The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Multiple Perforations of the ECRB Tendon Using an Innovative Standardized, Reproducible Technique; A Cadaveric Study on Accuracy and Prospective Clinical Safety Assessment Pilot Study. No Adverse Effects in the First 122 Patients with Lateral Epicondylitis

Document Type : RESEARCH PAPER

Authors
Renée Keijsers 1
Bart Ten Brinke 1
Laurens J. De Haan 1
Ronald L.A.W. Bleys 2
Michel P.J. van den Bekerom 3
1 Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
2 Department of Anatomy, University Medical Center Utrecht, the Netherlands
3 3 Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands 4 Department of Human Movement Sciences, Vrije Universiteit Amsterdam, the Netherlands
10.22038/abjs.2021.48405.2396
Abstract
Background: In LE (Lateral Epicondylitis) otherwise known as Tennis Elbow, the Extensor Carpi Radialis Brevis 
(ECRB) tendon is most commonly involved. In the majority of studies, injections are performed with a lack of 
standardization. The Instant Tennis Elbow Cure (ITEC) device has been developed to perform reproducible and 
standardized perforations by multiple needles. The goal of this pilot study was to estimate the accuracy of this ITEC 
device by means of a cadaveric study and to assess the clinical safety of this procedure. 
Methods: Ten cadaveric arms were injected using the ITEC device. The location and depth of the ECRB tendon was 
measured by ultrasound imaging. The accuracy of the infiltration was assessed by locating the injected dye through 
dissection and arthrotomy of the cadaveric elbow. 
A prospective clinical pilot study was conducted to assess the safety of the ITEC device in treating patients with chronic 
LE. An optional infiltration with an injection fluid was carried out?? Primary outcome measures were side effects and 
complications of the ITEC device occurring within a follow up period of 8 weeks after treatment.
Results: In all cadaveric elbows the injection fluid ( in this case an injection fluid) was located at the ECRB tendon. In 
one cadaver, a minimal amount of dye was found intra-articular and in 3 cadavers a small quantity was located in the 
surrounding tissue of the ECRB tendon. 122 patients with LE were treated with the ITEC device. No adverse effects or 
complications were reported at 8-week follow up. 
Conclusion: Treatment of LE using the ITEC device appears accurate and safe. It may improve future research since 
it is reproducible and it can be performed in a standardized way. 
Level of evidence: IV
Keywords
Cadaver study
Injection therapy
Lateral epicondylitis
Pilot study
Tennis elbow
  1. Keijsers R, de Vos RJ, Kuijer PPF, van den Bekerom MP, van der Woude HJ, Eygendaal D. Tennis Elbow. Shoulder Elbow. 2019: 11(5):384-392.
  2. Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006: 164(11):1065-74.
  3. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999: 81(2):259-78
  4. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010: 30(1):167-84.
  5. Regan W, Wold LE, Coonrad R, Morrey BF. Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med. 1992: 20(6):746-9.
  6. Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. Br J Sports Med, 2009. 43(4):252-8.
  7. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005:39(7):411-22.
  8. Branson R, Naidu K, du Toit C, Rotstein AH, Kiss R, McMillan D, et al. Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow. J Sci Med Sport. 2017:20(6):528-533.
  9. Creuzé A, Petit H, de Sèze M. Short-Term Effect of Low-Dose, Electromyography-Guided Botulinum Toxin A Injection in the Treatment of Chronic Lateral Epicondylar Tendinopathy: A Randomized, Double-Blinded Study. J Bone Joint Surg Am. 2018:100(10):818-826.
  10. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009:68(12):1843-9.
  11. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999: 319(7215):964-8.
  12. Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013: 41(6):1435-46.
  13. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013:41(3):625-35.
  14. Omar AS, Ibrahim ME, Ahmed AS, M Said. Local injection of autologous platelet rich plasma and corticosteroid in treatment of lateral epicondylitis and plantar fasciitis: randomized clinical trial. Egypt Rheumatol. 2012:34(2):43–9.
  15. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010:38(2):255–62.
  16. Sims SE, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (NY). 2014:9(4):419-46.
  17. Smidt N, Lewis M, Van der Windt DA, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006:33(10):2053-2059.
  18. Qian X, Lin Q, Wei K, Hu B, Jing P, Wang J. Efficacy and Safety of Autologous Blood Products Compared With Corticosteroid Injections in the Treatment of Lateral Epicondylitis: A Meta-Analysis of Randomized Controlled Trials. PM R. 2016:8(8):780-91.
  19. Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi A. Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. Am J Phys Med Rehabil.
  20. Ozturan KE, Yucel I, Cakici H, Guven M, Sungur I. Autologous blood and corticosteroid injection and extracoporeal shock wave therapy in the treatment of lateral epicondylitis. Orthopedics. 2010:33(2):84-91.
  21. Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am. 2011:36(8):1269-72.
  22. Dojode CM. A randomised control trial to evaluate the efficacy of autologous blood injection versus local corticosteroid injection for treatment of lateral epicondylitis. Bone Joint Res. 2012:1(8):192-7.
  23. Jindal N, Gaury Y, Banshiwal RC, Lamoria R, Bachhal V. Comparison of short term results of single injection of autologous blood and steroid injection in tennis elbow: a prospective study. J Orthop Surg Res. 2013:8(10).
  24. Arik HO, Kose O, Guler F, Deniz G, Egerci OF, Ucar M. Injection of autologous blood versus corticosteroid for lateral epicondylitis: a randomised controlled study. J Orthop Surg (Hong Kong). 2014:22(3):333-7.
  25. Gautam VK, Verma S, Batra S, Bhatnagar N, Arora S. Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation. J Orthop Surg (Hong Kong). 2015:23(1):1-5.
  26. Keijsers R, van den Bekerom MPJ, Koenraadt KLM, Bleys RLAW, van Dijk CN, Eygendaal D, et al. Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy. Knee Surg Sports Traumatol Arthrosc. 2017:25(7):2289-2292.
  27. Bunata RE, Brown DS, Capelo R. Anatomic factors related to the cause of tennis elbow. J Bone Joint Surg Am. 2007:89(9):1955-63.
  28. Cohen MS, Romeo AA, Hennigan SP, Gordon M. Lateral epicondylitis: anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment. J Shoulder Elbow Surg. 2008:17(6):954-60.
  29. Krogh TP, Fredberg U, Christensen R, Stengaard-Pedersen K, Ellingsen T. Ultrasonographic assessment of tendon thickness, Doppler activity and bony spurs of the elbow in patients with lateral epicondylitis and healthy subjects: a reliability and agreement study. Ultraschall Med. 2013:34(5):468-74.
  30. Nimura A, Fujishiro H, Wakabayashi Y, Imatani J, Sugaya H, Akita K. Joint capsule attachment to the extensor carpi radialis brevis origin: an anatomical study with possible implications regarding the etiology of lateral epicondylitis. J Hand Surg Am. 2014:39(2):219-25.
  31. Keijsers R, Koenraadt KLM, Turkenburg JL, Beumer A, The B, Eygendaal D. Ultrasound Measurements of the ECRB Tendon Shows Remarkable Variations in Patients with Lateral Epicondylitis. The Archives of Bone and Joint Surgery, 2020: 8(2):168-172.
  32. Evans JP, Metz J, Anaspure R, Thomas WJ, King A, Goodwin VA, et al. The spread of Injectate after ultrasound-guided lateral elbow injection - a cadaveric study. J Exp Orthop. 2018:5(1):27.

 

The Archives of Bone and Joint Surgery
Volume 10, Issue 5
May 2022
Pages 413-419

  • Receive Date 28 May 2020
  • Revise Date 29 August 2021
  • Accept Date 06 October 2021