Arthroscopic versus percutaneous release of common extensor origin for treatment of chronic tennis elbow

Does radiofrequency application improve function and reduce pain in patients with insertional Achilles tendinopathy? A retrospective study with a minimum 2-year follow-up

This case series study aimed to investigate patients with insertional Achilles tendinopathy (IAT) who underwent radiofrequency (RF), how much do their patient-reported outcomes scores improve and what percentage return to sport, and what patient-related factors are associated with improved scores and increased odds of return to sport, at a minimum of 2-year follow-up. Between 2012 and 2018, 41 patients were followed up. The median Victorian Institute of Sports Assessment-Achilles (VISA-A) score increased from 20 (range, 3-62) to 97 (range, 53-100), the median 11-point visual analogue scale (VAS) reduced from 8 (range, 1-10) to 0 (range, 0-3) and the median Tenger score increased from 1 (range, 0-1) to 3 (range, 2-8). Thirty-eight (92.7%) patients returned to sports with a mean time of 11 ± 4.8 months. In linear regression analysis, age was significantly associated with return-to-sports outcome (b = -0.07, 95% CI = -0.13 to -0.02, p = 0.02), while in logistic regression, symptoms duration revealed a significant impact on pain presence (OR = 1.07, 95% CI = 1.01 to 1.14, p = 0.02). In summary, RF for IAT had a 68.7 ± 14.5 VISA-A improvement at 5.4 years of follow-up regarding reliable functional restoration and pain reduction; however, the current evidence remains insufficient to support RF as an effective treatment for IAT.

Comparison of Clinical Outcomes After Different Surgical Approaches for Lateral Epicondylitis: A Systematic Review and Meta-analysis

Background

Lateral epicondylitis (LE) is one of the most common causes of lateral elbow pain. When nonoperative treatment fails, 1 of the 3 surgical approaches-open, percutaneous, or arthroscopic-is used. However, determining which approach has the superior clinical outcome remains controversial.

Purpose

To review the outcomes of different operative modalities for LE qualitatively and quantitatively.

Study Design

Systematic review; Level of evidence, 4.

Methods

This review was performed and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies published in PubMed, Medline (via EBSCO), and ScienceDirect databases that treated LE with open, percutaneous, or arthroscopic approaches with at least 12 months of follow-up were included. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies score. The primary outcome was the success rate of each operative treatment approach-open, percutaneous, and arthroscopic.

Results

From an initial search result of 603 studies, 43 studies (n = 1941 elbows) were ultimately included. The arthroscopic approach had the highest success rate (91.9% [95% CI, 89.2%-94.7%]) compared with the percutaneous (91% [95% CI, 87.3%-94.6%]) and open (82.7% [95% CI, 75.6%-89.8%]) approaches for LE surgery with changes in the mean visual analog scale pain score of 5.54, 4.90, and 3.63, respectively. According to the Disabilities of the Arm, Shoulder and Hand score, the functional outcome improved in the arthroscopic group (from 54.11 to 15.47), the percutaneous group (from 44.90 to 10.47), and the open group (from 53.55 to 16.13). The overall improvement was also found in the Mayo Elbow Performance Score, the arthroscopic group (from 55.12 to 90.97), the percutaneous group (from 56.31 to 87.65), and the open group (from 64 to 93.37).

Conclusion

Arthroscopic surgery had the highest rate of success and the best improvement in functional outcomes among the 3 approaches of LE surgery.

[Arthroscopic debridement of the extensor carpi radialis brevis]

Surgical treatment of lateral epicondylitis is reserved for patients who, despite extensive conservative therapy, do not experience satisfactory relief of symptoms. As an alternative to the open procedure, arthroscopic debridement of the extensor carpi radialis brevis (ECRB) muscle is a simple and standardized procedure. The arthroscopic approach also enables the additional treatment of intra-articular pathologies such as loose bodies or osteochondral lesions. After diagnostic arthroscopy, the attachment of the ECRB is visualized via the anteromedial portal, so that under visual control the debridement of the tendon fibers of the ECRB and its bony insertion site can be performed via the anterolateral portal. Postoperatively, there is no restriction of movement of the elbow joint. The outcome after arthroscopic ECRB debridement described in the literature is equivalent to that of other surgical techniques.

Functional recovery in the surgical treatment of tennis elbow: side-to-side vs. tendon-to-bone attachment using a knotless suture anchor: a randomized controlled trial

BACKGROUND

Lateral epicondylitis of the elbow sometimes does not respond to conservative treatment and requires surgical intervention. Many different surgical techniques have been described. The aim of this randomized study was to compare functional outcomes of open side-to-side suturing of the tendon and tendon-to-bone fixation with a knotless suture anchor.

METHODS

In total, 68 patients were included (4 were lost to follow-up) and were randomized into either the side-to-side tendon group or the suture anchor group. Demographic data consisted of age, sex, body mass index, affected arm, dominant arm, previous treatments, and symptom duration. Professional and sports activities were noted. Preoperative values of the Mayo Elbow Performance Index (MEPI) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and Numeric Pain Rating Scale (NRS) score were noted. Clinical features consisted of range of motion in flexion and extension, grip strength, and wrist flexion and extension strength. All measurements were noted at 6 weeks, 3 months, and 1 year postoperatively.

RESULTS

The MEPI and NRS scores did not differ between the 2 groups, but there was a significant improvement in the MEPI score at 6 weeks vs. preoperatively in both the suture group (from 70.6 to 87.4) and the anchor group (from 68 to 86.5). The NRS scores showed no difference at each time point in both groups. The QuickDASH and QuickDASH-Sport scores showed a faster improvement between 6 weeks and 3 months in the anchor group compared with the suture group. Grip and extension strength also showed a slightly faster improvement at 6 weeks postoperatively in the anchor group. No significant difference in the number of weeks required to return to work was found between the groups (10.4 weeks in both groups).

CONCLUSION

Our results of side-to-side tendon repair compared with bone-tendon interface restoration by a suture anchor showed no significant differences in functional outcomes. Patients who received a suture anchor did have faster rehabilitation at 6 weeks postoperatively in terms of both functional outcome scores and grip and wrist extension strength measures.

The comparison of the effectiveness of Kinesio Taping and dry needling in the treatment of lateral epicondylitis: a clinical and ultrasonographic study

BACKGROUND

The aim of this study was to investigate the short- and long-term effects of Kinesio Taping (KT) and dry needling (DN) applications on pain, functionality, and muscle strength in patients with lateral epicondylitis by use of questionnaires and ultrasonography.

METHODS

Seventy-eight patients were randomized into 3 groups. Each group followed a program that consisted of 9 treatment sessions in total, with 3 sessions per week for 3 weeks. Group 1 received KT and performed exercise, group 2 received DN and performed exercise, and group 3 performed exercise alone. Pain, functional status, grip strength, and the thickness and echogenicity of the common extensor tendon were evaluated before treatment, after treatment (at the end of the third week), and after 6 months.

RESULTS

In intragroup evaluations, KT and DN were found to be effective in the short and long term in terms of pain, functional status, muscle strength, and tendon thickness (P < .01). In intergroup evaluations, improvement in the KT and DN groups was superior to that in the control group for all parameters (P < .05). On comparison of the KT and DN groups, improvements in the clinical parameters and tendon thickness, heterogeneity, and elastography were significantly better in the DN group in the short and long term (P < .05).

CONCLUSIONS

The ultrasonographic outcomes in our study objectively demonstrated that although DN in general is superior in the treatment of lateral epicondylitis, KT treatment is also effective.

Outcomes of Continued Intensive Conservative Treatment Versus Arthroscopic Extensor Carpi Radialis Brevis Release for Recalcitrant Lateral Epicondylitis: A Non-randomized Controlled Trial

INTRODUCTION

There is no consensus on treatment of recalcitrant lateral epicondylitis (RLE). This is a prospective, non-randomized, interventional study comparing pain scores and functional outcomes between arthroscopic extensor carpi radialis brevis release and continued intensive conservative treatment.

MATERIALS AND METHODS

The study compared two groups: Group 1, consisting of 25 patients undergoing continued conservative treatment for 24 months, and Group 2, consisting of 25 patients undergoing arthroscopic extensor carpi radialis brevis release with decortication (ARD). VAS (Visual Analogue Scale) score for lateral elbow pain at rest and after routine daily activities were compared at 6 weeks, 24 weeks, 12 months and 24 months. Functional outcomes were compared with grip strength, and patients reported functional outcome scores, pre-intervention and 24 months post-intervention.

RESULTS

There was a significant improvement in VAS scores for pain, functional outcome scores, and grip strength in both the groups post-intervention (P < 0.05). VAS scores for pain at rest in both the groups were significantly better after the interventions, at all follow-up durations (P < 0.001). VAS scores for pain after routine daily activities were significantly better in group 2 at 24 weeks (P = 0.002) and afterward (P < 0.001). Group 2 had significantly better functional outcome scores at 24 months (P < 0.001) though the difference in grip strength was not statistically significant (P = 0.121).

CONCLUSION

The present study shows favourable functional outcomes and pain scores of ARD compared to continued intensive conservative treatment for RLE.

LEVEL OF STUDY

II, Non-randomized comparative study.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00649-w.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

To Improve Pain and Function, Platelet-Rich Plasma Injections May Be an Alternative to Surgery for Treating Lateral Epicondylitis: A Systematic Review

PURPOSE

To determine whether platelet-rich plasma (PRP) injection for lateral epicondylitis offers patients comparable outcomes to lateral epicondylar surgery.

METHODS

Embase, Cochrane Library, and MEDLINE databases were searched using the terms lateral epicondylitis, lateral elbow pain, tennis elbow, lateral epicondylalgia, and elbow tendinopathy individually and combined with the terms platelet-rich plasma injections and lateral epicondylar surgery. We compared pain relief, function between the 2 treatment options, and identified whether PRP injection reduced the incidence of lateral epicondylar surgery. Studies must have compared PRP injections with lateral epicondylar surgery for the treatment of lateral epicondylitis; be of Level I, II, or III evidence; and be written in the English language.

RESULTS

Three studies (1 Level II and 2 Level III) met inclusion criteria. Two of the studies suggested that PRP injections offer similar relief as surgery in the short and mid-term, one study reported that PRP injections and surgery had similar outcomes in pain improvement and return to work, whereas 1 study reported that surgery may be a better long-term solution.

CONCLUSIONS

In comparison with lateral epicondylar surgery, PRP injections offer similar improvements in pain and function for patients suffering from lateral epicondylitis, especially in the short- and mid-term in 2 of the 3 included investigations. Therefore, PRP injections are an appropriate alternative for the treatment of lateral epicondylitis.

LEVEL OF EVIDENCE

Level III, Systematic Review of Level III or greater evidence.

Arthroscopic lateral capsule resection is enough for the management of lateral epicondylitis

PURPOSE

Controversy exists with regards to the etiology and treatment of lateral epicondylitis and the role of the lateral capsule in this pathology. The aim of this study was to compare arthroscopic lateral capsule resection with or without extensor carpi radialis brevis (ECRB) tendon debridement for treatment of lateral epicondylitis.

METHODS

This is a retrospective study of 38 patients who underwent arthroscopic surgery for LE with two different techniques: Eighteen patients were treated with arthroscopic lateral capsular resection (LCR) + ECRB debridement and 20 patients were treated with arthroscopic LCR alone, without ECRB debridement. Both groups were assessed with Quick Disabilities of the Arm, Shoulder and Hand (QDASH) score for function and Visual Analog Scale (VAS) score for pain.

RESULTS

Quick DASH scores were 12 [Formula: see text] 5 and 13 [Formula: see text] 4 at Groups 1 and 2, respectively, without any statistically significant difference. VAS pain scores were 15 [Formula: see text] 2 for both groups. VAS function scores were 85 [Formula: see text] 22 and 86 [Formula: see text] 18 at Groups 1 and 2 respectively. Sick leave periods in terms of weeks were 7 [Formula: see text] 5 and 7 [Formula: see text] 4 at Groups 1 and 2, respectively. There was no statistically significant difference in outcome of the two groups compared in terms of VAS pain, function scores, failure (re-operation) rates and sick leave period at the end of final follow-up.

CONCLUSION

Both arthroscopic LCR alone and Arthroscopic LCR with ECRB debridement for the management of refractory LE provide significant improvement in pain and function. Isolated Arthroscopic LCR could be a sufficient surgical treatment for refractory LE. Thus, ECRB debridement or release may not be necessary in every case.

LEVEL OF EVIDENCE

IV.

Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Clinical and Sonographic Results at 90 Months

BACKGROUND

In a study from our institution, ultrasonic percutaneous tenotomy of the brevis and the common extensor tendon for recalcitrant lateral elbow tendinopathy showed excellent safety profiles, high tolerability, efficiency, sustained pain relief, functional improvement, and sonographic evidence of tissue healing in 20 patients at 3 years' follow-up.

PURPOSE

To explore the long-term clinical and sonographic results of ultrasonic percutaneous tenotomy of the brevis and the common extensor tendon.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The same cohort of 20 patients was recalled after 7 years, and visual analog scale (VAS) for pain and Disabilities of the Arm, Shoulder and Hand (DASH) scores, need for secondary intervention, and overall satisfaction were assessed. They were also reassessed using ultrasound imaging of the brevis and the common extensor tendon to evaluate tendon hypervascularity, tendon thickness, and the progress or the recurrence of the hypoechoic scar tissue.

RESULTS

We successfully scored 19 patients and performed ultrasound on 16 patients with a median follow-up of 90 months (range, 86-102 months). There were no adverse outcomes and satisfaction remained at 100% (6 patients, satisfied; 13 patients, very satisfied). No patient developed a recurrence of symptoms and signs of lateral elbow tendinopathy, and therefore no secondary intervention was required. The improvement from baseline and early term scores was sustained (P < .001 for all). At 90 months, there was a significant improvement in VAS scores and DASH-Compulsory scores compared with preprocedure scores and all follow-up times until 3 months. There was no difference in VAS scores and DASH-Compulsory scores at 90 months compared with 6 and 36 months. For DASH-Work scores, there was a significant improvement at 90 months compared with preprocedure scores, but there was no difference between DASH-Work scores at 90 months and scores at all other points of follow-up. At 90 months, hypervascularity remained resolved in 79% of patients, while all patients had reduced tendon swelling and sustained resolution or reduction of the hypoechoic lesion.

CONCLUSION

At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy of the brevis and the common extensor tendon, previously shown to enhance recovery of lateral elbow tendinopathy, demonstrated good durability of pain relief and functional recovery that was previously achieved. This was accompanied by sustained sonographic tissue healing with no significant deterioration.

Epicondylopathia humeri radialis

BACKGROUND

Lateral epicondylitis is a common orthopaedic condition often massively restricting the quality of life of the affected patients. There are a wide variety of treatment options - with varying levels of evidence.

METHOD

The following statements and recommendations are based on the current German S2k guideline Epicondylopathia radialis humeri (AWMF registry number: 033 - 2019). All major German specialist societies participated in this guideline, which is based on a systematic review of the literature and a structured consensus-building process.

OUTCOMES

Lateral epicondylitis should be diagnosed clinically and can be confirmed by imaging modalities. The Guidelines Commission issues recommendations on clinical and radiological diagnostic workup. The clinical condition results from the accumulated effect of mechanical overload, neurologic irritation and metabolic changes. Differentiating between acute and chronic disorder is helpful. Prognosis of non-surgical regimens is favourable in most cases. Most cases spontaneously resolve within 12 months. In case of unsuccessful attempted non-surgical management for at least six months, surgery may be considered as an alternative, if there is a corresponding structural morphology and clinical manifestation. At present, it is not possible to recommend a specific surgical procedure.

CONCLUSION

This paper provides a summary of the guideline with extracts of the recommendations and statements of its authors regarding the pathogenesis, prevention, diagnostic workup as well as non-surgical and surgical management.

Percutaneous ultrasonic tenotomy with the TX-1 device versus surgical tenotomy for the treatment of common extensor tendinosis

OBJECTIVE

To compare outcomes in patients treated for chronic common extensor tendinosis with percutaneous ultrasonic tenotomy (TX-1 device) versus surgical tenotomy.

MATERIALS AND METHODS

Outcomes from consecutive patients who underwent percutaneous tenotomy with the TX-1 device were compared with outcomes from consecutive patients who underwent surgical tenotomy. Patients were contacted to retrospectively assess their outcomes at 4 time points: before treatment, 2 weeks after treatment, 3 to 6 months after treatment, and 12 months after treatment. Outcomes were assessed using the quick disabilities of the arm, shoulder, and hand score (QuickDASH) and the Oxford elbow score (OES). Student's t tests were used to compare postprocedural versus preprocedural scores and percutaneous versus surgical tenotomy scores.

RESULTS

Response rates were 23 of 43 and 10 of 47 for surveyed percutaneous and surgical tenotomy patients, respectively. There were significant improvements from preprocedural scores in all primary outcome measures at 3-to-6-month and 12-month time points for both procedures. No significant changes from preprocedural scores were seen for either procedure at 2 weeks after treatment or between percutaneous and surgical tenotomy in preprocedural or postprocedural scores for any outcome measure. At 2 weeks, improved percutaneous tenotomy scores approached significance compared with percutaneous preprocedural QuickDASH (p = 0.060) and surgical 2-week OES function domain (p = 0.074) scores.

CONCLUSION

Ultrasonic percutaneous tenotomy with the TX-1 device and surgical tenotomy have similar outcomes for chronic common extensor tendinosis, with significant symptomatic improvement occurring after 3 to 6 months. Larger studies are needed to assess for differences at 2 weeks.

Effectiveness of extracorporeal shock wave therapy in patients with tennis elbow: A meta-analysis of randomized controlled trials

BACKGROUND

The aim of the present study was to investigate the effectiveness of Extracorporeal Shock Wave (ECSW) in the treatment of lateral epicondylitis (LE) of humerus.

HYPOTHESIS

ECSW therapy in people with LE effectively reduces the pain and gains functional rehabilitation.

MATERIALS/METHODS

Databases of PubMed, EMBASE, Web of Science and the Cochrane Library from inception to April 2020 was searched to identify all relevant RCTs comparing ECSW therapy with any other conservative treatment, including injection and local anesthetic versus placebo or control in patients aged 18 with LE. The primary outcome is the mean overall pain score at 12 weeks after treatment. Another secondary outcome mainly included Thomsen test, 50% pain reduction, grip strength and adverse effect at 12 weeks after treatment.

RESULTS

Nine studies were included in the meta-analysis. Compared with the placebo group, ECSW cannot significantly reduce the pain score (mean deviation [MD] = -4.23, 95% confidence interval [CI]: -8.78 to 0.32, P = .07), but make more people acquire 50% pain reduction (MD = 1.38, 95% CI: 1.09 to 1.75, P = .008). There was no significant difference between ECSW and control in decreasing the pain score of Thomsen test (MD = -3.22, 95% CI: -14.06 to 7.62, P = .56). ECSW was more effective in Grip strength as compared with control at 12 weeks-3 months (MD = 3.52, 95% CI: 2.43 to 4.60, P < .00001) CONCLUSIONS:: Results suggested that ECSW cannot effectively reduce the mean overall pain, but it showed more people acquire 50% pain reduction and might be a better option for the treatment of LE. Because of study limitations, additional high level of evidence, more rigorously designed large-samples and high-quality randomized controlled trials are needed to guide clinical practice.

Management of Lateral Epicondylitis: A Narrative Literature Review

Lateral epicondylitis, also termed as "tennis elbow," is the most common cause of elbow pain and dysfunction, mainly resulting from repetitive gripping or wrist extension during various activities. The exact pathogenesis remains largely elusive with putative tendinosis, a symptomatic degenerative process of the local tendon. It is usually diagnosed by clinical examinations. Sometimes, additional imaging is required for a specific differential diagnosis. Although most cases can be self-healing, the optimal treatment strategy for chronic lateral epicondylitis remains controversial. This article presents a landscape of emerging evidence on lateral epicondylitis and focuses on the pathogenesis, diagnosis, and management, shedding light on the understandings and treatment for healthcare professionals.

Management of lateral epicondylitis

Lateral epicondylitis is the most common cause of lateral elbow pain. Although also known as tennis elbow, lateral epicondylitis often develops as a work-related condition and therefore constitutes a major public health issue. This article reviews the pathophysiological factors involved in lateral epicondylitis, as well as the tools available for establishing the diagnosis and ruling out other causes of lateral elbow pain. Finally, the non-operative and surgical treatment options are discussed in detail.

Exclusive Posterolateral Arthroscopic and Endoscopic Approaches Used in the Treatment of Lateral Epicondylitis

Complications following arthroscopy of the elbow for the treatment of lateral epicondylitis are essentially related to the anterior arthroscopic approach. The principal aims of this study were to describe and evaluate the mixed arthroscopic and endoscopic surgical technique using posterolateral approaches exclusively. This was a retrospective study of consecutive patients operated on between 2005 and 2014 for lateral epicondylitis following more than 6 months of ineffective medical treatment. The exploration was arthroscopic via a distal posterolateral portal. The extensor carpi radialis brevis was disinserted via a proximal extra-articular posterolateral endoscopic portal. The postoperative clinical follow-up included subjective (visual analog scale, Nirschl) and objective (Mayo Clinic Elbow Performance Score) evaluations of pain, the time to return to work, the level of satisfaction, complications, and failures. Thirty-seven patients underwent the procedure, including 3 lost to follow-up. Mean±SD follow-up was 32.8±24.7 months. Mean±SD visual analog scale scores were 0.8±0.8 at rest, 2.4±1.3 during everyday activities, and 3.1±1.5 during effort. Mean±SD Mayo Clinic Elbow Evaluation Score was 10.1±1.0 of 12 and mean±SD Mayo Clinic Elbow Performance Score was 91.9±12.5 of 100. Mean±SD Nirschl score was 67.5±9.6 of 80. Mean±SD time to return to work was 2.0±2.6 months. The level of satisfaction was 94.1%. The failure rate was 2.9%, with no neurological lesions. With equivalent or even better results than those already published, this surgical procedure enables the treatment of lateral epicondylitis via posterolateral portals alone, thus avoiding the complications inherent to anterior and medial arthroscopic approaches. [Orthopedics. 2019; 42(6):e521-e527.].

Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis

Background

Lateral epicondylitis (LE)¹ affects between 1 and 3% of the population. Recently, platelet-rich plasma (PRP)² has gained popularity.

Aim

Assess the long-term outcomes of PRP for patients with refractory LE.

Methods

We assessed 31 patients who had failed conservative management using the Oxford Elbow Score (OES).³.

Results

Mean follow-up: 5.2 years (range 4.2-6.1 years).87.1% exhibited minimum clinically important difference (MCID)⁴ in pain scores between pre-op and long-term. 90.3% displayed MCID in function and psycho-social domains.Two patients had a repeat injection and six underwent open release.

Discussion

PRP is successful in treating refractory LE in most patients and avoiding surgery.

ARTHROSCOPIC TREATMENT FOR LATERAL EPICONDYLITIS: OUTCOMES IN 104 CASES OF A SINGLE INSTITUTION

OBJECTIVE

To evaluate the outcomes of patients that underwent arthroscopic surgery for lateral epicondylitis (LE), after failed conservative treatment.

METHODS

One hundred four patients with LE treated with arthroscopic debridement of the extensor carpi radialis brevis (ECRB) tendon were enrolled in this retrospective study. They were evaluated using Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scale. Mean age at surgery was 46.9 years. Duration of symptoms was 2.1 years (range: 6 m to 10 yrs.). Mean follow-up was 34.4 months (range: 6 to 68 m).

RESULTS

Mean postoperative scores were: 20.67 points on the DASH; 1.8 points on the VAS at rest, with 48 cases (46%) without pain, 40 (38%) with mild pain, 13 (13%) with moderate pain and 4 (4%) with severe pain; 4.7 points on the VAS in activity, with 21 (20%) without pain, 21 (20%) with mild pain, 35 (34%) with moderate pain and 27 (26%) with severe pain; and SF-36 was 66.8 points. Of the 23 patients who practiced sports regularly or with higher physical demand from the upper limbs, 17 (74%) were able to return to the same activity at the same level. No significant complications were observed postoperatively, except for 3 (2.8%) cases of postoperative superficial infection.

CONCLUSION

Surgical treatment with arthroscopy for recalcitrant LE is effective and safe, presenting positive outcomes in the studied patients. Level of evidence IV, Case Series.

Semicircumferential Detachment of the Extensor Enthesis For Surgical Treatment of Chronic Lateral Epicondylitis: A Prospective Study

About 10% of patients with lateral epicondylitis are nonresponsive to conservative treatment; as controversy persists on etiology and pathogenesis of this pathology, there is no surgical technique universally approved. The purpose of this study is to describe and evaluate the clinical outcomes of our technique consisting in a semicircumferential and partial detachment of the entire extensor apparatus enthesis. The technique was performed on 14 consecutive patients affected by painful chronic epicondylitis between January 2010 and April 2016. Two patients were lost during follow-up. At 6 months, 1 year, and 2 years after surgery patients were revaluated. Outcomes were assessed using Visual Analog Scale, DASH score (Disability of the Arm, Shoulder, and Hand), Jamar test, and time to return to work. The mean surgical time was 16 minutes. The postoperative outcomes were excellent in most patients as mean Visual Analog Scale score improved from 9.25 to 2.6 and mean DASH score improved from 82.9 to 29.6. No recurrence was recorded at 2 years of follow-up. The procedure is rapid to perform, reproducible and provides low complication rates and no relapse in our experience. As a result, we recommend this technique in nonresponding to conservative treatment lateral epicondylitis.

Chronic lateral epicondylitis: challenges and solutions

Lateral epicondylitis (LE) is a significant source of pain and dysfunction resulting from repetitive gripping or wrist extension, radial deviation, and/or forearm supination. Although most cases are self-limiting over several years, controversy exists regarding the best treatment strategy for chronic LE. Nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), shockwave therapy, and injections with corticosteroids or biologics are all conservative treatment options for LE. For refractory cases, surgical options include open, arthroscopic, and percutaneous techniques. In this review, the current evidence behind these treatment strategies is presented. The data demonstrate that NSAIDs, PT, bracing, and shockwave therapy provide limited benefit for treating LE. Biologics such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management of LE. Although the initial results are promising, larger comparative studies on stem cell injections are needed. For refractory LE, open, arthroscopic, and percutaneous techniques are all highly effective, with no method seemingly superior over another. Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work.

Open, Arthroscopic, and Percutaneous Surgical Treatment of Lateral Epicondylitis: A Systematic Review

Background: Approximately 10% of patients with lateral epicondylitis go on to have surgical treatment; however, multiple surgical treatment options exist. The purpose of this study was to review the literature for the clinical outcomes of open, arthroscopic, and percutaneous treatment of lateral epicondylitis. The authors hypothesized that the clinical outcome of all 3 analyzed surgical treatments would be equivalent. Methods: A systematic review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar in July 2016 to compare the functional outcome, pain, grip strength, patient satisfaction, and return to work at 1-year follow-up for open, arthroscopic, and percutaneous treatment of lateral epicondylitis. Results: Six studies (2 Level I and 4 Level II) including 179 elbows (83 treated open, 14 arthroscopic, 82 percutaneous) were analyzed. Three outcome measures (Disabilities of the Arm, Shoulder, and Hand [DASH] score, visual analog scale [VAS], and patient satisfaction) were reported for more than one category of surgical technique. Of these, the authors noted no clinically significant differences between the techniques. Conclusions: This is the first systematic review looking at high-level evidence to compare open, percutaneous, and arthroscopic techniques for treating lateral epicondylitis. There are no clinically significant differences between the 3 surgical techniques (open, arthroscopic, and percutaneous) in terms of functional outcome (DASH), pain intensity (VAS), and patient satisfaction at 1-year follow-up.

A Systematic Review of Tennis Elbow Surgery: Open Versus Arthroscopic Versus Percutaneous Release of the Common Extensor Origin

PURPOSE

To compare complications, function, pain, and patient satisfaction after conventional open, percutaneous, or arthroscopic release of the extensor origin for the treatment of lateral epicondylitis.

METHODS

A thorough review of 4 databases-PubMed, EBSCOhost, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus, and Scopus-was performed to identify all studies that addressed surgical management of lateral epicondylitis. We included (1) studies published between 2000 and 2015 and (2) studies with clearly defined surgical techniques. We excluded (1) non-English-language manuscripts, (2) isolated case reports, (3) studies with fewer than 10 subjects, (4) animal studies, (5) studies with additional adjunctive procedures aside from release of the extensor origin, (6) clinical or systematic review manuscripts, (7) studies with a follow-up period of 6 months or less, and (8) studies in which less than 80% of patients completed follow-up. Each study was analyzed for complication rates, functional outcomes, pain, and patient satisfaction.

RESULTS

Thirty reports were identified that included 848 open, 578 arthroscopic, and 178 percutaneous releases. Patients within each release group had a similar age (46 years vs 46 years vs 48 years; P = .9 and P = .4, respectively), whereas there was a longer follow-up time in patients who underwent surgery by an open technique (49.4 months vs 42.6 months vs 23 months, P < .001). There were no differences in complication rates among these techniques (3.8% vs 2.9% vs 3.9%; P = .5 and P = .9, respectively). However, open techniques were correlated with higher surgical-site infection rates than arthroscopic techniques (0.7% vs 0%, P = .04). Mean Disabilities of the Arm, Shoulder and Hand scores were substantially better with both open and arthroscopic techniques than with percutaneous release (19.9 points vs 21.3 points vs 29 points, P < .001). In addition, there was less pain reported in the arthroscopic and percutaneous release groups as opposed to their open counterparts (1.9 points vs 1.4 points vs 1.3 points, P < .0001). There were no differences among the techniques in patient satisfaction rate (93.7% vs 89% vs 88%; P = .08 and P = .07, respectively).

CONCLUSIONS

Functional outcomes of open and arthroscopic releases may be superior to those of percutaneous release. In addition, patients may report less pain with arthroscopic and percutaneous techniques. Although the risk of complications is similar regardless of technique, patients may be counseled that their risk of infectious complications may be slightly higher with open releases. However, it is important to note that this statistical difference may not necessarily portend noticeable clinical differences.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV evidence.

Arthroscopic surgical treatment of recalcitrant lateral epicondylitis - A series of 47 cases

OBJECTIVE

To evaluate the results of patients undergoing arthroscopic surgical treatment of refractory lateral epicondylitis, identifying poor prognosis factors.

METHODS

A retrospective study of 44 patients (47 elbows) who underwent arthroscopic debridement of the extensor carpi radialis brevis (ECRB) tendon to treat refractory lateral epicondylitis from February 2013 to February 2015, operated by a single surgeon at one center. Patients were assessed by DASH score, visual analog scale of pain (VAS), and ShortForm 36 (SF-36). The mean age at surgery was 44.4 years (32-60). The duration of symptoms prior to the surgery was approximately 2.02 years (range: 6 months to 10 years). Mean follow-up was 18.6 months (range of 6-31.9).

RESULTS

The mean postoperative DASH score was 25.9 points; mean VAS, 1.0 point at rest (all the patients with mild pain) and 3.0 points at activity, of which 31 (66%) cases presented mild pain, 10 (21%) moderate pain, and six (13%) severe pain; mean SF-36 score was 62.5. A moderate correlation was observed between duration of pain before surgery and the DASH score with the final functional outcome. No significant complications with the arthroscopic procedure were observed.

CONCLUSIONS

Arthroscopic surgical treatment for recalcitrant lateral elbow epicondylitis presented good results, being effective and safe. The shorter the time of pain before surgery and the lower the preoperative DASH score, the better the prognosis.

The Nirschl procedure versus arthroscopic extensor carpi radialis brevis débridement for lateral epicondylitis

BACKGROUND

The Nirschl technique and arthroscopic débridement are common surgical procedures for chronic lateral elbow tendinopathy. The purpose of this study was to compare outcomes following the use of these techniques to treat chronic lateral elbow tendinopathy.

METHODS

We retrospectively reviewed 59 elbows of 55 patients who did not improve after conservative treatment. Twenty-nine elbows of 26 patients were treated with the Nirschl procedure (Nirschl group), and 30 elbows of 29 patients were treated with arthroscopic débridement (arthroscopy group). Outcomes were assessed subjectively with the quick Disabilities of the Arm, Shoulder and Hand questionnaire and the visual analog scale (VAS) for pain in 3 domains (overall pain, pain at rest, and pain during hard work) and objectively with pain-free grip strength.

RESULTS

The Nirschl and arthroscopy groups showed significant improvements in subjective and objective outcomes at a mean of 28.5 months and 31 months, respectively (P <.05). No significant between-group differences were found in postoperative outcomes, including quick Disabilities of the Arm, Shoulder and Hand questionnaire scores; pain-free grip strength; and VAS scores for overall pain and pain at rest (P > .05). However, a small but significant difference was found in the postoperative VAS score for pain during hard work (1.6 ± 1.3 for Nirschl group vs 2.2 ± 2.0 for arthroscopy group, P = .042).

CONCLUSIONS

Both techniques are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy. Although the Nirschl technique provides slightly superior pain relief during hard work, the effect size is very small and the difference does not appear to be clinically important.

Outcomes of arthroscopic lateral epicondylitis release: Should we treat earlier?

BACKGROUND

When managed conservatively, lateral epicondylitis often subsides only after considerable time, during which social and occupational activities are severely disrupted. If conservative management fails, a recently introduced option is arthroscopic release of the extensor carpi radialis brevis (ECRB). The primary objective of this study was to compare clinical outcomes of this procedure according to preoperative symptom duration.

HYPOTHESIS

Earlier arthroscopic release is associated with better functional outcomes.

MATERIAL AND METHOD

Consecutive patients with arthroscopically managed lateral epicondylitis were included in a retrospective study. Arthroscopy was performed only after at least 6 months of conservative treatment. The criteria to evaluate the clinical outcomes were the Nirschl and Quick-DASH scores, muscle strength, time to pain relief, and percentage of functional recovery.

RESULT

Thirty-five patients were evaluated at a median of 4 years (range: 1-12 years) after surgery. Mean preoperative symptom duration was 18 months (range: 6-106 months) with a mean sick leave duration of 2.3±4.9 months. Postoperatively, mean time to recovery was 37.5 days (range: 7 days to 5 years) and mean sick leave duration was 2.4±2.4 months. The mean Quick-DASH score was 15.9±19.1. The Nirschl score improved significantly, from 26.4±7.9 to 66.3±16.3. The initial muscle strength deficit was 10.1±33.2% and muscle strength at last follow-up was increased by 4.3±30.3%. Symptom duration showed no correlations with any of the clinical outcome measures.

DISCUSSION AND CONCLUSIONS

Outcomes after arthroscopic release were not associated with symptom duration in this study. Nevertheless, the good clinical outcomes support treatment with arthroscopic release after only 6 months of conservative management.

LEVEL OF EVIDENCE

IV, retrospective study.

A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis

BACKGROUND

Tennis elbow is a common elbow pathology typically affecting middle-aged individuals that can lead to significant disability. Most cases resolve within 2 years of symptom onset, but a subset of patients will develop persistent symptoms despite appropriate conservative management. There are several surgical approaches used to treat chronic tennis elbow, with arthroscopic surgery becoming an increasingly popular approach to address this pathology in North America. This procedure involves the arthroscopic release of the extensor carpi radialis brevis tendon (ECRB) origin at the elbow. The potential benefit of arthroscopic treatment of this condition is improved patient outcomes and shorter recovery time following surgery. The results of this technique have been reported only in the context of case series, which have shown positive results. However, in order to justify its widespread use and growing popularity, a high level of evidence study is required. The purpose of this prospective, randomized sham-controlled trial is to determine whether arthroscopic tennis elbow release is effective at treating chronic lateral epicondylitis.

METHODS

We will conduct a prospective single center, double-blind, randomized sham-controlled parallel arm trial evaluating the efficacy of arthroscopic tennis elbow release in adult patients with symptoms for at least 6 months. Patients will undergo intraoperative randomization after diagnostic arthroscopy of the elbow to receive either ECRB release (through the creation of a lateral portal) or a sham lateral portal and no ECRB release. The primary outcome will be the Mayo Elbow Performance Score (MEPS) at 1 year follow-up. Secondary outcomes will be the abbreviated Disability of the Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons elbow (ASES-e) score and grip strength at 3, 6, 12 and 24 months as well as return-to-work time, ability to return to full duty and adverse outcomes.

DISCUSSION

Results of this study will provide empirical high quality evidence to guide clinical decision-making in patients with chronic tennis elbow.

TRIAL REGISTRATION

NCT02236689 (September 8, 2014).

Complications of Lateral Epicondylar Release

Reported complication rates are low for lateral epicondylitis management, but the anatomic complexity of the elbow allows for possible catastrophic complication. This review documents complications associated with lateral epicondylar release: 67 studies reporting outcomes of lateral epicondylar release with open, percutaneous, or arthroscopic methods were reviewed and 6 case reports on specific complications associated with the procedure are included. Overall complication rate was 3.3%. For open procedures it was 4.3%, percutaneous procedures 1.9%, and arthroscopic procedures 1.1%. In higher-level studies directly comparing modalities, the complication rates were 1.3%, 0%, and 1.2%, respectively.

Arthroscopic Treatment of Lateral Epicondylitis: Tenotomy Versus Debridement

PURPOSE

To compare the outcome of 2 arthroscopic techniques for treating recalcitrant lateral epicondylitis.

METHODS

The study included patients undergoing arthroscopic treatment of lateral epicondylitis during 2 different time periods: April 2005 to October 2007 (tenotomy) and May 2009 to June 2010 (debridement). By using a patient-administered form, baseline information including QuickDASH (disabilities of the arm, shoulder and hand) score (primary outcome), visual analog scale (VAS) of pain, and VAS of function was recorded prospectively. To have the same follow-up period of minimum 4 years in the 2 groups, the follow-up was conducted at 2 different points of time.

RESULTS

Of a total of 326 patients fulfilling the requirements for inclusion in the study, 283 patients (87%) were followed up (144 male and 139 female, median age 46 [21 to 65] years), 204 (87%) in the tenotomy group and 79 (88%) in the debridement group. In both groups, a significant improvement in the QuickDASH was found at the follow-up compared with baseline: from 60 to 12 in the debridement group (P < .001) and from 59 to 13 in the tenotomy group (P < .001). No statistically significant difference was found in baseline or follow-up QuickDASH, VAS of pain, VAS of function, or failure (reoperation) rate between the 2 groups. The mean length of sick leave was 2 weeks shorter in the debridement only group (P = .007).

CONCLUSIONS

Both arthroscopic methods lead to a significant improvement of pain and function, and no statistically significant difference was found in any outcome parameters between the 2 techniques at this minimum 4-year evaluation. The results indicate that tenotomy of the extensor carpi radialis brevis may be an unnecessary step in the arthroscopic treatment of lateral epicondylitis Debridement only is a potentially less costly procedure, and the current finding of a mean 2 weeks shorter sick leave in the debridement only group proposes a substantial cost saving in a societal perspective.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Prognostic Factors of Arthroscopic Extensor Carpi Radialis Brevis Release for Lateral Epicondylitis

PURPOSE

The purpose of this study was to analyze factors affecting the treatment outcomes and prognoses of arthroscopic debridement for refractory lateral epicondylitis.

METHODS

We included 45 patients who had undergone arthroscopic extensor carpi radialis brevis release for chronic refractory lateral epicondylitis between October 2008 and December 2012. Demographic data, magnetic resonance imaging studies, and arthroscopic findings were examined and analyzed.

RESULTS

The mean age of the enrolled patients (23 men and 22 women) was 45.9 ± 7.8 years, and the mean follow-up duration was 26.9 ± 9.0 months. All the patients showed significant clinical improvement on all parameters assessed using the visual analog scale (6.9 preoperatively to 0.9 postoperatively), the Upper Extremity Functional Scale (34.8 to 66.7), and the Mayo Elbow Score (63.5 to 92.3) (P < .05). There were no reports of serious surgical complications. At final follow-up, 37 patients (82.2%) were satisfied with their outcomes whereas 8 patients (17.8%) were dissatisfied. In terms of demographic factors, female sex was significantly different between the 2 groups. On preoperative magnetic resonance imaging, 7 patients in the satisfied group (18.9%) had a definite tendon lesion (grade III defect, ≥6 mm) whereas 6 patients in the dissatisfied group (75%) had a grade III defect (P = .016).

CONCLUSIONS

Overall, clinical outcome scores showed improvement after arthroscopic extensor carpi radialis brevis release for refractory lateral epicondylitis. However, preoperative tendon status and sex were associated with dissatisfaction and poor postoperative outcomes after the arthroscopic release procedure.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis: Mean 4.5-Year Clinical Follow-up

BACKGROUND

Chronic lateral epicondylitis (LE) induces cell apoptosis and autophagy, which lead to the reduction of tendon-derived cells in the torn tendon. Our previous study has shown that ultrasound-guided autologous tenocyte injection (ATI) to the torn tendon in patients with chronic resistant LE significantly improves pain, function, and structural repair at 1 year. This report is the continued assessment of the clinical outcomes of these patients at mean 4.5-year follow-up.

HYPOTHESIS

Improvements in LE clinical function and structural repair after ATI will be maintained at mean 4.5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with severe refractory LE underwent clinical evaluation and MRI before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Autologous tenocytes were injected into the central tendinopathy identified at the common extensor tendon origin under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations for up to 5 years after ATI, including the visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Upper Extremity Functional Scale (UEFS), and grip strength. Post-ATI MRI scanning was performed at 1 year and final follow-up.

RESULTS

A total of 16 patients (9 male, 7 female), aged between 37 and 63 years, were included in the study. The mean duration of symptoms before study recruitment was 29.24 months (range, 6-240 months). One patient elected to proceed to surgery 3 months after ATI due to reinjury at work, and 1 patient died of prostate cancer with metastases during the follow-up period. The mean final follow-up time for the remaining 15 patients was 4.51 years (range, 3.08-5.17 years). No complications were observed at the patellar tendon biopsy site for any patient. No adverse events, infection, or excessive fibroblastic reactions were observed in any patient at the injection site. Clinical evaluation revealed significant (P < .001) improvement in mean VAS pain score from 5.73 at initial assessment to 1.21 (78% improvement) at final follow-up. Mean QuickDASH, UEFS, and grip strength scores also significantly (P < .001) improved from initial assessment to final follow-up (from 45.88 to 6.61 [84%], from 31.73 to 9.20 [64%], and from 19.85 to 46.60 [208%], respectively). There was no difference in mean QuickDASH and UEFS scores at 1 year and final follow-up (P > .05); however, grip strength continued to improve (P < .001). A validated MRI scoring system indicated that the mean grade of tendinopathy at the common extensor origin improved significantly (P < .001) from initial assessment (4.31) to 1 year (2.88) and was maintained (P > .05) at final follow-up (2.87). At final follow-up, 93% of patients were either highly satisfied or satisfied with their ATI treatment.

CONCLUSION

ATI significantly improved clinical function and MRI tendinopathy scores for up to 5 years in patients with chronic resistant LE who had previously undergone unsuccessful nonsurgical treatment. This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy.

New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis

Lateral epicondylitis is a common source of elbow pain. Though it is often a self-limited condition, refractory lateral epicondylitis can lead to problems with activities of daily living and sometimes requires sick leave from work. Therefore prompt treatment is essential. Histopathologic studies have suggested that lateral epicondylitis is a tendinopathy, associated with apoptosis and autophagy, rather than a tendonitis associated with inflammation. Although corticosteroids have been used for short-term treatment, recent studies have suggested that they are not helpful and may even be harmful and delay healing in the treatment of lateral epicondylitis. Researchers have recently begun to investigate the use of biologics as potential treatment options for lateral epicondylitis. Autologous blood preparations including platelet rich plasma (PRP) and autologous whole blood injections (ABIs) have been proposed in order to deliver growth factors and other nutrients to the diseased tendon. Stem cell therapies have also been suggested as a method of improving tendon healing. This review discusses the current evidence for the use of PRP, ABI, and stem cell therapies for treatment of lateral epicondylitis. We also review the evidence for nonbiologic treatments including corticosteroids, prolotherapy, botulinum toxin A, and nitric oxide.

Systematic diagnosis and therapy of lateral elbow pain with emphasis on elbow instability

PURPOSE

In recalcitrant epicondylitis innumerable operative techniques have been published, nevertheless a certain percentage of patients remains symptomatic after operative treatment. We developed an individual, systematic diagnostic pathway including arthroscopic assessment of elbow stability to identify the optimal and respectively less invasive therapy.

METHODS

We so far included 40 patients with recalcitrant lateral epicondylitis (mean age 46 ± 11). 5 patients had previous surgery. In all patients, we did an elbow arthroscopy and a systematic arthroscopic stability testing. 25 patients were treated exclusively arthroscopically once instability was excluded. In 13 patients with slight instability, we did an open debridement of the lateral tendon complex and local refixation. Two patients with severe instability were treated with open debridement and additional stabilization of the LUCL with a trizeps graft. With a minimum follow-up of 1 year, we assessed the DASH score and subjective patient satisfaction.

RESULTS

Mean follow-up was 24 ± 12 months, mean duration of symptoms before surgery was 19 ± 18 months. The mean DASH score at follow-up was 22 ± 19.36 patients reported symptoms improvement, 34 patients would repeat surgery given the same situation; in 30 cases, patients expectations had been fulfilled. We did not observe any intraoperative complications or infections. One patient developed joint stiffness requiring reoperation.

CONCLUSION

Using a systematic diagnostic pathway including assessment of elbow stability and consecutive individualized, respectively, less invasive surgical procedure we acquired high patients satisfaction and good clinical outcome with a low complication rate.

LEVEL OF EVIDENCE

Level III.

The Boyd-McLeod procedure for tennis elbow: mid- to long-term results

BACKGROUND

Tennis elbow is a common condition that usually responds to conservative measures. In refractory cases, surgical intervention is indicated. A plethora of surgical techniques have been described. We report the mid- to long-term outcomes of the Boyd-McLeod procedure for refractory tennis elbow.

METHODS

A retrospective analysis and current review of patients that had undergone the Boyd-McLeod procedure over a 12-year period was undertaken. Demographics, time to discharge, length of follow-up and outcome scores were collected.

RESULTS

Seventy patients underwent surgery. Mean time to discharge was 15.35 weeks, with 88% successful outcomes. Fifty-four patients were available for current follow-up at mean of 5.52 years (range 1.17 years to 11.49 years). Range of motion in all patients was unchanged. There were no revision procedures. Mean (SD) Mayo Elbow Performance Score was 90.85 (13.11), with 75.5% returning a good or excellent score and 24.5% a fair outcome. The mean (SD) Oxford Elbow Score was 44.04 (6.92); mean (SD) pain score was 89.5 (17.58); mean (SD) function score was 95.34 (9.59) and mean (SD) socio-psychological score was 91.50 (17.01). Overall, 83% of patients had an Oxford Elbow Score of 43 or greater, suggesting excellent outcome.

CONCLUSIONS

We show that the Boyd-McLeod procedure is an excellent option over both the short- and long-term for refractory tennis elbow.

Time to functional recovery after arthroscopic surgery for tennis elbow

BACKGROUND

This study evaluated recovery from chronic lateral epicondylitis after arthroscopic treatment.

METHODS

Twenty-three consecutive patients (5 men, 18 women) with chronic lateral epicondylitis underwent arthroscopic surgery. Patients were a mean age of 49 years. Prospective outcome data were collected before the operation and at 1, 2, 3, 6, 12 and 24 months after surgery. Outcomes were assessed using a visual analog scale (VAS: 0-100), grip strength percentage (compared with the unaffected side), the Japanese Orthopaedic Association elbow score, and the Disability of the Arm, Shoulder and Hand questionnaire.

RESULTS

A mean VAS score at rest of 26 preoperatively improved to 8 (P = .0026), 6, and 3 at 1, 2, and 3 months after surgery, respectively. A mean VAS score during activity improved from 68 preoperatively to 35 (P < .001), 23, and 19 at 1, 2, and 3 months after surgery, respectively. Both VAS scores gradually decreased up to 24 months after surgery. The mean grip strength improved from 66.1% preoperatively to 88.7% at 2 months after surgery (P < .001). The mean Japanese Orthopaedic Association elbow score improved from 38 points preoperatively to 61 points at 1 month after surgery (P < .001). The mean Disability of the Arm, Shoulder and Hand score improved from 32 points preoperatively to 15 points at 3 months after surgery (P < .001).

CONCLUSION

Arthroscopic surgery for lateral epicondylitis provides significant improvement in pain and functional recovery up to 3 months after surgery. However, it takes more than 6 months for the VAS score during activity to fall below 10 points.

Evaluation of patients submitted to the arthroscopic treatment of the lateral epicondylitis refractory to the conservative treatment

Objective

to evaluate the results of the arthroscopic treatment of the lateral epicondylitis.

Methods

we evaluated 14 patients (15 elbows) submitted to the arthroscopic treatment of the lateral epicondylitis refractory to the conservative treatment, which was realized for a minimum period of 18 months. Beyond the demographic data collection, patients were evaluated according to the arthroscopic classification of Baker et al., the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance Score (MEPS). The patients’ ages ranged between 23 and 56 years (average 46 years) (eight males and six females). Of the 15 elbows, 12 were the dominant and one patient had bilateral lesion. The follow-up after surgery was minimum 24 months and maximum 72 months (average 41 months).

Results

we found, according to the arthroscopic classification of Baker et al., two patients with type I lesions, nine with type II lesions and three with type III lesions. We found the following complications: one patient with altered sensitivity in the region of the lateral portal, one with a deficit of ten degrees in length, one with synovial plica and one with synovitis in the lateral compartment. Our score on the DASH questionnaire was minimum of 32 points and maximum of 120 points (average 57 points) and the scale of MEPS had a minimum score of 60 points and a maximum of 100 points (average 90 points).

Conclusion

the arthroscopic treatment of the lateral epicondylitis, plus insurance, provides satisfactory results.

Lateral epicondylitis

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Cite this article: Bone Joint J 2013;95-B:1158–64.

Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows

PURPOSE

The purpose of this study was to compare the outcome of arthroscopic and open tendon release in tennis elbow (TE).

METHODS

We compared the outcome of patients treated by an open tendon release in the period from 2002 to 2005 (n = 80) with that of patients treated by an arthroscopic release of the extensor carpi radialis brevis in the period from 2005 to 2008 (n = 225). In both groups the inclusion criteria were symptomatic TE refractory to conservative care for a minimum of 6 months and a clinical follow-up of at least 3 years. The diagnosis was based on a typical history and positive clinical findings. Patients with previous surgery in the elbow, chondral or osteochondral lesions, osteoarthritis, or free bodies were excluded. To have a similar follow-up period in the 2 groups (median, 4 years), the follow-up was conducted at 2 different time points.

RESULTS

The groups did not differ significantly with regard to the age of the patients, distribution of gender, distribution of affected side, duration of symptoms, or baseline score on the short version of Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). We did not observe any major complications. The failure rate was not significantly different between the 2 groups. At follow-up, the mean QuickDASH score was statistically significantly better (P = .004) in the arthroscopic group (11.6 points; SD, 15.6 points) compared with that in the open group (17.8 points; SD, 19.4 points). The percentage of elbows with an excellent outcome at follow-up (QuickDASH score <20 points) was significantly higher in the arthroscopic group (78%) than in the open group (67%) (P = .04).

CONCLUSIONS

Both a traditional open approach and the newer arthroscopic method provide an effective treatment of recalcitrant TE without major complications. The arthroscopic method offers a small, but not insignificant, improvement in the outcome as evaluated by the QuickDASH score.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Lateral epicondylitis of the elbow

Lateral epicondylitis, or "tennis elbow," is a common musculotendinous degenerative disorder of the extensor origin at the lateral humeral epicondyle. Repetitive occupational or athletic activities involving wrist extension and supination are thought to be causative. The typical symptoms include lateral elbow pain, pain with wrist extension, and weakened grip strength. The diagnosis is made clinically through history and physical examination; however, a thorough understanding of the differential diagnosis is imperative to prevent unnecessary testing and therapies. Most patients improve with nonoperative measures, such as activity modification, physical therapy, and injections. A small percentage of patients will require surgical release of the extensor carpi radialis brevis tendon. Common methods of release may be performed via percutaneous, arthroscopic, or open approaches.

Fasciotomy and surgical tenotomy for recalcitrant lateral elbow tendinopathy: early clinical experience with a novel device for minimally invasive percutaneous microresection

BACKGROUND

The optimal choice for intervention for recalcitrant lateral elbow tendinopathy remains unclear as various treatment modalities have documented comparable results in the literature.

PURPOSE

To explore the safety, tolerability, and early efficacy of a new minimally invasive mode of treatment that delivers focused, calibrated ultrasonic energy, effectively microresecting the pathological tendon and removing only pathological tissue.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seven male and 13 female patients aged 33 to 65 years averaging 12.5 months (range, 4-48) of failed nonoperative therapy underwent the ultrasonic microresection procedure in an outpatient clinic setting. The procedure involved a sterile, ultrasound-guided percutaneous microresection with a proprietary device (TX1) performed through a stab incision under local anesthesia. The duration of the procedure and complications of the device or procedure were assessed. Outcome parameters included patient satisfaction; visual analog scale (VAS) pain scores; Disabilities of the Arm, Shoulder and Hand (DASH) scores at 1, 3, 6, and 12 months; and ultrasound assessment at 3 and 6 months.

RESULTS

The median duration for the sterile confirmatory ultrasound examination (phase 1) was 88.5 seconds (range, 39-211; SD, ±47.6), the median duration of the procedure proper (phase 2) was 10.1 minutes (range, 4.1-19.4; SD, ±3.7), and the median energy time (duration the TX1 device was activated) was 32.5 seconds (range, 18-58; SD, ±11.0). No complications were encountered. A significant improvement in VAS score (from 5.5 to 3.3; P < .001) occurred by 1 week, and significant improvements in both DASH-Compulsory (from 21.7 to 11.3; P = .001) and DASH-Work (from 25.0 to 6.3; P = .012) scores occurred by 1 month. The VAS scores further improved at 3, 6, and 12 months (from 2.0 to 1.0 to 0.50; P = .003 and .023). The DASH-Compulsory score improved significantly from 3 to 6 months (from 8.6 to 4.6; P = .003), and both the DASH-Compulsory and DASH-Work scores were sustained by 12 months. Sonographically reduced tendon thickness (19 patients), resolved or reduced hypervascularity (17 patients), and reduced hypoechoic area (18 patients) occurred by 6 months. Nineteen of the 20 patients (95%) expressed satisfaction with the procedure, with 9 patients being very satisfied with their overall experience at 6 months after the procedure, 10 patients somewhat satisfied, and 1 patient neutral.

CONCLUSION

Ultrasonic microresection of diseased tissue with the TX1 device provides a focally directed, safe, specific, minimally invasive, and well-tolerated treatment for recalcitrant lateral elbow tendinopathy in an office-based or ambulatory surgical setting with good evidence of some level of efficacy in 19 of 20 patients (95%) that is sustained for at least 1 year.

Evaluation and management of elbow tendinopathy

Context:

Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations.

Evidence Acquisitions:

The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy.

Results:

Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments.

Conclusions:

Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.