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ORIGINAL ARTICLE

Open  Release Technique In The Surgical Treatment Of Tennis Elbow

* Suhail Afzal # Ashish Devgunж Dinesh Dhar**

*Specialist, Department of Orthopaedics, Rustaq Hospital . OMAN.
#Senior Specialist and Head of department, Department of Orthopaedics, Rustaq Hospital. OMAN
жSpecialist, Department of Orthopaedics, Rustaq Hospital . OMAN.

Address for Correspondence
Suhail Afzal,
Post Box 427 .Postal Code-329, Burj Al Raddha, RUSTAQ. OMAN
Phone: + 968-95311945
E-Mail: drsuhaila@yahoo.com

Abstract

A prospective controlled   trial of 24 patients (24 elbows) with tennis elbow who underwent a formal release was conducted. 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 seven months. Statistical analysis showed significant improvements for patients satisfaction (p= 0.012), time to return to work (p=0.001), improvements in DASH score (p=0.001) and improvement in sports activities (p=0.046). Patients returned to work on an average of five weeks. This formal open release is a quicker and simpler procedure to undertake and produces significantly better results in patients with failed conservative treatment.
Key Words: tennis elbow, lateral epicondylitis, open release.

J.Orthopaedics 2006;3(4)e22

Introduction:

Tennis elbow or lateral epicondylitis refers to a syndrome of pain centered over the common  origin  of the extensor muscles of the fingers and wrist a the lateral epicondyle. It was first  reported in the literature in 1873 by Ringe1 . It occurs more commonly in non athletes than athletes and has a peek incidence in the fifth decade . The term epicondylitis is a misnomer as there is little evidence to suggest that there is an inflammatory process. It may be caused by repetitive microtrauma to the origin of extensor carpii radialis brevis(ECRB), but the precise aetiopathology remains unclear 1,2 . The diagnosis of tennis elbow is usually made by localizing pain when patient pinches with the wrist in extension and on resisted extension of the middle finger. The differential diagnosis can include Radial tunnel syndrome, lateral compartment arthritis and osteochondritis of the capitellum. The initial  treatment is with rest, modification of activity, local splints, steroid injections, and physiotherapy and about 90% of patients respond to conservative treatment2  . Steroid injections may provide relief of symptoms in upto 40% of patients. Patients who fail to respond to conservative measures may require surgery. Boyd and McLeod3, Posch, Goldberg and lauey4, reported that upto 8% of patients require surgery.

The many operations available have been reviewed by Bosworth5 and Rosen etal6, and include open release of ECRB, tenotomy of extensor tendon, excision of the damaged portion of the tendon, exploration of radio humeral joint and alterations to the length of the tendon of ECRB.

The purpose of this study was to assess the efficacy of the operative technique as described by Nirsch7.

Material and Methods :

We carried out a prospective controlled  trial in these patients. All patients had previously undergone conservative treatment for atleast 6 months. These include two injections of 80mg of hydrocortisone into the common extensor origins, modification of activities which involved them from refraining from repetitive activities that provoked pain over the lateral epicondyle, ultrasound therapy, analgesics and other measures.

All  patients were examined pre operatively. The diagnosis was confirmed by resisted extension of the middle finger and pinch grip with wrist in extension provoking pain over the ommon extensor origin . All patients had a normal cervical spine clinically and radiologically. All patients were assessed pre operatively using the American academy of Orthopaedic surgeons disability of arm, shoulder and hand (DASH) score. This outcome measured is a questionnaire designed to measure function and assess symptoms in patients with musculoskeletal disorders of the upper limb. It includes a disability measurement index for general function and symptoms as well as sport and msic functions and high performance work function. It is scored as a single scale with each of the 30 items scored on a scale of 1 to 5. A raw score of 150 points indicates maximum and 30 points minimum disability in order to convert the raw score to a scaled score, 30 is subtracted from the total which is then multiplied by 0.8, yielding a scaled range from 0 to 100. The specialist score for high demand work, sport or musical activity is calculated in a similar manner. The procedures were all carried out under general anesthesia and tourniquet control. The post operative physiotherapy regime was supported by the physiotherapist. The patients were followed  up  at 7 months  post operatively. Their subjective assessment and the time of  work  were recorded as well as the DASH score

Table I: Details of patients who underwent open technique for tennis elbow.

Mean age in years (range):                              46 (32 58).

Gender.     Male.                                              14

                 Female.                                          10

Follow Up( months).                                           7

Anatomy:

The anatomy of the common extensor origin has been well described and consists of the tendons of ECRB and ECRL, extensor digitorum, ECU and anconeus. The tendons of origin may continue as confluent mass. The tendon of ECRB arises from the anterior aspect of the lateral epicondyleand is deep and inferior to that of ECRL and extensor digitorum communis. The lateral collateral ligament is a primary stabilizer of the elbow and care must be taken to protect it. The body of ECRL is easily identified.

Operative technique:

The open procedure used was as described by Nirsch7 and  Nirsch and Petronne9. A 7 cm incision is centered over the common extensor origin and ECRL is reflected to expose the origin of ECRB and the damaged portion of the tendon is removed. This is commonly found to be white and oedematous . Three small drill holes are made in the Lateral condyle. The radiocapitellar joint is  exposed to check for degenerative changes or synovitis and joint lavage.

A wool and crepe bandage was applied and removed after seven days to allow the early commencement of exercise programme.

Results

There were  24 patients (24 elbows). The demographic variables are as Table-I.

The median pre operative DASH score was 78(67-86). As shown in Table II the median basic  normalized DASH score was 70(64-75). The median post operative basic normalised DASH score  was 53(48-57). The change in the median basic DASH score was 17(11-19). The sport function section of the DASH score showed pre operative normalized median scores of 68(65-78). The change in the median normalized sport scores was 11(6-19). The patients were also scored according to the high performance and work section of the DASH questionnaire. The median pre operative work score was 68(6072). The median post operative score was 52(49-59) producing a change in the median score of 14(7-20) (p<0.11).

 The patients subjective assessment was recorded (Table-IV) and showed that  2 in this study were dissatisfied, 16 were satisfied and 6 were very pleased with the outcome.

DASH scores for 24 elbows. Decrease in DASH score system indicates improvement. Values shown are median and inter quartile ranges. All data relate to notrmalised scores.

                                         Pre-Op                Post-Op.          Improvements        P Value.

DASH basic score.         70(64-75)             53(48-57)              17(11-19)             0.001

Dash Sport score.           68(65-78)             57(51-62)             11(6-19)               0.046

Dash high perform-         68(60-72)             52(49-59)               14(7-20)        amnce work      

0.11

Table-III:

The subjective outcome measures as determined by the patients assessment.

Very Pleased with result:                       06

Satisfied with result:                              16

Dissatisfied with result:                          02. 

Table-IV:

The time to return to work following surgery for tennis elbow:

Median time to return to work in weeks (range);                        5 (4-6).

 

It should be noted that one of the patients who was dissatisfied with the outcome was taking legal proceeding against his employer. This patient had a change in the DASH normalized score  of only 8(99-91) a change in the normalized sport score of 24 (81-57) but no change in

the normalized work score pre op 79 and post op 79. There were no other compensation claims in progress and no other patient attributed their condition solely to their occupation.

16 patients were engaged predominantly in manual work and 8 were office and non manual workers. The median time off work was five weeks(4-6).

Discussion :

The treatment of tennis elbow has been the subject of much debate. Numerous surgical techniques have been described including fasciotomy, Z lengthening of the tendon, osteotomy of the lateral epicondyle and excision of the damaged portion of ECRB as well as open and percutaneous tenotomy 1-4,7-10. Arthroscopy has also been advocated11. Grundenberg and Dobson10 reported good to excellent results in 29 of 32 elbows and Baumgard and Schwartz8, achieved 32 excellent and 3 dissatisfied patients in 35 elbows following percutaneous  release. Nirsch and Pettrone9, achieved an excellent outcome in 66 of 88 elbows using open technique similar to the technique used in this study. Our results compare favourably  with these results and show that the procedure produces significantly better results. The patients had significant improvement in the basic DASH scores and sporting and high demand work scores and the time off work was also better.

Although we do not advocate that all patients should be treated surgically our results indicate that if surgery is being considered this procedure gives significantly good results. It is quicker and although we carried it out under general anesthesia it may be undertaken under local anesthesia but we feel that when done under general anesthesia allows for good exploration of the radio capitellar joint. The procedure was safe in our patients and without significant complications.

We recommend  this procedure on patients with tennis elbow who have had adequate but failed conservative treatment.

Reference :

  1. Yerger B; Turner T:- percutaneous extensor tenotomy for chronic tennis elbow: an office procedure. Orthopaedics 1985; 8: 1261-3.

  2. Coonrad RW; Hooper WR: Tennis elbow, its course, natural history, conservative and surgical management. JBJS(Am). 1973; 55-A: 1177-82.

  3. Boyd HB; McLeod AC jr: Tennis Elbow. JBJS(Am)1973; 55-A: 1183-7.

  4. Posch JN; Golberg VM; Larrey R: Extensor fasciotomy for tennis elbow: a long term follow up study. Clin orthop 1978; 135. 179-82.

  5. Bosworth DM: surgical treatment of tennis elbow: a follow up study. JBJS(Am) 1965; 47-A. 1533-6.

  6. Rosen MJ; Duffy FP; Miller EH; Kremcheck EJ: Tennis elbow syndrome. Result of lateral release procedure. Ohio State Med J. 1980; 76: 03-9.

  7. Nirsch RP: Lateral extensor release for tennis elbow. JBJS(Am) 1994; 76-A: 951.

  8. Brumgard SH; Schwartz DR: Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J. sports med. 1982; 10: 233-6.

  9. Nirsch RP; Pettrone FA: Tennis elbow: the surgical treatment of lateral epicondylitis. JBJS(Am) 1979; 61-A: 832-9.

  10. Grundenberg AB; Dobson JF: Percutaneous release of extensor origin for tennis elbow. Clin. Orthop. 2000; 376. 137-40.

  11. Owens BP; Murphy KF : Arthroscopic release for lateral epicondylitis. Arthroscopy 2001;17: 582-7.

  12. Werner CO: Lateral elbow pain and post. Interosseous nerve entrapment . Acta orthop. Scand. Supl. 1979; 174: 1-62

 

 

This is a peer reviewed paper 

Please cite as : Suhail Afzal:Open  Release Technique In The Surgical Treatment Of Tennis Elbow

J.Orthopaedics 2006;3(4)e22

URL: http://www.jortho.org/2006/3/4/e22

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