Fig. 1 Photograph shows in situ decompression. Anterior subluxation of the ulnar nerve is shown after complete in situ ulnar nerve release. Reproduced from Gellman H: Compression of the Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome. Instr Course Lect 2008;57:187-197.

AAOS Now

Published 10/1/2015
|
Maureen Leahy

Surgical Morbidity Following Cubital Tunnel Procedures

Study compares in situ decompression, ulnar nerve transposition, and medial epicondylectomy

Study data presented at the 2015 annual meeting of the American Society for Surgery of the Hand indicate that in situ decompression is associated with less surgical site tenderness, fewer narcotic requirements, and less parasthesia, compared to ulnar nerve transposition and medial epicondylectomy for the treatment of cubital tunnel syndrome.

Despite a rise in surgical rates for the treatment of cubital tunnel syndrome, no single procedure has proven superior, according to Robert Staples, MD. “Therefore, assuming similar outcomes, differences in the surgical morbidity and early recovery among procedure options become increasingly important,” he said. “The primary objective of our study was to compare the relative morbidity of different surgical procedures for the treatment of cubital tunnel syndrome.”

Prospective cohort study
The researchers conducted a prospective cohort study involving 102 adult patients with cubital tunnel syndrome who had elected to undergo surgical intervention at a single tertiary care center. Revision cubital tunnel surgery patients were excluded, as were patients with a history of myelopathy or radiculopathy in the surgical extremity and patients taking preoperative narcotics.

At the surgeon’s discretion, patients underwent in situ decompression (n = 29), ulnar nerve transposition (n = 56), or medial epicondylectomy (n = 17). Demographics and preoperative pain levels were similar among all patients.

Outcome data (surgical site pain, narcotic usage, functional impairment) were assessed at 0–3 weeks, 4–8 weeks, and >8 weeks following surgery. A 0–10 visual analog scale (VAS) was used to measure surgical site pain when the patient was resting, moving, and touching a surface. Patient-rated disability was quantified with Levine-Katz functional scores. Incidences of olecranon paresthesia and wound complications—including hematoma, drainage, and infection—were also assessed.

Statistical analysis revealed that patients treated with in situ decompression had less surgical site pain than patients treated with either ulnar nerve transposition or medial epicondylectomy at early (0–3 weeks) follow-up (P < 0.01) (Fig. 1). However, no significant differences in surgical site pain were found among the groups at later follow-up. Patients treated with in situ decompression also used fewer narcotics at all time points, yet the differences were not statistically significant, and the frequency of narcotic use among all patients decreased over time. Olecranon paresthesia was present in all patients, but had completely resolved at final follow-up in patients treated with in situ decompression.

The researchers also found that patient-rated disability was higher among patients treated with ulnar nerve transposition at early follow-up, but decreased over time. The only wound complications that occurred were three hematomas in the ulnar transposition patient group.

Conclusions
“Lessened surgical morbidity favors in situ decompression as an index procedure for cubital tunnel syndrome,” Dr. Staples said. “However, surgical morbidity is only one factor when choosing among potential surgeries; expected outcomes and the potential for revision surgery should also be considered.”

Dr. Staples’ coauthors of “Comparative Morbidity of Cubital Tunnel Surgeries: A Prospective Cohort Study,” are Daniel London, MD, MSc; Daniel A. Osei, MD, MSc; Charles A. Goldfarb, MD; Andre Guthrie, BS; and Ryan Patrick Calfee, MD, MSc. The authors’ disclosure information can be accessed at www.aaos.org/disclosure

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Despite an increase in the incidence of surgical treatment for cubital tunnel syndrome, no consensus exists on the optimal surgical approach.
  • Differences in the relative risks and morbidity of the various surgical procedures are important considerations for patients considering surgery.
  • Data from this prospective cohort study indicate that in situ decompression results in less surgical morbidity than ulnar nerve transposition or medial epicondylectomy.