Original Research

Adipose Flap Versus Fascial Sling for Anterior Subcutaneous Transposition of the Ulnar Nerve

Am J Orthop. 2016 February;45(2):89-94

References

1. Latinovic R, Gulliford MC, Hughes RA. Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatry. 2006;77(2):263-265.

2. Robertson C, Saratsiotis J. A review of compression ulnar neuropathy at the elbow. J Manipulative Physiol Ther. 2005;28(5):345.

3. Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg. 1998;6(5):282-288.

4. Piligian G, Herbert R, Hearns M, Dropkin J, Landsbergis P, Cherniack M. Evaluation and management of chronic work-related musculoskeletal disorders of the distal upper extremity. Am J Ind Med. 2000;37(1):75-93.

5. 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. J Hand Surg Am. 2008;33(8):1314.e1-e12.

6. Soltani AM, Best MJ, Francis CS, Allan BJ, Panthaki ZJ. Trends in the surgical treatment of cubital tunnel syndrome: an analysis of the National Survey of Ambulatory Surgery database. J Hand Surg Am. 2013;38(8):1551-1556.

7. Osterman AL, Davis CA. Subcutaneous transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Hand Clin. 1996;12(2):421-433.

8. 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(5):722-727.

9. Seradge H, Owen W. Cubital tunnel release with medial epicondylectomy factors influencing the outcome. J Hand Surg Am. 1998;23(3):483-491.

10. Schnabl SM, Kisslinger F, Schramm A, et al. Subjective outcome, neurophysiological investigations, postoperative complications and recurrence rate of partial medial epicondylectomy in cubital tunnel syndrome. Arch Orthop Trauma Surg. 2011;131(8):1027-1033.

11. Filippi R, Charalampaki P, Reisch R, Koch D, Grunert P. Recurrent cubital tunnel syndrome. Etiology and treatment. Minim Invasive Neurosurg. 2001;44(4):197-201.

12. Vogel RB, Nossaman BC, Rayan GM. Revision anterior submuscular transposition of the ulnar nerve for failed subcutaneous transposition. Br J Plast Surg. 2004;57(4):311-316.

13. Gabel GT, Amadio PC. Reoperation for failed decompression of the ulnar nerve in the region of the elbow. J Bone Joint Surg Am. 1990;72(2):213-219.

14. Rogers MR, Bergfield TG, Aulicino PL. The failed ulnar nerve transposition. Etiology and treatment. Clin Orthop. 1991;269:193-200.

15. Kilic A, Ojo B, Rajfer RA, et al. Effect of white adipose tissue flap and insulin-like growth factor-1 on nerve regeneration in rats. Microsurgery. 2013;33(5):367-375.

16. Ebersole GC, Davidge K, Damiano M, Mackinnon SE. Validity and responsiveness of the DASH questionnaire as an outcome measure following ulnar nerve transposition for cubital tunnel syndrome. Plast Reconstr Surg. 2013;132(1):81e-90e.

17. Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. 1989;14(6):972-979.

18. Dützmann S, Martin KD, Sobottka S, et al. Open vs retractor-endoscopic in situ decompression of the ulnar nerve in cubital tunnel syndrome: a retrospective cohort study. Neurosurgery. 2013;72(4):605-616.

19. Dellon AL, Mackinnon SE, Crosby PM. Reliability of two-point discrimination measurements. J Hand Surg Am. 1987;12(5 pt 1):693-696.

20. Danoff JR, Lombardi JM, Rosenwasser MP. Use of a pedicled adipose flap as a sling for anterior subcutaneous transposition of the ulnar nerve. J Hand Surg Am. 2014;39(3):552-555.

21. Magee RB, Phalen GS. Tardy ulnar palsy. Am J Surg. 1949;78(4):470-474.

22. Feindel W, Stratford J. Cubital tunnel compression in tardy ulnar palsy. Can Med Assoc J. 1958;78(5):351-353.

23. Tsai TM, Bonczar M, Tsuruta T, Syed SA. A new operative technique: cubital tunnel decompression with endoscopic assistance. Hand Clin. 1995;11(1):71-80.

24. Hoffmann R, Siemionow M. The endoscopic management of cubital tunnel syndrome. J Hand Surg Br. 2006;31(1):23-29.

25. Luchetti R, Riccio M, Papini Zorli I, Fairplay T. Protective coverage of the median nerve using fascial, fasciocutaneous or island flaps. Handchir Mikrochir Plast Chir. 2006;38(5):317-330.

26. Kokkalis ZT, Jain S, Sotereanos DG. Vein wrapping at cubital tunnel for ulnar nerve problems. J Shoulder Elbow Surg. 2010;19(2):91-97.

27. Masear VR, Colgin S. The treatment of epineural scarring with allograft vein wrapping. Hand Clin. 1996;12(4):773-779.

28. Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. 1989;14(6):972-979.

29. Lundborg G. Surgical treatment for ulnar nerve entrapment at the elbow. J Hand Surg Br. 1992;17(3):245-247.

30. Strickland JW, Idler RS, Lourie GM, Plancher KD. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. J Hand Surg Am. 1996;21(5):840-848.

There was no recurrence of CuTS in either group. One adipose flap patient developed a wound infection that required reoperation.

Discussion

Ulnar neuropathy was described by Magee and Phalen²¹ in 1949 and termed cubital tunnel syndrome by Feindel and Stratford²² in 1958. Since then, numerous procedures, including in situ decompression, medial epicondylectomy, and endoscopic decompression,^23,24 have been advocated for the treatment of this condition. In addition, anterior transposition, which involves securing the ulnar nerve in a submuscular, intramuscular, or subcutaneous sleeve,⁶ remains a popular option. Despite more than half a century of surgical treatment for this condition, there is no consensus about which procedure offers the best outcomes. Bartels and colleagues⁸retrospectively reviewed surgical treatments for CuTS, examining 3148 arms over a 27-year period. They found simple decompression and anterior intramuscular transposition had the best results, followed by medial epicondylectomy and anterior subcutaneous transposition, with anterior submuscular transposition yielding the poorest outcomes. Despite these findings, the operative groups’ recurrence rates remained significant. These results were challenged in a 2008 meta-analysis⁵that found no significant difference among simple decompression, subcutaneous transposition, and submuscular transposition and instead demonstrated trends toward better outcomes with anterior transposition. Osterman and Davis⁷ reported a 5% to 15% rate of unsatisfactory outcomes with anterior subcutaneous transposition, a popular technique used by surgeons at our institution.

The causes for failure or recurrence of ulnar neuropathy after surgical intervention are multifactorial and include preexisting medical conditions and improper operative technique. It is well established that failure to excise all 5 anatomical points of entrapment, or creation of new points of tension during surgery, leads to poor outcomes.¹² Nevertheless, the contribution of perineural scarring to postoperative recurrent ulnar neuropathy is currently being recognized: Gabel and Amadio¹³ described postoperative fibrosis in one-third of their patients with surgically treated recurrent CuTS, Rogers and colleagues¹⁴ noted dense perineural fibrosis after intramuscular and subcutaneous transposition procedures, Filippi and colleagues¹¹ cited serious epineural fibrosis and fibrosis around the ulnar nerve as the main findings in their study of 22 patients with recurrent ulnar neuropathy, and Vogel and colleagues¹² found that 88% of their patients with persistent CuTS after surgery exhibited perineural scarring.

We think that use of a scar tissue barrier during ulnar nerve transposition reduces the incidence of cicatrix and produces better outcomes—a position largely echoed by the orthopedic community, as fascial, fasciocutaneous, free, and venous flaps have all been used for such purposes.^25,26 Vein wrapping has demonstrated good recovery of a nerve after perineural scarring.²⁷ Advocates of intramuscular transposition argue that their technique provides the nerve with a vascularized tunnel, as segmental vascular stripping is an inevitability in transposition. However, this technique increases the incidence of scarring and potential muscle damage.^28,29 We think the pedicled adipofascial flap benefits the peripheral nerve by providing a scar tissue barrier and an optimal milieu for vascular regeneration. Kilic and colleagues¹⁵ demonstrated the regenerative effects of adipose tissue flaps on peripheral nerves after crush injuries in a rat model, and Strickland and colleagues³⁰ retrospectively examined the effects of hypothenar fat flaps on recalcitrant carpal tunnel syndrome, showing excellent results for this procedure. It is hypothesized that adipose tissue provides not only adipose-derived stem cells but also a rich vascular bed on which nerves will regenerate.

For all patients in the present study, symptoms improved, though the adipose flap and fascial sling groups were not significantly different in their outcomes. We used the MBRS to quantify and compare the groups’ patient-rated outcomes. No statistically significant difference was found between the adipose flap and fascial sling groups. On the MBRS, excellent and good outcomes were reported by 62.5% and 37.5% of the adipose flap patients, respectively, and 59% and 41% of the fascial sling patients (Table 3). Likewise, objective measurements did not show a significant difference between the 2 interventions—indicating that, compared with the current standard of care, adipose flaps are more efficacious in securing the anteriorly transposed nerve.

Complications of the adipose flap technique are consistent with those reported for other techniques for anterior transposition of the ulnar nerve. The most common complication is hematoma, which can be avoided with meticulous hemostasis. Damage of the medial antebrachial cutaneous nerve or motor branches to the flexor carpi ulnaris has been reported for the fascial technique (we have not had such outcomes at our institution). Contraindications to the adipofascial technique include insufficient subcutaneous adipose tissue for covering the ulnar nerve.

This study was limited by its retrospective setup, which reduced access to preoperative objective and subjective data. The small sample size also limited our ability to demonstrate the advantageous effects of an adipofascial flap in preventing postoperative perineural scarring.