网球肘松解术 资料 知情同意

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

• The pathologic tissue in tennis elbow involves the extensor carpi radialis brevis tendon [1].
• The origin of the extensor carpi radialis brevis is located on the lateral epicondyle [1].
• The lateral epicondylar ridge is an anatomical structure associated with the lateral epicondyle [1].

Investigations

History and Physical Examination

• History should include the duration of the elbow contracture, initial injury, previous surgical procedures, trials of splinting/therapy/injections, complications of surgery, and the patient’s work/life demands and goals [3].
• Physical examination should assess the function of the upper extremity (shoulder, wrist, and hand) [3].
• The soft tissue surrounding the elbow should be examined for previous skin incisions/grafts, eschar, or infection [3].
• Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [3].
• The contralateral elbow should be examined for comparison during range of motion assessment [3].
• If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [3].
• Pain should be assessed during the mid arc or at the terminal ends of motion [3].
• Mid arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [3].
• The ulnar nerve is of utmost importance due to its anatomic proximity to the elbow [3].
• The posterior bundle of the MCL forms the floor of the cubital tunnel along the course of the ulnar nerve [3].
• Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [3].
• An assessment for ulnar nerve subluxation should be performed [3].
• Subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [3].
• If there is a history of prior surgical procedures, verify if the ulnar nerve has been transposed [3].
• The physical exam is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [5].

Imaging

• Radiographs should always be obtained for elbow evaluation [3].
• Standard radiographic views include AP, lateral, and oblique views [3].
• Serial radiography is used as follow-up when heterotopic ossification is present [3].
• Primary bony landmarks on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [3].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [3].
• Three-dimensional CT is used to check for heterotopic ossification [3].
• CT is not necessary when the stiffness is entirely soft-tissue related [3].
• CT is beneficial if any joint incongruity or abnormal bony anatomy is present [3].
• MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [3].
• Plain radiographs remain the hallmark and the best screening test for elbow evaluation [5].
• CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes posteromedial olecranon osteophytes and loose bodies in valgus extension overload syndrome [6].
• MRI may be most helpful in evaluating associated injuries including partial or complete tears of the MCL in valgus extension overload syndrome [6].
• Radiographic evaluations are essential when diagnosing an osteochondritis dissecans (OCD) lesion of the elbow [7].
• Important aspects of OCD lesions may be better seen with MRI [7].
• Standard AP and lateral radiographs typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa in elbow osteoarthritis [8].
• In elbow osteoarthritis, joint spaces at the ulnohumeral joint usually are preserved, and those at the radiocapitellar joint are mildly narrowed [8].
• Radiographs typically underestimate the number of loose bodies present in elbow osteoarthritis [8].
• CT may be useful for surgical planning in elbow osteoarthritis by allowing a detailed assessment of osteophytes and the presence of loose bodies [8].

Treatment

Operative Technique

• The patient is placed prone on the operating table with two rolled towels longitudinally under the thorax [1].
• All bony prominences are padded well [1].
• The affected extremity is positioned with the ipsilateral shoulder abducted to 90 degrees and supported by a precut foam holder [1].
• The joint is distended with 20 to 30 mL of saline through an 18-gauge needle introduced through the direct lateral portal [1].
• The proximal medial or superomedial portal is located approximately 2 cm proximal to the medial epicondyle and 1 cm anterior to the intermuscular septum [1].
• The trocar and sheath are introduced anterior to the intermuscular septum while maintaining contact with the anterior aspect of the humerus [1].
• The trocar is directed toward the radial head [1].
• A 2.7-mm, 30-degree arthroscope is inserted into the joint to perform the diagnostic portion of the procedure [1].
• The superolateral portal is established with an 18-gauge needle through the lesion after pathologic tissue is identified [1].
• A full-radius resector is used to excise the capsule to identify the undersurface of the extensor carpi radialis brevis tendon [1].
• The origin of the extensor carpi radialis brevis is viewed [1].
• The capsule and pathologic tendinous attachment of the extensor carpi radialis brevis are debrided using a curet and motorized shaver [1].
• The lateral epicondyle is decorticated [1].
• Decortication of the lateral epicondyle and lateral epicondylar ridge can be performed with an arthroscopic burr, handheld instruments, or electrocautery [1].
• A 30-degree arthroscope is adequate to view around the corner for most of the procedure [1].
• A 70-degree arthroscope may be required in rare instances [1].

References

[1] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > ARTHROSCOPIC TENNIS ELBOW RELEASE.

[3] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.

[5] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.

[6] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.

[7] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.

[8] Aaos Comprehensive Orthopaedic Review 3. Arthritis and Arthroplasty of the Elbow > I. Osteoarthritis.