顽固性肱骨外上髁炎的外科治疗

目的探讨顽固性肱骨外上髁炎的手术治疗效果。方法2007年1月至2009年12月,我科采用局部麻醉下Nirschl改良手术治疗顽固性肱骨外上髁炎21例,术后通过VAS疼痛评分和Nirschl＆Pettrone分级评估患肘疼痛和功能改善情况。结果21例患者平均随访时问23．6个月。VAS疼痛评分术前休息时为6．21,日常活动时7．10,体育活动时8．76;术后休息时为0．83,日常活动时1．46,体育活动时2．22。术前、术后两者比较差异均有统计学意义。术后Nirschl＆Pettrone肘关节功能分级优13例,良7例,中1例,优良率95．2％。1例患者术后出现肘关节囊壁破裂后关节滑液积聚形成的皮下囊性肿胀,局部麻醉下行关节囊修复后肿胀消失。结论外科治疗顽固性肱骨外上髁炎可以有效改善肘关节疼痛和恢复关节活动,手术效果好。     

Prospective Evaluation of the Effectiveness of a Home-Based Program of Isometric Strengthening Exercises: 12-Month Follow-up

Background

The aim of this prospective randomized clinical trial was to investigate the efficacy of a home-based program of isometric strengthening exercises for the treatment of the lateral epicondylitis (LE) of the distal humerus. We hypothesized that 1) use of isometric strengthening exercises would result in clinical benefits similar to those provided by medication and pain relief and 2) functional improvements after exercise would be time-dependent.

Methods

Patients were assigned to one of two groups: 1) an immediate physical therapy group (group I), or 2) a delayed physical therapy group (group D). Group I patients (n = 16) were instructed how to do the exercises at their first clinic visit and immediately carried out the exercise program. Group D patients (n = 15) learned and did the exercises after being on medications for 4 weeks.

Results

Outcomes at the 1-month clinic visit indicated that pain (measured using a visual analogue scale [VAS]) had been significantly reduced in group I compared to group D (p < 0.01). However, significant differences between groups were not found at 3-, 6-, and 12-month follow-up for either VAS scores or Mayo elbow performance scores. For modified Nirschl/Pettrone scores, a significant difference between groups was found only at the 1-month follow-up visit. By then, the number of participants who returned to all activities with no pain or occasional mild pain was six (37%) in Group I and two (13%) in Group D (p = 0.031). At the final follow-up visit, 88% of all participants performed physical activities without pain.

Conclusions

Isometric strengthening exercises done early in the course of LE (within 4 weeks) provides a clinically significant improvement.     

Platelet rich plasma versus laser therapy in lateral epicondylitis of elbow

Background:

Platelet rich plasma (PRP) extract has shown to be a general stimulation for repair and currently used widely in various sports injury. A prospective observational study was done to assess the efficacy of autologous PRP injection in lateral epicondylitis of elbow, and compare the result with low level laser therapy.

Materials and Methods:

The trial was conducted at a tertiary care center for a period of 2 years. Eighty-one patients with chronic lateral epicondylitis were divided into two groups. PRP group (n = 39) and laser therapy group (n = 42). The primary analysis included Nirschl pain score, local tenderness, pain on wrist extension, grip strength, elbow swelling were clinically assessed at different interval of followup (minimum followup: 52 weeks) and; clinical and functional outcome evaluated at final followup. The statistical analysis were done.

Results:

The mean Nirschl pain score decreased significantly from baseline in PRP when compared with low level laser therapy (P ≤ 0.05).

Conclusions:

Treatment of patients with chronic lateral epicondylitis with PRP extract reduced pain and significantly increased function, exceeding the effect of low level laser therapy on long term followup. Low-level laser therapy is better in the short term period, but on long term followup injection PRP therapy is better than laser therapy in lateral epicondylitis.     

Comparison of Clinical Outcomes of Platelet-Rich Plasma for Epicondylitis,Elbow: Simultaneous Lateral and Medial Versus Lateral Versus Medial

Objective

Lateral and medial epicondylitis are relatively common diseases, but they do not improve quickly and are known to reduce patients' quality of life. Much research has been done on Platelet-Rich Plasma (PRP) as a treatment for lateral epicondylitis, but research on medial epicondylitis is lacking. The purpose of this study is to compare: (i) the pain intensity; and (ii) the functional outcome between the simultaneous treatment of medial and lateral epicondylitis and the treatment of only lateral or medial epicondylitis using PRP.

Methods

In this retrospective study, 209 patients treated with PRP on epicondylitis between March 2018 and December 2021 were enrolled. Simultaneous treatment was underwent 68 patients (group I). Seventy patients were treated for lateral epicondylitis (group II). The remaining 71 patients were treated for medial epicondylitis (group III). The visual analogue scale for pain (VAS) and the Mayo elbow performance score (MEPS) were evaluated for clinical outcomes at the initial visit and 6 months after injection.

Results

VAS for pain and MEPS showed significant improvement in all three groups compared to before treatment. There was no significant difference between three groups on –ΔVAS (P > 0.05). However, in case of ΔMEPS, group III showed significantly lower compared to groups II and III (P < 0.05). No patients showed worsening of symptoms or complications during the treatment.

Conclusion

PRP injection for the patient with elbow medial and lateral epicondylitis can be treated effectively simultaneously in terms of pain. From a functional point of view, the effect of simultaneous treatment may be lessened than in the case of only lateral and medial treatment.     

Evaluation of pain in bilateral total knee replacement with and without tourniquet; a?prospective randomized control trial

Aim

Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty.

Method

Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014. Patient thigh pain was evaluated with the VAS score. The scale was applied on first, second, third day & second and six weeks after surgery.

Result

There were statistically significant difference in VAS score in non-tourniquet group on first, second, third post operative day. We did not find statistically significant difference at Second and Six weeks post operatively.

Conclusion

This Randomized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery.     

Does the quality,accuracy, and readability of information about lateral epicondylitis on the internet vary with the search term used?

Background

Concern exists over the quality, accuracy, and accessibility of online information about health care conditions. The goal of this study is to evaluate the quality, accuracy, and readability of information available on the internet about lateral epicondylitis.

Methods

We used three different search terms (“tennis elbow,” “lateral epicondylitis,” and “elbow pain”) in three search engines (Google, Bing, and Yahoo) to generate a list of 75 unique websites. Three orthopedic surgeons reviewed the content of each website and assessed the quality and accuracy of information. We assessed each website’s readability using the Flesch–Kincaid method. Statistical comparisons were made using ANOVA with post hoc pairwise comparisons.

Results

The mean reading grade level was 11.1. None of the sites were under the recommended sixth grade reading level for the general public. Higher quality information was found when using the terms “tennis elbow” and “lateral epicondylitis” compared to “elbow pain” (p < 0.001). Specialty society websites had higher quality than all other websites (p < 0.001). The information was more accurate if the website was authored by a health care provider when compared to non-health care providers (p = 0.003). Websites seeking commercial gain and those found after the first five search results had lower quality information.

Conclusions

Reliable information about lateral epicondylitis is available online, especially from specialty societies. However, the quality and accuracy of information vary significantly with the search term, website author, and order of search results. This leaves less educated patients at a disadvantage, particularly because the information we encountered is above the reading level recommended for the general public.     

Modic type I changes and recovery of back pain after lumbar microdiscectomy

Purpose

To investigate whether the presence of Modic changes type I (MC I) found on preoperative MRI scans represent a risk factor for persistent back pain 12 months after surgery amongst patients operated for lumbar disc herniation.

Methods

Cohort study of 178 consecutive patients operated with lumbar microdiscectomy. Preoperative MRI scans were evaluated by two independent neuroradiologists. Primary outcome measure was the visual analogue scale (VAS) for back pain. Secondary outcome measures were; VAS for leg pain, physical function (Oswestry Disability Index), and health-related quality of life (EQ-5D), self-reported benefit of the operation and employment status. The presence of MC I was used as exposition variable and adjusted for other risk factors in multivariate analyses.

Results

The Modic classification showed a high inter-observer reproducibility. Patients with MC I had less improvement of back pain 12 months after surgery, compared to those who had no or other types of MC, but this negative association no longer showed statistical significance when adjusted for smoking, which remained the only independent risk factor for persistent back pain.

Conclusions

Patients with preoperative MC I can expect less but still significant improvement of back pain 1 year after microdiscectomy, but not if they smoke cigarettes.     

The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Purpose:

To determine the effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities.

Methods:

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1, 1990 to March 14, 2015. Paired reviewers independently screened titles and abstracts for eligibility. The internal validity of studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Results from studies with a low risk of bias were synthesized using the best-evidence synthesis methodology.

Results:

We identified two randomized trials with a low risk of bias. Our review suggests that: 1) multimodal care and corticosteroid injections lead to faster pain relief and improvement than reassurance and advice in the short-term and similar outcomes in the long-term for patients with persistent lateral epicondylitis; and 2) providing health education material alone may be less effective than multimodal care for the management of persistent patellofemoral pain syndrome.

Conclusion:

Our systematic search of the literature demonstrates that little is known about the effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities. Two studies suggest that when used alone, structured patient education may be less effective than other interventions used to manage persistent lateral epicondylitis and persistent patellofemoral syndrome.     

Mini-Open Suture Bridge Repair with Porcine Dermal Patch Augmentation for Massive Rotator Cuff Tear: Surgical Technique and Preliminary Results

Background

The aim of this study was to describe the mini-open suture bridge technique with porcine dermal patch augmentation for massive rotator cuff tear and to assess preliminary clinical and radiological results.

Methods

Five patients with massive rotator cuff tear for which it was not possible to restore the anatomical footprint underwent mini-open suture bridge repair using a porcine dermal patch. The patients'' average age was 53.4 years (range, 45 to 57 years), and the average duration of follow-up was 20.6 months (range, 14 to 26 months). Patients were evaluated with preoperative and postoperative outcome measures, including a visual analog scale (VAS) for pain, the University of California Los Angeles (UCLA) score, and the American Shoulder and Elbow Surgeons (ASES) score. The structural integrity of repaired rotator cuffs was assessed by magnetic resonance imaging 6 months postoperatively.

Results

The average VAS pain score, UCLA score, and ASES score improved from 6.8, 15.4, and 39.4 preoperatively to 0.8, 31.2, and 86.4 postoperatively (p = 0.041, 0.042, and 0.043, respectively). Magnetic resonance images obtained at an average of 8 months after surgery showed that four patients had intact repair integrity with graft incorporation. One patient had a re-tear with partial healing but still had a satisfactory clinical outcome. There was no intraoperative or postoperative complication in any patient.

Conclusions

Mini-open suture bridge repair with porcine dermal patch augmentation can be an option in young patients with high physical demands and massive rotator cuff tears for which it is not possible to restore the anatomical footprint.     

Impairment assessment of lateral epicondylitis through electromyography and dynamometry

Objectives:

To investigate changes in muscular activity and strength of subjects diagnosed with lateral epicondylitis (LE). To assess the appropriateness of these measures in the patient’s follow-up.

Methods:

Twenty-four subjects (11 men and 13 women) with LE, were evaluated at baseline and after 5 weeks of an experimental treatment. Measurements included: the (1) pain-free grip (PFG), (2) maximal isometric strength, (3) surface electromyography (EMG) of forearm muscle (healthy and affected), (4) a visual analogue scale (VAS), and (5) the Patient Rated Tennis Elbow Evaluation (PRTEE) (Canadian-French version).

Results:

All subjects showed improvement in VAS and PRTEE. The maximal isometric strength during flexion and extension of the wrist and the EMG analysis failed to discriminate the affected from the healthy elbow during the initial assessment. Only the PFG measured with the elbow in extension could discriminate elbows with LE from the healthy ones.

Conclusions:

The use of the PFG with the elbow in extension seems to be the most indicated strength measurement to monitor the recovery of patients with LE. The EMG acquisition protocol used in this research was not adequate to monitor effectively the recovery of LE.     

Fractional lengthening of forearm extensors for resistant lateral epicondylitis

BACKGROUND: This study presents the surgical technique of fractional lengthening of extensor carpi radialis brevis, extensor digitorum communis and the superficial head of supinator, for chronic lateral epicondylitis. The anatomical basis for this surgical approach is reviewed. The results of surgical treatment in a consecutive series of patients with severe chronic lateral epicondylitis are reviewed. METHODS: Twenty-one elbows in 17 subjects underwent surgery. All elbows had severe resistant symptoms, unresponsive to a minimum 6 months (mean 14 months) of a non-operative treatment protocol. All elbows showed either tendonopathy or a partial tear in the common extensor tendon origin at preoperative imaging. RESULTS: All subjects were examined at a minimum of 1 year after surgery. The mean visual analogue pain (VAS) score reduced from 7.6 (maximum 10) preoperatively to 1.3 postoperatively (P<0.01). The mean preoperative ability to carry out normal work duties reduced from 4.3 (maximum 5) preoperatively to 1.5 postoperatively (P<0.01). Grip strength improved or remained equivalent following surgery. The mean VAS for patient satisfaction with surgery was 8.8 (maximum score 10). Using the Roles and Maudsley classification, 14 patients (82%) were rated good or excellent. Three subjects were rated fair or poor, were undergoing treatment for other pathology in the ipsilateral extremity and had ongoing compensation claims. CONCLUSION: Fractional lengthening of forearm extensors is effective treatment for severe and chronic lateral epicondylitis. Outcomes following fractional lengthening surgery are less predictable when other pathology in the upper extremity requires concomitant treatment.     

Do synovial leptin levels correlate with pain in end stage arthritis?

Purpose

We evaluated whether synovial fluid (SF) leptin concentrations correlate with pain severity in patients with hip or knee endstage osteoarthritis (OA) and whether they mediate the association between increased joint pain and (1) female gender and (2) obesity.

Methods

We conducted a cross-sectional study including patients with primary hip and knee OA undergoing joint replacement between January and December 2010. SF leptin concentrations obtained on the day of surgery were assessed. Main outcome was pain severity measured pre-operatively using WOMAC and VAS pain scales.

Results

A total of 219 patients were included, 123 hip and 96 knee arthroplasties. Mean age was 72 years, 59 % were women. Mean SF leptin levels were 22.9 (±25.6) ng/ml in women and 5.4 (±5.9) ng/ml in men. Levels >19.6 ng/ml (highest quartile) were significantly associated with increased pain on both WOMAC (mean difference −9.6, 95 % CI −15.1 to −4.0) and VAS scale (mean difference 0.8, 95 % CI 0.2–1.3). Associations remained unchanged after adjusting for age, co-morbidities, contra-lateral arthritic joint, OA site, and disability. The associations observed between increased pain and female gender or obesity were substantially reduced after adjusting for SF leptin.

Conclusion

Joint pain is associated with SF leptin concentrations. Increased pre-operative pain observed in women and obese may be related to high intra-articular leptin levels.     

Laparoscopic Total Extraperitoneal Repair in Femoral Hernia Without Fixation of the Mesh

Background & Objectives:

We report on laparoscopic total extraperitoneal repair without fixation of mesh for femoral hernia in 6 patients.

Methods:

During a 3-year period, laparoscopic total extraperitoneal repair of femoral hernia was performed without mesh fixation in 6 patients. The recurrence rate, pain scores, hospital stay, and other morbidity parameters were noted. Pain scores were 1=no pain, 2=mild pain, 3=moderate pain, 4=severe pain, and 5=intolerable pain.

Results:

All 6 patients were females and had unilateral hernias. Mean age was 33.8±18.6 years, and follow-up ranged from 12 months to 36 months. Four patients were operated on while under spinal anesthesia, and 2 patients were operated on while under general anesthesia. Mean operating time was 29.2±10.7 minutes. The mean pain scores 24 hours and the first week after operation were, respectively, 2.33±0.52 and 1.33±0.52. Mean hospital stay was 1.17±0.41 days, and mean days to resumption of normal activities were 8.5±2.1 days. No patient had urinary retention or seroma formation in the postoperative period. At follow-up, no hernia had recurred.

Conclusions:

Laparoscopic femoral hernia repair without fixing the mesh is safe, feasible, and associated with minimal morbidity and recurrence rates.     

Pain reduction following vertebroplasty and kyphoplasty

Purpose

To evaluate the clinical efficacy, especially the pain reduction, of vertebroplasty and balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures (OVCFs).

Methods

Eighty-six patients with OVCFs were treated with vertebroplasty or balloon kyphoplasty. All patients were followed up for seven–36 months. Visual analog scale (VAS), vertebral height, and local kyphotic angle were evaluated at pre-operation, postoperation, and final follow-up.

Results

The VAS pain score decreased significantly after surgery in both kyphoplasty and vertebroplasty groups (p < 0.001), and the improvement of VAS score had no significant difference between the two groups (p = 0.826). There was a significant difference in the improvement of vertebral height (p < 0.001) and local kyphotic angle (p < 0.001) between the two groups. Improvement of VAS score had no correlation with improvement of vertebral height (vertebroplasty: r = −0.029, p = 0.869; kyphoplasty: r = 0.175, p = 0.219) or local kyphotic angle (vertebroplasty: r = 0.159, p = 0.361; kyphoplasty: r = 0.144, p = 0.312) in either group.

Conclusion

Vertebroplasty and kyphoplasty are effective procedures for the reduction of pain in OVCFs, and they have the same efficient effect on pain reduction. Correction of vertebral height and local kyphosis may have minimal effect on pain reduction.     

Transverse Process and Needles of Medial Branch Block to Facet Joint as Landmarks for Ultrasound-Guided Selective Nerve Root Block

Background

Selective lumbar nerve root block (SNRB) is generally accepted as an effective treatment method for back pain with sciatica. However, it requires devices producing radioactive materials such as C-arm fluoroscopy. This study evaluated the usefulness of the longitudinal view of transverse process and needles for medial branch block as landmarks under ultrasonography.

Methods

We performed selective nerve root block for 96 nerve roots in 61 patients under the guidance of ultrasound. A curved probe was used to identify the facet joints and transverse processes. Identifying the lumbar nerve roots under the skin surface and ultrasound landmarks, the cephalad and caudal medial branch blocks were undertaken under the transverse view of sonogram first. A needle for nerve root block was inserted between the two transverse processes under longitudinal view, while estimating the depth with the needle for medial branch block. We then injected 1.0 mL of contrast medium and checked the distribution of the nerve root with C-arm fluoroscopy to evaluate the accuracy. The visual analog scale (VAS) was used to access the clinical results.

Results

Seven SNRBs were performed for the L2 nerve root, 15 for L3, 49 for L4, and 25 for L5, respectively. Eighty-six SNRBs (89.5%) showed successful positioning of the needles. We failed in the following cases: 1 case for the L2 nerve root; 2 for L3; 3 for L4; and 4 for L5. The failed needles were positioned at wrong leveled segments in 4 cases and inappropriate place in 6 cases. VAS was improved from 7.6 ± 0.6 to 3.5 ± 1.3 after the procedure.

Conclusions

For SNRB in lumbar spine, the transverse processes under longitudinal view as the ultrasound landmark and the needles of medial branch block to the facet joint can be a promising guidance.     

Total knee arthroplasty in elderly patients with severe Kashin-Beck disease of the knee

Purpose

The treatment of elderly KBD knee remains a significant clinical challenge, and clinical data are lacking. This study aimed to prospectively determine the functional outcomes of total knee arthroplasty (TKA) in adult patients with severe Kashin-Beck disease (KBD) of the knee.

Method

Fifteen cases that included 18 occurrences of KBD of the knee were treated by primary knee arthroplasty and followed up for at least two years. Clinical assessments for each patient were performed at time zero (pre-operatively), one, three, six and 12 months and yearly thereafter. The efficacy measures included the visual analogue scale (VAS) pain score, Hospital for Special Surgery (HSS) score, and Functional Score for Adult Tibetans with Kashin-Beck Disease (FSAT-KBD) as well as radiographic findings.

Results

All patients were followed for a mean length of 32.47±10.05 months. All force lines in the lower limbs had been improved significantly. No radiographic evidence of loosening or changes in component positioning was observed at the last follow up. The VAS decreased significantly during the first six months after surgery and was maintained until the last follow up (p < 0.01). Similar trends were found in both HSS and FSAT-KBD, which increased significantly post-operatively (p < 0.01).

Conclusion

Knee arthroplasty can reduce pain and improve function in patients with severe KBD of the knee. Additional studies will be necessary to confirm our findings.     

Precise nail tip positioning after tibial intramedullary nailing prevents anterior knee pain

Purpose

Anterior knee pain (AKP) is a common complication following intramedullary nailing of tibial shaft fractures. Our aim was, by analysing the postoperative lateral knee X-rays and clinical status (VAS score), to find the best intramedullary tip position of a non protruded nail that will provide the best postoperative outcome avoiding AKP.

Methods

We evaluated the postoperative outcome of 221 patients, from the last four years, with healed fractures initially treated with intramedullary reamed nails with two or three interlocking screws proximally and distally through a medial paratendinous incision for nail entry portal. Our aim was to analyse a possible relationship between AKP according to the VAS scale, and nail position marked as a distance from tip of nail to tibial plateau (NP) and to tibial tuberosity (NT), measured postoperatively on lateral knee X-rays.

Results

Two groups of patients were formed on the basis of presence of pain related to AKP (the level of pain was neglected): group A were patients with pain and group B without pain. The difference between the two groups concerning NP and NT measurements appeared to be statistically significant concerning NT measurement (p < 0.05), with high accuracy according to the classification tree.

Conclusions

We presume that the position of the proximal tip of the nail and its negative influence on the innervation pattern of the area dorsal to patellar tendon could be the key factor of AKP. We conclude that the symptoms of AKP will not appear if the tip of the nail position is more than 5.5 mm from the tibial plateau (NP) and more than 2.5 mm from the tibial tuberosity (NT).