Endoscopic decompression of the ulnar nerve in the cubital tunnel yields similar outcomes but a lower complication rate than open decompression: a systematic review and meta-analysis

Importance Cubital tunnel syndrome is the second most common peripheral nerve compression syndrome in the USA. There is controversy in the literature regarding the best surgical option. Objective The purpose of this investigation was to perform a systematic review to determine if there is a difference in clinical outcomes or complications between open and endoscopic cubital tunnel release in patients with compression of the ulnar nerve in the cubital tunnel. Evidence review A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS and Cochrane Central Register of Controlled Trials databases were searched for level I–IV therapeutic comparative studies of open versus endoscopic cubital tunnel decompression in adult human patients. The levels of evidence were then assigned based on the Oxford Centre for Evidence-Based Medicine. Study methodological quality was analysed using the Modified Coleman Methodology Score. Only the outcome measurements that 3 or more studies used were included in our data synthesis. Postoperative patient satisfaction, Bishop score, recurrence and complication rates were compared between the endoscopic and open groups using the χ test using p<0.05. Findings Six articles (507 patients, mean age of 48.2 years, with 28.8 months average follow-up) were analysed. 76.1% of patients were satisfied in the endoscopic group, and 73.8% were satisfied in the open group (p=0.7023). 87.4% of endoscopic patients and 81.2% of open patients had a Bishop score of excellent or good (p=0.236). The endoscopic group had a recurrence rate of 1.1%, and the open group had a 3.5% recurrence rate (p=0.0872). There were significantly fewer complications in the endoscopic group (7.9%) compared to the open group (12.9%) (p<0.01). Conclusions and relevance Equivalent clinical outcomes, patient satisfaction and recurrence rates were observed between open and endoscopic techniques. However, a significantly lower complication rate was observed with the endoscopic technique. Level of evidence Level IV, systematic review of level I–IV studies. INTRODUCTION Cubital tunnel syndrome is a compressive neuropathy of the ulnar nerve at the elbow. It is the second most common peripheral nerve compression syndrome with an incidence of 75 000 cases per year. It often presents in the advanced stages of the disease with decreased sensation and muscle atrophy that can have permanent deficits if left untreated. Surgical treatment is reserved for patients with persistent symptoms that have failed non-surgical (lifestyle modification and immobilisation) management. Historically, there have been three commonly used open surgical techniques for the treatment of cubital tunnel syndrome: in-situ decompression, anterior transposition (submuscular, subcutaneous) and medial epicondylectomy. Recent randomised controlled trials and meta-analyses have demonstrated similar outcomes between these techniques. More recently, endoscopic decompression of the ulnar has been suggested to improve recovery. 12 There has been no clear consensus comparing open and endoscopic techniques with regard to patientreported clinical outcomes and complication rates. The availability and effectiveness of multiple techniques has led to controversy in the literature regarding the best surgical option for the treatment of cubital tunnel syndrome. The purpose of this investigation was to determine if there is a difference in clinical outcomes or complications between open and endoscopic cubital tunnel release in patients with compression of the ulnar nerve in the What is already known ▸ Cubital tunnel syndrome is the second most common peripheral nerve compression syndrome. ▸ There has been no clear consensus comparing open and endoscopic techniques with regard to patient-reported clinical outcomes and complication rates. What are the new findings ▸ Equivalent clinical outcomes, patient satisfaction and recurrence rates were observed between open and endoscopic techniques. ▸ The endoscopic technique was associated with a significantly lower complication rate compared to open. Systematic review To cite: Sochacki KR, Bernstein DT, Harris JD, et al. JISAKOS 2017;2:8–13. Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA Correspondence to Dr Kyle R Sochacki; Houston Methodist Hospital, 6445 Main Street, Suite 2500, Houston, TX 77030, USA; ksochacki@houstonmethodist. org Received 11 September 2016 Revised 24 October 2016 Accepted 25 October 2016 Published Online First 15 November 2016 8 Sochacki KR, et al. JISAKOS 2017;2:8–13. doi:10.1136/jisakos-2016-000112. Copyright © 2017 ISAKOS group.bmj.com on January 5, 2018 Published by http://jisakos.bmj.com/ Downloaded from