title: Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis: Mean 4.5-Year Clinical Follow-up.
abstract: BACKGROUND
  Chronic lateral epicondylitis (LE) induces cell apoptosis and autophagy, which lead to the reduction of tendon-derived cells in the torn tendon. Our previous study has shown that ultrasound-guided autologous tenocyte injection (ATI) to the torn tendon in patients with chronic resistant LE significantly improves pain, function, and structural repair at 1 year. This report is the continued assessment of the clinical outcomes of these patients at mean 4.5-year follow-up.
  
  
  OBJECTIVE
  Improvements in LE clinical function and structural repair after ATI will be maintained at mean 4.5-year follow-up.
  
  
  METHODS
  Case series; Level of evidence, 4.
  
  
  METHODS
  Patients with severe refractory LE underwent clinical evaluation and MRI before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Autologous tenocytes were injected into the central tendinopathy identified at the common extensor tendon origin under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations for up to 5 years after ATI, including the visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Upper Extremity Functional Scale (UEFS), and grip strength. Post-ATI MRI scanning was performed at 1 year and final follow-up.
  
  
  RESULTS
  A total of 16 patients (9 male, 7 female), aged between 37 and 63 years, were included in the study. The mean duration of symptoms before study recruitment was 29.24 months (range, 6-240 months). One patient elected to proceed to surgery 3 months after ATI due to reinjury at work, and 1 patient died of prostate cancer with metastases during the follow-up period. The mean final follow-up time for the remaining 15 patients was 4.51 years (range, 3.08-5.17 years). No complications were observed at the patellar tendon biopsy site for any patient. No adverse events, infection, or excessive fibroblastic reactions were observed in any patient at the injection site. Clinical evaluation revealed significant (P < .001) improvement in mean VAS pain score from 5.73 at initial assessment to 1.21 (78% improvement) at final follow-up. Mean QuickDASH, UEFS, and grip strength scores also significantly (P < .001) improved from initial assessment to final follow-up (from 45.88 to 6.61 [84%], from 31.73 to 9.20 [64%], and from 19.85 to 46.60 [208%], respectively). There was no difference in mean QuickDASH and UEFS scores at 1 year and final follow-up (P > .05); however, grip strength continued to improve (P < .001). A validated MRI scoring system indicated that the mean grade of tendinopathy at the common extensor origin improved significantly (P < .001) from initial assessment (4.31) to 1 year (2.88) and was maintained (P > .05) at final follow-up (2.87). At final follow-up, 93% of patients were either highly satisfied or satisfied with their ATI treatment.
  
  
  CONCLUSIONS
  ATI significantly improved clinical function and MRI tendinopathy scores for up to 5 years in patients with chronic resistant LE who had previously undergone unsuccessful nonsurgical treatment. This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy.
authors.affiliation: Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia Centre for Orthopaedic Research, School of Surgery, The University of Western Australia, Crawley, Western Australia, Australia.
authors.forename: Allan
authors.initials: A
authors.lastname: Wang
authors.affiliation: Centre for Orthopaedic Research, School of Surgery, The University of Western Australia, Crawley, Western Australia, Australia.
authors.forename: Katherine
authors.initials: K
authors.lastname: Mackie
authors.affiliation: Centre for Musculoskeletal Studies, School of Surgery, The University of Western Australia, Crawley, Western Australia, Australia Perth Radiological Clinic, Subiaco, Western Australia, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Breidahl
authors.affiliation: Centre for Orthopaedic Research, School of Surgery, The University of Western Australia, Crawley, Western Australia, Australia.
authors.forename: Tao
authors.initials: T
authors.lastname: Wang
authors.affiliation: Centre for Orthopaedic Research, School of Surgery, The University of Western Australia, Crawley, Western Australia, Australia minghao.zheng@uwa.edu.au.
authors.forename: Ming H
authors.initials: MH
authors.lastname: Zheng
mesh_terms: D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007267:Injections; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology*; D010147:Pain Measurement; D017847:Patellar Ligament / Q000503:physiopathology; D052256:Tendinopathy / Q000628:therapy*; D013710:Tendons / Q000166:cytology*; D013716:Tennis Elbow / Q000628:therapy*
keywords: autologous tenocyte injection; elbow; lateral epicondylitis