Anterior subfascial transposition of the ulnar nerve

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.

Feasibility of a fascial flap to avoid anterior transposition of unstable Ulnar nerve: A cadaver study

Background

Compression of the ulnar nerve at the elbow is the second most frequent site of nerve compression in the upper limb. Upon release, anteposition of the nerve may be necessary to avoid dislocation of the latter when unstable. Numerous techniques are described in the literature (subcutaneous transposition, intramuscular transposition, subfascial transposition, medial epicondylectomy …), none of which is without complications. Based on Han's work, the authors propose a technique of covering the ulnar nerve with epicondylar fascial flap, avoiding transposition, but ensuring good stability of the ulnar nerve.

Methods

As part of the SICM (Italian Society of Hand Surgery) cadaver dissection course (ICLO, Verona, Italy) the authors dissected 36 elbows, of which 20 presented subluxation of the ulnar nerve after its decompression. The fascial flap was therefore made on these 20 elbows, coming from 14 different donors (9 men, 5 women) with an average age of 78 years. The diameter of the ulnar nerve was then measured (at the level of the passage in the cubital canal), the diameter of the newly formed canal, the difference between the two previous measurements (residual space in the flexed elbow canal), and it was verified whether the ulnar nerve was unstable once covered by the flap.

Results

The mean diameter of the ulnar nerve was 5.1 mm (range 4-6), while the mean diameter of the neo-canal was 10.1 mm (range 8-11) in elbow extension and 8.9 mm (range 7-10) in elbow flexion. The remaining space in the flexed elbow canal was 3.8 mm (range 3-5).In none of the 20 cases the ulnar nerve was dislocated after having made the fascial flap.

Conlusions

In light of the results obtained, the authors think that the use of the epicondylar fascial flap may be a solution to keep in mind to avoid dislocation of the ulnar nerve when it becomes unstable following its decompression. This work obviously needs clinical confirmation on living patients.

Level of evidence

V.

Ulnar nerve decompression and transposition with versus without supercharged end-to-side motor nerve transfer for advanced cubital tunnel syndrome: a randomized comparison study

OBJECTIVE

The objective of this prospective randomized study was to compare ulnar nerve decompression and anterior subfascial transposition with versus without supercharged end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for advanced cubital tunnel syndrome, to describe performing the nerve transfer through a small incision, and to investigate predictive factors for poor recovery following the procedure.

METHODS

Between January 2013 and October 2016, 93 patients were randomly allocated to a study group (n = 45) and a control group (n = 48). Patients in the study group were treated with supercharged motor nerve transfer via a 5-cm incision following decompression and anterior subfascial transposition. Patients in the control group were treated with decompression and anterior subfascial transposition alone. Postoperative pinch strength and compound muscle action potential amplitude (CMAPa) were assessed. Function of the limb was assessed based on the Gabel/Amadio scale. Between-group data were compared, and significance was set at p < 0.05. Potential risk factors were collected from demographic data and disease severity indicators.

RESULTS

At the final follow-up at 2 years, the results of the study group were superior to those of the control group with regard to postoperative pinch strength (75.13% ± 7.65% vs 62.11% ± 6.97%, p < 0.05); CMAPa of the first dorsal interossei (17.17 ± 5.84 mV vs 12.20 ± 4.09 mV, p < 0.01); CMAPa of abductor digiti minimi (11.57 ± 4.04 mV vs 8.43 ± 6.11 mV, p < 0.01); and excellent to good results (0.67 for the study group vs 0.35 for the control group, p < 0.05). Multivariate analysis showed that the advanced age (OR 2.98, 95% CI 2.25-4.10; p = 0.003) in the study group was related to unsatisfactory outcome in the patients.

CONCLUSIONS

In the treatment of advanced cubital tunnel syndrome, additional supercharged end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer may produce a better function of the hand. The authors also found that cases in the elderly were related to unsatisfactory postoperative results for these patients and that they could be informed of the possibility of worsening surgery results.

[Neurogenic paraosteopathy of the elbow: results of surgical arthrolysis (a retrospective study of 37 cases)]

Neurogenic paraosteoarthropathies are ectopic ossifications which develop near the joints. They are a process of neo-ectopic osteogenesis occurring after central or peripheral neurological lesions, in some types of comas (oxygen carbon intoxication, prolonged sedation) and following peripheral traumas including burns. They inolve almost exclusively the large proximal joints of the limbs. Elbow is the second area of involvment. The purpose of our study was to analyze the results of surgical arthrolysis in 37 patients with elbow stiffness due to neurogenic osteoarthropathy of the elbow. We conducted a retrospective study of 35 patients and 37 elbows over a 25-year period. Preoperative assessment included clinical and radiological examination. Since 2003 the patients had undergone systematic elbow arthroscopy. The gold standard surgical treatment was arthrolysis. All patients underwent functional rehabilitation protocol. Outcomes were analyzed after a mean 5-year follow-up period (6 months - 10 years). Neurogenic paraosteoarthropathy was caused by head injury with coma in 58.8% of cases. Preoperative assessment showed bending stiffness in the majority of cases (88%), severe or very severe in 64.7% of cases. Intraoperatively functional elbow range of motion from -30° to 130° was obtained in 61.7% of cases and in 41% of cases in the long term. Ulnar nerve liberation was satisfactory in 92% of cases. No postoperative instability of the elbow was reported. Two patients with definitive neurological lesions had osteoma recurrence. The results were equivalent regardless surgical delay. Surgical arthrolysis is an effective treatment for neurogenic osteomas of the elbow.

Fascia wrapping technique: a modified method for the treatment of cubital tunnel syndrome

Variations of the anterior transposition of the ulnar nerve for cubital tunnel syndrome include subcutaneous, submuscular, intramuscular, and subfascial methods. We introduce a modification of subfascial transposition, which is designed to facilitate nerve gliding by wrapping the nerve with fascia. Twenty patients with wrapping surgery following the diagnosis of cubital tunnel syndrome were reviewed retrospectively. Preoperative electrodiagnostic studies were performed in all patients and all of them were rechecked postoperatively. The preoperative mean value of motor conduction velocity (MCV) was 37.1 ± 6.7 m/s within the elbow segment and this result showed a decrease compared to the result of MCV with 53.9 ± 6.9 m/s in the below the elbow-wrist segment with statistical significance (P < 0.05). Postoperative mean values of MCV were improved in all of 20 patients to 47.6 ± 5.5 m/s (P < 0.05). 19 patients of 20 (95%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. The surgical treatment methods for cubital tunnel syndrome have their own advantages and disadvantages, and the preferred method differs depending on the surgeon. The wrapping method of anterior transposition is a newly designed alternative method modified from subfascial transposition. This method could be an alternative option to treat cubital tunnel syndrome.

SELF-REPORTED OUTCOME FOLLOWING ANTERIOR TRANSPOSITION OF ULNAR NERVE IN THE ELDERLY

Cubital tunnel syndrome is a common entrapment neuropathy of the upper limb. This condition can result in significant sensory disturbances and motor deficits in the distribution of the ulnar nerve. Surgical management of cubital tunnel syndrome is indicated when non-operative measures fail. However, in the elderly population, there may be a tendency to avoid surgery as nerve healing has been found to be poor. In our study, we reviewed the results of anterior transposition of ulnar nerve in patients 60 years of age and older. Our results were based on a self-reported outcome at a minimum of one year after surgery — 94.7% of our surgeries resulted in some improvement in symptoms experienced by the patients while there was an overall satisfaction rate of 83.3%. Based on our results, we recommend ulnar nerve transposition in the management of cubital tunnel syndrome in this group of patients if non-operative measures fail.

Outcome of partial medial epicondylectomy for cubital tunnel syndrome

Partial medial epicondylectomy aims to eliminate potential drawbacks of total epicondylectomy for treatment of cubital tunnel syndrome. In this series, we retrospectively evaluated 80 patients (80 elbows) who had partial medial epicondylectomies for established cubital tunnel syndrome. Our main purpose was to compare clinical outcomes among partial, minimal, and total epicondylectomies. Specific attention was given to the functional outcome in severely impaired patients, and potential postoperative complications of total epicondylectomy, such as elbow instability, and medial elbow pain. Preoperatively, 16 patients were classified as having McGowan Grade I lesions, 40 had Grade II lesions, and 24 had Grade III lesions. The mean followup was 32 months (range, 26 months-4.2 years). There was improvement of at least one McGowan grade in 86.2% of the patients, with a 66.7% improvement in severely impaired patients (McGowan Grade III lesions). There was no ulnar nerve palsy, no ulnar nerve subluxation, or medial elbow instability. However, 45% of patients reported mild pain at the 6-month followup. Partial medial epicondylectomy seems to be safe and reliable for treatment of cubital compression neuropathy at the elbow.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Simple Decompression versus Anterior Submuscular Transposition of the Ulnar Nerve in Severe Cubital Tunnel Syndrome: A Prospective Randomized Study

OBJECTIVE:

The authors report the results of a clinical series of selected patients with severe cubital tunnel syndrome. The degree of ulnar nerve compression was evaluated by use of a grading system that includes measurements of motor and sensitive function. The submuscular transposition with flexor-pronator mass Z lengthening was compared with simple decompression through a prospective randomized study.

METHODS:

From February 1998 to June 2003, 70 patients with severe cubital tunnel syndrome were included in this study: 35 patients were submitted to simple decompression (Group A), and 35 patients were treated by anterior deep submuscular transposition (Group B). The preoperative status was determined by use of Dellon's classification. The selected patients had Dellon's Grade 3 (severe syndrome). The mean follow-up period after surgery was 47 months for Group A and 46.94 months for Group B.

RESULTS:

Postoperative clinical and electrophysiological outcomes were assessed 6 months after surgery in all 70 patients. According to the Bishop scoring system, 19 patients (54.3%) of Group A were clinically graded as excellent, 9 (25.7%) were graded as good, and 7 (20%) were graded as fair; in Group B, 18 patients (51.43%) were graded as excellent, 11 (31.43%) as good, and 6 (17.14%) as fair. Neither severe complications nor recurrences were observed in the two groups.

CONCLUSION:

No statistically significant difference was found between the two groups with regard to the clinical or the electrophysiological outcome. The surgical treatment gains in Group A and B were 80% and 82.86%, respectively (good to excellent results).

[Cubital tunnel syndrome and heterotopic ossification. Eight case reports]

INTRODUCTION

The occurrence of cubital tunnel syndrome during heterotopic ossification is infrequent. Entrapment of the nerve requires early decompression whereas definitive elbow release is often delayed to reduce the risk of recurrence of periarticular ossification. The pathophysiology and treatment of these two conditions are discussed.

METHOD

The authors report a retrospective study of eight men (average age 37 years), all with previous head injury. The nerve entrapment was severe in two cases, moderate in four and mild in two. The elbow was ankylosed with a mean flexion deformity of 96 degrees (77 degrees-123 degrees). Management consisted of early decompression and neurolysis with anterior transposition of the ulnar nerve. In four cases elbow release was postponed until maturation of the ossification.

RESULTS

The neurolysis results were assessed according to the score of KLEIMAN modified by TEOH. They were excellent in two cases, good in five and bad in one.

DISCUSSION

Entrapment of the ulnar nerve in the context of heterotopic ossification seems related to compression and tension on the ulnar nerve. The compression may be due to prolonged pressure of the medial edge of the elbow on the bed of the nerve, or to a periarticular bony bridge and the initial inflammatory reaction of the heterotopic ossification. Ulnar nerve tension seems to be due to prolonged flexion of the elbow joint and to movements of the shoulder and the wrist, on either side of the ankyrozed elbow. Treatment should be by early decompression of the nerve and we recommend, in addition, anterior transposition to reduce the tension on the nerve. The elbow release can be combined with the neurolysis or delayed according to the state of activity of the heterotopic ossification.

The V-sling: a modified medial intermuscular septal sling for anterior transposition of the ulnar nerve

Subcutaneous anterior ulnar nerve transposition has been advocated by many surgeons as simple and effective. Techniques to maintain the nerve anterior to the medial epicondyle include subcutaneous pocket, subcutaneous-fascia tunnel, and fascial and fasciodermal sling. We describe a modified technique that uses the medial intermuscular septum as a sling to allow a more gentle transition of the ulnar nerve as it enters into the flexor carpi ulnaris muscle belly.