Submuscular Transposition Of Ulnar Nerve Research Articles

In Situ Stabilization of the Ulnar Nerve as an Alternative to Transposition in Traumatic Ulnar Nerve Instability: A Case Report.

We present the case of a 25-year-old male sports climber treated with in situ ulnar nerve stabilization for ulnar nerve instability (UNI) by using 2 fascial flaps. Symptomatic UNI has traditionally been managed with subcutaneous or submuscular ulnar nerve transposition. Transposition is relatively invasive and when performed subcutaneously, embeds the ulnar nerve in an exposed location, which may render it prone to mechanical injury in physically active patients. In situ stabilization may be a less invasive alternative to transposition in select patients involved in sports such as rock climbing.

No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis

Background: The most commonly used techniques for elbow ulnar collateral ligament reconstruction (UCLR) are the docking and modified Jobe figure-of-8 techniques. Previous literature has suggested that UCLR with the docking technique is associated with fewer complications; however, these studies included results from the original classic Jobe technique without controlling for the effects of flexor pronator mass (FPM) detachment and routine submuscular ulnar nerve transposition (UNT). Purpose/Hypothesis: This study sought to compare the rates of complications and subsequent unplanned surgical procedures between the docking and figure-of-8 techniques. We hypothesized that there would be no significant difference in the rates of complications or subsequent unplanned surgical procedures between the techniques when the FPM was preserved and no routine submuscular UNT was performed. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A series of mixed-effects multivariate metaregression models were implemented using the restricted maximum likelihood method. Complications and subsequent unplanned surgical procedures were modeled as Freeman-Tukey transformed incidence rates for variance stabilization, and nerve-specific complications were assessed as the Freeman-Tukey transformed proportion of cases, with back-transformation to estimate summary effects. Results: There were 19 studies eligible for qualitative analysis, consisting of 1788 cases of UCLR (303 docking, 1485 figure-of-8), 18 of which were suitable for quantitative analysis (1769 cases; 291 docking, 1478 figure-of-8). A total of 338 complications were reported (17 for docking, 321 for figure-of-8), the majority of which were nerve related. Additionally, a total of 75 subsequent unplanned surgical procedures were related to the index UCLR procedure. There was no significant difference in the rate of complications (P = .146) or proportion of cases with nerve-specific complications (P = .127) between the docking and figure-of-8 techniques when controlling for FPM preservation versus detachment with submuscular UNT. FPM detachment with submuscular UNT was independently associated with a significantly higher proportion of postoperative nerve-related complications (P = .004). There was also no significant difference in the rates of subsequent unplanned surgical procedures between the docking and figure-of-8 techniques (P = .961), although FPM detachment with routine submuscular UNT was independently associated with a significantly higher incidence of subsequent unplanned surgical procedures. Conclusion: The results of this study demonstrate no significant difference in the rates of complications or subsequent unplanned surgical procedures between the figure-of-8 and docking techniques for UCLR when controlling for FPM preservation versus detachment with submuscular UNT. With modern muscle-sparing approaches and avoiding submuscular UNT, the modified Jobe technique does not differ significantly from the docking technique in terms of complication rates, proportions of cases with nerve-specific complications, or rates of subsequent unplanned surgical procedures.

Review of Anterior Submuscular Transposition of Ulnar Nerve for Cubital Tunnel Syndrome

In this study, we report the results of patients who underwent ulnar nerve submuscular anterior transposition surgery due to cubital tunnel syndrome. Data of 46 patients who underwent anterior submuscular transposition surgery due to cubital tunnel syndrome between January 2010 and December 2014 were retrospectively reviewed. Twenty-seven patients with preoperative and postoperative complete medical records available and who had completed at least 24 months follow-up were included in the study. According to preoperative McGovan staging system, 1 patient was classified as stage 1, 8 were stage 2A, 3 were stage 2B, and 15 were stage 3. The mean follow-up time was 61.4 (35-88) months. The mean DASH score of the patients was calculated as 19 (0-81.81). Mayo elbow performance score was excellent in 13 patients, good in 7, fair in 6, and poor in 1. Anterior submuscular transposition of ulnar nerve had resolved symptoms 89% of our patients. The technique is a successful method with a low recurrence and complication rate.

Modified Jobe Versus Docking Technique for Elbow Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis of Clinical Outcomes

Background: The modified Jobe and docking techniques are the most common techniques used for elbow ulnar collateral ligament (UCL) reconstruction. Previous systematic reviews have suggested that the docking technique results in superior outcomes as compared with the Jobe (figure-of-8) technique. However, these included results from earlier studies in which the flexor-pronator mass (FPM) was detached and an obligatory submuscular ulnar nerve transposition was performed. Purpose/Hypothesis: The purpose was to compare the outcomes and return-to-play (RTP) time between the docking and figure-of-8 techniques for UCL reconstruction. We hypothesized that there would be no significant difference in the proportion of excellent outcomes between techniques when the FPM was preserved and no obligatory submuscular ulnar nerve transposition was performed. We also hypothesized that there would be no significant difference in RTP time between techniques. Study Design: Systematic review and meta-analysis. Methods: This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In the primary analysis, techniques were compared in random effects models by using the restricted maximum likelihood method, with weighted effect sizes calculated as the Freeman-Tukey double-arcsine transformed proportion of excellent outcomes for variance stabilization and with summary effects estimated from the inverse double-arcsine transformation per the harmonic mean of the sample sizes. Mean RTP times for techniques were compared in a separate model. Results: There were 21 eligible articles identified, with results for 1842 UCL reconstructions (n = 320, docking; n = 1466, figure-of-8). Without controlling for the effects of flexor-pronator detachment and submuscular ulnar nerve transposition, a significantly larger proportion of excellent outcomes was observed with docking reconstruction (86.58%; 95% CI, 80.42%-91.85%) than with figure-of-8 reconstruction (76.76%; 95% CI, 69.65%-83.25%; P = .031); however, there was no significant difference between techniques when controlling for FPM preservation or detachment with submuscular nerve transposition (P = .139). There was no significant difference between techniques in time to return to sports (P = .729), although no reconstructions with FPM detachment and submuscular ulnar nerve transposition were available for RTP time analysis. Conclusion: There was no significant difference in the proportion of excellent Conway Scale outcomes or RTP time between the docking and modified Jobe techniques for UCL reconstruction when the FPM was preserved and routine submuscular ulnar nerve transposition was not performed.

Submuscular transposition of ulnar nerve in two recurrent cases after surgically treated cubital tunnel syndrome

Submuscular transposition of ulnar nerve in two recurrent cases after surgically treated cubital tunnel syndrome

Subcutaneous versus submuscular ulnar nerve transposition in cubital tunnel syndrome

Introduction There are different surgical procedures for treatment of cubital tunnel syndrome (CubTS), which can be divided into two types, decompression and transposition procedures. Decompressive procedures include simple decompression with or without medial epicondylectomy without mobilizing the nerve. The transposition procedures mobilize the nerve anteriorly for more protection by subcutaneous, intramuscular, and submuscular methods, depending on the position in which the ulnar nerve is placed. Patients and methods A total of 24 patients with moderate CubTS (according to Dellon’s grading system) between March 2011 and April 2013 were classified according to age and sex into anterior subcutaneous transposition and anterior submuscular transposition groups. The two groups were prospectively followed up for 2 weeks, 6 months, and 12 months postoperatively, and outcome was assessed using the Bishop rating system. Results A total of 24 patients with moderate CubTS were used in this study to compare the operative technique (incision length and operative time), postoperative care (postoperative pain and complications), and the outcome between subcutaneous transposition and submuscular transposition of the ulnar nerve as two surgical modalities in treating moderate CubTS. Final results present that the subcutaneous transposition of the ulnar nerve was associated with shorter incision, shorter operative time, less postoperative pain, less postoperative complication, and better outcome compared with the submuscular transposition. Conclusion Subcutaneous ulnar nerve transposition in the treatment of CubTS, as compared with the submuscular approach, is an easier surgical technique with less operative time and postoperative pain, earlier postoperative mobilization, and better postoperative outcome.

Subcutaneous Versus Submuscular Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies.

Subcutaneous and submuscular anterior ulnar nerve transposition have been widely used in patients with cubital tunnel syndrome. However, the reliable evidence in favor of 1 of 2 surgical options on clinical improvement remains controversial.To maximize the value of the available literature, we performed a systematic review and meta-analysis to compare subcutaneous versus submuscular anterior ulnar nerve transposition in patients with ulnar neuropathy at the elbow.PubMed, Cochrane Library, and EMBASE databases were searched for randomized and observational studies that compared subcutaneous transposition with submuscular transposition of ulnar nerve for cubital tunnel syndrome. The primary outcome was clinically relevant improvement in function compared to the baseline. Randomized and observational studies were separately analyzed with relative risks (RRs) and 95% confidence intervals (CIs).Two randomized controlled trials (RCTs) and 7 observational studies, involving 605 patients, were included. Our meta-analysis suggested that no significant differences in the primary outcomes were observed between comparison groups, both in RCT (RR, 1.16; 95% CI 0.68–1.98; P = 0.60; I2 = 81%) and observational studies (RR, 1.01; 95% CI 0.95–1.08; P = 0.69; I2 = 0%). These findings were also consistent with all subgroup analyses for observational studies. In the secondary outcomes, the incidence of adverse events was significantly lower in subcutaneous group than in submuscular group (RR, 0.54; 95% CI 0.33–0.87; P = 0.01; I2 = 0%), whereas subcutaneous transposition failed to reveal more superiority than submuscular transposition in static two-point discrimination (MD, 0.04; 95% CI −0.18–0.25; P = 0.74; I2 = 0%).The available evidence is not adequately powered to identify the best anterior ulnar nerve transposition technique for cubital tunnel syndrome on the basis of clinical outcomes, that is, suggests that subcutaneous and submuscular anterior transposition might be equally effective in terms of postoperative clinical improvement. However, differences in clinical outcomes metrics should be noted, and these findings largely rely on the outcomes data from observational studies that are potentially subject to a high risk of selection bias. Therefore, more high-quality and adequately powered RCTs with standardized clinical outcomes metrics are necessary for proper comparison of these techniques.

The High-Resolution Ultrasonography and Electrophysiological Studies in Nerve Decompression for Ulnar Nerve Entrapment at the Elbow

To discuss a combination of high-resolution ultrasound and electrophysiological examination in diagnosis and evaluation of ulnar nerve entrapment at the elbow. We retrospectively reviewed 20 healthy volunteers and 278 patients of ulnar nerve entrapment divided into three groups by McGowan grade, and we treated patients with subcutaneous or modified submuscular ulnar nerve transposition randomly. All the patients were followed for 2 years. The diagnosis and effects were confirmed by preoperative or postoperative cross-sectional area (CSA), motor conduction velocity (MCV), sensory conduction velocity, and nerve action potential (NAP). Healthy volunteers and grade I patients had significant differences in CSA, MCV, and NAP; grade I, II, and III patients had significant differences in CSA, MCV, and NAP; all patients had significant differences in CSA, MCV, and NAP before and after operations. High-resolution ultrasound and electrophysiological examination can be used in diagnosis and evaluation of operations of ulnar nerve entrapment at the elbow.

Comparative Study of Different Surgical Transposition Methods for Ulnar Nerve Entrapment at the Elbow

This study compared the therapeutic effects of two techniques for surgical decompression treatment for ulnar nerve entrapment at the elbow: subcutaneous transposition and modified submuscular transposition with Z-lengthening of the pronator teres origin. A total of 278 patients with ulnar nerve entrapment (McGowan grades I - III) were randomly assigned to undergo one of these techniques. All patients were followed-up for 2 years. The effects were assessed by preoperative and postoperative cross-sectional area, motor conduction velocity, sensory conduction velocity and nerve action potential. All of these parameters improved after surgery in both groups. For patients with grade I disease, there were no significant differences between the two techniques. For patients with grade II and III disease, modified submuscular transposition was associated with significantly greater improvements compared with subcutaneous transposition. In conclusion, subcutaneous ulnar nerve transposition is recommended for grade I patients and modified submuscular ulnar nerve transposition for grade II and III patients.

Functional Outcomes in Young, Active Duty, Military Personnel After Submuscular Ulnar Nerve Transposition

Functional Outcomes in Young, Active Duty, Military Personnel After Submuscular Ulnar Nerve Transposition

Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus.

Although olecranon osteotomy provides excellent exposure of the distal humerus, enthusiasm for this approach has been limited by reports suggesting numerous complications. It has been suggested that specific techniques for creating and repairing an olecranon osteotomy may help limit complications. This paper describes a technique for olecranon osteotomy using an apex, distal, chevron-shaped osteotomy, Kirschner wires directed out the anterior ulnar cortex distal to the coronoid process and bent 180degrees and impacted into the olecranon proximally, and two 22- gauge, figure-of-eight, stainless steel tension wires. A single surgeon used this technique for exposure of a fracture (16 patients) or nonunion (29 patients) of the distal humerus in 45 consecutive patients. One patient returned to activity too soon, had loosening of the wire fixation, and required a second operation for plate fixation of the ulna. The remaining 44 osteotomies (98%) healed with good alignment within 6 months. There were no broken or migrated wires prior to healing. Twelve patients (27%) had removal of the wires used to repair the olecranon: in 6 patients, this was for symptoms related to the wires (13%); 1 for septic olecranon bursitis, and 5 at the time of another procedure (elbow capsular release in 4 patients and submuscular ulnar nerve transposition in 1). Olecranon osteotomy can be used for exposure of the distal humerus with a low rate of complications when specific techniques are used.

Functional outcomes in young, active duty, military personnel after submuscular ulnar nerve transposition

Purpose The purpose of this study was to report on the results of submuscular ulnar nerve transposition (SMUNT) for treatment of cubital tunnel syndrome in a young, active duty, military population. Methods Twenty patients (20 extremities) were evaluated retrospectively a minimum of 12 months after surgery. Outcome analyses were performed using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Bishop-Kleinman rating scales, physical examination, return-to-work analysis, evaluation of complication rate, and overall patient satisfaction. Results At an average follow-up evaluation of 24 months (range, 12–38 mo), 19 patients had returned to full military active duty work status. The average duration of limited work capacity after surgery was 4.8 months (range, 3–7 mo). The DASH scores improved from an average of 32.5 points before surgery to 6.2 points after surgery. In 19 patients the functional outcome evaluated with the Bishop-Kleinman rating system was excellent. There were no poor outcomes using this rating score. Statistically significant improvements in both key pinch and grip strength were noted. Complications included one permanent and 2 transient neuropraxias of the medial antebrachial cutaneous nerve. Overall 19 of 20 patients were satisfied with the procedure and would have the surgery again if required. Conclusions Submuscular ulnar nerve transposition for cubital tunnel syndrome provides a reliable rate of return to full active duty work in military personnel with good patient satisfaction and minimal complications.

Ulnar nerve decompression by transposing the nerve and Z-lengthening the flexor-pronator mass: Clinical outcome

Controversy surrounds the reliability of methods of treating ulnar nerve compression at the elbow. The effectiveness of submuscular anterior nerve transposition was evaluated in 33 limbs of 31 patients. The flexor-pronator Z-lengthening technique, without internal neurolysis, was used. Results were determined by patient chart reviews. Severity of preoperative nerve compression was measured using Dellon's classification. Of the 33 limbs, 6 had mild preoperative nerve compression; 7, moderate; and 20, severe. Overall outcome was evaluated using a modification of the Bishop rating system. At a mean follow-up period of 49 months, 12 limbs (36%) had excellent results, 20 limbs (61%) had good results, and 1 limb (3%) had a poor result. These findings indicate that submuscular ulnar nerve transposition using the flexor-pronator Z-lengthening technique without internal neurolysis is a reliable method of treating ulnar nerve compression at the elbow.