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Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome.
Baek GH, Kwon BC, Chung MS.
Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea.
The purpose of this study was to review the results of 2 surgical methods for treating cubital tunnel syndrome. From 1994 to 2001, minimal medial epicondylectomy was performed on 22 elbows, and anterior subcutaneous transposition of the ulnar nerve was done on 34 elbows. In the group treated by medial epicondylectomy, 9 of the results (41%) were excellent, 10 (45%) were good, 2 (9%) were fair, and 1 result (5%) was poor. In the group treated by anterior subcutaneous transposition of ulnar nerve, 14 of the results (41%) were excellent, 13 (38%) were good, 6 (18%) were fair, and 1 result (3%) was poor. No significant difference was found between the 2 groups (P < .05). Both methods can be used for the treatment of cubital tunnel syndrome with a high rate of satisfaction.
PMID: 16979058 [PubMed - in process] -
Outcome of open release for post-traumatic elbow stiffness.
Tan V, Daluiski A, Simic P, Hotchkiss RN.
Division of Hand and Microsurgery, Department of Orthopaedics, University of Medicine and Dentistry of New Jersey-The New Jersey Medical School, Newark, New Jersey 07101-1709, USA. tanvi@umdnj.edu
BACKGROUND: Post-traumatic elbow stiffness can be caused by a tether and/or a block, and these structures can exist both anteriorly and posteriorly about the joint to prevent motion. The purpose of this article is to report the outcome of elbow release performed for post-traumatic stiffness by a single surgeon. METHODS: A retrospective review of charts and radiographs was performed on 52 case of patients who underwent open surgical treatment for post-traumatic elbow contracture by the senior author (RHN). The mean age of the group was 35.1 years. There were 32 men and 20 women. Contracture release surgery was performed at an average of 14 months from the time of injury. Indication for operative release was functional loss of elbow arc of motion that failed nonoperative therapy and splinting program. Follow-up was 18.7 months. Comparison of ranges of motion was performed with Student's paired t tests. RESULTS: The average extension-flexion arc of motion improved from 57 to 116 degrees and forearm rotation improved from 119 to 145 degrees postoperatively. Fourteen patients (27%) required closed manipulation under anesthesia, in the early postoperative period. Five patients required a second contracture release at an average of 12 months after the index release. Four patients failed because of painful motion (n = 2) and elbow instability (n = 2). Other complications included wound infection (n = 3), cubital tunnel syndrome (n = 3) and reflex sympathetic dystrophy (n = 1). CONCLUSIONS: Open elbow release with excision of tethers and blocks is a valuable procedure for post-traumatic stiffness. Recurrence in postoperative period is common but is responsive to manipulation under anesthesia and repeat releases.
PMID: 16967006 [PubMed - in process]
Treatment of cubital tunnel syndrome: perspectives for the therapist.
Lund AT, Amadio PC.
Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
The treatment of cubital tunnel syndrome provides therapists the opportunity to use a wide variety of their skills. Whether managed surgically or nonoperatively, differential diagnosis, manual therapy, application of therapeutic modalities, splinting, pain management, and facilitating return to work are often all included in a comprehensive treatment plan for return to functional strength and mobility of the affected arm. When surgery is indicated due to a failure of nonoperative methods or the degree of nerve compression, the decision-making process for the specific procedure to perform is multifactorial. Anatomic factors, patient needs, and surgeon preference all play a role in determining which procedure is performed. As with many other conditions, an alliance of patient, therapist, and surgeon will provide the most effective therapeutic team, and the best chance for a good clinical outcome.
PMID: 16713864 [PubMed - in process]-
Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics.
Greenwald D, Blum LC 3rd, Adams D, Mercantonio C, Moffit M, Cooper B.
Bayshore Plastic Surgery, Tampa, Florida 33606, USA. docdan@bs-ps.com
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 the results of the method and protocol in two series of patients treated by a single surgeon. BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
PMID: 16641701 [PubMed - indexed for MEDLINE]
Postoperative clinical results in cubital tunnel syndrome.
Yamamoto K, Shishido T, Masaoka T, Katori Y, Tanaka S.
Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan.
This article reports on factors affecting the postoperative results in cubital tunnel syndrome. We evaluated 111 limbs of 107 patients who had been surgically treated for cubital tunnel syndrome. Average patient age was 43.9 years (range: 11-77 years). Postoperative follow-up ranged from 1 to 17 years (mean: 5.2 years). Causal diseases included cubitus valgus following fractures in childhood in 43 limbs, osteoarthritis in 45 limbs, and others in 23 limbs. Surgical treatment involved King's method for 66 limbs, anterior transposition for 41 limbs, and Osborne's method for 4 limbs. Preoperative severity and postoperative results were evaluated according to the critera for evaluation of ulnar nerve palsy of Yokohama City University. Preoperative severity was stage I in 19 limbs, stage II in 12 limbs, stage III in 41 limbs, and stage IV in 39 limbs. Postoperative results at final evaluation were excellent in 37 limbs, good in 39 limbs, fair in 26 limbs, and poor in 9 limbs. Age at surgery, duration of cubital tunnel syndrome, preoperative severity, and clinical symptom score and motor nerve conduction velocity in the early postoperative stage (one month after surgery) were found to be important prognostic factors of the syndrome.
PMID: 16628995 [PubMed - indexed for MEDLINE]
Arthroscopic neurolysis of the ulnar nerve at the elbow.
[Article in English, Italian]
Porcellini G, Paladini P, Campi F, Merolla G.
Unita Operativa di Chirurgia Ortopedica di Spalla e Gomito, Ospedale G Cervesi, Cattolica (RN), Italy. shoulder@orthoweb.net
Cubital tunnel syndrome is a frequent form of neuropathy caused by entrapment of the upper limb. Conservative treatment and physical therapy are the treatment of choice for at least 6 months prior to any type of surgery. The surgical techniques proposed for treatment of this syndrome include simple decompression, transposition and neurolysis. It is the purpose of this study to demonstrate the advantages of arthroscopy for neurolysis of the ulnar nerve at the elbow in a specific cohort of patients. The patients were evaluated preoperatively and postoperatively based on subjective (VAS) and objective (Bishop and Dellon) scales. The degree of patient satisfaction on the average was more than 60%. The mean increase in Bishop score was 5 points (minimum 3, maximum 7). Results appeared to be good and stable at 6 and 12-month follow-up evaluation.
PMID: 16422245 [PubMed - indexed for MEDLINE]-
The endoscopic management of cubital tunnel syndrome.
Hoffmann R, Siemionow M.
Hand and Plastic Surgery, Evangelisches Krankenhaus, Marienstr. 1, Oldenburg, Germany. dr.reimer.hoffmann@evangelischeskrankenhaus.de
The overall success rate of surgical interventions for cubital tunnel syndrome is reported to be within 80% to 90% (Szabo, 1999). The discussion, however, whether to perform in situ nerve decompression or anterior transposition continues. In this paper, we present the results of our endoscopic approach to in situ cubital tunnel release, its rationale, clinical and anatomical indications and a detailed description of the technique.
PMID: 16225971 [PubMed - indexed for MEDLINE] -
Strategies for nonrandomized clinical research in hand surgery.
Graham B.
University of Toronto/University Health Network Hand Program, Banting Institute, M5G IL5 Toronto, Canada. brent.graham@utoronto.ca
Most clinical research questions in hand surgery may be effectively explored using a variety of nonrandomized study designs. The main advantage of any of these methods is that they are almost always more feasible than a prospective randomized, controlled trial. Although the level of evidence associated with nonrandomized designs is always lower than that of a randomized trial there are many instances in which the inferences based on these designs are sufficiently strong that important and meaningful conclusions can be made. The key considerations in using nonrandomized designs are to frame the research question appropriately and to recognize and anticipate the limitations and biases that are inherent to each one of these approaches.
Publication Types:
PMID: 16139626 [PubMed - indexed for MEDLINE] -
Subtotal medial epicondylectomy as a surgical option for treatment of cubital tunnel syndrome.
Dinh PT, Gupta R.
Department of Orthopaedic Surgery, University of California, Irvine Irvine, CA 92868, USA.
Ulnar nerve compression at the elbow is commonly accepted as the second most frequent compressive peripheral neuropathy. The unique anatomic location of the ulnar nerve directly posterior to the medial epicondyle at the elbow places it at risk for injury. With normal motion of the elbow, the ulnar nerve is subjected to compression, traction, and frictional forces. Compression can occur at any of the 5 sites that begin proximally at the arcade of Struthers and end distally where the nerve exits the flexor carpi ulnaris in the forearm. Initial treatment of compressive neuropathy is nonoperative, usually consisting of rest, modification, and/or restriction of elbow or wrist movement. If symptoms persist, especially when accompanied by muscle weakness, surgery is usually indicated. Surgical options include decompression in situ, medial epicondylectomy, transposition of the ulnar nerve (subcutaneous, intramuscular, or submuscular), and/or a combination of these procedures. Careful decompression with a subtotal medial epicondylectomy is a valuable procedure that allows decompression at all levels with minimal risk of devascularizing the nerve or creating elbow instability.
Publication Types:
PMID: 16092820 [PubMed - indexed for MEDLINE] -
Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome.
Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI.
Department of Neurosurgery, University Hospital of Saarland, Homburg, Germany.
The purpose of this prospective randomised study was to evaluate which operative technique for treatment of cubital tunnel syndrome is preferable: subcutaneous anterior transposition or nerve decompression without transposition. This study included 66 patients suffering from pain and/or neurological deficits with clinically and electromyographically proven cubital tunnel syndrome. Thirty-two patients underwent nerve decompression without transposition and 34 underwent subcutaneous transposition of the nerve. Follow-up examinations evaluating pain, motor and sensory deficits as well as motor nerve conduction velocities, were performed 3 and 9 months postoperatively. There were no significant differences between the outcomes of the two groups at either postoperative follow-up examination. We recommend simple decompression of the nerve in cases without deformity of the elbow, as this is the less invasive operative procedure.
Publication Types:
PMID: 16061314 [PubMed - indexed for MEDLINE] -
Submuscular transposition of the ulnar nerve: review of safety, efficacy and correlation with neurophysiological outcome.
Davis GA, Bulluss KJ.
Department of Neurosurgery, Cabrini Hospital, Malvern, Victoria, Australia. gadavis@netspace.net.au
OBJECTIVE: The surgical management of ulnar nerve entrapment at the elbow is a controversial topic, with each surgeon believing his/her technique to be the best. The authors routinely perform submuscular transposition (SMT) of the ulnar nerve to treat entrapment neuropathy at the elbow. The aims of this review are (1) to review the results of SMT with respect to safety and complications, (2) to compare the efficacy of SMT with other studies previously published, and (3) to compare the clinical results with the neurophysiological outcome. METHODS: A retrospective review of patients who underwent SMT for ulnar nerve entrapment between April 2000 and May 2003 was performed. Forty-five ulnar nerves in 44 patients were operated, of which 40 nerves were first time operation (primary group), and 5 nerves had previously undergone a simple decompressive procedure elsewhere (redo group). All patients were graded using the Louisiana State University Medical Centre (LSUMC) system for grading of ulnar nerve entrapment. Pre- and post-operative nerve conduction studies were performed, and these results compared to clinical recovery post-operatively. RESULTS: For the primary group, function improved by one grade in 32.5%, two grades in 37.5% and three grades in 12.5% of patients. There was no change in 17.5%, and no patient deteriorated post-operatively. In the redo group there was improvement of at least one grade in 60% of patients. When clinical improvement was compared with electrophysiological improvement, no clear correlation was demonstrated. CONCLUSION: Submuscular transposition of the ulnar nerve is a safe, effective treatment for ulnar nerve entrapment at the elbow. When performed by trained peripheral nerve surgeons, good results are achievable for both primary and redo surgery.
PMID: 15975795 [PubMed - indexed for MEDLINE] -
A review of compressive ulnar neuropathy at the elbow.
Robertson C, Saratsiotis J.
OBJECTIVE: To review the anatomy, etiology, and symptoms associated with compressive ulnar neuropathy at the elbow and to discuss the diagnosis and treatment of this condition. DATA SOURCE: The following were searched for information relevant to cubital tunnel syndrome: MEDLINE, WorldCat, and Index to Chiropractic Literature. RESULTS: Cubital tunnel syndrome is the second most common nerve compression syndrome of the upper extremity. Clinical features of this syndrome are described along with electrodiagnostic techniques that can be used to provide evidence concerning the probable location, character, and severity of the lesion affecting the ulnar nerve. Conservative treatment of cubital tunnel syndrome is recommended for patients with intermittent symptoms and without changes in cutaneous sensation or muscle atrophy. CONCLUSION: A definitive diagnosis can best be made using clinical tests along with nerve conduction studies and electromyography, conservative treatment can be effective in treating this neuropathy in mild cases; in moderate or severe cases, surgery may be necessary.
Publication Types:
PMID: 15965409 [PubMed - indexed for MEDLINE] -
Cubital tunnel syndrome in adolescent baseball players: a report of six cases with 3- to 5-year follow-up.
Aoki M, Kanaya K, Aiki H, Wada T, Yamashita T, Ogiwara N.
Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Japan. maoki@sapmed.ac.jp
In this case report, we describe the clinical features and surgical outcome of cubital tunnel syndrome in adolescent baseball players. Two infielders, 2 pitchers, and 2 catchers who suffered cubital tunnel syndrome during adolescence (average age, 14 years) were surgically treated. Symptoms of medial elbow pain first appeared during throwing in competition games in summer or autumn seasons. After the onset, they suffered limitation of elbow extension and weakness on grabbing balls. They could not throw because of recurrent medial elbow pain. Laxity of the medial collateral ligament was not detected by stress radiography. Duration of symptoms from the onset to surgery was less than 6 months for 2 patients, 1 year for 2, and longer than 2 years for 2 patients. Anterior subcutaneous transposition of the ulnar nerve relieved symptoms up to 3.3 postoperative years. Medial protrusion of the triceps muscle was observed to cause irritation of the ulnar nerve. Fibrosis surrounding the ulnar nerve was observed without pseudoneuroma. Throwing performance returned completely to competitive level in 5 months postoperatively in 5 of 6 patients. Early diagnosis of cubital tunnel syndrome in adolescent baseball players is very important. Anterior subcutaneous transposition of the ulnar nerve relieves symptoms and restores throwing function.
Publication Types:
PMID: 15944636 [PubMed - indexed for MEDLINE] -
Surgical treatment for ulnar nerve entrapment at the elbow.
Asamoto S, Boker DK, Jodicke A.
Department of Neurosurgery, Justus-Liebig University of Giessen. spine-ns@sb.dcns.ne.jp
The outcomes of 81 operations were assessed for the treatment of ulnar nerve entrapment at the elbow performed on 55 males (bilateral operations in one) and 25 females during the period from January 1995 to December 2000. Before operation, neurophysiological examination was performed in all patients. Simple ulnar nerve decompression or anterior transposition of the ulnar nerve (subcutaneous or intramuscular) was performed with or without the operating microscope. Nine patients were lost to follow up. The outcome was excellent or good in 63 of 72 cases, no change in eight cases, and poor in one case. The outcomes of procedures performed with the operating microscope tended to be superior.
PMID: 15914963 [PubMed - indexed for MEDLINE] -
The elbow: diagnosis and treatment of common injuries.
Sellards R, Kuebrich C.
Department of Orthopaedic Surgery, Section of Sports Medicine, Louisiana State University, Health Sciences Center, 2025 Gravier Street, Suite 400, New Orleans, LA 70112, USA. rsella@lsuhsc.edu
This article deals with common injuries to the elbow. Elbow anatomy is reviewed. Diagnosis and treatment of pronator syndrome,lateral epicondylitis (tennis elbow), radial tunnel syndrome, posterior interosseous nerve syndrome, medial epicondylitis (golfer's elbow), ulnar collateral ligament injury, cubital tunnel syndrome,posterolateral rotatory instability, distal biceps injuries, tricepstendon injuries, and posterior elbow impingement are discussed.
Publication Types:
PMID: 15831310 [PubMed - indexed for MEDLINE]
Intermediate and long-term outcomes following simple decompression of the ulnar nerve at the elbow.
Nathan PA, Istvan JA, Meadows KD.
Portland Hand Surgery and Rehabilitation Center, Portland, OR 97210-2997, USA. drnathan@qwest.net
INTRODUCTION: There is currently little consensus regarding the appropriate surgical approach to treatment of cubital tunnel syndrome (CubTS), and few studies have reported long-term follow-up of patients who have received surgical treatment for ulnar nerve compression at the elbow. METHOD: Seventy-four patients with a total of 102 cases of CubTS treated with simple decompression of the ulnar nerve were examined 1.0-12.4 years postoperatively. Ulnar nerve conduction studies (slowest conducting 5 cm segment of ulnar nerve motor fibers measured at the elbow) were performed both pre- and postoperatively. The primary clinical outcome was percentage relief of symptoms, divided into "excellent" outcome group or less (> or = 90% improvement or < 90% improvement). RESULTS: Ulnar nerve conduction improved pre- to postoperatively, but clinical improvement was not related to changes in velocity. Women reported greater clinical improvement than men, and weight gain in men (but not women) predicted less improvement. Relief of cubital tunnel symptoms was greatest for those arms receiving carpal tunnel release surgery simultaneous or subsequent to cubital tunnel release. DISCUSSION: Simple decompression may offer excellent intermediate and long-term relief of symptoms associated with CubTS. Although improvement in ulnar motor nerve conduction velocity occurs following treatment of CubTS, it may not be a consistent marker of perceived symptom relief. Finally, these findings suggest that less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain.
PMID: 15754708 [PubMed - indexed for MEDLINE]-
Treatment of cubital tunnel syndrome by frontal partial medial epicondylectomy. A retrospective series of 55 cases.
Popa M, Dubert T.
Urgences Main de l'Est Parisien, Clinique la Francilienne, 16 Avenue de l'Hotel de Ville, 77340 Pontault-Combault, France.
The outcomes of 55 cases of cubital tunnel syndrome treated by a partial frontal epicondylectomy are presented at a mean follow-up of 38 months follow-up. According to McGowan classification, 25 cases were grade I (45%), 12 grade II (22%) and 18 grade III (33%). The results (Wilson and Krout classification) were excellent or good in 41 patients (75%), fair in nine patients and unchanged in five, without any worsening or recurrence. Total relief was reported in 80% of grade I, 75% of grade II and 66% of grade III patients. Seven painful scars and one persistent 15( composite function) elbow extension deficit were the only complications. The satisfaction rate was 93%. This technique preserves bony protection, the blood supply and gliding tissues for the nerve and nerve recovery were comparable to other surgical procedures. Residual pain at the osteotomy site was not a serious problem.
PMID: 15542216 [PubMed - indexed for MEDLINE] -
Ulnar nerve entrapment neuropathy at the elbow: simple decompression.
Huang JH, Samadani U, Zager EL.
Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
Ulnar nerve entrapment neuropathy at the elbow, or the cubital tunnel syndrome, is frequently encountered in neurosurgical practice as the second most common peripheral nerve entrapment after carpal tunnel syndrome. Patients typically present with weakness or atrophy of the hand as well as paresthesias in the ulnar nerve distribution. The diagnosis can be confirmed with a careful clinical examination and electrophysiological studies. Patients who have failed conservative therapy are considered for surgery. Although a number of surgical options are available, simple decompression of the ulnar nerve can achieve satisfactory results with appropriate patient selection. We describe the relevant anatomy and surgical techniques for simple in situ decompression of the ulnar nerve at the elbow.
Publication Types:
PMID: 15509321 [PubMed - indexed for MEDLINE] -
Pathogenesis and electrodiagnosis of cubital tunnel syndrome.
Jia ZR, Shi X, Sun XR.
Department of Neurology, First Hospital of Peking University, Beijing 100034, China. Jiazhirong@163.com
BACKGROUND: Cubital tunnel syndrome is a well-recognized clinical condition and is the second most common peripheral compression neuropathy. This study was designed to investigate the causes of cubital tunnel syndrome by surgical means and to assess the clinical value of the neurophysiological diagnosis of cubital tunnel syndrome. METHODS: Twenty-one patients (involving a total of 22 limbs from 16 men and 5 women, aged 22 to 63, with a mean age of 49 years) with clinical symptoms and signs indicating a problem with their ulnar nerve underwent motor conduction velocity examinations at different sites along the ulnar nerve and examinations of sensory conduction velocity in the hand, before undergoing anterior transposition of the ulnar nerve. RESULTS: Electromyographic abnormalities were seen in 21 of 22 limbs [motor nerve conduction velocity (MCV) range (15.9 - 47.5) m/s, mean 32.7 m/s] who underwent motor conduction velocity examinations across the elbow segment of the ulnar nerve. Reduced velocity was observed in 13 of 22 limbs [MCV (15.7 - 59.6) m/s, mean 40.4 m/s] undergoing MCV tests in the forearms. An absent or abnormal sensory nerve action potential following stimulation was detected in the little finger of 14 of 22 limbs. The factors responsible for ulnar compression based on observations made during surgery were as follows: 15 cases involved compression by arcuate ligaments, muscle tendons, or bone hyperplasia; 2 involved fibrous adhesion; 3 involved compression by the venous plexus or a concurrent thick vein; 2 involved compression by cysts. CONCLUSIONS: Factors inducing cubital tunnel syndrome include both common factors that have been reported and rare factors, involving the venous plexus, thick veins, and cysts. Tests of motor conduction velocity at different sites along the ulnar nerve should be helpful in diagnosis cubital tunnel syndrome, especially MCV tests indicating decreased velocity across the elbow segment of the ulnar nerve.
PMID: 15377420 [PubMed - indexed for MEDLINE] -
Functional outcomes in young, active duty, military personnel after submuscular ulnar nerve transposition.
Fitzgerald BT, Dao KD, Shin AY.
Division of Hand Surgery, Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA, USA.
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.
PMID: 15249085 [PubMed - indexed for MEDLINE] -
Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome.
Matsuzaki H, Yoshizu T, Maki Y, Tsubokawa N, Yamamoto Y, Toishi S.
Department of Orthopaedic Surgery, Niigata Chuo Hospital, Akita City, Japan.
PURPOSE: Functional outcomes of cubital tunnel surgery may decline as the severity of preoperative ulnar neuropathy increases. When functional recovery will be adequate, or whether tendon transfers should be required, may be unclear. We investigated the extent of functional recovery, the duration of the recovery process, and the necessity of restoring intrinsic muscle function in patients with severe cubital tunnel syndrome after surgery. METHODS: We retrospectively studied outcomes after cubital tunnel release in 15 patients with marked intrinsic muscle atrophy, claw-hand deformity, immeasurable (electrically silent) sensory and motor nerve conduction velocities, and Semmes-Weinstein test (SWT) results ranging from purple (3.84-4.31) to red (4.56-6.65). We evaluated subjective (numbness and activities of daily living [ADL] disturbances), objective (manual muscle testing [MMT] of index-finger abduction, and SWT), and neurophysiologic (nerve conduction velocity) outcomes. Overall functional outcome was evaluated by Akahori's criteria. RESULTS: At a median follow-up evaluation of 4.5 years all outcomes had improved. Numbness was gone in 5 patients and greatly reduced in 9 patients; 6 patients reported slight difficulties in ADLs; and 9 patients had no difficulties. Motor nerve conduction velocity was measurable (mean, 35.3 m/s) in all 15 patients and sensory nerve conduction velocity was measurable (mean, 43.4 m/s) in 12. Recoveries in nerve conduction velocities persisted beyond 2 years. The SWT results were blue (3.22-3.61) in 6 patients, purple (3.84-4.31) in 8 patients, and red (4.56-6.65) in 1 patient. MMT of index finger abduction was grade 4 or 5 in 11 of 15 patients. Half the patients over 70 years old, however, were grade 3 or less. Akahori's criteria were excellent in 3 patients, good in 6 patients, and fair in 6 patients. CONCLUSIONS: Patients with severe intrinsic muscle atrophy and absent motor and sensory nerve conduction velocities can expect satisfactory long-term functional results after surgery. Function continues to improve beyond 2 years. Restoring index finger abduction is not always necessary for ADLs, although recovery requires several years and is poorer in the elderly.
PMID: 15140474 [PubMed - indexed for MEDLINE] -
Nerves in a pinch: imaging of nerve compression syndromes.
Hochman MG, Zilberfarb JL.
Department of Musculoskeletal Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA. mhochman@bidmc.harvard.edu
Nerve compression is a common entity that can result in considerable disability. Early diagnosis is important to institute prompt treatment and to minimize potential injury. Although the appropriate diagnosis is often determined by clinical examination, the diagnosis may be more difficult when the presentation is atypical, or when anatomic and technical limitations intervene. In these instances, imaging can have an important role in helping to define the site and etiology of nerve compression or in establishing an alternative diagnosis. MR imaging and ultrasound provide direct visualization of the nerve and surrounding abnormalities. For both modalities, the use of high-resolution techniques is important. Bony abnormalities contributing to nerve compression are best assessed by radiographs or CT. For the radiologist, knowledge of the anatomy of the fibro-osseous tunnels, familiarity with the causes of nerve compression, and an understanding of specialized imaging techniques are important for successful diagnosis of nerve compression.
Publication Types:
PMID: 15049533 [PubMed - indexed for MEDLINE] -
Management of secondary cubital tunnel syndrome.
Lowe JB 3rd, Mackinnon SE.
SUMMARY: Learning Objectives: After studying this article, the participant should be able to: 1. Describe the general anatomical features and dynamics of the ulnar nerve, as well as its most common points of potential compression. 2. Describe the clinical presentation associated with secondary cubital tunnel syndrome, with the appropriate differential diagnoses. 3. Discuss the diagnostic test results and physical findings important for determining the correct treatment for patients presenting for revision surgical treatment. 4. Discuss the different nonsurgical and surgical interventions for patients with recurrent or persistent ulnar nerve compression at the elbow.Ulnar nerve compression at the elbow is a peripheral nerve disorder that is second in incidence only to carpal tunnel syndrome. The successful treatment of cubital tunnel syndrome can at times be unsatisfactory, with clinical failure rates of approximately 25 percent after surgical treatment. There are a variety of explanations for surgical failure or secondary ulnar nerve compression at the elbow, including improper diagnosis or treatment, incomplete release of the nerve, postoperative scarring, and improper postoperative rehabilitation. This article reviews the relevant history, anatomical features, and presentation of secondary ulnar nerve compression at the elbow. It also attempts to identify the important risk factors for recurrent, persistent, and new disease and to make clinical recommendations regarding diagnosis, management, and surgical treatment.
PMID: 14707699 [PubMed - in process] -
Cubital tunnel syndrome.
Matev B.
Hand Surgery Department, University Hospital of Orthopaedics, Sofia, Bulgaria.
During a 15-year period, 145 patients presenting with cubital tunnel syndrome were operated upon. They are divided into two groups: (1) Primary tunnel syndrome - 27 cases (18.6%), with a "pure" past history, and (2) secondary - 118 cases (81.4%) with the lesion occurring after a known causative event. Investigation of 100 healthy persons, 50 men and 50 women (200 extremities) show, when elbow flexes, the ulnar nerve moves around the epicondyle in 50% of men, whereas in the remainder nerve subluxation or dislocation anteriorly to the epicondyle occurs. In women, the figures are 72% and 28%, respectively. Apparently in men, the nerve being more mobile is more sensitive to gliding impairment in the tunnel compared to women. In the series of 145 patients, there is a 4.5 : 1 men-to-women ratio, the men being affected much more often. The role of traction in the pathomechanic is further suggested by two facts: the presence of elbow flexion contracture (52%) of the patients and firm ulnar nerve adhesions to the tunnel wall (73%). Skin electroresistance assessment using a high-sensitivity microamperimeter was conducted in 100 patients. Skin electroresistance may remain within normal limits even in cases of expressed sensory and motor impairment. This points to the great resistance of sympathetic fibres against the compression and traction within the canal. Concerning the type of anterior transfer, a combined procedure was used by placing the nerve subcutaneously for the proximal part, and intramuscularly for the distal one. Nerve recovery may proceed even ten years after anterior transfer.
PMID: 12923949 [PubMed - indexed for MEDLINE]
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