Tennis Elbow Repair

Suture Anchor Repair is More Effective for Chronic Lateral Epicondylitis Than Debridement Raymond Rocco Monto, MD

AAOS Annual Meeting, Chicago, 2013

Financial Disclosures ď Ž

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Consulting agreement: Exactech, Inc. No funding or grants were provided in support of this study or preparation of this work

Lateral Epicondylitis   

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Affects 1-3% of adults Only 4-11% seek MD 85% improve with conservative care Rest, ice, eccentric PT, NSAIDs, cortisone, bracing, ESWT, glyceryl nitrate, PRP, Botox-A, nitric oxide, etc.

Lateral Epicondylitis 

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Lunge (1873) Cyriax (1936) Coonrad (1973) Boyd (1973) Nirschl (1979) Baker (2000) Thorton (2005) No comparative studies in literature

Coonrad 1973

Lateral Epicondylitis 

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Pathophysiology similar to plantar fasciitis and Achilles tendinosis Degenerative micro-tears ECRB / EDC origin Apoptosis / autophagic cell damage (programmed death) Chaotic vascularity / local hypoxia Decreased collagen production / slower matrix turnover / CNS involvement

Nirschl 1999

Lateral Epicondylitis            

Prospective Randomized Double blinded Longitudinal cohort study 60 patients (30 in each arm) All patients with MRI evidence of ECRB tears / lateral epicondylitis All failed minimum 6 months conservative treatment (NSAIDS, bracing, HEP, cortisone injection, PT, oral steroids) All patients underwent elbow arthroscopy Open ECRB debridement / repair without suture anchor vs.

Open ECRB debridement / repair with suture anchor Follow-up clinical scoring (Mayo Elbow and DASH) at 1, 2, 3, 6 and 12 months post-operatively All patients sling for comfort and PT started @ 2 weeks

Lateral Epicondylitis Un-Anchored Repair Group:  Nirschl (Coonrad) procedure  ECRB / EDC debridement  Drill or decorticate lateral epicondyle  Side to side ECRB EDC repair  Sling for comfort/PT

Academy News 2/23/96

Lateral Epicondylitis Anchored Repair Group:  Debridement ECRB / EDC  Decorticate lateral epicondyle  ECRB reattached to bone  2 suture anchors (“snakebite”)  2.4 mm PLDLA BIOSUTURETAK anchors (Arthrex) 19/30 (2-0 UHWMPE suture)  2.0 mm PEEK DYNOMITE anchors (Smith Nephew) 11/30 (2-0 UHWMPE suture)

Left elbow / supine position

Lateral Epicondylitis

Standard Nirschl exposure

Lateral Epicondylitis

Extensive debridement of ECRB origin tear

Lateral Epicondylitis

Decortication of lateral epicodyle

Lateral Epicondylitis

Final soft tissue debridement

Lateral Epicondylitis

Drill lateral epicondyle origin of ECRB

Lateral Epicondylitis

Two parallel drill holes (“snake-bite “)

Lateral Epicondylitis

Placement of two small suture anchors

Lateral Epicondylitis

Suture anchors carry 2-0 UHMPE non-absorbable sutures

Lateral Epicondylitis

Repair of ECRB origin using the anchored sutures

Lateral epicondylitis

Final ECRB repair

RESULTS

Demographics 

Non-Anchored Group  Average age 48.2 (range 30-61)  Males/Females 16/14  Duration of Symptoms 8.9 mos (range 6-18)  Cortisone injections 1.54 (range 1-3)  No patients lost to f/u

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Anchored Group  Average age 49.3 (range 30-62)  Males/Females 18/12  Duration symptoms 10.4 mos (range 6-36)  Cortisone injections 2.10 (range 1-3)  No patients lost to f/u

Mayo Elbow Scores 

Non-Anchored Group   

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Preop Postop Postop Postop Postop Postop

1 mo 2 mos 3 mos 6 mos 12 mos

59.67 72.17 81.17 89.93 94.50 96.50

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Anchored Group      

Preop Postop Postop Postop Postop Postop

58.67 1 mo 89.5 2 mos 96.67 3 mos 99.33 6 mos 99.50 12 mos 99.50

Mayo Scores 100 90 80 70 60 50 40 30 20 10 0

No Anchors Anchors CI 95% P.001

0

1

2

3

6

Months After Surgery

12

DASH Scores 

Non-Anchored Group  Preop 52.97  Postop 1 mo 37.62  Postop 2 mos 26.03  Postop 3 mos 18.58  Postop 6 mos 11.52  Postop 12 mos 7.53

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Anchored Group  Preop 55.73  Postop 1 mo 15.80  Postop 2 mos 8.89  Postop 3 mos 3.47  Postop 6 mos 0.39  Postop 12 mos 0.14

DASH Scores 60 50 40 No Anchors Anchors

30 20

CI 95%

10 0

P .001 0

1

2

3

6

Months After Surgery

12

Results Un-Anchored Group 

Return to Work (light) 

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n/a

Return to Work (light) 

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50 minutes

Cost Differential 

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21 days (range 12-64)

Operative Time 

Anchored Group

Operative Time 

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11 days (range 4-42) 60 minutes (+8-15)

Cost Differential 

350 USD

MRI Pathology 

Extra-articular defects (MRI findings)  

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Partial ECRB tendon tears 59/60 Chronic ECRB tendonosis 60/60

Intra-articular defects (MRI findings)  

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Posterolateral synovial folds 18/60 Chondral defects capitellum 8/60 Radial head cartilage loss 4/60 Olecranon chondral damage 3/60 No significant difference between groups

MRI Pathology

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MRI findings of partial ECRB tendon tears, tendonosis, and edema seen in all patients

Arthroscopic Pathology 

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Arthrosocpic debridement / synovectomy in 22/50 patients Arthroscopic capitellar chondroplasty and microfracture in 5/50 All lesions present on preop MRI scans

Conclusions ď Ž

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2 failed un-anchored cases revised to anchored repairs after study completion MRI of a failed nonanchored ECRB repair later successfully revised to an anchored repair

Conclusions  

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Both groups did well ECRB debridement and repair with suture anchors is significantly more effective than repairs without anchors and has a faster recovery Better Mayo and DASH short and long term scores (CI 95% P=0.001)

SUMMARY ď Ž

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Consider surgical management of severe chronic lateral epicondylitis with anchors in cases that fail standard non-operative management Improved results and faster return to work may justify higher costs of anchored repairs (175 USD/anchor)

SUMMARY ď Ž

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Arthroscopy recommended only if MRI detects capitellar chondral defect, arthritis, or synovial fold Do not abandon traditional conservative treatment paradigms

SURGICAL TIPS CAUTION:  Remove all abnormal tissue  Repair capsule if needed to limit risk of synovial cyst  Stay anterior to lateral epicondyle to avoid LCL damage  Stay posterior to PIN  Watch for posterior cutaneous forearm nerve

Thank You

Special thanks to: ď Ž Nick Rocco Monto, BSc (statistics)