The Three-Portal Technique in Arthroscopic Lateral Epicondylitis Release.

Lateral epicondylitis, commonly referred to as tennis elbow, is a syndrome characterized by pain over the origin of the common extensor muscles of the fingers, hand and wrist at the lateral epicondyle. Reports of 70-90% response to conservative treatment at one year have been documented in the literature though refractory cases often require surgical management. Arthroscopic treatment of lateral epicondylitis allows for intra-articular visualization for concomitant pathology and localization of the Extensor Carpi Radialis Brevis tendon. Additionally, compared to the open technique, the arthroscopic technique has a lower morbidity and an earlier return to work and activity. Here we describe a three portal technique for improved visualization in arthroscopic lateral epicondylitis release.

Introduction

Lateral epicondylitis, commonly referred to as tennis elbow, is a syndrome characterized by pain over the origin of the common extensor muscles of the fingers, hand and wrist at the lateral epicondyle. One to three percent of the general population and a greater percentage of manual labors suffer from this condition.[1,2] Lateral epicondylitis occurs equally in men and women in their fifth decade and most commonly affects their dominant arm.[1-3]

Reports of 70-90% response to conservative treatment at one year have been documented in the literature.[4,5] For those who fail to improve with conservative treatment, open, percutaneous, and arthroscopic treatments exists.[6-8] Arthroscopic treatment of lateral epicondylitis allows for intra-articular visualization of concomitant pathology and localization of the Extensor Carpi Radialis Brevis (ECRB) tendon. Additionally, compared to the open technique, the arthroscopic technique has a lower morbidity and an earlier return to work and activity.[9] While intra-articular visualization is improved with arthroscopic treatment, in our experience, redundancy of capsular tissue can make localization of ECRB from within the capsule difficult. We describe a three portal technique for improved visualization when utilizing the arthroscopic lateral epicondylitis release technique.

Surgical technique

Arthroscopic lateral epicondylitis release is best performed in the lateral decubitus position with the affected extremity elevated as it provides arm stability. The involved extremity is flexed forward 90 degrees at the shoulder, internally rotated, and hung over a padded bolster flexing the elbow to 90 degrees. This position minimizes intra-articular pressure.[10] Care must be taken to not place the bolster too distally which decreases the available joint space. The primary advantage of the lateral decubitus position is to provide arm stability while allowing adequate airway access.

A tourniquet is placed on the arm and the elbow is prepped and draped in a sterile manner allowing access to both superior and inferior portal sites. Surface landmarks including the lateral epicondyle, medial epicondyle, radial head, capitellum, olecranon, and ulnar nerve are marked. An 18-gauge needle is used to inject up to 25 mL of saline through the anconeous triangle bordered by the lateral epicondyle, radial head, and the olecranon process to distend the joint (Figure 1a). A posteromedial portal is established 2 cm proximal to the medial epicondyle and 1 cm anterior to the intermuscular septum. A posterolateral portal is established 2 cm superior to the anterior aspect of lateral epicondyle (Figure 1b). A switching stick is introduced into the posterolateral portal and guided along the anterior joint capsule towards the medial aspect of the elbow. As the switching stick abuts the medial capsule, a skin incision is made allowing the switching stick to pass through the skin typically proximal and anterior to the posteromedial portal (Figure 1c). Laterally, the switching stick is intracapsular and is used to increase visualization through retraction of the anterior capsule (Figure 2). With the arthroscope in the posteromedial portal, an arthroscopic shaver is introduced through the lateral portal and, with the switching stick acting as an anterior capsule retractor, synovial tissue is debrided and a diagnostic arthroscopy including examination of the radiocapitellar joint and lateral capsule is performed.

Figure 1.

a) Positioning in the lateral decubitus position with joint distension through the anconeous triangle. b) After localization with an 18 gauge needle under direct visualization the posterolateral portal is established. c) A switching stick being passed medially to be used as a anterior capsule retractor.

Figure 2.

Arthroscopic view of the switching stick acting as a retractor on the anterior capsule.

Using an arthroscopic beaver blade (Figure 3) and 2.5 mm full radius resector, the lateral capsule is opened and the ECRB origin is released from the most proximal attachment to its inferior portion and along the condylar attachment to the radial head (Figure 4). Some surgeons advocate decorticating the lateral, nonarticular surface of the epicondyle with a shaver to promote bleeding.[11] A complete debridement and synovectomy is completed with attention to avoidance of the neurovascular structures and the overlying Extensor Carpi Radialis Longus (ECRL) muscle. Care must be taken with posterior resection adjacent to the radial head to avoid resecting below the equator to protect the lateral ulnar collateral ligament.

Figure 3.

Arthroscopic view of Extensor Carpi Radialis Brevis release using an arthroscopic beaver blade.

Figure 4.

a) Arthroscopic view of the radiocapitellar joint from the posteromedial portal with a cannula in the posterolateral portal. b) A resector through the posterolateral portal debriding the undersurface of the Extensor Carpi Radialis Brevis (ECRB) after opening the lateral joint capsule. c) Full debridement of the ECRB.

Postoperatively the patient is splinted in a neutral position for one week. Physical therapy is started at the first postoperative visit with anticipation of return to full activity at six weeks.

Case Report

Recently, we performed this technique in a healthy 55-year old right-hand dominant female who presented with two years of left elbow pain, tenderness over the lateral epicondyle, and increased pain with resisted wrist extension. Prior to surgical intervention she received intra-articular corticosteroid injections and physical therapy without improvement in symptoms. At initial presentation she reported her pain to be 3/10 at rest and 7/10 with activity on the Pain Visual Analog Scale (VAS).

One week postoperatively, the patient demonstrated full range of motion and well-healing surgical incisions. At that point, physical therapy was started. At four months post-procedure, the patient stated her left elbow felt much improved with occasional aches. At greater than one year follow up, she reported her pain improved to 1/10 at rest and 4-5/10 with certain activities on the VAS. She continued to wear a counterforce brace as needed.

Discussion

Pain in lateral epicondylitis is thought to be caused by pathologic degeneration from repetitive mechanical loading of the elbow resulting in cumulative microtrauma to the extensor tendon.[4,6] Histopathologic analysis of the tendinous origin demonstrates degeneration and vascular proliferation without appreciable inflammation.[12] Neovascularization is thought to represent a healing response.[13] Macroscopically, tendinosis appears as grey scar tissue and is friable or edematous.[6]

Boyd et al. have shown non-operative treatment to be effective in the majority of patients.[14] Treatment should be initiated with rest, modification of activity, bracing, acupuncture, cross-frictional massage, and, if needed, steroid injections. Surgical intervention is reserved for those who have not improved with nonsurgical treatment after a one-year duration. To date, a variety of surgical techniques have been described including fasciotomy, z-lengthening of the tendon, osteotomy of the lateral epicondyle with excision of the damaged portion of the ECRB, and open, percutaneous, or arthroscopic tenotomy.[4,6,7,9,14-17]

Fasciotomy alone has shown 86% good to excellent results at 8 year follow up, open release 75-91% good to excellent results at 5 year follow up, percutaneous release 91-96% good to excellent results at 2-3 year follow up, and arthroscopic release 75-95% with improvement at 2 year follow up.[7-9,15-20] A Cochrane review concluded there was insufficient evidence to support any one surgical procedure at this time.[21]

The three portal arthroscopic lateral epicondylitis release has several advantages when compared to existing techniques. First, a comparison of arthroscopic to open and minimally invasive techniques reported earlier return to work and higher satisfaction with less invasive techniques.[22,23] Second, the use of a switching stick as a retractor in the arthroscopic technique allows for an increased area of visualization for confounding intra-articular pathology reported to be seen in at least 5% of all cases.[24] Third, the use of the switching stick as a retractor of the anterolateral intracapsular tissue significantly reduces capsular redundancy allowing for improved localization of the ECRB tendon and reducing the proximity of the tendon to the lateral ulnar collateral ligament.

Conclusions

Lateral epicondylitis, or tennis elbow, is a common tendon injury treated by orthopedic surgeons that affects 1-3% of the population. Here we describe a three portal technique for better visualization in arthroscopic lateral epicondylitis release.