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.

Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

Background: Accurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GBL >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as magnetic resonance imaging (MRI) scans, can be used to quantify GBL prior to surgery using the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without using best-fit circle measurements on MRI. Methods: A retrospective review was performed which included 122 patients over an 8-year period that had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured using best-fit circle technique to determine true GBL and compare that to the surgeons' preoperative and intraoperative estimation of GBL. Results: GBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (12/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when using visual inspection of the MRI or intraoperative inspection alone. Conclusion: Simple visual inspection of glenoid images on MRI scan and visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of GBL especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan using the best-fit circle technique is recommended in all cases of instability surgery.