Development and validation of the patient-rated ulnar nerve evaluation

Clinical Outcomes of Ulnar Collateral Ligament Repair With Internal Brace Versus Ulnar Collateral Ligament Reconstruction in Competitive Athletes

BACKGROUND

The increasing prevalence of ulnar collateral ligament (UCL) injuries, particularly in young athletes, necessitates optimization of treatment options. The introduction of UCL repair with internal bracing offers an exciting alternative to traditional UCL reconstruction.

PURPOSE

To compare midterm outcomes between UCL repair with internal bracing and UCL reconstruction in competitive athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors identified competitive athletes who underwent primary UCL repair with internal bracing or UCL reconstruction between 2013 and 2021 and were at least 2 years postsurgery. To have qualified for repair, patients must have shown complete or partial UCL avulsion from the sublime tubercle or medial epicondyle. Relevant patient, injury, operative, and revision surgery data were collected via chart review. Preoperative American Shoulder and Elbow Surgeons Elbow assessment form (ASES-E), Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC), and Andrews-Carson scores were obtained from an ongoing data repository. ASES-E, KJOC, and Andrews-Carson scores, and return-to-sport (RTS) data were collected at follow-up. Linear regression modeling controlling for relevant covariates was utilized to compare patient-reported outcome (PRO) scores between groups. Proportions of athletes who successfully returned to sport and proportions of subsequent revision procedures between groups were compared using chi-square tests. Lastly, for those with baseline questionnaire data, the authors compared magnitude of change between preoperative and postoperative scores between groups using linear regression modeling with baseline scores and follow-up time as the covariates, and follow-up scores as the dependent variable.

RESULTS

A total of 461 athletes were eligible for inclusion with complete clinical and outcome data available (mean age at surgery, 19.1 years; 92% male). The UCL repair group had a significantly shorter follow-up time than the UCL reconstruction group (4.4 vs 6.3 years; P < .01). When controlling for follow-up time, the groups did not differ in ASES-E, KJOC, or Andrews-Carson scores at follow-up. There was no significant difference in proportion of revisions between UCL repair (9%) and UCL reconstruction (8%) (P = .77). Of the 268 athletes with complete follow-up in the repair group, 247 attempted to return to their preinjury sport, and 241 (98%) were able to RTS. Six athletes reported that they were unable to RTS due to limitations from their surgery. Of the 155 athletes with follow-up in the reconstruction group, 147 attempted to return to their preinjury sport; 145 (99%) were able to successfully RTS, and 2 were unable to return due to limitations from their surgery. The 2 groups, repair with internal brace versus reconstruction, did not statistically differ in the proportions that returned to preinjury sport (P = .20) but did differ regarding time in months to return to practice (6.7 ± 3.5 vs 10.2 ± 11.7) (P < .01) and time in months to return to competition (9.2 ± 4.6 vs 13.4 ± 13.3) (P < .01).

CONCLUSION

Athletes who underwent UCL repair with internal brace reported excellent midterm PROs statistically similar to those after UCL reconstruction, including proportion successfully returning to preinjury sport. There was no significant difference in revision rates between procedures. However, athletes who underwent UCL repair had a statistically significantly shorter time to RTS.

Comprehensive Assessment of Specific Patient-Reported Outcome Measures for Hand and Wrist Conditions in Adults: A Scoping Review

Purpose

This scoping review aims to assess the various patient-reported outcome measures (PROMs) specifically developed and validated for patients with hand and wrist conditions. The objective is to provide healthcare professionals with an up-to-date overview of the available PROMs, empowering them to make informed decisions in selecting the most appropriate PROM to support personalized care for their patients.

Methods

The review adhered to the PRISMA-ScR 2018 checklist and involved a systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL Registry of Trials. Inclusion and exclusion criteria were established, and 2 independent reviewers screened and selected relevant articles. Data were extracted from full-text articles to identify the conditions of the hand or wrist and the PROMs used for measurement.

Results

A total of 22 PROMs for hand and wrist conditions were identified, with the Disabilities of the Arm, Shoulder, and Hand (DASH) being the most frequently employed, followed by the Patient Rated Wrist Evaluation and QuickDASH. The utilization of these PROMs was prominent in articles focusing on traumatic hand and wrist conditions, nerve conditions, and joint/arthrosis problems. Additionally, 67 articles (19.7%) employed more than one hand/wrist-specific PROM, and 8 generic PROMs were used in conjunction with hand/wrist-specific PROMs.

Conclusion

This review offers a comprehensive overview of the available PROMs to assist healthcare professionals in selecting the most suitable measure for personalized care. The growing use and development of PROMs in this field highlights their increasing relevance in enhancing patient outcomes.

Study design

Scoping Review.

Outcome measurement instruments for adult brachial plexus injury: a systematic review of development and measurement properties

PURPOSE

To review candidate outcome measurement instruments (OMIs) for the core outcome set (COS) for brachial plexus injury (BPI) and identify those with the strongest measurement properties.

METHODS

We conducted a PRISMA-compliant systematic review to identify studies on the measurement properties of domain-specific OMIs for adult BPI. OMIs with adequate content validity were further evaluated. Two independent reviewers assessed the methodological quality of each study using the COSMIN Risk of Bias checklist and assessed overall quality using a modified GRADE approach.

RESULTS

Nineteen development/validation studies concerning nine OMIs were identified. The Brachial Assessment Tool (BrAT) and the Impact of Brachial Plexus Injury Questionnaire (IMBPIQ) (both measuring carrying out daily routine) had sufficient content validity to proceed to full evaluation. The BrAT had moderate quality evidence to support its psychometric properties. The IMBPIQ needs further research to evidence structural validity and internal consistency. The Brief Pain Inventory has strong psychometric properties in other populations and is recommended for the core measurement set (CMS) for chronic pain.

CONCLUSIONS

The BrAT and the Brief Pain Inventory are recommended for inclusion in the BPI CMS. Further consensus work is needed to identify the most appropriate OMI for voluntary movement.

Systematic Review Registration: PROSPERO (CRD42022307564).

Association of Ultrasound and Electrodiagnostic Studies in Patients Evaluated for Ulnar Neuropathy

PURPOSE

Our goal was to determine the association between the severity of electrodiagnostic (EDX) studies with the cross-sectional area (CSA) of the ulnar nerve at the cubital tunnel using diagnostic ultrasound. Based on our clinical experience, we hypothesized there would not be a positive correlation between the severity of EDX and ulnar nerve CSA.

METHODS

This was a retrospective analysis of patients 18 years or older evaluated from May 1, 2020, to June 31, 2021, referred for an upper limb EDX and neuromuscular ultrasound to evaluate for an upper limb neuropathy. History, physical examination, ultrasound imaging (ulnar nerve at elbow), and EDX were reviewed. Patients were excluded for age under 18 years or concomitant upper limb radiculopathy. Baseline sample characteristics were analyzed, including age, race, sex, ethnicity, body mass index (normal, overweight, obese, or morbid obesity), and smoking status.

RESULTS

Of 1,043 patients, there were more females than males (634 vs 409) with an average age (SD) of 54.0 (15.5). Most of the patients were White (863) compared to Black (113) and other races (67). The average CSA of the ulnar nerve at the elbow increased with increased severity based on EDX results. There was a significant association between increasing severity on EDX and the increased nerve CSA at the elbow.

CONCLUSIONS

We found a positive association between the EDX severity and the CSA of the ulnar nerve on diagnostic ultrasound at the cubital tunnel. As the severity of ulnar neuropathy at the elbow increases, the CSA of the ulnar nerve correspondingly increases at the elbow.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Porcine submucosal extracellular matrix wrapping of the ulnar nerve in revision cubital tunnel surgery

The wrapping technique aims to protect the nerve when the nerve bed is compromised or more commonly to prevent the recurrence of scar tethering following neurolysis. A wrap provides a physical barrier to scar and helps restore the paraneurial gliding layer. This study aimed to evaluate the results of the AxoGuard® nerve protector, a porcine-derived submucosal extracellular matrix (PECM), used as an adjunct in persistent or recurrent cubital tunnel syndrome (CuTS). This retrospective cohort study evaluated patients diagnosed, between 2012 and 2020, with neuropathic pain who underwent revision surgery. Patients were categorised into Group A (revision surgery only) and Group B (revision surgery and adjunctive PECM nerve wrapping). Disease severity was scored at the baseline and six months post-operatively using the McGowan classification. A linear regression model was used to assess the effect of wrapping the ulnar nerve on the clinical outcome at six months. Fifty-nine nerves were treated; among them, adjunctive PECM wrapping was used in 32 nerves. Disease severity at baseline was similar between the groups. After adjusting for differences in baseline characteristics, participants in Group B improved with a significant difference of 0.43 McGowan points over Group A (95% CI (0.01-0.86), p = 0.049). There were no implant-related complications. Group B improved with excellent or good outcomes in 84.4% patients at the final follow-up. Persistent or recurrent CuTS were associated with neuropathic pain and significant nerve scar tether. The use of PECM appears to lead to improved clinical symptoms, possibly by reducing adhesions and encouraging physiological glide. LEVEL OF EVIDENCE: Level III evidence.

The Effects of Photobiomodulation Therapy in Cubital Tunnel Syndrome, Clinical Trial

Aim: We aimed to evaluate the effects of laser therapy together with rest splint and exercise on muscle strength, function, activities of daily living, and pain in individuals suffering from cubital tunnel syndrome (CuTS) by comparing it with placebo treatment. Materials and Methods: This prospective, single-blind, and randomized controlled study was conducted with 64 patients with CuTS in total. They were divided into two groups by randomization: Group 1 (n = 32) was provided with low-energy laser therapy + splint + exercise, and Group 2 (n = 32) was provided with low-energy sham laser therapy + splint + exercise. Patients in both groups received resting splints and nerve release exercises. Pretreatment and posttreatment (3rd week, 3rd month) evaluations were made with the Visual Analog Scale (VAS), the Quick Disability of Arm, Shoulder, and Hand Questionnaire, hand grip strength, fingertip grip strength, the Patient-Rated Ulnar Nerve Evaluation Scale (PRUNES), and Short Form-12. An electrophysiological evaluation was performed at baseline and at the 3rd month. Results: We observed significant improvements in both groups regarding pain, function, muscle strength, health profile, and quality of life in the early posttreatment (3rd week) stage and at the 3rd-month follow-up. When both groups were compared, a significant difference was determined between the VAS-Rest, VAS-Movement, PRUNES-Pain, PRUNES-Function, and PRUNES-Total parameters in the posttreatment (3rd week follow-ups), as well as PRUNES-Pain scores in the post-treatment (3rd month) stage, of the groups in favor of those in Group 1 (p < 0.05). Conclusion: The findings of our study have shown that in the treatment of CuTS, laser treatment is superior to placebo in the short term, but they have equivalent effects in the medium term. Further studies with large patient populations are needed to provide more diverse information about the therapeutic effectiveness of low-intensity laser therapy.

Tailoring and Evaluating Treatment with the Patient-Specific Needs Evaluation: A Patient-Centered Approach

BACKGROUND

No patient-reported instrument assesses patient-specific information needs, treatment goals, and personal meaningful gain (PMG), a novel construct evaluating individualized, clinically relevant improvement. This study reports the development of the Patient-Specific Needs Evaluation (PSN) and examines its discriminative validity (ie, its ability to distinguish satisfied from dissatisfied patients) and test-retest reliability in patients with hand or wrist conditions.

METHODS

A mixed-methods approach was used to develop and validate the PSN, following Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines, including pilot testing, a survey (pilot, n = 223; final PSN, n = 275), cognitive debriefing ( n = 16), expert input, and validation. Discriminative validity was assessed by comparing the satisfaction level of patients who did and did not achieve their PMG ( n = 1985) and test-retest reliability using absolute agreement, the Cohen kappa, and intraclass correlation coefficients ( n = 102). The authors used a sample of 2860 patients to describe responses to the final PSN.

RESULTS

The PSN has only 5 questions (completion time, ±3 minutes) and is freely accessible online. The items and response options were considered understandable by 90% to 92% of the end-users and complete by 84% to 89%. The PSN had excellent discriminative validity (Cramer V, 0.48; P < 0.001) and moderate to high test-retest reliability (kappa, 0.46 to 0.68; intraclass correlation coefficients, 0.53 to 0.73).

CONCLUSIONS

The PSN is a freely available, patient-centered decision support tool that helps clinicians tailor their consultations to patients' individual needs and goals. It contains the PMG, a novel construct evaluating individualized, clinically relevant treatment outcomes. The PSN may function as a conversation starter, facilitate expectation management, and aid shared decision-making. The PSN is implementation-ready and can be readily adapted to other patient populations.

Novel Technique for Ulnar Nerve Transposition at the Elbow: The Neocubital Tunnel

Background

Many standard surgical procedures for cubital tunnel syndrome rely on ulnar nerve transposition at the elbow. Placing the ulnar nerve anterior to the axis of motion decreases compression during flexion. Subcutaneous, subfascial, and submuscular positioning of the ulnar nerve may predispose to nerve irritation, instability, and compression in the two first scenarios, and requires invasive dissection in the third one. With no single procedure demonstrating clear advantages and outcomes, this study reports the results of a novel technique using the epitrochleo-olecranon ligament to create a neo-tunnel, anatomically stabilizing the ulnar nerve.

Methods

Nine consecutive patients were enrolled. Patients were evaluated qualitatively for symptomatic improvements using physical examination. The Wilson and Krout, modified McGowan, and PRUNE grading scores were used for quantitative measurement.

Results

Postoperatively, all patients reported subjective improvement in symptoms and functional improvement. There were no intraoperative or postoperative complications. Baseline severity of disease was evaluated using the McGowan scale (modified by Goldberg): eight (89%) grade IIA patients and one (11%) grade III patient. Postoperatively, seven (78%) patients were reduced to grade 0, and two (22%) patients to grade 1 (P < 0.001). Using the Wilson and Krout criteria, outcomes were as follows: six (67%) excellent, two (22%) good, and one (11%) fair. The mean postoperative PRUNE survey score was 19.3 (SD ± 24.4).

Conclusions

The neocubital tunnel technique is a relatively noninvasive, safe surgical alternative that may be considered when an anterior transposition of the ulnar nerve is indicated for surgical decompression of the cubital tunnel.

The hand diagram: A novel outcome measure following supercharged end-to-side anterior interosseous nerve to ulnar nerve transfer in severe compressive ulnar neuropathy

BACKGROUND

With advances in the surgical management for severe ulnar neuropathy with the introduction of the super charged-end-to-side (SETS) anterior interosseous nerve (AIN) to ulnar nerve transfer, a simple and reliable outcome measure is required. There is currently not "one" standardized outcome measure used to represent and compare results.

PURPOSE

To present the abduction hand diagram as a "novel", reproducible, and simple outcome measure for patients with severe ulnar neuropathy.

STUDY DESIGN

Retrospective case series.

METHODS

Nine patients with severe entrapment/compressive ulnar neuropathy at the elbow were reviewed. Clinical parameters included preoperative and postoperative abduction tracings, Medical Research Grade (MRC) muscle strength, key pinch strength, Disability of the Hand Arm and Shoulder (DASH) score, and crossed finger test. Electrodiagnostic data included change in compound muscle action potentials (CMAP) amplitude of the first dorsal interosseous (FDI), and abductor digiti minimi (ADM). Summary statistics were used for demographic and clinical data.

RESULTS

Average follow-up was 22.8 ± 9.3 months. At 18-months of follow up, 44% had ADM MRC grade 3 strength or higher, mean key pinch strength improved to 72 ± 19.3%, and mean DASH was 33 ± 28.7. There was a mean increase of 16.7 ± 9.1 mm and 31.5 ± 12 mm in total and summed hand abduction tracing measurements respectively.

CONCLUSIONS

Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention.

Analysis of outcome reporting in sciatic neuropathy studies: a systematic review of the literature

PURPOSE

As a first step towards developing a core outcome set (COS) for sciatic neuropathy, the goal of the current study was to perform a systematic review of the literature to identify outcome measures that have been previously reported in studies on sciatic neuropathy.

METHODS

A systematic review of the literature from 2000-2024 was performed utilizing PubMed and Medical Subject Headings (MeSH). Identified articles were screened according to study inclusion/exclusion criteria. Outcome measures reported in each included study were recorded and categorized into motor, sensory, pain, patient-reported outcomes, electrodiagnostic outcomes, imaging outcomes, and composite outcomes. Descriptive statistics were performed.

RESULTS

A total of 1586 articles were initially identified, and 31 articles met criteria for inclusion and underwent analysis. The most common outcome domain was pain. A pain outcome was reported in 17 (63%) studies. A motor outcome was reported in 10 (37%) studies; 6 (22%) reported a sensory outcome; 1 (4%) reported a composite outcome; 4 (15%) reported an electrodiagnostic outcome; 5 (19%) reported a patient-reported outcome; 3 (11%) reported an imaging outcome. Across the included studies, 21 unique outcomes were reported.

CONCLUSIONS

We have identified the outcome measures that have previously been utilized in studies on sciatic neuropathy. Previously used outcome measures fell into seven domains: motor outcomes, sensory outcomes, pain outcomes, patient-reported outcomes, electrodiagnostic outcomes, imaging outcomes, and composite outcomes. Pain outcomes were most commonly used across the included studies.

The Unpredictable Ulnar Nerve-Ulnar Nerve Entrapment from Anatomical, Pathophysiological, and Biopsychosocial Aspects

Peripheral nerves consist of delicate structures, including a rich microvascular system, that protect and nourish axons and associated Schwann cells. Nerves are sensitive to internal and external trauma, such as compression and stretching. Ulnar nerve entrapment, the second most prevalent nerve entrapment disorder after carpal tunnel syndrome, appears frequently at the elbow. Although often idiopathic, known risk factors, including obesity, smoking, diabetes, and vibration exposure, occur. It exists in all adult ages (mean age 40-50 years), but seldom affects individuals in their adolescence or younger. The patient population is heterogeneous with great co-morbidity, including other nerve entrapment disorders. Typical early symptoms are paresthesia and numbness in the ulnar fingers, followed by decreased sensory function and muscle weakness. Pre- and postoperative neuropathic pain is relatively common, independent of other symptom severity, with a risk for serious consequences. A multimodal treatment strategy is necessary. Mild to moderate symptoms are usually treated conservatively, while surgery is an option when conservative treatment fails or in severe cases. The decision to perform surgery might be difficult, and the outcome is unpredictable with the risk of complications. There is no consensus on the choice of surgical method, but simple decompression is relatively effective with a lower complication rate than transposition.

Hereditary neuropathy associated with liability to pressure palsies: a 24-year experience with carpal and cubital tunnel surgery

The aim of this single-centre retrospective study was to evaluate the outcomes of carpal tunnel release surgery in patients with hereditary neuropathy with pressure palsies (HNPP). The secondary aims were to identify prognostic factors for the outcome of carpal tunnel release and to assess the outcome of cubital tunnel release. Our primary hypothesis was postoperative improvement. In total, 18 patients (26 carpal tunnel releases) with at least one symptomatic carpal tunnel syndrome were included. At a median follow-up of 8.5 years, more than 73% of the patients were satisfied with the results. The visual analogue scale (0 to 10) for discomfort decreased by 2.2 points (p < 0.001). The Boston Carpal Tunnel Questionnaire symptom severity scale decreased by 1.3 points (p < 0.001). The decrease in the Functional Status Scale was not significant. No significant prognostic factor for outcome was identified. A total of 12 patients also underwent cubital tunnel release, and three patients underwent just this procedure (23 procedures). Despite the lack of preoperative data, cubital tunnel release provided encouraging results. Level of evidence: III.

Comparison of in-situ release and submuscular anterior transposition of ulnar nerve for refractory cubital tunnel syndrome, previously treated with subfascial anterior transfer-A retrospective study of 24 cases

BACKGROUND

Although cubital tunnel syndrome is the second most common type of compressive neuropathy in the upper extremities, the indication and optimal surgical method for recurrent or refractory cubital tunnel syndrome remains controversial. This study evaluates the functional outcomes of revision surgery for cubital tunnel syndrome.

MATERIAL & METHODS

This study was a retrospective observational multicenter single-institution study including 660 patients who underwent surgery for cubital tunnel syndrome from 2010 to 2019. Among the 660 patients, 42(6.4%) received revision surgery due to remaining or recurrent symptoms confirmed with electromyography(EMG). After excluding those with concurrent elbow fracture, dislocation, osteoarthritis and wound infection, a total of 24 patients were included in the study. The patients were evaluated of disease severity, revision surgical method, time interval to recurrence, underlying diseases and postoperative functional outcomes.

RESULTS

All patients received ulnar nerve subfascial anterior transposition for the initial cubital tunnel syndrome surgery. Among the 24 patients (3.7%) who received revision surgery, nine received in situ neurolysis, 12 received submuscular transposition, and three received subcutaneous transfer. 21 patients (88%) reported improved mean VAS score of 4.3, while three patients complained of remaining symptoms that did not improve even after revision surgery. The patients with remaining symptoms all had underlying diabetes mellitus and were treated with subcutaneous transfer. The difference of surgical outcomes between the in situ neurolysis group and the nerve transfer groups were non-significant (p = 0.23). The most common cause of recurrent or persistent symptoms was adhesion and fibrosis at sling area. The mean follow up period before revision surgery was 26.3 months and postoperative follow up period after revision surgery was 8.5 months.

CONCLUSION

The outcomes of this study imply that in-situ neurolysis may be as effective as anterior submuscular transfer of ulnar nerve for refractory cubital tunnel syndrome after anterior subfascial transfer.

Computerized adaptive testing for the patient evaluation measure (PEM) in patients undergoing cubital tunnel syndrome surgery

In outcome measures, item response theory (IRT) validation can deliver interval-scaled high-quality measurement that can be harnessed using computerized adaptive tests (CATs) to pose fewer questions to patients. We aimed to develop a CAT by developing an IRT model for the Patient Evaluation Measure (PEM) for patients undergoing cubital tunnel syndrome (CuTS) surgery. Nine hundred and seventy-nine completed PEM responses of patients with CuTS in the United Kingdom Hand Registry were used to develop and calibrate the CAT. Its performance was then evaluated in a simulated cohort of 1000 patients. The CAT reduced the original PEM length from ten to a median of two questions (range two to four), while preserving a high level of precision (median standard error of measurement of 0.27). The mean error between the CAT score and full-length score was 0.08%. A Bland-Altman analysis showed good agreement with no signs of bias. The CAT version of the PEM can substantially reduce patient burden while enhancing construct validity by harnessing IRT for patients undergoing CuTS surgery.

Preoperative electrodiagnostic studies and postoperative outcomes for ulnar mononeuropathy at the elbow: A systematic review

OBJECTIVE

To analyze the association between preoperative electrodiagnostic (EDX) studies and postoperative pain and functional outcomes following ulnar nerve decompression and/or transposition for ulnar neuropathy at the elbow (UNE).

LITERATURE SURVEY

Protocol was submitted and database search was conducted by an experienced librarian of all available studies in the English language from 1990 to June 8, 2022. Databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Scopus.

METHODOLOGY

Inclusion criteria consisted of randomized controlled trials, prospective and retrospective longitudinal studies, and studies involving adults ≥18 years of age who underwent ulnar nerve decompression and/or transposition for UNE. Study quality and risk of bias were assessed using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality of Assessment Tool. Certainty in evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. A meta-analysis was not performed.

SYNTHESIS

A total of 289 studies were screened, and 8 retrospective cohort studies met inclusion criteria comprising 762 patients. A decreased or absent preoperative sensory nerve action potential amplitude (SNAP) showed significance with worse postoperative outcomes. The presence of preoperative conduction block showed significance in higher quality studies. There was limited evidence for slow preoperative motor conduction velocities or preoperative electromyography (EMG) abnormalities and postoperative outcomes. Overall quality assessment demonstrated that two studies had "good," four "fair," and two "poor" quality of evidence. Certainty in evidence was "low" due to risk of bias.

CONCLUSIONS

A decreased or absent preoperative ulnar SNAP may predict worse postoperative outcomes. Per higher quality studies, preoperative conduction block at the elbow may also predict worse postoperative outcomes. Careful interpretation is required with a full understanding of the limited evidence, risk of bias, and low certainty in evidence to support the use of preoperative EDX to predict postoperative outcomes in UNE.

Analysis of outcome reporting in common peroneal neuropathy studies: a systematic review of the literature

BACKGROUND

There is a strong need for the development of core outcome sets (COS) across nerve surgery to allow for improved data synthesis, meta-analyses, and reporting consistency. Development of a core outcome set typically starts with assessing the literature for previously reported outcome measures. Common peroneal neuropathy (CPN) is the most common compressive mononeuropathy of the lower extremity and can result in pain, motor, and sensory deficits. A COS for COmmon PEroneal neuropathy (COS-COPE) is needed to improve future study design and comparison and synthesis of data. The goal of the current study was to assess the literature for outcomes reported in studies on CPN as the first step in the development of a COS.

METHODS

A systematic review of the literature from 2000 to 2023 was performed utilizing PubMed and Medical Subject Headings (MeSH). Identified articles were screened according to study inclusion/exclusion criteria. Outcome measures reported in each included study were recorded and categorized into motor, sensory, pain, composite foot/ankle score, electrodiagnostics, function/disability patient-reported outcome (PRO), psychological, or other outcomes. Descriptive statistics were performed.

RESULTS

A total of 31 articles met criteria for inclusion. A motor outcome was reported in 26 (83.9%) studies; 12 (38.7%) reported a sensory outcome; 8 (25.8%) reported a pain outcome; 4 (12.9%) reported a composite foot/ankle score; 3 (9.7%) reported electrodiagnostics; 1 (3.2%) reported a function/disability PRO; 1 (3.2%) reported a psychological outcome; 2 (6.5%) reported an imaging outcome; 3 (9.7%) reported other outcomes. Across the studies, 29 distinct outcome measures were reported.

CONCLUSIONS

The outcomes reported in studies on CPN are varied and inconsistent. It is likely that a combination of motor, sensory, pain, and functional outcomes will be needed in a COS to best study CPN. These data will serve as a baseline for the ultimate development of the COS-COPE.

Reported Outcomes and Outcome Measures in Proximal Interphalangeal Joint Arthroplasty: A Systematic Review

Purpose: There is a lack of scientific consensus on the best arthroplasty implant option for proximal interphalangeal joint (PIPJ) arthritis, due to diversity in outcome reporting and measurement methods. The development of a standardized core outcome set (COS) and standard outcome measures could mitigate this issue. This study catalogs the reported outcomes and outcome measures found in PIPJ arthroplasty studies, which can be used in the first step of developing a COS. Methods: A database search of MEDLINE, EMBASE, and Web of Science (January 1, 2010, to March 10, 2021) was performed to retrieve studies that reported outcomes of the 3 most common primary PIPJ arthroplasty implants: silicone, pyrocarbon, and metal-polyethylene. The primary objectives of this study include reported outcomes and outcome measures. Secondary objectives include clinimetric properties of outcome measures, study design, and implant types. Results: Fifty articles met inclusion criteria. Of the included studies, 41 (82%) were case series, 8 (16%) were cohort studies, and 1 (2%) was a randomized control trial. Thirty-three unique outcomes were identified. Fifteen (46%) outcomes were clinician-reported and 26 (79%) were patient-reported. Eighteen unique outcome measures were identified. Of the outcome measures, 15 (83%) were patient-reported, 1 (6%) was clinician-reported, and 2 (11%) were reported by both patients and clinicians. Conclusions: Substantial heterogeneity was found in reported outcomes and outcome measures across studies evaluating PIPJ arthroplasty, impeding knowledge translation. The development of a COS for PIPJ arthroplasty is necessary to help compare and pool data across studies, and advance scientific knowledge.

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.

Quality of life and satisfaction in patients surgically treated for cubital tunnel syndrome

OBJECTIVE

Cubital tunnel syndrome (CuTS) results from compression of the ulnar nerve at the elbow, resulting in pain, weakness, and numbness of the hand and forearm. This work describes the Quality of Life (QoL) and satisfaction after CuTS surgery and identifies the factors associated with those outcomes.

METHODS

This cross-sectional study included patients surgically treated for CuTS from January 2011 to September 2021 at the Neurosurgery Clinic of the Clinic Center in Serbia. The questionnaires applied were the Short Form 36 (SF-36), EuroQol instrument (EQ-5D-5 L), Bishop's score and Patient-Rated Ulnar Nerve Evaluation (PRUNE).

RESULTS

Sixty-two patients met the inclusion criteria. Bishop's score: The median score was 10 (7.75-11), 54.8% of the cases presented excellent results. PRUNE: The median score for symptoms was 19 (6-38.5); for functional, was 14 (0.75-38); and the total was 18.25 (5.87-34.12). SF-36: The subscale with the best result was social functioning (84.68 ± 22.79). The scale with the worst value was emotional well-being (49.35 ± 7.87). EQ-5D-5L: Over 50% patients did not present problems with mobility, self-care, activity, and anxiety. The average EQ-VAS was 72.77 ± 18.70; and 0.72 ± 0.21 of the EQ-index, revealing a good QoL. Models for QoL and satisfaction: Ten models showed statistical significance. The variables with major involvement were body mass index and time evolution of the symptoms.

CONCLUSION

Surgical decompression has proved to diminish the symptoms, improving QoL and satisfaction. Many fixed and changeable factors can affect the satisfaction levels after surgery.

Psychometric Properties of the Patient-Reported Outcome Measures for People With Ulnar Nerve Entrapment at the Elbow: A Systematic Review

OBJECTIVE

The objective of this study was to systematically review, critically appraise, and synthesize evidence on the measurement properties of patient-reported outcome measures (PROMs) for people with ulnar nerve entrapment at the elbow (UNE).

METHODS

CINAHL, MEDLINE, Embase, and Scopus were searched for studies reporting on the psychometric properties of the PROMs used to assess pain, disability, and quality of life of people with UNE. Relevant data were extracted based on the Consensus-Based Standards for the Selection of Health Measurement Instruments 2018 checklist. Two authors independently rated the quality and risk of bias of the studies. A qualitative synthesis was performed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines. The results were categorized based on the identified PROMs, and all the psychometric properties were summarized and presented.

RESULTS

Eight included studies had a quality score of very good or higher. Among all the included PROMs, the Patient-Rated Ulnar Nerve Evaluation (PRUNE) was comprehensively evaluated in 4 studies and had high reliability, appropriate correlation to the physical component summary score of the 36-Item Short-Form Health Survey (r = -0.68), excellent content (cognitive interviews), structural (factor analysis) and discriminative validities, and high responsiveness. The Disabilities of the Arm, Shoulder and Hand Questionnaire was assessed in 5 studies and had appropriate properties, showing a high correlation with the 8-Item Short-Form Health Survey (r = 0.77) and PRUNE (r = 0.75) and moderate responsiveness.

CONCLUSIONS

The PRUNE was the most specific to UNE, had the most supporting studies and evidence of excellent reliability, validity, and responsiveness and therefore was the preferred PROM. The Disabilities of the Arm, Shoulder and Hand Questionnaire demonstrated more limited validation across 5 studies and had moderate responsiveness. Information on other included PROMs was limited in terms of psychometric properties.

IMPACT

This study provides insight into which PROM is potentially more suitable for measuring outcomes related to UNE.

A Comparison of Nerve-Specific, Condition-Specific, and Upper Extremity-Specific Patient-Reported Outcome Measures in Patients With Carpal and Cubital Tunnel Syndrome

PURPOSE

Arm-, region-, tissue-, and condition-specific patient-reported outcome measures (PROMs) are available to address idiopathic mononeuropathy. This study compared PROMs with varying specificities in patients with idiopathic neuropathy of the upper extremity with respect to correlations with each another, sources of variation in scores, and floor and ceiling effects.

METHODS

One hundred fifty patients (130 with carpal tunnel syndrome, 30 with cubital tunnel syndrome, and 10 with both conditions) completed a nerve-specific PROM (Impact of Hand Nerve Disorders), a condition-specific PROM (Boston Carpal Tunnel Syndrome Questionnaire and/or Patient-Rated Ulnar Nerve Evaluation), and an upper extremity-specific PROM (Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity 7). We also gathered demographic and condition-related data (side, electrodiagnostic studies present, muscle atrophy, static loss of sensibility), and patients completed questionnaires measuring self-efficacy, kinesiophobia, and symptoms of depression. Correlation of the PROMs with each another and factors accounting for their variation were assessed, as well as the number of items to complete, time to complete, and floor and ceiling effects.

RESULTS

Pearson correlations between PROMs were moderate to strong (0.56-0.90). Self-reported symptoms of depression were best able to account for the variations in symptom intensity and activity intolerance on all PROMs (adjusted R² between 0.09 and 0.31). The Impact of Hand Nerve Disorders is a long questionnaire and took the most time to complete. All instruments had comparable floor effects; Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity had a ceiling of effect of 16%.

CONCLUSIONS

This study adds to the evidence that specific and general PROMs correlate with each another, perhaps in part through their correlation with mental health. Based on this line of evidence and pending testing of potentially greater responsiveness in specific settings, we prefer to use a single simple, brief, and general PROM to quantify symptom intensity and activity intolerance for both routine patient care and research.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Reliability and validity of the modified McGowan grade in patients with cubital tunnel syndrome

INTRODUCTION

This study aimed to assess the reliability and validity of the modified McGowan grading system and to determine its ability to distinguish the severity of cubital tunnel syndrome (CuTS) between the different grades.

MATERIALS AND METHODS

We prospectively enrolled 39 consecutive patients with CuTS from March 2018 to December 2020. Inter- and intra-observer reliability was assessed by two orthopaedic surgeons with a minimum 2-week interval using Cohen kappa coefficients. Validity was assessed by Spearman's correlation with objective clinical outcomes (grip strength, Semmes-Weinstein monofilament test [SWMT], static two-point discrimination [2PD], and motor conduction velocity [MCV]). In addition, the relationship between the grading system and patient-reported outcomes (Disabilities of the Arm, Shoulder and Hand score and Boston Questionnaire) was evaluated using Spearman's correlation. The ability to distinguish the severity between the different grades was assessed using the Kruskal-Wallis analysis.

RESULTS

The inter-observer kappa value was 0.54 and intra-observer kappa value was 0.59, which imply a moderate reliability. The modified McGowan grade had a moderate correlation with objective clinical outcomes (grip strength [r = - 0.350, p = 0.029], SWMT [r = 0.552, p < 0.001], 2PD [r = 0.456, p = 0.004], and MCV [r = - 0.394, p = 0.021]). However, patient-reported outcomes did not correlate with this grading system. Kruskal-Wallis analysis revealed significant differences between grades in terms of SWMT, 2PD, grip strength, and Boston Questionnaire functional score (p = 0.006, 0.025, 0.014, and 0.043, respectively); however, these differences were statistically significant only for a limited number of parts.

CONCLUSIONS

The modified McGowan grade has a moderate inter- and intra-observer reliability. This grading system moderately correlates with objective sensory-motor functions and MCV of patients with CuTS. However, the modified McGowan grade does not reflect the patient's perceived disabilities and has a weakness in distinguishing the severity of patients' conditions among the different grades.

Research reporting in cubital tunnel syndrome studies: an analysis of the literature

PURPOSE

There is a strong need for a set of consensus outcomes to be utilized for future studies on cubital tunnel syndrome. The goal was to assess the outcome measures utilized in the cubital tunnel syndrome literature as a way of measuring popularity/acceptability and then to perform a literature review for the most commonly used outcomes.

METHODS

A literature search was performed using the pubmed.gov database and Medical Subject Headings (MeSH). For each article, the following data were abstracted: study type, motor outcome(s), sensory outcome(s), composite outcome(s), patient-reported outcome (PRO) metric(s), pain outcome(s), psychological outcome(s), electrodiagnostic outcome(s), and any other outcomes that were used.

RESULTS

A composite outcome was reported in 52/85 (61%) studies, with the modified Bishop score (27/85; 32%) most common. A motor outcome was reported in 44/85 (52%) studies, with dynamometry (38/85; 45%) most common. The majority of studies (55%) did not report a sensory outcome. The majority of studies (52%) did not report a PRO. A specific pain outcome was reported in the minority (23/85; 27%), with the visual analogue scale (VAS) (22/85; 26%) most common. Pre- and postoperative electrodiagnostic results were presented in 22/85 studies (26%).

DISCUSSION

Understanding current clinical practice and historical outcomes reporting provides a foundation for discussion regarding the development of a core outcome set for cubital tunnel syndrome. We hope that the data provided in the current study will stoke a discussion that will culminate in a consensus statement for research reporting in cubital tunnel syndrome studies.

Outcome of Simple Decompression of Primary Cubital Tunnel Syndrome Based on Patient-Reported Outcome Measurements

PURPOSE

To evaluate the patient-reported outcome measures of patients with primary cubital tunnel syndrome and to assess whether they are affected by preoperative symptom severity.

METHODS

Patients who underwent simple decompression for primary cubital tunnel syndrome were selected from a prospectively maintained database. Outcome measurements consisted of the Boston Carpal Tunnel Questionnaire at intake and at 3 and 6 months after surgery. Also, 6 months after surgery, the patients received a question about their satisfaction with the treatment result. To determine a possible influence of preoperative symptom severity on postoperative outcomes, the sample was divided into quartiles based on symptom severity at intake.

RESULTS

One hundred and forty-five patients were included in the final analysis. On average, all patients improved on the Boston Carpal Tunnel Questionnaire. The subgroup of patients with the mildest symptoms at intake did not improve significantly on symptom severity but did improve significantly on their functional status. In addition, the patients with the most severe symptoms at intake did improve on both aspects. Moreover, no difference in satisfaction with treatment result between the severity of symptoms at intake was found.

CONCLUSIONS

The patients with the mildest symptoms at intake may not improve on symptom severity, but they do improve on functional status after simple decompression for cubital tunnel syndrome. In addition, patients with the most severe symptoms at intake do improve on both symptom severity and functional status. Moreover, all patients reported to be equally satisfied with the treatment result, which suggests that satisfaction is not dependent on the symptom severity at intake. Even those patients with both the mildest symptoms before surgery and the least improvement still seem to benefit from simple decompression.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Patient-reported outcome measures for patients with hand-specific impairments-A scoping review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used to provide evidence for treatment effects and to guide rehabilitation. To our knowledge, no disease-specific PROM exists for the assessment of patients with flexor tendon lesions of the hand. We believe that PROMs used to assess hand function, regardless of diagnosis, contain relevant items for patients with flexor tendon lesions of the hand.

PURPOSE

The aim of our study was to identify and collect items from pre-existing PROMs used by clinical experts to assess the health status and function in patients with reduced hand function.

STUDY DESIGN

A scoping review searching for PROMs with hand-specific content was conducted to ensure face validity. As these items are assumed to have been through an evaluation process by the clinical specialists, they have the advantage and likelihood of being useful.

METHODS

We searched five bibliographic databases. All PROMs with hand-specific content used to assess hand function were considered for inclusion. Questionnaires written in English, Danish, Swedish, and Norwegian were included. An analysis of content redundancy was conducted, and items were grouped according to The World Health Organization's International Classification of Functioning, Disability and Health.

RESULTS

Seventy-three PROMs were included with a total of 1,582 items. The majority of the items were redundant across measurement instruments, and redundant items were consolidated, resulting in 179 nonredundant items. All nonredundant items were classified according to the International Classification of Functioning, Disability and Health components.

CONCLUSIONS

This review presents a collection of 179 items ensuring face validity for patients with hand-related disease/injury.

Ulnar nerve dislocation in ulnar nerve entrapment at the elbow. Influence on surgical outcome

Our aim was to assess the incidence of symptomatic ulnar nerve dislocation and its influence on surgical outcome after primary and revision surgeries in ulnar nerve entrapment at the elbow (ulnar neuropathy at the elbow (UNE) or cubital tunnel syndrome). The influence of pre- or intra-operative ulnar nerve dislocation on postoperative outcome was assessed in 548 surgically treated cases (548 nerves) from two hand surgery departments reporting to the Swedish National Quality Registry for Hand Surgery, using QuickDASH, a patient-reported outcome measure (PROM), before surgery and at 3 and 12 months postoperatively, and a doctor-reported outcome measure (DROM), grading as "cured-improved "or "unchanged-worsened," at a median follow-up of 3.0 months [IQR, 1.5-6.0]. 109 of the 548 cases (20%) showed documented pre- or intra-operative ulnar nerve dislocation; more often found at revision (35/75, 47%) than at primary surgery (74/473, 16%) (p < 0.0001). Cases with dislocation presented higher QuickDASH scores at 12 months (p = 0.026). A linear regression model, adjusted for age and gender, predicted higher QuickDASH scores at 12 months postoperatively for cases with dislocation (unstandardized B 11.3 [95% CI 0.4-22.2], p = 0.043). DROM grading as unchanged-worsened at a median 3 months predicted worse QuickDASH scores (p < 0.0001) than in cured-improved cases at 3 (unstandardized B, 18.4 [95% CI 9.4-27.3]) and 12 months (unstandardized B, 18.1 [9.1-27.0]). Primary surgeries had better DROM grading than revision surgeries (p = 0.033; cured-improved, 75% and 63%, respectively), but QuickDASH scores did not differ. Presence of a clinically relevant ulnar nerve dislocation resulted in worse outcome, perhaps due to more extensive surgery with transposition. Nerve dislocation needs attention when treating UNE patients.

Cubital tunnel syndrome

Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper limb, presenting with disturbance of ulnar nerve sensory and motor function.The ulnar nerve may be dynamically compressed during movement, statically compressed due to reduction in tunnel volume or compliance, and tension forces may cause ischaemia or render the nerve susceptible to subluxation, further causing local swelling, compression inflammation and fibrosis.Superiority of one surgical technique for the management of CuTS has not been demonstrated. Different techniques are selected for different clinical situations with simple decompression being the most common procedure due to its efficacy and low complication rate.Adjunctive distal nerve transfer for denervated muscles using an expendable motor nerve to restore the axon population in the distal nerve is in its infancy but may provide a solution for severe intrinsic weakness or paralysis. Cite this article: EFORT Open Rev 2021;6:743-750. DOI: 10.1302/2058-5241.6.200129.

Effects of serious games in strength and functionality of patients with ulnar nerve lesion: two single-case reports

The objective of this study was to investigate the effect of serious games on hand muscle strength and functionality in a series of cases with ulnar nerve damage. Two patients were included in this 16-week intervention study using biofeedback. Electromyography electrodes and dynamometers were used in treatment. Functionality was assessed by Rosen and Lundborg score, Disabilities of the arm, shoulder and hand (DASH) questionnaire and International Classification of Functioning, Disability and Health (ICF). Grip and pinch strength were assessed by dynamometers. Results revealed an increase in sensory domain of Rosen and Lundborg score of the two patients. Patients increased values from the DASH questionnaire; however, they got better results with ICF. Grip strength of the two patients increased; pinch strength varied between patients; key pinch had the best results. Serious games can be effective to enhance hand strength and improve functionality in patients with ulnar nerve damage.

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.

The needle electromyography findings in the neurophysiological classification of ulnar neuropathy at the elbow

Background/aim

Although ulnar neuropathy at the elbow (UNE) is the second most common entrapment mononeuropathy, there are few reports on its neurophysiological classification. In this study, we tried to find out the role of needle electromyography (EMG) in the neurophysiological classification of UNE.

Materials and methods

UNE patients who met the clinical and neurophysiological diagnostic criteria and healthy individuals were included in this study. Reference values of nerve conduction studies were obtained from healthy individuals. Needle EMG was performed to all UNE patients. According to the neurophysiological classification proposed by Padua, UNE patients were classified as mild, moderate, and severe.

Results

Thirty-one controls and thirty-five UNE patients were included in the study. There was mild UNE in 23 patients, moderate UNE in 8, and severe UNE in 4. Abnormal needle EMG findings were present in all patients with moderate and severe UNE and in 12 patients with mild UNE.

Conclusion

Abnormal needle EMG findings are seen in most of the UNE patients. Therefore, it is not practical to use needle EMG findings in the neurophysiological classification. Needle EMG abnormalities may also be present in patients with mild UNE due to axonal degeneration or motor conduction block.

Polish version of the Patient-Rated Ulnar Nerve Evaluation in preoperative patients: Translation and psychometric testing

STUDY DESIGN

Cross-sectional design.

INTRODUCTION

This study examined the translated English to Polish version of the Patient-Rated Ulnar Nerve Evaluation (PRUNE) for its internal consistency, test-retest reliability, and construct validity.

METHODS

During the first assessment validity testing, a total of 39 consecutive patients with cubital tunnel syndrome completed the PRUNE, Michigan Hand Outcome Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, and Patient Evaluation Measure in conjunction with the grip and key pinch tests and pain score (by Visual Analogue Scale). Cronbach's alpha (CA), intraclass correlation coefficient (ICC), and the Bland-Altman plot were used to evaluate internal consistency, test-retest reliability, and agreement, respectively. Analysis of variance compared the PRUNE score with the McGowan clinical stages.

RESULTS

After a 1-day interval, 19 patients completed the PRUNE for the second time. The total PRUNE score was 44.4 ± 20.4, CA = 0.93, and ICC = 0.921. The total PRUNE score limits of agreement varied from -9.87 to 7.55 points. PRUNE subscale CA ranged from 0.79 to 092; the ICC varied from 0.738 to 0.911. The construct validity revealed a strong association with Michigan Hand Outcome Questionnaire (R = -0.83; P < .000), and moderate with Disabilities of the Arm, Shoulder, and Hand (R = 0.75; P < .000), Patient Evaluation Measure (R = 0.75; P < .000), and Visual Analogue Scale (R = 0.69; P < .000). The grip and pinch tests had low and no correlation with the total PRUNE score, respectively.

CONCLUSION

The Polish version of PRUNE showed good psychometric properties for use in both clinical and research practice in patients with cubital tunnel syndrome of varying intensity.

Cross cultural adaptation and refinement of an English version of a Dutch patient-reported questionnaire for hand sensitivity: The Radboud Evaluation of Sensitivity

STUDY DESIGN

Longitudinal clinical measurement.

INTRODUCTION

Sensory alterations in the hand can present as both decreased sensation or numbness, and hyperesthesia, including mechanical allodynia and cold intolerance. However, few patient-reported outcomes have been developed and validated for evaluation, particularly for increased sensitivity. The Radboud Evaluation of Sensitivity was developed in the Netherlands for patient-reported evaluation of hand sensitivity in complex regional pain syndrome.

PURPOSE OF THE STUDY

The purpose of this study was to translate into English and culturally validate the Radboud Evaluation of Sensitivity for the North American context.

METHODS

Forward and backward translation, followed by a psychometric evaluation of the synthesized version of the translated tool, was undertaken in a heterogeneous group of persons after hand injury, including nerve injuries, hand trauma, and complex regional pain syndrome.

RESULTS

Thirty-six persons completed test-retest reliability testing, yielding an intraclass correlation coefficient of 0.92 (95% CI 0.85 to 0.96) for single measures. Internal consistency was also high at α = 0.96 in a larger sample (n = 56). Although some support for construct validity was generated, several validity hypotheses were not confirmed. Of interest, there appeared to be significant differences in the scores between persons with hypoesthesia as compared with those with hyperesthesia.

CONCLUSIONS

The Radboud Evaluation of Sensitivity, English version appears to be a reliable tool for the self-reported evaluation of sensory alterations in the hand, including both hypoesthesia and hyperesthesia. More research is needed to add to the extent of and confidence in the validity and responsiveness of this assessment.

LEVEL OF EVIDENCE

Level II.

Cubital Tunnel Decompression: Equivalent Outcome Scores when Procedure Performed with Local versus General Anesthetic

Background Ulnar nerve compression at the cubital tunnel is the second commonest upper limb neuropathy. Unlike carpal tunnel surgery, most of decompression procedures for this condition are undertaken using general anesthesia (GA). This has inherent economic and patient safety implications. We aimed to assess if there is a difference in early and medium-term outcome scores in patients who have cubital tunnel decompression under general versus local anesthesia (LA). Materials and Methods We undertook a patient outcome evaluation of patients who were under the care of two upper limb surgeons. Patients were evaluated postoperatively using the patient-related ulnar nerve evaluation (PRUNE) questionnaire. Patients were contacted by phone, mail, and face to face in clinics. Results A total of 34 patients were identified in the study. Eleven were excluded from the study. Thirteen patients underwent surgery under LA. The LA group had their procedures performed using local infiltration of the surgical site with 20 mL of 0.5% bupivacaine with adrenaline. Ten patients had their procedures using standard GA and tourniquet. The average PRUNE score in the LA group was 33.8, and that in the GA group was 34.1. This difference in PRUNE score was not statistically significant p > 0.05. Discussion Our data suggest that there is no significant difference in early and midterm outcomes between patients who undergo cubital tunnel decompression using either GA or LA. We advocate the use of LA as it does lead to decreased anesthetic risk and has obvious economic benefits such as lowering the demands on theater and anesthetic resources.

Development and validation of a new patient-reported outcome measure for peripheral nerve disorders of the hand, the I-HaND© Scale

Following guidelines from the Patient-Centred Outcomes Research Institute and using a mixed methods study, a new patient-reported outcome measure (PROM) for both nerve trauma and compression affecting the hand, the Impact of a Hand Nerve Disorders (I-HaND) Scale, was developed. Face-to-face interviews with 14 patients and subsequent pilot-testing with 61 patients resulted in the development of the 32-item PROM. A longitudinal validation study with 82 patients assessed the psychometric properties of the I-HaND. Content and construct validity was confirmed by cognitive interviews with patients and through principal component analysis. The I-HaND has high internal consistency (α = 0.98) and excellent test-retest reliability (intraclass correlation coefficient = 0.97). Responsiveness statistics showed that the I-HaND can detect change over 3 months and discriminate between improvers and non-improvers. We conclude that the I-HaND can be used as a PROM for people with a range of hand nerve disorders.

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.

Submuscular transposition with musculofascial lengthening for persistent or recurrent cubital tunnel syndrome in 34 patients

The two main surgical options for patients with persistent or recurrent cubital tunnel syndrome are subcutaneous and submuscular transposition. We retrospectively analysed the results of 34 patients with recalcitrant cubital tunnel syndrome who underwent submuscular transposition with musculofascial lengthening at our institutions. Of the 34 patients, 21 improved clinically after submuscular transposition with musculofascial lengthening, of which 16 were still satisfied at a mean follow-up of four years. In addition, all articles published between 1974 and January 2015 on subcutaneous and/or submuscular transposition of the ulnar nerve for recalcitrant cubital tunnel syndrome were reviewed. We found that previously published studies on this subject are too heterogeneous to compare. No recommendation can thus be made regarding the surgical technique for persistent or recurrent cubital tunnel syndrome. Our series shows that the musculofascial lengthening technique for submuscular transposition is a good option. More research is needed to compare the different surgical treatments.

LEVEL OF EVIDENCE

IV.

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.

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.

The relationship between the Patient-rated Ulnar Nerve Evaluation and the common impairment measures of grip strength, pinch strength, and sensation

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

Grip strength, pinch strength, and sensory threshold are common evaluations used on a daily basis. Identifying how these variables relate to function for patients allows these assessments to be used for screening to identify who may benefit from surgical intervention, and provides valuable information about what impairments patients think are important with respect to functional use of their upper extremity. Therapists can use this information to focus rehabilitation programs on the most important impairments.

PURPOSE

To evaluate the relationship between the Patient-rated Ulnar Nerve Evaluation (PRUNE) and impairment measures of grip strength, pinch strength, and one-point sensory threshold.

METHODS

Data was prospectively collected from 77 patients before surgery and during regular time points for 2 years following surgery. Patients completed the PRUNE, grip and pinch strength measures, and a one-point sensory threshold evaluation. Correlations between these variables were calculated at baseline, 2 years after surgery, and for change scores during the 2-year follow up. A multiple regression analysis was used to determine the contribution of the impairment variables for determining functional change.

RESULTS

Grip strength showed moderate, statistically significant correlation with PRUNE scores at both baseline (r = -0.38) and at two years (r = -0.29). There was also a statistically significant correlation between one point sensory threshold for the small finger at two years (r = 0.36), but not at baseline. Change in grip strength (r = -0.28) and pinch strength (r = -0.30) both demonstrated significant correlations with PRUNE change scores. Overall, changes in grip strength, pinch strength, and sensation accounted for 20% of the variance in PRUNE changes.

CONCLUSION

Since grip strength was most highly correlated with PRUNE scores at baseline and at two years, rehabilitation programs that target grip strengthening is supported. While neither grip nor pinch strength were significant contributors to the regression when used together, each showed significant contributions to PRUNE variability when used in the model independently. Therefore, a combination of grip and pinch strengthening may be important during rehabilitation for improving functional results in patients that undergo surgical intervention for cubital tunnel syndrome.

LEVEL OF EVIDENCE

2b.

Patient-reported outcomes: state-of-the-art hand surgery and future applications

Patient-reported outcome measures (PRO) can provide reliable and valid estimates of patient status and response to interventions to complete the final step in an evidence-based patient interaction. A variety of PRO are relevant to upper extremity surgery and rehabilitation outcomes. PRO provide feasible tools for clinical research or practice, although use in clinical decision making lags behind research applications. Recent trends in clinical measurement include better integration of International Classification of Functioning, Disability and Health in content validation, more modern methods of evaluating scaling properties (Rasch analysis), consensus exercise on establishing core measures, electronic data collection, and computer-adaptive testing.