Recalcitrant Lateral Epicondylitis Research Articles

Arthroscopic ligament debridement combined with tendon repair benefits lateral collateral ligament lesions in recalcitrant lateral epicondylitis patients: A retrospective comparative study

BackgroundUntreated lateral collateral ligament (LCL) lesions in recalcitrant lateral epicondylitis (RLE) may cause residual pain and progressed to elbow instability. However, there is not enough research on the effect of arthroscopic treatment of combined LCL degenerative lesions without instability in RLE patients. The purpose of this study was to 1) evaluate the clinical and radiological results of RLE patients with LCL degenerative lesions without instability who received arthroscopic LCL débridement and ECRB repair, and 2) compare clinical outcomes between RLE patients with LCL degenerative lesion and those without, which received ECRB repair alone. MethodsA retrospective study was performed in which 31 RLE patients with LCL degenerative lesions without instability, who underwent arthroscopic LCL débridement with shaver and radiofrequency combined with ECRB repair with suture anchor arthroscopically between September 2014 and September 2022, comprised the LCL group. The control group (N=31) was matched 1:1 for age (+/- 5 years), sex, involved side, hand dominance, body mass index (BMI), working status, duration of symptoms, steroid/ platelet-rich plasma (PRP) injections and follow-up time. 31 matched RLE patients without LCL lesions, who underwent arthroscopic ECRB repair with suture anchor alone. The visual analog scale (VAS), the Patient-Rated Tennis Elbow Evaluation (PRTEE), the Mayo Elbow Performance Score (MEPS) and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire were evaluated and compared between two groups at preoperative and follow-up periods (at 3, 6, 12 months follow-up). The time duration of back to work was also compared between two groups. Magnetic resonance imaging (MRI) in LCL group were collected. ResultsThere were no significant differences in any clinical outcome at each follow-up time between the two groups(P>0.05 for all). There were no significant differences in time duration of return to work between LCL group and control group (9.4±3.0 weeks vs 8.9±3.4 weeks; p=0.529). There were 26 patients showed abnormal MRI signal of LCL in LCL group preoperatively. At 12 months follow-up, none of them showed abnormal MRI signal. Additionally, there was no complication found in LCL group at the 12 months follow-up. ConclusionIn patients with RLE and degeneration of an intact LCL without instability, débridement of the LCL lesion while repairing the ERCB does not seem to impair outcomes in short-term follow-up when compared to patients with RLE treated by repair of the ERCB with intact LCLs.

Lateral collateral ligament complex insufficiency in recalcitrant lateral epicondylitis: MRI evaluation with arthroscopic findings.

To evaluate the concomitant pathology in recalcitrant LE using MRI with arthroscopic finding correlation. A total of 49 patients were diagnosed with chronic recalcitrant LE and divided into two: LCL complex-intact and LCL complex-involved groups by evaluating MRI as confirmed by a radiologist. Patient information for the history of steroid injection and symptom duration was extracted from the medical records. Arthroscopic images taken during arthroscopic extensor carpi radialis brevis release were evaluated to assess the quality of lateral capsule and concomitant plica. A total of 24 and 25 patients were included in the LCL-intact and LCL-involved groups, respectively. Among them, seven had complete RCL tears recorded in the LCL-involved group. Symptom duration (15 ± 9 vs. 22 ± 13, p = 0.029) and the number of steroid injections (3 ± 2 vs. 5 ± 3, p = 0.040) were significantly higher in the LCL-involved group than that in the LCL-intact group. A capsular tear was detected for 5 (20%) patients in the LCL-intact and 14 (56%) in the LCL-involved group (p = 0.027). Concomitant plica was observed in 15 (62%) patients in LCL-intact and seven (28%) in the LCL-involved group (p = 0.015). RC joint widening was observed in four patients in the LCL-involved group. The recalcitrant LE is highly a concomitant pathology including LCL complex insufficiency and pathologic elbow plica lesion. The risk factors of LCL insufficiency associated with refractory LE may include multiple steroid injections. Arthroscopic finding such as capsular tears and elbow drive-through signs can be suspected signs for LCL complex insufficiency.

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

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

EARLY SURGICAL RESULTS OF SUTURE ANCHOR TENDON REPAIR COMBINED WITH BONE DRILLING TECHNIQUE FOR RECALCITRANT LATERAL EPICONDYLITIS

Objectives: The aim of this study was to report the early results of patients who underwent surgical treatment with suture anchor tendon repair combined with the bone drilling technique for a diagnosis of recalcitrant lateral epicondylitis. Methods: A retrospective analysis was made of 11 patients (2 males, 9 females; mean age: 38.3 years) who underwent surgery with suture anchor tendon repair and the bone drilling technique for a diagnosis of recalcitrant lateral epicondylitis between September 2019 and January 2022. The demographic data of the patients, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, Visual Analog Scale (VAS) value, joint Range of Motion (ROM) values, and the wrist extension, pinch and grip muscle strength measurements at the final follow-up examination were recorded. Results: The mean follow-up period was 18 months (range, 12-26 months), and the time to return to pre-injury activity in 10 patients was determined to be mean 7.3 months (range, 6-9 months). No significant loss of ROM was observed in any patient. The postoperative DASH score was calculated as mean 8.3 (range, 0 -43.5). A decrease of 84% was determined in the VAS scores postoperatively. Wrist extension strength was evaluated as grade 5 in 10 patients and grade 4 in one. The mean pinch strength was +102% of the non-operated extremity, and the mean grip strength was +101% of the non-operated extremity. Conclusion: The suture anchor tendon repair combined with the bone drilling technique can be an effective method in the surgical treatment of recalcitrant lateral epicondylitis, providing an early return to pre-injury activity, pain reduction and maintaining muscle strength

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

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

Comparative study of functional outcomes of open versus arthroscopic surgery of lateral epicondylitis in a tertiary care hospital

Background: Lateral epicondylitis, a degenerative tendinopathy due to microtears in extensor tendons caused by repeated pronation-supination is commonly managed by NSAIDS, physiotherapy, local steroid injections and braces. Although most are self limited, some recalcitrant cases lead to chronic pain and reduction in quality of life. Surgical management by open or arthroscopic means is a viable option but there is a gap of knowledge in current literature regarding superiority of one over the other.Methods: A total of 32 patients with recalcitrant lateral epicondylitis admitted from March 2019 to August 2020 were enrolled and randomized into two groups, receiving either open or arthroscopic debridement of diseased tendons of extensor carpi radialis longus, brevis and communis. Patients were assessed for pain, functional outcome and complications with a 6 month follow-up.Results: VAS score for pain and DASH score for functional outcome improved in all patients after surgery and there was no difference between the two groups. Although mean duration of surgery was significantly longer by arthroscopy, time to return to work was significantly shorter in this group (p&lt;0.001). Difference in complication rate was not statistically significant.Conclusions: Based on this study, surgical management both open and arthroscopic are equally effective for recalcitrant lateral epicondylitis in terms of pain, functional score and patient satisfaction; arthroscopy however shows an earlier return to work. Either can be chosen depending on available skill, equipment and patient demands.

Long-Term Functional Outcomes Following Radiofrequency Microtenotomy for Lateral Epicondylitis of Elbow.

Background Lateral epicondylitis or 'Tennis elbow'is a common cause of elbow pain in the middle-aged group caused by tendinosis of the common extensor origin of the forearm muscles. Though no obvious aetiology is identified in most cases, it could be attributed to repetitive overuse of wrist extensors or supinator muscles. This condition is generally self-limiting but may become persistent in a few cases. Radiofrequency microtenotomy (RFM) is a minimally invasive surgical procedure for recalcitrant lateral epicondylitis of the elbow. This involves targeted coblation of pathological tissue at significantly lower temperatures. Objectives The aim of this study was to evaluate the therapeutic efficacy and report long-term results and recurrences in patients treated with RFM. Methods We present long-term results with a mean eight-year follow-up in a case series of 19 patients. All patients had a minimum of six months (mean 23.25 months and range: 6-36 months) of conservative management which included steroid injections prior to being offered RFM. This was a retrospective case series of 20 elbows (in 19 patients) who underwent RFM.The majority of patients (65%) were females. The operation was carried out in the dominant arm in 55% of patients. Results Results were analysed by comparing pre-operative and post-operative QuickDASH scores (Disabilities of the Arm, Shoulder and Hand Score) obtained at one year and eight years post-operatively. We found an improvement in QuickDASH scores from a mean of 61.7 pre-operatively to 18.9 (p-value < 0.0001) and 8.5 (p-value < 0.0001) at one year and eight years, respectively. The mean pain component of the QuickDASH scores decreased from 4.8 to 2.0 and 1.5, respectively, at one year and eight years (p-value < 0.0001). More than 83% of the patients had excellent to good functional improvement. Conclusion RFMis a reliable modality for treating recalcitrant lateral epicondylitis of the elbow with excellent long-term results.

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.

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

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. The study compared two groups: Group 1, consisting of 25 patients undergoing continued conservative treatment for 24months, 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 6weeks, 24weeks, 12months and 24months. Functional outcomes were compared with grip strength, and patients reported functional outcome scores, pre-intervention and 24months post-intervention. 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 24weeks (P = 0.002) and afterward (P < 0.001).Group 2 had significantly better functional outcome scores at 24months (P < 0.001) though the difference in grip strength was not statistically significant (P = 0.121). The present study shows favourable functional outcomes and pain scores of ARD compared to continued intensive conservative treatment for RLE. II, Non-randomized comparative study. The online version contains supplementary material available at 10.1007/s43465-022-00649-w.

Clinical outcome of percutaneous common extensor tenotomy for recalcitrant lateral humeral epicondylitis

Introduction: Tennis elbow is a commonly encountered problem in orthopaedic clinical practice. The patients are usually in their financially productive years and many a times, this is a work related disorder that becomes severe enough leading for lost work days. Conservative treatment is almost always the first choice; but once it fails, there is no clear consensus for the management of recalcitrant cases. We undertook this study to evaluate the clinical outcomes of percutaneous tenotomy in cases of resistant lateral epicondylitis. Materials and methods: This was a prospective study done over a period of 5 years. A total of 108 patients with recalcitrant tennis elbow were recruited and underwent percutaneous tenotomy. They were followed up for an average period of 14 months. The outcomes measured were: tenderness, DASH score, Roles & Maudsley scale, Visual analogue scale (VAS), and Grip strength. Statistical analysis was done using Paired t-test. Results: 95% patients were pain free after an average of 12 weeks. The 6 months postoperative improvement in VAS score was 6.84 and change in mean DASH score was 23.04. The average increase in mean grip strength was 13.30 kg. These results were statistically significant. Conclusion: Percutaneous tenotomy can be considered as a useful treatment option for resistant cases of tennis elbow.

Tenodesis with bone marrow venting under local anesthesia for recalcitrant lateral epicondylitis: results of 2 years of follow-up.

HypothesisWe hypothesized that the treatment of recalcitrant lateral epicondylitis requires accurate identification of the painful area to promote remodeling of the degenerated extensor insertion and to stabilize the tendon origin during tendon healing. Thus, we performed tenodesis with bone marrow venting under local anesthesia for recalcitrant lateral epicondylitis.MethodsTwenty patients (21 elbows) were treated with bone marrow venting at the painful area of the lateral epicondyle of the elbow and tenodesis using 2 soft anchors lateral to the capitellum (immediately distal to the painful area) and were followed up for ≥2 years. Patients were assessed using the numerical rating scale for pain and the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and objective evaluation included active range of motion.ResultsThe mean preoperative and postoperative pain scores were 7.5 and 0.5, respectively, indicating significant pain relief (P < .001). The mean preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 44.2 and 1.0, respectively (P < .001). Two elbows had a slightly positive Thomsen test at the final visit. No recurrence of intra-articular symptoms induced by synovial fringe impingement was observed. Patients experienced more pain at the bone-tendon junction of extensors than at the tendon parenchyma.ConclusionTenodesis with bone marrow venting under local anesthesia was effective for subjective patient satisfaction and positive clinical outcomes at ≥2 years of follow-up in patients with recalcitrant lateral epicondylitis. Intra-articular symptoms can be improved by stabilization of the lateral soft tissue without treatment for intra-articular lesions.

Hand-Grip Strength and Return to Heavy Manual Work at a Mean 5-Year Follow-up After Arthroscopic Release of Recalcitrant Lateral Epicondylitis

Background:Lateral epicondylitis of the elbow is a common degenerative disorder in middle-aged patients. Surgery is reserved for patients who do not respond to nonoperative treatment.Purpose:To evaluate hand-grip strength and return to heavy manual activities in patients engaged in work requiring heavy lifting after arthroscopic release of refractory lateral epicondylitis.Study Design:Case series; Level of evidence, 4.Methods:The study included consecutive patients who underwent arthroscopic release of the extensor carpi radialis brevis tendon to treat recalcitrant lateral epicondylitis of the elbow, with a minimum 48-month follow-up. Functional outcome measures included assessment of hand-grip strength, visual analog scale for pain, and Mayo elbow performance score. The recorded measurements were compared at postoperative 1 and 6 months and the final assessment. Pre- and postoperative data were compared using the paired t test, and the various postoperative assessments were compared using 1-way analysis of variance.Results:A total of 22 patients (mean ± SD; age, 34.6 ± 5.9 years) with a mean follow-up of 60.5 ± 4.7 months were included in our study. There were highly significant improvements between preoperative and 1-month postoperative results regarding hand-grip strength (17.5 ± 4.1 kg to 34.4 ± 6.8 kg), visual analog scale score for pain (7.86 ± 1.2 to 1.8 ± 1.09), and Mayo score (57.1 ± 7.9 to 89.3 ± 4.9; P < .00001 for all). Significant improvements were found on all 3 functional measures between 1 and 6 months postoperatively (P ≤ .05 was statistically significant), and there were nonsignificant improvements on all measures from 6-month to final follow-up. The patients regained 96.4% of their hand strength as compared with the unaffected side and returned to their previous activities without reporting serious complications.Conclusion:Minimally invasive arthroscopic release of recalcitrant lateral epicondylitis of the elbow provided a satisfactory functional result, as shown by regaining of hand-grip strength in patients engaged in heavy manual occupations without significant morbidities.

Predictive value of magnetic resonance imaging in outcomes of nonsurgical treatment of lateral epicondylitis.

BackgroundThe diagnosis of lateral epicondylitis is typically made on the basis of clinical history and examination. However, magnetic resonance imaging (MRI) is often used to supplement evaluation of the patient with a painful elbow and can identify extensor carpi radialis brevis (ECRB) tendon tears. The objective of this study was to determine if ECRB tear size on MRI could be used as a prognostic indicator for patients with recalcitrant lateral epicondylitis and partial ECRB tears.MethodsForty-one patients with recalcitrant lateral epicondylitis and a partial ECRB tear on MRI were identified (22 men and 19 women; age: 49 ± 8 years; height: 165 ± 36 mm; weight: 73 ± 18 kg). Patients were divided into two groups based on whether they underwent surgery or not. Nonsurgical treatment was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, and surgery was considered a failure of nonsurgical treatment. Nonsurgical treatment was variable and included a mixture of physical therapy, rest, injection therapy, and splinting.ResultsOf the 41 patients, 5 patients opted for immediate surgery and 36 patients were treated nonsurgically. Of those 36 patients, 11 patients had symptom relief, 19 patients had subsequent surgery, and 6 patients chose not to have surgery despite continued symptoms. Tear size on MRI did not differ significantly between the patients who had symptom relief with nonsurgical treatment and the other patients (7.7 ± 4.3 mm vs. 9.7 ± 2.5 mm, P = .07).DiscussionOnly 11 of 41 patients (27%) with recalcitrant lateral epicondylitis and ECRB tear had symptom relief with nonsurgical treatment. However, ECRB tendon defect size on MRI did not predict success or failure of nonsurgical treatment.

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.

BackgroundBased 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.MethodsAbout 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.ResultsThe 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.ConclusionsIn 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.

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

PurposeSurgical 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. MethodsA 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. ResultsAt 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. ConclusionTreatment 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 designCase series.

Arthroscopic Tennis Elbow Management: Prospective Cohort Study

Description of and Prospective analysis of long-term outcomes of arthroscopic tennis elbow release. 70 patients (72 elbows) with lateral epicondylitis, recalcitrant to a minimum of 6 months of supervised conservative management, underwent arthroscopic lateral epicondylar release. Each patient was clinically evaluated pre operatively and post-operatively and a quantitative assessment of the grip strength was collected on both sides with a dynamometer, in full elbow extension and in 90 degrees flexion. Functional assessment with the Mayo Elbow Performance Score and dynamometer grip strengths were collected for the first two years post-operation. Postoperative follow-up averaged 36 months (range 24-45months). The average MEPS increased from 57/100 to 89/100. 66 patients were graded as excellent outcomes, and 4 patients were noted to have fair outcomes. The latter 4 patients were assessed to have type 2 failure, with two subsequently requiring PIN releases, one requiring an osteochondroma excision from the distal lateral humerus, and one patient lost to follow-up. Dynamometer strength returned to above pre-operative level at an average of 3 months and were and average of 35% greater than the pre-operative level at final review. Complications consisted of synovial fistulae (n=8) all of which spontaneously resolved within one month, 2 portal superficial infections, 1 mild anterior capsular contracture, and no neurovascular injuries. Concurrent intra-articular pathology that was noted included radio-capitellar chondrosis (n=22), lateral trochlear chondrosis (n=20), anterolateral synovial plicae (n=17), synovitis (n=13), radial head instability (n=3), and synovial osteochondromatosis (n=1). Arthroscopic tennis elbow release is a valid technique for the treatment of recalcitrant lateral epicondylitis. The results show that pain relief and strength improve significantly up to 3 months post-surgery, and continue to improve for the first 12 months, with little improvement beyond that time.

A retrospective comparative study on arthroscopic suture anchors repair and tendon debridementversusarthroscopic 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

Efficacy of Botulinum Toxin in Treating Lateral Epicondylitis-Does Injection Location Matter?: A Systematic Review.

Clinical trials assessing the efficacy of botulinum toxin in treating recalcitrant lateral epicondylitis have demonstrated varied results and differed greatly in methodology. The objective of this systematic review was to demonstrate injection location as a significant contributor to outcome heterogeneity. Two reviewers independently conducted a systematic review using Scopus, Embase, and PubMed for randomized controlled trials assessing botulinum toxin in the treatment of lateral epicondylitis. After applying inclusion/exclusion criteria to abstracts and reviewing the full-text articles, seven studies were found representing six separate injection locations. Reduction in visual analog scale pain and change in grip strength were the principal outcomes of interest. The largest reduction in pain was seen in injection at 1/3 of the length of the forearm from the lateral epicondyle at 16-wk follow-up, whereas the smallest reduction was seen at 12-wk follow-up after injection at the 0-cm mark. Differences were also identified in grip strength, although all studies reported return to baseline strength by weeks 12-18. This study demonstrates injection location as a potential source of heterogeneity. This clinical question warrants further evaluation with direct comparison of outcomes at different injection locations while controlling for dosage, toxin type, and ultrasound/electromyographic guidance.

Midterm Results of Arthroscopic Treatment for Recalcitrant Lateral Epicondylitis of the Elbow.

An effective treatment for the elbow recalcitrant lateral epicondylitis is arthroscopic surgery. This study evaluated the midterm results of treating recalcitrant lateral epicondylitis with arthroscopic surgery. A total of 40 subjects with recalcitrant lateral epicondylitis prepared for arthroscopic surgery on their elbows participated in this study. The elbow function was evaluated using the Quick disabilities of the arm, shoulder, and hand (Quick DASH) score. Pain intensity was assessed before and after the surgery by the visual analog scale (VAS). Grip and pinch strengths were assessed by a dynamometer. In this study, the mean age of the participants was 42.9±6.4 years. The average follow-up time was 42 months. The mean of VAS (pain intensities) were 7.05 and 3.20 before and after the surgery, respectively (P=0.001). The Quick DASH score decreased from 63.18 to 25.68 from before to after the surgery (P=0.001). The mean grip strength of the operated and nonoperated sides was not significantly different after the surgery. Arthroscopic surgery seems to be an effective method with few complications in patients suffering from an elbow recalcitrant lateral epicondylitis in the midterm follow-up.

Recalcitrant lateral epicondylitis: Early results of a new technique combining ultrasonographic percutaneous tenotomy with Platelet-Rich Plasma injection

Aim:We hypothesized in this prospective study that the addition of an injection of PRP to a percutaneous epicondylar tenotomy under ultrasound control would optimize the results with an early gain on pain, strength, and with a rapid return to professional activities at three months postoperative.Backround:Surgical treatment of patients with recalcitrant epicondylitis remains difficult with suboptimals results. Recently, minimally invasive treatments such as percutaneous epicondylar tenotomy and PRP injections have been described. Few studies have examined the combination of the two techniques especially under ultrasound.Methods:261 patients with recalcitrant lateral epicondylitis were treated by percutaneous epicondylar tenotomy under ultrasound control, coupled with an injection of PRP. We analyzed prospectively the evolution of pain on the visual analogue scale (VAS-P), the functional scores: Quick DASH, PRTEE and MEPS, patient satisfaction (Self Evaluation Elbow), the grip strength and return to work.Results:At 3 months follow up significants improvements were observed in all scores. VAS-P decreased by 3.4 points (SD 2.2; p <0.0001)QuickDash decreased by 32.9 points (SD 18.9, 56.1 to 23.1; p <0.0001)PRTEE droped by 14.8 points (SD 19.1, 49.8 to 26.4; p = 0.017)MEPS rose 19.4 points (SD 13.1, 67.4 to 86.9; p <0.0001)Grip strength gained 8.3 Kg (SD 10.7; p<0.0001) and increased by 26% (SD 0.60, 0,7 to 0.96; p <0.0001) compared to the opposite side.Improvement rate perceived by the patient (SEE) was 78.3% (SD 19.4).Conclusion:Treatment of recalcitrant epicondylitis by percutaneous tenotomy combined with PRP injection under ultrasound control provides rapid recovery on pain and force with a high satisfaction rate at 3 months postoperative.