Decision-Making Factors for Ulnar Nerve Transposition in Cubital Tunnel Surgery

Abstract

Background We designed a survey to ascertain the current perspectives of hand surgeons on the evaluation and management of ulnar nerve instability at the elbow. The secondary aim was to assess the concordance of hand surgeons on definitions of the terms “subluxated” and “dislocated” for classification of ulnar nerve instability. Methods A questionnaire, including demographic practice variables, cubital tunnel practice patterns, preoperative imaging and electrodiagnostic evaluation, and a series of standardized intraoperative photographs of ulnar nerve instability at the elbow were developed and distributed to the current American Society for Surgery of the Hand (ASSH) membership. Results A total of 690 (26.8%) members completed the survey; 84.2% of respondents indicated that they evaluate for ulnar nerve instability preoperatively with clinical examination, whereas only 6.1% indicated they routinely obtained dynamic ultrasound. Respondents indicated that the factors most strongly influencing their decision to proceed with anterior transposition of the ulnar nerve were subluxation on physical examination (89.6%), history consistent with ulnar nerve subluxation (85.8%), and muscle atrophy (43.2%). On review of clinical photographs, respondents demonstrated varying degrees of agreement on the terms “subluxated” or “dislocated” and recommendations for ulnar nerve transposition at intermediate degrees of ulnar nerve instability. Conclusion ASSH members routinely evaluate for ulnar nerve instability with history and clinical examination without uniform use of preoperative ultrasound, and nearly half of the time the decision to transpose the ulnar nerve is made intraoperatively. Definitions for the degree of ulnar nerve instability at the elbow are not uniformly agreed upon, and further development of a classification system may be warranted to standardize treatment.

In Situ Neurolysis of Ulnar Nerve for Patients With Failed Anterior Subcutaneous Transposition – A Case Series

“…The technique has preference over in Situ decompression technique when the neuropathy is severe or when the nerve becomes unstable after simple decompression. 9 However, failure rate up to 25% after anterior transposition for CuTS were reported. 14 The unfavorable outcomes were related to incorrect diagnosis, adhesion after anterior transposition, and incomplete decompression.…”

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

“…I believe this is a dogma that is neither supported by evidence reported nor by outcomes from my own practice. A survey by DeGeorge and Kakar (2019) regarding decision-making factors for hand surgeons in the United States regarding ulnar nerve transposition in cubital tunnel surgery, demonstrated that 84% of respondents evaluated ulnar nerve instability preoperatively with clinical examination, and that the intraoperative perception of a ‘subluxing’ ulnar nerve was the strongest influencing factor to perform an anterior transposition. Half of these surgeons made the decision to transpose intraoperatively, but there were no precise indications for degrees of ulnar nerve instability, with substantial inter-rater variability demonstrated.…”

The prevalence of ulnar neuropathy at the elbow and ulnar nerve dislocation in recreational wheelchair marathon athletes

“…Ulnar nerve dislocation was diagnosed by ultrasound examination. Dynamic ultrasound has been demonstrated to have a diagnostic accuracy of 89 to 100% [ 26 ]. Two experienced orthopedic surgeons participated in the ultrasound examination, and one surgeon examined both upper limbs for one participant.…”