Arthroscopic Treatment of Lateral Epicondylitis

Champ L. Baker Jr

Introduction

• The aim of treatment of extensor tendinosis is resection of damaged tissue, either directly through an open incision or through arthroscopic means.

• Arthroscopic technique allows the ability to view the tendon from inside after the capsule has been released and to make a precise resection.

• It also allows evaluation of the joint for any associated pathology that may be causing lateral elbow symptoms, such as plica or so-called snapping elbow, which may be the cause of the lateral elbow pain.

Indications

• Persistent lateral elbow pain for 6 months or longer unrelieved by conservative nonoperative treatment is the no. 1 indication for surgery.

• Previous treatment should have included active rest, therapy, stretching techniques, and other modalities. Invasive techniques might have included cortisone injections or even platelet-rich plasma (PRP) injections.

• Surgery generally is indicated if, after conservative treatment, the patient still complains of discomfort with the arm extended and has difficulty performing daily chores, such as shaking hands or retrieving a carton of milk from the refrigerator with the elbow extended.

• Approximately 80%-90% of patients with lateral elbow pain can be successfully treated nonoperatively. Patient Positioning/Anesthesia

• General anesthesia typically is used, although the procedure can be done with a regional block.

• General anesthesia allows more accurate assessment of the postoperative neurovascular status.

• Patient positioning may dictate which type of anesthesia is used.

• The patient can be positioned supine or prone (Figs. 25-1 and 25-2) or in the lateral decubitus position. The lateral decubitus and prone positions are preferred because of the security of the elbow and the ability to perform secondary procedures.

• The arm is padded, and a tourniquet is placed proximal to the elbow.

• If the patient is prone, the arm is held in an arm holder, which allows external and internal rotation for access to the extensor or flexor portion of the elbow if needed for a secondary procedure (Fig. 25-3).

• If a commercial arm holder is not available, any type of U-shaped bolster that will hold the arm in place can be used.

• After “time out,” the arm is prepared and draped.

• I prefer a seated position and am present when the draping is done so that the drape can be fastened to my gown to insure a complete sterile field both above and below the elbow.

Figure 25-1 | A. The tourniquet and arm holder should be placed as proximal as possible to allow easy joint access with instruments. B. Position done sitting with the protective drape.

Figure 25-2 | The ulnar nerve and is outlined and protected during establishment of the medial portal.

Figure 25-3 | The lateral portal is established from outside in using needle localization.

• Evaluation before the procedure should determine if the ulnar nerve is subluxing or if the patient has had previous elbow surgery.

• If the ulnar nerve subluxes, it needs only to be reduced and held with a thumb to insure its safety.

• If a previous utility incision has been made and the ulnar nerve has been moved, a skin incision is made to identify the nerve so that it can be protected during portal placement.

Portal Placement

• A proximal medial portal is typically used for viewing and a proximal lateral portal for instrumentation.

• The olecranon tip is marked initially. The radial epicondyle is marked laterally, then the soft spot and the medial epicondyle.

• A line is drawn indicating the location of the ulnar nerve and the intramuscular septum.

• Identifying the ulnar nerve and its location helps insure its safety during the procedure.

• The joint is distended with 25 cc of normal saline through the lateral soft-spot portal to provide more space for entry and help prevent iatrogenic injury to the articular surface.

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