|Year : 2018 | Volume
| Issue : 2 | Page : 128-130
Treatment of resistant tennis elbow by a novel technique: Platelet-rich plasma injection and drilling of lateral humeral epicondyle
Medhat Tawfik Maaty
Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura City, Egypt
|Date of Web Publication||22-Nov-2018|
Dr. Medhat Tawfik Maaty
Faculty of Medicine, Mansoura University, Mansoura City
Source of Support: None, Conflict of Interest: None
Introduction: Tennis elbow is a common disease in orthopedic surgery. Recently, the high-rate outcomes of local injection of platelet-rich plasma (PRP) were reported. This study was conducted to evaluate and compare the results of combining the percutaneous drilling of lateral humeral epicondyle and local injection of PRP for resistant tennis elbow to other more invasive techniques. Patients and Methods: Between January 2014 and December 2015, 25 patients underwent this study. The patients underwent percutaneous drilling of lateral humeral epicondyle and local injection of PRP. Results: The average follow-up time was 18 months (range: 12–27 months). Eighteen patients (72%) were rated as having excellent results, 4 patients (16%) were rated as having good results, and 3 patients (12%) were rated as having a poor result without any improvement. Conclusions: Combining the percutaneous drilling of lateral humeral epicondyle and local PRP injection in tennis elbow improved the results and compared favorably with other techniques.
Keywords: Drilling, lateral humeral epicondyle, percutaneous, platelet-rich plasma injection, resistant tennis elbow
|How to cite this article:|
Maaty MT. Treatment of resistant tennis elbow by a novel technique: Platelet-rich plasma injection and drilling of lateral humeral epicondyle. J Orthop Traumatol Rehabil 2018;10:128-30
|How to cite this URL:|
Maaty MT. Treatment of resistant tennis elbow by a novel technique: Platelet-rich plasma injection and drilling of lateral humeral epicondyle. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2019 Jun 19];10:128-30. Available from: http://www.jotr.in/text.asp?2018/10/2/128/245990
| Introduction|| |
Tennis elbow is a common disease and its incidence ranges from 1% to 3%. Its pathology is poorly understood, and most structures on the lateral side of the elbow have been involved. The primary causes may be mechanical overload and repetitive stresses on the tendon with a degenerative lesion. The primary method of treatment is conservative measures using anti-inflammatory drugs, physical therapy, and local steroid injections. Although more than 90% of patients with tennis elbow respond to conservative measures, it can produce unsatisfactory results that can lead to chronicity. For resistant cases, surgery is reserved and it has been reported that up to 8% of patients require surgery., Surgical procedures available include lengthening of the extensor carpi radialis brevis, excision of damaged part of the tendon exploration of radiohumeral joint, and extensor tendon tenotomy., Recently platelet-rich plasma (PRP) is considered a possible adjunct to both conservative and operative treatments. Platelets present in PRP function as a tissue sealant initiating wound repair, whereas fibrin matrix acts as a drug delivery system slowly releasing various platelet-derived bioactive factors such as transforming growth factor-β1, vascular endothelial growth factor, platelet-derived growth factor, and insulin-like growth factor.,,, Our hypothesis is that percutaneous drilling of the lateral humeral epicondyle and local injection of PRP may be effective in the management of resistant tennis elbow. The aim of this study is to evaluate the results of treatment of resistant tennis elbow by a new minimally invasive technique of combining two procedures, percutaneous drilling of the lateral humeral epicondyle and local injection of PRP, and compare the results to other more invasive techniques.
| Patients and Methods|| |
The protocol of this study has been approved by the relevant Ethical Committee related to our institution in which it was performed. All individuals gave full informed consent to participate in this study. Between January 2014 and December 2015, 25 patients with resistant tennis elbow were included in this study after failure of conservative measures for at least 6 months. The patients were selected from the outpatient clinic at Mansoura University Hospital. All patients presented with resistant tennis elbow after a thorough history and full clinical examination of the upper extremity to exclude other conditions. Symptoms presented for an average of 10.8 months (range: 6–19 months). All patients were positive Cozen and Maudsley tests. Every patient gets the same conservative treatment in the form of anti-inflammatory drugs, rest, splint, physiotherapy, and 3 local steroid injections before surgery. All patients were male. All patients were right dominant hand. All patients were unilateral affection and were hard workers. The mean age of patients was 42 years (range: 31–57 years). Imaging studies included plain X-ray and magnetic resonance imaging (MRI). It was performed to all patients to exclude other pathologies, and there were positive findings of tennis elbow in MRI. All patients underwent drilling of the lateral humeral epicondyle and local injection of PRP. The average follow-up time was 18 months (range: 12–27 months).
Preparation of platelet-rich plasma
We get the PRP from the patient's own blood. The blood was drawn from the patient in a syringe (10 mL) preloaded with citrate phosphate dextrose and later centrifuged in two spins. The first spin was at 1800 rpm for 15 min to separate erythrocytes and white blood cells from other blood components. The second spin was at 3500 rpm for 10 min for further concentration of platelets. About 2–3 mL of PRP was pipetted out.
Surgery was performed under local anesthesia. The patient was placed in supine position, and then, the arm and forearm were prepared and draped percutaneous drilling of the lateral humeral epicondyle through small 3-mm lateral incision over the midpoint of the lateral epicondyle. It was done by drill bit 2.5 mm, and four drill holes were done under C-arm [Figure 1]. After wound closure, the PRP was injected at the origin of common extensor tendons. We inject the patient's own platelets. With 18-gauge needle, the injection was given directly into the area of maximum tenderness and also into the tendon using a “peppering” technique in which the needle, after being passed through the skin, is inserted several times into the tendon.
The patients were discharged on the same day of the operation and received oral antibiotics. The affected hand of the patient is immobilized in elastic crepe bandage and cuff and collar for 2–3 days, and the patient is strictly advised not to lift weights or participate in activities that involve wrist extension. Patients with tennis elbow were evaluated at 1, 2, 3, 6, 12, and 18 months after the procedure using the visual analog scale (VAS) scores. At the final follow-up, the patients were classified according to Grundberg and Dobson [Table 1].
| Results|| |
There were no complications intraoperative or postoperative as bleeding, infection, or tender scar. All patients had a full range of elbow motion during follow-up examination and were satisfied with the surgical scar. All improved patients were negative Cozen and Maudsley tests. All patients with excellent or good results returned to their former occupations and activities. Utilizing a visual analog pain scale, the results showed more improvement in regard to the preoperative pain level of 8.2 (±1.4) with a range of 7–10. The pain level at final follow-up was 2.1 (±2.1) with a range of 0–7 with a more significant difference. As regards the final results, 18 patients (72%) were rated as having excellent results, 4 patients (16%) were rated as having good results, and 3 patients (12%) were rated as having a poor result without any improvement.
According to pain, elbow pain was relieved within an average of 5 weeks after the surgery (range: 3–8 weeks). All patients with excellent or good results returned to their former occupations or activities.
| Discussion|| |
Tennis elbow is an overuse injury of the common extensor tendon origin. The pathology is poorly understood, and most structures on the lateral side of the elbow have been implicated. The patients should be examined carefully to exclude other pathologies such as entrapment of the anterior branch of radial nerve and lateral ligament complex injury. Surgical treatment is a challenge in resistant tennis elbow. After failure of conservative treatment, adjunctive and surgical interference is recommended. The benefits are rapid return to normal daily living activities, relief of pain, and short time for recovery. This study strongly suggests that local injection of PRP and drilling of lateral humeral epicondyle is a novel procedure of treatment that provides significant relief of pain and improvement in function in tennis elbow. It is possibly a safer option for patients suffering from resistant tennis elbow. The proposed mechanism of action of autologous PRP is improvement of early neotendon properties and improvement of tissue healing by enhancing cellular chemotaxis, angiogenesis, proliferation and differentiation, removal of tissue debris, and formation of extracellular matrix.,
In this study, the procedure of percutaneous drilling of lateral humeral epicondyle and injection of PRP is an acceptable alternative to other methods with many advantages and less complications. The injured tendon heals notoriously slowly. The blood platelets attract healing growth factors. Furthermore, drilling of lateral humeral condyle brings platelets from local bleeding. Furthermore, drilling of the lateral humeral epicondyle may relieve pain. The idea of pain relief with drilling may be due to decreasing both intraosseous pressure and bone marrow edema. As regards the final results, excellent outcomes were obtained in 18 patients (72%), and good outcomes were obtained in 4 patients (16%). The poor results obtained in 3 patients (12%) and did not feel any improvement of pain and underwent surgery. As regards the results, there was significant improvement of the results after combining percutaneous drilling of lateral humeral epicondyle and local injection of PRP, and the poor results decreased also in a significant manner. This technique was effective in resolving chronic elbow pain. The patients were able to return normal activities by 4–12 weeks postoperatively. The incision in our study being a minimal incision, approximately 3 mm in length with good healing. In this study, we reported 88% good-to-excellent relief in 22/25 patients who underwent percutaneous drilling of lateral humeral epicondyle and PRP injection which is comparable to other studies. Furthermore, the elbow pain was relieved early within an average of 5 weeks after the procedure (range: 3–8 weeks). All patients with excellent or good results returned to their former occupations or activities. No patients were dissatisfied with the incision scar. In our study, significant results were observed when VAS was compared before and after injection (P < 0.003); 88% patients had a decrease in VAS score (>50%). Furthermore, the results in this study were better than to those described by Mishra and Pavelko and who reported in their study a significant improvement of pain after 8 weeks in 60% of the patients treated with PRP injection. At the end of 12 months, patients treated with PRP and drilling noted 88% improvement in their VAS pain scores (P = 0.0001). In comparison to open and percutaneous techniques, Das and Maffulli in their study of open release of extensor tendon, 75% of the patients had excellent or good results and 73% of them were satisfied with the results of surgery. Baumgard and Schwartz, using percutaneous release of extensor origin, have reported excellent results in 32 (91.42%) and poor results in 3 (8.57%) out of 35 patients. Grundberg and Dobson claim good and excellent result in 29 out of 30 elbows (96.66%), by releasing the extensor origin using percutaneous method.
| Conclusions|| |
In this new technique, the combining of the percutaneous drilling of lateral humeral epicondyle and local injection of PRP in resistant tennis elbow improved significantly the results and considered comparable favorably with other techniques. It is a relatively short, simple, safe procedure, and it is not associated with serious complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin Orthop Relat Res 1992;278:73-80.
Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med 1979;7:234-8.
Boyd HB, McLeod AC Jr. Tennis elbow. J Bone Joint Surg Am 1973;55:1183-7.
Posch JN, Goldberg VM, Larrey R. Extensor fasciotomy for tennis elbow: A long-term follow-up study. Clin Orthop Relat Res 1978;135:179-82.
Bosworth DM. Surgical treatment of tennis elbow; a follow-up study. J Bone Joint Surg Am 1965;47:1533-6.
Rosen MJ, Duffy FP, Miller EH, Kremchek EJ. Tennis elbow syndrome: Results of the “lateral release” procedure. Ohio State Med J 1980;76:103-9.
Geaney LE, Arciero RA, DeBerardino TM, Mazzocca AD. The effects of platelet-rich plasma on tendon and ligament: Basic science and clinical application. Oper Tech Sports Med 2011;19:160-4.
Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: Implications for wound healing. Plast Reconstr Surg 2004;114:1502-8.
Everts PA, Knape JT, Weibrich G, Schönberger JP, Hoffmann J, Overdevest EP, et al.
Platelet-rich plasma and platelet gel: A review. J Extra Corpor Technol 2006;38:174-87.
Weibrich G, Kleis WK, Hafner G, Hitzler WE. Growth factor levels in platelet-rich plasma and correlations with donor age, sex, and platelet count. J Craniomaxillofac Surg 2002;30:97-102.
Landesberg R, Roy M, Glickman RS. Quantification of growth factor levels using a simplified method of platelet-rich plasma gel preparation. J Oral Maxillofac Surg 2000;58:297-300.
Grundberg AB, Dobson JF. Percutaneous release of the common extensor origin for tennis elbow. Clin Orthop Relat Res 2000;376:137-40.
Aspenberg P, Virchenko O. Platelet concentrate injection improves Achilles tendon repair in rats. Acta Orthop Scand 2004;75:93-9.
Sánchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants 2003;18:93-103.
Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34:1774-8.
Das D, Maffulli N. Surgical management of tennis elbow. J Sports Med Phys Fitness 2002;42:190-7.
Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. J Sports Med 1982;10:233-6.