Benha Medical Journal

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 32  |  Issue : 2  |  Page : 137--140

Percutaneous combined common extensor origin release and drilling of lateral humeral epicondyle resistant tennis elbow


Medhat T Maaty, Maged M El-Shennawy, Wail L Abdel-Naby, Mohib S Ahmad 
 Department of Orthopedic Surgery, Mansoura University, Mansoura, Egypt

Correspondence Address:
Wail L Abdel-Naby
PhD, Orthopedic Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Gomhoria Street, Mansoura 35516
Egypt

Abstract

Despite tennis elbow being a common disease in orthopedic surgery, its causative pathology is poorly understood. A prospective study b etween February 2012 and December 2014 of 16 patients (12 males and four females) of resistant tennis elbows after failure of conservative treatment for more than 6 months, had sustained to a combined percutaneous common extensor origin release and drilling of lateral humeral epicondyle. All patients were followed up for at least a year. Clinical results were evaluated in terms of pain relief, activity improvement and patient satisfaction. The results were excellent in 12 patients (75%) and good in three patients (18.75%) and poor i n one patient (6.25%). Pain relief was achieved on average 12 weeks after surgery. No wound complications were detected. Combining the percutaneous common extensor origin release with drilling of lateral humeral epicondyle in resistant tennis elbow cases improved the results and .increased patient«SQ»s satisfaction.



How to cite this article:
Maaty MT, El-Shennawy MM, Abdel-Naby WL, Ahmad MS. Percutaneous combined common extensor origin release and drilling of lateral humeral epicondyle resistant tennis elbow.Benha Med J 2015;32:137-140


How to cite this URL:
Maaty MT, El-Shennawy MM, Abdel-Naby WL, Ahmad MS. Percutaneous combined common extensor origin release and drilling of lateral humeral epicondyle resistant tennis elbow. Benha Med J [serial online] 2015 [cited 2022 Aug 12 ];32:137-140
Available from: http://www.bmfj.eg.net/text.asp?2015/32/2/137/180327


Full Text

 Introduction



Tennis elbow is a common disease and its incidence ranges from 1 to 3% [1]. Its pathology is poorly understood and most structures on the lateral side of the elbow have been involved [2]. The primary causes may be mechanical overload and repetitive stresses on the tendon with a degenerative lesion. The primary method of treatment is conservative measures using anti-inflammatory drugs, physical therapy, and local steroid injections. Although more than 90% of patients with tennis elbow respond to conservative measures, it can produce unsatisfactory results that can lead to chronicity [3]. For resistant cases, surgery is reserved and it has been reported that up to 8% of patients require surgery [3],[4]. Surgical procedures available include lengthening of the extensor carpi radialis brevis, excision of damaged part of the tendon, exploration of radio humeral joint, and extensor tendon tenotomy [5],[6]. Recently, the outcomes of the percutaneous release of the common extensor origin were reported [7],[8],[9],[10]. In our study, we evaluated the results of combining percutaneous release of the common extensor origin and drilling of the lateral humeral epicondyle in resistant tennis elbow cases.

 Patients and methods



A16 outpatient clinic of resistant tennis elbow cases had been sustained to this study betwee Fnebruary 2012 and December 2014, ethical code was considered. Cases were considered resistant after failed conservative measures in the form of anti-inflammatory drugs, rest, splint, physiotherapy, and local steroid injection for at least 6 months. All cases were clinically and radiologically evaluated. Twelve patients (75%) were male and four patients (25%) were female. All patients were of right side affection and also were the dominant side. The mean age of patients was 42 years (range = 30-56 years). Symptoms were present for an average of 9.8 months (range = 6-19 months).

Surgical technique: Surgery was performed under general anesthesia and a tourniquet control. The common extensor origin released by percutaneous technique involved a 1 cm incision over the mid-point of the lateral epicondyle to reveal the common extensor origin [Figure 1]. The elbow is flexed to protect the radial nerve [Figure 2]. A small pair of artery forceps is maneuvered under the common extensor origin which may, hence, be well visualized and divided [Figure 3]. The wrist is flexed to complete the defect and allow a 1 cm gap to be created at the common extensor origin [Figure 4]. In our technique, we added percutaneous drilling of lateral humeral epicondyle through the same incision. It was done by a drill pit of 2.5 mm and three drill holes were done under control of image intensifier [Figure 5] and [Figure 6]. The tourniquet was then released, hemostasis, skin closure and dressing.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

Postoperative follow-up: The patients were discharged at the same day of the operation and received oral antibiotics. No splint was applied to the upper extremity and the elbow was left free for use. The first follow-up was for suture removal and evaluating of the wound. Then the patients underwent follow-up every month for evaluation of the clinical results in terms of pain, activity level, and patient satisfaction. At the final follow-up, the patients were classified according to Grundberg and Dobson [11] [Table 1].{Table 1}

 Results



This study included 16 patients who sustained to a combined percutaneous common extensor origin release and drilling of lateral humeral epicondyle. The minimum follow-up was 12 months; the range was 12-26 months. All female patients were housewives. The male patients were manual workers. There were no postoperative wound complications. All patients were satisfied with the incision scar. The patients were evaluated for pain, activity, and patient satisfaction during the last examination [Table 1] [11] Twelve patients were rated as having excellent results. Three patients were rated as having a good result and one who was rated as having a poor result. Lateral epicondylar pain was relieved within an average of 12 weeks after the surgery ranged from 3 to 28 weeks. All patients had a full range of elbow motion at follow-up examination. All patients with excellent or good results returned to their former occupations and activities.

 Discussion



Tennis elbow is an overuse injury of the common extensor tendon origin. The pathology is poorly understood and most structures on the lateral side of the elbow have been implicated. The patients should be examined carefully to exclude other pathologies like entrapment of the anterior branch of radial nerve, lateral ligament complex injury. Surgical treatment is a challenge in resistant tennis elbow. After failure of conservative treatment, surgery is recommended. The benefits of surgical interference are rapid return to normal daily living activities, relief of pain, and short time for recovery. Many surgical techniques for tennis elbow include excision of the damaged portion of extensor carpi radialis brevis (ECRB), excision of lateral epicondylar ridge, z-lengthening of the tendon, arthroscopy and open and percutaneous tenotomy.

In our study, we used combined percutaneous common extensor origin release and drilling of lateral humeral epicondyle technique in resistant tennis elbow cases. In this study, excellent and good outcomes were obtained in 12 (75%) and three patients (18.75%), respectively. One patient had poor result (6.25%). Das and Maffulli [12] in their study of open release of extensor tendon, 75% of the patients had excellent or good results and 73% of them were satisfied with the results of surgery. Baumgard and Schwartz [7], using percutaneous release of extensor origin, have reported excellent results in 32 (91.42%) and poor results in three (8.57%) out of 35 patients. Grundberg and Dobson [11] claim good and excellent result in 29 out of 30 elbows (96.66%), by releasing the extensor origin using percutaneous method. Sahu and Guptha [13] claimed that the results were excellent in forty patients (86.95%) and good in six patients (26.08%) using percutaneous technique.

 Conclusion



Combining percutaneous common extensor origin release and drilling of lateral humeral epicondyle in resistant tennis elbow improves the results. It also increases the satisfaction of the patients. It is a relatively simple and minimally invasive procedure. It has the advantage of not being associated with serious complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin Orthop 1992; 278 :73-80.
2 Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow: incidence, recurrence and effectiveness of prevention strategies. Am J Sports Med 1979; 7 :234-238.
3 Boyd HB, Mcleod AC. Tennis elbow. J Bone Joint Surg Am 1973; 55 :1183 -1187.
4 Posch JN, Goldberg VM, Larrey R. Extensor fasciotomy for tennis elbow: a long - term follow -up study. Clin Orthop Relat Res 1978; 135 :179-182.
5 Bosworth DM. Surgical treatment of tennis elbow; a follow-up study. J Bone Joint Surg Am 1965; 47 :1533-1536.
6 Rosen MJ, Duffy FP, Miller EH, Kremchek EJ. Tennis elbow syndrome: results of the ′lateral release′ procedure. Ohio State Med J 1980; 76 :103-109.
7 Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med 1982; 10 :233-236.
8 Murtagh JE. Tennis elbow: description and treatment. Aust Fam Physician 1978; 7 :1307-1310.
9 Powell SG, Burke AL. Surgical and therapeutic management of tennis elbow: an update. J Hand Ther 1991; 4 :64-68.
10Yerger B, Turner T. Percutaneous extensor tenotomy for chronic tennis elbow: an office procedure. Orthopedics 1985; 8 :1261-1263.
11Grundberg AB, Dobson JF. Percutaneous release of the common extensor origin for tennis elbow. Clin Orthop Relat Res 2000; 376, 137-140.
12Das D, Maffulli N. Surgical management of tennis elbow. J Sports Med Phys Fitness 2002; 42 :190-197.
13Sahu RL, Guptha P. Percutaneous tennis elbow release under local anesthesia: a prospective study. J Med Sci Tech 2013;:4-7.