EVIDENCE-BASED APPROACH

1. Vaikunthan Rajaratnam1
1Hand and Reconstructive Microsurgery Service,
Department of Orthopaedic Surgery, KTPH
Operations I no longer do
Surgery for lateral epicondylitis

2. Village of Yishun,
Singapore

4. Operative
technique
 Majority day case under Bier`s block.
 Av tourniquet time was 30 minutes.
 longitudinal incision over the lateral epicondyle,
common extensor origin released & the radio
capitellar joint was exposed. Any hypertrophic
fold of synovium was excised if found & the
posterior interosseus nerve explored and
decompressed if necessary.
 Degenerative extensor origin was found in nearly
70% of patients whereas Posterior interosseus
nerve compression & an inflamed elbow was
found in 11% & 27% respectively.
 Postoperatively the patients were advised elbow
movements after the first change of dressing i.e
one week.

5. Materials & Methods
 Retrospective between May 2002 &
August 2005.
 symptoms for more than one year before
surgery
 Operated by single surgeon using
modified Boyd approach
 Notes review and Postal Questionnaire
 range of follow up was - 3 & 24 months
(Average:14.5 months).
Dharmarajan R, Harun Y, Pynsent P B , Rajaratnam V
Royal Orthopaedic Hospital, Birmingham
United Kingdom

6.  35 patients (39 cases as four patients had surgery to both
elbows) who had surgical treatment for tennis elbow)
 25 male & 14 female patients
 average age 44.4 years
 All had conservative treatment - splinting, physiotherapy or
injection.
 Surgery only after prolonged conservative treatment - avg 12
months

7. Questionnaire
A little about yourself:
 Name:
 Date of birth:
 Sex:
 Dominant hand:
 Hand affected
 Date that this questionnaire was filled in:
 Date of your surgery:
 Have you ever broken / had fractures of the elbow requiring plaster of Paris or an
operation?
 Are you a smoker?
 Occupation:
 Do you work?
 If yes, does your work require frequent bending / straightening of the elbow?
 Before the operation:
Did you have any of the following symptoms:
 Pain
 Tingling
 Numbness
 Weakness
 Wake you at night
 Dropping items
 Pain on lifting
 Pain on twisting movements
 Time off work / normal activities
 Duration of symptoms prior to surgery:
< 3months 4-12 months >12 months
 Did your symptoms stop you from your usual daily activities?
 Did you have any non-surgical treatment?
Injection , Physiotherapy , Elbow clasp or other treatment
During the last 2 weeks……
Please describe your symptoms now as compared to before the operation:
Better Same Worse
 Pain
 Tingling
 Numbness
 Weakness
 Wake you at night
 Dropping items
 Pain on lifting
 Pain on twisting movements
During the last 2 weeks…..
 How severe is the pain that you have been having?
None Mild Moderate Severe
 Do you have pain during the daytime?
 If yes, How often do you have pain during day time?
1-2 3-5 >5 times pain is constant
 Do you have pain at night?
 How often does the pain wake you during a typical night in the last 2 weeks?
0 1 2 -3 times 4-5 > 5
 Have the symptoms recurred in the same arm?
 Have the symptoms developed in the other arm?
 Would you have the surgery again if you needed it?
 If you work, (please answer the following 2 statements)
 Have you been back since the operation?
 If you are back at work, Is the work activity increased, same or different?

8. 0
5
10
15
20
25
Better Same Worse
Pain at rest Numbness
Weakness Waking up at night
Dropping things Pain on carrying
Pain on twisting

9. 75%
25%
Return to work
Did not return to work

10. 50%
30%
20%
Same Different Increased
70% of patients did the same or increased work

11. Reflection
 Only 50% of the patients who had pain on carrying things
felt better after surgery
 39% had recurrence of symptoms
 27% developed symptoms in the opposite arm
Conjectures and Refutations: The Growth of Scientific Knowledge, science philosopher Karl Popper wrote:
“Refutations have often been regarded as establishing the failure of a scientist, or at least of his theory. It
should be stressed that this is an inductivist error. Every refutation should be regarded as a
great success. … Even if a new theory … should meet an early death, it should not be forgotten;
rather its beauty should be remembered, and history should record our gratitude to it.”

12. Surgery for lateral elbow pain
Cochrane Database
 Insufficient evidence to support or refute the
effectiveness of surgery
 191 participants** with persistent symptoms of at least five
months duration and failed conservative
 Meta-analysis was precluded due to differing comparator
groups and outcome measures
Buchbinder R, Johnston RV, Barnsley L, Assendelft WJJ, Bell SN, Smidt N.
Surgery for lateral elbow pain.
Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD003525.
** 20% could have been added to this Cochrane database if our paper was published

13. Open, Arthroscopic, and Percutaneous
Surgical Treatment
Burn, M.B., Mitchell, R.J., Liberman, S.R., Lintner, D.M., Harris, J.D., McCulloch, P.C., 2017. Open,
Arthroscopic, and Percutaneous Surgical Treatment of Lateral Epicondylitis: A Systematic Review.
Hand (N Y) 1558944717701244.
no clinically significant differences between the 3 surgical techniques (open, arthroscopic, and
percutaneous) in terms of functional outcome (DASH), pain intensity (VAS), and patient satisfaction at
1-year follow-up

14. Transcatheter arterial embolization of abnormal vessels - for
lateral epicondylitis
A radial artery puncture was performed, and a 3F angiographic catheter was inserted intra-arterially toward
the target lesion. Digital subtraction angiography of the brachial artery proceeded with the injection of 3 to
5 mL of contrast medium. Then, we examined the radial recurrent artery, interosseous recurrent artery, and
radial collateral artery in all patients. After the abnormal vessels were localized, a microcatheter (was
inserted coaxially through the 3F catheter and was selectively placed in the targeted arteries to infuse
embolic materials. Abnormal vessels were characterized as having a “tumor blush”–type enhancement
that appeared at the arterial phase and often accompanied early venous drainage. We used imipenem–
cilastatin sodium (IPM-CS) as an embolic material.
• statistically significant (P < .001) change from baseline to the last observed value in all of the
clinical parameters,
• an improvement in tendinosis and tear scores compared with baseline, and no patients showed
bone marrow necrosis, obvious cartilage loss, or muscle atrophy
Iwamoto, W., Okuno, Y., Matsumura, N., Kaneko, T., Ikegami, H., 2017.
Transcatheter arterial embolization of abnormal vessels as a treatment for
lateral epicondylitis refractory to conservative treatment: a pilot study with a 2-
year follow-up. J Shoulder Elbow Surg 26, 1335–1341.

15. Uygur, E., Aktaş, B., Özkut, A., Erinç, S., Yilmazoglu, E.G., 2017. Dry needling in lateral epicondylitis: a
prospective controlled study. Int Orthop.
110 patients into groups using online randomization software. After completing the Patient-
rated Tennis Elbow Evaluation (PRTEE), patients in group I received dry needling, whereas those
in group II received first-line treatment, consisting of ibuprofen 100 mg twice a day and a proximal
forearm brace
dry needling is a safe method, and it might be an effective treatment option for LE
Hsieh, L.-F., Kuo, Y.-C., Lee, C.-C., Liu, Y.-F., Liu, Y.-C., Huang, V., 2017. Comparison Between
Corticosteroid and Lidocaine Injection in the Treatment of Tennis Elbow: A Randomized, Double-
Blinded, Controlled Trial. Am J Phys Med Rehabil.
70 patients were recruited, and 61 patients completed the study. Patients received an injection of
either 10 mg (1 ml) of triamcinolone (corticosteroid group, n = 30) or 1 ml of 1% lidocaine (lidocaine
group, n = 31).
No differences in the short-term outcomes were found between lidocaine and
corticosteroid injection

17. vaikunthan@gmail.com