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.
Childhood obesity is an epidemic of growing concern. There has been a dramatic increase in childhood obesity in the United Kingdom in the recent years. Previous studies demonstrated that this cohort of paediatric population demonstrated poorer balance with increased risk of falling during daily activities and with weight related increase in force, more likely to sustain a fracture. The goal of present investigation is to assess the incidence of fractures in paediatric population and if there is a role of socio economic status as a confounding factor. We prospectively looked at attendance of children at out-patient fracture clinics over a period of 8 months. The BMI is calculated and the centiles are determined on the charts using Cole’s LMS method which adjusts body mass index distribution for different degrees of skew ness at different ages. Children over 98 centile were considered as obese. The musculoskeletal injuries were documented. The social status was determined from the areas where they lived using the Neighbourhood Renewal Fund. A total of 405 children presenting to the trauma clinics with musculoskeletal injuries were measured. There were 252 boys and 153 girls. The mean age is 10.5 years with a median age of 12 years (range 2–16 years). The prevalence of obesity is 14.8% compared to the national average of 13.6%. Children from deprived areas had an increased prevalence of 17.3%. The incidence of fractures remains equal in obese and normal weight children. The most common anatomical region involved is wrist and hand. Upper limb injuries were significantly more common in the obese group (p<
0.05, Chi-square test) Parents should be educated regarding the adverse effects of obesity. Strategies should be in place to identify high risk groups. Local programmes should be developed involving parents, schools authorities and health services to provide targeted care and necessary education.
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).
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%).
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)
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.
Fresh frozen allograft bone was used to fill defects during revision total knee replacements in 21 patients (21 knees) using radial impaction grafting technique. Radial Impaction grafting technique produces a very rigid bone cement construct to allow for immediate weight bearing without any reinforcements. The strength of the graft substitute with stems allowed us to avoid metal augments in both type II and type III defects in majority of cases. At a minimum of 12 months follow up (12 to 60 months follow up, average 28 months), 19 of the knees showed radiological incorporation of the graft and no evidence of lysis of bone graft. Radiological incorporation of the graft was seen as early as six months and remodelling was continuing at three years. There were no cases of non-union. There were no cases of collapse of the graft or migration of the implant. There was one cases of osteolysis due to deep infection, which needed re-operation. There was one case of traumatic peri-prosthetic fracture, which was treated conservatively. Oxford knee scores improved from an average of 45 (35 to 53) to 17.4 (12 to 22) at an average follow up of 27.4 months. American Knee Society scores improved from an average of 39.8 (31 to 53) to 87.8 (30 to 70). Knee Society Function scores improved from an average of 45 (30 to 70) to 85 (65 to 100) at last follow-up. We recommend use of radial impaction grafting technique to fill defects of type II and type III in Tibias during revision knee arthroplasty.
