Obere Extremitäten. Epicondylitis. a chronic headache for patients and their doctors. Michael Glanzmann

Transkript

1 Epicondylitis a chronic headache for patients and their doctors Michael Glanzmann

2 Anatomie: Extensoren Gruppe Bedeutend für radiale, insbesondere die posterolaterale Rotationsstabilität des Ellbogengelenkes

3 Demographisches 4 7 pro 1000 pro Jahr 1 3% der Bevölkerung übers Leben Peak zwischen LJ Medial : lateral 1:3 Male : women 4:1 Mit Abstand das häufigste Ellbogenleiden

4 Medial epicondylitis Ueberbeanspruchung der flexor/pronator Einheit Werfer (pitchers) Microrupturen zwischen pronator teres and FCR Oft verbunden mit ulnarer Neuritis

5 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 2 nd ed Philadelphia, pp

6 Obere Extremitäten Clinical tests: lateral epicondylitis Cozen and Maudsley tests

7 Management Non-operative successful in 95% Operative only after failed non-operative treatment usually successful

8 Non-operative options Obere Extremitäten 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 noncoherent light Pulsed electromagnetic field Rx Rest Splinting Steroid injection Taping TENS Topical NSAID gel Ultrasound

9 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): 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

10 Physiotherapy Obere Extremitäten 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): Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Smidt N. Lancet 2002;359:

11 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 Obere Extremitäten 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

12 Non-operative options Obere Extremitäten 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 noncoherent light Pulsed electromagnetic field Rx Rest Splinting Steroid injection Taping TENS Topical NSAID gel Ultrasound

13 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

14 Vom Vollblut zu den Wachstumsfaktoren Sedimentationsrate = (Durchmesser) ² Rote BK: 7² = 49 Plättchen: 2² = 4

15 Platelet-rich plasma IGF-1 TGF-β Inflammationsphase VEGF PDGF bfgf EGF Proliferationsphase Molloy et al, Sports Medicine, 2003;33(5);381-94

16 Wann macht PRP/ACP Sinn? Bei subakuten und chronischen muskuloskelettalen Problemen Tendinopathien (degenerativer Schaden) Bänderzerrung (beschleunigte Bandheilung) Muskelzerrung Knorpelschaden/Arthrose Diskopathien, Radikulopathien

17 Wann ist PRP/ACP Unsinn? Kontraindikationen Störung der Thrombozyten Infektionen Kortison Infiltration < 1 Monat Perorale Kortison Therapie < 2 Wochen NSAR < 48h

18 ACP : Schulmedizinische Evidenz 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%

19 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

20 Operative options Open release Arthroscopic release Percutaneous release/microtenotomy

21 Lateral Epicondylitis Obere Extremitäten JBJS 1979 Sep;61(6A): Tennis elbow. The surgical treatment of lateral epicondylitis.

22 Lateral Epicondylitis Obere Extremitäten 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!

23 Lateral Epicondylitis Obere Extremitäten Hohmann: Quer-Einkerbung d. Extensoren-Sehnenspiegels Wilhelm: Denervation Goldie: Längssplittung des Sehnenspiegels

24 Open Lateral Epicondylitis Outcomes 85-90% return to FULL activities 10% have some pain 2% do not improve 10 year experience success rate 95% Failures due to Incomplete resection of pathologic tissue Poor soft tissue undetected/iatrogenic posterolateral rotatory instability

25 Open release Obere Extremitäten 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): The surgical treatment of chronic lateral humeral epicondylitis by common extensor release. Goldberg E et al. Clin Orthop 1998;Aug(233): 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

26 Percutaneous release Obere Extremitäten 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): 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

27 Arthroscopy Obere Extremitäten 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

28 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: Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin Orthop 1992;278:73 80.

29 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

30 Danke für die Aufmerksamkeit Obere Extremitäten