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Open Treatment of Medial Epicondylitis

DEFINITION

Medial epicondylitis, also known as golfer's elbow, is a condition characterized by tendinosis at the origin of the flexor-pronator mass. It is more commonly associated with racquet sports and manual labor rather than golf.

ANATOMY

The common flexor-pronator origin is primarily located on the anterior aspect of the medial epicondyle. This includes the pronator teres (PT), flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), and a small portion of the flexor digitorum superficialis (FDS). The palmaris longus also shares this origin but is usually not clinically relevant.

PATHOGENESIS

Medial epicondylitis develops due to repetitive microtrauma and an incomplete repair response, leading to tendinosis. It can be seen in cases of medial collateral ligament instability, which causes myotendinous overload and ulnar neuropathy.

NATURAL HISTORY

Conservative treatment options result in improvement for most patients with medial epicondylitis. However, a higher percentage of patients with this condition may eventually require surgical intervention compared to those with lateral epicondylitis.

PATIENT HISTORY AND PHYSICAL FINDINGS

Patients typically experience forearm pain rather than pain specifically at the elbow. Inflammation may irritate the ulnar nerve, leading to symptoms such as local irritation, numbness in the distal region, and tingling sensations. Medial epicondylitis usually has an insidious onset, although there may be an inciting event. It can coexist with lateral epicondylitis. Examination includes palpation of the medial epicondyle for tenderness, assessment of resisted pronation, evaluation of range of motion, and tests to elicit ulnar nerve symptoms.

IMAGING AND DIAGNOSTIC STUDIES

Plain radiographs may reveal calcifications at the flexor-pronator origin. Magnetic resonance imaging (MRI) can reliably show increased intratendon signal on T2-weighted sequences, along with possible tendon thickening on T1-weighted sequences.

NONOPERATIVE MANAGEMENT

Conservative treatment for medial epicondylitis involves:

• Avoiding activities that cause pain
• Using nonsteroidal anti-inflammatory drugs for symptomatic relief
• Applying ice to reduce inflammation
• Wearing daytime wrist bracing during exertional activities
• Undergoing physical or occupational therapy

Corticosteroid injections may provide temporary relief but do not alter the natural course of the condition and should be used with caution. Surgical intervention becomes necessary when nonoperative management fails.

SURGICAL MANAGEMENT

A minority of patients do not respond to nonoperative management, requiring surgical intervention. Careful patient selection is crucial to ensure excellent surgical outcomes.

Preoperative Planning

• Be prepared to address concurrent ulnar nerve pathology. If necessary, perform ulnar nerve decompression using subcutaneous or submuscular transposition.
• In thin patients, especially those exposed to frequent inner elbow trauma, submuscular transposition with flexor-pronator lengthening is preferred as it effectively treats epicondylitis.
• Be prepared to address flexor-pronator tears or avulsion, which may present with acute or chronic pain, swelling, and ecchymosis. Treatment involves débridement of the ruptured degenerative tissue and repair by retensioning it near the origin, closing the gap with healthier portions of the flexor-pronator origin down to the medial epicondyle.

Positioning

The patient is placed supine with the arm externally rotated at the shoulder, and padding under the elbow. This position allows unrestricted access to the medial aspect of the elbow without requiring constant assistance.

Approach

After administering anesthesia, evaluate the stability of the elbow, documenting the result in the operative note. The surgical goal is to débride the degenerative tissue at the flexor-pronator origin and create an environment conducive to proper tendon healing.

(To be continued...)

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FIG 1 • The common flexors can be seen ruptured and retracted distal to the medial epicondyle.

 

TECHNIQUES

• Medial Epicondylar Fasciectomy and Partial Ostectomy

Incision and Dissection

A 3- to 5-cm incision through the skin only is made beginning just proximal to and in the center of the medial epicondyle and extending distally along the axis of the forearm (TECH FIG 1A).

 

 

 

 

TECH FIG 1 • A. A 3- to 5-cm incision is started just proximal to the medial epicondyle. B. The medial antebrachial cutaneous nerve is identified and protected. (continued)

 

 

Blunt dissection with scissors is carried through the subcutaneous tissues, taking care to preserve medial antebrachial cutaneous nerve branches, which commonly cross the field (TECH FIG 1B).

 

The subcutaneous tissues are gently swept away, exposing the fascia of the flexor-pronator mass.

 

The ulnar nerve is palpated, and the elbow is put through a ROM to check for ulnar nerve subluxation. The result is documented in the operative note.

 

P.3902

 

 

 

TECH FIG 1 • (continued) C. The interval between the FCR and common flexors is used and split in line with the fibers. D. The FCR is elevated, and the deeper degenerative tendon is identified.

 

 

Most commonly, the fascia overlying the interval between the PT and FCR is then incised in line with the fibers to expose the tendon origin. Observe the orientation of the fibers of the overlying fascia to identify the correct interval. The fibers of PT can be seen coursing toward the radius while the rest of the flexorpronator tendons are oriented more longitudinally.

 

The exact interval can be altered depending on clinical and intraoperative examination. In the figure shown, the interval between FCR and the common flexors was chosen to better access the diseased

tissue (TECH FIG 1C).

 

The selected interval is then developed, exposing the abnormal, deeper tendon tissue (TECH FIG 1D).

Fasciectomy and Partial Ostectomy

 

The abnormal tissue is excised. It can be identified by its grayish, unorganized mucoid appearance. Abnormal tissue will scrape away with a no. 15 blade, but normal tendon will remain attached (ie, Nirschl scratch test).

 

 

 

TECH FIG 2 • A. Degenerative tissue is excised. The remaining healthy tendon is stable and cannot be scraped away with a no. 15 blade. B. The anterior portion of the medial epicondyle is scraped or rongeured to remove any remaining degenerative tendon. C. The bony cortex is not violated, however. (continued)

 

 

 

The pathologic tissue is débrided to margins showing an organized, tendinous appearance. The area of excision usually is 1 to 1.5 cm long and 3 to 5 mm wide (TECH FIG 2A).

 

A rongeur is used to roughen the anterior portion of the medial epicondyle to a bleeding surface without removing cortical bone (TECH FIG 2B,C).

 

The defect in the tendon is closed with a running absorbable suture, using 0 or 1-0 suture material with a tapered needle (TECH FIG 2D).

 

The subdermal layer is closed with buried, interrupted absorbable sutures, followed by a subcuticular skin closure and Steri-Strips (TECH FIG 2E).

 

P.3903

 

 

 

TECH FIG 2 • (continued) D. The muscle interval is closed with a running size 0 Vicryl suture and tied with inverted knots. E. Skin closure is done with a running 3-0 Prolene suture.

• Minimally Invasive Radiofrequency Débridement

 

In selected cases, a minimally invasive approach using the ArthroCare TOPAZ MicroDebrider (ArthroCare Sports Medicine, Sunnyvale, CA) may be used.

 

This procedure is indicated for areas of tendinosis within the common flexor-pronator tendon origin.

 

Contraindications include acute trauma, partial or complete tendon tear, neurogenic disease, and bone and joint abnormality.

Incision and Dissection

 

A 1.5-cm incision through the skin only is made over the area of tenderness. The incision usually begins at the medial epicondyle and extends distally along the axis of the forearm.

 

 

 

TECH FIG 3 • The tip of the ArthroCare TOPAZ MicroDebrider is placed perpendicular to the surface of the area of tendinosis. In this figure, the FCR is the area being treated.

 

 

The origin of the flexor-pronator mass is exposed and the location of the ulnar nerve is verified as described in the previous section.

Radiofrequency Débridement

 

Place the tip of the device on the tendon perpendicular to the surface (TECH FIG 3).

Using light pressure, perforate the tendon in the area of tendinosis to the desired depth.

Repeat this process with multiple perforations in a grid-like pattern (separating the perforations by approximately 5 mm) until the affected area has been covered.

Irrigate the wound and close the subdermal layer with buried, interrupted absorbable sutures followed by a subcuticular skin closure and Steri-Strips.

 

 

 

PEARLS AND PITFALLS

 

 

POSTOPERATIVE CARE

Postoperatively, the patient is placed in a soft dressing and a removable cock-up wrist brace. The elbow is not immobilized, and gentle ROM is allowed immediately.

The dressing is removed in 3 to 5 days. The patient may perform activities of daily living as tolerated with the wrist brace, removing the wrist brace several times daily for ROM.

Exertion is avoided.

A strengthening program is initiated in 6 weeks with a counterforce brace.

All restrictions are removed at 3 months, but impact activities are not allowed until 4 to 6 months postoperatively. Return of full, pain-free activity can take 6 to 24 months.

 

OUTCOMES

Over 85% of all patients will have return to full activities with no pain or only mild, occasional pain. Among highlevel athletes, 75% to 85% will return to their previous level. In patients with mild or no ulnar nerve symptoms, the success rate is greater than 95%.1,6

 

Indications

• A minimum of 3-6 months of symptoms and failed nonoperative management

Coexisting

conditions

• Ulnar nerve irritation, neuropathy, and subluxation may require

  decompression and anterior transposition.

• Flexor tendon origin rupture may require débridement and repair.

Failure to fully

excise devitalized tendon

• This will result in a poor result or recurrence; the rehabilitation protocol can

be delayed in cases that require more significant débridement.

Injury to the

medial collateral ligament

• The ligament is deep to the tendon and lies on the anterior capsule, more

posterior than the area of tendinosis, and can be distinguished from the rougher tendon origin.

 

In patients with more than moderate ulnar nerve symptoms, there is a trend toward less favorable and less predictable outcomes, although a satisfactory result still is possible.

It is uncommon for a patient to have absolutely no improvement in pain after surgery, even if the subjective outcome is unsatisfactory. Such a result should prompt consideration of incorrect diagnosis or the possibility of secondary gain issues.

 

 

COMPLICATIONS

Medial antebrachial cutaneous nerve injury Grip weakness

Weakness with wrist flexion or pronation Hematoma

Infection

Ulnar nerve injury

Medial collateral ligament injury

 

 

REFERENCES

1. Gabel GT, Morrey BF. Operative treatment of medial epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 1995;77(7):1065-1069.

    

    

2. Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol 1998;27:133-138.

    

    

3. O'Dwyer KJ, Howie CR. Medial epicondylitis of the elbow. Int Orthop 1995;19:69-71.

    

    

4. Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow: a prospective analysis. Am J Sports Med 1995;23:214-221.

    

    

5. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis: a prospective study of sixty elbows. J Bone Joint Surg Am 1997;79:1648-1652.

    

    

6. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis: results in 35 elbows. J Bone Joint Surg Br 1991;73:409-411.