Surgical Options From Tennis Elbow to Cuff

John D. Kelly IV

Director Shoulder Sports Med

Univ. of Penn

Tendinopathy

• Part of aging process

• Vascular issue

• Association with Hyperlidemia, Hypertension

• Associated with Eccentric Overload

Common Tendinopathies

• Medial Epicondylitis

• Lateral Epicondylitis

• Rotator Cuff

Medial Epicondylitis (least common)

• Golfer’s Elbow

• Worsened with hitting

‘fat shots’

Golfer’s Elbow

• Usually responds to eccentric rx

• PRP

• Braces

• Stubborn cases (rare) debridement

Debridement

• Small Medial Incision

• Surgically debride

devitalized tissue

Lateral Epicondylitis

• Tennis elbow

• Tendinosis, degeneration of ECRB

• Age related

• Eccentric stress induced

Path

• ECRB > 95%

• EDC superior 10-20% up to 1/3 cases

• Angiofibroblastic tendinosis ECRB

• Synovitis approx, 25%

Angiofibroblastic Tendinosis

• increased cellularity, vascularity

• cell morphology changes

• myxoid changes in the matrix

• increased glycosaminoglycan

• occasionally calcification and

lipid deposition

Nirschl

Anatomy

• ECRB origin: Deep to muscular ECRL

• ECRB Tendon Conjoined w/ EDC

• LUCL: posterior to ECRB

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

Imaging?????

• Radiographs: usually normal

• MRI: ?indications, able to demonstrate partial tears, other pathology, LUCL

• CT: helpful for OA

• Ultrasound: evolving

• Bone scan

MAN SCAN

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

Surgery

• Rarely needed!

• If your surgeon doing ‘100’ releases a year, beware

• Sometimes truly necessary

Indications Surgery

• Failure At least 4-6 mo non op rx (prp etc.)

• Severe sx

• <8% patients (at most!!!)

• (?MRI indications)

• (Response w/injection)

Surgical Options

• Open

• Scope

• Percutaneous

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

Percutaneous Release

• Quick

• Office based

• Less morbidity

• ‘Blind’

• Does not address anatomic lesion

• Potential LCL damage

Open Release

• Release origin extensors

• ‘full release’ with predictable decompression of tension tendons

• ‘overkill’?

• Release not targeted at

distinct pathology

• Weakness extensors?

Open Debridement

• ‘Nirschl’ procedure

• Degeneration ECRB excised, bone drilled, repair tendon

• Addresses ‘lesion’

Open debridement

• Pain

• Morbidity

• Does not address intra articular injury

• Pathology is deep…….. surgery starts superficially

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

Open

• Reattach ECRB (Hannafin, AJSM)

• Meticulous Closure of EDC/ECRL interval

• Lightly debride lat. epicondyle…? drilling

Scope Release

• Release deep ECRB

• Precise attention to lesion

• Less pain

• Joint evaluation

• Plica, synovitis

The posterolateral plica: A cause of refractory lateral elbow pain

Ruch et al 2006

Beware of the Plica

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….

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

Capsular Rent

Greco

Exposure Tendon

Greco

Tendon Release

Greco

Steinmann

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

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!

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

Failure

• Inadequate resection (Nirschl)

• Excessive resection

• LUCL, EDC injury

• Improper diagnosis: PLRI, PIN, Biceps, etc.

• Patient motivation

• Stiffness, arthrofibrosis, smokers

Iatrogenic LCL Injury

• Posterolateral instability secondary to LCL resection

• Pain with supination

• ‘rising from a chair’

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.

Rotator Cuff Tears

• Not all tears need surgery

• BUT…if active and require strong arm or……more than one tendon tear surgery best option

Supraspinatus – ‘It starts here’

• Tears propagate anteriorly >> Subscap

• Posterior propagation >>Infraspinatus, Teres minor

Tear Propagation Anterior or Posterior

Burkhart et al

Postero Inferior Supra + Infra

Antero Superior Subscap + Supra

Massive Cuff Tears

• Involve more than one tendon

• Generally over 5cm in width

• Fatty infiltration common

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

Massive Cuff Tears – Why Bother to Fix?

• Arthropathy may be delayed

• Reverse prosthesis is no picnic!

• Burns no bridges

• Pain relief predictable

Treatment GOALS

• Restore force couple

• ‘Reduce tear’

• Debride joint, release inferior capsule

• Mumford

• ‘Delicate’ acromioplasty, tuberosplasty

• Treat biceps

Force Couple: Opposing Moments rotation without translation

• Provide fulcrum

• Neutralize deltoid

• *Subscap

• *Infraspinatus

Inferior Half Infraspinatus and Upper Subscap:

Resists Upward Pull Deltoid

Rotator Cable: ‘Spans’ the Humeral Head

GO for the CABLE

Subscap/CHL: Key part of Cable

My Approach

• Thorough mobilization cuff

release CHL – only if subscap intact

release inferior capsule

excavate cuff from acromion

• Margin convergence

• Medialize repair

McLaughlin 1945 Recognized Tear Patterns

• Reduce the Tear

Tear Patterns

• Crescent tear – symmetric retraction

• L shaped – mobile limb anterior

• *Reverse L – mobile limb posterior

• (U shaped – anterior and posterior limbs equally mobile)

Pre Op Planning MRI

Davidson

Mobile Limb Indicates Pattern of Tear Extension

‘Reverse L’ (most common) Posterior Limb Mobile

Ant. Post.

Note Suture Pattern is Oblique

Margin Convergence

• Shifts tissue > defect

• Shortens medial – lateral dimensions

• Free margin “converges” to tuberosity

• Decreases strain cuff edge

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

‘Comma Sign’ >> Edge of Subscap

• Affords Infra Repair

Examples: Antero Superior Tear

Sew Posterior Cuff to CHL

Completed repair

Enhance Repair

• Avoid tension!!!

• Increase number of sutures

• MEDIALIZE!

• ‘Rip stop sutures’

• ‘Marrow stimulation’

Burkhart

‘Double Row Hysteria’

• Forgotten the art of ‘tear reduction’

• Margin convergence replaced by ‘more rows’

• ‘Dog Ear’ = NOT REDUCED

• Tension, ischemia?

‘Type 2 Failure’ Result of Tension Double Row

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.

Respect Anatomy!!

• This!!!! Use anchor to converge margin!

NOT THIS!!!!

Avoid Tension Medialize if Neccessary

Punch Holes Tuberosity ‘crimson duvet’, Stem Cells

• Snyder

Graft Augmentation

• Promising

• Scope vs Mini Open

• JDK seeing early ‘encouraging’ results

Oh AJSM 2011

• Large tears with ‘pseudoparalysis’

• Repaired arthroscopically or mini open

• 76% had psuedoparalysis resolve

Iagulli AOSSM 2011

• Partial repair of massive tears yielded results similar to complete repair

• Avg. pre op tear size 35.20cm2

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

THANK YOU