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Wade RG, Griffiths TT, Flather R, Burr NE, Teo M, Bourke G. Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2020; 3:e2024352. [PMID: 33231636 PMCID: PMC7686867 DOI: 10.1001/jamanetworkopen.2020.24352] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Cubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications. OBJECTIVE To evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure. DATA SOURCES PubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies. STUDY SELECTION Experimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier. DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact. MAIN OUTCOMES AND MEASURES The primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence. RESULTS A total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates. CONCLUSIONS AND RELEVANCE In this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.
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Affiliation(s)
- Ryckie G. Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Timothy T. Griffiths
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Robert Flather
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Nicholas E. Burr
- Cancer Epidemiology Group, Institute of Cancer and Pathology and Institute of Data Analytics, University of Leeds, United Kingdom
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Mario Teo
- Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - Grainne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
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Eroglu U, Bozkurt M, Tomlinson SB, Kahilogullari G, Al-Beyati ESM, Ozgural O, Orhan O, Ugur HC, Attar A, Caglar S, Unlu A, Cohen-Gadol AA. Anterior Subcutaneous Transposition With Expanded Polytetrafluoroethylene (ASTEP) for Cubital Tunnel Syndrome: Technical Note. Oper Neurosurg (Hagerstown) 2020; 19:E337-E342. [PMID: 32428226 DOI: 10.1093/ons/opaa081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/05/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ulnar nerve entrapment neuropathy at the elbow is the most common upper-extremity entrapment neuropathy after carpal tunnel syndrome. Surgical treatment can be complicated by perineural scarring and fibrosis, which may lead to recurrent symptoms. Expanded polytetrafluoroethylene (ePTFE) is a synthetic polymer with antiadhesive properties. OBJECTIVE To introduce the operative technique and outcomes of anterior subcutaneous transposition with ePTFE (ASTEP) in primary and recurrent cubital tunnel neuropathy. METHODS We studied 14 adult patients (11 men, 3 women; mean age, 45 yr) with cubital tunnel neuropathy (10 primary, 4 revision) who underwent surgery with the ASTEP technique between January 2008 and May 2018. Pain, numbness in the fourth/fifth fingers, and weakness of the intrinsic hand muscles were the most common presenting symptoms. Surgical outcomes were assessed using the modified McGowan and Wilson-Krout criteria. RESULTS The average (± standard deviation) preoperative symptom duration was 12.1 ± 5.2 mo (McGowan Grade 1, n = 5; Grade 2, n = 6; Grade 3, n = 3). No intraoperative or postoperative complications were observed with the ASTEP technique. Postoperative follow-up ranged from 9 mo to 7 yr (mean, 4.3 yr). All 14 patients experienced improvement in or complete resolution of their symptoms after this unique intervention. CONCLUSION Our novel technique of anterior transposition of the ulnar nerve with ePTFE was safe and highly effective in treating primary and recurrent ulnar nerve entrapment neuropathy at the elbow and represents an alternative to the current techniques.
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Affiliation(s)
- Umit Eroglu
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Samuel B Tomlinson
- School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | | | | | - Onur Ozgural
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Ozgur Orhan
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | | | - Ayhan Attar
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Sukru Caglar
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Agahan Unlu
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Aaron A Cohen-Gadol
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana
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Gallo L, Gallo M, Murphy J, Waltho D, Baxter C, Karpinski M, Mowakket S, Copeland A, Thoma A. Reporting Outcomes and Outcome Measures in Cubital Tunnel Syndrome: A Systematic Review. J Hand Surg Am 2020; 45:707-728.e9. [PMID: 32591175 DOI: 10.1016/j.jhsa.2020.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/29/2020] [Accepted: 04/03/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Lucas Gallo
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matteo Gallo
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Murphy
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Waltho
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Charmaine Baxter
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Marta Karpinski
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sadek Mowakket
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Copeland
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Achilleas Thoma
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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Risk factors for revision cubital tunnel surgery ✰. J Plast Reconstr Aesthet Surg 2020; 73:959-964. [PMID: 32059943 DOI: 10.1016/j.bjps.2019.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/12/2019] [Accepted: 12/13/2019] [Indexed: 11/20/2022]
Abstract
While surgical management of cubital tunnel syndrome (CuTS) results in the improvement of pain, paresthesia and restoration of motor function, there is a subset of patients who do not improve after primary surgery and require revision. The purpose of this study was to evaluate the incidence and risk factors for revision after primary CuTS. A retrospective review of patients who underwent revision CuTS after unsuccessful primary surgery from February 1989 to May 2009 was performed. Data regarding patients' demographics, age at primary and revision surgeries, handedness, presenting symptoms and the duration, physical examination, McGowan grading, electrodiagnostic findings and final outcomes were collected. A total of 1239 patients undergoing 1279 cubital tunnel surgeries were identified; of which 17 patients who underwent 18 revision CuTS met our inclusion criteria. Forty-one randomly selected consecutive patients who underwent primary CuTS (control cohort) were compared to identify the risk factors associated with revision CuTS. Younger age at presentation, greater static 2-point discrimination (S2PD) and a history of diabetes were associated with a greater number of revision surgeries. Patients requiring revision for primary CuTS were 8.4 years on average younger, had greater S2PD and were more likely to have diabetes. Pain as a presenting symptom compared to weakness and numbness was also a more common complaint in this cohort of patients. Future larger multicenter prospective studies are recommended.
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Said J, Van Nest D, Foltz C, Ilyas AM. Ulnar Nerve In Situ Decompression versus Transposition for Idiopathic Cubital Tunnel Syndrome: An Updated Meta-Analysis. J Hand Microsurg 2018; 11:18-27. [PMID: 30911208 DOI: 10.1055/s-0038-1670928] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022] Open
Abstract
Purpose Evidence for the superiority of in situ simple decompression (SD) versus ulnar nerve transposition (UNT) for cubital tunnel syndrome remains controversial. The purpose of this study was to compare the clinical improvement, complication rate, and revision rate of SD versus UNT using the available evidence. Materials and Methods We performed a literature search of relevant publications using PubMed, SCOPUS, Cochrane Library, and Springer Link. Inclusion criteria included (1) adult patients >18 years of age, (2) idiopathic cubital tunnel syndrome, (3) primary comparison studies including both SD versus UNT with discrete data for each procedure, (4) average follow-up of at least 2 months, and (5) a full English language manuscript available. Odds ratios of improvement, complications, and revision surgery after SD compared with UNT were calculated. Data were analyzed using both fixed and random effects models, and studies were assessed for publication bias and heterogeneity. Results A total of 1,511 articles from 1970 to 2017 were identified before inclusion, and exclusion criteria were applied. Ultimately 17 studies met the inclusion criteria and included 2,154 procedures. Of these, 1,040 were SD, and 1,114 were UNT procedures. Study heterogeneity was low. Odds ratios of clinical improvement and revision surgery with SD versus UNT were not significantly different. The odds ratio of complications with SD versus UNT was 0.449 (95% confidence interval [CI] of 0.290-0.695) and 0.469 (95% CI of 0.297-0.738) for fixed and random effect models, respectively. The difference in complications between SD versus UNT was significant ( P < 0.001). Conclusion There is no statistically significant difference in clinical outcomes or rate of revision surgery between SD versus UNT. However, there were significantly more complications with UNT. The current body of evidence regarding cubital tunnel syndrome lacks prospective, randomized, controlled trials, uniform reporting of indications, and standardized outcome scoring.
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Affiliation(s)
- Joseph Said
- Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Duncan Van Nest
- Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Carol Foltz
- Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Bouhelo-Pam KPB, Louckou EAM, Abdulrazak S, Chaibou B, Boussakri H, Shimi M, El Idrissi M, El Ibrahimi A, El Mrini A. Ulnar nerve entrapment complicating radial head excision. Int J Surg Case Rep 2018; 41:511-515. [PMID: 29546029 PMCID: PMC5723363 DOI: 10.1016/j.ijscr.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 11/17/2022] Open
Abstract
The cubital tunnel syndrome can be caused by iatrogenic elbow valgus after radial head excision. The radial head excision is a good procedure when indicated but must be followed by radial head replacement. A neurological examination should be systematically controlled for severe trauma to the elbow.
Introduction Several mechanisms are involved in ischemia or mechanical compression of ulnar nerve at the elbow. Presentation of case We hereby present the case of a road accident victim, who received a radial head excision for an isolated fracture of the radial head and complicated by onset of cubital tunnel syndrome. This outcome could be the consequence of an iatrogenic valgus of the elbow due to excision of the radial head. Hitherto the surgical treatment of choice it is gradually been abandoned due to development of radial head implant arthroplasty. However, this management option is still being performed in some rural centers with low resources. Discussion The radial head plays an important role in the stability of the elbow and his iatrogenic deformity can be complicated by cubital tunnel syndrome. Conclusion An ulnar nerve release was performed with favorable outcome.
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Affiliation(s)
| | | | - Saeed Abdulrazak
- Department of Trauma and Orthopedic Surgery B3, Hassan II University Hospital, Fès, Morocco
| | - Badarou Chaibou
- Department of Osteoarticular Surgery B4, Hassan II University Hospital, Fès, Morocco
| | - Hassan Boussakri
- Department of Osteoarticular Surgery B4, Hassan II University Hospital, Fès, Morocco
| | - Mohamed Shimi
- Department of Osteoarticular Surgery B4, Hassan II University Hospital, Fès, Morocco
| | - Mohamed El Idrissi
- Department of Osteoarticular Surgery B4, Hassan II University Hospital, Fès, Morocco
| | | | - Abdelmajid El Mrini
- Department of Osteoarticular Surgery B4, Hassan II University Hospital, Fès, Morocco
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Lauretti L, D'Alessandris QG, De Simone C, Legninda Sop FY, Remore LM, Izzo A, Fernandez E. Ulnar nerve entrapment at the elbow. A surgical series and a systematic review of the literature. J Clin Neurosci 2017; 46:99-108. [PMID: 28890032 DOI: 10.1016/j.jocn.2017.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/10/2017] [Indexed: 12/30/2022]
Abstract
Chronic compression of the ulnar nerve at the elbow is the second most common entrapment neuropathy. Various surgical options have been described. Timing of surgery is also debated. In this study we report the long-term results of a consecutive surgical series of anterior subcutaneous transpositions and review the pertinent literature. Sixty consecutive patients underwent anterior subcutaneous transposition at our Institution to treat ulnar nerve compression at the elbow. McGowan scale was used in the neurological exam before surgery. Bishop rating system was used to assess outcome. Seventy-eight% of patients scored good-excellent. None of the patients worsened. No complications and no recurrences were reported. Young age and good pre-operative neurological status (McGowan grade 1) were predictive of favorable outcome both at univariate and at multivariate analysis. No differences in outcome were observed between patients with intermediate (McGowan grade 2) and severe (McGowan grade 3) neuropathy. Thirty-four studies assessing outcome of different surgical techniques were reviewed. Anterior subcutaneous transposition had the lowest recurrence rate with an excellent effectiveness and safety profile. The favorable predictive role for outcome of preoperative neurological status was confirmed. The good long-term clinical results of the present series and the results of literature analysis confirm the value of anterior subcutaneous transposition of the ulnar nerve at the elbow. This technique has a particular effectiveness in most severe compressions, where outcomes are comparable with intermediate neuropathy cases. Moreover, our results suggest an aggressive attitude towards ulnar nerve compression at the elbow, particularly in younger patients.
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Affiliation(s)
- Liverana Lauretti
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | | | - Celestino De Simone
- Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | - Francois Yves Legninda Sop
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | - Luigi M Remore
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy.
| | - Alessandro Izzo
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
| | - Eduardo Fernandez
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Neurosurgery Unit, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy.
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Vanaclocha V, Blanco T, Ortiz P, Lopez-Trigo J, Capilla P, Bordes-Garcia V, Vanaclocha L. Can We Make Simple In Situ Decompression of the Ulnar Nerve at the Elbow Still Easier? World Neurosurg 2017. [PMID: 28647661 DOI: 10.1016/j.wneu.2017.06.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
| | | | - Pedro Ortiz
- Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Pau Capilla
- Hospital Clínico de Valencia, Valencia, Spain
| | | | - Leyre Vanaclocha
- Medical School, University College London, London, United Kingdom
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Suzuki T, Iwamoto T, Shizu K, Suzuki K, Yamada H, Sato K. Predictors of postoperative outcomes of cubital tunnel syndrome treatments using multiple logistic regression analysis. J Orthop Sci 2017; 22:453-456. [PMID: 28153376 DOI: 10.1016/j.jos.2017.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/20/2016] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND This retrospective study was designed to investigate prognostic factors for postoperative outcomes for cubital tunnel syndrome (CubTS) using multiple logistic regression analysis with a large number of patients. METHODS Eighty-three patients with CubTS who underwent surgeries were enrolled. The following potential prognostic factors for disease severity were selected according to previous reports: sex, age, type of surgery, disease duration, body mass index, cervical lesion, presence of diabetes mellitus, Workers' Compensation status, preoperative severity, and preoperative electrodiagnostic testing. Postoperative severity of disease was assessed 2 years after surgery by Messina's criteria which is an outcome measure specifically for CubTS. Bivariate analysis was performed to select candidate prognostic factors for multiple linear regression analyses. Multiple logistic regression analysis was conducted to identify the association between postoperative severity and selected prognostic factors. RESULTS Both bivariate and multiple linear regression analysis revealed only preoperative severity as an independent risk factor for poor prognosis, while other factors did not show any significant association. CONCLUSIONS Although conflicting results exist regarding prognosis of CubTS, this study supports evidence from previous studies and concludes early surgical intervention portends the most favorable prognosis.
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Affiliation(s)
- Taku Suzuki
- Department of Orthopaedic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan; Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Takuji Iwamoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kanae Shizu
- Department of Orthopaedic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Katsuji Suzuki
- Department of Orthopaedic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Harumoto Yamada
- Department of Orthopaedic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Kazuki Sato
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
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Abstract
Elbow pain is a frequent presenting symptom in athletes, particularly athletes who throw. The elbow can be injured as a result of acute trauma, such as a direct blow or a fall onto an outstretched hand or from chronic microtrauma. In particular, valgus extension overload during the throwing motion can precipitate a cascade of chronic injuries that can be debilitating for both casual and high-performance athletes. Prompt imaging evaluation facilitates accurate diagnosis and appropriate targeted interventions.
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Affiliation(s)
- Matthew D Bucknor
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 185 Berry St, Lobby 6, Suite 350, San Francisco, CA 94158
| | - Kathryn J Stevens
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 185 Berry St, Lobby 6, Suite 350, San Francisco, CA 94158
| | - Lynne S Steinbach
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 185 Berry St, Lobby 6, Suite 350, San Francisco, CA 94158
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Lancigu R, Saint Cast Y, Raimbeau G, Rabarin F. Dellon's anterior submuscular transposition of the ulnar nerve: Retrospective study of 82 operated patients with 11.5 years’ follow-up. ACTA ACUST UNITED AC 2015; 34:234-9. [DOI: 10.1016/j.main.2015.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/24/2015] [Accepted: 08/11/2015] [Indexed: 12/26/2022]
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Krogue JD, Aleem AW, Osei DA, Goldfarb CA, Calfee RP. Predictors of surgical revision after in situ decompression of the ulnar nerve. J Shoulder Elbow Surg 2015; 24:634-9. [PMID: 25660241 DOI: 10.1016/j.jse.2014.12.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 12/01/2014] [Accepted: 12/06/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study was performed to identify factors associated with the need for revision surgery after in situ decompression of the ulnar nerve for cubital tunnel syndrome. METHODS This case-control investigation examined all patients treated at one institution with open in situ decompression for cubital tunnel syndrome between 2006 and 2011. The case patients were 44 failed decompressions that required revision, and the controls were 79 randomly selected patients treated with a single operation. Demographic data and disease-specific data were extracted from the medical records. The rate of revision surgery after in situ decompression was determined from our 5-year experience. A multivariate logistic regression model was used based on univariate testing to determine predictors of revision cubital tunnel surgery. RESULTS Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period. Predictors of revision surgery included a history of elbow fracture or dislocation (odds ratio [OR], 7.1) and McGowan stage I disease (OR, 3.2). Concurrent surgery with in situ decompression was protective against revision surgery (OR, 0.19). DISCUSSION The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery.
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Affiliation(s)
- Justin D Krogue
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Alexander W Aleem
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Osei
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan P Calfee
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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Abstract
Ulnar neuropathy at the elbow is the second most common compression neuropathy of the upper extremity and poses a challenge for treating physicians. Lack of a standardized grading system, outcome measures, or surgical indications can make treatment decisions difficult to justify. Conclusions drawn from the available literature include similar rates of good to excellent outcomes for in situ decompression; transposition in the subcutaneous, submuscular, or intramuscular planes; and endoscopic decompression. Outcomes for revision surgery are generally less favorable. Development of standardized outcomes measures will be important in improving the quality and comparability of the literature on this subject.
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Affiliation(s)
- Peter C Chimenti
- Department of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
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Zhong W, Zhang W, Zheng X, Li S, Shi J. Comparative study of different surgical transposition methods for ulnar nerve entrapment at the elbow. J Int Med Res 2012; 39:1766-72. [PMID: 22117977 DOI: 10.1177/147323001103900519] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study compared the therapeutic effects of two techniques for surgical decompression treatment for ulnar nerve entrapment at the elbow: subcutaneous transposition and modified submuscular transposition with Z-lengthening of the pronator teres origin. A total of 278 patients with ulnar nerve entrapment (McGowan grades I - III) were randomly assigned to undergo one of these techniques. All patients were followed-up for 2 years. The effects were assessed by preoperative and postoperative cross-sectional area, motor conduction velocity, sensory conduction velocity and nerve action potential. All of these parameters improved after surgery in both groups. For patients with grade I disease, there were no significant differences between the two techniques. For patients with grade II and III disease, modified submuscular transposition was associated with significantly greater improvements compared with subcutaneous transposition. In conclusion, subcutaneous ulnar nerve transposition is recommended for grade I patients and modified submuscular ulnar nerve transposition for grade II and III patients.
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Affiliation(s)
- W Zhong
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Kongjiang Road 1665, Shanghai 200092, China
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Shi Q, MacDermid JC, Santaguida PL, Kyu HH. Predictors of surgical outcomes following anterior transposition of ulnar nerve for cubital tunnel syndrome: a systematic review. J Hand Surg Am 2011; 36:1996-2001.e1-6. [PMID: 22123047 DOI: 10.1016/j.jhsa.2011.09.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 09/20/2011] [Accepted: 09/22/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE Although cubital tunnel syndrome is the second most common nerve entrapment neuropathy, few studies explore potential predictor(s) of surgical outcomes. The purpose of this systematic review was to determine which factors affect the postoperative outcome for patients who undertake anterior transposition of the ulnar nerve. METHODS We included all studies reporting predictor(s) of clinical, electrophysiological study, or functional outcome after any anterior transposition of the ulnar nerve. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL from 1980 to April 2011 and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality, and data extraction independently of each other. RESULTS We assessed 26 studies including 2 randomized controlled trials, 10 cohort studies, and 14 case series. Overall, the methodological quality of the studies ranged from low to moderate. Six aspects of prognosis were sufficiently studied for a narrative evidence synthesis on age, duration of symptom, severity of operative status, preoperative electrodiagnostic testing results, type of surgery, and work compensation status. Evidence was conflicting across studies in terms of both the direction and intensity of the impact of these 6 potential predictors on surgical outcomes. CONCLUSIONS Because of conflicting results, we were unable to conclude which predictor(s) affect surgical outcomes after anterior transposition of the ulnar nerve. Surgeons who are aware of only a limited number of prognostic studies and their limited scope of evidence may not appreciate the extent of the inconsistency about whether factors commonly viewed as prognostic actually have a noteworthy impact on outcomes achieved. Such factors may be identified in the future with higher-quality studies, because limitations in the current research undoubtedly contribute to the controversies observed.
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Affiliation(s)
- Qiyun Shi
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
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16
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Hamidreza A, Saeid A, Mohammadreza D, Zohreh Z, Mehdi S. Anterior subcutaneous transposition of ulnar nerve with fascial flap and complete excision of medial intermuscular septum in cubital tunnel syndrome: A prospective patient cohort. Clin Neurol Neurosurg 2011; 113:631-4. [DOI: 10.1016/j.clineuro.2011.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/26/2011] [Accepted: 05/08/2011] [Indexed: 11/29/2022]
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Svernlöv B, Nylander G, Adolfsson L. Patient-reported outcome of surgical treatment of nerve entrapments in the proximal forearm. Adv Orthop 2011; 2011:727689. [PMID: 21991420 PMCID: PMC3170897 DOI: 10.4061/2011/727689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 06/23/2011] [Indexed: 11/20/2022] Open
Abstract
The outcome of decompression for long-standing symptoms of nerve entrapments in the proximal forearm was investigated in a retrospective study of 205 patients using a self-assessment questionnaire, 45 months after the operation. The questionnaire consisted of visual analogue scale recordings of pre- and postoperative pain during rest and activity, questions about remaining symptoms and appreciation of the result and the Disabilities of Arm, Shoulder and Hand form (DASH). Altogether, 59% of the patients were satisfied, 58% considered themselves improved, and 3% as being entirely relieved of all symptoms. Pain decreased significantly (P = 0.001). There was a significant correlation between preoperative duration and patient perceived post-operative pain. Preoperative pain was a chief complaint, and pain reduction appears to be the principal gain of the operation. Although the majority of the patients benefited from the operation, a substantial proportion was not satisfied. There is apparently room for improvement of the diagnostic and surgical methods applied in this study.
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Affiliation(s)
- Birgitta Svernlöv
- Department of Plastic Surgery, Hand Surgery and Burns, Linköping University Hospital, 581 85 Linköping, Sweden
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, 581 85 Linköping, Sweden
| | - Göran Nylander
- Department of Plastic Surgery, Hand Surgery and Burns, Linköping University Hospital, 581 85 Linköping, Sweden
| | - Lars Adolfsson
- Department of Orthopaedics and Sports Medicine, Linköping University Hospital, 581 85 Linköping, Sweden
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Jaddue DAK, Saloo SA, Sayed-Noor AS. Subcutaneous vs Submuscular Ulnar Nerve Transposition in Moderate Cubital Tunnel Syndrome. Open Orthop J 2009; 3:78-82. [PMID: 19746170 PMCID: PMC2738827 DOI: 10.2174/1874325000903010078] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Revised: 08/05/2009] [Accepted: 08/06/2009] [Indexed: 12/29/2022] Open
Abstract
Background: The surgical treatment of Cubital tunnel syndrome (CubTS) is still a matter of debate. No consensus exists about the necessity of anterior transposition of the ulnar nerve after decompression. However, this technique is fairly common in clinical practice. Material and Methodology: In the present study we compared the operative technique (incision length, operative time), postoperative care (postoperative pain and complications) and the outcome between subcutaneous transposition and submuscular transposition of the ulnar nerve as two surgical modalities in treating moderate CubTS. Between March 2004 and March 2007, twenty six patients with moderate CubTS (according to Dellon’s grading system) were stratified according to age and gender into these two surgical techniques. The two groups were prospectively followed up 2 weeks, 6 months and 12 months postoperatively by the same observer and the operation outcome was assessed using the Bishop rating system. Results: We found that the subcutaneous transposition of the ulnar nerve was associated with shorter incision, shorter operative time, less postoperative pain, less postoperative complication and better outcome compared with the submuscular transposition. Conclusion: The authors recommend the subcutaneous technique when considering anterior transposition of the ulnar nerve in treating moderate CubTS.
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Affiliation(s)
- Dhia A K Jaddue
- Department of Orthopaedic Surgery, Al-Kindy Teaching Hospital, Baghdad, Iraq
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Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg Am 2008; 33:1314.e1-12. [PMID: 18929194 DOI: 10.1016/j.jhsa.2008.03.006] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 03/11/2008] [Accepted: 03/12/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE Optimal surgical management of cubital tunnel syndrome remains uncertain despite the publication of numerous case series, observational studies, systematic reviews, and, in recent years, randomized controlled studies. The purpose of this meta-analysis was to compare simple decompression to anterior transposition of the ulnar nerve for the treatment of this condition, using comparative trials and randomized controlled trials. METHODS Computerized database searches of MEDLINE, EMBASE, Cochrane Central, and all relevant surgical archives were performed. Studies involving adults with cubital tunnel syndrome in whom surgical intervention was simple decompression or anterior transposition (subcutaneous or submuscular) were included. Analysis was limited to randomized controlled trials and comparative observational studies. Included studies were assessed for quality, heterogeneity, and publication bias. Odds ratios of clinical improvement comparing simple decompression to anterior transposition (submuscular or subcutaneous) were calculated for each study. RESULTS Ten studies involving a total of 449 simple decompressions, 342 subcutaneous transpositions, and 115 submuscular transpositions were included. There was little evidence of publication bias or statistical study heterogeneity. Odds of improvement with simple decompression versus anterior transposition were 0.751, 95% confidence interval (0.542, 1.040). Subanalyses on the basis of transposition technique (subcutaneous or submuscular) and study quality did not render a statistically significant result. CONCLUSIONS This report represents the best cumulative evidence to date examining the surgical management of cubital tunnel syndrome. In this study, we found no statistically significant difference, but rather a trend toward an improved clinical outcome with transposition of the ulnar nerve as opposed to simple decompression. Additional prospective, randomized studies that use reproducible preoperative and postoperative objective measures might add statistical power to this finding.
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