall, but higher for patients with prior elbow trauma and for patients undergoing ulnar nerve transposition.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Muscular atrophy in severe cases of cubital tunnel syndrome: prognostic factors and outcome after surgical treatment

BACKGROUND

Cubital tunnel syndrome (CuTS) is a frequent neuropathy, leading to sensor-motoric dysfunction. Many patients even present with muscular atrophy as a sign for severe and long-lasting nerve impairment, usually suggesting unfavourable outcome. We analysed if those patients benefit from surgical treatment on a long-term basis.

METHODS

Between January 2010 and March 2015, 42 consecutive cases of CuTS with atrophy of the intrinsic hand muscles were surgically treated in our department. Clinical data of the treatment course and postoperative results were collected. Follow-up was prospectively assessed according to McGowen grading and Bishop outcome score. Mean follow-up time was 39.8 (±17.0) months.

RESULTS

All patients were treated with in situ decompression; in 33%, submuscular transposition was performed. Forty-five percent showed improvement of sensory deficits and 57% showed improvement of motor deficits 6 months after the operation. Atrophy improved in 76%. At the time of follow-up, 79% were satisfied with the postoperative result and 77% of patients reached good or excellent outcome according to modified Bishop rating scale. Patients with improvement of atrophy had significantly shorter symptom duration period (7 ± 10 months vs 26 ± 33 months; p < 0.05). In the case of intraoperative pseudoneuroma observation, atrophy improvement was less likely (p < 0.05).

CONCLUSIONS

In severe cases of CuTS with atrophy of the intrinsic hand muscles, surgical treatment enables improvement of sensory function, motor function and atrophy even in cases with muscular atrophy. Atrophy improvement was more likely in cases of short symptom duration and less likely in cases with pseudoneuroma.

Open versus endoscopic in situ decompression in cubital tunnel syndrome: A systematic review and meta-analysis

OBJECTIVE

We conducted this systematic review and meta-analysis to compare the clinical efficacy and safety between open and endoscopic in situ decompression surgery methods for cubital tunnel syndrome (CuTS).

METHODS

PubMed, Medline, Embase, Cochrane Library and CNKI were searched for eligible studies. The data were extracted by two of the coauthors (WL, BYF) independently and were analyzed using RevMan statistical software, version 5.1. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool and the Newcastle-Ottawa Scale were used to assess the risk of bias.

RESULTS

Seven studies were included for systematic review, and six studies were included for meta-analysis. The CuTS patients received open in situ decompression (OISD) or endoscopic in situ decompression (EISD). A pooled analysis of postoperative Bishop score showed that the difference was not statistically significant between the EISD group and the OISD group (RR = 0.99, 95% CI = 0.88-1.12, P = 0.88). The overall estimate of postoperative satisfaction between the EISD group and the OISD group was not found to be significant (RR = 0.98, 95% CI = 0.89-1.08, P = 0.70). The overall estimate of complications (RR = 0.88, 95% CI = 0.24-3.29, P = 0.85) suggested that the difference was not statistically significant.

CONCLUSIONS

EISD and OISD for treating CuTS have equivalent efficacy for postoperative clinical improvement, whereas the incidences of complications of endoscopic surgical procedure were also same as those with the open surgical procedure. In situ decompression (especially EISD, with minor intraoperative trauma) could be treated as a valuable alternative to treat CuTS.

Endoscopically Assisted Anterior Subcutaneous Transposition of Ulnar Nerve

Ulnar nerve compression at the elbow is the most common neuropathy of the upper extremity. Surgical options include in situ decompression, decompression with anterior transposition of the ulnar nerve, and medial epicondylectomy with or without decompression. With the advancement of endoscopic surgery, techniques of endoscopic in situ decompression of the ulnar nerve and endoscopic anterior transposition of ulnar nerve have been reported. This article describes a technique of endoscopically assisted anterior subcutaneous transposition of ulnar nerve that is composed of an open release and mobilization of the ulnar nerve at and distal to the cubital tunnel and endoscopic release and mobilization of the ulnar nerve proximal to the cubital tunnel.

Anterior subcutaneous transposition of the ulnar nerve improves neurological function in patients with cubital tunnel syndrome

Although several surgical procedures exist for treating cubital tunnel syndrome, the best surgical option remains controversial. To evaluate the efficacy of anterior subcutaneous transposition of the ulnar nerve in patients with moderate to severe cubital tunnel syndrome and to analyze prognostic factors, we retrospectively reviewed 62 patients (65 elbows) diagnosed with cubital tunnel syndrome who underwent anterior subcutaneous transposition. Preoperatively, the initial severity of the disease was evaluated using the McGowan scale as modified by Goldberg: 18 patients (28%) had grade IIA neuropathy, 20 (31%) had grade IIB, and 27 (42%) had grade III. Postoperatively, according to the Wilson & Krout criteria, treatment outcomes were excellent in 38 patients (58%), good in 16 (25%), fair in 7 (11%), and poor in 4 (6%), with an excellent and good rate of 83%. A negative correlation was found between the preoperative McGowan grade and the postoperative Wilson & Krout score. The patients having fair and poor treatment outcomes had more advanced age, lower nerve conduction velocity, and lower action potential amplitude compared with those having excellent and good treatment outcomes. These results suggest that anterior subcutaneous transposition of the ulnar nerve is effective and safe for the treatment of moderate to severe cubital tunnel syndrome, and initial severity, advancing age, and electrophysiological parameters can affect treatment outcome.

Endoscopic cubital tunnel release: a systematic review

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.