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Ulnar nerve stability-based surgery for cubital tunnel syndrome via a small incision: a comparison with classic anterior nerve transposition.

Kang HJ, Koh IH, Chun YM, Oh WT, Chung KH, Choi YR - J Orthop Surg Res (2015)

Bottom Line: Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop scale.At the final follow-up, all outcome measures improved significantly in both groups and there were no significant differences between the two groups.However, there were fewer operation-related complications in group A (one revision surgery) than in group B (one superficial infection, two painful scars, and five cases of numbness at the medial elbow).

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Yonseiro 50-1, Seodaemun-gu, Seoul, 120-752, Republic of Korea.

ABSTRACT

Objective: The purpose of this study was to compare the clinical outcomes of ulnar nerve stability-based surgery via a small incision with those of classic anterior transposition of the ulnar nerve for cubital tunnel syndrome.

Methods: From March 2008 to December 2013, 107 patients with cubital tunnel syndrome underwent simple decompression or anterior transposition via a small incision, according to an ulnar nerve stability-based decision based on an assessment of intraoperative ulnar nerve stability (group A, n = 51), or anterior transposition via a classic incision (group B, n = 56). Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop scale.

Results: At the final follow-up, all outcome measures improved significantly in both groups and there were no significant differences between the two groups. However, there were fewer operation-related complications in group A (one revision surgery) than in group B (one superficial infection, two painful scars, and five cases of numbness at the medial elbow).

Conclusions: Outcomes after the ulnar nerve stability-based approach and anterior transposition were similar, although more patients experienced operation-related complications after anterior transposition via a classic incision. Making an ulnar nerve stability-based decision to perform either simple decompression or anterior transposition via a small incision seems to be a better strategy for patients with cubital tunnel syndrome.

No MeSH data available.


Related in: MedlinePlus

After releasing the proximal nerve compression structures, Osborne’s ligament, Osborne’s fascia, and the deep flexor-pronator aponeurosis were sequentially released
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Fig3: After releasing the proximal nerve compression structures, Osborne’s ligament, Osborne’s fascia, and the deep flexor-pronator aponeurosis were sequentially released

Mentions: In group A, a 2.5-cm longitudinal skin incision was made between the medial epicondyle and the olecranon. Then, the subcutaneous tissues were gently and carefully separated with dissecting scissors. With the help of mini retractors, the ulnar nerve was located by releasing the brachial fascia just proximal to the cubital tunnel. Blunt dissection was carried out proximally using a curved mosquito hemostat to create a cavity between the subcutaneous tissue and the brachial fascia. A Cobb elevator was then gently introduced into this cavity to extend it at least 8 cm proximal to the medial epicondyle. A long nasal speculum was introduced into the cavity, and the brachial fascia and arcade of Struthers were released under direct visualization (Fig. 2). To allow the operating light to reach the deep operating field, the shoulder of the patient was adducted about 20°, and the beam of the light was almost parallel to the upper arm. After removing the nasal speculum, Osborne’s ligament was released. Then, a distal cavity was created between the subcutaneous tissue and Osborne’s fascia, followed by the release of Osborne’s fascia and the deep flexor-pronator aponeurosis. A short nasal speculum was introduced at that moment to assist with clear visualization of the structures (Fig. 3). Only the superficial surface of the nerve was exposed, and neurolysis was not performed to decrease the possibility of nerve subluxation. After complete release of all potential sources of structural nerve compression, the stability of the ulnar nerve was tested by moving the elbow through the full range of motion. If the nerve remained within the cubital tunnel throughout elbow flexion, it was considered stable. If the nerve displaced onto the medial epicondyle during flexion or if it did not sit well within the cubital tunnel, it was considered unstable. In such cases where instability was identified intraoperatively, the skin incision was extended 1 cm proximally and distally to transpose the nerve anteriorly. The soft tissue above the flexor-pronator muscle group was elevated, and the ulnar nerve was then carefully lifted from its bed with its accompanying longitudinal vascular supply intact. Segmental feeding vessels were identified and ligated to prevent tethering. Neurolysis of the posterior motor branches from the main ulnar nerve was performed to allow adequate anterior transposition if there was tension. The medial intermuscular septum was also excised as part of the anterior transposition. A fascial sling raised from the underlying muscle fascia was created to prevent slippage of the nerve after transposition (Fig. 4).Fig. 2


Ulnar nerve stability-based surgery for cubital tunnel syndrome via a small incision: a comparison with classic anterior nerve transposition.

Kang HJ, Koh IH, Chun YM, Oh WT, Chung KH, Choi YR - J Orthop Surg Res (2015)

After releasing the proximal nerve compression structures, Osborne’s ligament, Osborne’s fascia, and the deep flexor-pronator aponeurosis were sequentially released
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4526197&req=5

Fig3: After releasing the proximal nerve compression structures, Osborne’s ligament, Osborne’s fascia, and the deep flexor-pronator aponeurosis were sequentially released
Mentions: In group A, a 2.5-cm longitudinal skin incision was made between the medial epicondyle and the olecranon. Then, the subcutaneous tissues were gently and carefully separated with dissecting scissors. With the help of mini retractors, the ulnar nerve was located by releasing the brachial fascia just proximal to the cubital tunnel. Blunt dissection was carried out proximally using a curved mosquito hemostat to create a cavity between the subcutaneous tissue and the brachial fascia. A Cobb elevator was then gently introduced into this cavity to extend it at least 8 cm proximal to the medial epicondyle. A long nasal speculum was introduced into the cavity, and the brachial fascia and arcade of Struthers were released under direct visualization (Fig. 2). To allow the operating light to reach the deep operating field, the shoulder of the patient was adducted about 20°, and the beam of the light was almost parallel to the upper arm. After removing the nasal speculum, Osborne’s ligament was released. Then, a distal cavity was created between the subcutaneous tissue and Osborne’s fascia, followed by the release of Osborne’s fascia and the deep flexor-pronator aponeurosis. A short nasal speculum was introduced at that moment to assist with clear visualization of the structures (Fig. 3). Only the superficial surface of the nerve was exposed, and neurolysis was not performed to decrease the possibility of nerve subluxation. After complete release of all potential sources of structural nerve compression, the stability of the ulnar nerve was tested by moving the elbow through the full range of motion. If the nerve remained within the cubital tunnel throughout elbow flexion, it was considered stable. If the nerve displaced onto the medial epicondyle during flexion or if it did not sit well within the cubital tunnel, it was considered unstable. In such cases where instability was identified intraoperatively, the skin incision was extended 1 cm proximally and distally to transpose the nerve anteriorly. The soft tissue above the flexor-pronator muscle group was elevated, and the ulnar nerve was then carefully lifted from its bed with its accompanying longitudinal vascular supply intact. Segmental feeding vessels were identified and ligated to prevent tethering. Neurolysis of the posterior motor branches from the main ulnar nerve was performed to allow adequate anterior transposition if there was tension. The medial intermuscular septum was also excised as part of the anterior transposition. A fascial sling raised from the underlying muscle fascia was created to prevent slippage of the nerve after transposition (Fig. 4).Fig. 2

Bottom Line: Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop scale.At the final follow-up, all outcome measures improved significantly in both groups and there were no significant differences between the two groups.However, there were fewer operation-related complications in group A (one revision surgery) than in group B (one superficial infection, two painful scars, and five cases of numbness at the medial elbow).

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Yonseiro 50-1, Seodaemun-gu, Seoul, 120-752, Republic of Korea.

ABSTRACT

Objective: The purpose of this study was to compare the clinical outcomes of ulnar nerve stability-based surgery via a small incision with those of classic anterior transposition of the ulnar nerve for cubital tunnel syndrome.

Methods: From March 2008 to December 2013, 107 patients with cubital tunnel syndrome underwent simple decompression or anterior transposition via a small incision, according to an ulnar nerve stability-based decision based on an assessment of intraoperative ulnar nerve stability (group A, n = 51), or anterior transposition via a classic incision (group B, n = 56). Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop scale.

Results: At the final follow-up, all outcome measures improved significantly in both groups and there were no significant differences between the two groups. However, there were fewer operation-related complications in group A (one revision surgery) than in group B (one superficial infection, two painful scars, and five cases of numbness at the medial elbow).

Conclusions: Outcomes after the ulnar nerve stability-based approach and anterior transposition were similar, although more patients experienced operation-related complications after anterior transposition via a classic incision. Making an ulnar nerve stability-based decision to perform either simple decompression or anterior transposition via a small incision seems to be a better strategy for patients with cubital tunnel syndrome.

No MeSH data available.


Related in: MedlinePlus