Stabilized Subcutaneous Ulnar Nerve Transposition with Immediate Range of Motion

Background: Anterior transposition of the ulnar nerve at the elbow produces generally good results regardless of whether the nerve is transposed subcutaneously, intramuscularly, or submuscularly. The eventual recovery of nerve function is related less to the specific surgical technique than to the severity of the intrinsic nerve pathology. A primary variable in surgical management is the duration of postoperative elbow immobilization. The purpose of this study was to review the longterm results of a specific technique of subcutaneous anterior transposition of the ulnar nerve that utilizes a stabilizing fasciodermal sling. The study compared the results of immediate and late institution of a range of motion postoperatively. Methods: Forty-seven patients with fifty-one elbows were reexamined, by an investigator who had not been involved in their treatment, at a minimum of two years (range, twenty-four months to fourteen years) after an anterior transposition. Of the fifty-one elbows, twentyone were immobilized for two to three weeks whereas thirty were managed with an immediate range of motion. Results: At the latest follow-up evaluation, there were occasional, mild paresthesias in 16 percent of the limbs and there was still subjective weakness of 19 percent. Both pinch and grip strength had increased substantially. No patient had lost elbow motion. A positive Tinel sign persisted in 31 percent of the limbs, but it was mildly positive in most of them. The elbow flexion test was uniformly negative. The results for 92 percent of the limbs were satisfactory to the patients, who stated that they would undergo the same procedure again if necessary. Overall, 73 percent of the limbs had an excellent result; 18 percent, a good result; 4 percent, a fair result; and 6 percent, a poor result. With the numbers available, no significant difference could be detected, with regard to these outcomes, between the group managed with elbow immobilization and that managed with immediate elbow mobilization. However, patients treated with a postoperative cast returned to work at an average of thirty days after surgery whereas the group treated with immediate motion of the elbow returned to work at an average of ten days. Conclusions: This technique of stabilized subcutaneous anterior transposition of the ulnar nerve yielded predictably good results for a wide spectrum of patients. Patients returned to their occupation sooner when the elbow had been mobilized immediately. Cubital tunnel syndrome is the second most common compressive neuropathy of the upper limb and usually responds to nonoperative treatment regimens. However, for cases that prove refractory to such measures, several surgical options are available. While the list of options includes decompression in situ and medial epicondylectomy, perhaps the most frequently utilized procedures that have predictably good results are those that transpose the ulnar nerve anteriorly and stabilize it in some manner. The decision to transpose the nerve subcutaneously, intramuscularly, or submuscularly is based largely on the surgeon’s preference. This may be primarily due to the fact that the relative benefits and efficacy of the various techniques have been difficult to compare. A review of the largely retrospective body of literature on the subject revealed that outcomes criteria have been variably reported and grading systems, if used at all, have not been consistent. Subcutaneous ulnar nerve transposition has yielded predictably good results in a majority of patients in several studies. In 1980, Eaton et al. reported the results of a procedure in which the ulnar nerve was stabilized in the anterior position with a fasciodermal sling. Subsequently, in an effort to accelerate the patients’ return to work and recreational activities, Eaton dispensed with the recommended two to three-week period of initial postoperative immobilization, and all patients were allowed an immediate active range of motion of the elbow. Weirich et al. recently reported on the advanA complete video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410. *No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. †Department of Orthopedics, St. Luke’s-Roosevelt Hospital Center, 114th Street and Amsterdam Avenue, New York, N.Y. 10025. ‡C. V. Starr Hand Surgery Center, 1000 Tenth Avenue, Third Floor, New York, N.Y. 10019. §Delaware Orthopaedic Center, 2501 Silverside Road, Wilmington, Delaware 19810. Copyright © 2000 by The Journal of Bone and Joint Surgery, Incorporated STABILIZED SUBCUTANEOUS ULNAR NERVE TRANSPOSITION WITH IMMEDIATE RANGE OF MOTION 1545 VOL. 82-A, NO. 11, NOVEMBER 2000 tages of an immediate-motion regimen following stabilized anterior subcutaneous transposition. We are not aware of any report in which the long-term results of subcutaneous ulnar nerve transposition were compared between a group treated with postoperative immobilization and one in which an immediate range of motion was encouraged. Our hypothesis, based initially on anecdotal observations, was that the latter group would return to work and recreational activities sooner than the group treated with immobilization of the elbow and that there would be no difference in long-term outcomes. Materials and Methods The cases of forty-seven patients who underwent a total of fiftyone stabilized anterior subcutaneous transpositions from 1973 to 1995 were retrospectively reviewed after a minimum of two years of followup. At the latest follow-up evaluation, all patients were interviewed and examined by one of three surgeons (B. T. B., O. A. B., or P. F. T.) who had not been directly involved in the treatment of the study patients. The patients were divided into two groups on the basis of whether the elbow had been immobilized postoperatively or an immediate range of motion had been begun. The patients were naturally divided into these two groups when the senior author (R. G. E.) and the other author whose patients were included in the study (S. Z. G.) ceased to utilize any postoperative immobilization. The latter author discontinued the use of postoperative immobilization at a later time than the former. This explains the somewhat longer average duration of follow-up for the patients treated with immobilization. Group I consisted of twenty patients with twenty-one elbows that were immobilized postoperatively for two to three weeks in a long arm cast. There were fourteen male patients and six female patients with an average age of 39.9 years (range, seventeen to sixty-eight years). The duration of follow-up averaged 6.6 years (range, two to thirteen years). Fifteen (71 percent) of the twenty-one procedures were performed in the dominant extremity. Two patients were involved in Workers’ Compensation cases. Group II consisted of thirty elbows in twenty-seven patients who began an active range of motion in the immediate postoperative period. There were fifteen men and twelve women with an average age of 46.5 years (range, nineteen to eighty-two years). The duration of follow-up for this group averaged 4.9 years (range, two to fourteen years). Seventeen (57 percent) of the thirty procedures were performed in the dominant extremity. Three patients were involved in Workers’ Compensation cases. The diagnosis of cubital tunnel syndrome was made primarily on the basis of a complete history and physical examination. Symptoms included some combination of pain in the elbow and hand, paresthesias affecting the hand and forearm, weakness of grip and pinch, and loss of hand dexterity. Typical physical findings included combinations of decreased sensibility to light touch and two-point discrimination in the ulnar nerve distribution, hypothenar wasting, diminished pinch and grip strength as measured with a calibrated grip dynamometer and a pinch gauge, a Tinel sign at the cubital tunnel, and a positive elbow flexion test. The percentages of patients with each of the findings are listed in Table I. Corroborative electrodiagnostic studies were not found in the retrospective chart review for eleven (22 percent) of the fifty-one elbows. Preoperative radiographs of the involved elbow (and the cervical spine when indicated) were required for all patients. In forty patients (forty-four elbows), the cause of the cubital tunnel syndrome was nonspecific. An elbow fracture was the cause in five of the remaining seven elbows, and blunt trauma was the cause in two; these cases were essentially equally divided between the two study groups. All patients were initially managed with a standard nonoperative treatment regimen, which included one or more courses of antiinflammatory medication, extension splinting of the elbow, and activity modifications for at least six weeks. The indication for surgery was a diagnosis of cubital tunnel syndrome that persisted despite nonoperative treatment modalities.