From 1997 to 2009 a total of 12 patients (14 elbows) required surgical debridement of the common flexor tendon via a Z-lengthening approach for medial epicondylitis due to failure of conservative treatment and had complete medical records with accurate telephone numbers and addresses. All Z-lengthening surgeries were performed by the senior author. All patients attempted several non-operative treatments prior to surgery. Radiologic findings were not assessed. Post-operatively patients were evaluated with: The VAS for pain, the DASH assessment, McGowan grading system, and the Nirschl and Pettrone grading system. The study conformed to the ethical guidelines outlined in the 1996 declaration of Helsinki and was approved by our Institutional Review Board.
Of the 12 patients analyzed, two underwent bilateral surgery for a total of 14 operations; 14 elbows. Of the 14 elbows, 10 (71%) were able to return to the office for an objective physical examination and strength testing. The four elbows who did not return did not want to make the long trip back into a major city as there was no incentive offered to the patients for participation in this study. A copy of the patient questionnaire is shown in the Appendix.
For patients who returned to clinic, written informed consent was obtained by the lead author and for those who did not, verbal informed consent was obtained by the lead author. All study, subject, and surgery parameters were collected. Descriptive statistics were reported as mean ± standard deviation.
Surgical Technique
The Z-lengthening surgical technique has been described in text but not published in the literature. The senior author will extend the approach to a Z-lengthening technique as when he feels exposure is not adequate to perform a thorough debridement. Before the induction of anesthesia, the surgeon must mark the point of maximal tenderness at the medial epicondyle to better guide the site of pathology intraoperatively. The procedure can be performed under regional or general anesthesia. The patient is placed supine and the arm prepped and draped free and placed on a hand table. The limb is exsanguinated with an Esmarch, and a non-sterile tourniquet is inflated. A gently curving 3 cm incision is made, extending slightly distal and posterior to the medial epicondyle. Dissection is carried through the subcutaneous tissue to the level of the flexor-pronator fascia. The medial antebrachial cutaneous nerve usually crosses distally to this incision and is not routinely visualized. Nevertheless, cutaneous nerve branches should be identified and protected. The anterior flap is then mobilized in order to visualize the entire width of the flexor pronator fascia, which most often appears normal. For this reason, the surgeon must have identified and marked the focal area of maximal tenderness pre-operatively.
A fiber splitting incision is made directly overlying this location. When in doubt, the surgeon should visualize the flexor- pronator mass as divided into thirds, and incise the junction between the upper one-third and the lower two thirds, which roughly corresponds to the pronator teres/flexor carpi radialis interval. The fascial incision extends approximately 3 cm distal to the medial epicondyle. Careful dissection is performed through the deeper layers. Involved tissue has a characteristic gray, amorphous appearance, distinctly different from the surrounding healthy tendon, and ligament.
All involved tissue should be debrided sharply. Thorough debridement usually exposes the anterior portion of the medial epicondyle. In this study, all patients underwent a Z-lengthening of the flexor- pronator origin as performed for the submuscular transposition, using the longitudinal fascial incision. This allowed improved exposure in these patients, so the entire flexor-pronator mass could be identified and properly debrided. The fibers of the medial collateral ligament must be protected during the debridement. Upon completion of the debridement, the exposed area of medial epicondyle is drilled several times using a 5/64-inch drill bit to stimulate revascularization.
The wound is irrigated copiously and the fascial incision is approximated with a running 2-0 absorbable suture. No effort is made to reattach the debrided tendon. The subcutaneous tissue is approximated with interrupted 4-0 absorbable suture, and the skin is approximated with a running subcuticular 3-0 pullout suture. Steri-strips, a sterile dressing, and a well-padded plaster posterior splint are applied, incorporating the wrist for comfort. The tourniquet is then deflated.
Post-operatively the patient is placed in a plaster splint and dressings, which are removed on the second post-operative day. Tubigrip is placed over the elbow and a wrist splint is applied. The patient begins gentle elbow motion exercises and resumes the stretching exercise which allows stretch of the flexor-pronator origin. With the wrist maintained in supination and extension, the patient actively extends the elbow until the pain is elicited. The wrist splint is worn during the day for 4 weeks. Depending on the rate of recovery, strengthening is begun cautiously at 4-6 weeks. Exercises are begun with one-pound weights, avoiding the extremes of extension and supination. Weight is increased gradually to three pounds. For athletes, a conservative return to sports begins 8-10 weeks post-operatively. A counterforce brace is used for approximately 6 months.
