Evolution of arthroscopic treatment from intra-capsular to extra-capsular for lateral epicondylalgia : Chinese Medical Journal

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Evolution of arthroscopic treatment from intra-capsular to extra-capsular for lateral epicondylalgia

Yang, Yuping1; Yuan, Shuo1,2; Chu, Hongling3; Yan, Hui1; Xiao, Jian1; Cheng, Xu1; Luo, Hao1; Liu, Yulei1; Tao, Liyuan3; Zhao, Yiming3; Cui, Guoqing1

Editor(s): Wang, Ningning; Guo, Lishao

Author Information
Chinese Medical Journal ():10.1097/CM9.0000000000002204, December 30, 2022. | DOI: 10.1097/CM9.0000000000002204

To the Editor: Lateral epicondylalgia, whose incidence rate is approximately 1.3%, not only occurs in tennis players (tennis players only account for 5%[1]), but is also related to smoking, poor social support, and heavy physical labor.[2] Surgical treatment should be considered when conservative treatment fails after 6 months, which occurs in 10% of lateral epicondylalgia cases.[3] Arthroscopic intra-capsular elbow surgery (the intra-capsular method) refers to an operation that selects the natural cavity of joint capsule as operating space. The intra-capsular method soon became the mainstream surgical method because of its minimally invasive nature, safety, and direct-vision feature compared with open surgery. However, the intra-capsular method requires damage to the joint capsule, and intra-capsular operation may cause intraoperative neurovascular injury and other complications. Rubenthaler et al[4] explored a new approach to arthroscopic treatment for lateral epicondylalgia, which was performed outside of the elbow joint capsule. Further studies[5] investigated the efficacy and specific surgical scheme of this extra-capsular arthroscopy (referred to as the “extra-capsular method”), which was soon launched in our clinical practice.

Through qualitative interviews and quantitative research methods, our study aimed to investigate the key theories, methods, and techniques involved in the transition from the intra-capsular method to the extra-capsular method, clarify the exploration history and technical specifications of the extra-capsular method, and explore the efficacy and safety of the extra-capsular method.

The research design is shown in Supplementary Figure 1, https://links.lww.com/CM9/B102. Exploratory sequential mixed methods design was used in the current study. Using the method of qualitative research, a focus group interview was held among sports medicine surgeons who were purposively sampled from an institute of sports medicine at a university hospital in China. A semi-structured interview guide was developed based on a group discussion. Two researchers (CH and YY) independently analyzed and coded the transcripts by selecting units of analysis, understanding the transcripts, developing codes, categorizing the data, and summarizing.[6] A detailed description of interview and qualitative analysis is presented in the Supplementary Material, https://links.lww.com/CM9/B102.

In quantitative analysis, patients were consecutively enrolled. Inclusion criteria included: (1) patient was aged between 18 years and 45 years; (2) diagnosis was refractory lateral epicondylalgia; and (3) standard extra-capsular method was used for surgery. Exclusion criteria included: (1) patient had past history of joint infection, joint tuberculosis, or osteomyelitis, or the upper limb had undergone surgery within the past 6 months; (2) diagnosis was combined with severe heart, brain, kidney, or another organ dysfunction; (3) case was complicated with other serious elbow joint diseases or injuries; (4) patient did not sign the informed consent form.

The data collected were demographic characteristics, baseline indicators, efficacy indicators, and prognosis indicators. The efficacy indicators were time to complete pain elimination and time to resume daily activities. The short-term prognosis indicators were Mayo Elbow Performance Score (MAYO), Disability of Arm, Shoulder and Hand Score (DASH), and Visual Analog Scale (VAS) at 3 months. The long-term prognosis indicators were MAYO, DASH, and VAS 12 months after surgery. Patients’ postoperative complications, including vascular injury and nerve injury, were recorded for the assessment of operative safety. Statistical analysis was performed using SPSS for Windows, version 24.0 (IBM, Armonk, NY, USA). Descriptive analysis was conducted to analyze the demographic characteristics and clinical outcomes after surgery.

The Peking University Third Hospital Ethics Review Board approved the study (No. 2018-219-011), including the interviews and quantitative data use. All participants provided written informed consent to participate in the interview, including the audio recording and transcription. Potentially identifying information was removed from each transcript, and each interviewee was assigned a unique identification number to protect anonymity.

Seven surgeons who had performed refractory lateral epicondylalgia surgery were included in a focus group interview. Detailed information of the seven surgeons is presented in Supplementary Table 1, https://links.lww.com/CM9/B102. The interview lasted 2.5 h. The development and the current treatment standard of arthroscopic treatment for refractory lateral epicondylalgia were clarified through interviews. The development of refractory lateral epicondylalgia treatment was summarized in Supplementary Table 2, https://links.lww.com/CM9/B102.

Through focus group interviews, the improvement of the safety and convenience of the extra-capsular method was discussed and summarized as follows:

Extra-capsular method allows surgeons to look at extensor carpi radialis brevis (ECRB) origin directly under the arthroscopy. Direct vision allows surgeons to perform suture, drilling, and decorticating more easily in comparison with the intra-capsular method, and the risk of vascular and nerve injury is significantly reduced. The method is simple even to surgeons with little arthroscopy experience [Figure 1].

Figure 1:
Extra-capsular method for refractory tennis elbow. (A) Postural diagram of the extra-capsular method. Routine supine position is adequate. Brachial plexus anesthesia. (B) Schematic of an arthroscopic operation using the extra-capsular method. (C) Extra-capsular arthroscopic debridement. (D) Tendon rupture after arthroscopic suturing and repair using the extra-capsular method. The rupture on the ECRB tendon was well closed after suturing. ECRB: Extensor carpi radialis brevis. ⋆Star: Extensor carpi radialis longus; ▪Square: Stump of ECRB tendon (remaining superficial layer of tendon after cleaning); •Dot: Exposed bone bed of lateral epicondyle (after decortication); ▸ Triangle: Relatively intact upper surface layer of the ECRB tendon (intratendinous tearing occurs between the upper and lower surface layers).

Detailed description of improvement from the intra-capsular method to the extra-capsular method is presented in Supplementary Table 3, https://links.lww.com/CM9/B102.

According to surgeons’ practical observations and extensive discussion, the surgical specifications of the extra-capsular method were summarized as follows: (a) Brachial plexus anesthesia. (b) Supine position [Figure 1A]. (c) A needle is positioned on the lateral epicondyle, and two approaches are made at 3 cm proximal and distal of the lateral epicondyle. The length of approaches is 0.5 cm [Figure 1B]. (d) A subcutaneous space is created, the arthroscope is inserted through a proximal approach, and a planer tool is inserted through the distal approach. (e) Clean the surface of common extensor origin (CEO). Look for weak or broken parts when cleaning. If found, use the scratch test principle to clean the damaged part [Figure 1C]. (f) In some patients with joint capsule rupture, intra-capsular exploration can be performed directly. (g) If tearing (i.e., exposure of the bone bed) is observed at the tendon origin, decortication treatment should be performed. (h) The remaining tendon on both sides of the slit is cleaned and percutaneously sutured with a needle, thread, polydioxanone (PDS) No. 0, and the sutures are tied and fixed with 3-0 absorbable thread [Figure 1D].

Building upon the standard surgery method established from qualitative study, data pertaining to 43 consecutive patients (14 men and 29 women) from March 2012 to January 2016 were collected retrospectively. The minimum age was 35 years and the maximum age was 55 years, with an average of 44.4 years. Detailed demographic data are presented in Supplementary Table 4, https://links.lww.com/CM9/B102.

Preoperative mean MAYO, DASH, and VAS scores were 54.44, 54.74, and 6.91, respectively. The median time to complete pain elimination was 3 months, and the median time to resume daily activities was 6 weeks. The mean MAYO, DASH, and VAS scores at 3 months were 83.00, 24.05, and 2.80, respectively. The long-term prognosis after the operation was expressed as the mean MAYO, DASH, and VAS scores at 12 months after the operation; these scores were 96.41, 7.525, and 1.000, respectively, as indicated in Supplementary Table 5, https://links.lww.com/CM9/B102. In addition, all of 43 patients exhibited no major complications.

The anatomical structure of the elbow joint is complex. The structures of joints, tendons, ligaments, nerves, and blood vessels are mutually adjacent and easily injured during operation. Common complications in the intra-capsular method include temporary nerve injury, suture infection, and large hematoma.[4,7] Elbow joint instability, permanent nerve injury, and deep infection are serious but rare complications.[8] In our study, no evident complications occurred, and the extra-capsular method greatly improved the safety of the operation.

Our institute has carried out the extra-capsular method since 2004 and achieved satisfactory surgical results.[5] Our study determined several advantages of the extra-capsular method. (1) Anatomical structure of CEO is easy to identify, avoiding speculation over the tendon lesion location in the intra-capsular method. (2) On the premise of protecting the radial collateral ligament, CEO is debrided to the maximum extent, and the risks of vascular and nerve injury are significantly reduced. (3) Debridement and arthroscopic suturing are convenient in the extra-capsular method. (4) The learning curve is gradual, and the method is simple even to surgeons inexperienced in arthroscopy. The quantitative data in the studies of our institute indicates that the operation appears to successfully avoid the complications that may be caused by the intra-capsular method, and this finding is of great clinical significance.

In the quantitative part of our study, the average postoperative recovery time for daily activities was 6 weeks. The median postoperative VAS in this study was 0, compared with 1.48[7] in previous literature. In this study, the mean postoperative VAS, MAYO, and DASH scores at 12 months after surgery were 1.00, 96.41, and 7.53, respectively, whereas the mean VAS, MAYO, and DASH scores in previous study were 1.48, 94.10, and 4.81.[7] Rubenthaler et al[4] reported that artificial subcutaneous space was created for tendon treatment outside the joint capsule, but they mainly discussed under-arthroscope release of the ECRB (referred to as the Hohmann operation) instead of the technical details such as whether the lateral epicondyle should be decorticated or drilled or whether the joint capsule needs to be sutured.

In this study, the key theories, methods, and techniques involved during the evolution from the intra-capsular method to the extra-capsular method were summarized. The exploration history and the technical specifications formed were clarified. The innovative technical exploration process is detailed and transparent, helping young surgeons to learn and understand it. This process lays a foundation for further verification and promotion of the effectiveness and safety of the operation.

In our study, the quantitative evaluation data were insufficient, there was no parallel control, and we only observed the efficacy and safety of extra-capsular surgery without comparing to other techniques. In addition, single-centre design limits the extrapolation of research results. However, few studies reporting the application of relevant technologies were found in China. This study integrated data from previous works, as mentioned in the discussion, and a mixed research method combining qualitative and quantitative methods was applied to overcome the shortcoming of using data from a single centre.

Based on qualitative and quantitative methods, we recognized that the extra-capsular method, which has been developed in clinical practice by international peers, avoids the complications of the intra-capsular method. The technical specifications demonstrated good clinical efficacy and safety in a small cohort sample.


This study was supported by National Key Research and Development Program of China (No. 2019YFF0302305). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of interest



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