Open Release for Lateral Epicondylitis

John Theodoropoulos, M.D., BSc, FRCSC
University of Toronto Sport Medicine Programme
Mount Sinai Hospital & Women's College Hospital
University of Toronto
Toronto, Ontario

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 labourers 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.

Advantages of Open Release
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 release6.

theofig1.jpg 
Figure 1. Calcifications found on extensor origin (black arrow). 

Although arthroscopic release has shown promising results, the learning curve is steep, the OR set-up long, and the complications associated with elbow arthroscopy are 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 lead to poorer patient outcomes2.

theofig2.jpg 
Figure 2. Small incision centered distally over lateral epicondyle. 

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 Szabo3 was nonrandomized and retrospective. In this study, no difference was found between the two techniques. Another study by Peart et al4 also found no difference between arthroscopic and open techniques with good to excellent results seen in 69% of open and 72% of arthroscopic cases.

theofig3.jpg
Figure 3. Origins of ECRB and EDC identified.

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 arthroscopy5. 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 MR can assist in determining the need for concomitant arthrotomy at the time of open release.

theofig4.jpg
Figure 4. ECRB elevated and degenerative tissue removed.

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 EDC6. 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.

theofig5.jpg
Figure 5. Lateral epicondyle decorticated with rongeur.

A small four centimetre incision is centered over lateral epicondyle (Figure 2). The extensor aponeurosis is identified and incised in line with its fibres. The ECRB is deep and posterior to the 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). Postoperatively, patients are kept in a sling until suture removal 7-10 days later. Early ROM is encouraged immediately and strengthening exercises are not started until four to six weeks postoperatively - depending on the extent of release. A counterforce brace is recommended for all activities for six weeks and a further six 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.

theofig6.jpg
Figure 6. Remaining ECRB and EDC sutured.

Conclusion
The majority of patients with lateral epicondylitis will improve with conservative management. Unfortunately, little 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 another7. Open, percutaneous, endoscopic and arthroscopic treatments have all been described with excellent results. If surgery is considered, then open release provides reproducible, safe method with excellent long-term results. Surgeons should decide on treatment based on personal experience and comfort with the procedure.

References

  1. Dunn J.H., Kim J.J., Davis L., Nirschl R.P. Ten to 14 year Follow-up of the Nirschl Surgical Technique for Lateral Epicondylitis. Am J Sports Med. 2008; 36; 261.
  2. Cummins C. Lateral Epicondylitis: In Vivo Assessment of Arthroscopic Debridement and Correlation with Patient Outcomes. Am J Sports Med 2006; 34; 1486-1491.
  3. Szabo S.J., Nagda S.H., Sennett B.J.: Tendinosis of the extensor carpi radialis brevis: An evaluation of three methods of operative treatment. J Shoulder Elbow Surg 2006; 15: 721-727
  4. Peart R.E., Strickler S.S., Scweitzer K.M. Jr. Lateral epicondylitis: A comparative study of open and arthroscopic lateral release. Am J Orthop 2004; 33: 565-567.
  5. Kelley E.W., Morrey B.F., O'Driscoll S.W. Complications of elbow arthroscopy. J Bone and Joint Surg Amer 2001; 83: 25-34.
  6. Nirschl R.P., Petrrone F.A: Tennis elbow: The surgical treatment of lateral epicondylitis. J Bone and Joint Surg Amer 1979; 61: 832-839.
  7. Buchbinder R., Green S., Bell S., Bamsley L., Smidt N., Assendelft W.J. Surgery for Lateral Elbow Pain. Cochrane Database Syst Rev. 2002; (1).

Submit Community Content

If you have orthopedic information that you would like to share with the Orthogate Community, please register/login and submit your news, event, job, article, case or workshop from the Submit Content menu under the My Account area. Learn more!