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Outcome analysis of percutaneous tenotomy in chronic lateral epicondylitis elbow of greater than 6 months duration

An overuse syndrome prevalent in fourth decade of life, lateral epicondylitis (tennis elbow) is the most common cause of elbow pain in patients attending the orthopaedic clinics. Pathology of condition is unclear, with a variety of conditions being used to explain its aetiology. Most likely, a combination of mechanical overloading and abnormal microvascular changes in the extensor tendon origin esp. extensor carpi radialis brevis are known to contribute to pathology of this condition. Disorganization of normal collagen architecture by invading fibroblasts in association with an immature vascular reparative response has been noted and termed as “angiofibroblastic hyperplasia”. Mostly tennis elbow responds well to conservative treatment involving rest and analgesics.


INTRODUCTION
An overuse syndrome prevalent in fourth decade of life, lateral epicondylitis (tennis elbow) is the most common cause of elbow pain in patients attending the orthopaedic clinics. Pathology of condition is unclear, with a variety of conditions being used to explain its aetiology. 1 Most likely, a combination of mechanical overloading and abnormal microvascular changes in the extensor tendon origin esp. extensor carpi radialis brevis are known to contribute to pathology of this condition. Disorganization of normal collagen architecture by invading fibroblasts in association with an immature vascular reparative response has been noted and termed as "angiofibroblastic hyperplasia". 2 Mostly tennis elbow responds well to conservative treatment involving rest and analgesics. 3 Still no standardized treatment is available for tennis elbow >6 month duration to promote healing and improve function. Tennis elbow >6 month duration is a distinct entity with an undefined management. The present study aims to evaluate percutaneous surgical release in this specific group of patients.

METHODS
This hospital based prospective study was performed at a tertiary care institute over a period of one year (2016-17). All patients who visited our department during above period with tennis elbow >6 mo. duration were included; while patients who refused consent, had previous elbow surgery or underlying elbow pathologies e.g., rheumatoid arthritis, osteoarthritis or radial tunnel syndrome were excluded from study. Patients were carefully evaluated by history and elbow examination. This included baseline numerical rating scale (NRS), disabilities of the arm, shoulder, and hand questionnaire (DASH) and Oxford elbow score measurements. Following these patients were treated by Percutaneous tenotomy (an outpatient department (OPD) based procedure). Patients were followed up at 3 month and 6 month interval and evaluated clinically and by using NRS, DASH and Oxford Score.

Percutaneous technique
After due consent and under local anesthesia, this OPD procedure was carried out placing limb in an attitude of flexion at elbow to protect the radial nerve. Onecentimeter incision over the mid-point of the lateral epicondyle was given to reveal common extensor origin. A small pair of artery forceps was manoeuvred under the common extensor origin to visualize and divide it. The wrist was flexed to complete the defect and allow one cm gap at the cut common extensor origin. This gap was palpated to confirm the completion of procedure. The wound was closed in layers and local pressure applied to achieve hemostasis. All patients were advised postoperative mobilization of wrist and elbow many times a day in a sequence of; forearm in full pronation; full extension of elbow; wrist flexion and finger flexion (Figures 1-4).

Outcome assessment
Outcome assessment was done at 3 mo. and 6 mo. follow ups using NRS, DASH score and Oxford elbow scores.

RESULTS
The present study aimed to prospectively evaluate percutaneous extensor tendon release in patients with tennis elbow >6 months duration. All patients had previously been exposed to irregular and intermittent conservative therapy in the form of rest and Nonsteroidal anti-inflammatory drugs (NSAIDs).
A total of 30 patients were treated by percutaneous tenotomy method (PT; n=30). The mean age of patients in was 41.74 years (range 26-67 years). Females were affected more than males in both groups (3:1). Dominant limb was involved in 86% of patients.73% of females were house wives exposed to household chores and manual activities while 40% of males were manual workers. Mean hospital stay was 35 minutes (range 20-43 minutes). Patients were followed up at 3 month and 6 month post intervention. Patients returned to normal activity in a mean period of 2 weeks. No complications were reported in both groups and all patients had full range of motion at elbow at follow ups.
NRS was used to assess pain at follow-up and compared with baseline. NRS was graded in 4 categories namely excellent, good, fair, and poor based on sum of scale score. At baseline, none of the patients were in excellent category in both groups, and four and one patient in CE and PT groups respectively present in poor category. Most of the patients were in good category. At 3 months, there were no patients in excellent and poor category while at 6 months, there were 12 patients in excellent category. The DASH score was graded as excellent (0-25 points), good (26-50 points), moderate (51-75 points), or poor (76-100 points). Majority of the patients were in poor score category while none of the patients was in excellent and good category at baseline. Number of patients increased to moderate category at 3 months and 6 months period (Tables 1-3).   (Figures 5-7).

DISCUSSION
Literature review mentions a variety of treatment options for tennis elbow which range from conservative therapy to operative treatment. 1 6,7 In another study percutaneous common extensor origin release and drilling of lateral humeral epicondyle technique was used in resistant tennis elbow cases with excellent and good outcomes in (75%) and 18.75% patients respectively. 8 Although at 3 and 6 month follow ups patients independently reported significant decrease in NRS, DASH and Oxford scores (p<0.05), meaning thereby that patients had significant improvement in function post percutaneous tenotomy. Hence percutaneous tenotomy is a viable option in patients with lateral epicondylitis >6 month duration.

Strength
The strength of the study lies in the fact that it was a prospective hospital-based study where pre intervention scores were available and multiple scoring systems were used.

Limitation
The study has small sample size and a shorter follow up.
Multicenter studies with large sample size and longer follow up are required.

CONCLUSION
The treatment of lateral elbow epicondylitis is frequently a self-limiting entity. In persisting lateral epicondylitis >6 month duration, the management is unclear and undefined. Percutaneous tenotomy is effective in managing tennis elbow (>6 months).