Anterior Subcutaneous Transposition Research Articles

Cubital Tunnel Syndrome Associated with Medial Elbow Ganglia and Osteoarthritis of the Elbow

Although transplantation of cryopreserved bone allografts has become a routine procedure in orthopaedic surgery, biological and immunological impairment remains an unsolved problem that causes clinical failures. Experimental and clinical evidence has indicated that bone grafts that are revascularized early remain viable and contribute to union at the recipient site. Unprotected cryopreservation, used in most bone banks to reduce graft antigenicity, is associated with complete loss of graft viability, potentially contributing to graft failure. The differences in the survival of various cell types during cryopreservation with use of dimethyl sulfoxide, particularly the increased sensitivity of leukocytes to fast freezing, has resulted in a new approach to modulate immunogenicity. On the basis of this concept, it was proposed that a reduction in the immune response and enhanced revascularization of osteochondral allografts could be achieved by rapid cryopreservation with dimethyl sulfoxide. To test this hypothesis, angiogenesis and immune tolerance were quantified in a murine model with use of intravital microscopy. Fresh osteochondral tissue and osteochondral tissue that had been cryopreserved with and without dimethyl sulfoxide was transplanted into dorsal skinfold chambers as isografts and as allografts in presensitized and nonsensitized recipient mice. To quantify angiogenesis, the onset of hemorrhages in the vicinity of the grafts and the revascularization of the grafts were determined by means of intravital fluorescence microscopy. To determine the recipient's intravascular immune response to the grafts, the leukocyte-endothelium interaction was assessed on the twelfth day after transplantation. Nine of nine fresh isografts were revascularized at a mean (and standard deviation) of 57 +/- 33 hours, eight of nine isografts that had been cryopreserved with dimethyl sulfoxide were revascularized at 98 +/- 50 hours, and zero of nine isografts that had been cryopreserved without dimethyl sulfoxide were revascularized. Seven of seven fresh allografts were revascularized at 53 +/- 6 hours, and ten of ten allografts that had been cryopreserved with dimethyl sulfoxide were revascularized at 82 +/- 29 hours. However, signs of revascularization faded in four of the seven fresh allografts whereas reperfusion was maintained in the majority (seven) of the ten grafts frozen in the presence of dimethyl sulfoxide. Similar to the findings associated with unprotected frozen isografts, zero of ten unprotected frozen allografts were revascularized. None of the allografts that had been transplanted into presensitized recipients were revascularized, regardless of whether they had been implanted fresh (nine grafts) or had been implanted after protected (eight grafts) or unprotected (nine grafts) freezing. Quantification of the leukocyte-endothelium interaction revealed a reduction in the intravascular immune response to frozen allografts (both protected and unprotected) compared with fresh allografts. Osteochondral allografts that had been pretreated by cryopreservation with dimethyl sulfoxide demonstrated improved angiogenesis induction and enhanced immune tolerance compared with unprotected frozen grafts. A selective reduction in donor passenger leukocytes is the proposed mechanism underlying this phenomenon. In the absence of presensitization, cryopreservation with dimethyl sulfoxide appears to reduce the immune response to allografts and to enhance their revascularization; in the presence of presensitization, alternatives to allograft transplantation should be considered since the allografts will be exposed to a deleterious immune response.

Short segment stimulation of the anterior transposed ulnar nerve at the elbow

Paternostro-Sluga T, Ciovika R, Turkof E, Zauner-Dungl A, Posch M, Fialka-Moser V. Short segment stimulation of the anterior transposed ulnar nerve at the elbow. Arch Phys Med Rehabil 2001;82:1171-5. Objective: To determine whether short segment stimulation after anterior subcutaneous transposition of the ulnar nerve reaches normal values and correlates with postoperative clinical findings. Design: Comparative cross-sectional study. Setting: Outpatient clinic of a university department of physical medicine and rehabilitation. Patients: Nineteen patients (15 men, 4 women) with 21 surgically treated ulnar neuropathies at the elbow; and 19 healthy controls (11 men, 8 women) with 24 measured nerves. Interventions: Assessed motor function of ulnar innervated muscles and staged into 4 categories; used questionnaire to assess clinical course of the nerve lesion and graded into 5 categories; took electrophysiologic recordings to measure motor conduction velocity and compound muscle action potentials; and studied short segment stimulation across elbow and lower arm. Main Outcome Measures: Mean ± standard deviation of ulnar short segment conduction time across the elbow, amplitude and motor conduction velocity; grading of ulnar nerve lesions; grading of the course of disease after surgery; and logistic regression and correlation (Spearman's correlation coefficient) for electrophysiologic and clinical parameters. Results: Sixteen nerves showed focal conduction slowing in patients. No significant correlation between the course of disease and electrophysiologic parameters was seen. For stepwise logistic regression, there was a significant effect between grade of nerve lesion and amplitude, but no significant effect between the course of disease and electrophysiologic parameters. Conclusion: A focal conduction slowing across the elbow after anterior subcutaneous transposition does not correlate with postoperative clinical findings. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Stabilized Subcutaneous Ulnar Nerve Transposition with Immediate Range of Motion

Anterior transposition of the ulnar nerve at the elbow produces generally good results regardless of whether the nerve is transposed subcutaneously, intramuscularly, or submuscularly. The eventual recovery of nerve function is related less to the specific surgical technique than to the severity of the intrinsic nerve pathology. A primary variable in surgical management is the duration of postoperative elbow immobilization. The purpose of this study was to review the longterm results of a specific technique of subcutaneous anterior transposition of the ulnar nerve that utilizes a stabilizing fasciodermal sling. The study compared the results of immediate and late institution of a range of motion postoperatively. Forty-seven patients with fifty-one elbows were reexamined, by an investigator who had not been involved in their treatment, at a minimum of two years (range, twenty-four months to fourteen years) after an anterior transposition. Of the fifty-one elbows, twenty-one were immobilized for two to three weeks whereas thirty were managed with an immediate range of motion. At the latest follow-up evaluation, there were occasional, mild paresthesias in 16 percent of the limbs and there was still subjective weakness of 19 percent. Both pinch and grip strength had increased substantially. No patient had lost elbow motion. A positive Tinel sign persisted in 31 percent of the limbs, but it was mildly positive in most of them. The elbow flexion test was uniformly negative. The results for 92 percent of the limbs were satisfactory to the patients, who stated that they would undergo the same procedure again if necessary. Overall, 73 percent of the limbs had an excellent result; 18 percent, a good result; 4 percent, a fair result; and 6 percent, a poor result. With the numbers available, no significant difference could be detected, with regard to these outcomes, between the group managed with elbow immobilization and that managed with immediate elbow mobilization. However, patients treated with a postoperative cast returned to work at an average of thirty days after surgery whereas the group treated with immediate motion of the elbow returned to work at an average of ten days. This technique of stabilized subcutaneous anterior transposition of the ulnar nerve yielded predictably good results for a wide spectrum of patients. Patients returned to their occupation sooner when the elbow had been mobilized immediately.

Ulnar Nerve Elongation and Excursion in the Cubital Tunnel After Decompression and Anterior Transposition

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.

Ulnar nerve elongation and excursion in the cubital tunnel after decompression and anterior transposition

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.

Cubital Tunnel Syndrome: A Retrospective Review of 53 Anterior Subcutaneous Transpositions

Fifty-three cases of cubital tunnel syndrome were treated by anterior subcutaneous transposition of the ulnar nerve. All patients were assessed by an independent examiner at a mean follow-up of 32 months. McGowan’s rating scale, as modified by Goldberg, was used preoperatively and at follow-up. Preoperatively, five cases were classified grade I, 37 grade IIA, eight grade IIB and three grade III. Thoracic outlet syndrome was also present in 7 cases. At follow-up, 44 cases were grade 0, three grade I, five grade IIA and one grade IIB. Forty-four of the 53 cases had resolved and the other nine had improved. Subcutaneous transposition is a reliable and effective surgical option. The result is less satisfactory if a thoracic outlet syndrome is also present.

Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome.

The current literature universally suggests that submuscular anterior transposition is the standard operative treatment for recurrent cubital tunnel syndrome. Regardless of the type of initial failed procedure, including submuscular transposition, 20 patients underwent anterior subcutaneous transposition of the ulnar nerve. All patients were monitored for a minimum of 2 years after surgery. The most common sites of compression were the medial intermuscular septum and the flexor-pronator aponeurosis. Fifteen patients had a good or excellent outcome; 5 patients had a fair or poor outcome. Relief of pain and paresthesias were the most consistent favorable results. Fair and poor outcomes were significantly associated with increasing age and the number of previous surgeries. Subcutaneous anterior transposition of the ulnar nerve proved to be an effective treatment for recurrent cubital tunnel syndrome.

Rehabilitation after subcutaneous transposition of the ulnar nerve: Immediate versus delayed mobilization

We studied 36 patients who had clinical signs and symptoms consistent with cubital tunnel syndrome and in whom nonoperative management failed. These patients underwent anterior subcutaneous transposition of the ulnar nerve followed by either immediate (20 patients) or delayed (16 patients) mobilization. All patients were evaluated with an outcomes assessment questionnaire, and 35 of the 36 were given repeat physical examinations. After surgery, there were no significant differences between the two groups in pain relief, weakness, or patient satisfaction (71% of the immediate mobilization group and 74% of the delayed group) were satisfied. Secondary quantitative outcomes such as grip strength, lateral pinch, or two-point discrimination were also not significantly different between the groups. Both groups had a statistically significant improvement in first dorsal interosseous and adductor pollicis muscle strength. In the immediate mobilization group, however, patients returned to work and resumed activities of daily living earlier (median 1 month) than patients in the delayed mobilization group (median 2.75 months). Therefore, we conclude that anterior subcutaneous transposition provides a high degree of satisfaction and relief of symptoms regardless of when mobilization is initiated. However, immediately mobilizing the patient significantly influenced how early the patient returned to work and resumed activities of daily living.

SUBMUSCULAR TRANSPOSITION OF THE ULNAR NERVE

Anterior submuscular transposition by the Learmonth technique is more demanding technically than other procedures described to treat cubital tunnel syndrome. I generally reserve submuscular transposition for patients who have failed previous anterior subcutaneous transposition and those who are very thin, in which case the nerve may be prominent immediately beneath the skin, resulting in an area of uncomfortable sensitivity. In patients who are candidates for reoperation following failed anterior submuscular transposition, it is common to find an area of compression that was not released during the initial operation. Most importantly, failure to release the arcade of Struthers, the arcuate ligament, and the flexor carpi ulnaris muscle fascia; excise the medial intermuscular septum; or provide ample room for the ulnar nerve beneath the flexor-pronator muscles will result in failure of surgical treatment. Range-of-motion exercises and hand strengthening facilitate early return of function.

Tardy ulnar nerve palsy caused by cubitus varus deformity

Fifteen patients with tardy ulnar nerve palsy caused by cubitus varus deformity were studied. All patients had a history of previous fracture of the humerus during childhood. The mean interval between fracture and onset of symptoms was 15 years. The severity of the palsy was classified as McGowan's grade I in 12 patients, grade II in 2 patients, and grade III in 1 patient. The mean carrying angle was -2 degrees before surgery. X-ray films showed a shallow ulnar nerve groove, a dysplastic humeral trochlea, medial shift of the ulna, and deformity of the medial epicondyle. The ulnar nerve was explored in all but one patient. Operative findings suggested that the main cause of the palsy was compression by a fibrous band running between the two heads of flexor carpi ulnaris. Surgical steps included release of the fibrous band in 14 patients with anterior subcutaneous transposition of the ulnar nerve in 5 of those patients. A corrective osteotomy was done in 11 patients who requested correction of the varus deformity. Traumatic cubitus varus deformity should be recognized as another cause of cubital tunnel syndrome.

INTERCONDYLAR FRACTURES OF THE DISTAL HUMERUS

Intercondylar fractures of the distal humerus in adults are rare and notoriously difficult to treat. The goals of open reduction are to preserve the articular surface and restore elbow function. We treated 20 patients by open reduction with dual-plate internal fixation and routine anterior subcutaneous transposition of the ulnar nerve. The follow-up period ranged from 15 to 35 months. The fractures were classified according to Muller's system. The results were evaluated using the Cassebaum rating system and subjective functional status. Excellent or good results were achieved in 15 elbows (75%), two had a fair result, and three, poor. A clearer understanding of fracture patterns, rigid dual-plate internal fixation, and early rehabilitation are needed to improve the results from this vexing injury. We recommended routine ulnar nerve anterior subcutaneous transposition using a posterior approach. Compared with published reports, our preliminary results demonstrated no postoperative ulnar nerve compression syndrome at follow-up. Routine anterior subcutaneous transposition of the ulnar nerve to avoid the postoperative ulnar nerve compression syndrome is required.

肘部管症候群の治療成績 皮下前方移動術とＫＩＮＧ変法について

From 1978 to 1991, we treated 77 patients with cubital tunnel syndrome using either an anterior subcutaneous transposition or a modified King's method. 34 patients with 34 cubital tunnel syndromes were followed-up for more than 1 year. Their preoperative stages were graded by Akahori's system from stages I to V. Nerve conduction studies were performed on all the patients at follow-up. The patients' postoperative recoveries were evaluated by Akahori's post-operative stages, which were classified into 4 categories from excellent to poor.All the cases, whose preoperative stages were I to III, were graded excellent but none of the patients with a preoperative stage V had recovered to a better stage than good at follow up, regardless of the surgical procedure or the duration of numbness of the ulnar nerve distribution. The preoperative stage of cubital tunnel syndrome showed a significant correlation with the prognosis, that is, the better the preoperative stage promised to be the better the post operative recovery was. However, the duration of numbness which we thought would correlate well with the severity of the disease did not correlate with the post operative recovery. Numbness is a subjective sign and there may be differences in how individuales feel the numbness threshold.We would like to conclude from this clinical reseach that the most important factor which affects the prognosis is the preoperative stage.

Syndrome de compression chronique du nerf cubital au niveau du coude A propos de 74 cas

Seventy-four patients were operated at Bichat hospital for chronic ulnar nerve entrapment at the elbow between 1982 and 1988. For 62 of them, the etiology of the compression was idiopathic and these cases were treated by neurolysis only or, if the nerve was unstable, by neurolysis associated with medial epicondylectomy. For 12 of them, the etiology of the compression was post-traumatic and these cases were treated by anterior subcutaneous transposition of the nerve using a fat sling. The average follow-up is 28 months and the results take into account the clinical preoperative grading according Mac Gowan's classification: grade I subjective symptoms combined with hypoesthesia in ulnar fingers grade II: weakness and wasting of the interossei combined with subjective symptoms, grade III: marked weakness and wasting of the interossei, adductor pollicis, and hypothenar muscles combined with anesthesia in ulnar fingers. The 62 idiopathic compressions treated by neurolysis only or, if the nerve was unstable, by neurolysis associated with medial epicondylectomy showed 51 very good and good results. The 12 post-traumatic compressions treated by anterior subcutaneous transposition of the nerve using a fat sling showed 9 very good and good results. The authors stress the importance of their approach which takes account of the clinical preoperative grading and the etiology of the compression in order to apply correct surgical treatment.

The postoperative rehabilitation of the Learmonth submuscular transposition of the ulnar nerve at the elbow

Compression of the ulnar nerve at the elbow, cubital tunnel syndrome, is a frequent compressive neuropathy of the upper extremity. Surgical treatment is recommended when conservative treatment fails to control pain and paresthesias or when there is evidence of muscle weakness.Simple decompression in situ, medial epicondylectomy, anterior subcutaneous transposition, intramuscular transposition, and the submuscular transposition as described by Learmonth have all been recommended as the surgical treatment for cubital tunnel syndrome. The Learmonth procedure is the most technically demanding of these procedures. Published literature regarding the rehabilitation after this procedure is scarce. This paper presents a rehabilitation protocol that was used in 25 consecutive patients treated by submuscular transposition.

The treatment of the cubital tunnel syndrome

Treatment by in situ release, submuscular transposition, and anterior subcutaneous transposition have all been reported to produce satisfactory results for ulnar neuropathy secondary to the cubital tunnel syndrome. A prospective study was done to determine which preoperative clinical and electrical factors and surgical approaches in patients with ulnar nerve palsy at the elbow had the best results. The 32 patients had an average age of 50 years, had symptoms for an average of 15 months before surgery, and underwent postoperative follow-up for an average of 13 months. All patients with good results had no atrophy or preoperative fibrillations in the intrinsic muscles and had an obtainable evoked sensory potential. The change in motor conduction velocity did not correlate with good results. There was no significant difference in the results of the three surgical procedures. Eight of the 37 operations yielded good results, 19 patients showed an improvement, but 10 of the operations yielded poor results. Our results also indicated that surgical results could be predicted by proper patient selection through the assessment of the preoperative physical examination and electromyogram.

Factors related to the outcome of surgically managed compressive ulnar neuropathy at the elbow level

Forty-eight of 59 patients who had undergone initial and no secondary treatment of compressive ulnar neuropathy at the level of the elbow during the period of January, 1968, to December, 1977, were reviewed by personal follow-up examination. Cubital tunnel decompression and anterior subcutaneous transposition of the ulnar nerve gave equal results as to the relief of pain and dysesthesia. However, anterior subcutaneous transposition gave better total relief of paresthesias and better return of intrinsic muscle function than did cubital tunnel decompression. Submuscular transposition was not evaluated in this study. The presence of intraoperative intraneural fibrosis or preoperative intrinsic muscle weakness were factors associated with a poor result. Prolonged duration of symptoms and advanced age were relative factors associated with a poor outcome. The presence of preoperative pain, paresthesias, or a widened two-point discrimination had no association with the eventual outcome.