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Arthroscopic Release for Lateral Epicondylitis: A Cadaveric Model
Arthroscopic Release for Lateral Epicondylitis: A Cadaveric Model Timothy R. Kuklo, M.D., J.D., Kenneth F. Taylor, M.D., Kevin P. Murphy, M.D., Richard B. Islinger, M.D., R. David Heekin, M.D., and Champ L. Baker, Jr., M.D.
Summary: At least 10 different surgical approaches to refractory lateral epicondylitis have been described, including an arthroscopic release of the extensor carpi radialis brevis tendon. The advantages of an arthroscopic approach include an opportunity to examine the joint for associated pathology, no disruption of the extensor mechanism, and a rapid return to premorbid activities with possibly fewer complications. A cadaveric study was performed to determine the safety of this procedure. Ten fresh-frozen cadaveric upper extremities underwent arthroscopic visualization of the extensor tendon and release of the extensor carpi radialis brevis tendon. The specimens were randomized with regard to the use of either a 2.7-mm or a 4.0-mm 30° arthroscope through modified medial and lateral portals. Following this, the arthroscope remained in the joint, and the portal, cannula track, and surgical release site were dissected to determine the distance between the cannula and the radial, median, ulnar, lateral antebrachial, and posterior antebrachial nerves, and the brachial artery and the ulnar collateral ligament. No direct lacerations of neurovascular structures were identified; however, the varying course of the lateral and posterior antebrachial nerves place these superficial sensory nerves at risk during portal placement. As in previous reports, the radial nerve was consistently in close proximity to the proximal lateral portal (3 to 10 mm; mean, 5.4 mm). The ulnar collateral ligament was not destabilized. Arthroscopic release of the extensor carpi radialis brevis tendon appears to be a safe, reliable, and reproducible procedure for refractory lateral epicondylitis. Cadaveric dissection confirms these findings. Key Words: Arthroscopy—Elbow— Lateral epicondylitis—Portal anatomy.
L
ateral epicondylitis, or tennis elbow, was first described by Runge more than 100 years ago.1 Today, controversy continues as to the pathophysiology and the treatment of this common condition. From the Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, D.C.; and the The Hughston Sports Medicine Foundation, Inc., The Hughston Clinic, Columbus, Georgia (C.L.B.), U.S.A. The opinions or assertions contained herein are the private views of the authors and are not to be construed as offıcial or as reflecting the views of the Department of the Army or the Department of Defense. Address correspondence and reprint requests to Kevin P. Murphy, M.D., Director, Sports Medicine, Walter Reed Army Medical Center, Orthopaedic Surgery Service, Washington, DC 20307, U.S.A. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1503-1816$3.00/0
While most patients respond to nonoperative measures, 5% to 10% of patients develop chronic symptoms.2-6 These individuals eventually require surgical intervention because of work- or lifestyle-limiting symptoms of pain and dysfunction. Numerous surgical procedures have been used to address this condition; however, none has been clearly established as the best approach for this difficult problem. Recently, arthroscopic treatment of intraarticular elbow pathology has attracted increasing interest and has been used with excellent results by the senior authors (K.P.M. and C.L.B.). The purpose of this article is to describe the arthroscopic technique for release of the extensor carpi radialis brevis (ECRB) tendon and to report our findings after arthroscopic release and dissection in a cadaver model.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 3 (April), 1999: pp 259–264
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T. R. KUKLO ET AL. MATERIALS AND METHODS
Ten fresh-frozen cadaveric upper extremities (five matched pairs) underwent arthroscopic evaluation and release of the ECRB tendon through proximal medial, proximal lateral, and posterior portals. Before they were included in the study, all upper extremities were screened for prior surgical intervention. Each specimen was amputated at the proximal humerus, thawed at room temperature for 24 hours, and secured to an armboard by C clamps through the midshaft of the humerus with the olecranon superior and the elbow at 90° of flexion to gravity. This position, which simulates the prone position introduced by Poehling et al.,7 does not require a suspension device, provides ready access to the various portals, and allows intraoperative movement through the full range of motion. The elbow joint was distended with 30 mL of water through a straight lateral approach to displace the neurovascular structures anteriorly. The proximal medial portal was established first through a 2- to 3-mm skin incision with a standard No. 11 blade scalpel, followed by blunt spreading through the subcutaneous tissue using a small hemostat. Next, a blunt trocar was inserted into the joint, followed by either a 2.7-mm 30° arthroscope (5 elbows) or a 4.0-mm, 30° arthroscope (5 elbows). The proximal lateral portal was then established under direct visualization using a spinal needle for placement followed by the skin incision and cannula introduction. (Care must be taken when inserting the cannula to ensure that the instruments remain anterior to the intermuscular septum and in direct contact with the anterior surface of the humerus.) A thorough joint inspection was then completed. Viewing through the proximal medial portal, the lateral capsule and undersurface of the ECRB tendon was seen. The undersurface of the tendon was evaluated for fraying or tears. A 4.5 synovial resector was then introduced through the lateral portal and the ECRB tendon was debrided back to its insertion on the lateral epicondyle. After the tendon was debrided, a 4.5 round burr was used to decorticate the lateral epicondyle and the distal portion of the lateral condylar ridge in the area of the insertion of the ECRB tendon. The cannulae remained in place for surgical dissection. Identification was made of the posterior antebrachial cutaneous, lateral antebrachial cutaneous, radial (superficial sensory branch and posterior interosseous nerves), ulnar and median nerves, and the brachial artery. The site of the ECRB tendon release and lateral epicondyle were also dissected to determine the adequacy of release and decortication, as well
TABLE 1. Distances from Portals to Neurovascular Structures in 10 Specimens Proximal Lateral Portal
Proximal Medial Portal
Specimen
Radial Nerve (mm)
LABC Nerve* (mm)
PABC Nerve† (mm)
Ulnar Nerve (mm)
1 2 3 4 6 7 8 9 10 Average Range
2 5 7 8 10 3 3 5 6 5.4 3-10
48 30 29 24 50 12 18 20 15 26.1 12-50
2 6 16 10 12 6 7 4 9 8.0 2-16
25 30 30 35 36 29 38 20 25 30.3 20-38
Note: Brachial artery ⬎15 mm and median nerve ⬎10 mm from proximal medial portal, ulnar collateral ligaments and radial collateral ligaments intact. ECRB not pierced. *Lateral antebrachial cutaneous nerve. †Posterior antebrachial cutaneous nerve.
as to visualize the radial collateral ligament for possible injury. Measurements were taken with a ruler with the elbow at 90° of flexion. Vital structures were also visualized with the elbow in full extension. RESULTS The cadaveric dissection results are shown in Table 1. Proximal Medial Portal The proximal medial portal was consistently made approximately 2 cm proximal and 2 cm anterior to the medial epicondyle (Fig 1). This portal site is similar to that first described by Poehling et al. 8 who noted that the best position was approximately 2 cm proximal to
FIGURE 1. The proximal medial portal is positioned 2-cm proximal and 2-cm anterior to the medial epicondyle.
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the medial humeral epicondyle and directly anterior to the intermuscular septum. Direct palpation of this area reveals a soft spot for portal placement. Distention of the joint with approximately 30 mL of fluid displaces the brachial artery and median nerve anteriorly, placing them farther from the risk of injury.8,9 This displacement is made possible by the relative position of these structures anterior to the brachialis tendon. As has been reported previously,9,10 the brachial artery was noted to be an average of 15 mm from the cannula without the joint distended at the completion of the procedure. The median nerve was similarly found to be 10 mm from the cannula. As reported by Stothers et al.,9 elbow flexion placed these structures farther from the cannula. The course of the posterior antebrachial cutaneous nerve varied markedly. It was found proximal to the portal site piercing the intermuscular septum just medial to the triceps. Its branching pattern was also found to be quite variable, with the nearest major branch ranging from 2 to 16 mm (mean, 8.2 mm) from the cannula. As reported in other studies,9-11 the ulnar nerve was not found to be at risk in any of the specimens. No specimens were noted to have a subluxating ulnar nerve, and consequently, the ulnar nerve averaged 30.3 mm from the portal site (range, 20 to 38 mm). (Despite this finding in our study, care should be taken to first ensure that the nerve does not subluxate or has not been surgically transposed in patients who are undergoing elbow arthroscopy.9) The proximal medial portal further provided excellent visualization of the ECRB origin and lateral epicondyle with both a 2.7-mm and 4.0-mm 30° arthroscope. In our arthroscopic procedures, we use the 2.7-mm arthroscope because it provides a slightly improved view of this area. Intraoperatively, two specimens were found to have a partial tear of the ECRB tendon (Fig 2). Extra-articular dissection of the ECRB confirmed adequate release of the tendon in all specimens. The amount of tendon resected averaged 23 mm. The decorticated area of the lateral epicondyle averaged 22 mm. One specimen had an incomplete decortication in the lateral recess. The lateral ulnar collateral ligament was identified at dissection and was found to be posterior to the epicondyle and was not at risk during the release. Proximal Lateral Portal The proximal lateral portal was placed approximately 2-cm proximal and 2-cm anterior to the lateral epicondyle in the ‘‘soft spot’’ (Fig 3). As with the proximal medial portal, the trocar was directed toward
FIGURE 2. (A) Cadaveric ECRB lesion as viewed from the proximal medial portal (capitellum is at 3 o’clock position). (B) Debriding ECRB lesion. (C) Debrided ECRB insertion and tendon undersurface with decorticated lateral epicondyle at 3 o’clock position.
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FIGURE 3. The proximal lateral portal is positioned 2-cm proximal and 2-cm anterior to the lateral epicondyle.
the center of the joint just anterior to the anterior humeral shaft. The radial nerve is at greatest risk with this portal’s placement. The nerve usually bifurcates into the posterior interosseous nerve and the superficial radial nerve just distal to this area. This was noted in the majority of the specimens; however, the division containing the posterior interosseous nerve appeared consistently closest to the cannula. On average, the cannula was 5.6 mm from the nerve (range, 3 to 10 mm). Our finding that elbow flexion and joint distention further displaced the radial nerve was consistent with previous studies.9,12 Posterior Portal The straight posterior portal traversed the triceps tendon at a point equidistant between the medial and lateral epicondyles. It is best used for visualization of the posterior joint. However, it is not used in the ECRB release. The ulnar nerve is the closest neurological structure to this portal, but it did not appear closer than 15 mm in any of the specimens. DISCUSSION Surgical Approaches A review of the literature reveals at least 10 different surgical approaches used in the treatment of lateral epicondylitis. Bosworth13 postulated that symptoms of tennis elbow were related to stenosing changes of the orbicular ligament frequently associated with tendinitis of the common extensor origin. He described four similar procedures to address this problem, noting that resection of the ligament and extensor origin did not cause elbow instability. Gardner5 sought to repair and shorten the acute or chronic tear of the common extensor tendon. He advocated resection of the common extensor origin, including the capsule and radial collateral ligament, preserving the orbicular ligament, and removing the lateral epicondyle down to cancel-
lous bone before reattaching the soft tissue. This shortening procedure permitted the area of acute tearing or fringe to heal through contact with raw cancellous bone. Boyd and McLeod2 used a modified Bosworth III procedure in which they released the common extensor origin and excised the proximal portion of the annular ligament, the bursa (if present), and the synovial fringe. Coonrad and Hooper4 resected the torn or scarred portion of the extensor tendon followed by suturing when feasible. Posch et al.14 used a simple transverse division of the deep fascia covering the common extensor group one centimeter distal to lateral epicondyle. Stovell and Beinfield15 described the Garden procedure in which a distal Z-type tenotomy of the ECRB is used at the musculotendinous junction near the wrist. Nirschl and Pettrone6 sought to use a specific surgical technique in which they attained exposure of the ECRB before excision and repair of the identified lesion. They also noted an 11% incidence of concurrent intra-articular pathology. Seeking to simplify this procedure, Baumgard and Schwartz16 advocated percutaneous resection of the tendinous origin of the common extensor, and Calvert et al.3 described a procedure in which they divided the common extensor origin but spared the extensor carpi radialis longus. Finally, Verhaar et al.17 recommended a return to simple release of the entire common extensor origin. Good results have been reported regardless of the technique used, yet the surgical management of tennis elbow remains a ‘‘last attempt’’ at resolving symptoms—primarily because of inconsistent pain relief. Hence, a less invasive, outpatient surgical approach that provides an opportunity to discover and treat associated intra-articular pathology, does not disrupt the common extensor mechanism, and allows a more rapid return to premorbid activities with possibly fewer complications, may present an excellent option.
ARTHROSCOPIC LATERAL RELEASE Elbow Arthroscopy Elbow arthroscopy is a technically demanding procedure. Inherent risks are associated with the proximity of neurovascular structures to selected portal sites. Guhl18 and Rupp and Tempelhof19 have reported injury to the radial nerve sensory branch. Posterior interosseous nerve damage has been described by Jones and Savoie20 and by Thomas et al.21 In their series of 71 elbow arthroscopies, O’Driscoll and Morrey22 report 7 complications. Three episodes of transient radial nerve palsy were attributed to extravasation of local anesthetic. They also describe four episodes of persistent aseptic drainage. As a result of one, the patient had a residual 15° elbow flexion contracture. Arthroscopic anatomy of the elbow has been well described in the literature,9,12,19,23,24 and numerous studies have been published in an effort to describe selection of optimal portal sites. Verhaar et al.10 described an anteromedial portal 2-cm distal and 1-cm anterior to the medial epicondyle with the elbow at 90° of flexion. Incorporation of 70° of forearm supination was designed to decrease the risk of injury to the median nerve, which ranged 12 to 25 mm (mean, 18 mm) from the cannula. Lindenfeld11 described a more proximal portal that was 1-cm proximal and 1-cm anterior to the medial epicondyle. They recommended a cannula course that was directed more parallel than perpendicular to the course of the median nerve—a technique facilitated by a puncture point more proximal than previously described. This resulted in a greater distance from cannula to the median nerve (20 to 24 mm with a mean of 22.3 mm) than seen with the more traditional perpendicular direction (10 to 12 mm with a mean of 10.7 mm). Stothers et al.9 compared an anteromedial portal, located 2-cm distal and 2-cm anterior to the medial epicondyle, with the proximal medial portal described by Poehling et al.,7 located 2-cm proximal to the medial epicondyle, directly anterior to the intermuscular septum, and in contact with the anterior humerus. With respect to the median nerve, the more proximal approach (7 to 20 mm with a mean of 12.4 mm) proved safer than the anteromedial (5 to 13 mm with a mean of 7 mm), while providing an excellent view of the anterior compartment. Similarly, our proximal medial portal site, 2-cm proximal and 2-cm anterior to the medial epicondyle was found to be an adequate distance from the brachial artery and the ulnar and median nerves, while still providing an excellent view of both the anterior aspect of the joint and the ECRB release site. When selecting a lateral portal site, one must
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consider the proximity of the radial nerve. Lindenfeld11 and Marshall et al.25 each described the location of the radial nerve as within 5 mm of an anterolateral portal located 3-cm distal and 1-cm anterior to the lateral epicondyle. In an effort to decrease the risk to the radial nerve, Verhaar et al.10 used a portal site that was 2-cm distal and 2-cm anterior to the lateral epicondyle with the elbow at 90° of flexion and the forearm pronated to 70°. The radial nerve was found to be an average of 17 mm from the cannula’s path while the deep posterior interosseous branch was found to be closer at 1 to 10 mm (mean, 7 mm). Although this site provided greater protection of the radial nerve, the cannula’s path was found to penetrate both supinator and ECRB muscles. In studies directly comparing standard distal (3-cm distal and 1-cm anterior to the lateral epicondyle) with more proximal portal sites, Field et al.12 (2-cm proximal and 1-cm anterior to the lateral epicondyle) and Stothers et al.9 (1- to 2-cm proximal to the lateral epicondyle on the anterior surface of the humerus) found the distance to the radial nerve to be doubled with the more proximal site. Elbow joint flexion and joint distention provided additional protection. Both studies reported improved visualization of the joint with the proximal portal. Field et al.12 also noted penetration of ECRB in all instances with distal portal placement. Again, our proximal lateral portal, located 2-cm proximal and 2-cm anterior to the lateral epicondyle, proved to be a safe distance from the lateral antebrachial cutaneous nerve. Although we still consider it safe, the distance from the portal to the radial nerve is of greater concern. It is important to note that because of its proximity to the anterolateral joint capsule, the deep posterior interosseous branch of the radial nerve is at greater risk than the more superficial sensory branch. Distending the joint, placing the portal proximal to the bifurcation of the radial nerve, and positioning the elbow in flexion all help to protect this important motor nerve. We agree with Lindenfeld11 and Verhaar et al.10 that establishing the medial portal first provides good visualization for placement of the lateral portal. Posterior portals have typically been described in the posterolateral location, 2- to 3-cm proximal to the tip of the olecranon and just lateral to the triceps tendon,9,10,25 or through the triceps tendon directly posterior and 1.5- to 2-cm proximal to the olecranon tip,8,24 or at the level of the epicondyles.9 We chose a direct posterior portal rather than the more lateral location to avoid the variable course of the posterior
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antebrachial cutaneous nerve while still maintaining a safe distance from the ulnar nerve. In addition to diagnostic arthroscopy, various authors report indications for elbow arthroscopy that include removal of loose and foreign bodies, osteophyte excision, synovectomy, and even radial head excision.19,24 To date, no authors have reported on surgical management and release of the ECRB tendon with arthroscopy. Currently, more than 50 patients have undergone this arthroscopic procedure by the senior authors (K.P.M. and C.L.B.) with excellent results and a more rapid return to premorbid activities and work (unpublished data). With Nirschl’s reported 11% associated intra-articular pathology6 and the intra-articular findings of Murphy and Baker,26 arthroscopic release of the ECRB origin appears particularly appealing. Our findings confirm the previously reported areas of danger in elbow arthroscopy—particularly with regard to the radial nerve’s proximity to the proximal lateral portal. Additionally, the course of the posterior antebrachial cutaneous nerve appeared quite variable, but it was often just adjacent to the proximal medial portal. This would place this sensory nerve at risk of direct laceration or contusion and could lead to development of a painful neuroma. The surgeon must take care to sharply incise only skin, and then to dissect the subcutaneous plane bluntly with a small hemostat to minimize this potential risk.9,25 To date, 50 procedures have been completed by the senior authors with no neuroma reported. Further, no injuries to the ulnar collateral ligament occurred in the cadaver specimens. To date, no patients report elbow instability. In conclusion, arthroscopic release of the ECRB tendon appears as safe as other described indications for elbow arthroscopy. The ECRB release and decortication of the lateral epicondyle appear complete in cadaveric dissections. Clinical results of the procedure with follow-up are needed, and a study is presently underway at Walter Reed and The Hughston Sports Medicine Foundation under the direction of the senior authors.
REFERENCES 1. Runge F. Zur genese und Behandlung des Schreibekrampfes. Berliner Klin Wchnschr 1873;10:245-248. 2. Boyd HB, McLeod AC. Tennis elbow. J Bone and Joint Surg Am 1973;55:1183-1187.
3. Calvert PT, Allum RL, Macpherson IS, Bentley G. Simple lateral release in treatment of tennis elbow. J R Soc Med 1985;78:912-915. 4. Coonrad RW, Hooper WR. Tennis elbow: Its course, natural history, conservative and surgical management. J Bone and Joint Surg Am 1973;55:1177-1182. 5. Gardner RC. Tennis elbow: Diagnosis pathology and treatment. Nine severe cases treated by a new reconstructive operation. Clin Orthop 1970;72:248-253. 6. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone and Joint Surg Am 1979;61:832839. 7. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224. 8. Poehling GG, Ekman EF. Arthroscopy of the elbow. J Bone Joint Surg Am 1994;76:1265-1271. 9. Stothers K, Day B, Regan WR. Athroscopy of the elbow: Anatomy, portal sites, and a description of the proximal lateral portal. Arthroscopy 1995;11:449-457. 10. Verhaar J, van Mameren H, Brandsma A. Risks of neurovascular injury in elbow arthroscopy: Starting anteromedially or anterolaterally? Arthroscopy 1991;7:287-290. 11. Lindenfeld TN. Medial approach in elbow arthroscopy. Am J Sports Med 1990;18:413-417. 12. Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL. Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607. 13. Bosworth DM. Surgical treatment of tennis elbow. A follow-up study. J Bone and Joint Surg Am 1965;47:1533-1536. 14. Posch JN, Goldberg VM, Larrey R. Extensor fasciotomy for tennis elbow. A long-term follow-up study. Clin Orthop 1978;135:179-182. 15. Stovell PB, Beinfield MS. Treatment of resistant lateral epicondylitis of the elbow by lengthening of the extensor carpi radialis brevis tendon. Surg Gyn Obstet 1979;149:526-528. 16. Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med 1982;10:233-236. 17. Verhaar J, Walenkamp G, Kester A, van Mameren H, van der Linden T. Lateral extensor release for tennis elbow. A prospective long-term follow-up study. J Bone Joint Surg Am 1993;75: 1034-1043. 18. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 1985;8:1290-1296. 19. Rupp S, Tempelhof S. Arthroscopic surgery of the elbow: Therapeutic benefits and hazards. Clin Orthop 1995;313:140145. 20. Jones GS, Savoie FH. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 1993;9: 277-283. 21. Thomas MA, Fast A, Shapiro D. Radial nerve damage as a complication of elbow arthroscopy. Clin Orthop 1987;215:130131. 22. O’Driscoll SW, and Morrey BF. Arthroscopy of the elbow. J Bone Joint Surg Am 1992;74:84-94. 23. Andrews JR, Baumgarten TE. Arthroscopic anatomy of the elbow. Orthop Clin North Am 1995;26:671-677. 24. Ekman EF, Poehling GG. Arthroscopy of the elbow. Hand Clin 1994;10:453-460. 25. Marshall PD, Fairclough JA, Johnson SR, Evans EJ. Avoiding nerve damage during elbow arthroscopy. J Bone Joint Surg Br 1993;75:129-131. 26. Murphy K, Baker CL: Arthroscopic findings associated with lateral epicondylitis. Orthop Trans 1997;21:222 (abstr).
Summary: At least 10 different surgical approaches to refractory lateral epicondylitis have been described, including an arthroscopic release of the extensor carpi radialis brevis tendon. The advantages of an arthroscopic approach include an opportunity to examine the joint for associated pathology, no disruption of the extensor mechanism, and a rapid return to premorbid activities with possibly fewer complications. A cadaveric study was performed to determine the safety of this procedure. Ten fresh-frozen cadaveric upper extremities underwent arthroscopic visualization of the extensor tendon and release of the extensor carpi radialis brevis tendon. The specimens were randomized with regard to the use of either a 2.7-mm or a 4.0-mm 30° arthroscope through modified medial and lateral portals. Following this, the arthroscope remained in the joint, and the portal, cannula track, and surgical release site were dissected to determine the distance between the cannula and the radial, median, ulnar, lateral antebrachial, and posterior antebrachial nerves, and the brachial artery and the ulnar collateral ligament. No direct lacerations of neurovascular structures were identified; however, the varying course of the lateral and posterior antebrachial nerves place these superficial sensory nerves at risk during portal placement. As in previous reports, the radial nerve was consistently in close proximity to the proximal lateral portal (3 to 10 mm; mean, 5.4 mm). The ulnar collateral ligament was not destabilized. Arthroscopic release of the extensor carpi radialis brevis tendon appears to be a safe, reliable, and reproducible procedure for refractory lateral epicondylitis. Cadaveric dissection confirms these findings. Key Words: Arthroscopy—Elbow— Lateral epicondylitis—Portal anatomy.
L
ateral epicondylitis, or tennis elbow, was first described by Runge more than 100 years ago.1 Today, controversy continues as to the pathophysiology and the treatment of this common condition. From the Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, D.C.; and the The Hughston Sports Medicine Foundation, Inc., The Hughston Clinic, Columbus, Georgia (C.L.B.), U.S.A. The opinions or assertions contained herein are the private views of the authors and are not to be construed as offıcial or as reflecting the views of the Department of the Army or the Department of Defense. Address correspondence and reprint requests to Kevin P. Murphy, M.D., Director, Sports Medicine, Walter Reed Army Medical Center, Orthopaedic Surgery Service, Washington, DC 20307, U.S.A. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1503-1816$3.00/0
While most patients respond to nonoperative measures, 5% to 10% of patients develop chronic symptoms.2-6 These individuals eventually require surgical intervention because of work- or lifestyle-limiting symptoms of pain and dysfunction. Numerous surgical procedures have been used to address this condition; however, none has been clearly established as the best approach for this difficult problem. Recently, arthroscopic treatment of intraarticular elbow pathology has attracted increasing interest and has been used with excellent results by the senior authors (K.P.M. and C.L.B.). The purpose of this article is to describe the arthroscopic technique for release of the extensor carpi radialis brevis (ECRB) tendon and to report our findings after arthroscopic release and dissection in a cadaver model.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 3 (April), 1999: pp 259–264
259
260
T. R. KUKLO ET AL. MATERIALS AND METHODS
Ten fresh-frozen cadaveric upper extremities (five matched pairs) underwent arthroscopic evaluation and release of the ECRB tendon through proximal medial, proximal lateral, and posterior portals. Before they were included in the study, all upper extremities were screened for prior surgical intervention. Each specimen was amputated at the proximal humerus, thawed at room temperature for 24 hours, and secured to an armboard by C clamps through the midshaft of the humerus with the olecranon superior and the elbow at 90° of flexion to gravity. This position, which simulates the prone position introduced by Poehling et al.,7 does not require a suspension device, provides ready access to the various portals, and allows intraoperative movement through the full range of motion. The elbow joint was distended with 30 mL of water through a straight lateral approach to displace the neurovascular structures anteriorly. The proximal medial portal was established first through a 2- to 3-mm skin incision with a standard No. 11 blade scalpel, followed by blunt spreading through the subcutaneous tissue using a small hemostat. Next, a blunt trocar was inserted into the joint, followed by either a 2.7-mm 30° arthroscope (5 elbows) or a 4.0-mm, 30° arthroscope (5 elbows). The proximal lateral portal was then established under direct visualization using a spinal needle for placement followed by the skin incision and cannula introduction. (Care must be taken when inserting the cannula to ensure that the instruments remain anterior to the intermuscular septum and in direct contact with the anterior surface of the humerus.) A thorough joint inspection was then completed. Viewing through the proximal medial portal, the lateral capsule and undersurface of the ECRB tendon was seen. The undersurface of the tendon was evaluated for fraying or tears. A 4.5 synovial resector was then introduced through the lateral portal and the ECRB tendon was debrided back to its insertion on the lateral epicondyle. After the tendon was debrided, a 4.5 round burr was used to decorticate the lateral epicondyle and the distal portion of the lateral condylar ridge in the area of the insertion of the ECRB tendon. The cannulae remained in place for surgical dissection. Identification was made of the posterior antebrachial cutaneous, lateral antebrachial cutaneous, radial (superficial sensory branch and posterior interosseous nerves), ulnar and median nerves, and the brachial artery. The site of the ECRB tendon release and lateral epicondyle were also dissected to determine the adequacy of release and decortication, as well
TABLE 1. Distances from Portals to Neurovascular Structures in 10 Specimens Proximal Lateral Portal
Proximal Medial Portal
Specimen
Radial Nerve (mm)
LABC Nerve* (mm)
PABC Nerve† (mm)
Ulnar Nerve (mm)
1 2 3 4 6 7 8 9 10 Average Range
2 5 7 8 10 3 3 5 6 5.4 3-10
48 30 29 24 50 12 18 20 15 26.1 12-50
2 6 16 10 12 6 7 4 9 8.0 2-16
25 30 30 35 36 29 38 20 25 30.3 20-38
Note: Brachial artery ⬎15 mm and median nerve ⬎10 mm from proximal medial portal, ulnar collateral ligaments and radial collateral ligaments intact. ECRB not pierced. *Lateral antebrachial cutaneous nerve. †Posterior antebrachial cutaneous nerve.
as to visualize the radial collateral ligament for possible injury. Measurements were taken with a ruler with the elbow at 90° of flexion. Vital structures were also visualized with the elbow in full extension. RESULTS The cadaveric dissection results are shown in Table 1. Proximal Medial Portal The proximal medial portal was consistently made approximately 2 cm proximal and 2 cm anterior to the medial epicondyle (Fig 1). This portal site is similar to that first described by Poehling et al. 8 who noted that the best position was approximately 2 cm proximal to
FIGURE 1. The proximal medial portal is positioned 2-cm proximal and 2-cm anterior to the medial epicondyle.
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the medial humeral epicondyle and directly anterior to the intermuscular septum. Direct palpation of this area reveals a soft spot for portal placement. Distention of the joint with approximately 30 mL of fluid displaces the brachial artery and median nerve anteriorly, placing them farther from the risk of injury.8,9 This displacement is made possible by the relative position of these structures anterior to the brachialis tendon. As has been reported previously,9,10 the brachial artery was noted to be an average of 15 mm from the cannula without the joint distended at the completion of the procedure. The median nerve was similarly found to be 10 mm from the cannula. As reported by Stothers et al.,9 elbow flexion placed these structures farther from the cannula. The course of the posterior antebrachial cutaneous nerve varied markedly. It was found proximal to the portal site piercing the intermuscular septum just medial to the triceps. Its branching pattern was also found to be quite variable, with the nearest major branch ranging from 2 to 16 mm (mean, 8.2 mm) from the cannula. As reported in other studies,9-11 the ulnar nerve was not found to be at risk in any of the specimens. No specimens were noted to have a subluxating ulnar nerve, and consequently, the ulnar nerve averaged 30.3 mm from the portal site (range, 20 to 38 mm). (Despite this finding in our study, care should be taken to first ensure that the nerve does not subluxate or has not been surgically transposed in patients who are undergoing elbow arthroscopy.9) The proximal medial portal further provided excellent visualization of the ECRB origin and lateral epicondyle with both a 2.7-mm and 4.0-mm 30° arthroscope. In our arthroscopic procedures, we use the 2.7-mm arthroscope because it provides a slightly improved view of this area. Intraoperatively, two specimens were found to have a partial tear of the ECRB tendon (Fig 2). Extra-articular dissection of the ECRB confirmed adequate release of the tendon in all specimens. The amount of tendon resected averaged 23 mm. The decorticated area of the lateral epicondyle averaged 22 mm. One specimen had an incomplete decortication in the lateral recess. The lateral ulnar collateral ligament was identified at dissection and was found to be posterior to the epicondyle and was not at risk during the release. Proximal Lateral Portal The proximal lateral portal was placed approximately 2-cm proximal and 2-cm anterior to the lateral epicondyle in the ‘‘soft spot’’ (Fig 3). As with the proximal medial portal, the trocar was directed toward
FIGURE 2. (A) Cadaveric ECRB lesion as viewed from the proximal medial portal (capitellum is at 3 o’clock position). (B) Debriding ECRB lesion. (C) Debrided ECRB insertion and tendon undersurface with decorticated lateral epicondyle at 3 o’clock position.
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FIGURE 3. The proximal lateral portal is positioned 2-cm proximal and 2-cm anterior to the lateral epicondyle.
the center of the joint just anterior to the anterior humeral shaft. The radial nerve is at greatest risk with this portal’s placement. The nerve usually bifurcates into the posterior interosseous nerve and the superficial radial nerve just distal to this area. This was noted in the majority of the specimens; however, the division containing the posterior interosseous nerve appeared consistently closest to the cannula. On average, the cannula was 5.6 mm from the nerve (range, 3 to 10 mm). Our finding that elbow flexion and joint distention further displaced the radial nerve was consistent with previous studies.9,12 Posterior Portal The straight posterior portal traversed the triceps tendon at a point equidistant between the medial and lateral epicondyles. It is best used for visualization of the posterior joint. However, it is not used in the ECRB release. The ulnar nerve is the closest neurological structure to this portal, but it did not appear closer than 15 mm in any of the specimens. DISCUSSION Surgical Approaches A review of the literature reveals at least 10 different surgical approaches used in the treatment of lateral epicondylitis. Bosworth13 postulated that symptoms of tennis elbow were related to stenosing changes of the orbicular ligament frequently associated with tendinitis of the common extensor origin. He described four similar procedures to address this problem, noting that resection of the ligament and extensor origin did not cause elbow instability. Gardner5 sought to repair and shorten the acute or chronic tear of the common extensor tendon. He advocated resection of the common extensor origin, including the capsule and radial collateral ligament, preserving the orbicular ligament, and removing the lateral epicondyle down to cancel-
lous bone before reattaching the soft tissue. This shortening procedure permitted the area of acute tearing or fringe to heal through contact with raw cancellous bone. Boyd and McLeod2 used a modified Bosworth III procedure in which they released the common extensor origin and excised the proximal portion of the annular ligament, the bursa (if present), and the synovial fringe. Coonrad and Hooper4 resected the torn or scarred portion of the extensor tendon followed by suturing when feasible. Posch et al.14 used a simple transverse division of the deep fascia covering the common extensor group one centimeter distal to lateral epicondyle. Stovell and Beinfield15 described the Garden procedure in which a distal Z-type tenotomy of the ECRB is used at the musculotendinous junction near the wrist. Nirschl and Pettrone6 sought to use a specific surgical technique in which they attained exposure of the ECRB before excision and repair of the identified lesion. They also noted an 11% incidence of concurrent intra-articular pathology. Seeking to simplify this procedure, Baumgard and Schwartz16 advocated percutaneous resection of the tendinous origin of the common extensor, and Calvert et al.3 described a procedure in which they divided the common extensor origin but spared the extensor carpi radialis longus. Finally, Verhaar et al.17 recommended a return to simple release of the entire common extensor origin. Good results have been reported regardless of the technique used, yet the surgical management of tennis elbow remains a ‘‘last attempt’’ at resolving symptoms—primarily because of inconsistent pain relief. Hence, a less invasive, outpatient surgical approach that provides an opportunity to discover and treat associated intra-articular pathology, does not disrupt the common extensor mechanism, and allows a more rapid return to premorbid activities with possibly fewer complications, may present an excellent option.
ARTHROSCOPIC LATERAL RELEASE Elbow Arthroscopy Elbow arthroscopy is a technically demanding procedure. Inherent risks are associated with the proximity of neurovascular structures to selected portal sites. Guhl18 and Rupp and Tempelhof19 have reported injury to the radial nerve sensory branch. Posterior interosseous nerve damage has been described by Jones and Savoie20 and by Thomas et al.21 In their series of 71 elbow arthroscopies, O’Driscoll and Morrey22 report 7 complications. Three episodes of transient radial nerve palsy were attributed to extravasation of local anesthetic. They also describe four episodes of persistent aseptic drainage. As a result of one, the patient had a residual 15° elbow flexion contracture. Arthroscopic anatomy of the elbow has been well described in the literature,9,12,19,23,24 and numerous studies have been published in an effort to describe selection of optimal portal sites. Verhaar et al.10 described an anteromedial portal 2-cm distal and 1-cm anterior to the medial epicondyle with the elbow at 90° of flexion. Incorporation of 70° of forearm supination was designed to decrease the risk of injury to the median nerve, which ranged 12 to 25 mm (mean, 18 mm) from the cannula. Lindenfeld11 described a more proximal portal that was 1-cm proximal and 1-cm anterior to the medial epicondyle. They recommended a cannula course that was directed more parallel than perpendicular to the course of the median nerve—a technique facilitated by a puncture point more proximal than previously described. This resulted in a greater distance from cannula to the median nerve (20 to 24 mm with a mean of 22.3 mm) than seen with the more traditional perpendicular direction (10 to 12 mm with a mean of 10.7 mm). Stothers et al.9 compared an anteromedial portal, located 2-cm distal and 2-cm anterior to the medial epicondyle, with the proximal medial portal described by Poehling et al.,7 located 2-cm proximal to the medial epicondyle, directly anterior to the intermuscular septum, and in contact with the anterior humerus. With respect to the median nerve, the more proximal approach (7 to 20 mm with a mean of 12.4 mm) proved safer than the anteromedial (5 to 13 mm with a mean of 7 mm), while providing an excellent view of the anterior compartment. Similarly, our proximal medial portal site, 2-cm proximal and 2-cm anterior to the medial epicondyle was found to be an adequate distance from the brachial artery and the ulnar and median nerves, while still providing an excellent view of both the anterior aspect of the joint and the ECRB release site. When selecting a lateral portal site, one must
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consider the proximity of the radial nerve. Lindenfeld11 and Marshall et al.25 each described the location of the radial nerve as within 5 mm of an anterolateral portal located 3-cm distal and 1-cm anterior to the lateral epicondyle. In an effort to decrease the risk to the radial nerve, Verhaar et al.10 used a portal site that was 2-cm distal and 2-cm anterior to the lateral epicondyle with the elbow at 90° of flexion and the forearm pronated to 70°. The radial nerve was found to be an average of 17 mm from the cannula’s path while the deep posterior interosseous branch was found to be closer at 1 to 10 mm (mean, 7 mm). Although this site provided greater protection of the radial nerve, the cannula’s path was found to penetrate both supinator and ECRB muscles. In studies directly comparing standard distal (3-cm distal and 1-cm anterior to the lateral epicondyle) with more proximal portal sites, Field et al.12 (2-cm proximal and 1-cm anterior to the lateral epicondyle) and Stothers et al.9 (1- to 2-cm proximal to the lateral epicondyle on the anterior surface of the humerus) found the distance to the radial nerve to be doubled with the more proximal site. Elbow joint flexion and joint distention provided additional protection. Both studies reported improved visualization of the joint with the proximal portal. Field et al.12 also noted penetration of ECRB in all instances with distal portal placement. Again, our proximal lateral portal, located 2-cm proximal and 2-cm anterior to the lateral epicondyle, proved to be a safe distance from the lateral antebrachial cutaneous nerve. Although we still consider it safe, the distance from the portal to the radial nerve is of greater concern. It is important to note that because of its proximity to the anterolateral joint capsule, the deep posterior interosseous branch of the radial nerve is at greater risk than the more superficial sensory branch. Distending the joint, placing the portal proximal to the bifurcation of the radial nerve, and positioning the elbow in flexion all help to protect this important motor nerve. We agree with Lindenfeld11 and Verhaar et al.10 that establishing the medial portal first provides good visualization for placement of the lateral portal. Posterior portals have typically been described in the posterolateral location, 2- to 3-cm proximal to the tip of the olecranon and just lateral to the triceps tendon,9,10,25 or through the triceps tendon directly posterior and 1.5- to 2-cm proximal to the olecranon tip,8,24 or at the level of the epicondyles.9 We chose a direct posterior portal rather than the more lateral location to avoid the variable course of the posterior
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antebrachial cutaneous nerve while still maintaining a safe distance from the ulnar nerve. In addition to diagnostic arthroscopy, various authors report indications for elbow arthroscopy that include removal of loose and foreign bodies, osteophyte excision, synovectomy, and even radial head excision.19,24 To date, no authors have reported on surgical management and release of the ECRB tendon with arthroscopy. Currently, more than 50 patients have undergone this arthroscopic procedure by the senior authors (K.P.M. and C.L.B.) with excellent results and a more rapid return to premorbid activities and work (unpublished data). With Nirschl’s reported 11% associated intra-articular pathology6 and the intra-articular findings of Murphy and Baker,26 arthroscopic release of the ECRB origin appears particularly appealing. Our findings confirm the previously reported areas of danger in elbow arthroscopy—particularly with regard to the radial nerve’s proximity to the proximal lateral portal. Additionally, the course of the posterior antebrachial cutaneous nerve appeared quite variable, but it was often just adjacent to the proximal medial portal. This would place this sensory nerve at risk of direct laceration or contusion and could lead to development of a painful neuroma. The surgeon must take care to sharply incise only skin, and then to dissect the subcutaneous plane bluntly with a small hemostat to minimize this potential risk.9,25 To date, 50 procedures have been completed by the senior authors with no neuroma reported. Further, no injuries to the ulnar collateral ligament occurred in the cadaver specimens. To date, no patients report elbow instability. In conclusion, arthroscopic release of the ECRB tendon appears as safe as other described indications for elbow arthroscopy. The ECRB release and decortication of the lateral epicondyle appear complete in cadaveric dissections. Clinical results of the procedure with follow-up are needed, and a study is presently underway at Walter Reed and The Hughston Sports Medicine Foundation under the direction of the senior authors.
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3. Calvert PT, Allum RL, Macpherson IS, Bentley G. Simple lateral release in treatment of tennis elbow. J R Soc Med 1985;78:912-915. 4. Coonrad RW, Hooper WR. Tennis elbow: Its course, natural history, conservative and surgical management. J Bone and Joint Surg Am 1973;55:1177-1182. 5. Gardner RC. Tennis elbow: Diagnosis pathology and treatment. Nine severe cases treated by a new reconstructive operation. Clin Orthop 1970;72:248-253. 6. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone and Joint Surg Am 1979;61:832839. 7. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224. 8. Poehling GG, Ekman EF. Arthroscopy of the elbow. J Bone Joint Surg Am 1994;76:1265-1271. 9. Stothers K, Day B, Regan WR. Athroscopy of the elbow: Anatomy, portal sites, and a description of the proximal lateral portal. Arthroscopy 1995;11:449-457. 10. Verhaar J, van Mameren H, Brandsma A. Risks of neurovascular injury in elbow arthroscopy: Starting anteromedially or anterolaterally? Arthroscopy 1991;7:287-290. 11. Lindenfeld TN. Medial approach in elbow arthroscopy. Am J Sports Med 1990;18:413-417. 12. Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL. Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607. 13. Bosworth DM. Surgical treatment of tennis elbow. A follow-up study. J Bone and Joint Surg Am 1965;47:1533-1536. 14. Posch JN, Goldberg VM, Larrey R. Extensor fasciotomy for tennis elbow. A long-term follow-up study. Clin Orthop 1978;135:179-182. 15. Stovell PB, Beinfield MS. Treatment of resistant lateral epicondylitis of the elbow by lengthening of the extensor carpi radialis brevis tendon. Surg Gyn Obstet 1979;149:526-528. 16. Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med 1982;10:233-236. 17. Verhaar J, Walenkamp G, Kester A, van Mameren H, van der Linden T. Lateral extensor release for tennis elbow. A prospective long-term follow-up study. J Bone Joint Surg Am 1993;75: 1034-1043. 18. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 1985;8:1290-1296. 19. Rupp S, Tempelhof S. Arthroscopic surgery of the elbow: Therapeutic benefits and hazards. Clin Orthop 1995;313:140145. 20. Jones GS, Savoie FH. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy 1993;9: 277-283. 21. Thomas MA, Fast A, Shapiro D. Radial nerve damage as a complication of elbow arthroscopy. Clin Orthop 1987;215:130131. 22. O’Driscoll SW, and Morrey BF. Arthroscopy of the elbow. J Bone Joint Surg Am 1992;74:84-94. 23. Andrews JR, Baumgarten TE. Arthroscopic anatomy of the elbow. Orthop Clin North Am 1995;26:671-677. 24. Ekman EF, Poehling GG. Arthroscopy of the elbow. Hand Clin 1994;10:453-460. 25. Marshall PD, Fairclough JA, Johnson SR, Evans EJ. Avoiding nerve damage during elbow arthroscopy. J Bone Joint Surg Br 1993;75:129-131. 26. Murphy K, Baker CL: Arthroscopic findings associated with lateral epicondylitis. Orthop Trans 1997;21:222 (abstr).