Lateral Epicondylitis Debridement

CHAPTER 1

With the operative limb prepped and draped and a sterile tourniquet applied, the incision's marked out, first by identifying the lateral epicondyle, then the radial head, and then the capitellum. The incision is placed along the anterior border of these structures.

The surgical site is then infiltrated with a local anesthetic. My preferred anesthetic is 0.5% bupivacaine with epinephrine. It's injected both in the incision site as well as deep.

CHAPTER 2

If desired, the limb is exsanguinated, and the tourniquet is inflated. The incision is then placed. Superficial bleeders are cauterized.

CHAPTER 3

Blunt dissection is then performed down to the level of the fascia where the extensor origin can be identified.

CHAPTER 4

With the extensor origin exposed, ideally, the interval between the ECRL and the EDC is developed to approach the ECRB, which will be deep to it. It can be difficult to identify, so a landmark that can be used as a proxy is the top of the capitellum and the top of the radial head. That tendinous interval is then split and then raised proximally and distally, in order to identify the ECRB origin. With the interval between the ECRL and EDC developed, the ECRL is elevated. And deep to it, the ECRB origin will be identified. It is often detached from its origin at the lateral epicondyle, as shown here with the freer, and should be superficial to the joint capsule.

CHAPTER 5

Once identified, the ECRB origin can be sharply excised, or debrided, off of the lateral epicondyle origin. Upon removal and inspection of the tissue, its quality will confirm a compromised state, often referred to as angiofibroblastic hyperplasia.

To confirm complete debridement of the ECRB origin, the interval can be extended proximally and distally. A concomitant release of the lateral joint capsule with a formal arthrotomy is recommended to confirm complete debridement. However, dissection should not be taken aggressively posteriorly again as to not compromise the lateral collateral ligament origin, although that will also be assessed later. Debridement is recommended to proceed proximally until only the muscular origin of the extensor mass and brachioradialis is in contact with the bone.

Finally, the debridement of the ECRB origin is completed by a decortication of the lateral epicondyle extensor mass origin, down to bleeding bone. The origin will then be repaired back down and the interval closed back down on this bleeding surface to enhance healing.

CHAPTER 6

Finally, the lateral collateral ligament complex origin is identified and examined. Tears are often present. These degenerative tears often cause pain but do not cause instability. The LCL origin can be assessed by carefully elevating the tissue off of the lateral aspect of the capitellum and epicondyle with a blunt instrument like a freer. If it raises off readily, the origin is compromised.

CHAPTER 7

If the LCL origin is confirmed, compromised and warrants repair, the LCL origin can be repaired with either a suture anchor or bone tunnels. In this illustration, a suture anchor is placed at the footprint of the LCL origin with a number 2 non-absorbable braided suture emanating from the anchor. With the anchor in position, a locking, Krackow-Style stitch is run distally and posteriorly towards the ulna and then back anteriorly and proximally towards the epicondyle. This repair, once tensioned is meant to serve as a hammock for the radial head and tension the lateral soft tissues proximally and anteriorly once sewn. Once the leading limb of the suture has been run distal and proximal as shown, the second limb is then also run in a simple fashion through the lateral soft tissue complex, resulting in the suture configuration shown here. Once satisfied, the lateral soft tissue and lateral collateral ligament complex is then sewn down with the knob placed over the soft tissue complex, but the limb ends are not cut. The two limb ends that are not cut are then run through the anterior tendinous interval for a later pants-over-vest closure to reinforce the lateral collateral complex ligamentous repair.

CHAPTER 8

Once satisfied with the ECRB origin debridement, lateral elbow capsulotomy, decortication of the lateral epicondyle, and evaluation and repair of the lateral collateral ligament complex if needed, closure is undertaken.

The wound and joint is first washed out thoroughly. The deep tendinous interval is closed with multiple absorbable figure-of-eight sutures. In this case, an 0 Vicryl is being used.

Once the interval is closed, as discussed previously, the two limbs of the braided non-absorbable suture anchor limbs are then tied over top in a pants-over-vest fashion. Next, an interrupted subcutaneous closure using 3-0 Vicryl is performed. Next, a subcuticular closure is performed with a running 4-0 Monocryl suture.

Lastly, a dressing is applied followed by a posterior splint. The splint is applied with the elbow in 90 degrees of flexion, slight forearm pronation, and wrist extension, to be worn for 1 to 2 weeks prior to initiating therapy. Thank you.