a. Mark Incision

b. Injection of Local Anesthesia

1. Patient Preparation

2. Incision

3. Exposure of Extensor Origin

4. Develop Interval Between ECRL and EDC to Expose ECRB Origin

a. Confirmation of Complete Debridement and Lateral Elbow Arthrotomy

b. Decortication of Lateral Epicondyle Extensor Mass Origin

5. Debridement of ECRB Origin off the Lateral Epicondyle Origin

6. Examination of LCL Complex Origin

7. LCL Origin Repair with Suture Anchor and Locking Krackow-Style Stitch Configuration

a. Close Deep Tendinous Interval

b. Pants-Over-Vest Closure of Suture Anchor Limbs to Reinforce LCL Complex Repair

c. Post-op Remarks

8. Closure

Lateral epicondylitis (LE), commonly referred to as “tennis elbow,” is a common condition of the extensor tendons of the forearm that can lead to pain along the lateral epicondyle with radiation into the forearm, decreased grip strength, and difficulty lifting objects. When LE symptoms progress and can no longer be managed with non-operative measures, LE debridement may be indicated. The approach presented here is an open debridement of the extensor carpi radialis brevis (ECRB) tendon origin. A 3–4-cm longitudinal incision was placed longitudinally over the lateral epicondyle, radial head, and capitellum. The ECRB was exposed then debrided, the lateral epicondyle was decorticated, the lateral collateral ligament was repaired, the wound was closed in layers, and a soft dressing and splint were placed.

Lateral Collateral Ligament Origin Repair 

<h4>CHAPTER 1</h4>

<p>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.</p>

<p>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.</p>

<h4>CHAPTER 2</h4>

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

<h4>CHAPTER 3</h4>

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

<h4>CHAPTER 4</h4>

<p>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.</p>

<h4>CHAPTER 5</h4>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<h4>CHAPTER 6</h4>

<p>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.</p>

<h4>CHAPTER 7</h4>

<p>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.</p>

<h4>CHAPTER 8</h4>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>


Watch this narrated surgical video of a lateral epicondylitis debridement performed by Dr. Asif Ilyas at the Rothman Institute.

DOI
Publication Date	2023/03/17
Article ID	332
Production ID	0332
Volume	2023
Issue	332
https://doi.org/10.24296/jomi/332

Lateral Epicondylitis Debridement

Procedure Outline

Table of Contents