The cause of chronic pain in the lateral elbow, somewhat misleadingly termed "tennis elbow," is still unknown, which may be why a variety of surgical procedures have been described to treat it, including denervation,18 extensor tendon release,15 and decompression of the posterior interosseus nerve (PIN).16
Surgery, in our opinion, is indicated if repeated attempts of nonoperative treatment have failed. Only in about 10% of our patients, where symptoms and physical signs suggest an isolated epicondylitis, do we limit surgery to the epicon-dylar area, denervating the lateral elbow and releasing all extensors originating from the lateral epicondyle. In all other cases, we combine this procedure with a decompression of the PIN. The reason for this combination is that most often the lateral epicondyle and the radial tunnel are equally tender. Both conditions seem inseparably connected to us and are almost indistinguishable by clinical examination. Electromyography is rarely helpful for patients with tennis elbow but may prove useful if a PIN palsy is present.
For many years, we have used standard incisions with little modification from those seen in most textbooks.4'5 Scars from these incisions cause problems, not only aesthetically. The more extensive the incision, the higher the risk of severing one of the many cutaneous nerve branches in this area and to produce a painful neuroma. There is hardly any soft tissue padding on the epicondyle, so the scar may tether down to the bone, become painful, and impair motion. Moreover, to allow access to the radial tunnel, it must be fairly long, up to 10 cm or more.
Following our principles for minimally invasive and endoscopic techniques, we now perform the combined operation from a 4-cm incision over the radial tunnel (Figure 6-20), about 5 cm distal from the epicondyle. The incision is oblique or transverse, depending on the direction of the skin creases, which are easily detected by lightly squeezing the skin. When exposing the fascia, all cutaneous branches of the area must be protected. With the tunneling forceps, we create a space in the periepicondylar area (Figure 6-21). An illuminated speculum (blade length 9 to 11 cm) is inserted, giving a perfect view of the epicondyle and its surrounding structures (Figure 6-22a). Through the speculum, we continue with the epifascial detachment of the flaps, thereby severing tiny pain-transmitting branches of the dorsal cutaneous antebrachial nerve.
Another small nerve branch running with the radial intermuscular septum is cauterized about 3 cm proximal of the epicondyle. The next step is the complete release of all extensor tendon origins between epicondyle and radial head, leaving the joint capsule intact (Figure 6-22b). Excellent vision allows for meticulous hemosta-sis with a bipolar micro forceps.
The radial nerve is approached transmuscu-larly in its plane between the extensor digitorum and the extensor carpi radialis brevis.7 If the
nerve is explored in connection with the procedure described above, we continue to separate the aponeurosis between the desoriginated muscles and develop the plane from there. If radial nerve decompression is done as a separate operation, it is easier to open the raphe between the extensor carpi radialis brevis and the extensor digitorum more distally.
After entering the intermuscular plane, dissection is usually blunt, and large Langenbecks are inserted to retract the brachioradialis muscle mass and the extensor muscles to either side, exposing the PIN. As a result of the very small incision, this part of the operation is tedious and difficult and requires experience with dissecting the anatomy around Frohse's arcade. It also requires excellent assistance because the retractors must be pulled fairly hard but, at the same time, no pressure is allowed on the nerve branches. Usually incising the tendinous margin of the extensor carpi radialis brevis greatly helps to expose the supinator muscle and Frohse's arcade at its proximal edge. We divide the arcade and all aponeurotic parts of the supinator, but not the fleshy part of the muscle. Sometimes vascular bundles crossing the PIN must be hemo-clipped or cauterized.
We palpate carefully in a proximal direction along the radial nerve, under the brachioradialis, for more proximal compression sites. A suction drain may be inserted, and the wound is always closed in two layers, using intracutaneous skin closure. An upper arm dorsal splint is applied for 2 days. Afterwards, patients are instructed to move their elbow, which is protected by an elastic bandage. Physiotherapy is prescribed if necessary.
We have used this minimally invasive technique since February 2004 in about 20 patients. It is much too early to recommend it, especially for radial nerve decompression "through a keyhole" because it is technically quite demanding. We have been impressed, however, with the very low morbidity and good functional results. Patients regained full range of motion earlier than with our conventional method, which
required immobilization for 8 to 12 days. All patients were delighted with the inconspicuous scar, especially those who had a larger longitudinal scar from a previous operation on the other elbow.
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