Nirschl surgical technique for concomitant lateral and medial elbow tendinosis: a retrospective review of 53 elbows with a mean follow-up of 11.7 years.

BACKGROUND: Combined lateral elbow tendinosis (tennis elbow) and medial elbow tendinosis (golfer's elbow) can be a disabling condition that, if unresponsive to nonoperative treatments, may be effectively treated surgically. The authors are not aware of any study that reports the outcome of a combined operation for lateral and medial elbow tendinosis (country club elbow) performed in the same operative setting. HYPOTHESIS: Combined surgical treatment of country club elbow in the same operative setting has similar outcomes to those seen in the literature for single operative procedures. STUDY DESIGN: Case series; Level of evidence 4. METHODS: Outcome measurements included the Numeric Pain Intensity Scale, the Nirschl tennis elbow scoring system, and the American Shoulder and Elbow Surgeons elbow form. Forty-eight patients (53 clinical elbows) were available by telephone, with a minimum time to follow-up of 5 years (range, 5-19 years; mean, 11.7 years). RESULTS: The average Nirschl tennis elbow score improved from 16.7 preoperatively to 70.8 postoperatively (P < .01). The average American Shoulder and Elbow Surgeons elbow score improved from 45.2 to 90.4 (P < .01). The Numeric Pain Intensity Scale score improved from 8.8 to 1.7 (P < .01). By the criteria of the Nirschl tennis elbow score, results were rated excellent in 38 elbows, good in 7 elbows, fair in 5 elbows, and poor in 3 elbows, with 85% (45 of 53) good to excellent results. Patient satisfaction with the surgery averaged 8.7 out of 10. Of the 46 patients who played sports, 44 (96%) reported returning to their sports. CONCLUSION: When nonoperative treatment of lateral and medial elbow tendinosis fails, combined surgical intervention via the Nirschl operative techniques for country club elbow is highly effective, with results similar to those of single-sided intervention.

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

BACKGROUND: Good to excellent short-term results have been reported for the surgical treatment of lateral epicondylitis using various surgical techniques. HYPOTHESIS: Surgical treatment for lateral epicondylitis using the mini-open Nirschl surgical technique will lead to durable results at long-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Records from 139 consecutive surgical procedures (130 patients) for lateral epicondylitis performed by 1 surgeon between 1991 and 1994 were retrospectively reviewed. Eighty-three patients (92 elbows) were available by telephone for a mean follow-up of 12.6 years (range, 10-14 years). Outcome measures included the Numeric Pain Intensity Scale, Nirschl and Verhaar tennis elbow-specific scoring systems, and American Shoulder and Elbow Surgeons elbow form. Preoperative data were collected retrospectively. RESULTS: The mean age of the study group was 46 years (range, 23-70 years) with 45 men and 38 women. Eighty-seven of the procedures were primary, and 5 were revision tennis elbow surgeries. Concomitant procedures were performed in 30 patients including ulnar nerve release in 24 patients, medial tennis elbow procedures in 23 patients, shoulder arthroscopy in 2 patients, carpal tunnel release in 1 patient, and triceps debridement and osteophyte excision in 1 patient. The mean duration of preoperative symptoms was 2.2 years (range, 2 months to 10 years). The mean Nirschl tennis elbow score improved from 23.0 to 71.0, and the mean American Shoulder and Elbow Surgeons score improved from 34.3 to 87.7 at a minimum of 10-year follow-up (P < .05). The Numeric Pain Intensity Scale pain score improved from 8.4 preoperatively to 2.1 (P < .05). Results were rated as excellent in 71 elbows, good in 6 elbows, fair in 9 elbows, and poor in 6 elbows by the Nirschl tennis elbow score. By the criteria of Verhaar et al, the results were excellent in 45 elbows, good in 32 elbows, fair in 8 elbows, and poor in 7 elbows. Eighty-four percent good to excellent results were achieved using both scoring systems. Ninety-two percent of the patients reported normal elbow range of motion. The overall improvement rate was 97%. Patient satisfaction averaged 8.9 of 10. Ninety-three percent of those available at a minimum of 10-year follow-up reported returning to their sports. CONCLUSION: The mini-open Nirschl surgical technique with accurate resection of the tendinosis tissue remains highly successful in the long term.

Arthroscopic rotator cuff debridement without decompression for the treatment of tendinosis.

PURPOSE: The treatment of rotator cuff injury in the absence of a full-thickness tear has traditionally consisted of acromioplasty. However, this disorder may also be treated by arthroscopic rotator cuff debridement without acromioplasty. Our previous study of 79 shoulders so treated reported 87% good or excellent results at an average 53-month follow-up. The purpose of this article is to report the long-term, average 9.5-year follow-up of this cohort. TYPE OF STUDY: Long-term follow-up of case series. METHODS: We retrospectively reviewed the records of 62 shoulders in 60 patients who had undergone arthroscopic rotator cuff debridement for partial-thickness rotator cuff tears. Demographic criteria, residual pain, and the ability to return to recreational athletics were noted. The UCLA Shoulder Score and the Simple Shoulder Test scores were determined and statistical analysis performed. RESULTS: Using the UCLA Shoulder Score, there were 79% excellent or good results at an average 114 months of follow-up. Patients with Workers' Compensation claims had significantly worse results, with only 40% rated good or excellent. Of the 60 patients, 77% had no or only minimal pain, 57% were still able to perform recreational athletics without difficulty, and 20% could participate at a lower level of intensity. CONCLUSIONS: Arthroscopic debridement of rotator cuff injury in the absence of a full-thickness tear has good long-term results and minimizes additional surgical trauma. LEVEL OF EVIDENCE: Level IV, case series.

Tennis elbow tendinosis (epicondylitis).

Tennis elbow tendinosis (epicondylitis) is most commonly caused by tendon overuse and failed tendon healing. The pathoanatomy of overuse tendinopathy is noninflammatory "angiofibroblastic tendinosis." The specific areas of elbow abnormality include the extensor carpi radialis brevis-extensor digitorum communis complex laterally, the pronator teres, flexor carpi radialis medially, and triceps posteriorly. The primary goal of nonsurgical treatment is to revitalize the unhealthy tissue that produces pain. Successful nonsurgical treatment comprises rehabilitative resistance exercise and progression of the exercise program. If rehabilitation fails, surgical treatment can be quite successful.

Elbow tendinopathy: tennis elbow.

The pathoanatomy of overuse tendinopathy is noninflammatory angiofibroblastic tendinosis. The areas of elbow abnormality are specific, including the ECRB-EDC complex laterally, the pronator teres, flexor carpi radialis medially, and triceps posteriorly. The goals of nonoperative treatment are to revitalize the unhealthy pain-producing tendinosis tissue. The key to nonoperative treatment is rehabilitative resistance exercise with progression of the exercise program. If rehabilitation fails, the surgical interventions as described are highly successful.

Internal impingement in the etiology of rotator cuff tendinosis revisited.

PURPOSE: The theory of internal impingement holds that, in overhead athletes, repeated contact between the undersurface of the rotator cuff and the posterosuperior glenoid rim leads to articular-sided partial-thickness rotator cuff tears and superior labral lesions. However, we have noted this same constellation of lesions in our general patient population. These recreational athletic patients do not routinely assume the position of extreme abduction and external rotation, and thus are unlikely to experience significant internal impingement forces. The goal of this study was to document the prevalence of superior labral lesions in patients being treated for partial-thickness undersurface rotator cuff tears. TYPE OF STUDY: Retrospective case series. METHODS: We retrospectively reviewed the records of 75 shoulders arthroscopically treated for partial-thickness articular-sided rotator cuff tears. With the exception of one professional tennis player, no patients were playing sports at a professional or major college level. No professional or collegiate throwing athletes were included. The prevalence of these lesions and their association with recreational athletics was noted. RESULTS: We found that 55 of 75 (73.3%) shoulders with articular-sided partial-thickness rotator cuff tears also had superior labral lesions. A statistically significant increased prevalence of superior labral lesions in the dominant shoulder was seen (P =.03). In addition, our patients who engaged in overhand throwing had significantly fewer superior labral lesions in the dominant shoulders than did nonthrowers (P =.017). CONCLUSIONS: The "kissing lesions" of undersurface rotator cuff tears and posterosuperior labral damage may be explained by mechanisms other than "internal impingement."

Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo-controlled study.

BACKGROUND: A better treatment modality is needed to control the pain of medial or lateral epicondylitis (tennis elbow). HYPOTHESIS: Dermal iontophoretic administration of dexamethasone sodium phosphate will be significantly more effective in controlling pain than a placebo in patients with medial or lateral elbow epicondylitis. STUDY DESIGN: Randomized, double-blinded, placebo-controlled study. METHODS: On six occasions, 1 to 3 days apart within 15 days, 199 patients with elbow epicondylitis received 40 mA-minutes of either active or placebo treatment. RESULTS: Dexamethasone produced a significant 23-mm improvement on the 100-mm patient visual analog scale ratings, compared with 14 mm for placebo at 2 days and 24 mm compared with 19 mm at 1 month. More patients treated with dexamethasone than those treated with placebo scored moderate or better on the investigator's global improvement scale (52% versus 33%) at 2 days, but the difference was not significant at 1 month (54% versus 49%). Investigator-rated pain and tenderness scores favored dexamethasone over placebo at 2 days. Patients completing six treatments in 10 days or less had better results than those treated over a longer period. CONCLUSIONS: Iontophoresis treatment was well tolerated by most patients and was effective in reducing symptoms of epicondylitis at short-term follow-up.

Arthroscopic debridement for the treatment of osteoarthritis of the knee: 2- and 5-year results.

PURPOSE: The purpose of this study was to evaluate the effect that arthroscopic debridement in osteoarthritic knees has on patient satisfaction and function. TYPE OF STUDY: Cohort observational study. METHODS: Thirty-six patients (mean age, 64.8 years) were available for 2- and 5-year follow-up after undergoing knee arthroscopy to treat arthritic symptoms refractory to conservative treatment. Surgical treatment included debridement of meniscal lesions, stabilization of chondral defects, removal of impinging osteophytes, and notchplasty. Age, symptoms, preoperative and postoperative Hospital for Special Surgery (HSS) scores, compartments involved, motion, impinging lesions, and level of satisfaction were evaluated. RESULTS: At 2 years, 32 of 36 patients were satisfied. Mean HSS scores improved from 29.2 to 48.0. All 4 early failures had tricompartment disease (mean preoperative HSS scores, 21.5; preoperative flexion contractures, 15.6 degrees ). At 5 years, 25 of the 36 patients were satisfied with good to excellent results. Mean HSS scores decreased slightly to 43.2. Three patients had some deterioration and were rated fair, and 8 were considered failures requiring further surgery. The 25 of 36 with satisfactory results had a mean preoperative flexion contracture of 7.3 degrees and average HSS scores of 33.2, whereas the other 11 of 36 had mean contractures of 15.0 degrees and average HSS scores of 20.1. Poor results were associated with contractures greater than 10 degrees (P =.05) and lower preoperative HSS scores (P =.05). CONCLUSIONS: Arthroscopic debridement of osteoarthritic knees has a favorable outcome in selected patients. Those patients with preoperative flexion contractures less than 10 degrees and preoperative HSS scores greater than 22 beneficially responded to this method of treatment.

Five-Step Treatment for Overuse Injuries.

In brief Overuse injuries can be particularly challenging to manage. An athlete's premature return to athletic activity often results in recurrent and recalcitrant injury. A five-step management plan that includes establishing a pathoanatomic diagnosis, controlling inflammation, promoting healing, increasing fitness, and controlling abusive activity offers athletes optimal opportunity to return successfully to athletic performance.