Arthroscopic Treatment of Lateral Epicondylitis

Arthroscopic Treatment of Lateral Epicondylitis

Christian Lattermann, Anthony A. Romeo, Brian J. Cole and D. Jeff Covell

Chapter Synopsis

• Lateral epicondylitis refractory to conservative management may benefit from arthroscopic release of the extensor carpi radialis brevis (ECRB) origin. This more recently described technique offers the benefit of direct visualization of the pathologic process, addresses concomitant intra-articular disease, is minimally invasive, and is well tolerated by patients. This chapter discusses the approach, relevant anatomy, and technique for arthroscopic release of the ECRB tendon, as well as postoperative management and outcomes.

Important Points

• Debridement is indicated for patients refractory to conservative therapy who have no contraindications to elbow arthroscopy.

• The ECRB tendon inserts on the superior aspect of the capitellum and extends distally to the midline of the radiocapitellar joint.

• Care must be taken during debridement to avoid accidental resection of the lateral collateral ligament and extensor digitorum communis.

Clinical and Surgical Pearls

• In case of a capacious anterior capsule that tends to obstruct viewing from the medial portal, a small key elevator can be inserted through a high anterolateral accessory portal to elevate the anterolateral capsule, greatly enhancing visualization from the medial portal.

Clinical and Surgical Pitfalls

• The resection of the capsule and the ECRB should not extend farther distally than the midline of the radiocapitellar joint. Resection past this landmark puts the lateral collateral ligament at risk.

• Once the debridement of the ECRB has been performed, do not debride the extensor digitorum communis. Debridement of the extensor digitorum communis and extensor aponeurosis can result in synovial fistula.

Lateral epicondylitis is a well-known musculoskeletal phenomenon that can occur after minor trauma or chronic overuse. In general, lateral epicondylitis responds well to nonoperative management, including activity modification, counterforce bracing, physical therapy, and corticosteroid injections. A relatively small number of patients, however, have refractory symptoms. In such situations an operative procedure may be warranted. Many different operative techniques have been developed for the treatment of lateral epicondylitis. The goal of this chapter is to describe a more recent technique—arthroscopic extensor carpi radialis brevis (ECRB) release. We believe that this technique is advantageous because it offers direct visualization of the pathologic process, enables the surgeon to concomitantly address intra-articular disease, and is minimally invasive in nature and thus well tolerated by the patient.

Preoperative Considerations

Typical History

• Traumatic onset (usually minor trauma) aggravated by repetitive motion.

• Insidious onset—chronic repetitive wrist and elbow motion at work or recreationally.

• Tenderness directly over the origin of the ECRB on the lateral epicondyle.

• Aggravation of symptoms with active resisted wrist extension and passive wrist flexion.

• Often previously treated with nonoperative measures.

• Pain with range of motion of the elbow and clicking may point to associated joint disease.

Physical Examination

Factors Affecting Surgical Indication

• Range of motion—should be normal

• Clicking with range of motion (synovial plica)

• Effusion (intra-articular disease)

Factors Affecting Surgical Planning

• Previous ulnar nerve transposition

• Ulnohumeral or radiocapitellar arthritis

• Previous distal humerus or olecranon fracture

It is important to perform a thorough neurovascular examination to rule out entrapment of the posterior interosseous nerve, subluxation of the ulnar nerve, or degenerative changes in the radiocapitellar joint.

Imaging

• Anteroposterior view of the elbow in full extension

• Lateral view of the elbow in 90 degrees of flexion

Optional Views:

• Axial view to outline the olecranon and its articulations

• Radial head view

Other Modalities

• Magnetic resonance imaging with or without the administration of gadolinium

Magnetic resonance imaging will demonstrate degenerative changes in the origin of the ECRB; it may show a synovial plica in the radiocapitellar joint when it is performed with the administration of contrast material. Visualization of loose bodies is generally better with magnetic resonance images than with plain radiographs, which will display loose bodies in only 25% of patients.

Indications and Contraindications

The ideal patient has localized symptoms directly anterior and inferior to the lateral epicondyle at the origin of the ECRB and has full range of motion. Conservative treatment options have failed.

Contraindications are those generally associated with elbow arthroscopy. These include significant alterations of the normal bone anatomy, previous placement of hardware, ankylosis of the elbow joint, acute or chronic soft tissue infections, and osteomyelitis of the elbow.

Surgical Technique

Anesthesia and Positioning

The patient is placed in the supine, prone, or lateral decubitus position, according to the surgeon’s preference for elbow arthroscopy. The procedure can be performed with the patient under general anesthesia or with regional block with simple sedation. However, some patients may not tolerate the prone position under sedation alone because of unrelated issues, such as shoulder pain in the ipsilateral or contralateral shoulder.

The patient is positioned prone with the arm hanging over the side in 90 degrees of abduction and neutral rotation (Fig. 45-1). Care needs to be taken that the arm is not abducted more than 90 degrees and that the shoulder is not hyperextended, to minimize the risk of neurovascular complications. A nonsterile tourniquet is used with inflation pressures of 200 to 250 mm Hg according to the size of the arm and systolic blood pressure. The procedure can be performed with the surgeon either standing or seated, and the operating table is adjusted accordingly.

Figure 45-1 Patient in the prone position. Note that the arm is hanging down, thus avoiding hyperextension of the shoulder.

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Tags: Surgical Techniques of the Shoulder Elbow and Knee in Sports

Sep 11, 2016 | Posted by admin in SPORT MEDICINE | Comments Off

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