Surgical approaches to treating tennis elbow may not offer additional benefit to patients, as discussed in research presented at the American Orthopaedic Society for Sports Medicine's (AOSSM) Specialty Day in San Diego. The study, a randomised, double-blinded clinical trial, explored patient responses to a common surgery aimed at repairing a damaged elbow, compared to a placebo procedure.
The study analysed 13 patients who underwent surgery to remove a degenerated portion of their extensor capri radialis brevis (ECRB), compared to a group of 13 who received an incision over their lateral elbow and no further repair. Patients included had experienced symptoms of tennis elbow for more than 6 months, and attempted at least two non-surgical treatment approaches such as physical therapy, massage, acupuncture, or splinting/bracing, but had no symptom relief over that period.
"Our data shows both groups experienced significant improvements in pain measures by 26 weeks after surgery, including frequency of pain with activity," commented lead author Dr Martin Kroslak, from the Orthopaedic Research Institute in Sydney, Australia. "Further, these results were consistent or improved after 1-4 years of follow-up, with no significant difference between the two groups at any point."
Patients were required to complete questionnaires, indicating symptoms including pain frequency and severity with activity and rest, during sleep, and also difficulty picking up objects or twisting motions. Frequency of elbow pain during activity was the primary outcomes measure for each group. Both groups were treated with the same rehab, including ice application, stretching, and strengthening rehab program within 2 weeks of surgery. At 2.5-year follow-up 22 patients completed a questionnaire and 11 returned for exam.
"Managing chronic tennis elbow is a challenge for a large portion of the active population," noted Kroslak. "Our research demonstrates the challenges in outlining a treatment plan for these patients, and the continued work to be done in developing both surgical and non-operative approaches."
Abstract
Objectives: A number of surgical techniques for managing tennis elbow have been described, one of the commonest (Nirschl & Pettrone. J Bone Joint Surg Am, 61(6A): 832-839) involves excising the affected portion of extensor carpi radialis brevis (ECRB) origin. The results of this technique, as well as most other described surgical techniques for this condition, have been reported as excellent, yet none have been compared with placebo surgery.
Methods: This study was a prospective, randomised, double blinded, placebo controlled clinical trial investigating the surgical excision of the macroscopically degenerated portion of ECRB (Nirschl technique; n=13) compared with a sham operation (skin incision and exposure of ECRB alone; n=13) to manage tennis elbow, in patients with tennis elbow for more than 6 months who failed at least two non-surgical modalities. The primary outcome measure was defined as patient rated frequency of elbow pain with activity at 6 months post-surgery. Secondary outcome measures included patient rated frequency and severity of pain, functional outcomes, range of motion, epicondyle tenderness and strength at 6 months and >12 months post-surgery.
Results: The two groups were matched for age, gender, hand dominance and duration of symptoms. Both the surgery and placebo procedures improved patient rated pain frequency and severity, elbow stiffness, difficulty with picking up objects, twisting motions and overall elbow rating over 6 months and at >12 months (p<0.01). Both procedures also improved epicondyle tenderness, pronation-supination range, grip strength and modified ORI-TETS at 6 months (p<0.05). No significant difference was observed between the groups in any parameter at any stage. No side effects or complications were reported. The study was stopped before the calculated number of patients were enrolled, as a post-hoc analysis showed over 6500 patients would need to be recruited in each group to see a significant difference between the groups at 26 weeks, when measuring patient rated frequency of elbow pain with activity.
Conclusion: This study indicates that the surgical excision of the degenerative portion of ECRB offers no additional benefit over and above placebo surgery for the management of chronic tennis elbow.
Authors
Martin Kroslak, George AC Murrell
[link url="https://www.sciencedaily.com/releases/2017/03/170318112643.htm"]American Orthopaedic Society for Sports Medicine material[/link]
[link url="http://www.sportsmed.org/AOSSMIMIS/Members/Downloads/MeetingResources/SD2017/KroslakAbstract.pdf"]Speciality Day abstract[/link]