In the Treatment of Lateral Epicondylitis by Percutaneous Perforation, Injectables Have No Added Value.

BACKGROUND: No single injection therapy has been proven to be superior in the treatment of lateral epicondylitis. In most studies, the injection technique is not standardized, which makes it challenging to compare outcomes. QUESTIONS/PURPOSES: (1) Does injection with autologous blood, dextrose, or needle perforation only at the extensor carpi radialis brevis tendon origin produce better VAS pain scores during provocation testing at 5 months of follow-up? (2) Which percutaneous technique resulted in better secondary outcome measures: VAS during rest and activity, VAS during maximum grip, Oxford elbow score (OES), QuickDASH, Patient-related Tennis Elbow Evaluation (PRTEE), or EuroQol-5D (EQ-5D)? METHODS: In this multicenter, randomized controlled trial performed from November 2015 to January 2020, 166 patients with lateral epicondylitis were included and assigned to one of the three treatment groups: autologous blood, dextrose, or perforation only. Complete follow-up data were available for the primary outcome measures at the 5-month follow-up interval for 77% (127 of 166) of patients. Injections of the extensor carpi radialis brevis tendon were conducted in an accurate and standardized way. The three groups did not differ in terms of key variables such as age, gender, duration of symptoms, smoking habits, pain medication, and physiotherapy use. Data were collected at baseline and 8 weeks, 5 months, and 1 year after treatment and compared among the groups. The primary endpoint was the VAS pain score with provocation at 5 months. Our secondary study outcomes were VAS pain scores during rest, after activity, and after maximum grip strength; functional recovery; and quality of life. Therefore, we report the VAS pain score (0 to 100, with higher scores representing more-severe pain, minimum clinically important difference [MCID] 10), OES (0 to 48, with higher scores representing more satisfactory joint function, MCID 10), QuickDASH (0 to 100, with higher scores representing more severe disability, MCID 5.3), PRTEE (0 to 100, with higher scores representing more pain or more disability, MCID 20), EQ-5D/QALY (EQ-5D sumscore 0 to 1, with the maximum score of 1 representing the best health state, MCID 0.04), and EQ-5D VAS (0 to 100, with higher scores representing the best health status, MCID 8). For analysis, one-way analysis of variance and a linear mixed-model analysis were used. The analyses were performed according to the intention-to-treat principle. Four patients from the perforation group opted to crossover to autologous blood after 5 months. RESULTS: No injection therapy proved to be superior to any other in terms of VAS pain scores during the provocation test at 5 months of follow-up (VAS for perforation: 25 ± 31; autologous blood: 26 ± 27; dextrose: 29 ± 32; p = 0.35). For the secondary outcomes, only a clinically important difference was found for the QuickDASH score. Both the perforation-only group (-8 [98% CI -4 to -12]) and autologous blood (-7 points [98% CI -3 to -11]) had improved QuickDASH scores over time compared with the dextrose group (MCID 5.3; p < 0.01). For the other outcomes, no clinically important differences were found. CONCLUSION: There is no benefit to injectable autologous blood and dextrose over perforation alone to treat lateral epicondylitis, and they are therefore not indicated for this condition. LEVEL OF EVIDENCE: Level I, therapeutic study.

Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up.

BACKGROUND: In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved. METHODS/DESIGN: A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in 'Visual Analogue Scale'). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment. DISCUSSION: When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy. TRIAL REGISTRATION: This study is registered in the Trial Register ( www.trialregister.nl ) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569.

Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy.

PURPOSE: Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE. METHODS: Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported. RESULTS: Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular. CONCLUSION: Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way.

Local infiltration analgesia following total knee arthroplasty: effect on post-operative pain and opioid consumption--a meta-analysis.

INTRODUCTION: Local infiltration analgesia (LIA) is a popular method for decreasing post-operative pain after total knee arthroplasty (TKA). The goal of this meta-analysis is to compare the effect of LIA with placebo on the intensity of post-operative pain and the consumption of opioids. METHODS: A search was performed in the PubMed/MEDLINE, Cochrane, EMBASE and TRIP databases. All (quasi)-randomized controlled trials (RCTs) were included. LIA consists of intra-operative infiltration with at least one analgesic component. Data were pooled using Cochrane software. RESULTS: Seven placebo-controlled RCTs were included, involving 405 TKAs. On the first post-operative day, LIA provides an average decrease in VAS scores at rest of 12.3 % compared to placebo. Six RCTs studied opioid consumption in patients following TKA. There was a decrease in opioid consumption of 14.8 % compared to placebo 24 h after surgery. This suggests a reduced pain perception due to LIA. On the second post-operative day, the effect on both outcome measures was diminished and no longer significant. Heterogeneity between the studies was 71 % for pain and 39 % for opioid consumption (p = 0.002 and p = 0.0005). No major complications were reported with the use of LIA. CONCLUSION: LIA might be able to decrease pain and the use of opioids on the first post-operative day following TKA. However, due to the high level of heterogeneity between the studies, no firm conclusions can be drawn. LEVEL OF EVIDENCE: Meta-analysis, Level II.

Multiple Perforations of the ECRB Tendon Using an Innovative Standardized, Reproducible Technique; A Cadaveric Study on Accuracy and Prospective Clinical Safety Assessment Pilot Study. No Adverse Effects in the First 122 Patients with Lateral Epicondylitis.

Background: In LE (Lateral Epicondylitis) otherwise known as Tennis Elbow, the Extensor Carpi Radialis Brevis (ECRB) tendon is most commonly involved. In the majority of studies, injections are performed with a lack of standardization. The Instant Tennis Elbow Cure (ITEC) device has been developed to perform reproducible and standardized perforations by multiple needles. The goal of this pilot study was to estimate the accuracy of this ITEC device by means of a cadaveric study and to assess the clinical safety of this procedure. Methods: Ten cadaveric arms were injected using the ITEC device. The location and depth of the ECRB tendon was measured by ultrasound imaging. The accuracy of the infiltration was assessed by locating the injected dye through dissection and arthrotomy of the cadaveric elbow. A prospective clinical pilot study was conducted to assess the safety of the ITEC device in treating patients with chronic LE. An optional infiltration with an injection fluid was carried out?? Primary outcome measures were side effects and complications of the ITEC device occurring within a follow up period of 8 weeks after treatment. Results: In all cadaveric elbows the injection fluid ( in this case an injection fluid) was located at the ECRB tendon. In one cadaver, a minimal amount of dye was found intra-articular and in 3 cadavers a small quantity was located in the surrounding tissue of the ECRB tendon. 122 patients with LE were treated with the ITEC device. No adverse effects or complications were reported at 8-week follow up. Conclusion: Treatment of LE using the ITEC device appears accurate and safe. It may improve future research since it is reproducible and it can be performed in a standardized way.

Ultrasound Measurements of the ECRB Tendon Shows Remarkable Variations in Patients with Lateral Epicondylitis.

BACKGROUND: Lateral epicondylitis (LE) most commonly affects the Extensor Carpi Radialis Brevis (ECRB) tendon and patients are generally treated with injection therapy. For optimal positioning of the injection, as well as an estimation of the surface area and content of the ECRB tendon to determine the volume of the injectable needed, it is important to know the exact location of the ECRB in relation to the skin as well as the variation in tendon length and location. The aim of this study was to determine the variation in location and size of the ECRB tendon in patients with LE. METHODS: An observational sonographic evaluation of the ECRB tendon was performed in 40 patients with LE. The length of the ECRB tendon, distance from the cutis to the center of the ECRB tendon, the length of the osteotendinous junction at the epicondyle and the distance from cutis to middle of the osteotendinous junction were measured. RESULTS: The average tendon length was 1.68cm (range 1.27-1.98; SD 0.177). Compared to women, the ECRB tendon of men was on average 0.12cm longer. Overall, the average distance from cutis to the center of the ECRB was 0.75cm (range 0.50-1.46cm; SD 0.210), the average length of the junction was 0.55cm (range 0.35-0.87; SD 0.130), and the distance from cutis to middle of the osteotendinous junction was 0.73cm (range 0.40-1.25cm; SD 0.210). CONCLUSION: The size and depth of the ECRB tendon in patients with LE is largely variable. While there are no studies yet suggesting sono-guided injection to be superior to that of blind injection, the anatomic variability of this study suggests that the accuracy of injection therapy for LE might be compromised when based solely on bony landmarks and therefore not fully reliable. As a result, there is value in further studies exploring the accuracy of the ultrasound guided injection techniques.

Imaging and classification of osteochondritis dissecans of the capitellum: X-ray, magnetic resonance imaging or computed tomography?

BACKGROUND: Diagnosing capitellar osteochondritis dissecans (OCD) can be difficult, causing delay in treating young athletes. The main aim of this retrospective diagnostic study was to determine which radiological technique is preferred to identify and classify elbow OCD. METHODS: We identified young patients who underwent elbow arthroscopy because of symptomatic OCD. We included all patients who had pre-operative radiographs, a computed tomography (CT) scan and magnetic resonance imaging (MRI) available. We assessed whether the osteochondral lesion could be identified using the various imaging modalities. All lesions were classified according to previous classifications for X-ray, CT and MRI, respectively. These results were compared with findings at arthroscopy. RESULTS: Twenty-five patients had pre-operative radiographs as well as CT scans and MRI. In six patients, the lesion was not visible on standard X-ray. In 20 patients, one or two loose bodies were found during surgery, consistent with an unstable lesion. Pre-operatively, this was seen on 11 X-rays, 13 MRIs and 18 CT scans. CONCLUSIONS: Capitellar OCD lesions are not always visible on standard X-rays. A CT appears to be the preferred imaging technique to confirm diagnosis of OCD. Loose bodies are often missed, especially on standard X-rays and MRIs.

Tennis elbow.

Tennis elbow is the most common cause of lateral-sided elbow pain with a major socioeconomic impact. The etiology of tennis elbow is not completely understood, but there are many different treatment options. This review gives an overview of the current concepts of diagnosis and treatment of tennis elbow and the impact on work participation.

Validity and Reliability of Elbow Range of Motion Measurements Using Digital Photographs, Movies, and a Goniometry Smartphone Application.

INTRODUCTION: Range of motion (ROM) is closely monitored before and after surgery for stiff elbow and during rehabilitation. Measurements in the home environment may be helpful to increase involvement and adherence of the patient. Therefore, our objective is to investigate the validity and inter- and intraobserver reliability of 3 alternative methods to assess the ROM by the patient in a home-based situation, in comparison to the universal goniometer (UG). We hypothesize that all 3 alternative methods will be valid alternatives and show a level of reliability equivalent to UG. METHODS: Goniometric measurements of elbow flexion, extension, pronation and supination using photography, movie, and a smartphone application were obtained. The validity of these measurement methods was compared to UG. The interobserver and intraobserver reliability were calculated for all measurement methods. RESULTS: Photography and movie based goniometry of the elbow showed good validity in flexion and extension. The interobserver and intraobserver reliability were found to be good to excellent for photo and movie but moderate to poor for UG and the smartphone application. CONCLUSIONS: Photo or movie based goniometry seems to be a useful option for initial and follow-up measurement of the elbow ROM, both in the outpatient clinic and in a home environment. Based on our study, the smartphone application we used is not recommended.

Continuous Local Infiltration Analgesia after TKA: A Meta-Analysis.

The analgesic effect of local infiltration analgesia (LIA) after total knee arthroplasty (TKA) has been reported to be less than 24 hours. The concept of continuous LIA (CLIA) has been developed to achieve prolonged analgesia by bolus injections or by pump infusion of analgesics. The purpose of this meta-analysis is to assess the effect of CLIA versus single-shot injection LIA (SLIA) and placebo on pain after TKA.A systematic search was performed in most relevant databases to identify all randomized controlled trials (RCTs) comparing intra-articular CLIA with SLIA or placebo for TKA. Primary outcome measures were visual analogue scale (VAS)-scores after 24, 48, and 72 hours at rest and during activity. Data were extracted for meta-analysis and pooled using Cochrane software. The results of comparable studies were pooled using the fixed effects model or random effects model.A total of 11 RCTs were included. Five articles were eligible for meta-analysis comparing CLIA versus placebo, involving 227 TKAs. VAS scores at rest 24 hours after surgery were in favor of CLIA with a decrease of pain scores of 46%. On the second and third postoperative day, the decrease in VAS scores was no longer significant. During activity VAS scores were also in favor of CLIA after 24 and 48 hours.Two studies were eligible for meta-analysis comparing CLIA versus SLIA. VAS scores at rest, 48 hours after surgery, were in favor of CLIA. CLIA can possibly provide a reduced pain perception for 24 hours postoperative at rest after performing a TKA. This effect may persist until 48 hours postoperative during activity. Due to the high level of heterogeneity no firm further conclusions can be drawn.