Challenging the dogma: anterior transposition of the ulnar nerve is indicated in recurrent cubital tunnel syndrome

Abstract

The current evidence for treatment of primary idiopathic cubital tunnel syndrome favours an in situ release. However, anterior transposition of the ulnar nerve remains a popular procedure in recurrent cubital tunnel syndrome. For more than 20 years, I have performed an extended in situ release only, and achieved similar or better results than with nerve transposition. In performing a systematic review of the evidence for surgery for recurrent cubital tunnel syndrome, I could only include 16 out of 296 studies regarding treatment of recurrent cases of cubital tunnel syndrome. A meta-analysis was not possible, due to selection bias and disparity of outcome measurements of the studies. However, I could not find robust evidence that supports the need of an anterior transposition of the ulnar nerve in recurrent cubital tunnel syndrome over an in situ decompression. My own experience of an extended in situ release with complete neurolysis with reasonable outcomes, in combination with the lack of literature support of anterior transposition in recurrent cases, have led me to the consideration that this dogma should be revised.

Management of Recalcitrant Cubital Tunnel Syndrome

“…22,33 Numerous procedures have been described, including external neurolysis, 35,36 nerve wrapping, [43][44][45] and various transpositions, 33,38,49 with the published literature largely comprising retrospective case series and no controlled studies exist to support a single method of reconstruction for recalcitrant CuTS. Three recent systematic reviews 18,34,43 are limited because all included studies suffered from methodological limitations (bias in participant selection, outcome measurements, reported results, and inconsistent data reporting). 34 The highest level of evidence available is one case-control study (level III) comparing reoperations with primary operations, 8 and no studies in the published literature compare varying treatments for revision surgery regarding outcomes.…”

“…Such findings have led authors to challenge the previous dogma that anterior transposition should "always" be done for revision CuTR. 34 Other authors have proposed algorithms based on recurrence or persistent symptoms after in situ decompression or various types of anterior transpositions, advocating the adjunct use of collagen nerve conduit in addition to transposition procedures. 30 Reported complications in revision CuTR procedures are limited owing to reporting bias and small sample sizes.…”

“…Historically, transposition has been recommended for revision CuTR, although this philosophy has been challenged recently. 34 Subcutaneous transposition involves transposing the UN anterior to the ME and suturing a segment of elevated flexor-pronator fascia to the overlying superficial adipose tissue or to adjacent flexor-pronator fascia to prevent posterior UN subluxation.…”

“…External neurolysis, anterior transposition, ulnar groove plasty, and nerve wrapping methods have been described, with no comparative studies confirming technique superiority. 18,34…”

Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment

“…Moreover, some authors recommend submuscular transposition after failed subcutaneous transposition (104). However, there is no robust evidence supporting the need for anterior transposition in recurrent cubital tunnel syndrome (105).…”