Arthroscopic Treatment of Lateral Elbow Pain Mimicking Lateral Epicondylitis: Long-term Follow-up of a Unique Surgical Protocol

Comparison of Clinical Outcomes After Different Surgical Approaches for Lateral Epicondylitis: A Systematic Review and Meta-analysis

Background

Lateral epicondylitis (LE) is one of the most common causes of lateral elbow pain. When nonoperative treatment fails, 1 of the 3 surgical approaches-open, percutaneous, or arthroscopic-is used. However, determining which approach has the superior clinical outcome remains controversial.

Purpose

To review the outcomes of different operative modalities for LE qualitatively and quantitatively.

Study Design

Systematic review; Level of evidence, 4.

Methods

This review was performed and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies published in PubMed, Medline (via EBSCO), and ScienceDirect databases that treated LE with open, percutaneous, or arthroscopic approaches with at least 12 months of follow-up were included. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies score. The primary outcome was the success rate of each operative treatment approach-open, percutaneous, and arthroscopic.

Results

From an initial search result of 603 studies, 43 studies (n = 1941 elbows) were ultimately included. The arthroscopic approach had the highest success rate (91.9% [95% CI, 89.2%-94.7%]) compared with the percutaneous (91% [95% CI, 87.3%-94.6%]) and open (82.7% [95% CI, 75.6%-89.8%]) approaches for LE surgery with changes in the mean visual analog scale pain score of 5.54, 4.90, and 3.63, respectively. According to the Disabilities of the Arm, Shoulder and Hand score, the functional outcome improved in the arthroscopic group (from 54.11 to 15.47), the percutaneous group (from 44.90 to 10.47), and the open group (from 53.55 to 16.13). The overall improvement was also found in the Mayo Elbow Performance Score, the arthroscopic group (from 55.12 to 90.97), the percutaneous group (from 56.31 to 87.65), and the open group (from 64 to 93.37).

Conclusion

Arthroscopic surgery had the highest rate of success and the best improvement in functional outcomes among the 3 approaches of LE surgery.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

Is There any Difference in Clinical Outcome between Open and Arthroscopic Treatment for Tennis Elbow? A Systematic Review and Meta-Analysis

There is considerable controversy regarding the optimal approach (open vs arthroscopic) of releasing and/or debridement for the treatment of tennis elbow (TE). The aim of this study was to determine the clinical outcomes of the two techniques by quantitatively synthesizing outcome data. The study was performed by searching the PubMed, EMBASE, Ovid, and Elsevier databases between January 1995 and April 2022 for a minimum follow-up of 6 months. The searching strategy was "(tennis elbow [Title/Abstract] OR lateral epicondylitis [Title/Abstract]) AND (open [Title/Abstract] OR arthroscopic [Title/Abstract] OR release [Title/Abstract] OR debridement [Title/Abstract] OR surgery [Title/Abstract])". The quality of each study was investigated using the Coleman Methodology Score. In total, 1411 (693 open, 718 arthroscopic) elbows in 1392 patients who underwent releasing and debridement for tennis elbow were identified. The mean Coleman Methodology Score for the included studies was 55.2 ± 8.6 (open: 55.0 ± 9.4, arthroscopic: 55.8 ± 8.2). Improved clinical results were achieved after treatment with either open or arthroscopic treatment. The surgical success rate was 95.6% in open surgery and 92.4% in arthroscopic management. The complication rates were 2.2% and 1.5% for open and arthroscopic procedures, respectively. Similar subjective and objective outcomes, and surgical success rate were observed in patients with both techniques. Patients who had undergone arthroscopic release seemed to return to work earlier (5.3 weeks vs 7.1 weeks). To draw more definite conclusions, high-quality long-term follow-up randomized controlled trials are needed.

Functional recovery in the surgical treatment of tennis elbow: side-to-side vs. tendon-to-bone attachment using a knotless suture anchor: a randomized controlled trial

BACKGROUND

Lateral epicondylitis of the elbow sometimes does not respond to conservative treatment and requires surgical intervention. Many different surgical techniques have been described. The aim of this randomized study was to compare functional outcomes of open side-to-side suturing of the tendon and tendon-to-bone fixation with a knotless suture anchor.

METHODS

In total, 68 patients were included (4 were lost to follow-up) and were randomized into either the side-to-side tendon group or the suture anchor group. Demographic data consisted of age, sex, body mass index, affected arm, dominant arm, previous treatments, and symptom duration. Professional and sports activities were noted. Preoperative values of the Mayo Elbow Performance Index (MEPI) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and Numeric Pain Rating Scale (NRS) score were noted. Clinical features consisted of range of motion in flexion and extension, grip strength, and wrist flexion and extension strength. All measurements were noted at 6 weeks, 3 months, and 1 year postoperatively.

RESULTS

The MEPI and NRS scores did not differ between the 2 groups, but there was a significant improvement in the MEPI score at 6 weeks vs. preoperatively in both the suture group (from 70.6 to 87.4) and the anchor group (from 68 to 86.5). The NRS scores showed no difference at each time point in both groups. The QuickDASH and QuickDASH-Sport scores showed a faster improvement between 6 weeks and 3 months in the anchor group compared with the suture group. Grip and extension strength also showed a slightly faster improvement at 6 weeks postoperatively in the anchor group. No significant difference in the number of weeks required to return to work was found between the groups (10.4 weeks in both groups).

CONCLUSION

Our results of side-to-side tendon repair compared with bone-tendon interface restoration by a suture anchor showed no significant differences in functional outcomes. Patients who received a suture anchor did have faster rehabilitation at 6 weeks postoperatively in terms of both functional outcome scores and grip and wrist extension strength measures.