Can You Get Cubital Tunnel Again a Year After Surgery

Purpose

To evaluate the recurrence of symptoms after an endoscopic cubital tunnel release using the technique of Hoffmann and Siemionow.

Methods

We retrospectively reviewed 286 consecutive patients who underwent Hoffmann and Siemionow'south technique of endoscopic cubital release past a single surgeon during an 8-year menses. Inclusion criteria were adult patients without previous elbow surgery, pathology, or trauma, and patients with a minimum 3-months' postoperative follow-up. We evaluated symptom recurrence charge per unit and assessed chance factors that would touch recurrence.

Results

A total of 223 patients met inclusion criteria, 204 of whom (91.5%) had improvement at 3 months afterwards surgery. 11 patients (4.9%) had persistent symptoms and 8 (three.6%) had recurrent symptoms at a mean of xvi months (range, 3–93 months) after the primary surgery. Intraoperative ulnar nerve subluxation had a statistically significant relationship with symptom recurrence.

Conclusions

Symptoms recurred at a rate of 3.vi% subsequently Hoffmann and Siemionow's endoscopic cubital tunnel release. This is comparable to other endoscopic or open techniques for cubital tunnel release. The procedure has the added advantage of less tissue autopsy. Intraoperative ulnar nerve subluxation seems to be associated with symptom recurrence.

Blazon of report/level of testify

Therapeutic Four.

Key words

• Cubital tunnel syndrome
• Endoscopic cubital tunnel release
• Hoffmann and Siemionow technique
• recurrence
• Subluxation of ulnar nerve

Cubital tunnel syndrome (CuTS), entrapment of the ulnar nerve around the elbow, is the second nigh mutual compressive neuropathy in the upper extremity after carpal tunnel syndrome.

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Clinical manifestations include numbness or tingling in the ulnar side of the hand, and wrist or medial elbow pain in some patients. Patients might also accept fatigue, loss of dexterity, weakness of grip, and intrinsic musculus wasting.

There are multiple surgical options for CuTS, merely there is even so a lack of consensus regarding the optimal surgical treatment.

In past decades, endoscopic cubital tunnel release (eCuTR) techniques take evolved. Afterwards it was originally proposed in 1995 by Tsai et al,

⁴

• Tsai T.M.
• Bonczar M.
• Tsuruta T.
• Syed South.A.

A new operative technique: cubital tunnel decompression with endoscope assistance.

• PubMed
• Google Scholar

various eCuTR techniques were subsequently proposed and reviewed by several authors.

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• Cobb T.K.
• Sterbank P.

Comparing of return to work: endoscopic cubital tunnel.

• Google Scholar

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• Campi F.
• Merolla Thousand.
• Staffa Grand.
• Paladini P.
• Porcellini G.

Endoscopic approach to cubital tunnel syndrome.

• PubMed
• Google Scholar

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¹⁵

• Stadie A.T.
• Keiner D.
• Fischer G.
• Conrad J.
• Welschehold S.
• Oertel J.

Simple endoscopic decompression of cubital tunnel syndrome with the Agee organisation: anatomic written report and first clinical results.

• PubMed
• Google Scholar

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The theoretical reward of this minimally invasive process is that of visualization using an endoscope through small peel incision with less soft tissue dissection compared with open release. Thus, information technology has the potential for shorter operative time and faster recovery with less scarring.

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• Cobb T.K.
• Sterbank P.

Comparing of render to piece of work: endoscopic cubital tunnel.

• Google Scholar

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Comparable functional and symptomatic improvement has been demonstrated between endoscopic and open cubital tunnel release.

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Of those options, the procedure described by Hoffmann and Siemionow

has many advantages. It requires no special instruments, has a relatively brusk learning bend, and allows for better visualization proximally and distally through a pocket-sized incision, allowing consummate exposure and visualization.

Like to the open technique, symptoms may recur after eCuTR. Lowe and Mackinnon

classified symptomology subsequently failed primary cubital tunnel release into 3 full general categories: patients with new, persistent, or recurrent symptoms. New symptoms are often reported as increased or new hurting afterward ulnar nerve release. Patients with persistent symptoms, who experience either no or incomplete relief later on a primary procedure, may have had incomplete decompression of the ulnar nerve, an inaccurate diagnosis, or irreversible intraneural pathology. In contrast, recurrence refers to when the patient had a symptom-costless period after primary surgery with render of symptoms more than iii months subsequently surgery, according to Seradge and Owens.

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Recurrent symptoms may result for various reasons including injuries to the medial antebrachial cutaneous nerve

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or the ulnar nervus itself, longitudinal tension in the nerve,

new points of compression such as scarring near the nervus,

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perineural fibrosis,

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or ganglion cysts.

Few articles accept clearly distinguished persistence and recurrence.

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³¹

• Puckett B.N.
• Gaston R.G.
• Lourie G.M.

A novel technique for the treatment of recurrent cubital tunnel syndrome: ulnar nervus wrapping with a tissue engineered bioscaffold.

• Crossref
• PubMed
• Scopus (18)
• Google Scholar

The 2 entities are unlike and may warrant distinctive surgical considerations.

³¹

• Puckett B.N.
• Gaston R.One thousand.
• Lourie Grand.M.

A novel technique for the treatment of recurrent cubital tunnel syndrome: ulnar nerve wrapping with a tissue engineered bioscaffold.

• Crossref
• PubMed
• Scopus (eighteen)
• Google Scholar

In this study, we focused on symptom recurrence.

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Hoffmann and Siemionow

described no recurrence of ulnar nerve symptoms in 76 patients who were observed for 11 months (range, ane–34 months) in 2006. To appointment, these findings take non been validated by other authors.

We hypothesized that the recurrence of CuTS symptoms afterwards eCuTR using the procedure of Hoffmann and Siemionow

would be comparable to those of other techniques. We also investigated factors that might have affected symptom recurrence.

Materials and Methods

The diagnosis of CuTS was made after a history and physical examination. Guyon canal syndrome or bear witness of proximal compression such every bit cervical radiculopathy, which can mimic CuTS or cause double-beat injury, was ruled out.

If conservative handling measures were unsuccessful, surgical decompression was offered mainly on the basis of clinical symptoms and physical examination. The nervus conduction study and EMG were obtained to support the indication for surgery. If the nerve conduction written report showed decreased motor or sensory conduction velocity or amplitude across the elbow and/or increased distal latency, the patient was a potential surgical candidate depending on the severity of symptoms. If there was abnormal ii-signal discrimination, muscular atrophy, and unrelieved pain despite conservative treatment, patients were considered severe. If the EMG consequence showed muscular denervation, severe compression neuropathy was suggested.

The senior author (T.O.) performed all consecutive 286 procedures between 2010 and 2017. All patients obtained nerve conduction study and EMG before surgery.

Later on the researchers obtained institutional review board approval, all patient charts were reviewed retrospectively. Patients were excluded if they were minor or had less than three-calendar month postoperative follow-up or associated pathology at the elbow to account for the nerve damage or compression.

Other exclusion criteria were a positive history of elbow trauma or previous ulnar nervus release. After exclusion criteria were applied, the study included 223 elbows (133 females and xc males) in 210 patients. All arms that underwent surgery had the diagnosis confirmed with a positive nervus conduction study. Surgical release was performed on the right side in 111 elbows and on the left side in 112 elbows. 13 patients (8 females and 5 males) had bilateral procedures at different times. Mean historic period was 53 years (range, 24–88 years). In 89.vii% of patients (200 patients), the right mitt was dominant. Average follow-upwardly after initial endoscopic release was xiii.half dozen months (range, 3–93 months).

All patients had 2-bespeak discrimination test for objective sensory disturbance. Standardized grip strength, Tinel sign, and/or elbow flexion test equally well every bit cross-finger adduction test were used for each patient. These tests were performed by the fellowship-trained paw surgeon or a hand surgery swain. Based on the data in chart, the authors retrospectively classified patients using Dellon's staging, which classifies the syndrome equally mild, moderate, or severe.

Pearson chi-square examination was used to calculate statistical differences to compare categorical variables in the independent groups. P < .05 was considered statistically significant.

Surgical technique

All surgeries were performed using the Hoffmann Cubital Tunnel Set (Karl Storz, Tuttlingen, Germany). Patients were placed in the supine position. Under regional or general anesthesia, the procedure was performed based on the technique described in previous articles.

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The ulnar nerve is marked in the proximal forearm and in the upper arm. A 3-cm longitudinal incision is made posteromedially proximal to the line connecting the medial epicondyle to the olecranon tip. The space between the superficial fascia and deep fascia is developed and tunneling is performed proximally and distally.

Through a pocket-size opening, the ulnar nerve is identified behind the medial epicondyle. After a speculum is introduced proximally, the ulnar nerve is visualized through an inserted endoscope; so, the upper-arm fascia, medial intermuscular septum, and bands within the triceps medial head over the nerve are released using long Metzenbaum pair of scissors.

Later on, a shorter speculum is introduced distally in the forearm and the ulnar nerve is visualized by the endoscope. The Osborne ligament, flexor carpi ulnaris aponeurosis, and deep fascia immediately over the ulnar nerve are released with the help of Metzenbaum scissors. The mesoneurium and epineurium are carefully preserved during decompression and then equally not to cause further instability in the ulnar nerve.

After complete release, dynamic intraoperative subluxation of the ulnar nerve over the medial epicondyle was evaluated under directly visualization through total range of motility. We defined ulnar nerve subluxation equally anterior displacement of the nerve out of its groove and perching on the medial epicondyle while the elbow is flexed. No patient underwent transposition, even if ulnar nervus subluxation was observed during surgery. Patients were kept in a bulky Jones dressing after the operation. Elbow range of motion and nerve glides were initiated after the solar day of surgery. The postoperative routine was the same in all cases: Patients were brought to the clinic for wound check at two weeks. All patients underwent short-term physical therapy or home exercises for nerve glide exercises. They were observed at three-month intervals later on to appraise symptom resolution until 1 year afterwards surgery.

Results

Of 223 arms, 204 (91.five%) had partial or complete subjective improvement of weakness or aberrant sensation afterwards eCuTR at an boilerplate of iii months after surgery. Among the other 19 cases, according to the 3 general categories, xi had persistent symptoms (4.9%) and eight had recurrent symptoms (3.6%) (Tables 1, 2). No new symptom categories were observed. In the persistent cases, most symptoms resolved afterward iii months and no patients required a repeat release. In these cases, nerve conduction studies and EMGs were repeated to ensure no worsening had occurred.

Table 2 Patient Characteristics (northward [%])

Clinical Progress	Postoperative Symptoms	Subluxation Cases
Improved	204 (91.five)	70
Persistent	11 (4.9)	3
Recurrent	viii (3.6)	7
Full	223	80 (35.9)

• Open tabular array in a new tab

Eight cases had initial relief, but symptoms recurred at an average of 16.5 months (range, 3–86 months). The principal study was render of clinically evident CuTS such as sensory disturbance in the ulnar one-half of the band and niggling fingers and/or the ulnar aspect of the paw. Positive electrodiagnostic studies were confirmed in one case again after surgery in the 8 patients for documentation. Based on these findings and after treating the patients conservatively at least for a year, we proceeded with revision surgery. None of the other 215 cases required revision surgery. No patients with recurrence had an associated medical condition such as diabetes. Ane patient had filed claims for workers' bounty. Another patient'southward case had been complicated with hematoma later on eCuTR.

Surgical findings in all recurrent cases revealed ulnar nerve subluxation during surgery at the fourth dimension of revision surgery. Ane patient had not shown subluxation at the fourth dimension of initial eCuTR simply was institute to have subluxation at revision. The other vii patients had subluxation noted initially. Anterior subcutaneous transposition was performed in all cases. All recurrent cases had scarring effectually the nerve, and 2 required minimal internal neurolysis to encounter normal fascicular architecture. I patient had scarring around both the ulnar nerve and medial antebrachial cutaneous nerve effectually the Arcade of Struthers, which was either not divided completely at the prior eCuTR or scarred back. All patients with symptom recurrence showed resolution of symptoms and required no further surgeries afterward the revision surgery.

We noted 80 ulnar nervus subluxations (48 female and 32 male person) of 223 patients (133 female and 90 male) during the initial surgery (35.9%). The sex ratio of subluxation was compared using Pearson chi-foursquare test. The female prevalence (60%) was not significantly greater than that for males (40%) (P = .935). Amongst eighty subluxation cases, 7 resulted in recurrence of symptoms (8.75%) (Table 2). Recurrence was significantly correlated with the presence of intraoperative subluxation using Pearson chi-square test (P = .002). Dellon'south scores were severe in 51 limbs (23%), moderate in 172 (77%), and mild in none earlier surgery. Among the recurrent cases, 4 of viii were severe. Using Pearson chi-square exam, severe cases did not have a significantly higher recurrence rate (P = .063). Patients with more severe preoperative Dellon's staging did not predict symptom recurrence in this report.

Give-and-take

Symptom recurrence may occur after whatever surgical procedures

for nerve compression, even subsequently many years. Published reports of recurrence rates later endoscopic or open operative decompression of the ulnar nervus at the elbow are variable (Tabular array 1).

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³⁶

• Schnabl S.Chiliad.
• Kisslinger F.
• Schramm A.
• et al.

Subjective outcome, neurophysiological investigations, postoperative complications and recurrence rate of partial medial epicondylectomy in cubital tunnel syndrome.

• Crossref
• PubMed
• Scopus (17)
• Google Scholar

Because of the lack of recognition of differences between symptom recurrence and persistence, it has been challenging to determine the truthful rate of recurrent CuTS later on surgery. Furthermore, techniques of primary cubital tunnel release and surgeons' skills vary. Our study computed the symptom recurrence rate from a large patient group treated in the same manner by a single surgeon. Although directly comparisons are difficult, our recurrence rate (3.6%) was comparable to that of other procedures for cubital tunnel release.

In 1999, Tsai and coworkers

⁴

• Tsai T.M.
• Bonczar M.
• Tsuruta T.
• Syed Southward.A.

A new operative technique: cubital tunnel decompression with endoscope aid.

• PubMed
• Google Scholar

reported recurrence in iii elbows (2 patients) of 85 elbows (76 patients) undergoing cubital tunnel release with endoscopic assistance. They were treated with anterior submuscular transposition of the ulnar nerve. Cobb et al

evaluated the recurrence rate of eCuTR in 2009 and reported a recurrence rate of 0.02% to 5.24%. They also ended that the recurrence rate was similar to open cubital tunnel release based on literature controls. In 2017, Sautier and colleagues

performed Hoffmann and Siemionow'due south

eCuTR on sixty patients (62 cubital tunnel operations) and reported that one patient described a recurrence of symptoms later initial improvement.

Ulnar nerve hypermobility occurs in over one-tertiary of the adult population (37%), co-ordinate to Calfee et al.

³⁷

• Calfee R.P.
• Manske P.R.
• Gelberman R.H.
• Van Steyn M.O.
• Steffen J.
• Goldfarb C.A.

Clinical assessment of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms.

• Crossref
• PubMed
• Scopus (45)
• Google Scholar

Interestingly, this number was like to our intraoperative subluxation rate of 35.9%. In that study, the authors suggested that ulnar nerve hypermobility was non associated with increased symptomatology attributable to the ulnar nerve. This is compatible with the predominantly asymptomatic nature of the hypermobile nerve as reported by Childress.

Nevertheless, provocative physical examination testing (Tinel sign) showed consistent trends toward heightened irritability in hypermobile nerves.

³⁷

• Calfee R.P.
• Manske P.R.
• Gelberman R.H.
• Van Steyn 1000.O.
• Steffen J.
• Goldfarb C.A.

Clinical cess of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms.

• Crossref
• PubMed
• Scopus (45)
• Google Scholar

In 2010, Cobb et al

reported one recurrence after eCuTR, even so subluxation of the nerve upon concrete exam occurred in 8 of 104 patients (7.7%), which was not associated with the recurrence. In 2014, Cobb et al

also reported that preoperative ulnar nerve subluxation did not impact outcomes. These findings advise that ulnar nervus instability in the absence of ulnar neuritis does not mandate an anterior or submuscular transposition. Furthermore, Cobb et al

reported that ulnar nerve subluxation was not significantly correlated with preoperative Dellon's classification (P = .26), postoperative resolution rates of pain (P = .69), numbness and tingling (Pp = .53), or satisfaction (P = .26).

In dissimilarity, Lankester and Giddins

reported one patient out of 20 patients with symptom recurrence that was thought to result from subluxation of the nerve over the epicondyle. The current study also revealed that symptom recurrence was affected by the presence of intraoperative subluxation (P = .002). However, the remaining 72 of fourscore intraoperative subluxation cases (xc%) did non bear witness recurrent symptoms after surgery. Intraoperative subluxation thus may take some impact on symptom recurrence, but information technology is unlikely to crusade symptom recurrence alone. This may also be related to the activity level of the patients in the current study. A sedentary patient with subluxation who avoids repetitive flexion may not evidence recurrent symptoms, whereas a similar patient with subluxation working on an associates line may.

Bartels et al

³⁹

• Bartels R.H.
• Verhagen W.I.
• van der Wilt K.J.
• Meulstee J.
• van Rossum 50.G.
• Grotenhuis J.A.

Prospective randomized controlled study comparing simple decompression versus inductive subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: part i.

• Crossref
• PubMed
• Scopus (161)
• Google Scholar

performed a randomized trial comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve. Ulnar nervus (sub)luxation was reported to be present in 42 of 152 participants (26.7%). They found no deviation in result between simple decompression and inductive subcutaneous transposition in cases of ulnar nerve instability. Therefore, their written report concluded ulnar nerve instability is not an indication for transposition. Because that simple in situ decompression has the advantage of preserving neural claret supply,

these reasons are why nosotros did not routinely perform anterior transposition for patients in whom intraoperative subluxation occurred. However, upon the findings of this review, there may exist patients with CuTS with intraoperative ulnar nerve instability who may do good from open up surgery with anterior transposition to avoid symptom recurrence. As a consequence, we currently perform open transpositions in patients in whom the nerve completely dislocates over the medial epicondyle during elbow flexion. Nosotros prefer anterior subcutaneous transposition with cosmos of a septum between the medial epicondyle and the pare. As well, in revision surgery, nosotros recommend anterior transposition in patients with intraoperative subluxation.

This study had several limitations. Although this procedure has a depression rate of recurrence with a mean follow-upwards of 14 months, it is possible that the recurrence rate could exist higher with longer follow-upwards. The intraoperative cess of ulnar nerve subluxation was confirmed if the nerve was perched or displaced out of the groove, only subclassification into a perchable, perched, or dislocating nervus, as advocated by Calfee and coworkers,

³⁷

• Calfee R.P.
• Manske P.R.
• Gelberman R.H.
• Van Steyn Grand.O.
• Steffen J.
• Goldfarb C.A.

Clinical cess of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms.

• Crossref
• PubMed
• Scopus (45)
• Google Scholar

was not performed. Finally, our study was retrospective without a control grouping and was based on the experience of a single surgeon. Our written report defined a depression rate of recurrence among a large cohort of adults managed with a like operative eCuTR technique and postoperative protocol. Multicenter, well-designed, prospective, randomized controlled studies that compare dissimilar cubital tunnel release techniques in a compatible patient population are needed to define recurrence rates better.

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Article Info

Publication History

Published online: April 27, 2020

Accepted: March eighteen, 2020

Received: January 22, 2020

Footnotes

Declaration of interests: No benefits in any form have been received or will be received by the authors related directly or indirectly to the subject of this article.

Identification

DOI: https://doi.org/10.1016/j.jhsg.2020.03.006

Copyright

© 2020 THE AUTHORS. Published by Elsevier Inc. on behalf of The American Social club for Surgery of the Mitt.

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