Abstract
Background:
Lateral epicondylitis (LE) also known as tennis elbow is a common disease of middle-aged population. Surgery is a treatment of choice in patients not responded to the conservative management. Open and arthroscopic release are the two main choices for LE surgery; however, an overall consensus is not available. This study was aimed to compare the clinical outcomes after conventional open and arthroscopic procedures.
Methods:
An electronic search of databases including, Medline, Web of Science, Embase, Cochrane Library, and Scopus was conducted to identify all eligible studies describing the post-operative clinical outcomes of patients with LE, up to October 2018. All studies considering the non-pediatric cases who received at least 6-month preoperative conservative treatment and were followed more than 6 months after surgery were included. Data on patient satisfaction, functional outcomes, pain, and complication rates, were extracted for each study. If appropriate, the meta-analysis was performed to combine the results for all outcomes that were reported in a minimum of 3 studies utilizing the same surgical technique.
Results:
A total of 34 eligible articles including 15 open studies, 13 arthroscopic studies, and 6 studies in both techniques were enrolled. Studies were from different parts of the world with a whole sample size of 1508 cases. Various outcome measuring methods including Quick DASH and VAS, and different clinical outcomes were reported. The results indicated no significant difference between arthroscopic and open surgery methods in terms of VAS, DASH score, time for returning to work, overall outcomes, and patients’ satisfaction (P >0.05). However, postoperative complications were significantly higher in the open group when compared with the arthroscopic procedure (57.3% vs 33.4% P=0.001).
Conclusion:
The present study suggests that despite no superiority for each techniques regarding the pain relief, subjective function, and better rehabilitation, arthroscopic method have been associated with less complications.
Key Words: Arthroscopy, Lateral epicondylitis, Open surgery, Systematic review, Tennis elbow
Introduction
Tennis elbow or Lateral epicondylitis (LE) is a common degenerative disorder with a prevalence rate of 1% to 3% in the general population and 7% in the handy workers, occurs most often between the ages of 40-60 years with equal gender distribution(1, 2). This condition is characterized by the tenderness of lateral epicondyle which is deteriorated with wrist dorsiflexion under resistance (3). The underlying physiopathology of LE is not fully known, but it has been proposed that it is caused due to repetitive activities and overuse of the extensor carpi radialis brevis that further activates the inflammatory processes Although it was termed to be a disease of sportsmen, nowadays is found to be an occupational disorder (4-6). Historically, LE was believed to be a self-limiting disease; however, persistent pain will be detected in the majority of patients even after 1 year of different conservative treatments (7-9) and subsequent local corticosteroid injections was also showed unfavorable results, mainly in those with a pain duration greater than 6 months (7-10). Several conservative treatment strategies, like manual work avoiding, immobilization, local or systemic anti-inflammatory drugs, physiotherapy, and radiofrequency have been established for pain alleviation (11-15). However, patients who have not respond to conservative treatments or those with a 6-month period of pain sensation are candidates for surgery intervention (9).
Different surgery techniques have been developed for LE are included denervation of the lateral epicondyle invented by Wilhelm and Gieseler and the incision of the extensor tendon described by Hohmann or the open Nirschl technique that was invented as a traditional open procedure in 1979 (16-19). Baumgard and Schwartz (1982) also proposed percutaneous release as a method without the need for general anesthesia (20). However, like other surgical procedures in different parts of the body such as the knee and the shoulder, there is a great tendency toward arthroscopic procedure, a technique that first was by baker et al. (21). Several studies reported that arthroscopic technique is more useful for intra-articular visualization with quick rehabilitation due to minimal incision and lower morbidity rate (21-29). However, there have been additional studies comparing the efficacy of arthroscopic technique with open procedure; which led to inconsistence results making the interpretation difficult for available reports. Despite more reports supporting the superiority of arthroscopic technique, the possibility of potential patient-related advantages of open approach cannot be ignored. Therefore, to investigate more subtle comparison between arthroscopic and open techniques in terms of patients’ satisfaction, functional outcomes, pain relief, and complication rates, this systematic review and meta-analysis was conducted to derive a more comprehensive conclusion.
Materials and Methods
Search strategy
The present systematic review and meta-analysis is conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (30). We comprehensively searched Medline, Web of Science, Embase, Cochrane Library, and Scopus databases for relevant publications up to October 2018. The search mesh terms and text words including “tennis elbows”, “Lateral Epicondylitis”, “surgery”, “operative”, “arthroscopy”, “arthroscopic” were used individually or in various combinations with no language restriction. References list of the potential eligible articles were also searched in manual, for more related articles. Regarding the studies published by the same author or overlapping study cases, only the most recent or complete study was included.
Study selection
Publications were eligible to be included in this systematic review and meta-analysis they met the following criteria: (1) Case series/cohort studies assessing patients with documented lateral epicondylitis according to the history and physical examination, (2) Studies reporting the results of isolated arthroscopic, or open surgical treatment for lateral epicondylitis, (3) Studies comparing the results of arthroscopic vs open surgical treatment for lateral epicondylitis. Reviews, editorials, letters to the editor, case reports, animal studies, and all other studies that were conducted on pediatric cases and those assessing patients with presence of any further pathology or lesions that could affect the function of the elbow including cartilage and bone lesions, osteoarthritis and history of the surgery at the interface, were excluded. Potential eligible articles with a follow-up period less than 6 months, and studies in which surgery was performed before six months of conservative treatments were also excluded. Two independent reviewers (PP and HMM) screened articles titles and abstract for relevancy and full text retrieved according to the inclusion and exclusion criteria. Any disagreement was resolved through discussion with a third reviewer (AM).
Data extraction and quality control
Data were extracted from the included studies by two authors (PP and HM). Briefly, for each study, the following data were extracted; the first author´s name and year of publication, country, study design, number of subjects and elbows, gender, mean age , duration of symptoms prior to surgical intervention, mean period of conservative treatment, mean follow-up duration, and type of surgical technique. All data related to the clinical outcomes including the pain sensation and the function of articular interface after surgery in terms of Quick DASH (The Disabilities of the Arm, Shoulder and Hand), VAS (visual analogue scale), and complication rate were recorded (31). Depending on the type of studies (observational or trials) two quality assessment tools including Newcastle-Ottawa Scale (NOS) and Jadad scoring system were used to assess the quality of studies included (32). This evaluation was performed by two authors (PP and HMM) independently and any disagreements were resolved through team consensus.
Data synthesis and meta-analysis
Data related to the continues/categorical variables from all studies were pooled and reported as weighted mean ± standard deviation and frequency with percentage respectively. In the case of outcome metrics reported in 3 or more publications, a meta-analysis was also performed to estimate a pooled risk ratio (RR) with 95% confidence interval (CI). Meta-analysis was conducted using Comprehensive Meta-analysis version 3 software. The heterogeneity was measured using the I2 index and Cochran Q test. An I2 > 50% with a significant Cochran Q test indicates considerable heterogeneity. In case of high heterogeneity, a random effect model was used; otherwise, we used a fixed model. Also, potential publication bias was assessed using Egger’s linear regression test. P <0.05 were considered significant.
Results
Literature Search
Using the aforementioned search strategy, 227 studies were identified. Following the title and abstract screening process, 43 studies were remained. After, a more detailed review on full-text 9 other studies were also extracted. Finally, a total of 34 studies were included in the analysis [Figure 1]. Among included studies, 15 studies examining open surgical technique, 13 studies assessed arthroscopic method and 6 compared both approaches (15, 21, 24, 25, 33-62).
Figure 1.
Flowchart of study selection process
Of the included studies, twenty three were retrospective cohorts, three case-control studies, six prospective cohort studies, and two non-randomized clinical trials (15, 21, 34-36, 45, 51, 54, 52, 60). Studies were from different parts of the world including USA, China, Korea, Norway, Germany, France, Japan, Belgium, UK, New Zeeland, and Canada. All the publications were written in English, except one in French (51). The main characteristics of the included studies such as the number of patients and elbows, mean age of the patients, mean period of symptom sensation, mean period of conservative treatment, follow up, and the measured outcomes are summarized in Table 1.
Table 1.
Characteristics of studies included and outcomes measured
| Study authors/year | Country | Study design | Study group or groups | Number and gender of patients (M/F) | Number of elbows and gender (M/F) | Mean age of the patients | Mean period of symptom sensation (months) | Mean period of conservative treatment (months) | Mean follow-up duration (months) | Outcome measured |
|---|---|---|---|---|---|---|---|---|---|---|
| Kwon BC et al, 2017 | Korea | Retrospective cohort | Arthroscopic | 55 (40/15) | 31 (22/9) | 50.5 | 17.3 | NR | 30 | VAS DASH PFG F-E arc Outcome |
| Open | 28 (20/8) | |||||||||
| Solheim, et al, 2013 | Norway | Case-control | Arthroscopic | 295 (151/144) | 225 (111/114) | 46 | NR | NR | 50 | DASH Excellent & poor outcome |
| Open | 80 (42/38) | |||||||||
| Yan H, 2009 | China | Retrospective cohort | Arthroscopic | 26 (NR) | 31 (22/9) | NR | NR | 23 | 17.4 | Excellent outcome |
| Open | 12 (NR) | |||||||||
| Szabo SJ et al, 2006 | USA | Retrospective cohort | Arthroscopic | NR | 41 (29/12) | 45.7 | NR | 13.2 | 47.8 | VAS Andrew-Carson score Recurrence Poor outcome |
| Open | 38 (21/16) | |||||||||
| Rubenthaler F et al, 2005 | Germany | Retrospective cohort | Arthroscopic | 30 (18/12) | 20 (11/9) | 49.3 | NR | 10.6 | 92.8 | VAS Roles & maudsley Morrey score |
| Open | 10 (7/3) | |||||||||
| Peart et al, 2004 | USA | Retrospective cohort | Arthroscopic | 75 | 20 (NR) | 45 | 19 | NR | 31.5 | Excellent & good & fair & poor outcome |
| Open | 46 (NR) | |||||||||
| Soeur et al, 2016 | France | Retrospective cohort | Arthroscopic | 35 (20/15) | NR | 48 | 18 | 6 | 48 | Quick-DASH Outcome Time for returning to work |
| Ruch et al, 2015 | USA | Retrospective cohort | Open | 27 (13/14) | NR | 49.5 | 21.4 | 5 | 7.3 | VAS DASH |
| Yoon et al, 2015 | Korea | Retrospective cohort | Arthroscopic | 45 (23/22) | NR | 45.9 | 15.7 | 6 | 26.9 | VAS patient satisfaction |
| Oki et al, 2014 | Japan | Retrospective case-control study | Arthroscopic | 23 (5/18) | 23 (5/18) | 49 | 32 | 6 | 24 | VAS DASH Patients’ satisfaction |
| Barth et al, 2013 | Belgium | Cohort | Open | 49 | 54 (23/31) | 44 | NR | NR | 33 | DASH VAS Outcome |
| Manon-Matos et al, 2013 | USA | Retrospective case-control study | Open | 56 (23/33) | NR | 51.4 | 7.95 | NR | NR | VAS Recurrence |
| Rhyou et al, 2013 | Korea | Retrospective cohort | Arthroscopic | 20 (4/16) | NR | 47 | 14 | NR | 46 | DASH VAS |
| Sauvage et al, 2013 | France | Cohort | Arthroscopic | 14 (6/8) | NR | 39.8 | NR | 32.5 | 7.15 | VAS DASH Outcome |
| Kim et al, 2011 | Korea | nonrandomized clinical trial | Arthroscopic | 19 (6/13) | 19 (6/13) | 46 | 6 | 6 | 29.5 | VAS |
| Reddy et al, 2011 | UK | Cohort | Open | 27 (13/14) | NR | 47 | 28 | 6 | 16 | Patients satisfaction Time for returning to work |
| Solheim et al, 2011 | Norway | Retrospective cohort | Open | 77 (38/39) | 80 | 46 | NR | 6 | 48 | Quick DASH |
| Coleman et al, 2010 | New Zealand | Retrospective cohort | Open | 158 (72/65) | 171 | 42 | 2.5 | NR | 117.6 | Outcome |
| Dwyer et al, 2010 | UK | Retrospective cohort | Open | 21 (12/9) | NR | 49.3 | 21 | NR | 24 | Outcome Patients satisfaction |
| Rayan et al, 2010 | UK | Retrospective cohort | Open | 40 (16/24) | 40 (16/24) | 43.7 | 12 | NR | 24 | VAS Outcome |
| Lattermann et al, 2010 | USA | Retrospective cohort | Arthroscopic | 36 (24/12) | NR | 42 | 19 | NR | 42 | VAS Time for returning to work |
| Grewal et al, 2009 | Canada | Cohort | Arthroscopic | 36 (20/16) | NR | 45.3 | 30 | NR | 42 | VAS Outcome Time for returning to work |
| Dunn et al, 2008 | USA | Retrospective cohort | Open | 83 (45/38) | 92 | 46 | 26.4 | NR | 151.2 | VAS Outcome Patients satisfaction |
| Cho et al, 2009 | Korea | Retrospective cohort | Open | 41 (28/13) | 42 (28/14) | 47.5 | NR | NR | 13.4 | VAS Outcome |
| Baker Jr et al/2000 | USA | Cohort | Arthroscopic | 40 (26/14) | 42 (27/15) | 42.7 | 14 | 14.4 | 34 | VAS |
| Wada et al , 2009 | Japan | Retrospective cohort | Arthroscopic | 18 (9/9) | 20 | 54 | 28 | 6 | 24 | VAS DASH |
| Backer and Backer, 2008 | USA | Retrospective cohort | Arthroscopic | 40 (26/14) | 42 (27/15) | 42.7 | 14 | 14.4 | 130 | Patients’ satisfaction |
| Thomas and Broome, 2007 | UK | Retrospective cohort | Open | 18 | 24 | NR | 23 | NR | NR | Patients’ satisfaction |
| Jerosch et al, 2006 | Germany | Retrospective cohort | Arthroscopic | 20 (13/7) | NR | 45.3 | 14 | 6 | 21.6 | VAS Time for returning to work |
| Balk et al, 2005 | USA | Retrospective cohort | Open | 57 | 63 | NR | NR | NR | 50 | Patients’ satisfaction |
| Mullett et al, 2005 | USA | Retrospective cohort | Arthroscopic | 30 (16/14) | 30 (16/14) | 46 | NR | 9 | 24 | Patients’ satisfaction Time for returning to work |
| Tasto et al, 2005 | USA | Nonrandomized clinical trial | Open | 13 (6/7) | NR | 48.3 | 4.4 | 6 | 24 | VAS DASH |
| Thornton et al, 2005 | USA | Cohort | Open | 20 (9/11) | 22 | 47.3 | 53 | 6 | 50.2 | VAS DASH |
| Rayan and Coray, 2001 | USA | Retrospective cohort | Open | 22 (13/9) | 23 | 43 | NR | 6 | 41.2 | VAS Outcome Patients’ satisfaction |
Abbreviations: VAS, visual analog scale; DASH, Disabilities of the Arm, Shoulder and Hand; PFG, pain-free grip strength; F-E arc, F-E, flexion-extension, NR, not reported; M/F, Male/Female,
The 34 included studies comprised 1508 patients and 1622 elbows; among these, 1005 (62.0%) elbows underwent open and 617 (38.0%) elbows underwent arthroscopic approach. The mean age of the patients was 46.64 in the open group and 46.14 in the arthroscopic group. Around 44.4% of the patients were male in the open group and 47.3% were male in arthroscopic. Mean period of symptom sensation were shorter in open group than arthroscopic group (8.27 vs. 10.62 months). Patients in open group had a mean period of 19.66 months of conservative treatment and were followed for an average duration of 44.46 months while the conservative treatment and follow up duration were 17.75 and 42.08 months respectively in arthroscopic group [Table 2].
Table 2.
Subject Demographics for Open & Arthroscopic
| Parameter | Open | Arthroscopic |
|---|---|---|
| Number of elbows | 1005 | 617 |
| Mean age | 46.64 | 46.14 |
| Male (%) | 44.4% | 47.3% |
| Female (%) | 55.56% | 52.7% |
| Mean period of symptom sensation (months) | 8.27 | 10.62 |
| Mean period of conservative treatment (months) | 19.66 | 17.75 |
| Mean follow-up duration (months) | 44.46 | 42.08 |
The values of postoperative outcomes measured either in arthroscopic or open groups as well as related complication are listed in Table 3.
Table 3.
The comparative values of postoperative outcomes
| First author name | Item | Type of surgery | p value | |||
|---|---|---|---|---|---|---|
| Open | Arthroscopic | |||||
| Kwon BC et al. (59) | Mean time for returning to work (month) | 10.2±4.1 | 8.7±3.4 | NR | ||
| VAS score | Overall pain | 1.1±1 | 1.1±1.8 | 0.08 | ||
| Pain during hard work | 1.6±1.3 | 2.2±2 | 0.042 | |||
| Pain at rest | 0.7±0.9 | 0.8±1.6 | 0.604 | |||
| Quick DASH score | 9.4±7 | 12.6±18.3 | 0.408 | |||
| PFG strength (kg) | 18±8 | 25±13 | 0.115 | |||
| F-E arc | 149±3 | 149±4 | 0.803 | |||
| Outcome | Excellent | 22 (84.6%) | 22 (75.9%) | 0.510 | ||
| Good | 4 (15.4%) | 5 (17.2%) | ||||
| Poor | 0 | 2 (6.9%) | ||||
| Complications | 1 (1.8%) | 1 (1.8%) case of mild flexion-extension limitation in open group | ||||
| Soeur et al. (48) | Quick DASH score | NR | 15.9 | NR | ||
| Good & excellent outcome | NR | 71% | NR | |||
| Mean time for returning to work (month) | NR | 72 | NR | |||
| Complications | 5 (12.5%) | 2 (5%) local injections, 2 (5%) revision surgery, 1 (2.5%) subjective elbow instability | ||||
| Ruch et al. (33) | VAS | 2.3 | NR | NR | ||
| DASH | 44 | NR | NR | |||
| complications | Without any complication | |||||
| Yoon et al. (47) | Overall VAS | NR | 0.9 | NR | ||
| Patients’ satisfaction | NR | 82% | NR | |||
| Complications | Without any complication | |||||
| Oki et al. (49) | VAS | At rest | NR | 8 | NR | |
| At activity | NR | 35 | NR | |||
| DASH score | NR | 15 | NR | |||
| Patients’ satisfaction | NR | 96% | NR | |||
| Complications | Without any complication | |||||
| Barth et al. (34) | Quick DASH score | 6 | NR | NR | ||
| VAS | Overall pain | 1 | NR | NR | ||
| Pain at rest | 9 | NR | NR | |||
| Mean time for returning to work (month) | 5.7 | NR | NR | |||
| Outcome | Excellent | 26 (54%) | NR | NR | ||
| Good | 15 (31%) | NR | NR | |||
| Poor | 8 (16%) | NR | NR | |||
| Complications | 2 (4%) | 1 (2%) hematoma and 1 (2%) wound infection | ||||
| Manon-Matos et al. (35) | VAS score | 3 | NR | NR | ||
| Recurrence | 2 | NR | NR | |||
| Rhyou et al. (50) | VAS pain score | NR | 0.3 | NR | ||
| VAS palpation pain score | NR | 0.9 | NR | |||
| DASH score | NR | 5.1 | NR | |||
| Complications | Without any complication | |||||
| Solheim, et al. (37) | Quick DASH score | 17.8±19.4 | 60.2 ±15.4 | 0.004 | ||
| Outcome | Excellent | 67% | 78% | 0.04 | ||
| Poor | 4% | 7% | 0.285 | |||
| Complications | 19 (6.2%) | 19 (6.2%) in Arthroscopic group & 3 (4%) in Open group revision surgery | ||||
| Sauvage et al. (51) | DASH | NR | 9.7 | NR | ||
| VAS | At rest | NR | 0.43 | NR | ||
| At activity | NR | 2.43 | NR | |||
| Mean time for returning to work (month) | NR | 9.1 | NR | |||
| Outcome | Excellent | NR | 11 | NR | ||
| Good | NR | 3 | NR | |||
| Complications | Without any complication | |||||
| Kim et al. (52) | VAS at activity | NR | 1.0 | NR | ||
| Mean time for returning to work (days) | NR | 24.2 ± 18.3 | NR | |||
| Complications | Without any complication | |||||
| Reddy et al. (36) | Patients’ satisfaction | 90% | NR | NR | ||
| Mean time for returning to work (month) | 5 | NR | NR | |||
| Complications | Without any complication | |||||
| Solheim et al. (60) | Quick DASH score | 18 | NR | NR | ||
| Complications | 7 (9.2%) | 3 (4%) revisions, 3 (4%) wound infections, and 1(1.2%)hematoma | ||||
| Coleman et al. (38) | Outcome | Excellent | 128 (85%) | NR | NR | |
| Good | 13 (8%) | NR | NR | |||
| Fair | 6 (5%) | NR | NR | |||
| Poor | 2 (2%) | NR | NR | |||
| Complications | 2 (1.5%) | 2 (1.5%) synovial fistulae | ||||
| Dwyer et al. (39) | Patients’ satisfaction | 95.2% | NR | NR | ||
| Outcome | Excellent | 19 (90.5%) | NR | NR | ||
| Good | 2 (9.5%) | NR | NR | |||
| Complications | Without any complication | |||||
| Lattermann et al. (53) | VAS score | NR | 1.9 | NR | ||
| Mean time for returning to work (month) | NR | 7 | NR | |||
| Complications | Without any complication | |||||
| Rayan et al. (40) | Overall VAS | 1.6 | NR | NR | ||
| Outcome | Excellent | 25 (62.5%) | NR | NR | ||
| Good | 10 (25%) | NR | NR | |||
| Fair | 2 (5%) | NR | NR | |||
| Poor | 3 (7.5%) | NR | NR | |||
| Complications | 2 (5%) | 2 (5%) patients required revision | ||||
| Cho et al. (42) | VAS | At rest | 0.3 | NR | NR | |
| Daily activity | 1.46 | NR | NR | |||
| Hard activity | 2.21 | NR | NR | |||
| Outcome | Excellent | 23 | NR | NR | ||
| Good | 18 | NR | NR | |||
| Fair | 1 | NR | NR | |||
| Poor | 0 | NR | NR | |||
| Complications | 1 (2.5%) | 1 (2.5%) case of forearm paresthesias for 2 weeks after surgery | ||||
| Grewal et al. (54) | Overall VAS | NR | 8 | NR | ||
| Mean time for returning to work with workers compensation (month) | NR | 24.5 ± 32.6 | 0.2 | |||
| Mean time for returning to work without workers compensation (month) | NR | 10.3 ± 16.6 | ||||
| Outcome | Good & excellent | NR | 22 | NR | ||
| Fair | NR | 9 | NR | |||
| poor | NR | 5 | NR | |||
| Complications | Without any complication | |||||
| Dunn et al. (41) | Overall VAS for pain | 2.1 | NR | NR | ||
| Patients’ satisfaction | 89% | NR | NR | |||
| Outcome | Excellent | 71 (77%) | NR | NR | ||
| Good | 6 (6.5%) | NR | NR | |||
| Fair | 9 (10%) | NR | NR | |||
| poor | 6 (6.5%) | NR | NR | |||
| Complications | Without any complication | |||||
| Yan et al. (61) | Mean time for returning to work (month) | 3 | 3.2 | NR | ||
| Excellent outcome | 100% | 93% | NR | |||
| Complications | Without any complication | |||||
| Wada et al. (55) | VAS | At rest | NR | 0.3 | NR | |
| At activity | NR | 0.9 | NR | |||
| Quick DASH score | NR | 10.6 | NR | |||
| Complications | Without any complication | |||||
| Baker and Baker (56) | Patients’ satisfaction | NR | 88% | NR | ||
| Complications | Without any complication | |||||
| Thomas and Broome (43) | Patients’ satisfaction | 83% | NR | NR | ||
| Complications | Without any complication | |||||
| Jerosch et al. (57) | VAS | At rest | NR | 0.5 | NR | |
| At daily activity | NR | 1.0 | NR | |||
| At athletic activities | NR | 1.2 | NR | |||
| Mean time for returning to work (month) | NR | 3.2 | NR | |||
| Complications | Without any complication | |||||
| Szabo SJ et al. (25) | VAS score at worst pain | 1.2 | 1 | >0.05 | ||
| Andrew-carson | 195.3 | 195.4 | >0.05 | |||
| Recurrence | 2 (4.9%) | 5 (10.5%) | NR | |||
| Poor outcome | 5.3% | 2.4% | NR | |||
| Complications | 9 (11.3%) | 1 (2.4%) Arthroscopic cases & 2 (5/3%) open cases revision surgery, and 2 (4.9%) Arthroscopic cases & 4(10/5%) open cases glucocorticoid injections | ||||
| Mullett et al. (58) | Patients’ satisfaction | NR | 93% | NR | ||
| Mean time for returning to work (month) | NR | 7 | NR | |||
| Complications | Without any complication | |||||
| Rubenthaler F et al. (62) | Mean time for returning to work (month) | 3 | 3.3 | >0.05 | ||
| VAS score | Pain | 2.6 | 1.95 | >0.05 | ||
| Function | 2.5 | 1.85 | >0.05 | |||
| Roles & Maudsley | 2 | 3.3 | >0.05 | |||
| Morrey score | 87.5 | 93.2 | >0.05 | |||
| Clinical tender spots on lateral epicondyle | 3.2 | 2.4 | >0.05 | |||
| Thompsen test | 3.5 | 1.6 | >0.05 | |||
| Chair test | 2.4 | 1.8 | >0.05 | |||
| Middle finger extetion test | 3 | 1.4 | >0.05 | |||
| Good & excellent outcome | 60% | 75% | >0.05 | |||
| Complications | 2 (6.6%) | (3.3%) 1 superficial subcutaneous infection (Arthroscopic) and 1 (3.3%) hematom (Arthroscopic) | ||||
| Tasto et al. (14) | VAS score | 0.7 | NR | NR | ||
| DASH | 0.8 | NR | NR | |||
| Complications | Without any complication | |||||
| Thornton et al. (45) | VAS score | 0.41 | NR | NR | ||
| DASH | 6.6 | NR | NR | |||
| ime for returning to work (month) | 4.1 | NR | NR | |||
| Balk et al. (44) | Patients’ satisfaction | 97% | NR | NR | ||
| Peart et al. (24) | Mean time for returning to work (month) | 2.5 | 1.7 | >0.05 | ||
| Outcome with worker’s compensation | Good & excellent | 55% | 72% | >0.05 | ||
| Fair | 27% | 18% | >0.05 | |||
| Poor | 0% | 18% | >0.05 | |||
| Outcome without worker’s compensation | Good & excellent | 83% | 73% | >0.05 | ||
| Fair | 17% | 9% | >0.05 | |||
| Poor | 0% | 18% | >0.05 | |||
| Total outcome | Good & excellent | 69% | 72% | >0.05 | ||
| Fair | 22% | 21% | >0.05 | |||
| Poor | 9% | 7% | >0.05 | |||
| Rayan and Coray (46) | Overall VAS | 1.4 | NR | NR | ||
| Patients’ satisfaction | 96% | NR | NR | |||
| Outcome | Excellent | 11 (50%) | NR | NR | ||
| Good | 3 (13.5%) | NR | NR | |||
| Poor | 8 (36.5%) | NR | NR | |||
| Complications | 3 (13.5%) | 1 (4.5%) mild to moderate pain, 1(4.5%) transient elbow stiffness, and 1 (4.5%) hematoma | ||||
| Baker Jr et al. (21) | VAS score at rest | NR | 1.9 | NR | ||
| Complications | Without any complication | |||||
NR: not reported; DASH: The Disabilities of the Arm, Shoulder and Hand; VAS: visual analogue scale; PFG: Pain Free Grip
Complications
The total amount of complications was 50 cases in both open and arthroscopic approaches. The complication rate was reported in 17 arthroscopic studies, 16 open studies [Table 4]. Complications noted were the flexion-extension limitation, revision surgery, superficial wound infection, hematoma, seroma, elbow instability, synovial fistulae, posterior interosseous nerve palsy, and need for further glucocorticoid injections. The rate of complications were significantly higher in open group than arthroscopic group (open: 57.3% vs. arthroscopic: 33.4%; p: 0.001) [Table 4].
Table 4.
Comparison of Postoperative clinical outcomes following surgery
| Parameter |
Open
|
Arthroscopic
|
p value | ||||
|---|---|---|---|---|---|---|---|
| Value | Studies | n | Value | Studies | n | ||
| Return to work (month) | 8.9±4.6 | 7 | 272 | 6.3±3.6 | 11 | 199 | 0.195 |
| Good and excellent outcome n (%) | 82.7% | 12 | 577 | 81.2% | 8 | 407 | 0.418 |
| Poor outcome | 10.6% | 13 | 628 | 8.4% | 8 | 418 | 0.127 |
| DASH | 14.7±14.4 | 7 | 241 | 11.5±3.6 | 7 | 402 | 0.584 |
| VAS | 1.45±0.72 | 13 | 347 | 1.62±1.96 | 10 | 187 | 0.78 |
| Complication n (%) | 57.3% | 16 | 737 | 33.4% | 17 | 515 | 0.7 |
| Patient satisfaction | 91.7% | 6 | 228 | 98.8% | 4 | 138 | 0.3 |
VAS for pain score
Postoperative VAS pain scores were reported in Thirteen arthroscopic studies and eleven open studies (15, 25, 34, 35, 40-42, 45-47, 49-57, 59, 62). At final follow-up, the mean VAS was higher in the arthroscopic group but, the difference was not statistically significant (arthroscopic: 1.62±1.96 vs. open: 1.45±0.72; P: 0.78) [Table 4].
DASH score
The postoperative DASH score was reported in 7 arthroscopic studies and 7 open studies (15, 33, 34, 37, 45, 48- 51, 55, 59, 60). At final follow-up, the mean DASH score was higher in the open group than in the arthroscopic approach; however, this was not statistically significant (arthroscopic: 11.5±3.6 vs. open: 14.7±14.4; P: 0.584) [Table 4].
Return to work
The duration to return to work following surgery was reported in 11 arthroscopic studies and 7 open studies (24, 34, 36, 45, 48, 51-54, 57-59, 61, 62). The mean time for returning to work was 6.3±3.6 months in arthroscopic group and 8.9±4.6 months in open group; however, no significant difference was found [Table 4].
Patient’s satisfaction
Four arthroscopic and five open studies reported the proportion of patients who were satisfied with the results of the procedure (36, 39, 41, 43, 44, 47, 49, 56, 58). Totally, 98.8% of the patients in the arthroscopic group and 91.7% of the patients in the open group felt that their condition had been improved as a result of surgery. However, this difference was not statistically significant (P = 0.30) [Table 4].
Overall outcomes
The rate of good/excellent outcomes were reported in 8 arthroscopic studies and 12 open studies (24, 25, 34, 38-42, 46, 48, 51, 54, 59-62). Furthermore, the poor outcomes were reported in 8 arthroscopic articles and 13 open articles (24, 25, 34, 38-42, 46, 51, 54, 59-62).There was no significant difference between the groups regarding the rate of excellent/good outcomes (arthroscopic: 81.2% vs. open: 82.7%; p: 0.418). Although the poor outcome was higher in open group, the difference was not statistically significant (arthroscopic: 8.4% vs. open: 10.6%; P: 0.127) [Table 4].
Discussion
The primary purpose of this review was to determine if definitive evidence suggests that any of open or arthroscopic surgical treatment is superior to the other in patients with lateral epicondylitis. We tried to find a superiority in one of the methods regarding relieving pain, improving functionality, accelerating return to work and the safety according to the number of complications. Therefore, VAS score, DASH score, outcomes, patients’ satisfaction, returning to work time, and complications were compared between the two approaches. The most striking finding of this study was that the rate of complications were significantly higher in open group than arthroscopic group (open: 57.3% vs. arthroscopic: 33.4%; P: 0.001). At final follow-up, there were no significant differences between groups regarding relieving pain, improving functionality, duration to return to work, overall good and excellent outcome, poor outcome and proportion who were satisfied. Average VAS and DASH scores at final follow-up showed no significant difference between the two study groups.
Seventeen arthroscopic studies and sixteen open studies (15, 21, 25, 33, 34, 36-43, 46-58, 59-62) reported the number of complication in their studies. Pooled results showed that the rate of complications was significantly higher in the open group than in the atheroscopic group (open: 57.3% vs. arthroscopic: 33.4%; P: 0.001).
The pooled results of the above-mentioned outcomes are summarized in table 4. As shown in this table only the rate of reported complications showed a notable differences which were higher in the open group. It is believed that arthroscopic method causes a minimal violation to the skin, underlying tissues, and extensor aponeurosis compared with the open method; therefore more complications such as postoperative bleeding and surgical traumas were observed in the open approach (25, 60).
It is in common that smaller incision leads to less pain and better function postoperatively. The percutaneous method has a smaller incision than open method; however, the open method provides a better visualization with the cost of greater incision and time-consuming recovery from surgery and maybe a bigger scar. Especially, in case of open surgery methods, the nirschl procedure needs much more care for rehabilitation. It is believed that the arthroscopic method combine the benefits of the two methods. While this method provides a good visualization of the surgery field, it is safe with small incision and scar. Although arthroscopic method is the most preferred surgery methods, the studies showed no superiority for each of the methods (24, 63-65). Our study showed no difference in the duration to return to work, VAS, and DASH scores between the two methods. In addition, both open and arthroscopic methods involved the removal of affected tissues with underlying bone decortication, and therefore there is no difference between the approaches regarding the function.
Some literatures suggested that there are several different open approaches; however, the top lied is Nirschl procedure or modified variations (3, 66-70). Each techniques had an underlying logic, and the majority of them showed good results; however, further randomized controlled trials are needed to assess the superiority of each technique. The development of different surgery approaches is due to different theories of the underlying pathology (71). Various ways are such as orbicular ligament releasing, wrist extensor muscles lengthening, common extensor origin releasing, and distal release of the extensor muscle (20, 71, 73). The reviewed literature suggested that the pathology lies in microscopic or macroscopic tears of the extensor muscle or tendons of the forearm mainly extensor carpi radialis brevis (ECRB) (11, 74, 75). Nirschl and Pettrone proposed ECRB tendon is the corner stone of the LE disease development (3). This pathology was further supported by electron microscopy findings such as hypervascularity, fibroblast accumulation, and abnormal contractile elements in the tendon (76).
In the arthroscopic approach, arthroscope can be used arthroscopically or endoscopically (77-79). Baker and Cummings (1998) proposed the technique being used arthroscopically for LE treatment (21). The technique was used to cut lateral capsule followed by debridement of observed abnormal tissue in ECRB and lateral epicondyle decortication. They proposed three types of involvement in LE macroscopic pathology during surgery. Type 1 was related to the inflammation and fraying of the ECRB in the absence of capsular tearing. Type 3 was presented with linear tears at the surface of the ECRB tendon. They found that the outcome of the patients was relatively good.
Our study had several limitations; the included studies were of different types; however, to the top of our knowledge no randomized controlled trial was conducted. Furthermore, the assessments were not complete in some studies, and some of them did not measure the pain and function scorings such as VAS or DASH. The sample sizes in most of the studies were low. Furthermore, only 6 studies compared the two methods; other studies reported one method outcomes which were further pooled and analyzed in this study. However, besides the above-mentioned limitations, this study can help to complete the superiority of each approaches to the other.
According to our analysis there is no superiority in the mentioned surgical methods regarding the function improvement with less pain sensation. However, the number of complications such as mild flexion-extension limitation, hematoma, wound infection, revision requirement, forearm paresthesias for 2 weeks after surgery, and glucocorticoid injections requirements are significantly lower in the arthroscopic group than in the open approach. Our pooled analysis is a statistical assessment and further support is needed to report it as a clinical finding.
Acknowledgements
We thank for the financial support of this study as a MD student dissertation by a grant from the Mashhad University of Medical Sciences (No. 960909). We also thank Clinical Research Development Unit of Ghaem Hospital for their assistance in this manuscript.
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