Publication History
Submitted: October 14, 2024
Accepted: October 20, 2024
Published: October 31, 2024
Identification
D-0337
DOI
https://doi.org/10.71017/djmi.3.10.d-0337
Citation
Mandeep Karki, Deepak Shrestha, Xiang Zhou, Kailash Kumar Bhandari, Sunima Lama, Rachit Sharma & Rajiv Prasad Shrestha (2024). Simple Decompression versus Anterior Transposition (Submuscular and Subcutaneous) of the Ulnar Nerve in Cubital Tunnel Syndrome: a Meta-Analysis. Dinkum Journal of Medical Innovations, 3(10):700-715.
Copyright
© 2024 The Author(s).
700-715
Simple Decompression versus Anterior Transposition (Submuscular and Subcutaneous) of the Ulnar Nerve in Cubital Tunnel Syndrome: a Meta-AnalysisOriginal Article
Mandeep Karki *1, Deepak Shrestha 2, Xiang Zhou 3, Kailash Kumar Bhandari 4, Sunima Lama 5, Rachit Sharma 6, Rajiv Prasad Shrestha 7
- Nepal Orthopedic Hospital, Kathmandu, Nepal
- Nepal Orthopedic Hospital, Kathmandu, Nepal
- Department of Orthopedics, West China Hospital, Sichuan University ,Chengdu, China
- Nepal Orthopedic Hospital, Kathmandu, Nepal
- Bhaktapur Cancer Hospital, Bhaktapur, Nepal
- Nepal Orthopedic Hospital, Kathmandu, Nepal
- Nepal Orthopedic Hospital, Kathmandu, Nepal
* Correspondence: mandeep.karki@gmail.com
Abstract: Cubital tunnel syndrome (CTS) is the second most common neuropathy of the upper extremity due to entrapment of ulnar nerve. Surgical management is the better intervention compared with conservative one. This study is to evaluate operative technique preferable for the treatment of cubital tunnel syndrome and compare between simple decompression versus anterior transposition, and subcutaneous anterior transposition versus sub muscular anterior transposition. Level III systematic review and network meta-analysis were performed to compare clinical improvement between subcutaneous anterior transposition and sub muscular anterior transposition, and simple decompression and anterior transposition. Two sub analysis was also performed: 1) comparing sub muscular anterior transposition to subcutaneous anterior transposition, 2) comparing Infection rate of Simple Decompression to Anterior transposition. We identified eighteen studies in which 5 studies were RCT and 13 were non RCT (8 Retrospective Case series and 5 Prospective study) which involved a total number of 491 simple decompressions, 307 sub muscular transpositions and 485 subcutaneous transposition patients. We also found evidence of publication bias or statistical study heterogeneity. Odds ratio of improvement with simple decompression versus anterior transposition were 0.781 with a 95% CI of [0.574, 1.063], I2 = 0%, p value =0.117. The odds ratio of improvement of subcutaneous transposition versus sub muscular transposition was 1.208 with a 95% CI of [0.609, 2.397], I2 = 0%, p value=0.588 and the odds ratio of post-op infection in simple decompression versus anterior transposition was 0.287 with 95% CI of [0.097, 0.845], I2 = 0%, with p value=0.024. Sensitivity analyses with use of fixed-effects methodology confirmed these findings to be robust and no heterogeneity was found. The result in this study showed that there is no significant difference between the treatment of cubital tunnel syndrome while comparing the improvement parameter for simple decompression vs anterior transposition and sub muscular transposition vs subcutaneous transposition but while doing a sub-analysis comparing the post op-infection between simple decompression and anterior transposition significant difference was found, and also with subcutaneous transposition and sub muscular transposition.
Keywords: anterior transposition, cubital tunnel syndrome, simple decompression, ulnar neuropathy
- INTRODUCTION
The term ‘cubital tunnel’ first appeared in the published literature in 1958 [1]. Cubital Tunnel Syndrome (CTS) is the second most common entrapment neuropathy of the upper extremity [2,3] which is associated with weakness of the hand and arm within the ulnar nerve distribution, pain and sensory abnormalities [4]. Out of the 5 possible sites responsible for nerve entrapment at the elbow, the cubital tunnel is the most common site for ulnar nerve compression [5]. It is undeniable that individuals who suffer from cubital tunnel syndrome experience significant health problems linked to their place of employment and the activities they engage in on a daily basis [6]. It is essential to locate the appropriate treatment that is necessary for the management of cubital tunnel syndrome, given the significance of this ailment. The majority of instances of cubital tunnel syndrome improve with non-surgical management, and the majority of these cases will improve with surgical intervention and treatment [7]. There are still a great deal of debates surrounding the optimal care of this diseased condition [8], despite the fact that there is a wide variety of clinical expertise in the management and treatment of this diseased condition. The diagnosis of this sick state is based on the clinical symptoms as well as the electrophysiological abnormalities that are present in the patient. It is possible to treat cubital tunnel syndrome using either an operational or non-operative approach. These are the two primary methods. Simple decompression, anterior transposition (submuscular and subcutaneous), and medial epicondyle Tomy are the three components that make up the surgical approach to the treatment of cubital tunnel syndrome [9]. The conventional surgical approach for simple decompression required a large incision of 6-8 centimeters above and below the elbow. However, in today’s world, it is possible to execute the treatment with a little skin incision of approximately 2 centimeters or less and achieve successful outcomes [10]. When performing anterior nerve transposition surgery, it is frequently necessary to decompress the ulnar nerve for a distance of up to 10 centimeters or more. This decompression results in a significant reduction in the regional blood flow of the nerve [11]. On the other hand, the medial epicondyle Tomy technique is a technique that is rarely used for ulnar nerve entrapment [12]. A simple decompression method in conjunction with differing degrees of medial epicondyle Tomy and numerous different methods of anterior transposition are the distinguishing characteristics of the management of cubital tunnel syndrome. Nevertheless, there are a variety of procedures that are being utilized in the treatment of this condition. As a result of a survey that was carried out in the Netherlands, it was discovered that the most prevalent approach for operational therapy of cubital tunnel syndrome is anterior transposition of the ulnar nerve [13]. Undoubtedly, ulnar nerve entrapment at the elbow, sometimes referred to as cubital tunnel syndrome, necessitates surgical treatments that range from straightforward decompression to anterior transposition. Moreover, the choice of a surgical method for cubital tunnel syndrome should be related to the understanding of the etiology of the ulnar nerve entrapment of the patients, the pathophysiology of the compression of the ulnar nerve at the elbow, and the associated disadvantages of the various operative procedures [14]. The authors of a meta-analysis that was just recently published [15] and a systemic review came to the conclusion that simple decompression might be a better option for surgical intervention for cubital tunnel syndrome. On the other hand, another meta-analysis [16] came to the conclusion that anterior transposition would be a better clinical outcome. On the other hand, the authors have also mentioned that there is a possibility of bias in the research because of the preoperative severity assessment of the patients. The purpose of this research is to conduct a meta-analysis on the treatment of this disorder, with the sole focus being on comparative observational studies and randomized controlled trials. The analysis will compare anterior transposition and simple decompression, with the ultimate goal of determining which treatment option for cubital tunnel syndrome generates the most favorable outcomes.
- MATERIALS & METHOD
Using search terms such as “ulnar nerve compression, cubital tunnel syndrome, ulnar nerve, submuscular transposition, anterior transposition, and subcutaneous transposition,” two writers conducted independent searches for different articles in the databases of OVID MEDLINE, PubMed MEDLINE, and EMBASE between the years 1979 and 2019. Additionally, the Cochrane Central Register of Controlled Trials was searched for additional information. In a similar manner, the archives of abstracts offered by medical organizations such as the American Association of Hand Surgeons (AAHS), the Canadian Society of Plastic Surgeons (CSPS), and the American Society for Surgery of the Hand (ASSH), as well as the Canadian Orthopedic Association (COA), were searched. The titles of the abstracts were checked to ensure that they were correct, and a reference check was carried out in order to ascertain whether or not the articles satisfied the specifications for inclusion. There were a total of 389 articles recovered from the search. Following an examination of the titles, 363 were disqualified due to the absence of titles that were relevant or comparisons that were not present. There were a total of 26 papers chosen for full text evaluation, three of which contained cadaver and animal investigations [17,18], while five articles that did not compare were not included. Last but not least, for the purpose of this meta-analysis, a total of 18 publications were incorporated [19,20]. Two authors carefully extracted relevant data for the intervention groups from each study. Details such as the name of the first author, the number of cases and controls, gender, age, loss of follow-up, country, severity and duration of preoperative outcome, postoperative outcome (as measured by improvement of symptoms or grading of excellent and good), infection (both superficial and deep), intervention protocol, and duration of the study were among the data that were extracted. The statistical analysis was carried out with the assistance of CMA, which stands for Comprehensive Meta-Analysis Software Version 2.2.064. Comparative observational studies and randomized controlled trials were the only types of research that qualified for analysis. We evaluated the heterogeneity of the included papers as well as the publication bias that existed. Within the same category as transposition, subcutaneous and submuscular transposition were categorized as “transposition.” In the case of dichotomous outcomes, the treatment effects were reported as odds ratios (OR) with confidence intervals (CI) of 95%. Each of the studies had their odds ratio determined. For example, the odds ratio compared the likelihood of improvement following transposition to the likelihood of improvement following basic decompression. An anterior transposition (submuscular or subcutaneous) and a simple decompression were both subjected to the determination of odds ratios for post-operative infections. In addition to that, the calculation for odds ratios of clinical improvement was carried out by contrasting submuscular anterior transposition with submuscular anterior transposition.
- RESULTS & DISCUSSION
As can be seen in table 01, this meta-analysis included a total of 18 investigations with a total of 1283 participants. Of these studies, 5 were randomized studies, and 13 were comparative observational studies. The inclusion criteria were met by all of these research. The individuals in the simple decompression procedure had a mean age of 52 years old, whereas the subcutaneous transposition participants had a mean age of 46 and the submuscular transposition participants had a mean age of 51. There were a total of 994 patients involved in 12 different investigations that compared simple decompression to anterior transposition. There were also two sub-analyses that were carried out, which compared post-operative infections in simple decompression and anterior transposition. These sub-analyses contained three trials with a total of 226 individuals. Moreover, a further sub-analysis was carried out on the subject of improved versus unimproved clinical outcomes. This particular sub-analysis comprised seven trials and a total of 292 participants.
Table 01: Study Characteristics
Author | Country | Design | Total no of patient included (N) | % Men | Mean Age (year) | Follow up (month) | Evaluation of Procedure |
Zhou, Y., et al (2012)
[23] |
China | Prospective study | 39
19(SMT) 20(SCT) |
N/A | N/A | 24-36 | Improved vs not improved/DASH Score |
Zare zadeh, A., et al. (2012)
[37] |
Iran | Prospective randomized trial | 38
24(SMT) 24(SCT) |
58(SMT)
54(SCT) |
47.4
(SMT) 47.58 (SCT)
|
12 | Clinical rating score (pain, sensation, muscle strength and atrophy) |
Luo, S., et al. (2010)
[36] |
China | Prospective study | 66
42(SMT) 24(SCT) |
N/A | N/A | 12-36 | Bishop Score |
Keiner et al., (2009)
[24] |
Germany | Prospective study | 33
17 (SD) 16(SMT) |
50 (SD)
25 (SMT) |
52 (SD)
46 (SMT) |
52(SD)
63.1 (SMT) |
Clinical
McGowan |
Charles, Y.P., et al (2009)
[25] |
France | Retrospective
Case series |
49
25(SMT) 24(SCT) |
72(SMT)
79(SCT) |
53(SMT)
46(SCT) |
84(SMT)
36(SCT) |
Modified MC Gowan |
Jad due, D.A(2009)[38] | Iraq | Prospective study | 26
13(SMT) 13(SCT) |
78(SMT)
78(SCT) |
34
34(SMT) 34(SCT) |
12 | Bishop Score |
Köse et al., (2007)[3] |
Turkey |
Retrospective
case series |
49
18 (SMT) 16 (SCT) |
N/A | 47.9 (SMT)
43.3 (SCT) |
7 – 49 | Improved vs not improved |
Biggs & Curtis [26](2006) | Australia | Prospective randomized study | 44
23 (SD) 21(SMT)
|
69 (SD)
81 (SMT) |
56 (SD)
61 (SMT) |
38.8 (SD)
42 (SMT) |
Clinical
(McGowan, LSUMC) |
Gervasio et al., (2005) [10] | Italy | Prospective randomized study | 70
35 (SD) 35 (SMT) |
50 (SD)
50 (SMT) |
53.1 (SD)
52.2 (SMT) |
47 (SD)
46.94 (SMT) |
Clinical rating score
(NCS, atrophy, weakness |
Bartels et al., (2005)[27] | The Netherlands | Prospective randomized study | 152
75 (SD) 77 (SCT) |
61(SD)
62 (SCT) |
47 (SD)
47 (SCT) |
12 | Improved vs not improved |
Nabhan et al., (2005)[28] | Germany | Prospective randomized study | 65
32 (SD) 33 (SCT) |
57 (SD)
43 (SCT) |
52 (SD)
48 (SCT) |
3 – 9 | Clinical rating score
(NCS, atrophy, weakness) |
Taha et al., (2004)[29] | USA | Retrospective
case series |
38
21 (SD) 17 (SCT) |
71 | 63 | 48 | Clinical
(Gabel) |
Bimmler et al., (1996)[31] | Switzerland | Retrospective
case series |
79
31 (SD) 48 (SMT) |
64 | 45 | 76 | McGowan scores |
Davies et al., (1991)[33] | Australia | Retrospective
case series |
130
76 (SCT) 54 (SD) |
70 | N/A | 0.45–60 | Improved vs not improved |
Adelaar et al., (1984)[30] | United States | Prospective study | 37
7 (SD) 22 (SCT) 8 (SMT) |
N/A | 51 | 11.7 – 14.25 | Clinical rating score
(NCS, atrophy, weakness) |
Foster et al., (1981)[34] | Sweden | Retrospective
case series |
48
29 (SD) 19 (SCT) |
56 | N/A | 50 | Clinical rating scale
(Sensation, pain, weakness) |
Chan et al., (1980)[32] | Canada | Retrospective
case series |
235
120 (SCT) 115 (SD) |
75 | 54 | 0.45–60 | Improved vs not improved |
MacNicol (1979)[35] | United Kingdom | Retrospective case series | 80
42 (SD) 38 (SMT) |
N/A | 50 | 172.8 | Clinical rating scale (sensation, motor) |
SCT: Subcutaneous transposition; SD: Simple decompression; SMT: Sub muscular transposition; NCS: Nerve conduction study; N/A: Not available; LSUMC: Louisiana State University Medical Center system for grading of ulnar nerve entrapment. Bold numbers are the total number of patients in each study.
Table 02: Summary of Patients
Surgical Procedure | Number of Patients | Mean Age (y) |
Simple decompression | 491 | 52 |
Subcutaneous transposition | 485 | 46 |
Sub muscular transposition | 307 | 51 |
By comparing the standard error of the effect estimate of the study against the long odds ratio, we were able to evaluate the possibility of publication bias. The funnel plot was symmetrical, with seven studies that were located on the left side of the summary estimate and five studies that were located on the right side. In order to demonstrate that the studies were distributed in a symmetrical manner, the software that was utilized for the analysis did not impute any additional studies. We found very little indication of bias. Forest plot asymmetry should only be utilized when there are at least ten studies included in a meta-analysis, according to a rule of thumb that was noted in the Cochrane handbook for systematic review of interventions [21]. Due to the fact that there were fewer than ten studies, a funnel plot for the sub analyses was not constructed. The summary of the heterogeneity testing for simple decompression vs anterior transposition for improvement is shown in Table 03. The threshold of heterogeneity statistical results was set at a value of p <0.10. Using the fixed effect model and random effect model, the analysis was equivalent. The Q test for heterogeneity was 4.206 with a p value of 0.117 and the value of I2 was 0% which is an indication of low heterogeneity. The summary of the heterogeneity testing for improvement with submuscular vs subcutaneous anterior transposition is shown in Table 04. The threshold of heterogeneity statistical results was set at a value of p <0.10. Using the fixed effect model and random effect model, the analysis was equivalent. The Q test for heterogeneity was 4.692 with a p value of 0.588 and the value of I2 was 0% shown in forest plot analysis.
Table 03: Heterogeneity for Simple Decompression vs Anterior Transposition for improvement
Number Studies | Point estimate | Lower limit | Upper limit | Z-value | P-value | Q-value | df (Q) | P-value | I-squared | Tau squared | Standard Error | Variance | Tau |
12 | 0.781 | 0.574 | 1.063 | -1.569 | 0.117 | 4.206 | 11 | 0.963 | 0.000 | 0.000 | 0.314 | 0.018 | 0.000 |
Table 04: Heterogeneity for Sub muscular vs Subcutaneous Anterior Transposition for improvement
Effect size and 95% interval | Test of null (2-Tail) | Heterogeneity | Tau-squared | |||||||||||
Number Studies | Point estimate | Lower limit | Upper limit | Z-value | P-value | Q-value | df (Q) | P- value | I-squared | Tau Squared | Standard Error | Variance | Tau | |
Fixed | 12 | 0.781 | 0.574 | 1.063 | -1.569 | 0.117 | 4.206 | 11 | 0.963 | 0.000 | 0.000 | 0.134 | 0.018 | 0.000 |
Random | 12 | 0.781 | 0.574 | 1.063 | -1.569 | 0.117 |
A further point to consider is that Table 05 provides a summary of the heterogeneity testing that was performed for infection using simple decompression as opposed to anterior transposition. In order to determine the level of heterogeneity in the statistical results, a criterion of p < 0.10 was established. Both the fixed effect model and the random effect model were successful in producing the same results in the analysis. In terms of heterogeneity, the Q test yielded a value of 0.981, with a p value of 0.024. Additionally, the value of I2 was 0%. In order to do a comparison between the trials, the authors decided to use the odds ratio of improvement of symptoms and post-operative infection as the outcome to compare. Between the studies, there was a great deal of diversity and heterogeneity.
Table 05: Heterogeneity for Simple Decompression vs Anterior Transposition for Post-op infection
Model | Effect size and 95% interval | Test of null (2-Tail) | Heterogeneity | Tau-squared | ||||||||||
Number Studies | Point estimate | Lower limit | Upper limit | Z-value | P-value | Q-value | df (Q) | P- value | I-squared | Tau Squared | Standard Error | Variance | Tau | |
Fixed | 7 | 1.208 | 0.609 | 2.397 | 0.541 | 0.588 | 4.692 | 6 | 0.584 | 0.000 | 0.000 | 0.508 | 0.258 | 0.000 |
Random | 7 | 1.208 | 0.609 | 2.397 | 0.541 | 0.588 |
|
The evaluation procedures that were utilized by certain authors, as indicated in the characteristics of the study, were different, which resulted in the conversion of the outcomes that were measured from their initial scales into the dichotomous categories of improvement and no improvement, as well as post-operative infection, as summarized in Tables 06, 07, and 08. We aggregated and evaluated the data from the included studies to determine the chances ratio of improvement and post-operative infection with simple decompression in comparison to anterior transposition on the other hand. To continue in the same vein, the odds ratio of improvement with submuscular anterior transposition was compared with subcutaneous anterior transposition, and the data from the included trials were pooled and evaluated.
Table 06: Results showing comparison of number of improved cases between simple decompression (SD) vs anterior transposition (SMT and SCT)
Author | Comparison | Number Improved with SD | Number Improved with Transfer |
Keiner et al., (2009) | SD vs SMT | 11/17 | 9/16 |
Biggs & Curtis (2006) | SD vs SMT | 14/23 | 14/21 |
Gervasio et al., (2005) | SD vs SMT | 33/35 | 35/35 |
Bartels et al., (2005) | SD vs SCT | 49/75 | 54/77 |
Nabhan et al., (2005) | SD vs SCT | 9/32 | 9/33 |
Taha et al., (2004) | SD vs SCT | 10/21 | 10/17 |
Bimmler et al., (1996) | SD vs SMT | 17/31 | 35/48 |
Davies et al., (1991) | SD vs SCT | 49/54 | 71/76 |
Adelaar et al., (1984) | SD vs transposition | 1/7 | 7/30 |
Foster et al., (1981) | SD vs SCT | 27/29 | 17/19 |
Chan et al., (1980) | SD vs SCT | 94/115 | 99/120 |
MacNicol (1979) | SD vs SM | 41/52 | 9/11 |
Table 07: Result for Sub muscular transposition (SMT) vs Sub cutaneous transposition (SCT)
Paper | Comparison | Number Improved with SMT | Number Improved with SCT |
Zhou, Y., et al (2012) | SMT vs SCT | 16/19 | 17/20 |
Zare zadeh, A., et al. (2012) | SMT vs SCT | 23/24 | 22/24 |
Luo, S., et al (2010) | SMT vs SCT | 39/42 | 22/24 |
Jad due, D.A(2009) | SMT vs SCT | 8/13 | 12/13 |
Charles, Y.P., et al (2009) | SMT vs SCT | 20/25 | 17/24 |
Köse et al., (2007) | SMT vs SCT | 14/16 | 13/18 |
Adelaar et al., (1984) | SMT vs SCT | 2/8 | 5/22 |
Table 08: Result for Wound infection (superficial and Deep) for Simple Decompression (SD) vs Anterior Transposition (SMT and SCT)
Paper | Comparison | Number of infections in SD | Number of infections in Anterior transposition |
Biggs & C. (2006) | SD vs SMT | 2/23 | 7/21 |
Gervasio et al. (2005) | SD vs SMT | 1/35 | 1/35 |
Bartels et al. (2005) | SD vs SCT | 2/75 | 7/77 |
It was determined that a value of p <0.05 would serve as the threshold for all statistical outcomes. According to Figure 3, the odds ratio of improvement with simple decompression was 0.781, with a 95% confidence interval ranging from [0.574 to 1.063], an I2 value of 0%, and a p value of 0.117 when applying the fixed effect model. This finding was the same for both the fixed effects model and the random effects model, which is something that the reader should take note of. Due to the fact that the results obtained were the same regardless of the model that was utilized, the assumption was that there was little statistical evidence of heterogeneity. There were also two sub-analyses carried out, which are as follows: The first thing to do is examine the differences between submuscular anterior transposition and subcutaneous anterior transposition, as presented in Table 07. In a study that utilized both fixed effects and random effects, the odds ratio of improvement of subcutaneous transposition (SCT) with submuscular transposition (SMT) was 1.208, with a 95% confidence interval ranging from [0.609 to 2.397]. The I2 value was 0%, and the p value was 0.588. Second, looking at the comparison between simple transposition and anterior transposition in post-operative infections caused by simple decompression and anterior transposition (submuscular and subcutaneous transposition), as indicated in table 8 and figure 6. When both fixed variables and random effects were considered, the odds ratio for post-operative infection of simple decompression (SD) with anterior transposition (SMT and SCT) was 0.287, with a 95% confidence interval ranging from 0.097 to 0.845, an I2 value of 0%, and a p value of 0.024. We conducted sensitivity analysis on a number of different parts of the trial. Investigating the consequences of excluding non-randomized controlled trials was one of these plans. Using the fixed effect model, the odd ratio of improvement after simple decompression versus anterior transposition was 0.781 in patients with cubital tunnel syndrome. The 95% confidence interval for this ratio was between 0.574 and 1.063, and the I2 value was 0%. The p value was 0.117. In this comparison, there were a total of 12 studies, four of which were randomised controlled trials (RCTs), and eight of which were not RCTs. We just used four randomised controlled trials (RCTs) and compared the data for the odd ratio of improvement after simple decompression versus anterior transposition. The results showed that the ratio was 0.813, with a 95% confidence interval (CI) of [0.486, 1.361], and a p value of 0.431 when using a fixed effect model. This allowed us to determine whether or not the non-RCT model is influencing the outcome of our analysis. Because the findings were comparable to those of the study, the analysis was reliable.
DISCUSSION
Using a fixed effect model, the findings of our meta-analysis showed that the odds ratio of improvement between simple decompression and anterior transposition (SMT and SCT) was 0.781, with a 95% confidence interval ranging from [0.574 to 1.063], I2 = 0%, and p value =0.117. Simple decompression and transposition (subcutaneous or submuscular) of the ulnar nerve produced the same level of postoperative clinical improvement; however, there was no discernible difference between the two. When compared to transposition (SMT and SCT), the odds ratio of post-operative infection with simple decompression (SD) was 0.287, with a 95% confidence interval ranging from 0.097 to 0.845. The interaction coefficient was 0%, and the p value was 0.024 when using a fixed effect model. While there was no heterogeneity detected, there was a significant difference in post-operative infection between simple decompression and anterior transposition. This difference demonstrated that there is an increase in the likelihood of post-operative infection in anterior transposition. An investigation revealed that the rate of complications among patients who were treated with SD was noticeably lower than the rate of complications among patients who were treated with AT. On the other hand, SD is not indicated in situations where the cubital tunnel is being constricted due to bony spurs and synovial edema, or even scarring, as well as in situations where the nerve is experiencing repeated or fixed subluxation [22]. Following this, the findings of the sub-analysis showed that the odds ratio of improvement for subcutaneous transposition (SCT) was 1.208, with a 95% confidence interval ranging from [0.609 to 2.397], I2 = 0%, and a p value of 0.588 when utilizing both the fixed effect model and the random effect model. The results of this study reveal that there is no significant difference between the odds ratio of improvement between subcutaneous transposition (SCT) and submuscular transposition (SMT), and there was also no heterogeneity detected. Our study also showed similar findings, which revealed that simple decompression can be a suitable choice for surgical intervention. These findings are consistent with the findings of a previous review study of non-randomized studies (n = 2652), which recorded that if the preoperative condition of the patients was not taken into consideration, simple decompression would be the best option of surgical intervention [23,24]. On the other hand, due to the fact that the conclusions were based on non-randomized data, it was believed that they were susceptible to major sources of selection bias. In a meta-analysis recently published in 2007, which included four studies with a total of 261 patients using randomized controlled trials comparing simple decompression with anterior ulnar nerve transposition (two submuscular and two subcutaneous), found out that there was no difference in clinical outcome scores or motor nerve-conduction velocities between simple decompression and anterior transposition for the treatment of cubital tunnel syndrome in patients with no prior surgical procedures or traumatic injuries involving the affected elbow [25]. The results of a meta-analysis that was only recently published revealed that the odds ratio was 0.751, with a 95% confidence interval ranging from [0.542,1.040], and a p value of 0.084 [26]. The meta-analysis included 10 studies with a total of 449 simple decompression and 457 anterior transposition procedures (342 subcutaneous transposition and 115 submuscular transposition). Our research, which consisted of a total of seventeen different studies. Among the twelve studies that compared simple decompression to anterior transposition, there were 491 simple decompression and 766 anterior transpositions, with 472 subcutaneous and 294 submuscular transpositions. The findings were comparable when comparing improved to unimproved patients, with an odds ratio of 0.781, a 95% confidence interval of [0.574, 1.063], an I2 value of 0%, and a p value of 0.117. However, when conducting a sub-analysis with three studies that compared post-operative infections with odds ratios of 0.287, 95% confidence intervals of [0.097, 0.845], I2 = 0%, and p value = 0.024, a significant difference was discovered, indicating that simple decompression could be an appropriate treatment option for cubital tunnel syndrome. Furthermore, there was no heterogeneity found in the data. When it comes to the treatment of cubital tunnel syndrome, this is an indicator that simple decompression is a potential alternative to anterior transposition. According to the findings of one published author [27], individuals who have simple decompression have a higher percentage of full recovery than those who undergo anterior transposition. After conducting four randomized control studies, researchers came to the conclusion that simple decompression is the most effective surgical treatment for cubital tunnel syndrome [28,29]. There was no statistically significant difference between submuscular transposition and subcutaneous transposition, according to the findings of the sub-analysis study that we conducted. On the other hand, contrary to what we discovered, a number of studies have also proposed that subcutaneous anterior transposition is a straightforward and efficient surgery [30,31]. An additional author demonstrated that the subcutaneous group experienced a much reduced incidence of adverse events compared to the submuscular group [32]. When compared to the subcutaneous approach, the submuscular method was shown to have healthier axons and less perineural scar tissue, according to the findings of a histologic investigation that was conducted on rats and published in 2009 [33]. When it comes to the treatment of cubital tunnel syndrome, an author came to the conclusion that both anterior subcutaneous transposition and submuscular transposition are comparable. However, the author believes that anterior subcutaneous transposition is the superior treatment option for elderly patients because it has a lower incidence of traumas [34], and post-operative immobilization is not required after subcutaneous transposition, as it is required after submuscular transposition [35,36]. The post-operative dash score was 7.27 out of 100, and the patient satisfaction rate was 96%, according to a study that was just recently published [40]. The study comprised 73 patients who had undergone anterior subcutaneous transposition of the ulnar nerve between January 2000 and January 2010, and the minimum follow-up period was three years. In conclusion, the author of this study came to the conclusion that anterior subcutaneous transposition is a successful surgical treatment for cubital tunnel syndrome, with good clinical results, physical function, and satisfaction [37,38]. After stating that anterior transposition results in lower ulnar nerve strains than simple decompression during elbow flexion and higher nerve strains during elbow extension, similar results were shown [39]. This was demonstrated by the fact that the anterior transposition was performed. In situations where the ulnar nerve has a tendency to subluxate, either during the preoperative or intraoperative assessment, the author [41] demonstrates that transposition is the recommended method. According to the findings of a researcher, the anterior transposition of the ulnar nerve in conjunction with epineurium decompression yields superior results when compared to simple decompression [42]. We have provided a better understanding of the many treatment choices that are available for cubital tunnel syndrome as a consequence of our study, which has extended past findings and supplied additional information.
- CONCLUSIONS
This meta-analysis of simple decompression versus anterior transposition of the ulnar nerve for the treatment of cubital tunnel syndrome suggests and emphasizes that simple decompression could be considered a reasonable alternative or viable surgical option for the treatment of cubital tunnel syndrome. This is because simple decompression is less invasive than anterior transposition. Furthermore, our findings were robust to different statistical strategies fixed effect model. Our research demonstrated that there is no significant difference between the treatment of cubital tunnel syndrome with subcutaneous transposition and submuscular transposition. This is despite the fact that some of the literature suggested that subcutaneous transposition should be considered the first choice for treatment rather than submuscular transposition. Compared to anterior transposition, the odds ratio of improvement with simple decompression was 0.781, with a 95% confidence interval ranging from 0.574 to 1.063. The I2 value was 0%, and the p value was 0.117. The odds ratio of improvement in subcutaneous transposition versus sub muscular transposition was 1.208 with a 95% confidence interval of [0.609, 2.397], I2 = 0%, and p value = 0.588. On the other hand, the odds ratio of post-operative infection in simple decompression versus anterior transposition was 0.287 with a 95% confidence interval of [0.097, 0.845], I2 = 0%, and p value = 0.024. Sensitivity studies that made use of the fixed-effects methodology indicated that these findings were reliable, and there was no evidence of heterogeneity detected. This study demonstrated that there is no significant difference between the treatment of cubital tunnel syndrome when comparing the improvement parameter for simple decompression versus anterior transposition and sub muscular transposition versus subcutaneous transposition. However, when conducting a sub-analysis comparing the post-operative infection between simple decompression and anterior transposition, a significant difference was discovered. This was also the case with subcutaneous transposition and sub muscular transposition.
REFERENCES
- Adelaar RS, Foster WC, McDowell C. The treatment of the cubital tunnel syndrome. The Journal of hand surgery 1984; 9A: 90-95.
- Amako M, Nemoto K, Kawaguchi M, Kato N, Arino H, Fujikawa K. Comparison between partial and minimal medial epicondylectomy combined with decompression for the treatment of cubital tunnel syndrome. The Journal of hand surgery 2000; 25: 1043-1050.
- Bartels RH, Menovsky T, Van Overbeeke JJ, Verhagen WI. Surgical management of ulnar nerve compression at the elbow: an analysis of the literature. J Neurosurg 1998; 89: 722-727.
- Bartels RHMA, Verhagen WIM, Van Der Wilt GJ, Meulstee J, Van Rossum LGM, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery 2005; 56: 522-529.DOI: 1227/01.neu.0000154131.01167.03
- Bednar MS, Blair SJ, Light TR. Complications of the treatment of cubital tunnel syndrome. Hand Clin 1994; 10: 83-92.
- Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery 2006; 58: 296-304; discussion 296-304. DOI: 1227/01.NEU.0000194847.04143.A1
- Bimmler D, Meyer VE. Surgical treatment of the ulnar nerve entrapment neuropathy: submuscular anterior transposition or simple decompression of the ulnar nerve? Long-term results in 79 cases. Annales de chirurgie de la main et du membre superieur : organe officiel des societes de chirurgie de la main = Annals of hand and upper limb surgery 1996; 15: 148-157.
- Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database of Systematic Reviews: 2011; CD006839.DOI: 1002/14651858.CD006839.pub2
- Carlton A, Khalid SI. Surgical Approaches and Their Outcomes in the Treatment of Cubital Tunnel Syndrome. Frontiers in surgery 2018; 5: 48. doi: 3389/fsurg.2018.00048
- Chan RC, Paine KW, Varughese G. Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transposition. Neurosurgery 1980; 7: 545-550.
- Charles YP, Coulet B, Rouzaud J-C, Daures J-P, Chammas M. Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. The Journal of hand surgery 2009; 34: 866-874. DOI: 1016/j.jhsa.2009.01.008
- Chen HW, Ou S, Liu GD, Fei J, Zhao GS, Wu LJ et al. Clinical efficacy of simple decompression versus anterior transposition of the ulnar nerve for the treatment of cubital tunnel syndrome: A meta-analysis. Clinical neurology and neurosurgery 2014; 126: 150-155.DOI: 1016/j.clineuro.2014.08.005
- Cho Y-J, Cho S-M, Sheen S-H, Choi J-H, Huh D-H, Song J-H. Simple decompression of the ulnar nerve for cubital tunnel syndrome. Journal of Korean Neurosurgical Society 2007; 42: 382-387.doi: 3340/jkns.2007.42.5.382
- Davies MA, Vonau M, Blum PW, Kwok BC, Matheson JM, Stening WA. Results of ulnar neuropathy at the elbow treated by decompression or anterior transposition. The Australian and New Zealand journal of surgery 1991; 61: 929-934.
- Dellon AL, Chang E, Coert JH, Campbell KR. Intraneural ulnar nerve pressure changes related to operative techniques for cubital tunnel decompression. The Journal of hand surgery 1994; 19: 923-930.
- Feindel W, Stratford J. Cubital tunnel compression in tardy ulnar palsy. Canadian Medical Association journal 1958; 78: 351-353.
- Foran I, Vaz K, Sikora-Klak J, Ward SR, Hentzen ER, Shah SB. Regional Ulnar Nerve Strain Following Decompression and Anterior Subcutaneous Transposition in Patients With Cubital Tunnel Syndrome. The Journal of hand surgery 2016; 41: e343-e350.doi: 10.1016/j.jhsa.2016.07.095.
- Foster RJ, Edshage S. Factors related to the outcome of surgically managed compressive ulnar neuropathy at the elbow level. The Journal of hand surgery 1981; 6: 181-192.
- Froimson AI, Anouchi YS, Seitz WH, Jr., Winsberg DD. Ulnar nerve decompression with medial epicondylectomy for neuropathy at the elbow. Clinical orthopaedics and related research 1991: 200-206.
- Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study. Neurosurgery 2005; 56: 108-117; discussion 117.DOI: 1227/01.neu.0000145854.38234.81
- Giöstad A, Nyman E. Patient Characteristics in Ulnar Nerve Compression at the Elbow at a Tertiary Referral Hospital and Predictive Factors for Outcomes of Simple Decompression versus Subcutaneous Transposition of the Ulnar Nerve. BioMed research international 2019; 2019: 5302462.https://doi.org/10.1155/2019/5302462
- Guinet V, Cordier-Fuzeau C, Auquit-Auckbur I. Étude rétrospective de 55 transpositions antérieures sous-cutanées pour syndrome canalaire du nerf ulnaire à 3 ans de recul minimum. Chirurgie de la Main 2013; 32: 292-298.Doi : 10.1016/j.main.2013.08.001
- Huang W, Zhang PX, Peng Z, Xue F, Wang TB, Jiang BG. Anterior subcutaneous transposition of the ulnar nerve improves neurological function in patients with cubital tunnel syndrome. Neural regeneration research 2015; 10: 1690-1695.doi: 4103/1673-5374.167770
- Jaddue DA, Saloo SA, Sayed-Noor AS. Subcutaneous vs Submuscular Ulnar Nerve Transposition in Moderate Cubital Tunnel Syndrome. The open orthopaedics journal 2009; 3: 78-82.doi: 2174/1874325000903010078
- 25 JPT CHH, Green S. Cochrane handbook for systematic reviews of interventions version 5.1. 0 [updated March 2011]. The Cochrane Collaboration 2011.ISBN 978-0470057964 Content :11.3
- Keiner D, Gaab MR, Schroeder HW, Oertel J. Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome–a prospective study. Acta neurochirurgica 2009; 151: 311-315; discussion 316.DOI: 1007/s00701-009-0218-4
- Kose KC, Bilgin S, Cebesoy O, Altinel L, Akan B, Guner D et al. Clinical results versus subjective improvement with anterior transposition in cubital tunnel syndrome. Advances in therapy 2007; 24: 996-1005. DOI: 1007/BF02877704
- Lascar T, Laulan J. Cubital tunnel syndrome: a retrospective review of 53 anterior subcutaneous transpositions. Journal of hand surgery (Edinburgh, Scotland) 2000; 25: 453-456.
- Lee SK, Sharma S, Silver BA, Kleinman G, Hausman MR. Submuscular versus subcutaneous anterior ulnar nerve transposition: a rat histologic study. The Journal of hand surgery 2009; 34: 1811-1814. DOI: 1016/j.jhsa.2009.08.007
- Liu CH, Wu SQ, Ke XB, Wang HL, Chen CX, Lai ZL et al. Subcutaneous Versus Submuscular Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Medicine (Baltimore) 2015; 94: e1207.DOI: 1097/MD.0000000000001207
- Liu Q-q, Li R. Cubital tunnel syndrome treated with ulnar nerve simple decompression, anterior intramuscular or subcutaneous transposition: a parallel randomized controlled clinical trial. Clinical Trials in Orthopedic Disorders 2016; 1: 15-21.DOI: 10.4103/2468-5674.178845
- Luo S, Zhao J, Su W, Li X. [Efficacy comparison between anterior subcutaneous and submuscular transposition of ulnar nerve to treat cubital tunnel syndrome]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery 2010; 24: 577-580.PMID: 20540264
- Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. The Journal of hand surgery 2008; 33: 1314.e1311-1312. DOI: 1016/j.jhsa.2008.03.006
- Macnicol MF. The results of operation for ulnar neuritis. The Journal of bone and joint surgery British volume 1979; 61-B: 159-164.
- MANSKE PR, JOHNSTON R, PRUITT DL, STRECKER WB. Ulnar nerve decompression at the cubital tunnel. Clinical orthopaedics and related research 1992; 274: 231-237.
- McPherson SA, Meals RA. Cubital tunnel syndrome. The Orthopedic clinics of North America 1992; 23: 111-123.
- Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. Journal of hand surgery (Edinburgh, Scotland) 2005; 30: 521-524.DOI: 1016/j.jhsb.2005.05.011
- Nathan PA, Myers LD, Keniston RC, Meadows KD. Simple decompression of the ulnar nerve: an alternative to anterior transposition. Journal of hand surgery (Edinburgh, Scotland) 1992; 17: 251-254.
- Ogata K, Manske PR, Lesker PA. The effect of surgical dissection on regional blood flow to the ulnar nerve in the cubital tunnel. Clinical orthopaedics and related research 1985: 195-198.
- Osterman AL, Davis CA. Subcutaneous transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Hand Clin 1996; 12: 421-433.
- Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. The Journal of the American Academy of Orthopaedic Surgeons 1998; 6: 282-288.
- Posner MA. Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instructional course lectures 2000; 49: 305-317.
- Robertson C, Saratsiotis J. A review of compressive ulnar neuropathy at the elbow. J Manipulative Physiol Ther 2005; 28: 345. DOI: 1016/j.jmpt.2005.04.005
- Shi Q, MacDermid J, Grewal R, King GJ, Faber K, Miller TA. Predictors of functional outcome change 18 months after anterior ulnar nerve transposition. Archives of physical medicine and rehabilitation 2012; 93: 307-312. doi:10.1016/j.apmr.2011.08.040
- Stuffer M, Jungwirth W, Hussl H, Schmutzhardt E. Subcutaneous or submuscular anterior transposition of the ulnar nerve? Journal of hand surgery (Edinburgh, Scotland) 1992; 17: 248-250.
- Sur YJ, Lee JS, Song SW. Comparison of the effects of subcutaneous anterior transposition and in situ decompression on the histologic and electrophysiologic properties of the ulnar nerve: an experimental study in a rabbit model. The Journal of hand surgery 2013; 38: 660-665.DOI:https://doi.org/10.1016/j.jhsa.2012.12.028
- Taha A, Galarza M, Zuccarello M, Taha J. Outcomes of cubital tunnel surgery among patients with absent sensory nerve conduction. Neurosurgery 2004; 54: 891-895; discussion 895-896. DOI: 1227/01.neu.0000115152.78918.61
- Weirich SD, Gelberman RH, Best SA, Abrahamsson SO, Furcolo DC, Lins RE. Rehabilitation after subcutaneous transposition of the ulnar nerve: immediate versus delayed mobilization. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons 1998; 7: 244-249.
- Willis B. Cubital tunnel syndrome. Practical Approaches to Peripheral Nerve Surgery Park Ridge, AANS 1992: 77-93.
- Wilson DH, Krout R. Surgery of ulnar neuropathy at the elbow: 16 cases treated by decompression without transposition. Technical note. J Neurosurg 1973; 38: 780-785.
- Wojewnik B, Bindra R. Cubital tunnel syndrome — Review of current literature on causes, diagnosis and treatment. J Hand Microsurg 2009; 1: 76-81.doi: 1007/s12593-009-0020-9
- Yahya A, Malarkey AR, Eschbaugh RL, Bamberger HB. Trends in the Surgical Treatment for Cubital Tunnel Syndrome: A Survey of Members of the American Society for Surgery of the Hand. Hand (New York, NY) 2018; 13: 516-521.doi: 1177/1558944717725377
- Zarezadeh A, Shemshaki H, Nourbakhsh M, Etemadifar MR, Moeini M, Mazoochian F. Comparison of anterior subcutaneous and submuscular transposition of ulnar nerve in treatment of cubital tunnel syndrome: A prospective randomized trial. Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences 2012; 17: 745-749.PMID: 23798941
- Zhou Y, Feng F, Qu X, Fang Z, Liu X, Pan X et al. [Effectiveness comparison between two different methods of anterior transposition of the ulnar nerve in treatment of cubital tunnel syndrome]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery 2012; 26: 429-432.PMID: 22568322
- Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. The Journal of bone and joint surgery American volume 2007; 89: 2591-2598.DOI: 2106/JBJS.G.00183
Publication History
Submitted: October 14, 2024
Accepted: October 20, 2024
Published: October 31, 2024
Identification
D-0337
DOI
https://doi.org/10.71017/djmi.3.10.d-0337
Citation
Mandeep Karki, Deepak Shrestha, Xiang Zhou, Kailash Kumar Bhandari, Sunima Lama, Rachit Sharma & Rajiv Prasad Shrestha (2024). Simple Decompression versus Anterior Transposition (Submuscular and Subcutaneous) of the Ulnar Nerve in Cubital Tunnel Syndrome: a Meta-Analysis. Dinkum Journal of Medical Innovations, 3(10):700-715.
Copyright
© 2024 The Author(s).