Lateral epicondylitis affects 1% to 3% of adults each year. Although common, symptoms of lateral epicondylitis resolve spontaneously within a year of symptom onset in 80% of cases, and only 3% of patients who seek medical treatment ultimately require surgical intervention within 2 years of symptom onset.1 Despite a relatively low percentage of patients who require surgery, Sanders and colleagues1 noted a significant increase in the rate of surgical intervention from 1.1% to 3.2% of cases in the last 15 years. Surgical intervention is generally indicated when pain and functional disability persist after 6 to 12 months of nonsurgical treatment. Traditional surgical treatment involves open release/débridement of the extensor carpi radialis (ECRB) origin; however, with the increasing prevalence of surgical intervention, surgeons have demonstrated a rising interest in less invasive techniques like arthroscopic release/débridement and percutaneous tenotomy as alternatives to traditional open débridement. While favorable results have been reported for all 3 techniques, there is no current consensus regarding the optimal surgical technique. In 2007, Lo and Safran2 reported no difference in the results of open, percutaneous, and arthroscopic techniques regarding any outcome measure in a systematic review of 33 papers. We conducted a repeat systematic review of the current literature to update Lo and Safran’s2 review and to ascertain if more recent literature demonstrates superiority of 1 technique regarding pain relief, subjective questionnaire data, subjective satisfaction, restoration of strength, and return to work. We hypothesized that return to work would be accelerated, pain decreased, and function improved in the early postoperative period in the arthroscopic and percutaneous groups, but there would be no difference in ultimate pain, functional outcome, or subjective satisfaction.
METHODS
SEARCH STRATEGY AND STUDY SELECTION
We conducted a systematic review of the literature to update the topic of surgical intervention with lateral epicondylitis since the publication of the most recent review by Lo and Safran2 in 2007, which included all relevant studies published up to 2004. To include all relevant studies published since that time, we searched PubMed (MEDLINE) for all literature published from January 1, 2004 to May 23, 2015 using the following key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). General search terms were utilized to avoid unintentional exclusion of relevant studies. Two authors reviewed the abstracts of all resultant citations. Table 1 outlines the inclusion and exclusion criteria for the search. References from all included studies were reviewed for applicable articles that were not captured by the initial broad search strategy. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial flow chart shows the study selection algorithm (Figure 1).
Table 1. Inclusion and Exclusion Criteria for the Analyzed Studies
Inclusion Criteria | Exclusion Criteria |
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DATA EXTRACTION AND ANALYSIS
Data were extracted from the included studies by 2 reviewers using data abstraction forms. All study, subject, and surgery parameters were collected. The study and subject demographic parameters analyzed included year of publication, level of evidence, presence of study financial conflict of interest, number of subjects and elbows, gender, age, proportion in whom the dominant extremity was involved, proportion who were laborers, proportion who had a workman’s compensation claim, duration of symptoms prior to surgical intervention, and surgical technique employed (open, arthroscopic, or percutaneous). We recorded the following clinical outcomes: proportion of patients with complete pain relief, proportion who were partially or completely satisfied, proportion who were improved, duration to return to work, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS) pain score, and complication rate.
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