Risk of delayed-onset ulnar neuritis after arthroscopic release of elbow contracture

1. 11% of patients undergoing arthroscopic release of elbow contracture experienced delayed-onset ulnar neuritis. 

2. Pre-operative identification of heterotropic ossification, neurological symptoms, and decreased flexion extension arc were all found to be significant risk factors for the development of delayed-onset ulnar neuritis. 

Evidence Rating Level: 3 (Average)

Study Rundown: Nerve injuries have been described following arthroscopic release of elbow contracture. One type, delayed-onset ulnar nerve neuritis (DOUN), has been reported after arthroscopic elbow release but only sparsely described. The authors of this paper sought to more systematically characterize DOUN and its clinical presentation. The study found that approximately 11% of patients who underwent release of elbow contracture developed DOUN and further subdivided such subjects into 3 distinct categories: rapidly progressive, slowly progressive, and non-progressive DOUN. The findings underscore the need for surgeons to maintain a high index of clinical suspicion for DOUN following arthroscopic elbow release. Early recognition is of particular significance for those with rapidly progressive DOUN who require immediate nerve transposition which, if not performed in a timely (<2 weeks post-surgery) manner, can manifest in a permanent neurological deficit. The authors were additionally able to identify three distinct pre-operative criteria in patients that were associated with significantly elevated risk for DOUN development post-surgery. Some deficiencies in the study include the single center, single surgeon design, which can limit applicability, as well as the evolution in surgical technique and approach over the 17 year duration of the study.

Click to read the study in the American Journal of Sports Medicine

Relevant Reading: Delayed Onset Ulnar Neuropathy after Arthroscopic Elbow Contracture Release

In-Depth [retrospective case series]: A total of 235 elbows from 219 patients undergoing arthroscopic elbow release were included in the analysis. All surgeries were performed by a single surgeon from June 1993 to June 2010. Continuous passive motion (CPM) was used in nearly all patients post-operatively, though the point at which CPM was initiated post-op varied along the length of the study. A total of 26 patients (11%) developed DOUN. Of these patients, 15 (58%) experienced DOUN described as rapidly progressive in nature, 8 (31%) non-progressive, and 3 (12%) slowly progressive. 17 patients underwent ulnar nerve transposition to relieve symptoms. Nerve exploration revealed compression predominantly during flexion as a cause of the neuropathy in 16 (94%) of these patients. Pre-operative diagnosis of heterotopic ossification (odds ratio, 31; 95% CI, 5-191; p=.001), neurological symptoms (odds ratio, 6; 95% CI, 2-19; p=.001), and flexion extension arc (odds ratio, 0.97 per degree of motion; 95% CI, 0.96-0.99; p=.02) were all identified as risk factors for the development of DOUN.

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