Karjalainen Teemu, Luokkala Toni, Lähdeoja Tuomas, Salmela Mikko, Ardern Clare, Karjalainen Venla-Linnea, Taimela Simo, Järvinen Teppo Lassi Nestori
Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland.
Central Finland Welfare Services, Jyväskylä, Finland.
Clin Orthop Relat Res. 2025 Feb 27;483(8):1489-1498. doi: 10.1097/CORR.0000000000003425.
Persisting symptoms after an attempt of nonoperative treatment represents one of the most common indications for surgery in many musculoskeletal conditions, such as tennis elbow. The rationale behind the practice of resorting to surgery in individuals with long-standing symptoms is that resolution of symptoms is believed to be unlikely without surgery after a certain period, and surgeons can identify a subgroup to benefit from surgery. For this approach to be sound, surgeons must be able to reliably distinguish between patients unlikely to improve without surgery and those who are likely to benefit from it.
QUESTIONS/PURPOSES: (1) Do patients with persistent tennis elbow symptoms (lasting > 10 months) who are referred to a surgeon improve without surgery over a 24-month follow-up period? (2) Are surgeons' or patients' predictions about improvement associated with actual improvement? (3) What patient characteristics, if any, are associated with predictions of improvement made by either surgeons or patients?
Between 2016 and 2018, we prospectively recruited 97 patients with persistent tennis elbow symptoms (> 10 months) who were dissatisfied with nonsurgical treatment and referred for surgical consultation at five secondary or tertiary public hospitals. Of these, 89% (86 of 97) agreed to continued nonoperative treatment and were included in this observational cohort study. To evaluate the outcomes of continued nonoperative treatment, we measured the Oxford Elbow Score (OES) and global improvement at 6 weeks and at 3, 6, 12, and 24 months. To assess whether either the surgeons or the patients could predict the likelihood of symptom improvement, we asked both parties at baseline to predict whether each patient would be satisfied with their symptom state without surgery within the next 6 months. We then evaluated the prognostic value of these predictions by comparing the OES and global improvement scores between (1) patients who believed that they would improve versus patients who did not and (2) patients whom the surgeons predicted would improve versus those whom the surgeons predicted would not. To explore factors that might explain the predictions, we assessed the correlation between the predictions and baseline characteristics, including age, sex, affected side, smoking status, duration of symptoms, disability (OES score), Pain Catastrophizing Scale score, prior corticosteroid injections, and any planned injection treatments. Data from patients who underwent surgery during the follow-up period were included only up to the time of surgery. The mean ± SD age of the patients was 49 ± 5.4 years, and prior to the initial consultation, they had had symptoms for a mean ± SD of 20 ± 12 months. One-half of the patients were female.
Nine percent (8 of 86) of patients eventually underwent operation during the 2-year follow-up period. The mean total OES of the cohort (range 0 to 100, with higher scores indicating better outcomes) increased from approximately 50 points at baseline to 80 points at the final 24-month follow-up visit. Surgeons' predictions about likelihood of improvement were not associated with the observed improvement, while patients who were more pessimistic about their likelihood of recovery at baseline had slightly inferior outcomes compared with patients who were more optimistic about their likelihood of recovery. As for factors associated with patients' predictions of recovery, both patients who had previously received corticosteroid injections (relative risk [RR] 1.4 [95% confidence interval (CI) 1.1 to 1.7]; p = 0.03) and those scheduled to receive botulinum toxin or platelet-rich plasma injections (RR 3.8 [95% CI 2.0 to 7.3]; p < 0.001) were more likely to predict improvement compared with those who opted to wait and see. Surgeons' predictions about the recovery were not associated with any of the measured patient characteristics, indicating that the predictions were based on heuristics, that is, mental shortcuts or rules of thumb that clinicians commonly use in clinical decision-making.
Our findings suggest that persistent tennis elbow symptoms are a poor indication for surgery, as the majority of patients experience symptom resolution without it, and surgeons are unable to reliably predict who will or will not improve with nonoperative treatment. Therefore, treatment decisions should not be based on the clinician's perception of the disease course. Patients' predictions, especially more pessimistic views, were found to more accurately reflect the likely recovery trajectory. Finally, despite evidence demonstrating the ineffectiveness of injections, they elevated patients' expectations for improvement.
Level II, therapeutic study.
在许多肌肉骨骼疾病（如网球肘）中，非手术治疗后症状持续存在是手术最常见的指征之一。对有长期症状的患者采取手术治疗的基本原理是，在一定时期后，若不进行手术，症状被认为不太可能缓解，并且外科医生能够识别出能从手术中获益的亚组患者。要使这种方法合理，外科医生必须能够可靠地区分那些不进行手术不太可能改善的患者和那些可能从手术中获益的患者。
问题/目的：（1）转诊至外科医生处的持续性网球肘症状（持续时间>10个月）患者，在24个月的随访期内不进行手术病情会改善吗？（2）外科医生或患者对病情改善的预测与实际改善情况相关吗？（3）外科医生或患者做出的改善预测与哪些患者特征相关（若相关的话）？
在2016年至2018年期间，我们前瞻性招募了97例持续性网球肘症状（>10个月）且对非手术治疗不满意并在五家二级或三级公立医院接受手术咨询的患者。其中，89%（97例中的86例）同意继续非手术治疗，并被纳入该观察性队列研究。为评估继续非手术治疗的结果，我们在6周以及3、6、12和24个月时测量了牛津肘关节评分（OES）和整体改善情况。为评估外科医生或患者是否能够预测症状改善的可能性，我们在基线时让双方预测每位患者在未来6个月内不进行手术是否会对其症状状态感到满意。然后，我们通过比较以下两组患者的OES和整体改善评分来评估这些预测的预后价值：（1）认为自己会改善的患者与认为自己不会改善的患者；（2）外科医生预测会改善的患者与外科医生预测不会改善的患者。为探究可能解释这些预测的因素，我们评估了预测与基线特征之间的相关性，这些特征包括年龄、性别、患侧、吸烟状况、症状持续时间、残疾程度（OES评分）、疼痛灾难化量表评分、既往皮质类固醇注射情况以及任何计划的注射治疗。随访期间接受手术的患者的数据仅纳入至手术时。患者的平均年龄为49±5.4岁，在初次咨询前，他们的症状平均持续时间为20±12个月。一半的患者为女性。
在2年的随访期内，9%（86例中的8例）的患者最终接受了手术。该队列的平均总OES（范围为0至100，分数越高表明结果越好）从基线时的约50分增加到最后24个月随访时的80分。外科医生对改善可能性的预测与观察到的改善情况无关，而与那些对恢复可能性更乐观的患者相比，在基线时对恢复可能性更悲观的患者的结果略差。至于与患者恢复预测相关的因素，与选择观望的患者相比，既往接受过皮质类固醇注射的患者（相对风险[RR]1.4[95%置信区间（CI）1.1至1.7]；p = 0.03）以及计划接受肉毒杆菌毒素或富血小板血浆注射的患者（RR 3.8[95%CI 2.0至7.3]；p < 0.001）更有可能预测病情改善。外科医生对恢复的预测与所测量的任何患者特征均无关，这表明这些预测是基于启发式方法，即临床医生在临床决策中常用的心理捷径或经验法则。
我们的研究结果表明，持续性网球肘症状并不是手术的有力指征，因为大多数患者在不进行手术的情况下症状也会缓解，并且外科医生无法可靠地预测哪些患者非手术治疗会改善或不会改善。因此，治疗决策不应基于临床医生对疾病进程的判断。发现患者的预测，尤其是更悲观的观点，能更准确地反映可能的恢复轨迹。最后，尽管有证据表明注射无效，但它们提高了患者对改善的期望。
II级，治疗性研究。
