Lateral epicondylitis, first described by Runge37 in 1873, is an entity defined by a constellation of clinical symptoms: pain with point tenderness at the lateral epicondyle, with resistant wrist dorsiflexion, and with passive wrist flexion. In the majority of patients (greater than 90%),29 lateral epicondylitis is successfully treated nonoperatively. For the minority of patients with pain refractory to nonoperative management, surgery is an option. Numerous surgical techniques are described in the literature, but no comprehensive review or consensus addresses the merits of alternative operations. This is partly the result of the lack of consensus on the pathology of this affliction. For example, in 1936, Cyriax12 proposed 26 different etiologies for lateral epicondylitis. It also is possible lateral epicondylitis is a final common pathway for multiple different afflictions of the elbow, which may explain why different surgical interventions work.
The more commonly proposed etiologies for tennis elbow can be grouped into three broad categories: (1) tendinous irritation from insertional tendinitis; (2) entrapment of neurologic structures; and (3) intraarticular abnormalities. More specifically, they include periosteal tearing of the extensor carpiradialis brevis (ECRB) related to muscle stress and strain of the common extensors, radial nerve entrapment, traumatic synovitis of a redundant synovial fringe of the radiohumeral joint, even stenosis by the orbicular ligament from the pulsating mechanism of radial head rotation, chondromalacia of the radial head, calcific tendinitis of the extensor muscles, posterior interosseous nerve entrapment, irritation of the articular branches of the radial nerve, and traumatic periostitis of the lateral epicondyles.5,12,17,29
Numerous papers describe surgery for lateral epicondylitis1,2,4,13,15,21,29,30 but only one reports a randomized, controlled trial, and that was only recently reported.15 In 2002, the Cochrane Collaboration Database (an international network of experts who conduct synthetic searches for relevant citations) was searched for surgery for lateral elbow pain. This review suggested no conclusions regarding the best surgery for lateral elbow pain could be drawn because there were no controlled trials to analyze.7
For the purposes of this review and for simplicity, the surgical techniques described for treatment of lateral epicondylitis can be grouped into three main categories: open, percutaneous, and arthroscopic. Our primary question was whether there was clear evidence suggesting one of these three approaches was superior in relieving pain, restoring strength, or reducing time to return to work.
MATERIALS AND METHODS
We performed a comprehensive literature search. A review using PubMed at the National Library of Medicine using the keywords “lateral epicondylitis AND surgery” returned 229 citations. With the additional limits of English language and studies on humans, the list was narrowed to 140. When the search was further limited to include only those with surgery or surgical outcome, we identified 33 papers. We then used additional terms such as “tennis elbow, operative treatment, and operation” but did not identify any other papers.
All papers were assessed by both authors (MYL, MRS) independently. Because of the paucity of comparative literature, we included all Level I (n = 2), Level II (n = 1), and Level III (n = 1) studies. Most of the Level IV (n = 28) and Level V (n = 1) studies include considerable description of surgical technique. The criteria we used for Level I studies included randomized prospective trials. Well-performed prospective studies that were comparative but not randomized were grouped as Level II studies. The criteria we used for Level III were retrospective case control (more than one cohort) studies. Level IV studies were case control studies with patient outcomes usually of a described operative technique.
We identified only one prospective randomized controlled trial, which examined outcomes between two different procedures, an open Nirschl-type procedure (whereby the ECRB is released, débrided, and repaired) versus percutaneous release of the common extensor origin.15 Additionally, we identified one study comparing arthroscopic, percutaneous, and open procedures for treatment of lateral epicondylitis, although it was nonrandomized and retrospective.40 Furthermore, a retrospective comparison of open and arthroscopic release was identified.33 The majority of publications were case series with surgical technique followed by a description of patients and postoperative function. Therefore, the literature was comprised of mainly Level IV or Level V studies and provided little evidence directly comparing one technique with another.
Summary of the Literature
The literature and clinical experience confirm greater than 90% of people with lateral epicondylitis are successfully treated nonoperatively.29 Although there is no good algorithm for the type of surgical treatment that is most effective, most surgical patients have a fairly similar profile; they are in their fifth decade of life (range, 30-63 years), have had symptoms of tennis elbow in their dominant arm for an average of 19 months (range, 6-132 months), and have had failure of nonoperative treatment, including an average of 3.1 corticosteroid injections with little to no improvement (Table 1). The majority of patients have surgery on their dominant elbow, with an average incidence of dominant arm involvement of 74%. Individuals with symptomatic tennis elbow who do not respond to rehabilitation and injections may be candidates for surgical intervention.
Numerous open surgical procedures have been described, the most commonly reported and current standard being the Nirschl procedure or its variations.22,23,27-30 Each technique has a convincing rationale, and most have good results; however, to date, there are no randomized, controlled trials suggesting one open technique is better than another. There are many reasons why there have been so many different open techniques described; however, one possible reason is there is no consensus of the pathology of lateral epicondylitis. As mentioned earlier, Cyriax12 described more than 20 different causes for the problem. To date, different procedures, such as release of the orbicular ligament,6 distal release of the extensor muscle,17 lengthening of the extensor muscles at the wrist,17 or even simple percutaneous release of the common extensor origin (CEO) without removing any pathologic tissue,4 all have had reasonable success. One commonly accepted theory is the pathology originates from the ECRB. Several authors have described macroscopic or microscopic tears and inflammation at the extensor muscles and/or tendons of the forearm.11,12,19 Nirschl and Pettrone29 suggest the ECRB tendon is the site of the main pathologic lesion in tennis elbow. They described the tendon as grayish, with immature scar tissue appearing shiny, edematous, and friable on gross examination with characteristic fibroblastic invasion and vascular granulation on light microscopy. These findings have been identified by other investigators.14 Additional studies using electron microscopy have identified fibroblasts with many vacuoles, open nuclear chromatin, contractile elements not normally seen in tendons, and abnormal vascularity,23 which contribute to the evidence that ECRB tendinosis is the main pathologic problem. Additionally, there was no noticeable spatial orientation by either light or electron microscopy of these fibroblasts in relation to the normal collagen fiber direction.23 This is supported clinically by another paper on revision surgery evaluating 34 patients (35 elbows) who previously had surgery for tennis elbow without relief.30 In seven patients, the pathologic ECRB tissue was incompletely excised, and in 27 patients, the ECRB was not addressed at all. The authors reported, when they débrided the ECRB in this group of patients undergoing revision surgery, they had an 83% rate of good or excellent results, providing additional evidence the ECRB is a common source of lateral epicondylitis.
The landmark paper of Nirschl and Pettrone29 retrospectively reviewing the results of 1213 patients diagnosed with lateral epicondylitis confirmed most patients could be treated successfully with nonoperative treatment. Approximately 7% of this study population (n = 82) was refractory to nonoperative treatment and underwent surgery. The procedure advocated by the authors included an open approach to the lateral aspect of the elbow, inspection and excision of the abnormal-appearing ECRB tendon (reportedly the abnormalities can be as much as 75% of the ECRB origin), and inspection of the anterior edge of the extensor digitorum communis with possible excisional débridement followed by inspection of the joint. They noted, in their experience, the orbicular ligament and the synovial fringe appeared normal by gross inspection. The next step was to drill or decorticate the lateral epicondyle to promote a healing response followed by repair of the extensor carpi radialis longus to the anterior edge of the extensor aponeurosis. Using their own rating system, they reported 75% excellent and 10% good results.
Doran et al14 released the CEO with a sliver of bone for their surgical treatment of lateral epicondylitis and subsequently studied the tissue histologically. They observed none of the operated specimens were normal when compared with cadaveric controls. In contradiction to a previous study,29 however, they were unable to identify macroscopic changes or abnormalities in the ECRB of the tendinous portion of the CEO. They observed microscopic tears at the tendinous portion and evidence of microavulsion fractures at the bone-tendon junction.14
Although there is a prevalence of bony exostosis of as much as 22% reported,27 its role in tennis elbow is unclear. Some studies report calcifications occur at the lateral epicondyle, including calcifications that cannot be seen on plain radiographs but can be seen only on fine-cut computed tomography.4,16,42 Nonetheless, the concept of decortication is to enhance the blood supply and healing of the débrided area.19,38 Only one Level I study compared decorticating and drilling with not doing any bony work and found, not only was there no advantage with drilling or decorticating the bone,22 but patients without surgery on the bony epicondyle actually seemed to do better in pain and strength outcomes. In a retrospective multisurgeon review, there was no benefit from drilling or decortication in addition to open débridement.13 There are little data to solve the controversy regarding the need or benefit for decortication or drilling of the lateral epicondyle in addition to resection or débridement.
Other reports suggest good results with simple release of the extensor tendons proximally or distally,9,17,35,39,42 which does not remove the pathologic tissue, like the Nirschl procedure. Some investigators believe the symptoms are the result of periostitis at the ECRB origin on the lateral epicondyle and performing the tenotomy will relieve the stress on the area. Published results for this technique are generally good and in some series improve with time.10,17,25,42
Another open procedure introduced by Bosworth5 in 1955 was based on a serendipitous discovery that cutting the orbicular ligament resulted in complete pain relief in one patient. In his treatment of patients with lateral epicondylitis, he used four techniques: (1) complete division of the common aponeurotic origin of the extensor muscles; (2) division of the common aponeurotic origin of the extensor muscles and removal of a synovial fringe of tissue between the radial head and capitellum; (3) division of the common aponeurotic origin of the extensor muscles and resection of the orbicular ligament letting it slide distally; and (4) resection of the orbicular ligament and repair of the CEO. Photomicrographs of the orbicular ligament showed hyaline degeneration, structure disorganization, and endarteritic changes consistent with degeneration. There were different numbers of patients in each group and the results were observational and preliminary at best. His results were good for each operation and others authors also have reported good success with these procedures.6,41
Several studies describe débridement and repair (with repair of the extensor carpi radialis longus to the common extensor aponeurosis,15,28,29 with other types of repair with suture anchors, or with direct repair of the extensor musculature to the lateral epicondyle),11,33,38 whereas other studies describe débridement of the ECRB alone without repair.4,18,35,42 Because of the numerous ways to address the repair and because of the multitude of variables involved, there is no good way to determine the best method or whether to repair the ECRB. Additionally, because there are no studies comparing ECRB débridement without repair and débridement with repair, it is not known if repair is necessary or beneficial. In the few comparative studies available, the extensor tendons were repaired in some way in the open techniques.15,40 The percutaneous and arthroscopic approaches do not repair the ECRB and have similar success rates.2,42
Another broad category of surgical approach is the percutaneous option. This involves performing a percutaneous release of the CEO, often using a Number 11 blade, in the office or operating room, releasing the CEO from the anterior aspect of the lateral epicondyle. Proponents of this procedure prefer this less invasive technique because the surgical results are similar to those of more complicated procedures.4 The overall results of the published series of percutaneous release approximate 90% good to excellent outcomes.4
The percutaneous procedures described are releases of the ECRB without repair. Baumgard and Schwartz4 reported the retrospective results of 37 lateral epicondyle percutaneous releases (three bilateral, three reoperations) performed in-office. The results were rated as 91% excellent (no symptoms under any circumstances), 0% fair (improvement but still symptomatic), and 9% unsatisfactory (no improvement) after an average followup of 34 months (range, 14-81 months). There was another case series of percutaneous release for epicondylitis with similar re sults.43
The arthroscope has been used endoscopically and arthroscopically to address lateral epicondylitis.2,8,20,34 Endoscopic release of the CEO as a treatment for lateral epicondylitis originally was described by Grifka et al20 in 1995. This procedure involved making two stab incisions, one 5 cm above the lateral epicondyle in the dorsolateral aspect of the arm and the second 3 to 4 cm distal to the lateral epicondyle with the arm bent 90° using a diaphanoscope. Using a small amount of fluid and a probe, the ECRB was identified and incised with an electrotome from the proximal to distal incision. Although the authors mention they performed this procedure in more than 30 cases, there were no data reported on patient outcomes of this procedure. Although an arthroscope was used in the surgical treatment of tennis elbow in this series, this was an endoscopic, not arthroscopic, technique.
Baker and Cummings2 described their experience with arthroscopic treatment of lateral epicondylitis in 1998. Their technique involved excision of the lateral capsule, débridement of any pathologic-appearing tendon on the undersurface of the ECRB, and decortication of the lateral epicondyle. They reported three different patterns of pathologic changes in the lateral capsule and at the undersurface of the ECRB tendon and classified them. Type 1 is inflammation and fraying deep to the ECRB without frank evidence of capsular tear; Type 2 is linear tears at the undersurface of the ECRB tendon and capsule; and Type 3 lesions are retracted capsular tears with partial or complete avulsions of the ECRB tendon. Baker et al found universally good results regardless of capsular status.3 Owens et al31 reported similar outcomes results with arthroscopic treatment of lateral epicondylitis, although they observed coexistent intraarticular pathology in only 18.8% of the cases.
There were initial concerns about the proximity of the lateral ulna collateral ligament and the possibility of posterolateral rotatory instability. This was addressed in cadaveric studies, which have verified the safety of portal placement and safe zones for débridement.24,38
Lateral epicondylitis has been addressed arthroscopically as well. Baker et al3 reported 95% improvement after a 34-month followup of 40 patients with 42 tennis elbows treated arthroscopically. Multiple outcome parameters were used, including the visual analog pain score, the functional portion of the Mayo Clinic elbow score, the pain phase score originated by Nirschl, and subjective rating. They also reported 69% of the patients they operated on for lateral epicondylitis had some type of intraarticular disorder: 55% synovitis or synovial thickening; 12% bone spurs; 5% valgus extension overload; 7.1% loose bodies; and 2% degenerative joint disease.
Owens et al31 reported similar success with arthroscopic treatment of tennis elbow, which included resection of the ECRB and decortication of the lateral epicondyle. In their series of 16 patients, they found intraarticular abnormalities in 18.8% of the cases (two with synovitis, one with a posterior osteophyte) in addition to ECRB tendinopathy in all 16 patients by gross visualization. Eighty-three percent of patients reported feeling much better at 24 months and no patients reported no improvement, no pain relief, or recurrence of symptoms. The average time to return to work was 6 days, although 14 of the 16 original patients had desk jobs; the one heavy manual laborer required 1 month before returning to work. There were no complications, although one patient reported not being able to return to golf.
Recently, Szabo et al40 published the only study comparing the surgical results of tennis elbow with all three techniques. They reported the retrospective results of a series of patients treated from 1997 to 2002 with the open technique (n = 41), percutaneous technique (n = 24), and arthroscopic technique (n = 44). They did not randomize the patients but let them choose or in some cases based the approach on other factors (eg, open approaches in patients requiring shoulder surgery as well for ease of intraoperative positioning). The open technique used was a modified Nirschl procedure: T incision into the extensor aponeurosis, anchor attachment of extensor digitorum and ECRB to the lateral epicondyle, and soft dressing and encouragement of immediate movement as pain allows. The average clinical followup was 47.8 months (range, 24-108 months). They used the Andrews-Carson score and the visual analog pain scale for their outcome measures. There were three failures in the percutaneous group, one in the arthroscopic group, and two in the open group. Additionally, in the arthroscopic group, 44% of the elbows had associated intraarticular abnormalities requiring treatment, 77% had plicae, 11.5% had loose bodies, and 11.5% needed posterolateral ligamentous repairs. All three groups improved substantially regarding the Andrews- Carson score and the visual analog scores. Using these same parameters, the outcomes of the three approaches were similar.
The study of Dunkow et al15 comparing the open Nirschl procedure with percutaneous release in 45 patients (47 elbows) is the only randomized, controlled trial of tennis elbow surgical treatment to date. They showed substantial improvement in Disabilities of the Arm, Shoulder, and Hand (DASH) scores and patient subjective assessment with open and percutaneous techniques, although the patients' perception of success was better in the percutaneous group. However, they did not compare DASH score improvement between the two groups, so it cannot be concluded whether the open or percutaneous approach was objectively better. They also reported a substantial difference in the mean time to return to work: 2 weeks for the percutaneous group and 5 weeks for the open group.
Peart et al33 published their results of a retrospective nonrandomized study comparing 54 open and 33 arthroscopic cases. They evaluated the differences for time to return to work. Although the authors evaluated the influence of workers' compensation, they did not stratify their patients based on type of occupation. They found a difference in time to return to work of 2.5 months for the open group and 1.7 months for the arthroscopic group. Of the patients available for review, in the open group 22 (48%) of the 46 patients patients received workers' compensation and in the arthroscopic group 18 (62%) of 29 patients received workers' compensation. Treatment success between patients receiving workers' compensation and those not receiving workers' compensation was similar. They also reported patients in the open and arthroscopic treatment groups were similar in postoperative function, although the number of patients studied was too small to have adequate power for most of their study parameters.
Overall, although the literature lacks sufficient numbers of good studies on which to base a conclusion, we interpret the literature (Table 2) as suggesting return to work is faster with less invasive approaches, such as the percutaneous technique15 and the arthroscopic technique,33 than with open procedures.
Although there are few studies that evaluate strength after surgery for lateral epicondylitis, the data are fairly uniform (Table 3). With the exception of one study26 that reported strength approximating 50% of the normal side, most of the other studies reported postoperative strength of the operated arm to be at least 90% of the unaffected side (Table 3).
Overall function has been determined in numerous ways and is a measurement that in most cases encompasses pain, function, and ability to return to activities unimpeded. Regardless of the method of treatment or surgical approach, the reported success rate of operative intervention is good, approximating 80% good to excellent results in most studies regardless of surgical technique used15,33,40 (Table 4).
Our primary question was whether there was clear evidence suggesting one of the three approaches for treating lateral epicondylitis, open, percutaneous, or arthroscopic, was superior for reducing pain, restoring strength, or reducing time to return to work. We systematically reviewed the available literature to address this question and concluded, although there are advantages and disadvantages to each procedure, no technique appears superior by any measure.
The major limitation to our review is that few Level I trials are available that compare these methods; most of the literature consists of Level IV studies accompanied by description of surgical technique. These studies are reports of relatively small single-cohort series with subsequent retrospective review. There are no consistent, validated, and uniform outcome measures for these studies and therefore no good way to compare them. In addition, postoperative protocols are different and therefore there often is more variability in the literature within one technique than between the different techniques. Finally, most of the studies lack scientific rigor in design and/or implementation (lack of randomization or control groups).7 To date, there has not been a randomized, controlled trial comparing all three methods of treatment, and this type of study would be particularly important. The one retrospective study comparing all three methods reported no difference in outcome.40 We did not check EMBASE for additional references. Our institution does not subscribe to this service and our statistical consultants did not believe it would yield many additional references or information changing conclusions considering our current review.
Time to return to work is an important consideration in deciding which of three types of surgical procedure to perform. Most studies do not distinguish manual labor from desk occupations and do not specify what return to work means (ie, does this include light duty, work modification, or full duty?); thus, comparing time to return to work across studies is not possible with the current published data. However, Dunkow et al15 reported time to return to work was 2 weeks after the percutaneous approach and 5 weeks after the open approach whereas Peart et al33 found time to return to work was 2.5 months after the open approach and 1.7 months for the arthroscopic approach. The time to return to work reported by Peart et al33 was double that found by Dunkow et al.15 Nirschl and Pettrone29did not report the amount of time to return to work in their original study, but other studies have reported a range in time to return to work of 2.2 weeks to 3 months after the open approach.18,22,25,26,33,41,42 When comparing other studies (Table 2), the variation in the return to work between reports of similar operations is in many cases more than the variation among open, percutaneous, and arthroscopic surgery. There are multiple confounders, including differences in postoperative therapy, study demographics and geographic populations, workers' compensation cases, and type of occupation seen in the given practice (manual labor versus desk jobs). The arthroscopic reports on return to work appear shorter (2.7 weeks to 1 month for laborers and 6 days to 2 weeks for nonlaborers), suggesting the arthroscopic approach is promising in reducing return to work time; although without direct comparisons in randomized, controlled trials, it is difficult to draw a conclusion.
There are numerous ways to monitor strength: subjectively as a function of perceived strength in comparison to preinjury levels, as a measure of original strength, or as a measure of the contralateral side. Measurements of the contralateral side will differ depending on whether the injured arm is the dominant side. Generally, the dominant arm is stronger than the nondominant arm. Thus, equal strength after surgery for lateral epicondylitis actually may be loss of full strength as compared with preoperative and presymptomatic levels. Different methods reported include subjective reporting, different types of dynamometer testing, spring balance testing, the modified chair lift,32 and resisted extension of the middle finger. Again, some studies do not specifically address strength in their results, and those that do report strength in many different ways. In comparing technique and approach, with the exception of one study,26 the results for strength are at least 90% of the opposite side regardless of the type of comparison studied. Equal strength when the dominant arm is involved actually may be a loss of strength relative to the premorbid state. Therefore, there is no conclusive evidence one technique is better than another regarding maintaining or re turning to premorbid strength, but all seem to do well (Table 3).
Most of the surgeries were successful (Table 4). As a result, there is no clear-cut answer regarding the best method of treatment with the few comparative studies to date showing minimal, if any, differences. Most of the procedures we reviewed produce similar results in overall preoperative and postoperative function and improvement.
The best surgical approach to lateral epicondylitis is not a simple issue. On whom should the clinician operate? Should the procedure be performed as open, percutaneous, or arthroscopic surgery? If one decides to débride the ECRB, should the surgeon then decorticate or drill the lateral epicondyle? What should the physician tell the patient regarding time to return to work or how much strength should be expected postoperatively? Based on this systematic review, one can see there is not much good evidence on which to base answers to these questions. Our goal was not to confuse the issue but to present all information currently available to help provide a basis on which one can attempt to answer some of these questions or at least provide some type of algorithm.
There is no distinct answer regarding the best way to surgically treat patients with lateral epicondylitis refractory to nonoperative treatment. The numerous studies suggest most patients have been refractory to nonoperative care for approximately 1 year, and after the first few corticosteroid injections, the efficacy decreases. Therefore, if a patient presents with a history of tennis elbow for which they have received adequate nonoperative treatment for an appropriate length of time and have had two or more injections, it is reasonable to consider surgical means. There is convincing evidence the ECRB exhibits abnormalities in many of these cases, so it is reasonable to consider surgical methods to address this disorder. Additionally, there is a reasonable association with intraarticular abnormalities, as much as 69%, but much of the concomitant problem includes synovitis that may not require surgery. It is reasonable to conclude one should have the option of intraarticular inspection with the ability to address any abnormalities that may arise. The question of addressing the lateral epicondyle with bony decortication or drilling is not clear, although at 3 and 6 months, patients in one study had better pain relief and better strength without violating the lateral epicondyle,22 and in another study, there was no difference in outcome at 2 years.13
Common principles dictate smaller incisions lead to decreased pain and easier return to function postoperatively, whereas the ability to address any tendinous abnormalities and additionally inspect the joint may lead to greater success. The percutaneous method has the smallest incision but does not allow the option of joint inspection, whereas the open method allows for good visualization, although the incision is bigger and therefore rehabilitation may be longer. Particularly with the Nirschl procedure, protection of the repair is needed, whereas release or débridement without repair may not need postoperative protection. It seems arthroscopic means for surgical treatment combine the best of both worlds with small incisions and the ability to safely inspect the joint and débride or address any intraarticular abnormalities. Although arthroscopy is the senior author's (MRS) preferred method of surgically man aging the elbow with lateral epicondylitis, no current evidence documents any one technique is superior. Most of the studies attempting to address these issues have a short followup period or are too small and therefore without sufficient power.
Although it is beyond the scope of this article, one point bears additional note. The role of postoperative rehabilitation has not been studied and generally is not described or addressed in most papers reporting the results of surgical treatment of lateral epicondylitis. Thus, its importance is unclear and may substantially affect the results of surgical treatment. In fact, postoperative treatment alone may account for the disparate results of similar procedures. Also, many surgical procedures are not performed in the exact manner as described by their main proponent. These minor or major variations in technique also may affect the results of the same procedure reported by different authors.
Therefore, because of the lack of good scientific evidence, meta-analyses and even systematic review are not able to resolve the issue of which surgical procedure is superior by any outcome measure. Thus, until more high quality randomized, controlled trials are done, it is reasonable to defer to the individual surgeon for their preference regarding their experience, familiarity, comfort, and ease of procedure.
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