Anterior Submuscular Transposition Research Articles

Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome—a prospective study

In order to assess their late benefits we present the long-term results of a comparison of treating cubital tunnel syndrome with anterior submuscular transposition or simple decompression. Of 40 patients initially recruited to this study 33 were available for long term follow-up. Sixteen patients underwent anterior submuscular transposition (group A); simple decompression was performed in 17 of the patients (group B). The indications for inclusion were a typical clinical presentation confirmed by abnormal nerve conduction studies. The mean duration of the symptoms before operation was 13 months (range 2 to 84 months) in group A and 8.4 months (range 1.5 to 36 months) in group B. All patients were seen 2 months after surgery and at least 3 years later. The mean duration of follow-up was 63.1 month in the first group and 52 months in the second group. No complications were seen in either group. In the group treated by anterior transposition, ten of 16 patients were completely free of signs and symptoms; slight residual hypesthesia or paresthesia was observed in two patients. Paresis and atrophy was observed in only one person. In the simple decompression group, 11 of 17 patients were completely free of signs and symptoms. In five patients slight residual symptoms were observed; no paresis or atrophy was reported in any of this group. These long-term results show that both surgical techniques have a good outcome. Thus, the less invasive simple decompression should be preferred.

The surgical treatment of cubital tunnel syndrome: a decision analysis

The objective of our study was to use decision analysis to compare four common surgical treatments for cubital tunnel syndrome: simple decompression of the cubital tunnel, medial epicondylectomy, anterior subcutaneous transposition and anterior submuscular transposition. The variables used for this decision analysis model were based on data from the literature. Extensive sensitivity analyses were carried out to test the impact of the values given to these variables on the outcome of the model. The highest expected utility, 0.973, was associated with simple decompression. The expected utility was 0.969 for subcutaneous transposition and 0.965 for submuscular transposition. Medial epicondylectomy had the lowest expected utility at 0.961. Simple decompression remained the preferred strategy in extensive one-way sensitivity analyses.

Effective Surgical Treatment of Cubital Tunnel Syndrome Based on Provocative Clinical Testing without Electrodiagnostics

This study evaluated the effectiveness of identifying surgically correctable ulnar nerve compression at the elbow based on provocative clinical testing alone in patients with cubital tunnel syndrome after failure of conservative treatment. Twenty-four patients were included in the study (mean age, 60 years). Three patients underwent bilateral procedures. Patients complaining of symptoms in the distribution of the ulnar nerve were tested by elicitation of Tinel's sign and combined flexion and pressure testing at the elbow and wrist. Two-point discrimination was determined. After a failed 6-week trial of conservative therapy patients underwent anterior submuscular transposition of the ulnar nerve with carpal tunnel release. Postoperatively, the change in two-point discrimination as measured at 6 months was significantly improved, with a mean improvement per digital nerve of 2.52 mm (p<0.001). Mean time to relief was 7.2 weeks. Complications included one hematoma and one seroma. A total of 26 of the 27 limbs chosen for surgical treatment by provocative clinical testing alone experienced relief of symptoms with anterior submuscular transposition of the ulnar nerve and carpal tunnel release. This study demonstrates the effectiveness of surgical therapy in patients with lesions identified by clinical examination without electrodiagnostic testing.

Anterior Submuscular Transposition of the Ulnar Nerve

Though the literature is unclear, ulnar nerve anterior submuscular transposition has a role in the surgical treatment of cubital tunnel syndrome in the primary and revision setting. Along with the submuscular transposition technique, this article reviews some of the history of cubital tunnel syndrome treatment, the strengths and criticisms of each of the procedures, and the literature as of 2006 in terms of treatment guidelines.

Effective Surgical Treatment of Cubital Tunnel Syndrome Based on Provocative Clinical Testing without Electrodiagnostics

After studying this article, the participant should be able to: 1. Describe a method of clinical evaluation for accurate diagnosis of ulnar compression syndrome at the elbow. 2. Evaluate the accuracy and efficacy of the described method in diagnosing surgically correctable nerve entrapment. 3. Present a protocol for conservative management followed by surgical correction. 4. Discuss the results of the method and protocol in two series of patients treated by a single surgeon. This study of two patient populations addresses the effectiveness of identifying surgically correctable ulnar nerve compression at the elbow based on provocative clinical testing alone in patients with cubital tunnel syndrome after failure of conservative treatment. Twenty-four patients were included in the preliminary study (mean age, 60 years). Three of these patients underwent bilateral procedures. Patients complaining of symptoms in the distribution of the ulnar nerve were tested by elicitation of Tinel's sign and combined flexion and pressure testing at the elbow and wrist. Two-point discrimination was determined. After a failed 6-week trial of conservative therapy, patients underwent anterior submuscular transposition of the ulnar nerve with carpal tunnel release. Postoperatively, the change in two-point discrimination as measured at 6 months was significantly improved, with a mean improvement per digital nerve of 2.52 mm (p < 0.001). Mean time to relief was 7.2 weeks. Complications included one hematoma and one seroma. A total of 26 of the 27 limbs chosen for surgical treatment by provocative clinical testing alone experienced relief of symptoms with anterior submuscular transposition of the ulnar nerve and carpal tunnel release. This study demonstrates the effectiveness of surgical therapy in patients with lesions identified by clinical examination without electrodiagnostic testing. After the completion of this study, an additional 87 patients were treated (18 bilateral) with cubital tunnel release. The data from these patients confirm the effectiveness of surgical treatment of ulnar entrapment neuropathy based on provocative clinical testing.

Simple neurolysis for failed anterior submuscular transposition of the ulnar nerve at the elbow

From 1996 to 2000, we reoperated nine patients totally dissatisfied after previous surgery for cubital tunnel syndrome. All patients had simple external neurolysis in situ of the transposed ulnar nerve. Only the anterior aspect of the ulnar nerve was dissected and released. Dense scarring around the ulnar nerve was found to be the main cause of recurrence but could not explain the three initial cases of persistent symptoms. All patients were reviewed 2 years after the secondary neurolysis. The patients were asked to describe their remaining symptoms and examination included palpation of the ulnar nerve at the elbow, Tinel's sign, two-point discrimination, and palpation of the scar. Pinch and grip strength were measured. According to the Wilson and Krout classification, there were four good results with complete alleviation of symptoms, four fair results, and one poor result. Simple neurolysis proved to be effective after failed anterior submuscular transposition of the ulnar nerve at the elbow.

Operative Treatment of Cubital Tunnel Syndrome: A Comparison of Medial Epicondylectomy and Anterior Transposition of the Ulnar Nerves

Purpose : The aim of this study was to compare the results of medial epicondylectomy and anterior submuscular transposition of the ulnar nerve in patients with primary cubital tunnel syndrome. Materials and Methods : Thirty patients with primary cubital tunnel syndrome formed the basis of this study. Eighteen patients underwent medial epicondylectomy and twelve patients underwent anterior submuscular transposition of the ulnar nerve. The mean follow-up period was 35 months. Postoperative clinical results were assessed using Gabel and Amadio's rating scale which evaluats pain, sensory and motor function in four grades. Clinical results were compared between two groups in McGowan grades two and three. Results : Two excellent, twelve good and six fair results were obtained in patients with McGowan grade II. In McGowan grade III, three were good, six fair and one was poor. No significant difference in the results was observed between two surgical groups. Conclusion : Medial epicondylectomy and anterior submuscular transposition of the ulnar nerve showed no difference in results between patients with primary cubital tunnel syndrome. It seems that medial epicondylectomy is more appropriate because of its simplicity during operation and in terms of postoperative management.

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.

Effective Surgical Treatment of Cubital Tunnel Syndrome Based on Provocative Clinical Testing without Electrodiagnostics

Learning Objectives: After studying this article, the participant should be able to: 1. Describe a method of clinical evaluation for accurate diagnosis of ulnar compression syndrome at the elbow. 2. Evaluate the accuracy and efficacy of the described method in diagnosing surgically correctable nerve entrapment. 3. Present a protocol for conservative management followed by surgical correction. 4. Discuss results of the method and protocol in a series of 24 patients operated on by a single surgeon with a minimum of 6 months of follow-up. This study evaluated the effectiveness of identifying surgically correctable ulnar nerve compression at the elbow based on provocative clinical testing alone in patients with cubital tunnel syndrome after failure of conservative treatment. Twenty-four patients were included in the study (mean age, 60 years). Three patients underwent bilateral procedures. Patients complaining of symptoms in the distribution of the ulnar nerve were tested by elicitation of Tinel's sign and combined flexion and pressure testing at the elbow and wrist. Two-point discrimination was determined. After a failed 6-week trial of conservative therapy patients underwent anterior submuscular transposition of the ulnar nerve with carpal tunnel release. Postoperatively, the change in two-point discrimination as measured at 6 months was significantly improved, with a mean improvement per digital nerve of 2.52 mm (p < 0.001). Mean time to relief was 7.2 weeks. Complications included one hematoma and one seroma. A total of 26 of the 27 limbs chosen for surgical treatment by provocative clinical testing alone experienced relief of symptoms with anterior submuscular transposition of the ulnar nerve and carpal tunnel release. This study demonstrates the effectiveness of surgical therapy in patients with lesions identified by clinical examination without electrodiagnostic testing. (Plast. Reconstr. Surg. 104: 215, 1999.)

Postoperative Drainage Is Recommended in Ulnar Nerve Transposition

EG Deune, SE Mackinnon. Postoperative drainage is recommended in ulnar nerve transposition. Can J Plastic Surg 1998;6(4):201-203. Surgery to transpose the ulnar nerve is a common treatment for cubital tunnel syndrome. Postoperative hematoma is a rare, but well recognized complication of this surgery, whereas postoperative bruising is a common sequela. A retrospective review of 138 cases of anterior submuscular transposition performed between December 1991 and December 1995 was conducted to evaluate the merits of postoperative drainage. Various parameters (patient, surgical, and anesthetic) were compared to determine their effect on drainage. Males had a higher postoperative drainage volume than females (P&lt;0.0001). Other patient, surgical and anesthetic factors did not correlate significantly with the drainage volume. The mean drainage during the first postoperative day was 41.2±2.5 mL (range 3 mL to 190 mL). This volume is significant and warrants drainage with an indwelling catheter when anterior submuscular transposition of the ulnar nerve is performed.

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.

Surgical treatment of the ulnar nerve entrapment neuropathy : submuscular anterior transposition or simple decompression of the ulnar nerve ?: Long-term results in 79 cases

The surgical treatment of the ulnar nerve entrapment neuropathy at the elbow is controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy, subcutaneous or submuscular anterior transposition of the ulnar nerve) has proven optimal regarding long-term results. We studied the outcome in 79 patients whose ulnar nerve had been operated on for the first time, either by simple decompression (31 cases) or by submuscular anterior transposition (48 cases). The mean follow-up was 76 months. Patients were classified according to McGowan pre- and postoperatively; we also applied a more detailed scoring system of our own. Preoperatively, the patients were distributed almost equally between the three McGowan classes. Postoperatively, about one out of three patients in both treatment groups experienced a distinct improvement, i.e. was upgraded to a better McGowan class. Using our own scoring system, the overall rate of objective improvement was 73% after transposition and 55% after simple decompression. Irrespective of the surgical method, roughly 90% of the patients considered their postoperative condition to be improved. However, one specific group of patients (people with habitual ulnar luxation or subluxation of the ulnar nerve) experienced a distinctly better result when treated by anterior transposition than by simple decompression. Our results show that simple decompression of the ulnar nerve can be recommended in all patients without cubital (sub)luxation of the nerve, whereas people with a tendency of cubital (sub)luxation of the ulnar nerve should be treated by submuscular anterior transposition.

Cubital tunnel syndrome

The tremendous forces generated by the upper extremity during throwing places the athlete at risk for developingvalgus tension injuries to the medial aspect of the elbow. Cubital tunnel syndrome, or ulnar neuritis, represents one component of a spectrum of medial elbow pathology that can affect the throwing athlete. This article reviews the pertinent anatomy, pathophysiology, clinical presentation, and surgical treatment for this condition. When nonoperative management fails, anterior submuscular transposition of the ulnar nerve deep to the flexor muscle group provides adequate protection from the trauma that occurs during athletic activity.

Anterior submuscular transposition of the ulnar nerve for cubital tunnel syndrome

48 patients with 50 involved limbs were retrospectively analyzed to determine factors influencing the outcome of surgical treatment for cubital tunnel syndrome. All patients were treated by anterior submuscular transposition of the ulnar nerve with Z-lengthening of the flexor-pronator origin. There were 24 men and 24 women with an average age of 42 years +/- 16.4 years (range, 5-75 years). The average follow-up time was 58 months (range, 12-156 months). A grading system was used pre- and post-operatively based on the severity of subjective complaints and objective findings. 92% of the patients were satisfied, or satisfied with some reservations, and only 8% were dissatisfied. All patients had either fair or poor pre-operative grades. 84% had excellent or good post-operative grades and only 16% had fair grades. There were no recurrences or poor post-operative grades in our series. Workers' compensation status had no statistically significant adverse effect on post-operative patient satisfaction or post-operative grade. Anterior submuscular transposition of the ulnar nerve in this series provided satisfactory subjective outcome, relief of symptoms and adequate decompression of the ulnar nerve at the elbow.

Bilateral Snapping Triceps Tendon After Bilateral Ulnar Nerve Transposition for Ulnar Nerve Subluxation

Reports of subluxation of the medial head of the triceps tendon over the medial epicondyle are rare. This may be associated with symptomatic ulnar nerve compression at the elbow. We report a case of bilateral snapping triceps tendon after bilateral ulnar nerve release at the elbow with anterior submuscular transposition. Careful inspection of the triceps tendon in flexion and extension at the time of the ulnar nerve submuscular transposition may prevent this potential complication.

Techniques for Successful Management of Ulnar Nerve Entrapment at the Elbow

The etiology, diagnosis, and pathophysiology of ulnar nerve entrapment at the elbow are reviewed briefly. This article describes the author's surgical technique and discusses the methods used to ensure predictable results with his approach to anterior submuscular transposition. Applications of the technique in both initial and recurrent ulnar nerve entrapment are included.

Recurrent Anterior Dislocation of the Ulnar Nerve at the Cubital Tunnel

Recurrent anterior dislocation of the ulnar nerve at the cubital tunnel is reported in two patients. This was due to traumatic attenuation of the flexor carpi ulnaris retinaculum. The mechanism of injury in both patients was a fall with the shoulder abducted and the elbow acutely flexed. Both patients had relief of their neurologic symptoms following anterior submuscular transposition of the ulnar nerve.

Review of treatment results for ulnar nerve entrapment at the elbow

A review of 50 published reports between 1898 and 1988, comprising more than 2000 patients treated for ulnar nerve compression at the elbow, demonstrated that little more than personal bias is available for guidance in selecting treatment. To provide uniform data, the degree of nerve compression of the patients from these articles was staged using a sensory plus motor classification based on contemporary concepts of the pathophysiology of chronic nerve compression. The results of these studies are reinterpreted in light of this staging system. This analysis suggests that for a minimal degree of compression, excellent results can be achieved in 50% of the patients by nonoperative techniques and in almost 100% of patients by any of five surgical techniques. For a moderate degree of compression, the anterior submuscular technique yields the most excellent results with the fewest recurrences. For a severe degree of compression, the anterior intramuscular transposition yielded the fewest excellent and the most recurrent results. This review suggests that an internal neurolysis, combined with an anterior submuscular transposition, may be the best approach when the ulnar nerve is severely compressed.

Anterior submuscular transposition of the ulnar nerves by the Learmonth technique

Thirty-eight patients with progressive posttraumatic ulnar neuropathy at the elbow underwent anterior submuscular transposition of their nerves. Multiple mechanical causes of neuropathy were identified. Fourteen patients had undergone previous surgery for ulnar neuropathy, while 24 had not. Postsurgical follow-up averaged 23.1 months. The operative technique is described and illustrated in detail. Complications attributable to surgery were minimal. No absolute prognostic factors could be identified, and even those patients with significant muscular atrophy or time delay before operation were generally benefited. If prior surgery had induced significant scarring and neural damage, the prognosis for recovery was considerably worse, as it also was for patients who had severe preoperative dysesthesia or pain. Four patients thought to represent examples of double crush or compression syndrome were identified.