Arthroscopic Treatment of Lateral Epicondylitis

Fig. 12.1

a Lateral view of cadaveric specimen. The ECRL has been reflected anteriorly (it has a purely muscular origin) and the extensor carpi ulnaris posteriorly revealing the common extensor tendon origin of the ECRB and EDC. These are indistinguishable when viewed from the outer surface. b The muscles and tendons have been reflected proximally. The origins of the ECRB anteriorly and the EDC posteriorly are identifiable on the undersurface of the extensor origin. Note the underlying lateral collateral ligament (probe) (Courtesy of Mark S. Cohen, Chicago, IL with permission.)

Fig. 12.2

a The EDC has been removed allowing better visualization of the bony ECRB origin on the humerus. b The ECRB footprint is identified with elevation of the tendon from the humerus (Courtesy of Mark S. Cohen, Chicago, IL with permission.)

Fig. 12.3

Schematic diagram depicting the relationship between the ECRB origin at the humerus and bony landmarks. Note that the ECRB footprint origin is diamond shaped and located between the midline of the joint and the top of the humeral capitellum beneath the most distal extent of the supracondylar ridge. The tendon does not originate on the epicondyle specifically. Note the relationship between the ECRB origin and the underlying lateral collateral ligament (Courtesy of Mark S. Cohen, Chicago, IL with permission.)

Technique

The patient is positioned in the lateral decubitus position with the arm supported and all bony prominences well padded. Regional anesthesia is favored by the authors. Bony landmarks are drawn out including the path of the ulnar nerve. Once the tourniquet is inflated, the elbow is insufflated with an 18-gauge needle introduced through the soft-spot of the elbow.

Next, a standard anteromedial portal is established (Fig. 12.4). This is started several centimeters proximal and anterior to the medial epicondyle and well anterior to the palpable intermuscular septum. Care is taken to slide along the anterior humerus and the joint is entered with a blunt introducer or a switching stick. This medial portal allows one to view the lateral joint including the radial head, capitellum, and the lateral capsule. It is often helpful at this point to open the inflow to allow distension of the capsule. If visualization is a problem, a retractor can be introduced through a proximal anterolateral portal 2–3 cm proximal and just anterior to the lateral supracondylar ridge. A simple Freer elevator is useful for this purpose. By tensioning the capsule anteriorly, improved visualization of the lateral capsule and soft tissues can be achieved.

Fig. 12.4

a Diagram depicting the medial portal used in visualization for the arthroscopic lateral epicondylar release. b Field of view from the medial portal. c Diagram depicting the relationship of the extensor tendon origins when viewed intraarticularly. These are located outside (behind) the elbow capsule. d Needle used to help establish a modified lateral portal. Note how this has begun slightly proximal and anterior to the proximal margin of the humeral capitellum. e Release of the capsule from the lateral humeral margin allowing visualization of the tendinous origins behind. The ECRL is more anteriorly located and is muscular. The ECRB is more posterior. f The ECRB is released from the top of the capitellum to the g midline of the radiocapitellar joint (Courtesy of Mark S. Cohen, Chicago, IL with permission.)

A modified anterolateral portal is established using an inside-out technique. This is started 2–3 centimeters above and anterior to the lateral epicondyle (Fig. 12.4). The portal is slightly more proximal than a standard anterolateral portal. This allows instrumentation down to the tendon origin rather than entering the joint through the ECRB tendon itself. If lateral synovitis is present, this can be debrided with a resector.

The capsule is released next. Occasionally in epicondylitis, one can find a disruption of the underlying capsule from the humerus (Fig. 12.5). Most commonly, the capsule is intact although small linear tears can be present (Fig. 12.6). We have found it easier to release the lateral soft tissues in layers using a monopolar thermal device. In this way, the capsule is first incised or released from the humerus. When it retracts distally, one can appreciate the ECRB tendon posteriorly and the ECRL, which is principally muscular, more anterior. As noted above, the ECRB tendon spans from the top of the capitellum to the midline of the radiocapitellar joint.

Fig. 12.5

Initial intraoperative view of a patient with recalcitrant lateral epicondylitis. Note the capsular disruption. In some cases, the capsule is noted to have torn away from its humeral origin (Courtesy of Mark S. Cohen, Chicago, IL with permission.)

Fig. 12.6

a Initial intraoperative view of a patient treated surgically for lateral epicondylitis. The lateral capsule obstructs the view of the extensor tendon origins. Note the small longitudinal rent in the capsule. b The capsule has been released revealing the muscular ECRL anteriorly and the tendinous ECRB more posteriorly. Note the capsular layer distally which is deep to the tendon. c The ECRB has been released. Behind this, one can see the muscular ECRL anteriorly and the extensor aponeurosis which lies behind the ECRB (asterisk). It is characteristically composed of longitudinally stripped tendinous fibers much less distinct than the ECRB. d Final close up view following ECRB release. One can see the thick ECRB origin which has retracted distally following release (Courtesy of Mark S. Cohen, Chicago, IL with permission.)

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