Epicondylitis - Swisshandsurgery · Open release of medial epicondylitis 83-94% success after max....
Transcript of Epicondylitis - Swisshandsurgery · Open release of medial epicondylitis 83-94% success after max....
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Epicondylitis
a chronic headache for patients and their doctors
Michael Glanzmann 25.10.2012
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Anatomie: Extensoren Gruppe
Bedeutend für radiale, insbesondere die posterolaterale Rotationsstabilität des Ellbogengelenkes
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Demographisches
4 – 7 pro 1000 pro Jahr 1 – 3% der Bevölkerung übers Leben Peak zwischen 35 – 54 LJ Medial : lateral → 1:3 Male : women→ 4:1 Mit Abstand das häufigste Ellbogenleiden
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Medial epicondylitis
Ueberbeanspruchung der flexor/pronator Einheit Werfer (pitchers) Microrupturen zwischen pronator teres and FCR Oft verbunden mit ulnarer Neuritis
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Differential diagnosis of ‘Tennis Elbow’
C6/7 radiculopathy Radial tunnel syndrome Posterior interosseous nerve syndrome Distal biceps tendon degeneration Radiocapitellar arthritis Capsular infolding Posterolateral instability
Management of nerve compression lesions of the upper extremity. Spinner M et al. Management of peripheral nerve problems 2nd ed. 1998 Philadelphia, pp.501-33
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Clinical tests: lateral epicondylitis
Cozen and Maudsley tests
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Management
Non-operative successful in 95%
Operative only after failed non-operative treatment usually successful
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Non-operative options
• Analgesia • Acupuncture • Blood injection • Bracing • Botulinum toxin • Casting • Change of job • Endurance training • Extracorporeal shockwave Rx • Heat • Ice • Iontophoresis • Low-level laser therapy • Manipulation
• Massage • Oedema control • Phonophoresis • Physio • Polarized polychromatic non-
coherent light • Pulsed electromagnetic field Rx • Rest • Splinting • Steroid injection • Taping • TENS • Topical NSAID gel • Ultrasound
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Steroid injection Good short-term relief for 6 weeks Poorer outcome in the longer term than
watch and wait physio placebo
Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bisset L et al. BMJ 2006 Nov 4;333(7575):939-44
Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Tonks J et al. Int J Clin Pract 2007 Feb;61(2):240-6
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Physiotherapy
At 6 weeks: better than ‘watch and wait’ worse than steroid injection
Long-term: better than steroid injection same as ‘watch and wait’
Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bisset L et al. BMJ 2006 Nov 4;333(7575):939-44
Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Smidt N. Lancet 2002;359: 657-62
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Predictors of poor outcome Dominant hand (OR=3.4) Manual labour (OR=2.3) High physical strain at work (OR=3.6) High level of baseline pain (OR=2.3) Lower social class
83% improved at 1yr, regardless of occupational input Intervention did not reduce visits
Prognostic factors in lateral epicondylitis: a randomised trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Haarh J, Andersen J. Rheumatology. Oct 2003, 42(10):1216
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Non-operative options
• Analgesia • Acupuncture • Platelet rich plasma injection • Bracing • Botulinum toxin • Casting • Change of job • Endurance training • Extracorporeal shockwave Rx • Heat • Ice • Iontophoresis • Low-level laser therapy • Manipulation
• Massage • Oedema control • Phonophoresis • Physio • Polarized polychromatic non-
coherent light • Pulsed electromagnetic field Rx • Rest • Splinting • Steroid injection • Taping • TENS • Topical NSAID gel • Ultrasound
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Was ist PRP überhaupt?
Blutbestandteil mit erhöhter Konzentration an Blutplättchen (platelets)
Konzentrationsfaktor ist aufbearbeitungsabhängig (2.5 bis 9x)
niedrig 2.5-3x
hoch 5-9x
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Vom Vollblut zu den Wachstumsfaktoren
Sedimentationsrate = (Durchmesser) ²
Rote BK: 7² = 49
Plättchen: 2² = 4
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IGF-1 TGF-β
VEGF PDGF bFGF EGF
Platelet-rich plasma
Inflammationsphase
Proliferationsphase
Molloy et al, Sports Medicine, 2003;33(5);381-94
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Bei subakuten und chronischen muskuloskelettalen Problemen
• Tendinopathien (degenerativer Schaden) • Bänderzerrung (beschleunigte Bandheilung) • Muskelzerrung • Knorpelschaden/Arthrose • Diskopathien, Radikulopathien
Wann macht PRP/ACP Sinn ?
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• Störung der Thrombozyten • Infektionen • Kortison Infiltration < 1 Monat • Perorale Kortison Therapie < 2 Wochen • NSAR < 48h
Wann ist PRP/ACP Unsinn ?
Kontraindikationen
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Peerbooms JC, Sluimer J, Bruijn DJ et al. (2011) Ongoing positive effect of Platelet-Rich Plasma versus Corticosteroid Injection in lateral Epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 39:6
Cortison (n=49) ACP (n=51)
Schmerzreduktion >25% 43% 73%
DASH >25% 39% 73%
ACP®: Schulmedizinische Evidenz
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Peerbooms JC, Sluimer J, Bruijn DJ et al. (2011) Ongoing positive effect of Platelet-Rich Plasma versus Corticosteroid Injection in lateral Epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 39:6
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Operative options
Open release Arthroscopic release Percutaneous release/Microtenotomy
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Lateral Epicondylitis
JBJS 1979 Sep;61(6A):832-9. Tennis elbow. The surgical treatment of lateral epicondylitis.
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Lateral Epicondylitis
Surgical Steps 1) Debride degenerative
tissue at ECRB origin 2) remove traction spurs 3) stimulate angiogenesis 4) repair defect/
superficial extensor closure
REINSERTION der EXTENSOREN !
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Lateral Epicondylitis
Hohmann: Quer-Einkerbung d. Extensoren-Sehnenspiegels
Wilhelm: Denervation
Goldie: Längssplittung des Sehnenspiegels
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Open Lateral Epicondylitis
Outcomes 85-90% return to FULL
activities 10% have some pain 2% do not improve 10 year experience
success rate 95% undetected/iatrogenic posterolateral rotatory
instability
Failures due to Incomplete resection of pathologic tissue Poor soft tissue
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Open release
Excellent / good 75 – 91% Poor / failed 2 – 11% 80 – 95% return to normal activity in 4 months
Lateral extensor release for tennis elbow. A prospective long-term follow-up study. Verhaar J et al. JBJS(Am) 1993;75(7):1034-43
The surgical treatment of chronic lateral humeral epicondylitis by common extensor release. Goldberg E et al. Clin Orthop 1998;Aug(233):208-12
Outcome of release of the lateral extensor muscle origin for epicondylitis. Svernlov B et al. Scand J Plast Recon Surg Hand 2006;40(3):161-5
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Percutaneous release
As good as open or arthroscopic May have earlier return to work
Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis. Rubenhaler F et al. Arthroscopy 2005;21(6):684-90
Surgical treatment of tennis elbow: percutaneous release of the common extensor origin. Kaleli T et al. Acta Orthop Belg 2004;70(2):131-3
Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. Szabo SJ et al. J Shoulder Elbow Surg 2006;15(6):721-7
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Arthroscopy
70% satisfactory to excellent 473 cases
4 deep infection 33 prolonged drainage 12 transient nerve palsies
Arthroscopic tennis elbow release. Kalainov D et al. Techniques in Hand and Upper Extremity Surgery. 2007;11(1):2-7
Arthroscopy leaves residual tendinopathy Gross and histological Results in poorer outcomes
Lateral Epicondylitis: In Vivo Assessment of Arthroscopic Debridement and Correlation With Patient Outcomes. Cummins CA. Am J Sports Med Sep 2006, 34(9):1486
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Open release of medial epicondylitis
83-94% success after max. follow-up of 7 years Less favorable results in concomitant ulnar
neuritis/treatment
Gabel GT, Morrey BT. Operative treatment of medial epicondylitis: the influence of Concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 1995;77:1065–9.
Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin Orthop 1992;278:73– 80.
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Summary
95% settle without surgery Platelet rich plasma: low risk, aprox. 50% chance Short-term: steroids +/- physio Long-term: ‘watch and wait’ as good as any
Surgery only after failed non-operative treatment high success rate consider other diagnoses: PLR Instability, Plica, Chondral
defects
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Danke für die Aufmerksamkeit