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This study aimed to explore the prognostic value of electrodiagnostic studies (EDS) to clarify their utility in clinical practice prior to cubital tunnel release surgery and to identify patient factors associated with patient-reported functional improvement after surgery. Our hypothesis was that patients with severe preoperative findings on EDS will tend to experience less functional improvement after surgery given the extent of ulnar nerve compressive injury. Patients with cubital tunnel syndrome and preoperative electrodiagnostic data treated from 2012 to 2022 with cubital tunnel release were assessed regarding demographic information, preoperative physical examination findings, EDS findings, postoperative complications, and patient-reported outcomes. Short- to midterm quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) scores were collected for all patients for further evaluation of preoperative EDS data. Patients were grouped into those who had met the minimal clinically important difference (MCID) in delta qDASH at short- to midterm follow-up and those who did not. EDS data included sensory nerve onset latency, peak latency, amplitude, conduction velocity, as well as motor nerve latency, velocity, and amplitude. Electromyographic (EMG) studies were also reviewed, which included data pertaining to fibrillations, presence of abnormal fasciculation, positive sharp waves, variation in insertional activity, motor unit activity, duration of activity, and presence of increasing polymorphisms. Of the 257 patients included, 160 (62.0%) were found to meet the MCID for short- to midterm qDASH scores. There were no significant differences between patients who did or did not meet the MCID regarding baseline demographics, comorbidities, preoperative examination findings, and operative technique. Patients who met MCID tended to have lower complication (3.80% vs. 7.20%, P =.248) and revision (0.60% vs. 4.10%, P =.069) rates, but these findings were not statistically significant. The cubital tunnel severity as determined by the EDS was similar between cohorts (14.1% vs. 14.3%, P =.498). Analysis of EMG testing showed there were no significant differences in preoperative, short- to midterm qDASH, or delta short- to midterm qDASH scores for patients with or without abnormal EMG findings. Multivariate regression suggested that only age (P =.003) was associated with larger delta qDASH scores. Patient-reported preoperative disease severity may predict the expected postoperative change in ulnar nerve functional improvement, and EDS may not have prognostic value for patients undergoing cubital tunnel decompression. Therefore, physicians may suggest surgical treatment without positive EDS findings and still expect postoperative improvement in functional outcomes. [ABSTRACT FROM AUTHOR]

Purpose: The ulnar nerve (UN) courses through the cubital tunnel, which is a potential site of entrapment. Anatomical variations of the cubital tunnel may contribute towards cubital tunnel syndrome (CuTS), however, these are not well described. The aim was to compare the range of variations and dimensions of the cubital tunnel and the UN between sexes and sides of the body. Methods: Sixty elbows from 30 embalmed bodies (17 males and 13 females) were dissected. The prevalence of the cubital tunnel retinaculum (CuTR) or anconeus epitrochlearis (AE) forming the roof of the tunnel was determined. The length, width, thickness, and diameter of the cubital tunnel and its roof were measured. The diameter of the UN was measured. Results: The AE was present in 5%, whereas the CuTR was present in the remaining 95% of elbows. The tunnel was 32.1 ± 4.8 mm long, 23.4 ± 14.2 mm wide, 0.18 ± (0.22–0.14) mm thick, and the median diameter was 7.9 ± (9.0–7.1) mm, while the median diameter of the UN was 1.6 ± (1.8–1.3) mm. The AE was thicker than the CuTR (p < 0.001) and the UN was larger in elbows with the AE present (p = 0.002). The tunnel was longer in males (p < 0.001) and wider on the right (p = 0.014). Conclusion: The roof of the cubital tunnel was more frequently composed of the CuTR. The cubital tunnel varied in size between sexes and sides. Future research should investigate the effect of the variations in patients with CuTS. [ABSTRACT FROM AUTHOR]

BACKGROUND: Cubital tunnel syndrome is a common entrapment neuropathy that affects about 30 per 100,000 population and follows carpal tunnel syndrome in prevalence. Its incidence rises with advancing age with more males affected than females. Patients harboring cubital tunnel syndrome suffer from sensory disturbance involving the medial side of the ring finger and the little finger. Exacerbation of symptoms is noted at night because during sleeping the elbow is flexed. In severe entrapment, patients may suffer from weakness in the small muscles of the hand. Patients with severe degree of compression usually do not recover completely following simple decompression at the elbow. OBJECTIVE: The aim of the study is to assess the results of end to side supercharge transfer of the pronator quadratus branch of the anterior interosseous nerve to the motor branch of the ulnar nerve, in patients suffering from severe cubital tunnel syndrome. PATIENTS AND METHODS: This study included 15 cases with severe cubital tunnel syndrome where the pronator quadratus branch of the anterior interosseous nerve was transferred in an end to side fashion to the motor branch of the ulnar nerve as an adjunctive to transposition of the ulnar nerve at the elbow and release at Guyon’s canal. The severity of the entrapment was classified according to the McGowan Grading system. Motor power was recorded according to the Medical Research Council (MRC) grading of motor power. RESULTS: Over an 18 months follow up period, we had improved motor function ≥ 3 on MRC in 13 out of 15 patients (85%) and all patients had some subjective sensory improvement. Muscle atrophy improved in 80% and claw hand deformity improved in 67% of the patients. CONCLUSION: In conclusion, the pronator quadratus branch of the anterior interosseous nerve reverse end-to-side transfer to the motor branch of the ulnar nerve, together with ulnar nerve transposition at the elbow and surgical decompression at the wrist, helps with enhancing the recovery of hand muscles motor functions and muscle atrophy in patients with severe ulnar entrapment at the elbow. [ABSTRACT FROM AUTHOR]

This is the second part of a two‐part article in which we focus on the ultrasound (US) appearance of the pathological ulnar nerve (UN) and its main branches. Findings in a wide range of our pathological cases are presented with high‐resolution US images obtained with the latest‐generation US machines and transducers. [ABSTRACT FROM AUTHOR]

Although surgical release of upper extremity nerve compression syndromes is highly effective, persistence or recurrence of symptoms and signs may occur. Thorough investigation is necessary in this situation before treatment is recommended. If the symptoms cannot be explained by other pathology than compression of the affected nerve and if conservative management has not provided improvement, reoperation may be considered. This review provides an overview of the diagnostic and surgical considerations in the revision of carpal tunnel syndrome, cubital tunnel syndrome and thoracic outlet syndrome. Level of evidence: V [ABSTRACT FROM AUTHOR]

Ulnar neuropathy is a common peripheral neuropathy, with cubital tunnel compression being the second most frequent upper extremity compression syndrome. Ganglion cysts, though rare, can contribute to ulnar nerve compression in the cubital tunnel. Here, we present a case of a 62-year-old farmer with longstanding diabetes and dyslipidemia who experienced progressive pain and numbness in his medial fingers, exacerbated by elbow flexion. Initially misdiagnosed and treated for Hansen’s disease. Clinico-radiological evaluation revealed a multiloculated cystic lesion in the posteromedial aspect of his left elbow, compressing the ulnar nerve. Surgical excision of the ganglion cyst alleviated symptoms, though residual motor deficits persisted postoperatively. This case underscores the importance of considering ganglion cysts in the differential diagnosis of cubital tunnel syndrome, highlighting the diagnostic challenges and therapeutic considerations in managing this rare etiology.

Radiographic and physical examination findings of ulnar nerve instability have been recognized in overhead throwing athletes, despite the fact that some of these abnormalities may be asymptomatic and represent adaptive changes. While recommendations for screening and early detection have been made that can adversely impact an athletes' career, the presence of bilateral ulnar nerve subluxation and its relationship with medial elbow symptoms has not been characterized in professional overhead throwing athletes. To characterize the prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers. A cross-sectional observational analysis was conducted utilizing standardized ultrasonographic examinations of bilateral elbows in 91 consecutive professional baseball pitchers (median age, 22 years; range, 17–30 years). The relationship between ulnar nerve subluxation and ulnar nerve signs, symptoms, and provocative physical examination maneuvers was also investigated. The prevalence of bilateral ulnar nerve subluxation was 26.4% (95% CI, 17.7%-36.7%; 24 of the 91 athletes). Thirty-five athletes (38.5%; 95% CI, 28.4%-49.2%) had subluxation in at least 1 elbow. No athletes with subluxation had positive ulnar nerve signs, symptoms, or provocative tests. Ulnar nerve subluxation is common among professional pitchers, and is more often than not bilateral. In this population of athletes, ulnar nerve subluxation does not appear to be associated with pathological findings. [ABSTRACT FROM AUTHOR]

Controversy exists regarding the best option for revision surgery in refractory cubital tunnel syndrome (CuTS). The purpose of this systematic review was to evaluate the effectiveness of revision surgery and determine the optimal surgical approach for patients requiring revision surgery for CuTS. A literature search was conducted. Characteristics of the included studies were summarized descriptively. The risk ratio between patient-reported preoperative and postoperative outcomes relating to pain, motor, and sensory deficits was calculated. A meta-regression analysis was performed to evaluate the postoperative symptom improvements based on the type of secondary surgery. Random-effects meta-analysis and descriptive statistics were used when appropriate. A total of 471 patients were evaluated in 20 studies. In total, 254 (53.9%) male and 217 (46.1%) female patients, with an average age of 49.2 ± 14.1 years, were included in this study. Pain was the most common symptom (n = 346, 81.6%), followed by sensory and motor dysfunction in 342 (80.6%) and 223 (52.6%) patients, respectively. Meta-analysis comparing preoperative and postoperative symptoms between patients who had submuscular transposition (SMT), subcutaneous transposition (SCT), and neurolysis showed that a significant subgroup difference exists between the types of revision surgery in sensory and motor improvements. Meta-regression showed that SMT was associated with better outcomes compared with SCT in motor and sensory improvements. Revision surgery for CuTS can be useful for addressing recurrent and persistent symptoms. Compared with neurolysis and SCT, SMT seems to be the superior option for revision surgery, demonstrating substantial improvement in all symptom domains. Therapeutic IV. [ABSTRACT FROM AUTHOR]

This is the first of a two‐part article in which we focus on the ultrasound (US) appearance of the normal ulnar nerve (UN) and its main branches. The detailed US anatomy of the UN course is presented with high‐resolution US images obtained with the latest‐generation US machines and transducers. [ABSTRACT FROM AUTHOR]

Given the relatively high false negative rate of electrodiagnostic studies (EDX) in patients with clinically diagnosed ulnar neuropathy at the elbow (UNE), we sought to determine whether an alternative objective test could more effectively detect UNE. Additionally, we proposed to determine the relationship between the cross-sectional area (CSA) of the ulnar nerve on ultrasound (US), EDX, and clinical symptoms. This was a retrospective study of patients presenting with symptomatic UNE. The performance characteristics of EDX versus ultrasound were calculated using the clinical diagnosis of UNE as the reference standard. Standard EDX studies and US of the ulnar nerve were analyzed. Maximal CSA of the ulnar nerve and EDX severity were analyzed for patients with each combination of US-positive/negative and EDX-positive/negative findings. Analysis was performed on 89 patients and 115 nerves with signs and symptoms of cubital tunnel syndrome. In total, 56 (49%) nerves were diagnosed as mild UNE, 32 (28%) nerves were diagnosed as moderate UNE, 17 (15%) nerves were diagnosed as severe UNE, and 10 (8%) nerves were negative for UNE by EDX. Maximal–maximal CSA was highly correlated with disease severity as determined by nerve conduction studies/electromyography. Compared with EDX+/US+, patients with EDX−/US+ showed higher rates of ulnar sensory loss and elbow tenderness with similar rates of positive Tinel and intrinsic muscle atrophy. In this sample of patients with clinically diagnosed UNE, 91.3% of the patients demonstrated positive EDX studies, whereas 94.8% had a positive US. Ultrasound is an alternative to EDX that could be incorporated clinically in the diagnosis and management of UNE. Ultrasound was able to consistently detect clinically positive cubital tunnel syndrome demonstrating its utility as a confirmatory or supplemental test to the clinical assessment if one is required. Ultrasound additionally may be able to better identify patients with early stages of UNE with negative EDX findings. Diagnostic IV. [ABSTRACT FROM AUTHOR]

Courtney R Carlson Strother,1 Lauren E Dittman,1 Marco Rizzo,1 Steven L Moran,2 Peter C Rhee1 1Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; 2Department of Plastic Surgery, Mayo Clinic, Rochester, MN, USACorrespondence: Peter C Rhee, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA, 55905, Tel +1 507-284-3422, Fax +1 507-266-2533, Email rhee.peter@mayo.eduPurpose: The aim of this study was to evaluate the occurrence of early (< 6 weeks) post-operative complications following ulnar nerve decompressions at the cubital tunnel performed under regional anesthesia compared to those performed under general anesthesia.Methods: In situ ulnar nerve decompressions at the cubital tunnel performed at a single institution from 2012 through 2019 were retrospectively reviewed. Post-operative complications were compared between subjects who underwent the procedure with regional versus general anesthesia.Results: Ninety-one ulnar nerve in situ decompressions were included in the study, which were performed under regional anesthesia in 55 and general anesthesia in 36 cases. The occurrence of post-operative complications was not significantly different between patients who received regional (n = 7) anesthesia and general (n = 8) anesthesia. None of the complications were directly attributed to the type of anesthesia administered. The change in pre- and post-operative McGowan scores were not significantly different between anesthesia groups (p = 0.81).Conclusion: In situ ulnar nerve decompression at the cubital tunnel under regional anesthesia does not result in increased post-operative complications compared to those surgeries performed under general anesthesia. In situ ulnar nerve decompression performed under regional anesthesia is a safe and reliable option for patients who wish to avoid general anesthesia.Level of Evidence: III.Keywords: cubital tunnel, regional anesthesia, ulnar neuropathy

Abstract Background The ulnar nerve has a long and complex anatomical course, originating from the brachial neural plexus in the neck with nerve trunk formation at the posterior neck triangle, and on to the axilla. This intricate anatomical pathway renders the nerve susceptible to compression, direct injury, and traction throughout its course. Compression of the ulnar nerve is the second most common compression neuropathy of the median nerve adjacent to the wrist joint, after carpal tunnel syndrome. Case presentation A 45-year-old Sudanese housewife complained of progressive right forearm and hand muscle wasting, pain, and neuropathic symptoms. She was diagnosed with right-sided cubital tunnel syndrome. The diagnosis was derived intraoperatively from a nerve conduction study suggesting the level of conduction block and recommending decompression. Magnetic resonance imaging was not done preoperatively due to financial limitations. An epineural ganglion (15 × 20 mm2) compressing and flattening the ulnar nerve was diagnosed intraoperatively. Surgical decompression of the ulnar nerve and removal of the epineural ganglion achieved a remarkable postoperative result and pleasing outcome. Conclusion Surgical management is the cornerstone of treatment for compressive neuropathy and ranges from simple nerve decompression to complex neurolysis procedures and nerve transposition to adjust the anatomical course of the nerve.

Percutaneous electrical stimulation has been performed for years with only the assistance of anatomical landmarks. The development of real-time ultrasonography guidance has improved the precision and safety of these percutaneous interventions. Despite ultrasound-guided and palpation-guided procedures being performed routinely for targeting nerve tissues in the upper extremity, the precision and safety of these techniques are unknown. The aim of this cadaveric study was to determine and compare the precision and safety of ultrasound-guided versus palpation-guided needling procedure with and without the handpiece of the ulnar nerve on a cadaveric model. Five physical therapists performed a series of 20 needle insertion tasks each (n = 100), 10 palpation-guided (n = 50) and 10 ultrasound-guided (n = 50) on cryopreserved specimens. The purpose of the procedure was to place the needle in proximity to the ulnar nerve at the cubital tunnel. The distance to target, time performance, accurate rate, number of passes, and unintentional puncture of surrounding structures were compared. The ultrasound-guided procedure was associated with higher accuracy (66% vs. 96%), lower distance from needle to the target (0.48 ± 1.37 vs. 2.01 ± 2.41 mm), and a lower frequency of perineurium puncture (0% vs. 20%) when compared with the palpation-guided procedure. However, the ultrasound-guided procedure required more time (38.33 ± 23.19 vs. 24.57 ± 17.84 s) than the palpation-guided procedure (all, p < 0.001). Our results support the assumption that ultrasound guidance improves the accuracy of needling procedures on the ulnar nerve at the cubital tunnel when compared with palpation guidance. [ABSTRACT FROM AUTHOR]

Abstract Background Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Surgical decompression of the ulnar nerve aims to improve complaints and prevent permanent damage to the nerve. Open and endoscopic release of the cubital tunnel are both used in common practice, but none has proven to be superior. This study assesses patient reported outcome and experience measures (PROMs and PREMs respectively), in addition to objective outcomes of both techniques. Methods A prospective single-center open randomized non-inferiority trial will take place at the Plastic Surgery Department in the Jeroen Bosch Hospital, the Netherlands. 160 patients with cubital tunnel syndrome will be included. Patients are allocated to endoscopic or open cubital tunnel release by randomization. The surgeon and patients are not blinded for treatment allocation. The follow-up time will take 18 months. Discussion Currently, the choice for one of the methods is based on surgeon’s preferences and degree of familiarity with a particular technique. It is assumed that the open technique is easier, faster and cheaper. The endoscopic release, however, has better exposure of the nerve and reduces the chance of damaging the nerve and might decrease scar discomfort. PROMs and PREMs have proven potential to improve the quality of care. Better health care experiences are associated with better clinical outcome in self-reported post-surgical questionnaires. Combining subjective measures with objective outcomes, efficacy, patient treatment experience and safety profile could help differentiating between open and endoscopic cubital tunnel release. This could aid clinicians in evidence based choices towards the best surgical approach in patients with cubital tunnel syndrome. Trial registration This study is registered prospectively with the Dutch Trial Registration under NL9556. Universal Trial Number (WHO-UTN) U1111-1267–3059. Registration date 26–06-2021. The URL: https://www.trialregister.nl/trial/9556

Background: The ulnar nerve has a long and complex anatomical course, originating from the brachial neural plexus in the neck with nerve trunk formation at the posterior neck triangle, and on to the axilla. This intricate anatomical pathway renders the nerve susceptible to compression, direct injury, and traction throughout its course. Compression of the ulnar nerve is the second most common compression neuropathy of the median nerve adjacent to the wrist joint, after carpal tunnel syndrome. Case presentation: A 45-year-old Sudanese housewife complained of progressive right forearm and hand muscle wasting, pain, and neuropathic symptoms. She was diagnosed with right-sided cubital tunnel syndrome. The diagnosis was derived intraoperatively from a nerve conduction study suggesting the level of conduction block and recommending decompression. Magnetic resonance imaging was not done preoperatively due to financial limitations. An epineural ganglion (15 × 20 mm2) compressing and flattening the ulnar nerve was diagnosed intraoperatively. Surgical decompression of the ulnar nerve and removal of the epineural ganglion achieved a remarkable postoperative result and pleasing outcome. Conclusion: Surgical management is the cornerstone of treatment for compressive neuropathy and ranges from simple nerve decompression to complex neurolysis procedures and nerve transposition to adjust the anatomical course of the nerve. [ABSTRACT FROM AUTHOR]

Background: Primary elbow osteoarthritis usually presents with pain and global restriction of range of motion and rarely presents with features of cubital tunnel syndrome. Ulnar claw hand is debilitating to the patient and interferes in the activities of daily living. Cubital tunnel syndrome is a rare presentation of primary elbow OA and can easily be missed. Medial osteophytes and loose bodies from the joints of the elbow (ulno-trochlear and radio-ulnar) can cause compression of the ulnar nerve at the cubital tunnel and present with features of ulnar nerve palsy without substantial symptoms in the elbow. Case report: We present a case of ulnar claw hand due to compression neuropathy in an undiagnosed case of primary OA of the elbow. The patient was thoroughly investigated for about an year for all possible etiologies of the Ulnar nerve palsy the cause of compression was not clearly identified. Radiologically the site of compression was identified to be at the cubital tunnel caused by a medial osteophyte and a loose body arising from the degenerated ulno humeral joint. After a thorough work up ulnar nerve decompression at the cubital tunnel was offered, which involved loose body and osteophyte excision with anterior transposition and debulking the ulno humeral joint. Patient had a good postoperative outcome with recovery of neurological symptoms and grip strength at 6 months, though the wasting persisted. Conclusion: Primary OA of the elbow rarely presents as an ulnar claw hand and has to be kept in mind by the practicing clinician. Ulnar nerve decompression with anterior transposition with loose body excision gives good results.

Epineural scarring following previous carpal or cubital tunnel release can lead to pain and permanent dysfunction. To prevent this cascade, nerve wraps are an option. The purpose of this study was to evaluate outcomes following use of VersaWrap nerve protector during surgical decompression and neurolysis in patients with recurrent compressive neuropathies in the upper extremity. Twenty patients comprised the patient cohort, with a mean postoperative follow-up time of 139 days (range: 42–356 days). There were 13 females and 7 males, with a mean age of 43.4 years. Fourteen surgeries were performed for revision cubital tunnel, 5 for revision carpal tunnel, and 1 for revision radial tunnel syndrome. Average duration of symptoms prior to revision surgery with VersaWrap was 2 years (range 9 months to 6 years). Postoperatively, the mean DASH score was 57.7 and VAS 3.1. Mean s2PD median distribution was 7.3, s2PD ulnar distribution 8.9, m2PD median distribution 6.9 and m2PD ulnar distribution 7.3. All patients had subjective improvement of symptoms and were satisfied with their result. No patients in our cohort required further revisional surgery. In conclusion, the use of VersaWrap as a nerve protector following revision surgery for recurrent compressive neuropathies in the upper extremity was safe and effective.Level of Evidence: IV; retrospective case series

Background: Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Surgical decompression of the ulnar nerve aims to improve complaints and prevent permanent damage to the nerve. Open and endoscopic release of the cubital tunnel are both used in common practice, but none has proven to be superior. This study assesses patient reported outcome and experience measures (PROMs and PREMs respectively), in addition to objective outcomes of both techniques. Methods: A prospective single-center open randomized non-inferiority trial will take place at the Plastic Surgery Department in the Jeroen Bosch Hospital, the Netherlands. 160 patients with cubital tunnel syndrome will be included. Patients are allocated to endoscopic or open cubital tunnel release by randomization. The surgeon and patients are not blinded for treatment allocation. The follow-up time will take 18 months. Discussion: Currently, the choice for one of the methods is based on surgeon's preferences and degree of familiarity with a particular technique. It is assumed that the open technique is easier, faster and cheaper. The endoscopic release, however, has better exposure of the nerve and reduces the chance of damaging the nerve and might decrease scar discomfort. PROMs and PREMs have proven potential to improve the quality of care. Better health care experiences are associated with better clinical outcome in self-reported post-surgical questionnaires. Combining subjective measures with objective outcomes, efficacy, patient treatment experience and safety profile could help differentiating between open and endoscopic cubital tunnel release. This could aid clinicians in evidence based choices towards the best surgical approach in patients with cubital tunnel syndrome. Trial registration: This study is registered prospectively with the Dutch Trial Registration under NL9556. Universal Trial Number (WHO-UTN) U1111-1267–3059. Registration date 26–06-2021. The URL: https://www.trialregister.nl/trial/9556 [ABSTRACT FROM AUTHOR]

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome. A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods. A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4–4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9–4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error. The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1–3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms. Patient-reported outcomes may have varied responsiveness depending on the condition studied. [ABSTRACT FROM AUTHOR]

Introduction: The anconeus epitrochlearis (AE) muscle is an accessory muscle located between the medial cortex of the olecranon and the inferior surface of the medial epicondyle, posterior to the ulnar nerve. This muscle may compress the ulnar nerve causing a clinical neuropathy. We aimed to determine the gender and side characteristics of the AE muscle in patients who underwent elbow magnetic resonance imaging (MRI) and report its prevalence in a Turkish population. Materials and methods: A total of 209 patients (210 elbows) who underwent elbow MRI between January and December 2020 were retrospectively evaluated. Cases with the AE muscle were included in the study. The craniocaudal (CC) dimension was examined from the coronal section, and the transverse (TR) and anteroposterior (AP) dimensions from the axial sections. Statistical analyses were performed to determine the relationship between the presence of the AE muscle and age, gender, and side (right/left). Differences between sexes and sides in terms of muscle sizes were evaluated using statistical tests. Results: The AE muscle was detected in 17 patients (18 elbows) (8.1%). The mean age of the patients was 41.52 ± 14.63 years. There was no statistically significant difference between the male and female patients in terms of age. This accessory muscle was found in nine female (9.8%) and eight male (6.3%) patients in total. There was one (0.5%) patient with the bilateral AE muscle, who was female. The accessory muscle was located in the right elbow in 13 patients (10.71%), and left elbow in five (4.10%). It was more common in the right elbow in both genders. The muscle was larger in the male patients and the right elbow, but this was not statistically significant. Conclusion: The prevalence of the AE muscle was determined to be 8.1% in a Turkish population, and this muscle was more common among the women and in the right elbow. [ABSTRACT FROM AUTHOR]

Objective: Carpal tunnel syndrome (CTS) and Cubital tunnel syndrome (CuTS) are the median nerve compressions under the carpal ligament and ulnar nerve at the wrist, the most common peripheral nerve entrapment of the upper extremity. The fatty tissue due to the high body mass index (BMI) differs the severity of the entrapment symptoms. The study aims to evaluate the association between BMI and symptoms of CTS and CuTS by analyzing the patients whose entrapments are at the same extremity and onset at the same time. Method: The patients were divided into two groups according to the neuropathy sit (CTS and CuTS) and four subgroups according to the BMI (Overweight, grade 1 obese, grade 2 obese, and morbidly obese). All patients were followed up with EMG and performance scale before and after surgical treatment. Results: A total of 31 patients were included in the study. The mean BMI of the patients was 29.63 kg/m². The average BMI of male patients was 29.02 kg/m², while the average BMI of female patients was 30.3 kg/m². Conclusion: In contrast to the previous hypotheses that claim the high body mass index increases the severity of CTS but reduces the formation of CuTS, our study revealed that body mass index was not related to the severity of symptoms. [ABSTRACT FROM AUTHOR]

Purpose: Despite its widespread prevalence, the cost of cubital tunnel syndrome (CuTS) in the United States to patients and insurers is not well understood. The purpose of this study was to quantify the direct payments associated with operative treatment of CuTS. We hypothesized that CuTS represents a substantial cost to the payer in facility fees, surgeon fees and other expenses., Methods: Utilizing the MarketScan database of insured patients (commercial and Medicaid), we identified a cohort of 41,777 patients aged 18-64 years with surgically treated CuTS from 2006 to 2018. We estimated the median 90-day payments from encounters associated with cubital tunnel release (CuTR) and/or ulnar nerve transposition surgery by summing all payments for claims within 90 days after the index surgery. Published estimates of the annual number of cubital tunnel surgeries were used to calculate the annual expenditure., Results: Of 41,777 patients, the median (interquartile range [IQR]) values of total direct payments were $5,522 [$3,426, $9,541]. With an estimated 94,645 cases/year, this leads to an annual payment of more than $522 million. Index facility payments (median[IQR] $2,555 [$1,359, $4,708] were the highest, followed by index provider payments ($1,691 [$1,328, $2,217]). The median index surgeon payment (median[IQR] $905 [$707, $1,184]) represented just over half of the provider payments. Post-operative care had a median [IQR] payment of $377 ($424, $1,987). Limitations of claims databases prevented assessment of other indirect costs associated with cubital tunnel surgery., Conclusions: Payments for the surgical treatment of CuTS from the index surgery to 90 days post-operatively have an estimated median of $5,522 per patient, totaling $52 million annually. Index facility fees are responsible for more than 46% of payments, while index payments to surgeons represent approximately 16%. Defining this data is critical to understanding one component of the economic impact of CuTS., Level of Evidence: Level IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: We investigated the differences in the prevalence of ulnar nerve instability (UNI) by hand dominance and evaluated the relationship between UNI and morphologic changes in the ulnar nerve and the clinical findings and upper limb function. Methods: This study examined 153 healthy participants (n = 306 elbows; 44 men, 112 women; mean age 65.4 years) who underwent ultrasonography to assess the ulnar nerve cross-sectional area (UNCSA) at three points of the bilateral cubital tunnel at 30° of elbow flexion. Participants were divided into three groups based on the ultrasonography findings of UNI: no instability (type N), subluxation (type S), and dislocation (type D). For the dominant and nondominant sides, we assessed the relationship between the UNCSA and clinical factors, including the age, gender, height, weight, body mass index, fat mass, grip strength, key pinch strength, UNCSA, and Patient-Rated Elbow Evaluation score. Results: We identified 75 cases without instability in both elbows and 78 cases with some instability. The prevalence of UNI was 51%. No significant difference was found between hand dominance and the prevalence of UNI. The UNCSA at 1 cm proximal to the medial epicondyle on the bilateral sides in type S was the most increased among three types. Conclusion: UNI was identified in almost half of the participants, with no marked difference found in the hand dominance. The UNCSA at 1 cm proximal to the medial epicondyle was significantly increased the most in type S. UNI does not appear to be associated with elbow symptoms in the general population.

Objective: Carpal tunnel syndrome (CTS) and Cubital tunnel syndrome (CuTS) are the median nerve compressions under the carpal ligament and ulnar nerve at the wrist, the most common peripheral nerve entrapment of the upper extremity. The fatty tissue due to the high body mass index (BMI) differs the severity of the entrapment symptoms. The study aims to evaluate the association between BMI and symptoms of CTS and CuTS by analyzing the patients whose entrapments are at the same extremity and onset at the same time. Method: The patients were divided into two groups according to the neuropathy sit (CTS and CuTS) and four subgroups according to the BMI (Overweight, grade 1 obese, grade 2 obese, and morbidly obese). All patients were followed up with EMG and performance scale before and after surgical treatment. Results: A total of 31 patients were included in the study. The mean BMI of the patients was 29.63 kg/m2. The average BMI of male patients was 29.02 kg/m2, while the average BMI of female patients was 30.3 kg/m2. Conclusion: In contrast to the previous hypotheses that claim the high body mass index increases the severity of CTS but reduces the formation of CuTS, our study revealed that body mass index was not related to the severity of symptoms.

Percutaneous electrical stimulation has been performed for years with only the assistance of anatomical landmarks. The development of real-time ultrasonography guidance has improved the precision and safety of these percutaneous interventions. Despite ultrasound-guided and palpation-guided procedures being performed routinely for targeting nerve tissues in the upper extremity, the precision and safety of these techniques are unknown. The aim of this cadaveric study was to determine and compare the precision and safety of ultrasound-guided versus palpation-guided needling procedure with and without the handpiece of the ulnar nerve on a cadaveric model. Five physical therapists performed a series of 20 needle insertion tasks each (n = 100), 10 palpation-guided (n = 50) and 10 ultrasound-guided (n = 50) on cryopreserved specimens. The purpose of the procedure was to place the needle in proximity to the ulnar nerve at the cubital tunnel. The distance to target, time performance, accurate rate, number of passes, and unintentional puncture of surrounding structures were compared. The ultrasound-guided procedure was associated with higher accuracy (66% vs. 96%), lower distance from needle to the target (0.48 ± 1.37 vs. 2.01 ± 2.41 mm), and a lower frequency of perineurium puncture (0% vs. 20%) when compared with the palpation-guided procedure. However, the ultrasound-guided procedure required more time (38.33 ± 23.19 vs. 24.57 ± 17.84 s) than the palpation-guided procedure (all, p < 0.001). Our results support the assumption that ultrasound guidance improves the accuracy of needling procedures on the ulnar nerve at the cubital tunnel when compared with palpation guidance.

Ulnar nerve is one of the terminal branches of the medial cord of brachial plexus. Owing to its superficial location and unprotected course ulnar nerve is susceptible to physical impingement at specific sites. Although clinical and electrophysiological assessment can diagnose ulnar neuropathy and site of compression, they do not provide aetiological information which is important for management. High Resolution Ultrasonography (HRUS) is a non invasive imaging tool that has been used widely to evaluate peripheral nerves. In the present case series, HRUS imaging findings in seven distinct cases of entrapment of ulnar nerve or its branches are presented. In cases 1, 2, 3 and 4, ulnar nerve was entrapped at the elbow; by synovial thickening due to degeneration, claw osteophyte arising from ulna, synovial cyst and epineural ganglion cyst respectively. In cases 5 and 6, ulnar nerve was entrapped at the wrist by a pisotriquetral ganglion cyst and an ulnar artery pseudoaneurysm respectively. In case 7, the Dorsal Cutaneous Branch (DCB) of ulnar nerve was entrapped over the Extensor Carpi Ulnaris (ECU) tendon. In all the aforementioned cases, HRUS accurately identified the site of entrapment, the status of ulnar nerve and the underlying cause of entrapment, which was subsequently confirmed surgically. The non invasive, inexpensive and accurate qualities make HRUS a potential first line imaging tool in the evaluation of entrapment neuropathies of superficial nerves. [ABSTRACT FROM AUTHOR]

Compression of peripheral nerves and associated syndromes are of importance to a variety of clinical practitioners. They represent a common elective orthopaedic pathology with clinical assessment and knowledge of underlying pathological processes critical to their diagnosis and management. Peripheral nerve compression syndromes of the median, ulnar, and less commonly, radial nerves, are primarily a clinical diagnosis, with the need for further investigation based on specific pathology suspected. Both non-operative and operative treatments play key roles in their management depending on exact aetiology and severity of compressive neuropathy encountered. Carpal tunnel and cubital tunnel syndromes represent the majority of presentations; however, knowledge and understanding of other potential sites of compression, as well as differential diagnosis for upper limb neurological symptoms is crucial to ensuring holistic and appropriate management of these patients. [ABSTRACT FROM AUTHOR]

Ulnar nerve is one of the terminal branches of the medial cord of brachial plexus. Owing to its superficial location and unprotected course ulnar nerve is susceptible to physical impingement at specific sites. Although clinical and electrophysiological assessment can diagnose ulnar neuropathy and site of compression, they do not provide aetiological information which is important for management. High Resolution Ultrasonography (HRUS) is a non invasive imaging tool that has been used widely to evaluate peripheral nerves. In the present case series, HRUS imaging findings in seven distinct cases of entrapment of ulnar nerve or its branches are presented. In cases 1, 2, 3 and 4, ulnar nerve was entrapped at the elbow; by synovial thickening due to degeneration, claw osteophyte arising from ulna, synovial cyst and epineural ganglion cyst respectively. In cases 5 and 6, ulnar nerve was entrapped at the wrist by a pisotriquetral ganglion cyst and an ulnar artery pseudoaneurysm respectively. In case 7, the Dorsal Cutaneous Branch (DCB) of ulnar nerve was entrapped over the Extensor Carpi Ulnaris (ECU) tendon. In all the aforementioned cases, HRUS accurately identified the site of entrapment, the status of ulnar nerve and the underlying cause of entrapment, which was subsequently confirmed surgically. The non invasive, inexpensive and accurate qualities make HRUS a potential first line imaging tool in the evaluation of entrapment neuropathies of superficial nerves.

Three major arteries supplying the ulnar nerve in the cubital tunnel are commonly known. However, their vascular territories (angiosomes) have not been described yet. Contrast-enhanced ultrasound was used to identify the angiosomes of posterior ulnar recurrent artery, inferior ulnar collateral artery and superior ulnar collateral artery in 20 fresh, non-frozen human body donors. The arteries were cannulated, and physiologic blood flow was simulated. Contrast agent was applied in each vessel in a randomized sequence, and the length of the contrast-enhancing ulnar nerve segment was measured by a radiologist blinded to the sequence. The angiosome of the posterior ulnar recurrent artery overlaps both other angiosomes. It fully covers the cubital tunnel in 63.6% of specimens. In addition, collateral flow via nerve and muscle branches of the arterial anastomotic network around the elbow (rete articulare cubiti) partly maintains the intra-neural blood flow in the absence of a vascular pedicle. The posterior ulnar recurrent artery is the dominant nutrient vessel of the ulnar nerve in the cubital tunnel. A potential watershed zone exists proximal to the Osborne ligament. Knowledge of these angiosomes may advance surgery of the ulnar nerve in the cubital tunnel. [ABSTRACT FROM AUTHOR]

Background: The gold standard for surgical treatment of cubital tunnel syndrome is in situ decompression. However, this procedure does not come without complications. Subluxation of the ulnar nerve and ulnar nerve neuritis from adhesion formation remain 2 potential complications after this procedure. It has been shown in the literature that young, active, male patients are most likely to have these complications postoperatively. We have developed a modification to in situ decompression by developing a fascial turnover flap and using a porcine submucosa extracellular matrix (Axogen) to help reduce both ulnar nerve subluxation and adhesion formation postoperatively. Methods: Thirteen patients underwent cubital tunnel surgery by the highlighted technique to prevent postoperative ulnar nerve subluxation and adhesion formation. Patient outcomes including elbow range of motion, functional status, paresthesia, and grip strength were recorded. Results: Of the 13 patients, 10 had excellent results, 1 had a good result, and 2 required revision with anterior transposition of the nerve. The mean Mayo Elbow Performance Score of the 11 patients not needing revision was 92.7. Conclusion: The described surgical technique provides surgeons with the ability to directly decompress the ulnar nerve while decreasing postoperative complications such as instability and adhesion formation.

The purpose of this study was to examine the effect of follow-up time on revision rates of in situ decompression and ulnar nerve transposition for the surgical treatment of cubital tunnel syndrome. A comprehensive literature search was performed to identify prospective and retrospective primary comparison studies assessing the revision rates of in situ decompression and ulnar nerve transposition for the treatment of cubital tunnel syndrome. Meta-regression analyses were used to assess the effect of average study follow-up on the revision rates of both cubital tunnel syndrome treatments. Modeling results were then used to estimate revision rates between decompression and transposition at increasing follow-up times. Sixteen studies including 2,225 patients were included. Average study follow-up time was a statistically significant moderator of revision rates. Model predictions show that in situ decompression operations had an increased risk for revision as compared to ulnar transposition after 48 months of follow-up. In studies with follow-up time ≥48 months, revision rates for in situ decompression (11.9%) were significantly greater than in ulnar transposition (3.2%). In situ decompression for cubital tunnel syndrome is associated with an increased risk of revision surgery as compared to ulnar nerve transposition, particularly when assessed at longer follow-up intervals. The effect of follow-up duration on revision rates demonstrates the need for additional studies to compare outcomes of these operative approaches at follow-up times ≥48 months. This study provides evidence that ulnar nerve transposition may ultimately lead to lower revision rates and demonstrates the need for prospective, randomized trials to corroborate this effect., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Reichenbach et al.)