Original Article
Delayed-Onset Ulnar Neuritis After Release of Elbow Contracture: Preventive Strategies Derived From a Study of 563 Cases

https://doi.org/10.1016/j.arthro.2014.03.022Get rights and content

Purpose

The purposes of this study were to determine whether delayed-onset ulnar neuritis (DOUN) after elbow contracture release can be prevented and to compare the efficacy of ulnar nerve decompression versus subcutaneous transposition.

Methods

A retrospective study of 563 consecutive arthroscopic elbow contracture releases was conducted. The prophylactic efficacy of (1) subcutaneous transposition, (2) ulnar nerve decompression, (3) limited ulnar nerve decompression (7 to 8 cm), and (4) mini-decompression (4 to 6 cm) was assessed prospectively. The efficacy of prophylactic strategies (transposition, decompression, limited decompression, or mini-decompression) in preventing DOUN was compared by univariate survival analysis. Patients who underwent a subcutaneous transposition were matched with patients who underwent a standard open decompression or a limited decompression, according to gender, age (±10 years), diagnosis, and preoperative motion. This analysis was repeated after we excluded the patients who underwent associated open procedures (e.g., hardware removal).

Results

DOUN occurred in 26 of 235 patients (11%) who did not undergo any prophylactic procedure versus 8 of 295 patients (3%) who underwent a prophylactic ulnar nerve decompression or transposition at the time of contracture release (P < .001). The neurologic impairment was significantly less severe after prophylactic decompression compared with patients without any prophylactic intervention (grade on Neuropathy Grading Scale, 2 v 4; P = .03). Ulnar nerve transposition and decompression were equally protective. The decompression length was the only factor significantly related to the failure of the prophylactic intervention (odds ratio, 0.19; P = .02). A mini-decompression was not as effective as a prophylactic procedure, whereas a limited decompression was equal to a standard decompression. The case-control analysis showed that the decompression and transposition had equal preventive effects but the transposition was associated with a higher rate of wound complications (19% v 4%, P = .03).

Conclusions

DOUN is a complication of arthroscopic elbow contracture release. Its incidence and severity can be reduced by limited open ulnar nerve decompression or transposition.

Level of Evidence

Level II, prospective comparative study with retrospective analysis.

Section snippets

Methods

This study is composed of both a retrospective analysis and a prospective comparative study. The latter was conducted from February 2004 to June 2010.

After institutional review board approval, a retrospective study of 565 consecutive arthroscopic contracture releases of the elbows in 521 patients, from June 1993 to June 2010, was conducted. The patient chart review was performed by 2 investigators not involved in the patients' care.

A DOUN was defined as (1) new ulnar nerve symptoms in a patient

Incidence

DOUN developed in a total of 34 patients over the study period (6%) (Fig 1). DOUN occurred in 26 of 235 patients (11%) who did not undergo prophylactic ulnar nerve decompression or transposition compared with 8 of 295 patients (3%) in whom a prophylactic ulnar nerve decompression or transposition was performed at the time of contracture release (P < .001). DOUN did not develop in any of the 33 patients who had previously undergone an ulnar nerve transposition, before the arthroscopic

Discussion

This article reports the results of our efforts to prevent the occurrence of DOUN over the course of approximately 20 years of experience. The chronology of the strategies to prevent DOUN was the consequence of some observations that the senior author made during this experience. In the first series of patients (group A), the prophylactic strategy was in line with the traditional philosophy of preventing DOUN and a prophylactic subcutaneous ulnar nerve transposition was indicated for patients

Conclusions

DOUN is a complication of arthroscopic elbow contracture release. Its incidence and severity can be reduced by limited open ulnar nerve decompression or transposition.

Acknowledgment

The authors gratefully acknowledge the contributions of Russell G. Huffman for his assistance with the chart review for this study.

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    The authors report the following potential conflict of interest or source of funding: S.W.O. receives royalties from Acumed, Tornier, Aircast.

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