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.

Snapping of the annular ligament: a uncommon injury characterised by snapping or locking of the elbow with good surgical outcomes.

PURPOSE: Snapping annular ligament is an uncommon cause of lateral elbow pain. The purpose of this case series was to evaluate the clinical presentation and surgical outcomes for snapping annular ligament. METHODS: Included were 23 patients with snapping annular ligament who received surgical treatment between 2007 and 2016. There were two treatment groups with either resection (arthroscopic or open procedure, n = 15) or open annular ligament reconstruction (n = 8). Patients were assessed with the Mayo Elbow Performance Index and the Oxford Elbow Score. Preoperative and postoperative scores were compared with a paired t test. RESULTS: Pain was located laterally in nine patients (39.1%), anteriorly in three patients (13.0%), anterolaterally in two patients (8.7%), and diffusely in nine patients (39.1%). In total, 16 patients (69.6%) experienced a snapping sensation and ten patients (43.5%) locking of the elbow. According to the patients' reported outcomes, their symptoms improved significantly after both procedures. CONCLUSIONS: This is the largest case series in the literature on snapping annular ligament, an uncommon cause of lateral elbow pain. Good treatment results are expected with resection of the interpositioned part of the annular ligament or annular ligament reconstruction. LEVEL OF EVIDENCE: IV.

[Complaints after total joint arthroplasty: caused by infection or metal hypersensitivity?] / Klachten na plaatsing van een gewrichtsprothese.

Besides periprosthetic joint infection, metal hypersensitivity should be considered when complaints persist after total joint arthroplasty. To date, there is no consensus on the diagnosis, and believers and non-believers of metal hypersensitivity exist. The pathogenesis of metal hypersensitivity is complex and involves a type-4 delayed hypersensitivity reaction with both a cutaneous and systemic response. It is unclear if complaints after total joint arthroplasty (after eliminating other causes) are caused by metal hypersensitivity. Furthermore, it is not known whether sensitization is a cause or a consequence of complaints after total joint arthroplasty. Currently, the patch test is the best screening test to diagnose metal hypersensitivity, but the accuracy has not been defined. We present a female patient with a painful left elbow three years after total elbow replacement. Because of the increasing volume of total joint prostheses, we aim to create awareness for metal hypersensitivity and the according diagnostic dilemmas.

[Complaints after total joint arthroplasty: caused by infection or metal hypersensitivity?] / Klachten na plaatsing van een gewrichtsprothese.

Besides periprosthetic joint infection, metal hypersensitivity should be considered when complaints persist after total joint arthroplasty. To date, there is no consensus on the diagnosis, and believers and non-believers of metal hypersensitivity exist. The pathogenesis of metal hypersensitivity is complex and involves a type-4 delayed hypersensitivity reaction with both a cutaneous and systemic response. It is unclear if complaints after total joint arthroplasty (after eliminating other causes) are caused by metal hypersensitivity. Furthermore, it is not known whether sensitization is a cause or a consequence of complaints after total joint arthroplasty. Currently, the patch test is the best screening test to diagnose metal hypersensitivity, but the accuracy has not been defined. We present a female patient with a painful left elbow three years after total elbow replacement. Because of the increasing volume of total joint prostheses, we aim to create awareness for metal hypersensitivity and the according diagnostic dilemmas.

Partial matrix excision or segmental phenolization for ingrowing toenails.

OBJECTIVE: To decide whether partial nail extraction with phenolisation or with partial excision of the matrix should be the standard treatment in patients with ingrowing toenails of the hallux. DESIGN: Randomized clinical trial with 12-month follow-up evaluations performed by observers who did not know which procedure was applied. SETTING: Outpatient department of a surgical teaching hospital. PATIENTS: Fifty-eight consecutive patients with a total of 63 ingrowing toenails were randomized. INTERVENTION: Thirty-four partial matrix excisions ("matrix" group) and 29 phenolizations ("phenol" group) were performed. MAIN OUTCOME MEASURES: Recurrence rate, postoperative morbidity (pain, wound exudates, and scar discomfort), and time to complete recovery (wearing shoes, performing normal activities/work). RESULTS: Recurrences were seen after 7 procedures in the matrix group and also after 7 procedures in the phenol group, of which patients were symptomatic and required a second operation in 4 and 3 instances, respectively. None of the observed differences in wound healing, postoperative pain, and recovery were statistically significant. CONCLUSIONS: Partial matrix excision and phenolization are equally effective in treating ingrowing toenails. Because the use of the toxic agent phenol should be avoided, partial matrix excision is the preferable procedure. But in view of the high recurrence rate, there is a need for further improvement of the treatment of ingrowing toenails.

Direct treatment comparison of DAbigatran and RIvaroxaban versus NAdroparin in the prevention of venous thromboembolism after total knee arthroplasty surgery: design of a randomised pilot study (DARINA).

INTRODUCTION: Two novel agents, dabigatran and rivaroxaban, recently gained market authorisation for prevention of venous thromboembolism (VTE) after hip and knee arthroplasty. However, safety data of the new oral anticoagulants with a long-term use of 42 days are not available for total knee arthroplasty (TKA). Furthermore, there are no clinical trials comparing dabigatran and/or rivaroxaban with nadroparin, which is used in most Dutch departments of orthopaedic surgery. Our aim is to compare the 42-day use of dabigatran and rivaroxaban versus nadroparin after TKA in a clinical explorative pilot study by assessing the incidence of major bleeding and clinically relevant non-major bleeding using a standardised model of bleeding definitions. METHODS AND ANALYSIS: A randomised open-label pilot study was conducted. Patients ≥18 years and weighing more than 40 kg who were scheduled for a primary elective TKA were included. Patients were randomly assigned to three groups. Patients took either a daily oral dose of dabigatran etexilate 220 mg (n=50), 10 mg of oral rivaroxaban (n=50) or subcutaneous nadroparin 0.3 ml (n=50) for 42 days. The primary safety outcome measure was the incidence of bleeding events. Major bleeding events and clinically relevant non-major bleeding events were defined according to accepted guidelines. The secondary measures of this study were the occurrence of VTE, time until the bleeding event, compliance, duration of hospital stay, rehospitalisation, outpatient clinic visits and interventions following complications. Additionally, coagulation monitoring, knee flexion range of motion and Knee injury and Osteoarthritis Outcome Score were evaluated. DISSEMINATION: The results of this trial provided insight into the validity of design for an adequately powered multicentre study investigating the safety of the new oral anticoagulants compared with nadroparin, an anticoagulant applied for prevention of VTE after knee arthroplasty in the Dutch situation. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT01431456.