Partial medial epicondylectomy for cubital tunnel syndrome: Outcome and complications

Is simple decompression enough for the treatment of idiopathic cubital tunnel syndrome: A prospective comparative study analyzing the outcomes of simple decompression versus partial medial epicondylectomy

Objectives

This study aims to compare the clinical and functional outcomes of simple in-situ decompression and partial medial epicondylectomy for the treatment of idiopathic cubital tunnel syndrome (CuTS).

Patients and methods

Between March 2014 and December 2016, 71 patients (31 males, 40 females; mean age 46.7 years; range, 38 to 62 years) with CuTS scheduled to undergo simple in-situ decompression (group 1) or partial medial epicondylectomy (group 2) were prospectively reviewed. All patients were analyzed with clinical examination (Tinel sign, Froment’s and Wartenberg’s signs, elbow flexion test, subluxation), and McGowan scores before and after surgery. Final outcomes were reviewed with Wilson and Krout grading system.

Results

There was no significant difference between the study groups in regard to Wilson and Krout grading and McGowan scores postoperatively. Group 1 had significantly better grip and key pinch strength values compared to group 2 at the final follow-up control.

Conclusion

In-situ decompression and partial medial epicondylectomy represent efficient and safe methods for the treatment of idiopathic CuTS. When their efficiency is compared, in-situ decompression had better grip and key pinch strength values and more excellent outcomes compared to partial medial epicondylectomy.

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.

Intraoperative Subluxation of the Ulnar Nerve: Use of a Triceps Sling Reconstruction Technique

PURPOSE

To determine whether the triceps sling reconstruction technique is a safe and effective treatment of intraoperative ulnar nerve subluxation after in situ decompression.

METHODS

Twelve patients who underwent a triceps sling reconstruction for intraoperative ulnar nerve subluxation after in situ release were retrospectively reviewed. The triceps sling technique consists of harvesting a small, distally based strip of triceps tendon and suturing the proximal end of the strip to the posterior aspect of the released Osborne ligament. Thus, a sling is created between the medial epicondyle and the olecranon, preventing the nerve from subluxating. Patients were clinically evaluated before and after surgery. Visual analog scale pain scores, static 2-point discrimination, strength, and Disabilities of the Arm, Shoulder, and Hand score were assessed.

RESULTS

At a mean follow-up of 31 months (range, 24-38 months), there was a significant improvement in mean visual analog pain scores from 8.6 to 0.2. Static 2-point discrimination was improved from a mean of 9.1 mm before surgery to 5.7 mm afterward. Strength improved by a mean of 33% and 30% with grip and pinch, respectively. Mean Disabilities of the Arm, Shoulder, and Hand score improved from 45.9 to 3.7. No subluxation of the ulnar nerve was noted after surgery. No other complications were noted. No reoperations were required during the follow-up period.

CONCLUSIONS

Triceps sling reconstruction is a safe treatment in patients with intraoperative ulnar nerve subluxation after in situ decompression.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

BACKGROUND

Cubital tunnel syndrome is the second most common compression neuropathy affecting the upper extremity. The aim of this study was to determine the preferred surgical treatment for cubital tunnel syndrome by members of the American Society for Surgery of the Hand (ASSH).

METHODS

We invited members of the ASSH research mailing list to complete our online survey. They were presented with 6 hypothetical cases and asked to choose their preferred treatment from the following options: open in situ decompression, endoscopic decompression, submuscular transposition, subcutaneous transposition, medial epicondylectomy, and conservative management. This was assessed independently and anonymously through an online survey (SurveyMonkey).

RESULTS

1069 responses were received. Seventy-three percent of the respondents preferred to continue conservative management when a patient presented with occasional paresthesias for greater than 6 months with a normal electromyogram (EMG) or nerve conduction velocity (NCV). Sixty-five percent picked open in situ decompression if paresthesias, weakness of intrinsics, and EMG/NCV reports of mild to moderate ulnar nerve entrapment was present. More than 50% of respondents picked open in situ decompression, as their preferred treatment when sensory loss of two-point discrimination of less than 5 or more than 10 was present in addition to the findings mentioned above. Seventy-nine percent of the respondents said their treatment algorithm would change if ulnar nerve subluxation was present.

CONCLUSIONS

Our survey results indicate that open in situ decompression is the preferred operative procedure, if there is no ulnar nerve subluxation, among hand surgeons for cubital tunnel syndrome.

V-Y Lengthening Technique of the Flexor-Pronator Mass for Anterior Submuscular Transposition of the Ulnar Nerve in Severe Cubital Tunnel Syndrome: A Long-Term Follow-Up Study

PURPOSE

This study aimed to retrospectively analyze the clinical results of anterior submuscular transposition of the ulnar nerve using a flexor-pronator V-Y lengthening technique in patients with severe cubital tunnel syndrome (CTS).

MATERIALS AND METHODS

From January 2007 to May 2015, 36 patients with grade III CTS based on McGowan's classification were enrolled. All patients were treated with anterior submuscular transposition of the ulnar nerve using a flexor-pronator V-Y lengthening technique. To evaluate clinical outcomes, all patients underwent preoperative and final follow-up assessments of disabilities of the arm, shoulder, and hand scores, nerve conduction velocity, 2-point discrimination, and pinch and grip strength. Overall functional outcomes were evaluated after a mean follow-up of 53 months using the Modified Bishop rating system. We analyzed the statistical correlation of patients' duration of symptom and age with clinical results.

RESULTS

At the final follow-up, the average disabilities of the arm, shoulder, and hand, nerve conduction velocity, 2-point discrimination, and grip and pinch strengths significantly improved in all patients. At least a 1-McGowan grade improvement was achieved in 34 extremities (94.4%). According to the modified Bishop scores, 30 patients (83.3%) achieved good or excellent outcomes and 2 extremities (5.5%) had poor outcomes. There was a significant negative correlation between prolonged symptom duration and the Modified Bishop score at the final follow-up, but age did not affect the functional outcome.

CONCLUSIONS

In McGowan grade III severe CTS, anterior submuscular transposition of the ulnar nerve using a flexor-pronator V-Y lengthening technique leads to satisfactory outcomes. Longer symptom duration is associated with poorer results, and the outcome is not correlated with age. Therefore, active surgical treatment should be considered regardless of age before severe disease occurs.

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

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

Treatment of Cubital Tunnel Syndrome by Frontal Partial Medial Epicondylectomy. A Retrospective Series of 55 Cases

The outcomes of 55 cases of cubital tunnel syndrome treated by a partial frontal epicondylectomy are presented at a mean follow-up of 38 months follow-up. According to McGowan classification, 25 cases were grade I (45%), 12 grade II (22%) and 18 grade III (33%). The results (Wilson and Krout classification) were excellent or good in 41 patients (75%), fair in nine patients and unchanged in five, without any worsening or recurrence. Total relief was reported in 80% of grade I, 75% of grade II and 66% of grade III patients. Seven painful scars and one persistent 15° elbow extension deficit were the only complications. The satisfaction rate was 93%. This technique preserves bony protection, the blood supply and gliding tissues for the nerve and nerve recovery were comparable to other surgical procedures. Residual pain at the osteotomy site was not a serious problem.

Cubital compressive neuropathy in the elbow: in situ neurolysis versus anterior transposition - comparative study

OBJECTIVE

To compare the results from two of the most commonly used surgical techniques: in situ decompression and subcutaneous transposition. The processes of patients treated surgically in a public university hospital between January 2004 and December 2011 were reviewed. Cases of proximal compression of the nerve, angular deformity of the elbow and systemic diseases associated with non-compressive neuropathy were excluded.

METHODS

Ninety-seven cases were included (96 patients). According to the modified McGowan score, 14.4% of the patients presented grade Ia, 27.8% grade II, 26.8% grade IIb and 30.9% grade III. In situ neurolysis of the cubital was performed in 64 cases and subcutaneous anterior transposition in 33.

RESULTS

According to the modified Wilson and Knout score, the results were excellent in 49.5%, good in 18.6%, only satisfactory in 17.5% and poor in 14.4%. In comparing the two techniques, we observed similar numbers of excellent and good results. Grades IIb and III were associated with more results that were less satisfactory or poor, independent of the surgical technique.

CONCLUSION

Both techniques were shown to be efficient and safe for treating cubital tunnel syndrome.

Entrapment neuropathy of the wrist, forearm, and elbow

This review discusses key diagnostic points and treatment guidelines for compression neuropathies of the wrist, forearm, and elbow. Recent treatment progress is reviewed, controversies are highlighted, and consensus is summarized. Limited or mini-open releases and endoscopic carpal tunnel releases are considered equally safe and efficient. Both methods are currently mainstays of surgical treatment.

A simple, safe and reliable surgical landmark for medial epicondylectomy

BACKGROUND

Various surgical strategies have been described for the treatment of cubital tunnel syndrome, including medial epicondylectomy. This aims to decompress the ulnar nerve and allow a 'mini anterior transposition'. The major concern over medial epicondylectomy is the potential for postoperative iatrogenic valgus instability.

METHODS

We utilized a surgical landmark for medial epicondylectomy based on the medial aspect of the ulnar nerve with the elbow in 90° of flexion in 12 cadaveric upper limbs. The size of the resultant fragment was measured and, subsequently, the medial collateral ligament was dissected and the elbow stressed to assess its integrity.

RESULTS

This technique resulted in the excision of a fragment of mean width 8 mm (range 6 mm to 11 mm) and allowed the ulnar nerve to smoothly translate anteriorly in flexion. The anterior band of the ulnar collateral ligament was macroscopically preserved in all cases and there was no valgus instability.

CONCLUSIONS

The medial border of the ulnar nerve is a simple, safe and reliable surgical landmark for medial epicondylectomy. This technique offers advantages over other described methods of assessing the location at which to perform a medial epicondylectomy.

Ulnar neuropathy at the elbow: an evidence-based algorithm

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.

Outcomes following modified oblique medial epicondylectomy for treatment of cubital tunnel syndrome

PURPOSE

To quantify and define objective and patient-rated outcomes after our modification of medial epicondylectomy for the treatment of cubital tunnel syndrome. Although medial epicondylectomy has been previously studied, data are lacking regarding elbow-specific outcomes after our technique that aims to minimize complications historically associated with medical epicondylectomy.

METHODS

A total of 27 subjects with clinical and electrodiagnostic evidence of cubital tunnel syndrome underwent a modified oblique medial epicondylectomy that was designed to minimize bony resection and preserve the origin of the ulnar collateral ligament of the elbow. Average age was 57 years, mean duration of symptoms was 24 months, and mean postoperative follow-up was 29 months. Eight patients had McGowan stage I disease, 14 had stage II, and 5 had stage III. Preoperatively, we measured intrinsic hand strength, 2-point discrimination, and residual medial elbow pain, and assessed for continuing signs and symptoms of nerve compression. Postoperatively, we added to the clinical examination elbow stability testing, elbow range of motion, and assessment of medial antebrachial cutaneous nerve injury. We collected patient-reported outcomes, including Quick Disabilities of the Shoulder, Arm, and Hand; Levine-Katz Severity Score; and Patient-Rated Elbow Evaluation.

RESULTS

We noted improvement of at least 1 McGowan grade in 20 of 27 patients (74%). Three of the 7 patients who had no change in McGowan grade still reported excellent patient-rated outcomes. Good to excellent results were achieved in 25 of 27 patients (93%). One patient had long-term severe medial elbow pain. Three patients had postoperative medial elbow pain that resolved with a single corticosteroid injection. One patient had a 30° flexion contracture; preoperative motion was not available for comparison. No patients had signs of elbow instability or numbness in the medial antebrachial cutaneous nerve distribution.

CONCLUSIONS

Modified oblique medial epicondylectomy was effective in improving symptoms in cubital tunnel syndrome. This medial collateral ligament sparing technique minimized complications previously associated with the original technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Distal medial epicondylectomy. A modification of partial medial epicondylectomy for cubital tunnel syndrome: preliminary results

INTRODUCTION

The medial epicondyle behaves as a fulcrum and a pulley that tethers the ulnar nerve during flexion. Excision of the distal half of the medial epicondyle sets the point of contact of the bone with the nerve proximally and decreases the traction effect of the medial epicondyle on the ulnar nerve. In this study, we aim to investigate the surgical and clinical results of excision of the distal half of the medial epicondyle in cubital tunnel syndrome (CuTS).

PATIENTS AND METHODS

Cubital tunnel release with excision of the distal half of the medial epicondyle was performed in 19 patients. The patients were evaluated preoperatively and postoperatively with clinical examinations, McGowan and Wilson-Krout scores, Semmes-Weinstein monofilament and two-point discrimination tests, and grip and pinch strength measurements.

RESULTS

A one-grade improvement in McGowan classification was observed in 79 % of patients and a two-grade improvement in 21 % of patients at the time of the first postoperative examination. At 24 months after surgery, 18 patients reported the Wilson-Krout scores as excellent (95 %). Statistically significant improvements in sensory and motor strength measurements were achieved at all postoperative examinations.

CONCLUSION

The objective and subjective outcome measures achieved with distal medial epicondylectomy are comparable with other epicondylectomy techniques. The complication rates seem to be lower than those of total or partial medial epicondylectomy. This procedure is an acceptable and safe alternative for the surgical treatment of CuTS.

Minimal epicondylectomy improves neurologic deficits in moderate to severe cubital tunnel syndrome

BACKGROUND

Previous studies of minimal medial epicondylectomy for cubital tunnel syndrome included patients with mild disease, making it difficult to determine how much this procedure improved sensory and motor impairments in patients with moderate to severe disease.

QUESTIONS/PURPOSES

We asked if minimal epicondylectomy improved sensory and motor impairments in patients with moderate to severe cubital tunnel syndrome.

METHODS

We retrospectively reviewed 25 patients treated with minimal medial epicondylectomy for advanced cubital tunnel syndrome involving motor weakness between January 2003 and February 2009. Preoperatively, five patients had Medical Research Council (MRC) Grade 4 motor strength without atrophy (McGowan Grade IIA), nine had MRC Grade 3 motor strength with detectable atrophy (McGowan Grade IIB), and 11 had MRC Grade 3 or less motor strength with severe atrophy (McGowan Grade III). Postoperatively we obtained DASH scores and evaluated improvement of sensory impairment and motor impairment: excellent with minimal sensory deficit and motor deficit, good with mild deficits, fair with improved but persistent deficit(s), and poor with no improvement. The minimum followup was 13 months (mean, 46 months; range, 13-86 months).

RESULTS

The mean DASH score was 14 points (range, 2-47 points). Of the 25 patients, sensory improvement and motor improvement were excellent in 16 patients, good in five, fair in two, and poor in two. Twenty-three of the 25 patients improved at least one McGowan grade. There were no complications, such as medial elbow instability.

CONCLUSIONS

Minimal medial epicondylectomy can improve sensory and motor impairments for patients with moderate to severe cubital tunnel syndrome.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

Subjective outcome, neurophysiological investigations, postoperative complications and recurrence rate of partial medial epicondylectomy in cubital tunnel syndrome

The aim of the study was to evaluate the clinical outcome with subjective and neurophysiological parameters following partial medial epicondylectomy (pME) and to evaluate complications and recurrence rates. A retrospective analysis was performed in 29 patients (18 males and 11 females) with cubital tunnel syndrome (CuTS) who underwent pME. Mean time follow-up was 41.4 months. For subjective parameters, DASH (Disabilities of Arm, Shoulder and Hand), a self-created questionnaire about postoperative satisfaction and a visual pain scale (VAS) have been used. All patients were classified according to the Mc Gowan Classification (McG) and Wilson & Krout Classification (WKC). The patients were examined by nerve conduction velocity. Total mean of the DASH score was 24.8 points. In a questionnaire with integrated pain score (1-5), 96% of the patients declared a postoperative improvement, whereas 41.4% patients of the latter group were very contented with the results, 37.9% were contented, 17.2% were less contented and 3.4% were discontented. The VAS for evaluation of postoperative pain showed an average of 2.36 (0-5.9) out of 10. Of the patients, 68.0% were classified as grade I according to McG and 68.0% as excellent or good according to WKC. Motor nerve conduction velocity improved from 34.8 m/s preoperatively to 48.2 m/s postoperatively. One patient developed a haematoma and three patients (10.3%) had to be classified as recurrence. High postoperative rates of patient satisfaction and improved neurophysiological results could be achieved by pME.

Objective outcome of partial medial epicondylectomy in cubital tunnel syndrome

AIM

Goal of the study was to evaluate the clinical outcome in cubital tunnel syndrome (CuTS) after partial medial epicondylectomy (pME) with objective parameters.

METHOD

A retrospective analysis was performed in 29 (18 male/11 female) patients with CuTS who underwent pME. Mean time follow-up was 41.4 months. Parameters assessed sensibility (two point discrimination (2PD) and Semmes Weinstein Monofilaments (SW)) of the fifth finger and grip and pinch strength. In addition, elbow range of motion, elbow instability, medial elbow pain, Froment sign and Tinel`s sign were evaluated.

RESULTS

Postoperative static 2PD of the fifth finger was 12.6 mm. SW values on the operated side (mean 3.58; 2.44-6.65) were comparable to the non-operated side (mean 3.28; 2.44-4.93). Tinel's sign over the ulnar sulcus was positive in 13 cases preoperative and in 16 cases postoperatively. Range of motion of the elbow joint achieved normal values in flexion/extension and pronation/supination with no significant difference in comparison to the non-operated side. Froment sign was positive in 2 cases, negative in 23 cases. Grip strength averaged 48.1 kg in man versus 24.4 kg in women. Pinch strength was 8.6 versus 5.3 kg. Grip strength on the operated side reached up to 91.0% values of the opposite arm.

CONCLUSION

Good postoperative objective results were reached by pME. pME is an adequate treatment option in CuTS.

Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature

PURPOSE

The primary objective of this systematic review was to identify and analyze the outcomes measures that have been used to evaluate postoperative results following surgery for cubital tunnel syndrome. The secondary objective was to compare the postoperative results among patients evaluated using patient-satisfaction instruments to those evaluated using surgeon-reported scales.

METHODS

Computerized database searches of MEDLINE, EMBASE, and MEDLINE In-Process were performed. Studies involving adults with cubital tunnel syndrome in whom the surgical intervention was simple decompression, anterior transposition (subcutaneous, submuscular or intramuscular), endoscopic decompression, or medial epicondylectomy were included. A systematic review was performed that included randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series.

RESULTS

This systematic review of the literature identified 42 studies that satisfied the inclusion criteria. The authors identified 21 health outcomes measures used in cubital tunnel studies. These consisted of 2 generic instruments; 10 symptom-specific, author-reported instruments; 3 symptom-specific, patient-reported instruments; and 6 patient questionnaires. No measure demonstrated adequate development or validation for use in its target population. Available data revealed a consistently high level of patient satisfaction following simple decompression or submuscular transposition (65% to 92%). The results of the author-reported, symptom-specific scales varied widely and showed no obvious association with patient satisfaction. The variation in reporting of results prevented statistical comparisons between author-reported results and patient-reported results.

CONCLUSIONS

To the best of our knowledge, this is the first systematic review to delineate the outcomes measures used to evaluate the treatment of cubital tunnel syndrome. Our results show that reliable, reproducible, and valid outcomes measures are lacking from the surgical literature. A standardized assessment protocol for ulnar neuropathy is required for future comparison trials.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Patient-rated outcome of ulnar nerve decompression: a comparison of endoscopic and open in situ decompression

PURPOSE

To report patient-rated outcomes after ulnar nerve decompression at the elbow and to compare the outcome after open in situ decompression with that after endoscopic in situ decompression.

METHODS

Patients having ulnar nerve decompression were evaluated using patient-rated outcome measures. Fifty-five patients were recruited; 3 were lost to follow-up, and 18 were excluded because they had anterior transposition. Of the thirty-four patients followed up for 12 months, 19 had endoscopic decompression and 15 had open in situ decompression. Patient demographics, presenting symptoms, range of elbow movement, grip and pinch strength, and sensation were recorded preoperatively and at 12 months by an independent observer. Postoperative patient satisfaction, pain, and ongoing paresthesia were recorded using visual analog scales. Subgroup analysis was performed to compare the outcome of open in situ decompression with that of endoscopic in situ decompression.

RESULTS

At 12 months after surgery, the proportion of patients satisfied with the outcome was 9 of 15 (60%) for open in situ surgery and 15 of 19 (79%) for endoscopic in situ surgery. The postoperative complication rate was significantly higher after open in situ decompression than that after endoscopic in situ decompression surgery (10%). Preoperative function scores were predictive of patient-rated satisfaction and were related to McGowan grade.

CONCLUSIONS

The patient-reported outcome of surgical treatment of cubital tunnel syndrome is good but is affected by preoperative symptom severity. Outcomes after open and endoscopic in situ decompression, including the proportion of patients reporting satisfaction and functional improvement, are equivalent, but more patients reported complications after open decompression.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Severe tardy ulnar nerve palsy caused by traumatic cubitus valgus deformity: functional outcome of subcutaneous anterior transposition

Ten male patients with McGowan's grade III ulnar neuropathy due to traumatic cubitus valgus deformity underwent anterior subcutaneous ulnar transposition. Evaluation was performed using subjective and objective measures, and a modified Bishop score. After operation, subjective sensory and motor disturbances were improved or resolved in most of the patients, while objective measures improved less well. Improvement in two-point discrimination (2PD) was consistently associated with symptom relief. All of the patients reported satisfaction with the operation. There were no complications or recurrences. The results of ulnar nerve transposition in our patients were comparable to the results of this operation in patients with severe idiopathic cubital tunnel syndrome. Although the outcome of surgery is not always satisfactory in severe ulnar neuropathy, symptom relief may justify performing the operation.

Simple decompression of the ulnar nerve for cubital tunnel syndrome

OBJECTIVE

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients.

METHODS

According to Dellon's criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less).

RESULTS

Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbow-below the elbow) was 41.8+/-15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8+/-6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8+/-12.1 m/s to 47.8+/-12.1 m/s (p<0.05). After an average follow-up of 4.8+/-5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve.

CONCLUSION

Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.

Treatment of cubital tunnel syndrome: perspectives for the therapist

The treatment of cubital tunnel syndrome provides therapists the opportunity to use a wide variety of their skills. Whether managed surgically or nonoperatively, differential diagnosis, manual therapy, application of therapeutic modalities, splinting, pain management, and facilitating return to work are often all included in a comprehensive treatment plan for return to functional strength and mobility of the affected arm. When surgery is indicated due to a failure of nonoperative methods or the degree of nerve compression, the decision-making process for the specific procedure to perform is multifactorial. Anatomic factors, patient needs, and surgeon preference all play a role in determining which procedure is performed. As with many other conditions, an alliance of patient, therapist, and surgeon will provide the most effective therapeutic team, and the best chance for a good clinical outcome.

Outcome of partial medial epicondylectomy for cubital tunnel syndrome

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

LEVEL OF EVIDENCE

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

Subtotal medial epicondylectomy as a surgical option for treatment of cubital tunnel syndrome

Ulnar nerve compression at the elbow is commonly accepted as the second most frequent compressive peripheral neuropathy. The unique anatomic location of the ulnar nerve directly posterior to the medial epicondyle at the elbow places it at risk for injury. With normal motion of the elbow, the ulnar nerve is subjected to compression, traction, and frictional forces. Compression can occur at any of the 5 sites that begin proximally at the arcade of Struthers and end distally where the nerve exits the flexor carpi ulnaris in the forearm. Initial treatment of compressive neuropathy is nonoperative, usually consisting of rest, modification, and/or restriction of elbow or wrist movement. If symptoms persist, especially when accompanied by muscle weakness, surgery is usually indicated. Surgical options include decompression in situ, medial epicondylectomy, transposition of the ulnar nerve (subcutaneous, intramuscular, or submuscular), and/or a combination of these procedures. Careful decompression with a subtotal medial epicondylectomy is a valuable procedure that allows decompression at all levels with minimal risk of devascularizing the nerve or creating elbow instability.

[Should we divide Osborn's ligament during epicondylectomy and in situ decompression of the ulnar nerve?]

INTRODUCTION

Two groups of patients with cubital tunnel syndrome were treated by neurolysis and medial epicondylectomy. In the first group, the operative procedure consisted solely of dividing Osborn's ligament and fascia but in the second group Osborn's ligament was reinserted after epicondylectomy to avoid dislocation of the nerve. The aim of this retrospective study was to compare the level of complete recovery after surgery and the frequency of dislocation of the nerve.

MATERIAL AND METHOD

Group one: Nineteen patients, with a mean age of 47.7 (15-65), and 52% female, with the dominant hand involved in 63% cases, were treated. According to Mac Gowan's criteria, 32% of the elbows were classified preoperatively as grade I, 52% as grade II and 16% as grade III. Sensory nerve conduction velocity across the elbow was less than 40 m/s in 40% of cases. The mean duration of the disease was longer than 3 years in 16% of cases. Group two: Twenty three patients, with a mean age of 54.1 (33-75), and 56% female, with the dominant hand involved in 56% cases, were treated. According to Mac Gowan's criteria, three 17% of the elbows were classified preoperatively as grade I, 47% as grade II and 34% as grade III. Sensory nerve conduction velocity across the elbow was less than 40 m/s in 60% of cases. The mean duration of the disease was longer than 3 years in 4% of cases. Both groups were evaluated by a surgeon not involved in the treatment by clinical examination and DASH scoring.

RESULTS

DASH scoring is correlated with functional recovery, grip strength and Mac Gowan preoperative scoring. In group one, (divided and reinserted ligament) with younger patients, half the incidence of Mac Gowan stage II and a shorter follow up, there were no dislocations, but less complete resolution of preoperative symptoms (68%/82%) and a higher DASH scoring (30.6/24.9). In group two (resected ligament), dislocation of the nerve was noted in 17% of cases. In both groups, pain at the epicondylectomy site was noted in 20% of cases. The chance of complete recovery was inversely related to the age (>50), and to the duration of the disease (>1 year).

DISCUSSION

Surgical treatment of ulnar nerve entrapment at the elbow remains controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy or transposition of the ulnar nerve) has proven optimal regarding long-term results. In both groups in this study, neurolysis of ulnar nerve by section of Osborn's ligament and fascia together with medial epicondylectomy proved to be an effective surgical procedure for treating grade I to II ulnar neuropathy. Section of Osborn's ligament without its reattachment is followed by more cases of complete recovery as well as more dislocation of the nerve although the latter elicited no subjective complaints from the patients. DASH scoring is effective in evaluating the recovery.

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

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