Nirschl surgical technique shows long-term success

By Elaine Fiedler

Although most people respond well to nonoperative treatment of lateral epicondylitis (tennis elbow), some experience chronic symptoms and persistent pain. In such cases, surgery is often recommended. A 10- to 14-year follow-up of patients who were treated with the mini-open Nirschl surgical technique found excellent long-term results, according to the authors of Paper 078.

Lateral elbow tendinosis exposure of ECRB. The ECRL is elevated with a skin hook revealing the angiofibroblastic tendinosis of the underlying ECRB tendon.

Figure 4b. Resection of angiofibroblastic tendinosis of the ECRB tendon. Note the pathologic tissue displayed on the wound superficially. Also, there is no retraction of the ECRB after tendinosis resection due to retained additional attachments of the tendon.

The Nirschl technique, first introduced in 1979, focuses on resection of the tendinosis tissue within the extensor carpi radialis brevis tendon and anatomic repair of the normal tissues. Short-term results of this procedure have been reported as good-to-excellent in 85 percent of the cases, with an overall improvement rate of 98 percent. However, no long-term results on any technique have been published to date.

In a retrospective review of 139 consecutive surgical procedures performed by the senior author (RPN) between 1991 and 1994, the authors found 83 patients (92 elbows) who were available by telephone. The average follow-up was 12.6 years (range: 10 to 14 years). Retrospectively collected outcome measures included the visual analog pain scale (VAS), tennis elbow specific scoring systems (Nirschl and modified Veerhar), and the American Shoulder and Elbow Surgeons (ASES) elbow form.

The study group had an average age at the time of surgery of 46 years (range: 23 to 70 years) and included 48 males and 44 females. Eighty-seven primary procedures and five revision tennis elbow surgeries were performed during the study period. Thirty patients also had concomitant procedures including ulnar nerve release, medial tennis elbow procedures, shoulder arthroscopy, carpal tunnel release, and triceps debridement and osteophyte excision.

The average duration of preoperative symptoms was 2.1 years (range: six months to 10 years). The average Nirschl tennis elbow score improved from 23.0 to 71.0, and the average ASES score improved from 34.3 to 87.7 at a minimum of 10-year follow-up (p<0.001). The VAS pain scale improved from 8.4 preoperatively to 2.1 postoperatively (p<0.001). The overall improvement rate was 97 percent, and patient satisfaction averaged 8.9 out of 10.

Although this retrospective study lacked a control group and relied on subjective reports of final range of motion and grip strength, the authors note that the outcome measures used did not rely on preoperative assessments and, as reported in other studies, “postoperative collection of preoperative tennis elbow symptoms…most accurately represent the overall improvement at the time of follow-up.”

The authors included Jonathan Dunn, MD of Baltimore; John J. Kim, MD, of Manassas, Va.; and Lonnie D. Davis, MD; Eric J. Guidi, MD; Patrick St. Pierre, MD; and Robert P. Nirschl, MD, MS, all of Arlington, Va. Dr. Nirschl is a consultant in the design of the Count’R Force braces for Medical Sports, Inc.

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