Risk factors and outcomes in 385 cases of ulnar nerve submuscular transposition


      • Patients were included in this study with risk factors commonly excluded in other series.
      • Application of published exclusion criteria would have resulted in exclusion of ½–⅔ of our cohort.
      • Symptomatic improvement reported in 91.05% patients.
      • Improved results were observed in younger patients and those without peripheral neuropathy.
      • There were no deep infections.


      Submuscular transposition (SMT) for treatment of ulnar nerve entrapment is commonly performed, however published comparisons of surgical techniques exclude a high proportion of the at-risk population encountered in real world practice. To examine the influence of risk factors on the clinical outcome following SMT we performed a retrospective review of all patients who underwent SMT, including patient self-reported outcome and Louisiana State University Medical Centre ulnar nerve grading scale. A total of 403 ulnar nerves were operated, with follow-up data available for 385 cases (359 patients). Risk factors (including smoking, diabetes, previous elbow trauma/pathology, subluxation, workers’ compensation) were reported in 266 of 385 surgeries (69.09%). SMT was the primary procedure in 339 nerves (88.05%), revision procedure in 46 nerves (11.95%). At last follow up 91.05% reported symptomatic improvement. Nerve grade improvement in 71.09% of primary and 67.39% revision surgery (p = 0.605). No significant difference in improvement was identified between demographic and risk categories, except for patient reported improvement in those without peripheral neuropathy (90.59% vs 73.33%, p = 0.027), and those not improved were on average older than those improved (62.94 vs. 55.68 years, p = 0.012). Superficial infection occurred in 2.6% and there were no deep infections. Application of published exclusion criteria would have resulted in exclusion of ½–⅔ of our cohort. SMT in patients with a history of elbow trauma, diabetes, workers compensation, smoking history, nerve subluxation or revision surgery have similar outcomes compared to those without these factors, whilst improved results were observed in younger patients and those without peripheral neuropathy.


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        • Mondelli M.
        • Giannini F.
        • Ballerini M.
        • Ginanneschi F.
        • Martorelli E.
        Incidence of ulnar neuropathy at the elbow in the province of Siena (Italy).
        J Neurol Sci. 2005; 234: 5-10
      1. Bartels RH. History of the surgical treatment of ulnar nerve compression at the elbow. Neurosurgery. 2001;49(2):391-399; discussion 399-400.

      2. Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. The Cochrane database of systematic reviews. 2011(2):CD006839.

      3. Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery. 2006;58(2):296-304; discussion 296-304.

      4. 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(1):108-117; discussion 117.

      5. Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, 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(3):522-530; discussion 522-530.

        • Davis G.A.
        • Bulluss K.J.
        Submuscular transposition of the ulnar nerve: review of safety, efficacy and correlation with neurophysiological outcome.
        J Clin Neurosci. 2005; 12: 524-528
        • Kim D.H.
        • Han K.
        • Tiel R.L.
        • Murovic J.A.
        • Kline D.G.
        Surgical outcomes of 654 ulnar nerve lesions.
        J Neurosurg. 2003; 98: 993-1004
        • Learmonth J.R.
        A technique for transplanting the ulnar nerve.
        Surg Gynecol Obstet. 1942; 75: 792-793
        • Ehlers M.
        • Davis G.A.
        • Hanna A.
        Ulnar nerve submuscular transposition.
        in: Wolfla C.E. Resnick D.K. Neurosurgical operative atlas: spine and peripheral nerves. 3rd ed. Thieme Medical Publishers, New York2016
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
        Am J Ind Med. 1996; 29: 602-608
      6. Song JW, Waljee JF, Burns PB, et al. An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group. Neurosurgery. 2013;72(6):971–981; discussion 981–972; quiz 982.

        • Rhodes N.G.
        • Howe B.M.
        • Frick M.A.
        • Moran S.L.
        MR imaging of the postsurgical cubital tunnel: an imaging review of the cubital tunnel, cubital tunnel syndrome, and associated surgical techniques.
        Skeletal Radiol. 2019;
        • Bacle G.
        • Marteau E.
        • Freslon M.
        • et al.
        Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months.
        Orthop Traumatol Surg Res. 2014; 100: S205-208
        • Goldberg B.J.
        • Light T.R.
        • Blair S.J.
        Ulnar neuropathy at the elbow: results of medial epicondylectomy.
        J Hand Surgery. 1989; 14: 182-188
        • 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.
        J Bone Joint Surgery Am. 2007; 89: 2591-2598
        • Nabhan A.
        • Ahlhelm F.
        • Kelm J.
        • Reith W.
        • Schwerdtfeger K.
        • Steudel W.I.
        Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome.
        J Hand Surgery. 2005; 30: 521-524
      7. Williams EH, Dellon AL. Anterior submuscular transposition. Hand Clinics. 2007;23(3):345-358, vi.

        • Mass D.P.
        • Silverberg B.
        Cubital tunnel syndrome: anterior transposition with epicondylar osteotomy.
        Orthopedics. 1986; 9: 711-715
        • Sunderland S.
        The intraneural topography of the radial, median and ulnar nerves.
        Brain. 1945; 68: 243-299
        • McGowan A.J.
        The results of transposition of the ulnar nerve for traumatic ulnar neuritis.
        J Bone Joint Surgery Br. 1950; 32: 293-301
        • Dellon A.L.
        Review of treatment results for ulnar nerve entrapment at the elbow.
        J Hand Surgery. 1989; 14: 688-700
        • Kleinman W.B.
        • Bishop A.T.
        Anterior intramuscular transposition of the ulnar nerve.
        J Hand Surgery. 1989; 14: 972-979
        • Black N.
        Patient reported outcome measures could help transform healthcare.
        BMJ. 2013; 346f167