Andrew G. Titchener

Risk factors in lateral epicondylitis (tennis elbow): a case-control study

Lateral epicondylitis is a common condition, but relatively little is known about its aetiology and associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and quantify the relative contributions of some constitutional and environmental risk factors for lateral epicondylitis in the community. Our dataset included 4998 patients with lateral epicondylitis who were individually matched with a single control by age, sex, and general practice. The median age at diagnosis was 49 (interquartile range 42–56) years . Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology (OR 4.95), De Quervain’s disease (OR 2.48), carpal tunnel syndrome (OR 1.50), oral corticosteroid therapy (OR 1.68), and previous smoking history (OR 1.20). Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis.

An epidemiological study of rotator cuff pathology using The Health Improvement Network database

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100,000 person-years. It was more common in women than in men (90 cases per 100,000 person-years in women and 83 per 100,000 person-years in men; p < 0.001). The highest incidence of 198 per 100,000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100,000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100,000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.

Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current UK specialist practice and a call for clinical guidelines

Background Tennis elbow is a common condition with a variety of treatment options, but little is known about which of these options specialists choose most commonly. Corticosteroid injections in tennis elbow may reduce pain in the short-term but delay long-term recovery. We have undertaken a UK-wide survey of upper limb specialists to assess current practice. Methods Cross-sectional electronic survey of current members of the British Elbow and Shoulder Society (BESS) and the British Society for Surgery of the Hand (BSSH). Results 271 of 1047 eligible members responded (25.9%); consultant surgeons constituted the largest group (232/271, 85%). 131 respondents (48%) use corticosteroid injections as their first-line treatment for tennis elbow. 206 respondents (77%) believed that corticosteroid injections are not potentially harmful in the treatment of tennis elbow, while 31 (11%) did not use them in their current practice. In light of recent evidence of the potential harmful effects of corticosteroid therapy, 136 (50%) had not changed their practice while 108 (40.1%) had reduced or discontinued their use. 43 respondents (16%) reported having used platelet-rich plasma injections. Conclusions Recent high-quality evidence that corticosteroids may delay recovery in tennis elbow appears to have had a limited effect on current practice. Treatment is not uniform among specialists and a proportion of them use platelet-rich plasma injections.

Outcome following first metatarsophalangeal joint replacement using TOEFIT-PLUS™: A mid term alert

BACKGROUND We aim to evaluate the mid-term results of first metatarsophalangeal joint replacement for hallux rigidus using Toefit-Plus™ in a single surgeon series. METHODS We prospectively studied the outcomes of 86 toes in 73 patients using the AOFAS-HMI score and radiological follow up. The mean follow up was 33 months (2-72). Ten patients have been lost to follow up. RESULTS Eight patients sustained intraoperative fractures or impending fractures requiring circlage wiring. Eighteen joints have either been revised or listed for revision giving a revision rate of 24%; this occurred at a mean of 33 months post-surgery. CONCLUSIONS First MTPJ replacement is an option in hallux rigidus and patients who are not revised experience significant improvement in AOFAS scores in the medium term. We have previously published satisfactory results with this prosthesis. However the revision rate is unacceptably high and we have discontinued its use completely. Future design evolutions should address the issue of osteointegration on the phalangeal side.

Study of lateral epicondylitis (tennis elbow) using the health improvement network database

Background Lateral epicondylitis has been studied mainly in work related and occupational groups, however little is known about the incidence or demographic associations in the general population. We have undertaken a large study using The Health Improvement Network (THIN) database to examine the epidemiology of lateral epicondylitis in the UK general population. Methods Diagnoses of lateral epicondylitis between 1987 and 2006 were used to calculate the incidence stratified by age, gender, deprivation score, UK health authority, and year. The age standardised rates for lateral epicondylitis in the UK were calculated with reference to the European Standard Population. Results The incidence rate of lateral epicondylitis was 2.45 per 1000 person-years. This was more common in males than females (males 2.63, females 2.55 per 1000 person-years, p < 0.001). After direct standardization, the age adjusted rates were 2.38 for males and 2.43 for females. The highest incidence rate of 7.35 per 1000 person-years was found in the age group 45-50 years. Regional distribution of the incidence rates showed a fairly even spread across 13 UK Health Authorities with the exception of London where incidence rates were significantly lower (1.75 per 1000 person-years, p < 0.001). Social deprivation was assessed using the Townsend score. The least deprived areas of the population had the highest incidence rates (2.86 per 1000 person years). Conclusions Our study represents the largest general population study of lateral epicondylitis reported to date. The results obtained provide the clinician with a better understanding of the epidemiology of lateral epicondylitis in the community.

Management of tennis elbow: a survey of UK clinical practice:

Background Tennis elbow is a common condition in the UK but there are no guidelines on how best to manage the condition. The purpose of the present study was to establish the current UK practice in managing patients with chronic tennis elbow. Methods A cross-sectional online survey of UK surgeons and therapists was conducted in June 2017. Results In total, 275 responses were received, the majority from consultant surgeons and experienced physiotherapists. In total, 81% recommended exercise-based physiotherapy as the first-line intervention. Second-line treatments varied widely, with corticosteroid injections being the most popular (27%), followed by shockwave therapy, platelet-rich plasma injection, surgery, acupuncture and a wait-and-see policy. Conclusions There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow. The majority of second-line interventions lack evidence to support their use and, in the case of corticosteroid injections, may even be harmful in the long term. There is a clear need for national guidance based on best evidence to aid clinicians in their treatment approach.

Carpal tunnel syndrome secondary to Masson's tumour.

We present a case of a Massons tumour causing carpal tunnel syndrome. Space occupying lesions should be considered as a differential in refractory cases of carpal tunnel syndrome, especially those in whom the symptoms are dynamic. Once radiological investigation confirms such a diagnosis, we advocate surgical excision, as malignancy can only be excluded via histological examination.