Anterior Transposition Research Articles

Investigating the Overaction of the Inferior Oblique Muscle and Associated Vertical Strabismus: Indications, Timing, and Methods of Surgical Intervention

Treatment of the vertical strabismus due to the overaction of the inferior oblique extraocular muscle usually requires surgical intervention. In addition to the cosmetic issues, the main indications for surgical treatment of the inferior oblique overaction are the presence of cyclotropia and torsional diplopia. Most procedures target the weakening of the inferior oblique muscle; however, there is the risk of some intraoperative and postoperative complications, including highly invasive procedures, difficulty of technical implementation because of the need for manipulations in inaccessible locations of the globe near the optic nerve, macular area, and large vessels, long duration of the surgery, inability to determine the dosage of the outcomes of the surgery, and poor functional outcomes. Most complications are absent in the procedure of anterior transposition in which the neuro-fibrovascular bundle serves as the axis of rotation of the inferior oblique muscle. This technique changes the inferior oblique muscle’s action field and increases treatment effectiveness. Despite the advantages of this technique, its application is still limited because of the lack of methods for controlling the amount of anterior transposition to treat inferior oblique overaction, particularly of small degrees.

Is anterior transposition of the ulnar nerve necessary for post-traumatic elbow stiffness? A retrospective study

ObjectiveTo explore whether anterior transposition of the ulnar nerve is necessary in patients with post-traumatic elbow stiffness.MethodThis was a retrospective study of 177 patients with post-traumatic elbow stiffness treated at Shandong Provincial Hospital from 1 January 2012 to 31 October 2022. Sixty-one patients presented with ulnar nerve symptoms, and 116 patients had no nerve symptoms. Outcomes between patients with and without symptoms were compared using a range of clinical measures, namely range of motion (ROM), ulnar nerve symptoms, and various standardized scoring systems, namely, the Mayo Elbow Performance Score (MEPS), visual analog scale (VAS), improved Broberg and Morrey Score (BMS), Quick disabilities of the Arm, Shoulder, and Hand (DASH) score, Oxford Elbow Score (OES), and Amadio score.ResultsOpen elbow release surgery significantly improved elbow joint function in patients with post-traumatic elbow stiffness, regardless of the presence of ulnar nerve symptoms. Patients with ulnar nerve symptoms showed significant improvement after anterior transposition compared with in situ release. For patients without ulnar nerve symptoms, there was no significant difference in outcomes between the two types of ulnar nerve surgery.ConclusionAnterior transposition of the ulnar nerve is preferable for patients with ulnar nerve symptoms, while the choice between anterior transposition and in situ release can be individualized for patients without symptoms, based on intraoperative findings.

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.

Anterior Nasal Superior Oblique Tendon Syndrome: A Case Series

PurposeTo evaluate the clinical characteristics and management of patients with an anteriorly and nasally inserted superior oblique tendon. DesignRetrospective interventional case series. MethodsInstitutional clinical records between 2020 and 2024 were retrospectively reviewed for 9 consecutive patients in whom the superior oblique (SO) tendon was inserted anterior to the equator and nasal to the superior rectus muscle. Information collected included age, sex, ocular and surgical history, preoperative and postoperative data (ophthalmologic examinations, strabismus measurements, ductions and versions), intraoperative findings, need for additional surgery, and follow-up time. ResultsAll nine patients were found to have an anomalous insertion of the SO tendon. Three were of congenital origin and six were acquired following ocular surgery. Among the acquired cases, all but one resulted from incarceration of the tendon from post-surgical scar tissue formation. The remaining acquired case was due to a prior deliberate anterior and nasal transposition of the superior oblique. This case series demonstrated varying degrees of vertical deviations, lateral incomitance, and limited depression. Repositioning the SO to its normal insertion site yielded equivocal improvement in ocular alignment. ConclusionAnterior nasal superior oblique tendon syndrome is a rare clinical entity characterized by an anti-depressor effect. Vertical deviations, hypertropia worse in downgaze, limited depression worse in adduction for congenital cases and in abduction for acquired cases, and lateral incomitance may be indicative of this anomaly. In acquired cases following surgery, additional findings may include limited depression worse in abduction, esotropia in abduction, V-pattern esotropia, and enophthalmos in downgaze. Surgical repositioning of the SO along its normal anatomical trajectory is recommended for treatment. However, outcomes may be variable and achieving a complete resolution of this syndrome can be challenging.

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.

One- vs Two- vertical muscle surgery in the management of unilateral superior oblique muscle palsy with hypertropia over 20 PD

ABSTRACT Purpose: To compare the surgical outcomes of One- versus Two-vertical muscle surgery in patients with unilateral superior oblique muscle palsy (SOP) with primary position hypertropia (HT) over 20 PD. Patients in Group 1 underwent inferior oblique anterior transposition plus resection (IOATR), while patients in Group 2 underwent inferior oblique anterior transposition (IOAT) along with contralateral inferior rectus (IR) recession. Methods: Medical data of all SOP patients treated by either procedure from 2000 to 2023 in our strabismus center were recruited. We compared surgical outcomes between Group 1 and Group 2 by analyzing HT correction, rate of under-correction, and over-correction. Results: The study included 33 patients in Group 1 and 23 in Group 2. Both groups were similar in age, sex, etiology, affected side, diplopia, and head tilt. Group 2 achieved higher HT correction in all measured gazes. Group 1 had a higher risk of under-correction (18.18% in Group 1 vs 8.69% in Group 2) while Group 2 had a higher rate of over-correction (21.73% vs 0% in Group 1). Conclusion: In patients with severe unilateral SOP, Two-vertical muscle surgery achieved higher amounts of HT correction in all gazes despite a significantly higher risk of over-correction.

Effect of Tourniquet-Related Nerve Ischemia on Response to Handheld Nerve Stimulation in Ulnar Nerve Transposition.

Tourniquet-related nerve ischemia has been well studied in several reconstructive procedures, but the time-course of impaired response to intraoperative stimulation is unclear. The present study evaluated ischemic effects on conduction during ulnar nerve transposition and examined the relationship between intra- and pre- operative diagnostics. We hypothesized that intraoperative ischemia would have minimal impact on conduction. Thirty patients scheduled for anterior transposition were enrolled after preoperative examination, electrodiagnostic testing, and ultrasound. Demographic and symptom severity data were recorded. A handheld biphasic nerve stimulator was used intraoperatively to assess minimum amplitude and pulse duration needed for muscle response. Measurements were taken at 15-minute intervals after placement. Changes in threshold amplitude and pulse duration were calculated between each 15-minute interval; no significant difference was found in the change of either value (p = 0.70 and 0.178). A weak negative correlation existed between preoperative CMAP amplitudes and average intraoperative pulse duration, which increased to a moderate correlation when compared to 45-minute pulse duration (r=-0.62, p<0.01). Preoperative ulnar nerve cross-sectional area (CSA) demonstrated no significant correlation with average pulse duration but a moderate correlation with pulse duration at 45 minutes (r=0.63, p=0.01). Tourniquet use did not prevent effective intraoperative stimulation of the ulnar nerve for at least 45 minutes. The window for meaningful stimulation with tourniquet usage appears to be greater than previously thought. Preoperative nerve CMAP amplitude and CSA does appear to influence pulse duration required after 45 minutes of ischemia, suggesting that injured nerves are more susceptible to ischemia. 1.

Intra-operative subperiosteal elevation of the ulnar nerve is a safe and effective way to minimize post-operative ulnar neuritis in distal humerus fractures.

To describe subperiosteal elevation of the ulnar nerve and compare to anterior transposition and in situ decompression techniques. Design: Retrospective comparative study. Urban Level 1 trauma center. Distal humerus fractures (OTA/AO 13) treated with open reduction internal fixation between 2014-2022. Rate of pre- and post-operative neuritis grouped by management of the ulnar nerve. During subperiosteal elevation, the ulnar nerve was identified and raised off the ulna subperiosteally and mobilized submuscularly anterior to the medial epicondyle to protect the nerve. The nerve was released only laterally off the triceps and the medial soft tissue attachment is maintained. The main outcomes measurements was rate of neuritis documented within physical exam. Within the 125 patients, 35 underwent subperiosteal elevation (mean age of 56 ± 21 years, 57% female), 63 in situ decompression (mean age of 60 ± 18 years, 46% female), and 27 anterior transposition (mean age of 55 ± 20 years, 59% female). Pre-operative ulnar neuritis was present in 34%, 21%, and 33% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively (p=0.26). At post-operative evaluation symptom resolution occurred in 100%, 69%, and 33% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively (p=0.003). New cases of post-operative ulnar neuritis occurred in 6%, 8%, and 26% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively (p=0.054). Subperiosteal elevation outperformed anterior transposition regarding post-operative ulnar neuritis (p=0.019) and symptom resolution (p=0.002) and performed similarly to in situ decompression (p>0.05). On multiple regression analysis, anterior transposition was an independent risk factor for post-operative neuritis (OR=5.2, p=0.023). Subperiosteal elevation is an effective way to minimize post-operative neuritis and similar to an in-situ decompression during distal humerus fracture fixation. Based on the results of this cohort, authors recommended that anterior transposition of the ulnar nerve be used with caution due to association with post-operative ulnar neuritis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Novel Technique for Ulnar Nerve Transposition at the Elbow: The Neocubital Tunnel.

Many standard surgical procedures for cubital tunnel syndrome rely on ulnar nerve transposition at the elbow. Placing the ulnar nerve anterior to the axis of motion decreases compression during flexion. Subcutaneous, subfascial, and submuscular positioning of the ulnar nerve may predispose to nerve irritation, instability, and compression in the two first scenarios, and requires invasive dissection in the third one. With no single procedure demonstrating clear advantages and outcomes, this study reports the results of a novel technique using the epitrochleo-olecranon ligament to create a neo-tunnel, anatomically stabilizing the ulnar nerve. Nine consecutive patients were enrolled. Patients were evaluated qualitatively for symptomatic improvements using physical examination. The Wilson and Krout, modified McGowan, and PRUNE grading scores were used for quantitative measurement. Postoperatively, all patients reported subjective improvement in symptoms and functional improvement. There were no intraoperative or postoperative complications. Baseline severity of disease was evaluated using the McGowan scale (modified by Goldberg): eight (89%) grade IIA patients and one (11%) grade III patient. Postoperatively, seven (78%) patients were reduced to grade 0, and two (22%) patients to grade 1 (P < 0.001). Using the Wilson and Krout criteria, outcomes were as follows: six (67%) excellent, two (22%) good, and one (11%) fair. The mean postoperative PRUNE survey score was 19.3 (SD ± 24.4). The neocubital tunnel technique is a relatively noninvasive, safe surgical alternative that may be considered when an anterior transposition of the ulnar nerve is indicated for surgical decompression of the cubital tunnel.

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.

Surgical treatment of tardy ulnar nerve palsy due to non-neurogenic heterotopic ossification in the elbow.

Heterotopic ossification (HO) is characterized by the formation of pathological bone within the soft tissues. HO predominantly affects elbow joints and may be accompanied by tardy ulnar nerve palsy. This study aimed to explore the clinical and functional outcomes of patients with tardy ulnar nerve palsy caused by HO following surgical treatment, with a review of the relevant literature. A retrospective study was conducted on 4 patients with tardy ulnar nerve palsy caused by HO, who underwent anterior subcutaneous ulnar nerve transposition between 2015 and 2020. The patients were followed up for more than 1 year and the cause of HO was also identified. Clinical and functional outcomes were evaluating using the grip strength and pinch strength, visual analog scale (VAS) pain score and Quick disabilities of the arm, shoulder and hand (DASH) score. The causes of HO were repetitive micro-trauma in 1 case and excessive physical or rehabilitation therapy in 3 cases. The average follow-up period was 15.6 months (range; 12-21 months). The grip strength increased from an average of 14kg to 26.5kg. The pinch strength increased from an average of 1.5 kg to 3.63 kg. The Quick DASH score decreased from an average of 55.6 to 6.15. The VAS score for pain decreased from an average of 7 to 0.25. Rapid surgical treatment, including removal of the heterotopic bone and ulnar nerve anterior transposition, might improve outcomes in patients with tardy ulnar nerve palsy caused by HO.

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.

Anterior transposition of the inferior oblique and anti-elevation syndrome – how far to go?

ABSTRACT Purpose: To study the incidence of postoperative anti-elevation syndrome in relation to the magnitude of anterior transposition of the inferior oblique. Methods: A retrospective chart review was conducted for all patients submitted to anterior transposition of the inferior oblique from 2000 to 2020. Anti-elevation syndrome was defined as limitation of elevation of the abducting eye, resulting in a secondary upshoot of the contralateral adducting eye. Results: A total of 312 eyes of 170 patients were enrolled in the study. The incidence of anti-elevation syndrome was 20.4% when the inferior oblique was positioned 4 mm posterior to the temporal border of the inferior rectus insertion; 23.5% when sutured 2 mm posterior to the temporal border of the inferior rectus insertion and 32.8% when placed at the same level of the inferior rectus insertion with two sutures vertically aligned. When the posterior border of the inferior oblique was horizontally aligned with the anterior border and positioned adjacent to the inferior rectus insertion, in a “J shape” fashion, the incidence of anti-elevation was 41.8%. Conclusions: The anterior transposition of the inferior oblique with “J” deformity increases the risk of anti-elevation syndrome. Additionally, placing the sutures more anteriorly than 2 mm posterior to the inferior rectus insertion increases the incidence of this finding.

Round table discussion: the management of idiopathic cubital tunnel syndrome.

Idiopathic cubital tunnel syndrome is the second most common neuropathy in the upper limb. Best evidence regarding the surgical management of this condition has evolved from anterior or submuscular transposition as the former reference standard, to in situ simple release. Differences of opinion remain regarding the timing of surgery, type of surgery and adjunctive surgery. Four surgeons with Level 5 expertise were asked to answer specific questions regarding this condition.

Evaluating Prescriber Adherence to a Standardized Postoperative Opioid Prescription Protocol for Cubital Tunnel Surgery

Concerns regarding the ongoing opioid epidemic have led to the implementation of standardized postoperative opioid-prescribing protocols for many common hand surgical procedures. This study investigated patient- and procedure-specific factors affecting adherence to a standardized postoperative opioid-prescribing protocol after cubital tunnel surgery. A retrospective review of patients who underwent primary cubital tunnel surgery within one academic medical system between October 1, 2016 (after the implementation of a standardized postoperative opioid-prescribing protocol) and March 1, 2020 was performed. Patients aged <18 years or with a history of revision surgery, prior traumatic ulnar nerve injury, additional concurrent surgical procedures, or a surgeon not participating in the protocol were excluded. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was adherence to the standardized postoperative opioid-prescribing protocol. A bivariate statistical analysis was performed. Ninety-eight patients were included. The median initial postoperative prescription amount was 75 morphine equivalent units (100% of protocol target) for 78 patients (80% of cohort) who underwent in situ decompression and 75 morphine equivalent units (50% of protocol target) for 20 patients (20% of cohort) who underwent decompression with ulnar nerve transposition. Forty-nine percent of initial opioid prescriptions adhered to protocol, compared with 26% below target and 26% above target. In the bivariate analysis, recent opioid prescriptions within 3 months preoperatively were associated with improved prescriber protocol adherence; longer tourniquet time and anterior transposition were associated with prescriptions below target, and in situ decompression was associated with prescriptions above target. Variation in postoperative opioid-prescribing patterns persists despite the implementation of a standardized postoperative opioid-prescribing protocol. Recent opioid prescriptions were associated with protocol adherence, possibly reflecting increased provider vigilance in this patient population. Differing target prescription amounts for in situ decompression versus decompression with anterior transposition may be unnecessary. Therapeutic IV.

Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery.

Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery. A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed. Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions. While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.

A COMPARATIVE STUDY OF MEDIAL EPICONDYLECTOMY VERSUS ANTERIOR TRANSPOSITION IN THE MANAGEMENT OF ULNAR NEUROPATHY, AT ELBOW IN HANSEN’S DISEASE

Objective: The objective of the study is to know the better results after medial epicondylectomy with regards to sensory recovery and patient satisfaction. Methods: We operated on a total of 36 patients of Hansen’s disease suffering from ulnar nerve neuritis at the elbow from 1999 to 2003. They were alternately operated either by epicondylectomy or anterior transposition by the same unit. All these patients had either completed MDT or were on MDT for a minimum of 2 months before surgery. Results: The mean age of the patient was 28.6 years (range 15–45 years). The average follow-up was 3.2 years (range 1–5 years). The male-to-female ratio was 7: 4. The patients who were operated on within 4 months of the onset of symptoms showed a satisfaction rate of 70% as compared to 50% in patients who were operated on after 4 months of the onset of symptoms. Conclusion: Our study showed better results after medial epicondylectomy with regard to sensory recovery and patient satisfaction. There was no statistically significant difference in motor power recovery and post-operative pain, among both procedures none of the procedures had any significant effect on elbow function or stability.

Fundus torsion following inferior oblique muscle weakening

PurposeTo determine the postoperative fundus torsion following surgical inferior oblique (IO) weakening in patients with inferior oblique overaction (IOOA). MethodsIn this interventional case series, 37 patients with IOOA ≥ +1 and reliable preoperative fundus photographs were included. IO weakening was accomplished through myectomy or anterior transposition. Fundus photography was repeated at 3 months’ follow-up. The primary outcome was change of disk foveal angle (DFA), measured as the angle between the line connecting the center of the fovea and optic disk and horizontal. Success or normal fundus torsion was defined as a postoperative angle of 0° to 8° of extorsion. Residual extorsion was defined as postoperative extorsion of > 8°. Postoperative intorsion was defined as any amount of induced intorsion. ResultsMean age of patients (56% females) was 6.46 ± 6.79 years. At follow-up at least 3 months after surgery, the mean change of DFA was 7.79 ± 6.24° of reduction of extorsion after IO myectomy (P < 0.001) and 6.05 ± 6.07° after IO anterior transposition (P = 0.005). Normal fundus torsion was achieved in 50% of patients after myectomy and 36.4% of patients after anterior transposition. Residual extorsion was observed in 49% of patients; induced intorsion in 5%. ConclusionsUsing objective measurement of fundus photographs, fundus extorsion was decreased in 94.7% of patients after myectomy or anterior transposition.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.