SCIENTIFIC ARTICLE

Patient-Rated Outcome of Ulnar Nerve

Decompression: A Comparison of Endoscopic and
Open In Situ Decompression
Adam C. Watts, MBBS, Gregory I. Bain, MD, PhD

Purpose To report patient-rated outcomes after ulnar nerve decompression at the elbow and
to compare the outcome after open in situ decompression with that after endoscopic in situ
decompression.
Methods Patients having ulnar nerve decompression were evaluated using patient-rated
outcome measures. Fifty-five patients were recruited; 3 were lost to follow-up, and 18 were
excluded because they had anterior transposition. Of the thirty-four patients followed up for
12 months, 19 had endoscopic decompression and 15 had open in situ decompression. Patient
demographics, presenting symptoms, range of elbow movement, grip and pinch strength, and
sensation were recorded preoperatively and at 12 months by an independent observer.
Postoperative patient satisfaction, pain, and ongoing paresthesia were recorded using visual
analog scales. Subgroup analysis was performed to compare the outcome of open in situ
decompression with that of endoscopic in situ decompression.
Results At 12 months after surgery, the proportion of patients satisfied with the outcome was
9 of 15 (60%) for open in situ surgery and 15 of 19 (79%) for endoscopic in situ surgery. The
postoperative complication rate was significantly higher after open in situ decompression
than that after endoscopic in situ decompression surgery (10%). Preoperative function scores
were predictive of patient-rated satisfaction and were related to McGowan grade.
Conclusions The patient-reported outcome of surgical treatment of cubital tunnel syndrome is
good but is affected by preoperative symptom severity. Outcomes after open and endoscopic
in situ decompression, including the proportion of patients reporting satisfaction and func-
tional improvement, are equivalent, but more patients reported complications after open
decompression. (J Hand Surg 2009;34A:1492–1498. © 2009 Published by Elsevier Inc. on
behalf of the American Society for Surgery of the Hand.)
Type of study/level of evidence Therapeutic III.
Key words Cubital tunnel syndrome, decompression, endoscopic, outcome, ulnar nerve.

is the second most and women is reported to be 235 and 170 per 100,000,

C
UBITAL TUNNEL SYNDROME
common neuropathy affecting the upper limb, respectively.1 The syndrome has been stratified by
after carpal tunnel syndrome. The annual age- McGowan into three grades2: grade I, sensory alteration
standardized incidence in the United Kingdom for men only; grade II, muscle weakness; grade III, muscle

From Modbury Public Hospital, North Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Aus- No benefits in any form have been received or will be received related directly or indirectly to the
tralia; Royal Adelaide Hospital, Adelaide, SA, Australia; and the Department of Orthopaedic Surgery, subject of this article.
University of Edinburgh, Edinburgh, United Kingdom.
Corresponding author: Gregory I. Bain, MD, PhD, 196 Melbourne Street, North Adelaide, SA 5006,
The authors would like to acknowledge the important contribution made to this study by Ron Hept- Australia; e-mail: greg@gregbain.com.au.
install, Enid Buckton, and Rob Maurmo.
0363-5023/09/34A08-0017$36.00/0
Received for publication December 21, 2008; accepted in revised form May 19, 2009. doi:10.1016/j.jhsa.2009.05.014

1492 䉬 ©  Published by Elsevier, Inc. on behalf of the ASSH.

Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 OUTCOME OF ULNAR NERVE DECOMPRESSION
paresis and wasting. Current treatment for patients with
notable persistent symptoms of paresthesia or pain in
the ulnar nerve distribution or weakness with wasting of
the small muscles of the hand due to ulnar nerve en-
trapment at the elbow is surgical decompression.3 There
is controversy in the literature regarding the best surgi-
cal treatment. The options include in situ decompres-
sion, subcutaneous or submuscular anterior transposi-
tion, and medial epicondylectomy. Current evidence
suggests that the results of in situ decompression are
equivalent to nerve transposition.4,5 More recently,
techniques for endoscopic in situ decompression have
been described.6 –10
The aims of this study were to evaluate the outcome
after surgery for cubital tunnel syndrome using patient-
reported measures. The secondary aims were to com-
pare the outcomes for open in situ decompression and
endoscopic in situ decompression.
MATERIALS AND METHODS
With local ethics committee approval, data were col-
lected on all consenting patients having ulnar nerve
surgery either as an endoscopic or open procedure un-
der the care of a single surgeon between May 1997 and
March 2006. The diagnosis of ulnar nerve entrapment
at the elbow was made based on a history including
paresthesia or numbness in the ulnar nerve distribution,
weakness or wasting of the small muscles of the hand,
and a positive elbow flexion provocation test. Nerve
conduction studies were performed on all patients pre-
operatively. A slowed motor conduction velocity in the
ulnar nerve across the elbow to below 50 m/s supported
the clinical diagnosis. Patients were excluded from the
study if nerve conduction studies were normal.
Endoscopic group
The senior author has developed a technique using the
Agee device to perform endoscopic in situ ulnar nerve
decompression. After a study demonstrating the safety
and efficacy of this technique in a cadaveric model,6
patients were offered endoscopic ulnar nerve decom-
pression as an alternative to open surgery. Patients
consenting to endoscopic ulnar nerve decompression
were included in this group. Patients with previous
surgery at the elbow, with an unstable nerve on exam-
ination, or who declined endoscopic surgery had an
open decompression procedure with transposition if the
nerve was unstable and were allocated to the open
group. The nerve was determined to be unstable if it
was felt to subluxate over the medial epicondyle on
passive elbow flexion.
JHS 䉬 Vol A, October 
Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
1493
FIGURE 1: Patient flow.
Open in situ group
The open group consisted of consenting patients having
surgery prior to the development of the endoscopic
technique, patients who met the exclusion criteria for
endoscopic decompression (unstable ulnar nerve or pre-
vious surgery), and patients who declined endoscopic
surgery. Open in situ decompression was performed
unless the nerve was unstable at the time of surgery,
assessed by passively flexing the elbow and observing
the position of the nerve relative to the medial epicon-
dyle. For the unstable nerve, an anterior transposition
was performed using either subcutaneous or submuscu-
lar techniques. Patients having subcutaneous and sub-
muscular transposition were excluded from study. No
patients had medial epicondylectomy.
Baseline data
Fifty-five patients were recruited to the study. Three
were lost to follow-up: 2 from the endoscopic group
and 1 from the open in situ group (Fig. 1). Eighteen
patients had anterior transposition and were excluded
from the study. The mean age of the 34 patients fol-
lowed up for 12 months was 46 years (range, 21–74
years). The rest of the baseline data were presented in
Table 1. Preoperatively, at the time of consent to inclu-
sion in the study, data on presenting symptoms were
recorded. Function was measured using the American
Shoulder and Elbow Society Function Score (Table 2),
with a maximum score of 100 for normal function. An
independent observer measured range of elbow move-
ment with a goniometer, grip strength using a Jamar
dynamometer (Preston, Jackson, MI), pinch strength
using a Pinch Gauge (North Coast Medical, San Jose,
CA), and sensation using Semmes-Weinstein monofila-
ments (North Coast Medical).
1494 OUTCOME OF ULNAR NERVE DECOMPRESSION

TABLE 1. Demographics of Subjects by Surgical Group

Endoscopic Open In Situ Decompression Total
Group n ⫽ 19 n ⫽ 15 N ⫽ 34 p Value

Median age in years (range) 49 (22–70) 36 (21–74) 46 (21–74) .158

Number of men (percentage of total) 13 (68) 6 (40) 19 (55) .097
Number with dominant arm involved (%) 7 (37) 6 (40) 13 (38) .851
McGowan grade (%)
Grade I 10 (53) 4 (27) 14 (41) .311
Grade II 5 (26) 6 (40) 11 (32)
Grade III 4 (21) 5 (33) 9 (27)

proportion of patients with a positive test between treat-

TABLE 2. Patient Self-Evaluation: Function
ment groups (p ⫽ .406).
Circle the number that indicates your ability to do the
following activities. Semmes-Weinstein monofilament test
0 ⫽ unable to do; 1 ⫽ very difficult to do; Preoperatively, 5 of 34 patients had normal sensation on
2 ⫽ somewhat difficult; 3 ⫽ not difficult.
monofilament testing of the little finger of the affected
ACTIVITY SCORE limb, 21 had diminished light touch, and 8 had dimin-
1. Do Up Top Button on Shirt 0 1 2 3 ished protective sensation. There were no statistical
2. Manage Toileting 0 1 2 3 differences between the groups in the monofilament test
3. Comb Hair 0 1 2 3 results.
4. Tie Shoes 0 1 2 3
5. Eat with Utensils 0 1 2 3
Subjective outcome assessment
6. Carry a Heavy Object 0 1 2 3 At 12-month follow-up, the patients were asked to com-
7. Rise from Chair Pushing with Arms 0 1 2 3
plete a questionnaire administered by an independent
observer. The primary outcome of this study was patient-
8. Do Heavy Household Chores 0 1 2 3
rated satisfaction, which was recorded using yes/no an-
9. Turn a Key 0 1 2 3
swers and was scored by the patient using a 100-mm
10. Throw a Ball 0 1 2 3
visual analog scale (VAS). Patient-reported persistent
Note: Scores averaged and multiplied by 33 to give a score out of 100. pain, weakness, or numbness in the ulnar nerve distri-
Reprinted with permission from Elsevier. King GJ, Richards RR, bution were recorded using yes/no answers and were
Zuckerman JD, Blasier R, Dillman C, Friedman RJ, et al. A stan-
dardized method for assessment of elbow function. J Shoulder Elbow rated by the patient using a 100-mm VAS. Functional
Surg 1999;8:351–354. Copyright 1999. scores were repeated using the American Shoulder and
Elbow Society Questionnaire (Table 2). Changes in
work and recreational sport status were also recorded.

Nerve conduction studies Objective outcome assessment

The preoperative nerve conduction studies supported
the diagnosis of ulnar nerve entrapment at the elbow in
all cases included in the study. In the endoscopic group,
the mean motor conduction velocity (MCV) across the
elbow was 39.1 m/s (range, 33.3– 48.0 m/s), and in the
open in situ group it was 34 m/s (range, 30.0 – 40.0
m/s). This difference was not statistically significant
(p ⫽ .127). No patient had an MCV greater than 50 m/s.
Provocative test results
Preoperatively, 21 of 34 patients had a positive elbow
flexion test. There was no statistical significance in the
The patients were reviewed at 12 months after surgery
by an independent observer. Repeat measures were
performed of range of movement of the elbow, strength
of grip and pinch, and sensation using the same meth-
ods as at recruitment.
Complications
Patients were invited to report any ongoing complica-
tions of surgery. Patients were specifically asked to
record the presence of pain or numbness at the
elbow to identify possible cutaneous nerve injury
secondary to the surgical procedure. Complications

JHS 䉬 Vol A, October 

Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 OUTCOME OF ULNAR NERVE DECOMPRESSION 1495

TABLE 3. Subjective Outcomes by Surgical Group

Endoscopic In Situ Decompression Total
Group n ⫽ 19 n ⫽ 15 N ⫽ 34 p Value

Number of patients satisfied (%) 15 (79) 9 (60) 24 (70) .229

Median VAS score/100, % (interquartile range) 90 (69–100) 60 (50–73) 78 (52–99) .022

of surgery and any subsequent surgical intervention

TABLE 4. Median VAS Scores for Ongoing Hand
were recorded prospectively. Symptoms Preoperatively and Postoperatively by
Surgical Group
Statistical analysis
Statistical analysis was performed using SPSS Package In Situ
Endoscopic Decompression Total
for Windows (version 14; SPSS Inc, Chicago, IL). Data
Group n ⫽ 19 n ⫽ 15 N ⫽ 34
comparisons were made between the endoscopic group
and the in situ decompression group. All patient data Pain (interquartile
were analyzed on an intent-to-treat basis, so patients range)
remained in their initial groups even if the surgery was Preoperative 40 (0–70) 60 (20–73) 56 (0–70)
altered. Comparison of categorical data was performed Postoperative 0 (0–10) 20 (0–50)* 0 (0–43)‡
with the chi-square test. Comparisons of continuous Numbness
variables with normal distribution of data were per- (interquartile
formed with Student’s t-test with the average expressed range)
as means and standard deviation. Continuous data that Preoperative 70 (60–70) 74 (71–95) 70 (60–80)
were not normally distributed were compared using the Postoperative 10 (0–78) 40 (10–70) 29 (0–74)§
Mann-Whitney U test, with averages expressed as me- Weakness
dians and interquartile range. Comparison of normally (interquartile
range)
distributed continuous data recorded before and after
surgery was performed using paired Student’s t-test or Preoperative 50 (50–60) 43 (29–59) 50 (30–60)
Wilcoxon signed ranks test if not normally distributed. Postoperative 0 (0–50) 25 (0–50)† 10 (0–50)
Linear regression analysis was performed to examine Significant reduction in median score from preoperatively on VAS
for factors predictive of patient-rated satisfaction. Dif- ( *p ⫽ .018, †p ⫽ .028, ‡p ⫽ .007, §p ⫽ .047).
ferences were considered statistically significant if the
p value was less than .05.
pain, p ⫽ .982; weakness, p ⫽ .154). Ongoing
RESULTS
numbness in the hand was reported by 12 of 15
Results of subjective assessment patients after open in situ decompression and 10 of
A greater proportion of patients in the endoscopic group 19 patients in the endoscopic in situ decompres-
(15 of 19; 79%) reported that they were satisfied with sion group. Four of 15 patients in the open in situ
the outcome of the procedure at 12 months than that in decompression group had ongoing pain in the ul-
the open in situ decompression group (9 of 15; 60%) nar nerve distribution compared with 5 of 19 pa-
but the difference was not statistically significant (p ⫽ tients in the endoscopic in situ group. Ten of 15
.229) (Table 3). patients reported ongoing weakness in the hand
The degree of self-reported patient satisfaction mea- after in situ decompression, compared with 8 of 19
sured on a VAS was a median of 90 for the endoscopic patients after endoscopic in situ decompression.
decompression group and 60 for the open in situ group. Based on self-reported VAS, there was a significant
The difference between the scores for the endoscopic improvement in pain scores (p ⫽ .018) and weakness
and open in situ groups was statistically significant (p ⫽ scores (p ⫽ .028) from preoperative to 12-month post-
.022). operative assessments for the open in situ decompres-
There were no statistically significant differences in sion group only (Table 4). Improvements were seen in
outcome using patient self-reported measures of ongo- the endoscopic in situ group but did not reach statistical
ing symptoms in the hand (numbness, p ⫽ .096; significance (pain, p ⫽ .141; weakness, p ⫽ .496).

JHS 䉬 Vol A, October 

Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
1496 OUTCOME OF ULNAR NERVE DECOMPRESSION
Given the sample size of 19 patients and the change in
the means, the study had 84% power to detect a differ-
ence in the pain scores and 9% power for the weakness
scores.
Function scores improved overall from 79 of 100
(interquartile range, 63–92) up to 93 of 100 (interquar-
tile range, 78 –100), but this did not reach statistical
significance (p ⫽ .053). The improvements in the en-
doscopic (92 of 100 to 97 of 100, p ⫽ .462) and open
in situ (69 of 100 to 83 of 100, p ⫽ .065) groups were
not statistically significant.
Results of objective outcome assessment
For the endoscopic group, grip strength improved from
86% of the contralateral unaffected side (interquartile
range, 57% to 107%) to 91% (interquartile range, 84%
to 100%). In the open in situ group, grip strength
improved from 76% (interquartile range, 42% to
90%) to 91% (interquartile range, 47% to 102%).
These improvements were not statistically significant
(endoscopic, p ⫽ .176; open, p ⫽ .735). Pinch
strength did not change significantly for any group:
endoscopic 90% (interquartile range, 66% to 113) to
91% (interquartile range, 64% to 100%; p ⫽ .753);
open in situ 94% (interquartile range, 50% to 105%)
to 93% (interquartile range, 52% to 106%; p ⫽ .249).
The monofilament test scores in the little finger of
the affected hand improved by 1 level for 8 of 34
patients. One patient’s score changed from diminished
light touch to diminished protective sensation, and 1
patient’s score changed from diminished protective sen-
sation to loss of protective sensation.
No significant changes in range of elbow movement
as a percentage of the contralateral side were observed
in any group before and after surgery (endoscopic, p ⫽
.655; open, p ⫽ .500).
Employment and recreation status
At 12-month follow-up, 15 of 34 patients were still
employed in their original employment, 5 of 34 patients
had changed their jobs, and 13 of 34 patients were not
working. Data were not available for 1 patient. Sixteen
of 34 patients were participating in their usual sport or
recreation, 9 of 34 patients were participating at a lower
level, 1 patient was unable to play his usual sports, 6 of
34 patients were not participating in any sport, and data
were not available for 2 patients. There were no signif-
icant differences between treatment groups (work, p ⫽
.680; sport, p ⫽ .569).
Complications of surgery
There was 1 patient in the endoscopic group who was
converted to open in situ decompression because peri-
JHS 䉬 Vol A, October 
Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
TABLE 5. Complications by Surgical Group
In Situ
Endoscopic Decompression Total
Group n ⫽ 19 n ⫽ 15 N ⫽ 34
New elbow pain 1 1 2
Scar tenderness 0 2 2
Numbness at elbow 0 3 3
Hematoma requiring 1 0 1
decompression
Infection 0 0 0
Total (%) 2 (11)* 6 (40) 8 (24)
*Significantly lower overall postoperative complication rate when
compared with open in situ decompression (p ⫽ .044).
neural adhesions prevented safe endoscopic decompres-
sion. This patient had a good outcome with 100%
satisfaction and no complications and remained in the
endoscopic group for data analysis.
Postoperative complications included pain or scar
tenderness at the elbow that had not been reported
preoperatively (4 patients), numbness around the elbow
(3 patients), and need for further surgery (1 patient; this
patient in the endoscopic group had open in situ decom-
pression performed 4 weeks postoperatively because of
an exacerbation of symptoms thought to be due to
hematoma). There were significantly fewer postopera-
tive complications in the endoscopic group compared
with the in situ decompression group (Table 5, p ⫽
.044). There were no infections and no ulnar nerve
injuries.
Analysis of potential confounding variables
No considerable differences in outcome criteria were
identified between genders.
The differences in McGowan grade severity between
the groups were not statistically significant (p ⫽ .311).
Linear regression analysis was performed to examine
which factors influenced the primary outcome of pa-
tient-reported satisfaction. The single factor that pre-
dicted the reported satisfaction was the preoperative
function score (R ⫽ .637, p ⫽ .19). There was signif-
icant correlation between functional scores preopera-
tively (p ⫽ .015) and postoperatively (p ⫽ .050) and
McGowan grade of cubital tunnel syndrome. Both pre-
operative and postoperative median function scores de-
creased with increasing McGowan grade, but the
amount of improvement in functional score at 1 year
after surgery was similar for all grades (Fig. 2).
 OUTCOME OF ULNAR NERVE DECOMPRESSION
FIGURE 2: Preoperative and 12-month median functional
scores by McGowan grade. Error bars indicate 75th percentile.
DISCUSSION
The optimal treatment for cubital tunnel syndrome is
widely debated. Some authors argue that the primary
problem is nerve compression by overlying structures11
and that the syndrome is best treated by decompression
of the nerve without removing it from its bed, therefore
causing minimal disruption to the vascular supply. Oth-
ers argue in favor of ulnar nerve transposition or medial
epicondylectomy,12–14 citing evidence that the nerve is
under tension with elbow flexion15 that can only be
relieved by placing the nerve anterior to the medial
epicondyle. If transposition is performed, the surgeon
must decide whether to leave the nerve in a subcutane-
ous plane16,17 where it may be prone to repeated trauma
or to bury it beneath muscle, which is a more techni-
cally demanding procedure. 18 –20 Recent meta-
analyses of available evidence suggest that in situ
decompression has outcomes comparable with ante-
rior transposition but is associated with a lower risk
of complication.4,5 This is supported by a detailed
decision analysis model that favors in situ decom-
pression.21
With the acceptance of in situ decompression as an
effective treatment for cubital tunnel syndrome, meth-
ods for minimally invasive22 and endoscopic-assisted
ulnar nerve decompression have been investigated. A
technique for endoscopic in situ decompression was
first described by Tsai et al.9 Subsequently, alternative
techniques have been described,7,8,10,23 with supporting
anatomic studies.6 The outcome of endoscopic decom-
pression has been shown to be good in cohort stud-
ies7,8,22 and appears equivalent to the reported outcome
with open techniques.24,25
The advantage of endoscopic release is a smaller
skin incision, approximately 3 cm, and minimal soft
JHS 䉬 Vol A, October 
Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
1497
tissue dissection, which decreases the vascular insult to
the nerve and improves the cosmetic appearance of the
scar. Open decompression techniques are routinely per-
formed through a longitudinal incision centered on and
posterior to the medial epicondyle. Anatomic studies
have demonstrated the proximity of the medial antebra-
chial cutaneous nerve,26 particularly the posterior
branch, to the dissection, and these nerves may be
inadvertently injured during surgical dissection. Persis-
tent elbow pain, numbness around the elbow, and scar
tenderness are recognized complications of the open
techniques and may be related to injury to these cuta-
neous nerves. Three of the 8 patients reporting compli-
cations at 12 months in this study were complaining of
symptoms directly attributable to cutaneous nerve in-
jury, and a further 4 patients had scar tenderness or
persistent elbow pain. All but one of these complica-
tions were reported in patients who had an open tech-
nique. A potential drawback of the endoscopic tech-
nique is the management of the unstable ulnar nerve
after decompression. No cases of instability were ob-
served in this study, but preoperative assessment was
performed, and patients with an unstable nerve were
excluded from endoscopic decompression.
The literature reports an 80% to 90% success rate for
open cubital tunnel surgery.3 The rates of satisfaction
reported here appear relatively low, especially for open
decompression; however, it is important to emphasize
that the outcomes in this study are patient-rated and not
based on the surgeon’s perspective. Previous studies
have recorded patient self-reported satisfaction of 83%
after medial epicondylectomy,27 and 19 of 20 young,
healthy military personnel were satisfied with the out-
come after submuscular transposition.28 The number of
patients reporting ongoing symptoms of numbness is
high, but this is in keeping with reviews of previously
published literature.29 This figure of up to 80% may be
higher than many surgeons appreciate and certainly
needs further attention.
The weaknesses of this project include a relatively
small study sample, nonrandom allocation of patients to
the 2 treatment arms of the study, and differences in
preoperative symptom severity between groups. Al-
though the McGowan grades were not significantly
different on statistical analysis (p ⫽ .311), these differ-
ences may have affected the results because functional
scores, which were predictive of patient satisfaction,
were related to McGowan grade. Taking account of
these drawbacks, the results of this study indicate that
the outcome of open in situ decompression and endo-
scopic in situ ulnar nerve decompression are equivalent
1 year after surgery. The proportion of patients experi-
1498 OUTCOME OF ULNAR NERVE DECOMPRESSION
encing persistent complications was significantly lower
in the endoscopic group (p ⫽ .044), indicating a pos-
sible advantage of this method. The patient reports of
ongoing symptoms and functional deficit appear to be
related to preoperative syndrome severity. This should
encourage prompt intervention and preoperative coun-
seling of patients with more advanced stages not to
expect full return of function, but rather some persistent
symptoms at 12 months.
REFERENCES
1. Latinovic R, Gulliford MC, Hughes RA. Incidence of common
compressive neuropathies in primary care. J Neurol Neurosurg Psy-
chiatry 2006;77:263–265.
2. McGowan AJ. The results of transposition of the ulnar nerve for
traumatic ulnar neuritis. J Bone Joint Surg 1950;32B:293–301.
3. Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar
nerve. J Am Acad Orthop Surg 2007;15:672– 681.
4. 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 random-
ized, controlled trials. J Bone Joint Surg 2007;89A:2591–2598.
5. Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decom-
pression versus anterior subcutaneous and submuscular transposition
of the ulnar nerve for cubital tunnel syndrome: a meta-analysis.
J Hand Surg 2008;33A:1314.e1–1314.e12.
6. Bain GI, Bajhau A. Endoscopic release of the ulnar nerve at the
elbow using the Agee device: a cadaveric study. Arthroscopy 2005;
21:691– 695.
7. Ahcan U, Zorman P. Endoscopic decompression of the ulnar nerve
at the elbow. J Hand Surg 2007;32A:1171–1176.
8. Hoffmann R, Siemionow M. The endoscopic management of cubital
tunnel syndrome. J Hand Surg 2006;31B:23–29.
9. Tsai TM, Bonczar M, Tsuruta T, Syed SA. A new operative tech-
nique: cubital tunnel decompression with endoscopic assistance.
Hand Clin 1995;11:71– 80.
10. Nakao Y, Takayama S, Toyama Y. Cubital tunnel release with
lift-type endoscopic surgery. Hand Surg 2001;6:199 –203.
11. Iba K, Wada T, Aoki M, Oda T, Ozasa Y, Yamashita T. The
relationship between the pressure adjacent to the ulnar nerve and the
disease causing cubital tunnel syndrome. J Shoulder Elbow Surg
2008;17:585–588.
12. Popa M, Dubert T. Treatment of cubital tunnel syndrome by frontal
partial medial epicondylectomy. A retrospective series of 55 cases.
J Hand Surg 2004;29B:563–567.
13. Osterman AL, Spiess AM. Medial epicondylectomy. Hand Clin
2007;23:329 –337, vi.
JHS 䉬 Vol A, October 
Downloaded for Anonymous User (n/a) at UCLA -Cedars Sinai Medical Center from ClinicalKey.com by Elsevier on August 25, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
14. Craven PR Jr, Green DP. Cubital tunnel syndrome. Treatment by
medial epicondylectomy. J Bone Joint Surg 1980;62A:986 –989.
15. Gelberman RH, Yamaguchi K, Hollstien SB, Winn SS, Heidenreich
FP Jr, Bindra RR, et al. Changes in interstitial pressure and cross-
sectional area of the cubital tunnel and of the ulnar nerve with flexion
of the elbow. An experimental study in human cadavera. J Bone
Joint Surg 1998;80A:492–501.
16. Lascar T, Laulan J. Cubital tunnel syndrome: a retrospective review
of 53 anterior subcutaneous transpositions. J Hand Surg 2000;25B:
453– 456.
17. Messina A, Messina JC. Transposition of the ulnar nerve and its
vascular bundle for the entrapment syndrome at the elbow. J Hand
Surg 1995;20B:638 – 648.
18. Leone J, Bhandari M, Thoma A. Anterior intramuscular transposi-
tion with ulnar nerve decompression at the elbow. Clin Orthop Relat
Res 2001;387:132–139.
19. Pasque CB, Rayan GM. Anterior submuscular transposition of the
ulnar nerve for cubital tunnel syndrome. J Hand Surg 1995;20B:
447– 453.
20. Glowacki KA, Weiss AP. Anterior intramuscular transposition of the
ulnar nerve for cubital tunnel syndrome. J Shoulder Elbow Surg
1997;6:89 –96.
21. Brauer CA, Graham B. The surgical treatment of cubital tunnel
syndrome: a decision analysis. J Hand Surg 2007;32E:654 – 662.
22. Taniguchi Y, Takami M, Takami T, Yoshida M. Simple decompres-
sion with small skin incision for cubital tunnel syndrome. J Hand
Surg 2002;27B:559 –562.
23. Krishnan KG, Pinzer T, Schackert G. A novel endoscopic technique
in treating single nerve entrapment syndromes with special attention
to ulnar nerve transposition and tarsal tunnel release: clinical appli-
cation. Neurosurgery 2006;59(1 Suppl 1):ONS89 –100; discussion
ONS89 –100.
24. Nathan PA, Keniston RC, Meadows KD. Outcome study of ulnar
nerve compression at the elbow treated with simple decompression
and an early programme of physical therapy. J Hand Surg 1995;20B:
628 – 637.
25. Dellon AL, Coert JH. Results of the musculofascial lengthening
technique for submuscular transposition of the ulnar nerve at the
elbow. J Bone Joint Surg 2004;86A(Suppl 1 Pt 2):169 –179.
26. Lowe JB III, Maggi SP, Mackinnon SE. The position of crossing
branches of the medial antebrachial cutaneous nerve during cubital
tunnel surgery in humans. Plast Reconstr Surg 2004;114:692– 696.
27. Muermans S, De Smet L. Partial medial epicondylectomy for cubital
tunnel syndrome: outcome and complications. J Shoulder Elbow
Surg 2002;11:248 –252.
28. Fitzgerald BT, Dao KD, Shin AY. Functional outcomes in young,
active duty, military personnel after submuscular ulnar nerve trans-
position. J Hand Surg 2004;29A:619 – 624.
29. Dellon AL. Review of treatment results for ulnar nerve entrapment
at the elbow. J Hand Surg 1989;14A:688 –700.