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Open vs Percutaneous vs Arthroscopic Surgical Treatment of Lateral Epicondylitis: An Updated Systematic Review

June 11, 2018 | Surgery
Andrew J. Riff, MD ; Bryan M. Saltzman, MD ; Gregory Cvetanovich, MD ; Jonathan M. Frank, MD ; Mohamad R. Hemu, BS ; Robert W. Wysocki, MD
Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Dr. Riff is an Attending, Indiana University, Bloomington, Indiana. He was a resident at the time the article was written. Dr. Saltzman is a Resident and Dr. Wysocki is Assistant Professor, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois. Dr. Frank is an Attending Surgeon, Los Angeles, California. Mr. Hemu is a Medical Student, Rosalind Franklin University of Medicine and Science, Chicago, Illinois.

Address correspondence to: Bryan M. Saltzman, MD, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 (tel, 312-243-4244; fax, 312-942-1517; email, bryan.m.saltzman@gmail.com).

Andrew J. Riff, MD Bryan M. Saltzman, MD Gregory Cvetanovich, MD Jonathan M. Frank, MD Mohamad R. Hemu, BS Robert W. Wysocki, MD . Open vs Percutaneous vs Arthroscopic Surgical Treatment of Lateral Epicondylitis: An Updated Systematic Review. Am J Orthop. June 11, 2018

TAKE-HOME POINTS

  • While favorable results have been reported for open, arthroscopic, and percutaneous surgical techniques, there is no current consensus regarding the optimal technique for lateral epicondylitis.
  • There is no difference between open, arthroscopic, and percutaneous surgical treatment for lateral epicondylitis regarding return to work and subjective satisfaction.
  • Open treatment led to a greater percentage of patients being pain free at final follow-up.
  • While arthroscopic treatment led to better pain and functional scores at final follow-up, the absolute differences were quite small and likely not clinically significant.
  • We recommend open débridement as the best means of minimizing cost and achieving a pain-free outcome in the long-term.

SUBJECTIVE IMPROVEMENT AND SATISFACTION

Nine open studies, 6 arthroscopic studies, and 1 percutaneous study reported the proportion of patients who felt that their condition had been improved as a result of surgery. There was no difference in the proportion of patients who experienced improvement between the open and arthroscopic cohorts. Four open studies,3,11,12 5 arthroscopic studies,22,26,28,29,32 and 2 percutaneous studies29,36 reported the proportion of patients who were satisfied or partially satisfied with the results of the procedure. There was no difference between the open and arthroscopic groups in the proportion of patients who were satisfied or partially satisfied (Table 4).

RETURN TO WORK

The duration to return to work following surgery was reported in 5 open studies,4,5,10,13,14 9 arthroscopic studies,14,23-29,32 and 2 percutaneous studies.29,36 There was no statistically significant difference between the open and arthroscopic groups with regard to duration to return to work (O = 6.5 weeks, A = 6 weeks; P = .601). The percutaneous technique could not be included in the meta-analysis due to the presence of only 2 studies, but the pooled mean duration to return to work in these 2 studies was 5.5 weeks (Table 4).

GRIP STRENGTH

Postoperative grip strength was reported in 2 open studies,10,19 4 arthroscopic studies,28,30,32 and 2 percutaneous studies.35-36 A meta-analysis could not be performed on all the groups due to the presence of only 2 open and 2 percutaneous studies reporting grip strength. The pooled averages were O = 38.3 kg, A = 34.8 kg, and P = 27.1 kg (Table 4).

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DASH SCORE

The postoperative DASH score was reported in 4 open studies,4,15,17,19,20 5 arthroscopic studies,28-31 and 3 percutaneous studies.29,33,36 At final follow-up, the mean DASH score was higher in the arthroscopic group than in the open and percutaneous groups (A = 12.8, O = 19.5, P = 25.3; P < .001 for both comparisons), and the mean DASH score was significantly higher in the open group than in the percutaneous group (P = .029). The reporting of DASH scores in the early postoperative period was not sufficiently consistent to allow us to test our hypothesis that there would be early differences in function between groups (Table 4).

VAS PAIN SCORE

Postoperative VAS pain scores were reported in 11 open studies,6,8-10,12,15,19-21 8 arthroscopic studies,24-26,29-32 and 5 percutaneous studies.29,33,35-37 At final follow-up, there was a lower mean VAS score in the arthroscopic group than in the open and percutaneous groups (A = 1.1, O = 1.9, and P = 2.5; P < .001 for both comparisons) and a lower mean VAS score in the open group than in the percutaneous group (P = .002) (Table 4). Reporting of VAS scores in the early postoperative period in the included studies wan not sufficiently consistent to allow us to test our hypothesis that there would be early differences in pain between groups.

COMPLICATIONS

The complication rate was reported in 15 open studies, 10 arthroscopic studies, and 3 percutaneous studies. There was no difference in the complication rate between the open and arthroscopic techniques (O = 2.4%, A = 1.9%; P = .629) (Table 4). Complications noted in the open cohort included superficial wound infection (6), hematoma (5), synovial fistula (2), seroma (2), and posterior interosseous nerve palsy (1). Complications noted in the arthroscopic cohort included superficial infection (3), hematoma (1), and transient paresthesia (1). Of note, there were no complications in the percutaneous group.

Continue to: Discussion...

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