Failed surgical treatment for lateral epicondylitis: literature review and treatment considerations for successful outcomes.

Background: Lateral epicondylitis is a common cause of elbow pain in the general population. It is recognized as a degenerative tendinopathy of the common extensor origin believed to be multifactorial, involving elements of repetitive microtrauma associated with certain physiologic and anatomic risk factors. Methods: Initial treatment typically involves a combination of conservative treatment measures, with up to 90% success at 12-18 months. Surgical treatment is reserved for recalcitrant disease; traditionally involving open surgical débridement of the common extensor origin with reported success rates greater than 90%. Results: Failure of surgical treatment can be multifactorial and present a challenge in determining the optimum management. Residual symptoms may be due to an incorrect initial diagnosis, inadequate surgical débridement, new pathology as a complication of the initial surgery and/or other patient-related and physician- related factors. Even more of a challenge is the possibility that etiology can be due to a combination of listed factors. Discussion: In this review, we review the classification scheme for evaluating failed surgical treatment of LE first proposed by Morrey and expand on this classification system based on the senior author's experience. We present the senior author's preferred systematic approach to evaluation and management of these patients, as well as a salvage surgery technique used by the senior author to address the most common etiologies of surgical failure in these patients.

Isolated Fourth Carpometacarpal Joint Injury in High-Level Baseball Players: A Case Series.

BACKGROUND: We present a case series of high-level baseball players having sustained a rare, isolated injury to the fourth carpometacarpal joint of the nondominant or bottom hand during a jammed swing. METHODS: Ten patients were evaluated for ulnar-sided wrist pain and were subsequently diagnosed with fourth carpometacarpal joint synovitis based on physical examination and magnetic resonance imaging revealing increased signal intensity within the joint. RESULTS: Conservative treatment modalities including rest, nonsteroidal anti-inflammatory medications, splinting, and corticosteroid injections resulted in return to play within 4 weeks for all patients. CONCLUSIONS: We propose a mechanism of injury involving the bottom hand in relative pronation receiving a dorsally directed force from bat during a jammed swing resulting in isolated injury to the fourth carpometacarpal joint. This report serves to highlight this rare injury in high-level baseball players and recommend a treatment algorithm for early return to play.

Surgical Excision of Postaxial Polydactyly Type B in the Office Setting.

BACKGROUND: Simple postaxial polydactyly (type B) is a common congenital hand malformation often treated by suture or clip ligation. METHODS: We present a case series of patients with simple postaxial polydactyly treated by surgical excision using local anesthesia in an office setting. RESULTS: The procedure was performed on 78 digits in 48 children with a mean age of 10.2 weeks. There were no intraoperative or early postoperative complications. A follow-up by phone interview was performed at an average of 3.2 years postoperatively. All patients were reported to be pain-free and have normal function without a perceived range of motion deficits. All parents selected the highest level of satisfaction regarding cosmetic outcomes and overall experience with the procedure. CONCLUSIONS: These results demonstrate that an office-based surgical excision is a safe, effective, and economical treatment option and has developed into our standard of care for this common condition.

A Combined Revision Surgical Technique for Failed Operative Lateral Epicondylitis With Concomitant Radial Tunnel Syndrome.

Lateral epicondylitis afflicts a large percentage of the population with most recovering through conservative treatment. The 5% to 10% of patients who undergo operative intervention are met with mixed results. Those that fail to improve often demonstrate a complex presentation of inadequate debridement of the "angiofibroblastic tissue," missed concomitant radial tunnel syndrome, and iatrogenic residual devascularized tissue resulting from the index procedure. To address all 3 of these causes of failure, the authors have developed a revision procedure that includes repeat debridement of residual tendinosis, decompression of the posterior interosseous nerve, and a vascularized anconeus muscle flap to help cushion soft tissue defects and promote a healthier environment for healing. Performed initially in part in 20 patients, this combined procedure has developed into our recommended treatment for these challenging patients.