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Managing Surgical Failure in Tennis Elbow
Introduction
Surgical intervention is not commonly required to treat epicondylitis, and nonoperative management is usually successful in about 90% of patients. Similarly, when surgery is performed, a 90% success rate is typically reported, interestingly, regardless of the surgical technique. a
a References .
On the other hand, when surgical intervention is not successful, there are few reports of subsequent management. Hence there is relatively little known about the management of surgical failure for epicondylitis. The intent of this chapter is to share our experience with this problem and to provide a basis for determining the cause of failure and a basis for further management. I have found that a disciplined and systematic approach to the problem is of great value.
This type of problem is readily determined with a careful interview.
Patient Evaluation
Careful History
The first step in the evaluation process is to critically assess the patient and motives. Initially, the most frequent explanation for residual symptoms is too brief a period after surgery or inadequate rehabilitation. The latter may be due to noncompliance or an inadequate program. If concern exists about either point, the patient is treated for symptoms and reassessed. If at least 6 to 9 months has passed since surgery and there are no worrisome personality features, litigation, or compensation issues, the problem may be further studied.
Hallmark Question
The single most important determination at this point is whether the symptom complex is similar to, or different from, that issue for which the original surgery was performed. This allows the failure to be classified as one of three types: type I, inaccurate initial diagnosis; type II, inadequate treatment; type III, iatrogenic: introduction of new pathology.
Classification
Type I: Inaccurate Initial Diagnosis; Improper Patient Selection
Alternative causes of lateral elbow pain include degenerative arthrosis, anconeus or extensor muscle compartment syndrome, lateral ligament instability especially with a history of trauma, and entrapment of the posterior interosseous nerve (PIN) in the region of the arcade of Frohse ( Fig. 62.1 ), cutaneous nerve entrapment, and intraarticular plica.
The distinction between lateral epicondylitis and PIN entrapment has been well discussed in the literature. The differentiation is made even more difficult because PIN entrapment may coexist with lateral epicondylitis in about 5% percent of individuals. In one series, a concurrent and unrecognized PIN entrapment also was suspected as the cause of failure in 2 of 15 patients. I have found a reliable triad to help make this diagnosis, consisting of localization of pain at the arcade of Frohse reproduced by direct palpation; pain aggravated by resisted supination; and pain relief by injection of 2 mL of lidocaine (Xylocaine). Electromyographic changes, on the other hand, are not usually present, nor are they necessary to diagnose nerve entrapment. Today, I rely on ultrasonic imaging to help make or confirm PIN entrapment (see Chapter 9 ).
If the onset has followed trauma and if catching or locking is an element of the complaint, possible insufficiency of the lateral ligament complex or an intraarticular cause is suspected. Magnetic resonance imaging (MRI) is ordered, and arthroscopy is considered to make the diagnosis.
Improper Patient Selection
It should also be noted that patient-specific issues such as adequate motivation, compliance, and consideration of secondary gain are also considerations. The same factors that resulted in a failure of nonoperative treatment are present in the patient undergoing surgery. The best solution for this difficult problem is obvious: avoid the initial surgical procedure in patients known to be at risk for secondary gain. And, of course, avoid additional surgery at all costs.
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