Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results

Recalcitrant Lateral Epicondylitis: A Systematic Review on Current Nonoperative and Operative Treatment Modalities

BACKGROUND

Lateral epicondylitis is a common cause of elbow pain that is generally self-limiting. For patients who have persistent symptoms refractory to conservative treatment, there is still no clear consensus on the most favorable treatment modality. The purpose of this systematic review was to synthesize the available literature regarding both nonoperative and operative treatment modalities for recalcitrant lateral epicondylitis (RLE) to provide insight into the efficacy of treatment options.

METHODS

A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, where the PubMed, MEDLINE/Ovid, CINAHL, Cochrane, and Scopus databases were queried to identify studies evaluating treatment options for RLE.

RESULTS

A total of 27 studies with 1,958 patients were included. Of the reviewed studies, there were a wide variety of treatments including platelet-rich plasma injections, percutaneous tenotomies, and various arthroscopic and open procedures.

CONCLUSION

There are a wide variety of treatment modalities available for RLE that have promising efficacy in the short, medium, and long terms. A comprehensive approach combining evidence-based and patient-centered care is critical for effective management of refractory symptoms.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

A Novel Surgical Treatment Management Algorithm for Elbow Posterolateral Rotatory Instability (PLRI) Based on the Common Extensor Origin Integrity

Background: Here, we introduce a comprehensive treatment algorithm for posterolateral rotatory instability (PLRI) of the elbow, a condition affecting elbow mobility. We outline a diagnostic approach and a novel surgical management plan through the arthroscopic surgeon's point of view. Methods: The central focus of this management approach is the integrity of common extensor origin (CEO). High clinical suspicion must be evident to diagnose PLRI. Special clinical and imaging tests can confirm PLRI but sometimes the final confirmation is established during the arthroscopic treatment. The most appropriate treatment is determined by the degree of CEO integrity. Results: The treatment strategy varies with the CEO's condition: intact or minor tears require arthroscopic lateral collateral ligament imbrication, while extensive tears may need plication reinforced with imbrication or, in cases of retraction, a triceps tendon autograft reconstruction of the lateral ulnar collateral ligament alongside CEO repair. These approaches aim to manage residual instability and are complemented using a tailored rehabilitation protocol to optimize functional outcomes. Conclusion: PLRI is a unique clinical condition and should be treated likewise. This algorithm offers valuable insights for diagnosing and treating PLRI, enhancing therapeutic decision-making.

Posterior Translation of the Radial Head in Magnetic Resonance Imaging of Lateral Epicondylitis

Background

Posterolateral rotatory instability is produced by disruption of the lateral collateral ligament complex (LCLC); it is commonly induced by trauma, with few cases reported due to lateral epicondylitis. We examined the amount of posterior transition of the radial head with or without LCLC injury, common extensor tendon (CET) injury, and Baker classification in lateral epicondylitis.

Methods

We retrospectively studied patients with lateral epicondylitis of the humerus who underwent surgery between April 2016 and July 2021. Fifteen elbows with coronal and sagittal images on preoperative magnetic resonance imaging (MRI) were included. We investigated the amount of posterior transition of the radial head in sagittal MRI images of the elbow, which were compared based on LCLC and CET lesion.

Results

The mean age of patients was 49 years. The lesions in four, nine, and two patients were classified as LCLC0, LCLC1, and LCLC2, respectively. The mean radio-humeral distance values among the LCLC lesions were 0.65, 2.46, and 2.22 mm in LCLC0, LCLC1, and LCLC2, respectively, with the RHD between LCLC0 and LCLC1 differing significantly. In five, six, and four patients, the lesions were classified as CET1, CET2, and CET3, respectively. The mean RHD values among the CET lesions were 1.33, 2.68, and 1.48 mm in CET1, CET2, and CET3, respectively.

Conclusions

Our results showed that posterior transition of the radial head is greater in patients with lateral epicondylitis with LCLC lesions on MRI than those with normal findings of LCLC.

Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study

OBJECTIVE

To assess the applicability of a semiquantitative index for symptomatic minor instability of the lateral elbow (SMILE).

MATERIALS AND METHODS

CT arthrograms of consecutive patients with lateral elbow pain who underwent ultrasound-guided CT arthrography at our orthopedic center between April 2019 and May 2022 were included. Images were acquired at 100 kVp and 80 mAs. An expert radiologist (R1) and a radiology resident (R2) retrospectively performed an independent, blinded evaluation of the arthrograms to assess the presence of imaging findings suggestive of elbow instability. The SMILE index (0-8) was obtained adding (I) radial head chondromalacia (0 - 1); (II) humeral capitellum chondromalacia (0 - 1); (III) humeral trochlear ridge chondromalacia (0 - 1); (IV) annular ligament laxity (0 - 2); (V) synovial thickening (0 - 1); (VI) humeroradial joint asymmetry (0 - 1); and (VII) capsular tear (0 - 1). R1 repeated the assessment after 14 days. Cohen's weighted κ statistic and raw concordance were used to appraise reproducibility.

RESULTS

Eighty patients (median age 49 years, interquartile range 40-53 years, 49, 61% males) underwent CT arthrography at our center, and 10 (12%) of them underwent bilateral elbow examination, leading to 90 included CT arthrograms. Median SMILE index was 4 (IQR: 2-5) for R1, 4 (IQR: 2-5) for R2, and 4 (IQR: 2-5) for the second assessment by R1. Intra-reader agreement was excellent (κ = 0.94, concordance 87%), while inter-reader agreement was substantial (κ = 0.75, concordance 67%).

CONCLUSION

The proposed SMILE index showed good reproducibility; further studies are warranted to correlate our index with clinical and surgical data.

CLINICAL RELEVANCE STATEMENT

Our scoring system allows a standardized evaluation of patients with lateral elbow pain and instability suitable for application into clinical practice, complementing the orthopedic surgeon's clinical diagnosis with imaging findings that may aid treatment choices.

KEY POINTS

• Lateral elbow pain is often interpreted clinically as lateral epicondylitis, but it can also encompass intra-articular pathology. • The proposed arthrographic index allows comprehensive quantification of lateral elbow pathology with good reproducibility and application times. • Our index provides the orthopedic surgeon with information regarding intra-articular findings, aiding treatment choices.

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.

A Clinical Overview of the Natural Course and Management of Lateral Epicondylitis

Lateral epicondylitis (LE), also often called tennis elbow, is a frequent cause of elbow pain. The most characteristic symptom of LE is pain and burning around the lateral epicondyle of the humerus that may radiate to the forearm or to the upper arm. Ultrasonography is a quick and noninvasive tool used to confirm (or exclude) the diagnosis of LE. Management of LE symptoms should be directed to the management of pain, protection of movement, and improvement of arm performance. Treatment of LE includes nonoperative techniques and surgery. [Orthopedics. 2023;46(4):e210-e218.].

[Epicondylosis : Open surgical procedure-when and how for lateral and medial epicondylitis?]

BACKGROUND

Epicondylosis of the elbow are common pathologies, with a higher incidence for radial epicondylosis. Approximately 90% are self-limiting under conservative treatment.

TREATMENT

Multiple surgical procedures exist for the treatment of refractory cases. Arthroscopic treatment has been described for both radial and medial pathologies. Open and arthroscopic procedures show equivalent results in the surgical treatment of radial epicondylosis. This paper describes the most common open surgical procedures for the treatment of radial epicondylosis. Furthermore, the pros and cons of the arthroscopic versus the open approach are discussed, and the indications for an open surgical procedure for radial pathologies are highlighted. The authors believe that the open technique represents the standard treatment in the surgical treatment of ulnar epicondylosis.

LIMITATIONS

Arthroscopic procedures have been described, but studies comparing the clinical outcome versus open surgical treatment are lacking. The anatomic proximity of the flexor origin to the ulnar nerve with the risk of iatrogenic damage is another limiting factor. In addition, concomitant pathologies on the ulnar side can better be ruled out preoperatively, so that arthroscopy has a rather low significance in the treatment of ulnar epicondylosis.

[Arthroscopic debridement of the extensor carpi radialis brevis]

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The 100 most cited articles in lateral epicondylitis research: A bibliometric analysis

Introduction

Lateral epicondylitis is a significant clinical problem in orthopaedics. There have been numerous articles written about this. Bibliometric analysis is critical for determining a field's most influential study. We attempt to identify and analyze the top 100 citations in lateral epicondylitis research.

Materials and methods

On December 31, 2021, an electronic search was conducted in the Web of Science Core Collection and the Scopus search engine with no restrictions on publication years, language, or study design. We reviewed each article's title and abstract until the top 100 were documented and evaluated in various ways.

Results

Between 1979 and 2015, the 100 most cited articles were published in 49 journals. The total number of citations ranged from 75 to 508 (mean ± SD, 145.5 ± 90.9), with citation densities ranging from 2.2 to 37.6 citations per year (mean ± SD, 8.7 ± 6.5). The United States is the most productive country, and the 2000s witnessed a surge in lateral epicondylitis research. The year of publication had a moderately positive correlation with citation density.

Conclusion

Our findings offer readers a fresh perspective on historical development hotspot areas of lateral epicondylitis research. Disease progression, diagnosis, and management have always been topics of discussion in articles. PRP-based biological therapy has emerged as a promising area for future research.

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.

Small-Bore Needle Arthroscopic Extensor Carpi Radialis Brevis Release Results in Improved Outcomes at One Year Postoperatively

Purpose

To evaluate outcomes of patients who underwent small-bore needle arthroscopic extensor carpi radialis brevis (ECRB) release for the management of recalcitrant lateral epicondylitis.

Methods

Patients who underwent elbow evaluation and ECRB release using a small-bore needle arthroscopy system were included in this study Thirteen patients were included. Quick Disabilities of the Arm Shoulder and Hand and Single Assessment Numerical Evaluation scores, as well as overall satisfaction scores, were collected. A 2-tailed paired t-test was conducted to assess the statistical significance of the differences observed between preoperative and 1-year postoperative scores with significance set at P < .05.

Results

There was a statistically significant improvement in both outcome measures (P < .001) and a 92.3% satisfaction rate with no significant complications at a minimum 1-year follow-up.

Conclusions

Patients with recalcitrant lateral epicondylitis treated with ECRB release using needle arthroscopy demonstrated significantly improved Quick Disabilities of the Arm Shoulder and Hand and Single Assessment Numerical Evaluation scores postoperatively, without complications.

Level of Evidence

IV, retrospective case series.

Arthroscopic Debridement for Refractory Lateral Epicondylitis Results for Substantial Improvement in Tendinosis Scores and Good Clinical Outcomes: Qualitative and Quantitative Magnetic Resonance Imaging Analysis

PURPOSE

To qualify and quantify the changes in magnetic resonance imaging (MRI) signals in the extensor tendons after arthroscopic debridement for lateral epicondylitis and evaluate the association between MRI findings and temporal clinical results by comparisons between recovered and unrecovered cases.

METHODS

Thirty-four patients with refractory lateral epicondylitis treated with arthroscopic debridement were divided into recovered (n = 24) and unrecovered (n = 10) groups according to the Japanese Orthopaedic Association-Japan Elbow Society score. This study included any patients who underwent both the pre- and postoperative MRI and excluded patients with a previous history of any elbow surgery. Pre- and postoperative MRI findings were qualitatively categorized into 4 grades, quantified by measuring the percentage of tendinopathy area, and compared between the groups.

RESULTS

Preoperatively, grading scores and percentages did not show significant differences between groups (P = .050 and .519). The respective numbers of patients with grades 1, 2, 3, and 4 were 1 (4%), 3 (13%), 10 (42%), and 10 (42%) in the recovered group; and 1 (10%), 2 (20%), 7 (70%), and 0 (0%) in the unrecovered group. The average percentages in the recovered and unrecovered groups were 42.3% (73.9 mm²/168.4 mm²); and 36.5% (50.5 mm²/131.0 mm²). However, postoperatively, they were significantly lower in the recovered group than in the unrecovered group (P = .007 and .014). The numbers and percentages in the recovered and unrecovered groups were 15 (63%), 8 (33%), 1 (4%), and 0 (0%) and 17.0% (28.6mm²/169.8mm²) and 2 (20%), 3 (30%), 5 (50%), and 0 (0%) and 30.5% (39.0 mm²/131.8 mm²).

CONCLUSIONS

Qualitative and quantitative MRI is useful for evaluating the progress of tendon healing after arthroscopic debridement. In the recovered and unrecovered groups, improvement of tendinopathy area were 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes.

LEVEL OF EVIDENCE

IV, case series with subgroup analysis.

Substantiation of safe and effective arthroscopic approaches to the elbow joint in case of enthesopathy of the distal humerus

Background: With the development of arthroscopic surgical techniques, diagnostic and therapeutic possibilities have significantly expanded, but they have not become widely used in everyday clinical practice in the treatment of elbow joint pathology. This is due to the small volume of the joint, the close location of the neurovascular formation and the complexity of manipulation. Elbow arthroscopy is a dynamic procedure with a change in the ratio of neurovascular structures and portals in different elbow positions. The risk of damage to neurovascular formations during arthroscopy of the elbow joint is up to 14%. Purpose: determination of the safest areas promising for the formation of arthroscopic approaches to the elbow joint in the treatment of patients with enthesopathy of the distal humerus.. Methods: To achieve this goal, a complex topographic- anatomical and clinical study was performed on 30 non-fixed anatomical preparations of the upper limb, which included 4 stages, where the topographic and anatomical features of the tendon-muscular and neurovascular structures forming the elbow joint were studied, depending on the angle of flexion of the elbow joint at 3 different levels: level I - 5 cm above the joint space, level II - joint space, level III - the neck of the radius, additionally the above structures were studied using MRI studies in 30 patients. Results: When the elbow joint is flexed to 90, the brachial artery at level I moves away from the bone and is located at a distance from 27,8 (27.7-28,1) mm to 28,6 (28,4-28,7). The radial nerve at the II level from СMEL is located at 16,4 (16,5-18,8) mm. Median nerve from СMEL by 17,5 (16,6-18,1) mm. The brachial artery is 23,7 (20,522,8) mm distant from the СMEL. The anterior bundle of the MCL has: an average proximal width of 6,2 1,4 mm, an average width of the middle part of 6,5 1,5 mm, an average distal width of 9,3 1,4 mm. The average area of attachment on the medial epicondyle of the humerus is 45,5 9,3 mm, it has a rounded shape. The radial collateral ligament has an average length of 20,5 1.9 mm and a bundle width of 5,2 0,8mm. The average area of attachment on the humerus is 13,6 mm. The average area of ECRB on the lateral epicondyle of the humerus was 53,1 3,7mm. The mean area of the FCR on the medial epicondyle was 58,3 6.3mm. The distance from the entrance of the deep branch of the radial nerve to the canalis sapinatorius to the joint space is 28 (25,529,6) mm. Conclusion: The results of this study allow the operating surgeon to decide on the choice and placement of arthroscopic access to the elbow joint, which in turn helps to minimize the risk of damage to neurovascular structures.

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.

Arthroscopic surgery versus open surgery for lateral epicondylitis in an active work population: a comparative study

BACKGROUND

Lateral epicondylitis is common in workers who perform repetitive movements of the entire upper limb. Approximately 85%-90% of patients respond satisfactorily to conservative treatment, but in resistant patients, surgical treatment is considered. Classic open surgery is successful in between 70% and 97% of patients, similarly to more modern techniques such as arthroscopy. We sought to demonstrate the superiority of the Wolff technique in terms of clinical results. The goals of this study were to compare the functional and pain outcomes of arthroscopic surgery with open surgery using fasciotomy via the Wolff technique in the treatment of lateral epicondylitis.

METHODS

This was a retrospective study of 47 working-age patients with resistant lateral epicondylitis: 27 underwent arthroscopic surgery and 20 underwent open surgery. Visual analog scale scores for pain and function, as well as the QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Mayo Elbow Performance Score, and Broberg and Morrey Rating System score, were collected preoperatively and postoperatively; return to patients' previous work and surgical time were also recorded.

RESULTS

No statistically significant differences were observed between the groups in the reduction in the visual analog scale score (5.26 in arthroscopy group vs. 5.75 in fasciotomy group, P = .5), QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score (19 vs. 19.4, P = .9), Mayo Elbow Performance Score (82 vs. 81.5, P = .8), or Broberg and Morrey Rating System score (81.9 vs. 82.6, P = .9). The differences in terms of time off were also not statistically significant. The period of work leave corresponded, on average, to 83.78 days in the arthroscopy group and 89.95 days in the Wolff group. The mean surgical time was 44.2 minutes in the group undergoing arthroscopic intervention and 27.5 minutes in the fasciotomy group, showing a statistically significant difference (P < .001).

CONCLUSIONS

Arthroscopic surgery and open surgery provide similar functional results and pain reduction in the treatment of lateral epicondylitis.

Lateral epicondylitis: New trends and challenges in treatment

Lateral epicondylitis (LE) is a chronic aseptic inflammatory condition caused by repetitive microtrauma and excessive overload of the extensor carpi radialis brevis muscle. This is the most common cause of musculoskeletal pain syndrome in the elbow, inducing significant pain and limitation of the function of the upper limb. It affects approximately 1-3% of the population and is frequently seen in racquet sports and sports associated with functional overload of the elbow, such as tennis, squash, gymnastics, acrobatics, fitness, and weight lifting. Typewriters, artists, musicians, electricians, mechanics, and other professions requiring frequent repetitive movements in the elbow and wrists are also affected. LE is a leading causation for absence from work and lower sport results in athletes. The treatment includes a variety of conservative measures, but if those fail, surgery is indicated. This review summarizes the knowledge about this disease, focusing on risk factors, expected course, prognosis, and conservative and surgical treatment approaches.

Platelet-rich plasma injection vs. operative treatment for lateral elbow tendinosis: a systematic review and meta-analysis

BACKGROUND

Although surgical treatment is considered reliable for lateral elbow tendinosis, local injection therapy may be preferable, as it avoids surgery. Among a number of local injections, platelet-rich plasma has been used successfully to treat lateral elbow tendinosis. The purpose of this study was to compare the outcomes in patients treated with either platelet-rich plasma injections or surgery for lateral elbow tendinosis using a systematic literature review and meta-analysis.

METHODS

MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 1, 2021, that compared platelet-rich plasma with operative treatment for lateral elbow tendinosis. The pooled analysis was designed to compare the visual analog scale scores and the Patient-Related Tennis Elbow Evaluation scores between the platelet-rich plasma and surgical treatment groups at serial time points.

RESULTS

We included 5 studies involving 340 patients with lateral elbow tendinosis, comprising of 154 patients treated with platelet-rich plasma and 186 patients who underwent surgical treatment. The pooled analysis showed no statistically significant differences in the visual analog scale scores at any of the follow-up time points, namely, 2 months (mean difference [MD] 1.11, 95% confidence interval [CI] -2.51 to 4.74, P = .55, I² = 94%), 6 months (MD 0.80, 95% CI -2.83 to 4.42, P = .67, I² = 92%), and 12 months (MD -0.92, 95% CI -4.63 to 2.80, P = .63, I² = 93%) postintervention and in the Patient-Related Tennis Elbow Evaluation scores at 12 weeks (MD -1.86, 95% CI -22.30 to 18.58, P = .86, I² = 81%), 24 weeks (MD -3.33, 95% CI -21.82 to 15.17, P = .72, I² = 74%), and 52 weeks (MD -3.64, 95% CI -19.65 to 12.37, P = .66, I² = 69%) postintervention.

CONCLUSIONS

Local platelet-rich plasma injections and surgical treatment produced equivalent pain scores and functional outcomes in patients with lateral elbow tendinosis. Thus, platelet-rich plasma injections may represent a reasonable alternative treatment for patients who are apprehensive to proceed with surgery or for poor surgical candidates.

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.

Extra-articular arthroscopic release of lateral epicondylitis: a prospective study

Background

Operative management of lateral epicondylitis can be managed with percutaneous, arthroscopic, or open surgical release. Extraarticular arthroscopic release is a new technique, and no study has compared its outcomes and risk profile.

Methods

A 26-patient cohort was reviewed before and after extraarticular arthroscopic release, which was performed by the senior author. The Mayo Elbow Performance Scores were used as a functional outcome score and obtained via a phone interview. Results were analyzed using a paired t-test with a statistical significance set at P < .05.

Results

Of the 26 patients, 10 were being treated under workers compensation. Preoperative Mayo Elbow Performance Score was 47.5, and the postoperative score was 90.2 with a significant difference of 42.7 (P value = .05). The workers compensation group scored 13.3 points lower postoperatively than the remainder of patients, which was shown to also be significant with a P value of .002.

Discussion and Conclusion

The advantage of extraarticular arthroscopic release was better visualization of affected structures, which improved accuracy of debridement, and a small capsulotomy, which decreased the risk of a transient radial nerve palsy. Overall, extraarticular arthroscopic results were found to be good and comparable to the results of other operative techniques with the added advantage of a lower risk profile.

How one treats lateral epicondylitis - a survey among Brazilian orthopedists

BACKGROUND

Lateral epicondylitis (LE), also known as tennis elbow, is the most common painful elbow condition. It affects approximately 1-3% of adults. There are various possible treatments described in the literature, but evidence to support a gold standard management protocol is lacking. Therefore, the objective of this study was to evaluate how Brazilian orthopaedists diagnose and treat lateral epicondylitis and compare these results with the available evidence.

METHODS

This is an observational, analytical, cross-sectional study. A questionnaire was prepared to obtain information from the participants with eight specific questions (2 on diagnosis and 6 on treatment). These questions were answered voluntarily by participants at 3 major congresses of orthopaedists in Brazil in 2018. The results were analysed in accordance with the overall number of responses and were evaluated among groups according to subspecialty.

RESULTS

We obtained a total of 501 questionnaires. Of these, 33 were excluded. The mean age was 38.67 years. The majority of respondents (91%) were male. We obtained 26.7% from specialists in hand surgery (Hand group), 36.5% from subspecialists in shoulder and elbow (Shoulder and Elbow group), and 36.8% from generalists in orthopaedics or from other subspecialties (General Orthopaedists group). For diagnosis, 24.4% did not initially request any imaging method. The most requested exam was ultrasonography (54.9%). The most prominent indication for initial treatment was physical therapy. For refractory cases, 78.3% of the respondents preferred doing a local infiltration. The most commonly used substance for local infiltrations was corticosteroids (89.6%). With respect to the surgical treatment option, 75.8% of those who recommend it prefer open techniques, and 24.2% prefer arthroscopic treatment. Of the total respondents, 12.8% did not recommend surgical treatment for LE.

CONCLUSION

Among Brazilian orthopaedists, the Cozen test is most frequently chosen, and ultrasound is the most commonly used imaging tool. Nonsurgically, oral nonsteroidal anti-inflammatory drugs (NSAIDs) plus physiotherapy is the most popular initial therapy, and corticosteroids are the most popular type of infiltration agent. Most surgeons recommended surgery after 6 months of nonsurgical treatment, and 75.8% preferred the open technique.

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.

Preoperative sonographic ulnar nerve mapping in the postoperative elbow

OBJECTIVE

To describe the technique of sonographic ulnar nerve mapping in the postoperative elbow for surgical planning.

MATERIALS AND METHODS

A retrospective review of a surgical databank identified 24 patients, all aged 18 years and older with a history of orthopedic elbow surgery, who were referred for preoperative sonographic mapping of the ulnar nerve prior to subsequent surgery. All cases were reviewed for patient demographics, clinical presentation, prior surgical interventions, and ultrasound technique. Charts were reviewed for intraoperative and postoperative outcomes, including nerve injury.

RESULTS

The cohort included 12 males and 12 females with a mean age of 51 years (range 22-68 years) and a mean BMI of 29 (range 20-48). Preoperative sonographic ulnar nerve mapping occurred following various elbow surgeries including ulnar nerve transposition to assess nerve location prior to subsequent elbow surgery. Of the 24 patients with preoperative sonographic ulnar nerve mapping, subsequent surgery was performed arthroscopically in 14 and open in 10 cases. In 11 of the 24 cases, there was specific mention of a modified approach to joint access which was guided by the ulnar nerve map. There were no perioperative ulnar nerve-related complications, such as nerve transection.

CONCLUSION

Preoperative mapping can facilitate planning of surgical access and ulnar nerve dissection. Sonographic mapping of the ulnar nerve reduces the potential uncertainty of nerve palpation in a complex postoperative elbow following ulnar nerve transposition. This technique may mitigate the risk of ulnar nerve injury.

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.

Risk factors associated with atraumatic posterolateral rotatory instability

Background

Traumatic posterolateral rotatory instability after elbow dislocation or fracture dislocation has been well described. However, few reports cover atraumatic posterolateral rotatory instability as a cause of lateral-sided elbow pain. We assessed the risk factors and epidemiology of atraumatic posterolateral rotatory instability in a case-control study.

Methods

A retrospective review of all patients treated operatively for atraumatic posterolateral rotatory instability during a 6-year period was compared with a group of patients with extensor carpi radialis brevis tendinopathy without instability treated during the same time period. Bivariate and multiple logistic regression statistical analyses were used to investigate the following risk factors: gender, age, hand dominance, diabetes, smoking, body mass index, corticosteroid injection history, and duration of symptoms. Disabilities of the Arm, Shoulder, and Hand and pain scores were obtained preoperatively and postoperatively.

Results

Thirteen patients with atraumatic posterolateral rotatory instability were compared with 12 patients with extensor carpi radialis brevis tendinopathy. Multivariate analysis revealed patients with atraumatic posterolateral rotatory instability were more likely to have multiple corticosteroid injections (P = .05) and present with a longer duration of symptoms (P = .03). Postoperative pain scores improved in both groups.

Conclusions

Atraumatic posterolateral rotatory instability should be considered in the differential diagnosis of lateral elbow when patients present with a protracted clinical course. Statistically, posterolateral rotatory instability patients more often present with a history of multiple corticosteroid injections.

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.

Recalcitrant lateral epicondylitis: Early results with a new technique combining ultrasonographic percutaneous tenotomy with platelet-rich plasma injection

PURPOSE

Surgical treatment of recalcitrant lateral epicondylitis [LE] remains difficult, with suboptimal results. This prospective study aimed to determine whether percutaneous epicondylar tenotomy combined with PRP injection under ultrasonography control would optimize the surgery results, with an early gain on pain and strength and a rapid return to professional activities at 3 months. The secondary objective was to determine whether clinical or biological risk factors (e.g., composition of the PRP) affected the outcomes.

METHODS

A total number of 261 Patients with recalcitrant LE underwent percutaneous epicondylar tenotomy under ultrasonography control, coupled with PRP injection. All patients were clinically assessed using VAS pain scale, the functional scores: QuickDASH [Disabilities of the Arm, Shoulder and Hand], Patient-Rated Tennis Elbow Evaluation [PRTEE] and MEPS [Mayo Elbow Performance Score]; Elbow Self-Assessment Score [ESAS]; grip strength; and return to work.

RESULTS

At 3-month follow-up, the VAS score decreased by 3.4 points (SD 2.2; p<0.0001), the QuickDASH decreased by 32.9 points (SD 18.9, range 56.1-23.1; p<0.0001), the PRTEE decreased by 14.8 points (SD 19.1, 49.8-26.4; p=0.017), and the MEPS increased by 19.4 points (SD 13.1, 67.4-86.9; p<0.0001); grip strength increased to 8.3kg (SD 10.7; p<0.0001) and increased by 26% (SD 0.60, 0.7-0.96; p<0.0001) as compared with the opposite side. The ESAS showed 78.3% improvement.

CONCLUSION

Treatment of recalcitrant LE by percutaneous tenotomy combined with PRP injection under ultrasonography control provides rapid recovery in terms of pain and strength, with a high level of satisfaction and a high rate of early return to work.

STUDY DESIGN

Case series.

Long-term outcomes of the modified Nirschl technique for lateral Epicondylitis: a retrospective study

Background

Although the Nirschl technique was introduced approximately 40 years ago, only limited information is available about the long-term results, especially concerning extensor power changes after surgery.

The purpose of this study was to investigate long-term clinical results of surgical treatment of lateral epicondylitis using the modified Nirschl technique. The main outcome variable was muscle strength for wrist extension because the extensor origin was not reattached after removal of the degenerative extensor tendon.

Methods

Data from 99 patients who underwent surgical lateral epicondylitis treatment between 2007 to 2012 were included in the study. The mean follow-up period was 8.5 years (5 to 10, ± 1.1 years) and the mean age at surgery was 44.8 years (32 to 70, ± 9.8 years). The surgeries were performed using the modified Nirschl method and did not include extensor origin reattachment. Outcome measurements included the Visual Analogue Scale (VAS) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, the MAYO elbow performance score, and Nirschl and Pettrone’s grades. Wrist extension and grip strength were analyzed using a digital handgrip dynamometer (microFET2TM system) and JAMA hand dynamometer.

Results

Mean time required to return to work was 2.4 months after surgery. At the last follow-up after surgery, the mean VAS score had significantly improved, from 4.9 to 1.1. Mean MAYO elbow performance scores significantly improved, from 64 to 90, and mean DASH scores improved from 50 to 13. The Nirschl and Pettrone’s grades were 80% rated as ‘excellent’ and 16% rated as ‘good’. After adjusting for power differences between the dominant and non-dominant arms, the difference between wrist extensor power of the operated elbow and the non-operated opposite elbow at the final follow-up was not statistically significant. No patients complained about wrist extension weakness.

Conclusion

Although reattachment of the extensor origin was not performed during the modified Nirschl surgical technique, there was no significant weakness in wrist extension power and the long-term follow-up revealed favorable clinical results.

Level of evidence

Level IV (case series). Retrospective study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04079-x.

Lateral ulnar collateral ligament (LUCL) reconstruction for the treatment of recalcitrant lateral epicondylitis of the elbow: a comparison with open débridement of the extensor origin

Background

Based on the controversy over whether the extensor tendon is the only lesion of lateral epicondylitis of the elbow and numerous reports of concomitant lateral collateral ligament involvement, potential damage to the lateral collateral ligament complex should be considered for the treatment.

Methods

About 25 elbows in 23 patients (débridement group) and 22 elbows in 20 patients (reconstruction group) who were diagnosed with lateral epicondylitis and had an average of 22 months of symptoms revealing anatomical lesion on MRI were included. The capitellum-sublime tubercle-radial head (CSR) angle was measured on both sides preoperatively, and the visual analog scale (VAS) and Mayo elbow performance score (MEPS) were measured over 12 months, postoperatively.

Results

The initial preoperative mean VAS was statistically significant with 4.6 in the débridement group and 6.5 in the reconstruction group (P < .05). Postoperative VAS was continuously decreased in both groups with no significant difference at each assessment period (P < .05) but showed more rapid improvement in the reconstruction group compared with the débridement group. For MEPS, the reconstruction group showed significant improvement during the follow-up periods, and at the final follow-up MEPS, 3 cases in the débridement group and 0 cases in the reconstruction group showed a poor result, which was considered as surgery failure. The CSR angle of the affected side (7.2 ± 1.9) was significantly larger than that of the normal side (3.6 ± 1.5) (P < .05) in the reconstruction group. Increased CSR by more than 5 degrees was identified as a significant predictive indicator for potential concomitant ligament insufficiency (area under curve = 0.875, P < .001) showing 80.9% of the sensitivity, 82.1% of the specificity.

Conclusions

In the surgical treatment of recalcitrant lateral epicondylitis, lateral ulnar collateral ligament reconstruction added to the débridement of extensor origin may provide better results for the patients with suspicious lateral ligament insufficiency or failed previous surgery.

Lateral Epicondylitis-Narrative Review on Surgical Options for Recalcitrant Cases

PURPOSE

Lateral epicondylitis or lateral elbow tendinopathy is a common condition which needs to be addressed appropriately. This condition usually responds well to non-operative treatment. However, an orthopaedic physician needs to be aware of the recalcitrant cases and equip surgical armamentarium to provide adequate care.

METHODOLOGY

The literature search was performed on PubMed, Medline and Google scholar using the keywords Tennis elbow, recalcitrant, thorntons technique, surgical options, for this narrative review.

CONCLUSION

This article focuses on the causes for recalcitrant tendinopathy and review of its surgical options.

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.

Strategy for the treatment of lateral epicondylitis of the elbow using denervation surgery

Background

A number of treatments for lateral epicondylitis of the elbow have been described. We have developed a strategy for the treatment of this condition.

Methods

We diagnosed lateral epicondylitis of the elbow in 86 patients. Conservative treatment resulted in resolution in 71 patients. Surgery was required in the remaining 15 patients. If the posterior branch of the posterior cutaneous nerve of the forearm showed a positive response to local anesthesia (block test), we performed denervation surgery on the posterior branch of the posterior cutaneous nerve of the forearm. Patients were asked to rate the degree of pain and sensory disturbance using a visual analog scale; the 11-item version of the Disabilities of the Arm, Shoulder and Hand measure; and the Patient-Rated Elbow Evaluation.

Results

A positive response to the block test was seen in 10 elbows (67%). After denervation surgery, pain relief was seen in 9 of 10 elbows (90%). The mean follow-up period was 30.4 months. At final follow-up, the average scores on the visual analog scale, 11-item version of the Disabilities of the Arm, Shoulder and Hand, and Patient-Rated Elbow Evaluation were 4.3 mm, 10.45 points, and 5.9 points, respectively. In the early period after denervation surgery, sensory disturbance was observed in 9 cases (90%).

Conclusion

Our strategy of denervation surgery for lateral epicondylitis of the elbow was effective for pain relief among patients showing a positive response to the block test.

Management of lateral epicondylitis

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

Current Trends for Treating Lateral Epicondylitis

Lateral epicondylitis, also known as 'tennis elbow', is a degenerative rather than inflammatory tendinopathy, causing chronic recalcitrant pain in elbow joints. Although most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, few refractory lateral epicondylitis are candidates for alternative non-operative and operative modalities. Other than standard conservative treatments including rest, analgesics, non-steroidal anti-inflammatory medications, orthosis and physical therapies, nonoperative treatments encompass interventional therapies include different types of injections, such as corticosteroid, lidocaine, autologous blood, platelet-rich plasma, and botulinum toxin, which are available for both short-term and long-term outcomes in pain resolution and functional improvement. In addition, newly emerging biologic enhancement products such as bone marrow aspirate concentrate and autologous tenocyte injectates are also under clinical use and investigations. Despite all non-operative therapeutic trials, persistent debilitating pain in patients with lateral epicondylitis for more than 6 months are candidates for surgical treatment, which include open, percutaneous, and arthroscopic approaches. This review addresses the current updates on emerging non-operative injection therapies as well as arthroscopic intervention in lateral epicondylitis.

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.].

Comparison of arthroscopic debridement and open debridement in the management of lateral epicondylitis: A systematic review and meta-analysis

BACKGROUND

Previous studies have reported that both arthroscopic debridement (AD) and open debridement (OD) of extensor carpi radialis brevis are effective in the treatment of lateral epicondylitis. Despite this, few studies have focused on the comparative outcomes of these 2 procedures. The aim of this study was to assess whether AD is superior to OD in managing lateral epicondylitis.

METHODS

A systematic search of the literature was conducted to identify relevant articles that were published in MEDLINE, Embase, and Cochrane Library databases during January 2019. All studies comparing the efficacy of AD and OD in terms of failure rate, complication rate, and clinical outcome measures were included. Statistical analysis was performed using Review Manager.

RESULTS

Six clinical trials were included in the current meta-analysis. There was no significant difference with regard to disabilities of the arm, shoulder, and hand scores, visual analog scale, and failure rate. There was a statistically significant difference in surgical time in favor of the OD (mean difference [MD], -11.45, 95% confidence interval [CI], -12.45 to -10.44, I = 0%, P < .001). There was no significant difference of complication rate between the OD group (0.6%) and the AD group (1.0%) (MD, 0.62; 95% CI, 0.12-3.06; P = .55) CONCLUSION:: There was no significant difference between arthroscopic and open surgery with regards to failure rate, functional outcome score, and complication rate. The current meta-analysis found that arthroscopic surgery had a longer surgical time than open surgery for lateral epicondylitis.

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.

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.

Effect of Radial Nerve Release on Lateral Epicondylitis Outcomes: A Prospective, Randomized, Double-Blinded Trial

PURPOSE

The purpose of our study was to examine the result of lateral epicondylitis surgery with and without posterior interosseous nerve release.

METHODS

We conducted a prospective, randomized, double-blind single-center clinical trial in 54 patients treated surgically for lateral epicondylitis, without any EMG or imaging sign of compression of the posterior interosseous nerve at the arcade of Frohse. The patients were equally divided into intervention (supplemental radial nerve release) and control groups (no radial nerve release). Clinical symptoms and disability related to the upper extremity were assessed by a blinded assessor prior to surgery, using both the Quick Disabilities of the Arm, Shoulder, and hand (QuickDASH) and Mayo Elbow Performance Score (MEPS) and again at 1-, 3-, and 6-month intervals after surgery.

RESULTS

Significant improvement was observed in both groups from the first month after surgery and for the whole evaluation period for both the MEPS and the QuickDASH scores.

CONCLUSIONS

Radial nerve release, in association with surgical treatment for lateral epicondylitis, was not associated with greater improvement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

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.