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The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis Bong Cheol Kwon, Yong Shin Kwon and Kee Jeong Bae Am J Sports Med 2014 42: 1731 originally published online April 23, 2014 DOI: 10.1177/0363546514530664 The online version of this article can be found at: http://ajs.sagepub.com/content/42/7/1731
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The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis Bong Cheol Kwon,* MD, PhD, Yong Shin Kwon,* MD, and Kee Jeong Bae,yz MD Investigation performed at the Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, South Korea Background: Medial epicondylitis is a tendinopathy of the common flexor-pronator origin, and surgical treatment is required when this condition fails to respond to nonoperative methods. This study details the development of a new technique, termed fascial elevation and tendon origin resection (FETOR), which facilitates the complete visualization and resection of the CFPO with limited soft tissue dissection. Purpose: To evaluate the outcomes of FETOR for the treatment of chronic recalcitrant medial epicondylitis. Study Design: Case series; Level of evidence, 4. Methods: The electronic medical records of patients who underwent FETOR from January 2008 to July 2011 were retrospectively reviewed. Outcome assessments included the visual analog scale (VAS) for average pain, pain at rest, and pain experienced during hard work or heavy lifting; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and pain-free grip strength. Preoperative and postoperative data were compared. Results: A total of 22 elbows in 20 patients with a mean age of 48.8 years (range, 29-58 years) were included. At a mean follow-up of 35.6 months (range, 16-77 months), the VAS score decreased by 93% for average pain, 94% for pain at rest, and 83% for pain during hard work or heavy lifting (P \ .001). The patients’ perception of arm function as assessed using the DASH recovered to the level of the healthy population (from a mean of 51.6 6 18.0 to 8.0 6 11.1; P \ .001). The mean pain-free grip strength improved significantly from 53.7% 6 30.3% to 97.3% 6 19.8% of the uninvolved arm (P \ .001). Eighteen (90%) patients were satisfied with the surgical outcomes, while 2 patients changed their jobs because of decreased elbow function. No major complications occurred. Conclusion: The FETOR technique is an effective and safe method for the treatment of chronic recalcitrant medial epicondylitis. Keywords: elbow; tendinopathy; medial epicondylitis; surgery
Medial epicondylitis is a tendinopathy of the common flexor-pronator origin (CFPO).1,9 The CFPO is a bone-totendon interface and is therefore subject to high stress and frequent injuries because of the differing physical properties of the bone and tendon.11 Medial epicondylitis is estimated to be present in 0.4% to 0.6% of the working-age population, and the highest prevalence occurs in those
aged between 45 and 55 years, with no significant differences in the prevalence of this condition between men and women.12,18 Although the natural history of medial epicondylitis has not been well investigated, one prospective study has suggested that most cases of acute or subacute medial epicondylitis heal spontaneously.15 Thus, patients are initially managed with nonoperative measures including rest, nonsteroidal anti-inflammatory drugs, physical therapy, and various types of injections. If the symptoms persist for more than several months despite the exhaustion of nonoperative treatments, surgical treatments are recommended.9,16 The key component of the surgical technique is complete removal of the degenerated tendon.9 However, previously described techniques have shown limitations such as incomplete visualization of the CFPO or the use of wide soft tissue dissection, which has hindered the rapid recovery of arm function.9,16 We have modified previous techniques to overcome these limitations. Our modified procedure, termed fascial elevation and tendon origin
z Address correspondence to Kee Jeong Bae, MD, Department of Orthopedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, 153, Gyo-dong, Chuncheon, 200-704, South Korea (e-mail: [email protected]). *Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, South Korea. y Department of Orthopedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 42, No. 7 DOI: 10.1177/0363546514530664 Ó 2014 The Author(s)
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resection (FETOR), includes elevation of the flexorpronator fascia, instead of the entire flexor-pronator mass, for complete visualization of the CFPO, and resection of the degenerated tendon, with limited soft tissue dissection. The purpose of this study was to evaluate the outcomes of FETOR for the treatment of chronic recalcitrant medial epicondylitis.
MATERIALS AND METHODS Study Participants Institutional review board approval was obtained before the commencement of this study. All the participants gave informed written consent. The indications of surgery for chronic pain in the region of the medial epicondyle of the elbow were a diagnosis of medial epicondylitis, symptom duration for .6 months, a visual analog scale (VAS) for pain score of 5, and resistance to nonoperative treatments for .3 months. The diagnosis of medial epicondylitis was based on typical findings from physical examinations and ultrasonography. The typical physical findings included tenderness to the anterior medial epicondyle and the provocation of pain at the medial elbow through resistance to active pronation of the forearm and active flexion of the wrist.4,9,16 Ultrasonographic examination, including grayscale and color Doppler imaging, was performed by a musculoskeletal radiologist with 12 years of experience. Medial epicondylitis was ultrasonographically diagnosed when a focal hypoechoic (degeneration) or anechoic (tear) region with increased vascularity was present at the medial epicondyle with or without calcification (Figure 1).2,10 The exclusion criteria were a postoperative follow-up period shorter than 1 year; the presence of another disease or trauma at the same or opposite arm, neck, or shoulder; or use of a surgical technique other than FETOR. We retrospectively reviewed the electronic medical records at our institution and identified 24 consecutive patients who underwent surgery by the senior author (B.C.K.) from January 2008 to July 2011. These 24 patients, none of whom had concomitant lesions on the arms, neck, or shoulder, underwent surgical treatment with the FETOR technique. Four patients were excluded because they had a follow-up period of less than 1 year, leaving 20 patients eligible for this study. Of the remaining 20 patients, 2 patients with bilateral involvement had operations for both elbows simultaneously. Therefore, a total of 22 elbows in 20 patients were included in this study.
Surgical Technique After general or regional anesthesia was administered, a sterile tourniquet was inflated, and the patient’s arm was positioned with the shoulder in abduction and external rotation and the elbow in flexion, so that the anteromedial side of the medial epicondyle faced the surgeon. A 5- to 8-cm oblique incision was made anterior to the medial epicondyle (Figure 2A), and subcutaneous dissection was
Figure 1. Ultrasonographic findings in medial epicondylitis. (A) Longitudinal grayscale imaging of the common flexor-pronator origin in a 49-year-old man showed a focal hypoechoic lesion (arrow), which corresponded to tendon degeneration. (B) Color Doppler imaging revealed increased vascularity in the focal hypoechoic lesion. (C) Calcification was seen as hyperechoic punctuated lesions (arrowheads). performed while the medial antebrachial cutaneous nerve was identified and protected. After the fascial layer was reached, the pronator muscle fibers, the common flexor tendon, and the flexor carpi ulnaris tendon were easily identifiable. A flipped L-shaped incision, which was centered on the medial corner of the medial epicondyle, was marked such that a 3-cm long arm was along the proximal pronator muscle fibers, and the other one with the same length was along the flexor carpi ulnaris tendon (Figure 2B). By use of a No. 10 blade, the forearm fascia was incised along the markings and elevated. The superficial part of the common flexor-pronator tendon, which has a thickness of 1 to 2 mm, was elevated along with the forearm fascia because the former was firmly attached to the latter and therefore difficult to separate. After fascial
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elevation was completed, the CFPO was able to be fully visualized (Figure 2C). The bony insertion of the CFPO was removed from the anterior medial epicondyle by using a No. 10 blade in a proximal-to-distal direction (Figure 2D). The dissection was restricted to the anterior medial epicondyle to prevent injuries to the medial collateral ligament. The cut end of the CFPO was removed by 1 cm, which usually included the degenerated part of the tendon. The remnant of the degenerated tendon, the calcification, and the fibrocartilage at the medial epicondyle were removed with a curette (Figure 2E). The associated conditions were surgically treated simultaneously at the time of performing the FETOR technique. If cubital tunnel syndrome was present, subcutaneous dissection was extended posterior to the medial epicondyle. The ulnar nerve was identified and protected with a sling. Afterward, simple decompression of the cubital tunnel was performed by releasing the Osborne ligament. If chronic lateral epicondylitis was present in the same elbow, it was surgically treated using the Nirschl technique.8 The fascia was repaired using a 3-0 Vicryl suture (Ethicon, Somerville, New Jersey, USA) (Figure 2F). Placement of the patient’s arm in forearm pronation and wrist flexion facilitated the repair. A drain was placed, and the wound was closed layer by layer. A compressive dressing was placed, and a longarm splint was applied.
Postoperative Rehabilitation At day 2 after the operation, the drain was removed, and the long-arm splint was changed to a removable one. The patient started active flexion-extension exercises of the elbow out of the splint, with exercises performed 10 times per session at 3 sessions per day. Forearm rotation was not allowed. At 2 weeks after surgery, the removable long-arm splint was removed, and forearm rotation exercises were begun. From this time onward, the patients were allowed to use their arms freely and were advised to increase their use as much as painfully tolerable.
Outcome Measures Preoperative and postoperative elbow functions were assessed with subjective and objective measures. The subjective assessments included the VAS for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Objective assessments included the patient’s verbal rating of pain induced by the physical examination, pain-free grip (PFG) strength, and elbow range of motion (ROM). Pain was assessed using the VAS in 3 different domains: average pain in the past 1 week, pain at rest, and pain at hard work or heavy lifting. A 10-cm line with 0 on the left end and 10 on the right end was used for each pain measurement. The scores of 0 and 10 indicated no pain and the worst pain imaginable, respectively. The DASH is a validated arm-specific outcome measure and has been used for the assessment of elbow function in a variety of disease and traumatic conditions.3,7 The DASH questionnaire consists of 30 items measuring difficulties related to specific tasks, social/work
Figure 2. The fascial elevation and tendon origin resection (FETOR) technique. (A) A 5- to 8-cm oblique incision is made just anterior to the medial epicondyle. (B) After the fascial layer is reached, a flipped L-shaped line is drawn on the fascia. The medial antebrachial cutaneous nerve is protected with a sling. (C) The fascia is elevated along the marked lines, after which the common flexor tendon (arrow) and its origin at the medial epicondyle (arrowhead) are fully visualized. Note that the tendon at the medial epicondyle has lost its fibrillar and shiny appearance, which is the typical appearance of a degenerated tendon (arrowhead). The common flexorpronator origin (CFPO) is removed from the medial epicondyle, and (D) the remaining calcification (arrowhead) or (E) degenerated tendon is removed with a curette. (F) The CFPO is left detached, while the fascia is repaired with a 3-0 absorbable suture. An, anterior; Ds, distal; Pr, proximal. functions, sleep, confidence, and symptoms. The DASH score ranges from 0 to 100, with higher scores representing worse disability. The mean 6 standard deviation of the DASH score in the general population is 10.0 6 14.7, and the minimal clinically important difference is considered to be a 10-point difference.5,6,14 Pain induced by a physical examination (ie, tenderness to the medial epicondyle and pain produced by resistance to active pronation) was verbally rated by the patients as absent, mild, moderate, or severe. Moreover, PFG strength is the amount of grip force generated at the onset of pain.17 For the measurement of PFG strength, patients were seated in a position with the shoulder in adduction and at 90° of forward elevation, the elbow in full extension, and the forearm and wrist in a neutral position. With a Jamar dynamometer (Patterson Medical, Warrenville, Illinois, USA), PFG strength was
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measured 3 times with a 1-minute interval between the measurements; the mean value was compared with that of the uninvolved hand. Elbow ROM was measured using a handheld goniometer. We also rated overall patient satisfaction with the surgical outcomes at the final follow-up using a Likert-type scale as follows: 1, very unsatisfied; 2, unsatisfied; 3, neither unsatisfied nor satisfied; 4, satisfied; and 5, very satisfied.
Association of Ultrasonographic Findings With Preoperative and Postoperative Elbow Function To explore the association of the ultrasonographic findings with the outcomes of FETOR, we allocated patients into 2 groups according to these findings: tendon degeneration and increased vascularity without calcification (group 1) and with calcification (group 2). The 2 groups were compared with respect to clinical and demographic data and preoperative and postoperative elbow functions.
Statistical Analysis The data were shown to have a Gaussian distribution by the Kolmogorov-Smirnov test, and thus, parametric tests were used for the statistical analysis. The paired t test was used to compare the preoperative and postoperative values of the VAS for pain, DASH, PFG, and elbow ROM. The McNemar test was used to compare the preoperative and postoperative values of the categorical variables. For comparing the 2 groups with different ultrasonographic findings, the Student t test was used to compare continuous variables, while the x2 test or Fisher exact test was used to compare categorical variables.
RESULTS Demographic and Clinical Characteristics The demographic and clinical characteristics are shown in Table 1. The mean age of the patients (4 men, 16 women) was 48.8 years (range, 29-58 years). The mean duration of symptoms was 34.2 6 50.1 months (range, 8-240 months). The dominant hand was involved in 14 (70%) elbows. No patient had a history of trauma at the elbow. Nineteen elbows had received a mean of 4.2 steroid injections (range, 1-20 injections) at the medial epicondyle, while 3 elbows had received no injections. Other nonoperative treatments included nonsteroidal anti-inflammatory drugs, rest, physical therapy, and acupuncture. Two elbows had received extracorporeal shock wave therapy. Seven patients were involved in heavy manual labor, 5 were involved in office-type work, and 8 patients were housewives. Associated conditions included cubital tunnel syndrome (2 elbows) and lateral epicondylitis (4 elbows).
Outcomes After FETOR After a mean follow-up of 35.6 months (range, 16-77 months), the patients showed significant improvements in
TABLE 1 Demographic and Clinical Dataa Parameter Age, y Sex, male/female, n Symptom duration, mo Manual laborer, n (%) Smoker, n (%) Height, cm Weight, kg Body mass index, kg/m2 Involved hand, right/left/both, n Dominant arm involvement, n (%) Associated elbow conditions, n Cubital tunnel syndrome Lateral epicondylitis
Value 48.8 6 6.7 (29-58) 4/16 34.2 6 50.1 (8-240) 7 (35) 1 (5) 159.3 6 7.3 (150-176) 59.6 6 8.4 (46-72) 23.5 6 3.1 (17.5-28.9) 12/6/2 14 (70) 2 4
a Data are expressed as mean 6 standard deviation (range) unless otherwise indicated.
all the subjective and objective outcome measures (Table 2). After surgery, the VAS score decreased by 93% for average pain, 94% for pain at rest, and 83% for pain during hard work or heavy lifting (P \ .001). The number of elbows with resting pain reduced significantly from 21 to 4 (P \ .001). The patients’ perception of arm function as assessed using the DASH recovered to the level of the healthy population (from a mean of 51.6 6 18.0 to 8.0 6 11.1; P \ .001). The mean PFG strength of the involved arm improved significantly from 53.7% 6 30.3% to 97.3% 6 19.8% compared with the uninvolved arm, which was measured in all the patients except 2 with bilateral involvement (P \ .001). At the final evaluation, the number of elbows with moderate to severe tenderness at the medial epicondyle significantly decreased from 21 (96%) to 6 (27%) (P = .001), while the number of elbows experiencing pain produced by resistance to active pronation significantly decreased from 21 (96%) to 2 (9%) (P \ .001). Eighteen (90%) patients were satisfied with the surgical outcomes. Of the 5 patients who changed their jobs, only 2 of the patients did so because of decreased elbow function.
Complications Two patients complained of hypoesthesia over the skin at the proximal medial forearm. This symptom was attributable to traction injuries to the medial antebrachial cutaneous nerve and spontaneously resolved within a few months. No other complications occurred.
Surgical Findings For 2 elbows, the CFPO was detached from the medial epicondyle, and there was degeneration at the proximal end involving the entire tendon layer. In the other elbows, the superficial part of the CFPO was normal in appearance; however, the deep part had a gray, amorphous appearance, indicating a degenerated tendon.
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TABLE 2 Comparison of Preoperative and Postoperative Elbow Functions After FETORa Measures
Preoperative Status
VAS score Average pain Pain at rest Pain at hard work or heavy lifting DASH score Flexion-extension arc, deg PFG strength Of contralateral arm, % Of uninvolved arm, kg Of involved arm, kg Tenderness at medial epicondyle, n Severe Moderate None or mild Pain by resisted pronation, n Severe Moderate None or mild
6.8 3.4 8.0 51.6 143.6
0.5 0.2 1.4 8.0 147.7
P Value
1.0 0.5 1.5 11.1 4.0
\.001 \.001 \.001 \.001 .047
53.7 6 30.3 23.2 6 10.2 13.8 6 9.2
97.3 6 19.8 25.6 6 9.4 24.8 6 9.9
\.001 .12 \.001 .001
17 4 1
3 3 16
19 2 1
1 1 20
6 6 6 6 6
1.7 3.0 1.6 18.0 6.8
Postoperative Status
6 6 6 6 6
\.001
a Data are expressed as mean 6 standard deviation unless otherwise indicated. DASH, Disabilities of the Arm, Shoulder and Hand; FETOR, fascial elevation and tendon origin resection; PFG, pain-free grip; VAS, visual analog scale.
Imaging Findings and Their Association With Clinical and Surgical Outcome Variables Radiographs of the elbows revealed an absence of abnormalities in 11 elbows and the presence of calcification at the medial epicondyle in 11 elbows. Ultrasonography demonstrated a focal hypoechoic region with increased vascularity at the medial epicondyle in all 22 elbows. Additionally, partial tearing of the deep layer of the CFPO was observed in 1 elbow. Moreover, calcification in the latter group of 11 elbows was also observed ultrasonographically. Thus, there were 11 elbows in 10 patients in both groups 1 (no calcification) and 2 (calcification) (Table 3). No significant differences were observed between the groups with respect to clinical and demographic data (P . .05) (Table 3). However, the mean DASH score at the final follow-up was significantly decreased in group 2 compared with that in group 1 (2.7 6 2.8 vs 14.9 6 13.4, respectively; P = .011), while other measures of elbow function were not significantly different between the groups (P . .05) (Table 3). Associated conditions were more common in group 2 than in group 1 (2 elbows with cubital tunnel syndrome and 2 elbows with lateral epicondylitis in group 2 vs 2 elbows with lateral epicondylitis in group 1), but the incidence of associated conditions did not achieve statistical significance (P = .635).
DISCUSSION In this study, we demonstrated that FETOR was an effective and safe method for the treatment of chronic recalcitrant medial epicondylitis. At a mean follow-up of 35.6
months, the pain level was reduced by about 90%, and the mean DASH score decreased to the level of the healthy population. Further, PFG strength was restored to the level of the uninvolved arm. No major complications occurred. Two surgical techniques have been described for complete removal of the degenerated tendon in the surgical treatment of medial epicondylitis.9,16 The Nirschl technique described by Ollivierre et al9 uses longitudinal splitting of the fascia and the common flexor-pronator tendon to visualize degeneration at the CFPO. While this technique can produce excellent results and shorten rehabilitation time when performed by experienced surgeons, the limited surgical field provided by this technique may lead to incomplete removal of the degenerated tendon and injuries to the medial collateral ligament in inexperienced hands. Meanwhile, the Jobe technique, described by Vangsness and Jobe,16 requires an elevation of the entire flexorpronator mass for visualizing the CFPO and reattachment to the medial epicondyle, which necessitates protection of the repair site for up to 8 weeks. Although this technique allows the complete visualization of the CFPO, the increased risks of joint contracture and ulnar nerve adhesion may be present because of the long period of immobilization and the wide dissection of the muscle around the nerve. We have modified these previous methods such that complete visualization and resection of the CFPO can be obtained without wide muscle and tendon dissection. Our technique included a 5- to 8-cm incision, an elevation of only the flexor-pronator fascia in a flipped L shape for full visualization of the CFPO, and only resection of the CFPO containing the degenerated tendon without reattachment to the medial epicondyle. Based on these surgical
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TABLE 3 Comparison Between Patients Without Calcification (Group 1) and With Calcification (Group 2)a Measures
Group 1 (n = 10 Patients)
Group 2 (n = 10 Patients)
P Value
49.8 6 6.2 2 6 3 40.8 6 70.6 2
47.8 6 7.4 2 6 4 27.5 6 14.5 4
.519 ..999 ..999 ..999 .567 .635
7.0 3.9 7.9 57.6 12.6
6 6 6 6 6
2.9 3.2 1.7 19.2 6.7
6.9 3.0 8.2 45.7 14.9
6 6 6 6 6
1.5 2.8 1.5 15.4 11.4
.905 .466 .648 .145 .581
0.8 0.4 1.7 14.9 22.7
6 6 6 6 6
1.3 0.7 1.5 13.4 10.7
0.2 0.1 1.1 2.7 27.0
6 6 6 6 6
0.4 0.3 1.4 2.8 9.0
.124 .235 .321 .011 .319
Age, y Male sex, n Dominant arm involvement, n Manual labor, n Symptom duration, mo Associated elbow conditions, n Preoperative VAS score for average pain VAS score for pain at rest VAS score for pain at hard work or heavy lifting DASH score PFG strength of involved arm, kg Postoperative VAS score for average pain VAS score for pain at rest VAS score for pain at hard work or heavy lifting DASH score PFG strength of involved arm, kg
a Data are expressed as mean 6 standard deviation unless otherwise indicated. DASH, Disabilities of the Arm, Shoulder and Hand; PFG, pain-free grip; VAS, visual analog scale.
components, the degenerated area in the CFPO can be easily identified and completely resected, while soft tissue dissection and the risk for injuries to the surrounding structures are minimized. Although immobilization was applied intermittently for 2 weeks, complications related to wrist flexor or pronator muscle weakness were not observed likely because these muscles had multiple origins and their attachments to the surrounding muscle fascia were preserved. Furthermore, our modified technique allowed a fast recovery and return to the job because of early rehabilitation. Our results appear to be comparable with the findings of other techniques, although comparisons across retrospective studies are difficult because of differences between them. Ollivierre et al9 performed the Nirschl technique in 50 elbows of 48 patients with a mean age of 42 years. At a mean follow-up of 32 months, most of the patients improved substantially in pain and grip strength. However, 8 patients (16%) had severe pain with sports or occupational activities, and 10 patients (20%) were not able to return to sporting or occupational activities. One case of a complication related to medial collateral ligament insufficiency occurred and required later reconstruction. In a study of 35 patients with chronic medial epicondylitis who underwent the Jobe technique, Vangsness and Jobe16 obtained good to excellent results in 34 patients (97%) at a mean follow-up of 85 months. However, 14% of the patients continued to have limitations in heavy lifting. Complications included 2 cases of ulnar neuropathy at the elbow and 1 case of hematoma. In another study, the Jobe technique was used in conjunction with decompression or transposition of the ulnar nerve for associated cubital tunnel syndrome.4 The study reported that the results were good to excellent in 26 elbows (87%), fair in 2 elbows, and
poor in 2 elbows among 26 patients at a mean follow-up of 7 years. The authors pointed out that moderate to severe associated ulnar neuropathy resulted in a significantly worse outcome. To our knowledge, this is the first study that used a validated subjective outcome measure, that is, the DASH, in assessing the outcomes of surgery for the treatment of medial epicondylitis. By using the DASH, the patient’s perceived arm functions after FETOR could be interpreted in the context of normative values in the general population. Furthermore, use of the DASH enabled the outcomes of this study to be compared with those of other studies in a more valid manner. In addition, our data can be used in estimating a sample size for a prospective comparative study in the future. Another strength of our study is that patients with medial epicondylitis were clearly defined using clinical examination, radiography, and ultrasonography. With these modalities, we were able to confirm the presence of tendon degeneration at the CFPO and to differentiate conditions mimicking medial epicondylitis, such as synovial plica, osteoarthritis, and ligament injuries. One interesting finding in this study is that the DASH score significantly decreased in patients with calcification at the medial epicondyle compared with those without calcification. Furthermore, the mean difference of 12.7 points in the DASH score between the 2 groups was greater than the minimal clinically important difference for the DASH (10.0 points).6 This finding was unexpected because cubital tunnel syndrome, a well-known risk factor for a poor outcome after surgery for medial epicondylitis,4 coexisted only in the calcification group. Moreover, all the other measures of outcomes, such as the VAS score and PFG strength, were also consistently better in the calcification group than in the noncalcification group, although the
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differences did not achieve statistical significance. This consistency in the differences in the various outcome measures suggests that the observed statistical insignificances might stem from the small sample size. Taken together, our results suggest the possibility that patients with calcification at the medial epicondyle are more likely to have better outcomes than those without calcification after the surgical treatment of medial epicondylitis with the FETOR technique. Although providing an explanation as to why calcification at the CFPO positively affected the surgical outcomes is difficult, one possibility is that calcified tissue is more easily identifiable and therefore results in a more complete excision of the degenerated region, which subsequently leads to better outcomes. Further studies using a larger cohort are required to confirm the association of ultrasonographic findings with the surgical outcomes. This study had several limitations. First, the study was a retrospective one, and biases associated with this design could be inevitable. However, we believe that potential biases, such as recall bias, were minimized because all of the outcome measures were conducted routinely per protocol before the patients underwent the FETOR procedure. Second, this study lacked a control group for comparing the effectiveness of FETOR. Because epicondylitis has a self-limiting disease course, the inclusion of a matched, nonoperated control group might have provided information for addressing whether FETOR can change the natural course of medial epicondylitis. Third, the superiority of FETOR over the previous methods cannot be concluded based on this study. A randomized prospective study is necessary to determine which method is the best option for the treatment of chronic recalcitrant medial epicondylitis. Finally, we could not analyze the effect of preoperative steroid injections on the surgical outcomes because of the diverse nonoperative treatments given to our cohort. As steroid injections have been known to adversely affect the natural course of epicondylitis,13 it is clinically important to answer the question of whether steroid injections also have negative effects on surgical outcomes. This question needs to be addressed in a future study. Medial epicondylitis, despite being self-limited, is sometimes resistant to nonoperative treatments and can seriously affect the quality of life of the affected patient. We demonstrated here that our new technique, FETOR, is an effective and safe method for the treatment of this condition. The FETOR technique facilitates complete exposure of the CFPO without wide soft tissue dissection and thus minimizes the risk of incomplete removal of the degenerated tendon and allows for a rapid rehabilitation. By using FETOR, the pain level was reduced by about 90%, and the perceived arm disability was reduced to normal levels in patients with chronic recalcitrant medial epicondylitis. Prospective randomized studies in the future will elucidate
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how FETOR compares to other techniques and will help to establish a comprehensive management algorithm for chronic medial epicondylitis.
REFERENCES 1. Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004;23(4):693705, xi. 2. Clarke AW, Ahmad M, Curtis M, Connell DA. Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability. Am J Sports Med. 2010;38(6):1209-1214. 3. De Smet L. The DASH questionnaire and score in the evaluation of hand and wrist disorders. Acta Orthop Belg. 2008;74(5):575-581. 4. Gabel GT, Morrey BF. Operative treatment of medical epicondylitis: influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995;77(7):1065-1069. 5. Gummesson C, Atroshi I, Ekdahl C. The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11. 6. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84(2):208-215. 7. Longo UG, Franceschi F, Loppini M, Maffulli N, Denaro V. Rating systems for evaluation of the elbow. Br Med Bull. 2008;87:131-161. 8. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839. 9. Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow: a prospective analysis. Am J Sports Med. 1995;23(2):214-221. 10. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. 2008; 89(4):738-742. 11. Shaw HM, Benjamin M. Structure-function relationships of entheses in relation to mechanical load and exercise. Scand J Med Sci Sports. 2007;17(4):303-315. 12. Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065-1074. 13. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657-662. 14. Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-rated outcomes instruments. J Hand Surg Am. 2013;38(4):641-649. 15. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis: a prospective study of sixty elbows. J Bone Joint Surg Am. 1997;79(11):1648-1652. 16. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis: results in 35 elbows. J Bone Joint Surg Br. 1991;73(3):409-411. 17. Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A. Initial effects of elbow taping on pain-free grip strength and pressure pain threshold. J Orthop Sports Phys Ther. 2003;33(7):400-407. 18. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Occupation and epicondylitis: a population-based study. Rheumatology (Oxford). 2012;51(2):305-310.
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The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis Bong Cheol Kwon, Yong Shin Kwon and Kee Jeong Bae Am J Sports Med 2014 42: 1731 originally published online April 23, 2014 DOI: 10.1177/0363546514530664 The online version of this article can be found at: http://ajs.sagepub.com/content/42/7/1731
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The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis Bong Cheol Kwon,* MD, PhD, Yong Shin Kwon,* MD, and Kee Jeong Bae,yz MD Investigation performed at the Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, South Korea Background: Medial epicondylitis is a tendinopathy of the common flexor-pronator origin, and surgical treatment is required when this condition fails to respond to nonoperative methods. This study details the development of a new technique, termed fascial elevation and tendon origin resection (FETOR), which facilitates the complete visualization and resection of the CFPO with limited soft tissue dissection. Purpose: To evaluate the outcomes of FETOR for the treatment of chronic recalcitrant medial epicondylitis. Study Design: Case series; Level of evidence, 4. Methods: The electronic medical records of patients who underwent FETOR from January 2008 to July 2011 were retrospectively reviewed. Outcome assessments included the visual analog scale (VAS) for average pain, pain at rest, and pain experienced during hard work or heavy lifting; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and pain-free grip strength. Preoperative and postoperative data were compared. Results: A total of 22 elbows in 20 patients with a mean age of 48.8 years (range, 29-58 years) were included. At a mean follow-up of 35.6 months (range, 16-77 months), the VAS score decreased by 93% for average pain, 94% for pain at rest, and 83% for pain during hard work or heavy lifting (P \ .001). The patients’ perception of arm function as assessed using the DASH recovered to the level of the healthy population (from a mean of 51.6 6 18.0 to 8.0 6 11.1; P \ .001). The mean pain-free grip strength improved significantly from 53.7% 6 30.3% to 97.3% 6 19.8% of the uninvolved arm (P \ .001). Eighteen (90%) patients were satisfied with the surgical outcomes, while 2 patients changed their jobs because of decreased elbow function. No major complications occurred. Conclusion: The FETOR technique is an effective and safe method for the treatment of chronic recalcitrant medial epicondylitis. Keywords: elbow; tendinopathy; medial epicondylitis; surgery
Medial epicondylitis is a tendinopathy of the common flexor-pronator origin (CFPO).1,9 The CFPO is a bone-totendon interface and is therefore subject to high stress and frequent injuries because of the differing physical properties of the bone and tendon.11 Medial epicondylitis is estimated to be present in 0.4% to 0.6% of the working-age population, and the highest prevalence occurs in those
aged between 45 and 55 years, with no significant differences in the prevalence of this condition between men and women.12,18 Although the natural history of medial epicondylitis has not been well investigated, one prospective study has suggested that most cases of acute or subacute medial epicondylitis heal spontaneously.15 Thus, patients are initially managed with nonoperative measures including rest, nonsteroidal anti-inflammatory drugs, physical therapy, and various types of injections. If the symptoms persist for more than several months despite the exhaustion of nonoperative treatments, surgical treatments are recommended.9,16 The key component of the surgical technique is complete removal of the degenerated tendon.9 However, previously described techniques have shown limitations such as incomplete visualization of the CFPO or the use of wide soft tissue dissection, which has hindered the rapid recovery of arm function.9,16 We have modified previous techniques to overcome these limitations. Our modified procedure, termed fascial elevation and tendon origin
z Address correspondence to Kee Jeong Bae, MD, Department of Orthopedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, 153, Gyo-dong, Chuncheon, 200-704, South Korea (e-mail: [email protected]). *Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, South Korea. y Department of Orthopedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, South Korea. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 42, No. 7 DOI: 10.1177/0363546514530664 Ó 2014 The Author(s)
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resection (FETOR), includes elevation of the flexorpronator fascia, instead of the entire flexor-pronator mass, for complete visualization of the CFPO, and resection of the degenerated tendon, with limited soft tissue dissection. The purpose of this study was to evaluate the outcomes of FETOR for the treatment of chronic recalcitrant medial epicondylitis.
MATERIALS AND METHODS Study Participants Institutional review board approval was obtained before the commencement of this study. All the participants gave informed written consent. The indications of surgery for chronic pain in the region of the medial epicondyle of the elbow were a diagnosis of medial epicondylitis, symptom duration for .6 months, a visual analog scale (VAS) for pain score of 5, and resistance to nonoperative treatments for .3 months. The diagnosis of medial epicondylitis was based on typical findings from physical examinations and ultrasonography. The typical physical findings included tenderness to the anterior medial epicondyle and the provocation of pain at the medial elbow through resistance to active pronation of the forearm and active flexion of the wrist.4,9,16 Ultrasonographic examination, including grayscale and color Doppler imaging, was performed by a musculoskeletal radiologist with 12 years of experience. Medial epicondylitis was ultrasonographically diagnosed when a focal hypoechoic (degeneration) or anechoic (tear) region with increased vascularity was present at the medial epicondyle with or without calcification (Figure 1).2,10 The exclusion criteria were a postoperative follow-up period shorter than 1 year; the presence of another disease or trauma at the same or opposite arm, neck, or shoulder; or use of a surgical technique other than FETOR. We retrospectively reviewed the electronic medical records at our institution and identified 24 consecutive patients who underwent surgery by the senior author (B.C.K.) from January 2008 to July 2011. These 24 patients, none of whom had concomitant lesions on the arms, neck, or shoulder, underwent surgical treatment with the FETOR technique. Four patients were excluded because they had a follow-up period of less than 1 year, leaving 20 patients eligible for this study. Of the remaining 20 patients, 2 patients with bilateral involvement had operations for both elbows simultaneously. Therefore, a total of 22 elbows in 20 patients were included in this study.
Surgical Technique After general or regional anesthesia was administered, a sterile tourniquet was inflated, and the patient’s arm was positioned with the shoulder in abduction and external rotation and the elbow in flexion, so that the anteromedial side of the medial epicondyle faced the surgeon. A 5- to 8-cm oblique incision was made anterior to the medial epicondyle (Figure 2A), and subcutaneous dissection was
Figure 1. Ultrasonographic findings in medial epicondylitis. (A) Longitudinal grayscale imaging of the common flexor-pronator origin in a 49-year-old man showed a focal hypoechoic lesion (arrow), which corresponded to tendon degeneration. (B) Color Doppler imaging revealed increased vascularity in the focal hypoechoic lesion. (C) Calcification was seen as hyperechoic punctuated lesions (arrowheads). performed while the medial antebrachial cutaneous nerve was identified and protected. After the fascial layer was reached, the pronator muscle fibers, the common flexor tendon, and the flexor carpi ulnaris tendon were easily identifiable. A flipped L-shaped incision, which was centered on the medial corner of the medial epicondyle, was marked such that a 3-cm long arm was along the proximal pronator muscle fibers, and the other one with the same length was along the flexor carpi ulnaris tendon (Figure 2B). By use of a No. 10 blade, the forearm fascia was incised along the markings and elevated. The superficial part of the common flexor-pronator tendon, which has a thickness of 1 to 2 mm, was elevated along with the forearm fascia because the former was firmly attached to the latter and therefore difficult to separate. After fascial
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elevation was completed, the CFPO was able to be fully visualized (Figure 2C). The bony insertion of the CFPO was removed from the anterior medial epicondyle by using a No. 10 blade in a proximal-to-distal direction (Figure 2D). The dissection was restricted to the anterior medial epicondyle to prevent injuries to the medial collateral ligament. The cut end of the CFPO was removed by 1 cm, which usually included the degenerated part of the tendon. The remnant of the degenerated tendon, the calcification, and the fibrocartilage at the medial epicondyle were removed with a curette (Figure 2E). The associated conditions were surgically treated simultaneously at the time of performing the FETOR technique. If cubital tunnel syndrome was present, subcutaneous dissection was extended posterior to the medial epicondyle. The ulnar nerve was identified and protected with a sling. Afterward, simple decompression of the cubital tunnel was performed by releasing the Osborne ligament. If chronic lateral epicondylitis was present in the same elbow, it was surgically treated using the Nirschl technique.8 The fascia was repaired using a 3-0 Vicryl suture (Ethicon, Somerville, New Jersey, USA) (Figure 2F). Placement of the patient’s arm in forearm pronation and wrist flexion facilitated the repair. A drain was placed, and the wound was closed layer by layer. A compressive dressing was placed, and a longarm splint was applied.
Postoperative Rehabilitation At day 2 after the operation, the drain was removed, and the long-arm splint was changed to a removable one. The patient started active flexion-extension exercises of the elbow out of the splint, with exercises performed 10 times per session at 3 sessions per day. Forearm rotation was not allowed. At 2 weeks after surgery, the removable long-arm splint was removed, and forearm rotation exercises were begun. From this time onward, the patients were allowed to use their arms freely and were advised to increase their use as much as painfully tolerable.
Outcome Measures Preoperative and postoperative elbow functions were assessed with subjective and objective measures. The subjective assessments included the VAS for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Objective assessments included the patient’s verbal rating of pain induced by the physical examination, pain-free grip (PFG) strength, and elbow range of motion (ROM). Pain was assessed using the VAS in 3 different domains: average pain in the past 1 week, pain at rest, and pain at hard work or heavy lifting. A 10-cm line with 0 on the left end and 10 on the right end was used for each pain measurement. The scores of 0 and 10 indicated no pain and the worst pain imaginable, respectively. The DASH is a validated arm-specific outcome measure and has been used for the assessment of elbow function in a variety of disease and traumatic conditions.3,7 The DASH questionnaire consists of 30 items measuring difficulties related to specific tasks, social/work
Figure 2. The fascial elevation and tendon origin resection (FETOR) technique. (A) A 5- to 8-cm oblique incision is made just anterior to the medial epicondyle. (B) After the fascial layer is reached, a flipped L-shaped line is drawn on the fascia. The medial antebrachial cutaneous nerve is protected with a sling. (C) The fascia is elevated along the marked lines, after which the common flexor tendon (arrow) and its origin at the medial epicondyle (arrowhead) are fully visualized. Note that the tendon at the medial epicondyle has lost its fibrillar and shiny appearance, which is the typical appearance of a degenerated tendon (arrowhead). The common flexorpronator origin (CFPO) is removed from the medial epicondyle, and (D) the remaining calcification (arrowhead) or (E) degenerated tendon is removed with a curette. (F) The CFPO is left detached, while the fascia is repaired with a 3-0 absorbable suture. An, anterior; Ds, distal; Pr, proximal. functions, sleep, confidence, and symptoms. The DASH score ranges from 0 to 100, with higher scores representing worse disability. The mean 6 standard deviation of the DASH score in the general population is 10.0 6 14.7, and the minimal clinically important difference is considered to be a 10-point difference.5,6,14 Pain induced by a physical examination (ie, tenderness to the medial epicondyle and pain produced by resistance to active pronation) was verbally rated by the patients as absent, mild, moderate, or severe. Moreover, PFG strength is the amount of grip force generated at the onset of pain.17 For the measurement of PFG strength, patients were seated in a position with the shoulder in adduction and at 90° of forward elevation, the elbow in full extension, and the forearm and wrist in a neutral position. With a Jamar dynamometer (Patterson Medical, Warrenville, Illinois, USA), PFG strength was
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measured 3 times with a 1-minute interval between the measurements; the mean value was compared with that of the uninvolved hand. Elbow ROM was measured using a handheld goniometer. We also rated overall patient satisfaction with the surgical outcomes at the final follow-up using a Likert-type scale as follows: 1, very unsatisfied; 2, unsatisfied; 3, neither unsatisfied nor satisfied; 4, satisfied; and 5, very satisfied.
Association of Ultrasonographic Findings With Preoperative and Postoperative Elbow Function To explore the association of the ultrasonographic findings with the outcomes of FETOR, we allocated patients into 2 groups according to these findings: tendon degeneration and increased vascularity without calcification (group 1) and with calcification (group 2). The 2 groups were compared with respect to clinical and demographic data and preoperative and postoperative elbow functions.
Statistical Analysis The data were shown to have a Gaussian distribution by the Kolmogorov-Smirnov test, and thus, parametric tests were used for the statistical analysis. The paired t test was used to compare the preoperative and postoperative values of the VAS for pain, DASH, PFG, and elbow ROM. The McNemar test was used to compare the preoperative and postoperative values of the categorical variables. For comparing the 2 groups with different ultrasonographic findings, the Student t test was used to compare continuous variables, while the x2 test or Fisher exact test was used to compare categorical variables.
RESULTS Demographic and Clinical Characteristics The demographic and clinical characteristics are shown in Table 1. The mean age of the patients (4 men, 16 women) was 48.8 years (range, 29-58 years). The mean duration of symptoms was 34.2 6 50.1 months (range, 8-240 months). The dominant hand was involved in 14 (70%) elbows. No patient had a history of trauma at the elbow. Nineteen elbows had received a mean of 4.2 steroid injections (range, 1-20 injections) at the medial epicondyle, while 3 elbows had received no injections. Other nonoperative treatments included nonsteroidal anti-inflammatory drugs, rest, physical therapy, and acupuncture. Two elbows had received extracorporeal shock wave therapy. Seven patients were involved in heavy manual labor, 5 were involved in office-type work, and 8 patients were housewives. Associated conditions included cubital tunnel syndrome (2 elbows) and lateral epicondylitis (4 elbows).
Outcomes After FETOR After a mean follow-up of 35.6 months (range, 16-77 months), the patients showed significant improvements in
TABLE 1 Demographic and Clinical Dataa Parameter Age, y Sex, male/female, n Symptom duration, mo Manual laborer, n (%) Smoker, n (%) Height, cm Weight, kg Body mass index, kg/m2 Involved hand, right/left/both, n Dominant arm involvement, n (%) Associated elbow conditions, n Cubital tunnel syndrome Lateral epicondylitis
Value 48.8 6 6.7 (29-58) 4/16 34.2 6 50.1 (8-240) 7 (35) 1 (5) 159.3 6 7.3 (150-176) 59.6 6 8.4 (46-72) 23.5 6 3.1 (17.5-28.9) 12/6/2 14 (70) 2 4
a Data are expressed as mean 6 standard deviation (range) unless otherwise indicated.
all the subjective and objective outcome measures (Table 2). After surgery, the VAS score decreased by 93% for average pain, 94% for pain at rest, and 83% for pain during hard work or heavy lifting (P \ .001). The number of elbows with resting pain reduced significantly from 21 to 4 (P \ .001). The patients’ perception of arm function as assessed using the DASH recovered to the level of the healthy population (from a mean of 51.6 6 18.0 to 8.0 6 11.1; P \ .001). The mean PFG strength of the involved arm improved significantly from 53.7% 6 30.3% to 97.3% 6 19.8% compared with the uninvolved arm, which was measured in all the patients except 2 with bilateral involvement (P \ .001). At the final evaluation, the number of elbows with moderate to severe tenderness at the medial epicondyle significantly decreased from 21 (96%) to 6 (27%) (P = .001), while the number of elbows experiencing pain produced by resistance to active pronation significantly decreased from 21 (96%) to 2 (9%) (P \ .001). Eighteen (90%) patients were satisfied with the surgical outcomes. Of the 5 patients who changed their jobs, only 2 of the patients did so because of decreased elbow function.
Complications Two patients complained of hypoesthesia over the skin at the proximal medial forearm. This symptom was attributable to traction injuries to the medial antebrachial cutaneous nerve and spontaneously resolved within a few months. No other complications occurred.
Surgical Findings For 2 elbows, the CFPO was detached from the medial epicondyle, and there was degeneration at the proximal end involving the entire tendon layer. In the other elbows, the superficial part of the CFPO was normal in appearance; however, the deep part had a gray, amorphous appearance, indicating a degenerated tendon.
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TABLE 2 Comparison of Preoperative and Postoperative Elbow Functions After FETORa Measures
Preoperative Status
VAS score Average pain Pain at rest Pain at hard work or heavy lifting DASH score Flexion-extension arc, deg PFG strength Of contralateral arm, % Of uninvolved arm, kg Of involved arm, kg Tenderness at medial epicondyle, n Severe Moderate None or mild Pain by resisted pronation, n Severe Moderate None or mild
6.8 3.4 8.0 51.6 143.6
0.5 0.2 1.4 8.0 147.7
P Value
1.0 0.5 1.5 11.1 4.0
\.001 \.001 \.001 \.001 .047
53.7 6 30.3 23.2 6 10.2 13.8 6 9.2
97.3 6 19.8 25.6 6 9.4 24.8 6 9.9
\.001 .12 \.001 .001
17 4 1
3 3 16
19 2 1
1 1 20
6 6 6 6 6
1.7 3.0 1.6 18.0 6.8
Postoperative Status
6 6 6 6 6
\.001
a Data are expressed as mean 6 standard deviation unless otherwise indicated. DASH, Disabilities of the Arm, Shoulder and Hand; FETOR, fascial elevation and tendon origin resection; PFG, pain-free grip; VAS, visual analog scale.
Imaging Findings and Their Association With Clinical and Surgical Outcome Variables Radiographs of the elbows revealed an absence of abnormalities in 11 elbows and the presence of calcification at the medial epicondyle in 11 elbows. Ultrasonography demonstrated a focal hypoechoic region with increased vascularity at the medial epicondyle in all 22 elbows. Additionally, partial tearing of the deep layer of the CFPO was observed in 1 elbow. Moreover, calcification in the latter group of 11 elbows was also observed ultrasonographically. Thus, there were 11 elbows in 10 patients in both groups 1 (no calcification) and 2 (calcification) (Table 3). No significant differences were observed between the groups with respect to clinical and demographic data (P . .05) (Table 3). However, the mean DASH score at the final follow-up was significantly decreased in group 2 compared with that in group 1 (2.7 6 2.8 vs 14.9 6 13.4, respectively; P = .011), while other measures of elbow function were not significantly different between the groups (P . .05) (Table 3). Associated conditions were more common in group 2 than in group 1 (2 elbows with cubital tunnel syndrome and 2 elbows with lateral epicondylitis in group 2 vs 2 elbows with lateral epicondylitis in group 1), but the incidence of associated conditions did not achieve statistical significance (P = .635).
DISCUSSION In this study, we demonstrated that FETOR was an effective and safe method for the treatment of chronic recalcitrant medial epicondylitis. At a mean follow-up of 35.6
months, the pain level was reduced by about 90%, and the mean DASH score decreased to the level of the healthy population. Further, PFG strength was restored to the level of the uninvolved arm. No major complications occurred. Two surgical techniques have been described for complete removal of the degenerated tendon in the surgical treatment of medial epicondylitis.9,16 The Nirschl technique described by Ollivierre et al9 uses longitudinal splitting of the fascia and the common flexor-pronator tendon to visualize degeneration at the CFPO. While this technique can produce excellent results and shorten rehabilitation time when performed by experienced surgeons, the limited surgical field provided by this technique may lead to incomplete removal of the degenerated tendon and injuries to the medial collateral ligament in inexperienced hands. Meanwhile, the Jobe technique, described by Vangsness and Jobe,16 requires an elevation of the entire flexorpronator mass for visualizing the CFPO and reattachment to the medial epicondyle, which necessitates protection of the repair site for up to 8 weeks. Although this technique allows the complete visualization of the CFPO, the increased risks of joint contracture and ulnar nerve adhesion may be present because of the long period of immobilization and the wide dissection of the muscle around the nerve. We have modified these previous methods such that complete visualization and resection of the CFPO can be obtained without wide muscle and tendon dissection. Our technique included a 5- to 8-cm incision, an elevation of only the flexor-pronator fascia in a flipped L shape for full visualization of the CFPO, and only resection of the CFPO containing the degenerated tendon without reattachment to the medial epicondyle. Based on these surgical
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TABLE 3 Comparison Between Patients Without Calcification (Group 1) and With Calcification (Group 2)a Measures
Group 1 (n = 10 Patients)
Group 2 (n = 10 Patients)
P Value
49.8 6 6.2 2 6 3 40.8 6 70.6 2
47.8 6 7.4 2 6 4 27.5 6 14.5 4
.519 ..999 ..999 ..999 .567 .635
7.0 3.9 7.9 57.6 12.6
6 6 6 6 6
2.9 3.2 1.7 19.2 6.7
6.9 3.0 8.2 45.7 14.9
6 6 6 6 6
1.5 2.8 1.5 15.4 11.4
.905 .466 .648 .145 .581
0.8 0.4 1.7 14.9 22.7
6 6 6 6 6
1.3 0.7 1.5 13.4 10.7
0.2 0.1 1.1 2.7 27.0
6 6 6 6 6
0.4 0.3 1.4 2.8 9.0
.124 .235 .321 .011 .319
Age, y Male sex, n Dominant arm involvement, n Manual labor, n Symptom duration, mo Associated elbow conditions, n Preoperative VAS score for average pain VAS score for pain at rest VAS score for pain at hard work or heavy lifting DASH score PFG strength of involved arm, kg Postoperative VAS score for average pain VAS score for pain at rest VAS score for pain at hard work or heavy lifting DASH score PFG strength of involved arm, kg
a Data are expressed as mean 6 standard deviation unless otherwise indicated. DASH, Disabilities of the Arm, Shoulder and Hand; PFG, pain-free grip; VAS, visual analog scale.
components, the degenerated area in the CFPO can be easily identified and completely resected, while soft tissue dissection and the risk for injuries to the surrounding structures are minimized. Although immobilization was applied intermittently for 2 weeks, complications related to wrist flexor or pronator muscle weakness were not observed likely because these muscles had multiple origins and their attachments to the surrounding muscle fascia were preserved. Furthermore, our modified technique allowed a fast recovery and return to the job because of early rehabilitation. Our results appear to be comparable with the findings of other techniques, although comparisons across retrospective studies are difficult because of differences between them. Ollivierre et al9 performed the Nirschl technique in 50 elbows of 48 patients with a mean age of 42 years. At a mean follow-up of 32 months, most of the patients improved substantially in pain and grip strength. However, 8 patients (16%) had severe pain with sports or occupational activities, and 10 patients (20%) were not able to return to sporting or occupational activities. One case of a complication related to medial collateral ligament insufficiency occurred and required later reconstruction. In a study of 35 patients with chronic medial epicondylitis who underwent the Jobe technique, Vangsness and Jobe16 obtained good to excellent results in 34 patients (97%) at a mean follow-up of 85 months. However, 14% of the patients continued to have limitations in heavy lifting. Complications included 2 cases of ulnar neuropathy at the elbow and 1 case of hematoma. In another study, the Jobe technique was used in conjunction with decompression or transposition of the ulnar nerve for associated cubital tunnel syndrome.4 The study reported that the results were good to excellent in 26 elbows (87%), fair in 2 elbows, and
poor in 2 elbows among 26 patients at a mean follow-up of 7 years. The authors pointed out that moderate to severe associated ulnar neuropathy resulted in a significantly worse outcome. To our knowledge, this is the first study that used a validated subjective outcome measure, that is, the DASH, in assessing the outcomes of surgery for the treatment of medial epicondylitis. By using the DASH, the patient’s perceived arm functions after FETOR could be interpreted in the context of normative values in the general population. Furthermore, use of the DASH enabled the outcomes of this study to be compared with those of other studies in a more valid manner. In addition, our data can be used in estimating a sample size for a prospective comparative study in the future. Another strength of our study is that patients with medial epicondylitis were clearly defined using clinical examination, radiography, and ultrasonography. With these modalities, we were able to confirm the presence of tendon degeneration at the CFPO and to differentiate conditions mimicking medial epicondylitis, such as synovial plica, osteoarthritis, and ligament injuries. One interesting finding in this study is that the DASH score significantly decreased in patients with calcification at the medial epicondyle compared with those without calcification. Furthermore, the mean difference of 12.7 points in the DASH score between the 2 groups was greater than the minimal clinically important difference for the DASH (10.0 points).6 This finding was unexpected because cubital tunnel syndrome, a well-known risk factor for a poor outcome after surgery for medial epicondylitis,4 coexisted only in the calcification group. Moreover, all the other measures of outcomes, such as the VAS score and PFG strength, were also consistently better in the calcification group than in the noncalcification group, although the
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Vol. 42, No. 7, 2014
FETOR Technique for Medial Epicondylitis
differences did not achieve statistical significance. This consistency in the differences in the various outcome measures suggests that the observed statistical insignificances might stem from the small sample size. Taken together, our results suggest the possibility that patients with calcification at the medial epicondyle are more likely to have better outcomes than those without calcification after the surgical treatment of medial epicondylitis with the FETOR technique. Although providing an explanation as to why calcification at the CFPO positively affected the surgical outcomes is difficult, one possibility is that calcified tissue is more easily identifiable and therefore results in a more complete excision of the degenerated region, which subsequently leads to better outcomes. Further studies using a larger cohort are required to confirm the association of ultrasonographic findings with the surgical outcomes. This study had several limitations. First, the study was a retrospective one, and biases associated with this design could be inevitable. However, we believe that potential biases, such as recall bias, were minimized because all of the outcome measures were conducted routinely per protocol before the patients underwent the FETOR procedure. Second, this study lacked a control group for comparing the effectiveness of FETOR. Because epicondylitis has a self-limiting disease course, the inclusion of a matched, nonoperated control group might have provided information for addressing whether FETOR can change the natural course of medial epicondylitis. Third, the superiority of FETOR over the previous methods cannot be concluded based on this study. A randomized prospective study is necessary to determine which method is the best option for the treatment of chronic recalcitrant medial epicondylitis. Finally, we could not analyze the effect of preoperative steroid injections on the surgical outcomes because of the diverse nonoperative treatments given to our cohort. As steroid injections have been known to adversely affect the natural course of epicondylitis,13 it is clinically important to answer the question of whether steroid injections also have negative effects on surgical outcomes. This question needs to be addressed in a future study. Medial epicondylitis, despite being self-limited, is sometimes resistant to nonoperative treatments and can seriously affect the quality of life of the affected patient. We demonstrated here that our new technique, FETOR, is an effective and safe method for the treatment of this condition. The FETOR technique facilitates complete exposure of the CFPO without wide soft tissue dissection and thus minimizes the risk of incomplete removal of the degenerated tendon and allows for a rapid rehabilitation. By using FETOR, the pain level was reduced by about 90%, and the perceived arm disability was reduced to normal levels in patients with chronic recalcitrant medial epicondylitis. Prospective randomized studies in the future will elucidate
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how FETOR compares to other techniques and will help to establish a comprehensive management algorithm for chronic medial epicondylitis.
REFERENCES 1. Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004;23(4):693705, xi. 2. Clarke AW, Ahmad M, Curtis M, Connell DA. Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability. Am J Sports Med. 2010;38(6):1209-1214. 3. De Smet L. The DASH questionnaire and score in the evaluation of hand and wrist disorders. Acta Orthop Belg. 2008;74(5):575-581. 4. Gabel GT, Morrey BF. Operative treatment of medical epicondylitis: influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995;77(7):1065-1069. 5. Gummesson C, Atroshi I, Ekdahl C. The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11. 6. Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84(2):208-215. 7. Longo UG, Franceschi F, Loppini M, Maffulli N, Denaro V. Rating systems for evaluation of the elbow. Br Med Bull. 2008;87:131-161. 8. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839. 9. Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow: a prospective analysis. Am J Sports Med. 1995;23(2):214-221. 10. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. 2008; 89(4):738-742. 11. Shaw HM, Benjamin M. Structure-function relationships of entheses in relation to mechanical load and exercise. Scand J Med Sci Sports. 2007;17(4):303-315. 12. Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065-1074. 13. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657-662. 14. Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-rated outcomes instruments. J Hand Surg Am. 2013;38(4):641-649. 15. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis: a prospective study of sixty elbows. J Bone Joint Surg Am. 1997;79(11):1648-1652. 16. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis: results in 35 elbows. J Bone Joint Surg Br. 1991;73(3):409-411. 17. Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A. Initial effects of elbow taping on pain-free grip strength and pressure pain threshold. J Orthop Sports Phys Ther. 2003;33(7):400-407. 18. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Occupation and epicondylitis: a population-based study. Rheumatology (Oxford). 2012;51(2):305-310.
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