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Persistent Pain After Surgery for Enthesopathy of the Extensor Carpi Radialis Brevis Origin
EVIDENCE-BASED MEDICINE
Evidence-Based Medicine
Persistent Pain After Surgery for Enthesopathy of the Extensor Carpi Radialis Brevis Origin David J. Graham, MBBS, Geoffrey C. S. Smith, MBChB THE PATIENT A 52-year-old man presents with persistent pain in his right dominant lateral elbow one year after open debridement of the extensor carpi radialis brevis (ECRB) origin for enthesopathy (eECRB). His pain is moderate at rest and worse with movement and gripping. He feels that he is unable to return to work as a mechanic because of his pain. There is localized tenderness over the lateral epicondyle. There is a full range of elbow and forearm motion. Passive wrist flexion and resisted wrist extension provoke pain. There is no varus instability. The posterolateral rotatory instability test1 (subluxation with axial compression, valgus, supination, and extension) and the push-up test (apprehension using the supinated arm to push up from a chair) are normal. Radiographs are normal. THE QUESTION What is the best option for a patient with persistent pain after surgery for enthesopathy of the ECRB origin? CURRENT OPINION Operative treatments for eECRB include release of the common extensor origin (open or percutaneous, with or without repair) and open or arthroscopic debridement of the pathologic tissue in the ECRB. On average, approximately 75% of patients are improved after surgery, but not all of those patients are pain-free.2,3 From the Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, and the Department of Orthopaedic Surgery, St. George Hospital, Kogarah, Australia. Received for publication January 24, 2015; accepted in revised form January 30, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David J. Graham, MBBS, Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards NSW 2065, Australia; e-mail: [email protected]. 0363-5023/15/4005-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.031
1012
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
Pain that persists more than 12 months after surgery for eECRB is sometimes evaluated for inadequate debridement, instability, symptomatic synovial plica, previously overlooked arthrosis or osteochondral lesions, and debatable diagnoses such as radial tunnel syndrome. Diagnostic injection, stress radiographs, magnetic resonance imaging (MRI), examination under anesthesia, and arthroscopy are often considered. The self-limited nature of the illness; the correlation of pain intensity and magnitude of disability with stress, distress, and ineffective coping strategies; and the negative influence of secondary gain should also be considered. THE EVIDENCE The natural history of eECRB seems to be spontaneous resolution. Around 80% of patients are symptomatically improved after one year with no treatment or any form of treatment.4 Nonsurgical modalities do not seem to alter the natural history of eECRB. A recent Cochrane review concluded that there was insufficient evidence to recommend surgery either over no treatment or over nonsurgical treatment.5 In spite of this a small percentage of patients (between 4% and 11%) request operative intervention.3 In a retrospective case series reporting the outcome of open surgical treatment for eECRB, Coleman et al6 stated that 12 weeks after surgery 85% of patients were pain-free, which is curious given that incisions are tender for longer than 3 months. The remaining 15% had mild ongoing pain that persisted an average of 9 years after surgery. In a retrospective series of 23 patients, Oki et al7 found that pain scores with activity continued to improve up to 24 months after arthroscopic debridement of the ECRB origin. They evaluated elbow pain at rest and during activity using visual analogue scale (VAS), grip strength, and the Japanese Orthopaedic Association elbow scoring system. The average VAS score for pain at rest improved from 26 preoperatively to 8 one month after surgery, and reached a
plateau thereafter. The VAS score with activity improved from 68 preoperatively to 35 at 1 month, 23 at 2 months, and 8 at 24 months after surgery. Mean grip strength improved from 66% of the opposite arm prior to surgery, to 89% at 2 months, and 98% at 12 months after surgery. Morrey8 described 13 consecutive patients who had surgery for persistent pain after surgery for eECRB over a 9-year period. Patients were divided into those that had pain identical to that prior to the index procedure (suggesting inadequate surgery or an incorrect diagnosis) and those who had a distinct pain (suggesting a possible complication). Diagnostic interventions included selective radiographs (including stress views), diagnostic injection (of the lateral epicondyle and/or posterior interosseous nerve in the region of the arcade of Frohse), bone scans, and diagnostic arthroscopy. An arthrogram was used to demonstrate a synovial fistula. Elbow arthroscopy was used to diagnose subtle instability. Among the 8 patients with the same pain as prior to the initial surgery, 4 patients in whom local anaesthetic injection to the lateral epicondyle relieved symptoms had repeat debridement of the ECRB origin and all 4 were satisfied. Two patients underwent posterior interosseus nerve release after local anaesthetic injection around the arcade of Frohse led to symptomatic relief (one had a satisfactory result, the other unsatisfactory). One patient underwent repeat ERCB debridement and a posterior interosseus nerve release after injections at both sites led to symptomatic relief and was satisfied. One patient had lateral collateral ligament (LCL) plication after clinical examination, arthrogram, and arthroscopy were suggestive of varus instability; this patient was satisfied. Of the five patients who had different symptoms than preoperatively, 2 were diagnosed with iatrogenic instability. One treated with plication of the LCL was satisfied, and the other treated with LCL reconstruction was unsatisfied, even after a later radial head excision. One patient was thought to have combined persistent eECRB and LCL insufficiency and was treated by ECRB debridement and LCL plication (satisfactory outcome). One patient had closure of a synovial fistula identified on arthrogram (satisfactory outcome). One other patient had pain at the lateral epicondyle that was relieved by local injection and was treated by excision of what was described as an “adventitial bursa” in the region of the lateral epicondyle (satisfactory outcome). MRI shows high signal intensity in the ECRB tendon on T1- and T2-weighted images in patients with ECRB, though magnetic resonance severity does J Hand Surg Am.
1013
not correlate with symptoms and imaging abnormalities may persist despite clinical improvement.9 MRI is also used to diagnose osteochondral lesions, synovial plica, and ligamentous injury.10 The use of MRI specifically in the setting of persistent pain after surgery to debride eECRB has not, to our knowledge, been studied. Additional pathologies are noted during arthroscopic debridement of eECRB including radiocapitellar synovitis or synovial thickening (28% to 55%), loose body (3% to 7%), bone spur (12%), and degenerative joint disease (2%).11,12 Perhaps these are responsible for some of the persistent pains after surgery for eECRB. Baker13 described capsular tears on the undersurface of the ECRB tendon in patients undergoing arthroscopic surgery for eECRB. A classification system was proposed: type 1 ¼ a smooth capsule without irregularity; type 2 ¼ a linear or longitudinal tear in the capsule; and type 3 ¼ a complete rupture and retraction of the capsule and the frayed ECRB tendon, which is visible behind it. Sasaki et al14 studied the sensitivity of computed tomography arthrogram and MRI for detection and classification of the described radiocapitallar joint capsular pathology in patients with a clinical diagnosis of chronic eECRB who were planned to undergo surgery and reported that computed tomography angiography was 90%, 100%, and 80% sensitive for the radiologist, surgeon, and fellow, respectively. The specificity rates were 89%, 89%, and 100%. MRI had a low sensitivity rate and a relatively high specificity rate. The sensitivity rates were 60%, 70%, and 50%, for the radiologist, surgeon, and fellow, respectively, and the specificity rates were 89%, 67%, and 78%. Nevertheless, the severity of the capsular pathology has not been shown to correspond to VAS pain scores at rest, with activities of daily living or with sport/work or with function measured by the Mayo function score.11 To our knowledge, no studies address the effect of various injections on persistent pain after surgery. Corticosteroid injections and extracorporeal shock waves do not modify the natural course of eECRB prior to surgery. Other types of injections, low-level laser therapy, and acupuncture are, to date, inadequately studied to know if they are more palliative than placebo or able to modify the course of the disease. The systematic review by Krogh et al15 did show a benefit of platelet-rich plasma over placebo for pain relief, although they noted there was a paucity of evidence from unbiased trials. r
Vol. 40, May 2015
Evidence-Based Medicine
ENTHESOPATHY OF THE ECRB
1014
ENTHESOPATHY OF THE ECRB
Evidence-Based Medicine
Organ et al16 described a retrospective cohort of 34 patients (35 elbows) with persistent pain after surgery for lateral epicondylitis that underwent open revision surgery. Diagnosis was made based on history, examination, and radiographs. The time after the index procedure was not described. The authors mentioned that an equal number of patients improved with time and a nonsurgical treatment protocol consisting of strengthening and flexibility (specifics not recorded). There were 34 elbows with macroscopic residual tendinosis in the ECRB origin evident at the time of revision surgery. The other elbow was said to have “an unexplained failure to generate any healing tissue in the area of previous complete resection of the ECRB tendon”. Twenty-seven of the 34 patients with residual ECRB tendinosis had no scarring in the ECRB origin, making the surgeons question the original surgery. The following additional procedures were performed: Excision of tendinotic tissue in the anterior margin of the extensor aponeurosis as well as the ECRB (N ¼ 10); excision of exostosis (N ¼ 12), reattachment of extensor mechanism (N ¼ 5); resection of impinging fibrous tissue tissue radiocapitellar joint (N ¼ 5); treatment of instability (N ¼ 1; technique not described). Following the repeated debridement, they reported 20 excellent, 9 good, 5 fair, and 1 poor results using a patient-reported outcome questionnaire with a maximum value of 40 (0e10 ¼ poor; 10e20 ¼ fair; 21e30 ¼ good; 31e40 ¼ excellent). The 29 patients (83%) with good or excellent results all returned to their previous level of work and activity. Almquist et al17 retrospectively compared 61 patients treated for both primary and recurrent lateral epicondylitis with either a limited surgical resection of the lateral extensor aponeurosis (16 patients with primary lateral epicondylitis), a wide surgical excision of the aponeurosis and coverage by a vascularized rotational pedicle flap of the anconeus muscle (31 patients with primary lateral epicondylitis), or limited wide fasciectomy and ancouneus muscle transfer following a previously unsuccessful fasciectomy (14 patients). The mean postoperative grip strength (compared with contralateral side) was 70% in the fasciectomy group and 78% in the anconeus flap groups—both primary and revision surgery. Eighty-one percent of the fasiectomy group patients returned to work as opposed to 96% of the primary anconeus flap patients and 86% of the revision anconeus flap patients. They also showed a statistically significant difference in pain relief between the fasciectomy group and both the primary and the revision anconeus flap groups (P < .05). J Hand Surg Am.
Degreef et al18 treated 10 patients with one year of persistent symptoms after surgery or percutaneous release of eERCB with an anconeus muscle transposition. The result was graded as Excellent in 3, Good in 4, and Poor in 3, as per the Roles and Maudsley criteria (excellent ¼ no pain and full movement, full activity; good ¼ occasional discomfort, full movement and full activities; fair ¼ some discomfort after prolonged activity; poor ¼ pain limiting activities). Rose et al19 described denervation of the posterior cutaneous nerve of the forearm branches in patients with more than 6 months of symptoms from eECRB and subjective improvement after a diagnostic nerve block. They reported 80% good or excellent pain relief and an average improvement of grip strength of 13e24 kg. The results of this technique should be equally applicable to primary and revision surgery. SHORTCOMINGS OF THE EVIDENCE The existing data regarding time to recovery after primary ECRB debridement procedures are limited and conflicting. The few available studies are small retrospective case series, many highlighting a specific operative technique. Persistent symptoms after surgery are uncommon and therefore difficult to study. There is limited evidence to guide the choice of diagnostic tests and treatments. Reported improvements after repeat surgery may reflect the natural history of the condition, regression to the mean, or the placebo effect rather than any direct benefit from surgery. The few studies to consider unsatisfied patients after surgery for eECRB have focused on biomedical issues. Given the benign natural history of the condition and that good outcomes are the norm in the small group of patients that undergo surgery, a biopsychosocial model may be more appropriate in patients that have persistent symptoms. This has not yet been investigated. DIRECTIONS FOR FUTURE RESEARCH A prospective cohort study of recovery after surgery for eECRB could establish the total duration of recovery before which revision surgery should not be offered in the absence of adverse events. Multicenter, prospective, randomized, double blind, placebocontrolled (including sham surgery) trials of injections, revision eECRB debridement, denervation, or another procedure would help determine the degree to which improvements are related directly to treatment of pathophysiology. Further well-conducted randomized r
Vol. 40, May 2015
controlled trials are required to assess the effectiveness of platelet-rich plasma injections in both primary and recalcitrant lateral epicondylitis. It would be useful to study psychosocial issues in patients who are unsatisfied after surgery for eECRB. Such studies could screen for psychological distress, ineffective coping strategies, and social influences that might be contributing to more pain and disability than expected. Randomized trials comparing cognitive behavioral therapy to surgery or other biomedical treatments might be worthwhile.
4. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthalsde Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet. 2002;359(9307):657e662. 5. Buchbinder R, Johnston R, Barnsley L, Assendelft W, Bell S, Smidt N. Surgery for lateral elbow pain. Cochrane Database Syst Rev. 2011;(3):CD003525. 6. Coleman B, Quinlan JF, Matheson JA. Surgical treatment for lateral epicondylitis: A long-term follow-up of results. J Shoulder Elb Surg. 2010;19(3):363e367. 7. Oki G, Iba K, Sasaki K, Toshihiko Y, Wada T. Time to functional recovery after arthroscopic surgery for tennis elbow. J Shoulder Elb Surg. 2014;23(10):1527e1531. 8. Morrey B. Reoperation for failed surgical treatment of refractory lateral epicondylitis. J Shoulder Elb Surg. 1992;1(1):47e55. 9. Savnik A, Jensen B, Norregaard J, et al. Magnetic resonance imaging in the evaluation of the treatment response of lateral epicondylitis of the elbow. Eur Radiol. 2004;14(6):964e969. 10. Cerezal L, Rodriguez-Sammartino M, Canga A, et al. Elbow synovial fold syndrome. Am J Roentgenol. 2013;201(1):88e96. 11. Baker CL, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: Two year clinical results. J Shoulder Elb Surg. 2000;9(6):475e482. 12. Lattermann C, Romeo A, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elb Surg. 2010;19(5):651e656. 13. Baker CL, Cummings PD. Arthroscopic management of miscellaneous elbow disorders. Oper Techn Sport Med. 1998;6:16e21. 14. Sasaki K, Tamakawa M, Onda K, et al. The detection of capsular tear at the undersurface of the extensor carpi radialis brevis tendon in chronic tennis elbow: The value of magnetic resonance imaging and computed tomography arthrography. J Shoulder Elb Surg. 2011;20(3):420e425. 15. Krogh T, Bartels E, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: A systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435e1446. 16. Organ SW, Nirschl RP, Kraushaar BS, Guidi EJ. Salvage surgery for lateral tennis elbow. Am J Sports Med. 1997;25(6):746e750. 17. Almquist EE, Necking L, Bach AW. Epicondylar resection with anconeus muscle transfer for chronic lateral epicondylitis. J Hand Surg Am. 1998;23(4):723e731. 18. Degreef I, Van Raebroeckx A, De Smet L. Anconeus mucle transposition for failed surgical treatment of tennis elbow: Preliminary results. Acta Orthop Belg. 2005;71(2):154e156. 19. Rose NE, Forman SK, Dellon AL. Denervation of the lateral humeral epicondyle for treatment of chronic lateral epicondylitis. J Hand Surg Am. 2013;38(2):344e349.
OUR CURRENT CONCEPTS FOR THIS PATIENT We felt confident that this patient’s symptoms were from pathophysiology more so than stress, distress, or ineffective coping strategies. Our diagnosis of persistent eECRB was based on normal radiographs and a diagnostic injection of local anaesthetic into the origin of the ECRB that provided temporary relief from symptoms. In our experience symptoms after primary surgery can continue to improve for 1 or 2 years and we recommended nonspecific palliative treatment in the anticipation of ongoing recovery and reinforced to the patient the high likelihood of symptom resolution with time. If the symptoms and signs persist 2 years after surgery, we would offer the patient repeat open debridement of ECRB origin unless we had concerns about the patient’s illness behavior. REFERENCES 1. O’Driscoll SW, Bell DF, Morrey BF. Postero-lateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440e446. 2. Nirschl RP, Pettrone F. Tennis elbow: The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832e841. 3. Faro F, Wolf JM. Lateral epicondyitis: Review and current concepts. J Hand Surg Am. 2007;32(8):1271e1279.
J Hand Surg Am.
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Vol. 40, May 2015
Evidence-Based Medicine
ENTHESOPATHY OF THE ECRB
Evidence-Based Medicine
Persistent Pain After Surgery for Enthesopathy of the Extensor Carpi Radialis Brevis Origin David J. Graham, MBBS, Geoffrey C. S. Smith, MBChB THE PATIENT A 52-year-old man presents with persistent pain in his right dominant lateral elbow one year after open debridement of the extensor carpi radialis brevis (ECRB) origin for enthesopathy (eECRB). His pain is moderate at rest and worse with movement and gripping. He feels that he is unable to return to work as a mechanic because of his pain. There is localized tenderness over the lateral epicondyle. There is a full range of elbow and forearm motion. Passive wrist flexion and resisted wrist extension provoke pain. There is no varus instability. The posterolateral rotatory instability test1 (subluxation with axial compression, valgus, supination, and extension) and the push-up test (apprehension using the supinated arm to push up from a chair) are normal. Radiographs are normal. THE QUESTION What is the best option for a patient with persistent pain after surgery for enthesopathy of the ECRB origin? CURRENT OPINION Operative treatments for eECRB include release of the common extensor origin (open or percutaneous, with or without repair) and open or arthroscopic debridement of the pathologic tissue in the ECRB. On average, approximately 75% of patients are improved after surgery, but not all of those patients are pain-free.2,3 From the Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, and the Department of Orthopaedic Surgery, St. George Hospital, Kogarah, Australia. Received for publication January 24, 2015; accepted in revised form January 30, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David J. Graham, MBBS, Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards NSW 2065, Australia; e-mail: [email protected]. 0363-5023/15/4005-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.031
1012
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
Pain that persists more than 12 months after surgery for eECRB is sometimes evaluated for inadequate debridement, instability, symptomatic synovial plica, previously overlooked arthrosis or osteochondral lesions, and debatable diagnoses such as radial tunnel syndrome. Diagnostic injection, stress radiographs, magnetic resonance imaging (MRI), examination under anesthesia, and arthroscopy are often considered. The self-limited nature of the illness; the correlation of pain intensity and magnitude of disability with stress, distress, and ineffective coping strategies; and the negative influence of secondary gain should also be considered. THE EVIDENCE The natural history of eECRB seems to be spontaneous resolution. Around 80% of patients are symptomatically improved after one year with no treatment or any form of treatment.4 Nonsurgical modalities do not seem to alter the natural history of eECRB. A recent Cochrane review concluded that there was insufficient evidence to recommend surgery either over no treatment or over nonsurgical treatment.5 In spite of this a small percentage of patients (between 4% and 11%) request operative intervention.3 In a retrospective case series reporting the outcome of open surgical treatment for eECRB, Coleman et al6 stated that 12 weeks after surgery 85% of patients were pain-free, which is curious given that incisions are tender for longer than 3 months. The remaining 15% had mild ongoing pain that persisted an average of 9 years after surgery. In a retrospective series of 23 patients, Oki et al7 found that pain scores with activity continued to improve up to 24 months after arthroscopic debridement of the ECRB origin. They evaluated elbow pain at rest and during activity using visual analogue scale (VAS), grip strength, and the Japanese Orthopaedic Association elbow scoring system. The average VAS score for pain at rest improved from 26 preoperatively to 8 one month after surgery, and reached a
plateau thereafter. The VAS score with activity improved from 68 preoperatively to 35 at 1 month, 23 at 2 months, and 8 at 24 months after surgery. Mean grip strength improved from 66% of the opposite arm prior to surgery, to 89% at 2 months, and 98% at 12 months after surgery. Morrey8 described 13 consecutive patients who had surgery for persistent pain after surgery for eECRB over a 9-year period. Patients were divided into those that had pain identical to that prior to the index procedure (suggesting inadequate surgery or an incorrect diagnosis) and those who had a distinct pain (suggesting a possible complication). Diagnostic interventions included selective radiographs (including stress views), diagnostic injection (of the lateral epicondyle and/or posterior interosseous nerve in the region of the arcade of Frohse), bone scans, and diagnostic arthroscopy. An arthrogram was used to demonstrate a synovial fistula. Elbow arthroscopy was used to diagnose subtle instability. Among the 8 patients with the same pain as prior to the initial surgery, 4 patients in whom local anaesthetic injection to the lateral epicondyle relieved symptoms had repeat debridement of the ECRB origin and all 4 were satisfied. Two patients underwent posterior interosseus nerve release after local anaesthetic injection around the arcade of Frohse led to symptomatic relief (one had a satisfactory result, the other unsatisfactory). One patient underwent repeat ERCB debridement and a posterior interosseus nerve release after injections at both sites led to symptomatic relief and was satisfied. One patient had lateral collateral ligament (LCL) plication after clinical examination, arthrogram, and arthroscopy were suggestive of varus instability; this patient was satisfied. Of the five patients who had different symptoms than preoperatively, 2 were diagnosed with iatrogenic instability. One treated with plication of the LCL was satisfied, and the other treated with LCL reconstruction was unsatisfied, even after a later radial head excision. One patient was thought to have combined persistent eECRB and LCL insufficiency and was treated by ECRB debridement and LCL plication (satisfactory outcome). One patient had closure of a synovial fistula identified on arthrogram (satisfactory outcome). One other patient had pain at the lateral epicondyle that was relieved by local injection and was treated by excision of what was described as an “adventitial bursa” in the region of the lateral epicondyle (satisfactory outcome). MRI shows high signal intensity in the ECRB tendon on T1- and T2-weighted images in patients with ECRB, though magnetic resonance severity does J Hand Surg Am.
1013
not correlate with symptoms and imaging abnormalities may persist despite clinical improvement.9 MRI is also used to diagnose osteochondral lesions, synovial plica, and ligamentous injury.10 The use of MRI specifically in the setting of persistent pain after surgery to debride eECRB has not, to our knowledge, been studied. Additional pathologies are noted during arthroscopic debridement of eECRB including radiocapitellar synovitis or synovial thickening (28% to 55%), loose body (3% to 7%), bone spur (12%), and degenerative joint disease (2%).11,12 Perhaps these are responsible for some of the persistent pains after surgery for eECRB. Baker13 described capsular tears on the undersurface of the ECRB tendon in patients undergoing arthroscopic surgery for eECRB. A classification system was proposed: type 1 ¼ a smooth capsule without irregularity; type 2 ¼ a linear or longitudinal tear in the capsule; and type 3 ¼ a complete rupture and retraction of the capsule and the frayed ECRB tendon, which is visible behind it. Sasaki et al14 studied the sensitivity of computed tomography arthrogram and MRI for detection and classification of the described radiocapitallar joint capsular pathology in patients with a clinical diagnosis of chronic eECRB who were planned to undergo surgery and reported that computed tomography angiography was 90%, 100%, and 80% sensitive for the radiologist, surgeon, and fellow, respectively. The specificity rates were 89%, 89%, and 100%. MRI had a low sensitivity rate and a relatively high specificity rate. The sensitivity rates were 60%, 70%, and 50%, for the radiologist, surgeon, and fellow, respectively, and the specificity rates were 89%, 67%, and 78%. Nevertheless, the severity of the capsular pathology has not been shown to correspond to VAS pain scores at rest, with activities of daily living or with sport/work or with function measured by the Mayo function score.11 To our knowledge, no studies address the effect of various injections on persistent pain after surgery. Corticosteroid injections and extracorporeal shock waves do not modify the natural course of eECRB prior to surgery. Other types of injections, low-level laser therapy, and acupuncture are, to date, inadequately studied to know if they are more palliative than placebo or able to modify the course of the disease. The systematic review by Krogh et al15 did show a benefit of platelet-rich plasma over placebo for pain relief, although they noted there was a paucity of evidence from unbiased trials. r
Vol. 40, May 2015
Evidence-Based Medicine
ENTHESOPATHY OF THE ECRB
1014
ENTHESOPATHY OF THE ECRB
Evidence-Based Medicine
Organ et al16 described a retrospective cohort of 34 patients (35 elbows) with persistent pain after surgery for lateral epicondylitis that underwent open revision surgery. Diagnosis was made based on history, examination, and radiographs. The time after the index procedure was not described. The authors mentioned that an equal number of patients improved with time and a nonsurgical treatment protocol consisting of strengthening and flexibility (specifics not recorded). There were 34 elbows with macroscopic residual tendinosis in the ECRB origin evident at the time of revision surgery. The other elbow was said to have “an unexplained failure to generate any healing tissue in the area of previous complete resection of the ECRB tendon”. Twenty-seven of the 34 patients with residual ECRB tendinosis had no scarring in the ECRB origin, making the surgeons question the original surgery. The following additional procedures were performed: Excision of tendinotic tissue in the anterior margin of the extensor aponeurosis as well as the ECRB (N ¼ 10); excision of exostosis (N ¼ 12), reattachment of extensor mechanism (N ¼ 5); resection of impinging fibrous tissue tissue radiocapitellar joint (N ¼ 5); treatment of instability (N ¼ 1; technique not described). Following the repeated debridement, they reported 20 excellent, 9 good, 5 fair, and 1 poor results using a patient-reported outcome questionnaire with a maximum value of 40 (0e10 ¼ poor; 10e20 ¼ fair; 21e30 ¼ good; 31e40 ¼ excellent). The 29 patients (83%) with good or excellent results all returned to their previous level of work and activity. Almquist et al17 retrospectively compared 61 patients treated for both primary and recurrent lateral epicondylitis with either a limited surgical resection of the lateral extensor aponeurosis (16 patients with primary lateral epicondylitis), a wide surgical excision of the aponeurosis and coverage by a vascularized rotational pedicle flap of the anconeus muscle (31 patients with primary lateral epicondylitis), or limited wide fasciectomy and ancouneus muscle transfer following a previously unsuccessful fasciectomy (14 patients). The mean postoperative grip strength (compared with contralateral side) was 70% in the fasciectomy group and 78% in the anconeus flap groups—both primary and revision surgery. Eighty-one percent of the fasiectomy group patients returned to work as opposed to 96% of the primary anconeus flap patients and 86% of the revision anconeus flap patients. They also showed a statistically significant difference in pain relief between the fasciectomy group and both the primary and the revision anconeus flap groups (P < .05). J Hand Surg Am.
Degreef et al18 treated 10 patients with one year of persistent symptoms after surgery or percutaneous release of eERCB with an anconeus muscle transposition. The result was graded as Excellent in 3, Good in 4, and Poor in 3, as per the Roles and Maudsley criteria (excellent ¼ no pain and full movement, full activity; good ¼ occasional discomfort, full movement and full activities; fair ¼ some discomfort after prolonged activity; poor ¼ pain limiting activities). Rose et al19 described denervation of the posterior cutaneous nerve of the forearm branches in patients with more than 6 months of symptoms from eECRB and subjective improvement after a diagnostic nerve block. They reported 80% good or excellent pain relief and an average improvement of grip strength of 13e24 kg. The results of this technique should be equally applicable to primary and revision surgery. SHORTCOMINGS OF THE EVIDENCE The existing data regarding time to recovery after primary ECRB debridement procedures are limited and conflicting. The few available studies are small retrospective case series, many highlighting a specific operative technique. Persistent symptoms after surgery are uncommon and therefore difficult to study. There is limited evidence to guide the choice of diagnostic tests and treatments. Reported improvements after repeat surgery may reflect the natural history of the condition, regression to the mean, or the placebo effect rather than any direct benefit from surgery. The few studies to consider unsatisfied patients after surgery for eECRB have focused on biomedical issues. Given the benign natural history of the condition and that good outcomes are the norm in the small group of patients that undergo surgery, a biopsychosocial model may be more appropriate in patients that have persistent symptoms. This has not yet been investigated. DIRECTIONS FOR FUTURE RESEARCH A prospective cohort study of recovery after surgery for eECRB could establish the total duration of recovery before which revision surgery should not be offered in the absence of adverse events. Multicenter, prospective, randomized, double blind, placebocontrolled (including sham surgery) trials of injections, revision eECRB debridement, denervation, or another procedure would help determine the degree to which improvements are related directly to treatment of pathophysiology. Further well-conducted randomized r
Vol. 40, May 2015
controlled trials are required to assess the effectiveness of platelet-rich plasma injections in both primary and recalcitrant lateral epicondylitis. It would be useful to study psychosocial issues in patients who are unsatisfied after surgery for eECRB. Such studies could screen for psychological distress, ineffective coping strategies, and social influences that might be contributing to more pain and disability than expected. Randomized trials comparing cognitive behavioral therapy to surgery or other biomedical treatments might be worthwhile.
4. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthalsde Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet. 2002;359(9307):657e662. 5. Buchbinder R, Johnston R, Barnsley L, Assendelft W, Bell S, Smidt N. Surgery for lateral elbow pain. Cochrane Database Syst Rev. 2011;(3):CD003525. 6. Coleman B, Quinlan JF, Matheson JA. Surgical treatment for lateral epicondylitis: A long-term follow-up of results. J Shoulder Elb Surg. 2010;19(3):363e367. 7. Oki G, Iba K, Sasaki K, Toshihiko Y, Wada T. Time to functional recovery after arthroscopic surgery for tennis elbow. J Shoulder Elb Surg. 2014;23(10):1527e1531. 8. Morrey B. Reoperation for failed surgical treatment of refractory lateral epicondylitis. J Shoulder Elb Surg. 1992;1(1):47e55. 9. Savnik A, Jensen B, Norregaard J, et al. Magnetic resonance imaging in the evaluation of the treatment response of lateral epicondylitis of the elbow. Eur Radiol. 2004;14(6):964e969. 10. Cerezal L, Rodriguez-Sammartino M, Canga A, et al. Elbow synovial fold syndrome. Am J Roentgenol. 2013;201(1):88e96. 11. Baker CL, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: Two year clinical results. J Shoulder Elb Surg. 2000;9(6):475e482. 12. Lattermann C, Romeo A, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elb Surg. 2010;19(5):651e656. 13. Baker CL, Cummings PD. Arthroscopic management of miscellaneous elbow disorders. Oper Techn Sport Med. 1998;6:16e21. 14. Sasaki K, Tamakawa M, Onda K, et al. The detection of capsular tear at the undersurface of the extensor carpi radialis brevis tendon in chronic tennis elbow: The value of magnetic resonance imaging and computed tomography arthrography. J Shoulder Elb Surg. 2011;20(3):420e425. 15. Krogh T, Bartels E, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: A systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435e1446. 16. Organ SW, Nirschl RP, Kraushaar BS, Guidi EJ. Salvage surgery for lateral tennis elbow. Am J Sports Med. 1997;25(6):746e750. 17. Almquist EE, Necking L, Bach AW. Epicondylar resection with anconeus muscle transfer for chronic lateral epicondylitis. J Hand Surg Am. 1998;23(4):723e731. 18. Degreef I, Van Raebroeckx A, De Smet L. Anconeus mucle transposition for failed surgical treatment of tennis elbow: Preliminary results. Acta Orthop Belg. 2005;71(2):154e156. 19. Rose NE, Forman SK, Dellon AL. Denervation of the lateral humeral epicondyle for treatment of chronic lateral epicondylitis. J Hand Surg Am. 2013;38(2):344e349.
OUR CURRENT CONCEPTS FOR THIS PATIENT We felt confident that this patient’s symptoms were from pathophysiology more so than stress, distress, or ineffective coping strategies. Our diagnosis of persistent eECRB was based on normal radiographs and a diagnostic injection of local anaesthetic into the origin of the ECRB that provided temporary relief from symptoms. In our experience symptoms after primary surgery can continue to improve for 1 or 2 years and we recommended nonspecific palliative treatment in the anticipation of ongoing recovery and reinforced to the patient the high likelihood of symptom resolution with time. If the symptoms and signs persist 2 years after surgery, we would offer the patient repeat open debridement of ECRB origin unless we had concerns about the patient’s illness behavior. REFERENCES 1. O’Driscoll SW, Bell DF, Morrey BF. Postero-lateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440e446. 2. Nirschl RP, Pettrone F. Tennis elbow: The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832e841. 3. Faro F, Wolf JM. Lateral epicondyitis: Review and current concepts. J Hand Surg Am. 2007;32(8):1271e1279.
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Evidence-Based Medicine
ENTHESOPATHY OF THE ECRB