Phase I
Mild pain after exercise activity, resolves within 24 h
Phase II
Pain after exercise activity, exceeds 48 h, resolves with warm-up
Phase III
Pain with exercise activity that does not alter activity
Phase IV
Pain with exercise activity that alters activity
Phase V
Pain caused by heavy activities of daily living
Phase VI
Intermittent pain at rest that does not disturb sleep
Pain caused by light activities of daily living
Phase VII
Constant rest pain (dull aching) and pain that disturbs sleep
The contraindications to surgical intervention include an inadequate nonoperative program [4]; and patients who have demonstrated lack of compliance with the recommendations, particularly that of activity modification. Individuals on worker’s compensation disability should be assessed on several occasions to assure that the above indications have been met.
Preoperative Planning
Physical findings include local tenderness to palpation over the tendon origin at the epicondyle. Provocative tests of pain with resisted wrist extension for lateral involvement are invariably positive especially with the elbow in full extension. In some cases the symptoms may be aggravated by performing the test with the elbow in 90° flexion (a sign indicating substantial tendinosis) [1, 4]. If forearm pain is a component (which is unusual), examine for posterior interosseous nerve irritation (an independent malady) [6]. The most sensitive test is pain on resistive supination [7].
The most commonly involved tissue, the pathological process, and the principles of the surgical intervention should be reviewed prior to undertaking the surgical procedure [8].
The hallmarks of good surgical concept and technique include precise identification of the pathologic tissue, resection of all involved pathology, maintenance of normal tissue attachments, protection of normal tissue, enhancement of vascular supply, firm repair of the operative site, and quality postoperative rehabilitation.
Kraushaar and Nirschl have now defined the histopathology in precise detail utilizing the methods of electron microscopy and histoimmunochemistry [1]. The ECRB and the anterior edge of the EDC are the tissues most commonly involved laterally (100 % and ~ 35 %, respectively) [9−12]. Histologically, the pathological tissue is devoid of inflammatory cells, but has a characteristic pattern of immature fibroblasts and vascular elements (Fig. 11.1a, b) [1, 13]. Recent electron microscopic evidence reveals lack of extracellular cross-linkage (Fig. 11.2a, b, c) [11]. The recommended surgical technique specifically focuses on demonstrated pathoanatomy. It should be noted that although the classical case, in our experience, is angiofibroblastic tendinosis in the ECRB; the anteromedial edge of the EDC origin has concomitant pathology in 35 % of cases and when present, should be addressed (Fig. 11.3). Additional pathologies include bony exostosis of the lateral epicondyle in 20 % of cases, and anterolateral compartment intraarticular pathology such as synovitis, plica, and chondromalacia (5 %) [14].
Fig. 11.1
a Histology of lateral extensor tendinopathy. Note the predominance of giant cells and monocytes, and the absence of neutrophils. b Cross-section of extensor carpi radialis brevis, with abnormal tissue pictured above, compared to normal tissue
Fig. 11.2
a–c Transmission electron microscopy of the extensor tendon origin showing discontinuity of fibers and lack of cross-linkage seen in normal tendon
Fig. 11.3
Pathology is often seen both at the ECRB and EDC origin
Intraarticular changes as noted above have also been observed with the advent of elbow arthroscopy as a therapeutic tool. Today we specifically assess by clinical exam and imaging studies, the possibility of any symptom producing intraarticular elements (5 % in our experience) and proceed accordingly with possible arthroscopy or limited arthrotomy in such cases [3, 15, 16].
Surgery for Lateral Tendinosis
The described technique and illustrations apply for the large majority of cases. It should be noted, however, that individual variations can and do occur. In these instances, the pathological variations should be addressed as presented.
The data on arthroscopic debridement are incomplete at this time to draw a conclusion or to recommend this treatment with the exception of clearly identified symptoms producing intraarticular issues [1]. For the typical extraarticular symptomatology, there is no advantage of arthroscopy over our described mini-open technique [16]. Disadvantages of arthroscopy include increased risk to nerves and joint surfaces plus increased costs of OR time and instrumentation. More importantly, the excision of pain producing tendinosis tissue may be incomplete [17].
Technique
After anesthesia (general or arm block) is induced, a tourniquet is applied and the arm is draped free and placed on an arm board.
The incision extends proximal and just anteromedial to the lateral epicondyle for 2 to 3 cm down to the level just proximal to the joint (i.e., 1 cm distal to the epicondyle) (Fig. 11.4). It is important to place the incision accurately so as not to compromise the identification of the extensor carpi radialis longus (ECRL)-EDC interface at the deeper level. The subcutaneous tissue and superficial fascia are incised and retracted, locating the interface between the ECRL and the firm anterior edge of the extensor aponeurosis of the EDC. A palpable crevice is present at this interface as the fascia over the ECRL is thin and the anterior edge of the aponeurosis is firm and thick. A splitting incision 1 to 2 mm in depth is made between the ECRL and the extensor aponeurosis in the identified interface extending from 1 cm proximal to the lateral epicondyle distally to the level just proximal to the joint line. The ECRL is undermined with sharp dissection and retracted anteromedially approximately 1.5 cm. This retraction brings the ECRB, under the ECRL, into direct view (Fig. 11.5) [3, 18].
Fig. 11.4
The standard skin incision is approximately 4 cm extending 1–2 cm proximal and just anterior to the lateral epicondyle distally 1–2 cm to the level of the elbow joint and carried further distally 1 cm if the joint is explored. The circled area identifies the lateral epicondyle
Fig. 11.5
An incision in the extensor longus aponeurosis interface with anteromedial retraction of extensor longus exposes the patholgoical origin of the extensor brevis. A key technical point is not to incise too deeply but more medially as the extensor longus is only 2–3 mm in depth at this level
Technical note: A common error in the incision at the ECRL interface is to penetrate too deeply by vertical dissection. As noted, the extensor longus is only 1 to 2 mm thick at this region. Once the 1 to 2 mm depth is reached, the dissection is primarily horizontal progressing medially. This technical subtlety is important to avoid iatrogenic distortion as well as confusing the identification of the ECRB tendon. Such iatrogenic distortion can easily complicate the identification of the pathological tendinosis tissue in the ECRB origin.
With proper case selection and appropriate exposure, the entire origin of the ECRB is easily identified. The gross appearance of the pathological tendinosis change is most often a dull-grayish tissue, which is typically edematous and friable, and, on occasion, ruptured (Figs. 11.6, 11.7, 11.8a). Normal tendon tissue in contrast is shiny, firm, and has a slightly yellowish-white hue. The pathological tissue often encompasses the entire origin of the ECRB, and in our series, the anterior 10 % edge of the extensor aponeurosis is abnormal in approximately 35 % of cases [6, 16] (Fig. 11.7).
Fig. 11.6
Exposure for resection of pathological tissue. In this rendering, 100 % of the origin is involved and a partial rupture is depicted. In no circumstance is the extensor aponeurosis totally released from the epicondyle
Fig. 11.7
Surgical photograph of resection of pathological extensor brevis origin shows major tendinosis with an underside rupture. Note a small strip of normal tendon at the edge of the extensor longus muscle. The remaining pathological alteration has a dull-grayish edematous gross appearance typical of angiofibroblastic tendinosis
Fig. 11.8
a Degenerated extensor brevis origin. b Resection specimen of ECRB origin
Excision of all pathological tissue at the ECRB origin is performed en bloc. This tissue block is somewhat triangular in shape with the base distal. The typical size of the tissue excised is 2 × 1 cm (Fig. 11.8b). It should be noted that in this dissection, the brevis origin is released from the lateral epicondyle and the anterior edge of the extensor aponeurosis. If the anterior aponeurosis has pathological alteration, the pathological tissue is also removed (but not normal tendon). Release of the normal EDC aponeurosis from the epicondyle is unnecessary, potentially harmful, and should be avoided.
Pathological tissue in the EDC and ECRB is easily identified by its visual appearance and confirmed by the “Nirschl scratch test” (Fig. 11.9) [3, 16]. This makes use of the friability of pathological tissue, which easily peels off by utilizing a vigorous scratching motion with the scalpel. When healthy tissue is reached, it no longer peels off with the scratching motion. This technique is especially helpful when removing the pathological changes in the anterior edge of the aponeurosis. The scratching technique should be vigorous to remove all pathological tissue.
Fig. 11.9
Demonstration of “scratch test.” A scalpel edge is used to scrape off degenerated friable tissue
In the 20 % of cases that present with an exostosis or prominence of the lateral epicondyle, the proximal anteromedial edge of the EDC aponeurosis is temporarily peeled off the epicondyle for adequate exposure and the exostosis removed by rongeur and smoothed by a rasp. When this does occur, the exostosis usually occupies about 15 % of the anteromedial edge of the epicondyle (not the entire epicondyle). Thus the majority of the epicondyle and aponeurosis attachment is left undisturbed. We believe that it is unnecessary and contraindicated to do further epicondylar resection.
Once the pathological tissue is adequately resected, a defect is present in the area of the ECRB tendon origin. The more distal aspect of the extensor brevis is still attached to the orbicular ligament, distal anterior aponeurosis, and underside of the ECRL. The ECRB, therefore, does not retract distally to any appreciable degree, thereby maintaining an essentially normal working length of the entire extensor muscle-tendon unit (i.e., from elbow to wrist). It is therefore not necessary to reattach the remaining brevis with sutures or a bone anchor. The goal of the operation is resection of all pathological tissue, not tendon release (e.g. the common expression of describing the operation as a tendon release operation is erroneous). It is to be emphasized that all normal tendon attachments are not disturbed and not released.
In the 5 % of cases whose preoperative evaluation indicates intraarticular abnormality, a small synovial opening may be made at this time to inspect the anterolateral joint compartment. This can be easily accomplished by extending the incision distally 5–10 mm [1]. Unless the patient presents with clear intraarticular signs and symptoms preoperatively, it is rare to find intraarticular changes, and the arthrotomy incision is therefore, in the majority of cases, unnecessary and not recommended.
To enhance vascular supply, one small hole is drilled through the cortical bone in the area of ECRB resection (not the epicondyle) (Fig. 11.10). This technique is theorized to encourage rapid replacement of this ECRB resection tissue void with healthy fibrotendinous tissue.
Fig. 11.10
The cortical region distal to epicindyle is drilled to increase blood supply
The interface between the posterior edge of the ECRL and the remaining anterior edge of the extensor aponeurosis is now firmly closed (Fig. 11.11). Current choice is an absorbable number 1 polydioxanone suture (PDS). It is unnecessary to suture the distal ECRB, since a firm attachment is retained to the orbicular ligament, distal aponeurosis, and underside of ECRL distally. The anterior medial edge of the extensor aponeurosis is therefore firmly repaired to the ECRL. In thin patients, place the knots deeply or use a polyglactin (Vicryl) suture. Since the proximal attachment of the EDC is largely undisturbed, rapid mobilization postoperatively is possible and encouraged. The subcutaneous layer is closed in routine fashion by the subcuticular skin technique with absorbable suture. The author’s preference is 2–0 or 3–0 poliglycaprone (Monocryl) supported by adhesive skin strips.
Fig. 11.11
Repair of tendon interface. In all cases the interface between the extensor longus and the extensor aponeurosis is firmly closed. It is theorized that blood clot transformed to biologically healthy fibrous tissue (painless) replaces the proximal defect of the resected area further reinforcing the security of the ultimate brevis origin
New Technique & Technology
Recent ultrasound treatment technology utilizing the above principles of tendinosis pathology identification and excision is on the horizon. The concept is to emulsify tendinosis tissue by a specifically designed high frequency ultrasound probe. The first published article of 20 cases, although preliminary, appears promising. Further investigation and long-term follow-up are indicated [19].
Postoperative Management
The arm is placed in an elbow immobilizer with four Velcro straps (Fig. 11.12). The joint is then immobilized for 2 days at 90° flexion, the forearm is in neutral, and the wrist and hand are free. Motion exercises are usually started within 48 h postoperatively.
Fig. 11.12
Light elbow immobilizer with Velcro straps provides comfortable support in the immediate postoperative period. Motion exercises are usually started 48 h postoperative but intermittent immobilizer protection is usually maintained for 6 to 7 days (Courtesy of Medical Sports Inc.)
Intermittent immobilizer protection is usually maintained intermittently for another 3–4 days, at which time normal activities of daily living are resumed. Counterforce support (forearm band) [20] providing protective function is utilized until full forearm strength returns (usually 3–6 months). The brace is used at times of rehabilitation exercise and more vigorous forearm activities such as heavier household activities. A gradual return to sports often is initiated at 4–6 weeks with brace protection. Participation in more intensive sports, particularly competitive athletics such as tennis [21], usually takes 3–5 months.
Results
We have shown that with the described lateral side surgery, 97 % of patients can expect improvement and 93 % of patients can expect full return of all prior activities [21]. In 3 % no improvement is observed. Thus, less than 3 % of patients are considered failures. Success with other techniques has been reported, with 85 to 90 % response rates [9, 10, 12, 15].
Complications and Surgical Failure
The most frequent complication after surgery for lateral tennis elbow is residual pain. This is not common with the technique described above. When pain after surgery is present, a logical analysis is conducted and the following determinations must be considered [22]:
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