Anconeus Muscle Flap repair of a previous surgery

[Robert N]

Hi, Dr. Tomaino
Following up on our discussion during my 9/3 4:40 appointment, will you please explain in detail the Anconeus Muscle Flap procedure scheduled for September 21st? I couldn't find it on your www.DrTomaino.com website. What procedures (and hopefully, improvements) will you perform that was not performed by my previous surgeon's unsuccessful surgery? What muscles, tendons, etc. will be moved, adjusted, etc. to what new areas to relieve the inflammation and pain? Will you go in through the same incision area as my previous surgeon? How common is this Anconeus Muscle Flap repair of a previous surgery? Thank in advance for your response.

[mtomaino]

The literature regarding failed tennis elbow surgery supports the use of local muscle transfer to allow "coverage" following a more complete debridement of the extensor origin. The anconeus muscle is a good local donor because it can be rotated on its blood supply, and its function is not missed. This transfer also allows the introduction of tissue with a healthy blood supply. Up to now the anconeus transfer has been described only twice as a useful option for tennis elbow treatment(1, 3) , but despite the rarity of "publication", these reports suggest a very valuable role for patients like yourself in whom pain persists and function is compromised.

In 1998 Almquist (1) used anconeus muscle transposition in 31 patients as a primary procedure, and in 14 patients as a revision procedure. In 1999 Schmidt (3) described the anatomy of the anconeus flap, and reported 6 salvage operations for failed tennis elbow surgery, with the anconeus flap. Only one other large recent series addresses the surgical treatment of failed tennis elbow surgery. Organ et al (2) operated on 34 patients. A simple re-do débridement was done, without anconeus transposition. They obtained 83% of good and excellent results.

In short, reoperation for persistent pain after tennis elbow surgery is infrequent because in most cases patients elect to "live with" the pain. When persistent disability exists,we must ensure that other causes of pain do not exist including nerve entrapment ("radial tunnel syndrome"), ligament injury ("lateral collateral ligament" incompetence), or arthritis ("radiocapitellar arthritis"). In your case EMG's were normal and I did not suspect radial tunnel, which may coexist with tennis elbow in up to 5% of cases. Your MRI and exam ruled out ligament injury and arthritis. So, we are left with the posssibility that persistent tendinosis exists (damaged tendon). I plan to redebride the area, and, if required,transfering the anconeus muscle allows a more compltete debridement because it brings in good quality tissue with a blood supply.

Your incision will need to be a bit longer, and your elbow will be immobilized for 2 or so weeks, but based on my experience and the reports I have referenced above, I think your prognosis is good---------remembering that, in a perfect world, I would hope not to have to perform a revision operation. But---assuming you would like to try one more time to improve your level of function and to diminish you pain-- this is a reasonable option.

I have attached an illustration of this muscle.

REFERENCES
1. Almquist EE, Necking L, Bach AW. Epicondylar resection
with anconeus muscle transfer for chronic lateral
epicondylitis. J Hand Surg 1998 ; 23-A : 723-731.
2. Organ SW, Nirschl RP, Kraushaar BS, Guidi EJ.
Salvage surgery for lateral tennis elbow. Am J Sports Med
1997 ; 25 : 746-750.
3. Schmidt CC, Kohut GN, Greenberg JA, Kann SE,
Idler RS, Kiefhaber TR. The anconeus muscle flap :
its anatomy and clinical application. J Hand Surg 1999 ;
24-A : 359-369

[Robert N]

Wow! Thank you so much for taking the time to compose such a detailed and referenced response. I'm very glad I was referred to you and look forward to my surgery on the 21st.