A, Transmuscular transposition (black arrowhead indicates ulnar nerve; white arrowhead indicates fascial slip). B, In situ release (black arrowhead indicates ulnar nerve).
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Coady-Fariborzian L, McGreane A, Anstead C, Lawler R, Jones-Lawson A, Richards W. Ten-Year Retrospective Review of Cubital Tunnel Surgery at the Malcom Randall Veterans Affairs Medical Center, 2005 to 2014. JAMA Surg. 2016;151(11):1088–1089. doi:https://doi.org/10.1001/jamasurg.2016.2306
Compression of the ulnar nerve at the level of the elbow is the second most common nerve compression after carpal tunnel syndrome.1 There are multiple surgical options for treating this problem with favorable outcomes and low morbidity. The objective of this study was to determine whether a particular method of decompression performed at our facility or a perioperative risk factor carried a greater risk of postoperative local complications.
This study was approved by the institutional review boards of the University of Florida and the North Florida/South Georgia Veterans Health Service Research and Development Committee. It was a retrospective medical record review of all cubital tunnel decompressions by the Malcom Randall VA plastic surgery service over a 10-year period (2005-2014). Informed consent was wavied because of the nature of the study (retrospective medical record review). The methods of decompression (in situ, subcutaneous, transmuscular, submuscular, and alloderm sling) and local complications (neurapraxia, infection, seroma, hematoma, and dehiscence) over a 6-month postoperative period were recorded. Perioperative risk factors studied were tobacco use, diabetes status, tourniquet time, perioperative antibiotics, and body mass index. A Fisher exact test was used to determine whether a specific type of decompression or a perioperative risk factor had a statistically significant higher rate of postoperative complications. A P value of less than .05 was used to determine statistical significance.
A total of 387 patients had their ulnar nerve decompressed at the elbow. Twelve plastic surgeons performed 5 different types of decompression. Various methods of transposition (n = 375; submuscular, subcutaneous, transmuscular, and alloderm sling) (Figure, A) were favored over the open in situ technique (n = 12) (Figure, B). There were 66 patients (17%) who were noted to have an objective local complication. Two complications (0.5%) required surgical intervention (1 subluxation and 1 hematoma). A Fischer exact test did not find a statistically significant increased rate of complications with any of the 5 different nerve decompressions (Table 1). Current smokers were found to have a statistically significant complication risk (risk ratio, 0.8; 95% CI, 0.47-1.36; P = .03) (Table 2). Local complications identified were cutaneous neurapraxia (n = 35), infection (n = 10), seroma (n = 9), dehiscence (n = 9), hypertrophic scar (n = 1), hematoma (n = 1), and subluxation (n = 1).
Cubital tunnel syndrome is diagnosed by a combination of patient symptoms, physical examination findings, and nerve conduction studies. Patients present with reports of intermittent or persistent numbness or tingling in the ulnar nerve distribution distal to the elbow, often exacerbated by prolonged flexion of the elbow or direct pressure on the ulnar nerve. Long-term compression can result in loss of sensation in the small and ring fingers, weakness of grip, loss of coordination, and atrophy of the interosseous muscles. Nerve conduction studies objectively confirm the point of compression. Studies have failed to definitively support 1 method of decompression over the other.2
The open in situ method appears to be gaining traction as a favored procedure in clinical practice.3 The in situ method release decompresses the points of compression; however, the nerve is still under tension when the elbow is flexed.4 It is also at risk for symptomatic subluxation postoperatively. The concern for devascularizing the nerve during transposition has been addressed and does not appear to offer long-term morbidity.5 Transposition continues to be favored at our facility with a low rate of serious complications.
None of 5 different methods of ulnar nerve decompression were found to have a statistically significant increased rate of local morbidity. Body mass index, diabetes, tourniquet time, and perioperative antibiotic use did not affect post operative local complications. Tobacco users had a statistically significant higher risk of local complications. The surgeons at our institution will continue to do the decompressive surgery they feel most appropriate for a particular patient, while emphasizing the benefits of nicotine cessation. Educational efforts will be focused toward emphasizing the anatomy of antebrachial cutaneous nerve branches.6
Corresponding Author: Loretta Coady-Fariborzian, MD, Malcom Randall VA Medical Center, Plastic Surgery Section, EB06-1, 1601 SW Archer Rd, Gainesville, FL 32608 (firstname.lastname@example.org).
Published Online: August 31, 2016. doi:10.1001/jamasurg.2016.2306.
Author Contributions: Dr Coady-Fariborzian had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Coady-Fariborzian, McGreane, Richards.
Acquisition, analysis, or interpretation of data: All Authors.
Drafting of the manuscript: Coady-Fariborzian, McGreane, Anstead.
Critical revision of the manuscript for important intellectual content: Coady-Fariborzian, Lawler, Jones-Lawson, Richards.
Statistical analysis: McGreane.
Administrative, technical, or material support: Coady-Fariborzian, McGreane, Anstead, Lawler, Jones-Lawson.
Study supervision: Coady-Fariborzian, McGreane.
Conflict of Interest Disclosures: None reported.
Funding/Support: This project is the result of work supported with resources and use of facilities at the Malcom Randall VA Medical Center, Gainesville, Florida.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents of this article do not represent the views of the US Department of Veterans Affairs or the US government.
Additional Contributions: We thank Justine Pierson, MS, research coordinator at the University of Florida, for statistical analysis. Funding is through salary.
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