Morphological Changes of Medial Epicondyle-Olecranon Ligament and Ulnar Nerve in the Cubital Tunnel Syndrome: An Ultrasonic Study.

OBJECTIVE: Few studies have performed detailed ultrasound measurements of medial epicondyle-olecranon (MEO) ligament that cause the entrapment of ulnar nerve. This study aims to comprehensively evaluate dynamic ultrasonographic characteristics of MEO ligament and ulnar nerve for clinical diagnosis and accurate treatment of cubital tunnel syndrome (CuTS). METHODS: Thirty CuTS patients (CuTS group) and sixteen healthy volunteers (control group) who underwent ultrasound scanning from October 2016 to October 2020 were retrospectively collected, with 30 elbows in each group. Primary outcomes were thickness at six points, length and width of MEO ligament. Secondary outcomes were thickness of ulnar nerve under MEO ligament at seven parts and the cross-sectional area (CSA) of ulnar nerve at proximal end of MEO ligament (P0 mm ). The thickness of MEO ligament and ulnar nerve in different points of each group was compared by one-way ANOVA analysis with Bonferroni post hoc test, other outcomes were compared between two elbow positions or two groups using independent-samples t test. RESULTS: Thickness of MEO ligament in CuTS group at epicondyle end, midpoint in transverse view, olecranon end, proximal end, midpoint in axial view, and distal end was 0.67 ± 0.31, 0.37 ± 0.18, 0.89 ± 0.35, 0.39 ± 0.21, 0.51 ± 0.38, 0.36 ± 0.25 at elbow extension, 0.68 ± 0.34, 0.38 ± 0.27, 0.77 ± 0.39, 0.32 ± 0.20, 0.48 ± 0.22, 0.32 ± 0.12 (mm) at elbow flexion, respectively. Compared with control group, they were significantly thickened except for proximal end at elbow flexion. MEO ligament thickness at epicondyle end and olecranon end was significantly larger than midpoint in two groups. No significant difference was found in length and width of MEO ligament among different comparisons. Ulnar nerve thickness at 5 mm proximal to MEO ligament (P5 mm , 3.25 ± 0.66 mm) was significantly increased than midpoint of MEO ligament (Mid), distal end of MEO ligament (D0 mm ), 5 mm (D5 mm ), 10 mm (D10 mm ) distal to MEO ligament at extension in CuTS group. Compared with control group, ulnar nerve thickness at P5 mm in CuTS group was significantly increased at extension position, at D5 mm and D10 mm was significantly decreased at flexion position. CSA of ulnar nerve at extension position (14.44 ± 4.65 mm2 ) was significantly larger than flexion position (11.83 ± 3.66 mm2 ) in CuTS group, and CuTS group was significantly larger than control group at two positions. CONCLUSIONS: MEO ligament in CuTS patients was thickened, which compressed ulnar nerve and caused its proximal end swelling. Ultrasonic image of MEO ligament thickness was a significant indicator for CuTS and can guide surgeons in selecting the appropriate treatment.

Ultrasound-Assisted Precise In Situ Decompression for Cubital Tunnel Syndrome.

OBJECTIVE: To explore the effect of locating the ulnar nerve compression sites and guiding the small incision so as to decompress the ulnar nerve in situ on the elbow by high-frequency ultrasound before operation. METHODS: A retrospective analysis was conducted on 56 patients who underwent ultrasound-assisted in situ decompression for cubital tunnel syndrome from May 2018 to August 2019. The patients' average age was 51.13 ± 7.35 years, mean duration of symptoms was 6.51 ± 1.96 months, and mean postoperative follow-up was 6.07 ± 0.82 months. Nine patients had Dellon's stage mild, 39 had stage moderate, and eight had stage severe. Ultrasound and electromyography were completed in all patients before operation. The presence of ulnar nerve compressive lesion, the specific location, and the reason and extent of compression were determined by ultrasound. A small incision in situ surgery was given to decompress the ulnar nerve according to the pre-defined compressive sites. RESULTS: All patients underwent in situ decompression. The compression sites around the elbow were as follows: two in the arcade of Struthers, one in the medial intermuscular septum, four in the anconeus epitrochlearis muscle, five beside the cyst of the proximal flexor carpi ulnaris (FCU), and the remaining 44 cases were all from the compression between Osborne's ligament to the two heads of the FCU. The compression localizations diagnosed by ultrasound were confirmed by operations. Preoperative ultrasound confirmed no ulnar nerve subluxation in all cases. The postoperative outcomes were satisfactory. There was no recurrence or aggravation of symptoms in this group of patients according to the modified Bishop scoring system; results showed that 43 cases were excellent, 10 were good, and three were fair. CONCLUSIONS: High-frequency ultrasound can accurately and comprehensively evaluate the ulnar nerve compression and the surrounding tissues, thus providing significant guidance for the precise minimally invasive treatment of ulnar nerve compression.

Outcomes of Surgical Management of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Bayesian Perspective.

PURPOSE: To provide a summary of the relevant evidence on outcomes of transaxillary first rib excision (TAFRE), supraclavicular first rib excision with scalenectomy (SCFRE), and supraclavicular release leaving the first rib intact (SCR) for patients with neurogenic thoracic outlet syndrome (TOS), and interpret the treatment effects from a Bayesian perspective. METHODS: A systematic literature search and review were performed. Random-effects meta-analyses were conducted to estimate success rate and complete relief rate of each procedure. The probabilities of specified success rates and complete relief rates were calculated using a Bayesian method. Sensitivity analyses for TOS type, neck trauma, and cervical rib were performed. Complications of each procedure were also reviewed. RESULTS: Data were extracted from 17 studies of TAFRE, 9 of SCFRE, and 14 of SCR to conduct the meta-analyses. The pooled success rate and complete relief rate were 0.76 (95% confidence interval [95% CI)], 0.65-0.85) and 0.53 (95% CI, 0.38-0.68) for TAFRE, 0.77 (95% CI, 0.68-0.85) and 0.57 (95% CI, 0.41-0.72) for SCFRE, and 0.85 (95% CI, 0.76-0.92) and 0.61 (95% CI, 0.35-0.84) for SCR, respectively. The probabilities of success rate greater than 70% were 90%, 87%, and 99% for TAFRE, SCFRE, and SCR, respectively. If the success rate of 80% or greater was considered, the probabilities were 34%, 31%, and 91%, respectively. The probabilities of complete relief rate of 50% or greater were 67%, 71%, and 69% for TAFRE, SCFRE, and SCR, respectively. Sensitivity analyses showed similar results. The complication rates for TAFRE, SCFRE, and SCR were, respectively, 22.5%, 25.9%, and 12.6%. CONCLUSIONS: The SCR has a high probability of success rate greater than 80%; both TAFRE and SCFRE have high probabilities of a success rate greater than 70% but only low probabilities of success rate greater than 80%. The TAFRE and SCFRE have more complications than SCR. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Wide-Awake Hand Surgery in Two Centers in China: Experience in Nantong and Tianjin with 12,000 patients.

This article summarizes the application of local anesthesia no tourniquet in 2 hand surgery centers in China, Nantong and Tianjin, where more than 12,000 patients were operated on with the new approach. This approach achieves excellent anesthetic and vasoconstrictive effects. In Nantong, surgeons performed fracture fixation, soft tissue tumor excision, and flap transfer in the hand with this approach. In Tianjin, surgeons applied it to cases of hand trauma emergency surgery. The authors' experience shows that this approach to hand surgery is safe, economical, and patient friendly, with no increase in infection rate.

Performing Hand Surgery Under Local Anesthesia Without a Tourniquet in China.

In China, wide-awake surgeries are increasingly used by surgeons in a growing number of hospitals for hand and upper extremity surgeries. Experience suggests that wide-awake surgery is safe, economical, and patient-friendly, optimizing hospital resource allocation and increasing efficiency. This article discusses which procedures are most suitable, variations in procedures, departmental impacts, and future direction.

Strong Digital Flexor Tendon Repair, Extension-Flexion Test, and Early Active Flexion: Experience in 300 Tendons.

Over the past 2 decades, repair and rehabilitation methods of primary repair of the digital flexor tendon have changed. In this article, we outline interim results from ongoing investigations in several units. Surgeons in these units now perform digital flexor tendon repairs according to a treatment protocol. Before adopting the protocol, they had no history of tendon-related research; they had not used any of the repair and rehabilitation methods described in the protocol. The surgeons involved are junior or midlevel attending surgeons. At the end of this article, we outline current practice of digital flexor tendon repair in Asian countries.

Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures.

OBJECTIVES: The aim of this study was to assess the cost effectiveness of multiple competing diagnostic strategies for suspected scaphoid fractures. METHODS: With published data, the authors created a decision-tree model simulating the diagnosis of suspected scaphoid fractures. Clinical outcomes, costs, and cost effectiveness of immediate computed tomography (CT), day 3 magnetic resonance imaging (MRI), day 3 bone scan, week 2 radiographs alone, week 2 radiographs-CT, week 2 radiographs-MRI, week 2 radiographs-bone scan, and immediate MRI were evaluated. The primary clinical outcome was the detection of scaphoid fractures. The authors adopted societal perspective, including both the costs of healthcare and the cost of lost productivity. The incremental cost-effectiveness ratio (ICER), which expresses the incremental cost per incremental scaphoid fracture detected using a strategy, was calculated to compare these diagnostic strategies. Base case analysis, 1-way sensitivity analyses, and "worst case scenario" and "best case scenario" sensitivity analyses were performed. RESULTS: In the base case, the average cost per scaphoid fracture detected with immediate CT was $2553. The ICER of immediate MRI and day 3 MRI compared with immediate CT was $7483 and $32,000 per scaphoid fracture detected, respectively. The ICER of week 2 radiographs-MRI was around $170,000. Day 3 bone scan, week 2 radiographs alone, week 2 radiographs-CT, and week 2 radiographs-bone scan strategy were dominated or extendedly dominated by MRI strategies. The results were generally robust in multiple sensitivity analyses. CONCLUSIONS: Immediate CT and MRI were the most cost-effective strategies for diagnosing suspected scaphoid fractures. LEVEL OF EVIDENCE: Economic and Decision Analyses Level II. See Instructions for Authors for a complete description of levels of evidence.