A key opinion leader in the field of orthopedics discusses how he or she would manage and treat a difficult case presentation.

How would you treat a 52-year-old man with persistent elbow pain 1 year after ‘tennis elbow repair’?

I am asked to evaluate a 52-year-old right-hand dominant radiology technician who had a "tennis elbow repair" approximately 1 year ago. The patient presents with persistent elbow pain and is not exactly sure what his original surgery was.

Imaging

A 52-year-old, right hand dominant radiology tech underwent an open “tennis elbow repair” approximately 1 year ago. Rehabilitation and injections were not helpful. Bracing had questionable efficacy. T1 coronal view.

Credit: Sotereanos DG

T2 axial view.

Credit: Sotereanos DG

T2 sagittal view.

Credit: Sotereanos DG

After review of the provided MRI scans (Figure), the images show susceptibility artifact at the lateral epicondylar origin of the common extensor tendon consistent with suture material within the tendon. No anchor can be visualized. The lateral collateral ligament deep to the common extensor tendon is not visible and presumably torn. Muscular anatomy distal to the surgical site appears to have either retraction of muscle bellies or fatty replacement of muscle. The sagittal images show posterior shift of the radial head with respect to the capitellum.

Treatment plan

Prior to performing any other imaging studies, I would first do a thorough physical examination. I would initiate the physical examination with palpation of the epicondylar region. I would test the patient with resisted wrist extension with the elbow extended for persistent evidence of epicondylar pain. I would also examine the radial tunnel with palpation, to be certain that there is no radial nerve involvement through the supinator muscle and arcade of Frohse.

Dean G. Sotereanos

My obvious suspicion of posterolateral rotatory instability of the elbow joint would then be evaluated. I would put the patient through an elbow range of motion, stressing, valgus, supination and axial load to determine if the radial head subluxates relative to the capitellum and creates apprehension. If there is apprehension while performing this test, I would strongly consider the diagnosis of posterolateral rotatory instability.

The patient is now approximately 1-year status post tennis elbow repair with assumed injury to the lateral collateral ligament of his elbow. A primary repair of the lateral collateral ligament will likely be more difficult, due to retraction of the tendon origin. I would therefore consider a formal reconstruction of the lateral ulnar collateral ligament with a graft of choice. The graft choices I would consider would be palmaris longus from his wrist, hamstring tendon, or possibly plantaris from the foot. Some surgeons are using allograft tendon for these types of reconstruction.

References:

Anakwenze OA. Am J Sports Med. 2014; doi:10.1177/0363546513494579.

McGuire D. Oper Tech Orthop. 2013;23:205-214.

O'Driscoll SW. Acta Orthop Belg. 1999;65(4):404-415.

Reichel LM. J Hand Surg Am. 2013; doi:10.1016/j.jhsa.2012.10.030..

Dean G. Sotereanos, MD, is a clinical professor, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, and director of Hand Surgery Orthopaedic Specialists – University of Pittsburgh Medical Center in Pittsburgh.

Disclosure: Sotereanos is a consultant for Smith & Nephew, Arthrex and AxoGen Inc.