Arthroscopic release for 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.

Modified arthroscopic tenotomy of the extensor carpi radialis brevis for refractory lateral epicondylitis: a cohort study

BACKGROUND

Different arthroscopic techniques exist for managing the extensor carpi radials brevis (ECRB) when treating refractory lateral epicondylitis. The purpose of this study is to compare the outcomes of a standard arthroscopic débridement with ECRB tendon release to an arthroscopic ECRB tenotomy distal to its insertion without débridement using a retrospective cohort study design.

METHODS

This study included patients underwent arthroscopic treatment of lateral epicondylitis during 2 different time periods: 2016-2019 (débridement) and 2019-2021 (modified tenotomy without débridement). Patients were assessed preoperatively and at the last follow-up with Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analog Scale of pain.

RESULTS

A total of 69 patients completed the follow-up (38 in the débridement group and 31 in the tenotomy group). Patients in both groups showed significant improvements were found in MEPS, DASH, and Visual Analog Scale after surgery. Patients in the tenotomy group had higher MEPSs and reported less pain with a minimum 2 year follow-up after surgery. DASH scores between groups were similar at all time periods.

CONCLUSION

Arthroscopic modified tenotomy of the ECRB without débridement improves function and pain significantly for patients with refractory lateral epicondylitis, which is not inferior to arthroscopic débridement technique.

Failed surgical treatment for lateral epicondylitis: literature review and treatment considerations for successful outcomes

Background

Lateral epicondylitis is a common cause of elbow pain in the general population. It is recognized as a degenerative tendinopathy of the common extensor origin believed to be multifactorial, involving elements of repetitive microtrauma associated with certain physiologic and anatomic risk factors.

Methods

Initial treatment typically involves a combination of conservative treatment measures, with up to 90% success at 12-18 months. Surgical treatment is reserved for recalcitrant disease; traditionally involving open surgical débridement of the common extensor origin with reported success rates greater than 90%.

Results

Failure of surgical treatment can be multifactorial and present a challenge in determining the optimum management. Residual symptoms may be due to an incorrect initial diagnosis, inadequate surgical débridement, new pathology as a complication of the initial surgery and/or other patient-related and physician- related factors. Even more of a challenge is the possibility that etiology can be due to a combination of listed factors.

Discussion

In this review, we review the classification scheme for evaluating failed surgical treatment of LE first proposed by Morrey and expand on this classification system based on the senior author's experience. We present the senior author's preferred systematic approach to evaluation and management of these patients, as well as a salvage surgery technique used by the senior author to address the most common etiologies of surgical failure in these patients.

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.

The role of the lateral collateral ligament-capsule complex of the elbow under gravity varus

BACKGROUND

The lateral collateral ligament complex along with the capsule is likely to be at risk during arthroscopic extensor carpi radialis brevis release for lateral epicondylitis. We hypothesized that disruption of the lateral collateral ligament-capsule complex (LCL-cc) would increase the mean contact pressure on the coronoid under gravity varus.

MATERIALS AND METHODS

Eight cadaveric elbows were tested via gravity varus and weighted varus (2 Nm) stress tests using a custom-made machine designed to simulate muscle loads while allowing passive flexion of the elbow. Mean articular surface contact pressure data were collected and processed using intra-articular thin-film sensors and software. Sequential testing was performed on each specimen from stage 0 to stage 3 (stage 0, intact; stage 1, release of anterior one-third of LCL-cc; stage 2; release of anterior two-thirds of LCL-cc; and stage 3, release of entire LCL-cc). The mean contact pressure on the coronoid and the mean ratio of contact pressure on the medial coronoid to that on the lateral coronoid (M/L ratio) were used for comparisons among the stages and the intact elbow.

RESULTS

The overall mean contact pressure significantly increased in stage 2 (P = .0004 in gravity varus and P = .0001 in weighted varus) and stage 3 (P < .0001 in gravity varus and P < .0001 in weighted varus) compared with that in stage 0. In contrast, release of the anterior one-third of the LCL-cc (stage 1) did not significantly increase the mean contact pressure on the coronoid in any degree of flexion under gravity varus (P = .09) or weighted varus loading (P = .6). The M/L ratio difference between stage 0 and stage 1 was 1.1 ± 1.1 under gravity varus (P = .8) and 2.1 ± 1.0 under weighted varus (P = .2). The overall M/L ratios in stage 2 and stage 3 were significantly higher than those seen in stage 0 under gravity varus (P = .04 in stage 2 and P = .02 in stage 3) and weighted varus (P = .006 in stage 2 and P < .0001 in stage 3).

CONCLUSIONS

Loss of the anterior two-thirds or more of the LCL-cc significantly increases the overall mean contact pressure on the coronoid, especially the medial coronoid, under both gravity varus and weighted varus. The LCL-cc also plays a role in the distribution of coronoid contact pressure against gravity varus loads.

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.

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.

Ultrasonographic Measurement of Elbow Varus Laxity With a Sequential Injury Model of the Lateral Collateral Ligament-Capsular Complex

Background

There is no consensus how to determine the varus laxity due to the LCL injury using the ultrasonography. There is a risk of lateral collateral ligament injury during or after arthroscopic extensor carpi radialis brevis release for tennis elbow. The equator of the radial head has been suggested as a landmark for the safe zone to not increase this risk; however, the safe zone from the intra-articular space has not been established.

Hypothesis

Increased elbow varus laxity due to lateral collateral ligament-capsular complex (LCL-cc) injury could be assessed reliably via ultrasound.

Study Design

Descriptive laboratory study.

Methods

Eight cadaveric elbows were evaluated using a custom-made machine allowing passive elbow flexion under gravity varus stress. The radiocapitellar joint (RCJ) space was measured via ultrasound at 30° and 90° of flexion during 4 stages: intact elbow (stage 0), release of the anterior one-third of the LCL-cc (stage 1), release of the anterior two-thirds (stage 2), and release of the entire LCL-cc (stage 3). Two observers conducted the measurements separately, and the mean RCJ space in the 3 LCL-cc injury models (stages 1-3) at both flexion angles was compared with that of the intact elbow (stage 0). We also compared the measurements at 30° versus 90° of flexion.

Results

At 30° of elbow flexion, the RCJ space increased 2 mm between stages 0 and 2 (95% confidence interval [CI], 1-3 mm; P < .01) and 4 mm between stages 0 and 3 (95% CI, 2-5 mm; P < .01). At 90° of elbow flexion, the RCJ space increased 1 mm between stages 0 and 2 (95% CI, 1-2 mm; P < .01) and 2 mm between stages 0 and 3 (95% CI, 2-3 mm; P < .01).

Conclusion

Elbow varus laxity under gravity stress can be reliably assessed via ultrasound by measuring the RCJ space.

Clinical Relevance

Because ultrasonographic measurement of the RCJ space can distinguish the increasing varus laxity seen with release of two-thirds or more of the LCL-cc, the anterior one-third of the LCL-cc, based on the diameter of the radial head, can be considered the safe zone in arthroscopic extensor carpi radialis brevis release for tennis elbow.

Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?

BACKGROUND

Elbow instability, particularly posterolateral rotatory instability (PLRI), has been reported in patients with refractory lateral epicondylitis (LE). However, evidence of diagnostic approach and surgical outcomes is lacking.

PURPOSE

To identify (1) the risk factors, clinical and radiologic-diagnostic characteristics, and (2) the treatment options and clinical outcome of LE with PLRI.

STUDY DESIGN

Systematic review.

METHODS

We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, Scopus, and EMBASE databases using keywords as well as Medical Subject Headings terms and Emtree using "(lateral epicondylitis OR tennis elbow) AND (instability OR posterolateral rotatory instability)" for English-language studies. We conducted a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

In total, 8 articles comprising 6 level 4 and 2 level 3 studies were identified, including 249 patients (254 elbows). The main triggering factor was heavy labor activity (74/172; 43%). A total of 184 patients (73.9%) received either single (4/184; 2.2%) or multiple (180/184; 97.8%) steroid injections. Clinically, instability was always accompanied by pain in 9% of study individuals. Magnetic resonance imaging (MRI) revealed that radial collateral ligament (RCL) and lateral ulnar collateral ligament (LUCL) lesions were most common (18/79; 23%). The most common surgical procedure performed was arthroscopic RCL plication (62/120; 52%) followed by LUCL reconstruction (30/120; 25%). A ligament patholaxity sign was shown intraoperatively for 64% (44/69). Clinical outcomes ranged from good to excellent in all studies. The most common residual symptom was limited range of motion (11/18; 61%).

CONCLUSION

Instability can coexist and may be associated with refractory LE. The risk factors of instability associated with refractory LE are heavy labor and multiple steroid injections. A systematic approach to identify the clinical and MRI presentation of the condition followed by examination under anesthesia are necessary for affirmative diagnosis, as independent presentations may be misleading.

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.

A retrospective comparative study on arthroscopic suture anchors repair and tendon debridement versus arthroscopic tendon debridement for treatment of recalcitrant lateral epicondylitis

Aim

To compare the outcomes between the arthroscopic debridement of the extensor carpi radialis brevis (ECRB) tendon alone and repairs to the ECRB tendon with suture anchor for the treatment of refractory lateral epicondylitis (LE).

Methods

We retrospectively reviewed our patients who underwent arthroscopic surgical treatment for refractory LE by a single surgeon from January 2008 to June 2018 with a minimum follow-up of 12 months. The visual analog scale (VAS), the Mayo Elbow Performance Score (MEPS), the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, the Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, the Verhaar scoring system and the time of back to work were compared between two groups.

Results

Both groups showed a significant postoperative improvement regarding the VAS, MEPS, DASH, PRTEE and the Verhaar scoring system (p < 0.05). The repair group showed better results regarding the MEPS, DASH, PRTEE and Verhaar scoring system comparing with the debridement group, which were statically significant (p < 0.05). There were no significant differences between the two groups regarding the VAS both at rest and activity at the final follow-up. There were no significant differences for the average time for return to work (p = 0.229). There were 11 patients in the debridement group and six patients in the repair group, who completed the MRI evaluation at 6 months postoperatively.

Conclusion

Compared with arthroscopic release and debridement of the ECRB tendon, arthroscopic suture anchor repairing of the origin of the ECRB tendon provides better outcomes when addressing the refractory LE.

Level of Evidence

Case Series: Level IV.

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: A clinical review article

Lateral epicondylitis, or tennis elbow is a common condition that presents with pain and tenderness around the common extensor origin of the elbow. Tennis elbow is estimated to affect 1-3% of the adult population each year and is more common in the dominant arm. It is generally regarded as an overuse injury involving repeated wrist extension against resistance, although it can occur as an acute injury (trauma to the lateral elbow). Up to 50% of all tennis players develop symptoms due to various factors including poor swing technique the use of heavy racquet. It's also seen in labourers who utilise heavy tools or engage in repetitive gripping or lifting task. In this article, we discuss the existing literature in the field and the current thinking on optimum treatment modalities. We have reviewed the literature available on med line and have discussed the condition with our specialist colleagues in the field.

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.

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 Versus Open Lateral Release for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled Trial

PURPOSE

The purpose of this randomized clinical trial was to determine whether quality of life and function, as measured using subjective questionnaires and clinical assessment, are different after open versus arthroscopic debridement of the pathologic extensor carpi radialis brevis origin in the treatment of lateral epicondylitis at 1 year postoperatively.

METHODS

Patients older than 16 years with a minimum of 6 months of nonoperative management for lateral epicondylitis were recruited into this prospective, single-blinded randomized clinical trial. Patients were randomized intraoperatively to undergo open or arthroscopic release. Scores on the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure; visual analog scale (VAS); and Patient-Rated Tennis Elbow Evaluation (PRTEE) were recorded preoperatively and 3, 6, and 12 months postoperatively. Grip strength was assessed by an independent assessor. All patients followed the same physiotherapy regimen.

RESULTS

Between 2002 and 2014, we randomized 37 patients to the open technique and 38 to the arthroscopic technique. Both groups improved significantly from preoperatively to 12 months postoperatively (P < .001). There were no significant differences between the 2 groups when comparing the DASH score, VAS score, PRTEE score, or grip strength at any time point. The only significant difference between study groups was that the arthroscopic technique resulted in a longer surgery time: 34.0 minutes (standard error of the mean, 2.9 minutes) versus 22.5 minutes (standard error of the mean, 1.3 minutes) (P = .005).

CONCLUSIONS

Comparing the open versus arthroscopic technique in the surgical management of lateral epicondylitis through a randomized clinical trial, we determined that there was no difference between the 2 operative modalities when examining the DASH score, VAS score, PRTEE score, grip strength, or complication rate at 12 months postoperatively. A shorter operative time coupled with potentially less setup time may favor open release.

LEVEL OF EVIDENCE

Level II, lower-quality randomized trial.

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.

Comparison of the Clinical Outcomes of Open Surgery Versus Arthroscopic Surgery for Chronic Refractory Lateral Epicondylitis of the Elbow

Numerous surgical options have been introduced for the treatment of chronic refractory lateral epicondylitis of the elbow, but it remains unclear which option is superior. The clinical outcomes of an open surgery group and an arthroscopic surgery group were evaluated, and the results of the 2 procedures were compared. From among patients with lateral epicondylitis refractory to 6 months of conservative treatment, 68 patients satisfying study criteria were recruited. Open surgery was performed in 34 cases (group 1), and arthroscopic surgery was performed in 34 cases (group 2). Compared with preoperatively, the 2 groups had significantly improved values for grip strength, range of motion, and Disabilities of the Arm, Shoulder and Hand score at 12 months postoperatively. Group 1 had significantly greater improvements in grip strength and visual analog scale pain score compared with group 2 (P=.048 vs P=.006). Group 2 had significantly greater (P=.045) improvement in pronation compared with group 1. Group 2 returned to work sooner than group 1. On the questionnaire regarding satisfaction with surgery 24 months postoperatively, 4 patients (12%) in group 2 reported dissatisfaction compared with no patients in group 1. Open surgery and arthroscopic surgery both yielded good clinical results. Nonetheless, for patients requiring muscle strength or having severe pain at work, open surgery would be more effective. [Orthopedics. 2018; 41(4):237-247.].

A Comparison of Radiofrequency-Based Microtenotomy and Arthroscopic Release of the Extensor Carpi Radialis Brevis Tendon in Recalcitrant Lateral Epicondylitis: A Prospective Randomized Controlled Study

PURPOSE

To compare the clinical effects of radiofrequency (RF)-based microtenotomy and arthroscopic release of the extensor carpi radialis brevis (ECRB) tendon in patients with recalcitrant lateral epicondylitis through a prospective randomized controlled study.

METHODS

A total of 46 patients were randomly assigned to receive arthroscopic release (group A, 24 patients) or RF-based microtenotomy (group B, 22 patients). The visual analog scale (VAS) score for pain, flexion-extension arc, operation time, Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Mayo Elbow Performance Score (MEPS), and grip power of groups A and B were compared during the recovery phases for up to 2 postoperative years.

RESULTS

Both groups showed statistically significant functional improvement compared with their preoperative grip strength and DASH, VAS, and MEPS scores at 2 years after surgery (P < .05). There were no differences in postoperative pain relief or functional restoration between the 2 groups during the recovery phases, however the mean operation time for group B (41.4 ± 5.2 minutes) was significantly shorter than that for group A (15.6 ± 3.6 minutes, P < .001). In group B, 1 patient underwent revision surgery due to postoperative ECRB rupture, and 1 patient in group A underwent open release for persistent postoperative discomfort.

CONCLUSIONS

RF-based microtenotomy for treating recalcitrant lateral epicondylitis provided clinical outcomes comparable with those from arthroscopic release of ECRB tendon during the recovery phase. RF-based microtenotomy is considered as one of the surgical procedures for treating recalcitrant lateral epicondylitis, with the advantages of reliable elbow functional restoration and significantly shorter operation time.

LEVEL OF EVIDENCE

Level I, prospective randomized trial.

Does Kinesiotaping improve pain and functionality in patients with newly diagnosed lateral epicondylitis?

PURPOSE

This study aimed to compare the short-term effects of kinesiotaping and extracorporeal shock wave therapy (ESWT) along with physiotherapy on pain, functionality, and grip strength in patients with newly diagnosed lateral epicondylitis undergoing rehabilitation.

METHODS

Forty-five voluntary patients (mean age 48 years) were randomly assigned to three groups. Patients in all groups received physiotherapy consisting of a cold pack and transcutaneous electrical nerve stimulation five times per week for a total of 15 sessions and a home exercise programme including stretching and eccentric strength exercises. In the second group, patients received kinesiotaping 5 days a week for 3 weeks. In the third group, ESWT was applied three times for 3 weeks. Patients were assessed by visual analogue scale for pain intensity, pain-free grip strength using a hand dynamometer, Cyriax Resisted Muscle Test, and Patient-Rated Tennis Elbow Evaluation Scale. All measurements were collected at baseline and after treatment.

RESULTS

There were no significant differences in the demographic characteristics of the patients in all groups at baseline. Intra-group analysis revealed that pain intensity decreased, whereas maximum grip strength and functionality increased in all groups at the end of the treatment (p < 0.05). Inter-group analysis revealed that the kinesiotaping group yielded better results in decreasing pain intensity than the other groups (p < 0.05). The kinesiotaping group (p < 0.001) and ESWT group (p = 0.002) yielded better results in improving functionality than the physiotherapy group. There were significant differences in recovering pain-free grip strength in the kinesiotaping group (p < 0.05).

CONCLUSION

Kinesiotaping was found to be effective for decreasing pain intensity, recovering grip strength, and improving functionality in patients with lateral epicondylitis undergoing rehabilitation.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

Arthroscopic surgical treatment of medial epicondylitis

BACKGROUND

The study purpose was to evaluate the outcomes of patients who received arthroscopic surgical treatment for medial epicondylitis refractory to conservative treatment.

METHODS

This was a retrospective study of 7 patients who underwent arthroscopic surgical débridement of the common flexor tendon for treatment of medial epicondylitis refractory to conservative treatment. The patients were assessed using the Disabilities of the Arm, Shoulder and Hand score; visual analog scale for pain; and Short Form 36 Health Survey. The mean age at the time of surgery was 50 years (range, 36-67 years). The mean duration of symptoms before surgery was approximately 2 years (range, 8 months to 4 years). The mean follow-up duration was 17 months (range, 6-48 months).

RESULTS

The average postoperative scores were 17 points on the Disabilities of the Arm, Shoulder and Hand outcome measure; 2 points on the visual analog scale at rest for 6 subjects (86%) with slight pain and 1 (14%) with moderate pain; and 78 on the Short Form 36 Health Survey. No significant complications were observed when the procedure was performed via arthroscopy.

CONCLUSION

Arthroscopic surgical treatment for medial epicondylitis of the elbow exhibits good outcomes and is safe and effective.

Tendinopathies around the Elbow Part 1: Lateral Elbow Tendinopathy

Tendinopathies of the elbow and in particular of the common extensor origin are a common cause of elbow pain. Part one of this two part review of tendinopathies of the elbow will focus on the pathophysiology and management of lateral elbow tendinopathy, frequently referred to as tennis elbow. Lateral elbow tendinopathy is a common condition with an incidence of 1 – 2%. The pathology arises from the origin of extensor carpi radialis brevis where changes, consistent with all tendinopathies, of angiofibroblastic hyperplasia occur secondary to repetitive micro trauma. It is not an inflammatory condition. Clinical history and examination is usually sufficient for diagnosis although MRI and ultrasound can be used. The many treatment options that have been proposed have a mixed quality of supporting evidence. Thus management protocols are difficult to define. Treatment depends on the length of symptoms. Acute presentation is managed through conservative measures including activity modification, topical NSAIDs and physiotherapy. For patients with recalcitrant symptoms, injection therapy with, for example, platelet rich plasma can be used. Alternatively surgical excision of the diseased tissue can be performed. This review article will consider the available evidence in order to identify both treatments that are effective and those that are not.

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.

The Three-Portal Technique in Arthroscopic Lateral Epicondylitis Release

Lateral epicondylitis, commonly referred to as tennis elbow, is a syndrome characterized by pain over the origin of the common extensor muscles of the fingers, hand and wrist at the lateral epicondyle. Reports of 70-90% response to conservative treatment at one year have been documented in the literature though refractory cases often require surgical management. Arthroscopic treatment of lateral epicondylitis allows for intra-articular visualization for concomitant pathology and localization of the Extensor Carpi Radialis Brevis tendon. Additionally, compared to the open technique, the arthroscopic technique has a lower morbidity and an earlier return to work and activity. Here we describe a three portal technique for improved visualization in arthroscopic lateral epicondylitis release.

Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature

OBJECTIVE

To analyze the literature to determine whether controlled studies on percutaneous tenotomy have been published, and if so, to systematically assess the efficacy of percutaneous tenotomy for the treatment of tendinosis at the lateral epicondyle of the elbow.

DESIGN

Systematic review of the available literature.

METHODS

Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, and Web of Science databases were searched in November 2015, unrestricted by date. After the initial search, we excluded conference proceedings, theses, reviews, expert opinions, and publications written in languages other than English. Next, 2 independent reviewers screened all of the remaining records with regard to their titles and abstracts, and subsequently, the full texts of identified publications potentially relevant to the present study.

RESULTS

Six articles focused on percutaneous tenotomy, none of which were controlled against a placebo or conservative treatment group. The absence of true randomized controlled trials created a great deal of heterogeneity between the studies; thus we could not include any of our studies in the intended final quantitative analysis with meta-analysis tools. We describe all 6 studies identified by this systematic review with a detailed analysis of the procedural methods, outcome measures, and conclusions of each study.

CONCLUSIONS

Percutaneous tenotomy presents an alternative to surgical release of the common extensor tendon for the treatment of chronic tendinosis at the lateral epicondyle of the elbow. Current research supporting the efficacy of this procedure, however, is of low quality (level II to level IV).

LEVEL OF EVIDENCE

III.

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.

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.

[Chronic lateral epicondylitis : The Nirschl procedure]

PURPOSE

Reduction of burden insufficiency.

INDICATION

Chronic lateral epicondylitis.

CONTRAINDICATIONS

Acute infection in the surgical area. C6/7 nerve root and plexus irritation. Frohse Arcade syndrome. Posterolateral rotatory instability.

SURGICAL TECHNIQUE

Incision slightly cranial to the radial epicondyle. Identification of the extensor carpi radial brevis tendon (ERCB) and longus (ECRL). Mobilisation of the ECRL tendon, identification of degenerative tendons of the ECRB. Excision of degenerative tissue. Drill holes in the area of the smoothed radial epicondyle, thermal denervation.

POSTOPERATIVE MANAGEMENT

Arm plaster splint for 14 days. Unrestricted activity after 4-6 weeks. Maximum loading after 6 months.

RESULTS

Of the 24 consecutively operated patients, 83.3 % were included. High patient satisfaction. Nirschl tennis and elbow score improved from 35 to 75 points postoperatively. Pain levels decreased from 6.8 to 1.4 points postoperatively.

Arthroscopic treatment for chronic lateral epicondylitis

OBJECTIVE

To report the clinical and functional results from arthroscopic release of the short radial extensor of the carpus (SREC) in patients with chronic lateral epicondylitis that was refractory to conservative treatment.

METHODS

Over the period from January 2012 to November 2013, 15 patients underwent arthroscopic treatment. The surgical technique used was the one described by Romeo and Cohen, based on anatomical studies on cadavers. The inclusion criteria were that the patients needed to present lateral epicondylitis and that conservative treatment (analgesics, anti-inflammatory agents, corticoid infiltration or physiotherapy) had failed over a period of more than six months. The patients were evaluated based on the elbow functional score of the Mayo Clinic, Nirschl's staging system and a visual analog scale (VAS) for pain.

RESULTS

A total of 15 patients (9 men and 6 women) were included. The mean Mayo elbow functional score after the operation was 95 (ranging from 90 to 100). The pain VAS improved from a mean of 9.2 before the operation to 0.64 after the operation. On Nirschl's scale, the patients presented an improvement from a mean of 6.5 before the operation to approximately one. There were significant differences from before to after the surgery for the three functional scores used (p < 0.01). No correlations were observed using the Spearman test between the results and age, gender, length of time with symptoms before the operation or injury mechanism (p > 0.05).

CONCLUSION

Arthroscopic treatment for lateral epicondylitis was shown to be a safe and effective therapeutic option when appropriately indicated and performed, in refractory cases of chronic lateral epicondylitis. It also allowed excellent viewing of the joint space for diagnosing and treating associated pathological conditions, with a minimally invasive procedure.

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.

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.

Lateral epicondylitis treatment: international survey of surgeons' preferences and literature review

BACKGROUND

Lateral epicondylitis (LE) is a common cause of elbow pain. Despite a relatively high prevalence and morbidity, there is still no single effective ('gold standard') treatment for LE. We hypothesised that a surgeon's experience, country of origin and area of expertise would influence choices concerning patient management. The purpose of this survey was to describe the current trends and common practices in treating LE worldwide.

MATERIAL AND METHODS

A total of 291 orthopaedic surgeons of 12 subspecialties from 57 countries were surveyed on their choice of LE treatment modalities. Their preferences were analysed according to country of origin, field of expertise and seniority. The results were compared with current published level-1 evidence.

RESULTS

The most popular modalities of treatment among all of the surveyed orthopaedic surgeons were non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid (CS) injection (38% of recommendations each). The most popular Modalities of treatment among the hand surgeons was NSAIDs (48%) and CS injection (30%). There was no significant difference in recommendations based on geography, seniority or specialisation (i.e., hand surgeons among others).

CONCLUSIONS

Neither geography, seniority nor medical specialty affects surgeons' preferences in the treatment of LE. There appears to be little correlation between scientific evidence and therapeutic choices for managing LE.

LEVEL OF EVIDENCE

Level V, Study.

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.

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.

Elbow arthroscopic surgery update for sports medicine conditions

Elbow arthroscopic surgery can now effectively treat a variety of conditions that affect athletes. Advances in instrumentation, increased surgeon familiarity, and expanded indications have led to significant growth in elbow arthroscopic surgery in the past few decades. While positioning, portal placement, and specific instruments may vary among surgeons, anatomic considerations guide surgical approaches to minimize neurovascular compromise. Arthroscopic procedures vary in difficulty, and surgeons should follow stepwise advancement with experience. Removal of loose bodies, debridement of synovial plicae, and debridement of the extensor carpi radialis brevis for lateral epicondylitis are considered simple procedures for novice elbow arthroscopic surgeons. More advanced procedures include management of osteochondritis dissecans, valgus extension overload in the throwing athlete, and capsular release. With proper technique, a variety of athletic elbow conditions can be treated arthroscopically with predictable results and minimal morbidity.

Innervation pattern at the undersurface of the extensor carpi radialis brevis tendon in recalcitrant tennis elbow

PURPOSE

We investigated the general, sensory, and sympathetic innervation patterns at the undersurface of the extensor carpi radialis brevis (ECRB) origin in patients with recalcitrant tennis elbow.

METHODS

Eight elbows in eight consecutive patients (6 females and 2 males) with tennis elbow who underwent arthroscopic surgery were included in this study. The mean age was 45 years (38-66 years), and the mean duration of symptoms before surgery was 23 months (13-52 months). Operative treatment consisted of an arthroscopic inspection and debridement of the ECRB origin. Control tissues were obtained from biopsy of the ECRB capsule in two patients with osteochondritis dissecance of the capitellum who underwent arthroscopic resection of loose bodies. The tissue specimens were investigated immunohistochemically with antibodies delineating general (PGP9.5), sensory (SP/CGRP), and sympathetic (NPY) nerve patterns.

RESULTS

In the non-tendinosis control tissue, SP/CGRP and NPY immunoreactions were heterogeneously distributed in association with blood vessels. Pathologic evaluation of the biopsy tissue showed atypical fibrous granulation containing numerous vessels and nerve structures in all eight patients. Marked reactions to PGP 9.5 took the form of nerve fibers associated with arteries and arterioles in the atypical granulation. Most of the perivascular innervation was found to express NPY. The immunoreactions for SP and CGRP were invariably weak.

CONCLUSION

Increased perivascular sympathetic innervation accompanied with loss of sensory innervation at the undersurface of the ECRB tendon may play a role in chronic pain generation in recalcitrant tennis elbow.

LEVEL OF EVIDENCE

Diagnostic, Level IV.

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.

[Arthroscopic treatment of lateral epicondylitis: a prospective study on 14 cases]

Lateral epicondylitis of the elbow is a relatively common pathology and would involve 1-3% of the overall population. Lack of consensus on surgical techniques reflects the difficulty of understanding and treating this disease. Our prospective study reports the results of its arthroscopic treatment on 14 patients operated on between 2009 and 2012. The mean follow-up was 7.15 months. All patients underwent a well conducted medical treatment for an average of 32.5 months. The operation was carried out under regional anesthesia in an outpatient. The technique included a time of joint exploration, joint capsulotomy and a transverse division of the pathological tendon of extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC). The value on the visual analogic scale (VAS) at rest and during exercise increased from 2.85 to 0.43 and from 7.71 to 2.43, respectively, then remained stable over time. Professional activity was resumed on average at 9.1 weeks. Neither intraoperative nor postoperative complications were found. No laxity was observed. The Mayo Clinic and DASH scores were significantly improved from 52.14 to 92.5 and from 54.11 to 9.7, respectively. Overall, we observed 11 very good and three good results. Although our prospective series has a few patients and limited follow-up, our results are better or similar than those reported in the literature on pain relief and functional recovery. In contrast, the average recovery of professional activity was longer. Elbow arthroscopy, less invasive than open procedures, and allowing further joint exploration, seems an excellent alternative technique in this indication.

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.