Lateral Epicondylitis Debridement
Transcription
CHAPTER 1
With the operative limb prepped anddraped 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 alongthe anterior border of these structures.
The surgical site is then infiltratedwith a local anesthetic.My preferred anesthetic is 0.5% bupivacainewith 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 levelof the fascia where the extensor origin can be identified.
CHAPTER 4
With the extensor origin exposed,ideally, the interval between the ECRLand 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 topof the capitellum and the top of the radial head.That tendinous interval is then splitand 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 thelateral 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 capsulewith a formal arthrotomy is recommended to confirm completedebridement. However, dissection should notbe taken aggressively posteriorly againas to not compromise the lateralcollateral ligament origin,although that will also be assessed later.Debridement is recommended to proceed proximallyuntil only the muscular origin of the extensor massand brachioradialis is in contact with the bone.
Finally, the debridement of the ECRB origin is completedby a decortication of the lateralepicondyle extensor mass origin,down to bleeding bone.The origin will then be repaired back downand the interval closed back downon this bleeding surface to enhance healing.
CHAPTER 6
Finally, the lateral collateral ligamentcomplex origin is identified and examined.Tears are often present.These degenerative tears often cause painbut do not cause instability.The LCL origin can be assessedby carefully elevating the tissue off of the lateral aspectof the capitellum and epicondyle with ablunt instrument like a freer.If it raises off readily, the origin is compromised.
CHAPTER 7
If the LCL origin is confirmed, compromisedand warrants repair, the LCL origin can be repairedwith either a suture anchor or bone tunnels.In this illustration, a suture anchor is placedat the footprint of the LCL originwith a number 2 non-absorbable braided suture emanatingfrom the anchor.With the anchor in position,a locking, Krackow-Style stitch is run distallyand posteriorly towards the ulna and then back anteriorlyand proximally towards the epicondyle.This repair, once tensioned is meant to serveas a hammock for the radial head and tensionthe lateral soft tissues proximallyand anteriorly once sewn.Once the leading limbof the suture has been run distaland proximal as shown,the second limb is then also run in a simple fashionthrough the lateral soft tissue complex, resultingin the suture configuration shown here.Once satisfied, the lateral soft tissueand lateral collateral ligament complex is then sewndown with the knob placed overthe soft tissue complex,but the limb ends are not cut.The two limb ends that are not cut are then runthrough the anterior tendinous intervalfor a later pants-over-vest closureto reinforce the lateral collateral complexligamentous repair.
CHAPTER 8
Once satisfied with the ECRB origin debridement,lateral elbow capsulotomy, decorticationof the lateral epicondyle, and evaluation and repairof the lateral collateral ligament complex if needed,closure is undertaken.
The woundand joint is first washed out thoroughly.The deep tendinous interval is closedwith 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 limbsof the braided non-absorbable suture anchor limbsare then tied over top in a pants-over-vest fashion.Next, an interrupted subcutaneous closureusing 3-0 Vicryl is performed.Next, a subcuticular closure is performedwith a running 4-0 Monocryl suture.
Lastly, a dressing is appliedfollowed by a posterior splint.The splint is applied with the elbowin 90 degrees of flexion, slight forearm pronation,and wrist extension, to be wornfor 1 to 2 weeks prior to initiating therapy.Thank you.
