Rev. bras. ortop. vol.52 número3

rev bras ortop.2017;52(3):315–318

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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

Original

Article

Percutaneous

golfer’s

elbow

release

under

local

anesthesia:

a

prospective

study

夽

Ramji

Lal

Sahu

ShardaUniversity,SchoolofMedicalScienceandResearch,GreaterNoida,India

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Articlehistory: Received18April2016 Accepted13June2016

Availableonline20September2016

Keywords: Golferselbow Percutaneous Localanesthesia

Minimalinvasiveprocedure

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Objectives: Toevaluatetheresultsofpercutaneousgolfer’selbowreleaseunderlocal anes-thesia.

Methods:FromDecember2010toDecember2013,34elbowsin34patients(10malesand24 females)thatpresentedgolfer’selbowforoveroneyearwererecruitedfromtheoutpatient department.Allpatientswereoperatedunderlocalanesthesiaandwerefollowed-upfor 12months.ThefunctionaloutcomewasevaluatedthroughtheMayoElbowPerformance Index(MEPI).

Results:Painreliefwasachievedonaverageeightweeksaftersurgery.Theresultswere excellentin88.23%(30/34)casesandgoodin11.76%(4/34)cases.Neitherwound-related complicationsnorulnar nervecomplicationswereobserved.Onsubjectiveevaluations, 88.23%(30/34)patientsreportedfullsatisfactionand11.76%(4/34)patientsreportedpartial satisfactionwiththeresultsoftreatment.

Conclusion: Percutaneousgolfer’selbowreleaseunderlocalanesthesiaisaminimally inva-siveprocedurethatcanbeperformedinanoutpatientsetting.Thisprocedureiseasy,quick, andeconomical,presentingalowcomplicationratewithgoodresults.

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

Liberac¸ão

percutânea

do

cotovelo

de

golfista

sob

anestesia

local:

um

estudo

prospectivo

Palavras-chave: Cotovelodegolfista Percutânea Anestesialocal

Procedimentominimamente invasivo

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Objetivo:Avaliarosresultadosdaliberac¸ãopercutâneadocotovelodegolfistasobanestesia local.

Métodos:Entredezembrode2010edezembrode2013,34cotovelosem34 pacientes(10 homense24mulheres)queapresentavamcotovelodegolfistahámaisdeumanoforam recrutadosdoambulatório.Todosospacientesforamoperadossobanestesialocaleforam acompanhadospor12meses.OresultadofuncionalfoiavaliadopeloMayoElbow Perfor-manceIndex(MEPI).

夽

StudyconductedintheShardaUniversity,SchoolofMedicalSciencesandResearch,OrthopaedicsDepartment,GreaterNoida,India. E-mail:drrlsahu@gmail.com

http://dx.doi.org/10.1016/j.rboe.2016.06.007

316

Resultados: Oalíviodadorfoialcanc¸adoemmédia,oitosemanasapósacirurgia.Os result-adosforamexcelentesem88,23%(30/34)doscasosebonsem11,76%(4/34)doscasos.Não seobservaramcomplicac¸õesrelacionadasàferidanemcomplicac¸õesdonervoulnar.Em avaliac¸õessubjetivas,88,23%(30/34)dospacientesrelataramsatisfac¸ãototale11,76%(4/34) dospacientesrelataramsatisfac¸ãoparcialcomosresultadosdotratamento.

Conclusão: Aliberac¸ãopercutâneadocotovelodegolfistasobanestesialocaléum procedi-mentominimamenteinvasivoquepodeserrealizadoemambulatório.Esteprocedimentoé fácil,rápidoeeconômico,apresentandoumbaixoíndicedecomplicac¸õesebonsresultados. ©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Golfer’selbowormedialepicondylitisisconsideredthemost commoncauseofelbowpain,affecting1–2%ofthepopulation andresultinginsignificantactivityrestrictionandeconomic burden.1,2 _{The chronic symptoms are typically associated}

with tendon degeneration resulting from repetitive micro-trauma,cellularapoptosis,andautophagiccelldeath.2_More

specifically,patientswithchronicsymptomsdemonstratea histologicpatternofangiofibroblastichyperplasia, character-izedbyfibroblastproliferation,increasedgroundsubstance, disorganizedcollagen,andpoorlyfunctionalneovascularity.3

Majorityofthepatientsrespondtoactivitymodification, non-steroidalanti-inflammatorydrugs,bracing,physicaltherapy, modalities(e.g.,ice,electricalstimulation),andvarious injec-tions,approximately10–15%willberefractoryandtherefore consideredsurgicalcandidates.3_{Multipleopen,arthroscopic,}

andpercutaneoussurgicalprocedureshavebeendescribedto treatelbowtendinopathy,allsharingthefundamentalgoals ofremovingthe pathologictendinotic tissueand stimulat-ingahealingresponse.4_{Sonographicallyguidedpercutaneous}

tenotomyusingultrasonicenergytoremovediseasedtissue hasrecently becomeavailablewith the release ofthe TX1 device.5 _{Theseprocedureshavebeen effectivein75–90%of}

patientsbutexposepatientstooperativerisksandarecovery thatisoftenprolonged.4_{Thepurposeofthisstudywastofind}

outtheoutcomeresultsofpercutaneousgolfer’selbowrelease underlocalanesthesia.

Methods

ThisprospectivestudywascarriedoutatOrthopaedics depart-mentofSMS&R,Sharda University,Greater Noida,UPfrom December2010toDecember2013.Itwasapprovedby insti-tutional medicalethics committee.A totalof 34elbows in 34patientswithgolfers-elbowadmittedtoourinstitutewere includedinthepresentstudy.Twenty-fourpatients(70.58%) werewomenandtenpatients(29.41%)weremale.Allpatients hadunilateralgolferselbow.26casesofgolferselbowwere foundontherightsideandeightcaseswereseenontheleft side.The mean ageofpatients was 45years (range: 30–60 years). A written informed consentwas obtainedfrom all thepatients. Allpatientswere followedfortwelvemonths. The indications for surgery were as follows: more than six monthsofpersistent symptoms despite the aggressive

conservative treatments, suchasrest,drugtherapy, splint-ing,physiotherapy,andahistoryofmorethanthreesteroid injectionsfortreatment,andfunctionalimpairmentatwork and home.Caseswereexcludediftherehad beenprevious surgeryorotherelbowpathologysuchasrheumatoidarthritis, osteoarthritis,orradialtunnelsyndrome.Differential diagno-sisofpainonthemedialaspectoftheelbowincludePronator Syndrome,referredpainfrommyofascialtriggerpointsinthe shoulderandcervical,anyofwhichmaymimicorcoexistwith golfer’selbow.Medialepicondylalgiaandulnarnerve neuro-praxiaarecommonlyassociated.Furthermore,golfer’selbow andulnarnerveneuropraxiaareverycommonlypresentwhen chronicmedialulnarcollateralinsufficiencyexists.

Percutaneous

technique

Thispercutaneousoperativeprocedurewasperformedonan outpatientbasiswithuseoflocalanesthesiaandapneumatic tourniquet.Agentlecurvedstabincisionof0.5cmlongwas madedirectlyoverthe medialepicondyle.Theflexororigin wasexposedandwascompletelydividedtransverselycloseto itsattachmenttothemedialepicondyle.Noremovalofbone anddebridementoftissuewereperformed.Theskinisclosed inroutinefashion.Thereafterlocalpressureappliedto cre-atehaemostasiswhenthetourniquetisreleased.Awooland crepebandagewasappliedthatwasremovedaftersevendays toallowtheearlycommencementofanexerciseprogramme. FunctionaloutcomewasevaluatedaccordingtotheMEPI (MayoElbowPerformanceindex)asdescribedbyTurchinetal.6

MEPIisafour-partscalewhereclinicalinformationisrated basedona100-pointscale,asfollows:

• 90–100:excellent • 75–89:good • 60–74:fair • Below60:poor

1. Pain:Thetherapistasksthepatienthowseverethepain isandhowfrequentlythepainappears.45pointsarefor patients who do not have pain, 30 points are given to patientswhohavemildpain,andmoderatepainresults in15points;patientswithseverepainget0points. 2. Thearcofelbowmotion:20pointsaregivenwhenthearm

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100◦_and50◦_{thepatientisgiven15points.Whenthe}

max-imumflexionisnomorethan50◦_{,then5pointsaregiven.}

3. Stability:Whentheelbowisconsideredstable,10points arescored.Amildlyunstableelbowresultsin5points.An unstableelbowreceives0points.

4. ADL(ActivitiesofDailyLiving):fiveADLsareeach given 5points,viz.combinghair,performingpersonalhygiene, eating,andputtingonshirtandshoes.

Rehabilitation:Atthe2-weekand6-weekfollow-up assess-ments,thewoundwasinspectedforcomplications,and patientswerespecificallyaskedaboutcomplicationsor sig-nificantdiscomfort.Atthe6-weekfollow-up,MEPSscores (MayoElbowPerformanceScore)wereobtained,as previ-ouslynoted.Thereafter,MEPSscoreswereobtainedat3,6, and12months.

Results

There were 34 patients in this study. Out of 100% (34/34), 29.41%(10/34)casesweremaleand70.58%(24/34)caseswere female.Allpatientshadunilateralgolferselbow.76.47%(26/34) cases of golfers elbow were found on the right side and 23.52% (8/34) cases were seen on the left side. The mean ageofpatientswas45years(range:30–60years).Allpatients werefollowedfortwelvemonths.Painreliefwasachievedon averageeightweeksaftersurgery. Functionaloutcomewas evaluatedaccording to theMayo Elbow PerformanceIndex (MEPI).Theresultswereexcellentinthirtypatients(88.23%) andgoodinfourpatients(11.76%).Nowoundrelated compli-cationswereencountered.Noulnarnervecomplicationswere seen.Onsubjectiveevaluations,30patientsreportedfull sat-isfactionandfourpatientsreportedpartialsatisfactionwith theresultsoftreatment.Allpatientshadafullrangeofelbow motionatfollow-upexamination.Allpatientswithexcellent orgoodresultsreturnedtotheirformeroccupationsor activ-ities.Allweresatisfiedwiththeincisionscar.

Discussion

Golfer’selbowoccursinmiddle-agedpeopleofteninvolvedin sportsoroccupationalactivitiesthatrequireastrong hand-grip.Insportscontributingfactors include:over-exertionof thetrailingarmingolf,openinguptoquicklyanddragging thearmbehindthebodywhenpitchingabaseball.Peoplemay alsogetitfromusingtoolslikescrewdriversandhammers, raking, or painting. Initial clinical management of medial epicondylitis involves cessation of the provocative activity, applicationofcoldpackstotheelbow,andoralNSAID ther-apy.Ifthesemeasuresfailtobringrelief,nighttimeuseofa splintandoneormorelocalcorticosteroidinjectionsmaybe necessary.7,8_{Othertreatmentoptionsincludetheapplication}

ofultrasound waves or high-voltage galvanicstimulation.8

Thesetherapiesarefollowedbyaguidedrehabilitation pro-gram in which the intensity and frequency of activity is graduallyincreased,withtheeventualgoalofreinitiationinto fullparticipationinthesuspendedsportingoroccupational activity.Duringrehabilitation,sportingequipmentand tech-niquearereevaluatedandmodifiedifnecessary;forexample, older golfingirons mightbe replaced withlightergraphite

clubs.Thesuccessratesfornonsurgicaltreatmentsofmedial epicondylitisvaryacrosstheliterature,rangingfrom26%to 90%.8 _{Theuse ofMRimagingisthereforemorecommonly}

indicatedinmedialepicondylitisthaninlateralepicondylitis. Surgeryisoftenperformedifthereisnoclinicalresponseafter threetosixmonthsofconservativetreatment.Inourstudy, wealsoincluded34caseswhohadnotrespondedafterthree tosixmonthsofconservativetreatment.Surgicaltechniques includeopen and arthroscopic approaches withdissection, release,anddébridementofthedegeneratedtendon.9,10_For

professionalathletes,earliersurgerymaybeindicatedifthere isevidenceoftendondisruptionatphysicalexaminationand imaging evaluation.Various surgical procedures have been employedformedialepicondylitisasforlateralepicondylitis. Thesurgicaltechniquethatwepreferbeginswithacurvilinear posteriorincisiontosparethemedialcutaneousnerve.Care mustbetakentoprotecttheulnarnerve,aswell.8

Degener-atedperitendinoustissueintheintervalbetweenthepronator teresandtheflexorcarpiradialisisremovedwithaggressive débridement.Multipleholesarethendrilledintotheexposed medialepicondyletoenhancelocalvascularityandpromote amorerobusthealingresponse.Unliketheprocedureusedto treatlateralepicondylitis,thisprocedureincludesfirm reat-tachmentofthe flexor-pronator tendontoits origin atthe medial epicondyle.8 _{An abnormality ofthe ulnar nerve or}

MCL,ifpresent,maybetreatedsurgicallyatthesametime. Because ofthe closeproximityof thenerve and ligament, aggressivetendondébridementisnotperformedformedial epicondylitis.8_{Inacross-sectionalstudyofabout10,000}

ran-domlyselectedadults,11%reportedelbowpainintheprevious week.Ofthosesurveyed,0.6%were diagnosedwithmedial epicondylitis.11 _{Poorprognosticatingfactorsformedial}

epi-condylitis includework activitieswithhigh levelsofstrain, particularlywithnon-neutralwristpostures.12_Immediately

aftersurgery,withtheelbowinflexionat90◦ _andthe

fore-arminneutralposition,aposteriorplastersplintisapplied. Early postoperativemobilization isfollowed by strengthen-ingexercisesatsix–eightweeksandfullactivityatfour–five monthsaftersurgery.8 _{Weprefera percutaneousapproach}

thatallowsashorterrecoverytime,andweencourageearly postoperativemobilizationtherapy.Thegoalinrehabilitation istheeventualreintroductionoftheimplicatedactivitywith correctedbiomechanics.Theliteraturereportsahighsuccess rateforsurgicalprocedures,withoverallpatientsatisfaction andfullreturntopreinjuryactivities.9,10,13_Althoughthe

lit-erature about surgical treatmentof medialepicondylitis is limited, goodtoexcellent resultsarereported, with85%of patientsreturning topreinjuryactivity levelsand reporting overallsatisfaction.8_{Inourstudytheresultswereexcellentin}

88.23%patientsandgoodin11.76%patients.

Conclusion

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relativelysimpleandminimallyinvasiveprocedure.Ithasthe advantageofnotbeingassociatedwithseriouscomplications.

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

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