Arthroscopic Release for Tennis Elbow
Abstract & Commentary
Synopsis: Arthroscopic release for recalcitrant tennis elbow yielded subjective improvement for all patients, with a rapid return to work averaging just 6 days.
Source: Owens BD, et al. Arthroscopic release for lateral epicondylitis. Arthroscopy. 2001;17(6):582-587.
Tennis elbow, or lateral epicondylitis, is a common musculoskeletal complaint among active people. The etiology is accepted to involve microscopic or macroscopic rupture of the extensor carpi radialis brevis (ECRB) tendon origin from the lateral epicondyle. About 90% of these patients improve with nonoperative measures that include steroid injections, anti-inflammatory medications, and therapy. Those who do not improve may come to surgery. Owens and colleagues from the Walter Reed Army Medical Center have provided the first clinical paper that looks at using the arthroscope to treat this problem. Kuklo, one of the researchers, previously had described the technique in a cadaver study.
Sixteen patients had lateral epicondylitis that was refractory to treatment for at least 6 months. Patients had an average of 2.4 steroid injections per elbow. The average length of conservative treatment was almost 3 years. The surgery involved placing the patient prone and using proximal medial and proximal lateral portals to access the joint. While visualizing the joint from a proximal medial portal, the shaver was introduced through the proximal lateral portal. They described the pathology as falling into equal distributions, with about one third of the patients having a frayed undersurface of the ECRB, one third having linear tears within the ECRB, and a one third having partial or complete avulsion of the ECRB origin. Arthroscopic treatment involved using a shaver to resect the synovium plus damaged portion of the ECRB followed by a burr to decorticate the lateral epicondyle. A fairly generous epicondyle resection was performed averaging 22 mm on their cadaver study with 23 mm of ECRB tendon release. No attempt at repair was made.
The patients were immobilized in a simple sling for 2-3 days with early active range and return to activity as tolerated. This averaged just 6 days with a maximum of 28 days for full return to work. They lost one quarter of the patients to follow-up because of military transfer, but in the remaining patients followed an average of 2 years, 10 of the 12 reported feeling much better and none reported feeling the same or worse. They documented this with a visual analogue scale and also found all but 1 patient returned to sports.
Comment by David R. Diduch, MS, MD
This is an interesting paper for a common problem. Treatment options for lateral epicondylitis that fail nonoperative measures are varied to include simple percutaneous release of the ECRB origin, open ECRB excision of the degenerative tissue, + or - repair, and lateral epicondylar decortication. Owens et al now effectively demonstrate that arthroscopic treatment offers a viable alternative. The advantages they tout are to allow visualization of associated intraarticular pathology. However, only 3 elbows had any pathology that required treatment. This included synovitis or small spurs. They do make a case for the arthroscopic method allowing safe and effective release of the ECRB and decortication of the lateral epicondyle. They previously demonstrated with a cadaver study that the limits of visualization through the scope basically prevent excessive resection of the lateral epicondyle that could lead to damage to the lateral ligaments and subsequent instability.
Although the number of patients treated is small, the follow-up appears adequate and the results, I think, are valid. The major question is whether this is technically demanding in that Owens et al are the same ones that described the cadaveric study originally and have been doing this for 5 years. The return to work is amazingly short and is a testimony to the minimum morbidity encountered with arthroscopic or minimally invasive procedures. If these results can be reproduced by other arthroscopists, then it offers an encouraging alternative to open surgical treatment for this common problem.
Dr. Diduch, Editor of Sports Medicine Reports, is Associate Professor in the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville.
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