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Introduction Medial skin incision is obligatory for ulnar nerve transposition in cubital tunnel syndrome. However, inadvertent surgical damage to the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) has been a concern in the current surgical approach. Hypothesis We hypothesized a modified curved skin incision to avoid the damage to the medial cutaneous nerve. Materials and methods The numbers and locations of MACN and MBCN terminal branches were investigated; also, the location of the posterior branch of MACN in ten fresh frozen cadaveric upper extremities. Using modified incision which is more anterior than classic approach and includes antegrade dissection of the cutaneous branches, same measurement was performed in clinical cases. We described the techniques. Results The average number of MACN posterior terminal branches was 2.6 ± 1.6 and 4.4 ± 2.4 branches in the cadaveric specimens and clinical cases, respectively. The average number of MBCN terminal branches was 2.1 ± 0.87 branches. The MACN posterior terminal branches were located at an average of 19 mm proximal and 45 mm distal from the medial epicondyle. In clinical cases, we could preserve all MBCN terminal branches and posterior terminal branches of MACN using the indexed skin incision. Discussion Our modified medial skin incision technique with antegrade subcutaneous dissection exposed all the terminal branches of MACN and thus, could reduce the risk of inadvertent injury. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN. Level of proof IV, Cadaveric and Therapeutic study.

Introduction: The paper aims to present the advantages and disadvantages related to using the anterior transposition technique for the treatment of the cubital tunnel syndrome. Materials and Methods: The study presents the surgical treatment of a 58 years old woman. The therapeutic protocol included the decompression of the ulnar nerve at the level of the elbow, followed by the anterior transposition, the new position being maintained by anchoring in a fascial sling. Results: The electromyographic evaluation performed 12 months after the surgical intervention indicated that the parameters of motor nerve conduction were within normal limits on all segments, normal sensory velocities from the V finger, orthodromic and from the dorsal branch, sign of a very good postoperative recovery. Conclusions: Anterior transposition of the ulnar nerve may be a firm solution for the treatment of the compressive ulnar neuropathies located at the level of the elbow.

Medial epicondyle fracture associated with incarcerated intra‐articular fragment and ulnar nerve palsy is uncommon and frequently missed. We report a case of 13‐year‐old boy with incarcerated medial epicondyle fracture fragment in ulnohumeral joint and ulnar nerve palsy, which was managed successfully by open reduction internal fixation and ulnar nerve transposition.

Cases We present 3 patients who underwent ulnar nerve transposition and wrapping of the nerve with human amniotic membrane (HAM). All 3 patients subsequently required a reoperation for the original pathologic condition (not for ulnar nerve symptoms), necessitating the exploration and dissection of the transposed ulnar nerve. We demonstrate the lack of scar formation and ease of separation between nerve and surrounding tissue, as well as histology in one case taken from the perineural tissues (previous amniotic membrane), demonstrating no inflammatory cells or absence of scar tissue formation. Conclusion Exploration and dissection of a previously transposed ulnar nerve can be facilitated by wrapping the nerve with HAM to prevent scarring and perineural fibrosis.

Background: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. Purpose: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. Study Design: Case series; Level of evidence, 4. Methods: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. Results: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. Conclusion: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

BACKGROUND: Open excision remains the gold standard of treatment for posttraumatic heterotopic ossification (HO) of the elbow. The purpose of this study is to evaluate the functional outcome of early surgical excision done by adhering to a proposed surgical protocol with exclusive posttraumatic HO of the elbow. METHODS: A retrospective study was conducted with 31 patients (25 males and 6 females) with a mean follow-up of 40.5 ± 27.44 months. Excision was done according to our surgical protocol based on the location of HO, associated fractures, stability, need for ulnar nerve transposition, previous operative scar. Improvement in elbow function, Mayo elbow performance score (MEPS) preoperatively and at final follow-up was compared, and statistical analysis was done. RESULTS: Mean flexion–extension arc, supination-pronation arc and MEPS improved by 74.68° ± 29.32°, 26.13° ± 32.93°, 30.48 ± 11.57, respectively. Flexion arc deteriorated by 10.81° ± 10.42° from intraoperative to final follow-up. Improvement at final follow-up was significant in all the cases (P

The medial epicondyle may act as a fulcrum causing deformation of the ulnar nerve during elbow flexion. Furthermore, ulnar neuropathy can be potentiated by dynamic instability of the ulnar nerve around and over the medial epicondyle. Anterior transposition techniques were designed to eliminate traction on the nerve from the medial epicondyle or mechanical irritation in the presence of dynamic instability. Subcutaneous anterior transposition has been advocated as a less morbid alternative to deeper transposition techniques (i.e. intramuscular or submuscular) as it requires less dissection. Multiple techniques have been reported to maintain the nerve in its subcutaneous position after transposition, utilizing a fasciodermal sling from the flexor-pronator mass, an adipose flap, the medial intermuscular septum, or even Osborne’s ligament. Care must be taken with anterior transposition to avoid creation of new sites of compression, particularly at the medial intermuscular septum and the flexor carpi ulnaris fascia. Subcutaneous ulnar nerve transposition has been found to be comparable to in situ decompression as well as submuscular and intramuscular transposition techniques in several randomized trials and large outcomes series.

Objectives: Injury to the ulnar collateral ligament (UCL)—leading to medial elbow instability and concomitant ulnar neuropathy symptoms—is common in the overhead throwing athlete secondary to the repetitive stress that these individuals place on the elbow during the throwing motion. Treatment customarily involves UCL reconstruction (UCLR) and for those with preoperative ulnar neuropathy symptoms, concomitant ulnar nerve transposition (UNT) may also be warranted. The purpose of this study was to evaluate the return to play rates, clinical outcomes and more specifically rates of persistent ulnar nerve symptoms after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuropathy symptoms. Methods: Patients who underwent concomitant UCLR and UNT from January 2008 to June 2018 were identified at one institution with a minimum of 2 years of follow-up. Additional inclusion criteria included athletes who identified as baseball players with a confirmed history of ulnar neuropathy symptoms. Exclusion criteria included patients who had any other concomitant open procedures at the time of surgery. After identifying the cohort, patients were contacted via phone to complete a Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score (KJOC), Andrews-Timmerman (AT) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score and a custom return to play questionnaire. Evidence for preoperative and postoperative ulnar nerve symptoms was elicited within the custom survey and corroborated with the provider’s clinical notes. Sensory ulnar nerve symptoms were defined as having numbness and/or tingling sensations in the 5th and ulnar half of the 4th fingers. Motor ulnar nerve symptoms were defined as either exhibiting 1st dorsal interosseous muscle weakness by inability to maintain finger abduction resistance, ulnar-sided hand grip weakness of inability to control precise movement of the 5th digit. Results: During this time period, a total of 22 male baseball players underwent concomitant UCLR and UNT at a mean age of 18.9+/-2.1 years (range, 16-25). The mean follow-up was 6.1+/-2.4 years (range, 2.5-11.7 years). The cohort consisted of 15 pitchers and 7 position players. In total, 7 players competed in high school and 15 competed in college. Preoperatively, all 22 patients reported ulnar nerve sensory symptoms while only 4 (18.2%) patients reported ulnar nerve motor symptoms. Overall, 16 (72.3%) players were able to return to competitive play at an average of 11.2 months. Of the 6 that failed to return to play after surgery, 3 reported that persistent elbow symptoms were the reason for not returning to play while the other 3 reported losing the desire to return to play. At final follow-up, 7 (31.8%) patients reported of persistent sensory ulnar nerve sensory symptoms while 1 (4.5%) of these patients additionally reported persistent ulnar nerve motor symptoms. The mean postoperative patient reported outcome scores were as follows: KJOC: 77.9+/-20.9 (range, 14-100); MEPS: 92.7+/-12.7 (range, 45-100); AT Elbow Score: 86.1+/-17.1 (range, 30-100); SANE score: 85.5+/-14.8 (range, 50-100). Conclusions: While patient-reported outcome scores and return to play rates are reasonably high, this study demonstrates that following concomitant UCL reconstruction and ulnar nerve transposition for UCL insufficiency and associated ulnar neuropathy, rates of persistent ulnar neuropathy symptoms are persistently present in over 30% of patients. Currently, handling of the ulnar nerve in the setting of UCL insufficiency is debated and thus further investigation is warranted to optimize outcomes for this group of patients.

Background: Elite-level women's fastpitch softball players place substantial biomechanical strains on the elbow that can result in medial elbow pain and ulnar neuropathic symptoms. There is scant literature reporting the expected outcomes of the treatment of these injuries. This study examined the results of treatment in a series of these patients. Methods: We identified 6 female softball pitchers (4 high school and 2 collegiate) with medial elbow pain and ulnar neuropathic symptoms. Trials of conservative care failed in all 6, and they underwent surgical treatment with subcutaneous ulnar nerve transposition. These patients were subsequently monitored postoperatively to determine outcome. Results: All 6 female pitchers had early resolution of elbow pain and neuropathic symptoms after surgical treatment. Long-term follow-up demonstrated that 1 patient quit playing softball because of other injuries but no longer reported elbow pain or paresthesias. One player was able to return to pitching at the high school level but had recurrent forearm pain and neuritis 1 year later while playing a different sport and subsequently stopped playing competitive sports. Four patients continued to play at the collegiate level without further symptoms. Conclusions: Medial elbow pain in women's softball pitchers caused by ulnar neuropathy can be treated effectively with subcutaneous ulnar nerve transposition if nonsurgical options fail. Further study is necessary to examine the role of overuse, proper training techniques, and whether pitching limits may be necessary to avoid these injuries.

Intra articular fractures of the distal humerus cause considerable morbidity to the patients. There are several controversies regarding the approach and fixation of the fracture. AO advocated 90-90 plating of both columns while recent biomechanical studies demonstrated superior mechanical strength with parallel plating. But parallel plating is associated with many complications. We performed bicolumnar perpendicular plating in 15 intraarticular AO type C fractures through transolecranon approach. Ulnar nerve was isolated and carefully protected, but ulnar nerve transposition was not done. We achieved union in all cases with functional range of movement in 13 patients. We had no case of post-operatively developed ulnar nerve neuropathy or heterotopic ossification. The average Mayo Elbow Performance Score was 85 points. We infer that 90-90 plating is effective in intercondylar fractures of distal humerus with minimal complications.

Ulnar collateral ligament (UCL) reconstruction is now being performed more commonly and on younger patients than in prior decades. As a result, radiologists will increasingly be asked to evaluate elbow imaging of patients presenting with pain who have had UCL reconstruction. It is essential for radiologists to understand the normal and abnormal imaging appearances after UCL reconstruction and ulnar nerve transposition, which is also commonly performed in overhead-throwing athletes. Doing so will allow radiologists to provide accurate interpretations that appropriately guide patient management.

Anterior transposition for cubital tunnel syndrome consists of the surgical decompression of the ulnar nerve followed by movement of the nerve anterior to its native retrocondylar location relative to the medial epicondyle. Three different types of anterior transposition have been described, including subcutaneous, intramuscular, and submuscular transpositions. These procedures were developed to not only decompress the ulnar nerve but also to reduce nerve traction during elbow flexion that is not addressed by in situ ulnar nerve decompression alone. However, transposition procedures may pose a greater risk of complications (Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA, J Hand Surg Am 33:1314.e1–12, 2008; Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W, J Bone Joint Surg Am 89:2591–2598, 2007; Staples R, London DA, Dardas AZ, Goldfarb CA, Calfee RP, J Hand Surg Am 43:207–213, 2018; Zhang D, Earp BE, Blazar P, J Hand Surg Am 42:294.e1–294.e5, 2017). Evidence for the superiority of in situ decompression vs transposition and the type of transposition is lacking. Rather, surgeons may choose to perform an ulnar nerve transposition based on specific clinical settings or simply surgical preference. The goals of this chapter are to define various indications for anterior transposition, to outline controversies regarding in situ ulnar nerve decompression vs anterior transposition, to describe operative techniques, and to report outcomes comparing transposition procedures and in situ decompression.

Critical review of surgical outcomes is vital to optimizing patient care. Multiple studies have ventured to address outcomes after cubital tunnel surgery. Due to variation in surgical technique, limited objective data, and inconsistency in measured outcome variables between studies, obtaining any generalized conclusions on anticipated postoperative outcomes remains somewhat challenging. This chapter reviews the available literature on outcomes after cubital tunnel release.

Introduction Medial skin incision is obligatory for ulnar nerve transposition in cubital tunnel syndrome. However, inadvertent surgical damage to the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) has been a concern in the current surgical approach. Hypothesis We hypothesized a modified curved skin incision to avoid the damage to the medial cutaneous nerve. Materials and methods The numbers and locations of MACN and MBCN terminal branches were investigated; also, the location of the posterior branch of MACN in ten fresh frozen cadaveric upper extremities. Using modified incision which is more anterior than classic approach and includes antegrade dissection of the cutaneous branches, same measurement was performed in clinical cases. We described the techniques. Results The average number of MACN posterior terminal branches was 2.6 ± 1.6 and 4.4 ± 2.4 branches in the cadaveric specimens and clinical cases, respectively. The average number of MBCN terminal branches was 2.1 ± 0.87 branches. The MACN posterior terminal branches were located at an average of 19 mm proximal and 45 mm distal from the medial epicondyle. In clinical cases, we could preserve all MBCN terminal branches and posterior terminal branches of MACN using the indexed skin incision. Discussion Our modified medial skin incision technique with antegrade subcutaneous dissection exposed all the terminal branches of MACN and, thus, could reduce the risk of inadvertent injury. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN. Level of proof IV, cadaveric and therapeutic study.

Primary repair of a nerve is preferable over nerve grafting when a tension-free environment can be achieved. The purpose of this cadaveric study was to evaluate the facility of nerve-gap closure gained by removing the hamate hook, eliminating the circuitous path of the motor branch of the ulnar nerve in the hand. Six cadaveric specimens were dissected and the length of the motor branch coursing through Guyon’s canal before and after hamate hook excision and nerve transposition was recorded. Average length was significantly shorter in specimens after transposition, with a mean 21% reduction relative to the nerve’s original course. This knowledge may help guide surgeons on whether excision of the hamate hook will allow for primary repair of the nerve when a segmental defect or retraction and scarring of the nerve stumps is encountered.

Background Overlapping surgery is attracting increased scrutiny. The American College of Surgeons states that the attending surgeon must be present for all critical portions of a surgical procedure; however, critical portions of surgical procedures are not defined. We hypothesized that a Delphi panel process would measure consensus on critical portions of 3 common hand surgical procedures. Methods We used a Delphi process to achieve consensus on the critical portions of carpal tunnel release, ulnar nerve transposition, and open reduction and internal fixation of the distal part of the radius. The panelists were 10 hand surgeons (7 fellowship-trained surgeons and 3 fellows). Following an in-person discussion to finalize steps for each procedure, 2 online rounds were completed to rate steps from 1 (not critical) to 9 (extremely critical). We operationalized consensus as ≥80% of ratings within the same range: 1 to 3 (not critical), 4 to 6 (somewhat critical), and 7 to 9 (critical). Because of a lack of consensus on some steps after round 2, another in-person discussion and a third online round were conducted to rate only steps involving disagreement or somewhat critical ratings using a dichotomous scale (critical or not critical). Results Following the first 2 rounds, there was consensus on 19 of 24 steps (including 3 steps being somewhat critical) and no consensus on 5 of 24 steps. At the end of round 3, there was consensus on all but 2 steps (identification of the medial antebrachial cutaneous nerve in ulnar nerve transposition and clinical assessment of joint stability in open reduction and internal fixation of the distal part of the radius), with moderate disagreement (3 compared with 7) for both. Conclusions The panel reached consensus on the designation of critical or noncritical for all steps of a carpal tunnel release, all but 1 step of an ulnar nerve transposition, and all but 1 step of open reduction and internal fixation of the distal part of the radius. The lack of consensus on whether 2 of the steps are critical leaves this determination at the discretion of the attending surgeon. The findings of our Delphi panel provide guidance to our division on which portions of the surgical procedure are critical and thus require the attending surgeon's presence.

Background: While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. Purpose: The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. Study Design: Systematic review and meta-analysis. Methods: A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. UCLR case series that contained complications data were included. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Meta-analysis of the pooled data was completed. Results: Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. There were no cases of intraoperative ulnar nerve injury reported. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). Conclusion: Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature.

Cubital tunnel syndrome is a common neuropathy of the upper extremity. Patient symptoms typically consist of numbness in the ulnar side of the side and hand intrinsic muscle weakness. Physical examination and EMG/NCV are usually adequate to establish a diagnosis. Nonoperative management works approximately 50% of the time and consists of rest and splinting. Operative management can help the symptoms and prevent progression of disease. During surgical decompression, all sites of potential compression should be evaluated to give the patient the best chance for a successful outcome.

The aim of the study is to introduce a new minimally invasive technique for ulnar nerve release and transposition.From January 2010 to May 2011, 51 patients with cubital tunnel syndrome were treated through a 1.5 to 2 cm incision. Limb functional recovery, scar esthetics, sensitivity of scar, numbness of the operating area, and patient satisfaction were assessed.No wound hematoma nor infection was observed in the group. The time of operation was 36 ± 17.2 minutes. At the final follow-up of 63 ± 7.3 months, 2-point discrimination of the small finger was improved from 6.3 ± 2.2 mm to 5.2 ± 2.4 mm. Grip and pinch strength of the hand were improved from 14.2 ± 7.7 kg and 3.7 ± 2.4 kg to 35.2 ± 12.7 kg and 4.1 ± 2.8 kg, respectively. The motor nerve conduction velocity was improved from 36.5 ± 11.2 to 44.6 ± 6.7 (m/sec). The Disabilities of the Shoulder, Arm, and Hand questionnaire score was improved from 37.2 ± 23.8 to 10.5 ± 9.6. No patients reported scar pain, sensitivity of scar, or numbness of the operating area. No revision surgery was needed. Michigan Hand Outcome score for aesthetics was 94.6%±5.1 and satisfaction was 92 ± 8, respectively. We obtained 33 excellent, 12 good, 5 fair, and 1 poor result.Ulnar nerve decompression with anterior transposition can be safely and effectively accomplished through the small incision. It can be an alternative technique producing good appearance.

The most common site of ulnar nerve compression is within the cubital tunnel. Surgery has historically involved an open cubital tunnel release with or without transposition of the nerve. A comparative study has demonstrated that endoscopic decompression is as effective as open decompression and has the advantages of being less invasive, utilizing a smaller incision, producing less local symptoms, causing less vascular insult to the nerve, and resulting in faster recovery for the patient. Ulnar nerve transposition is indicated with symptomatic ulnar nerve instability or if the ulnar nerve is located in a "hostile bed" (eg, osteophytes, scarring, ganglions, etc.). Transposition has previously been performed as an open procedure. The authors describe a technique of endoscopic ulnar nerve release and transposition. Extra portals are used to allow retractors to be inserted, the medial intermuscular septum to be excised, cautery to be used, and a tape to control the position of the nerve. In our experience this minimally invasive technique provides good early outcomes. This report details the indications, contraindications, surgical technique, and rehabilitation of the endoscopic ulnar nerve release and transposition.

Ulnar nerve anterior transmuscular transposition is a well-accepted surgical technique for the treatment of ulnar nerve entrapment or subluxation at the elbow. The procedure, which addresses both compression and traction forces on the nerve, may be performed with the patient in the lateral decubitus position, allowing direct access to and excellent visualization of the ulnar nerve through an incision on the posteromedial aspect of the elbow. This report reviews the surgical indications and contraindications, pertinent anatomy, patient positioning rationale and method, surgical technique, postoperative management, and potential complications for this ulnar nerve transposition procedure. Discussion of the technique and an illustrative case are also provided.

Purpose The purpose of this study was to contrast the rate and types of complications and secondary surgeries for in situ cubital tunnel release and ulnar nerve transposition. Methods A retrospective cohort study was performed by query of hospital billing records for all patients who underwent cubital tunnel surgery from August 2008 to July 2013, yielding 421 patients. Exclusion criteria were acute trauma, revision surgery, neoplasm, age younger than 18 years, incomplete records, and postoperative follow-up less than 3 months. Of the remaining 234 patients, 147 patients underwent 157 in situ cubital tunnel releases and 87 patients underwent 90 ulnar nerve transpositions. Results In 157 in situ cubital tunnel releases, there were 6 complications (3.8%), including 3 cases (1.9%) of ulnar nerve instability, 2 cases (1.3%) of postoperative infection, and 1 case (0.6%) of a postoperative seroma. In 90 ulnar nerve transpositions, there were 2 complications (2.2%), including 1 case (1.1%) of postoperative infection and 1 case (1.1%) of medial antebrachial cutaneous nerve injury. The secondary surgery rate was 5.7% overall, 2.5% for in situ cubital tunnel release, and 11.1% for ulnar nerve transposition. Chronic kidney disease was associated with complication after cubital tunnel surgery. Prior trauma to the elbow and ulnar nerve transposition were associated with secondary surgery. Conclusions The short-term complication rates of cubital tunnel surgery are low (3.2%), but higher for patients with chronic kidney disease. The secondary surgery rate after cubital tunnel surgery was 5.7% overall, but higher for patients with prior elbow trauma and for patients undergoing ulnar nerve transposition. Type of study/level of evidence Therapeutic IV.

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.

Purpose The 2 most common methods of ulnar nerve anterior transposition are submuscular and subcutaneous. Controversy exists as to which technique yields superior results. The purpose of this study was to examine the histologic differences between the 2 methods in a rat model. Methods Twenty forelimbs in 10 adult Sprague-Dawley rats had bilateral ulnar nerve transpositions; one side with the submuscular method, and the other side with the subcutaneous method. Animals were killed 6 weeks after the index surgery and the forelimbs were examined for histologic evidence of the health of the axons and perineural scar formation. Results Nerve health was assessed using a 4-part classification in which 4=normal nerve, 3=abnormal axons in one-third cross-sectional area (CSA), 2=abnormal axons in two-thirds CSA, and 1=abnormal axons in 100% CSA. Perineural scar formation was assessed using a 3-part classification in which 3=scar completely encasing nerve, 2=scar formation partially surrounding nerve, and 1=no scar. The submuscular method displayed healthier ulnar nerve axons. In addition, the submuscular method displayed less perineural scar tissue. Conclusions On this basis of this rat model, the submuscular method of ulnar nerve anterior transposition displayed histologically healthier axons and less perineural scar tissue when compared to the subcutaneous method.

To determine retrospectively whether the technique of ulnar nerve transposition (subcutaneous versus submuscular) is associated with clinical sensory and motor recovery in cubital tunnel syndrome, and whether recovery is influenced by prognostic factors such as preoperative McGowan stage, age, and duration of symptoms.Twenty-five patients (average age, 53 years; follow-up, 7 years) with cubital tunnel syndrome had submuscular transposition, and 24 patients (average age, 46 years; follow-up, 3 years) were treated by subcutaneous transposition. There were 11 McGowan stage II and 14 stage III patients in the submuscular group and 14 stage II and 10 stage III patients in the subcutaneous group. Preoperatively, all patients presented with diminished 2-point discrimination. Postoperative sensory and motor recovery was evaluated clinically.There was no significant difference between subjective results in the submuscular and subcutaneous groups: 20 of 25 patients in the submuscular group versus 17 of 24 patients in the subcutaneous group were clearly improved, and 3 of 25 patients in the submuscular group versus 6 of 24 patients in the subcutaneous group partially improved. The logistic multivariate regression analysis indicated that sensory and motor function were both significantly improved following both surgical techniques. Sensory function recovered (2-point discrimination6 mm) in 17 of 25 patients in the submuscular group and in 17 of 24 patients in the subcutaneous group, and motor function recovered (intrinsic strength grade 5) in 19 of 25 patients in the submuscular group and in 19 of 24 patients in the subcutaneous group. Symptoms lasting more than 6 months were associated with a poor prognosis.Sensory and motor recovery for patients with McGowan stages II and III of cubital tunnel syndrome were similar following submuscular and subcutaneous transposition techniques, and patients with symptoms lasting longer than 6 months had a worse prognosis regardless of surgical technique.

OBJECT Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. METHODS The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. RESULTS An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle. CONCLUSIONS The common aponeurosis encountered between the FDS and FCU muscles represents a potential site of posttransposition entrapment, which may account for a subset of failed anterior transpositions. Exploration of this region with release of this structure is recommended to provide an unconstrained distal course for a transposed ulnar nerve.

Prior to Jobe’s description of a reconstruction technique for ulnar collateral ligament (UCL) insufficiency, the injury was career ending. Despite successful results in about 70 % of cases, concerns with elevation of the flexor-pronator mass, ulnar nerve complications and relatively large bone tunnels in the medial epicondyle of the humerus led to modifications to Jobe’s technique. One of the most novel modifications was the “docking technique.” Differences included: (1) arthroscopic evaluation and management, when indicated, of concomitant intra-articular pathology, (2) maintenance of the ulnar nerve in situ unless symptoms specifically indicate transposition, (3) use of a muscle splitting approach through the flexor mass, and (4) “docking” of the graft into a humeral socket. Ulnar preparation remained the same as originally described Jobe. These modifications facilitated improved graft tensioning while minimizing the number of large tunnels drilled in the relatively small medial epicondyle. Intraoperative morbidity was minimized by the muscle-splitting approach and the reservation of ulnar nerve transposition only when indicated based on preoperative exam. Clinical results have been excellent using this technique, and it is our preferred technique for UCL reconstruction.

Purpose: To evaluate the clinical results of anterior subcutaneous ulnar nerve transposition operation and the factors that influence the results for cubital tunnel syndrome. Materials and Methods: Seventeen cases of cubital tunnel syndrome were treated by anterior subcutaneous transposition between March 2001 and December 2003. The mean age was 56 years and mean follow up period was 20.4 months. All patients were reviewed retrospectively. The preoperative evaluation was done by Dellon`s classification and the clinical results were evaluated by Messina’s classification. We analyzed the effect of the operation and the relations between the results and the preoperative factors, for example, duration of symptom, age, cause of illness, present of association with diabetes mellitus or preoperative flexion contracture of the elbow were analyzed. Results: The results according to Messina`s classification were 4 cases of excellent, 9 cases of good, 3 cases of fair, and 1 case of poor. The preoperative factors like duration of symptom, age, cause of illness and flexion contracture of the elbow didn`t show any statistical difference in the result of operation, but the cases which have diabetes mellitus were unsatisfactory with statistical difference (p

Subjective outcome was assessed in 100 patients with cubital tunnel syndrome at least 2 years after anterior transmuscular transposition of the ulnar nerve. The mean time from surgery was 37 months (standard deviation, 10 months). The patient sample of 119 operated cases included 81 unilateral procedures and 19 patients had bilateral procedures. The mean time between surgeries was 7 months. Sixty-one patients who underwent unilateral procedures reported improvement, and there was no difference in 13 unilateral cases. Thirteen patients who underwent bilateral procedures reported improvement in both arms. Postoperatively symptoms were significantly less than those preoperatively: pain, p = 0.001; cold sensitivity, p = 0.001; tingling, p = 0.05; and numbness p = 0.08. In 51 cases, patients reported normal sensation and in 45 cases patients reported normal strength. Reported outcome was significantly better in nonsmokers than in smokers (p = 0.02) but was not significantly different in patients with workers' compensation/litigation (p = 0.51), obesity (p = 0.16), abnormal preoperative nerve conduction studies (p = 0.21), concomitant carpal tunnel syndrome (p = 0.95), or brachial plexus nerve compression (p = 0.35).

Purpose To report the safety of using the proximal anteromedial portal, using a simplified ulnar nerve management strategy derived from an earlier study, in a series of patients with previously transposed ulnar nerves. Methods A retrospective review of all elbow arthroscopies performed by a single surgeon from 2009 to 2014 was performed. The following techniques were used if, by palpation, localization of the ulnar nerve was considered to be certain (group 1) or uncertain (group 2): In group 1 (certain) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (uncertain) a 1- to 3-cm incision was made at the planned proximal anteromedial portal site, and blunt dissection down to the capsule was performed without identification of the nerve. The nerve was not visualized but sometimes was palpated through the wound to confirm its location anteriorly or posteriorly. If there was a disparity between the prior operative records and the physical examination findings, the nerve was explored through a 3- to 4-cm incision. Results We reviewed 394 elbow arthroscopy cases, 22 of which had a prior transposed ulnar nerve (21 subcutaneous and 1 submuscular) that required anterior-compartment arthroscopic surgery. Group 1 (certain location) consisted of 9 elbows (41%), whereas group 2 (uncertain location) consisted of 13 (59%). In 2 cases in group 2, the ulnar nerve was explored because of the disparity between the previous medical records and the physical examination findings. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal. Conclusions The proximal anteromedial portal was able to be used safely in patients with prior transposition of the ulnar nerve. This was achieved by using an algorithm based on the degree of certainty with which the nerve can be localized in the region of the planned portal by clinical palpation. Level of Evidence Level IV, therapeutic case series.

OBJECTIVES The purpose of this study was to test the hypothesis that symptomatic transposed ulnar nerves have a larger average cross-sectional area (CSA) than symptomatic in situ ulnar nerves. METHODS We conducted a retrospective review of the charts and sonograms of 68 patients who had failed ulnar nerve transposition compared to 48 patients with cubital tunnel syndrome who had not undergone surgical management. In addition, postoperative sonograms were compared with preoperative studies when available. Failure was defined as persistence or recurrence of symptoms of ulnar neuropathy postoperatively. The cross-sectional area of the nerve, subjective echogenicity, and residual sites of compression were recorded. Groups were subsequently compared by t tests. RESULTS The failed ulnar nerve transposition group showed a mean cross-sectional area ± SD of 17.26 ± 9.93 mm(2), whereas the control group showed a mean cross-sectional area of 13.45 ± 7.33 mm(2). This difference was statistically significant (P= .018). Nontransposed nerves were more likely to have identifiable sites of compression (P< .05). There was a trend toward postoperative enlargement in the 6 patients with available preoperative imaging (P = .17). No difference in subjective echogenicity was found in this analysis. CONCLUSIONS Patients with failed ulnar nerve transposition show a significantly enlarged cross-sectional area when compared to symptomatic nerves in situ. Although a specific etiology for this difference cannot be determined, the data suggest that the reference ranges for the cross-sectional area of the ulnar nerve may need to be revised for those who have undergone surgery.

Prophylactic release of the ulnar nerve to reduce the incidence of postoperative nerve symptoms in stiff elbows has been recommended. However, the necessity for routine anterior transposition remains unclear. In this study, we aim to gain an insight into the value of routine transposition in open release of stiff elbows.We retrospectively reviewed 94 patients suffering from elbow stiffness with no pre-operative ulnar nerve symptoms. Simple decompression (with in situ decompression or epicondylectomy) and subcutaneous anterior transposition were chronologically performed in 53 and 37 patients, respectively. Another four patients were treated by a single lateral approach with no intervention of the ulnar nerve. Pre- and postoperative range of motion and incidence of ulnar nerve symptoms were recorded. The function of ulnar nerve was measured by Amadio rating scale.The incidence of ulnar nerve dysfuction was 18.9% (ten of 53) and 8.1% (three of 37) in the simple decompression and transposition groups, respectively. The mean Amadio scores were 7.62 and 8.22, respectively. All these data showed a statistically significant difference (P 0.05). In the lateral approach group, 50 % (two of four) of patients developed nerve symptoms with a mean Amadio score of 6.50.The transposition group exhibited a superior nervous outcomes compared with the simple decompression group. No comparison was conducted between the transposition and lateral approach groups because of too few patients in the latter. According to related literature and our experience, we conclude that routine transposition is necessary to prevent postoperative nerve symptoms.

This study sought to determine the validity and responsiveness of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire in cubital tunnel syndrome.Consecutive patients with cubital tunnel syndrome treated by anterior ulnar nerve transposition between September of 2009 and December of 2011 were reviewed retrospectively. Questionnaires were completed preoperatively and 1.5, 3, 6, and 12 months postoperatively. The relationship of the questionnaire to measures of pain, health status (Short Form-8), and pinch and grip strength was evaluated using Spearman's correlation coefficients. Responsiveness of the questionnaire was analyzed using Cohen's effect size, and was compared with responsiveness of the physical examination, pain, and Short Form-8 measures.The final cohort included 69 patients with isolated cubital tunnel syndrome and 39 with concurrent cubital and carpal tunnel syndrome. Questionnaire scores correlated as expected with other measures. Moderate to strong correlations were observed with pain visual analogue scale and Short Form-8 scores, and weak to moderate correlations were observed with pinch and grip strength. Effect sizes for the DASH questionnaire were small (0.3) at 6 weeks and moderate (0.35 to 0.57) at 3, 6, and 12 months postoperatively in both groups. Pain visual analogue scale scores demonstrated large effect sizes (0.8) at all postoperative time points, whereas Short Form-8 and pinch and grip strength were poorly responsive.The Disabilities of the Arm, Shoulder, and Hand questionnaire is a valid measure in cubital tunnel syndrome, and is moderately responsive to change beyond 3-month follow-up.Diagnostic, II.

The patient was identified and the affected extremity was marked before transfer to the operating room. A regional block was administered by the anesthesiologist. IV antibiotics were given. A well-padded tourniquet was placed on the right/left proximal arm. The right/left upper extremity was then prepped and draped in the usual sterile fashion. The extremity was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mmHg.

Subcutaneous anterior ulnar nerve transposition has been advocated by many surgeons as simple and effective. Techniques to maintain the nerve anterior to the medial epicondyle include subcutaneous pocket, subcutaneous-fascia tunnel, and fascial and fasciodermal sling. We describe a modified technique that uses the medial intermuscular septum as a sling to allow a more gentle transition of the ulnar nerve as it enters into the flexor carpi ulnaris muscle belly.

Controversy remains regarding the surgical treatment of cubital tunnel syndrome. Similar outcomes with ulnar nerve transposition, both subcutaneous and submuscular, and simple decompression have recently been reported. We describe an endoscopically assisted cubital tunnel release through a 2-cm incision using readily available standard equipment. Seventeen of 21 procedures successfully alleviated symptoms of cubital tunnel syndrome in these patients. Four patients who developed ulnar nerve subluxation intraoperatively who were treated with medial epicondylectomy failed to experience relief of symptoms and were successfully treated with anterior submuscular transposition. Patients with more profound motor weakness and/or electrodiagnostic studies had less complete relief of symptoms.