Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis

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 assessment for lateral collateral ligament complex deficiency of the elbow: a cadaveric study

PURPOSE

To evaluate whether elbow instability due to lateral collateral ligament complex injury can be assessed reliably through arthroscopy.

METHODS

Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. The radiocapitellar joint (RCJ) gap and ulnohumeral joint (UHJ) gap (mm) were measured with different sizes of probes from the posterolateral viewing portal. The elbow was 90 degrees flexed with neutral forearm rotation for RCJ gap measurement and 30 degrees flexed with full supination for UHJ gap measurement. Sequential testing was performed from Stage 0 to Stage 3 (Stage 0: intact; Stage 1: the release of the anterior 1/3 LCL complex; Stage 2: the release of the anterior two thirds of the LCL complex; and Stage 3: the release of the entire LCL complex) on each specimen. The mean gap of RCJ and lateral UHJ was used for the comparison between stages with the intact elbow.

RESULTS

The mean RCJ gap distance in Stage 2 and Stage 3 was significantly increased compared to that in Stage 0 (Stage 0 vs. Stage 2: P = .008; Stage 0 vs. Stage 3: P = .010). The mean UHJ gap distance of Stage 1, Stage 2, and Stage 3 was significantly increased compared to that in Stage 0 (Stage 0 vs. Stage 1: P = 0.025; Stage 0 vs. Stage 2: P = .010; Stage 0 vs. Stage 3: P = .011). In contrast, the release of the anterior 1/3 of the LCL complex (Stage 1) was not significantly increased compared to the mean joint gap distance of RCJ (P = .157).

CONCLUSION

Arthroscopic measurement of joint gap widening in RCJ and UHJ is a reliable assessment method to detect LCL complex deficiency that involves the anterior two thirds or more.

Is There any Difference in Clinical Outcome between Open and Arthroscopic Treatment for Tennis Elbow? A Systematic Review and Meta-Analysis

There is considerable controversy regarding the optimal approach (open vs arthroscopic) of releasing and/or debridement for the treatment of tennis elbow (TE). The aim of this study was to determine the clinical outcomes of the two techniques by quantitatively synthesizing outcome data. The study was performed by searching the PubMed, EMBASE, Ovid, and Elsevier databases between January 1995 and April 2022 for a minimum follow-up of 6 months. The searching strategy was "(tennis elbow [Title/Abstract] OR lateral epicondylitis [Title/Abstract]) AND (open [Title/Abstract] OR arthroscopic [Title/Abstract] OR release [Title/Abstract] OR debridement [Title/Abstract] OR surgery [Title/Abstract])". The quality of each study was investigated using the Coleman Methodology Score. In total, 1411 (693 open, 718 arthroscopic) elbows in 1392 patients who underwent releasing and debridement for tennis elbow were identified. The mean Coleman Methodology Score for the included studies was 55.2 ± 8.6 (open: 55.0 ± 9.4, arthroscopic: 55.8 ± 8.2). Improved clinical results were achieved after treatment with either open or arthroscopic treatment. The surgical success rate was 95.6% in open surgery and 92.4% in arthroscopic management. The complication rates were 2.2% and 1.5% for open and arthroscopic procedures, respectively. Similar subjective and objective outcomes, and surgical success rate were observed in patients with both techniques. Patients who had undergone arthroscopic release seemed to return to work earlier (5.3 weeks vs 7.1 weeks). To draw more definite conclusions, high-quality long-term follow-up randomized controlled trials are needed.

Editorial Commentary: Arthroscopic Debridement of Tennis Elbow Nonresponsive to Nonoperative Measures Is a Good Option and Clinical Outcomes Are Associated With Radiographic Outcomes

Chronic lateral epicondylitis, or "tennis elbow," is rare and affects 1% to 3% of adults annually. The initial treatment should be nonoperative and include physical therapy, nonsteroidal anti-inflammatory medication, rest, bracing, extracorporeal shock wave therapy, and injection therapy with various agents such as autologous blood, dextrose, corticosteroids, or platelet-rich plasma. The condition is self-limited, and approximately 80% of cases resolve. In refractory cases, arthroscopic release with debridement is a good surgical option but is not superior to open or percutaneous techniques. Recent research shows that a reduction in magnetic resonance imaging signal intensity in patients who respond to arthroscopic treatment correlates with pain reduction and functional outcome improvement.

Complications of Elbow Arthroscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Elbow arthroscopic surgery has been popularized and has made significant progress during the past 3 decades. The elbow joint is relatively small and is in close proximity to many neurovascular structures. These factors make elbow arthroscopic surgery technically demanding and liable to complications.

PURPOSE

To evaluate the rate of complications after elbow arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis. PubMed, Web of Science, and Embase were searched up to July 2021. All clinical studies that reported complications after elbow arthroscopic surgery were included; a total of 1208 articles were initially found. Case reports, reviews, abstracts, imaging studies, technique studies, nonclinical studies, and those not reporting postoperative complications were excluded. Complication rates were pooled across studies and reported as percentages. Complications were expressed as weighted proportions with 95% CIs.

RESULTS

A total of 95 studies (14,289 elbows) were included in the meta-analysis. The overall weighted complication rate was 11.0% (95% CI, 8.8%-13.5%), with postoperative stiffness being the most commonly encountered complication (4.5% [95% CI, 2.1%-7.6%]; 158/8818 procedures). The second most encountered complication was the need for subsequent surgery with a weighted proportion of 4.1% (95% CI, 2.9%-5.6%; 177/8853 procedures) followed by nerve injury with a weighted proportion of 3.4% (95% CI, 2.6%-4.3%; 267/13,725 procedures). The ulnar nerve was the most commonly injured nerve (2.6% [95% CI, 1.9%-3.4%]; 123/6290 procedures).

CONCLUSION

The results of this study showed that elbow arthroscopic surgery is a relatively safe procedure with low complication rates.

Validation of a novel magnetic resonance imaging classification and recommended treatment for lateral elbow tendinopathy

BACKGROUND

Lateral epicondylitis is one of the most common upper extremity problems presented to orthopedic surgeons. Despite a rapid and accurate arrival at a diagnosis by clinical examination, there exists no consensus classification for this condition, which hampers clinical approaches for treatment of the disease based on its severity. Thus, the aim of this study was to propose and valiadate a new magnetic resonance imaging (MRI) classification of lateral epicondylitis, staging by tendinosis, the degree of thickness tears of the common extensor tendon (CET) and bone bruise lesion.

METHOD

MRI assessment of the elbow of 75 patients (57 women and 18 men; mean age:51.4 years (range,34-73) from Jan 2014 to Jan 2021 who were diagnosed with lateral epicondylitis were included in the study. MR images were reviewed retrospectively by two independent upper extremities orthopedists and one musculoskeletal radiologist. Inter- and intra-observer reliabilities for the classification were calculated using kappa statistics for the analysis of interrater agreement. Correlation between the stage of the disease and the duration of symptom before MRI was calculated using Kruskal-wallis test.

RESULTS

Various degrees of CET lesions were demonstrated in this population (Stage I-17, IIA-7, IIB-22 and III-29). Intra-observer agreements of MRI staging were substantial to satisfactory. Inter-observer agreements were moderate to substantial. There was no significant correlation between the disease stage and the patient age or the duration of symptom before MRI.

CONCLUSION

Our MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. At the end, we have suggeted a clearer direction for understanding the disease pathology as well as an appropriate management protocol for each stage of the disease in line with the recent body of literature.

Arthroscopic Extensor Carpi Radialis Brevis Tenotomy and Debridement Versus Debridement Alone for Refractory Lateral Epicondylitis: Clinical and MRI Evaluation

Background:

Arthroscopic debridement of the extensor carpi radialis brevis (ECRB) tendon is a widely accepted procedure used in refractory lateral epicondylitis. However, residual pain occurs in some patients.

Purpose:

To investigate the clinical effectiveness of arthroscopic extended debridement (ECRB tenotomy and debridement) in the treatment of lateral epicondylitis.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients with refractory lateral epicondylitis were consecutively recruited for this study. They underwent traditional ECRB debridement (control group) or extended ECRB debridement (ED group) under arthroscopy. The Disabilities of the Arm, Shoulder and Hand (DASH) score, visual analog scale (VAS) for pain, and Mayo Elbow Performance Score (MEPS) were used to compare elbow function between the groups at 3, 6, and 12 months postoperatively. Magnetic resonance imaging (MRI) was also performed to evaluate pathology at 12 months.

Results:

A total of 69 patients participated in the study (33 patients in the ED group and 36 in the control group). After surgery, all patients showed improvement on all 3 outcome scores. Compared with the control group, the ED group had significantly better postoperative MEPS and VAS scores at 3 months (P ≤ .001 for both) and 6 months (P ≤ .03 for both) but similar values at 12 months. DASH scores between groups were similar at all time periods. At the 12-month follow-up, no patients in the ED group reported pain with strenuous work. Return-to-work (RTW) times were also shorter in the ED group compared with the controls (8 ± 4 vs 18 ± 8 weeks; P < .001). Postoperative MRI assessments revealed no high signal intensities on the lateral epicondyle in the ED group, while there was an increased internal signal intensity on the lateral epicondyle in 83% of the controls.

Conclusion:

Collectively, the extended ECRB debridement technique resulted in enhanced pain relief in the early postoperative period as well as providing faster RTW times compared with the traditional debridement technique. At 1 year follow-up, there were no differences in outcome measures between groups, but residual abnormal MRI findings were more common in the traditional debridement group.

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.

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.

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.

Open Versus Arthroscopic Treatment of Chronic Lateral Epicondylitis and Worker's Compensation

Purpose

To compare the short-term outcomes between arthroscopic and open procedures for the treatment of lateral epicondylitis. Because a significant portion of patients have worker’s compensation (WC), the outcomes in these subgroups were separately analyzed.

Methods

A retrospective analysis of patients who had surgical treatment of lateral epicondylitis by a single surgeon from 2010 to 2017 was performed. Patients who were symptomatic after 9 months of conservative treatments including nonsteroidal medications, steroid injections, and physical therapy were offered surgical intervention. The type of surgery was selected after detailed consultation with the patient. Charts were reviewed for preoperative pain, grip strength as measured by dynamometer, smoking status, and WC status. Postoperative assessments included pain and grip strength at 6 weeks and time taken to return to full duty. Two groups were compared using unpaired t test and chi-squared tests. Results were compared with similar studies in the literature.

Results

The study included 30 patients in the arthroscopic debridement group and 42 patients in the open tenotomy and reinsertion group. Eighteen patients (25%) had WC. Compared with the open group, the arthroscopic group had earlier return to full duty (mean 7.13 weeks, confidence interval [CI] 6.21 to 8.05 versu mean of 12.22 weeks, CI 11.21 to 13.24; P < .001) and less time for complete pain relief (mean 7.4 weeks, CI 7.02 to 7.93 versus 9.5 , CI 8.68 to 10.44; P = .043). No difference was seen among the groups in terms of unfavorable outcome (persistent pain and recurrence of pain), JAMAR hand dynamometer score at 6 weeks, and visual analog score at 6 weeks. A total of 11 patients (15%) had unfavorable outcome. Incidence of unfavorable outcomes was more in patients with WC insurance (36% in WC versus 7% in non-WC; P = .023). No association was seen with smoking status. WC patients also had a longer time to return to full duty (16.68 weeks for WC versus 7.65 weeks for non-WC; P < .001) and a longer time to get complete pain relief (12.4 weeks for WC versus 7.5 weeks for non-WC; P < .001).

Conclusion

The arthroscopic technique offers advantages of earlier return to work and shorter recovery period along with additional advantages of joint inspection and ability to treat coexisting pathologies. WC patients had a longer time to return to full duty and time for complete pain relief.

Level of Evidence

Level III, retrospective comparative study.

Arthroscopic Modified Bosworth Procedure for Refractory Lateral Elbow Pain With Radiocapitellar Joint Snapping

Background:

Radiocapitellar joint snapping due to the presence of synovial plica has been described as a contributory intra-articular pathology of lateral epicondylitis (LE).

Hypothesis:

The arthroscopic modified Bosworth technique can provide a safe and favorable outcome for refractory LE with radiocapitellar snapping.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients treated with the arthroscopic modified Bosworth procedure for refractory LE with radiocapitellar joint snapping were included in this study. The sequential surgical procedures included excision of the upper portion of the anterolateral annular ligament, removal of the synovial plicae, and release of the extensor carpi radialis brevis for all patients. Clinical outcomes were measured at a minimum 1-year follow-up.

Results:

A total of 22 patients with a mean ± SD age of 51.2 ± 10.4 years were included in this study. The mean follow-up was 29.4 ± 7.7 months (range, 21-42 months). The overall visual analog scale score (from preoperative to final follow-up) was 7.5 ± 1.2 vs 2.5 ± 1.8 (P < .001); flexion-extension motion arc was 133.8° ± 11.2° vs 146.4° ± 7.1° (P = .001); pronation-supination motion arc was 101.8° ± 9.2° vs 141.7° ± 10.2° (P = .001); Disabilities of the Arm, Shoulder and Hand score was 54.5 ± 13.2 vs 3.6 ± 4.1 (P < .001); and Mayo Elbow Performance Score was 51.9 ± 12.2 vs 84.3 ± 10.3 (P < .001).

Conclusion:

Radiocapitellar joint snapping may coexist with LE as a disease spectrum. The arthroscopic modified Bosworth technique provides safe and favorable outcomes for patients with refractory LE associated with radiocapitellar joint snapping.

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.].

Tennis elbow

Tennis elbow is the most common cause of lateral-sided elbow pain with a major socioeconomic impact. The etiology of tennis elbow is not completely understood, but there are many different treatment options. This review gives an overview of the current concepts of diagnosis and treatment of tennis elbow and the impact on work participation.

Does use of the 70° arthroscope improve the outcomes of arthroscopic débridement for chronic recalcitrant tennis elbow?

BACKGROUND

The use of a 70° arthroscope has been reported to provide better visualization of the extensor carpi radialis brevis origin at the lateral epicondyle. We aimed to compare the surgical outcomes of arthroscopic débridement using an additional 70° arthroscope with those using a 30° arthroscope alone in the treatment of chronic recalcitrant tennis elbow.

METHODS

A total of 68 consecutive patients who received arthroscopic débridement for chronic recalcitrant tennis elbow were retrospectively reviewed. A 30° scope was used in 41 patients (mean age, 47 years; range, 26-61 years), whereas an additional 70° scope was used in 27 patients (mean age, 50 years; range, 34-61 years). Outcomes were assessed using a visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire at the preoperative visit and at 3 months, 6 months, and 12 or more months after surgery.

RESULTS

Both groups showed significant and progressive improvements in visual analog scale pain scores and Quick Disabilities of the Arm, Shoulder and Hand scores at 3 months, 6 months, and final follow-up (P < .05). However, no significant differences were found between the groups at all time points of measurement regarding those outcome measures (P > .05). In addition, the proportions of patients with excellent outcomes and those with clinically meaningful improvements were comparable between the groups (P = .397 and P = .558, respectively).

CONCLUSION

The use of an additional 70° arthroscope did not provide a significant improvement in the outcomes of arthroscopic débridement for chronic recalcitrant tennis elbow.

Arthroscopic chronic tennis elbow surgery preserves elbow proprioception

STUDY DESIGN

Retrospective cohort study.

INTRODUCTION

A new method of accurately assessing the compromised elbow's proprioception was developed for this postsurgical population using information from previous neurophysiologic proprioception studies of healthy elbows.

HYPOTHESIS

This retrospective cohort study investigated the patterns and the degree of proprioceptive impairment and recovery following arthroscopic surgery for chronic lateral epicondylitis.

MATERIAL AND METHODS

Participants had undergone arthroscopic elbow surgery two years prior to this study (n=15). Healthy, non-injured volunteers with similar demographics (n=15) served as controls. Both groups were evaluated using quantitative measures of joint position sense for proprioceptive functioning. In order to obtain the most accurate proprioceptive measurements, interindividual interaction and visual input biases were eliminated. Retrospective chart reviews were performed to compare qualitative self-reported measures of proprioceptive function in arthroscopic surgery patients before surgery and two years post-surgery.

RESULTS

Active and passive joint repositioning outcome measurements were similar between groups (p>0.05). No significant differences were found among any angles except one: passive joint position sense at 120° of flexion (p<0.05). At this angle, the arthroscopy group showed greater deviation from target angles than the control group. The novel proprioceptive testing method we developed was found to be accurate and reliable.

DISCUSSION

Outcomes of arthroscopic treatment of chronic lateral epicondylitis with no decortication yielded outcomes measure similar to those of healthy controls. The sole significant difference was at 120° flexion passive joint repositioning, with a higher negative angular deviation from the target point. We propose that our study results and specific proprioception method may have implications for improving accuracy of future elbow arthroscopy and proprioceptive recovery in this population.

LEVEL OF EVIDENCE

II, low-powered prospective randomized trial.

A Novel Technique for the Surgical Management of Chronic Lateral Epicondylitis

Lateral epicondylitis is the most common condition affecting the elbow and is self-limiting in most cases. However, when conservative treatment fails, surgery is required for resistant cases. In this study, we describe a novel technique for the management of chronic lateral epicondylitis. The advantage of our technique is that all the 3 major components of the disease (as also all types of failure described by Morrey) are simultaneously dealt with, that is, pathology of the tendon, posterior interosseous nerve compression and intra-articular pathology are all addressed. We prospectively reviewed 14 consecutive cases of resistant lateral epicondylitis operated with our technique at our Institute from 2008 to 2013 with a minimum 2 years follow up. We included patients between 18 and 65 years of age who in addition to lateral epicondylitis also had an intra-articular pathology along with symptoms/signs suggestive of posterior interosseous nerve compression and had undergone a conservative trial of atleast 12 months. Excluded were those cases with localized infection and severe ankylosis, whereas previous surgery on the same elbow was a relative contraindication. Postoperatively all patients showed improvement in the VAS score and grip strength. Twelve of the 14 patients (85.7%) in our series had good to excellent functional outcomes on the Mayo Elbow Performance Index. This technique can therefore be recommended for wider surgical use; however, prospective randomized studies with a longer follow-up would add further evidence about the effectiveness of our technique.

Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis

BACKGROUND

Medial epicondylitis and lateral epicondylitis are among the most common elbow pathologies affecting people aged between 40 and 50 years. Although epicondylitis is often a self-limiting condition that improves with conservative treatment, the condition can be difficult to eradicate. The purpose of this study was to compare the effectiveness of platelet-rich plasma (PRP) injections and ultrasound-guided percutaneous tenotomy (Tenex) for the treatment of medial or lateral epicondylitis. Our hypothesis was that the Tenex procedure would not be inferior to PRP injections in the treatment of medial or lateral epicondylitis.

METHODS

In this retrospective review, 62 of 75 patients were available for contact via phone and e-mail to complete post-procedure patient-reported outcome surveys. Subjective assessment of pain and function included a visual analog scale for pain; the Quick Disabilities of the Arm, Shoulder and Hand questionnaire; and the EuroQol-5D questionnaire. The inclusion criteria included age of 18 years or older and previous failure of nonoperative treatment.

RESULTS

The average ages in the PRP and Tenex groups were 47 years and 51 years, respectively. The PRP cohort (n = 32) included 10 female and 22 male patients, whereas the Tenex cohort (n = 30) included 12 female and 18 male patients. The PRP and Tenex groups both demonstrated clinical and statistical improvement in visual analog scale pain scores; Quick Disabilities of the Arm, Shoulder and Hand scores; and EuroQol-5D scores. No statistically significant difference was found between the 2 treatment modalities.

CONCLUSION

The PRP and Tenex procedures were both successful in producing clinically and statistically significant improvements in pain, function, and quality of life.

Arthroscopic Treatment of Lateral Elbow Pain Mimicking Lateral Epicondylitis: Long-term Follow-up of a Unique Surgical Protocol

HYPOTHESIS AND/OR BACKGROUND

The failure rate of extensor carpi radialis brevis debridement for refractory lateral epicondylitis is reported around 15%. Our novel arthroscopic treatment is predicated on the hypothesis that lateral epicondylitis is an intra-articular problem related to a variation of the capsule-meniscal anatomy that impinges on the radiocapitellar joint. We report long-term outcomes of 35 patients treated with a novel arthroscopic resection of their capsulosynovial fringe.

METHODS

All patients failed nonoperative treatment but had temporary improvement with an intra-articular injection. Arthroscopic treatment involved resecting the meniscus and the proximal edge of the orbicular ligament, followed by a tendon-sparing anterolateral capsulectomy. 35 patients underwent evaluation on average 9.2 years after surgery. Outcome measures included VAS, DASH, and questions on return to sports, satisfaction, and perceived benefit of surgery.

RESULTS

Median pain scores improved from 8 of 10 preoperatively to 0 of 10 postoperatively. This change was clinically and statistically significant, with 1 patient still requiring pain medication. Median DASH score at final follow-up was 1. Overall, 30 patients rated their postoperative outcome as much better, 5 rated it as better, and 0 reported their symptoms to be unchanged or worsened. All 35 patients stated they were happy they underwent the procedure and perceived a benefit. Totally, 4 of 35 patients had postoperative complications (2 with ulnar nerve symptoms, 2 with persistent pain), with one requiring revision surgery for persistent pain.

DISCUSSION AND/OR CONCLUSIONS

We report promising long-term clinical and functional results of a novel arthroscopic resection of the capsulosynovial complex in lateral epicondylitis.

Trends in Surgical Practices for Lateral Epicondylitis Among Newly Trained Orthopaedic Surgeons

Background:

Much controversy exists regarding the optimal surgical intervention for lateral epicondylitis because of a multitude of options available and the lack of comparative studies. Knowledge of the current practice trends would help guide the design of comparative studies needed to determine which surgical technique results in the best outcome.

Purpose:

To review the latest practice trends for the surgical treatment of lateral epicondylitis among newly trained surgeons in the United States utilizing the American Board of Orthopaedic Surgery (ABOS) database.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

The ABOS database was utilized to identify surgical cases for lateral epicondylitis submitted by Part II board certification examination candidates from 2004 through 2013. Inclusion criteria were predetermined using a combination of International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Cases were organized by open and arthroscopic treatment groups and by fellowship training and were analyzed to determine differences in surgical techniques, complication rates, and concomitant procedures.

Results:

In total, 1150 surgeons submitted 2106 surgical cases for the treatment of lateral epicondylitis. The number of surgical cases for lateral epicondylitis performed per 10,000 submitted cases significantly decreased from 26.7 in 2004 to 21.1 in 2013 (P = .002). Among all cases, 92.2% were open and 7.8% were arthroscopic, with no change in the incidence of arthroscopic surgeries over the study period. Shoulder and elbow (18.1%) and sports medicine (11.4%) surgeons were more likely to perform surgery arthroscopically compared with hand surgeons (6.1%) (P < .001). There was no difference in overall self-reported complication rates between open (4.4%) and arthroscopic (5.5%) procedures (P = .666). Percutaneous tenotomy, debridement only, and debridement with tendon repair comprised 6.4%, 46.3%, and 47.3% of open treatment, respectively. Sports medicine, hand, and shoulder and elbow surgeons were more likely to repair the tendon after debridement compared with other surgeons, who were more likely to perform debridement alone (P < .001). Hand surgeons were most likely to perform concomitant procedures, of which the majority were neuroplasties.

Conclusion:

Although comparative studies are ultimately necessary for determining the optimal surgical technique, researchers should be mindful of the differences in practices according to training and the extent to which concomitant procedures are being performed, as both these factors may confound any future results.

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.

Tips to avoid nerve injury in elbow arthroscopy

Elbow arthroscopy is a technical challenging surgical procedure because of close proximity of neurovascular structures and the limited articular working space. With the rising number of elbow arthroscopies being performed nowadays due to an increasing number of surgeons performing this procedure and a broader range of indications, a rise in complications is foreseen. With this editorial we hope to create awareness of possible complications of elbow arthroscopy, particularly nerve injuries, and provide a guideline to avoid complications during elbow arthroscopy.

The Top 10 Most Cited Indian Articles in Arthroscopy in Last 10 Years

The interest in the field of arthroscopy is increasing globally and exponentially in the recent past, including in India. Clinicians interested in this area of super specialization have started publishing their research work in reputed journals in this field. The publication from Indian authors is contributed equally by both the teaching government institutions and nonteaching private hospital specialists. The contributions by the Indian teaching institutes have predominantly Indian authors only, whereas those from the private sectors usually have an association with the foreign authors in their research and publications. The publications with higher hierarchy and level of evidence (1 and 2) are associated with greater citations. In addition, the publications in high-impact, reputed journals attract more citations and therefore it is recommended that the "good" scientific research work should preferably be submitted to these journals to create greater impact and awareness about ones' research and publication.

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.

Controversies in Surgical Management of Recalcitrant Enthesopathy of the Extensor Carpi Radialis Brevis

Enthesopathy of the extensor carpi radialis brevis, often referred to as "tennis elbow," is common and responds to nonsurgical treatment in 80% to 90% of patients within 1 year. For those who proceed with surgery, much remains unclear regarding the ideal treatment. This paper discusses controversies in surgical management of extensor carpi radialis brevis enthesopathy including clinical outcomes of open versus arthroscopic techniques, the relevance of concomitant pathology addressed arthroscopically, and avenues for assessing comparative cost data.

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.

Critical review on the socio-economic impact of tendinopathy

There are currently no studies that determine the total burden that tendinopathy places on patients and society. A systematic search was conducted to understand the impact of tendinopathy. It demonstrated that the current prevalence is underestimated, particularly in active populations, such as athletes and workers. Search results demonstrate that due to the high prevalence, impact on patients' daily lives and the economic impact due to work-loss, treatments are significantly higher than currently observed. A well-accepted definition by medical professionals and the public will improve documentation and increase awareness, in order to better tackle the disease burden.

Outcome Evaluation in Tendinopathy: Foundations of Assessment and a Summary of Selected Measures

Synopsis Clinical measurement studies that address outcome evaluation for patients with tendinopathy should consider conceptual, clinical, practical, and measurement issues to guide the selection of valid measures. Clinical outcomes reported in research studies can provide benchmarks that assist with interpretation of scores during clinical decision making. Given the pathophysiology and functional impacts of tendinopathy, there is a need for outcome measures that assess physical impairments, activity performance, and patient-reported symptoms and function. Tendinopathy-specific patient-reported outcome measures have been shown to be superior to more generic tools for some conditions, such as lateral epicondyle tendinopathy (Patient-Rated Tennis Elbow Evaluation) and Achilles tendinopathy (Victorian Institute of Sport Assessment-Achilles), whereas both generic shoulder outcome measures and disease-specific measures perform similarly in individuals with rotator cuff tendinopathy. A patient-reported outcome measure that captures pain and limitation in function should be fundamental to outcome evaluation in patients with tendinopathy. The current measurement literature does not yet provide comprehensive empirical data to define optimal outcome measures for all types of tendinopathy. This article reviews concepts, instruments, and measurement properties that should provide clinicians with a foundation for assessment of condition severity and treatment outcomes in patients with tendinopathy. J Orthop Sports Phys Ther 2015;45(11):950-964. Epub 15 Oct 2015. doi:10.2519/jospt.2015.6054.

Factors associated with failure of nonoperative treatment in lateral epicondylitis

BACKGROUND

Lateral epicondylitis is a common cause of elbow pain that is treated with a variety of nonoperative measures and often improves with time. Minimal research is available on patients in whom these nonoperative treatments fail.

PURPOSE

To identify baseline patient and disease factors associated with the failure of nonoperative treatment of lateral epicondylitis, defined as surgery after a period of nonoperative treatment.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

A total of 580 patients treated for lateral epicondylitis at a tertiary center between 2007 and 2012 were analyzed. Disease-specific and patient demographic characteristics were compared between patient groups (nonoperative vs surgical treatment). A multivariable logistic regression model was created based on preliminary univariate testing to determine which characteristics were associated with failure of nonoperative treatment.

RESULTS

Of the 580 patients, 92 (16%) underwent surgical treatment at a mean of 6 months (range, 0-31 months) from their initial visit. Univariate analysis demonstrated a potential association (P < .10) between operative management and the following factors at initial diagnosis: increased age, body mass index, duration of symptoms, presence of radial tunnel syndrome, prior injection, physical therapy, splinting, smoking, workers' compensation, a labor occupation, use of narcotics, use of antidepressant medications, and previous orthopaedic surgery. In the final multivariable model, a workers' compensation claim (odds ratio [OR], 8.1), prior injection (OR, 5.6), the presence of radial tunnel syndrome (OR, 3.1), previous orthopaedic surgery (OR, 3.2), and duration of symptoms >12 months (OR, 2.5) remained significant independent predictors of surgical treatment.

CONCLUSION

This study identifies risk factors for surgical treatment for lateral epicondylitis. While these findings do not provide information regarding causal factors associated with surgery, these patient and disease-specific considerations may be helpful when counseling patients regarding treatment options and the likelihood of the success of continued nonoperative treatment.

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.

Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis

Background Deep transverse friction massage, one of several physical therapy interventions suggested for the management of tendinitis pain, was first demonstrated in the 1930s by Dr James Cyriax, a renowned orthopedic surgeon in England. Its goal is to prevent abnormal fibrous adhesions and abnormal scarring. This is an update of a Cochrane review first published in 2001.Objectives To assess the benefits and harms of deep transverse friction massage for treating lateral elbow or lateral knee tendinitis.Search methods We searched the following electronic databases: the specialized central registry of the Cochrane Field of Physical and Related Therapies,the Cochrane Central Register of Controlled Trials (CENTRAL),MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, and the Physiotherapy Evidence Database (PEDro), up until July 2014. The reference lists of these trials were consulted for additional studies.Selection criteria All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing deep transverse friction massage with control or other active interventions for study participants with two eligible types of tendinitis (ie, extensor carpi radialis tendinitis (lateral elbow tendinitis, tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri) and iliotibial band friction syndrome (lateral knee tendinitis)) were selected. Only studies published in English and French languages were included.Data collection and analysis Two review authors independently assessed the studies on the basis of inclusion and exclusion criteria. Results of individual trials were extracted from the included study using extraction forms prepared by two independent review authors before the review was begun.Data were cross-checked by a third review author. Risk of bias of the included studies was assessed using the "Risk of bias"tool of The Cochrane Collaboration. A pooled analysis was performed using mean difference (MD) for continuous outcomes and risk ratio (RR)for dichotomous outcomes with 95% confidence intervals (CIs).Main results Two RCTs (no new additional studies in this update) with 57 participants met the inclusion criteria. These studies demonstrated high risk of performance and detection bias, and the risk of selection, attrition, and reporting bias was unclear.The first study included 40 participants with lateral elbow tendinitis and compared (1) deep transverse friction massage combined with therapeutic ultrasound and placebo ointment (n = 11) versus therapeutic ultrasound and placebo ointment only (n = 9) and (2)deep transverse friction massage combined with phonophoresis (n = 10) versus phonophoresis only (n = 10). No statistically significant differences were reported within five weeks for mean change in pain on a 0 to 100 visual analog scale (VAS) (MD -6.60, 95%CI -28.60 to 15.40; 7% absolute improvement), grip strength measured in kilograms of force (MD 0.10, 95% CI -0.16 to 0.36) and function ona 0 to 100 VAS (MD -1.80, 95% CI -0.18.64 to 15.04; 2% improvement), pain-free function index measured as the number of painfree items (MD 1.10, 95% CI -1.00 to 3.20) and functional status (RR 3.3, 95% CI 0.4 to 24.3) for deep transverse friction massage,and therapeutic ultrasound and placebo ointment compared with therapeutic ultrasound and placebo ointment only. Likewise for deep transverse friction massage and phonophoresis compared with phonophoresis alone, no statistically significant differences were found for pain (MD -1.2, 95% CI -20.24 to 17.84; 1% improvement), grip strength (MD -0.20, 95% CI -0.46 to 0.06) and function (MD3.70, 95% CI -14.13 to 21.53; 4% improvement). In addition, the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the quality of evidence for the pain outcome, which received a score of "very low".Pain relief of 30% or greater, quality of life, patient global assessment, adverse events, and withdrawals due to adverse events were not assessed or reported.The second study included 17 participants with iliotibial band friction syndrome (knee tendinitis) and compared deep transverse friction massage with physical therapy intervention versus physical therapy intervention alone, at two weeks. Deep transverse friction massage with physical therapy intervention showed no statistically significant differences in the three measures of pain relief on a 0 to 10 VAS when compared with physical therapy alone: daily pain (MD -0.40, 95% CI -0.80 to -0.00; absolute improvement 4%), pain while running (scale from 0 to 150) (MD -3.00, 95% CI -11.08 to 5.08), and percentage of maximum pain while running (MD -0.10, 95% CI -3.97 to 3.77). For the pain outcome, absolute improvement showed a 4% reduction in pain. However, the quality of the body of evidence received a grade of "very low."Pain relief of 30% or greater, function, quality of life, patient global assessment of success, adverse events, and withdrawals due to adverse events were not assessed or reported.Authors' conclusions We do not have sufficient evidence to determine the effects of deep transverse friction on pain, improvement in grip strength, and functional status for patients with lateral elbow tendinitis or knee tendinitis, as no evidence of clinically important benefits was found.The confidence intervals of the estimate of effects overlapped the null value for deep transverse friction massage in combination with physical therapy compared with physical therapy alone in the treatment of lateral elbow tendinitis and knee tendinitis. These conclusions are limited by the small sample size of the included randomized controlled trials. Future trials, utilizing specific methods and adequate sample sizes, are needed before conclusions can be drawn regarding the specific effects of deep transverse friction massage on lateral elbow tendinitis.

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.

70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament

PURPOSE

To determine whether the radial component of the lateral collateral ligament (R-LCL) and extensor carpi radialis brevis (ECRB) are consistently visible, using a 70° arthroscope, as parallel structures in the extra-articular space of the elbow, and to evaluate the clinical outcomes of these techniques in a series of patients.

METHODS

An arthroscopic ECRB tendon release was performed between 2008 and 2010. Eighteen patients were retrospectively evaluated at a minimum of 24 months' follow-up. The surgeon performed the ECRB release while protecting the R-LCL and viewing the structures extra-articularly with a 70° arthroscope through the anteromedial portal. Patients underwent surgery if they presented with localized tenderness and pain not responding to conservative treatment for 12 months and had magnetic resonance imaging scans indicating tendinopathy or degeneration. Arthritis, posterolateral rotatory instability, trauma, and previous surgeries were exclusion criteria. Intraoperative videos were reviewed and a clinical examination was performed by an independent reviewer at 24 months postoperatively. Patients were also evaluated with the Mayo Elbow Performance Score; Andrews-Carson score; and shortened Disabilities of the Arm, Shoulder and Hand questionnaire. Direct varus stress was applied in extension and flexion (40°), and the posterolateral pivot-shift and chair tests were performed.

RESULTS

Visualization with the 70° arthroscope through the anteromedial portal was successful in all of the cases (100%). Visualization of the residual ECRB tendon stump, as well as the posterior common extensor tendon, was also achieved 94% of the time. The final mean Mayo Elbow Performance Score and Andrews-Carson score were 82.5 (range, 60 to 100) and 185.3 (range, 125 to 200), respectively. The mean postoperative score on the shortened Disabilities of the Arm, Shoulder and Hand questionnaire was 20.14 (range, 5 to 57.5). Clinical tests showed stability in all the cases.

CONCLUSIONS

The 70° arthroscope allows visualization of the ECRB insertion and R-LCL frontally and in parallel. A surgical plane could be created between the structures. The clinical outcome was good or excellent in 78% of the cases.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Relationships between biomechanics, tendon pathology, and function in individuals with lateral epicondylosis

STUDY DESIGN

Single-cohort descriptive and correlational study.

OBJECTIVES

To investigate the relationships between tendon pathology, biomechanical measures, and self-reported pain and function in individuals with chronic lateral epicondylosis.

BACKGROUND

Lateral epicondylosis has a multifactorial etiology and its pathophysiology is not well understood. Consequently, treatment remains challenging, and lateral epicondylosis is prone to recurrence. While tendon pathology, pain system changes, and motor impairments due to lateral epicondylosis are considered related, their relationships have not been thoroughly investigated.

METHODS

Twenty-six participants with either unilateral (n = 11) or bilateral (n = 15) chronic lateral epicondylosis participated in this study. Biomechanical measures (grip strength, rate of force development, and electromechanical delay) and measures of tendon pathology (magnetic resonance imaging and ultrasound) and self-reported pain and function (Patient-Rated Tennis Elbow Evaluation) were performed. Partial Spearman correlations, adjusting for covariates (age, gender, weight, and height), were used to evaluate the relationship between self-reported pain, function, and biomechanical and tendon pathology measures.

RESULTS

Statistically significant correlations between biomechanical measures and the Patient-Rated Tennis Elbow Evaluation ranged in magnitude from 0.44 to 0.68 (P<.05); however, no significant correlation was observed between tendon pathology (magnetic resonance imaging and ultrasound) measures and the Patient-Rated Tennis Elbow Evaluation (r = -0.02 to 0.31, P>.05). Rate of force development had a stronger correlation (r = 0.54-0.68, P<.05) with self-reported function score than with grip strength (r = 0.35-0.47, P<.05) or electromechanical delay (r = 0.5, P<.05).

CONCLUSION

Biomechanical measures (pain-free grip strength, rate of force development, electromechanical delay) have the potential to be used as outcome measures to monitor progress in lateral epicondylosis. In comparison, the imaging measures (magnetic resonance imaging and ultrasound) were useful for visualizing the pathophysiology of lateral epicondylosis. However, the severity of the pathophysiology was not related to pain and function, indicating that imaging measures may not provide the best clinical assessment.

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.

Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow?

BACKGROUND

Arthroscopic treatments for lateral epicondylitis including débridement of the extensor carpi radialis brevis (ECRB) origin (Baker technique) or resection of the radiocapitellar synovial plica reportedly improve symptoms. However the etiology of the disease and the role of the plica remain unclear.

QUESTIONS/PURPOSES

We asked if posterior radiocapitellar synovial plica excision made any additional improvement in pain or function after arthroscopic ECRB release.

METHODS

We retrospectively reviewed 38 patients who had arthroscopic treatment for refractory lateral epicondylitis between November 2003 and October 2009. Twenty patients (Group A) underwent the Baker technique and 18 patients (Group B) underwent a combination of the Baker technique and posterior synovial plica excision. The minimum followup was 36 months (mean, 46 months; range, 36-72 months) for Group A and 25 months (mean, 30 months; range, 25-36 months) for Group B. Postoperatively we obtained VAS pain and DASH scores for each group.

RESULTS

Two years postoperatively, we found no differences in the VAS pain score or DASH: the mean VAS pain scores were 0.3 points in Group A and 0.4 points in Group B, and the DASH scores were 5.1 points and 6.1 points respectively.

CONCLUSIONS

The addition of débridement of the posterior synovial fold did not appear to enhance either pain relief or function compared with the classic Baker technique without decortication.

Tendinopathy treatment: where is the evidence?

Tendinopathy is a common and debilitating condition that results in significant deficits in performance and prolonged time away from activity. For this reason, much effort has been placed in defining beneficial and cost-effective treatments. This review has outlined the current literature on some of the most widely used therapies for cases of tendinopathy. As such, recommendations remain limited by the evidence available. The variability in both quantity and quality of research into tendinopathy treatments makes it difficult to make definitive treatment recommendations. In general, however, a reasonable first line of treatment for tendinopathy should include a course of NSAIDs and eccentric exercise-based physical therapy. Corticosteroid injections seem to offer excellent short-term pain relief but lack long term efficacy. Alternative injections, such as PRP, have shown short-term efficacy for tendinopathy sufferers; data are lacking to support sclerosing agents and proteinase inhibitors. Operative management seems to offer some benefit in symptomatic relief but carries a higher complication rate than other treatment options and should be reserved only for patients recalcitrant to other more conservative options. Although the inability to make definitive therapeutic recommendations in some instances is discouraging, it is important to note that a lack of high-quality evidence supporting specific treatments does not necessarily imply that they are inherently ineffective. Given the growing prevalence of tendinopathy and the impact it has on the general public, it is more important now than ever to continue the search for the most effective and accessible treatment modalities.

Effectiveness of different methods of resistance exercises in lateral epicondylosis--a systematic review

STUDY DESIGN

Systematic Review.

INTRODUCTION

Lateral epicondylosis (LE) is relatively common with an annual incidence in the general population of 1% to 3%. Systematic reviews have identified exercise is effective, but have not established specific exercise parameters.

PURPOSE

The purpose of this systematic review was to synthesize the quality and content of clinical research addressing type and dosage of resistance exercises in lateral epicondylosis.

METHODS

Computerized bibliographic databases (1990-2010) were searched using relevant keywords; bibliographies of included papers were hand searched. Of 594 screened abstracts, 11 articles (12 studies) met inclusion criteria. Articles were randomly allocated to pairs of reviewers who independently verified data extraction and appraised the full text, using a structured critical appraisal tool with 24 items. Data extraction was limited by a lack of consistent reporting of elements of exercise dosage.

RESULTS

The mean quality rating of the studies was 72%, with 2 papers exceeding 75% quality. Of the 12 studies, 9 addressed the effects of isotonic (eccentric/concentric) exercises, 2 studied the effect of isometric and one studied isokinetic exercises. The exercise programs ranged over a period of 4 to 52 weeks. Exercises were prescribed 1 to 6 times per day, with an average duration of 15 minutes per session, and average of 15 repetitions (range: 3 to 50), with 1 to 4 sets per session.

CONCLUSION

All the studies reported that resistance exercise resulted in substantial improvement in pain and grip strength; eccentric exercise was most studied. Strengthening using resistance exercises is effective in reducing pain and improving function for lateral epicondylosis but optimal dosing is not defined.

LEVEL OF EVIDENCE

2a.

Radiocapitellar cartilage injuries associated with tennis elbow syndrome

PURPOSE

A recent anatomical study has suggested that considerable contact between the undersurface of the extensor carpi radialis brevis (ECRB) and the lateral edge of the capitellum is the cause of tendon injury in lateral epicondylosis. We hypothesized that this contact might concurrently induce cartilage injuries of the capitellum. The purpose of the present study was to determine the prevalence, location, and severity of cartilage lesions of the radiocapitellar joint accompanying lateral epicondylosis and to identify their correlation with ECRB status.

METHODS

Arthroscopic assessment of the articular cartilage was performed for 31 elbows in 31 patients with lateral epicondylosis who had surgery. The study group consisted of 18 women and 13 men with a mean age of 50 years (range, 35 to 67 y). The relationship between the presence of the cartilage lesions and patient demographics, preoperative pain visual analog scale score, number of cortisone injections, and surgical findings including ECRB tears were investigated.

RESULTS

Cartilage injuries of the capitellum were found in 20 (65%) and cartilage injuries of the radial head were found in 25 (81%) of 31 elbows. Most of the lesions were located on the lateral aspect of the capitellum and radial head. Multivariate logistic regression analysis revealed that the absence of ECRB tears was independently associated with a higher risk of cartilage injuries of the capitellum.

CONCLUSIONS

Cartilage injury was frequently found in the lateral edge of the capitellum and radial head. Lesions of the capitellum were related to the absence of ECRB tears.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Evidence-based indications for elbow arthroscopy

PURPOSE

The purpose was to review the literature on the outcomes of elbow arthroscopy and to make evidence-based recommendations for or against elbow arthroscopy for the treatment of various conditions. Our hypothesis was that the evidence would support the use of elbow arthroscopy in the management of common elbow conditions.

METHODS

A literature search was performed by use of the PubMed database in October 2010. All therapeutic studies investigating the results of treatment with elbow arthroscopy were analyzed for outcomes and complications. The literature specific to common elbow arthroscopy indications was summarized and was assigned a grade of recommendation based on the available evidence.

RESULTS

There is fair-quality evidence for elbow arthroscopy in the treatment of rheumatoid arthritis of the elbow and lateral epicondylitis (grade B recommendation). There is poor-quality evidence for, rather than against, the arthroscopic treatment of degenerative arthritis, osteochondritis dissecans, radial head resection, loose bodies, post-traumatic arthrofibrosis, posteromedial impingement, excision of a plica, and fractures of the capitellum, coronoid process, and radial head (grade C(f) recommendation). There is insufficient evidence to give a recommendation for or against the arthroscopic treatment of posterolateral rotatory instability and septic arthritis (grade I recommendation).

CONCLUSIONS

The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used. The quality of the evidence, however, is generally fair to poor.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis

BACKGROUND

In patients with lateral epicondylitis recalcitrant to nonsurgical treatments, surgical intervention is considered. Despite the numerous therapies reported, the current trend of treatment places particular emphasis on minimally invasive techniques.

PURPOSE

The authors present a newly developed minimally invasive procedure, ultrasonographically guided percutaneous radiofrequency thermal lesioning (RTL), and its clinical efficacy in treating recalcitrant lateral epicondylitis.

CASE SERIES

Level of evidence, 4.

METHODS

Thirty-four patients (35 elbows), with a mean age of 52.1 years (range, 35-65 years), suffered from symptomatic lateral epicondylitis for more than 6 months and had exhausted nonoperative therapies. They were treated with ultrasonographically guided RTL. Patients were followed up at least 6 months by physical examination and 12 months by interview. The intensity of pain was recorded with a visual analog scale (VAS) score. The functional outcome was evaluated using grip strength, the upper limb Disability of Arm, Shoulder and Hand (QuickDASH) outcome measure, and the Modified Mayo Clinic Performance Index (MMCPI) for the elbow. The ultrasonographic findings regarding the extensor tendon origin were recorded, as were the complications.

RESULTS

At the time of the 6-month follow-up, the average VAS score in resting (from 4.9 to 0.9), palpation (from 7.6 to 2.5), and grip (from 8.2 to 2.9) had improved significantly compared with the preoperative condition (P < .01). The grip strength (from 20.6 to 27.0 kg) and QuickDASH score (from 54.3 to 21.0) had also improved significantly (P < .01). The MMCPI score improved from "poor" to "excellent." The ultrasonographic finding revealed that the thickness of the common extensor tendon origin did not change significantly. At the final follow-up (mean, 14.3 months; range, 12-21 months), the patients reported a 78% reduction in pain compared with the preoperative status. No major complications were noted in any patient.

CONCLUSION

Ultrasonographically guided RTL for recalcitrant lateral epicondylitis was found to be a minimally invasive treatment with satisfactory results in this pilot investigation. This innovative method can be considered as an alternative treatment of recalcitrant lateral epicondylitis before further surgical intervention.

The detection of the capsular tear at the undersurface of the extensor carpi radialis brevis tendon in chronic tennis elbow: the value of magnetic resonance imaging and computed tomography arthrography

HYPOTHESIS

This study compared the diagnostic efficacy of magnetic resonance imaging (MRI) and computed tomography arthrography (CTA) in the assessment of capsular tears at the undersurface of the extensor carpi radials brevis tendon in chronic tennis elbow using arthroscopy as a gold standard. Because of the higher spatial resolution of CT, we hypothesized that CTA is superior to MRI for assessing capsular tears.

MATERIALS AND METHODS

We retrospectively reviewed 19 consecutive patients with chronic tennis elbow with preoperative MRI and CTA studies who underwent arthroscopic surgery. Three observers with different levels of training and experience (musculoskeletal radiologist, experienced elbow surgeon, and hand fellow) evaluated the capsular tear by MRI and CTA in a blinded manner. The results of the MRI and CTA were compared and the agreement among the 3 observers was determined using an intraclass correlation coefficient (ICC). Then, the results of the MRI and CTA examinations were compared with the intraoperative findings of the arthroscopic examination. The sensitivity, specificity, and κ value were calculated.

RESULTS

The ICC of CTA (0.855) was superior to MRI (0.645). The sensitivity, specificity, and κ value of CTA were superior to those of MRI in each of the 3 observers. The κ value was 0.79, 0.89, and 0.79 for CTA, and 0.48, 0.48, and 0.27 for MRI for the radiologist, surgeon, and fellow, respectively.

CONCLUSIONS

CTA was a reliable and accurate diagnostic modality compared with MRI to detect the capsular tear in patients with chronic tennis elbow. CTA was less influenced by the observer's experience.