LATERAL EPICONDYLE RELEASE: ARTHROSCOPIC APPROACH

Lateral Epicondyle Release

Arthroscopic Approach

Champ L. Baker and Jeffrey A. Dlabach

Lateral epicondylitis, or “tennis elbow,” is a repetitive use injury of the common extensor origin, specifically the extensor carpi radialis brevis (ECRB) tendon. Symptoms can be debilitating and may lead to significant loss of function. Nonoperative treatment is successful in most patients. Surgical treatment is reserved for patients whose symptoms persist despite 6 months of nonoperative care. The most widely accepted surgical procedure involves an open debridement of the pathologic tendon and décortication of the lateral epicondyle. The arthroscopic technique is analogous to the open procedure. The arthroscopic release, however, allows the pathoanatomy of the ECRB tendon and capsule to be addressed without disruption of the common extensor origin. The extent of injury to the ECRB tendon can be classified arthroscopically into three types: type I with an intact capsule, type II with linear tears of the undersurface of the tendon, and type III with complete tears of the tendon and overlying capsule. Arthroscopic treatment of lateral epicondylitis is effective and has a success rate equal to that of the open procedure. Arthroscopic release is less traumatic, allows for treatment of concomitant elbow disorders, and results in a quicker return to function than the traditional open technique.

Indications

Persistent pain and dysfunction related to lateral epicondylitis for 6 months despite nonoperative treatment.

Contraindications

1. Previous ulnar nerve transposition

2. Local infection

3. Severe ankylosis

Mechanism of Injury

Repetitive microtrauma (strain) to the common extensor origin results in tendinosis of the ECRB tendon. Overuse leads to microscopic tears and eventual rupture of the ECRB tendon.

Physical Examination

1. Tenderness of the common extensor origin at the lateral epicondyle

2. Pain with resisted wrist extension

3. Wrist extensor weakness

4. Pain with passive wrist palmar flexion

Diagnostic Tests

1. Anteroposterior, lateral, and axial radiographic views of the elbow are taken. Soft tissue calcification may be seen in patients with a history of multiple steroid injections.

2. Computed tomography and magnetic resonance imaging may be needed to exclude other disorders if the diagnosis is in question.

Special Considerations

Lateral compartment degenerative disease, posterior interosseous nerve syndrome, and posterolateral rotatory instability can mimic lateral epicondylitis. These entities can be excluded with a thorough physical examination and appropriate tests if the diagnosis is uncertain. Concomitant elbow pathology is not uncommon. The most common findings are loose bodies, osteophytes, and synovitis.

Preoperative Planning and Timing of Surgery

Surgical intervention should be considered in patients with refractory symptoms after 6 months of nonoperative treatment. Documentation of preoperative neurovascular examination and the presence or absence of ulnar nerve subluxation with range of motion is imperative.

Special Instruments

1. 4.0 or 2.7 mm, 30-degree arthroscope (Smith & Nephew Dyonics, An-dover, MA)

2. Flow pump (Smith & Nephew Dyonics, Andover, MA)

3. Arm holder (Arthrex, Inc., Naples, FL)

4. 3.5 mm full-radius resector (Smith & Nephew Dyonics, Andover, MA)

5. 2.3 mm, 35-degree bipolar (ArthroCare Corp., Sunnyvale, CA) or 60-degree monopolar (Oratec Interventions, Inc., Menlo Park, CA) radio-frequency probe.

6. Tourniquet

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