Extensor Brevis Release and Lateral Epicondylectomy

Published on 16/03/2015 by admin

Filed under Orthopaedics

Last modified 16/03/2015

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 3 (2 votes)

This article have been viewed 3666 times

Extensor Brevis Release and Lateral Epicondylectomy

Kelly Akin Kaye, Kristen G. Lowrance and James H. Calandruccio

The pathologic condition of the elbow commonly termed lateral epicondylitis or simply tennis elbow refers to pathologic alterations in the extensor tendon origin(s), which often are solely alterations in the extensor carpi radialis brevis (ECRB) tendon. However, this syndrome of lateral elbow pain is rarely accompanied by acute inflammatory cells and hence is now termed lateral epicondylosis. Moreover, many patients who have focal tenderness just distal and anterior to the lateral epicondyle and localized pain in the same region with wrist extension do not play tennis nor related to athletic activity.1

Surgical Indication And Considerations

Etiology

Injury to the extensor tendons at the elbow often can be attributed to repetitive trauma or overuse, leading to mechanical fatigue or biomechanical overload. Some literature reports the possibility of exostosis in the area of the extensor tendons or a degenerative process that causes pain at the lateral epicondyle.2 Symptoms may be described as an ache at the elbow with sharp pain that infrequently radiates to the dorsal forearm and occasionally to the middle and ring fingers with attendant loss of grip.3

The most frequently involved tendon is that originating from the extensor carpi radialis brevis (ECRB). It is responsible for static and dynamic wrist extension required for certain tasks and stabilizes the wrist while grasping. Lesions can occur at the extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi, and supinator tendon. According to the current literature, microtraumatic ECRB tendon tears may propagate to include the common extensors.1 Plancher and associates1 report that gross tendon rupture is noted in a large number of patients at the time of surgical intervention.

Microtears can result from repeated sprains, repetitive forceful wrist extension and gripping, and suboptimal mechanics in hitting. Inadequate racquet size or improper tool grip size also can predispose to injury. Other factors that may influence the onset of symptoms are inadequate strength, endurance, and flexibility of the forearm musculature; changes in regular activity; increasing age; and hormonal imbalance in women.3 The incidence is equal in men and women during the fourth and fifth decades, with 75% of all cases involving the dominant arm.1 Among the older population, the insult can possibly be work-related, in contrast to the sports-related injuries seen in the younger population.

Lateral epicondylitis can be successfully managed nonsurgically in 90% of patients with a combination of activity modification, nonsteroidal antiinflammatory medication, functional and counterforce bracing, various therapeutic modalities, and injection therapy. A small percentage of patients with persistent and disabling symptoms require surgical intervention.4 Lesions caused by overuse during job-related activities are more likely to require surgical intervention secondary to an inability to stop the aggravating activity.

Indications for surgery are individualized according to patient demands and activity level. The period of disability and previous conservative management must be considered before surgical management is chosen. There are no absolute indications for surgical intervention to treat lateral epicondylitis, and the clinician must exercise caution in cases in which secondary gain may be important.

The most important factors in considering surgical intervention are the intensity, frequency, and duration of disability caused by pain. The Nirschl classification system indicating the severity phase of pain, its relation to activity and exercise, and symptom resolution following these activities may have some impact on the therapeutic intervention (Table 8-1). Constant and unrelenting focal lateral elbow discomfort is not tolerated well by active individuals and pain that accompanies exercise and activity (phase 4) may indicate pathologic tendon architectural alteration. Most patients treated surgically have symptoms for 1 year, but special consideration may be given to patients in whom other therapies have failed after 6 months of compliance with a well-tailored therapeutic regimen. Calcification around the lateral aspect of the elbow may portend a less favorable outcome to conservative measures. When symptoms are present for more than 12 months, they will rarely respond to further therapeutic management. Although cortisone injections have been the historical standard for acute pain relief in significant cases of tennis elbow, the high recurrence rate has prompted autologous whole blood, platelet rich plasma, sclerosing agents, botulinum toxin, and periarticular hyaluronate injections to provide more long-lasting results. At this time, despite some compelling reports, no consensus exists regarding the ideal injection for a given patient in a particular phase of their lateral epicondylosis malady.

Similarly, less invasive surgical interventions are being investigated by some authors for a quicker return to activity and exercise. Arthroscopic treatment when compared with open management may provide athletes a shorter time period to functional recovery. In contrast to percutaneous release, arthroscopic release appears to achieve outcomes more quickly and provide a clearer visualization of the pathology. Nonetheless, the benchmark procedure for this condition is an open release for which various modifications have been proposed. Regardless of the open method chosen, these procedures are technically simple and provide predictable and long-lasting results and rely on readily available instrumentation. No single technique has been or will be adopted by all surgeons.

Surgical Procedure (Modified Nirschl Method)

The common denominator for most lateral epicondylosis procedures, however, is the débridement of the diseased tendinous tissue, most notably the ECRB origin. Hypervascular granulation tissue is characteristically found on the undersurface of the ECRB attachment to the lateral epicondyle and appears on gross inspection as dull, tan-gray, and sometimes gritty degenerative regions. A limited approach commonly incorporated into surgical techniques consists of resection of the diseased section of the tendon and lateral epicondylectomy.

A skin pen is used to outline the intended surgical incision which is 4 to 5 cm long, gently curved, and centered over the lateral epicondyle along the lateral supracondylar ridge proximally and along a line from the lateral epicondyle center toward the Lister tubercle. The skin incision is made under tourniquet control and the skin edges are retracted. Gentle spreading of the subcutaneous tissue is done to protect any cutaneous nerves, often passing through a very superficial bursa over the lateral epicondyle. The extensor fascia is identified through this opening (Fig. 8-1, A). The anterior edge of the ECRB tendon origin is clearly developed by elevating the posterior border of the extensor carpi radialis longus, which at this level is muscular and partially overrides the ECRB origin. The extensor digitorum communis origin may partially obscure the deeper portion of the ECRB (Fig. 8-1, B). The ECRB portion of the conjoined tendon is elevated at the midportion of the lateral epicondyle, distally in line with the forearm axis toward the radiocapitellar joint. The abnormal-appearing ECRB tendon is sharply dissected from the normal-appearing Sharpey fibers. The diseased tissue may appear fibrillated and discolored, and can contain calcium deposits.

Occasionally the disease process also involves the extensor digitorum communis origin. Entrance into the radiocapitellar joint may not be routinely indicated; however, an intraarticular process such as loose bodies, degenerative joint disease, effusion, and synovial thickening on preoperative examination may require a larger incision and arthrotomy for joint exploration.

The lateral 0.5 cm of the lateral epicondyle is decorticated with a rongeur or osteotome, with the surgeon taking care not to damage the articular cartilage or destabilize the joint (Fig. 8-1, C). The ECRB is intimately associated with the annular ligament just proximal to the radial head, thereby limiting distal migration of the ECRB tendon. However, the remaining normal ECRB tendon may be sutured to the fascia or periosteum or attached with nonabsorbable sutures through drill holes in the epicondyle.

The extensor tendon interval is closed with absorbable sutures, with the elbow in full extension to reduce the possibility of an elbow flexion contracture. The skin incision is closed (often with absorbable subcuticular suture material reinforced with adhesive strips) and a soft dressing applied. An arm sling is given for comfort and home range of motion exercises are encouraged before the first office visit in 10 to 14 days postoperative.

Surgical Outcomes

According to Nirschl,5,6 85% of patients were able to return to all previous activities without pain. Pain that occurred during aggressive activities was noted in 12% of the cases observed, and no improvement was apparent in 3% of the cases. When both medial and lateral releases are performed, a high level of patient satisfaction was achieved in a group of 53 patients followed an average of 11.7 years, and 96% of patients returned to their sports activity. Reasons for failure include misdiagnosis or the concomitant diagnosis of entrapment of the posterior interosseous nerve, intraarticular disorders, or lateral elbow instability. Poor prognostic factors include poor initial response to cortisone injections, numerous previous cortisone injections, bilateral lateral epicondylitis, other concomitant associated disorders, and smoking.

Therapy Guidelines For Rehabilitation

Phase I

TIME: 1 to 14 days after surgery

GOALS: Achieve full range of motion (ROM) of adjacent joints, promote wound healing, control edema and pain, and increase active range of motion (AROM) of the elbow (Table 8-2)

TABLE 8-2

Extensor Brevis Release and Lateral Epicondylectomy

< ?comst?>

< ?comen?>< ?comst1?>

< ?comen1?>

Image

< ?comst1?>

< ?comen1?>

AROM, Active range of motion; HVGS, high-voltage galvanic stimulation; PROM, passive range of motion; ROM, range of motion.

After surgery, the therapist instructs the patient concerning the need to elevate the site to avoid edema and initiates gentle AROM exercises for the hand and shoulder. The patient is to remain immobilized in the postoperative splint with the elbow positioned at 90°. On the fifth day after surgery, the postsurgical dressing and splint are removed and therapy is initiated to the elbow.

The initial postoperative examination is conducted by a physical or occupational therapist. Upon removal of the postsurgical dressing, the examination conducted should measure and address ROM, edema, pain, functional ability, and wound healing. ROM of the hand, wrist, elbow, and shoulder along with girth measurements of the hand, forearm, elbow, and upper arm are taken. Pain levels can be monitored using a 0 to 10 VAS (Visual Analog Scale). It is recommended to have patients use this during therapy sessions and with the home exercise program for optimum accuracy. Functional ability can be monitored using the DASH (disabilities of the arm, shoulder, and hand) or PRTEE (patient-rated tennis elbow evaluation) questionnaire. The above recorded data should be taken at subsequent visits for comparison and assessment of the patient’s progress.

In this phase the patient’s wounds are kept clean and dry until the sutures are removed 10 to 14 days after surgery. After the operative site has been exposed, other forms of edema control can be used, including ice, pneumatic intermittent compression (performed at a 3 : 1 on/off ratio at a pressure of 50 mm Hg), and high-voltage galvanic stimulation (HVGS). The recommended settings for the use of HVGS to prevent edema are negative polarity with continuous modulation at 100 intrapulse microseconds and intensity to the sensory level.7

Buy Membership for Orthopaedics Category to continue reading. Learn more here