LATERAL EPICONDYLITIS (TENDINOSIS): OPEN DEBRIDEMENT AND REPAIR

Lateral Epicondylitis (Tendinosis)

Open Debridement and Repair

Robert P. Nirschl

Lateral epicondylitis as a term is a misnomer. The pathoanatomy does not primarily affect the lateral epicondyle, nor is the malady inflammatory. The primary histopathology is a degenerative process (angiofibroblastic tendinosis), invariably located in the extensor carpi radialis brevis (ECRB) tendon and, to statistical less degree (35%), in the extensor digitorum communis (EDC) tendon. Associated pathoanatomy may include bony exostosis at the anteromedial tip of the lateral epicondyle (20%) and intraarticular abnormalities such as synovitis, plica, and chondromalacia (5%).

The hallmark of nonoperative rehabilitative treatment is to revitalize the abnormal tendinosis tissue with the biological goal of neovascularization, fibroblastic infiltration with collagen production, and the restoration of strength, endurance, and flexibility.

Indications

Failure of a quality rehabilitative program. Note: The comfort treatment of rest, nonsteroidal anti-inflammatory drugs, or cortisone injection does not constitute a quality or meaningful rehabilitative program.

Contraindications

General systemic surgical contraindications. No specific local contraindications other than infection.

Mechanisms of Injury

Repetitive overuse such as tennis or carpentry is the classical mechanism of injury. The average age of onset is 42 years. Hereditarial predisposition may be a contributing factor. A direct blow to, or repetitive needling about, the lateral epicondyle may result in an associated reactive bony exostosis. Iatrogenic cortisone atrophy of adjacent skin and subcutaneous tissue may be a complicating factor.

Physical Examination

1. Tenderness directly over ECRB and EDC

2. No tenderness over the lateral epicondyle unless there is an associated bony exostosis or iatrogenic cortisone atrophy

3. ECRB and EDC origin pain with provocative stress testing of wrist and finger extension

Diagnostic Tests

Anteroposterior and lateral X-rays are obtained to rule out intraarticular abnormality or lateral epicondyle exostosis.

Special Considerations

Patients may have associated medial elbow tendinosis and ulnar nerve neuropraxia secondary to compression in zone 3 of the medial epicondylar groove. If present, a combined surgical intervention of resection and repair of the medial elbow and decompression of the ulnar nerve may be in order.

If associated lateral abnormalities are present (bony exostosis, skin atrophy, or intraarticular disorders), additional surgical intervention is indicated, such as excision of the exostosis, rotational fat graft over the epicondyle, or arthrotomy with joint debridement.

Preoperative Planning and Timing of Surgery

1. There is no medical urgency for surgical intervention. Surgical success is not altered if symptoms are chronic, provided intervening iatrogenic treatment harm such as atrophy from repetitive cortisone injections has not occurred.

2. The goal of surgery is to identify and excise the pathoanatomical tendinosis without weakening the force generator (which occurs with ill-advised release techniques).

Special Instruments

A power drill is helpful to drill cortical bone.

Anesthetic Options

1. General anesthesia.

2. Axillary block.

3. Bier block. This may be less desirable as identification of the tendinosis pathoanatomy may be obscured by edema from the anesthetic.

Patient and Equipment Position

1. Supine position.

2. The forearm and arm are prepped with the arm draped free.

3. A tourniquet is elevated to 100 mm Hg over the systolic blood pressure.

4. A standard hand-arm board is used.

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