Tennis elbow (lateral epicondylitis or lateral elbow tendinopathy) is a self-limiting condition in most patients. Surgery is often offered to patients who fail to improve with conservative treatment. However, there is no evidence to support the superiority of surgery over continued nonoperative care or no treatment. New evidence also suggests that the prognosis of tennis elbow is not influenced by the duration of symptoms, and that there is a 50% probability of recovery every three to four months. This finding challenges the belief that failed nonoperative care is an indication for surgery. In this annotation, we discuss the clinical and research implications of the benign clinical course of tennis elbow. Cite this article: Bone Joint J 2023;105-B(2):109–111

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments. Cite this article: Bone Joint J 2013;95-B:1158–64

Objectives. Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade. Methods. A total of 60 patients were included in this prospective randomised study: 30 patients received 2 ml autologous blood drawn from contralateral upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received 2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral epicondyle. Outcome was measured using a pain score and Nirschl staging of lateral epicondylitis. Follow-up was continued for total of six months, with assessment at one week, four weeks, 12 weeks and six months. Results. The corticosteroid injection group showed a statistically significant decrease in pain compared with autologous blood injection group in both visual analogue scale (VAS) and Nirschl stage at one week (both p < 0.001) and at four weeks (p = 0.002 and p = 0.018, respectively). At the 12-week and six-month follow-up, autologous blood injection group showed statistically significant decrease in pain compared with corticosteroid injection group (12 weeks: VAS p = 0.013 and Nirschl stage p = 0.018; six months: VAS p = 0.006 and Nirschl p = 0.006). At the six-month final follow-up, a total of 14 patients (47%) in the corticosteroid injection group and 27 patients (90%) in autologous blood injection group were completely relieved of pain. Conclusions. Autologous blood injection is efficient compared with corticosteroid injection, with less side-effects and minimum recurrence rate

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic tennis elbow release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 29 consecutive patients (30 elbows) with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon. At surgery, arthroscopic assessment of the elbow joint was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral, anteromedial and anterolateral portals. Associated intra-articular pathology was noted. The ECRB lesions were classified according to their gross morphology and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and at 3 months using the DASH score. 29 patients with tennis elbow were treated with arthroscopic release of the ECRB origin on the lateral epicondyle. Of the 30 elbows undergoing surgery, 22 were noted to have a Nirschl type I lesion (intact capsule), 7 had a type II lesion (linear capsular tear) and 1 had a type 3 lesion (capsular rent). Degenerative articular changes were noted in 18 elbows. Arthroscopic debridement was undertaken if appropriate. Three elbows had eccentric radial heads. Radial plicae which were impinging on the radial head were present in three patients. Mean follow up is 9 months (1–23). 1 patient was lost to follow up. There was a significant improvement in DASH scores (p< 0.05) at 2 weeks post operatively. This improvement became more significant at 3 months post operatively. This is a worst case scenario analysis using a paired t test. 6 patients failed to improve, 1 partially improved and 1 was revised and improved. There were no surgical complications; however, one patient has post operative stiffness which required an arthroscopic release. The early results of this study would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology if required. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation and return to normal activities

Purpose: It is known from previous studies that reduced grip strength is associated with tennis elbow; however; assessment of muscular strength over other parts of upper limb, particularly wrist and shoulder, has received a little or no attention in the literature. To address possible other upper extremity muscular strength weakness-imbalances in Tennis Elbow, this study aimed to investigate the strength of various upper limb muscle groups in tennis elbow patients and compare them with those of healthy subjects. Methods: A total of 32 participants were assigned into two groups of Control (N=16) and Tennis Elbow (N=16). In both groups, upper limb maximal isometric muscular of dominant and non-dominant sides was measured at various joints including metacarpophalan-geal (extension & flexion), wrist extension & flexion), grip, and shoulder (internal and external rotation and abduction) using appropriate either commercial or purpose-built dynamometers. Muscular strength and important strength ratios were analyzed and compared in each group (dominant vs non-dominant) and also between Control and Tennis Elbow group using various statistical methods. Results: Significant dominance difference was found in all strength measurements for Control group but not for Tennis Elbow group indicating a generalized and widespread upper limb muscular weakness associated with tennis elbow. In addition, significant differences were found not only for various hand strength measurements but also for shoulder strength between Control and Tennis Elbow groups (p < 0.05). Conclusion: This is the most comprehensive study of upper limb isometric muscular strength assessment in Tennis Elbow during recent years. Distributed upper limb muscle strength weakness exists in Tennis Elbow which needs to be addressed within both preventative and treatment strategies

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 28 consecutive patients with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon. At surgery, arthroscopic joint assessment was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral and medial portals. The ECRB lesions were classified and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and 3 months using the DASH score. Of the 28 elbows 21 were noted to have a Nirschl type I lesion (intact capsule), 6 had a type II lesion (linear capsular tear) and 1 a type III (capsular rent). Degenerative articular changes were noted in 19 elbows. If arthroscopic debridement was required it was undertaken. Three elbows were noted to have eccentric radial heads. Radial plicae which were impinging on the radial head were noted in three patients. 1 patient was lost to follow up. There was a significant improvement in DASH scores (p< 0.002) at 2 weeks post operatively. This improvement was sustained at 3 months. This is a worst case scenario analysis using a paired t test. 1 patient had post operative stiffness and 6 failed to improve of which 2 were revisions. The early results would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation

This study describes percutaneous method of tennis elbow release and medium term results. Materials and Methods: Eighteen patients (20 elbows) were reviewed following percutaneous tennis elbow release. All patients in this series underwent non-operative management with limited or no relief prior to surgery. The mean duration of treatment was 34.04 months prior to surgery. A percutaneous release of common extensor origin was performed under local anaesthetic. A small 1 cm skin incision was employed in all cases. Mean follow- up was 73 months with a range of 8–121 months. All patients except returned to work and normal level of activity. There was one poor result. The mean time to return to work was 5 weeks, with a range of 1 day –12 weeks. Thirteen patients (fifteen elbows) have been clinically examined. Five patients were contacted by phone. Results: Pain after surgery was evaluated with a visual analogue scale. Eighteen elbows (90% of cases) had an excellent result. Pain was rated at zero in seventeen cases. One case rated at zero at rest and two after heavy activity. One elbow (5%) had a good result with pain at zero at rest and raising four on the visual analogue scale after sporting activities (playing tennis for more than one hour). There was no improvement in one case (5%) with a visual analogue score of eight before and after surgery. There were no complications recorded. These results prove that percutaneous elbow release is a viable option in treatment of failed conservative tennis elbow management though astringent selection criteria should be observed

1. Tennis elbow is largely an affliction of middle age, and it is believed that degenerative changes in the orbicular ligament may underlie its pathology. 2. It has been shown that most patients may be relieved by either extra-articular or intra-articular injection of hydrocortisone, and operative intervention is required only in a minority of cases. 3. Contraction of the extensor carpi radialis brevis is considered to be the principal pain-producing factor, and Z-lengthening of the tendon of this muscle has been found to relieve the symptoms when conservative measures have failed. 4. The late results in fifty patients have shown that this operation causes diminution neither of the power of wrist dorsiflexion nor in the efficiency of the grip. The operation may therefore be undertaken with every prospect of relieving the discomfort of tennis elbow without inviting alternative disability

Aim: Description of and Prospective analysis of long-term outcomes of arthroscopic tennis elbow release. Materials and Methods: 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. Results: 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 laeral humerus, and one patient lost to follow-up. Dynamometr 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). Conclusion: Arthroscopic tennis elbow release is a valid technique for the treatment of recalcitrant lateral epicondylitis

The efficacy of extracorporeal shock-wave therapy for tennis elbow was investigated using a single fractionated dosage in a randomised, double-blind study. Outcomes were assessed using the Disabilities of Arm, Shoulder and Hand questionnaire, measurements of grip strength, levels of pain, analgesic usage and the rate of progression to surgery. Informed consent was obtained before patients were randomised to either the treatment or placebo group. In the final assessment, 74 patients (31 men and 43 women) with a mean age of 43.4 years (35 to 71), were included. None of the outcome measures showed a statistically significant difference between the treatment and control groups (p > 0.05). All patients improved significantly over time, regardless of treatment. Our study showed no evidence that extracorporeal shock-wave therapy for tennis elbow is better than placebo

Introduction: Different surgical options are available for the treatment of Tennis Elbow. One of the most simple is percutaneous lateral release. Patients and methods: This prospective study consists of 24 patients; who had persistent symptoms of tennis elbow for an average of 21 months before being operated. All patients received conservative treatment before surgery; only those who did not improve were surgically treated. All of them had percutaneous lateral release of the common extensor tendon under local anaesthetic as a day case. Results: Patients returned to work after an average of four weeks. Pain relief was achieved at an average of eight weeks. Patient satisfaction was 91.6%. The clinical results were evaluated according to pain relief, level of activity and patient satisfaction. The results were good in 22 patients, fair in 1 and poor in 1. Conclusion: We believe that percutaneous release should be offered at an earlier stage for patients who failed conservative treatment. It is a simple, reliable and cost effective surgical procedure

Tennis elbow (lateral epicondylitis) is a common upper limb condition, possibly resulting from angiofibroblastic degeneration. Conservative treatment comprises corticosteroid injections, rest and splints, however, occasionally surgery is necessary. Recent data comparing Botulinum Toxin Type A (BTX-A) (Botox®, Allergan Inc, Irvine, CA) with surgery suggested BTX-A is effective in treating resistant tennis elbow by providing temporary, reversible paralysis of affected muscle, thereby alleviating tensile forces and allowing tissue healing. This double-blind, randomised, controlled trial compared BTX-A with placebo in 40 patients with chronic tennis elbow (> 6 months). Recruited patients were randomised to 50U BTX-A+2mL normal saline or 2mL normal saline (placebo). Injections were administered 5cm distal to the maximal area of lateral epicondyle tenderness. Quality of life (SF-12), pain (visual analogue scale) and grip strength (Jamar dynamometer) were assessed pre- and 3 months post-injection in both affected and non-affected arms. Following BTX-A treatment patients had average 19% improvement in grip strength in the affected arm compared to average 2% for placebo, however, this difference did not reach statistical significance (p=0.08, 95% CI −2.31, 35.64). No difference between the groups was seen for the unaffected arm (BTX-A 4% improvement, placebo 1% improvement). Both groups showed similar improvements in pain assessment and also in quality of life. BTX-A treated-patients demonstrated improved grip strength in the affected arm compared to placebo, however this difference was not statistically significant

Introduction: Tennis Elbow affects 2% of the general population. 90% respond well to conservative management. Different surgical options are available for the treatment of recalcitrant Tennis Elbow. One of the most simple is percutaneous lateral release. Methods: Prospective analysis of 31 patients, who failed a trial of conservative treatment, and underwent a lateral release of the common extensor origin under local anaesthetic as a day case. The symptoms had been present for an average of 21 months. Patients were scored for pain, activity and satisfaction. Results: Pain relief was achieved in 90.3%, patient satisfaction in 90.3% and a return to full activity in 93.5%. The results were good in 28, fair in 2 and poor in 1. Return to work was on average after 4 weeks. Conclusion: It is a simple, safe and effective procedure. It should be offered at an earlier stage, in those who failed conservative treatment. If all other procedures are equally effective, it is logical to choose the simplest

Summary Statement. Applying appropriate upper limb regional-specific and joint-specific tools along with suitable psychologic tools provides an effective assessment of supportive, interventional, and treatment strategies in TE. Background. Tennis elbow (TE) is a painful pathologic condition with its origin in the common wrist extensor muscles at the lateral epicondyle. As the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting, with an annual incidence of 4 to 7 cases per 1000 patients in general practice (with a peak at 35 to 54 yrs of age), TE has considerable socioeconomic costs. As pain relief and improvement in functional performance are the 2 common aims of all treatment strategies, the importance of using appropriate tools for the assessment of pain and functional disability in TE is evident. In view of the high prevalence of TE, uncertainties about its treatment, and its substantial socioeconomic consequences, using more specific, patient-centred assessment tools is essential for providing more useful information on the level of pain and functional disability in TE. The Study aimed to: 1) compare pain and functional disability in tennis elbow (TE) patients with healthy controls; and 2) evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. Methods. Sixteen consecutive TE patients were recruited at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localised lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. Results. Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). Discussion. TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of “upper limb” and “psychologic” assessment tools

We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation. Methods: Three senior orthopaedic surgeons were asked to blindly grade 0.2T dedicated extremity contrast free MRI images of elbows of patients who presented with varying degrees of symptomatic tennis elbow. Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used. Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon. Each surgeon graded 176 MRI images twice. The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5. Results: With regards to the intra observer agreement, consultant A showed 90.1% agreement, consultant B showed 90.6% agreement and consultant C 96.0% agreement. The mean intra observer agreement rate was 92.2%. The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%. It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time. Conclusion: The intra observer agreement rate is high. There is however a greater inter observer variation but this variation is consistent. We suggest that the inter observer differences can be improved by (1) reducing the grades to positive or negative and (2) by group reeducation of the observers

The aim of this study was to evaluate the analgesic effect of extracorporeal shock wave lithotripsy (ESWL) in patients with refractory tennis elbow, golfer’s elbow and plantar fasciitis. Patients with tennis elbow (34), golfer’s elbow (11) and plantar fasciitis lesions (14) who had not responded to a minimum of six months’ conservative treatment were included in this three-year study of ESWL. Patients who were pregnant or had neurological problems, coagulation disorder and tumour in the area of treatment were excluded. Patients received 2 000 shock waves of 0.04 to 0.12 mj/mnf three times at monthly intervals. Patients were followed up for a minimum of six months and maximum of 36 months. The effectiveness of ESWL was assessed in terms of improvement in duration and severity of pain, functional disability, complication of treatment and recurrence. Good or excellent results were achieved in 67.65% of patients with tennis elbow, 45.45% with golfer’s elbow and 71.42% with plantar fasciitis. ESWL seems a useful treatment option, as effective administered monthly as weekly. Its effectiveness in cases of golfer’s elbow in questionable

Failure of conservative treatment for tennis elbow is an indication for surgical decompression. The Topaz® technique utilises radiofrequency to decompress(detension) the tendon and in addition, it is thought to stimulate angiogenesis thereby facilitating healing. Initially we reviewed the three month follow up of 25 tennis elbow decompressions performed using the Topaz® technique. The case notes were reviewed and findings recorded on a structured proforma. After a minimum of 1 year we re-reviewed the case notes to identify recurrences or patients requiring revision surgery. The majority of patients were aged between 35–50 years. 87% of patients had symptoms for more than 12 months and symptoms experienced were mainly pain (100%). All patients had a full trial of physiotherapy and had minimum of two steroid injections. At three month follow up symptoms were completely relieved or improved in 88%. All patients were given an open appointment to review if symptoms recurred. On review of the notes after a minimum of one year, 84% had no further clinic attendances. Four elbows re-attended with symptom recurrence, two underwent traditional open release and two declined revision surgery. In the two patients who declined further surgery, symptoms had resolved at one year. The results of the Topaz® technique are comparable to that of the results of the traditional release from the literature both in terms of success and problems. It would be important to compare it to the traditional release to gauge its benefits against the standard practice

Objective: The main objective of our study was to compare the outcome and complications between open and percutaneous tennis elbow release using the Total Elbow Scoring System (TESS). Our null hypothesis is that there is no difference in patient based outcome measures and morbidity between both groups. Methods: We evaluated a cohort of 40 patients (41 elbows) with clinical evidence of tennis elbow that had surgery after failed conservative treatment. All patients were followed up for a minimum of 12 months and information entered into a structured questionnaire. Other outcomes measures assessed include; Visual Analogue Score (VAS), length of time to return to work, and wound complications. Results: Seventeen (17) and Twenty-four (24) elbows were managed by percutaneous release and open surgery respectively. There were twenty-one female patients (22 elbows) and nineteen male patients (19 elbows). The mean age of the study population was 45years (s.d.: 8.4yrs). The mean duration of symptoms before surgery was 20 months (s.d.: 9.1mths). All 17 elbows that had percutaneous release procedures had a TESS score greater than 80, in comparison to 19 out of 24 elbows with open procedures, although this was not quite significant. (p=0.06). A score of between 80 and 100 is considered good or excellent. Patients that had open surgery had a significantly higher pain (Visual analogue score) VAS in comparison to closed procedures (p=0.01). A significantly higher proportion of patients that had percutaneous procedures were able to return to work within 2 weeks in comparison to open procedures (p-=0.03). There were 4 cases of wound complication that occurred only in patients with open surgery. Conclusion: We conclude that percutaneous release for tennis elbow can produce satisfactory outcomes, with lower morbidity and earlier return to work compared with open procedures

We undertook a prospective, randomised study to compare the analgesic effect of injection of steroid and of extracorporeal shock-wave therapy (ESWT) for the treatment of tennis elbow. Group 1 received a single injection of 20 mg of triamcinolone with lignocaine while group 2 received 2000 shock waves in three sessions at weekly intervals. After six weeks there was a significant difference between the groups with the mean pain score for the injection group falling from 66 to 21 compared with a decrease from 61 to 35 in the shock-wave group (p = 0.05). After three months, 84% of patients in group 1 were considered to have had successful treatment compared with 60% in group 2. In the medium term local injection of steroid is more successful and 100 times less expensive than ESWT in the treatment of tennis elbow

Aim: To assess the outcome of open release of the common extensor origin in the management of tennis elbow after the failure of non operative treatment methods. Methods: 18 patients (24 elbows) between the age group of 38 to 59 who underwent open release of the common extensor origin by the same team after a mean waiting time of 23 months from the onset of pain and a trial of failed non operative methods like analgesics/nsaids, physiotherapy, local steroid injections were contacted and asked to score the effectiveness of surgery after a gap of six months. Since the predominant troubling symptom for all patients was pain they were asked to score the pain relief correlating with the surgery. Results: In 15 patients (83%) excellent pain relief (defined as an 8 or more out of 10 improvement) was achieved and they regained normal use of the limb. One patient (5%) had moderate improvement (score between 6 and 7 out of 10) and two further (11%) patients gained minimal benefit with persistent symptoms (score 5 out of 10). None of the patients suffered deterioration as a result of surgery. Conclusion: This study proves that despite new advances in the treatment of tennis elbow, release of the extensor origin by the open method which is a simple and economical day case procedure, still remains an excellent option in cases where trial of non operative management has failed

We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results

Aims of the Study: To compare the outcome of percutaneous release and formal open release for tennis elbow. Material and Methods: We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by 1 surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOVA were performed. Results: The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=0.012), time to return to work (p=0.0001), improvements in DASH Score (p=0.002) and improvement in sporting activities (p=0.046). There was a trend to improvement in work related activity. Repeated measures ANOVA comparing the pre-operative data for each group were also significant for standardized DASH scores (p=0.0082) and sporting activities (p=0.043). Discussion/Conclusion: Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average 3 weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure

The aim of this study was to review the effectiveness of percutaneous release of the common extensor origin for tennis elbow. The operative technique is similar to that previously reported by Hohmann in 1949. There were 29 patients (31 elbows) that underwent the procedure between 1991 and 1998. There were 14 males and 15 females; 19 were right handed, and 17 had the dominant arm involved. The mean age was 51.8 years (range 34–65); the mean duration of symptoms was 21.7 months (range 8–60 months). All patients had a minimum of 12 months of conservative treatment including NSAIDs, splinting, physical therapy and local anaesthetic and steroid injections (2–6 injections). All operations were performed as day case procedures, with the majority (25) done under local anaesthetic. 24 patients were independently reviewed using Hospital for Special Surgery Elbow Assessment and a questionnaire. Grip strength measurements were performed using JAMAR Dynanometer and the level of patient satisfaction was recorded. 5 patients could not attend the special review clinics. They were contacted over the phone and necessary data recorded. The mean follow up was 45.2 months (range 8–88 months). 24 patients scored above 70 points and were very satisfied, 6 patients were considered failures as their symptoms warranted formal open release operation; only two reported an improvement following the open releases, with the remainder still symptomatic at the last follow up. An overall success rate of 81% was recorded. Complications were rare - one patient who had bruising of forearm after the procedure. In conclusion this procedure can be recommened as an efficacious first line of surgical treatment, with advantages of being safe, quick to perform and with minimal morbidity

We report a controlled, prospective study to investigate the effect of treatment by low-energy extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm. 2. and group II, the control group, 30 impulses. The patients were reviewed after 3, 6 and 24 weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with 6% and 24%, respectively, in group II

Aims: Primary aim of this study was to evaluate the inßuence of simultaneous local anesthesia on the clinical outcome after repetitive low-energy extracorpreal shock wave therapy (ESWT) for chronic tennis elbow. Methods: 51 patients were treated in a randomized single-blind international multicenter trial with a parallel-group design and blinded independent observer to evaluate low-energy ESWT with local anesthesia versus placebo ESWT with local anesthesia for patients with a chronic tennis elbow at three-month follow-up. 85% of patients of the verum group did not achieve good/ excellent results in the Roles & Maudsley score, they were offered once again application of the identical active treatment concept, this time without local anesthesia. 80% of the patients of the placebo group did not achieve good/excellent results, they were offered crossover therapy, i.e. identical active treatment with local anesthesia. Results: Reception of active therapy without local anesthesia resulted in excellent or good outcomes in 80% of patients of the original verum group at three-month follow-up, while application of active therapy with local anesthesia lead to good outcomes in 27% of the original placebo group (p= 0.0092, power= 0.8). Conclusions: Local anesthesia has a negative inßuence on the clinical outcome after repetitive low-energy ESWT for chronic tennis elbow

We performed a prospective, randomised trial on 106 patients to compare the effects of local corticosteroid injections with physiotherapy as advocated by Cyriax in the treatment of tennis elbow. The main outcome measures were the severity of pain, pain provoked by resisted dorsiflexion of the wrist, and patient satisfaction. At six weeks 22 of 53 patients in the injection group were free from pain compared with only three in the physiotherapy group. In the corticosteroid-treated group 26 patients had no pain on resisted dorsiflexion of the wrist compared with only three in the physiotherapy group. Thirty-five patients who had injections and 14 who had physiotherapy were satisfied with the outcome of treatment at six weeks. At the final assessment there were 18 excellent and 18 good results in the corticosteroid group and one excellent and 12 good results in the physiotherapy group. There was a significant increase in grip strength in both groups but those with injections had a significantly better result. After one year there were no significant differences between the two groups. Half of the patients, however, had received only the initial treatment, 20% had had combined therapy and 30% had had surgery. We conclude that at six weeks, treatment with corticosteroid injections was more effective than Cyriax physiotherapy and we recommend it because of its rapid action, reduction of pain and absence of side-effects

We have reviewed 185 articles published since 1966 to assess the scientific evidence for methods of treatment for lateral epicondylitis of the elbow. Of the 185 articles, 78 discussed treatment, but since the natural history of the syndrome is uncertain we considered only those series with concurrent control groups. Only 18 of these were randomised and controlled studies. We then graded these papers for scientific validity, using the methods of Chalmers et al (1981). The mean score of the 18 articles was only 33%, with a range from 6% to 73%. A minimum of 70% is required for a valid clinical trial, and we therefore concluded that there was insufficient scientific evidence to support any of the current methods of treatment. There were too many methodological differences to allow a quantitative meta-analysis, but our qualitative review established the importance of the natural evolution of the syndrome and of the placebo effect of all treatments. Properly designed, controlled trials are needed

Introduction and Aims: To compare the outcome of percutaneous release and fonnal open release for tennis elbow. Method: We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by one surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOV A were performed. Results: The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=O.OI2), time to return to work (p=O.OOOI), improvements in DASH Score (p=O. OO2) and improvement in sporting activities (p=O. O46). There was a trend to improvement in eight in work related activity. Repeated measures ANOV A comparing the pre-operative data for each group were also significant for standardised DASH scores (p=O. OO82) and sporting activities (p=O.O43). Conclusion: Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure

We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by 1 surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOVA were performed.

The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=0.012), time to return to work (p=0.0001), improvements in DASH Score (p=0.002) and improvement in sporting activities (p=0.046). There was a trend to improvement in work related activity. Repeated measures ANOVA comparing the pre-operative data for each group were also significant for standardized DASH scores (p=0.0082) and sporting activities (p=0.043).

Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average 3 weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure.

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience

The June 2024 Shoulder & Elbow Roundup. 360. looks at: Reverse versus anatomical total shoulder replacement for osteoarthritis? A UK national picture; Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; acid for rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials; Metal or ceramic humeral head total shoulder arthroplasty: an analysis of data from the National Joint Registry; Platelet-rich plasma has better results for long-term functional improvement and pain relief for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials; Quantitative fatty infiltration and 3D muscle volume after nonoperative treatment of symptomatic rotator cuff tears: a prospective MRI study of 79 patients; Locking plates for non-osteoporotic proximal humeral fractures in the long term; A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

The August 2013 Shoulder & Elbow Roundup. 360 . looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty

Introduction. Lateral epicondylitis, also known as “tennis elbow,” is a degenerative disorder of the common extensor origin of the lateral humeral epicondyle. The mainstay of treatment is non-operative and includes physiotherapy, activity modification, bracing, nonsteroidal anti-inflammatory drugs, and injections. There is a subgroup of patients however who do not respond to non-operative measures and require operative intervention. Methods. We conducted a retrospective review of prospectively collected data to assess whether the introduction of PRP injections for lateral epicondylitis led to a reduction in patients subsequently undergoing surgical release. Results. Prior to the introduction of PRP injections, a mean of 12.75 patients a year underwent arthroscopic release for tennis elbow. Since PRP introduction this reduced to a mean of 4.25 patients a year. Using a Pearsons chi squared test this is a significant fall in the number of releases required, P<0.001. This significant reduction in patients requiring surgery since PRP introduction leads to an absolute risk reduction of 0.773 and number needed to treat on “as-treated” basis of only 1.3. Conclusion. In conclusion we consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

Musculoskeletal disorders have been recognised as common occupational risks for all orthopaedic surgeons. The nature of tasks performed by hip surgeons often requires both forceful and repetitive manoeuvres, potentially putting them at higher risk of musculoskeletal injuries compared to other orthopaedic sub-specialities. This study aimed to investigate the prevalence of musculoskeletal conditions among hip surgeons and evaluate the association between their workplace and lifestyle factors and musculoskeletal health. An online questionnaire consisting of 22 questions was distributed to UK-based consultant hip surgeons via email and social media platforms. This survey was completed by 105 hip surgeons. The mean age of the respondents was 49 years (range 35–69), with an average of 12 years (range 1–33) in service. 94% were full-time and 6% worked part-time. 49% worked at a district general hospital, 49% at a tertiary centre and 4% at a private institution. 80% were on the on-call rota and 69% had additional trauma commitments. 91% reported having one or more, 50% with three or more and 13% with five or more musculoskeletal conditions. 64% attributed their musculoskeletal condition to their profession. The most common musculoskeletal conditions were base of thumb arthritis (22%), subacromial impingement (20%), degenerative lumbar spine (18%) and medial or lateral epicondylitis (18%). 60% stated that they experienced lower back pain. Statistical analysis showed that being on the on-call rota was significantly (P<0.001) associated with a higher musculoskeletal burden. Regular resistance and/or endurance training and BMI<30 were statistically significant protective factors (P<0.001). Over the last few decades, most of the hip-related literature has focused on improving outcomes in patients, yet very little is known about the impact of hip surgery on the musculoskeletal health of hip surgeons. This study highlights a high prevalence of musculoskeletal conditions among UK-based hip surgeons. Hip surgeons have a pivotal role to play in the ongoing recovery of elective orthopaedics services. There is a pressing need for the identification of preventative measures and improvement in the surgical environment of our hip surgeons

Purpose: It is known from the literature that gripping, which is commonly used in various work-related, sport-related, and daily activities, activates both wrist extensors and flexors. Pain aggravation occurs during grip due to over-exertion of the extensor muscle group in lateral epicondylitis and grip strength is reduced. Of grip strength studies, few studies have simultaneously investigated muscular response using electromyography as a method of monitoring muscular fatigue or muscular activity of forearm muscles. The fatigability and activity of wrist antagonistic muscles in patients with lateral epicondylitis has not been previously investigated. Methods: 16 tennis elbow patients (Tennis Elbow Group) and 16 healthy volunteers (Control Group) were participated in this study. In both groups, local muscular fatigue and muscular activity were measured for 3 forearm muscles contributing to the wrist extension and 2 muscles contributing to the wrist flexion using EMG and during gripping at 50% maximum voluntary contraction (MVC). Fatigability and activity of muscles then were compared between control and tennis elbow groups. Results: Grip strength was significantly lower in tennis elbow group than that in control group (p < 0.05). Median frequency (MDF) and root mean square (RMS) of electromyographic signals were used as parameters to measure muscular fatigue and muscular activity, respectively. Further analysis showed no significant difference in the fatigability of forearm muscles between two groups. The activity of Extensor Carpi Radialis (ECR) showed statistically significant reduction in tennis elbow group compared to the control group (p < 0.05). Conclusion: This is the first study to simultaneously investigate the fatigability and activity of the forearm antagonistic muscle groups in patients with lateral epi-condylitis. The fact that ECR showed similar level of muscular fatigue to other muscles despite decreased muscular activity may indicate of higher fatigability of this muscle in tennis elbow. Furethermore, decreased muscular activity of ECR may be a part of mechanism to protect the muscle from further injury in tennis elbow patients

Several surgical techniques have been described of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeons experience with a modified surgical technique for the treatment of resistant lateral epicondylitis. Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulate developed in two patients by day ten postoperatively. One patient required further surgery for a synovial fistula which healed with no sequelae. There were no other complications following surgery. The postoperative range of motion improved in all patients but remained reduced in four patients. There was a significantly worse outcome for patients with Worker’s compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain free by twelve weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis

Introduction and Aims: Several surgical techniques have been described for the treatment of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeon’s experience, with a modified surgical technique for the treatment of resistant lateral epicondylitis. Method: Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow-up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Results: Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulae developed in two patients by day 10 post-operatively. One patient required further surgery for a synovial fistula, which healed with no sequelae. There were no other complications following surgery. The post-operative range of motion improved in all patients, but remained reduced in four patients. There was a significantly worse outcome for patients with a Workers’ compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain-free by 12 weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. Conclusion: The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis

OBJECTIVE: The purpose of this study is to examine the effect of a single percutaneous injection of platelet-rich-plasma compared to an injection of corticosteroids in patients with chronic lateral epicondylitis. BACKGROUND: Lateral epicondylitis is a common problem that usually resolves with nonoperative treatments. Platelet Rich Plasma (PRP) is a component of whole blood that contains concentrated amounts of powerful growth factors. PRP has been used for a variety of orthopedic applications including tendinopathy, wound healing and spinal fusion with varying degrees of success. Buffered PRP has also been used to enhance cell proliferation in-vitro. HYPOTHESIS: Treatment of chronic severe lateral epicondylitis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem. METHODS: One hundred patients with persistent lateral epicondylar pain were evaluated in this study. All these patients were initially given a variety of nonoperative treatments. These patients had significant persistent pain for at least 3 months despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (experimental group, n = 50) or corticosteroids (control group, n = 50). RESULTS: PRP has a significant better effect on lateral epicondylitis than corticosteroid injections. CONCLUSION: This in-vivo data suggest that tendon healing is occurring in lateral epicondylitis using PRP

Autologous injection of platelet rich plasma (PRP) stimulates healing process in degenerated tendons. The purpose of this study is to compare the functional outcome of lateral epicondylitis treated with PRP and steroid injection. Tennis elbow patients who failed conservative medical therapy were included and were allocated randomly steroid group (n=70) and PRP group (n=63). Data were collected before procedure, at 4, 8, 12 weeks, 1 year and 2 years after procedure. The main outcome measures were visual analogue score, Mayo elbow performance score, DASH score and hand grip strength. Successful treatment was defined as more than a 25% reduction in visual analogue score or DASH score and more than 75 score in Mayo elbow performance score. We observed that 35 of the 70 patients (50%) in corticosteroid group and 47 of the 63 patients (75%) in PRP group were successful, which was significantly different (p<.001), according to DASH score 37 of the 70 patients (53%) and 47 of the 63 patients (75%) in the PRP group were successful which was also significantly different (P = .005), Mayo elbow performance score was successful in 36 of the 70 patients (51%) in corticosteroid group and 49 of the 63 patients (78%) in PRP group. The improvement in hand grip strength of hand from 24.7kg (mean) 26kg in corticosteroid group and 23.5kg (mean) to 32.9kg (mean) in PRP group. PRP injection for chronic lateral epicondylitis reduces pain, improve functionality and hand grip strength when compared to steroid injection

The aim of this study was to document the findings and the pathology of tennis elbow during arthroscopy in patients who had failed conservative treatment for lateral elbow pain with a presumptive diagnosis of lateral epicondylitis (tennis elbow). Materials and Methods: We carried out a prospective study of a consecutive series of 397 patients who underwent elbow arthroscopy for lateral elbow pain previously diagnosed as lateral epicondylitis. All the patients had a period of atleast six months of various conservative treatment modalitiesin the nature of NSAIDS, bracing physiotherapy and ultrasound. The arthroscopy procedures were performed by one of two surgeons using identical standard techniques and the findings were carefully documented. Results: There were 238 men and 159 women in the study group: mean age 51 years (range 21 to 80 years). Synovitis was present in 173(44%), degenerative changes in 232 (58%), common extensor origin inflammation in 173(44%), radial head plica in 121(30%), loose bodies in 85(21%), ostephyte formation in 45(11%) and intra-articular adhesions in 26(6%). Of the 232 patients who had degenerative changes 186(80%) had articular cartilage changes in the lateral compartment(radial head & capitellum), partial thickness loss in n=94(51%) and full thickness cartilage loss in n=92(49%). Conclusion: The clinical diagnosis of lateral epicondylitis is applied to patients who have a variety of pathologies involving the tissues of the lateral compartment of the elbow. In addition to inflammation and degenerative tears of common extensor origin other pathologies such as synovitis, radial head plica, loose bodies and degenerative osteoarthritis should be considered. This diagnosis of tennis elbow is often applied to patients with degenerative changes(osteoarthritis) involving the lateral compartment. Advanced degenerative changes involving the articular cartilage of the lateral compartment can be present in patients with little or no abnormality visible on x-ray. We conclude that arthroscopy is a definitive diagnostic tool to evaluate the various pathologies giving rise to lateral elbow pain and also helps in planning and initiating the appropriate treatment plan directed against specific and accurate conditions causing lateral elbow pain(lateral epicondylitis)

Platelet Rich Plasma (PRP) has shown to be a general stimulation for repair and 1 year results showed promising success percentages. To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a two-year follow-up. A double-blind randomized controlled trial was conducted between May 2006 and January 2008. The trial was conducted in two Dutch teaching hospitals. 100 patients with chronic lateral epicondylitis were randomly assigned to a leucocyte-enriched PRP group (n=51) or in the corticosteroid group (n=49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included Visual Analogue Scale (VAS) pain scores and Disabilities of the Arm, Shoulder, and Hand Outcome (DASH) scores. The PRP group was more often successfully treated than the corticosteroid group (p<.0001). Success was defined as a reduction of 25% on VAS or DASH scores without a re-intervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2 years follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned back to baseline levels, while the PRP significantly improved (as-treated principle). There were no complications related to the use of PRP. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of two years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits

The February 2015 Shoulder & Elbow Roundup. 360 . looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow

The October 2014 Shoulder & Elbow Roundup. 360 . looks at: PRP is not effective in tennis elbow; eccentric physiotherapy effective in subacromial pain; dexamethasone in shoulder surgery; arthroscopic remplissage for engaging Hill-Sach’s lesions; a consistent approach to subacromial impingement; delay in fixation of proximal humeral fractures detrimental to outcomes

The April 2013 Shoulder & Elbow Roundup. 360 . looks at: biceps, pressure and instability; chronic acromio-clavicular joint instability; depression and shoulder pain; shoulder replacement and transfusion; cuff integrity and function; iatropathic plexus injury; the accuracy of acromio-clavicular joint injection; and tennis as a risk factor for tennis elbow

This study presents the clinical outcome of Boyd-McLeod procedure for lateral epicondylitis of elbow. 29 cases with lateral epicondylitis with failed conservative management (rest, physiotherapy, analgesia and steroid injections) were included in the study. There were 14 male, and 15 female cases of which two had bilateral surgery. Data collection included details of patients’ occupation, number of steroid injections, radiograph evaluation and postoperative complications. Post-operative clinical out come was evaluated by Hospital for Special Surgery Total Elbow Scoring System (HSS2), clinical notes review, and telephone questionnaire. Average age: 47 years (range: 34–65), mean post-op follow up time: 16 months (range: 6–32). 93% were manual workers. Dominant elbow involvement was seen in 64%. Mean number of steroid injections: 3 (range: 1–10). Conservative measures included NSAIDS (90%) and physiotherapy (83%). Average tourniquet time: 32 min (range: 18–59). Mean HSS2 score pre-op and post-op were 38 and 92 respectively (p value: 0.0001). 91% reported excellent/good results. Average post-op time for the continuation of professional/recreational activity was 5 weeks. 2 cases (9%) had poor results. One case had ectopic bone formation. Boyd-McLeod procedure is done as a day case procedure involving excision of degenerative tissue from common extensor origin, decortication and decompression of lateral epicondyle and partial release of annular ligament. Although an extensive procedure, this procedure addresses the management of all offending factors that are likely to contribute to pain and disability in tennis elbow. There are few studies regarding the outcome of Boyd-McLeod procedure. There was no evidence to suggest that late presentation had any adverse effect on the post-op success. This study revealed a high success rate and a low complication rate. We conclude that Boyd-McLeod procedure is an effective treatment option in patients with resistant lateral epicondylitis

This is a retrospective review and analysis of cases of tennis elbow or lateral epicondylitis treated from 1996 to 2002. Of 191 patients treated, only 150 were contactable. These were sent self-administered Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires, which 55% patients returned completed. The rest of the patients were interviewed telephonically. Treated conservatively with avoidance of painful activities,non-steroidal anti-inflammatory medication, steroid injection, bracing, and physiotherapy, 83% of patients responded favourably and did not require surgical treatment. DASH scores ranged from 38 to 105 (mean disability < 12%) and compared favourably with those reported in the literature. Conservative treatment of lateral epicondylitis is usually successful and minimal residual disability can be anticipated. The few patients who fail to respond to conservative treatment can be salvaged predictably with low residual disability

Following the recognition of platelet rich plasma (PRP) as an interventional procedure by NICE, patients who had failed standard conservative treatment for chronic elbow tendinitis and referred for surgery were recruited prospectively into a PRP injection study. 52 patients at Torbay Hospital, Devon, UK received PRP injections in 18 months and 37 had a minimum of 6 months follow up. The outcomes in these patients are summarised. There were 16 males and 21 females. 30 had tennis elbow and 7 had golfers elbow. All patients had their symptoms for a minimum of 6 months and had failed to improve with standard conservative treatment. 2 had a failed outcome from previous tennis elbow release surgery. The PRP injections were carried out under ultrasound guidance after correlating the tender spot with neovascularisation on flow Doppler. 31 patients had a single injection; the other 21 patients had 2 injections. Quick DASH score and patients own self-satisfaction was used to measure outcome. 18 patients (48%) were discharged by 6 months. DASH score worsened in 7 patients (19%) and 2 of these patients opted to have surgery, which had no benefit either. No complications were observed with the use of PRP. Overall, by using PRP injections, surgery was avoided in 35 patients (95%) at 18 months and nearly half of the patients were discharged from follow up by 6 months

The best surgical treatment of lateral epicondylitis remains uncertain. Recently radiofrequency microtenotomy (RFMT) has been proposed as a suitable surgical treatment. We aim to compare open release with RFMT and present the results of our randomised controlled trial. Patients with symptoms of tennis elbow for at least 6 months who had failed to respond to conservative management were included in the trial. They were randomised to open release or RFMT. Outcome measures included grip strength, pain and DASH scores. 41 patients were randomised, 23 to RFMT and 18 to open release, 2 patients withdrew from the study. Our results show that both treatments give a significant benefit at all time points for DASH and pain scores, but only open release gives a significant improvement in grip strength. Comparing the two treatments the only significant difference is the open group have better pain scores at 6 weeks, but this is not seen at later follow up. In conclusion both groups have shown benefit from the treatments, but one is not shown to be clearly superior

Aims. Lateral epicondylitis is a frequent pathology usually resolved with conservative methods but ocasionally evolve to chronic unresolved tendinosis. Bipolar Radiofrequency has potentially the effect to stimulate a healing response on chronic tendinosis. We present the results of 15 cases with chronic epicondylitis treated with Bipolar Radiofrequency. Methods. Fifteen patients with chronically lateral epicondylitis and previously failed conservative treatment during 6 months with antiinflamatory drugs, phisiotherapy and at least 3 corticosteroid injections were treated with open Bipolar Radiofrequency. Using local anesthesia, and through a 2 cm incision the tendon was stimulated using the TOPAZ ward (Arthrocare,CA). It was done at 5 mm. distance intervals in a clock-wise fashion in the symptomatic area. The incision was closed with 2 sutures and a compressive bandage was applied. No movement was restricted and rehabilitation began immediately. Results. After an average follow-up of 18 months (6–24), results were excellent in 14 cases and good in one case. The postoperative VAS scores were decreased by 60% at 7 days postoperative, 80% at three weeks and 95% at 6 months. Return to job was at an average of 3 weeks (15 days–4 weeks). All patients were satisfied with the result. Conclusions. Bipolar Radiofrequency is an alternative, effective and safe method for treatment of chronic lateral epicondylitis when conservative treatments are not effective

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humero-ulnar (medial) compartment remains remarkably well preserved. The significance of this post-mortem findings,in an elderly population, with unknown elbow symptom logy, who died from diverse causes, is unknown. There has been no clinically based,in vivo,study of this subject. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment. The findings presented in this work are in full agreement with previous work on the articular wear and biomechanics of the elbow joint. Previous studies which have been on cadaveric specimens, with findings of uncertain symptomatic relevance. To our knowledge, this finding has not previously been demonstrated in a symptomatic, young population. Unicompartmental lateral degeneration of the elbow is therefore a real clinical entity rather than a interesting post mortem finding. As such, it demands consideration in terms of investigation, diagnosis and treatment. It is likely that in the past, many patients have been misdiagnosed as having chronic lateral epicondylitis. We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treatment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes

Purpose: The purpose of this study was to clinically evaluate the efficiency of extracorporal shockwave therapy for enthesopathies. Materials, Methods and Results: 26 patients with mean age of 51 (range: 18–73) which suffered from enthesopathies in different regions were included in this study. Prior to treatment pain and function were assessed subjectively by using a visual analog scale ranging from 1 (maximum pain/minimum function) to 10 (no pain, full function). The follow-up period was 6–18 months with an average follow-up period of 13 months. All patients were treated with ESWT. One to three treatment sessions were provided to each patient with an interval of one week between the sessions. After all sessions were finished, pain and function were reassessed in the same method that was used before the beginning of the treatment. The overall mean pain value was 1.96 before the treatment and 5.92 after the treatment. 8 patients (30.7%) reported no pain at all after the treatment and in 6 patients (23%) a significant improvement in pain was achieved. 7 patients (19%) reported of only slight relief of pain and 4 patients (15.4%) reported no change in pain level. Only in one patient (3.9%) worsening of the pain was observed. The overall mean function capacity was 5.76 before the treatment and 8.65 after the treatment. 11 patients (42%) returned to full functional capacity and in 7 patients (27%) a significant improvement in functional capacity was observed. In 8 patients (30.7%) no change in the functional capacity was noticed. Good results of improvement in pain severity and functional capacity were observed in cases of plantar fasciitis and tennis elbow. Conclusion: We think the EWST is helpful for treatment of enthesopathies, especially plantar fasciitis and tennis elbow, and suggest to include it in treatment algorithms

Introduction: Radial Tunnel Syndrome is characterised by pain over the anterolateral proximal forearm. It is thought to result from compression of the posterior interosseous nerve, and is estimated to be present in 5% of tennis elbow syndrome. This condition has been treated with surgical decompression with varying success. Other nerve compression syndromes are treated with steroid injections and these are reliable in giving relief, even if only temporary. Blind injections have been used as a diagnostic tool in Radial Tunnel Syndrome, but guided steroid injections have not yet been evaluated. Methods: Patients attending one hospital over three years with unresolved lateral epicondylitis were clinically diagnosed with radial tunnel syndrome. They underwent injection of the radial tunnel guided by a nerve stimulator. The patients were evaluated prior to the injection with a brief pain inventory score produced by the British Pain Society. They were evaluated three months after the injection with a further brief pain inventory score. The scores were compared with Student’s t test. Results: Ten patients were recruited over three years. The average pain score before and after injection was not significantly different ( P = 0.4386). An interference score reflecting impeding of function as a result of pain was also not significantly different ( P = 0.095). Discussion: The results of guided injection are worse than a series of blind injections in the literature. We question why this has occurred when the opposite would have been expected. There are several possible explanations. There may have been a double hit phenomenon with the injection only affecting one of two pathological areas. The area of compression may be more proximal to the site of injection. The pathology of radial tunnel syndrome has not been definitively described and the pathology may not be one suitable for treatment with a steroid injection. Post mortem examination of the posterior interosseous nerve in patients with this syndrome may reveal the pathology of the syndrome. Conclusion: Guided injections for radial tunnel syndrome are not effective. The pathology of this syndrome may be different to conventional nerve compression syndromes. We question indications for surgical decompression and suggest further work to investigate this syndrome

Introduction A procedure of selective musculo-tendinous lengthenings is presented as treatment for chronic lateral elbow pain. The rationale for surgery is to decrease tensile force at the lateral epicondyle and simultaneously reduce posterior interosseous nerve compression in the radial tunnel. This study presents biomechanical and clinical data on this surgical technique. Methods In a human cadaver study, force transducer measurements were made in the common extensor tendon, and after sequential tensioning of the muscles arising from the lateral epicondyle. In a separate cadaver study, a balloon catheter measured pressure in the radial tunnel after sequential musculo-tendinous lengthening of the forearm extensor muscles. A preliminary clinical study was performed on 12 subjects (13 elbows). All had failed extensive conservative treatment and subsequently underwent combined musculo-tendinous lengthening of ECRB, EDC, and superficial head of supinator (SHS). In the clinical series, 75% of subjects were involved in Work Cover claims. Clinical outcomes in this small series were reviewed. Results ECRB and EDC tensioning produced the largest force transducer measurements in the common extensor tendon at the lateral epicondyle. SHS increased force transducer measurements moderately, suggesting this muscle may also contribute to the clinical syndrome of lateral epicondylitis. ECRL and ECU tensioning lead to non significant increases in force transducer measurements. Radial tunnel pressure dropped substantially (77%) after musculo-tendinous lengthening of SHS. Lengthening of other forearm extensors had little effect on measured radial tunnel pressure. All subjects recorded improvement in visual analogue pain scores, with post-operative scores between zero and two. Grip strength was preserved or improved. By the criteria of Roles and Maudsley, nine elbows were excellent, two good, one fair and one poor. Overall 11 of the 12 subjects reported they would have the procedure again. Conclusions This study demonstrates a biomechanical basis for SHS in the aetiology of lateral epicondylitis and radial tunnel syndrome, and supports a combined musculo-tendinous lengthening of ECRB, EDC, and SHS in the treatment of chronic lateral elbow pain. Satisfactory clinical results are reported in this group of patients including those involved in Work Cover claims

Introduction. Orthopaedic trauma surgery is characterised by repetitive, forceful tasks that are physically demanding, thus theoretically increasing the risk of musculoskeletal injuries in these surgeons. The aim of this study is to assess prevalence, characteristics and impact of musculoskeletal disorders among orthopaedic trauma surgeons. Methods. A modified version of the physical discomfort survey was sent to surgeon members of the Orthopaedics Trauma Association (OTA) via e-mail. For data analysis, one-way ANOVA and Fisher Exact test were performed to compare the variables where appropriate. P values<0.05 were considered statistically significant. Results. A total of 86 surgeons completed the survey during the period of data collection. Of the respondents 84.9% were males and more than half were aged between 30–45 years old. The majority of musculoskeletal complaints and disorders were low back pain (29.3%), wrist or forearm tendinitis (18.0%), elbow lateral epicondylitis (15.4%), plantar fasciitis (14.7%). When data was analysed according to number of years in practice the results yielded a significant difference between the groups in both number of regions involved (p<0.05) and number of musculoskeletal disorders (p<0.05), as a higher proportion of these were documented in surgeons practicing for 16–20 years and more than 30 years. Also surgeons working in a private setting (p<0.005), surgeons working in more than one institute (p<0.005), increased number of regions involved (p<0.001) and increased number of musculoskeletal disorders (p<0.001) were significantly more likely to require time-off work. Conclusion. To our knowledge, our study is the first of its kind that shows a high percentage of orthopaedic trauma surgeons sustain occupational injuries some time in their careers. Cost of management and rehabilitation of these injuries, in addition to the amount of missed workdays due to these injuries indicate that these injuries have a significant economic burden on the health-care system

The December 2022 Shoulder & Elbow Roundup³⁶⁰ looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae.

Lateral Epicondylitis is a common condition caused by angiofibroblastic hyperplasia of the tendinous insertion. Its treatment is varied and includes rest, physiotherapy, corticosteroid injection and surgical release. Of late, the role of Platelet Rich Plasma (PRP) injections have been explored, with positive results. We prospectively assessed the outcomes of lateral epicondylitis treated with PRP injections and compared the outcomes of ultrasound guided and ‘blind’ injection. This was a single centre prospective cohort study. Patient were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) Score. PRP was injected into and around the common extensor origin either with or without ultrasound guidance. The primary outcome measure was DASH score at 3 months. 45 (23F:22M) patients were recruited. The mean age was 50 years (range 35 to 79). The mean duration of follow-up was 106 days. The average pre-injection DASH score for both groups combined was 45.5 (11.7–87.5). The mean DASH score at 3 months follow-up was 27.7. The ultrasound guided injection group had a mean improvement in DASH score from 45.5 to 31.2. The “blind” injection group had a mean improvement in DASH from 44.4 to 27.7. No complications were noted. There was no statistically significant difference in improvement in DASH score between the two groups. Our study provides further evidence to support of the use of PRP injections in the treatment of epicondylitis of the elbow. Interestingly, however, we found that the use of Ultrasound guidance does not appear to improve patient outcomes

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

1. Resistant cases of tennis elbow are explained on the basis of an entrapment neuropathy of the radial nerve and its branches. 2. An operation is described to explore these nerves through an anterior muscle-splitting incision. 3. Thirty-eight elbows in thirty-six patients have been operated on with improvement in all

Background. Since its first description, the pathology, natural history and treatment of lateral epicondylitis have remained controversial. For those who fail conservative management, surgery remains an option. The optimal method of surgery remains debatable and is further confounded by a relative lack of long-term follow up studies. Material and methods. This study describes a previously unpublished surgical technique and presents its long term results. Patients undergoing this open technique were reviewed using the HSS-1 and Mayo elbow performance assessment tools as well as having grip strength and subjective outcome recorded. Results. From June 1986 to December 2001 inclusive, 158 consecutive patients (171 elbows) underwent surgery in a single surgeon series. They were followed up to a mean of 9.8 years. The mean age of the group was 42 years and 86.7% of patients were available for follow up. Subjectively, 94.6 % were good to excellent with 92.6-94.0% good to excellent using the HSS-1 and Mayo scores respectively. No differences were noted in grip strength. No patient required revision surgery. Discussion/Conclusions. This repeatable open technique offers excellent results with low complications at a mean follow up of 9.8 years. These results compare favourably in terms of numbers followed up, length of follow up and outcome and offer strong evidence of its efficacy

Microtenotomy coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no studies to show the effectiveness of such a procedure for plantar fasciitis. Fourteen patients with plantar fasciitis with failed conservative treatment underwent. TOPAZ RF treatment for their symptoms between 2007 and 2008. The RF-based microdebridement was performed using the TOPAZ Microdebrider device (ArthroCare, Sunnyvale, CA). They were followed-up for up to six months thereafter. Pre-operative, three and six months post-operative VAS, AOFAS ankle-hindfoot and SF-36 scores were analysed. There were six men and eight women, with an average age of 44.0 years (23–57). There were 15 feet, with six right and nine left feet. They were followed up for six months post-operatively. There was a significant improvement in mean pre-op and six-month VAS scores from 8.13 to 3.27(p=0.00), and AOFAS hindfoot scores from 34.37 to 71.33 (p=0.00). There was a significant decrease in SF-36 for bodily pain, and significant increases in physical and social function scores. Twelve out of 14 (85.7%) patients reported ‘good’ to ‘excellent’ satisfaction results at six months, and 11 out of 14 (78.6%) patients had their expectations met from the procedure at six months follow-up. TOPAZ RF coblation is a good and effective method for the treatment of plantar fasciitis. Early results are encouraging, and we believe that the pain experienced by the patients in the follow-ups will subsequently improve

Fifteen patients with identical symptoms of pain and tenderness at the tip of the greater trochanter are reviewed. Diagnosis by the referring doctor was usually osteoarthritis of the hip or sciatica, but localised tenderness and pain on resisted abduction were the only clinical signs. Radiographs were usually normal. Most cases were relieved by one or more local steroid injections. This disorder has much in common with tennis elbow, golfer's elbow, coccydynia and policeman's heel. We suggest that all these conditions may be traction syndromes

The cause of elbow tendinosis is most likely a combination of mechanical overloading and abnormal microvascular responses. Numerous methods of treatment have been advocated. In this study, we evaluated the use of platelet-rich plasma (PRP) as a treatment for resistant epicondylitis. The rationale for using platelets is that they participate predominantly in the early inflammation phases and degranulation. They constitute a reservoir of critical growth factors and cytokines which when placed directly into the damaged tissue, may govern and regulate the tissue healing process. We looked at 25 patients (19 with lateral and 6 with medial) who failed to improve after physiotherapy, cortisone injections and application of epicondylar clasps and assessed the efficacy of platelet-rich plasma injections using Gravitational platelet separation system (GPS). The cohort of patients included over a period of three years had physiotherapy, stretches, epicondylar clasp and an average of 2.9steroid injections (1–6) before having a PRP injection. The mean patient age was 43 years ranging between 24 and 54. There were 11 men and 14 women. The study included 19 patients with lateral epicondylitis and 6 patients with symptoms on the medial side. The ratio between dominant and nondominant side was according to the literature: 76%. The quick DASH scores imroved by 14% on an average in the first 3 months and further 26% in the following 9 months. 4 patients needed reintervention, 3 lateral and 1 medial and had surgical release between 6 and 12 months. 2 of them had reinjections before surgery. No local infections except mild inflammation and no systemic effects were noted. Within the limitations of being a case series and limited follow-up PRP injections provided a safe and progressive benefit over a period of 1 year in refractory cases, providing a good nonoperative alternative

We studied the origin of extensor carpi radialis brevis using 40 fresh frozen human cadaver specimens. Ten were stained with haematoxylin and eosin and trichrome which showed the collagenous structure of the extensor tendons at their origin. Gross anatomical observation showed that there was no definitive separation between brevis and communis at the osseotendinous junction. The histological findings confirmed the lack of separation between the two tendons. The extensor tendons were in close proximity to the joint capsule but trichrome staining showed no interdigitation of the tendon with the capsule. The validity of ascribing the pain of lateral epicondylitis to extensor carpi radialis brevis must be questioned. It appears to arise more from the ‘common extensor’ origin

During the last four years the author has used extracorporeal shock wave therapy (ESWT) to treat tendonoses, including 82 cases of tennis elbow, 108 cases of plantar fasciitis and 42 cases of related conditions. Treatment is administered in the consulting room without analgesia. This paper discusses the protocol used in selected cases. In 78% of cases, overall subjective and objective results were good to excellent, in 15% fair. In only 17% was the result poor, with no improvement. No cases of degeneration were encountered. There were few complications and these were minor. Because of the obvious clinical benefits in selected cases, this new modality of orthopaedic treatment is still being used daily after four years

Problem: Surgical technique and short term results of ligament reconstruction with trizeps tendon graft in posterolateral rotational instability of the elbow. Methods: From 2003 to 2006 posterolateral ligament reconstruction with a single strand trizeps tendon graft was performed in 38 patients with posterolateral instability of the elbow, mainly associated with refractory lateral epicondylitis. The reconstructions were performed with the original O Driscoll technique (6), interference screw fixation (30) and transfixation screw (2). There were no neurological complications, one superficial wound infection resolved by revision and 3 arthroscopic revisions for intraarticular scaring. The first 21 operated patients with a minimum follow up of twelve months were reviewed with a subjective 100 point rating score. Results: From 21 patients 4 could not be reached by letter or telephone, 2 patients were excluded for pre-operative stiffness and previous operations other than extensor release. 15 patients could be evaluated. Average follow up was 15,1, min 12, max 24 months. Patients satisfaction with the operation was rated very good by 6 patients (40%), good by 5 (33,3%) unchanged by 4 (26,7 %), none worsened. Mean postoperative score was 83/100 points. Mean score for pain was 22,2/30, for ADL 7,3/8, sleep 1,9/2, range of arm motion 9,2/10, extension 9,2/10, flexion 4,6/5, supination 4,7/5, pronation 4,2/5 and strength 20,1/25 points. Conclusion: Single strand posterolateral ligament reconstruction with a trizeps tendon graft in posterolateral instability of the elbow shows reliable short term results. More secure fixation is achieved with bone tunnel fixation and tenodesis or transfixation

Aims

The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes.

Purpose: The aim our study was to establish the existence of a symptomatic humero-radial synovial plica causing lateral elbow pain and the resection of which has improved pain and restored elbow function. Materials & Methods: Our study included 117 consecutive elbow arthroscopies performed by two surgeons for a period of 18 months from January 2002 to July 2003. All patients were treated non operatively before undergoing arthroscopy. Conservative treatment included rest, activity modification, physiotherapy including ultrasound bracing, NSAIDS and corticoste-riod injection. Results: Radial head plica were found in 21(18%) out of 117 elbow arthroscopies and were resected using a soft tissue resector. There were 16 men and 5 women in the study group,all of whom were young and active: mean age 38 years (range 24 to 56 years). All patients were scored pre op and post op using the Mayo clinic performance index for the elbow. Of the 21 patients 17(81%) had a post op score 90 or more(excellent) and 5(19%) had a score 75-89(good). Conclusion: The synovial fold of the humero-radial joint is documented and considered as a meniscus between the two articulation(Duparc f etal 2002). They can also present present as symptoms suggesting intra articular loose bodies(Clarke R.P etal 1998). In the case of resistant tennis elbow the existence of a radial head synovial plica should be considered. Our study concludes that by resecting the synovial plical fold will relieve the pain and restore the elbow motion

Between 1994 and 2006, 58 patients underwent decompression of radial tunnel. The senior author using an anterior approach performed all procedures. 43 patients were available for follow-up evaluation at an average of 47.3 months (12–156 months). The average age of patients was 49.7 years (35 – 72 years) and the mean duration of their symptoms was 18 months (6 – 56 months). There were 12 patients (13 extremities) over 5 years follow-up. All had a trial of conservative treatment with steroid injections, physiotherapy and ultrasound therapy. All except 2 had nerve conduction studies which were inconclusive. The results were evaluated using Mayo elbow scores and DASH scores. Mayo scores improved from a mean of 62.37 pre-op to 87.13 post-op (p< 0.05) and DASH scores improved from 67.58 pre-op to 40.12 post-op (p< 0.04). 35 patients (81.3%) were satisfied with the surgery while 8 patients were not (4 patients had other pathologies). There were few complications – neuropathic pain-1, neuropraxia – 1 and residual pain – 2. Six patients who had simultaneous release of lateral epicondylar muscles and radial tunnel did extremely well and were satisfied. Hence there is a role for simultaneous decompression of tennis elbow and radial tunnel as recent studies suggest that extensor carpi radialis brevis tendon forms a continuous fascial sheath from lateral epicondyle to radial tunnel structures blending with supinator muscle. Based on our results, surgical decompression of radial tunnel gives good results in majority of patients with persistent radial tunnel symptoms with long-term relief

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humeroulnar (medial) compartment remains remarkably well preserved. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment. The post mortem studies carried out on mainly elderly subjects demonstrated that the degree of degenerative change in the elbow is age dependant and involves predominantly the lateral compartment of the joint. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought. We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treat ment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes

The NHS Plan (2000) identified the need for change in the way patients are asked to give consent for surgery to make the process more explicit. A new NHS operation consent form was introduced in April 2002 following the Bristol enquiry into deaths associated with Cardiac Surgery. Methods: We have addressed the obtaining of consent for surgery as an evidence-based exercise. The published literature has been reviewed and we have attempted to accurately quantify the success rates for surgery, complication rates and poor outcomes in order to identify what the likely benefits and risks are for our common operations –. Shoulder – Arthroscopic Sub-Acromial Decompression, Anterior stabilisation, Rotator Cuff repair, excision lateral end of clavicle and Shoulder Arthroplasty. Elbow – Tennis elbow release, Arthroscopic Debridement, OK Operation and Elbow Replacement We became increasingly aware throughout this exercise that although there were many papers published; collating the relevant evidence based information for patients was either difficult or impossible. Evidence was therefore been categorised into 4 levels:. National & International published results. Our own results, either published or presented at scientific meetings. Our own results as identified in internal audited outcome studies – unpublished. Our opinion of the risks or benefits unsupported by any scientific or published evidence. Results: We have taken the standard NHS Consent Form and modified it in a printed format to present to the patient a clearer description of the anticipated outcome from their surgery (with percentages). This evidence based consent form was evaluated in a combined prospective and retrospective survey of 60 patients who attended our pre-operative assessment clinic. We will present the results of the survey and demonstrate the standardised Consent Forms. Conclusions: The majority of the information the patient wished to know was Level 4 evidence!

The aim of the study is to assess the humero radial plica which could be a factor in causing lateral elbow pain. The cause of lateral elbow pain has been an enigma for the orthopaedic surgeons over the years. The synovial fold of the humeroradial joint has been well documented and considered as a meniscus between the articulation. They can also present as symptoms suggesting intra articular loose bodies causing pain in these patients. Our study included 117 consecutive elbow arthroscopies performed by two surgeons for a period of 18 months. All patients were initially treated non-operatively as a ‘tennis elbow’ before undergoing arthroscopy. Conservative treatment included rest, activity modification, physiotherapy including ultrasound bracing, nsaids and local corticosteroid injection. All patients were assessed using the Mayo clinic performance index for elbows both pre and post operatively. Radial head plica was found in 21(18%) out of 117 elbow arthroscopies and was resected using a soft tissue resector. There were 16 (76%) men and 5(24%) women in this affected group and all of whom were young and active with a mean age 38 years. Of the 21 patients 16(76%) had a post operative score of 90 or more (excellent) and 5(24%) had a score 75–89(good). This study addresses the fact that cause of lateral elbow pain can be due to various pathologies in the elbow and in the cases of ‘resistant tennis elbows’ we recommend that the existence of a radial head synovial plica should be considered and if present treatment should be directed at this. Our study demonstrates that by resecting the synovial plical fold, pain will be relieved and these patients regained elbow function. Since this was noted in the young active age group this could reduce the morbidity and the time for rehabilitation required especially for those involved in active sports. A similar series has not been cited in English literature

Extracorporal shock wave therapy (ESWT) seems to be a promising new tool for the treatment of chronic pain due to tendinopathies such as tennis elbow or a painful heel. Mechanisms of ESWT-induced analgesia are still unknown. One major system for controlling pain is the endogenous opioid system that could be the biochemical basis of the ESWT-effects. The aim of the study was to investigate the possible influence of low energy ESWT on the endogenous opioid-system in the lumbar spinal cord of the rat. Immunohistochemical analysis of the expression of opioids Met-Enkephalin (MRGL), and dynorphin (Dyn) were performed in rats treated either once with 1000 impulses or three times with 1000 impulses with two different energy flux densities each (0.04 and 0.11 mJ/mm. 2. ) at 4 or 72 h after ESWT. No different immunoreactivity of MRGL and Dyn was seen after single ESWT treatment in comparison with the sham group. This result was not influenced by different energy flux doses or repetitive ESWT treatment. Met-Enk and Dyn expression was similar on ipsi- and contralateral side and was unchanged at later time points after ESWT treatment. Low energy ESWT had no influence on the opioid-systems and therefore does not trigger this endogenous anti-nociceptive system under basal conditions. Furthermore these results show that low energy ESWT had no side effects on rat spinal cord (e.g. neuronal destruction or enhanced permeability of the blood brain barrier for leukocytes) even after the application of 3 x 1000 impulses with the energy flux density as high as 0.11 mJ/mm. 2. Although applications in orthopaedics have outnumbered those in urology, there is no firm evidence of efficacy of ESWT in orthopaedics from well-designed randomised clinical trials and the molecular mechanisms of the of the anti-nociceptive effect of ESWT are still unknown

Shockwave treatment in our unit is provided in conjunction with our Urological colleagues. Shock Wave Therapy has been used as a last option in patients with difficult and chronic Orthopaedic conditions with an informed consent for all patients. Material and Methods: 28 patients from Ealing Hospital and West Middlesex Hospital were referred to The Lithotripsy unit at Charing Cross Hospital for Shock wave therapy. Patients were consented by the Orthopaedic surgeon and the treatment was administered by urologist. The cases included:. 4 Humeral fractures: 1 Case in HIV +ve 19 years old. 5 Femoral non-union: 1 case bilateral in Osteogenesis imperfecta. 4 Tibial non-union: 1 Recurent Fracture in 65 years old man. 2 Osteochondritis of the Talus. 2 Osteochondritis of the knee. 4 Scaphoid fractures: 1 case had been fixed and grafted. Medial Epicondyle fracture non union. 5. th. Metacarpal Fracture. Trochanteric Bursitis. Tennis Elbow. 4 Planter fasciitis. – The Shock wave Machine used is Storz SLX – F2 Electromagnetic shock wave generator which focus the shock wave low energy high frequency in focal zone with no harm to other tissues. Frequency 4 htz = 4 shockwave/sec. – Energy level 1–3 generate pressure value in the focal area of 5–30 megapascal. – Size of focal zone 9X 50 mm or 6X 28 mm. – Total shock wave applied per session 2000 to 3000 shock. – large focus and small focus were used in fracture of large bones and small bones respectively. Most of cases required 2–3 session with 4–6 weeks interval. – in Soft tissue Treatment Less energy was used and patients required 1 to 2 sessions. Results: There was complete resolution of symptoms in the 4 cases of soft tissues. – Clinical and radiological union in 3 of the 4 Humeral Fracture including HIV+ve and in 2 of 3 tibial fracture and 1 of 2 scaphoid. – 50% pain relief in Psedo arthrosis. – Union is promoted by Cellular stimulation and pain relief is by unknown mechanism but explained by increase vascularity and neuro-modulation. – None of the patient’s have so far required subsequent operative interventions, several had residual symptoms. Discussion: Shock wave therapy is a new consevative treatment modality used in orthopaedic as the last option before surgery but there is a need for RCT

Aims

We conducted a study to identify factors that are prognostic of the outcome of extracorporeal shockwave therapy (ESWT) for calcific tendinitis of the shoulder.

The December 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions

Modern athletes are constantly susceptible to performance-threatening injury as they push their bodies to greater limits and endure higher physical stresses. Loss of performance and training time can adversely and permanently affect a sportsperson’s career. Now more than ever with advancing medical technology the answer may lie in biologic therapy. We have been using peripheral blood stem cells (PBSC) clinically and have been able to demonstrate that stem cells differentiate into target cells to enable regenerative repair. The potential of this technique as a regenerative agent can be seen in three broad applications: 1) articular cartilage, 2) bone and 3) soft tissue. This article highlights the successful cases, among many, in all three of these applications.

Aims

Our purpose was to determine the quality of current randomised controlled trials (RCTs) in hand surgery using standardised metrics.

We present a review of claims made to the NHS Litigation Authority (NHSLA) by patients with conditions affecting the shoulder and elbow, and identify areas of dissatisfaction and potential improvement. Between 1995 and 2012, the NHSLA recorded 811 claims related to the shoulder and elbow, 581 of which were settled. This comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total of £18.2 million was paid out in settled claims. Overall diagnosis, mismanagement and intra-operative nerve injury were the most common reasons for litigation. The highest cost paid out resulted from claims dealing with incorrect, missed or delayed diagnosis, with just under £6 million paid out overall. Fractures and dislocations around the shoulder and elbow were common injuries in this category. All 11 claims following wrong-site surgery that were settled led to successful payouts.

This study highlights the diagnoses and procedures that need to be treated with particular vigilance. Having an awareness of the areas that lead to litigation in shoulder and elbow surgery will help to reduce inadvertent risks to patients and prevent dissatisfaction and possible litigation.

Cite this article: Bone Joint J 2014; 96-B:574–9.

Aims

The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation.

The April 2015 Foot & Ankle Roundup³⁶⁰ looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.

Objectives

To investigate the appropriate dose and interval for the administration of triamcinolone acetonide (TA) in treating tendinopathy to avoid adverse effects such as tendon degeneration and rupture.

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15).

Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04).

Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability.

The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy (rESWT) on patients with chronic tendinitis of the rotator cuff. This was a randomised controlled trial in which 82 patients (mean age 47 years (24 to 67)) with chronic tendinitis diagnosed clinically were randomly allocated to a treatment group who received low-dose rESWT (three sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm², 8 Hz) or to a placebo group, with a follow-up of six months. The patients and the treating orthopaedic surgeon, who were both blinded to the treatment, evaluated the results. A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group. A visual analogue scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple shoulder test (SST) score significantly improved in both groups at three and six months compared with baseline (all p ≤ 0.012). The mean VAS was similar in both groups at three (p = 0.43) and six months (p = 0.262). Also, the mean CMS and SST scores were similar in both groups at six months (p = 0.815 and p = 0.834, respectively).

It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment.

Cite this article: Bone Joint J 2013;95-B:1521–6.

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative.