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Lateral epicondylitis effectively treated with open or arthroscopic procedures
Little clinical evidence supports either procedure, but arthroscopy offers a faster recovery time.
While no clinical evidence exists yet to verify arthroscopic management’s superiority over open procedures for treatment of lateral epicondylitis, anecdotal evidence and some literature points to an equality of outcomes between the two and a quicker recovery period for the arthroscopic technique.
A comparison between the two and a general outline on the treatment of the condition was presented by William N. Levine, MD, at Orthopedics Today Hawaii 2009, wherein he explained his stance on the matter and his own experiences with both options.
Non-operative treatments
Most lateral epicondylitis patients receive nonoperative treatment such as sport or work activity modification, physical therapy and pharmacologic modalities. Workplace activity modification involves decreasing the force or repetition associated with daily activities, as well as avoiding vibration.
Braces have also shown to be well-tolerated and display ease of use, transferring forces away from the extensor carpi radialis brevis (ECRB).
“As a card-carrying lateral epicondylitis member, it is the only way I can play squash anymore,” Levine said.
Sports equipment also plays a role, Levine pointed out, as different rackets can have different tension on the wrist and forearm, possibly contributing to the development of the condition.
Corticosteroid treatment
Though corticosteroid treatments are popular, the level of evidence supporting their long-term use in patients with lateral epicondylitis is unimpressive at best. Additionally, Levine said, physicians should give thought to where they are injecting their patients.
“Most of us were trained to inject the lateral epicondyle, which may be the most painful injection that we perform other than the plantar fascia,” he said.
In response, Levine added, he has started to perform injections into the elbow itself. Efficacy is seemingly unaltered and the patient responds much more favorably.
Open versus arthroscopic
Surgical treatment is only recommended for patients who continue to have pain after a reasonable course of nonoperative management spanning 6 to 12 months, and typically only a small percentage of patients will actually require such a measure. Contraindications for surgery include patients who haven’t had an appropriate nonoperative course of treatment or display noncompliance.
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Image: Trace R, Orthopedics Today |
The goals of surgery, whether open or arthroscopic, are straightforward: resection of pathologic tissue. There are several intra-articular issues which lead to discussion between open and arthroscopic techniques, but minimization of morbidity remains a primary goal, he said. Differences in morbidity between the open and arthroscopic methods are miniscule.
Some literature for the open technique reports a 94% to 95% success rate, but Levine believes those figures are overstated and considers the actual rate to be around 84%.
The primary reason for supporting an arthroscopic procedure over an open procedure, Levine said, is a faster return to work and sports.
How does the scope stack up?
In terms of technical goal achievement, the arthroscopic method displays efficacy – enabling the resection of pathologic tissue, release of the ECRB and, importantly, avoidance of injury to the lateral ulnar collateral ligament (LUCL).
“This comes back to understanding basic anatomy,” Levine said. “When you are in there arthroscopically, you want to keep in mind where the equator of the radial head is and make sure you do not get on the posterior aspect of that line. That is where the LUCL is.”
“Anatomy, anatomy, anatomy,” he added. “You need to know where the ulnar nerve is and you need to know if the ulnar nerve subluxes if you are going to do these elbow arthroscopic procedures.”
No clearly superior option
Postoperative rehabilitation is straightforward, with full extension enabled within 3 to 5 days. If necessary, patients are sent for physical therapy. Return to work can come as quickly as 1 day in some cases and take an extended period of time in others.
Some literature supports the notion that there is a learning curve to the procedure.
Levine backed up his support of the arthroscopic technique.
“Is this technology over reason? I don’t believe so,” he said. “I think you can support the arthroscopic approach for the reasons I’ve shown. Patients’ recovery seems to be enhanced, and the outcome is equivalent.”
“I cannot say it is definitively better,” he added. “However, there is no increased rate of complications. Still, there is no clinical evidence to support one over the other at this point in time. There are no controlled trials, so it’s really begging for a nice prospective, well-controlled trial.”
For more information:Reference:
- William N. Levine, MD, is the Director of Sports Medicine at the Center for Shoulder, Elbow and Sports Medicine at Columbia University Medical Center. He can be reached at Columbia University, 622 W. 168th St., PH1117, New York, NY 10032; 212-305-0762; e-mail: wnl1@columbia.edu. He has no direct financial interest in any companies or products mentioned in the article.
- Levine, WN. Lateral epicondylitis: open vs. arthroscopic management. Presented at Orthopedics Today Hawaii 2009. Jan. 11-13, 2009. Kohala Coast, Hawaii.