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Open Release for Lateral Epicondylitis

Open Release for Lateral Epicondylitis

Lateral epicondylitis, or "tennis elbow," is a common cause of pain in today's active population. Not isolated to athletes in racquet sports, it is often seen in manual laborers and those whose occupation involves repetitive wrist extension and alternating supination and pronation.

Although a common injury, the optimal treatment for lateral epicondylitis has yet to be determined. Most physicians will initially treat conservatively with good results. This usually involves the use of braces/straps, exercises, and injections. New modalities — such as shockwave, botulism injections, laser, and platelet-rich plasma injections — have shown mixed results. Although most cases of lateral epicondylitis will improve with time, some patients continue to have residual symptoms and eventually seek out surgical treatment. Unfortunately, no single nonsurgical or surgical treatment has been shown to be superior.

There are several described approaches, including open, percutaneous, and arthroscopic release. Open release is simple and reproducible with excellent results and still considered the "gold standard". Open release has good long-term results. A study by Dunn1 showed that 84% of patients had good to excellent results and 93% returned to sports at minimum 10-year follow-up. Nirschl and Petrone also reported excellent results in 75% of patients with open release.2

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Although arthroscopic release has shown promising results, the learning curve is steep, the OR set-up long, and the complications associated with elbow arthroscopy unnecessary. In addition, it is unclear whether arthroscopy is effective in identifying and removing the degenerative portion of the extensor tendon. One study revealed that residual microscopic tendinopathy was observed in 10 of 18 patients after arthroscopic release. This led to poorer patient outcomes.3

There are no prospective randomized trials comparing open versus arthroscopic release for lateral epicondylitis in the literature. Furthermore, few comparative studies exist comparing arthroscopic and open techniques. The largest study comparing open with arthroscopic release by Szabo4 was non-randomized and retrospective. In this study, no difference was found between the two techniques. Another study by Peart et al5 also found no difference between arthroscopic and open techniques, with good to excellent results seen in 69% of open and 72% of arthroscopic cases.

In addition to the increased operative time and cost associated with arthroscopic release for lateral epicondylitis, there is a risk of nerve injury, heterotopic ossification, and posterolateral instability. Kelly found a 2% incidence of transient nerve palsy in elbow arthroscopy.6 On the other hand, arthroscopists feel that assessment for intra-articular pathology is important in the treatment of "lateral elbow pain." If the clinical diagnosis is in question, advanced imaging such as MRI can assist in determining the need for concomitant arthrotomy at the time of open release.

Open Release Technique

The term “epicondylitis” is a misnomer, as it is not an inflammatory condition. The underlying lesion is in the origin of the extensor carpi radialis brevis (ECRB). Microscopic tears in the origin lead to tendinonis and subsequent replacement with immature reparative tissue, angiofibroblastic hyperplasia. Nirchl found that 35% to 50% of patients also have degeneration within the extensor digitorum communis (EDC). Calcific tendinosis is sometimes observed (Figure 1). Many procedures have been described that release the damaged tendon, remove the degenerative tissue and/or lengthen the ECRB. Below is a brief description of open ECRB release.


Figure 1. Calcifications found on extensor origin (black arrow).


A small 4-cm incision is centered over the lateral epicondyle (Figure 2). The extensor aponeurosis is identified and incised in line with its fibers. The ECRB is deep and posterior to the extensor carpi radialis longus (ECRL), its tendinous origin a sharp contrast to the muscular origin of the ECRL (Figure 3). The ECRB is released (and the EDC, if involved) and degenerative tissue is removed (Figure 4). The epicondyle is decorticated with a rongeur and the ECRB is reattached (Figures 5, 6).


Figure 2. Small incision centered distally over lateral epicondyle.


Figure 3. Origins of ECRB and EDC identified.


Figure 4. ECRB elevated and degenerative tissue removed.


Figure 5. Lateral epicondyle decorticated with rongeur.


Figure 6. Remaining ECRB and EDC sutured.


Postoperatively, patients are kept in a sling until suture removal 7-10 days later. Early range of motion is encouraged immediately, and strengthening exercises are not started until 4 to 6 weeks postoperatively, depending on the extent of release. A counterforce brace is recommended for all activities for 6 weeks and a further 6 weeks for high-demand sports (golf, tennis). Complications such as posterolateral instability, extensor weakness and neuroma from the posterior cutaneous nerve of the forearm have not been encountered.

Conclusion

Most patients with lateral epicondylitis will improve with conservative management. Unfortunately, few prospective randomized trials support either arthroscopic or open release. A 2002 Cochrane review found that no conclusion could be drawn on the success of one operative treatment over another.7 Open, percutaneous, endoscopic, and arthroscopic treatments have all been described with excellent results. If surgery is considered, then open release provides a reproducible, safe method with excellent long-term results. Surgeons should decide on treatment based on personal experience and comfort with the procedure.

Reprinted with permission from the Fall 2008 issue of COA Bulletin

References

  1. Dunn JH, Kim JJ, Davis L, Nirschl RP, 2008. "Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis." Am J Sports Med 36 (2): 261-6
  2. Nirschl RP, Pettrone FA, 1979. "Tennis elbow. The surgical treatment of lateral epicondylitis." J Bone Joint Surg Am 61 (6A): 832-9
  3. Cummins CA, 2006. "Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes." Am J Sports Med 34 (9): 1486-91
  4. Szabo SJ, Savoie FH, Field LD, Ramsey JR, Hosemann CD, 2006 Nov-Dec. "Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment." J Shoulder Elbow Surg 15 (6): 721-7
  5. Peart RE, Strickler SS, Schweitzer KM, 2004. "Lateral epicondylitis: a comparative study of open and arthroscopic lateral release." Am J Orthop (Belle Mead NJ) 33 (11): 565-7
  6. Kelly EW, Morrey BF, O'Driscoll SW, 2001. "Complications of elbow arthroscopy." J Bone Joint Surg Am 83-A (1): 25-34
  7. Buchbinder R, Green S, Bell S, Barnsley L, Smidt N, Assendelft WJ, 2002. "Surgery for lateral elbow pain." Cochrane Database Syst Rev (1): CD003525
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