Open Treatment of Medial and Lateral Epicondylitis

Champ L. Baker III, MD

John Akins, MD

Champ L. Baker Jr, MD

Dr. Champ L. Baker, III or an immediate family member has stock or stock options held in Arthrex. Dr. Champ L. Baker, Jr, or an immediate family member has received royalties from Arthrex; serves as an unpaid consultant to Arthrex and Smith & Nephew; and has stock or stock options held in Arthrex. Neither Dr. Akins nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

PATIENT SELECTION

Lateral and medial epicondylitis are common elbow conditions that cause pain, local tenderness, and limitations of activity. Most of these conditions can be managed successfully with nonsurgical treatment. Surgical intervention is reserved for patients with persistent symptoms and disability despite appropriate nonsurgical management of a minimum of 6 months’ duration.

When considering surgical treatment of lateral epicondylitis, the surgeon should take care to differentiate this condition from other causes of lateral elbow pain, such as cervical radiculopathy, radial tunnel syndrome, posterolateral impingement, posterolateral rotatory instability, or radiocapitellar arthrosis, which require different treatment. For medial epicondylitis, the surgeon must examine the patient for associated ulnar neuritis and must consider other conditions causing medial elbow pain, such as attenuation of the ulnar collateral ligament with resultant instability or flexor pronator muscle ruptures.

Open, percutaneous, and, more recently, arthroscopic techniques have all been proven successful in the surgical management of recalcitrant epicondylitis.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸ This chapter presents open treatment of lateral and medial epicondylitis.

PREOPERATIVE IMAGING

Lateral and medial epicondylitis are clinical diagnoses. However, imaging may provide additional information and may be useful to rule out other conditions. Plain radiographs can demonstrate calcifications about the epicondyle in approximately 20% of patients. MRI is useful to evaluate for intra-articular pathology, assess the collateral ligaments, and determine the extent of tearing of the extensor or flexor pronator origin.⁹ Increased signal intensity on T2-weighted images may be seen in the extensor carpi radialis brevis (ECRB) tendon origin or the common flexor origin (Figure 1).

PROCEDURE

Room Setup/Patient Positioning

The operating room setup is essentially the same for open treatment of lateral or medial epicondylitis. General anesthesia is preferred as long as patient comorbidities permit. Regional anesthesia can be used if needed but may not allow for an appropriate postoperative neurologic examination.

The patient is positioned supine on the operating table with the surgical arm placed on an arm board. A tourniquet is applied to the upper arm as high as possible. Standard sterile draping techniques are used. The hand and lower arm can be covered with a stockinette, although the entire upper extremity from fingertips to upper arm is prepped.

Special Instruments/Equipment/Implants

No special equipment or implants are required for the open treatment of lateral or medial epicondylitis. For surgeons who prefer to drill the epicondyle to stimulate a
healing response, a 0.062-inch Kirschner wire or a 5/64-inch drill bit can be used.

FIGURE 1 T2-weighted sagittal short-tau inversion recovery MRI of the elbow demonstrates medial epicondylitis. Note the increased signal intensity in the flexor pronator origin.

Surgical Technique

Lateral Epicondylitis

The lateral epicondyle is palpated and outlined on the skin. An incision of approximately 4 cm is made anteromedial to the epicondyle (Figure 2, A). The subcutaneous tissues are divided to the level of the deep fascia overlying the extensor tendons. The interface between the extensor carpi radialis longus (ECRL) and the extensor digitorum communis (EDC) is identified. This interface is split superficially to a depth of 2 to 3 mm (Figure 2, B). The ECRL is then separated from the underlying ECRB by scalpel dissection and is retracted anteriorly. The ECRB tendon origin is now readily visible. The pathologic angiofibroblastic tendinosis tissue is apparent by its dull, gray, friable appearance. All abnormal tissue is sharply excised en bloc with a scalpel (Figure 2, C). Using what is known as the Nirschl scratch test, the surgeon uses a scalpel to scrape away the remaining abnormal edematous tendinosis tissue, which peels off while leaving the healthy tendon intact.⁴^,⁵ A drill or rongeur is used on the lateral condyle to enhance the vascular supply (Figure 2, D). The ECRL and EDC (extensor digitorum communis) aponeurosis is reapproximated with a running No. 1 absorbable suture (Figure 2, E). The subcutaneous tissues and skin are closed in a routine fashion. A well-padded posterior splint is applied with the elbow flexed to 90°.

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