Anterior Subcutaneous Transposition Research Articles

Clinical significance of upper arm motor nerve conduction velocity in cubital tunnel syndrome

Background Retrograde denervation occurs in severe entrapment neuropathy. This study aimed to investigate changes in motor nerve conduction velocity (MNCV) at the upper arm, specifically proximal to the elbow, in cubital tunnel syndrome (CuTS) and to correlate these changes with preoperative severity and postoperative outcomes. Methods We retrospectively reviewed 95 elbows with 81 patients with CuTS for preoperative severity, and then 67 elbows with 60 of these patients who underwent anterior subcutaneous transposition surgery for postoperative outcome, classified into favorable and unfavorable groups according to Messina grade. Results The reduction of upper arm MNCV was correlated with aging, decreased compound muscle action potentials of abductor digiti minimi muscle, loss of sensory nerve action potentials, and modified McGowan grade. Postoperative assessment revealed lower MNCV values in the “unfavorable” group compared to the “favorable” group at 1 month, 6 months, and the last follow up. At each time point, the optimal cut-off value of upper arm MNCV for predicting postoperative outcomes was 54.1 m/s. Discussion Upper arm MNCV might be a useful predictor of poor surgical outcome. Ulnar nerve MNCV at the upper arm should be measured alongside routine assessment of MNCV at the elbow and forearm, especially in clinically severe cases considering surgery.

Revision surgery for recurrent ulnar nerve compression following failed subcutaneous transposition.

Recurrent ulnar nerve compression after primary anterior subcutaneous transposition is relatively rare, and revision surgery is challenging. This study retrospectively evaluated the clinical outcomes of revision anterior subcutaneous transposition for recurrent ulnar nerve compression. Eight patients who underwent revision anterior subcutaneous transposition for recurrent ulnar nerve compression were enrolled in this study. The outcomes were based on preoperative and postoperative symptoms, physical examination findings, and electromyographic evaluation. Ulnar nerve enlargement was preoperatively found in all patients with a mean cross sectional area of 0.15 cm2 (range, 0.14-0.18 cm2). Intraoperative findings showed that recurrent compression occurred in three areas, including the medial intermuscular septum (n = 5), the medial epicondyle (n = 6) and nerve entrance to forearm fascia (n = 1). Post-operation, significant improvements were observed in ring/little finger numbness (from severe to mild, p = 0.031), grip strength (from 48.00% to 80.38% of the intact side, p < 0.001) and McGowan grade (from Grade III to Grade I, p = 0.049). Postoperative electromyography test also showed significant improvement in motor nerve conduction at elbow (velocity, 23.30 ± 9.598 vs. 35.30 ± 9.367, p = 0.012; amplitude, 3.40 ± 3.703 vs. 5.65 ± 2.056, p = 0.007) and sensory nerve conduction at wrist (velocity, 27.04 ± 22.450 vs. 36.45 ± 18.099, p = 0.139; amplitude, 1.44 ± 1.600 vs. 4.00 ± 2.642, p = 0.011). Seven of the eight patients reported satisfaction with the postoperative results. Revision anterior subcutaneous transposition was an effective treatment for recurrent ulnar nerve compression from prior failed procedures.

Elbow hemiarthroplasty for coronal shear fractures of the distal humerus

The aim of the operation is to replace the articular surface of the distal humerus in cases of nonreconstructible fractures of the distal humerus. Active patients with high functional requirements, in whom weight limitation of total elbow arthroplasty should be avoided. Contraindications include fractures with irreconstructible epicondyles and/or irreconstructible collateral ligaments, as well as ulnohumeral, or radiohumeral osteoarthritis. Following subcutaneous anterior transposition of the ulnar nerve, surgical dislocation of the elbow joint is achieved through aparatricipital approach with release of the soft tissue structures from the humerus. After resection of the trochlea, the intramedullary canal of the humerus is prepared using rasps in order to implant the hemiprosthesis with retrograde cementing. Finally, the medial and lateral collateral ligaments as well as the flexors and extensors are repaired. Early functional rehabilitation in ahinged elbow orthosis while avoiding varus/valgus stress after wound healing is completed. Between 2018 and 2022, 18patients with coronal shear fractures were treated with elbow hemiarthroplasty. The mean Mayo Elbow Performance Score (MEPS) was 79 (70-95) after amean follow-up of 12months. The mean range of motion was 99° (70-130°) in extension-flexion and 162° (90-180°) in pronation-supination.

Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment.

Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing1. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques1,2. The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner. Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate. The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures1-3. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches3. OO has not been associated with triceps weakness, unlike some of the alternative techniques2. The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures4. Osteotomies united in all patients in 2 reported series, totaling 84 cases1,2. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients1,2. Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the OO because of its natural lack of cartilage5,6. This non-articular bare area is located just distal to the deepest portion of the trochlear notch, approximately 2 to 2.5 cm distal to the olecranon tip5,6.An (apex-distal) chevron osteotomy angle of ∼130° will help to keep the osteotomy within the non-articular bare area6.Beginning on the dorsal surface of the ulna, directly posterior to the bare area, an oscillating saw is utilized to create a chevron osteotomy to subchondral bone, perpendicular to the long axis of the ulna5,6.The OO is completed by fracturing through the osteochondral surface, which leaves an irregular chondral cancellous surface that can accurately interdigitate. This facilitates later reduction and stability of the osteotomy.Anatomic articular reduction of the OO is not solely judged on the dorsal cortical bone because of the kerf removed by the saw blade. Instead, examination of the articular surface of the trochlear notch is the primary assessment of reduction.Placement of suture through the proximal portion of the plate aids in the repair of the longitudinal split of the distal triceps.Successful treatment of distal humeral fractures requires accurate reduction and rigid fixation aided by adequate exposure achieved through OO. ORIF = open reduction and internal fixationOT = occupational therapyHWR = hardware removalK-wire = Kirschner wireROM = range of motion.

Subcutaneous Anterior Transposition With Modified Procedures to Prevent Recurrence Associated With the Transposed Ulnar Nerve.

Subcutaneous anterior transposition of the ulnar nerve is a common surgical treatment for cubital tunnel syndrome. However, there are surgical failures associated with the new compressive sites at the edge of flexor carpi ulnaris (FCU) and resubluxation posterior to the medial epicondyle of the transposed nerve. To reduce the muscle volume at the edge of FCU, we approach the ulnar nerve by dividing the muscle belly of the FCU humeral heads. This procedure can reduce repeated traction forces on the transposed nerve at the edge of the FCU. To keep the transposed ulnar nerve anteriorly, we use a fat flap including the membranous superficial fascia. This flap can softly stabilize the ulnar nerve and act as a pliable cover to prevent perineural scarring or further constriction around the flap. Ninety-three elbows in 90 patients who had undergone this procedure for cubital tunnel syndrome were evaluated. According to Messina's criteria, the numbers of patients showing excellent, good, fair, and poor recovery were 41 (44%), 47 (51%), 5 (5%), and 0 (0%), respectively. Most patients experience resolution of symptoms and good functional outcomes. None of the patients suffered recurrence, infection, or nerve injury.

Radiofrequency Ablation of Palmar Digital Branches of Ulnar Nerve in a Patient with Ulnar Neuropathy

Ulnar Tunnel Syndrome (UTS) is ulnar neuropathy at the wrist or hand typically caused by ganglion cysts, lipomas, wrist or hand compression, carpal bone fractures, carpal tunnel syndrome, or anything else that can impinge on the nerve. The symptoms of UTS can be uncomfortable and debilitating, with numbness and tingling of the 4th and 5th digits being the most common. Weakness of the ulnar portion of the hand can lead to decreased grip strength. UTS is typically managed with conservative treatment including anti-inflammatory oral medications, splinting, physical therapy, activity modification, acupuncture, and stretching. Second line treatment includes corticosteroid injections, although these have shown to have little efficacy. Surgery is also an option but may lead to iatrogenic ramifications. Radiofrequency ablation (RFA) is a treatment modality used for chronic pain, which utilizes heat to target nociceptive fibers. Traditionally, RFA is used in treating cervical and lumbar radiculopathy, but it is less studied in peripheral nerve areas. This case report examines a patient who had clinically significant pain relief after RFA to the palmar digital branches of the ulnar nerve. The patient was 63-year-old male who presented with left ulnar neuropathy that had been ongoing for 3 years. Despite conservative management, his symptoms of pain, paresthesia, and weakness persisted. The patient then elected to have a left cubital tunnel release at the elbow with anterior subcutaneous transposition. The surgery provided relief for three months but then led to worsening contractures and pain in the 4th and 5th digits of the left hand. Due to persistent symptoms after conservative management and surgical intervention, he was referred to interventional pain clinic. A decision was made to trial a digital nerve block of the left medial and lateral digital palmar nerves. Following the nerve block, the patient reported 100% improvement in pain and increased range of motion and function. Four weeks later, the patient returned for a radiofrequency ablation of the same nerves. In the week following the procedure, the patient reported that the pain in the little finger was entirely resolved. While radiofrequency ablation has become increasingly popular for the treatment of chronic back pain, its use in peripheral nerve pain has been limited to case reports and few randomized control trials. This case report highlights the successful use of radiofrequency ablation in the treatment of little finger pain and ulnar neuropathy by targeting the median and lateral branches of the palmar digital nerve.

Recurrence of ulnar tunnel syndrome: Long-term clinical and functional results of surgical management using revision neurolysis and subcutaneous anterior transposition

ObjectiveRecurrence after primary ulnar tunnel syndrome surgery is observed in 1.4%–25% of patients. However, the outcome of revision surgery is uncertain and limited. This study aimed to assess the clinical and functional outcomes of neurolysis combined with anterior subcutaneous transposition in cases of recurrence. Patients and methodsThis retrospective single-center study included patients who were operated on for iterative ulnar tunnel syndrome at the elbow between January 1996 and December 2020, with a minimum follow-up of 24 months. Demographic data, pre- and post-operative clinical evaluations, surgical details, and satisfaction levels were collected. ResultsTwenty-eight patients were reviewed. Mean follow-up was 11.7 years (range, 2.1–26.4 years). The secondary procedure led to significant improvement in mean Quick-DASH score, from 25.3 (range, 11–50) to 20.0 (range, 11–49) (p = 0.023), with a satisfaction rate of 78.5%. Symptoms of pain (p = 0.033), amyotrophy (p = 0.013), hypoesthesia (p < 0.01), and paresthesia (p < 0.001) also showed significant improvement. There were 7 cases of failure (25.0%). ConclusionThe combination of neurolysis and anterior subcutaneous transposition was a reliable technique, improving clinical outcome in recurrent ulnar tunnel syndrome after previous surgery. Level of evidenceIV — retrospective study.

Application of ulnar nerve diameter changes examined by HRUS in patients with cubital tunnel syndrome

To evaluate the value of high-resolution ultrasound the diagnosis and prognosis of cubital tunnel syndrome. From January 2018 to June 2019, 47 patients with cubital tunnel syndrome were treated with ulnar nerve release and anterior subcutaneous transposition. There were 41 males and 6 females, aged from 27 to 73 years old. There were 31 cases on the right, 15 cases on the left, and 1 case on both sides. The diameter of ulnar nerve was measured by high-resolution ultrasound pre-and post-operatively, and measured directly during the operation. The recovery status of the patients was evaluated by the trial standard of ulnar nerve function assessment, and the satisfaction of the patients was assessed. All the 47 cases were followed up for an average of 12 months and the incisions healed well. The diameter of ulnar nerve at the compression level was (0.16±0.04) cm pre-operatively, and the diameter of ulnar nerve was (0.23±0.04) cm post-operatively. The evaluation of ulnar nerve function:excellent in 16 cases, good in 18 cases and fair in 13 cases. Twelve months post-operatively, 28 patients were satisfied, 10 patients were general and 9 patients were dissatisfied. The preoperative examination of ulnar nerve by high-resolution ultrasound is consistent with the intuitive measurement during operation, and the result of postoperative examination of ulnar nerve by high-resolution ultrasound is consistent with follow-up results. High-resolution ultrasound is an effective auxiliary method for the diagnosis and treatment of cubital tunnel syndrome.

Surgery for Cubital Tunnel Syndrome: A Comparative Study of Small Incision with Classic Anterior Nerve Transposition

Objective: To evaluate the clinical outcomes of ulnar neuropathy, and cubital tunnel syndrome (CuTS) surgery via a small incision with that of anterior transposition of the ulnar nerve. Materials &amp; Methods: In this comparative cross-sectional study, 108 patients were recruited from the Neurosurgery Department of Qazi Hussain Ahmad Medical Complex, Nowshera. Two Groups were made. Group A patients undergo either ulnar nerve anterior transposition or simple decompression via a small skin incision, while Group B patients undergo ulnar nerve subcutaneous anterior transposition through a classic skin incision. Results: Totally 108 patients were enrolled. Males were 67 and females were 41 with a mean age of 45.6 ± 12.97 years. During follow-up visits, an increase in clinical outcome measures was noted, but no statistically significant difference was seen in both groups. Nevertheless, in comparison to the two groups, complications were more in group B, in terms of superficial infection, numbness of skin at the medial elbow, revision surgery, and painful scar. Conclusion: It is concluded that keeping in view the stability/anatomical position of the ulnar nerve to undergo either simple decompression or anterior transposition through small skin incision is effective and an excellent procedure as compared to classic incision procedure in treating patients suffering from cubital tunnel syndrome.

Distal anterior interosseous nerve to ulnar nerve motor branch reverse end-to-side transfer in a case of severe ulnar neuropathy.

Reverse end-to-side (RETS) distal transfer is gaining popularity in cases of proximal nerve damage with the nerve in continuity, allowing the nerve to potentially retain its ability to regenerate and recover. While preserving the original axon pool, RETS could provide an additional pool of motor axons and/or possibly "babysit" the muscle endplates and distal denervated nerve Schwann cells until reinnervation from the original pool occurs. The authors present a video demonstrating anterior subcutaneous transposition of the ulnar nerve at the elbow coupled with a distal anterior interosseous nerve to ulnar nerve RETS in a case of severe posttraumatic ulnar neuropathy at the elbow. The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID2282.

Intraneural or extraneural ganglion cysts as a cause of cubital tunnel syndrome: A retrospective observational study.

PurposeCubital tunnel syndrome caused by ganglion cysts has rarely been reported. The purpose of this study was to evaluate the surgical treatment outcomes of a patient diagnosed with cubital tunnel syndrome caused by intraneural or extraneural cysts and to summarize our experience.MethodIn total, 34 patients were evaluated retrospectively from January 2011 to January 2020 with a follow-up of more than 24 months. Preoperative data, such as demographic data, clinical symptoms, physical examination findings, and laboratory tests, were all recorded and pre-operative and post-operative data were compared. The function was evaluated by the modified Bishop scoring system and the McGowan grade at the last follow-up.ResultsImprovement of interosseous muscle strength, the Visual Analog Scale (VAS), 2-point discrimination (2-PD), electromyogram (EMG) result, Wartenberg sign, claw hand, and weakness could be clearly observed in all patients. Extraneural cysts were completely removed and the pedicles of the cysts were ligated. Intraneural cysts were incised and drained, and part of their cyst walls were removed using a microsurgical technique. All patients underwent anterior subcutaneous transposition (AST). At the last follow-up, McGowan's (0-IIa) grade increased from seven patients (20.6%) preoperatively to 27 patients (79.4%); the excellent and good rate according to the modified Bishop scoring system was 82.4% (28 patients), and all patients had no symptoms of recurrence after surgery.ConclusionThe treatment of cubital tunnel syndrome caused by intraneural or extraneural cysts achieved good long-term results through extraneural cyst resection or intraneural cyst incision and drainage combined with subcutaneous transposition. Early diagnosis and surgical treatment are essential for the patient's postoperative recovery.

In Situ Placement Versus Anterior Transposition of the Ulnar Nerve for Distal Humerus Fractures Treated With Plate Fixation: A Multicenter Randomized Controlled Trial.

To compare clinical scores and electrodiagnostic evidence of ulnar neuropathy, between ulnar nerve mobilization and placement back in the cubital tunnel versus anterior transposition, during plate and screw fixation of a bicolumnar fracture of the distal humerus. Multicenter randomized controlled trial. Eight tertiary care centres in Canada. Fifty-eight patients with distal humerus fractures undergoing plate fixation of both columns were recruited and randomized. All patients underwent bicolumnar plate fixation for an acute, displaced fracture of the distal humerus with identification, mobilization, and protection of the ulnar nerve as part of the surgical approach. At the conclusion of the procedure, they were randomized to either (1) replacing the nerve in situ in the cubital tunnel or (2) anterior transposition. The primary outcome was the Gabel & Amadio rating scale for ulnar neuropathy. Secondary outcomes included a functional outcome score (Mayo Elbow Performance Score), disabilities of the arm, shoulder and hand instrument, 2-point discrimination, nerve conduction testing, complications, and secondary surgeries. Thirty-one patients were randomized to in situ placement and 27 to anterior transposition. The mean age was 53 years, and 60% were women. There was no difference between the 2 groups with regards to age, gender, body mass index, smoking, diabetes, injury characteristics, time to operation, length of operation, or surgical approach. There was no difference in outcome between the 2 groups at any time point with regards to Gabel & Amadio ulnar neuropathy scores, Mayo Elbow Performance Score, disabilities of the arm, shoulder and hand instrument, or 2-point discrimination. The incidence of ulnar nerve dysfunction, as measured by use of the Gabel & Amadio ulnar neuropathy score, was poor in both groups acutely; however, there was significant improvement at 12 months postoperatively (6.0-7.8, P < 0.001). This study was unable to demonstrate any significant difference in outcomes when comparing ulnar nerve mobilization and in situ placement and anterior subcutaneous transposition after bicolumnar plate fixation of a distal humerus fracture. Either strategy for managing the ulnar nerve is acceptable and can be used at the discretion of the treating surgeon. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Subcutaneous Ulnar Nerve Transposition

Cubital tunnel syndrome is one of the most common compression neuropathies affecting the upper extremity. Physical exam findings include loss of sensation, muscle weakness, and clawing of the fingers. More severe cases also show irreversible muscle atrophy, hand contractures, and loss of function. There are several approaches to treating cubital tunnel syndrome. Here, a subcutaneous anterior transposition was performed on this patient. The patient’s ulnar nerve subluxed upon elbow flexion and extension upon physical examination, which was a primary indication for choosing this surgical approach over other techniques. This procedure not only decompresses the affected nerve but also transposes the nerve anterior to the medial epicondyle so as to relieve strain on the nerve upon the full range of motion of the elbow.

Dynamic Evaluation of Intraneural Microvascularity of the Ulnar Nerve Using Contrast-Enhanced Ultrasonography in Patients With Cubital Tunnel Syndrome

The purpose of this study was to compare the intraneural microvascular patterns of the ulnar nerve at 2 elbow flexion angles in asymptomatic volunteers and patients with cubital tunnel syndrome (CuTS) and to evaluate the effects of surgery on the microvascular pattern in patients with CuTS by using contrast-enhanced ultrasonography (CEUS). This study included 10 elbows in 10 asymptomatic volunteers (control group) and 10 elbows in 10 patients with CuTS who underwent anterior subcutaneous transposition of the ulnar nerve (CuTS group). The CuTS group underwent clinical and electrophysiologic examinations and CEUS before surgery and at 1, 2, and 3 months after surgery. The intraneural enhancement pattern was calculated as an area under the curve (AUC) value in the entrapment site of the ulnar nerve within the cubital tunnel and in the area 1 cm proximal to the site (proximal site) at elbow flexion angles of 20° and 110°. Serial electrophysiologic examinations showed improvements at 1, 2, and 3 months after surgery compared with before surgery. In the control group, the AUC values of the central part of the cubital tunnel and proximal sites showed no substantial changes with the increase in elbow flexion. In the CuTS group, the AUC in the proximal site at 110° of elbow flexion was decreased compared with that at 20° of flexion before surgery. The AUC values for both the entrapment and proximal sites at 20° and 110° of elbow flexion were the most increased at 2 months after surgery compared with before surgery. Increased elbow flexion in patients with CuTS influences the intraneural blood flow of the ulnar nerve. Surgery for CuTS alters the intraneural blood flow. Quantitative evaluation of the intraneural blood flow of the ulnar nerve using CEUS may be a new supplementary diagnostic tool for CuTS and an indicator for the evaluation of postoperative recovery from nerve damage.

In Situ Neurolysis of Ulnar Nerve for Patients With Failed Anterior Subcutaneous Transposition - A Case Series.

BACKGROUNDVarious surgical techniques have been attempted to treat patients with failed anterior subcutaneous transposition performed for cubital tunnel syndrome.OBJECTIVETo analyze intraoperative findings of failed anterior subcutaneous transposition and to report the outcome of in Situ neurolysis of ulnar nerve.METHODSPatients who, under diagnosis of failed anterior subcutaneous transposition of ulnar nerve, underwent in Situ neurolysis between 2001 and 2018 were included in this study. We excluded patients with follow-up of less than one year, records of traumatic ulnar nerve injury, and concomitant double crush syndrome such as cervical spondylosis causing radicular pain, ulnar tunnel syndrome, or thoracic outlet syndrome. Surgical outcomes were evaluated using visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder, and Hand (DASH) score, which were assessed before and after surgery. A total of 28 elbows in 27 patients whose average age was 58.5 (range, 31-76) yr were enrolled, and the duration of follow-up was 5.8 (range, 1.0-14.9) yr.RESULTSThe most common pathologic finding identified during operation was severe adhesion of the transposed nerve in all elbows, followed by incomplete decompression of deep flexor-pronator aponeurosis in 26 elbows (93%). The average VAS pain score improved from 4.9 (range, 2-7) to 1.3 (range, 0-5), and the average DASH score from 31.7 (range, 18.1-66.7) to 14.1 (range, 5.0-46.6). Of the 28 elbows, 27 (96.4%) showed improvement of preoperative symptoms.CONCLUSIONIn Situ neurolysis of ulnar nerve for patients with failed anterior subcutaneous transposition resulted in satisfactory outcome.

The Relationship between Plate and Screw to Ulnar Nerve in Distal Humeral Fracture: A Cadaveric Study

Background: Plate and screw fixation during the treatment of distal humeral fracture in adults is considered to be a gold standard that makes anatomic and articular reduction. Injury of the ulnar nerve is a common condition that can be found in pre-operative, intraoperative, and postoperative. Intraoperative anterior subcutaneous transposition is still a controversial issue. Objective: To understand the variation of distance of the ulnar nerve during elbow motion with the anatomical landmark of distal humeral bone and plate position after fixation. Materials and Methods: The authors have studied ten fresh adult cadavers, who underwent autopsy at the Department of Forensic Medicine of Srinakharinwirot University. Results: The results showed that in zone 2, the Center of the medial condyle was the position of the distal humeral bone with the most variation in position changing during elbow flexion/extension. In the sagittal plane (+2.56 to –4.58 mm), the mean difference equaled to 7.14 mm, while in the coronal plane (+1.70 to –5.14 mm), the mean difference equaled to 6.84 mm, with the highest percentage of irritation up to 70%. Furthermore, 14 cases of ulnar nerve subluxation were found in 20 studies (70%). Conclusion: From the present study, the Medial condyle was the landmark with the most irritation and position changing of ulnar nerve during elbow flexion. The incidence of ulnar subluxation occurred after in situ release for plate fixation was also found higher than in previous studies. Keywords: Plate and screw fixation; Ulnar nerve injury; Distal humeral fracture; Anterior subcutaneous nerve transposition; Cadaveric study; Anatomical bony landmark of distal humeral bone; Ulnar nerve subluxation

Decision Making via 3D Computed Tomography in the Surgical Treatment of Cubital Tunnel Syndrome: Surgical Technique and Results.

To investigate the importance of elbow 3D computed tomography in surgical planning when deciding on the treatment surgical treatment method of the ulnar nerve entrapment in the cubital tunnel. In this study, 21 patients with cubital tunnel syndrome in our clinic were included and retrospectively analyzed. All of the patients were diagnosed with EMG, and surgical planning was performed based on the anatomy of the cubital tunnel diagnosed via 3D computed tomography. In addition to the classical simple decompression of the ulnar nerve, 15 patients underwent cubital tunnel reconstruction with high-speed drill, whereas 6 patients underwent ulnar nerve anterior subcutaneous transposition. The results were evaluated based on the modified Wilson & Krout criteria. Fourteen of the patients were female and seven were male. The average age was 42.2 years. Fifteen patients underwent simple decompression of the ulnar nerve and cubital tunnel reconstruction. Transposition was performed in six patients. The patients were followed up for an average of 107.5 months (3-144). Based on the Wilson & Krout criteria, excellent results were obtained in 14 patients (66.7%), good results in 6 (28.6%), and poor results in 1 (4.8%). The evaluation of the cubital tunnel via 3D computed tomography before the operation is effective in determining the optimal surgical technique and obtaining more successful clinical results. The cubital tunnel reconstruction in addition to simple decompression increases surgical success and minimizes complications and the possibility of relapse due to the fact that the nerve remains in its natural position.

Benefits of a collagen membrane for recurrent ulnar nerve entrapment at the elbow: A series of 40 cases

The rate of failure or recurrence after ulnar nerve release at the elbow is up to 25%. Various biomaterials have been developed to protect nerves from postoperative adhesions. The aim of this study was to review a case series of 40 surgical revision procedures of the ulnar nerve at the elbow, protected by a collagen membrane (Cova™ ORTHO). Forty patients who had this revision surgery between January 2013 and December 2017 were reviewed: 34 were evaluated in person, 6 were evaluated over the phone. The operation consisted in release of the ulnar nerve, anterior subcutaneous transposition and nerve protection using a collagen membrane. We assessed the following parameters with an average follow-up of 4 years and 3 months: paresthesia, night awakening, quality of life (QuickDASH score) and neuropathic pain (DN4 questionnaire). The outcome was determined with the Gabel & Amadio score. The patients’ satisfaction was evaluated. A significant decrease in paresthesia and night awakening was found (p < 0.05). The average Gabel & Amadio score improved from 4.4 to 6.7 with 5 excellent, 19 good, 9 fair, and 1 poor result. The average DN4 was 5/10 and the QuickDASH score was 40.1. Eighty percent of patients were satisfied or very satisfied with the outcome. Surgical revision of the ulnar nerve at the elbow remains a delicate operation without a gold standard. This case series found good or excellent results in 70% of patients. Surgical revision of the ulnar nerve with a collagen membrane is a reliable alternative among other possibilities for ulnar nerve release at the elbow.

The role of ulnar nerve subcutaneous anterior transposition during open reduction and internal fixation of distal humerus fractures: a retrospective cohort study

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.

Anterior Subcutaneous Transposition With Expanded Polytetrafluoroethylene (ASTEP) for Cubital Tunnel Syndrome: Technical Note.

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. To introduce the operative technique and outcomes of anterior subcutaneous transposition with ePTFE (ASTEP) in primary and recurrent cubital tunnel neuropathy. 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. 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. 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.