Delayed-onset ulnar neuritis after release of elbow contracture: preventive strategies derived from a study of 563 cases.

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 vs. 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% vs. 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.

A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single-column plating.

OBJECTIVES: The study aimed (1) to examine if there are equivalent results in terms of union, alignment and elbow functionally comparing single- to dual-column plating of AO/OTA 13A2 and A3 distal humeral fractures and (2) if there are more implant-related complications in patients managed with bicolumnar plating compared to single-column plate fixation. DESIGN: This was a multi-centred retrospective comparative study. SETTING: The study was conducted at two academic level 1 trauma centres. PATIENTS/PARTICIPANTS: A total of 105 patients were identified to have surgical management of extra-articular distal humeral fractures Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 13A2 and AO/OTA 13A3). INTERVENTION: Patients were treated with traditional dual-column plating or a single-column posterolateral small-fragment pre-contoured locking plate used as a neutralisation device with at least five screws in the short distal segment. MAIN OUTCOME MEASUREMENTS: The patients' elbow functionality was assessed in terms of range of motion, union and alignment. In addition, the rate of complications between the groups including radial nerve palsy, implant-related complications (painful prominence and/or ulnar nerve neuritis) and elbow stiffness were compared. RESULTS: Patients treated with single-column plating had similar union rates and alignment. However, single-column plating resulted in a significantly better range of motion with less complications. CONCLUSIONS: The current study suggests that exposure/instrumentation of only the lateral column is a reliable and preferred technique. This technique allows for comparable union rates and alignment with increased elbow functionality and decreased number of complications.

A modification in technique of abductor digiti minimi (Huber) opponensplasty.

Abductor digiti minimi opponensplasty is a well-established method of restoring opposition following median nerve trauma or in congenital deficiency of thenar intrinsic musculature. The abductor digiti minimi is detached distally and rerouted through a subcutaneous tunnel for insertion into the area of the thumb metacarpophalangeal joint. The pivot point for this rotation is the pisiform bone and it is at this site that the ulnar nerve is vulnerable to compression by the transferred muscle. We describe a modification of technique which involves complete islanding of the muscle without re-insertion of its proximal end. This eliminates the possibility of this complication without detracting from the efficacy of opposition produced by the transferred muscle.