Open Treatment of Lateral Epicondylitis

Murphy M. Steiner

James H. Calandruccio

Preoperative Evaluation

• Before surgery is considered, conservative treatment measures, consisting of physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), counterforce bracing, activity modification, ultrasound, and other modalities, should be exhausted.

• All patients scheduled for surgery for lateral epicondylitis should be evaluated for concomitant radial tunnel syndrome, which may be present in up to 5% of patients.

• Anteroposterior and lateral radiographs of the affected elbow should be obtained before surgery to rule out fractures and arthritis (Fig. 26-1). A radiocapitellar view may show concomitant radiocapitellar changes more clearly.

Figure 26-1 | Anteroposterior radiograph demonstrating calcifications of the common extensor tendon origin in a patient with lateral epicondylitis.

• MRI of the elbow may be beneficial for documenting tendinosis or tears of the common extensor tendon (Fig. 26-2), although MRI is not necessary for diagnosis.

Figure 26-2 | MRI of the elbow demonstrating tendinosis of the common extensor origin in a patient with lateral epicondylitis.

Operative Anatomy

• Lateral epicondylitis or “tennis elbow” is a degenerative condition isolated to the extensor carpi radialis brevis (ECRB) tendon origin, although other parts of the common extensor origin may be involved (Fig. 26-3).

Figure 26-3 | The extensor radialis brevis (ECRB) originates from the lateral epicondyle on the distal humerus. The origin of the extensor radialis longus (ECRL) is proximal to the ECRB on the supracondylar ridge. The extensor digitorum communis (EDC) origin borders the ECRB origin distally.

• Repetitive stress on the lateral epicondylar tendon origin(s) causes microtears of the tendon, and an incomplete reparative process leads to angiofibroblastic hyperplasia. A paucity of acute inflammatory cells has led some to suggest that epicondylitis should be redefined as epicondylosis.

• It is important to preserve the lateral ulnar collateral ligament (LUCL), which lies deep and posterior to the ECRB (Fig. 26-4).

Figure 26-4 | The lateral ulnar collateral ligament (LUCL) originates from the lateral epicondyle and inserts on the supinator crest of the proximal ulna. This structure must be preserved to prevent posterolateral elbow rotatory instability.

Sterile Instruments/Equipment

• Tourniquet

• Stockinette

• Hand table

• Bipolar cautery

• No. 15 scalpel

• Freer elevator

• Small rongeur

Positioning

• The patient should be positioned supine on a stretcher or operating table with an attached hand table.

• If a nonsterile tourniquet is used, it should be placed as close to the axilla as possible to avoid interference with the operative field.

Surgical Approach

• It is helpful to palpate the bony prominences of the lateral elbow (lateral epicondyle, radial head, capitellum, and olecranon) for orientation.

• A 3- to 5-cm skin incision is made centered over the lateral epicondylar prominence. The incision should be extended proximally toward the supracondylar ridge and distally in line with and parallel to the extensor tendon fibers (Fig. 26-5).

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