Orthopedics

Feature Article 

Exclusive Posterolateral Arthroscopic and Endoscopic Approaches Used in the Treatment of Lateral Epicondylitis

Romain Colombi, MD; Adrien Bevand, MD; Alexandre Devillier, MD; Emmanuel Baulot, MD; Abdelilah Ezzahoui, MD; Pierre Martz, MD

Abstract

Complications following arthroscopy of the elbow for the treatment of lateral epicondylitis are essentially related to the anterior arthroscopic approach. The principal aims of this study were to describe and evaluate the mixed arthroscopic and endoscopic surgical technique using posterolateral approaches exclusively. This was a retrospective study of consecutive patients operated on between 2005 and 2014 for lateral epicondylitis following more than 6 months of ineffective medical treatment. The exploration was arthroscopic via a distal posterolateral portal. The extensor carpi radialis brevis was disinserted via a proximal extra-articular posterolateral endoscopic portal. The postoperative clinical follow-up included subjective (visual analog scale, Nirschl) and objective (Mayo Clinic Elbow Performance Score) evaluations of pain, the time to return to work, the level of satisfaction, complications, and failures. Thirty-seven patients underwent the procedure, including 3 lost to follow-up. Mean±SD follow-up was 32.8±24.7 months. Mean±SD visual analog scale scores were 0.8±0.8 at rest, 2.4±1.3 during everyday activities, and 3.1±1.5 during effort. Mean±SD Mayo Clinic Elbow Evaluation Score was 10.1±1.0 of 12 and mean±SD Mayo Clinic Elbow Performance Score was 91.9±12.5 of 100. Mean±SD Nirschl score was 67.5±9.6 of 80. Mean±SD time to return to work was 2.0±2.6 months. The level of satisfaction was 94.1%. The failure rate was 2.9%, with no neurological lesions. With equivalent or even better results than those already published, this surgical procedure enables the treatment of lateral epicondylitis via posterolateral portals alone, thus avoiding the complications inherent to anterior and medial arthroscopic approaches. [Orthopedics. 2019; 42(6):e521–e527.]

Abstract

Complications following arthroscopy of the elbow for the treatment of lateral epicondylitis are essentially related to the anterior arthroscopic approach. The principal aims of this study were to describe and evaluate the mixed arthroscopic and endoscopic surgical technique using posterolateral approaches exclusively. This was a retrospective study of consecutive patients operated on between 2005 and 2014 for lateral epicondylitis following more than 6 months of ineffective medical treatment. The exploration was arthroscopic via a distal posterolateral portal. The extensor carpi radialis brevis was disinserted via a proximal extra-articular posterolateral endoscopic portal. The postoperative clinical follow-up included subjective (visual analog scale, Nirschl) and objective (Mayo Clinic Elbow Performance Score) evaluations of pain, the time to return to work, the level of satisfaction, complications, and failures. Thirty-seven patients underwent the procedure, including 3 lost to follow-up. Mean±SD follow-up was 32.8±24.7 months. Mean±SD visual analog scale scores were 0.8±0.8 at rest, 2.4±1.3 during everyday activities, and 3.1±1.5 during effort. Mean±SD Mayo Clinic Elbow Evaluation Score was 10.1±1.0 of 12 and mean±SD Mayo Clinic Elbow Performance Score was 91.9±12.5 of 100. Mean±SD Nirschl score was 67.5±9.6 of 80. Mean±SD time to return to work was 2.0±2.6 months. The level of satisfaction was 94.1%. The failure rate was 2.9%, with no neurological lesions. With equivalent or even better results than those already published, this surgical procedure enables the treatment of lateral epicondylitis via posterolateral portals alone, thus avoiding the complications inherent to anterior and medial arthroscopic approaches. [Orthopedics. 2019; 42(6):e521–e527.]

Release of the extensor carpi radialis brevis (ECRB) tendon by arthroscopy is a validated surgical technique for the treatment of lateral epicondylitis refractory to medical treatment for more than 6 months.1 However, this arthroscopic technique is associated with neurological complications inherent to the use of anterior and medial approaches.2–5

Grifka et al6 were the first to publish an exclusively extra-articular approach with endoscopic technique for the treatment of lateral epicondylitis. This technique was taken up by others7,8 but criticized because there was no intra-articular exploration or detailed series. The principal aim of the current study was to describe a technique that associates arthroscopy and endoscopy via 2 exclusively posterolateral portals to avoid the complications of the anterior or medial approaches used in classical arthroscopic treatment. The authors' hypothesis was that this combined technique would provide results equivalent to those of arthroscopy alone but with less morbidity.

Materials and Methods

Population of the Study

This was a retrospective, single-center, single-operator study of 37 consecutive patients operated on between June 2005 and August 2014 using arthroscopy/endoscopy of the elbow for lateral epicondylitis. Inclusion criteria were all patients older than 18 years with a lateral epicondylitis refractory to more than 6 months of medical treatment, which included various associations of analgesics, corticosteroid infiltrations, rest orthoses, or physiotherapy. The diagnosis of lateral epicondylitis was based on a physical examination and ultrasonography. The following exclusion criteria were applied: follow-up of less than 6 months, patients younger than 18 years, and patients who had already undergone surgery for their epicondylitis.

Surgical Technique

All operations were performed in an outpatient setting and under locoregional anesthesia. Patients were placed in a lateral decubitus position with a pneumatic tourniquet around the root of the upper arm with the forearm hanging down at 90° of flexion. The principal anatomical landmarks and the 2 portals were identified and marked with a skin marker before the incision (Figure 1).

Photograph showing the anatomical landmarks in a right elbow in lateral decubitus.

Figure 1:

Photograph showing the anatomical landmarks in a right elbow in lateral decubitus.

The distal posterolateral optical portal was situated on the lateral edge of the insertion of the brachial triceps. After injecting 15 to 20 mL of physiological saline into the soft point to distend the joint capsule and to displace the vessel and nerve structures forward, a conventional optical device (4-mm diameter, angle of 30°)9 was used for the posterior arthroscopic exploration of the elbow to rule out differential diagnoses (Figure 2).

The patient is placed in a lateral decubitus position with a pneumatic tourniquet around the root of the upper arm and the forearm hanging down at 90° of flexion (A). Fifteen to 20 mL of physiological saline is injected into the soft point to distend the joint capsule and to displace the vessel and nerve structures forward (B). The blunt trocar is inserted via the distal posterolateral approach, remaining in contact with the distal humerus (C). Instruments are guided toward the lateral crest of the humerus to create a cavity using the radiofrequency probe and hydraulic pressure, and then the extensor carpi radialis brevis is released (D). A bone curette, inserted via the proximal approach, was used to complete the disinsertion of the extensor carpi radialis brevis tendon (E). The disinsertion is checked and completed by inverting approaches (proximal for the optical and distal for the instrumental) (F).

Figure 2:

The patient is placed in a lateral decubitus position with a pneumatic tourniquet around the root of the upper arm and the forearm hanging down at 90° of flexion (A). Fifteen to 20 mL of physiological saline is injected into the soft point to distend the joint capsule and to displace the vessel and nerve structures forward (B). The blunt trocar is inserted via the distal posterolateral approach, remaining in contact with the distal humerus (C). Instruments are guided toward the lateral crest of the humerus to create a cavity using the radiofrequency probe and hydraulic pressure, and then the extensor carpi radialis brevis is released (D). A bone curette, inserted via the proximal approach, was used to complete the disinsertion of the extensor carpi radialis brevis tendon (E). The disinsertion is checked and completed by inverting approaches (proximal for the optical and distal for the instrumental) (F).

Instruments were inserted via a proximal posterolateral approach situated approximately 3 cm proximal and 1 cm lateral to the distal optical approach (Figure 3). Concerning the endoscopic procedure, a blunt trocar was inserted through the distal approach, remaining in contact with the distal humerus; the instruments were then guided toward the lateral crest of the humerus to create a cavity using the radiofrequency probe and hydraulic pressure (between 25 and 40 mm Hg).

Disinsertion of the extensor carpi radialis brevis tendon in a right elbow in lateral decubitus using a radiofrequency probe. General view (top). Arthroscopic view (bottom left) and its schema (bottom right). Abbreviations: L, lateral edge; M, medial edge; 1, posterior aspect of the lateral epicondyle; 2, disinsertion of the extensor carpi radialis brevis using proximal/medial to lateral movement of the radiofrequency probe; 3, extensor carpi radialis brevis.

Figure 3:

Disinsertion of the extensor carpi radialis brevis tendon in a right elbow in lateral decubitus using a radiofrequency probe. General view (top). Arthroscopic view (bottom left) and its schema (bottom right). Abbreviations: L, lateral edge; M, medial edge; 1, posterior aspect of the lateral epicondyle; 2, disinsertion of the extensor carpi radialis brevis using proximal/medial to lateral movement of the radiofrequency probe; 3, extensor carpi radialis brevis.

Release of the ECRB tendon insertion started with the superficial fibers and was performed using a mediolateral movement of the radiofrequency probe until the lateral humeral crest (Figure 4). The lateral collateral ligament insertion is anterior to the crest and de facto out of the working visual field (Figure 3). This disinsertion was performed carefully while monitoring for any extension movements of the wrist, which would reveal the proximity of the motor branches of the radial nerve. During the disinsertion, the authors take care to remove the maximum amount of angiofibrodysplastic tissue with a radiofrequency probe. A bone curette, inserted via the proximal approach, was used to complete the disinsertion of the ECRB tendon if necessary (Figure 5). By inversing the approaches (proximal for the optical and distal for the instrumental), it was possible to check the disinsertion from another angle and to complete if necessary.

Intraoperative arthroscopic photograph of the extensor carpi radialis brevis disinsertion in a right elbow in lateral decubitus. Extensor carpi radialis brevis origin just before disinsertion (A). Arthroscopic photograph of the extensor carpi radialis brevis origin after disinsertion (B). Arthroscopic photograph showing view just after the extensor carpi radialis brevis disinsertion (C). Abbreviations: 1, posterior aspect of the lateral epicondyle; 2, radiofrequency probe; 3, extensor carpi radialis brevis; 4, extensor carpi radialis brevis footprint after disinsertion; 5, lateral crest of the epicondyle visible after extensor carpi radialis brevis disinsertion with a distal posterolateral look.

Figure 4:

Intraoperative arthroscopic photograph of the extensor carpi radialis brevis disinsertion in a right elbow in lateral decubitus. Extensor carpi radialis brevis origin just before disinsertion (A). Arthroscopic photograph of the extensor carpi radialis brevis origin after disinsertion (B). Arthroscopic photograph showing view just after the extensor carpi radialis brevis disinsertion (C). Abbreviations: 1, posterior aspect of the lateral epicondyle; 2, radiofrequency probe; 3, extensor carpi radialis brevis; 4, extensor carpi radialis brevis footprint after disinsertion; 5, lateral crest of the epicondyle visible after extensor carpi radialis brevis disinsertion with a distal posterolateral look.

Inversion of the approaches to complete extensor carpi radialis brevis tendon disinsertion in a right elbow in lateral decubitus. Arthroscopic view (top and bottom left) and its schema before inversion of the approaches (top right) and just after (bottom right). Abbreviations: 1, camera; 2, instruments (ie, radiofrequency probe).

Figure 5:

Inversion of the approaches to complete extensor carpi radialis brevis tendon disinsertion in a right elbow in lateral decubitus. Arthroscopic view (top and bottom left) and its schema before inversion of the approaches (top right) and just after (bottom right). Abbreviations: 1, camera; 2, instruments (ie, radiofrequency probe).

Finally, using the distal posterolateral approach once again to view the field, the quality of the therapeutic procedure was assessed by examining the posterior head of the radius, which is the only arthroscopic diagnosis available. The procedure ended with an extra-articular infiltration of corticosteroids via the distal approach (5 mL of betamethasone), and patients were required to wear a sling for 2 weeks. Immediate mobilization of the elbow was authorized; muscle-strengthening physiotherapy and resistance training were started 4 weeks postoperatively, and return to sports activities was possible after 8 weeks.

Method of Evaluation

The epidemiological data for patients included age, sex, and dominant side. The postoperative clinical follow-up investigated pain, time to return to work, level of satisfaction, complications, and treatment failures. Assessment was done after least at 6 months of follow-up. Success was defined as a pain decrease until a low level at rest and with effort (visual analog scale score, <4), and failure was defined as the persistence or recurrence of symptoms at the last follow-up.

A visual analog scale score from 0 to 10 was used to evaluate subjective pain at rest, during everyday activities, and with effort. The functional result was evaluated using the Mayo Clinic elbow evaluation from 0 to 12,10 the Mayo Elbow Performance Score (MEPS),10 and the Nirschl score11 (additional data). Satisfaction was evaluated by asking patients whether they were satisfied with the operation, whether they felt better (“worse,” “the same,” “better,” or “much better”), and whether they would undergo this procedure again.

Results

A total of 37 patients were included in the initial study, with 3 (8.1%) excluded because they were lost to follow-up. Thirty-four patients (13 [38.2%] men and 21 [61.8%] women; mean±SD age, 47.6±8.1 years) were seen again after a mean±SD follow-up of 32.8±24.7 months. Of the 13 (38.2%) left elbows and 21 (61.8%) right elbows, 32 (94.1%) procedures concerned the dominant limb.

Among the patients, 94.1% (32 of 34) were satisfied and 28 patients (82.4%) felt better or much better, so there was a high level of satisfaction with this procedure. Thirty-one (91.2%) patients said they would agree to undergo this surgical procedure again.

Mean±SD visual analog scale score was 0.8±0.8 at rest, 2.4±1.3 during everyday activities, and 3.1±1.5 during effort. Mean±SD functional results were 10.1±1.0 for the Mayo Clinic elbow evaluation, 91.9±12.5 for the MEPS, and 67.5±9.6 for the Nirschl score. The complication rate was 5.9% (2 of 34 patients) without any nerve damage but 2 paitents had complex regional pain syndromes that resolved without sequelae after physiotherapy. The authors did not note any posterolateral instability. The failure rate was 2.9% (1 of 34), with 1 patient requiring an open surgical release. Mean±SD time to the return to work was 2.0±2.6 months, although 2 patients did not return to work until 12 months postoperatively, thus explaining the large SD. One of these patients had recurrent epicondylitis, and the other had a complex regional pain syndrome.

Discussion

Release of the ECRB tendon insertion via an exclusive posterolateral approach showed good results in the treatment of lateral epicondylitis recalcitrant to medical treatment.

Indication between surgical and medical treatment for chronic lateral epicondylitis is still a matter of debate. Nonetheless, when surgery becomes necessary, there are many techniques available: open, percutaneous, endoscopic, or (more recently) arthroscopic; however, no consensus exists as to whether one technique is superior to another.2,12–14 Medical treatment is recommended for at least 6 months to stop the inflammatory process15,16 and to initiate healing of the tendon before contemplating surgery.17

The arthroscopic procedure has been validated previously, with mean postoperative MEPS scores ranging from 78.618 to 9519 (Table 1); the current study found a mean MEPS score in the higher range at 91.9. Similarly, the mean Mayo Clinic elbow evaluation of 10.1 in the current study was similar to scores reported in the literature, which range from 10.920 to 11.7.21 Mean Nirschl scores ranged between 61.722 and 76.3,22 whereas the current authors reported a mean score of 67.5. Good or excellent results were obtained in 82.3% of patients, which was in the average of what has been reported in the literature (between 64%23 and 100%24,25).

Series in the Literature

Table 1:

Series in the Literature

Altogether, 94.1% of the current patients were satisfied with this procedure compared with 82.2%26 to 92.9%27 for arthroscopic surgery using an anterior approach (Table 1). Time to functional recovery was up to 18.5 weeks after arthroscopic surgery according to Grewal et al,18 which is inferior to the current study which reported a mean of 2,0 months to return to work.

The fact that the current authors used posterolateral approaches exclusively enabled them to avoid complications inherent to anterior and medial approaches2,28,29 related to the proximity of neurovascular structures.28 In the literature, the current authors found up to 14% of neurological complications after arthroscopic surgeries for various conditions (not only for lateral epicondylitis), with involvement of the radial, ulnar, posterior interosseous, anterior interosseous, and medial cutaneous nerves of the forearm.3,30

Nevertheless, neurologic complications after arthroscopic treatment with a standard anterior approach to lateral epicondylitis are not commonly reported in the literature (Table 1). Some authors have reported superficial3,20,23,31 or deep infections,3 skin burns,23,31 recurrent symptoms relieved by infiltrations,22,32 or subjective instability,22 none of which are specific complications inherent to anterior and medial approaches. In addition, posterolateral approaches make it possible to extend the indications by including patients with instability of the ulnar nerve (operated on or not).

In the current study, there were 2 cases of complex regional pain syndromes. However, in the literature, few authors report the emergence of this complication after elbow arthroscopy. The 2 complex regional pain syndrome cases occurred in at-risk patients (women 45 to 55 years old)33; nevertheless, no intraoperative factor was observed (surgical duration, tourniquet time, immobilization). The arthroscopic anterior-based, intra-articular approach (especially when using a 30° scope) has a limitation of poor visualization of the whole ECRB tendon (which is an extra-articular structure). A recent study showed that this limitation can be overcome in part by use of a 70° scope.34 An advantage of this technique is better visualization of the ECRB tendon using a standard 30° scope compared with standard technique.

In the literature, only 3 studies have dealt with endoscopy of the elbow for the treatment of lateral epicondylitis, one of which is a German series reported by Krämer in 1993 (written in German), with the results presented in English by Grifka et al6 in 1995. They reported 34 endoscopies with no complications but did not provide details of the patients characteristics.6

Similarly, in 2005, Rubenthaler et al7 presented a retrospective cohort comparing 20 endoscopic procedures with 10 mini-open surgery procedures and a mean follow-up of 93.6 months. They reported similar results in the 2 groups in terms of function. They concluded that the endoscopic technique was interesting and should be developed provided that no new complications related to this surgery were discovered.7

The current authors found no neurological complications in the current series and the overall rate of complications was low compared with the literature. Indeed, the exclusive use of posterolateral approaches in their technique avoided risks related to the proximity of the radial nerve.

In 2008, Brooks-Hill and Regan8 published an article describing a technique that used an anterolateral arthroscopic approach for visualization associated with an anterolateral endoscopic approach for instrument insertion in the treatment of lateral epicondylitis. The capsulotomy allowed endoscopic debridement, thus avoiding capsulectomy and the associated risks (nerve lesions, instability and the extravasation of liquid leading to compartment syndrome).8 In addition, El Hajj et al35 described an arthroscopic arthrolysis procedure exclusively using an anterolateral approach with the patient in dorsal decubitus with encouraging results.

The limitations of this study included the retrospective design and the absence of a control group. Although the number of patients was small, it is one of the largest series to date, in comparison with published studies (Table 1). The lack of preoperative measurements of clinical scores is also a limitation of this study.

Conclusion

This original procedure of the release of the ECRB tendon insertion, which associates arthroscopy and endoscopy via 2 posterolateral approaches, showed good results in the treatment of lateral epicondylitis recalcitrant to medical treatment. These results seem to be at least equivalent to purely arthroscopic techniques published in the literature but avoid the risks of complications of standard anterior and medial approaches.

This study has reported an improvement regarding the endoscopy-alone technique. It would be interesting to perform a prospective study comparing the current technique with standard arthroscopic treatment to have a precise assessment of their relative results and complications.

References

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Series in the Literature

Study (Year)Mean Follow-up, yNo. of CasesMeanGood and Excellent ResultsSatisfactionComplicationsNeurological ComplicationsFailures

Pain at RestPain in Everyday LifePain on EffortMayo Elbow Score/12MEPS/100Return to Work, wk
Grifka et al6 (1995)340NA
Baker et al36 (2000)2130.91.51.911.193.6595%00
Owens et al37 (2001)2110.61.63.20.983%00
Peart et al12 (2004)3372%NA
Sennoune et al23 (2005)11464%14.3%0
Rubenthaler et al7 (2005)7.82093.2NA
Latterman et al38 (2006)2361.911.172.8%5.6%
Jerosch and Schunck20 (2006)1.8200.511.210.9893.285%5%0
Szabo et al32 (2006)3.9414.9%02.4%
Baker and Baker21 (2008)10.830011.911.797%87%0NA
Wada et al24 (2009)2.3203.4100%00
Grewal et al18 (2009)3.53678.618.583%NA
Yan et al13 (2009)1.41593.3%0NA
Kim et al19 (2011)2.538954.500
Othman27 (2011)114392.9%00
Beauthier and Dumontier31 (2012)4.2260.40.84.1901081%7.7%NA15.4%
Solheim et al2 (2012)4.222578%NA7%
Sauvage et al25 (2013)0.6140.42.492.59.1100%00
Yoon et al26 (2015)2.24592.382.2%0
Sœur et al22 (2016)43910.371%7.7%05.1%
Current2.7340.82.43.110.191.97.982.3%94.1%5.9%02.9%
Authors

The authors are from the Department of Orthopaedic Surgery (RC, AB, EB, PM), Dijon University Hospital, Dijon; the Department of Orthopaedic Surgery (AD, AE), Hospital Les Chanaux, Macon; and INSERM (EB, PM) and Burgundy University (EB, PM), Dijon, France.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Romain Colombi, MD, Department of Orthopaedic Surgery, Dijon University Hospital, CHU Dijon, 14 rue Paul Gaffarel, 21079 Dijon CEDEX, France ( romain.colombi@chu-dijon.fr).

Received: July 25, 2018
Accepted: November 15, 2018
Posted Online: October 07, 2019

10.3928/01477447-20191001-03

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