Abstract
The most efficacious treatment for patients with persistent lateral epicondylitis who have not adequately improved despite undergoing extended nonoperative measures may be arthroscopic. One advantage is the capability of the surgeon to fully assess the elbow intra-articularly. Second, the incision is often considered less appealing to both patients and surgeons than portal-site incisions. A final potential benefit is the opportunity for the occasional elbow arthroscopist to take advantage of a “best-case” clinical setting to perform a thorough arthroscopic diagnostic evaluation of both the anterior and posterior elbow compartments and improve his or her elbow arthroscopic skills, because patients with lateral epicondylitis rarely have advanced arthritis or capsular contractures and have infrequently undergone prior elbow surgery. Moreover, if technical difficulties arise during an arthroscopic release, the procedure can be easily converted to a standard open release technique without compromising the patient's condition or the procedure.
Lateral epicondylitis is a commonly occurring and painful condition that is estimated to affect between 1% and 3% of the general population and up to 7% of manual workers during their respective careers.
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A thorough history should be obtained and a detailed physical examination should be performed in all patients with elbow complaints in an effort to make an accurate diagnosis of lateral epicondylitis and to aid in recognizing any concomitant pathologic conditions. Nonoperative treatment is the mainstay of management for lateral epicondylitis and is successful in 90% to 95% of patients.3
For individuals with recalcitrant lateral epicondylitis despite extensive nonoperative measures, a variety of surgical techniques have been shown to provide excellent patient outcomes.4
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In 1979, Nirschl and Pettrone
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performed open excision of the extensor carpi radialis brevis tendon in 82 elbows and reported excellent results in 97.7% of patients at 2 years' follow-up. Both Verhaar et al.5
and Rosenberg and Henderson6
also reported good to excellent results in 89% and 95% of patients, respectively, after open extensor carpi radialis brevis release.Arthroscopic lateral epicondylitis release has been used routinely by many surgeons over the past decade or longer and is now commonly accepted as an effective form of surgical treatment. A variety of clinical studies have shown its efficacy.
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Baker et al.7
originally described the arthroscopic technique and reported on 42 elbows in 40 patients with recalcitrant lateral epicondylitis who underwent arthroscopic lateral epicondylitis debridement. A total of 37 patients (39 elbows) available for follow-up at 2 years rated themselves as “better” or “much better.” Patients returned to work, on average, 2.2 weeks after surgery, and grip strength at follow-up averaged 96% of the strength of the unaffected limb.7
In a long-term follow-up of the same patient population, Baker and Baker8
were able to contact 30 of the original patients (30 elbows) and found that, at an average of 130 months, 87% were satisfied and 93% would undergo the surgical procedure again if needed. It is interesting, however, that studies directly comparing arthroscopic versus open lateral epicondylitis release have been sparingly reported.11
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In the Level I prospective, randomized study entitled “Arthroscopic Versus Open Lateral Release for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled Trial” by Clark, McRae, Leiter, Zhang, Dubberley, and MacDonald,
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patients were recruited between 2002 and 2014 and then randomized intraoperatively to undergo either an open lateral release (37 patients) or an arthroscopic release (38 patients) after failure to adequately improve after a minimum of 6 months of nonoperative management for lateral epicondylitis. The Disabilities of the Arm, Shoulder and Hand score, visual analog scale score, and Patient-Rated Tennis Elbow Evaluation score were recorded before surgical intervention and at 3, 6, and 12 months postoperatively. Grip strength was also assessed. The patients in these 2 groups were demographically very similar, and the postoperative regimens were the same.Both groups improved significantly and consistently at each assessment (at 3, 6, and 12 months) during the 12-month follow-up period. There were no significant differences identified between these 2 groups in any measured parameter or at any postoperative time point. The only statistically significant difference identified between the 2 groups was that the arthroscopic procedure resulted in a longer surgery time (34 minutes vs 22.5 minutes, P = .005).
Despite the study not having identified any statistically significant differences among the parameters assessed except for operative time (11.5-minute difference), arthroscopic and open lateral release procedures are obviously not the same. There are, in fact, distinct advantages that the arthroscopic procedure affords. One such advantage is the capability of the surgeon to fully assess the elbow intra-articularly. In the current study, Clark et al.
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reported arthroscopically identifying and addressing intra-articular abnormalities such as synovitis and osteophytes in a number of study patients. Such comprehensive assessment and treatment of the elbow are simply not possible with open lateral epicondylitis release. Likewise, the authors used a 7.5-cm lateral incision for the open release procedure, and although reasonably well accepted by most patients, such an incision is often considered less appealing to both patients and surgeons than portal-site incisions.A final potential benefit for the surgeon to consider when deciding whether to carry out an arthroscopic or open release relates to the possibility for the surgeon to take advantage of an opportunity to perform elbow arthroscopy in a “best-case” clinical setting. Patients with lateral epicondylitis rarely have significant concomitant pathology such as advanced arthritis or capsular contractures and have infrequently undergone prior elbow surgery. As such, an arthroscopic release offers the chance to perform a thorough arthroscopic diagnostic evaluation of both the anterior and posterior elbow compartments and thus practice and improve one's elbow arthroscopic skills. If technical difficulties arise during the arthroscopic procedure because of challenges with intra-articular arthroscopic access, visualization, or orientation, then the arthroscopic procedure can be easily converted to a standard open release technique without compromising the patient's condition or the procedure. Clark et al.
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successfully recruited 75 patients over a 12-year period to participate in this prospective study comparing arthroscopic and open lateral epicondylitis release and should be commended for their efforts and for reporting the results of their high-quality Level I investigation.Supplementary Data
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Footnotes
The author reports the following potential conflicts of interest or sources of funding: L.D.F. receives consulting income from Smith and Nephew, and research and educational support from Arthrex, Mitek, and Smith & Nephew. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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- Arthroscopic Versus Open Lateral Release for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled TrialArthroscopyVol. 34Issue 12
- PreviewThe purpose of this randomized clinical trial was to determine whether quality of life and function, as measured using subjective questionnaires and clinical assessment, are different after open versus arthroscopic debridement of the pathologic extensor carpi radialis brevis origin in the treatment of lateral epicondylitis at 1 year postoperatively.
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