A prospective controlled trial of 24
patients (24 elbows) with tennis elbow who underwent a formal
release was conducted. All patients had pre and post operative
assessment using the Disability of Arm, Shoulder and Hand (DASH)
scoring system. Both groups were followed up for a minimum of
seven months. Statistical analysis showed significant
improvements for patients satisfaction (p= 0.012), time to
return to work (p=0.001), improvements in DASH score (p=0.001)
and improvement in sports activities (p=0.046). Patients
returned to work on an average of five weeks. This formal open
release is a quicker and simpler procedure to undertake and
produces significantly better results in patients with failed
Key Words: tennis elbow, lateral epicondylitis, open
Tennis elbow or lateral epicondylitis refers
to a syndrome of pain centered over the common origin of the
extensor muscles of the fingers and wrist a the lateral
epicondyle. It was first reported in the literature in 1873 by
Ringe1 . It occurs more commonly in non athletes than athletes
and has a peek incidence in the fifth decade . The term
epicondylitis is a misnomer as there is little evidence to
suggest that there is an inflammatory process. It may be caused
by repetitive microtrauma to the origin of extensor carpii
radialis brevis(ECRB), but the precise aetiopathology remains
unclear 1,2 . The diagnosis of tennis elbow is usually made by
localizing pain when patient pinches with the wrist in extension
and on resisted extension of the middle finger. The differential
diagnosis can include Radial tunnel syndrome, lateral
compartment arthritis and osteochondritis of the capitellum. The
initial treatment is with rest, modification of activity, local
splints, steroid injections, and physiotherapy and about 90% of
patients respond to conservative treatment2 . Steroid
injections may provide relief of symptoms in upto 40% of
patients. Patients who fail to respond to conservative measures
may require surgery. Boyd and McLeod3, Posch, Goldberg and
lauey4, reported that upto 8% of patients require surgery.
The many operations available have been
reviewed by Bosworth5 and Rosen etal6, and include open release
of ECRB, tenotomy of extensor tendon, excision of the damaged
portion of the tendon, exploration of radio humeral joint and
alterations to the length of the tendon of ECRB.
The purpose of this study was to assess the
efficacy of the operative technique as described by Nirsch7.
Material and Methods :
We carried out a prospective controlled
trial in these patients. All patients had previously undergone
conservative treatment for atleast 6 months. These include two
injections of 80mg of hydrocortisone into the common extensor
origins, modification of activities which involved them from
refraining from repetitive activities that provoked pain over
the lateral epicondyle, ultrasound therapy, analgesics and other
All patients were examined pre operatively.
The diagnosis was confirmed by resisted extension of the middle
finger and pinch grip with wrist in extension provoking pain
over the ommon extensor origin . All patients had a normal
cervical spine clinically and radiologically. All patients were
assessed pre operatively using the American academy of
Orthopaedic surgeons disability of arm, shoulder and hand (DASH)
score. This outcome measured is a questionnaire designed to
measure function and assess symptoms in patients with
musculoskeletal disorders of the upper limb. It includes a
disability measurement index for general function and symptoms
as well as sport and msic functions and high performance work
function. It is scored as a single scale with each of the 30
items scored on a scale of 1 to 5. A raw score of 150 points
indicates maximum and 30 points minimum disability in order to
convert the raw score to a scaled score, 30 is subtracted from
the total which is then multiplied by 0.8, yielding a scaled
range from 0 to 100. The specialist score for high demand work,
sport or musical activity is calculated in a similar manner. The
procedures were all carried out under general anesthesia and
tourniquet control. The post operative physiotherapy regime was
supported by the physiotherapist. The patients were followed
up at 7 months post operatively. Their subjective assessment
and the time of work were recorded as well as the DASH score
Table I: Details of patients who underwent
open technique for tennis elbow.
Mean age in years (range): 46 (32 –
Follow Up( months).
The anatomy of the common extensor origin has
been well described and consists of the tendons of ECRB and ECRL,
extensor digitorum, ECU and anconeus. The tendons of origin may
continue as confluent mass. The tendon of ECRB arises from the
anterior aspect of the lateral epicondyleand is deep and
inferior to that of ECRL and extensor digitorum communis. The
lateral collateral ligament is a primary stabilizer of the elbow
and care must be taken to protect it. The body of ECRL is easily
The open procedure used was as described by
Nirsch7 and Nirsch and Petronne9. A 7 cm incision is centered
over the common extensor origin and ECRL is reflected to expose
the origin of ECRB and the damaged portion of the tendon is
removed. This is commonly found to be white and oedematous .
Three small drill holes are made in the Lateral condyle. The
radiocapitellar joint is exposed to check for degenerative
changes or synovitis and joint lavage.
A wool and crepe bandage was applied and
removed after seven days to allow the early commencement of
There were 24 patients (24 elbows). The demographic variables
are as Table-I.
The median pre operative DASH score was 78(67-86). As shown in
Table II the median basic normalized DASH score was 70(64-75).
The median post operative basic normalised DASH score was
53(48-57). The change in the median basic DASH score was
17(11-19). The sport function section of the DASH score showed
pre operative normalized median scores of 68(65-78). The change
in the median normalized sport scores was 11(6-19). The patients
were also scored according to the high performance and work
section of the DASH questionnaire. The median pre operative work
score was 68(6072). The median post operative score was
52(49-59) producing a change in the median score of 14(7-20)
The patients subjective assessment was recorded (Table-IV)
and showed that 2 in this study were dissatisfied, 16 were
satisfied and 6 were very pleased with the outcome.
DASH scores for 24 elbows. Decrease in DASH
score system indicates improvement. Values shown are median and
inter quartile ranges. All data relate to notrmalised scores.
Post-Op. Improvements P Value.
score. 70(64-75) 53(48-57)
score. 68(65-78) 57(51-62)
perform- 68(60-72) 52(49-59)
14(7-20) amnce work
The subjective outcome measures as determined by the patients
Very Pleased with result: 06
Satisfied with result: 16
Dissatisfied with result:
The time to return to work following surgery for tennis elbow:
Median time to return to work in weeks
(range); 5 (4-6).
It should be noted that one of the patients
who was dissatisfied with the outcome was taking legal
proceeding against his employer. This patient had a change in
the DASH normalized score of only 8(99-91) a change in the
normalized sport score of 24 (81-57) but no change in
the normalized work score pre op 79 and post
op 79. There were no other compensation claims in progress and
no other patient attributed their condition solely to their
16 patients were engaged predominantly in
manual work and 8 were office and non manual workers. The median
time off work was five weeks(4-6).
The treatment of tennis elbow has been the
subject of much debate. Numerous surgical techniques have been
described including fasciotomy, Z lengthening of the tendon,
osteotomy of the lateral epicondyle and excision of the damaged
portion of ECRB as well as open and percutaneous tenotomy
1-4,7-10. Arthroscopy has also been advocated11. Grundenberg and
Dobson10 reported good to excellent results in 29 of 32 elbows
and Baumgard and Schwartz8, achieved 32 excellent and 3
dissatisfied patients in 35 elbows following percutaneous
release. Nirsch and Pettrone9, achieved an excellent outcome in
66 of 88 elbows using open technique similar to the technique
used in this study. Our results compare favourably with these
results and show that the procedure produces significantly
better results. The patients had significant improvement in the
basic DASH scores and sporting and high demand work scores and
the time off work was also better.
Although we do not advocate that all patients
should be treated surgically our results indicate that if
surgery is being considered this procedure gives significantly
good results. It is quicker and although we carried it out under
general anesthesia it may be undertaken under local anesthesia
but we feel that when done under general anesthesia allows for
good exploration of the radio capitellar joint. The procedure
was safe in our patients and without significant complications.
We recommend this procedure on patients with
tennis elbow who have had adequate but failed conservative
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