A case report of primary synovial chondromatosis of the elbow

Objective To compare the clinical effects of anterior subcutaneous transposition and anterior subfascial transposition of the ulnar nerve in the treatment of cubital tunnel syndrome. Methods A total of 37 patients with cubital tunnel syndrome were retrospectively analyzed. 18 cases were treated with subcutaneous transposition of ulnar nerve, and 19 cases with anterior transposition of ulnar nerve. The scores of sensory deficits in the ulnar nerve innervation area, the intrinsic muscle strength, claw deformity and ulnar nerve conduction velocity were compared between the two groups. Results Postoperative follow-up period ranged from 6 to 18 months. There was no significant difference between anterior subcutaneous and anterior subfascial transposition of the ulnar nerve. The clinical effects of patients with moderate cubital tunnel syndrome treated by the two anterior transposition operations were much better than that of patients with severe cubital tunnel syndrome. Conclusion There was no difference between the two methods of anterior subcutaneous transposition and anterior subfascial transposition. However, the anterior subfascial transposition combines the advantages of anterior subcutaneous transposition and anterior submuscular transposition. Cubital tunnel syndrome should be actively intervened after being definitely diagnosed. Key words: Cubital tunnel syndrome; Treatment outcome; Anterior subcutaneous transposition; Anterior subfascial transposition

Regional Ulnar Nerve Strain Following Decompression and Anterior Subcutaneous Transposition in Patients With Cubital Tunnel Syndrome

PurposeTo compare the rates of ulnar nerve neuropathy following ulnar nerve subcutaneous anterior transposition versus no transposition during open reduction and internal fixation (ORIF) of distal humerus fractures.MethodsThis was a retrospective cohort study at an academic level I trauma centre. A total of 97 consecutive patients with distal humerus fractures underwent ORIF between 2011 and 2018. All included patients were treated with plates (isolated lateral plates excluded) and had no pre-operative ulnar neuropathy. Subcutaneous ulnar nerve anterior transposition was compared versus no transposition at the time of ORIF. The main outcome measure was the rate of ulnar nerve neuropathy. The secondary outcomes were the severity of the ulnar nerve neuropathy and the rate of ulnar nerve recovery.ResultsTwenty-eight patients underwent subcutaneous ulnar nerve anterior transposition during ORIF, whereas 69 patients had no transposition. Transposition was associated with significantly higher rates of ulnar nerve neuropathy (10/28 versus 10/69; P = 0.027). An adjusted logistic regression model demonstrated an odds ratio of 4.8 (1.3, 17.5; 95% CI) when transposition was performed. Ulnar nerve neuropathy was classified as McGowan grades 1 and 2 in all neuropathy cases in both groups (P = 0.66). Three out of ten cases recovered in the transposition group, and five out of ten cases recovered in the no transposition group over a mean follow-up of 11.2 months (P = 1.00).ConclusionWe do not recommend performing routine subcutaneous ulnar nerve anterior transposition during ORIF of distal humerus fracture as it was associated with a significant 5-fold increase in ulnar nerve neuropathy.

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

Cubital tunnel syndrome (CTS) is the second most common neuropathy of the upper extremity due to entrapment of ulnar nerve. Surgical management is the better intervention compared with conservative one. This study is to evaluate operative technique preferable for the treatment of cubital tunnel syndrome and compare between simple decompression versus anterior transposition, and subcutaneous anterior transposition versus sub muscular anterior transposition. Level III systematic review and network meta-analysis were performed to compare clinical improvement between subcutaneous anterior transposition and sub muscular anterior transposition, and simple decompression and anterior transposition. Two sub analysis was also performed: 1) comparing sub muscular anterior transposition to subcutaneous anterior transposition, 2) comparing Infection rate of Simple Decompression to Anterior transposition. We identified eighteen studies in which 5 studies were RCT and 13 were non RCT (8 Retrospective Case series and 5 Prospective study) which involved a total number of 491 simple decompressions, 307 sub muscular transpositions and 485 subcutaneous transposition patients. We also found evidence of publication bias or statistical study heterogeneity. Odds ratio of improvement with simple decompression versus anterior transposition were 0.781 with a 95% CI of [0.574, 1.063], I2 = 0%, p value =0.117. The odds ratio of improvement of subcutaneous transposition versus sub muscular transposition was 1.208 with a 95% CI of [0.609, 2.397], I2 = 0%, p value=0.588 and the odds ratio of post-op infection in simple decompression versus anterior transposition was 0.287 with 95% CI of [0.097, 0.845], I2 = 0%, with p value=0.024. Sensitivity analyses with use of fixed-effects methodology confirmed these findings to be robust and no heterogeneity was found. The result in this study showed that there is no significant difference between the treatment of cubital tunnel syndrome while comparing the improvement parameter for simple decompression vs anterior transposition and sub muscular transposition vs subcutaneous transposition but while doing a sub-analysis comparing the post op-infection between simple decompression and anterior transposition significant difference was found, and also with subcutaneous transposition and sub muscular transposition.

The optimal treatment for cubital tunnel syndrome is widely debated. The purpose of this study is to describe the technique of an endoscopic-assisted ulnar nerve decompression using carbon dioxide insufflation in association with subcutaneous anterior transposition and to assess the success or failure of the method of treatment. In all, 8 male and 4 female patients with an average age of 42 years (range, 25-56) who presented signs, symptoms, and abnormal neurophysiological studies of cubital tunnel syndrome were recruited in the retrospective study. Between August 2008 and June 2009, they were operated on using a 0-degree lens endoscope. Preoperatively, they were classified according to the Dellon scale, and the Bishop rating system was used to evaluate the postoperative outcomes. Preoperatively, 5 patients were rated as mild, another 5 as moderate, and the remaining 2 as severe. The average length of the incision was 15 ± 3 mm, the mean length of the ulnar nerve decompression was 18 ± 2 cm, and the whole duration of surgery (skin to skin) lasted 30 ± 5 minutes. The endoscopic-assisted cubital tunnel release under carbon dioxide insufflation and subcutaneous anterior transposition surgeries in all patients were performed with no difficulty. All the patients had improvement in symptoms of cubital tunnel syndrome and 10 of 12 patients scored excellent according to the modified Bishop Rating System at a minimum of 1 year after surgery. Endoscopy-assisted cubital tunnel release under carbon dioxide insufflation demonstrated similar results compared with conventional open surgeries, besides, it may avoid problems such as long incision, painful scarring, and have additional advantages of providing an extended endoscopic view, which is safe and mini-invasive with favorable results in a 12-month follow-up.

Objective: Anterior subcutaneous transposition of the ulnar nerve is one of the accepted treatments for cubital tunnel syndrome, but it is often performed under general or regional anesthesia. We have analyze our experience with less invasive local anesthesia for this procedure. Methods: We retrospectively reviewed the records of 51 patients (53 elbows) undergoing anterior subcutaneous transposition of the ulnar nerve under local anesthesia between January 1999 and June 2005. The elbows were assessed both clinically and electrophysiologically. A modification of the McGowan classification was used preoperatively, and Amadio's classification, consisting of four grades (excellent, good, fair and poor) based on a 9-point rating scale, was used postoperatively to assess the results. Excellent and good grades were considered significant improvement, while fair and poor were considered no significant improvement. Results: Preoperatively, of the 53 elbows, 13 were classified as grade I, 16 as grade IIA, 14 as grade IIB, and 10 as grade III. Significant improvement was achieved in 39 (74%), and 42 (79%) were at lest one grade better after surgery. The outcome was correlated with the pre-operative McGowan and electrophysiologic grading. All patients tolerated the procedure well, and 90% of them would again choose to have the operation performed under local anesthesia. Conclusions: Anterior subcutaneous transposition of the ulnar nerve can be performed reliably and effectively under local anesthesia. This has benefits in avoiding the potential complications of regional or general anaesthesia, especially in a group of elderly patients who are poor-risk, and it can be considered as an option for surgical management of ulnar nerve entrapment.

:Background:Ulnar nerve neuropathy is one of the most common peripheral nerve dysfunctions. Elbow is the most common area affected by ulnar nerve which is mainly because of fractures or dislocations of this area. Delayed ulnar nerve palsy (Tardy Ulnar Nerve Palsy) in children due to a malpositioning of upper extremity during hospitalization is an uncommon cause of ulnar nerve injury which we have already reported it.Methods:An eight-year-old conscious patient who had weakness, paresthesia and tingling in the right 4th and 5th fingers, as well as right claw hand deformity was evaluated, he had attended once before in 4 months ago due to head trauma in coma state. The child had no clinical and radiological indications of arm or elbow fractures causing nerve compression or entrapment. Elbow malposition had caused ulnar nerve neuropathy during hospitalization. Surgery was attempted, ulnar nerve decompression and anterior transposition done. Results:After three weeks post operatively, active physical therapy was started on the right upper extremity and the hand returned to normal activity after 6 months.Conclusions:In patients with decreased level of consciousness or coma state who need prolonged hospitalization, the limbs must remain in correct position to prevent superficial nerve injuries and neuropathies. Furthermore, careful and scrutinized attention to the traumatic patients and doing on time and targeted imaging, regular follow up of patients, complete and perfect neurological examinations can prevent peripheral nerve injuries or develop on-time treatments which improve the patients' quality of life.Keywords:Ulnar nerve, Elbow malposition, Ulnar nerve decompression

BackgroundPrimary elbow osteoarthritis usually presents with pain and global restriction of range of motion and rarely presents with features of cubital tunnel syndrome. Ulnar claw hand is debilitating to the patient and interferes in the activities of daily living. Cubital tunnel syndrome is a rare presentation of primary elbow OA and can easily be missed. Medial osteophytes and loose bodies from the joints of the elbow (ulno-trochlear and radio-ulnar) can cause compression of the ulnar nerve at the cubital tunnel and present with features of ulnar nerve palsy without substantial symptoms in the elbow. Case reportWe present a case of ulnar claw hand due to compression neuropathy in an undiagnosed case of primary OA of the elbow. The patient was thoroughly investigated for about an year for all possible etiologies of the Ulnar nerve palsy the cause of compression was not clearly identified. Radiologically the site of compression was identified to be at the cubital tunnel caused by a medial osteophyte and a loose body arising from the degenerated ulno humeral joint. After a thorough work up ulnar nerve decompression at the cubital tunnel was offered, which involved loose body and osteophyte excision with anterior transposition and debulking the ulno humeral joint. Patient had a good postoperative outcome with recovery of neurological symptoms and grip strength at 6 months, though the wasting persisted. ConclusionPrimary OA of the elbow rarely presents as an ulnar claw hand and has to be kept in mind by the practicing clinician. Ulnar nerve decompression with anterior transposition with loose body excision gives good results.

Cubital tunnel decompression is a commonly undertaken upper limb procedure. Most studies compare the different techniques of decompression; however, only a few have specifically investigated the outcome of ulnar nerve decompression. The aim of this study was to investigate the outcome of ulnar nerve decompression following cubital tunnel syndrome. A total of 174 ulnar nerve decompression cases were identified from the upper limb surgery database with complete data available for 136 cases. Simple decompression was performed in 110 (80.88%) cases, and in 26 (19.12%), anterior subcutaneous transposition was also supplemented. These operations were performed at three different hospitals by surgeons of different levels of experience. The most common cause of cubital tunnel syndrome was idiopathic. The outcome was satisfactory in 86% of cases. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. This is the largest outcome analysis of the results of ulnar nerve decompression at the elbow. Good results following nerve decompression were attained in 86% of cases without any significant effect of duration of symptoms or co-morbidities on the outcome of surgery. It is hoped that the findings of the current study will help general practitioners, junior doctors and surgeons in their management and pre-operative consultation with patients having cubital tunnel syndrome.

Background: Ulnar nerve compression at the elbow level is the second-most common entrapment neuropathy. The aim of this study was to use shear-wave elastography for the quantification of ulnar nerve elasticity in patients after ulnar nerve decompression with anterior transposition and in the contralateral non-operative side. Method: Eleven patients with confirmed diagnosis and ulnar nerve decompression with anterior transposition were included and examinations were performed on an AixplorerTM ultrasound system (Supersonic Imagine, Aix-en-Provence, France). Results: We observed significant differences at 0-degree (p < 0.001), 45-degree (p < 0.05), 90-degree (p < 0.01) and 120-degree (p < 0.001) elbow flexion in the shear elastic modulus of the ulnar nerve in the operative and non-operative sides. There were no statistically significant differences between the elasticity values of the ulnar nerve after transposition at 0-degree elbow flexion and in the non-operative side at 120-degree elbow flexion (p = 0.39), or in the ulnar nerve after transposition at 120-degree elbow flexion and in the non-operative side at 0-degree elbow flexion (p = 0.09). Conclusion: Shear-wave elastography has the potential to be used postoperatively as a method for assessing nerve tension noninvasively by the estimation of mechanical properties, such as the shear elastic modulus.

Objective To investigate the outcome between endoscopically assisted and routine anterior transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Methods From Februray 2008 to June 2010, forty-four patients with cubital tunnel syndrome were treated with routine anterior subcutaneous transposition (routine group,28 cases) and endoscopically assisted anterior subcutaneous transposition (endoscope group,16 cases).The operate time,drug administration,scar and postoperative hospital stay were compared.The patients were followed 1-12 month postoperatively,postoperative time back to work and function of ulner nerve were recorded. Results The results of endoscope group were as follows: operative time was (67.20 ± 19.69)min; postoperative scar length was (1.5％ ± 0.58) cm; rate of administration of anodyne was 6.3％; postoperative hospital stay was (2.4％ ± 1.42) days; postoperative time back to work,(14.6 ± 4.69)days; the results of open surgery group were as follows:operative time (62.8％ ± 11.06) min; postoperative scar length was (8.7％ ± 1.42) cm; rate of administration of anodyne was 42.8％; postoperative hospital stay was (5.7％ ± 2.53) days; postoperative time back to work was (29.40 ± 8.75) days; all differences of the results were significant between two groups (P ＜ 0.05).According to function of ulner nerve scoring system,one year postoperatively, excellent or good results were 82.14％ in routine group and 81.25％ in endoscope group,no significant difference between two groups (P ＞ 0.05). Conclusion Compared with routine anterior transposition of the ulnar nerve,endoscopically assisted anterior transposition has the following advantages: smaller incision and less tissue damage,less postoperative pain and sooner returning to work.And similar outcome was achieved from the two group. Key words: Cubital tunnel syndrome; Endoscope; Ulnar nerve; Nerve release

Background There is no consensus on the most effective surgical technique in the treatment of cubital tunnel syndrome. Anterior subcutaneous transposition (AST) and anterior intramuscular transposition (AIT) are common surgical treatments in this regard. The aim of this study was to compare the clinical outcomes of these two surgeries for cubital tunnel syndrome. Methods In a retrospective study, we compared surgical outcomes (pain, sensation, motor recovery, atrophy, and total satisfaction) in 40 patients undergoing AIT and 43 undergoing AST of the ulnar nerve. Results The patients undergoing AIT showed a significant improvement in all the outcomes after the surgery (P=0); however, those undergoing AST only experienced an improvement in pain and sensation after the surgery (P=0). Comparing the two surgeries, we found that there was a high total satisfaction with AIT compared with AST (P=0). When we independently compared each outcome in the two groups, we found that the muscle force recovery was significantly improved in the AIT group compared with the AST group (P=0). Conclusions AIT is preferable to AST for the surgical treatment of cubital tunnel syndrome. In particular, AIT achieves a better motor recovery of the ulnar nerve compared with AST.

NICHE Solutions – Fourteenth in a series: Sensory changes

We studied the elongation and excursion of cadaveric ulnar nerves during elbow flexion in control conditions and after in situ decompression and anterior subcutaneous transposition. We found that the normal nerve had the greatest elongation (23%) and excursion (14 mm) in the epicondylar groove. Decompression did not alter the excursion, but significantly reduced the elongation in the groove (6%) and increased it proximally (19%). After anterior subcutaneous transposition, the nerve segment which was originally in the groove elongated with elbow extension to the same extent as occurred with the normal nerve during flexion.