Arthroscopic Management of Lateral Epicondylitis

Introduction

It has been nearly 17 years since the use of the arthroscope to resect the extensor carpi radialis brevis (ECRB) tendon was introduced, and the current treatment protocol for recalcitrant lateral epicondylitis was formulated. Numerous studies demonstrating the technique involved as well as its accuracy and long-term results have been published, and this arthroscopic technique is now routinely taught in cadaveric courses in surgical learning centers throughout the United States.

The arthroscopic technique for resecting the damaged ECRB tendon by viewing structures from the inside rather than the outside is simple and straightforward. Far less invasive than traditional techniques, the procedure can be likened to climbing up the stairs into the attic as opposed to going down into it through the roof. Moreover, because the joint capsule of the elbow is adjacent to the tendon, once it has been released arthroscopically, the undersurface of the tendon is exposed and can be visualized, making it easy to access for resection. This contrasts with the technique in an open procedure where, after we make the skin incision, we must divide the tendons and the common extensor and/or extensor pollicis longus to access the damaged tissue for resection. As the goal of the surgery, regardless of technique, is to resect the damaged tendon, either method is acceptable, but the arthroscopic technique is a more direct way to visualize the anatomical structures and offers the additional benefit of enabling the surgeon to look inside the joint for any associated pathology that may be present and/or causing a patient's lateral elbow pain.

Cohen and Romeo have done excellent work in demonstrating just how close the elbow joint capsule is to the ECRB and elucidating the various relevant anatomical relationships. We are also indebted to Kuklo et al. for composing one of the first articles on this subject based on a cadaveric model. Additionally, in a series comparing arthroscopic and open technique, Cummins has shown that all damaged tissue—both gross and histologic—can be resected. In this study he identified gross evidence of residual tendinopathy in 6 out of the 18 patients and found histological evidence in 10. Poor surgical outcomes were associated with those patients who had residual histologic tendinopathy. We can therefore conclude that the more tissue that is left intact after surgery rather than resected, the less favorable the outcome.

Indications

Patients with persistent lateral elbow pain unrelieved by treatment—including injections, bracing, therapy, active rest, and modification of activity—are prime for a change in their treatment protocol. At the present time, this will often involve a surgical procedure. Our experience has shown that, in addition to being a means of resecting the damaged tissue, using the arthroscope allows for the most direct and complete evaluation of the entire elbow joint.

Patients who are candidates for arthroscopic surgery also include those with so-called atypical lateral epicondylitis whose pain lies more in the posterior recess or underneath the radial head or is accompanied by a clicking on pronation and supination of the elbow ( Fig. 19.1 ). These patients may have what is called snapping elbow and/or plica syndrome around the joint; this makes them excellent candidates for arthroscopic evaluation of the intraarticular problem. An open resection of the ECRB that does not involve looking inside the joint via capsule arthrotomy will not adequately treat such patients. Furthermore, any patient who has had a previous open procedure and remained symptomatic becomes a candidate for arthroscopic evaluation to assess the intraarticular pathology that may be present. If a patient does remain symptomatic after an arthroscopic procedure, we recommend open resection of the ECRB. In the vast majority of those patients who continue to experience symptoms following surgical treatment for lateral epicondylitis, the resection of the damaged tissue has been inadequate.

Both the traditional open procedure for lateral epicondylitis and the new ultrasound-guided percutaneous tenotomy technique seem to be effective for most patients—those who have classic lateral elbow pain aggravated on extension and volar flexion against resistance and who are unresponsive to conservative treatment for a period of at least 4 to 6 months. Corticosteroids have not proven to be truly effective in deterring persistent pain and typically have only short-term benefit. The use of platelet-rich plasma injections (PRP), while proven in some studies to be beneficial, would not appear to offer any clear advantage over other nonoperative treatments and has not been completely effective. The hallmark treatment for recalcitrant lateral epicondylitis therefore continues to be protective rest and stretching and strengthening along with different types of modality exercises, such as friction massage, to reduce the pain.

Technique

The technique for resecting the damaged ECRB tendon is straightforward and is routinely performed with the patient either in the supine, lateral decubitus, or prone position. We prefer the prone position with the use of a general anesthetic as it allows for an accurate assessment of postoperative nerve function. Frequently, an arm holder is used, although any bolster that keeps the elbow at 90 degrees while allowing for full extension and hyperflexion can suffice. A tourniquet is also placed on the upper arm and this can then be inflated or not at the surgeon's discretion. The tourniquet and arm holder should be placed as proximal as possible to allow easy joint access with instruments ( Fig. 19.2A ). The arm is then prepared and draped in standard sterile fashion (see Fig. 19.2B ). To safely create the arthroscopic portals, the following anatomic landmarks are identified and outlined on the skin: medial epicondyle, intermuscular septum, ulnar nerve, olecranon tip, lateral epicondyle, and radial head ( Fig. 19.3 ). The lateral soft spot is marked in the center of the triangle created by the radial head, olecranon, and lateral epicondyle. We then wrap the forearm with a compressive dressing to prevent leakage of fluid into the distal soft tissues. Finally, the limb is exsanguinated and the tourniquet inflated to approximately 250 mmHg. The overall time required for the actual surgery is usually quite brief, thus eliminating any concerns about the consequences of using a tourniquet for a prolonged period of time.