MICROSURGERY FOR TENNIS ELBOW

by Raymond K. Wurapa, M.D.

What is Tennis Elbow?

Tendonosis of the lateral elbow, also known as tennis elbow or lateral epicondylitis, is a common orthopaedic complaint. Injury is most commonly associated with overuse of forearm muscles required in forearm rotation and wrist extension. A direct blow to the lateral elbow can also trigger lateral epicondylitis. Patients typically report severe pain over the lateral elbow and dorsal forearm with activity. Untreated, this condition may be self-limited, however a prolonged period of activity restriction can lead to significant deconditioning and weakness in the affected arm.

This condition most commonly affects patients between the ages of 30 and 60 years. The affected population is diverse, including professional and recreational athletes, as well as non-athletes who perform repetitive work tasks.

Although traditionally thought to be inflammatory in origin, studies have shown the condition to be chronic and degenerative. Histologically, the condition is characterized by fibroblastic hypertrophy, unorganized collagen, chaotic vascular hyperplasia with avascular tendon fascicles and a distinct paucity of inflammatory cells. This suggests a dysvascular, non-inflammatory tendonosis, in contrast to a tendonitis, which is inherently inflamatory. In this paradigm, the growth of new blood vessels from pre-existing vessels is thought to help reverse the avascular effects caused by chronic injury.

How is Tendonosis of the Lateral Elbow commonly treated?

Numerous conservative treatments have been employed over the years. Beyond elimination of inciting activities, other common therapies include protective orthototics, oral anti-inflammatory therapy, physical therapy with topical modalities, and steroid injections. Some patients fail conservative measures and are faced with a final option of surgical debridement of the avascular tissue and repair of the tendon.

What’s new?

Studies have demonstrated distinct benefits from the use of radiofrequency (RF) – based ablation therapy to initiate a cellular response leading to accelerated healing, and angiogenesis. It is safe and routinely used for procedures like cardiac catheterization and tonsillectomies. Coblation, in contrast to simple RF-based ablation, uses a device that allows for a more controlled plasma-mediated process with a more precise ablation pathway, lower temperatures, and thus minimizes thermal injury to surrounding tissue. A combined, minimally invasive RF-coblation technique, also known as microtenotomy surgery, has been shown to induce a healing response and improve clinical function and pain. The procedure is typically performed under sedation with a local block. The advantages over the standard surgical procedure include a smaller less invasive incision, shorter surgical time, and typically a faster recovery.

Who is the ideal candidate for Microtenotomy Surgery?

Ideal patients should have a history of symptomatic lateral elbow tendonosis for greater than six months, which has failed extensive non-surgical therapy. Major contraindications are pregnancy, large tears in the extenser tendon, prior elbow surgery, and retained hardware adjacent to treatment area.