CHAPTER 46 Surgical Failure of Tennis Elbow
Lateral epicondylitis is the most common elbow affliction in adults. Surgical intervention appears to be increasing, in part due to the introduction of orthopedic releases. Failures after surgery are recognized, but the cause and the means of re-evaluation are seldom addressed. Initially, the most frequent explanation for residual symptoms is too brief a period after surgery or inadequate rehabilitation. The latter may be due to noncompliance or an inadequate program of strengthening and stretching exercises.22 This type of problem is readily determined with a careful interview. The reliability of surgical procedures for lateral epicondylitis makes the need for reoperation uncommon. For this reason, few surgeons have extensive experience with the management of patients after failed intervention for epicondylitis, and reports of such experience in the literature are lacking. The intent of this chapter is to share our experience with this problem and to provide a basis for determining the cause of failure and a basis for further management. Specific focus is on determining which patients might benefit from a second surgical procedure. To be perfectly candid, a review of the literature on this subject over the last 10 years has, I feel, obscured rather than clarified this particular problem.
Because the treatment of surgical failure in large measure relates to the etiology and pathology of the condition, analysis of treatment failure logically begins with a brief consideration of the pathoanatomy of lateral epicondylitis. This is discussed in detail in Chapter 44. It is well accepted that the pathology involves the extensor carpi radialis brevis tendon.4,6,8,13,15,22,25
Although generally considered an inflammatory lesion, as many as 14 pathologic features are reported in the literature (Box 46-1).26 A careful blinded study of pathologic and control material reported that the material removed at surgery reveals hyaline degeneration with neovasculature. This represents an aborted effort of healing but is not inflammation. Inappropriate or inaccurate initial diagnoses may occur,32 such as interosseous nerve entrapment,1,6,19,31,33 or even intra-articular plica.29
Regardless of the etiology or underlying pathology, nonoperative management is usually successful in 90% of patients.22 Similarly, when surgery is performed, a 90% success rate is typically reported. The interesting feature of these data is that the success of surgery seems independent of the surgical technique.2,3,6,14,21,22,26,28,34 On the other hand, when surgical intervention is not successful, there are few reports of subsequent management.9,12,18,19,23
The first step in the evaluation process is to critically assess the patient and motives. Next, determine whether an adequate period has elapsed since surgery, including whether the patient has exhibited adequate compliance with the rehabilitation program. If concern exists about either point, the patient is treated for symptoms and reassessed. If at least 6 to 9 months has passed since surgery and there are no worrisome personality features, litigation, or compensation issues, the problem may be further studied.
The most important determination at this point is to determine whether the symptom complex is identical to or different from that for which the original surgery was performed. This allows the failure to be classified as one of three types: type I, inaccurate initial diagnosis; type II, inadequate treatment; type III, introduction of new pathology.
Several other possible causes of lateral elbow pain include degenerative arthrosis,20 anconeus or extensor muscle compartment syndrome,1,25 lateral ligament instability especially with a history of trauma,23 and entrapment of the posterior interosseous nerve (PIN) in the region of the arcade of Frohse17,30,33 (Fig. 46-1), cutaneous nerve entrapment,10 and intra-articular plica.29
The distinction between lateral epicondylitis and PIN entrapment has been well discussed in the literature.5,11,20,27,28,33 The distinction is made even more difficult because PIN entrapment may coexist with lateral epicondylitis in about 5% percent of individuals.33 In one series, a concurrent and unrecognized PIN entrapment also was suspected as the cause of failure in 2 of 15 patients.33 I have found a reliable triad to help make this diagnosis, consisting of: localization of pain at the arcade of Frohse reproduced by direct palpation; pain aggravated by resisted supination; and pain relief by injection of 2 mL of lidocaine (Xylocaine). Electromyographic changes, on the other hand, are not usually present, nor are they necessary to diagnose nerve entrapment.
It should also be noted that patient selection is a consideration with a type I failure. Issues include adequate motivation, compliance, and consideration of secondary gain.31 The same factors that resulted in a failure of nonoperative treatment are present in the patient undergoing surgery. The best solution for this difficult problem is obvious: avoid the initial surgical procedure in patients known to be at risk for secondary gain. Avoid additional surgery at all costs.
In some patients, an incomplete release or excision of the pathologic tissue is the cause of persistent symptoms. This was the most common finding in our19 and Nirschl’s experience. In fact, of 35 secondary procedures by Nirschl, the extensor carpi radialis brevis (ECRB) was felt not to have been addressed at all in 27, and inadequately excised in 7.23 By excising this area, 83% experienced a good or excellent result.