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Address correspondence to Larry D. Field, M.D., Upper Extremity Service, Mississippi Sports Medicine & Orthopaedic Center, 1325 East Fortification St, Jackson, MS 39202, U.S.A.
Upper Extremity Service, Mississippi Sports Medicine & Orthopaedic Center, Jackson, Mississippi, U.S.A.Department of Orthopaedic Surgery, University of Mississippi School of Medicine, Jackson, Mississippi, U.S.A.
Most patients diagnosed with lateral epicondylitis respond well to conservative management. For patients who do not respond to nonoperative modalities, surgical treatment represents a viable option for long-term symptomatic relief. The arthroscopic surgical technique described in this article has been consistently used by the senior author for the treatment of recalcitrant lateral epicondylitis for more than 5 years (198 patients) without the occurrence of any major complications and appears to be a safe, reliable, and efficacious surgical intervention for the management of lateral epicondylitis.
Technique Video
See video under supplementary data.
Most patients diagnosed with lateral epicondylitis respond well to conservative management.
However, on the basis of the current medical literature, conclusions regarding the superiority of either open or arthroscopic surgical treatment are difficult to draw given the limited number of randomized controlled trials and relatively small sample sizes.
Several case series documenting the efficacy of arthroscopic lateral epicondylitis release and debridement for the management of recalcitrant lateral epicondylitis have been published.
The decision regarding whether an arthroscopic or open surgical procedure is performed should be based, in part, on an individual patient's symptoms and on the experience, skill, and preferences of the surgeon.
We describe the details of our current technique developed and consistently used by the senior author for the arthroscopic release and debridement of symptomatic lateral epicondylitis patients undergoing arthroscopic release from December of 2007 to December 2012 (198 consecutive patients) (Video 1).
Surgical Technique
The patient is placed in the prone position with the operative extremity stabilized in an arm holder. A tourniquet is inflated to 250 mm Hg after the limb has been exsanguinated. The palpable bony landmarks of the olecranon and medial and lateral humeral epicondyles are identified and marked. The ulnar nerve is palpated and marked as well to ensure that it is located in the cubital tunnel and remains so with digital manipulation of the nerve. In addition, the elbow joint is flexed and extended while the ulnar nerve is palpated to confirm that the nerve does not subluxate during elbow motion. Next, arthroscopic portal sites for both routine diagnostic assessment and lateral epicondylitis release are localized and marked. Three portal sites are marked: a proximal anteromedial portal, used for visualization of the lateral epicondylitis release; a midline posterior portal, used for diagnostic evaluation of the posterior elbow compartment; and a unique anterolateral “tennis-elbow” portal, located immediately adjacent and anterior to the palpable lateral epicondyle, through which the procedure is carried out (Fig 1).
Fig 1The patient is in the prone position with an arm holder (Weston Arm Holder; Smith & Nephew, Andover, MA) allowing circumferential access to the elbow. The lateral epicondyle is identified after the appropriate bone landmarks have been marked. The lateral tennis-elbow working portal is marked slightly anterior and directly adjacent to the palpable prominence of the lateral epicondyle.
The joint is then insufflated with approximately 30 mL of normal saline solution. Adequate insufflation is confirmed when the elbow can be seen to slightly extend and supinate as the joint capsule fully distends. In addition, resistance to further insufflation can be palpated with the syringe plunger. Next, the 30° arthroscope is placed in the proximal anteromedial portal to view and diagnostically evaluate the anterior elbow compartment.
Once diagnostic evaluation of the anterior compartment is completed, a spinal needle is used to assess the appropriate location and angle for establishing the tennis-elbow portal anterolaterally (Fig 2). By use of a No. 15 scalpel blade, the trajectory of the spinal needle is followed and the scalpel blade is advanced through the skin and subcutaneous tissues (Fig 3). The knife is then advanced deeper so that the origin of the extensor carpi radialis brevis (ECRB) is detached from the lateral epicondyle origin in a “blind” fashion, with care taken to maintain direct contact between the scalpel blade and the anterior bony surface of the lateral epicondyle. This sharp release of the ECRB tendon is very similar technically to percutaneous tennis-elbow release.
Next, scalpel blade advancement is continued until the knife blade is directly visualized arthroscopically as the blade penetrates the anterior compartment of the elbow. After insertion of the knife into the elbow joint, the blade is used to incise the anterolateral elbow capsule twice, at the superior and at the inferior tendinous extent of the ECRB tendon. The incised and proximally released ECRB tendon is then “shelled out” by passing the knife blade circumferentially around it. Using the knife blade in this capacity allows for a very controlled and defined release of the ECRB tendon, minimizing risk to the adjacent neurovascular and ligamentous structures. In addition, sharp release of the ECRB tendon helps facilitate the subsequent excision of this tissue by providing a leading edge of tissue that can be easily resected with the arthroscopic shaver. The scalpel blade is used to release the ECRB much as a bayonet might be used to “slice” through tissue; this is the basis for the name of the technique. The superior margin of the intra-articular capsular and ECRB scalpel blade incision is confirmed arthroscopically when the extensor carpi radialis longus muscle fibers are seen (Fig 4). Care is taken not to incise the inferior anterior capsule and ECRB tendon below the equator of the radiocapitellar joint, ensuring that the dissection and release avoid injury to the adjacent lateral collateral ligament complex.
After release of the ECRB tendon, a 4.5-mm full-radius arthroscopic shaver (Smith & Nephew, Andover, MA) is placed directly through the tennis-elbow portal (Fig 5), and the released ECRB is excised for approximately 1 cm distally until healthy-appearing ECRB tendon is visualized (Fig 6). Adequate arthroscopic visualization is almost always possible using the 30° arthroscope, with the 70° arthroscope used very sparingly. Moreover, an additional arthroscopic portal, created to allow for placement of an arthroscopic retractor, is rarely required.
Fig 2A 30° arthroscope is used to view from the proximal-anterior medial portal. This is the only viewing portal required to perform the arthroscopic ECRB tendon release. A spinal needle is used for percutaneous localization of the tennis-elbow lateral portal. The oblique entry of the spinal needle should be noted. This will allow sharp dissection of the ECRB from the lateral epicondyle at the tendon's origin.
Fig 3With the 30° arthroscope viewing from the proximal-anterior medial portal and following the trajectory established with the spinal needle, a No. 15 blade scalpel is used to incise the skin and release the ECRB tendon along the anterior cortical margin of the lateral epicondyle.
Fig 4As viewed through the proximal-anterior medial portal with a 30° arthroscope, the ECRB has been released from its insertion on the lateral epicondyle. After the ECRB has been circumferentially released and debrided, the extensor carpi radialis longus (ECRL) muscle fibers become visible, as shown.
Fig 5As viewed through the proximal-anterior medial portal with the 30° arthroscope, a 4.5-mm full-radius arthroscopic shaver (Smith & Nephew) is placed directly through the tennis-elbow portal and used to debride the ECRB tissue.
Fig 6As viewed through the proximal-anterior medial portal with the 30° arthroscope, the arthroscopic probe is shown, palpating the leading edge of the ECRB tendon, which has been released and resected from its origin on the lateral epicondyle.
After completion of ECRB release and debridement, the arthroscope is placed into the anterolateral tennis-elbow portal so as to identify any additional pathology that may be present on the medial aspect of the anterior compartment. The posterior compartment is also accessed and visualized in all patients. A posterocentral portal is placed in the midline through the triceps, and diagnostic arthroscopy is performed. The medial and lateral gutters are viewed, and any additional identified pathology is addressed as necessary. After completion of the procedure, the portal sites are sutured and a soft dressing is applied. Patients are allowed to use the arm without restriction immediately after surgery, and gentle range-of-motion and strengthening exercises are started 1 week postoperatively. Typically, physical therapy is continued for 4 to 8 weeks postoperatively.
Discussion
Management of patients with recalcitrant lateral epicondylitis can be challenging. Various open and arthroscopic surgical techniques have been described, and debate continues regarding the ideal surgical management in this patient population.
Given the lack of high-quality randomized controlled trials and the heterogeneity of operative techniques, surgical intervention should be reserved for patients in whom extensive, nonoperative management has failed.
One of the limitations of the described “bayonet” technique relates to the necessity to possess the surgical skills required to perform elbow arthroscopy safely and efficiently. Although arthroscopic techniques to examine and address elbow pathology date back to the early 1930s, elbow arthroscopy is still performed much less commonly than arthroscopy of the shoulder or knee.
Furthermore, some surgeons may choose to avoid elbow arthroscopy for lateral epicondylitis management because open surgical debridement for lateral epicondylitis is an established surgical treatment option.
documenting the outcomes and complications associated with a single surgeon's first 100 elbow arthroscopies, the risk of complications was only 5%, and all of these complications were considered minor. Additional studies have reported similarly low complication rates, with the risk of minor complications ranging from 5% to 12% and serious complication occurring in fewer than 1% of patients.
One of the potential benefits of the arthroscopic surgical approach is the ability to directly access the ECRB pathologic tissue intra-articularly, which affords the surgeon an opportunity to perform a thorough diagnostic arthroscopy of the entire elbow joint.
the incidence of associated capitellar and radial head articular cartilage abnormalities was 65% and 81%, respectively. Thus some patients with symptoms due to concomitant intra-articular pathology may not have all of their symptoms addressed using a conventional open operative technique.
However, the results comparing open versus arthroscopic surgical techniques have been mixed, with large systematic reviews failing to show the superiority of either technique.
The bayonet technique described in this article enables the surgeon to perform a very defined and controlled release of the ECRB tendon without the necessity for a 70° arthroscope or arthroscopic retractor. In addition, advancing the knife blade into the elbow joint while remaining immediately adjacent to the anterior cortical surface of the lateral humeral epicondyle helps ensure complete release of the pathologic tissue. This sharp release of the ECRB also facilitates subsequent arthroscopic debridement and excision of the tissue by providing for a leading edge of detached tendon to resect. No major complications such as deep infection or neurovascular injury have occurred using this technique since 2007.
When proper and careful technique is followed, arthroscopic ECRB debridement and release comprise a safe and efficacious surgical intervention for the management of recalcitrant lateral epicondylitis.
Pitfalls
1.
Posterior placement of the medial viewing portal will make viewing the lateral aspect of the radiocapitellar joint challenging. One can avoid this pitfall by ensuring that the portal is localized far enough anterior, in front of the medial intermuscular septum, and the angle of penetration into the capsule is obliquely oriented anterior to posterior.
2.
Anterior placement of the lateral tennis-elbow working portal will make it difficult to carry out release of the ECRB tendon from its attachment to the lateral epicondyle. One can avoid this pitfall by making the portal directly adjacent to the palpable anterior edge of the epicondyle and localizing under direct visualization with a spinal needle.
3.
Debridement posterior to the radiocapitellar equator may result in iatrogenic injury to the lateral collateral ligament complex.
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