Arthroscopy remains a viable, reliable method for treating lateral epicondylitis

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During the last decade, clinical and basic scientific research has shown that recalcitrant lateral epicondylitis can be successfully and reproducibly treated with arthroscopy.

Cadaveric studies have helped surgeons to identify key anatomic landmarks and the bony origin of the extensor carpi radialis brevis (ECRB), thus increasing the safety of the technique of arthroscopic resection. Previous investigators have published results showing that resection of all gross or histological pathological tissue can be accomplished arthroscopically, and that patients report significant improvement in symptoms of lateral epicondylitis. Published long-term studies have shown arthroscopic resection of the ECRB to be safe and effective.

We present a four-step technique, also described by the orthopedic surgeons at Rush University Medical Center, for arthroscopic release of the ECRB: 1) identification of the pathology via diagnostic arthroscopy; 2) resection of the capsule to expose the ECRB and the extensor communis radius longus (ECRL); 3) resection of the ECRB between the longus and the lateral epicondyle taking care to stay above the mid-portion of the radiocapitellar joint to avoid injury to the lateral collateral ligament and extension proximal to the origin of the extensor communis; and 4) decortication of the origin of the ECRB is left to the discretion of the surgeon.

Prone position preferred

Surgery can be done with the patient in the supine, lateral decubitus or prone position. We prefer the prone position using a proximal medial portal for visualization. We use the proximal medial portal for visualization and a proximal lateral portal as the operative portal (Figure 1). If needed, an accessory superior lateral portal can be used for retraction.

Figure 1. The arthroscope is placed in the medial portal, and the lateral portal is used as the operative portal.

Figure 2. The surgeon establishes the medial portal. Images: Baker Jr. CL

After the joint is distended with fluid via the direct lateral portal, a proximal medial portal is established using a nick-and-spread technique (Figure 2). Diagnostic arthroscopy then determines the pathology (i.e., the classification of the tear and any associated radiocapitellar chondromalacia, loose bodies, or significant hypertrophy or thickening of the annular ligament or plica of the elbow).

Figure 3a. With the scope in the medial portal, an “outside-in” needle technique is used to localize the lateral portal.

Figure 3b. The needle localizes the portal.

Next, an outside-in needle technique is used to establish the anterolateral portal (Figure 3a). A needle localizes the area (Figure 3b), and a scalpel is used to make a small skin and capsular incision for insertion of a small cannula and trocar (Figures 4a and 4b). To prevent fluid extravasation, we use a cannula with no side portals.

Figure 4a. A trocar is used to establish the lateral portal.

Figure 4b. The cannula is depicted in the joint.

Capsular debridement

The capsule is debrided proximally to distally (Figure 5). Care is taken not to enter the anterior capsule so as to avoid damage to the radial nerve, which lies anterior to it. The capsular release is done primarily for exposure of the ECRB. Studies have shown that the tendon is contiguous with the ECRB against the capsule.

We have found the best means of resecting the ECRB is with a radiofrequency probe and our preference is to use a small 2-0 60°-angled monopolar ablator, although other devices can be used (Figure 6). We have used shavers and cutters in the past, but the angle is too difficult to resect the thickening from the fibrotic tissue. Studies have shown that staying superior to the superior half of the diameter of the radial head keeps the lateral collateral ligament out of harm’s way. A 70°-angled scope can be used for visualization “around the corner,” but we do not believe this is necessary.

Figure 5. The shaver is used to debride the capsule.

Figure 6. A radiofrequency probe is then used to resect the ECRB tissue.

The tissue to be resected lies between the bony lateral epicondyle and the fascia of the ECRL and extensor digitorum communis that is easily seen (Figures 7a and 7b). It is resected and lifted distally all the way to proximal.

Figure 7a. An angled scope is used to visualize the exposed ECRL and ECRB.

Figure 7b. The completed resection of the ECRB is shown.

No muscle-splitting incision

If the surgeon decides to decorticate, a small burr or shaver can be used at this time. In our experience, results with or without decortication are similar and, therefore, we no longer routinely perform decortication.

The advantage of arthroscopic evaluation of the elbow for release of the ECRB is that it eliminates a muscle splitting incision. The recovery is quicker, and patients have been shown to return to work and sports in a shorter period of time. Another advantage of the arthroscopic vs. open technique is the ability to see inside the joint and look for associated surgical pathology. Oftentimes, in a typical patient with tennis elbow, the culprit is the thickened annular ligament or a plica of the elbow that would not have been seen if the joint was not entered.

We have found this procedure can be performed by any competent elbow arthroscopist with a short learning curve. The portals are safe. The debridement is straightforward, and there are now 10 years of follow-up results equal to those of open surgery.

References:

• Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: Two-year clinical results. J Shoulder Elbow Surg. 2000;9:475-482.
• Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008;36:254-260.
• Cohen MS, Romeo AA, Hennigan SP, Gordon M. Lateral epicondylitis: Anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment. J Shoulder Elbow Surg. 2008;17:954-960.
• Cummins CA. Lateral epicondylitis: In vivo assessment of arthroscopic debridement and correlation with patient outcomes. Am J Sports Med. 2006;34:1486-1491.
• Kuklo TR, Taylor KF, Murphy KP, et al. Arthroscopic release for lateral epicondylitis: A cadaveric model. Arthroscopy. 1999;15:259-264.
• Champ L. Baker Jr., MD, FACS, can be reached at The Hughston Clinic, 6262 Veterans Parkway, Columbus, GA 31908; email: cbaker@hughston.com.
• Champ L. Baker III, MD, can be reached at The Hughston Clinic, 6262 Veterans Parkway, Columbus, GA 31908; email: cbaker20@hotmail.com.
• Disclosures: Champ L. Baker Jr., MD, FACS, is an unpaid consultant to and receives royalties from Arthrex and is a consultant to Smith & Nephew. Champ L. Baker III, MD, has no relevant financial disclosures.