Rev. bras. ortop. vol.52 número1

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Arthroscopic

surgical

treatment

of

recalcitrant

lateral

epicondylitis

–

A

series

of

47

cases

夽

Alexandre

Tadeu

do

Nascimento

_,

_Gustavo

_Kogake

_Claudio

HospitalOrthoservice,GrupodeOmbroeCotovelo,SãoJosédosCampos,SP,Brazil

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Articlehistory:

Received14December2015 Accepted18March2016

Availableonline21December2016

Keywords:

Tenniselbow/pathology Tenniselbow/therapy Tenniselbow/surgery Arthroscopy

Retrospectivestudies

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Objective:Toevaluatetheresultsofpatientsundergoingarthroscopicsurgicaltreatmentof refractorylateralepicondylitis,identifyingpoorprognosisfactors.

Methods:A retrospective study of44 patients (47 elbows)who underwent arthroscopic debridementoftheextensorcarpiradialisbrevis(ECRB)tendontotreatrefractorylateral epicondylitisfromFebruary2013toFebruary2015,operatedbyasinglesurgeonatone cen-ter.PatientswereassessedbyDASHscore,visualanalogscaleofpain(VAS),andShortForm 36(SF-36).Themeanageatsurgerywas44.4years(32–60).Thedurationofsymptomsprior tothesurgerywasapproximately2.02years(range:6monthsto10years).Meanfollow-up was18.6months(rangeof6–31.9).

Results:ThemeanpostoperativeDASHscorewas25.9points;meanVAS,1.0pointatrest (allthepatientswithmildpain)and3.0pointsatactivity,ofwhich31(66%)casespresented mildpain,10(21%)moderatepain,andsix(13%)severepain;meanSF-36scorewas62.5.A moderatecorrelationwasobservedbetweendurationofpainbeforesurgeryandtheDASH scorewiththefinalfunctionaloutcome.Nosignificantcomplicationswiththearthroscopic procedurewereobserved.

Conclusions:Arthroscopicsurgicaltreatmentforrecalcitrantlateralelbowepicondylitis pre-sentedgoodresults,beingeffectiveandsafe.Theshorterthetimeofpainbeforesurgery andthelowerthepreoperativeDASHscore,thebettertheprognosis.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheHospitalOrthoservice,GrupodeOmbroeCotovelo,SãoJosédosCampos,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](A.T.Nascimento). http://dx.doi.org/10.1016/j.rboe.2016.03.008

Tratamento

cirúrgico

artroscópico

da

epicondilite

lateral

recalcitrante

–

Série

de

47

casos

Palavras-chave:

Cotovelodetenista/patologia Cotovelodetenista/terapia Cotovelodetenista/cirurgia Artroscopia

Estudosretrospectivos

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o

Objetivo:Avaliarosresultadosdospacientessubmetidosatratamentocirúrgicoartroscópico da epicondilitelateral refratáriaa tratamentoconservadore identificar fatoresde pior prognóstico.

Métodos: Estudoretrospectivode44pacientes(47cotovelos)submetidosadesbridamento cirúrgicoartroscópicodotendãoextensorradialcurtodocarpo(ERCC)paratratamentode epicondilitelateralrefratáriaatratamentoconservadordefevereirode2013a fevereiro de2015,operadosporumúnicocirurgiãoemumúnicocentro.Ospacientesforamavaliados peloescoredeDASH,pelaclassificac¸ãovisualanalógicadedor(EVA)epeloShort-Form36 (SF-36).Amédiadeidadenacirurgiafoide44,4anos(32a60).Otempodesintomasantes dacirurgiafoide2,02anos(variac¸ãodeseismesesa10anos).Oseguimentomédiofoide 18,6meses(variac¸ãodeseisa31,9).

Resultados:Amédiadosescorespós-operatóriosfoide25,9pontosnoDASH;1pontonoEVA derepouso(todososcasosdedoresleve)e3pontosnaEVAematividade,31(66%)casos dedoresleves,10(21%)demoderadaseseis(13%)deintensas;SF-36de62,5.Observou-se umacorrelac¸ãomoderadaentreotempodedorantesdacirurgiaeapontuac¸ãonoescore deDASHcomoresultadofuncionalfinal.Nãoforamobservadascomplicac¸õessignificativas comoprocedimentoporviaartroscópica.

Conclusões: Otratamentocirúrgicoartroscópicoparaepicondilitelateralrecalcitrantedo cotoveloapresentabonsresultados,éeficazeseguro.Quantomenorotempodedorantes dacirurgiaequantomenoroDASHpré-operatório,melhoroprognóstico.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Lateralepicondylitis,or“tenniselbow”isthemostcommon complaintrelatedtotheelbow,affecting1–3%oftheadult pop-ulationannually.1,2 _{Despite theclassicaldescriptionrelated} totennis practice, only5–10% ofpatients with epicondyli-tispracticethissport;theconditionismorerelatedtowork activities.3_{Althoughthenamesuggestsaninflammatory} pro-cess, epicondylitis is characterizedas a non-inflammatory condition,atypeoftendinosis withfibroblastandvascular response,calledangiofibroblasticdegeneration.4_Thisisa self-limitingpathology,andthevastmajorityofpatientsimprove withconservativetreatmentonly.However,somefactorssuch asduration ofsymptoms, previousinfiltration, prior ortho-pedic surgery, and work-related compensation, are known toberelatedtopoorprognosis, increasingthe chanceofa needforsurgery.5_{Therecurrencerateis8.5%,andpatients} whosesymptoms last oversix monthshavea highrisk of presentingthemforlong periodsandwillprobablyrequire surgicalintervention6_{;theseareestimatedtorepresent4–16%} ofcases.5,7,8_{Numeroussurgicalprocedurestotreatthis} con-ditionhavebeen described.4,9–11 _{Thevast majorityhave in} commonthereleaseordebridementoftheextensorcarpi radi-alisbrevis(ECRB)tendon.Somefactorshavebeenattributedto poorprognosisaftersurgicaltreatment,especiallyfemale gen-derandinjuryofthecommonextensortendongreaterthan 6mminmagneticresonanceimaging12_(Fig.1).

Arthroscopic surgical treatment of lateral epicondylitis has advantagesover open surgery,including the ability to

debridetheinferiorsurfaceofthetendonwithoutinvading theaponeurosisofthecommonextensor(Fig.2),theability toassessthejointforintra-articularpathology,andashorter rehabilitationperiod.7,13

Material

and

methods

Patients included in this study were operated from Febru-ary 2013 to February 2015by a single surgeon at a single center. Thestudy includedpatients diagnosed with lateral epicondylitis who showedeitherno improvementor unsa-tisfactoryimprovementafterconservativetreatment,which consistedofsixmonthsofphysicaltherapyassociatedwithan orthosisforlateralepicondylitis,twoinfiltrationsortwo intra-muscularsteroidinjections,andmedicationsforpainrelief.

Patients with lateral epicondylitis who had chondral lesions, incipient arthrosis, or cases with previous elbow surgerywereexcluded.

TheDASH,VAS,andSF-36scoreswerecalculatedforall patientspreoperativelyandatthepostoperativefollow-up.

Surgicaltechnique

The surgical technique adopted was based on published reports,1,9_{withsomeadjustments.}

Fig.1–Magneticresonanceimagingshowingcommon

extensortendonlesion(arrow).

tobemovedfrom 90◦ _{offlexion tofullextension.A} pneu-matictourniquetwasplacedattherootofthearm.Surgical landmarksweredrawnontheelbow,includingtheolecranon, lateralepicondyle,medialepicondyle,radialhead,andulnar nerve.

Theelbowjointwasinflatedwith40mLofsaline,placedat theelbowpuncturesiteinthemiddleofatriangleformedby thelateralepicondyle,theradialhead,andtheolecranon,to facilitateentranceofthearthroscopeintotheintra-articular space.

Theanterosuperomedialand anterosuperolateralportals werepreferred,startingwiththeformer,wherethetrochanter andthearthroscopewereplaced.Thesecondportalismade withthehelpofaneedleunderintra-articularvisualizationto

enhanceitspositioning.Acompleteanalysisoftheanterior compartmentoftheelbowjointismade,includingthejoint andthecapsulesurfaces.

Then,a partialcapsulotomyofthe lateralregion is per-formedtoallowthevisualizationoftheECRBorigin,whichis extra-articular.Witharadiofrequencydevice,theECRBtendon isdetachedfromthehumerus.Then,thedisengagedtendon isdebridedwithasofttissueshaverandthelateralportionof thehumerus,withaboneshaver,inordertocausebleeding andcellmigrationtotheregion.TheoriginoftheECRBtendon isnotreinserted.

The collateral ligament may be damaged if the ECRB resectionismade“blindly,”duetothecollapseoftheanterior softtissueinto theviewingspace.Forthis reason,an infu-sionpumpwasusedinallcases(approximately60mmHg), maintainingthejointinflated.

Postoperativeperiod

Intheimmediatepostoperativeperiod,patientswere immo-bilizedwithasling(forthreetofivedays),forcomfortonly; movementwasauthorizedaccordingtopain,andonly exer-tion withthe affected limbwasavoided. Physiotherapyfor range ofmotiongain wasstarted aftertwoweeks; isomet-ricstrengtheningwasinitiatedafterfullrangeofmotionwas achieved,typicallyaroundfourweekspostoperatively. Resis-tanceexerciseswereinitiatedfourtosixweeksaftersurgery. Unrestricted use ofthelimbwas authorizedafter approxi-mately12weeks.

Statisticalanalysis

Statisticalanalysiscomparedthepre-andpostoperative mea-surementswithStudent’st-test.Two-tailedpairedtestswere usedinallcases;p-values<0.05were consideredas signifi-cant.Pearson’scoefficientwasusedtoassesspossiblefactors thatinterfereinthefinalresult;valuesbetween0and0.3were consideredasweakcorrelation,between0.3and0.6,as mod-erate,andgreaterthan0.6,asstrong.Negativevaluesindicate aninversecorrelation;positivevalues,adirectcorrelation.

Results

Inclusioncriteriaweremetby44patients(47elbows),30men and14women.Meanageatsurgerywas44.4years(32–60). The mean duration of symptoms before surgery was 2.02

Fig.2–ArthroscopicimagesshowingacaseofaBakerIIepicondylitis,7_{openingofthelateralcapsule,debridement,and}

Table1–ResultsofDASHandVASscores.

DASH VAS

Preoperativeperiod 50.1±19.9(3.33–90)a _{7.8±1.8(3–10)}a

Postoperativeatrest 25.9±23.8(0–85)a _{1.0±0.9(0–3)}a

Postoperativeduring activity

25.9±23.8(0–85)a _{3.0±2.7(0–9)}a

p-Value <0.001 <0.001

a _{Valuesareexpressedasmeanandstandarddeviation;therange}

ispresentedinparentheses.

years(range: sixmonths to10 years).Meanfollow-up was 18.6months(range:6–31.9).Atotalof31rightelbowsand16 leftwere operated.Thedominantarmwasaffectedin65% ofcases.Overall,82%ofallpatientsdescribedtheirworkas “repetitivemotion”;24%receivedsomesocialsecurity bene-fit.Thecauseofthediseasewasclassifiedasassociatedwith laboractivityin32patients(73%);inthree(7%),duetotennis practice;andinfive(11%),duetotrauma.

The study included patients diagnosed with lateral epicondylitiswho showed eithernoimprovementor unsa-tisfactoryimprovementafterconservativetreatment,which consistedofsixmonthsofphysicaltherapyassociatedwithan orthosisforlateralepicondylitis,twoinfiltrationsortwo intra-muscularsteroidinjections,andmedicationsforpainrelief. TheresultsfortheimprovementintheVASandDASHscores areshowninTable1.ThemeanpostoperativeDASHscorewas 25.9points.Meanpost-operativeVASwas3points;31patients (66%)presentedmildpain,10(21%),moderatepain,andsix (13%),intensepain. For theVAS,painwas assessedduring activities,notduringrest.MeanSF-36was62.5.Threepatients (6.3%)showednoimprovementwiththeprocedure.Thirteen patients(29%)wereamateurathletes;aftertheprocedure,10 (77%)wereabletoreturntothesamelevelofactivitypriorto theinjuryandthree(23%)wereunabletoreturntoprevious sport.Pearson’scoefficientdemonstratedamoderate correla-tionbetweendurationofpainbeforesurgeryandDASHscore withfinalfunctionaloutcome.

TheresultsofSF-36weresubdividedaccordingtoitsareas; thedetailedresultsarepresentedinTable2.

Afterevaluatingresultsofscores,thecorrelationofsome variableswiththeoutcomewasassessed(Table3).Pearson’s coefficientwas usedforthis analysis, and novariable was showntohaveastrong correlationwith theoutcome.Two variablesshowedmoderate correlationwiththe finalDASH

Table3–Pearson’scoefficientforthecorrelation betweenthevariablesandtheoutcomeoftreatmentby DASHandVAS.

DASH VAS

Patientreceivespensionbenefit 0.25 0.20

Repetitivework 0.01 0.01

Age −0.24 −0.15

Durationofpreoperative 0.30 0.16

Pre-opfunctionalcapacitybySF-36 −0.09 −0.16 Pre-oplimitationduetophysicalaspectsby

SF-36

0.3 0.18

Pre-oppainbySF-36 −0.22 −0.13

Pre-opgeneralhealthbytheSF-36 −0.17 −0.09

Pre-opvitalitybySF-36 −0.18 −0.21

Pre-opsocialaspectsbySF-36 −0.29 −0.29 Pre-oplimitationsduetoemotionalaspects −0.13 −0.10

Pre-opmentalhealth −0.13 −0.18

DASH 0.58 0.52

VAS 0.15 0.22

Femalegender 0.1 0.17

10

5

0

20

0 40 60 80 100

DASH pre-op Linear (Series 1)

Relation between pre-op DASH and post-op VAS

VAS post-po

–5

Fig.3–Scatterplot(variable:DASHpre-op).

10 5 0 50 0 DASH pre-op

Relation between DASH pre-op and post-op

DASH post-op

Series 1

Linear (Series 1)

100 –5

Fig.4–Scatterplot(variable:DASHpre-op).

andVAS;thecorrelationwasstrongerforpreoperativeDASH scorethan forduration ofpain beforesurgery.This superi-orityinthecorrelationcanbeobservedinTable3(Pearson’s coefficient),andinthescatterplotsshowninFigs.3–5.

Table2–SF-36–comparisonofthepre-andpostoperativeperiods.a

Functional capacity Limitationdue tophysical aspects Pain General health Vitality Social aspects Limitationsdue toemotional aspects Mental health

Pre-op 67.5±16.9 (25–100)

22.4±35.7 (0–100)

35.8±21.3 (0–80)

69±19.6 (30–100)

55.4±24.5 (5–100)

78.3±27.2 (0–100)

39.5±45.1 (0–100)

63.5±23 (4–100) Post-op 72±21.5

(15–100)

37.5±46.2 (0–100)

55.5±25.2 (10–90)

65.7±21 (15–100)

68±23.5 (0–100)

76.9±24.6 (0–100)

47±45.3 (0–100)

77.7±17.6 (28–100)

p-Value 0.03 0.01 0.000003 0.25 0.004 0.007 0.40 0.0003

100

50

0

0 100

Duration of pain in months

Series 1 Linear (Series 1) Relation between duration of pain pre-op

and DASH post-op

DASH post-op

200 300

Fig.5–Scatterplot(variable:durationofpainbefore

surgery).

Complications

Twopatientshadsuperficialinfection,whichimprovedafter oneweekoforalantibiotictherapy. Asecond debridement was not necessary, and no additional complications were observed.

Discussion

Lateralepicondylitisisacommondiagnosisthatrespondswell toconservativetreatment.Surgicalinterventionisnecessary when symptomsdo notimprove or whenimprovement is unsatisfactoryafteratleastsixmonthsoftreatment,which occurs in 4–16% of cases.5,7,8 _{Thepresent study evaluated} the functional responseand pain inthis groupofpatients withrecalcitrantepicondylitis whounderwent arthroscopic debridementoftheECRB tendon.Significantimprovements wereobservedinscoresstudied,withtheexceptionofonly twoitemsfromSF-36.ResultsobtainedattheVASare con-sistentwiththeliterature,whichshowsslightlybetterresults whenthescoreismeasuredwiththepatientatrestthan dur-ingactivitywiththeupperlimb.14

TheliteratureindicatesthattheDASHscoreresultsforthis typeoftreatmentaregood.Inastudycomparingthe arthro-scopicprocedure withapercutaneoustechnique,theDASH scorewasassessedbeforeandaftersurgery,showing signifi-cantresults(p<0.05).TheDASHscorechangedfrom72to48 pointsinarthroscopiccasesandfrom70to50inthe percu-taneousgroup.15_{Inthepresentstudy,patientshadalower} meanfinalscore(25.9points),butthemeanpreoperative val-ueswerealsolower.OtherBrazilianstudieshavealsoshown goodresultswiththissurgery,observingasignificant improve-mentinthescoresevaluated.16–18

Despitethegoodresults,itshouldbenotedthat approxi-mately23%ofpatientswhowereamateurathletesfailedto returnto the level ofactivity priortothe injury or had to changesports.Anotherpointtoconsideristhatthreepatients (6%ofcases)didnotobserveanyimprovementwithsurgical treatment.

Somestudies indicate that, regardless ofthe technique used,resultsofepicondylitissurgeryarenotuniform.Verhaar etal.19_{reportedapatientsatisfactionrateof66%inoneyearof} follow-up.Onlyone-thirdofthepatientshadreturnedtowork. NirschlandPettrone4_{reportedthat 85%ofpatients treated} withopentechniquehad completereliefofsymptomsand hadnoactivityrestrictions.Inthepresentstudy,onlyseven patients(15%)hadcompleteremissionofsymptomseven dur-ingmanualactivity.

Oneoftheadvantagesofthearthroscopictreatmentis ear-lierrehabilitation.Owensetal.11_{reportedimprovementsin16} patientsafterarthroscopicrelease,withameanreturntowork withoutrestrictionofsixdays.

Baker and Baker20 _{publishedthe long-termresults ofa} cohortstudyandindicatedthattheydidnotdeteriorateover time.Patientswhowerewellaftertwoyearsmaintainedtheir functionallevel,withoutworseningpaininsomecases,even tenyearsaftertheprocedure.

Asforprognosticfactors,preoperativeDASHandduration ofpainpresentedamoderatecorrelation.Thesefactorsmay berelatedtotheseverityofthecondition.Otherstudies12_have detectedasprognosticfactors the femalegender, whichin thepresentstudyshowednoassociation,andthestageofthe conditionatresonance,notassessedinthepresentstudy.

Conclusions

Arthroscopicsurgeryforthetreatmentofrecalcitrantlateral epicondylitis showed good results, representing an effec-tive and safe technique. With this treatment, a significant improvementinallscoreswasobserved.Theshorterthe dura-tion ofpain beforesurgery and thelower the preoperative DASH,thebetterthepostoperativeresultsare.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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