Open and arthroscopic debridement for lateral epicondylitis: a systematic review and meta-analysis based on comparative studies

Abstract

Objective

To systematically compare and meta-analyse the clinical efficacy of open and arthroscopic debridement for patients with lateral epicondylitis.

Methods

A retrieval and systematic review of comparative studies of lateral epicondylitis treated with open versus arthroscopic debridement was conducted, and further pooled analysis was performed to compare the overall differences in clinical outcomes, including pain and elbow function scores, surgical time, complications and revision surgery rate.

Results

A total of 10 comparative studies involving 20,060 patients with lateral epicondylitis who were followed up for 12–93.6 months were included. Preliminary meta-analysis revealed that the visual analogue scale (VAS) score for pain was greater in the arthroscopic group than in the open group (MD: 0.01 [− 0.27–0.29], p = 0.93; I² = 0%, p = 0.98). Additionally, the Disabilities of the Arm, Shoulder and Hand (DASH) and quickDASH scores were worse in the arthroscopic group than in the open group (MD: 0.59[− 1.01–2.20], p = 0.47; I² = 68%, p = 0.02), and the surgical time was significantly longer in the arthroscopic group than in the open group (MD: 13.36[12.42–14.29], p < 0.00001; I² = 98%, p < 0.00001). There were not significant differences of complication rate, revision surgery rate between the arthroscopic group and the open group (RR: 0.82 [0.54–1.25], p = 0.36; I² = 0%, p = 0.80; RR: 1.30 [0.90–1.88], p = 0.16; I² = 0%, p = 0.76). Radial nerve injury represented the most prevalent complication within the arthroscopy group, and its incidence was slightly higher in the arthroscopic group compared to the open group [0.46% (12/2562) VS 0.33% (58/17409), X² = 1.169, p = 0.281].

Conclusions

In this systematic review and meta-analysis, we did not observe any significant advantage of arthroscopic debridement over open debridement in the treatment of lateral epicondylitis, but the surgical duration was significantly longer in the arthroscopic group, and we could assume that arthroscopic debridement may be more expensive. It was important to highlight that radial nerve injury represented the most prevalent complication within the arthroscopy group, which suggested that arthroscopic procedures for lateral epicondylitis should be performed in experienced hands. Therefore, the decision between arthroscopic and open debridement should take into account various factors, including the advantages of minimally invasive techniques, cost–benefit analysis, potential complications, and the surgeon's level of expertise.

Introduction

Lateral epicondylitis is a common elbow disorder that affects 1% to 3% of the US population [1]. It is typically a self-limiting condition or can be successfully managed by conservative treatment, mainly including rest, nonsteroidal anti-inflammatory drugs, eccentric exercise, acupuncture, and steroid injection [2]. However, surgical treatment may be indicated for 5% to 10% of recalcitrant lateral epicondylitis patients after conservative treatment fails for 6 to 12 months [3]. Open debridement of the pathologic lesion of the extensor carpi radialis brevis (ECRB) tendon is one of the most widely used methods [4]. Later, arthroscopic debridement has gained increasing popularity, and satisfactory clinical results have been reported in a series of studies [5,6,7]. The advantages of arthroscopic debridement include being less invasive, being able to address intra-articular pathology and not violating the extensor aponeurosis [8, 9]. Further comparative studies on open and arthroscopic debridement for lateral epicondylitis have reported similar clinical results [10, 11]. However, it should be mentioned that these comparative studies mainly involved fewer than 50 patients or were retrospective in design, and the results should be interpreted cautiously. Moreover, different results have been reported in systematic reviews. In a systematic review by Pierce et al., they reported that arthroscopic debridement had less pain for lateral epicondylitis than did open debridement at a minimum follow-up period of 7 months [12]. In 2018, Riff et al. performed a systematic review to compare the outcomes of open and arthroscopic surgical techniques for lateral epicondylitis and reported that 70% of patients in the open group were pain free, while 60% of patients in the arthroscopic group were pain free [13]. Furthermore, these systematic reviews rarely perform a quantitative pooled analysis based on comparative studies, and there is still controversy regarding the ideal surgical method for treating lateral epicondylitis.

Fortunately, with the increasing number of comparative studies published recently [14, 15], a systematic review and meta-analysis based on comparative studies can be performed to further clarify differences in clinical outcomes related to lateral epicondylitis that can be managed by open or arthroscopic debridement. Our hypothesis was that there would be no significant differences between these two treatment methods.

Materials and methods

Search strategies

According to the PRISMA guidelines [16], two review authors (Tang B and He Y) performed an electronic database and manual search of the PubMed, Cochrane, and Embase databases to identify trials that compared the clinical outcomes of lateral epicondylitis patients treated with open or arthroscopic debridement. All the available literature without language restrictions was retrieved, with the last search performed on January 1, 2024. The search terms included “lateral epicondylitis”, “tennis elbow”, “open” and “arthroscopic surgery”. A combination search using the subject terms (Medical Subject Heading, MeSH) and free terms was carried out in PubMed, but only keywords were used to search the Cochrane and Embase databases. We also reviewed the references of these full-text articles.

A combination search in PubMed revealed the following:

#1 (lateral epicondylitis or tennis elbow).

#2 (arthroscopic or open surgery).

#3 clinical trials.

#1 AND #2 AND #3

The eligibility criteria

Studies were included if they met the following strict criteria:

Patients: Lateral epicondylitis.

Interventions: Open or arthroscopic release or debridement.

Outcome measures: VAS score; elbow function score; surgical time; revision surgery rate; complications.

Study design

Comparative studies included randomized controlled clinical trials (RCTs) and cohort and case‒control trials with two comparative groups (open versus arthroscopic release or debridement).

Data extraction

For each study, two independent reviewers (Bo, Tang and Yuan He) extracted the following information: surname of the first author, publication year, country where the study was conducted, design of the study, sample size, follow-up times (months), therapeutic outcomes and presence of adverse events.

Statistical analysis

Review Manager statistical software (version RevMan 5.4) was used to analyse all the datasets. The mean difference (MD) was used to compare measurement data. The relative risk (RR) was calculated for counting data. A chi-squared test was employed to assess heterogeneity between the studies and compare counting data. Values of p > 0.1 and I² < 50% reflected low heterogeneity, indicating that it was necessary to employ a fixed effect model. If the statistical heterogeneity was p < 0.1 and I² > 50%, a random effect model was employed. The heterogeneous studies were analysed, and further subgroup analysis was performed to isolate the possible factors causing heterogeneity. If heterogeneity between the 2 groups was still significant, descriptive statistics were employed. A p value ≤ 0.05 indicated a significant difference, and all the statistical tests were two-sided.

Publications assessment

Cochrane bias risk assessment tools were used to assess the quality and risk of bias for all included studies [17]. This tool mainly included random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting of study results and other biases. Two authors (Bo Tang and Yuan He) worked together to evaluate each item, and after the completion of the evaluation, a risk of bias evaluation table was generated.

Results

Selection of publications

In total, 1,618 studies were retrieved from the PubMed, Cochrane Library, and Embase databases. A total of 1,596 literature articles remained for further evaluation after the removal of duplicates. A total of 1,544 studies were screened through title and abstract evaluation, and 10 comparative studies were ultimately included according to the inclusion criteria [10, 11, 14, 15, 18,19,20,21,22,23] (Fig. 1).

Fig. 1

Flow diagram for the included studies

The 10 comparative studies involved 20,060 patients with lateral epicondylitis who were followed up for 12 to 93.6 months; 2608 patients received arthroscopic debridement, and 17,452 patients received open debridement. These studies included 1 case‒control study, 1 prospective cohort study, 2 RCTs, and 6 retrospective cohort studies. Three of these studies were conducted in Korea, 3 in the USA, 1 in Canada, 1 in Germany, 1 in Spain and 1 in Norway (Table 1).

Table 1 Basic information about the included studies

Quality assessment of included studies

The level of evidence was relatively higher in the 10 included studies, with an evidence level of 1 in 2 studies and 3 in 8 studies. Random sequence generation, allocation concealment, blinding of participants and personnel, and blinding of outcome assessment were reported in 2 RCTs. Incomplete outcome data were not found in these 10 studies, and the risk of selective reporting of study results was also low in these 10 studies, while other biases were considered to be unclear in the 7 cohort or case‒control studies. (Fig. 2).

Fig. 2

Pooled bias risk of the included studies

Comparison of surgical details between the arthroscopic and open debridement groups

In terms of arthroscopic debridement, all ten studies included in this analysis employed a consistent surgical technique. This primarily involved intra-articular joint inspection, removal of the joint capsule located beneath the extensor carpi radialis brevis (ECRB), debridement of the ECRB up to its origin at the lateral epicondyle, and decortication on both the lateral epicondyle and its ridge at the ECRB's origin. Similarly, for open debridement, all ten studies utilized comparable surgical techniques that mainly encompassed debridement of the affected ECRB tissue, decortication on the lateral epicondyle, and suturing of both the fascia associated with extensor carpi radialis longus and the common extensor tendon. Decortication was performed in three studies (11, 18, 19) using both techniques; however, it was not conducted in three other studies (15, 20, 21), nor mentioned in another three (10, 14, 23). Notably, one study (22) exclusively performed decortication within an open technique framework. Concerns regarding potential bias arising from additional intra-articular procedures carried out during arthroscopic surgery prompted us to conduct a detailed comparison between additional interventions undertaken in both open and arthroscopic debridement groups. Three studies reported addressing intra-articular pathologies during surgery (11, 18, 19), which included one case of mild synovitis and one instance of radial capitellum joint adhesion within the arthroscopic group (19). Additionally noted were one loose body present in both groups (18) as well as fourteen plicae along with two loose bodies and two posterolateral ligamentous repairs specifically within the arthroscopic cohort (11). It is important to highlight that the study (11) was excluded from pooled analyses concerning VAS pain scores, DASH scores, complications rates as well as surgical duration. Thus these supplementary procedures are unlikely to significantly influence overall clinical outcomes derived from pooled results.

Comparison of DASH scores between the arthroscopic and open debridement groups

The DASH or quickDASH score was employed in 6 studies [15, 18,19,20,21,22] and was not displayed as the mean or standard deviation in 2 studies [15, 21]; therefore, the pooled analysis was conducted in 4 studies, and the pooled DASH or quickDASH score was greater in the arthroscopic group than in the open group (MD: 0.59[−1.01–2.20], p = 0.47; I² = 68%, p = 0.02). (Fig. 3).

Fig. 3

Differences in the pooled DASH score between the arthroscopic and open debridement groups

Comparison of VAS scores between the arthroscopic debridement group and the open debridement group

The VAS score was employed in 7 studies [11, 15, 18,19,20,21, 23] and was not displayed as the mean or standard deviation in 3 studies [11, 15, 23]. Pain was assessed using a 5-question visual analogue scale (VAS) questionnaire in the study by Clark et al. [19]. Therefore, pooled analysis was conducted for 3 studies, and the pooled VAS score was greater in the arthroscopic group than in the open group, but without significant difference (MD: 0.01 [−0.27- 0.29], p = 0.93; I² = 0%, p = 0.98) (Fig. 4).

Fig. 4

Comparison of the pooled VAS score between the arthroscopic and open debridement groups

Comparison of surgical time between the arthroscopic and open debridement groups

The surgical time was reported in 7 studies [15, 19, 21, 23] and was not reported as the mean or standard deviation in 1 study [15]. Therefore, pooled analysis was conducted in 3 studies, and the pooled surgical time was significantly longer in the arthroscopic group than in the open group (MD: 13.36[12.42–14.29], p < 0.00001; I² = 98%, p < 0.00001) (Fig. 5).

Fig. 5

Comparison of the pooled surgical time between the arthroscopic and open debridement groups

Comparison of complications between the arthroscopic and open debridement groups

Complications were reported in 9 studies [10, 14, 15, 18,19,20,21,22,23], including 25 events in 2562 patients (0.96%) in the arthroscopic group and 209 events in 17,409 patients (1.20%) in the open group, with surgical site infection as the most common complication in the overall group (0.56%, 112/19971) and in the open debridement group (0.60%, 105/17409) and radial nerve injury as the most common complication in the arthroscopic debridement group (0.46%, 12/2562) (Table 2). Further pooled analysis suggested that there was not significant difference of complication rate between the arthroscopic group and the open group (RR: 0.82 [0.54–1.25], p = 0.36; I² = 0%, p = 0.80) (Fig. 6). A further comparative analysis was conducted to assess the incidence of radial nerve injury between the arthroscopic and open surgical groups [0.46% (12/2562) VS 0.33% (58/17409), X² = 1.169, p = 0.281]. This finding indicated that the incidence of radial nerve injury was slightly higher in the arthroscopic group compared to the open group; however, this difference was not statistically significant. Nevertheless, given that radial nerve injury is the most common complication associated with arthroscopic debridement, it is imperative for each elbow surgeon to remain vigilant regarding this risk when performing arthroscopic debridement for lateral epicondylitis.

Table 2 Summary of the complications in these involved studies

Fig. 6

Comparison of the pooled complication rates between the arthroscopic and open debridement groups

Comparison of the revision surgery rate between the arthroscopic and open debridement groups

Revision surgery was reported in 6 studies [10, 11, 14, 15, 21, 22], including 48 of 1056 patients (4.55%) in the arthroscopic group and 173 of 5864 patients (2.95%) in the open group, and the pooled revision surgery rate was greater in the arthroscopic group than in the open group, but without significant difference (RR: 1.30 [0.90–1.88], p = 0.16; I² = 0%, p = 0.76) (Fig. 7).

Fig. 7

Pooled results of the revision surgery rate between the arthroscopic and open debridement groups

Discussion

The main finding from this systematic review and meta-analysis was that there were no significant differences in the VAS score, elbow function assessed by the DASH score, complications or revision surgery rates between the open and arthroscopic debridement groups, except for a significantly longer surgical time in the arthroscopic debridement group. It was important to highlight that radial nerve injury represented the most prevalent complication within the arthroscopy group, although there was no statistically significant difference when compared to the open group. To our knowledge, this is the first meta-analysis based on comparative studies involving a total of 20,060 patients, including 2608 patients who underwent arthroscopic debridement and 17,452 who underwent open debridement.

Theoretically, these two kinds of surgical techniques have their own strengths. Arthroscopic debridement does not violate the extensor aponeurosis and can address intra-articular pathology simultaneously [24], while the open technique may provide complete debridement without residual tendinopathy [25]. Therefore, there is a concern whether these two kinds of techniques will lead to different clinical outcomes. In our systematic review and meta-analysis, we did not find any significant differences in the VAS score, elbow function assessed by the DASH score, or complication or revision surgery rates between the open and arthroscopic debridement groups, which is similar to the findings of other systematic reviews [9, 26]. However, in the systematic review by Pierce et al. [12], less pain was reported in the arthroscopic and percutaneous surgical release groups than in their open counterparts at a minimum follow-up period of 7 months (1.9 points vs 1.4 points vs 1.3 points, P < 0.0001). It should be mentioned that their pooled results were not mainly based on comparative studies but on case series; the methodological quality may not robust, and the results may be interpreted cautiously. Regarding the subjective scores, including the VAS and DASH scores, 244 and 503 patients from 4 comparative studies, respectively, were included in our pooled analysis, and the subsequent results were considered convincing.

After a comprehensive comparison of arthroscopic and open surgical techniques, we found that the fundamental surgical steps were largely analogous. In a cadaveric study conducted by Kuklo et al., ten fresh-frozen cadaveric upper extremities underwent arthroscopic visualization of the extensor tendon and release of the extensor carpi radialis brevis (ECRB) tendon. The authors reported successful arthroscopic release of all tendons and satisfactory decortication in all specimens except for one [27]. This finding suggests that traditional open release procedures can be effectively managed using minimally invasive arthroscopic techniques. Furthermore, it is important to acknowledge that there may be slight variations in the degree of debridement or release among individual surgeons. However, the principle that debridement of the ECRB lesion should remain confined anterior to the midline of the radial head—thereby avoiding injury to the lateral collateral ligament—was consistently adhered to across these included studies.

We did not find any significant difference in complications between the open and arthroscopic debridement groups in this meta-analysis. Various complication rates after these two techniques for lateral epicondylitis have been reported. Pomerantz et al. reported complication rates of 4.3% for open procedures and 1.1% for arthroscopic procedures [24]. In a cross-sectional study utilizing the American Board of Orthopaedic Surgery (ABOS) database, 2106 surgical cases for the treatment of lateral epicondylitis were included, and the authors reported that there was no difference in the overall self-reported complication rate between open (4.4%) and arthroscopic (5.5%) procedures (P = 0.666) [28]. These results were similar to our pooled data (0.96% in the arthroscopic group and 1.20% in the open group). However, in a systematic review by Moradi et al. in 2019, the authors reported that postoperative complications were significantly greater in the open group than in the arthroscopic group (57.3% vs 33.4%, P = 0.001), which was distinctly different from our results [29]. We performed a detailed analysis of this review and found that the authors reported a total of 50 cases of complications in both the open and arthroscopic approaches, and the total number of involved patients was 737 in the open group and 515 in the arthroscopic group, which could not be used to determine a complication rate of 57.3% or 33.4%, respectively. Nevertheless, the reported complication rates were similar in most of the studies [9, 12, 14, 24, 28], and we also found that the most common complication was surgical site infection (0.60%, 105/17452) in the open debridement group and radial nerve injury (0.46%, 12/2608) in the arthroscopic debridement group. The former could be easily managed clinically, while the latter may have serious consequences. This would be a major concern for the management of lateral epicondylitis with arthroscopic techniques. Unlike the knee arthroscopic technique, there was no quick swift elbow arthroscopy, mainly due to the relatively greater learning curve and serious consequences, and this could also be further confirmed by the significantly longer surgical time in the arthroscopic debridement group than in the open group in our meta-analysis (MD: 13.36[12.42–14.29], p < 0.00001; I² = 98%, p < 0.00001). Therefore, the protection against radial nerve injury should be considered by every elbow arthroscopic surgeon when performing arthroscopic debridement in lateral epicondylitis patients.

In this study, there was also no significant difference in the revision surgery rate between the arthroscopic and open debridement groups (4.55%, 48/1056 VS 2.95%, 173/5864), which was also similar to the findings of other reports. A systematic review by Wang et al. revealed no significant difference in the rate of revision surgery between open debridement (n = 10, 5.9%) and arthroscopic debridement (n = 20, 6.4%) [9]. Therefore, these findings suggest that lateral epicondylitis can be managed by either open or arthroscopic debridement techniques with a low rate of revision surgery.

Interestingly, Kroslak et al. compared the clinical efficacy of surgical excision of the degenerative portion of the ECRB with sham surgery(skin incision and exposure of the ECRB alone) for the management of chronic tennis elbow in a randomized, double-blinded, placebo-controlled trial in 2018, 13 patients were involved in each group, they found that the former did not offer additional benefit over and above placebo surgery, and the authors also stated that the study was stopped before the calculated number of patients were enrolled (40 per group) [30]. However, we did not identify any additional reports or evidence to support the above result; Therefore, a further analysis was not conducted in this system review.

There are several limitations to our study. First, there were only two randomized controlled studies involved in this meta-analysis; the others were retrospective cohort studies, the overall evidence level was not high, and selection bias may exist. Second, various elbow assessment tools and data presentations were used in the included studies, preventing further quantitative pooled analysis. Thirdly, while the included studies did not report data on costs and benefits, it can be inferred that arthroscopic debridement may incur higher expenses due to the utilization of specialized arthroscopic instruments and an extended surgical duration.

Conclusions

In this systematic review and meta-analysis, we did not observe any significant advantage of arthroscopic debridement over open debridement in the treatment of lateral epicondylitis, but the surgical duration was significantly longer in the arthroscopic group, and we could assume that arthroscopic debridement may be more expensive. It was important to highlight that radial nerve injury represented the most prevalent complication within the arthroscopy group, which suggested that arthroscopic procedures for lateral epicondylitis should be performed in experienced hands. Therefore, the decision between arthroscopic and open debridement should take into account various factors, including the advantages of minimally invasive techniques, cost–benefit analysis, potential complications, and the surgeon's level of expertise.