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Proximal Disinsertion of the Common Extensor Tendon for Lateral Elbow Tendinopathy

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Proximal Disinsertion of the Common Extensor Tendon for Lateral Elbow Tendinopathy Journal of Orthopaedic Surgery 2013;21(1):100-2 Proximal disinsertion of the common extensor tendon for lateral elbow tendinopathy Xavier Cusco,1 Montserrat Alsina,2 Roberto Seijas,1 Oscar Ares,1 Pedro Alvarez-Diaz,1 Ramon Cugat1 1 Fundación García Cugat Hospital Quiron Barcelona, Barcelona, Spain 2 Hospital Verge Cinta de Tortosa, Barcelona, Spain and reactive dermatitis (n=2). Late complications included Frohse’s arcade syndrome (n=1) and carpal ABSTRACT tunnel syndrome (n=2). conclusion. Disinsertion of the proximal common purpose. To evaluate surgical outcomes of disinsertion tendon is a good option for treating lateral elbow of the common extensor tendon for lateral elbow tendinopathy. tendinopathy. Methods. Records of 277 men and 128 women who Key words: tendinopathy; tennis elbow underwent surgery for lateral elbow tendinopathy were reviewed. The indication for surgery was insufficient improvement of pain and inability introduction to return to work after 3 weeks of physiotherapy (stretching, ultrasound) and local corticosteroid The prevalence of lateral elbow tendinopathy (also injections. According to the Tavernier technique, the known as epicondylitis and tennis elbow) in the origin of the tendons of the extensor carpi radialis general population is 1 to 3%. It is characterised brevis and extensor digitorum communis was by pain at the lateral epicondyle and surrounding located, and proximal disinsertion of the common structures1 secondary to repetitive movements extensor tendon was performed. and activities that require strength.2 Conservative results. Outcome was excellent in 344 (85%) of the treatment (rehabilitation, physical therapy, steroid patients, good in 46 (11.5%), regular in 9 (2%), and injections, and platelet-rich plasma injections) is poor in 2 (0.5%). The mean time to return to work effective for 80 to 85% of patients with epicondylitis.2–4 was 29 (range, 5–93) days. Immediate complications When conservative treatments fail, surgical treatment included infection (n=1), seroma (n=1), cicatricial is opted for, which occurs in 3 to 5% of athletes.1,2,5 fibrosis (n=10), radial neuritis (sensory) [n=4], Open surgery involves release, excision or repair Address correspondence and reprint requests to: Roberto Seijas, Orthopedic Surgery Fundación García Cugat Hospital Quiron Barcelona, Pza Alfonso Comín 5-7 Planta-1, Hospital Quiron, 08023 Barcelona, Spain. Email: [email protected] Vol. 21 No. 1, April 2013 Proximal disinsertion of the common extensor tendon for lateral elbow tendinopathy 101 of the common extensor tendon. Percutaneous or (a) endoscopic techniques are also used.6 We evaluated surgical outcome of disinsertion of the common extensor tendon for lateral elbow tendinopathy. MATERIALS and Methods Between 1984 and March 2008, 1840 patients underwent conservative treatment for lateral elbow tendinopathy. Among these, 22% (277 men and 128 women) opted for surgery and their records were reviewed. The indication for surgery was insufficient improvement of pain and inability to return to work after 3 weeks of physiotherapy (stretching, ultrasound treatment) and local corticosteroid injections. Patients (b) with lateral elbow pain caused by cervical disease or any other causes were excluded. All patients were covered by the same workers’ health insurance system. Of these patients, 20% were basketball players and 80% were job holders. 22% were aged 20 to 35 years, 66% were aged 36 and 50 years, and 12% were aged 51 to 65 years. 77% were treated for their right elbow. Patients were under regional anaesthesia with tourniquet placement. According to the Tavernier technique,7 the anconeus muscle, skin, and subcutaneous tissue down to fascia were approached. The origin of the tendons of the extensor carpi radialis brevis and extensor digitorum communis was located. Proximal disinsertion of the common Figure (a) Pain location over the epincondyle (asterisk), extensor tendon was performed, as was extraction of and (b) approach in the Tavernier’s technique to disinsert the a tendinous band to prevent recurrence secondary to proximal common tendon. BR denotes braquiradialis, ECRL extensor carpi radialis longus, ECRB extensor carpi radialis fibrosis (Fig.). brevis, ECD extensor communis digitorum, EPDM extensor Additional procedures were performed for digiti minimi, and ECU extensor carpi ulnaris. associated pathologies that included epitrochlear algias (n=7), Frohse’s arcade syndrome (n=4), ulnar nerve compression at the elbow (cubital tunnel syndrome) [n=3], lipomas-granulomas (n=2), mucoid cyst (n=1), trigger finger (n=1), and ulnar or median 2 (0.5%). The mean time to return to work was nerve compression in the forearm (n=4). 29 (range, 5–93) days. Immediate complications A compression bandage was placed for 3 to included infection (n=1), seroma (n=1), cicatricial 4 days. Stitches were removed on days 6 or 7. fibrosis (n=10), radial neuritis (sensory) [n=4], Rehabilitation (kinesitherapy, ultrasound treatment, and reactive dermatitis (n=2). Late complications and tonification with isometric exercises) was included Frohse’s arcade syndrome (n=1) and carpal provided for a minimum of 8 weeks. Outcome was tunnel syndrome (n=2). evaluated at months 3 and 6, according to the Roles and Maudsley scoring system (Table). discussion RESULTS Differential diagnosis of lateral elbow tendinopathy includes epicondylalgia originating from irritation of Outcome was excellent in 344 (85%) of the patients, the 6th or 7th cervical root, entrapment neuropathy good in 46 (11.5%), regular in 9 (2%), and poor in of the posterior interosseous nerve (Frohse’s arcade 102 X Cusco et al. Journal of Orthopaedic Surgery Table Roles and Maudsley score Grade Outcome Excellent No pain with excellent mobility and full physical activity Good Discomfort caused by mobility and full physical activity Regular Discomfort after prolonged physical activity Bad Pain limiting physical activity syndrome), pathology of the radiohumeral joint, Percutaneous or endoscopic techniques achieve radiohumeral osteochondral lesions (Panner’s a higher percentage of favourable results, lower disease), and pathology of the serous bursa.2 complications rates, and earlier return to work.6,10 Physical therapy includes hydrotherapy, use of The most used techniques in open surgery for the microwave, laser and ultrasound, transcutaneous common extensor tendon are disinsertion, elongation, electrical nerve stimulation, and stretching exercises and excision or repair of damaged tissue. (supinated flexion to extension followed by supinated Results of different types of surgery have been flexion to pronated extension).2,8,9 Cortico-anaesthetics compared.11 All our patients received economic are also used. Platelet-rich plasma injections and compensation during the period they were unable radiofrequency-based electromagnetic currents are to work. The high rate of excellent and good results used to restructure collagen, as they may increase (97%) achieved in our patients indicated the efficacy circulation, help to form new collagen, and promote of the surgery. Only 21 (5.2%) of the 405 patients fibroblast migration.8 These forms of treatment are developed complications, which mostly resolved painless and result in only redness of the skin; each after conservative management; only 9 patients of a total of 10 treatment sessions lasts only a few underwent revision surgery. minutes.8 In the current study, the relatively high proportion of patients opting for surgery was due to the need to disclosure return to work early. Open surgery enables broader visualisation and treatment of concomitant diseases.6 No conflicts of interest were declared by the authors. REFERENCES 1. Rayan F, Rao V Sr, Purushothamdas S, Mukundan C, Shafqat SO. Common extensor origin release in recalcitrant lateral epicondylitis - role justified? J Orthop Surg Res 2010;5:31. 2. De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. Br J Sports Med 2007;41:816–9. 3. Whaley AL, Baker CL. Lateral epicondylitis. Clin Sports Med 2004;23:677–91. 4. Buchbinder R, Johnston RV, Barnsley L, Assendelft WJ, Bell SN, Smidt N. Surgery for lateral elbow pain. Cochrane Database Syst Rev 2011;3:CD003525. 5. Bisset L, Coombes B, Vicenzino B. Tennis elbow. Clin Evid (Online) 2011;2011:1117. 6. Karkhanis S, Frost A, Maffulli N. Operative management of tennis elbow: a quantitative review. Br Med Bull 2008;88:171– 88. 7. Tavernier L. A propose du traitment de l’epicondylite des joueurs de tennis [in French]. Presse Med 1936;5;99. 8. Assendelft WJ, Hay EM, Adshead R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic overview. Br J Gen Pract 1996;46:209–16. 9. Rabago D, Best TM, Zgierska AE, Zeisig E, Ryan M, Crane D. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med 2009;43:471–81. 10. Yerger B, Turner T. Percutaneous extensor tenotomy for chronic tennis elbow: an office procedure. Orthopedics 1985;8:1261– 3. 11. Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res 2007;463:98–106..
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