Is medication or surgery indicated for a patient with a history of distal biceps tendon rupture and triceps tendon repair, presenting with arm weakness and ulnar nerve paresthesia?

Surgical Intervention is Medically Indicated for This Patient

This 45-year-old male with recurrent tendon rupture, persistent arm weakness, and ulnar nerve paresthesia requires surgical evaluation and likely intervention for ulnar nerve decompression, given the high probability of cubital tunnel syndrome following his complex elbow reconstruction.

Clinical Rationale for Surgical Indication

Ulnar Nerve Compression Requires Surgical Decompression

• Ulnar nerve entrapment at the elbow (cubital tunnel syndrome) is the second most common peripheral nerve entrapment and typically presents with hand weakness, atrophy, and paresthesias in the ulnar distribution 1
• Patients who fail conservative therapy are considered surgical candidates, and simple in situ decompression can achieve satisfactory results with appropriate patient selection 1
• This patient's history of multiple elbow surgeries, including triceps repair/reconstruction with allograft and bursa excision, places him at high risk for nerve compression from scar tissue, altered anatomy, or direct surgical trauma 2

Post-Surgical Nerve Complications Are Common After Distal Biceps/Triceps Repair

• Iatrogenic nerve injuries, particularly to the posterior interosseous nerve (PIN) and lateral antebrachial cutaneous nerve, occur frequently after single-incision distal biceps repair techniques 2
• Paresthesia of the lateral antebrachial cutaneous nerve occurs in 21-31.8% of patients after biceps tendon repair, with higher rates in delayed repairs 3
• When loss of function occurs in nerve-innervated muscles after elbow tendon refixation, neurological evaluation including electrophysiology must be conducted 2

Diagnostic Workup Required Before Surgery

Immediate Imaging and Electrodiagnostic Studies

• Plain radiographs of the elbow are the most appropriate initial imaging to identify any osseous pathology, heterotopic ossification, or hardware complications 4, 5
• MRI elbow without IV contrast should be obtained if radiographs are normal or nonspecific but clinical suspicion remains high for soft tissue pathology, nerve compression, or tendon re-rupture 4
• Electrophysiological studies (EMG/NCS) are essential to confirm ulnar nerve entrapment and localize the site of compression 1
• Ultrasound assessment of the ulnar nerve should guide the decision between conservative versus surgical treatment, particularly in evaluating nerve continuity and compression 2

Clinical Examination Findings to Document

• Assess for Tinel sign at the cubital tunnel, which indicates ulnar nerve irritation 6
• Evaluate grip strength asymmetry and specific muscle weakness in ulnar nerve distribution (interossei, hypothenar muscles) 6, 1
• Document sensory deficits in the ulnar 1.5 fingers and medial forearm 6
• Examine for muscle atrophy in the hand, which suggests chronic nerve compression requiring urgent intervention 1

Surgical Decision Algorithm

Indications for Immediate Surgical Exploration

1. Progressive motor weakness or muscle atrophy in ulnar nerve distribution 1
2. Electrophysiological evidence of severe nerve compression or axonal loss 2
3. Ultrasound findings showing nerve compression, discontinuity, or entrapment in scar tissue 2
4. Failure of conservative management (if attempted) over 6-12 weeks 1

Surgical Approach

• Intraoperative neurography should guide the decision between neurolysis alone versus partial nerve grafting 2
• Simple in situ decompression of the ulnar nerve at the elbow is the preferred initial approach for most cases of cubital tunnel syndrome 1
• If nerve is entrapped in scar tissue from previous surgeries, extensive neurolysis with possible transposition may be required 1
• All patients require postoperative rehabilitation protocol to facilitate nerve regeneration and motor function recovery 2

Conservative Management is Unlikely to Succeed

Limited Role for Non-Operative Treatment

• While chiropractic manipulation, soft tissue mobilization, and ergonomic modifications have shown benefit in some cases of ulnar nerve compression 6, this patient's complex surgical history and persistent symptoms suggest structural nerve compromise
• Conservative therapy with activity modification, NSAIDs, and physical therapy may be attempted for 6-12 weeks only if there is no evidence of severe nerve compression or progressive motor loss 5, 1
• Given the recurrent tendon rupture and multiple prior surgeries, conservative management is unlikely to address the underlying anatomical problem causing nerve compression

Critical Pitfalls to Avoid

• Do not delay surgical intervention if there is progressive motor weakness or muscle atrophy, as prolonged nerve compression leads to irreversible axonal damage 1
• Ensure comprehensive preoperative electrodiagnostic testing to differentiate between neuropraxia (which may recover) versus axonotmesis or neurotmesis (which require surgical intervention) 2
• Be aware that heterotopic ossification can develop after elbow surgery and may contribute to nerve compression—radiographs must specifically evaluate for this 3
• The presence of significant arm weakness suggests possible concurrent issues with the repaired triceps tendon or biceps tendon, which may require simultaneous surgical revision 3