Procedures

Before considering surgery, the surgeon should re-examine the patient to confirm the exact location of the tenderness and to assess the results of provocative maneu-

Epicondylar Bursitis Elbow
FIGURE 6.3. Axial view of the elbow reveals calcification at the lateral epicondylar extensor tendon attachment site. This finding suggests a chronic and advanced pathologic process.

vers to ensure that he or she has made the correct diagnosis. For patients who have medial epicondylitis, the presence of ulnar nerve symptoms and signs is important to note so that, if indicated, the nerve can be released appropriately. Quality anteroposterior, lateral, and oblique radiographic views should be assessed for the presence of calcification or a bony exostosis (Fig. 6.3). In patients who have medial epicondylitis, a cubital tunnel, or pos-teroanterior axial, view can be substituted for the oblique view.

Surgical treatment of lateral epicondylitis has been directed toward the structures that the surgeon believes are abnormal elements. Bosworth initially described excision of the orbicular ligament in 1955; he later modified his procedure to include release of the ECRB.13 Other procedures involve removal of a radiohumeral bursa or excision of the radiohumeral synovial fringe.4 Procedures to address possible neurologic causes include denerva-tion by neurotomy of articular branches of the radial nerve14 and radial tunnel release.15

Researchers widely accept that the ECRB is the location of the disease process, and current surgical approaches to lateral epicondylitis are directed at either complete removal of what is believed to be the diseased tissue, release of tension in the ECRB, or a combination of these techniques. Release of the ECRB or common extensor origin has been reported to give excellent pain relief, but concerns exist over possible weakening.16 In Germany, Hohmann originally described lateral release of the common extensor origin in 1926.17 Several authors have reported on variations of this procedure, with success rates generally around 90%. Percutaneous extensor teno-tomy recently has been reported and can be performed as an office procedure. The authors reported a 93.5% success rate with at least 1-year follow-up in 109 patients.18 Initially, authors reported that proximal extensor fas-ciotomy and distal ECRB lengthening gave good results.19,20 However, further studies have been unable to reproduce these findings.21

The senior author (GMM) favors a surgical technique similar to the technique that Nirschl and Pettrone or Coonrad described.10,12 Abnormal portions of the tendon are excised and, if the common extensor origin is violated, it is reattached. The goal is removal of all abnormal material and prevention of postoperative extensor weakness due to release of the common extensor tendon. Using this described technique, Nirschl and Pettrone reported 97% good to excellent results in a series of 88 patients.10

Lateral Epicondylitis Technique

The patient is placed in the supine position. A nonsterile tourniquet is used, and the arm is draped free on a hand table. The extremity is exsanguinated, and the tourniquet is inflated to 250 mm Hg. The lateral incision begins just anterior to the epicondyle and extends distally 3 to 4 cm (Fig. 6.4). Dissection is carried down through the subcutaneous tissue until the superficial fascia is identified. The superficial fascia is incised in line with the skin incision, and the interval between the extensor carpi radialis longus (ECRL) and the common extensor tendon is identified (Fig. 6.5). The ECRB tendon is under the ECRL at this point. The interval between the longus and the common extensor tendon is incised, extending from just anterior to the epicondyle to the level of the joint. The depth of this incision should be limited to 2 to 3 mm because the

FIGURE 6.4. The lateral incision begins just anterior to the epicondyle and extends distally for about 4 cm.
Extensor Carpi Ulnaris Interval
FIGURE 6.5. The interval between the common extensor aponeurosis and the extensor carpi radialis longus is incised.

ECRL is very thin at this point. Next, the ECRL is elevated sharply and retracted anteriorly to expose the ECRB tendon (Fig. 6.6).

The entire origin of the brevis tendon should be exposed. At this point, abnormal tissue should be identified (Fig. 6.7). Universally, the ECRB is involved, and in 35% of patients the anterior edge of the common extensor aponeurosis concurrently is affected.11 Abnormal tissue is identified by its dull gray hue and edematous, friable consistency.3 Typically, this tissue is easily distinguished from the surrounding normal tendon. The affected tendon is excised completely. This excision usually involves releasing the tendon origin from the epicondyle and the anterior edge of the extensor aponeurosis. If the aponeu-rosis is involved, this abnormal tissue is also excised.

In about 20% of patients, an exostosis is present at the lateral epicondyle. In this case, the leading edge of the

Friable Tendon
FIGURE 6.6. Anterior retraction of the extensor carpi radialis longus exposes the underlying extensor carpi radialis brevis tendon origin.
Friable Tendon
FIGURE 6.7. Pathologic tissue involving the extensor carpi radialis brevis tendon and occasionally the common extensor tendon should be excised. The lateral intra-articular compartment of the elbow joint should also be inspected following incision of the capsule.

aponeurosis is elevated sharply from the epicondyle, and the prominence is removed by rongeur and smoothed with a rasp. The aponeurosis is reattached later through drill holes or using suture anchors into the epicondyle.

Resection of the diseased tissue leaves a defect at the origin of the ECRB tendon. The tendon does not shorten because of its attachments to the orbicular ligament, extensor aponeurosis, and ECRL. At this time, the surgeon usually makes a small synovial opening and inspects the radiocapitellar joint. Intra-articular abnormalities rarely are identified; however, this arthrotomy does not add morbidity to the procedure, and it may prevent overlooking a concomitant loose body or other abnormality.

Next, the lateral epicondyle is drilled with a ¿-in. bit (Fig. 6.8). By encouraging revascularization, drilling is believed to promote healing of the defect that resection of the abnormal tendon leaves.11 Watertight closure of the interval between the ECRL and extensor aponeurosis is accomplished with no. 1 absorbable sutures in an interrupted, or running, fashion (Fig. 6.9). The subcutaneous layer is closed, and skin closure is obtained through a running subcuticular stitch using 3-0 nonabsorbable sutures and Steri-Strips.

The extremity is dressed and immobilized in a posterior splint at 90° of flexion and neutral rotation. At the patient's first postoperative visit, the splint is removed and range of motion is initiated.

Arthroscopic Lateral Epicondylitis Technique

Baker and coworkers presented an arthroscopic technique to address lateral epicondylitis (Fig. 6.10).22-24 They retrospectively reviewed the results in 40 patients (42 elbows) who had arthroscopic treatment of recalcitrant lateral epicondylitis.23 Three types of lesions were identified through the arthroscope. Arthroscopically, type I lesions

Lateral Epicondylitis Arthroscopic
FIGURE 6.8. Drilling of the lateral epicondyle promotes vascularization and healing of soft tissues to bone.

appeared as an intact capsule (15 elbows). Type II changes appeared as linear capsular tears (15 elbows). Type III lesions appeared as complete ruptures and retraction of the capsule with a frayed extensor carpi radialis brevis tendon (12 elbows). Of the 39 elbows in the 37 patients who were available for follow-up, 37 were improved. These results compared favorably with results that Nirschl and Pettrone found (i.e., 97.7% improvement rate).10 Patients returned to work in an average of 2.2 weeks. No correlation could be found between the type of lesion and clinical outcome.23

The surgical indications for endoscopic intervention are the same as for open procedures. Taking a thorough history and physical examination is essential. Previous surgery, especially an ulnar nerve transposition, may al-

Nirschl Procedure
FIGURE 6.9. Anatomic repair of the interval between the posterior edge of the extensor carpi radialis longus and the common extensor aponeurosis allows early postoperative range of motion.

FIGURE 6.10. Arthroscopic visualization of the lateral compartment reveals the capsular and extensor carpi radialis brevis tendon injury. Debridement of pathologic tissue can be performed arthroscopically.

ter portal placement. In addition, the surgeon should note any instability of the nerve in the epicondylar groove on flexion and extension of the elbow. A complete neuro-vascular examination should be documented in the medical record.

A general anesthetic is administered to the patient, then he or she is positioned prone. Rolled towels are placed under the thorax. Bony prominences are padded and checked to make sure that no undue pressure is placed on them. The extremity is positioned with the shoulder abducted to 90° and the arm supported in a precut foam holder. The forearm hangs freely over the edge of the table with the elbow flexed to 90°. A tourniquet is applied proximally to the arm.

After preparing and draping the extremity in a sterile fashion, the surgeon identifies and outlines landmarks, including the medial and lateral epicondyles, radial head, ulnar nerve, and olecranon. Next, potential portal sites are located and marked.

The joint is distended with 30 mL of saline injected through the direct lateral portal using an 18-gauge needle. Distention of the joint increases the distance between the portals and neurovascular structures. The tubing is removed from the spinal needle, and backflow is confirmed to ensure adequate distention.

The proximal medial or superomedial portal is located approximately 2 cm proximal to the medial epicondyle and 1 cm anterior to the intermuscular septum. The portal is created using a no. 11 blade to incise the skin, followed by blunt, hemostat dissection to spread the underlying tissue. A blunt trocar is passed into the joint capsule through the proximal flexor muscle mass near the bra-chialis muscle. The trocar is advanced toward the radial head, maintaining contact with the anterior humerus at all times. A 2.7-mm 30° arthroscope is placed into the joint, and diagnostic arthroscopy is initiated.

Abnormal changes are present at the lateral capsule and undersurface of the ECRB tendon. After identifying abnormal tissue, the surgeon establishes the proximal lateral portal. If the lateral capsule has remained intact, it is debrided with a motorized shaver to expose the undersurface of the ECRB tendon. The tendon is removed using a motorized shaver or radiofrequency ablator. The lateral epicondyle is decorticated using a curette or motorized shaver.

Care must be taken to limit epicondylar resection to protect the lateral collateral ligament. Resecting too far posteriorly on the epicondyle places the ligament at risk for injury. After the ECRB tendon has been debrided and released, the fibers of the overlying extensor musculature should be visible.

Postoperatively, the patient's arm is placed in a sling, and gentle range-of-motion exercises are initiated. Gradual progression to wrist extension strengthening and upper extremity conditioning are added as indicated.

Medial Epicondylitis Technique

Little has been published regarding operative techniques for medial epicondylitis. Vangsness and Jobe reported good to excellent results in 88% of patients following excision of the diseased tendon and reattachment of the pronator teres and flexor carpi radialis origin.25 The association of medial epicondylitis and ulnar neuropathy has been well documented.26,27 Gabel and Morrey elucidated the influence of associated ulnar neuropathy.26 They developed a classification system that they showed to be prognostically significant.

Before proceeding with surgery for medial epicondy-litis, examination of the ulnar nerve is necessary. Ulnar nerve involvement is found in 40% to 60% of patients.26,27 Electromyography and nerve conduction velocity testing can be useful when ulnar nerve symptoms are present. Progressive ulnar neuritis is an indication for surgical intervention regardless of the response of the epi-condylitis to nonoperative treatment. The surgeon should suspect damage to the ulnar collateral ligament in patients who present with acute symptoms or in throwing athletes who apply a significant valgus load to the elbow (e.g., baseball and javelin throwers). Valgus stability of the elbow should be examined, and stress radiographs or magnetic resonance imaging should be obtained if indicated. If damage to the ulnar collateral ligament is suspected, the surgeon should be prepared to explore the anterior bundle of the ligament and, if indicated, to reconstruct it.

To treat medial epicondylitis, we favor a technique similar to the technique that Ollivierre, Nirschl, and Pet-trone described28 (Fig. 6.11). The incision begins about 2 cm proximal to the medial epicondyle and parallels the epicondylar groove to a point 5 cm distal to the epicon-dyle (Fig. 6.11 A). Straying anterior to the epicondyle places the medial antebrachial cutaneous nerve at risk for injury. A bothersome neuroma can result from transection of the nerve. Dissection through the subcutaneous tissue exposes the deep fascia overlying the ulnar head of the flexor carpi ulnaris. Dissection should proceed an-terolaterally over the epicondyle to expose the common flexor tendon. Normally, at this point, disease is not evident because the degeneration is deep. A longitudinal incision is made in the tendon overlying the area of maximal point tenderness. This incision is usually at the origin of the pronator teres and flexor carpi radialis. Gabel and Morrey described the "accessory anterior oblique ligament" (Fig. 6.11B); this structure defines the interval between the flexor carpi ulnaris and flexor carpi radialis and serves as a critical landmark in medial epicondylitis surgery.4 Because involvement of the flexor carpi ulnaris in medial epicondylitis is rare, dissection should remain anterior to the accessory anterior oblique ligament. The anterior oblique ligament is immediately posterior to the accessory anterior oblique ligament. Dissection of the flexor-pronator origin posterior to the accessory anterior oblique ligament may result in iatrogenic valgus instability secondary to injury of the anterior oblique ligament.

If abnormal tissue is present, it is readily apparent after incision of the pronator teres-flexor carpi radialis origin. As in lateral epicondylitis surgery, all diseased tendon is excised, usually leaving an elliptical defect (Fig. 6.11C).

Preoperative and intraoperative findings dictate ulnar nerve management. The typical site of ulnar nerve compression is at the cubital tunnel; in rare cases, the compression may be proximal to the epicondyle.27 Nirschl et al. described three possible zones of median nerve compression: zone 1 is proximal to the epicondyle (medial intramuscular septum), zone 2 is at the level of the epicondyle, and zone 3 is distal to the epicondyle where the nerve passes between the heads of the flexor carpi ul-naris.11 In more than 90% of cases, the compression is found in zone 3.

If ulnar neuropathy is mild, the nerve can simply be decompressed at the cubital tunnel. However, if the neuropathy is moderate to severe with more than a single site of compression, a subcutaneous transposition is performed. Other indications for transposition include instability of the nerve in the epicondylar groove as the elbow is placed through range of motion, epicondylitis associated with ulnar neuropathy, and the need for ulnar collateral ligament reconstruction.11 We do not favor a sub-muscular transposition because it is technically more difficult, adds morbidity to the procedure, and has not been shown to affect functional results.

After addressing the ulnar nerve if needed, the surgeon addresses the tendon defect. The epicondyle is drilled with a ¿-in. bit to produce a bleeding surface. The defect is closed with no. 1 absorbable sutures, and the subcutaneous layer is closed (Fig. 6.11D). The skin is closed with a running, subcuticular stitch using 3-0 nonab-sorbable sutures.

Kocher Elbow
A
Epizondylus RadialVangsness Jobe Medial Epicondylitis

FIGURE 6.11. (A) The medial skin incision begins about 2 cm proximal to the medial epicondyle, parallels the epicondylar groove, and ends at a point 5 cm distal to the epicondyle. (B) The pronator teres and flexor carpi radialis are identified and incised. Pathologic tissue generally is located on the undersurface of these flexor tendons. (C) The pathologic soft tissue is excised, and the medial epicondyle is drilled to promote vascularization and healing. (D) The flexor-pronator tendons are reattached anatomically to the medial epicondyle if they were detached from bone, or they are repaired side to side if the bony attachment was not disturbed.

FIGURE 6.11. (A) The medial skin incision begins about 2 cm proximal to the medial epicondyle, parallels the epicondylar groove, and ends at a point 5 cm distal to the epicondyle. (B) The pronator teres and flexor carpi radialis are identified and incised. Pathologic tissue generally is located on the undersurface of these flexor tendons. (C) The pathologic soft tissue is excised, and the medial epicondyle is drilled to promote vascularization and healing. (D) The flexor-pronator tendons are reattached anatomically to the medial epicondyle if they were detached from bone, or they are repaired side to side if the bony attachment was not disturbed.

Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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