Surgical treatment for lateral epicondylitis: A long-term follow-up of results

doi:10.1016/j.jse.2009.09.008

Journal of Shoulder and Elbow Surgery

Volume 19, Issue 3, April 2010, Pages 363-367

https://doi.org/10.1016/j.jse.2009.09.008 Get rights and content

Hypothesis

Since its first description, the pathology, natural history, and treatment of lateral epicondylitis have remained controversial. For patients in who conservative management fails, 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.

Materials and methods

This study describes a modification of the Nirschl surgical technique and presents its long-term results. Patients undergoing this open technique were reviewed by use of the Hospital for Special Surgery and Mayo elbow performance assessment tools, as well as having grip strength and subjective outcome recorded.

Results

From June 1986 to December 2001, 158 consecutive patients (171 elbows) underwent surgery in a single-surgeon series. Of these patients, 137 (86.7%) were available for follow-up at a mean of 9.8 years. The mean age of the group was 42 years. Subjectively, the results were good to excellent in 94.6% of patients and in 92.6% to 94.0% of patients by use of the Hospital for Special Surgery and Mayo scores, respectively. No differences were noted in grip strength. No patient required revision surgery.

Conclusions

This repeatable open technique offers excellent results with a low rate of complications at a mean follow-up of 9.8 years. These results compare favorably in terms of numbers followed up, length of follow-up, and outcome and offer strong evidence of its efficacy.

Section snippets

Preoperative

Between June 1986 and December 2001, surgical procedures were carried out on 158 consecutive patients (171 elbows) by the senior author.

Preoperative clinical assessment showed localized tenderness over the lateral epicondyle in all patients. Furthermore, resisted extension of the middle finger and the wrist performed with the elbow extended was painful in all patients. Of the patients, 12 (8.1%) had a reduced range of motion compared with the unaffected arm, with a mean loss of extension of 14°

Results

Of the 158 patients (171 elbows) operated on in this series, 137 (149 elbows) are included in the results, giving a follow-up rate of 86.7%. Four patients died of unrelated causes during the follow-up period, and a further seventeen could not be contacted.

There were 72 men and 65 women in the study cohort. The mean age of the group was 42 years (range, 23-64 years). The dominant arm was affected in 103 cases (69.1%) and the nondominant arm in 46 (30.9%). The right arm underwent surgery on 100

Discussion

The results of this series show a subjective rating of good to excellent of 94.6% and an objective rating of good to excellent of 92.6% to 94.0%. These results compare favorably with the previously quoted rates of good to excellent results of 75% to 91% at up to 5 years' follow-up.11, 15 Furthermore, the mean follow-up in this series is 9.8 years. A lack of studies with long-term follow-up is highlighted in the recent review of Dunn et al¹³ of the results of the Nirschl procedure at a minimum

Disclaimer

The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article and have no potential conflicts of interest related to this manuscript.

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The Weekend Warrior: Common Shoulder and Elbow Injuries in the Recreational Athlete
2022, American Journal of Medicine
Citation Excerpt :
Operative intervention is considered in debilitating refractory cases and can be performed open, percutaneously, or arthroscopically, with the degenerate tendon debrided and reaffixed to the lateral epicondyle. Open surgery has an overall improvement rate of 84%-97%, with generally similar outcomes seen in percutaneous surgery.13,14 No significant differences in outcomes between surgical techniques have been observed, with all regarded as effective, suggesting surgical approach can be based more on physician experience and patient preference.
“Weekend warriors” are recreational athletes who compress their physical activity into 1-2 weekly exercise sessions. These individuals are generally older than the conventionally discussed athlete, and can live otherwise sedentary lifestyles that contribute to limited opportunities for regular exercise. The combination of high-energy physical activity with relative deconditioning, as well as older age and a potential history of competitive athletic play, can predispose these weekend warriors to a plethora of sports injuries. The shoulder and elbow are dynamically involved in a multitude of common recreational sports, such as baseball, softball, tennis, golf, and volleyball, and forms of casual exercise, such as swimming or climbing. A lack of proper conditioning and supplemental training in weekend warriors, particularly in comparison to elite athletes in these respective sports, can contribute to the development of both acute and chronic conditions of the shoulder and elbow. Inconsistency in physical activity can minimize the prominence of symptoms, leading patients to delayed presentations with injuries that severely impact their ability to engage in their exercise of choice, and therefore remain active at all. This narrative review aims to present the etiology, presentation, and management of common shoulder and elbow injuries that may afflict this patient population. Prevention strategies will also be discussed.
Lateral and medial epicondylitis
2022, Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine, Third Edition
Surgical management of lateral epicondylitis combined with ligament insufficiency
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Therefore, a lateral pivot-shift test and posterolateral rotatory drawer test under anesthesia are needed in cases of suspected instability, followed by appropriate surgical intervention. Previous studies have reported good to excellent outcomes in 90% to 100% of cases treated with arthroscopic or open surgery for LE.4,11,19,29 Morrey21 reported 13 cases of surgical failure, including 4 cases with instability.
Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency.
We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone débridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery.
The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency.
Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.
Percutaneous Ultrasonic Tenotomy for Refractory Common Extensor Tendinopathy After Failed Open Surgical Release: A Report of Two Cases
2018, PM and R
Common extensor tendinopathy (CET) is a common, painful overuse and degenerative condition of the lateral elbow, affecting an estimated 2 million patients per year. Although many cases resolve with conservative treatment, recalcitrant cases may progress to open surgical intervention. For patients who do not improve with surgical management, treatment options are extremely limited. In this article, we present 2 cases of recalcitrant surgically treated CET successfully treated with sonographically guided percutaneous ultrasonic tenotomy with 1-year follow-up. To our knowledge, this is the first publication demonstrating successful treatment of recalcitrant CET after open surgical repair, with the use of ultrasonic tenotomy.
V
A Systematic Review of Tennis Elbow Surgery: Open Versus Arthroscopic Versus Percutaneous Release of the Common Extensor Origin
2017, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
A total of 30 reports were analyzed for this review. Among patients who underwent an open release, there were 848 procedures, with a mean age of 46 years and a mean follow-up period of 49 months.23-38 In the group that underwent surgery by use of arthroscopy, there were 578 patients, with a mean age of 46 years and a mean follow-up period of 43 months.3,14-17,28,30,31,39-43
To compare complications, function, pain, and patient satisfaction after conventional open, percutaneous, or arthroscopic release of the extensor origin for the treatment of lateral epicondylitis.
A thorough review of 4 databases—PubMed, EBSCOhost, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus, and Scopus—was performed to identify all studies that addressed surgical management of lateral epicondylitis. We included (1) studies published between 2000 and 2015 and (2) studies with clearly defined surgical techniques. We excluded (1) non–English-language manuscripts, (2) isolated case reports, (3) studies with fewer than 10 subjects, (4) animal studies, (5) studies with additional adjunctive procedures aside from release of the extensor origin, (6) clinical or systematic review manuscripts, (7) studies with a follow-up period of 6 months or less, and (8) studies in which less than 80% of patients completed follow-up. Each study was analyzed for complication rates, functional outcomes, pain, and patient satisfaction.
Thirty reports were identified that included 848 open, 578 arthroscopic, and 178 percutaneous releases. Patients within each release group had a similar age (46 years vs 46 years vs 48 years; P = .9 and P = .4, respectively), whereas there was a longer follow-up time in patients who underwent surgery by an open technique (49.4 months vs 42.6 months vs 23 months, P < .001). There were no differences in complication rates among these techniques (3.8% vs 2.9% vs 3.9%; P = .5 and P = .9, respectively). However, open techniques were correlated with higher surgical-site infection rates than arthroscopic techniques (0.7% vs 0%, P = .04). Mean Disabilities of the Arm, Shoulder and Hand scores were substantially better with both open and arthroscopic techniques than with percutaneous release (19.9 points vs 21.3 points vs 29 points, P < .001). In addition, there was less pain reported in the arthroscopic and percutaneous release groups as opposed to their open counterparts (1.9 points vs 1.4 points vs 1.3 points, P < .0001). There were no differences among the techniques in patient satisfaction rate (93.7% vs 89% vs 88%; P = .08 and P = .07, respectively).
Functional outcomes of open and arthroscopic releases may be superior to those of percutaneous release. In addition, patients may report less pain with arthroscopic and percutaneous techniques. Although the risk of complications is similar regardless of technique, patients may be counseled that their risk of infectious complications may be slightly higher with open releases. However, it is important to note that this statistical difference may not necessarily portend noticeable clinical differences.
Level IV, systematic review of Level III and IV evidence.
Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients
2017, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
The most significant predictor for requiring revision surgery was a history of ≥3 preoperative, ipsilateral elbow injections. Although most patients do well after primary surgical treatment of lateral epicondylitis, with good to excellent results in approximately 84% to 94% in longitudinal follow-up,6,10 the incidence of revision surgery has remained unclear. In their recent longitudinal review, Dunn et al10 reported 92 patients, with a mean age of 46 years (range, 23-70 years), who underwent surgical treatment for lateral epicondylitis, with a mean follow-up of 12.6 years.
This study was conducted to identify the rate of failure of operative treatment of lateral epicondylitis, defined as progression to ipsilateral revision surgery, and associated patient-specific risk factors for failure.
A national database was used to identify patients undergoing surgical treatment of lateral epicondylitis from 2005 to 2012. Patients undergoing concomitant procedures were excluded. Patients who then required subsequent ipsilateral extensor carpi radialis brevis débridement or release within 2 years were identified using similar methods. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for revision surgery. In addition, the number of preoperative injections (1, 2, or ≥3) in the ipsilateral elbow was identified and included in the regression analysis. Adjusted odds ratios (OR) and 95% confidence intervals were calculated for each risk factor.
Of 3863 patients who underwent operative treatment of lateral epicondylitis, 58 (1.5%) required ipsilateral revision surgery. Risk factors for revision surgery included age <65 years (OR, 2.95; P = .003), male gender (OR, 1.53; P = .017), morbid obesity (OR, 2.13; P = .002), tobacco use (OR, 1.87; P < .001), and inflammatory arthritis (OR, 1.79; P = .009). Having ≥3 ipsilateral preoperative injections was the most significant risk factor (OR, 3.55; P < .001), whereas having 2 (OR, 1.44; P = .135) or 1 (OR, 1.15; P = .495) was not significant.
The incidence of failure requiring revision surgery for lateral epicondylitis in the studied population is low (1.5%). Risk factors for revision surgery include younger age, male gender, morbid obesity, tobacco use, and inflammatory arthritis. The most significant risk factor for revision surgery is having ≥3 ipsilateral preoperative injections.

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ElbowSurgical treatment for lateral epicondylitis: A long-term follow-up of results

Hypothesis

Materials and methods

Results

Conclusions

Section snippets

Preoperative

Results

Discussion

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Sports Med

Arthroscopy

J Shoulder Elbow Surg

Long-term follow-up of arthroscopic treatment of lateral epicondylitis

Am J Sports Med

Percutaneous release of the epicondylar muscles for humeral epicondylitis

Am J Sports Med

The role of the orbicular ligament in tennis elbow

J Bone Joint Surg Am

Efficacy of nonoperative treatment for lateral epicondylitis

Am J Orthop

Tennis elbow

J Bone Joint Surg Am

Management of lateral epicondylitis: current concepts

J Am Acad Orthop Surg

Tennis elbow: its course, natural history, conservative and surgical management

J Bone Joint Surg Am

Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes

Am J Sports Med

Surgical management of tennis elbow

J Sports Med Phys Fitness

A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow

J Bone Joint Surg Br

Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis

Am J Sports Med

Elbow
Surgical treatment for lateral epicondylitis: A long-term follow-up of results