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Surgical Options From Tennis Elbow to Cuff
John D. Kelly IV
Director Shoulder Sports Med
Univ. of Penn
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Tendinopathy
• Part of aging process
• Vascular issue
• Association with Hyperlidemia, Hypertension
• Associated with Eccentric Overload
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Common Tendinopathies
• Medial Epicondylitis
• Lateral Epicondylitis
• Rotator Cuff
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Medial Epicondylitis (least common)
• Golfer’s Elbow
• Worsened with hitting
‘fat shots’
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Golfer’s Elbow
• Usually responds to eccentric rx
• PRP
• Braces
• Stubborn cases (rare) debridement
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Debridement
• Small Medial Incision
• Surgically debride
devitalized tissue
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Lateral Epicondylitis
• Tennis elbow
• Tendinosis, degeneration of ECRB
• Age related
• Eccentric stress induced
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Path
• ECRB > 95%
• EDC superior 10-20% up to 1/3 cases
• Angiofibroblastic tendinosis ECRB
• Synovitis approx, 25%
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Angiofibroblastic Tendinosis
• increased cellularity, vascularity
• cell morphology changes
• myxoid changes in the matrix
• increased glycosaminoglycan
• occasionally calcification and
lipid deposition
Nirschl
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Anatomy
• ECRB origin: Deep to muscular ECRL
• ECRB Tendon Conjoined w/ EDC
• LUCL: posterior to ECRB
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Diagnosis
• Pain with Handshake, lifting ‘milk carton’
• Pronated more painful than supinated
• Wrist extension pain
• Tenderness ant to LE
• Diff Dx: OA, radial tunnel, LUCL, triceps, discogenic, synovitis, plica
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Imaging?????
• Radiographs: usually normal
• MRI: ?indications, able to demonstrate partial tears, other pathology, LUCL
• CT: helpful for OA
• Ultrasound: evolving
• Bone scan
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MAN SCAN
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Non Op Rx
• Pt Education:
• Activity modification
• Supinated lifting
• Braces, splints
• Cortisone injection….
• ECSWT: Buchbinder, 2005
• Prolotherapy • PRP…some evidence • Accupuncture • Botox ?
• Eccentric strength training
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Surgery
• Rarely needed!
• If your surgeon doing ‘100’ releases a year, beware
• Sometimes truly necessary
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Indications Surgery
• Failure At least 4-6 mo non op rx (prp etc.)
• Severe sx
• <8% patients (at most!!!)
• (?MRI indications)
• (Response w/injection)
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Surgical Options
• Open
• Scope
• Percutaneous
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Which to choose?
• Surgeon preference • Data not clear • Goal: Excise all the bad stuff !! • • Studies generally show no difference • Prob earlier RTW & pain relief w/
arthroscopy
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Percutaneous Release
• Quick
• Office based
• Less morbidity
• ‘Blind’
• Does not address anatomic lesion
• Potential LCL damage
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Open Release
• Release origin extensors
• ‘full release’ with predictable decompression of tension tendons
• ‘overkill’?
• Release not targeted at
distinct pathology
• Weakness extensors?
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Open Debridement
• ‘Nirschl’ procedure
• Degeneration ECRB excised, bone drilled, repair tendon
• Addresses ‘lesion’
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Open debridement
• Pain
• Morbidity
• Does not address intra articular injury
• Pathology is deep…….. surgery starts superficially
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Open
• Identify ECRL/EDC interval
• Incise 2-3 mm..Retract ECRL, undermine EDC
• Define ECRB…resect proximal to distal
• Arthrotomy not necessary…
• Key: excision of all pathological tissue
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Open
• Reattach ECRB (Hannafin, AJSM)
• Meticulous Closure of EDC/ECRL interval
• Lightly debride lat. epicondyle…? drilling
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Scope Release
• Release deep ECRB
• Precise attention to lesion
• Less pain
• Joint evaluation
• Plica, synovitis
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The posterolateral plica: A cause of refractory lateral elbow pain
Ruch et al 2006
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Beware of the Plica
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Technique
• Lateral decub
• Two portals
• Sometimes distractor portal
• Stay above mid portion capitellum
• Identify, release, debride
• Resect above the capitellum until ECRL seen
• Debride to the EDC ridge and fibrous origin….
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Scope Technique
• Identify ECRB
• Shave away capsule
• Release tendon off origin
• Burr or shave bone for healing response
• Explore radiocapitellar joint
• Explore remainder of joint
Greco
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Capsular Rent
Greco
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Exposure Tendon
Greco
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Tendon Release
Greco
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Steinmann
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Post Op
• Early ROM
• Same for scope or open
• Avoid pronated lifting
• Slow for first 6-8 weeks
• Eccentric exercise
• Sports and heavy labor 3-4 mos
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Results
• Nirschl open 85% returned to full activity
• Walenkamp open release 89% good/exc
• Baker scope 37/39 ‘better or much better’
• Grundberg percutaneous release 29/32 good/exc
• Dunkow open vs percutaneous: perc group better results!
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Tendinosis of the extensor carpi radialis brevis: An evaluation of three methods of operative treatment
Szabo et al
• Open, scope, percutaneous
• 109 patients
• Min 2 year follow up
• No difference in
Andrews/Carson score
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Failure
• Inadequate resection (Nirschl)
• Excessive resection
• LUCL, EDC injury
• Improper diagnosis: PLRI, PIN, Biceps, etc.
• Patient motivation
• Stiffness, arthrofibrosis, smokers
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Iatrogenic LCL Injury
• Posterolateral instability secondary to LCL resection
• Pain with supination
• ‘rising from a chair’
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Bottom Line
• Surgery RARELY indicated
• Literature implies edge to scope since earlier return to activity.
• JDK favors scope:
less pain
precise release
concomitant treatment associated path.
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Rotator Cuff Tears
• Not all tears need surgery
• BUT…if active and require strong arm or……more than one tendon tear surgery best option
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Supraspinatus – ‘It starts here’
• Tears propagate anteriorly >> Subscap
• Posterior propagation >>Infraspinatus, Teres minor
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Tear Propagation Anterior or Posterior
Burkhart et al
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Postero Inferior Supra + Infra
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Antero Superior Subscap + Supra
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Massive Cuff Tears
• Involve more than one tendon
• Generally over 5cm in width
• Fatty infiltration common
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Do ‘MAN SCAN’ to see what is TORN
• Chao, Kelly et al
• EMG Study
• Best Test Upper Subscap?
Bear Hug at 45 Degrees
forward flexion
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Massive Cuff Tears – Why Bother to Fix?
• Arthropathy may be delayed
• Reverse prosthesis is no picnic!
• Burns no bridges
• Pain relief predictable
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Treatment GOALS
• Restore force couple
• ‘Reduce tear’
• Debride joint, release inferior capsule
• Mumford
• ‘Delicate’ acromioplasty, tuberosplasty
• Treat biceps
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Force Couple: Opposing Moments rotation without translation
• Provide fulcrum
• Neutralize deltoid
• *Subscap
• *Infraspinatus
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Inferior Half Infraspinatus and Upper Subscap:
Resists Upward Pull Deltoid
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Rotator Cable: ‘Spans’ the Humeral Head
GO for the CABLE
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Subscap/CHL: Key part of Cable
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My Approach
• Thorough mobilization cuff
release CHL – only if subscap intact
release inferior capsule
excavate cuff from acromion
• Margin convergence
• Medialize repair
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McLaughlin 1945 Recognized Tear Patterns
• Reduce the Tear
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Tear Patterns
• Crescent tear – symmetric retraction
• L shaped – mobile limb anterior
• *Reverse L – mobile limb posterior
• (U shaped – anterior and posterior limbs equally mobile)
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Pre Op Planning MRI
Davidson
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Mobile Limb Indicates Pattern of Tear Extension
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‘Reverse L’ (most common) Posterior Limb Mobile
Ant. Post.
Note Suture Pattern is Oblique
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Margin Convergence
• Shifts tissue > defect
• Shortens medial – lateral dimensions
• Free margin “converges” to tuberosity
• Decreases strain cuff edge
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Job1: Restore Force Couple
• *Do your best to repair upper subscap
• Do your best to repair lower half of infraspinatus
• Partial repair is better than no repair!
• DON’T SWEAT SUPRASPINATUS
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‘Comma Sign’ >> Edge of Subscap
• Affords Infra Repair
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Examples: Antero Superior Tear
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Sew Posterior Cuff to CHL
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Completed repair
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Enhance Repair
• Avoid tension!!!
• Increase number of sutures
• MEDIALIZE!
• ‘Rip stop sutures’
• ‘Marrow stimulation’
Burkhart
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‘Double Row Hysteria’
• Forgotten the art of ‘tear reduction’
• Margin convergence replaced by ‘more rows’
• ‘Dog Ear’ = NOT REDUCED
• Tension, ischemia?
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‘Type 2 Failure’ Result of Tension Double Row
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Wang et al Arthroscopy 2012
• 5x increase tension double-row vs single row
• Tears >2 cm require significantly more tension to reapproximate to articular margin and lateral tuberosity.
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Respect Anatomy!!
• This!!!! Use anchor to converge margin!
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NOT THIS!!!!
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Avoid Tension Medialize if Neccessary
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Punch Holes Tuberosity ‘crimson duvet’, Stem Cells
• Snyder
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Graft Augmentation
• Promising
• Scope vs Mini Open
• JDK seeing early ‘encouraging’ results
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Oh AJSM 2011
• Large tears with ‘pseudoparalysis’
• Repaired arthroscopically or mini open
• 76% had psuedoparalysis resolve
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Iagulli AOSSM 2011
• Partial repair of massive tears yielded results similar to complete repair
• Avg. pre op tear size 35.20cm2
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Bottom Line – Cuff Repair
• You will help many!
• Most patients are satisfied, despite residual weakness!!
• May arrest progression to arthropathy
• Subscap may hold the key
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THANK YOU