Rev. bras. ortop. vol.48 número6

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

Original

Article

Evaluation

of

patients

submitted

to

the

arthroscopic

treatment

of

the

lateral

epicondylitis

refractory

to

the

conservative

treatment

夽

Fábio

Alexandre

Martynetz

a,b,c

,

Fernando

Ferraz

Faria

c,∗

,

Mauro

José

Superti

c

,

Salim

Mussi

Filho

c

_,

_Larissa

_Martins

_Mourão

_Oliveira

a

a_Pontifícia_Universidade_Católica_do_Paraná,_Curitiba,_PR,_Brazil

b_Institute_of_Orthopedics_and_Traumatology_of_Toledo,_Toledo,_PR,_Brazil

c_Orthopedics_and_Traumatology_Service,_Cajuru_University_Hospital,_Curitiba,_PR,_Brazil

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o

Articlehistory:

Received6November2012 Accepted9April2013

Keywords:

Tenniselbow/surgery Tenniselbow/complications Tenniselbow/therapy Arthroscopy

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b

s

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t

Objective:toevaluatetheresultsofthearthroscopictreatmentofthelateralepicondylitis. Methods:weevaluated14patients(15elbows)submittedtothearthroscopictreatmentof thelateralepicondylitisrefractorytotheconservativetreatment,whichwasrealizedfor aminimumperiodof18months.Beyondthedemographicdatacollection,patientswere evaluatedaccordingtothearthroscopicclassificationofBakeretal.,theDisabilitiesofthe Arm,Shoulder,andHand(DASH)questionnaireandtheMayoElbowPerformanceScore (MEPS).Thepatients’agesrangedbetween23and56years(average46years)(eightmales andsixfemales).Ofthe15elbows,12werethedominantandonepatienthadbilateral lesion.Thefollow-upaftersurgerywasminimum24monthsandmaximum72months (average41months).

Results:wefound,accordingtothearthroscopicclassificationofBakeretal.,twopatients withtypeIlesions,ninewithtypeIIlesionsandthreewithtypeIIIlesions.Wefoundthe followingcomplications:onepatientwithaltered sensitivityintheregionofthelateral portal,onewithadeficitoftendegreesinlength,onewithsynovialplicaandonewith synovitisinthelateralcompartment.OurscoreontheDASHquestionnairewasminimum of32pointsandmaximumof120points(average57points)andthescaleofMEPShada minimumscoreof60pointsandamaximumof100points(average90points).

Conclusion:thearthroscopictreatmentofthelateralepicondylitis,plusinsurance,provides satisfactoryresults.

夽

WorkperformedattheOrthopedicsandTraumatologyService,CajuruUniversityHospital,Curitiba,PR,Brazil.

∗ _{Corresponding}_author_.

E-mail:ferrazfaria@hotmail.com(F.F.Faria).

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Avaliac¸ão

de

pacientes

submetidos

ao

tratamento

artroscópico

da

epicondilite

lateral

refratária

ao

tratamento

conservador

Palavras-chave:

Cotovelodetenista/cirurgia Cotovelode

tenista/complicac¸ões Cotovelodetenista/terapia Artroscopia

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Objetivo: avaliarosresultadosdotratamentoartroscópicodaepicondilitelateral.

Métodos:foramavaliados14pacientes(15cotovelos)submetidosaotratamentoartroscópico daepicondilitelateralrefratáriaaotratamentoconservador,oqualfoifeitoporumperíodo mínimode18meses.Alémdacoletadedadosdemográficos,ospacientesforam avalia-dossegundoaclassificac¸ãoartroscópicadeBakeretal.,oquestionárioDisabilitiesofthe Arm,Shoulder,andHand(DASH)eoMayoElbowPerformanceScore(MEPS).Asidadesdos pacientesvariaramentre23e56anos(médiade46)eforamoitodosexomasculinoeseis dofeminino.Dos15cotovelos,12eramdomembrodominanteeumpacientetinhalesão bilateral.Oseguimentoapósacirurgiafoidenomínimo24mesesenomáximo72meses (médiade41).

Resultados: foramconstatadas,segundoaclassificaçãoartroscópicadeBakeretal.,dois pacientescomlesãodotipoI,novecomlesãodotipoIIetrêscomlesãodotipoIII. Encon-tramosasseguintescomplicações:umpacientecomalteraçãodasensibilidadenaregião doportallateral,umcomdéficitdedezgrausnaextensão,umcomplicasinovialeum comsinoviteemcompartimentolateral.NossapontuaçãonoquestionárioDASHfoideno mínimo32pontosenomáximo120pontos(médiade57)eaescaladeMEPSapresentou pontuaçãomínimade60pontosemáximade100pontos(médiade90pontos).

Conclusão: otratamentoartroscópicodaepicondilitelateral,além deseguro,apresenta resultadossatisfatórios.

Introduction

Lateralepicondylitis,alsoknownas“tenniselbow”,isa condi-tioncommonlyfoundinmedicalpractice.Itaffectsbetween 1%and 3%ofthe populationand is mostfrequentamong individualsbetween35and50yearsofage.Althoughitwas originallythoughtthatthispathologicalconditionwasmostly associatedwiththeactofplayingtennis,theetiologyofthis pain in the lateral region of the elbow ismore related to overuseorrepetitivedorsiflexionandpronosupination exer-tion ofthe wrist. Thediagnosis ismade clinicallythrough identifyingitoccupationallyandfromphysicalexamination. Imagingexaminationsarerarelyneeded.1,2

Lateralepicondylitiswas firstdescribedbyRungeinthe German literaturein 1873. The association with the game of tennis was suggested by Morris ten years later, which led to the term “tennis elbow”, although it also occurs in otherracquetsportsandingolf.Sincethen,therehasbeen discussionregardingthecauses,pathogenesisand possible treatments.1–3

Thepathogenesisoflateralepicondylitisisstilla contro-versialmatter,butitisknownthatnotonlythetendonofthe extensorcarpiradialisbrevis(ECRB)musclebutalsothe annu-larligament,lateralcapsule,radialnerveandsomebandsof thetendonoftheextensordigitorumcommunismuscleare involved.2

It was originally thought that the cause of lateral epi-condylitiswasaninflammatoryprocess,whichwouldthen resultinthesymptoms. However,histologicalstudies have demonstrated that, through repetitive injuries at the site, thereisadegenerativeprocessandafailureofrepairinthe

ECRB tendon. Thisismorepronouncedthan inflammation in other structures. The normal tissue of the ECRB ten-donisinvadedbyimmaturefibroblastsandnon-functioning vascular buds,thereby characterizing what todayis called “angiofibroblasticdegeneration”,whichconsistsof fibroblas-ticandvascularresponsesthataremorecommonlyreferred toastendinosis.2–4

Thereisstillnoconsensusregardingthebestapproachto takeincasesoflateralepicondylitis.Althoughitisa patholog-icalconditionwitheminentlyconservativetreatment,some patientspresentsymptomsthatarerefractorytothis treat-ment.Inthesecases,surgicalinterventionmaybeindicated, and this can be done by means of either an open or an arthroscopic technique. Arthroscopic treatment for lateral epicondylitiswasdescribedrecentlyandpresentsthe advan-tagesofenablingtendondebridement withoutdividingthe aponeurosisoftheextensordigitorumcommunis,evaluation ofintra-articularpathologicalconditionsand,possibly, reha-bilitationwithinashorterperiod.5

Manystudieshavedemonstratedtheimmediatesuccess ofsurgicaltreatmentforlateral epicondylitis.However,few have demonstrated the long-termresults.3 _The_aim_of _the

presentstudywastoreportthelong-termresultsfrom arthro-scopicsurgicaltreatmentinpatientswithlateralepicondylitis that was refractoryto conservative treatment, focusing on theimprovementofthestateofpainandfunctionalityofthe elbow.

Materials

and

methods

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Theresearch project was approvedbythe Research Ethics Committee of the Paraná Culture Association (Associac¸ão ParanaensedeCultura,PUC-PR),bymeansoftheBrazil Plat-form,onMay22,2012(CAAE:01542912.6.0000.0020).

Twentypatientswithlateralepicondylitisthatwas refrac-torytoconservativetreatment,whoweretreatedbymeansof arthroscopicsurgerybetweenAugust2000andOctober2012, wereidentified.Ofthesepatients,16werelocatedtoarrange interviewsinanoutpatientclinicand14cametothe inter-views,totaling15elbows.

The inclusion criteria were that there needed to be a clinicaldiagnosisoflateralepicondylitis,positivesemiology and receipt of conservative treatment for a minimum of 18 months. Patients with neurovascular deficits, cognitive deficits or polyarthralgia, or who had undergone previous surgeryonthisjoint,wereexcluded.

The following data were gathered: sex, age, dominant limb, operated limb, profession, symptoms before surgery, dateofstartofsymptoms,previoustreatmentthathadbeen instituted, duration ofphysiotherapy, number of glucocor-ticoidinfiltrations, date ofthe surgery, complicationsfrom theprocedure,postoperativecomplaintsandrange-of-motion measurementsbeforeandafterthesurgery.

Thepatientswereclassifiedsurgicallyinaccordancewith thescale ofBakeret al.6 _into _lesions_of_type_I_(intact_joint

capsule), typeII (linear/partialcapsule lesion) and typeIII (completecapsulelesion).Duringtheinterviews,thepatients wereaskedtoanswertheDASHquestionnaireandtheywere also assessed functionally bymeans of MEPS.7 _They _were

alsoaskedabouttheirdegreeofsatisfactionwiththe surgi-calresult,throughtheirresponsetobeingaskedwhetherthey wouldundergotheprocedureagain.

Theresults were analyzeddescriptively using the Excel softwaretoconstructtablesandgraphs.

Surgical

technique

Arthroscopywasperformedwiththepatientinventral decu-bitus, under intravenous and plexus anesthesia, with a tourniquetattherootofthelimb.Cefazolin(1g)was adminis-teredintravenouslytoinduceanesthesia.Firstly,theboneand nervestructuresoftheelbowwereidentifiedanddemarcated. Insufflationofthejointwasperformedbymeansofinjection of15mLofphysiologicalserum,andthen ananteromedial portalwasconstructedinorder toclosely inspectthejoint bymeansof30◦_arthroscopy._Following_this,_the_ECRB_tendon waslocated,whichmadeitpossibletoclassifythelesionin accordancewithBakeretal.6₍_Fig.₁_)._An_{anterolateral}_portal

wasconstructedunderdirectviewing,inordertoinsertthe arthroscopy instruments,while the proximal anteromedial portalwasusedtoinsertthecapsuleretractor.

Withthe aid ofa5mmshaver blade,the compromised tissue and the entire origin of the tendon were debrided. Theinsertionbedwasthenscarified(Fig.2).Afterafurther inspection of the joint, the portals were sutured using 3-0monofilament thread.The operatedlimb waspositioned flexedat80◦_using_a_bag-type_sling.

Afterthepatienthad recoveredfrom anesthesia, mobil-ity of the fingers and wrist were stimulated and the limb

Fig.1–Identificationoftheoriginoftheextensorcarpi radialisbrevis(ECRB).

remained immobilizedfor oneweek.Afterthis period, the stitches were removed and the specialized physiotherapy workwasstarted.

Results

SomeofthedatagatheredarepresentedinTable1.

Thepatients’ agesrangedfrom 23 to56years (meanof 46).Therewereeightmalesandsixfemales.Amongthe15 elbows,12wereonthedominantlimb,onewasonthe non-dominant limband onepatient had bilateral injuries.The lengthoffollow-up afterthesurgerywasaminimumof24 monthsandamaximumof72months(mean:41).Themain symptomsreportedbythepatientsbeforethesurgerywere pain,edema,paresisandparesthesia.

Theassociatedcomorbiditiesincludedonecaseof tendini-tisinthewristflexors,onecaseofrotatorcuffinjuryandone caseofuseofantidepressants.

In our sample, all the patients had previously been treated conservatively for a minimum of 18 months and a maximum of 72 months (mean: 30). The treatments instituted had included: relativerest, modification todaily activities,acupuncture,administrationofnon-steroidal anti-inflammatorydrugs(NSAIDs),corticoidinjectionsand phys-iotherapy.Sixpatientshadundergonelocalinfiltration,with anaverageoftwoapplicationsperpatient.

Complicationswere observedin28.5%ofthe cases(one patientwithlocalalterationsofsensitivityintheregionofthe lateral portal,onewithadeficitof10degreesofextension, onewithasynovialplicaandonewithsynovitisinthelateral

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Table1–Resultsobtainedafteroutpatientassessment(n=14).

Patient Sex Age(years) Dominantlimb Sideoperated Profession Durationofprevious treatment(months)

1 M 47 D R Securityman 24

2 F 54 D R Seamstress 72

3 F 36 D L Tilloperator 24

4 M 50 D R Electrician 36

5 M 53 D RandL Electrician 18

6 M 44 D R Electrician 18

7 M 44 D R Metalworker 18

8 F 48 D R Teacher 24

9 F 23 D R Housewife 24

10 M 47 D R Stoneworker 24

11 F 56 D R Retired 60

12 M 51 D R Retired 18

13 M 54 D R Toolmaker 18

14 F 37 D R Cook 24

Patient ROMbefore ROMafter Baker MEPS DASH Wouldyougo

throughthisagain?

1 Noabnormalities Noabnormalities I 100 32 Yes

2 Noabnormalities Noabnormalities II 85 85 No

3 Noabnormalities Noabnormalities II 85 120 Yes

4 Noabnormalities Noabnormalities III 85 65 Yes

7 Noabnormalities Deficitof10degreesofextension III 80 70 Yes

8 Noabnormalities Noabnormalities III 85 52 Yes

9 Noabnormalities Noabnormalities II 60 86 No

14 Noabnormalities Noabnormalities I 100 36 Yes

M,male;F,female;R,right;L,left;ROMbefore,rangeofmotionbeforeoperation;ROMafter,rangeofmotionafteroperation;MEPS,MayoElbow PerformanceScore;DASH,DisabilitiesoftheArm,ShoulderandHand.

compartment).Nocasesofinfectionorpersistentdrainageat theaccessportalswereobserved.

Regarding the postoperative complaints, only three patientsreportedhavinglocalpain.

AccordingtotheclassificationofBakeretal.,6_there_were

twopatientswithtypeIlesions,ninewithtypeIIandthree withtypeIII.OurscoringfromtheDASHquestionnairewasa minimumof32pointsandamaximumof120points(mean: 57),andtheMEPSscoresrangedfromaminimumof60points toamaximumof100points(mean:90).

Discussion

Despite the advances already achieved in relation to the etiopathogenesis of lateral epicondylitis, there is still no consensus regarding its management.3 _In _most _cases, _the

symptoms of lateral epicondylitis are effectively resolved throughrest,modificationofphysicalactivities,useofNSAIDs andphysiotherapy.Newtypesoftreatmentinclude extracor-porealshockwaves,laserapplication,filament lighttherapy andinjectionsofplatelet-richplasma.1,2,8

Onlyafewcases(around8%)presentpainthatisrefractory totheabovementionedmeasures.Aftersixmonthsof inef-fectiveconservativetreatment,surgicalinterventionisthen

indicated.Thismaybeundertakenthroughanopen, percu-taneousorarthroscopicapproach.1,8_Although_six_months_of

conservativetreatmentisrecommendedintheliterature,we choseinourstudytomaintainthistreatmentforaminimum of18monthsbecauseofdifficultyinstartingandfollowingup physiotherapyinthehealthcaresystem.

Themajorityofthesurgicalproceduresfollowthesame principle,consistingofdebridementorreleaseoftheoriginof theECRBtendon.1,5_Open_surgical_intervention_presents_good

results,butfailstoidentifyassociatedintra-articularlesions, whicharepresentin11–69%ofthepatients.9_Moreover,_open

surgerycarriesrisksofligamentinjuries,whichmayleadto elbowinstability.10

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Thearthroscopictechniqueenablesgood viewingofthe elbowjointandthepathological conditionsthatmayexist. However,this technique takes along time to performand surgeonsrequiretrainingandexperienceinordertoachieve goodresults.Theprocedurepresentsresultsthataresimilarto thosefromconventionaltechniquesbut,asreportedby stud-iesinthisregard,thefailurerateislowerandanearlyreturn toactivitiesisenabled.8

InaccordancewiththesurgicalclassificationofBakeretal., itwasfoundthattwopatientshadtypeIlesions,ninehad typeIIlesionsandthreehadtypeIIIlesions.Inthepatient withbilaterallesions,bothofthemweretypeII.Thisshows thatpartialcapsule-tendonlesionswere themostfrequent occurrenceinoursample,whichwasprobablybecauseofthe activitiesperformedbyourpatients.Studieshaveindicated thatthereisnorelationshipbetweenthetypeoflesionand thepostoperativeclinical-functionalevolution.5,6_This_type_of

relationshipwasalsonotfoundinourresults.

InotherstudiesthatmadeevaluationsusingMEPSscores, theresultsweresimilartoours.Kimetal.4_divided₃₈_patients

who underwent the procedure according to the technique used:19patientswhounderwentdebridementandreleaseof theECRBandanother19whoonlyunderwentrelease.Both groupspresentedameanof40pointsonMEPS.Thestudyby Bakeretal.6_included_a_population_of₄₀_patients₍₄₂_elbows)

whounderwentoperationsusingthetechniqueinquestion. Outofthistotal,37patients(39elbows)werefollowedup.Of these,13patientswhoreturnedforasubjectiveclinical exam-inationpresentedamean of93.6points. Inananalysison eightpatientswhounderwentarthroscopy,ZoppiFilhoetal.10

foundscoresgreaterthan90points.Ourscoresrangedfroma minimumof60pointstoamaximumof100points(meanof 90),whichcorroboratesthedataintheliteratureinrelationto satisfactoryfunctionalresults.

TheresultsfromtheDASHquestionnairefoundinthe liter-aturearepromising.Othman8_divided₃₃_patients_with_lateral

epicondylitisintotwogroups:onewith14patientswho under-wentarthroscopyandonewith19patientswhounderwenta percutaneoustechnique.ThescoresfromtheDASH question-nairewereevaluatedbeforeandaftersurgeryandtheresults werefoundtobesignificant(p<0.05).Inthefirstgroup,the scoreimprovedfrom72to48points,andinthesecond,from 70to50 points. Comparingthe postoperativescoresinthe twogroups,therewasnosignificantdifference(p=0.5002).In astudy on18patients whounderwent arthroscopic opera-tions,Wadaetal.12_used_the_Japanese_Hand_Surgery_Society’s

version ofthe DASHquestionnaire.From analysis ontheir results,theseauthorsobservedthatthereweretwofactors relatingtoworseresultsfromthequestionnaire.Thefirstwas lowT2signalattheoriginoftheECRBonpreoperative mag-neticresonanceimaging,andthesecondwasreceiptofpublic assistance.Our patients presentedaminimum scoreof32 pointsandamaximumof120points(mean:57),whichwas alsosimilartotheresultsfromotherstudies.

According to the studies reviewed, most patients who underwent theprocedure declared thatthey were satisfied withtheresultsfromthesurgery.BakerandBakerfoundthat 28(93%)oftheir30patientssaidthattheywouldundergothe surgeryagain.3_In_a_{postoperative}_analysis_on₂₀_patients_with

ameanfollow-upof20months,Miyazakietal.9_found_that

100 52.58 85 93.33 6 8 5 8 60 90 80 70 60 50 40 30 20 10 0

A B C

MEPS DASH

Fig.3–ScoringforpatientsontheMEPSandDASHscales accordingtotheirresponsesrelatingtowhethertheywould gothroughthisoperationagain.(A)Meannumberof patientswhoanswered“yes”;(B)and(C),scoresofthetwo patientswhoanswered“no”.MEPS,MayoElbow

PerformanceScore;DASH,DisabilitiesoftheArm,Shoulder andHand.

onlyonepatientwasdissatisfied withtheresults,and this wasbecausethepatientpresentedreflexsympathetic dystro-phyasasurgicalcomplication.Withameanfollow-upof14 months,ZoppiFilhoet al.10 _found_that_their_eight_patients

weresatisfiedwiththeresults.Lattermanetal.5_reported_that,

outof32patientswithameanfollow-upof3.5years,20(63%) wouldundergothesurgeryagain.Thesedatashowthatthe technique usedpresentedsatisfactory clinicresultsforthe patients,particularlyregardingpaincontrol.

Ourstudy,inagreementwiththosereviewed,alsofound thatthemajorityoftheresponseswerepositivewithregard to satisfaction.Twelve patients (85%)said that they would undergotheprocedureagainandonlytwo(15%)responded negatively.However,thefunctionalevaluationscoresofthese patientsafterthesurgerydidnotjustifytheirdissatisfaction and,thus,noexplanationcouldbefoundfortheirresponses onthebasisoftheresultsfromtheprocedure(Fig.3).

The possiblecomplicationsafter the procedure are rare andconsistofneurovascularlesions,posterolateralligament lesions, hematomas and infection of the surgical wound.8

Moststudies havenotreported anycomplications.6,9,10,12,13

Inananalysison18patientsoperatedusingthistechnique, Cumins14 _also _did _not _report _any _{complications,} _but _this

author’shistologicalanalysisshowedmicroscopicfindingsof residualtendinopathyintenpatients.Lattermanetal.5_had

onepatientwhopresentedparesthesiaintheforearmfortwo weeksafterthesurgery,withspontaneousresolution.Inour sample,wefoundacomplicationrateof28.5%(onepatient withlocalalterationsofsensitivityintheregionofthe lat-eralportal,onewithadeficitof10degreesofextension,one withasynovialplicaandonewithsynovitisinthelateral com-partment).Nonetheless,theprocedurewasshowntohavelow morbidityratesifperformedbyatrainedprofessional.

Lattermanetal.5_considered_that_the_technique_presented

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etal.6_demonstrated_that_only_10%_of_their_patients_presented

painduringtheirdailyactivities.Cummins14_made_a

compari-sonbetweenpreandpostoperativepainamongtheirpatients, bymeansofsomepaincategories.Amongtheir18patients, onlytwodidnotpresentapostoperativeimprovementofpain, andthiswasrelatedonlytothecategoryof“worstpainlevel”. Thisauthorconcludedthatthis resultoccurredinpatients who presented residual microscopic disease. All the eight patientsinthestudybyZoppiFilhoetal.10_evolved_without

painandwithout anylimitationofrangeofmotion.Inour sample,onlythreepatientsreportedhavinglocalpain.

Conclusion

Weconcludethatarthroscopictreatmentoflateral epicondyli-tis presents low morbidity, whichmakes it safe, and good resolutioncapacity,whichenablesimprovementofthestate ofpainandfunctionalityoftheelbow.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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