Comparative study of different surgical transposition methods for ulnar nerve entrapment at the elbow

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.

Reverse End-to-Side Anterior Interosseous Nerve-to-Ulnar Motor Transfer for Severe Ulnar Neuropathy

BACKGROUND

Reverse end-to-side anterior interosseous nerve transfer has been reported to enhance treatment of severe, proximal ulnar neuropathy. The authors report on patients with severe neuropathy treated with ulnar nerve transposition and distal reverse end-to-side anterior interosseous nerve transfer.

METHODS

Thirty patients with severe ulnar neuropathy at the elbow were reviewed. Clinical parameters included preoperative and postoperative Medical Research Council muscle strength, clawing, and degree of wasting. Electrodiagnostic data included compound motor action potential and sensory nerve action potential amplitudes. Summary statistics were used for demographic and clinical data. The t test and Wilcoxon signed rank test were used where appropriate.

RESULTS

Average follow-up was 18.6 months. Preoperatively, 20 patients had Medical Research Council less than or equal to grade 1 in hand intrinsics, small finger sensory nerve action potentials were absent in all patients except for three, and average compound motor action potentials were severely reduced (absent in nearly 40 percent) confirming severity. All groups had a statistically significant increase in strength. More than three-quarters of patients noted partial or complete resolution of clawing and intrinsic muscle wasting. Seventy-three percent of patients regained Medical Research Council greater than or equal to grade 3 and 47 percent achieved Medical Research Council greater than or equal to grade 4. Mean time to observation of nascent units was 8.5 months, and 77 percent of patients demonstrated an augmentation of motor unit numbers with forearm pronation on needle electromyography CONCLUSION:: Proximal subcutaneous ulnar nerve transposition when combined with reverse end-to-side anterior interosseous nerve-to-ulnar nerve transfer demonstrates significant clinical and electrodiagnostic improvement of intrinsic muscle function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

Ultrasound Measurements and Assessments of the Ulnar Nerve at the Elbow and Cubital Tunnel: A Scoping Review

Ulnar neuropathy at the elbow (UNE) is the second most frequent peripheral nerve entrapment neuropathy in the upper extremity. The diagnosis is determined through a combination of history, physical examination, and electrodiagnostic testing. However, the use of high-resolution sonography is increasing, with sonographic measurements of ulnar nerve dimension established as a reliable diagnostic criterion for UNE. Sonographic imaging can describe anatomical features beyond ulnar nerve size, and therefore additional observations could potentially be used in UNE diagnosis and treatment follow-up. This review was a scoping of the literature on different sonographic measurements and assessments that have been reported to evaluate the ulnar nerve and cubital tunnel. This should provide a guide to scanning protocols for sonographers.

Multiple rare causes of post-traumatic elbow stiffness in an adolescent patient: A case report and review of literature

BACKGROUND

Joint stiffness after elbow surgery is not a rare complication, and is always accompanied by deformity. The causes of joint stiffness are multiple in different patients, and divided into intrinsic and extrinsic causes. Herein, we report an unusual case of posttraumatic elbow stiffness due to multiple and rare causes.

CASE SUMMARY

A 19-year-old male was hospitalized with the loss of motion of the left elbow for over ten years. Left limb computed tomography revealed left elbow stiffness with bony block and connection. The patient underwent surgery, and the etiology of joint stiffness was found to be a rare combination of common and uncommon causes. During an 18-mo follow-up period, the patient’s left elbow had normal motion and he was symptom-free.

CONCLUSION

However, this case combined with multiple and rare causes highlights that the patient with scar physique is likely to be accompanied with more severe soft tissue, nerve contracture, and heterotypic ossification, even during recurrence.

Use of High-Resolution Ultrasonography in Anterior Subcutaneous Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome

OBJECTIVES

Cubital tunnel syndrome (CTS) is the most common form of ulnar nerve entrapment. In this study, ultrasonography (US) was used not only for diagnosis but also for operation. US findings could be used to establish the diagnosis of CTS and could demonstrate the pathological anatomy in the cubital tunnel region to guide anterior subcutaneous transposition of the ulnar nerve.

METHODS

Sixty-two patients with clinical and electrophysiological evidence of ulnar nerve entrapment were included. All patients received ultrasonographic examination and anterior subcutaneous transposition of the ulnar nerve. The maximal diameter of the ulnar nerve (MDU) was measured in longitudinal views and the range of the hypoechoic area around the nerve was observed. The cross-sectional area (CSA) was also measured on transverse scans. The actual MDU was measured during operation.

RESULTS

The actual MDU was 6.4 ± 0.4 mm, measured during operation. The preoperative MDU was 3.1 ± 0.2 mm. The MDU values recorded in CTS patients were greater than those in normal subjects. The range of the hypoechoic area observed on longitudinal US scans was 2.9-5.6 mm (mean, 4.1 ± 0.4 mm).

CONCLUSIONS

High-resolution US can be used not only in the diagnosis of CTS, also for providing effective preoperative evaluation for the anterior subcutaneous transposition of the ulnar nerve in CTS.

Treatment for ulnar neuropathy at the elbow

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Quality of research and quality of reporting in elbow surgery trials

BACKGROUND

Randomized controlled trials (RCTs) are high in the hierarchy of scientific evidence, but possible sources of bias should be identified or even excluded. This systematic review assessed the methodologic quality and the quality of reporting of the RCTs on the treatment of elbow pathology.

METHODS

A systematic review of RCTs was performed on the treatment of elbow pathology. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for relevant trials. Thirty-five of the initial 540 articles being an (pseudo) RCT on invasive treatment of elbow pathology in humans were included. These were scored with the use of an adapted Checklists to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). To assess quality of reporting, points were administered to the articles based on the results from CLEAR-NPT list. The highest possible score for quality is 26 points.

RESULTS

The average quality score was 18.1 points (range, 10-25 points). The mean scores were 19.5 for trials published in the American Journal of Sports Medicine, 19.8 for those published in the Journal of Bone and Joint Surgery, and 20.3 for those published in the Journal of Shoulder and Elbow Surgery.

CONCLUSIONS

The most important finding was that the overall quality and the quality of reporting has not improved over the years and that the overall quality of the selected studies and the quality of reporting in these trials is not related to the journal they are published in.

Subcutaneous Versus Submuscular Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Subcutaneous and submuscular anterior ulnar nerve transposition have been widely used in patients with cubital tunnel syndrome. However, the reliable evidence in favor of 1 of 2 surgical options on clinical improvement remains controversial. To maximize the value of the available literature, we performed a systematic review and meta-analysis to compare subcutaneous versus submuscular anterior ulnar nerve transposition in patients with ulnar neuropathy at the elbow. PubMed, Cochrane Library, and EMBASE databases were searched for randomized and observational studies that compared subcutaneous transposition with submuscular transposition of ulnar nerve for cubital tunnel syndrome. The primary outcome was clinically relevant improvement in function compared to the baseline. Randomized and observational studies were separately analyzed with relative risks (RRs) and 95% confidence intervals (CIs). Two randomized controlled trials (RCTs) and 7 observational studies, involving 605 patients, were included. Our meta-analysis suggested that no significant differences in the primary outcomes were observed between comparison groups, both in RCT (RR, 1.16; 95% CI 0.68-1.98; P = 0.60; I2= 81%) and observational studies (RR, 1.01; 95% CI 0.95-1.08; P = 0.69; I2 = 0%). These findings were also consistent with all subgroup analyses for observational studies. In the secondary outcomes, the incidence of adverse events was significantly lower in subcutaneous group than in submuscular group (RR, 0.54; 95% CI 0.33-0.87; P = 0.01; I2 = 0%), whereas subcutaneous transposition failed to reveal more superiority than submuscular transposition in static two-point discrimination (MD, 0.04; 95% CI -0.18-0.25; P = 0.74; I = 0%). The available evidence is not adequately powered to identify the best anterior ulnar nerve transposition technique for cubital tunnel syndrome on the basis of clinical outcomes, that is, suggests that subcutaneous and submuscular anterior transposition might be equally effective in terms of postoperative clinical improvement. However, differences in clinical outcomes metrics should be noted, and these findings largely rely on the outcomes data from observational studies that are potentially subject to a high risk of selection bias. Therefore, more high-quality and adequately powered RCTs with standardized clinical outcomes metrics are necessary for proper comparison of these techniques.

Anterior Subcutaneous versus Submuscular Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis

Objective

To pool reliable evidences for the optimum anterior transposition technique in the treatment of cubital tunnel syndrome by comparing the clinical efficacy of subcutaneous and submuscular anterior ulnar nerve transposition.

Methods

A comprehensive search was conducted in PubMed MEDLINE, Cochrane Library, EMBASE, Web of Science, OVID AMED, EBSCO and potentially relevant surgical archives. Risk of bias of each included studies was evaluated according to Cochrane Handbook for Systematic Reviews of Interventions. The risk ratio (RR) and 95% confidence intervals (CI) were calculated for the clinical improvement in function compared to baseline. Heterogeneity was assessed across studies, and subgroup analysis was also performed based on the study type and follow-up duration.

Results

Three studies with a total of 352 participants were identified, and the clinically relevant improvement was used as the primary outcomes. Our meta-analysis revealed that no significant difference was observed between two comparison groups in terms of postoperative clinical improvement in those studies (RR 1.04, 95% CI 0.86 to 1.25, P = 0.72). Meanwhile, subgroup analyses by study type and follow-up duration revealed the consistent results with the overall estimate. Additionally, the pre- and postoperative motor nerve conduction velocities were reported in two studies with a total of 326 patients, but we could not perform a meta-analysis because of the lack of concrete numerical value in one study. The quality of evidence for clinical improvement was ‘low’ or ‘moderate’ on the basis of GRADE approach.

Conclusions

Based on small numbers of studies with relatively poor methodological quality, the limited evidence is insufficient to identify the optimum anterior transposition technique in the treatment of cubital tunnel syndrome. The results of the present study suggest that anterior subcutaneous and submuscular transposition might be equally effective in patients with ulnar neuropathy at the elbow. Therefore, more high-quality randomized controlled trials with standardized clinical improvement metrics are required to further clarify this topic and to provide reproducible pre- and postoperative objective outcomes.

Treatment for ulnar neuropathy at the elbow

BACKGROUND

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

OBJECTIVES

To determine the effectiveness and safety of conservative and surgical treatments in ulnar neuropathy at the elbow.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 February 2012), CENTRAL (2012, Issue 2), MEDLINE (January 1966 to February 2012), EMBASE (January 1980 to February 2012), AMED (January 1985 to February 2012), CINAHL Plus (January 1937 to February 2012), LILACS (January 1982 to Feburary 2012), PEDro (January 1980 to February 2012), and the papers cited in relevant reviews.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We identified six RCTs (430 participants), with moderate quality evidence, for inclusion in the review. When the searches were updated in 2012 we found no further studies. The sequence generation was not adequate in one study and not described in two studies. We performed two meta-analyses to evaluate the clinical (three trials, 261 participants included) and neurophysiological (two trials, 101 participants included) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). In the simple decompression group 91 out 131 patients clinically improved; in the transposition group 97 out 130 patients improved. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85).In one trial (47 participants) the authors compared medial epicondylectomy with anterior transposition and found no difference in the clinical and neurophysiological outcomes.One trial (51 participants) assessed conservative treatment in clinically mild or moderate ulnar neuropathy at the elbow. The authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to the information did not produce further improvement.

AUTHORS' CONCLUSIONS

The available evidence is not sufficient to identify the best treatment for idiopathic ulnar neuropathy at the elbow on the basis of clinical, neurophysiological and imaging characteristics. We do not know when to treat a patient conservatively or surgically. However, the results of our meta-analysis suggest that simple decompression and decompression with transposition are equally effective in idiopathic ulnar neuropathy at the elbow, including when the nerve impairment is severe. In mild cases, evidence from one small RCT of conservative treatment showed that information on movements or positions to avoid may reduce subjective discomfort.