Anterior subcutaneous transposition of the ulnar nerve

Anterior, subcutaneous ulnar nerve transposition decompresses the ulnar nerve and, by transposing anterior to the medial epicondyle, eliminates longitudinal traction forces applied to the nerve during elbow flexion. This article reviews the indications and contraindications of the technique and describes the surgical technique in detail.     

Anterior intramuscular transposition of the ulnar nerve

Anterior intramuscular transposition is a seldom considered alternative to other surgical methods in management of cubital tunnel syndrome. Placement of the ulnar nerve anteriorly within the flexor-pronator mass removes it from a vulnerable subcutaneous position without extensive dissection. Of 52 sequential procedures, 45 extremities in 40 persons were available for follow-up (mean, 28 months after operation). By use of a 12-point scale of objective and subjective parameters, there were 87% good or excellent results; 4% were graded fair, and 9% were graded poor. Age, duration of symptoms, and conduction velocity were not of prognostic value. Although 69% of patients had other compressive neuropathy or tendinitis, this did not adversely affect results. Those with changes seen by electromyogram or work-related compensable injury had a poorer prognosis.     

带血管蒂尺神经肌筋膜下前置术治疗中度肘管综合征

[目的]评价带血管蒂尺神经肌筋膜下前置术治疗中度肘管综合征的疗效。[方法]通过对6例防腐成人上肢标本观察测量肘部尺神经血供来源和血管外径及血管长度的相关数据,对30例中度肘管综合征患者,分为两组,分别采用带血管蒂尺神经肌筋膜下前置术和单纯肌筋膜下前置术,参照中华医学会手外科学会制定的尺神经修复后功能评定试用标准,Lascar分级法和术前术后尺神经神经电生理变化,对疗效进行评价比较。[结果]尺神经的营养伴行血管有3条。伴神经走行的长度分别为尺侧上副动脉(144.0±3.3)mm、尺侧下副动脉(47.6±7.2)mm、尺侧返动脉后支(66.2±8.3)mm。带血管尺神经筋膜下前置术优良率为93.3%,单纯肌筋膜下前置术优良率为80%,两组比较差异有统计学意义。神经电生理检查:带血管尺神经肌筋膜下前置术优于单纯肌筋膜下前置术,两组比较差异有统计学意义。[结论]带血管蒂尺神经肌筋膜下前置术疗效可靠,方法简便,是治疗中度肘管综合征的有效方法。     

Anterior intramuscular transposition with ulnar nerve decompression at the elbow

The effectiveness of decompression and anterior intramuscular transposition of the ulnar nerve for treatment of severe cubital tunnel syndrome was evaluated. A consecutive series of 39 anterior intramuscular transpositions were reviewed. One surgeon performed the transpositions between 1993 and 1997 in 34 patients who presented with clinically severe cubital tunnel syndrome. Clinical outcome and satisfaction with surgery were assessed. The results showed early clinical improvement of 77% of patients (mean followup, 3.34 months). With repeated assessments later, the same group of patients had clinical improvement of 62% (mean followup, 30.9 months). Patients younger than 50 years, individuals who underwent external neurolysis, or patients who had a previously failed subcutaneous transposition had fewer satisfactory results.     

Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling

Sixteen elbows of fourteen patients were analyzed five to sixty months after treatment for ulnar neuritis or neuropathy by anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling to maintain the anterior position. This procedure creates a septum in the mid-lateral plane that lies posterior to the transposed nerve at the level of the medial epicondyle. Unlike previous procedures, no structure other than subcutaneous fat is located superficial to the nerve. Seven patients were baseball pitchers who had experienced transient but severe ulnarnerve paresthesias during the act of throwing. Of the sixteen extremities only one, the limb of a severely diabetic patient with bilateral ulnar neuropathy, was not relieved of preoperative complaints. There were no complications. The procedure is simple, postoperative immobilization is needed for only a brief period, and rehabilitation is rapid.     

尺神经肌下前置术治疗肘管综合征

目的 探讨尺神经松解加肌下前置术治疗肘管综合征的有效性。方法 观测２０例成人尸体上肢标本及３２例患者尺神经移置前后的解剖变化,临床应用３２例。结果 尺侧上副动脉可与尺神经一前置;皮下前置伸肘位时尺神经易受牵拉,肌下前置伸、屈肘时均不受牵拉;新肘管可充分容纳尺神经。３２例中获完整随访２６例。随访期１～３年,１６例（６１．５％）恢复正常。结论 尺神经松解加肌下前置术为治疗肘管综合征较佳术式。     

Submuscular transposition of the ulnar nerve

A retrospective study of 26 submuscular ulnar nerve transpositions was performed with the specific use of grip and pinch analysis to evaluate this form of objective testing. Twenty-six patients were treated by submuscular transposition of the ulnar nerve between 1981 and 1985 and were followed an average of 21 months. Preoperative and postoperative analysis consisted of subjective questioning, clinical examination, quantitative two-point discrimination, quantitative pinch and grip analysis, and electromyographic (EMG) and nerve conduction velocity (NCV) evaluation. Many of the patients suffered from associated problems such as alcohol abuse, diabetes mellitus, and concurrent Guyon's canal compression, which adversely affected the outcome. Subjectively, 62% were improved, 31% were no better, and 7% were worse. Clinical examination demonstrated 46% improved, 35% no better, and 19% worse. Quantitative two-point discrimination was better in 59%, unchanged in 26%, and worse in 15%. Quantitative pinch and grip analysis revealed 28% improved, 56% with little improvement, or the same, and 16% worse, while EMG/NCV showed one-third of the patients in each category postoperatively. Quantitative pinch and grip analysis provided good preoperative and postoperative documentation, which is absent from previous studies in the literature concerning ulnar nerve transportation.     

Stabilized subcutaneous transposition of the ulnar nerve

We treated 50 patients (average age 47.9 years) with a stabilized subcutaneous transposition of the ulnar nerve. The average follow-up period was 42.4 months. The indication was cubital tunnel syndrome in 19 patients and injuries around the elbow in 31 patients. Postoperatively, satisfactory results were obtained in all the patients, and there was no complication or aggravation of the preoperative symptoms. None of the patients experienced slipping back of the nerve to the cubital tunnel. In the 31 patients with injuries around the elbow, there was only one patient with transient aggravation of parasthaesiae in the ulnar nerve region. Stabilized subcutaneous transposition is a simple and less invasive procedure that can facilitate decompression and prevent slipping back of the nerve. This procedure also can be applied to patients with injuries around the elbow that require ulnar nerve transfer.

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Résumé Nous avons traité 50 malades (âge moyen 47.9 années) avec une transposition sous-cutanée stabilisée du nerf cubital. La durée du suivi moyen était 42.4 mois. L'indication était un syndrome du tunnel cubital chez 19 malades et une blessure autour du coude chez 31 malades. Des résultats post-opératoires satisfaisants ont été obtenus pour tous les malades, et il n'y avait aucune complication ou aggravation des symptômes pré-opératoires. Aucun des malades n'a souffert du recul du nerf cubital en arrière. Chez les 31 malades avec une blessure, seulement un patient a eu une aggravation transitoire des paresthésies dans le territoire cubital. La transposition sous-cutanée stabilisée est une procédure simple et moins envahissante qui peut faciliter la décompression et prévenir le déplacement du nerf en arrière. Cette procédure peut aussi être appliquée aux malades avec une blessure du coude qui exige un transfert cubital.

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First presented at the SICOT World Congress 2002, San Diego, California, USA     

Anterior submuscular transposition of the ulnar nerve. For post-operative focal neuropathy at the elbow

Outcome studies of revision surgical treatment for recurrent or persistent neuropathy of the ulnar nerve at the elbow are relatively rare and none involves patient self-assessment. In this study of 40 patients (41 elbows), a clear discrepancy is shown between clinical assessment and the patient's own view. From clinical assessment, 20% of patients had an excellent result, whereas only one (2.5%) patient self-reported a complete cure. More reports using patient self-assessment and validated scores are required.     

Modified intramuscular transposition of the ulnar nerve

The ulnar nerve passes posterior to the medial epicondyle and experiences longitudinal strain when subjected to elbow flexion. Furthermore, Osborne's ligament and the arcade of fibers between the 2 heads of the flexor carpi ulnaris (Osborne's fascia) compress the nerve during elbow flexion with narrowing of the cubital tunnel passageway. Some patients experience the added element of nerve subluxation over the posterior edge of the epicondyle. When changes to daytime ergonomic behavior and sleep posture prove insufficient to relieve a patient's symptoms, surgical treatment is warranted. A range of procedures exists from simple decompression, to medial epicondylectomy, to anterior transposition. Transposition has been the most widely used method of treatment with the final position of the nerve lying subcutaneous, intramuscular, or submuscular. Each of the transposition methods has proponents with a variety of arguments made in favor of specific aspects of the surgery. This article presents a form of anterior transposition that seeks to draw the best elements from previously reported techniques with the goal of optimizing results.     

Anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome. Personal experience

AIM: The authors report the results of anterior submuscular transposition, on a clinical series of selected patients with severe cubital tunnel syndrome. In these patients, the degree of ulnar nerve compression was valued using a grading system that includes measurements of motor and sensitive function. In this series, a technique of flexor-pronator mass Z-lengthening was adopted. METHODS: From 1998 to 2002, 18 patients were surgically treated with anterior deep submuscular transposition for cubital tunnel syndrome. The preoperative status was determined using Dellon's classification. Fifteen out of 18 patients were graded as Dellon's grade 3 (severe syndrome). The mean duration of follow-up after surgery was 27.6 months. RESULTS: Postoperative outcome was assessed in all the 15 patients according to a modified Bishop scoring system. Based on this score, 6 patients (40%) were graded as excellent, 7 (47%) were graded as good and 2 (13%) were graded as fair. The complete recovery occurred about 6 months after surgery. None complication was observed. CONCLUSION: Treatment of severe cubital syndrome by means of a technique of flexor-pronator mass Z-lengthening was linked to 87% rate of good to excellent results. The present study demonstrate the feasibility of this technique with restitutio ad integrum in spite of the severity of the syndrome. None failure nor recurrence was present in this series.     

Anterior transposition for advanced ulnar neuropathy at the elbow

Previous studies have shown good clinical results after anterior transposition of the ulnar nerve for compression neuropathy. However, it has been suggested that younger patients with a shorter duration of preoperative symptoms benefit most from surgical therapy. To determine what factors adversely affect the prognosis in patients with advanced disease, 23 of 24 anterior transpositions performed consecutively over 6 years were observed at a mean of 33.2 months. The mean age was 52.1 years. Symptoms were present for a mean of 11.3 months. Before the operation, 30% were graded moderate and 70% severe. After the operation, 70% of the patients improved, with 40% having a good result and 30% fair. Advanced age, duration of preoperative symptoms, diabetes, hypertension, alcoholism, etiology, type of transposition, tourniquet time, or atrophy did not predict a poor outcome. Severe clinical findings confirmed by electrophysiologic studies did not contraindicate surgery or preclude a reasonable rate of success in this small but relatively homogeneous group of patients.     

Operative position for ulnar nerve transposition

An improved method of operative positioning of a patient for ulnar nerve transposition is described. It lends itself admirably in any procedure requiring approach to the mesial aspect of the elbow.     

尺神经肌下前置术与皮下前置术治疗肘管综合征的Meta分析

目的 :通过Meta分析对尺神经皮下前置术(ASCT)与肌下前置术(ASMT)治疗肘管综合征的有效性和安全性进行比较。方法:按照Cochrane系统评价方法,计算机检索Medline,荷兰医学文摘(EMBase),Cochrane图书馆、Cochrane协作网专业实验数据库、中国生物医学文献数据库(CBM)、CNKI等,并采用手工检索方法收集相关随机对照试验及半随机对照试验。采用Review Manager 5.3软件进行Meta分析。结果:共纳入7个研究,Meta分析结果显示:尺神经皮下前置术与肌下前置术治疗肘管综合征在手术后小指指端两点辨别觉、手术优良率、手术并发症、手术切口长度方面差异无统计学意义。在手术时间方面,皮下前置术较肌下前置术短。结论:皮下前置术(ASCT)与肌下前置术(ASMT)均是治疗肘管综合征的有效方法。尺神经皮下前置术操作简单,手术后无须进一步固定,恢复较快,尤其适用于肥胖及老年患者。尺神经肌下前置术适用范围较广但操作较复杂。由于部分文献质量不高,可能存在各种偏移,需要更多高质量的随机对照试验来得出更可靠的结论。     

Patient self-reported outcome after ulnar nerve transposition

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).     

Anterior submuscular transposition of the ulnar nerves by the Learmonth technique

Thirty-eight patients with progressive posttraumatic ulnar neuropathy at the elbow underwent anterior submuscular transposition of their nerves. Multiple mechanical causes of neuropathy were identified. Fourteen patients had undergone previous surgery for ulnar neuropathy, while 24 had not. Postsurgical follow-up averaged 23.1 months. The operative technique is described and illustrated in detail. Complications attributable to surgery were minimal. No absolute prognostic factors could be identified, and even those patients with significant muscular atrophy or time delay before operation were generally benefited. If prior surgery had induced significant scarring and neural damage, the prognosis for recovery was considerably worse, as it also was for patients who had severe preoperative dysesthesia or pain. Four patients thought to represent examples of double crush or compression syndrome were identified.     

Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries

Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.