Surgical treatment of the ulnar nerve entrapment neuropathy : submuscular anterior transposition or simple decompression of the ulnar nerve ?

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Surgical treatment of the ulnar nerve entrapment neuropathy: submuscular anterior transposition or simple decompression of the ulnar nerve ? Long-term results in 79 cases D. BIMMLER, V.E. MEYER

SUMMARY : The surgical treatment of the ulnar nerve entrapment neuropathy at the elbow is controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy, subcutaneous or submuscular anterior transposition of the ulnar nerve) has proven optimal regarding long-term results. We studied the outcome in 79 patients whose ulnar nerve had been operated on for the first time, either by simple decompression (31 cases) or by submuscular anterior transposition (48 cases). The mean follow-up was 76 months. Patients were classified according to McGowan pre- and postoperatively; we also applied a more detailed scoring system of our own. Preoperatively, the patients were distributed almost equally between the three McGowan classes. Postoperatively, about one out of three patients in both treatment groups experienced a distinct improvement, i.e. was upgraded to a better McGowan class. Using our own scoring system, the overall rate of objective improvement was 73 % after transposition and 55 % after simple decompression. Irrespective of the surgical method, roughly 90 % of the patients considered their postoperative condition to be improved. However, one specific group of patients (people with habitual ulnar luxation or subluxation of the ulnar nerve) experienced a distinctly better result when treated by anterior transposition than by simple decompression. Our results show that simple decompression of the ulnar nerve can be recommended in all patients without cubital (sub)luxation of the nerve, whereas people with a tendency of cubital (sub)luxation of the ulnar nerve should be treated by submuscular anterior transposition. Ann Chir Main (Ann Hand Surg), 1996, 16, n ° 3, 148-157. K E Y - W O R D S : Cubital ulnar neuropathy. - Nerve entrapment. - C o m p r e s s i o n neuropathy. Ulnar nerve.

Manuscrit regu ~ la R~daction le 29 novembre 1995. Accept6 le 4 mars 1996.

Department of Surgery, Division o f Hand, Plastic and Reconstructive Surgery, University of Zurich, Medical School, CH-8091 ZURICH (Switzerland).

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T A B L E I. -Scoring system.

INTRODUCTION

T A B L E A U I. - P r i n c i p e d ' ~ v a l u a t i o n .

The operative treatment of the ulnar neuropathy at the elbow is controversial. Presently at least four different procedures are being advocated: simple decompression of the ulnar nerve [9, 24, 29], medial epicondylectomy [12, 16, 18], subcutaneous [8, 10, 34, 35] or submuscular [14, 19, 23] anterior transposition of the ulnar nerve. None of these methods has consistently proven optimal regarding longterm results. Only two types of procedures have been applied at our division since 1975, i.e. the simple decompression and the submuscular anterior transposition o f the ulnar nerve. We have evaluated the long-term results of these two surgical methods, considering both the subjective j u d g e m e n t o f the patients and their objective status based on the specific findings.

T A B L A I. - S i s t e m a

Findings that contr/buted to the score, which was compared preand postoperatively: Sensory (tip of dig. V) :

These 87 patients underwent 90 operations. In 79 cases this was the first operative procedure concerning the ulnar nerve while 11 patients had to be treated for a r e c u r r e n c e . Without regard to the latter, 48 (61%) submuscular anterior transpositions and 31 (39%) simple decompressions of the ulnar nerve were performed. During certain periods of the time surveyed one or the other surgical method was clearly favoured. Only submuscular anterior transpositions were performed from 1975 to 1979, then almost exclusively simple decompressions, and from 1986 onward the former was again the preferential treatment (fig. 1). The two therapy groups therefore do not contain preselected patients. The severeness of the ulnar neuropathy was rated according to the classification introduced by Anna McGowan [28] : Grade I : <>. Grade II :

points

• normal sensitivity to touch • hypaesthesia, dysaesthesia, hyperaesthesia • anaesthesia

2 1 0

• normal sensitivity to pain • hypalgesia, hyperalgesia • analgesia • two-point discrimination

< 6mm 8mm 10ram >10mm

Motor: muscles dependant of the ulnar nerve: normal aspect atrophy clawing

negative positive

sign of Wartenberg

negative positive

sign of Froment

negative positive

MATERIAL AND METHODS At our division a total of 111 patients had surgery for cubital ulnar neuropathy between December 1975 and November 1988. We were able to trace 87 of these patients (78%) in the course of this survey, and they were clinically examined by one investigator (first author), who was not involved in the treatment of any of these patients. The mean time of follow-up was 76 months (standard deviation SD: 49). The average age of the 31 (36 %) female and 56 (64 %) male patients at the time of the operation was 45 (SD: 13) years, the youngest being 13 years old.

d e puntaje.

ab- and adduction of the Iongfingers (in particular dig. V) : normal strength* reduced strength* impossible flexion of the distal interphalangeal joint dig. V normal strength* reduced strength* impossible * Compared with contralateral (healthy)hand.

Points were added up preoperatively and postoperatively. A higher postoperative score (compared to the preoperative one) was rated as an improvement. Cases with insufficient documentation were regarded as unchanged (cf. fig. 4).

<. Grade III : <>. This classification is fairly rough; it has nevertheless been widely adopted thanks to its simplicity [2, 12, 14, 16, 24, 32, 33]. Each of our patients was classified according to McGowan both pre- and postoperatively based on the respective findings. However, only distinct changes can be detected using this approach. The McGowan II grading in particular covers a rather wide range of signs and symptoms, and a patient that is classified McGowan II pre- and postoperatively may well have

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n

•

m

Decompression

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6 4 2 0

[-], ii, 75

76

, 77

, 78

i

79

i

80

i

81

~

i

82 83

i

i

84 85

i

86 87

i

88

Year of operation

Fig. 1. - Application of the two surgical methods over time. One or other surgical method was clearly favoured during certain phases of the study period. Fig. 1, - Emploi des deux techniques chirurgicales pendant la p&iode en question. Pendant certaines ann~es une des deux m6thodes op&atoires 6tait favoris~e. Fig. 1, - Empleo de los dos rn~todos quirfirgicos en el trascurso del tiempo. Durante algunos periodos del tiempo analizado, uno u otro m~todo era distintamente preferido.

Cases 8O

60

40 • • •

20

ALL PATIENTS

Decompression

MG MG MG

Transposition

Fig. 2. - Preoperative M c G o w a n classification of the patients. Preoperatively, the 79 patients were almost equally distributed between the three M c G o w a n classes. The two patient subgroups (decompression, n = 31 ; transposition, n = 48) show a similar distribution, although slightly more severe cases can be found among the patients treated by simple decompression. M G : McGowan. Fig. 2. - Classification pr6-operatoire des patients selon McGowan. En pr~-op&atoire les 79 patients se distribuaient entre les trois classes de McGowan d'une fa~on presque ~quilibr6e. Les deux groupes th&apeutiques (neurolyse in situ isol~e, n = 31 ; transposition, n = 48) se pr~sentent avec une distribution similaire, bien que les cas s~veres sont un peu plus frequents chez les patients trait6s par neurolyse in situ isol6e. MG : McGowan. Fig 2. - Clasificaci6n preoperatoria de los pacientes seg0n McGowan. Preoperatoriamente, los 79 pacientes eran distribuidos casi homogeneamente entre las tres clases seg0n McGowan. Los dos subgrupos (neurolisis aislada, n =31 ; trasposici6n, n = 48) muestran distribuciones parecidas, si bien que pacientes algo mils graves se encuentran en el grupo tratado mediante neurolisis aislada. MG: McGowan.

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1 case 3%

3 cases 10%

4 cases 8%

2 cases 4%

12 cases 25% 8 cases 26%

17 cases

•

55%

• [] [] []

improved by 2 MG grades improved by 1 MG grade unchanged deteriorated by 1 MG grade deteriorated by 2 MG grades

Decompressions (n=31)

30 cases 63%

Transpositions (n=48)

Fig. 3. - Results based on the M c G o w a n classification only. The majority of the patients remained in the same McGowan (MG) class as preoperatively. Fig. 3. - R~sultats selon la classification de McGowan. La majorite des patients restait dans la m~me classe de McGowan (MG) comme en pre-operatoire. Fig. 3. - Resultados basados solamente en la clasificaci6n segt]n McGowan. La mayoria de los pacientes permanecieron en la misma clase seg0n McGowan (MG) como preoperatoriamente.

achieved distinct improvements, e.g. with respect to strength. We therefore evaluated the findings of patients remaining in the same McGowan class by applying our own score system (table I) which takes into consideration several sensory and motor criteria [4]. This enabled us to detect less spectacular changes after surgical treatment, too. Preoperatively the patients were distributed among the three McGowan classes almost equally, and the two therapy groups did not differ from each other to a relevant degree, although there was a slight tendency for less severe cases to be in the group that underwent anterior transposition (fig. 2) ; neither did they show conspicuous differences concerning demografic data or concomitant conditions [4]. The most common preoperative complaints were numbness and paresthesia in the areas innervated by the ulnar nerve, less frequent were loss of strength or pain.

tively, 8 % of the former and l0 % o f the latter a deterioration. The majority of the patients (63 % and 55%, respectively) remained in the same McGowan class as preoperatively (fig. 3). A more detailed evaluation of the findings of the patients remaining in the same McGowan (MG) class was done using our own score system. It demonstrated an objective improvement in another 44 % o f the cases with transposition and 19% o f the cases with simple decompression (fig. 4). Thus, the overall rate of objective improvement is 73 % after transposition and 55 % after simple decompression, a difference which is not statistically significant. Postoperatively normal sensory findings were present in four cases after simple decompression (13 %) and in 18 cases after anterior transposition (38 %) ; complete motor recovery was found in six (of22) cases after decompression and in eight (of 32) cases after transposition (leaving aside the ones that had been classified MG I already preoperatively).

RESULTS

After decompression, objectively complete sensory and motor restitution occurred in four cases (one preoperatively MG I, two MG II, one MG III), of which only one was subjectively asymptomatic, too (preop. MG II). After transposition, objectively complete sensory and motor restitution occurred in

Based on the McGowan classification, 29 % of the cases with submuscular anterior transposition and 36 % of the cases with simple decompression of the ulnar nerve showed an improvement postopera-

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1 case O~

2 ca,~ 6% 8 cases 17%

9 cases 29%

2 cases

• •

improved by 2 MG grades improved by 1 MG grade

[]

no change of MG grading, score improved unchanged (or insufficient documentation) no change of MG grading, score worse deteriorated by 1 MG grade deteriorated by 2 MG grades

[]

[]

19%

[] [] Decompressions (n=31)

21 c a s e s 44%

Transpositions (n=48)

Fig. 4. - Results based on a more detailed evaluation. The findings of those patients who remained in the same M c G o w a n class as preoperatively (cf. fig. 3) were evaluated by applying our own scoring system (see table I), which allowed detection of minor changes not distinguished by the three M c G o w a n (MG) grades. Fig. 4. - R~sultats selon notre classification plus d6taill~e. Les signes moteurs et sensitifs des patients qui restaient dans la m6me classe de McGowan comme en pr~-op6ratoire (voir fig. 3) furent ~valu6s en utilisant notre classification plus d6taillee (voir tableau I), que les trois classes de McGowan (MG). Fig, 4. - Resultados basados en una evaluaci6n m&s detallada. Los resultados de los pacientes que permanecieron en la misma clase segt]n McGowan como preoperatoriamente (fig. 3) fueron analizados utilizando nuestra propia clasificaci6n (tabla 1). Asi se detectaron paquefias diferencias escondidas dentro de la amplitud nosol6gica de las tres clases segt~n McGowan (MG). TABLE II.-Outcome according to the patients (n = 79) TABLEAU I1. - E~tatfinal selon les patients. TABLA I1. - Resultado en funci6n de los pacientes.

Improved Unchanged

TABLE III.- Postoperative satisfaction of the patients (n = 79) TABLEAU II1.- Degr~ de satisfaction des patients. TABLA II1.- Resultado subjetivo de los pacientes en post operatorio.

Worse

Entirely satisfied

Partially satisfied

No satisfied

Transposition(n = 48)

44 (92 %)

2

Transposition(n = 48)

39 (81%)

6 (13 %)

3 (6 %)

Decompression(n = 31)

27 (87 %)

3

Decompression(n=31)

20 (64%)

8 (26%)

3 (10 %)

12 cases (ten preop. MG I, two MG II) ; only four of these were without complaints, too (three preop. MG I, one MG II). The patients t h e m s e l v e s rated the results o f the operations much better: Irrespective of the surgical method, roughly 90 % of the patients considered their postoperative condition improved, only about 4 % worse (table II). Less than 10% (simple decompression) or 6 % (anterior transposition) were

not satisfied, 64 % and 81%, respectively, declared themselves entirely satisfied with the result (table III). Regarding the postoperative inability to work, we could not detect a relevant difference between the two therapy groups, either (fig. 5). However, we experienced complications only after anterior transpositions : once an infected wound which healed by secondary intention without further problems, in another case a hematoma with

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weeks 20 181 ................................................................................................................................................................................................................... 16 ........................................................... T " ........................................................................................ ~ ............................................ 14 ...............................................................................................................................................................................................................

illl il

EIIIZEZZZEIIII

EZZZZZIIIIIII ...........i

Decompression

IIIIEIIIIII

Transposition

Fig. 5. - Postoperative inability to work. The median duration of postoperative inability to work of at least 50 % was about 7 weeks with no obvious difference between the two subgroups • , decompression,, (n = 24) and ,,transposition, (n = 29). The box plots mark the 10th, 25th, 50th, 75th and 90th percentiles. Fig. 5. - Incapacite de travail post-operatoire. La duree moyenne d'une incapacite de travail d'au moins 50 % etait environ 7 semaines (sans diff&ence 6vidente entre les deux groupes therapeutiques) ; , decompression ,, : neurolyse in situ isolee (n = 24); -transposition,, : transposition anterieure sous-musculaire (n = 29). Les - b o x plots- marquent 10, 25, 50, 75 et 90 %. Fig. 5. - Incapacidad postoperatoria para el trabajo. La duraci6n promedio de una incapacidad postoperatoria para el trabajo de por Io menos 50 % era de 7 semanas sin diferencias nitidas entre los dos subgrupos -neurolisis- (n =24) y -transposici6n- (n =29). Las cajas graficas sefialan las porcentiles 10, 25, 50, 75 y 90.

30 ]

postop.

cases

[] • • •

20

MG Ill MG II MGI MG 0

10-

0 Trans. Decomp. preop. MG I

I

Trans. Decomp. preop. MG II

I

Trans. Decomp. preop. MG Ill

Fig. 6. - Postoperative MG grading with respect to preoperative MG class. Postoperatively, the patients' status changed irrespective of the severity of their preoperative status or the surgical method applied. However none of our patients, who preoperatively had been graded M c G o w a n (MG) grade III improved to MG 0 (MG 0 : patient free of pathological sensory and motor findings and not complaining of any symptoms). Every patient may obviously benefit from surgical treatment, but the final result d e p e n d s on the preoperative severity of the disease. Anterior submuscular transposition (n = 48). Simple decompression (n = 31). Fig. 6. - Classification post-op~ratoire selon McGowan selon la classification pr6-operatoire. En post-operatoire I'etat des patients se changeait independamment de la gravite pr6-operatoire ou de la technique chirurgicale appliquee. Pourtant aucun de nos patients classes McGowan (MG) III pre-op6ratoirement atteignit MG 0 (MG 0 : patient libre de signes sensitifs ou moteurs pathologiques et ne se plaignant d'aucun sympt6me). Chaque patient apparemment a une chance d'amelioration gr&ce & la th6rapie chirurgicale, mais le resultat definitif depend de la severit6 pre-op&atoire de la maladie. Transposition anterieure sous-musculaire (n = 48). Neurolyse in situ isol~e (n = 31). Fig. 6. - Clasificacion postoperatoria seg0n McGowan relativa a la clasificacion preoperatoria. Las diferencias entre la clasificaci6n preoperatoria y la postoperatoria era independiente de la primera y del metodo quir0rgico empleado. Sin embargo, ninguno de los pacientes clasificados preoperativamente como - McGowan III ,, mejor6 para alcanzar la clase - McGowan 0 (definida como - paciente sin problemas sensitivos o motores patol6gicos y sin queja-). Obviamente, cada paciente tiene la possibilidad de mejoria mediante un tratamiento quir0rgico, pero el resultado final depende del grado de la enfermedad. Transposicion submuscular anterior (n = 48). Neurolisis in situ aislada (n = 31).

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TABLE IV. - O u t c o m e in patients with habitual cubital (sub) luxation of the ulnar nerve (based on McGowan grading and our own score system [n =36]). TABLEAU IV. - I~tat final des patients qui pr6sentaient en pr6operatoire une subluxation habituelle du neff ulnaire (selon la classification de McGowan et notre propre score [n = 36]. TABLA IV. - Resultado de los pacientes con una (sub)luxaci6n habitual cubital del nervio cubital.

Improved

Unchanged

Worse

Transposition (n = 29)

17 (59 %)

8 (27 %)

4(14%)

Decompression (n = 7)

2 (29 %)

5 (71%)

subsequent compartment syndrome, requiring a fasciotomy. In both cases the final result regarding ulnar nerve function was favourable. A m o n g the patients operated for the first time in our institution we witnessed four recurrences (5 %), one occurring after anterior transposition, three after simple decompression. Evaluating all 11 patients operated for a recurrence - including those that had originally been treated in other hospitals - we found a reversed ratio" nine cases of anterior t r a n s p o s i t i o n ( s u b m u s c u l a r and other surgical methods), two of simple decompression. Preoperative factors like age, length of symptomatic period or concomitant diseases did not significantly influence the outcome in our patients [4]. The degree of the Dostot~erative change is largely i n d e p e n d e n t o f (he p r e o p e r a t i v e s e v e r e n e s s o f the u l n a r n e u r o p a t h y [4], the f i n a l r e s u l t (i.e. the postoperative condition), however, is not (fig. 6). One specific group of patients achieved a better result when treated by anterior transposition than by simple decompression: these are the people with habitual luxation or subluxation of the ulnar nerve, an a n a t o m i c variant we f o u n d in 36 o f 79 patients (46 %) preoperatively, whereas Childress had described an incidence of 16 % in the population [7]. Based on the McGowan grading supplemented by our own score system, we could demonstrate an improvement in 17 of 29 cases with anterior transposition (59 %), but only in two of seven cases with simple decompression (29 %) (table IV). DISCUSSION Regarding the therapy of the ulnar neuropathy we are as far from an <>as ever: every method has its critics and its advocates, and at least four therapeutic approaches are currently used: simple decompression of the ulnar nerve, medial epi-

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condylectomy, subcutaneous and submuscular anterior transposition o f the ulnar nerve. N u m e r o u s reports dealing with the outcome of these surgical methods have been published [2, 3, 5, 6, 8-13, 15-19, 22-25, 27-30, 32-36]. To our knowledge there is, however, only one study that compares the simple decompression and the submuscular anterior transposition in a large number of patients [26]. Many investigators gave a detailed description of the postoperative condition only or judged the result with rather unprecise characterizations like <>or <> and similar [1, 15, 17, 18, 21, 29, 33, 36]; only few tried to rate the postoperative change of condition with respect to the preoperative state [12, 14, 16, 19, 23-25, 28, 30, 33] ; details concerning the severeness of the preoperative neuropathy are frequently missing [3, 6, 8, 10, 26, 29]. Several authors did not clearly distinguish between objective changes in findings and subjective judgments of the patients [1, 3, 8, 11, 17, 18,26, 36]. We were in the favorable position of having ample documentation on every patient in this survey since every one had been examined in our out-patient hand clinics preoperatively. On this basis we have tried to comprehensively evaluate the data concerning the 79 reported cases in order to describe the outcome as precisely as possible. The epidemiologic data (age, sex, profession) of our patients [4] did not differ from already published material [6, 18, 35]. The outcome in our series is age-independent which confirms a report by Adelaar et al. [1], but is contrary to the findings of Brantschen and Kfipfer [5]. The duration of the p r e o p e r a t i v e s y m p t o m a t i c p e r i o d and the severeness of the neuropathy were not correlated in our p a t i e n t s ( c o n t r a r y to the f i n d i n g s o f Jensen [20]), and the outcome was independent of the f o r m e r , too ; the same has b e e n r e p o r t e d by Adelaar et al. [1], whereas others report the contrary [6, 10]. Most of our patients assess the surgical therapy as successful: Nine out of ten report an improvement, seven out of ten are entirely satisfied with the result. Viewed objectively, the findings are less impressive: Very few patients recovered in every respect (objectively and subjectively); counting all patients that showed no pathologic signs with regard to the ulnar nerve (irrespective of their subjective complaints), the proportion of recovered patients is still only 20 %. To us, however, the changes with respect to the preoperative status seem more important than the postoperative condition alone. We found an objective improvement in two out of three cases. In every eighth case (ten out of 79), however, the condition deteriorated. Similarly dissatisfying results have so far been r e p o r t e d only by few a u t h o r s [1, 8, 19, 25]. Goldberg et el. [16] documented an improvement

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based on the McGowan classification in 50% o f the cases after medial epicondylectomy. Amadio [3] reported a change to the better in well over 60 % o f the patients after submuscular anterior transposition o f the ulnar nerve. Other authors described a rate of recovery or improvement due to different surgical methods of about 80 % [2, 6,

12, 17, 24, 27, 34] or even 90% [9, 11, 18, 23, 31]. Comparing the outcome after simple decompression or submuscular anterior transposition o f the ulnar nerve, we did not find an unequivocal tendency in favour of one or the other surgical method,

which confirms the data presented by Macnicol [26]. Patients with habitual (sub)luxation of the ulnar nerve, however, have achieved better results with submuscular anterior transposition than with simple decompression of the nerve. Although the number of treated patients is too small to render

this difference statistically significant, it is nevertheless quite remarkable and demonstrates a clear tendency in favour o f the anterior transposition.

CONCLUSION We therefore conclude that in most cases the technically less demanding simple decompression of the ulnar nerve can be recommended as preferential treatment, whereas the submuscular anterior transposition should be chosen whenever a cubital dislocation of the ulnar nerve is found. It has furthermore become our policy when performing a simple decompression to intraoperatively check whether after decompression the ulnar nerve dislocates during elbow flexion. If a dislocation of the ulnar nerve over the medial epicondyle occurs during flexion of the elbow, the operative strategy is changed and a submuscular anterior transposition carried out.

REFERENCES 1. ADELAAR R.S., FOSTER W.C., MCDOWELL C. - The treatment of the cubital tunnel syndrome. J. Hand Surg. (Am O, 1984, 9A, 90-95. 2. ALNOT J.Y., FRAJMAN J.M. - Syndrome de compression chronique du neff cubital au niveau du coude. Ann. Chir. Main, 1992, ll, 5-13. 3. AMADIO P.C. - Anatomical basis for a technique of ulnar nerve transposition. Surg. RadioL Anat., 1986, 8, 155-161. 4. BIMMLER D. - Ergebnisse der operativen Therapie des Sulcus ulnaris Syndromes : submuskul~ire Vorverlagerung versus einfache Dekompression des N. ulnaris. Inaugural-Dissertation, Universitat Zfirich, 1992. 5. BRANTSCHEN R., K(JPFER K. Langzeitresultate nach Neurolyse und Palmarverlagerung des Nervus ulnaris. Chirurg., 1991, 62, 314-316. 6. CHAN R.C., PAINE K.W.E., VARUGHESE G. - Ulnar neuropathy at the elbow : Comparison of simple decompression and anterior transposition. Neurosurgery. 1980, 7, 545-550. 7. C H I L D R E S S H . M . - Recurrent ulnar-nerve dislocation at the elbow. 32 Bone Joint Surg., 1956, 38A, 978-984. 8. DAS GUPTA K., SENNERICH T., DEGREIF J., KUROCK W. Klinische und n e u r o l o g i s c h e E r g e b n i s s e nach o p e r a t i v e r Versorgung des Ulnarisrinnensyndromes. Handchir. Mikrochir. Plast. Chir., 1993, 25, 311-315. 9. DAVIES M.A., VONAU M., BLUM P.W. et coll. - Results of ulnar neuropathy at the elbow treated by decompression or anterior transposition. Aust. NZ J. Surg., 1991, 61, 929-934. 10. DEUTINGER M., MAYR N., FREY M. et coll. - Klinische und elektroneurografische Ergebnisse nach operativer Behandlung des Sulcus nervi ulnaris-Syndromes. Z. Orthop., 1989, 127, 63%642. 11. F O S T E R R.J., EDSHAGE S. - Factors related to the outcome of surgically managed compressive ulnar neuropathy at the elbow level. J. Hand Surg., 1981, 6, 181-192. 12. FROIMSON A.I., ANOUCHI Y.S., SEITZ W.H., W1NSBERG D.D. - Ulnar nerve decompression with medial epicondylectomy for neuropathy at the elbow. Clin. Orthop. Rel. Res., 1991, 265, 200-206. 13. FROIMSON A.I., ZAHWARI F. - Treatment of compression neuropathy of the ulnar nerve at the elbow by epicondylectomy and neurolysis. J. HandSurg., 1980, 5, 391-395. 14. GABEL G.T., AMADIO P.C. - Reoperation for failed decompression of the ulnar nerve in the region of the elbow. 32 Bone Joint Surg., 1990, 72A, 213-219.

15. GERL A., THORWIRTH V. - Ergebnisse der Ulnarisverlagerung. Acta Neurochir., 1974, 30, 227-246. 16. GOLDBERG B.J., LIGHT T.R., BLAIR S.J. - Ulnar neuropathy at the elbow: results of medial epicondylectomy. J. Hand Surg. (Am.), 1989, 14A, 182-188. 17. HAGSTROM P. - Ulnar nerve compression at the elbow : Results of surgery in 85 cases. Scand. 32 Plast. Reconst. Surg., 1977, 11, 59-62. 18. H E I T H O F F S.J., M I L L E N D E R L.H., N A L E B U F F E.A., PETRUSKA A.J. - Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow. J2 Hand Surg. (Am.), 1990, 15A. 22-29. 19. JANES P.C., MANN R.J., FARNWORTH T.K. Submuscular transposition of the ulnar nerve. Clin. Orthop., 1989, 238, 225-232. 20. JENSEN E. - Ulnar Perineuritis. A survey with a follow-up examination of 39 operated cases. Acta Psychiatr. Scand,, 1959, 34, 205-221. 21. JONES R.E., GAUNTT C. - Medial epicondylectomy for ulnar nerve compression syndrome at the elbow. Clin. Orthop. Rel. Res., 1979, 139, 174-178. 22. KING T., MORGAN F.P. - Late results of removing the medial humeral epicondyle for traumatic ulnar neuritis. J. Bone Joint Surg., 1959, 41B, 51-55. 23. LEFFERT R.D. - Anterior submuscular transposition of the ulnar nerve by the Learmonth technique. J. Hand Surg., 1982, 7, 147155. 24. LEROUX P.D., TODD D.E., BURCHIEL K.J. - Surgical decompression without transposition for ulnar neuropathy : factors determining outcome. Neurosurgery, 1990, 27, 709-714. 25. LUGNEGARD H., WALHEIM G., WENNBERG A. - Operative treatment of ulnar nerve neuropathy in the elbow region. A clinical and electrophysiological study. Acta Orthop., Scand., 1977, 48, 168-176. 26. MACNICOL M.F. - The results of operation of ulnar neuritis. J. BoneJoint Surg., 1979, 61B, 159-164. 27. MANSKE P.R., JOHNSTON R., PRUITT D.L., STRECKER W.B. - Ulnar nerve decompression at the cubital tunnel. Clin. Orthop., 1992, 274, 231-237. 28. McGOWAN A.J. - The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J. Bone Joint Surg., 1950, 32B, 293301.

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29. NATHAN P.A., MYERS L.D, KENISTONR,C., MEADOWS K.D. - Simpledecompressionof the ulnar nerve: an alternativeto anterior transposition.J. Hand Surg., 1992, 17B, 251-254. 30. NIGSTH. - Die traumatische Neuritis des Nervus ulnaris. Eine Analyse yon 73 operierten Fallen. Helv. Chir. Acta, 1953, 20, 37-51. 31. NIGST H. - Ergebnisse der operativen Behandlung der Neuropathie des N. ulnaris im Ellbogenbereich. Handchirurgie, 1983, 15, 212-220. 32. ROBINSOND., AGHASIM.K., HALPERINN. - Medial epicondylectomyin cubital tunnel syndrome:an electrodiagnosticstudy. J. Hand Surg. (Br.), 1992, 17B, 255-256.

33. SOKOLOWC., PARISERP., LEMERLEJ.P. - Atteintes du nerf cubital au coude. Approche 6tiologique. Ann, Chir. Main, 1993, 12, 12-18. 34. STUFFER M., JUNGWIRTH W., HUSSL H., SCHMUTZHARDT E, - Subcutaneousor submuscular anterior transposition of the ulnar nerve?J. Hand Surg. (Br.), 1992, 17B, 248-250. 35. SUDEN R., WILHELM A. - Das proximale Ulnariskompressionssyndrom unter besonderer Beriicksichtigung des M. epitrochleo-anconaeus.Handchirurgie, 1987, 19, 33-42, 36. WILSOND.H., KROUTR. - Surgery of ulnar neuropathy at the elbow: 16 cases treated by decompressionwithout transposition. J. Neurosurg., 1973, 38, 780-785.

BIMMLER D., MEYER V . E . - Traitement chirurgical des compressions du nerf ulnaire du coude : transposition sousmusculaire ou d6compression nerveuse simple ? R6sultats ~t long terme de 79 cas. (En Anglais). A n n Chir Main (Ann H a n d Surg), 1996, 15, n ° 3, 148-157.

BIMMLER D., MEYER V.E. - Tratamiento quirfirgico de la neuropatia compresiva del nervio cubital: Trasposici6n anterior submuscular o neurolisis simple del nervio cubital ? Resultados a largo plazo de 79 casos. Ann Chir Main (Ann H a n d Surg), 1996, 15, n° 3, 148-157.

RI~SUMI~ • Le traitement chirurgical du syndrome de compression chronique du n e f f cubital au niveau du coude reste sujet g controverse. Aucune des techniques op6ratoires propos6es (neurolyse in situ isol6e du nerf cubital, 6pitrochl6ectomie partielle, t r a n s p o s i t i o n ant6rieure sous-cutan6e ou sous-musculaire du nerf cubital) a prouv6 ~tre sup6rieure aux autres en regard des r6sultats tardifs. Nous avons analys6 les r6sultats chez 79 patients qui ont 6t6 op6r6s d'une compression chronique du nerf cubital au coude pour la premi6re fois, ou par neurolyse in s i t u isol6e (31 cas), ou par transposition ant6rieure sous-musculaire (48 cas). Le recul moyen est de 76 mois. Les patients 6taient class6s selon M c G o w a n pr6- et post-op6ratoirement ; en outre nous proposons une classification plus d6taill6e. En pr6-op6ratoire les patients se distribuaient entre les trois classes M c G o w a n d'une faqon presque 6quilibr6e. En post-op6ratoire environ un des trois patients dans les deux groupes th6rapeutiques a atteint une am61ioration marqu6e, ainsi qu'il 6tait attribu6/l une classe McGowan meilleure. Selon notre classification, le quota globale d'am61ioration est 73 % aprbs transposition et 55 % apr6s neurolyse in situ isol6e. Quelle que soit la m6thode chirurgicale, environ 90 % des patients consid6raient meilleur leur condition post-op6ratoire. Cependant, un groupe de patients (les gens avec luxation ou subluxation habituelle du nerf cubital) atteignait un r6sultat 6videmment meilleur apr6s transposition sous-musculaire qu'apr6s neurolyse in situ isol6e. Nos r6sultats montrent que la neurolyse in situ isol6e du nerf cubital peut ~tre recommand6e pour t o u s l e s patients sans (sub)luxation du nerf cubital, mais que les patients avec (sub)luxation habituelle du nerf cubital devraient ~tre trait6s par une transposition ant6rieure sous-musculaire.

RESUMEN" E1 tratamiento quirfirgico del sindrome de la compresi6n cr6nica del nervio cubital a nivel del codo es controvertible. Ninguna de las t6cnicas actualmente recomendadas (neurolisis in situ aislada, epicondilectornia medial, trasposici6n anterior subcut~mea o submuscular del nervio) se ha rnostrado superior a las demfis en lo relativo a los resultados tardios. H e m o s analizado los resultados tardios de 79 pacientes operados del nervio cubital por la prim e r a vez mediante o una neurolisis in situ aislada (31 casos) o una trasposici6n anterior submuscular (48 casos). E1 seguimiento promedio era de 76 meses. Los pacientes fueron clasificados segfin la clasificaci6n de McGowan antes y despu6s de la intervenci6n. Adem/is, hemos utilizado una clasificaci6n propia m/is detallada. Antes de la intervenci6n, los pacientes se repartieron casi h o m o g e n e a m e n t e en los tres tipos segfin la c l a s i f i c a c i 6 n de M c G o w a n . P o s t o p e r a toriamente, casi un tercio de los pacientes en ambos grupos de tratamiento mostr6 una distinta mejoria, es decir que alcanz6 una clase m/is alta en la clasificaci6n segfin McGowan. Usando nuestra clasificaci6n propia, la proporci6n de mejoria global era de 73 % despu4s de trasposici6n y de 55 % despu4s de neurolisis aislada. I n d e p e n d i e n t e m e n t e del m h t o d o quirfirgico empleado, aproximadamente el 90 % de los pacientes juzgaron su estado postoperatorio mejorado. Todavia, un grupo especifico de pacientes, aquellos con luxaci6n o subluxaci6n dinfimica del nervio, mostraron resultados distintamente mejores despu4s de tratamientos mediante trasposici6n anterior que mediante neurolisis aislada. Nuestros resultados muestran que la neurolisis en situ aislada puede ser recomendada en todos los pacientes sin (sub)luxaci6n din/imica del nervio cubital, mientras que pacientes con una tendencia a la (sub)luxaci6n deberian ser tratados mediante una trasposici6n submuscular.

MOTS-CLI~S : Nerf cubital. - Syndrome canalaire. Compression au coude.

PALABRAS-CLAVE : Nervio cubital. - Sindrome del canal cubital. - Compresi6n a nivel del codo.

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