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Lateral epicondylitis treated arthroscopically
Lateral epicondylitis, commonly referred to as tennis elbow, is the most common etiology of elbow pain and occurs in 1% to 3% of adults. Degenerative tendinosis of the origin of the extensor carpi radialis brevis has been proposed as the central pathology (Figure 1).
Research has shown that lateral epicondylitis is a self-limited condition, and thus, surgical intervention is infrequently required. Six months to 9 months of conservative management is usually recommended prior to consideration of operative intervention. Nonoperative modalities include activity modification, NSAIDs, physical therapy with eccentric extensor strengthening and stretching, counterforce bracing or a cock-up wrist splint, corticosteroid injection and platelet-rich plasma injection. For patients who remain significantly symptomatic despite all of these nonoperative measures, surgical intervention is recommended. Current options include open and arthroscopic procedures.
Arthroscopic technique set-up
For elbow arthroscopy, we prefer the prone position; although in the literature, successful access to the elbow has been achieved with supine, lateral decubitus or prone positioning. Therefore, the ideal position is based on the surgeon’s education and experience. An arthroscopic arm-holding device is used for positioning, which allows full access to the anterior and posterior compartments of the elbow. We prefer regional anesthesia combined with sedation. The elbow should be positioned without any padding pressing against the antecubital fossa to allow the anterior neurovascular structures to fall away from the joint. A sterile tourniquet is applied after draping the arm.
Figure 1. This coronal T2-weighted MRI
is of a patient with lateral epicondylitis.
This slice at the level of the extensor carpi
radialis brevis tendon shows increased
signal intensity at the level of the tendon
(marked with a red asterisk).
Images: Chalmers PN, Cohen MS
Several specialized instruments help improve the safety of elbow arthroscopy. Because the joint offers little working space, the tip of the cannula will often be just inside of the joint capsule. Cannulas without side holes avoid unintentional insufflation of irrigation fluid into the periarticular soft tissues. Elbow arthroscopy requires less pressure than shoulder or knee arthroscopy. Thus, a nitrogen powered pump that allows manual pressure is useful. Gravity-assisted irrigation using a hanging intravenous bag is also an effective alternative. If a pump is used, the pressure setting should be maintained at about 30 mmHg.
Portal positioning
Accurate portal placement is critical to avoid neurovascular injury. Once the patient is securely positioned, draw the bony landmarks on the skin with an emphasis on tracing the path of the ulnar nerve. An anteromedial portal for the camera and an anterolateral portal for instruments are required for extensor carpi radialis brevis (ECRB) release. A higher lateral portal can be established to use a small retractor.
The anteromedial portal is placed several centimeters proximal to the medial epicondyle and anterior to the medial intermuscular septum, which protects the ulnar nerve. A common error occurs when this portal is made too posterior. As the anterior humerus is convex, this portal must be anterior enough to allow for a direct path to the lateral joint.
The anterolateral portal is typically placed just anterior to the top of the capitellum. The skin incision is made about 2 cm to 3 cm proximal to the lateral epicondyle and slightly anterior. It is helpful to use a needle through the skin to locate the proper position while visualizing from the anteromedial portal.
Diagnostic arthroscopy
The elbow joint is distended with 20 mL to 30 mL of normal saline placed through the soft-spot between the posterior aspect of the radial head, the lateral epicondyle and the olecranon. Check for retrograde flow to ensure intra-articular placement of the needle.
The incision for the anteromedial portal is then made. The blunt trocar or a switching stick is used to slide through the subcutaneous tissue and down the anteromedial humeral cortex, aiming for the center of the elbow joint. Take care to enter the joint capsule as medial as possible to permit the best visualization of the articular surfaces. After confirming return of fluid, the camera is inserted.
The anterolateral portal is then placed under direct visualization, and a routine diagnostic arthroscopy is performed.
ECRB release
Knowledge of the anatomy and humeral origins of the extensor tendons of the elbow and their relationship to both the radiocapitellar joint and the lateral collateral ligament (LCL) is crucial to safely perform an arthroscopic ECRB release. From an open surgery perspective, the tendinous origin of the ECRB is located posterior and deep to the muscular origin of extensor carpi radialis longus (ECRL). The ECRB origin is just anterior to the extensor digitorum communis origin.
However, the perspective of the arthroscopic approach requires familiarity with the osseous origins about the lateral elbow to clearly define the pertinent anatomy. The footprint of the ECRB is diamond-shaped, coursing from the top of the capitellum to the midline of the radiocapitellar joint. The LCL lies deep to the extensor muscle origins, blending with the annular ligament. Its primary fibers will not be disturbed if the release remains anterior to the midline of the radiocapitellar articulation. The elbow joint capsule lies deep to tendons and must be released to visualize the entire footprint of the ECRB (Figure 2).
Figure 2. An anatomical schematic shows the origin of the extensor carpi radialis brevis (ECRB) relative to the lateral collateral ligament (LCL), radial nerve, posterior interosseous nerve (PIN) and superficial branch of the radial sensory nerve. As long as resection remains proximal to the midline of the radiocapitellar articulation (marked with a dashed line), the entirety of the ECRB can be released without damaging the LCL or PIN. The PIN lies 3 cm +/-0.7 cm distal to the capitellum.
From an arthroscopic perspective (i.e., from deep to superficial), the ECRB is the first visible structure in the anterior half of the radiocapitellar joint after the proximal lateral capsule has been detached from the humerus. After completely releasing the ECRB tendon, the muscular ECRL origin and the fibrous extensor retinaculum will be visible.
Technical tips
In practice, the arthroscopic shaver can be used to establish a plane between the capsule and the ECRB, which are intimately related (Figure 3). Again, the capsular and tendon releases are started from the proximal-lateral edge of the articular cartilage of the capitellum. A small radiofrequency device can be helpful to allow for visualization of the different tissue layers during the procedure. Once the origin of the ECRB is clearly identified (Figure 4), the tendon is released distally to the level of the midpoint of the radiocapitellar joint, avoiding the origin of the LCL (Figure 5). Only short bursts of energy should be used to avoid high intra-articular temperatures.
Figure 3. This arthroscopic image of a right elbow viewed from the anteromedial portal shows a radiofrequency ablation wand from the anterolateral portal as the capsular resection begins.
Figure 4. This arthroscopic image of a right elbow viewed from the anteromedial portal shows the beginning of the capsular resection and ECRB release. The retracted capsule (a), the ECRB tendon (b) and the fascia of the extensor carpi radialis longus (c) can be seen.
An elevator, such as a standard freer elevator or a switching stick, can be used to place the anterior capsule and lateral tissues under tension. Avoid capsular removal over the anterior aspect of the radiocapitellar joint. Posterior interosseous nerve injury is a devastating complication that can only occur if the surgeon deviates more than 2 cm from the ECRB origin. In addition to releasing the entire soft tissue origin of the ECRB, some surgeons believe in a local “periostitis” of the ECRB origin and prefer to debride the footprint bone, but there is no clear evidence that this improves the outcome.
At the completion of ECRB origin resection, the camera should be moved across the joint to confirm that the resection reached the midpoint of the elbow joint. An incomplete resection is most common at the posterior origin.
Figure 5. This arthroscopic image of a right elbow viewed from the anteromedial portal depicts the completed ECRB release with the retracted capsule (a), the ECRB tendon (b), the extensor carpi radialis longus (c) and the extensor retinaculum (d) shown.
Figure 6. This arthroscopic image of a right elbow viewed from the anterolateral portal depicts the partially completed ECRB release with the proximal portion footprint visible and debrided to cancellous bone.
When visualizing from the anteromedial portal, the ECRL muscle should be visible at the anterior area of the resection, and the extensor aponeurosis, which typically has transverse tendon fibers, should be visible at the posterior area of the resection. The arthroscopic camera may then be switched from the anterior-medial portal into the anterior-lateral portal to allow direct visualization of the ECRB origin (Figure 6). The surgeon can thus confirm the absence of any remaining ECRB tissue within the boundaries of the resection, which is bordered by the articular cartilage of the capitellum anteriorly, the origin of the LCL distally, the extensor digitorum communis fibrous origin posteriorly and the proximal origin of the capitellum proximally.
The portals are closed with interrupted nonabsorbable sutures, a posterior-mold split is placed with the elbow at 90° flexion and the arm is placed in a sling.
Rehabilitation and results
Postoperatively, patients are typically immobilized for few days for comfort and support. For the first 4 weeks to 6 weeks, the therapeutic goals are to reduce pain and swelling and to regain full motion. Isometric strengthening should begin at about 6 weeks, and patients are usually back to full activities within 3 months.
Previous series have shown good or excellent results in 70% to 85% of patients treated with arthroscopic techniques, which is similar to the reported success with open methods. In a review by Lattermann and colleagues of 36 patients treated at our institution with the arthroscopic release that we described above, the mean functional component of the Mayo Elbow Performance Score was 11.1 points out of 12 points and the mean visual analog scale pain score was 1.9 points (on a scale of one to 10) at a mean follow-up of 3.5 years. One patient had a transient forearm paresthesia, but there were no other complications.
Arthroscopic ECRB release is an effective technique for the treatment of lateral epicondylitis in patients who fail to respond to nonoperative treatment. Although it is a technically complex procedure, appropriate knowledge of the arthroscopic anatomy of the lateral elbow and extensor tendon origins allows it to be performed safely with successful clinical outcomes and a low risk of complications.
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Disclosures: Cohen receives royalties from Integra Inc., is on the speakers bureau for Mylad Inc., is a paid consultant for Mylad and Acumed Inc. and receives research support from Integra Inc; Romeo is the Chief Medical Editor of Orthopedics Today, receives royalties, is on the speakers bureau and is a consultant for Arthrex Inc., does contracted research for Arthrex Inc. and DJO Surgical, receives institutional grants from AANA and MLB, and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Chalmers and Frank have no relevant financial disclosures.
