V-Y slide of the common extensor origin for lateral elbow tendonopathy

Novel Ultrasound-Guided Radiofrequency Ablation of the Medial Epicondylar Sensory Nerve for Recalcitrant Medial Epicondylosis: A Case-Based Technical Report

Recalcitrant medial epicondylosis (ME) is a chronic tendinopathy affecting the common flexor-pronator tendon origin which causes significant pain and functional limitations. Recalcitrant ME is difficult to manage with non-surgical treatment options. The medial epicondylar sensory nerve (MEsn) is a small sensory nerve that travels within the medial intermuscular septum to innervate the osseous-tendinous structures of the medial epicondyle. In this report, we describe a novel technique for the treatment of recalcitrant ME via radiofrequency ablation (RFA) of the MEsn under ultrasound guidance. The MEsn is localized under ultrasound in the medial distal arm, just proximal to the medial epicondyle. Patients with a positive prognostic block of the MEsn subsequently underwent RFA of the MEsn. We have performed this procedure on two patients who have demonstrated improvement in pain and function for up to nearly one year after the procedure. The relief from pain and improvement in function of these patients warrants further investigation and comparative trials with respect to conventional treatment options, as MEsn RFA may be a viable treatment option for recalcitrant ME.

Open Debridement Alone Versus Open Debridement With Tendon Repair for Lateral Epicondylitis: A Comparison of Complications and 5-Year Reoperation Rates From a Large Insurance Database

Background

Open debridement (OD) of the extensor carpi radialis brevis tendon, both with and without repair to the lateral epicondyle, are effective treatments for recalcitrant lateral epicondylitis. However, few comparative studies exist within the literature.

Purpose

To (1) compare the 5-year reoperation rates of patients who underwent OD alone versus OD with tendon repair (ODR) and (2) identify the 90-day adverse event rates, total same-day reimbursement amounts, and national usage trends for these 2 procedures from 2010 to 2019.

Study Design

Cohort study; Level of evidence, 3.

Methods

The PearlDiver MUExtr database was reviewed for patients diagnosed with lateral epicondylitis who underwent OD alone and ODR or reattachment between January 2010 and December 2019. These patients were stratified into 2 cohorts: the OD cohort and ODR cohort. The 5-year reoperation rates were assessed and compared, and the incidence of 90-day postoperative complications and risk factors were identified. The number of ODs and ODRs performed each year and the mean same-day reimbursement amounts (in US$) for both procedures were assessed.

Results

Overall, 41,932 lateral epicondylitis patients who underwent debridement were identified, with 17,139 OD patients and 24,793 ODR patients. There were no significant changes in the proportion of OD versus ODR procedures performed during the study period (P = .18). A significantly higher incidence of hematoma was seen after OD compared with ODR (0.19% vs 0.12%; P = .04), but ODR had a significantly lower 5-year reoperation rate than OD (2.8% vs 3.9%; P = .006), with an absolute risk reduction of 1.1% and a number needed to treat of 91. Finally, ODR ($1683.17 ± $12.15) had a higher mean same-day reimbursement than OD ($1479.05 ± $15.78) (P = .001).

Conclusion

Both OD and ODR had low complication rates. The 5-year reoperation rates were low for both procedures, but they were significantly higher for OD. Over the 10-year study period, there were no significant changes in the relative percentages of OD versus ODR performed. ODR had a significantly higher mean same-day reimbursement.

A Combined Revision Surgical Technique for Failed Operative Lateral Epicondylitis With Concomitant Radial Tunnel Syndrome

Lateral epicondylitis afflicts a large percentage of the population with most recovering through conservative treatment. The 5% to 10% of patients who undergo operative intervention are met with mixed results. Those that fail to improve often demonstrate a complex presentation of inadequate debridement of the "angiofibroblastic tissue," missed concomitant radial tunnel syndrome, and iatrogenic residual devascularized tissue resulting from the index procedure. To address all 3 of these causes of failure, the authors have developed a revision procedure that includes repeat debridement of residual tendinosis, decompression of the posterior interosseous nerve, and a vascularized anconeus muscle flap to help cushion soft tissue defects and promote a healthier environment for healing. Performed initially in part in 20 patients, this combined procedure has developed into our recommended treatment for these challenging patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Lateral elbow tendinopathy: surgery versus extracorporeal shock wave therapy

Lateral elbow pain caused by tendinopathy - tendinosis - or tennis elbow is a highly prevalent problem. Unfortunately, no treatment method can guarantee clinical success. Inspired by the lithotripsy technique used for kidney stones, extracorporeal shock wave therapy (ESWT) has been introduced as an alternative to surgical treatment 25 years ago. In a randomized prospective study, we compared 15 patients with lateral elbow tendinopathy who were operated and 14 who underwent ESWT. Almost all patients had good or excellent outcomes according to the criteria by Verhaar. Subjective improvement was 57% for the ESWT group and 76% for the surgery group. No significant differences between both groups were found (p = 0.07). We therefore recommend considering non-invasive techniques such as ESWT treatment prior to surgery in tennis elbow.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

The Innervation of the Medial Humeral Epicondyle: Implications for Medial Epicondylar Pain

The purpose of this study was identification of the innervation of the medial humeral epicondyle which has not been described before. In 20 patients, the medial intermuscular septum was evaluated histopathologically: the nerve was identified in 15 specimens without S-100 staining, and in the remaining 5 with S-100 staining. In six fresh cadavers, bilateral dissections identified the source of this nerve as the radial nerve in the axilla, coursing adjacent to the ulnar nerve in the upper arm, then moving laterally to be superficial to, or within, the medial intermuscular septum, until the nerve terminated in the periosteum of the medial humeral epicondyle, at the origin of the flexor-pronator muscle mass. In one specimen, a branch from the ulnar nerve in the axilla contributed to this nerve to the medial humeral epicondyle.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined common extensor and supinator aponeurotomy for the treatment of lateral epicondylitis

Pain at the lateral epicondyle and the extensor origin that is attributable to lateral epicondylitis can be successfully treated with a combined aponeurotomy of the supinator and the extensor muscles. This technique has been used at our institution for over 3 decades with good results. Aponeurotomy of the supinator decompresses the posterior interosseous nerve, whereas the extensor aponeurotomy relieves the stresses on the extensor carpi radialis brevis origin. We retrospectively reviewed a series of 56 patients clinically diagnosed with resistant lateral epicondylitis who underwent surgery by a single surgeon with our technique between 2002 and 2010. Patients experienced a subjective improvement in symptoms, visual analog pain score, and grip strength (Jamar II). Only 3% of patients experienced recurrence requiring further treatment.

Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review

BACKGROUND

Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment.

OBJECTIVE

To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis.

METHODS

Searches in PubMed, Embase, Cinahl and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality.

RESULTS

One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found.

CONCLUSIONS

Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.

Change in electromyographic activity of wrist extensor by cylindrical brace

PURPOSE

To verify the effect of a newly-developed cylindrical type forearm brace, which was designed to give focal counterforce perpendicularly on the muscle belly of the wrist extensor.

MATERIALS AND METHODS

The dominant hands of 24 (12 males, 12 females) healthy subjects were tested. Two types of forearm braces (focal cylindrical type and broad pneumatic type) were examined. The braces were applied at the extensor carpi radialis brevis, 5 to 7 cm distal to the lateral epicondyle. Two surface electrodes were attached to the proximal and distal parts of the brace. By quantitative electromyography, the mean amplitudes of voluntary extensor carpi radialis brevis contraction before and after applying each brace were recorded and analyzed.

RESULTS

The mean amplitudes of the focal cylindrical brace and broad pneumatic brace were reduced significantly compared to no brace (p<0.05), with a larger reduction for the cylindrical brace than the pneumatic brace (p<0.05). There was no significant difference between the proximal and distal mean amplitudes with each brace.

CONCLUSION

A cylindrical type brace decreased electromyographic activity in the wrist extensor more effectively than did the pneumatic type brace.

Common extensor origin release in recalcitrant lateral epicondylitis - role justified?

The aim of our study was to analyse the efficacy of operative management in recalcitrant lateral epicondylitis of elbow. Forty patients included in this study were referred by general practitioners with a diagnosis of tennis elbow to the orthopaedic department at a district general hospital over a five year period. All had two or more steroid injections at the tender spot, without permanent relief of pain. All subsequently underwent simple fasciotomy of the extensor origin. Of forty patients thirty five had improvement in pain and function, two had persistent symptoms and three did not perceive any improvement. Twenty five had excellent, ten had well, two had fair and three had poor outcomes (recurrent problem; pain at rest and night). Two patients underwent revision surgery. Majority of the patients had improvement in pain and function following operative treatment. In this study, an extensor fasciotomy was demonstrated to be an effective treatment for refractory chronic lateral epicondylitis; however, further studies are warranted.

Self-reported symptoms of cold intolerance in workers with injuries of the hand

Cold intolerance is a well-recognized complication of crushing injuries and amputations in the hand. These symptoms are usually thought to resolve within 2 years of injury. The objectives of our study were to determine the prevalence and course over time of self-reported symptoms of cold intolerance in workers with hand injuries. Files from a large worker's compensation carrier were randomly selected from index years 2, 4, 6, and 10 after a claim was made. Cohorts comprising cases with diagnostic codes corresponding to traumatic hand injuries and codes referring to non-trauma diagnoses in the hand were assembled for each of the years under consideration. A questionnaire was mailed to a total of 7,088 asking questions related to the symptom of cold intolerance. Twenty-five percent of the surveys were returned. Over 90% of trauma patients from all 4 years reported symptoms of cold intolerance. The rate of cold intolerance in the non-trauma group was between 59% and 69%. Individuals reporting cold intolerance indicated worsening over time in 50% of cases and improvement in only 9%. The severity of injury did not appear to be a factor in the development of cold intolerance. Symptoms of cold intolerance are highly prevalent in workers with significant hand injuries. Workers with non-trauma hand conditions also report a substantial prevalence of this symptom. The development of cold intolerance is not related to injury severity. The symptoms remain either static or deteriorate slightly over time. Improvement is experienced by less than 10% of patients.

Operative management of tennis elbow: a quantitative review

INTRODUCTION

The results of operative management of tennis elbow are varied, and the indications for surgery are not well codified. Many operative techniques are reported, but a clear consensus on whether a given surgical procedure is more effective over another is yet to be reached.

METHODS

We conducted a MEDLINE, CINAHL and EMBASE search on all available scientific articles that reported the outcomes of surgery for lateral epicondylopathy. Keywords used were 'tennis elbow', 'lateral epicondylitis', 'lateral epicondylalgia', 'tendinopathy', 'tendonitis' and 'tendon'. Subheadings used were 'surgery', 'outcomes', 'pathology', 'physiology' and 'operation'. All relevant articles were retrieved. Each article was scored using the Coleman methodology score (CMS), a highly repeatable methodology score, by two independent reviewers, followed by data analysis.

RESULTS

The mean CMS for the 45 studies identified was 43 +/- 9 (of a possible 100 points), with 'number of patients', 'type of study', 'outcome criteria and assessment' and 'subject selection process' being the major low scorers. Also, there was no improvement in the CMS, and hence study design, over the years (intra-class correlation coefficient = 0.45).

DISCUSSION

There is a dearth of quality evidence available to be able to advocate one operative technique over another.

CONCLUSION

We stress the need for well-designed adequately powered randomized controlled trials to be able to understand which of these operative techniques is really superior to the others.

Lateral epicondylitis: review and current concepts

Lateral epicondylitis is a painful and functionally limiting entity affecting the upper extremity and is frequently treated by hand surgeons. The anatomic basis of the injury to the extensor carpi radialis brevis origin appears to be multifaceted, involving hypovascular zones, eccentric tendon stresses, and a microscopic degenerative response. Although many treatments have been advocated, there is little clear consensus on which modality works best, for both conservative and operative options. In this article, we present an overview of this difficult problem and an evidence-based review of treatment choices.

A unified approach to radial tunnel syndrome and lateral tendinosis

Two of the most common diagnoses assigned to patients presenting with lateral elbow and proximal forearm pain are lateral tendinosis and radial tunnel syndrome. Traditionally, these 2 conditions have been treated as distinct and separate entities with most patients being diagnosed with either one or the other, but not both. The extensor carpi radialis brevis (ECRB) and, to a lesser the degree, a portion of the extensor digitorum communis that form the conjoined lateral extensor tendon are thought to be primarily responsible for the excessive traction that induces lateral tendinosis (a degenerative process of microtears in the tendon with impaired healing), but the supinator blends with these same fibers and shares a role in the pathology. The supinator, primarily the arcade of Frohse, has been thought to play the majority role in compressing the posterior interosseous nerve in radial tunnel syndrome, but the undersurface thick tendon of the ECRB may also cause substantial nerve compression. Reduction of the linear tension transmitted by the ECRB is the common element in the various surgical treatments for lateral tendinosis, performed anywhere from directly at the lateral epicondyle to the distal myotendinous junction. Nerve decompression by division of fascial bands is the goal in surgery for radial tunnel syndrome. These 2 surgical approaches need not be mutually exclusive. In fact, this separation of the 2 clinical entities may play a role in the unpredictable results reported in the literature. This article presents a unified approach to treating both pathologies simultaneously including short-term clinical results.

Magnetic resonance imaging findings of refractory tennis elbows and their relationship to surgical treatment

Treatment of tennis elbow is a problem. We performed magnetic resonance imaging (MRI) examinations of 11 elbows in 11 patients who were referred to us with refractory tennis elbow. Of the 11 elbows, 6 showed a high signal intensity focus on MRI T2 images in the tendon of the extensor carpi radialis brevis at the lateral epicondyle. The other 5 elbows showed various abnormal findings on MRI. The mean age of the 6 patients with a high T2 signal focus was 52.0 years, and the mean morbidity period was 25 months. We performed enucleation of the granulation focus through a surgical approach without detachment of the tendon origin of the extensor carpi radialis brevis. Pain was relieved and elbow function recovered in all 6 cases. This study demonstrates that MRI is an important decision-making tool in the surgical treatment of this condition. Enucleation of the granulation focus with high T2 signal has proved to be effective in 6 selected cases.