A Systematic Review of Tennis Elbow Surgery: Open Versus Arthroscopic Versus Percutaneous Release of the Common Extensor Origin

Abstract

Purpose: To compare complications, function, pain, and patient satisfaction after conventional open, percutaneous, or arthroscopic release of the extensor origin for the treatment of lateral epicondylitis.

Methods: A thorough review of 4 databases-PubMed, EBSCOhost, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus, and Scopus-was performed to identify all studies that addressed surgical management of lateral epicondylitis. We included (1) studies published between 2000 and 2015 and (2) studies with clearly defined surgical techniques. We excluded (1) non-English-language manuscripts, (2) isolated case reports, (3) studies with fewer than 10 subjects, (4) animal studies, (5) studies with additional adjunctive procedures aside from release of the extensor origin, (6) clinical or systematic review manuscripts, (7) studies with a follow-up period of 6 months or less, and (8) studies in which less than 80% of patients completed follow-up. Each study was analyzed for complication rates, functional outcomes, pain, and patient satisfaction.

Results: Thirty reports were identified that included 848 open, 578 arthroscopic, and 178 percutaneous releases. Patients within each release group had a similar age (46 years vs 46 years vs 48 years; P = .9 and P = .4, respectively), whereas there was a longer follow-up time in patients who underwent surgery by an open technique (49.4 months vs 42.6 months vs 23 months, P < .001). There were no differences in complication rates among these techniques (3.8% vs 2.9% vs 3.9%; P = .5 and P = .9, respectively). However, open techniques were correlated with higher surgical-site infection rates than arthroscopic techniques (0.7% vs 0%, P = .04). Mean Disabilities of the Arm, Shoulder and Hand scores were substantially better with both open and arthroscopic techniques than with percutaneous release (19.9 points vs 21.3 points vs 29 points, P < .001). In addition, there was less pain reported in the arthroscopic and percutaneous release groups as opposed to their open counterparts (1.9 points vs 1.4 points vs 1.3 points, P < .0001). There were no differences among the techniques in patient satisfaction rate (93.7% vs 89% vs 88%; P = .08 and P = .07, respectively).

Conclusions: Functional outcomes of open and arthroscopic releases may be superior to those of percutaneous release. In addition, patients may report less pain with arthroscopic and percutaneous techniques. Although the risk of complications is similar regardless of technique, patients may be counseled that their risk of infectious complications may be slightly higher with open releases. However, it is important to note that this statistical difference may not necessarily portend noticeable clinical differences.

Level of evidence: Level IV, systematic review of Level III and IV evidence.