Evaluation of Different Surgical Techniques for Revision Cubital Tunnel Release: A Meta-Analysis of Patient-Reported Symptoms.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Electrodiagnostic severity does not predict short- to midterm outcomes of cubital tunnel release surgery.

HYPOTHESIS: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

What Factors Are Associated With Revision Cubital Tunnel Release Within 3 Years?

BACKGROUND: It has been shown that patient demographics such as age, payer factors such as insurance type, clinical characteristics such as preoperative opioid use, and disease grade but not surgical procedure are associated with revision surgery to treat cubital tunnel syndrome. However, prior studies evaluating factors associated with revision surgery after primary cubital tunnel release have been relatively small and have involved patients from a single institution or included only a single payer. QUESTIONS/PURPOSES: (1) What percentage of patients who underwent cubital tunnel release underwent revision within 3 years? (2) What factors are associated with revision cubital tunnel release within 3 years of primary cubital tunnel release? METHODS: We identified all adult patients who underwent primary cubital tunnel release from January 1, 2011, to December 31, 2017, in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology codes. We chose this database because it includes all payers and nearly all facilities in a large geographic area where cubital tunnel release may be performed. We used Current Procedural Terminology modifier codes to determine the laterality of primary and revision procedures. The mean age of the cohort overall was 53 ± 14 years, 43% (8490 of 19,683) were women, and 73% (14,308 of 19,683) were non-Hispanic White. The Statewide Planning and Research Cooperative System database organization does not include a listing of all state residents and thus does not allow for censoring of patients who move out of state. All patients were followed for 3 years. We developed a multivariable hierarchical logistic regression model to model factors independently associated with revision cubital tunnel release within 3 years. Key explanatory variables included age, gender, race or ethnicity, insurance, patient residential location, medical comorbidities, concomitant procedures, whether the procedure was unilateral or bilateral, and year. The model also controlled for facility-level random effects to account for the clustering of observations among these entities. RESULTS: The risk of revision cubital tunnel release within 3 years of the primary procedure was 0.7% (141 of 19,683). The median time to revision cubital tunnel release was 448 days (interquartile range 210 to 861 days). After controlling for patient-level covariates and facility random effects, and compared with their respective counterparts, the odds of revision surgery were higher for patients with workers compensation insurance (odds ratio 2.14 [95% confidence interval 1.38 to 3.32]; p < 0.001), a simultaneous bilateral index procedure (OR 12.26 [95% CI 5.93 to 25.32]; p < 0.001), and those who underwent submuscular transposition of the ulnar nerve (OR 2.82 [95% CI 1.35 to 5.89]; p = 0.006). The odds of revision surgery were lower with increasing age (OR 0.79 per 10 years [95% CI 0.69 to 0.91]; p < 0.001) and a concomitant carpal tunnel release (OR 0.66 [95% CI 0.44 to 0.98]; p = 0.04). CONCLUSION: The risk of revision cubital tunnel release was low. Surgeons should be cautious when performing simultaneous bilateral cubital tunnel release and when performing submuscular transposition in the setting of primary cubital tunnel release. Patients with workers compensation insurance should be informed they are at increased odds for undergoing subsequent revision cubital tunnel release within 3 years. Future work may seek to better understand whether these same effects are seen in other populations. Future work might also evaluate how these and other factors such as disease severity could affect functional outcomes and the trajectory of recovery. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. CLINICAL RELEVANCE: Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Wound Dehiscence Following Cubital Tunnel Surgery.

PURPOSE: Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described. METHODS: Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence. RESULTS: The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2-57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12-32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence. CONCLUSIONS: Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Research reporting in cubital tunnel syndrome studies: an analysis of the literature.

PURPOSE: There is a strong need for a set of consensus outcomes to be utilized for future studies on cubital tunnel syndrome. The goal was to assess the outcome measures utilized in the cubital tunnel syndrome literature as a way of measuring popularity/acceptability and then to perform a literature review for the most commonly used outcomes. METHODS: A literature search was performed using the pubmed.gov database and Medical Subject Headings (MeSH). For each article, the following data were abstracted: study type, motor outcome(s), sensory outcome(s), composite outcome(s), patient-reported outcome (PRO) metric(s), pain outcome(s), psychological outcome(s), electrodiagnostic outcome(s), and any other outcomes that were used. RESULTS: A composite outcome was reported in 52/85 (61%) studies, with the modified Bishop score (27/85; 32%) most common. A motor outcome was reported in 44/85 (52%) studies, with dynamometry (38/85; 45%) most common. The majority of studies (55%) did not report a sensory outcome. The majority of studies (52%) did not report a PRO. A specific pain outcome was reported in the minority (23/85; 27%), with the visual analogue scale (VAS) (22/85; 26%) most common. Pre- and postoperative electrodiagnostic results were presented in 22/85 studies (26%). DISCUSSION: Understanding current clinical practice and historical outcomes reporting provides a foundation for discussion regarding the development of a core outcome set for cubital tunnel syndrome. We hope that the data provided in the current study will stoke a discussion that will culminate in a consensus statement for research reporting in cubital tunnel syndrome studies.

Outcome of Simple Decompression of Primary Cubital Tunnel Syndrome Based on Patient-Reported Outcome Measurements.

PURPOSE: To evaluate the patient-reported outcome measures of patients with primary cubital tunnel syndrome and to assess whether they are affected by preoperative symptom severity. METHODS: Patients who underwent simple decompression for primary cubital tunnel syndrome were selected from a prospectively maintained database. Outcome measurements consisted of the Boston Carpal Tunnel Questionnaire at intake and at 3 and 6 months after surgery. Also, 6 months after surgery, the patients received a question about their satisfaction with the treatment result. To determine a possible influence of preoperative symptom severity on postoperative outcomes, the sample was divided into quartiles based on symptom severity at intake. RESULTS: One hundred and forty-five patients were included in the final analysis. On average, all patients improved on the Boston Carpal Tunnel Questionnaire. The subgroup of patients with the mildest symptoms at intake did not improve significantly on symptom severity but did improve significantly on their functional status. In addition, the patients with the most severe symptoms at intake did improve on both aspects. Moreover, no difference in satisfaction with treatment result between the severity of symptoms at intake was found. CONCLUSIONS: The patients with the mildest symptoms at intake may not improve on symptom severity, but they do improve on functional status after simple decompression for cubital tunnel syndrome. In addition, patients with the most severe symptoms at intake do improve on both symptom severity and functional status. Moreover, all patients reported to be equally satisfied with the treatment result, which suggests that satisfaction is not dependent on the symptom severity at intake. Even those patients with both the mildest symptoms before surgery and the least improvement still seem to benefit from simple decompression. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reliability and validity of the modified McGowan grade in patients with cubital tunnel syndrome.

INTRODUCTION: This study aimed to assess the reliability and validity of the modified McGowan grading system and to determine its ability to distinguish the severity of cubital tunnel syndrome (CuTS) between the different grades. MATERIALS AND METHODS: We prospectively enrolled 39 consecutive patients with CuTS from March 2018 to December 2020. Inter- and intra-observer reliability was assessed by two orthopaedic surgeons with a minimum 2-week interval using Cohen kappa coefficients. Validity was assessed by Spearman's correlation with objective clinical outcomes (grip strength, Semmes-Weinstein monofilament test [SWMT], static two-point discrimination [2PD], and motor conduction velocity [MCV]). In addition, the relationship between the grading system and patient-reported outcomes (Disabilities of the Arm, Shoulder and Hand score and Boston Questionnaire) was evaluated using Spearman's correlation. The ability to distinguish the severity between the different grades was assessed using the Kruskal-Wallis analysis. RESULTS: The inter-observer kappa value was 0.54 and intra-observer kappa value was 0.59, which imply a moderate reliability. The modified McGowan grade had a moderate correlation with objective clinical outcomes (grip strength [r = - 0.350, p = 0.029], SWMT [r = 0.552, p < 0.001], 2PD [r = 0.456, p = 0.004], and MCV [r = - 0.394, p = 0.021]). However, patient-reported outcomes did not correlate with this grading system. Kruskal-Wallis analysis revealed significant differences between grades in terms of SWMT, 2PD, grip strength, and Boston Questionnaire functional score (p = 0.006, 0.025, 0.014, and 0.043, respectively); however, these differences were statistically significant only for a limited number of parts. CONCLUSIONS: The modified McGowan grade has a moderate inter- and intra-observer reliability. This grading system moderately correlates with objective sensory-motor functions and MCV of patients with CuTS. However, the modified McGowan grade does not reflect the patient's perceived disabilities and has a weakness in distinguishing the severity of patients' conditions among the different grades.

Current Concepts in Compressive Neuropathies of the Upper Extremity.

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.

Validity of computed tomographic measurements and morphological comparison of cubital tunnel in idiopathic cubital tunnel syndrome.

BACKGROUND: Ulnar neuropathy is a common reason for referral to hand surgeons, and 10 to 30% of cubital tunnel syndrome (CuTS) is idiopathic. We hypothesized that the cause of idiopathic CuTS is in the bony structure. METHODS: We analyzed 79 elbows (39 idiopathic CuTS and 40 without CuTS symptom) using computed tomography and Materialize Mimics software to compare the differences between the two groups. We proposed a new bony cubital tunnel with a new boundary that could play a role in ulnar nerve compression symptom. RESULTS: The mean cubital tunnel volume was 1245.6 mm3 in all patients, 1180.6 mm3 in CuTS patients, and 1282.3 mm3 in the control group. A significant difference (p = 0.015) between two groups was found. Bony cubital tunnel cross-sectional area, cubital tunnel depth, and cubital tunnel angle also showed significant differences. CONCLUSION: The shape of the bony cubital tunnel is an important cause of CuTS, and the normal variation of the volume and cross-sectional area of the cubital tunnel and cubital tunnel angle could influence the occurrence of idiopathic CuTS.

Features of the Ulnar Nerve Predicting Postoperative Prognosis in Idiopathic Cubital Tunnel Syndrome: Three Distinct Features of the Ulnar Nerve.

PURPOSE: This retrospective case-control study was performed to determine the relationships between features of the ulnar nerve and postoperative outcomes following in situ decompression in idiopathic cubital tunnel syndrome (CuTS). METHODS: The study population consisted of 86 patients who had undergone surgery for CuTS. We evaluated demographic factors, hand dominance, symptom onset time, time from diagnosis to surgery, findings of electrodiagnosis (nerve conduction velocity/electromyography), and preoperative clinical status. Intraoperatively, the ulnar nerve was defined as a definitively compressed, abnormally enlarged, or inflammatory lesion. Clinical improvements were evaluated at least 2 years after surgery. RESULTS: Fifty-four patients showed improvement after surgery in terms of the modified McGowan grade and were designated as group 1. Meanwhile, 32 patients with unchanged or aggravated status were classified as group 2. Preoperative status, as determined by the modified McGowan grade, Boston Symptom Severity Scale score, severity of electrodiagnosis, and predominant symptoms were similar between the groups (all, P > 0.05). On regression analysis, only the classification of nerve lesions and the time from diagnosis to surgery had an impact on postoperative outcome (all, P < 0.05). Especially, enlarged ulnar lesion predicted poor prognosis (P = 0.003). CONCLUSIONS: Ulnar nerve enlargement, grossly detected intraoperatively, and long interval between diagnosis and surgery were independently associated with poor prognosis of CuTS. Among the anatomic structures involved in the generation of CuTS, the medial epicondyle showed a strong association with enlarged nerve lesions.

Evaluation of the Scratch Collapse Test for Carpal and Cubital Tunnel Syndrome-A Prospective, Blinded Study.

PURPOSE: To clarify the sensitivity, specificity, and interrater reliability of the scratch collapse test for carpal tunnel syndrome (CTS) and cubital tunnel syndrome, using blinded observers in a general patient population. METHODS: Ninety-two subjects were recruited from all patients referred for electrodiagnostic studies for upper extremity symptoms that were thought to be related to an entrapment mononeuropathy. The scratch collapse test was performed twice on each patient, once by the resident and once by a nerve conduction technician. Both observers were blinded to all aspects of the patient's presentation. Sensitivity and specificity for the scratch collapse test were calculated twice, once using electrodiagnostic testing results and a second time using a validated clinical tool (the CTS-6) as the reference standard. The interrater reliability was also calculated. RESULTS: Using electrodiagnostic criteria as a reference standard, the scratch collapse test had a sensitivity of 7% and a specificity of 78% for CTS. Using clinical criteria as a reference standard, the test had a sensitivity of 15% and a specificity of 87%. For cubital tunnel syndrome, the sensitivity was 10% and the specificity was 90%. For the resident/technician 1, kappa was -0.025 (worse than chance alone). For the resident/technician 2, kappa was 0.211 (fair strength of agreement). CONCLUSIONS: The sensitivity of the scratch collapse test for CTS and cubital tunnel syndrome was lower than that found in other studies, regardless of whether a clinical or an electrodiagnostic reference standard was used. The specificity was high. Overall interrater agreement was lower than previously reported. These results call into question the sensitivity and interrater reliability of the scratch collapse test for CTS and cubital tunnel syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Associations Between Insurance Type and the Presentation of Cubital Tunnel Syndrome.

PURPOSE: In the setting of cubital tunnel syndrome (CuTS), delays in diagnosis can have permanent effects including sensory loss, muscle weakness, and atrophy of intrinsic hand muscles. This study sought to evaluate the association of insurance type on the severity of CuTS. We hypothesized that publicly insured patients will have delayed presentation to the orthopedics office and more significant condition severity. METHODS: A retrospective chart review was conducted for all patients evaluated for CuTS between December 2013 and January 2018 by a fellowship-trained orthopedic hand and upper extremity surgeon at our tertiary referral center. Insurance type, demographics, and measures of CuTS severity were compared. RESULTS: Patients presenting with CuTS of severity greater than or equal to McGowan stage 2A had 4.4-fold greater odds of being publicly insured than privately. Motor and sensory velocities across the elbow were diminished at 42.2 ± 13.9m/s and 33.0 ± 20.8m/s in publicly insured patients compared with 47.5 ± 11.3 m/s and 47.0 ± 16.4m/s for privately insured patients. The same trend was present for motor and sensory amplitudes at 6.6 ± 3.8 µV and 16.9 ± 17.8 µV in publicly insured patients compared with 8.5 ± 3.2 µV and 26.0 ± 18.9 µV in privately insured patients. Patients with public insurance were symptomatic for longer prior to their initial visit, on average 82.8 ± 86.5 weeks, compared with 42.4 ± 58.9 weeks for patients with private insurance. CONCLUSIONS: Publicly insured patients were significantly delayed in seeing an orthopedic surgeon for evaluation and treatment of CuTS and presented with more severe clinical and electrodiagnostic findings compared with privately insured patients. These findings suggest that insurance type, among other socioeconomic factors, may be a barrier to CuTS care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prevalence IV.

The Management of Persistent and Recurrent Cubital Tunnel Syndrome.

Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy in the upper extremity. There are considerable diagnostic and therapeutic challenges associated with treating patients after a failed primary procedure for CuTS. Distinguishing cases of recurrence versus persistence and identifying concomitant pathology can guide treatment. Conditions that mimic CuTS must be carefully ruled out and coexisting dysfunction of the medial antebrachial cutaneous nerve needs to be addressed. Results of revision procedures are not as reliable as primary procedures for CuTS; however, improvements in pain and paresthesias are noted in approximately 75% of patients. Nerve wraps represent a promising adjuvant treatment option, but long-term outcome data are lacking. External neurolysis and anterior transposition after failed CuTS procedures are supported by case series; multicenter, prospective randomized trials are needed to guide treatment further and improve outcomes.

Modified simple decompression of ulnar nerve in the treatment of cubital tunnel syndrome: Report of a series of cases.

BACKGROUND/AIM: Ulnar compressive neuropathy is the second most common nerve compression in the upper extremity. Although numerous operative procedures have been defined for the treatment of cubital tunnel syndrome (CuTS), the best operative intervention remains controversial. The aim of this study is to discuss the efficacy of a modified simple decompression (MSD) of the ulnar nerve in the treatment of CuTS. MATERIALS AND METHODS: Each patient was preoperatively examined, and the following data were recorded: initial complaint, duration of symptoms, and presence of Tinel's sign around the elbow, results of provocation by the elbow flexion test, and results of electrodiagnostic studies. Patients' preoperative clinical manifestations were determined based on Dellon's staging system and Bishop scores. Pre- and post-operative motor conduction velocity (MCV) of the ulnar nerve were also recorded. Under the regional anesthesia, 4 cm long curved skin incision, above and below the elbow, was made posterior to the medial epicondyle of the humerus and the ulnar nerve was seen. The nerve was released proximally as it passed through the medial intermuscular septum. The cubital tunnel retinaculum and flexor carpi ulnaris aponeurosis were then cut distally. Only the compressive fascial bands are released. Then, the cubital tunnel reticulum was sutured to subcutaneous tissue loosely to prevent subluxation of the ulnar nerve. RESULTS: A total of 15 patients were operated. Postoperative electrophysiological study assessed at 3 months following surgery in 8 patients. In 7 of these patients (86%), the mean value of MCV had improved from 38.9 ± 12.0 m/s to 48.1 ± 11.9 m/s (P < 0.05). According to Bishop scoring system, 13 patients (86.7%) were clinically graded as excellent, 1 patient (6.7%) was graded as good, and only 1 patient (6.7%) was graded as fair. CONCLUSION: MSD is a technically simple, safe, and effective method without annoying complications.

Ulnar nerve entrapment at elbow in obstructive sleep apnea patients: a randomized controlled trial.

PURPOSE: Obstructive sleep apnea (OSA) is a highly prevalent disease. For diagnostic and therapeutic purposes, OSA has been divided into several subgroups. Positional OSA (POSA), the most frequent subgroup (56 %), is described as overall apnea hypopnea index (AHI) ≥5 and supine AHI at least twice as high when compared to non-supine AHI. We aimed to investigate the frequency of ulnar nerve entrapment neuropathy at the elbow (UNEE) in OSA patients without clinical signs and symptoms of ulnar neuropathy and intended to find if sleeping position in OSA had an impact on UNEE development. METHODS: Fifty POSA, 48 non-positional OSA (NPOSA) patients, and 45 healthy controls without diabetes mellitus, hypothyroidism, rheumatic diseases, and cervical radiculopathy underwent nerve conduction studies. RESULTS: We found that UNEE was highly frequent in OSA patients (42.9 %) and significantly more frequent in moderate to severe POSA patients than mild POSA patients (65.4 vs. 33.3 %, p < 0.05). Furthermore, when compared to non-positional ones, UNEE was significantly more frequent in moderate to severe POSA patients (65.4 vs. 36.4 %, p < 0.05). CONCLUSIONS: Our results showed that the severity of OSA in positional patients was correlated with increased frequency of UNEE. OSA patients should be informed about the predisposition of UNEE and questioned for the symptoms in periodical controls. POSA patients should be alerted about the additional effect of sleeping position on UNEE and the necessity of OSA treatment should be emphasized.

Gradual Onset Diseases: Misperception of Disease Onset.

PURPOSE: Gradual onset diseases (eg, carpal tunnel syndrome, cubital tunnel syndrome, and trapeziometacarpal arthrosis) tend to go unnoticed for years. When a slowly progressive disease transitions from asymptomatic to symptomatic, it may seem like an acute event. The primary aim of this study was to determine the percentage of patients who perceive the slowly progressive disease as having started within 1 year. We also hypothesized that (1) there would be no factors associated with perception of an onset of disease within 1 year, more specifically among patients with advanced disease; and (2) there would be no difference in a decision to pursue operative treatment between patients who perceived the onset of the disease to be recent and those who perceived it to be long-standing. METHODS: In this retrospective study, we reviewed the medical records of 732 patients newly diagnosed with carpal tunnel syndrome (n = 114), cubital tunnel syndrome (n = 276), or trapeziometacarpal arthrosis (n = 342), for the onset of symptoms. Multiple factors were assessed for (1) association with perception of disease onset within 1 year, and (2) choice for operative treatment in bivariate and multivariable analyses. RESULTS: A total of 69% of all subjects and 68% of patients with advanced disease perceived the disease as having started within 1 year. A perceived provocation (such as an injury or surgery) was associated with a perception of recent onset. A decision to pursue operative treatment was not different between the 2 groups. CONCLUSIONS: Slowly progressive diseases are often misperceived as relatively new. CLINICAL RELEVANCE: Effective communication strategies are important to ensure that people make choices consistent with their values and not based on misconceptions.

Surgical Demographics of Carpal Tunnel Syndrome and Cubital Tunnel Syndrome Over 5 Years at a Single Institution.

PURPOSE: Carpal tunnel and cubital tunnel syndrome are the 2 most common upper-limb compressive neuropathies. However, whether the characteristics of patient populations undergoing surgery for these conditions are similar is unclear in terms of demographics and concomitant pathologies. Our null hypothesis was that there are no identifiable differences between these patient populations. METHODS: A retrospective cohort study was performed by billing system query using Common Procedural Terminology (CPT) codes for all patients who underwent open carpal tunnel release (CTR) (CPT code 64721) and/or open cubital tunnel surgery (CPT code 64718) by 1 of 4 hand surgeons from August 2008 to July 2013. Application of exclusion criteria of acute trauma, revision surgery, neoplasm, age less than 18 years, and inaccurate or insufficient records resulted in identification of 1,114 patients who underwent CTR, 264 patients who underwent cubital tunnel surgery, and 76 patients who underwent both. Computerized medical records were analyzed for demographic variables, medical comorbidities, and other procedures performed under the same anesthetic. RESULTS: In the multivariable analysis, older age, female sex, higher body mass index, trigger finger, and de Quervain tenosynovitis were associated with CTR. Prior trauma to the anatomic site was more common in the cubital tunnel group. Diabetes mellitus was associated with patients who had both procedures. CONCLUSIONS: The populations of patients who undergo surgery for different upper-extremity compressive neuropathies are not homogenous: CTR is associated with older age, female sex, higher body mass index, and hand tendinopathies. Cubital tunnel decompression is associated with prior trauma to the anatomic site. Diabetic patients are more likely to have both procedures. Diabetic patients undergoing either procedure should be evaluated for other peripheral nerve compression pathologies. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Predictors of postoperative outcomes of cubital tunnel syndrome treatments using multiple logistic regression analysis.

BACKGROUND: This retrospective study was designed to investigate prognostic factors for postoperative outcomes for cubital tunnel syndrome (CubTS) using multiple logistic regression analysis with a large number of patients. METHODS: Eighty-three patients with CubTS who underwent surgeries were enrolled. The following potential prognostic factors for disease severity were selected according to previous reports: sex, age, type of surgery, disease duration, body mass index, cervical lesion, presence of diabetes mellitus, Workers' Compensation status, preoperative severity, and preoperative electrodiagnostic testing. Postoperative severity of disease was assessed 2 years after surgery by Messina's criteria which is an outcome measure specifically for CubTS. Bivariate analysis was performed to select candidate prognostic factors for multiple linear regression analyses. Multiple logistic regression analysis was conducted to identify the association between postoperative severity and selected prognostic factors. RESULTS: Both bivariate and multiple linear regression analysis revealed only preoperative severity as an independent risk factor for poor prognosis, while other factors did not show any significant association. CONCLUSIONS: Although conflicting results exist regarding prognosis of CubTS, this study supports evidence from previous studies and concludes early surgical intervention portends the most favorable prognosis.