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The patient’s pain will continue to worsen
1%
5/558
The patient’s pain may improve but they will have a decline in functional outcome measures
6%
33/558
The patient will experience no difference in pain or function if they had just continued with non-operative treatment
20%
112/558
The patient’s pain may worsen but they will have an improvement in functional outcome measures
2%
12/558
The patient’s pain and functional outcome scores would be expected to improve
69%
387/558
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The patient has medial epicondylitis that has failed an appropriate trial of non-operative management. Operative treatment of recalcitrant medial epicondylitis would be expected to lead to improvement in both the patient’s pain and function. Medial epicondylitis of the elbow is an overuse injury characterized by angiofibroblastic hyperplasia (as described for lateral epicondylitis) of the common flexor-pronator origin. Diagnosis is made clinically with tenderness around the medial epicondyle made worse with resisted forearm pronation and wrist flexion. Patients often present with insidious onset of pain over the medial epicondyle that is worse with wrist and forearm motion. It is thought to be caused by micro-trauma to the insertion of the flexor-pronator mass as a result of repetitive activities. Over time, patients can experience loss of grip strength and begin to experience difficulty with routine tasks. Non-operative modalities include rest, ice, activity modification, PT (passive stretching), bracing, NSAIDS, and extracorporeal shockwave therapy, which is successful in relieving pain in about 90% of cases. For those patients that fail up to 6 months of non-operative management, open debridement and reattachment of the pronator teres and flexor carpi radialis is the treatment of choice. This procedure has 80-90% good to excellent outcomes in appropriately selected patients. Vinod and Ross performed a retrospective review evaluating surgically treated patients with recalcitrant medial epicondylitis. They reported pronation weakness at 90° was a critical physical examination finding. Postoperatively, they reported significant increases in both Mayo Elbow Performance Scores as well as pain. They concluded debridement with restoration of the flexor-pronator origin is an efficacious procedure for patients with recalcitrant medial epicondylitis. Han et al. performed a study reporting on their results of surgical treatment in patients with recalcitrant medial epicondylitis monitored for more than 5 years. They reported significant improvements in VAS, Mayo Elbow Performance Scores, DASH scores and mean grip strength. They concluded that surgical treatment of medial epicondylitis could be an effective and safe treatment when conservative treatment fails. Gabel and Morrey performed a retrospective review of the long-term results of operative treatment of medial epicondylitis in thirty elbows (26 patients). They reported that debridement of the origin of the flexor-pronator tendon mass, with decompression or transposition of the ulnar nerve when indicated, was associated with an 87% rate of good or excellent results at an average of 7 years after the operation. Incorrect Answers: Answers 1-4: This patient with recalcitrant medical epicondylitis would be expected to have improvement in both pain and function after operative management.
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