EVIDENCE-BASED MEDICINE The Role of Prophylactic Ulnar Nerve Release During Elbow Contracture Release Neal C. Chen, MD, Andrew Liu, BS THE PATIENT A 40-year-old right-handed man presents with a 50  flexion contracture and only 80  flexion 1 year after open reduction and plate fixation of an olecranon fracture. He reports no tingling or numbness in the fingers. He has a negative Tinel’s sign over the ulnar nerve at the elbow, no atrophy, and normal sensation. Radiographs demonstrate a healed olecranon fracture, congruent ulnohumeral joint, and posterior plate with no errant or loose implants. His operative note in- dicates that the ulnar nerve was not addressed during surgery. The patient is interested in surgical man- agement of the elbow stiffness. THE QUESTION What is the role of prophylactic ulnar nerve decom- pression in a patient without ulnar nerve symptoms undergoing release for posttraumatic elbow stiffness? CURRENT OPINION There is consensus that patients with symptoms of ulnar neuropathy and no surgery for the ulnar nerve before contracture release benefit from concomitant ulnar nerve release. In patients who do not have ulnar nerve symptoms preoperatively, it is unclear whether prophylactic ulnar nerve release is helpful. The study by Antuna and colleagues 1 of patients with operative treatment of primary osteoarthritis reinforced a rec- ommendation for prophylactic ulnar nerve decom- pression when patients have less than 90  or 100  preoperative flexion or there are anticipated gains of range of motion greater than 30  to 40  , but the relationship between preoperative flexion and post- operative ulnar neuropathy is inconsistent and the balance of risks and benefits with prophylactic ulnar nerve release is an area of debate. THE EVIDENCE To our knowledge, the incidence of ulnar neuropathy defined by electromyographic studies/nerve conduc- tion velocity studies in patients with elbow stiffness is unknown. Some data about the incidence of ulnar neuropathy can be extrapolated from studies doc- umenting splint treatment of posttraumatic elbow contractures. Of 22 patients treated with turnbuckle splinting, Gelinas et al 2 noted that 2 (9%) had tran- sient paresthesias in the ulnar nerve distribution. Lindenhovius et al 3 reported ulnar neuropathy in 3 of 31 subjects (10%) treated with dynamic splinting and 3 of 35 subjects (9%) treated with static splinting at initial enrollment. At 12 months, patients had mean flexion arc improvements of 47  with dynamic splinting and 49  with static splinting. Three patients underwent ulnar nerve release and 9 underwent capsular release in conjunction with treatment of ul- nar neuropathy, excision or heterotopic ossification, or treatment of nonunion during the course of the study. Of the patients available for follow-up, 2 of 21 (10%) treated with dynamic splinting and 2 of 28 (7%) treated with static splinting had symptoms of ulnar neuropathy. Antuna et al 1 performed arthroscopic capsular release and debridement on 46 patients with primary ulnohumeral arthritis. Thirteen patients had ulnar nerve symptoms postoperatively. Seven patients had preoperative symptoms and had concomitant ulnar nerve release. Six patients developed new ulnar nerve symptoms postoperatively. The average preoperative flexion of the 13 patients who had postoperative ulnar neuropathy was 112  compared with 113  for the 32 patients who did not. Blonna et al 4 performed arthroscopic capsular release for athletes with a mean preoperative flexion From the Department of Orthopaedic Surgery, Philadelphia Hand Center, PC, Thomas Jefferson University Hospital, Philadelphia, PA. Received for publication April 1, 2014; accepted in revised form April 12, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Neal C. Chen, MD, Department of Orthopaedic Surgery, Philadelphia Hand Center, PC, Thomas Jefferson University Hospital, 834 Chestnut Street, G 114, Philadelphia, PA 19107; e-mail: nealchen@yahoo.com. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.009 Ó 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 1