Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results

[Extra-articular elbow arthroscopy.]

Extra-articular elbow arthroscopy has to be considered as the evolution of the elbow surgery to a mini invasive endoscopically assisted surgery developed by the recent advance of the elbow arthroscopy. Various pathologies, such as lateral epicondylitis, ulnar nerve entrapment, distal Biceps tendon rupture, synovial cysts, or olecranon bursitis have been treated arthroscopically. Extra-articular pathologies can be treated through an intra-articular endoscopic approach. The true endoscopic extra-articular technique is proced through a real anatomical space or inside a space of work created de novo by the surgeon. The difficulty of using endoscopy in extra-articular pathologies of the elbow is related to the vasculo-nervous structures sourrounding the articulation wich are directly subject to potential injury. Elbow extra-articular endoscopy must be considered as a difficult and sometimes dangerous procedure reserved to experimented elbow arthroscopic surgeons. Those techniques are yet to demonstrate their superiority in term of results and security compare to the open techniques.

Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow

OBJECTIVE

Chronic tendinosis of the common extensor tendon of the lateral elbow can be a difficult problem to treat. We report our experience with sonographically guided percutaneous needle tenotomy to relieve pain and improve function in patients with this condition.

METHODS

We performed sonographically guided percutaneous needle tenotomy on 58 consecutive patients who had persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle was advanced into the common extensor tendon, and the tip of the needle was used to repeatedly fenestrate the tendinotic tissue. Calcifications, if present, were mechanically fragmented, and the adjacent bony surface of the apex and face of the epicondyle were abraded. Finally, the fenestrated tendon was infiltrated with a solution containing corticosteroid mixed with bupivacaine. After the procedure, patients were instructed to perform passive stretches and to undergo physical therapy. During a subsequent telephone interview, patients answered questions about their experience, their functioning level, and their perceptions of procedure outcome.

RESULTS

Fifty-five (95%) of 58 patients were contacted by telephone and agreed to participate in the study. Thirty-five (63.6%) of 55 respondents reported excellent outcomes, 16.4% good, 7.3% fair, and 12.7% poor. The average follow-up time from the date of the procedure to the date of the interview was 28 months (range, 17-44 months). No adverse events were reported; 85.5% stated that they would refer a friend or close relative for the procedure.

CONCLUSIONS

Sonographically guided percutaneous needle tenotomy for lateral elbow tendinosis is a safe, effective, and viable alternative for patients in whom all other nonsurgical treatments failed.

Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment

Many procedures have been described for treating lateral epicondylitis with good success. The purpose of this report is to compare 3 operative methods for treatment of recalcitrant lateral epicondylitis-open, arthroscopic, and percutaneous. All patients with lateral epicondylitis who were operated on over a 7-year period were retrospectively reviewed. A minimum of 3 months of conservative care before surgery had failed in these patients, and they had a minimum of 2 years of follow-up. Concomitant pathology, complications, and necessary further care were noted. The outcomes were evaluated preoperatively and postoperatively with the Andrews-Carson score and visual analog scale scores for pain at rest, worst pain, and pain with activity. We included 109 patients in the study: 24 percutaneous, 44 arthroscopic, and 41 open procedures. The mean duration of conservative care was 13.2 months, including 2.5 conservative measures and 1.35 cortisone injections. The mean follow-up was 47.8 months. The preoperative Andrews-Carson score was 160.3. The postoperative Andrews-Carson score was 195. There was a statistically significant difference between preoperative and postoperative Andrews-Carson scores for each of the groups. There were no significant differences among the populations regarding age, gender, dominance, conservative measures used, cortisone injections, recurrences, complications, failures, visual analog scale scores, and preoperative and postoperative Andrews-Carson scores. In addition, no difference in outcome scores was noted when intraarticular and concomitant pathology was addressed in comparison to the population in which tendinosis alone was addressed. Open, arthroscopic, and percutaneous treatments of lateral epicondylitis offer 3 highly effective ways for the clinician to address this common clinical problem.

Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes

BACKGROUND

Surgical management of lateral epicondylitis has traditionally consisted of an open incision with debridement of the affected extensor tendon tissue. More recently, arthroscopy has been reported as a surgical option for this condition.

PURPOSE

To evaluate the effectiveness of arthroscopic debridement in excising the characteristic tendinopathy of chronic lateral epicondylitis and determine if residual tendinopathy correlated with poorer patient outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected on all patients who underwent arthroscopic debridement of chronic lateral epicondylitis during a 2-year period. The arthroscopic debridement was assessed in regard to its effectiveness in excising the characteristic tendinopathy through a traditional open procedure by gross and histologic analysis. Outcomes data were collected on all patients preoperatively and at a minimum of 1 year postoperatively. Patient outcomes were then correlated with the residual histologic tendinopathy after arthroscopic debridement.

RESULTS

Eighteen patients were enrolled in the investigation. Gross evidence of residual tendinopathy was identified in 6 patients, with all 6 cases occurring during the first year of the study. Of the 18 patients, 10 had residual histologic evidence of tendinopathy after arthroscopic debridement. Poorer outcomes were identified in those patients who had residual histologic tendinopathy on their rating of worst level of pain (P = .03).

CONCLUSION

Residual microscopic tendinopathy is often present after arthroscopic debridement. Clinically, residual microscopic tendinopathy correlated with poorer surgical outcomes in regard to patient's rating of their worst level of pain.

Arthroscopic treatment of lateral epicondylitis: indication, technique and early results

The purpose of this study is to present the results of the arthroscopic treatment of lateral epicondylitis. Twenty patients with lateral epicondylitis (mean age 42 years) were treated arthroscopically. The average duration of symptoms prior to surgery was 14 months. The arthroscopic joint inspection showed an intact capsule in seven patients (type-I lesion), in eight patients a linear capsule tear (type-II lesion) and in six patients a complete rupture of the capsule (type-III lesion). An associated intraarticular pathology was documented in eight patients. Within an average follow-up period of 1.8 years, local pain and function were documented and analyzed. Subjective pain at rest was reduced from 5.0 to 0.5 points, pain at daily living activities from 6.0 to 1.0 points and pain at athletic activities from 7.3 to 1.2 points in the VAS score. Function increased from 5.2 to an average value of 10.9 (max. 12 points). Patients returned back to work after 3.2 weeks. In conclusion, the arthroscopic release in patients with radial epicondylitis is a reproducible method with a marked postoperative increase in function within a short rehabilitation period.

Treatment of recalcitrant lateral epicondylitis with suture anchor repair

BACKGROUND

Chronic lateral epicondylitis has been treated with various surgical procedures with varying and often less-than-satisfactory outcomes.

HYPOTHESIS

The use of suture anchor repair of the extensor carpi radialis brevis to the lateral epicondyle in the treatment of chronic lateral epicondylitis will result in a more anatomical repair, with resultant improvements in strength, pain, and return to previous sport.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 20 patients (22 elbows) were treated surgically and were observed for a minimum of 2 years. All patients had debridement of the degenerative tissue, followed by repair of the extensor carpi radialis brevis to the lateral epicondyle with a suture anchor. The average time to follow-up was 4.2 years (range, 2.2-9.5 years). All patients completed a Disabilities of the Arm, Shoulder, and Hand questionnaire to assess residual disability, and 16 patients underwent a physical examination. The objective evaluation included the assessment of range of motion, grip strength, and pinch strength. Pain was assessed preoperatively and postoperatively using a visual analog pain scale. Patients were also questioned with regard to a return to their previous level of activities.

RESULTS

The grip and pinch strengths achieved for the operative extremity were 110% and 106%, respectively, of the nonoperative limb. The 16 patients who underwent a physical examination had achieved full range of motion, with 15 (94%) returning to their previous level of activity at an average time of 4.1 months. The mean preoperative pain score was 8.1 (range, 4.0-10.0), whereas the mean postoperative pain score was 0.41 (range, 0-1.5), indicating significant pain relief (P < .001). The Disabilities of the Arm, Shoulder, and Hand scores demonstrated only mild residual disability (mean, 6.6) at follow-up.

CONCLUSION

The use of a suture anchor to repair the extensor carpi radialis brevis to the epicondyle after debridement was a satisfactory procedure for recalcitrant lateral epicondylitis with regard to strength, return to previous activities, and pain relief.

Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies

Clinical and cadaveric studies were done to investigate the role of a degenerative fringe of the radiocapitellar complex subluxating in the radiocapitellar joint in patients with lateral epicondylitis. In the clinical study, arthroscopic resection of this capsular complex was done. Thirty patients with recalcitrant symptoms of lateral epicondylitis for a minimum of 9 months had surgery. In all patients at arthroscopy, a collar-like band of radiocapitellar capsular complex was found to impinge on the radial head and subluxate into the radiocapitellar joint with manipulation under direct vision. Histologic analyses of the resected tissue showed hyaline degeneration and fibrosis. There were no complications in this series. Twenty-eight patients had complete relief of symptoms by this procedure within 2 weeks of surgery. The average time until return to work was 7 days. Elbow arthroscopy was done in 34 cadaveric elbows to examine the relationship of the annular ligament, the lateral joint capsule, and the radial head. A degenerative capsular fold impinging on the radial head was seen in 15 elbows. A classification system, based on the relationship of the capsular fold to the radial head is described. In Type 1 (19 elbows), the radial head is completely exposed. In Type 2 (six elbows), there is partial coverage of the radial head by the capsuloligamentous complex without interposition into the joint in any position. In Type 3 elbows (six elbows), there is subluxation of the capsular edge into the joint, whereas in Type 4 elbows (three elbows), the radial head is completely obscured throughout the range of motion. The lesion was equally prevalent in men and women. The arthroscopic findings at the time of surgery in the clinical group were the same as the Grade 2 and Grade 3 changes that were seen in cadaveric specimens.

Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis

PURPOSE

The long-term outcome of this new endoscopic technique was compared with that of the classical open Hohmann procedure.

TYPE OF STUDY

Retrospective cohort study.

METHODS

During 1992 and 1995, 37 patients were surgically treated with the Hohmann procedure after failed intensive conservative treatment. At an average of 92 months after the operation, 30 patients (81%) could be clinically re-examined and were evaluated with a standard questionnaire including the scores of Roles and Maudsley and Morrey et al.

RESULTS

Twenty of these patients were treated endoscopically and 10 with the open technique. There were no differences in demographic data between the 2 groups. At follow-up in both groups, similar results were seen for the function of the elbow, the scores of Roles and Maudsley and Morrey et al., the subjective rating of pain and function of the elbow, and complication rate. The results in the score of Morrey showed an average scoring of 93.2 for the endoscopic group and 87.5 for the open group (P > .05).

CONCLUSIONS

The endoscopic technique showed results comparable to the open technique and can therefore be recommended for wider surgical use so as to learn more details concerning possible complications and results of the new technique.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability

This study evaluates the relative roles of the radial collateral ligament, the lateral ulnar collateral ligament, and the overlying musculature in posterolateral rotatory instability of the elbow. Fourteen cadaveric upper limbs underwent sequential arthroscopic sectioning of the lateral collateral ligament complex. After sectioning, arthroscopic and fluoroscopic evaluation of a lateral pivot shift test was done. Minimal instability was noted after the first section, but no difference between radial collateral or lateral ulnar collateral ligament sectioning was found. A greater degree of instability was seen between the first and second cut ( P = .0001), but no significant difference was seen between sectioning the 2 groups ( P = .61). Complete instability occurred only after sectioning the overlying musculature. On the basis of this study, injury to both the radial collateral and lateral ulnar collateral ligaments is necessary to cause significant posterolateral rotatory instability of the elbow. Furthermore, the overlying musculature plays an important role in overall stability.

Biomechanics and pathophysiology of overuse tendon injuries: ideas on insertional tendinopathy

Tendons behave viscoelastically and exhibit adaptive responses to conditions of increased loading and disuse. High-resolution, real-time ultrasound scanning confirms the applicability of these findings in human tendons in vivo. In addition, recent biomechanical studies indicate that strain patterns in tendons may not be uniform, as tendons show stress-shielded areas and areas subjected to compressive loading at the enthesis. These areas correspond to the sites where tendinopathic characteristics are typically seen. This indicates that some tendinopathies may, paradoxically, be considered as 'underuse' lesions despite the common beliefs that they are overuse injuries. Classic inflammatory changes are not frequently seen in chronic athletic tendon conditions and histopathology features in tendinopathic tendons are clearly different from normal tendons, showing an exaggerated dysfunctional repair response. Tendinopathies are traditionally considered overuse injuries, involving excessive tensile loading and subsequent breakdown of the loaded tendon. Biomechanical studies show that the strains within the tendons near their insertion site are not uniform. If the material properties are similar throughout the tendon, forces transferred through the insertion site preferentially load the side of the tendon that is usually not affected initially in tendinopathy. In that case, the side affected by tendinopathy is generally 'stress shielded'. Thus, the presence of differential strains opens the possibility of alternative biomechanical explanations for the pathology found in these regions of the tendon. The traditional concept of tensile failure may not be the essential feature of the pathomechanics of insertional tendinopathy. Certain joint positions are more likely to stress the area of the tendon commonly affected by tendinopathy. Incorporating different joint position exercises may exert more controlled stresses on these affected areas of the tendon, possibly allowing better maintenance of the mechanical strength of that tendon region and, therefore, prevent injury. Such exercises could stress a healing area of the tendon in a controlled manner and thus stimulate healing once an injury has occurred. Additional work is needed to prove whether such principles should be incorporated in current rehabilitation techniques.

Traitement arthroscopique de l’épicondylalgie d’origine tendineuse

The purpose of the study was to report our experience in a preliminary series of patients who underwent arthroscopic treatment of tennis elbow in order to appreciate effectiveness of this method. Between September 2000 and February 2004, we treated arthroscopically fourteen patients with epicondylitis which failed to respond to medical treatment given for a mean duration of 15.8 months. We used the technique described by Baker in 1999. Briefly, the external capsule was sectioned followed by section of the extensor carpi radialis brevis and extensor digitorum communis insertions on the epicondyle. Section was continued until muscle fibers were visible. Mean patient age was 45 years (range 36-55). Five patients were victims of occupational accidents and one had an occupational disease. One patient suffered from fibromyalgia. All patients were reviewed at a mean follow-up of 11.5 months. We used the Mayo Clinic score to assess outcome which was excellent or good in nine patients, fair in one and poor in four. Despite these modest preliminary results, arthroscopy appears to be well indicated for this pathological condition. The ideal treatment remains a question of discussion.

Lateral epicondylitis

Lateral epicondylitis is a diagnostic term that describes a pattern of pain and localized tenderness at the lateral epicondyle of the distal humerus. In this article, we discuss the pathology, clinical presentation, and treatment of this disorder. After a description of nonoperative treatment, we focus on the operative techniques for treating the disorder, and touch on postoperative care and results of treatment.

Return to sport following elbow surgery

Although less common than injuries to the knee or shoulder, elbow injuries can be a substantial challenge to sports medicine providers. Many elbow problems respond to routine nonoperative measures including periods of activity modification and physical therapy, but others may ultimately require surgery. Following surgery, appropriate attention to rehabilitation is important to achieve optimal function. This article addresses some of the more common sports-related operative elbow pathology, basic principals of surgery (with an emphasis on techniques only where it may impact rehabilitation or return-to-sport decisions), and return-to-play decisions (including typical "targeted" time frames). The emphasis is on an understanding of sport-specific functional demands and the difficult assessment of reinjury risk following surgery.

Compression etiology in tendinopathy

Recent studies have emphasized that the etiology of tendinopathy is not as simple as was once thought. The etiology is likely to be multifactorial. Etiologic factors may include some of the traditional factors such as overuse, inflexibility, and equipment problems; however, other factors need to be considered as well, such as age-related tendon degeneration and biomechanical considerations as outlined in this article. More research is needed to determine the significance of stress-shielding and compression in tendinopathy. If they are confirmed to play a role, this finding may significantly alter our approach in both prevention and in treatment through exercise therapy. The current biomechanical studies indicate that certain joint positions are more likely to place tensile stress on the area of the tendon commonly affected by tendinopathy. These joint positions seem to be different than the traditional positions for stretching exercises used for prevention and rehabilitation of tendinopathic conditions. Incorporation of different joint positions during stretching exercises may exert more uniform, controlled tensile stress on these affected areas of the tendon and avoid stresshielding. These exercises may be able to better maintain the mechanical strength of that region of the tendon and thereby avoid injury. Alternatively, they could more uniformly stress a healing area of the tendon in a controlled manner, and thereby stimulate healing once an injury has occurred. Additional work will have to prove if a change in rehabilitation exercises is more efficacious that current techniques.

Arthroscopic resection of the common extensor origin: anatomic considerations

This study examines the intra-articular anatomy and safe zones for arthroscopic resection of the common extensor origin for the treatment of lateral epicondylitis. The extensor complex was arthroscopically debrided in 7 cadaveric elbows to determine the percentage of each tendinous origin that was resectable. Elbow stability was assessed, and safe zones of resection were determined. The extensor carpi radialis brevis and extensor digitorum communis origin was resected a mean of 100% and 90%, respectively. Elbow stability was maintained when resection did not extend posteriorly to an intra-articular line bisecting the radial head. Posterolateral rotatory instability occurred when debridement was continued posteriorly to the axis of the radial head. In conclusion, complete resection of the extensor carpi radialis brevis-extensor digitorum communis common origin is achievable via standard arthroscopic techniques. The lateral ulnar collateral ligament remains intact and elbow stability is maintained when debridement of the extensor origin does not extend posteriorly to a line bisecting the radial head.

V-Y slide of the common extensor origin for lateral elbow tendonopathy

Twenty-two patients (23 limbs) with chronic lateral elbow tendonopathy were examined retrospectively after surgical management. Thirteen men and 9 women with an average age of 43 years (range, 32-54 years) had a mean follow-up time of 41.2 months (range, 9-97 months). All patients underwent at least 6 months of nonsurgical treatment without favorable response. V-Y slide of the common extensor origin was done for all patients. Sixteen patients (17 elbows) were examined after surgery and 6 were interviewed by telephone. None of the patients had major complications or permanent loss of elbow motion. A pain rating scale of 1 to 10 (10 being the worst) showed a difference from a rating of 9.0 (range, 7-10) before surgery to 1.4 (range, 0-4) after surgery. Grip strength increased from 57 lb (range, 5-125 lb) to 99 lb (range, 60-135 lb). Five patients (23%) reported some degree of cold intolerance. Twenty-one patients (95%) returned to their preoperative occupation with 1 patient not returning to work because of elbow pain caused by heavy and repetitive elbow stress especially from vibrating tools. Twenty-one patients (95%) reported no limitations in daily activities; 1 patient reported difficulty with opening jars. Seven people (32%) reported limitations in high-demand recreational activities. All patients were rated as poor before surgery and excellent or good after surgery by a grading scale. All patients were satisfied with the outcome of surgery. After surgical treatment for lateral elbow tendonopathy, pain relief and restoration of elbow function can be achieved. V-Y slide of the extensor origin has low morbidity, does not violate the joint space or lateral stabilizing ligaments of the elbow, allows adequate release, and has a high rate of satisfaction.