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Arthroscopic Technique for Medial Epicondylitis: Techniqueand Safety Analysis

Alan Zonno, M.D., Jennifer Manuel, M.D., Gregory Merrell, M.D., Paul Ramos, P.A.,Edward Akelman, M.D., and Manuel F. DaSilva, M.D.

Purpose: The goals of this study are to report on a novel arthroscopic technique for the treatment ofmedial epicondylitis and to further describe the anatomic relations between the site of arthroscopicdebridement and both the ulnar nerve and medial collateral ligament (MCL) complex. Methods:Arthroscopic debridement of the medial epicondyle was performed on 8 fresh-frozen cadavericspecimens. Each specimen was dissected, and the shortest distance from the debridement site to boththe ulnar nerve and MCL complex was measured with a 3-dimensional motion-tracking system.Results: The mean distance between the debridement site and the ulnar nerve was 20.8 mm (range,14.4 to 25.1 mm), and the mean distance between the medial debridement site and the origin of theanterior bundle of the MCL was 8.3 mm (range, 5.9 to 10.4 mm). Conclusions: Our results suggestthat arthroscopic debridement of the medial epicondyle can be performed with low risk of injury tothe ulnar nerve or MCL complex. Clinical Relevance: This cadaveric study indicates a potential rolefor elbow arthroscopy in the surgical management of refractory medial epicondylitis.

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here is an abundance of literature addressing thetopic of arthroscopic debridement for the treat-

ent of lateral epicondylitis.1-4 There are even limitedata that suggest advantages in return to work andunction after arthroscopic lateral release comparedith traditional open debridement.4 Recalcitrant me-ial epicondylitis can likewise be managed opera-ively. The open treatment of medial epicondylitis haseen well described.5-8 However, to our knowledge,here are no published reports on the subject of arthros-

From the Department of Orthopaedics, The Warren Alpertchool of Medicine at Brown University/Rhode Island HospitalA.Z., E.A., M.F.D.), Providence, Rhode Island; Jacksonville Or-hopedic Institute (J.M.), Jacksonville, Florida; Indiana Hand Cen-er (G.M.), Indianapolis, Indiana; and University OrthopaedicsP.R.), East Greenwich, Rhode Island, U.S.A.

The authors report no conflict of interest.Received December 26, 2008; accepted September 30, 2009.Address correspondence and reprint requests to Manuel F.aSilva, M.D., Department of Orthopaedics, The Warren Alpertedical School of Brown University, 1405 S County Trail, Ste 115,ast Greenwich, RI 02818, U.S.A. E-mail: Manuel_Dasilva_1@rown.edu© 2010 by the Arthroscopy Association of North America

m0749-8063/10/2605-8723$36.00/0doi:10.1016/j.arthro.2009.09.017

10 Arthroscopy: The Journal of Arthroscopic and Related

opic release for the management of medial epicondyli-is. It has been proposed that the close proximity of bothhe ulnar nerve and the medial collateral ligament (MCL)omplex renders the arthroscopic debridement of theedial epicondyle unsafe.6 The goals of this study are to

escribe a novel arthroscopic technique for the treatmentf medial epicondylitis and to further delineate the ana-omic relation between the site of arthroscopic medialebridement and both the ulnar nerve and MCL com-lex. We hypothesize that arthroscopic debridement ofhe medial epicondyle can be performed while maintain-ng a safe distance from the ulnar nerve and the origin ofhe MCL.

METHODS

Eight fresh-frozen cadaveric upper extremity spec-mens (four matched pairs) underwent arthroscopicvaluation and debridement of the origin of the flexor-ronator mass. No specimen was observed to havevidence of previous elbow surgery or gross bonyeformity, and all specimens were therefore includedn the study. Each specimen was amputated at the

id-humerus level, thawed to room temperature, and

Surgery, Vol 26, No 5 (May), 2010: pp 610-616

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611DEBRIDEMENT FOR MEDIAL EPICONDYLITIS

igidly mounted onto a suspension device by way of a-clamp applied to the first metacarpal. Next, thelbow was positioned in neutral pronation at 90° ofexion and the proximal aspect of the humerus se-ured to the suspension device. This setup was de-igned to mimic the position of the arm during elbowrthroscopy performed in the supine position, with thehoulder in 90° of abduction and the elbow in 90° ofexion. No traction was used to obtain or maintainlbow position.

The elbow joint was distended with 20 mL of nor-al saline solution, and a No. 11 blade was used to

reate a 3-mm skin incision approximately 1 cm prox-mal and 1 cm anterior to the medial epicondyle. Wenserted a blunt trocar and cannula into the elbow jointlong the anterior surface of the distal humerus, firstreating a medial portal. After insertion of a 2.7-mm0° arthroscope to confirm safe entry into the elbow,

thorough joint space inspection was performed.ext, after removal of the arthroscope, a long switch-

ng stick was inserted through the medial cannula. Theadiocapitellar joint was felt with the switching stick,hich was then elevated slightly and advanced later-

lly through the joint capsule to a subcutaneous posi-ion. Once visualization confirmed subcutaneous posi-ioning, a 3-mm skin incision was made approximately 1m proximal and 1 cm anterior to the base of the lateralpicondyle, thereby creating a lateral portal. Thewitching stick was further advanced out the lateralortal such that a single switching stick spanned thentire joint space, with one end protruding laterallynd the other end medially. The switching stick wasithdrawn laterally to allow the arthroscope back into

he medial portal. Visualization of the lateral epicon-yle is easily performed with the described approach.owever, visualization of the medial aspect of the

lbow is more difficult.To increase visualization of the medial joint space,

second medial capsular entry site (by use of the samekin incision) was created according to the followingechnique. The camera and cannula were removedrom the medial portal as the switching stick wasdvanced across the joint from lateral to medial. Ex-reme care is taken to maintain the position of thewitching stick along the anterior aspect of the distalumerus. As the switching stick was advanced medi-lly through the capsule, a second capsular entry siteas created adjacent to the anterior cortex of theumerus. Once through the medial capsule, thewitching stick was advanced subcutaneously to exithe previously made medial skin incision. Next, the

annula and arthroscope were inserted through the

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ateral portal over the switching stick; the cannula forhe shaver was likewise advanced into the medial jointpace through the second capsular entry site as thewitching stick was withdrawn medially. This se-uence is the preferred technique of the senior author,ho generally prefers to start medially so that the joint

an be thoroughly inspected before approaching thenteromedial side of the elbow. Alternatively, thenterior compartment can be approached by creatinghe initial entry site with an anterolateral portal in theulcus between the radial head and the capitellum, 1m distal and 1 cm anterior to the lateral epicondyle.

The flexor-pronator origin on the anterosuperiorspect of the medial epicondyle was visualizedhrough the laterally placed 2.7-mm 30° arthroscope.he “pathologic lesion” is the area where the deepexor-pronator fibers (pronator teres and flexor carpiadialis tendons) insert onto the anteromedial epicon-yle and is located just proximal to the MCL complex.ntra-articular inspection of the coronoid processerves as the landmark to begin debridement proxi-ally and medially (Fig 1), by use of a 2.9-mm

ull-radius shaver inserted through the medial cannula.partial capsulectomy was carried out, starting at the

nteromedial aspect of the distal humerus (Fig 2). Asebridement continues medial and posterior, a “cliffiew” from the arthroscope gives excellent visualiza-ion of the flexor-pronator origin on the anterosuperior

IGURE 1. Arthroscopic view of medial aspect of a right elbowith a 30° arthroscope viewing from laterally. The coronoid pro-

ess is shown distally, with the shaver resting on the anteromedialumerus.

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spect of the medial epicondyle (Fig 3). Subsequentebridement and decortication of the flexor-pronatorrigin were performed until the superficial fibers ofhe anterior band of the MCL were visualized. Allrthroscopic procedures were performed by 2 of theuthors, both attending orthopaedic surgeons.

After thorough arthroscopic debridement, all 8 ca-averic specimens were dissected. The medial cannulaemained in place during the initial surgical dissectionFig 4). An anterior arthrotomy was used so as not toisturb the medial structures. Next, the ulnar nerveas identified in the cubital tunnel through a directedial approach, similar to that used for an ulnar

erve transposition or neurolysis (Fig 5). With thepecimen still rigidly suspended, a 3-dimensional mo-

IGURE 2. A full-radius shaver is used to complete a partialapsulectomy before the debridement continues medially andosteriorly.

IGURE 3. Arthroscopic view showing medialpicondyle flare (yellow arc) and appearance ofexor-pronator mass after debridement.

ion-tracking system (Optotrak 3020 system; Northernigital, Waterloo, Ontario, Canada) was used to mea-

ure the closest distance between the ulnar nerve andhe debridement zone, as indicated by the underlyingecorticated area (Fig 6). All measurements were per-ormed by 1 author.

The Optotrak 3020 system uses 3 cameras and aigitalizing stylus to which 6 infrared light-emittingiodes are attached. First, the stylus was placed at theenter of the decorticated area; next, it was placed onhe ulnar nerve at its closest point to the decorticatedrea. The Optotrak cameras capture the infrared signalmitted from each stylus and calculate the linear dis-ance between these 2 points. The distance from eachamera (x, y, z) to each stylus (1, 2) is presented as aeries of coordinates in 3-dimensional space (x1, x2,1, y2, z1, z2). The distance between each stylus (inillimeters) was calculated according to the formula(x1 � x2)2 � (y1 � y2)2 � (z1 � z2)2. Within our

orking distance, the precision for a 95% repeatabil-

IGURE 4. Medial perspective of elbow leaving cannula in placeuring initial stages of open dissection after arthroscopic debride-ent. The syringe is in the medial epicondyle.

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ty limit of the Optotrak 3020 system has been mea-ured at 0.29 mm.9

Next, the entire MCL complex was carefully dis-ected such that the anterior and posterior bundles, asell as the transverse band, were visualized fully.ith the specimen still in the suspension device, the

tylus was again placed at the center of the decorti-ated area and then moved to the most proximal aspectf the anterior bundle of the MCL complex. The linearistance between the stylus probes was again calcu-ated by the Optotrak system according to the previ-usly described formula.

RESULTS

Four matched cadaveric pairs (3 female and 1 male)ith a mean age of 58 years were included in this

IGURE 6. Medial perspective showing relation of area of de-ridement and location of MCL and ulnar nerve.

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tudy. In all 8 specimens, dissection allowed completeisualization of the decorticated area of the medialpicondyle, the ulnar nerve, and the MCL complex.o obvious injuries to the ulnar nerve or the MCL

omplex were observed. The mean distance betweenhe center of the decorticated area on the medialpicondyle and the ulnar nerve was 20.8 mm (range,4.4 to 25.1 mm). Similarly, the mean distance be-ween the center of the decorticated area on the medialpicondyle and the most proximal portion of the MCLomplex was 8.3 mm (range, 5.9 to 10.4 mm). Allistances measured are summarized in Table 1.

DISCUSSION

The initial management of epicondylitis uses con-ervative measures. Provocative maneuvers should bevoided, and a short course of anti-inflammatory med-cations or corticosteroid injection may be indicated.n initial period of rest (with or without the aid ofharmacologic agents) is followed by a formal reha-ilitation program and gradual return to activity. Ad-unct therapies include the use of counterforce bracingnd ultrasound.

FIGURE 5. Dissection of area of debridementwith corresponding arthroscopic view of samearea.

TABLE 1. Distance Between Debridement Site of MedialEpicondyle and Both MCL Complex and Ulnar Nerve

Debridement Siteto MCL (mm)

Debridement Site toUlnar Nerve (mm)

pecimen No.1 6.0 14.42 10.4 16.83 9.7 25.14 8.6 20.45 5.9 21.26 8.7 24.67 7.9 23.08 9.2 21.3

ean (range) 8.3 (5.9-10.4) 20.8 (14.4-25.1)

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Surgical intervention is indicated for persistent painnd dysfunction despite at least 3 to 6 months ofonservative management and possibly sooner in elitehrowing athletes with medial-sided pathology.6 The

ost widely accepted surgical technique includes thexcision of pathologic tissue, repair of the resultingefect, and reattachment of the flexor or extensorrigin.7 Residual strength deficits remain a commononcern after the open management of both medialnd lateral epicondylitis.7

Elbow arthroscopy is a technically demanding pro-edure that offers potential advantages over open tech-iques for the treatment of recalcitrant lateral epicon-ylitis.4 Arthroscopic release of lateral epicondylitisay permit an abbreviated postoperative rehabilita-

ion program and earlier return to work.5 Additionaldvantages include the preservation of the commonxtensor origin and intra-articular examination of thelbow.10 One recent publication addresses the ques-ion of durability after arthroscopic release of lateralpicondylitis, suggesting that initial success at a meanf 2.8 years was maintained at a mean long-termollow-up of 130 months.11

No such studies investigating the arthroscopic treat-ent of medial-sided elbow pathology exist. In addi-

ion to injury of the MCL complex, infection and theisk of harm to nearby neurovascular structures remainommon concerns. In 2001 Kelly et al.12 reported theiresults of 473 consecutive elbow arthroscopies. Com-lications included deep infection in 4 elbows, pro-onged drainage or superficial infection in 33, persis-ent contracture of 20° or less in 7, and transient nervealsy in 12. Of these transient nerve palsies, 5 in-olved the ulnar nerve, 4 involved the superficialadial nerve, and 1 each involved the posterior in-erosseous nerve, medial antebrachial cutaneouserve, and anterior interosseous nerve.12

Advances in surgical technique have broadened thendications for and improved the safety of elbow ar-hroscopy.13-16 The second medial capsular entry siteby use of the same skin incision) is what makes ourechnique unique. We believe this “mobile portal”llows improved access to the anterosuperior medialpicondylar ridge and the tendinous origin of theexor-pronator mass.To further minimize injury to surrounding anatomic

tructures, a body of research focusing on arthroscopicortal placement and portal relation to nearby neuro-ascular structures has been detailed in the litera-ure.17-22 Direct measurements to neurovascular struc-ures other than the ulnar nerve were not conducted as

part of this study. However, our medial portal mir- A

ors that described by Unlu et al.,22 and our lateralortal closely approximates the mid-anterolateral por-al described by Field et al.19 Unlu et al. describe auperomedial portal established 1 cm proximal and 1m anterior to the medial epicondyle. With the arm in0° of flexion, only the medial antebrachial nerve wasetermined to be less than 1 cm from the superomedialortal (7 � 2.6 mm), with the median nerve (13.8 �.6 mm), ulnar nerve (16.2 � 2.2 mm), and brachialrtery (17.6 � 3.3 mm) at progressively further dis-ances.22 The mid-anterolateral portal of Field et al. islaced 1 cm directly anterior to the lateral epicondyle.he mean distance between this portal and the radialerve with the elbow in 90° of flexion is 9.8 mm.19

ontrolled and accurate placement of arthroscopicortals can help minimize injury to adjacent structurest risk.

We anticipate that as surgeon experience with el-ow arthroscopy continues to grow, so will the num-er of indications. Nevertheless, it has been stated thathe close proximity of the ulnar nerve and the MCLomplex renders the arthroscopic treatment of medialpicondylitis unsafe.6 Our results suggest that arthro-copic treatment of medial epicondylitis may be per-ormed with a low risk of injury to the ulnar nerve or

CL. This procedure involves the debridement ofathologic tissue associated with the flexor-pronatorass and underlying capsule, as well as a variable

mount of decortication. According to Baker et al.,23

ecortication may not be necessary in the arthroscopicreatment of lateral epicondylitis, particularly in casesf shorter duration that lack sclerotic bone at theendinous insertion site. However, for the purposes ofhis study, aggressive decortication of the underlyingone was performed to facilitate later identification ofhe flexor-pronator origin.

In 8 cadaveric specimens we found the ulnar nerveo be a minimum of 14 mm (mean, 20.8 mm; range,4.4 to 25.1 mm) from the center of the debridementone of the flexor-pronator origin, which is located onhe anterior supracondylar ridge. This is consistentith the fact that the entire anterior-posterior width of

he medial epicondyle lies between the site of debride-ent and the ulnar nerve. Nevertheless, the impor-

ance of obtaining a thorough preoperative history anderforming a thorough physical examination must betressed. Patients should be questioned about previouslbow surgeries (in particular, ulnar nerve transposi-ion) and examined for evidence of healed surgicalncisions and ulnar nerve subluxation. Repeat exami-ation under anesthesia is likewise recommended.

ny evidence of ulnar nerve subluxation that occurs

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615DEBRIDEMENT FOR MEDIAL EPICONDYLITIS

ither preoperatively or after the induction of anesthe-ia should be an indication for open management.atients should be counseled accordingly at the timef surgical consent.The MCL complex consists of an anterior and a

osterior bundle, as well as a transverse band. In 1992’Driscoll et al.24 studied the origin of the MCL

omplex in 10 cadaveric specimens. Their findingsndicate that the ligament complex originates from theentral 65% of the anteroinferior aspect of the medialpicondyle, and no attachment to the medial condylef the distal humerus was noted. Similarly, whenisualized intra-articularly with an arthroscope, theexor-pronator origin was found to be more proximaln the medial epicondyle than the anteroinferior in-ertion of the anterior bundle of the MCL complex.24

iven their close proximity, it is reasonable to assumehat the MCL complex is at risk for injury duringrthroscopic debridement of the flexor-pronator ori-in. Injury to the MCL complex (especially the ante-ior bundle) may then predispose the patient’s elbowo valgus instability. Our results indicate that the dis-ance between the center of the decorticated area andhe most proximal portion of the MCL is a minimumf 5.9 mm (mean, 8.3 mm; range, 5.9 to 10.4 mm). Bynderstanding the anatomy of the soft-tissue attach-ents to the medial aspect of the distal humerus and

estricting the debridement of the flexor-pronator ori-in to the anterosuperior quadrant of the medial epi-ondyle, risk of injury to the MCL complex can beinimized.There were several limitations to this study includ-

ng the small number of specimens and the potentialor anatomic variation in cadaveric tissue because ofhe lack of muscle tone. Once the ulnar nerve with itsurrounding soft-tissue envelope is transected proxi-ally, it becomes a static structure that is no longer

ubject to posteromedial compressive forces andranslation during elbow flexion. It can be hypothe-ized that with the addition of posteromedial soft-issue compressive forces in vivo, the ulnar nerve maye at increased risk for subluxation and injury.A second limitation with cadaveric specimens is the

ack of pathologic tissue to guide debridement. Afterhe initial partial capsulectomy, debridement and de-ortication started at the origin of the flexor-pronatorass and continued until the superficial fibers of theCL complex were identified. In vivo debridementith or without decortication can be limited to includeiseased soft tissue—“tendinosis” and underlyingclerotic bone. Accordingly, our measurements were

ade from the center of the debridement zone, which

1

s believed to more closely represent the origin of theexor-pronator mass. Alternative or additional mea-urements could have included the diameter or radiusf the debridement zone, as well as the distance fromhe edge of the debridement zone to the superficialbers of the anterior band of the MCL complex.owever, each of these measurements would also beiased by the excessive, purposeful decortication initro, although having 1 surgeon responsible for theebridement may have reduced variability.Valgus stress testing could have been performed

oth before and after the procedure as a means ofirectly assessing elbow stability. Instead, we relypon surrogate measurements and gross visual inspec-ion. Lastly, by restricting our debridement to thenterosuperior quadrant of the medial epicondyle, it isnclear whether this treatment will be as effective ashe more traditional open release. The best indicationor arthroscopic release of medial epicondylitis maye refractory disease with maximum tenderness toalpation at the anterosuperior quadrant of the medialpicondyle.

CONCLUSIONS

The results of this study suggest that arthroscopicebridement of the medial epicondyle can be per-ormed with a low risk of injury to the ulnar nerve or

CL complex.

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