In the JournalsPerspective

Ulnar nerve anterior transmuscular transposition yielded favorable results for cubital tunnel syndrome

 
Lisa M. Frantz
 
Bernard F. Hearon

Results showed favorable outcomes in patients who underwent ulnar nerve anterior transmuscular transposition for treatment of cubital tunnel syndrome.

“Ulnar nerve subluxation is more prevalent than previously reported and is a common cause for persistent or recurrent paresthesia after simple decompression for cubital tunnel syndrome,” Lisa M. Frantz, MD, lead author of the study, told Healio.com/Orthopedics. “Surgeons who routinely perform simple decompressions should consider ulnar transmuscular transposition as their primary procedure to decrease intraneural pressure and to reduce the likelihood of revision surgery due to postoperative ulnar nerve subluxation following simple decompression.”

Frantz, Bernard F. Hearon, MD, and colleagues collected demographic and disease-specific data and performed a short-term assessment of 156 patients with cubital tunnel syndrome who underwent primary or revision ulnar nerve anterior transmuscular transposition in the lateral decubitus position. Researchers stratified ulnar neuropathy severity using McGowan grade. Patient outcome surveys were completed by 49 patients with a minimum 2-year follow-up, and researchers noted some patients presented for an ulnar nerve-focused examination to assess long-term outcomes.

Results showed an overall patient satisfaction rate of 92%. Patients had statistically significant improvements in ulnar sensation and intrinsic strength at short- and long-term follow-up. Researchers found better outcomes among patients with lower McGowan grades and who underwent primary ulnar nerve anterior transmuscular transposition compared with patients who had higher McGowan grades and revision cases. Results showed 43% of cases had ulnar nerve instability and 4.3% of patients experienced major complications, all of which were mitigated by contributory patient-related factors. Researchers noted 2.5% of cases required reoperation for recurrent ulnar paresthesia. The lateral decubitus position did not compromise any operations or outcomes in this cohort, according to results.

“There are many indications for ulnar nerve transposition as opposed to simple decompression including prior elbow trauma, elbow arthropathy with contracture, severe ulnar entrapment neuropathy, symptomatic ulnar nerve subluxation or prior failed simple decompression,” Hearon told Healio.com/Orthopedics. “Surgeons who advocate simple decompression for most patients may be overlooking some of these surgical indications, which we believe may be present in about 50% of patients with cubital tunnel syndrome.” – by Casey Tingle

 

Disclosures: The authors report no relevant financial disclosures.

 
Lisa M. Frantz
 
Bernard F. Hearon

Results showed favorable outcomes in patients who underwent ulnar nerve anterior transmuscular transposition for treatment of cubital tunnel syndrome.

“Ulnar nerve subluxation is more prevalent than previously reported and is a common cause for persistent or recurrent paresthesia after simple decompression for cubital tunnel syndrome,” Lisa M. Frantz, MD, lead author of the study, told Healio.com/Orthopedics. “Surgeons who routinely perform simple decompressions should consider ulnar transmuscular transposition as their primary procedure to decrease intraneural pressure and to reduce the likelihood of revision surgery due to postoperative ulnar nerve subluxation following simple decompression.”

Frantz, Bernard F. Hearon, MD, and colleagues collected demographic and disease-specific data and performed a short-term assessment of 156 patients with cubital tunnel syndrome who underwent primary or revision ulnar nerve anterior transmuscular transposition in the lateral decubitus position. Researchers stratified ulnar neuropathy severity using McGowan grade. Patient outcome surveys were completed by 49 patients with a minimum 2-year follow-up, and researchers noted some patients presented for an ulnar nerve-focused examination to assess long-term outcomes.

Results showed an overall patient satisfaction rate of 92%. Patients had statistically significant improvements in ulnar sensation and intrinsic strength at short- and long-term follow-up. Researchers found better outcomes among patients with lower McGowan grades and who underwent primary ulnar nerve anterior transmuscular transposition compared with patients who had higher McGowan grades and revision cases. Results showed 43% of cases had ulnar nerve instability and 4.3% of patients experienced major complications, all of which were mitigated by contributory patient-related factors. Researchers noted 2.5% of cases required reoperation for recurrent ulnar paresthesia. The lateral decubitus position did not compromise any operations or outcomes in this cohort, according to results.

“There are many indications for ulnar nerve transposition as opposed to simple decompression including prior elbow trauma, elbow arthropathy with contracture, severe ulnar entrapment neuropathy, symptomatic ulnar nerve subluxation or prior failed simple decompression,” Hearon told Healio.com/Orthopedics. “Surgeons who advocate simple decompression for most patients may be overlooking some of these surgical indications, which we believe may be present in about 50% of patients with cubital tunnel syndrome.” – by Casey Tingle

 

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Christopher J. Dy

    Christopher J. Dy

    Lisa M. Frantz, MD, MPAS, and colleagues present the results of retrospective, single-surgeon case series in which patients with cubital tunnel syndrome were treated with a transmuscular ulnar nerve transposition in the lateral decubitus position. The authors demonstrate the effectiveness and safety of the procedure, which corroborates previously published case series. The authors were able to obtain long-term follow-up via questionnaire for 40 patients who underwent primary ulnar nerve transposition. The patient-reported satisfaction rate was 90%. Of note, 62% of patients did not have complete resolution of symptoms. This is consistent with the literature but provides additional information for perioperative counseling and expectation setting. The authors did not include an assessment of predictors for persistence of symptoms but were likely underpowered to perform this evaluation. The authors discuss the relative merits of ulnar nerve transposition compared to in situ decompression, highlighting the current equipoise in the literature.

    The morbidity of ulnar nerve transposition has recently been described by Robert Staples, MD, and colleagues, but the relatively unfavorable results of revision surgery after a prior in situ decompression are worth noting. Additional work is needed to help delineate the appropriate indications for in situ ulnar nerve decompression vs. ulnar nerve transposition, balancing the severity of ulnar neuropathy and the relatively morbidity of each procedure. Detailed examination of motor amplitudes during nerve conduction studies may provide one opportunity to answer this question.

    References:

    Aleem AW, et al. J Hand Surg Am. 2014;doi:10.1016/j.jhsa.2014.07.013.

    Dy CJ, et al. Curr Rev Musculoskelet Med. 2016;doi:10.1007/s12178-016-9327-x.

    Dy CJ. J Bone Joint Surg Am. 2019;doi:10.2106/JBJS.18.00058.

    Krogue JD, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2014.12.015.

    Power HA, et al. J Bone Joint Surg Am. 2019;doi:10.2106/JBJS.18.00554.

    Staples R, et al. J Hand Surg Am. 2018;doi:10.1016/j.jhsa.2017.10.033.

    • Christopher J. Dy, MD, MPH, FACS
    • Assistant Professor
      Washington University Orthopedics
      St. Louis

    Disclosures: Dy reports no relevant financial disclosures.