Bryan M. Saltzman, MD

Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

Author(s)

Timothy S. Leroux, MD

Bryce A. Basques, MD

Bryan M. Saltzman, MD

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

ABSTRACT

It has been suggested that the utilization of joint arthroplasty in patients with rheumatoid arthritis (RA) is decreasing; however, this observation is largely based upon evidence pertaining to lower-extremity joint arthroplasty. It remains unknown if these observed trends also hold true for shoulder arthroplasty. The purpose of this study is to utilize a nationally representative population database in the US to identify trends in the utilization of shoulder arthroplasty among patients with RA. Secondarily, we sought to determine the rate of early adverse events, length of stay, and hospitalization costs associated with RA patients undergoing shoulder arthroplasty and to compare these outcomes to those of patients without a diagnosis of RA undergoing shoulder arthroplasty. Using a large population database in the US, we determined the annual rates of shoulder arthroplasty (overall and individual) in RA patients between 2002 and 2011. Early adverse events, length of stay, and hospitalization costs were determined and compared with those of non-RA patients undergoing shoulder arthroplasty. Overall, we identified 332,593 patients who underwent shoulder arthroplasty between 2002 and 2011, of whom 17,883 patients (5.4%) had a diagnosis of RA. Over the study period, there was a significant increase in the utilization of shoulder arthroplasty in RA patients, particularly total shoulder arthroplasty. Over the same period, there was a significant increase in the number of RA patients who underwent shoulder arthroplasty with a diagnosis of rotator cuff disease. There were no significant differences in adverse events or mean hospitalization costs between RA and non-RA patients. Non-RA patients had a significantly shorter length of stay; however, the difference did not appear to be clinically significant. In conclusion, the utilization of shoulder arthroplasty in patients with RA significantly increased from 2002 to 2011, which may partly reflect a trend toward management of rotator cuff disease with arthroplasty rather than repair.

Continue to: It has been suggested...

It has been suggested that the utilization of total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA) is decreasing over time;¹ however, this observation is largely based upon evidence pertaining to lower extremity TJA.² It remains unknown if these observed trends also hold true for shoulder arthroplasty, whereby the utilization of shoulder arthroplasty in RA patients is not limited to the management of end-stage inflammatory arthropathy. In this study, we used a nationally representative population database in the US to identify trends in the utilization of shoulder arthroplasty among patients with RA. As a secondary objective, we sought to determine the rate of early adverse events, length of stay, and hospitalization costs associated with RA patients undergoing shoulder arthroplasty and compare these outcomes to those of patients without a diagnosis of RA undergoing shoulder arthroplasty. We hypothesize that the utilization of shoulder arthroplasty in RA patients would be decreasing, but adverse events, length of stay, and hospitalization costs would not differ between patients with and without RA undergoing shoulder arthroplasty.

METHODS

We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) from 2002 to 2011.³ The NIS comprises a 20% stratified sample of all hospital discharges in the US. The NIS includes information about patient characteristics (age, sex, insurance status, and medical comorbidities) and hospitalization outcomes (adverse events, costs, and length of stay). The NIS allows identification of hospitalizations according to procedures and diagnoses using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Given the anonymity of this study, it was exempt from Institutional Review Board ethics approval.

Hospitalizations were selected for the study based on ICD-9-CM procedural codes for hemiarthroplasty (81.81), anatomic total shoulder arthroplasty (TSA) (81.80), and reverse TSA (81.88). These patients were then stratified by an ICD-9-CM diagnosis of RA (714.X). We also utilized ICD-9-CM diagnosis codes to determine the presence of rotator cuff pathology at the time of shoulder arthroplasty (726.13, 727.61, 840.4) and to exclude patients with a history of trauma (812.X, 716.11, 733.8X). In a separate analysis, all patients in the NIS database with an ICD-9-CM diagnosis of RA were identified for each calendar year of the study, and a national estimate of RA patients was generated annually to assess overall and individual utilization rates of shoulder arthroplasty in this population (the national estimate served as the denominator).

Preoperative patient data withdrawn from the NIS included age, sex, insurance status, and medical comorbidities. An Elixhauser Comorbidity Index (ECI) was generated for each patient based on the presence of 29 comorbid conditions. The ECI was chosen because of its capacity to accurately predict mortality and represent the patient burden of comorbidities in similar administrative database studies.^4-6

Early adverse events were also chosen based on ICD-9-CM diagnosis codes (Appendix A), and included the following: death, acute kidney injury, cardiac arrest, thromboembolic event, myocardial infarction, peripheral nerve injury, pneumonia, sepsis, stroke, surgical site infection, urinary tract infection, and wound dehiscence. The overall adverse event rate was defined as the occurrence of ≥1 of the above adverse events in a patient.

Appendix A. ICD-9-CM Codes Corresponding to Postoperative Adverse Events

Event	*ICD-9-CM*
Acute kidney injury	584.5-584.9
Cardiac arrest	427.41, 427.5
Thromboembolic event	453.2-453.4, 453.82-453.86, 415.1
Myocardial Infarction	410.00-410.92
Peripheral nerve injury	953.0-953.9 954.0-954.9, 955.0-955.9, 956.0-956.9
Pneumonia	480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 484.1-484.8, 485, 486
Sepsis	038.0-038.9, 112.5, 785.52, 995.91, 995.92
Stroke	430, 432, 433.01-434.91, 997.02
Surgical site infection	998.51, 998.59, 996.67
Urinary tract infection	599
Wound dehiscence	998.30-998.33

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

Length of stay and total hospital charges were available for each patient. Length of stay represents the number of calendar days a patient stayed in the hospital. All hospital charges were converted to hospitalization costs using the HCUP Cost-to-Charge Ratio Files. All hospitalization costs were adjusted for inflation using the US Bureau of Labor statistics yearly inflation calculator to represent charges in the year 2011, which was the final and most recent year in this study.

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Statistical analyses were conducted using Stata version 13.1 (StataCorp, LP). All analyses took into account the complex survey design of the NIS. Discharge weights, strata, and cluster variables were included to correctly estimate variance and to produce national estimates from the stratified sample. Pearson’s chi-squared test was used to compare age, sex, ECI, and insurance status between RA and non-RA patients undergoing shoulder arthroplasty.

Bivariate and multivariate logistic regressions were subsequently used to compare the rates of adverse events between RA and non-RA patients undergoing shoulder arthroplasty (non-RA cases were used as the reference). Multivariate linear regressions were used to compare hospital length of stay and hospitalization costs between RA and non-RA patients undergoing shoulder arthroplasty. The multivariate regressions were adjusted for baseline differences in age, sex, ECI, and insurance status. Cochran-Armitage tests for trend were used to assess trends over time. All tests were 2-tailed, and the statistical difference was established at a 2-sided α level of 0.05 (P < .05).

RESULTS

Overall, we identified 332,593 patients who underwent shoulder arthroplasty in the US between 2002 and 2011, of which 17,883 patients (5.4%) had a diagnosis of RA. In comparison with non-RA patients undergoing shoulder arthroplasty, patients with RA at the time of shoulder arthroplasty were significantly younger (65.2 ± 12.5 years vs 68.4 ± 11.0 years, P < .001), included a significantly greater proportion of female patients (76.7% vs 53.8%, P < .001), and included a significantly higher proportion of patients with Medicaid insurance (3.6% vs 2.3%, P < .001). There were no significant differences in the mean ECI between patients with and without a diagnosis of RA (Table 1). As depicted in Table 1, there were significant differences in the utilization of specific shoulder arthroplasty types between patients with and without RA, whereby a significantly greater proportion of RA patients underwent hemiarthroplasty (HA) (31.6% vs 29.3%, P = .002) and reverse TSA (7.7% vs 6.6%, P = .002), whereas a significantly greater proportion of non-RA patients underwent anatomic SA (64.0% vs 60.8%, P = .002).

Over the study period from 2002 to 2011, there was a significant increase in the overall utilization of shoulder arthroplasty in RA patients, as indicated by both the absolute number and the proportion of patients with a diagnosis of RA (P < .001) (Table 2, Figure). More specifically, 0.39% of RA patients underwent shoulder arthroplasty in 2002, as compared with 0.58% of RA patients in 2011 (P < .001) (Table 2). With respect to specific arthroplasty types, there was an exponential rise in the utilization of reverse TSA beginning in 2010 and a corresponding decrease in the rates of both HA and anatomic TSA (Table 2, Figure). In addition to changes in shoulder arthroplasty utilization over time among RA patients, we also observed a significant increase in the number of RA patients undergoing shoulder arthroplasty with a corresponding diagnosis of rotator cuff disease (9.7% in 2002 to 15.2% in 2011, P < .001).

Table 2. The Annual Utilization of Shoulder Arthroplasty Among Patients with a Diagnosis of Rheumatoid Arthritis.

Proportion of RA patients
Year	Overall Rate of Shoulder Arthroplasty^a	HA	Anatomic TSA	Reverse TSA
2002	0.39	0.23	0.16	0
2003	0.37	0.19	0.18	0
2004	0.46	0.25	0.21	0
2005	0.46	0.21	0.25	0
2006	0.47	0.20	0.27	0
2007	0.55	0.22	0.33	0
2008	0.47	0.17	0.30	0
2009	0.50	0.15	0.35	0
2010	0.58	0.15	0.37	0.06
2011	0.58	0.12	0.23	0.23
Absolute number of RA patients
2002	1295	768	527	0
2003	1247	650	597	0
2004	1667	906	761	0
2005	1722	776	946	0
2006	1847	794	1053	0
2007	2249	910	1339	0
2008	2194	799	1395	0
2009	2407	724	1683	0
2010	2869	722	1857	290
2011	3193	649	1261	1283

^aRate determined as number of RA patients undergoing shoulder arthroplasty compared to the number of patients with an RA diagnosis in the stated calendar year.

Abbreviations: HA, hemiarthroplasty; RA, rheumatoid arthritis; TSA, total shoulder arthroplasty.

Continue to: Among patients with RA...

Among patients with RA undergoing shoulder arthroplasty, the overall rate of early adverse events was 3.12%, of which the most common early adverse events were urinary tract infections (1.8%), acute kidney injury (0.66%), and pneumonia (0.38%) (Table 3). As compared with patients without a diagnosis of RA undergoing shoulder arthroplasty, there were no significant differences in the overall and individual rates of early adverse events (Table 3).

Table 3. A Comparison of Early Adverse Events, Length of Stay, and Cost Between Patients With and Without Rheumatoid Arthritis (RA) Undergoing Shoulder Arthroplasty

Comparison of Early Adverse Event Rates
	Non-RA Patients	RA Patients	Multivariate Logistic Regression
	Non-RA Patients	RA Patients	Odds Ratio	P-Value
Overall adverse event rate	3.02%	3.12%	1.0	0.83
Specific adverse event rate
Death	0.08%	0.05%	0.9	0.91
Acute kidney injury	0.85%	0.66%	0.9	0.59
Cardiac arrest	0.05%	0.05%	1.3	0.70
Thromboembolic event	0.01%	0.00%	-	-
Myocardial Infarction	0.22%	0.06%	0.4	0.17
Peripheral nerve injury	0.08%	0.11%	1.5	0.45
Pneumonia	0.47%	0.38%	0.9	0.70
Sepsis	0.08%	0.08%	1.3	0.62
Stroke	0.07%	0.05%	0.9	0.93
Surgical site infection	0.09%	0.13%	1.4	0.52
Urinary tract infection	1.44%	1.80%	1.1	0.46
Wound dehiscence	0.01%	0.05%	3.6	0.09
Comparison of Length of Stay and Hospital Charges
	Non-RA Patients (percent)	RA Patients (percent)	Multivariate Linear Regression
	Non-RA Patients (percent)	RA Patients (percent)	Beta	P-Value
Length of stay^a	2.3±2.0	2.4±1.6	+0.1	0.002
Hospitalization cost^b	14,826±8,336	14,787±7,625	+93	0.59

^aReported in days. ^bReported in 2011 US dollars, adjusted for inflation.

The mean length of stay following shoulder arthroplasty in RA patients was 2.4 ± 1.6 days, and the mean hospitalization cost was $14,787 ± $7625 (Table 3). As compared with non-RA patients undergoing shoulder arthroplasty, there were no significant differences in the mean hospitalization costs; however, non-RA patients had a significantly shorter length of stay by 0.1 days (P = .002) (Table 3).

DISCUSSION

In this study, we observed that the utilization of shoulder arthroplasty in patients with RA increased significantly in the decade from 2002 to 2011, largely related to a rise in TSA. Interestingly, we also observed a corresponding rise in the proportion of RA patients undergoing shoulder arthroplasty with a diagnosis of rotator cuff disease, and we believe that this may partly account for the recent increase in the use of the reverse TSA in this patient population. Additionally, we found shoulder arthroplasty in RA patients to be safe in the early postoperative period, with no significant increase in cost as compared with patients undergoing shoulder arthroplasty without a diagnosis of RA. Although we did observe a significant increase in length of stay among RA patients as compared with non-RA patients, the absolute difference was only 0.1 days, and given the aforementioned similarities in cost between RA and non-RA patients, we do not believe this difference to be clinically significant.

It has been theorized that the utilization of TJA in RA patients has been decreasing with improvements in medical management; however, this is largely based upon literature pertaining to lower extremity TJA.² On the contrary, past research pertaining to the utilization of shoulder arthroplasty in RA patients has been highly variable. For instance, a Swedish study demonstrated a statistically significant decrease in admissions associated with RA-related upper limb surgery and a stable rate of shoulder arthroplasty between 1998 and 2004.⁷ Similarly, a Finnish study demonstrated that the annual incidence of primary joint arthroplasty in RA patients had declined from 1995 to 2010, with a greater decline for upper-limb arthroplasty as compared with lower-limb arthroplasty.⁸ Despite these European observations, Jain and colleagues⁹ reported an increasing rate of TSA among RA patients in the US between the years 1992 and 2005. In this study, we demonstrate a clear increase in the utilization of shoulder arthroplasty among RA patients between 2002 and 2011. What was most striking about our observation was that the rise in utilization appeared to be driven by an increase in TSA, whereas the utilization of HA decreased over time. This change in practice likely reflects several factors, including the multitude of studies that have demonstrated improved outcomes with anatomic TSA as compared with HA in RA patients.^10-14

Perhaps the most interesting aspect of our data was the recent exponential rise in the utilization of the reverse TSA. Despite improved outcomes following TSA as compared with HA in RA patients, these outcomes all appear to be highly dependent upon the integrity of the rotator cuff.¹⁰ In fact, there is evidence that failure of the rotator cuff could be as high as 75% within 10 years of TSA in patients with RA,¹⁵ which ultimately could jeopardize the long-term durability of the TSA implant in this patient population.¹¹ For this reason, interest in the reverse TSA for the RA patient population has increased since its introduction in the US in 2004;¹⁶ in fact, in RA patients with end-stage inflammatory arthropathy and a damaged rotator cuff, the reverse TSA has demonstrated excellent results.^17-20 Based upon this evidence, it is not surprising that we found an exponential rise in the use of the reverse TSA since 2010, which corresponds to the introduction of an ICD-9 code for this implant.²¹ Prior to 2010, it is likely that many implanted reverse TSAs were coded as TSA, and for this reason, we believe that the observed rise in the utilization of TSA in RA patients prior to 2010 may have been partly fueled by an increase in the use of the reverse TSA. To further support this theory, there was a dramatic decrease in the use of anatomic TSA following 2010, and we believe this was related to increased awareness of the newly introduced reverse TSA code among surgeons.

Another consideration when examining the utilization of shoulder arthroplasty in RA patients is its versatility in managing different disease states, including rotator cuff disease. As has been documented in the literature, outcomes of rotator cuff repair in RA patients are discouraging.²² For this reason, it is reasonable for surgeons and patients with RA to consider alternatives to rotator cuff repair when nonoperative management has failed to provide adequate improvement in symptoms. One alternative may be shoulder arthroplasty, namely the reverse TSA. In this study, we observed a significant increase in the rate of diagnosis of rotator cuff disease among RA patients undergoing shoulder arthroplasty from 2002 to 2011 (9.7% in 2002 to 15.2% in 2011, P < .001), and it is our belief that the simultaneous increase in the diagnosis of rotator cuff disease and use of TSA is not coincidental. More specifically, there is likely an emerging trend among surgeons toward using the reverse TSA to manage rotator cuff tears in the RA population, rather than undertaking a rotator cuff repair that carries a high rate of failure. Going forward, there is a need to not only identify this trend more clearly but to also compare the outcomes between reverse TSA and rotator cuff repair in the management of rotator cuff tears in RA patients.

Continue to: In this study, we observed...

In this study, we observed that RA patients undergoing shoulder arthroplasty were significantly younger than non-RA patients undergoing shoulder arthroplasty. At first, this observation seems to counter recent literature suggesting that the age of patients with inflammatory arthropathy undergoing TJA is increasing over time;¹ however, looking more closely at the data, it becomes clearer that the mean age we report is actually a relative increase as compared with past clinical studies pertaining to RA patients undergoing shoulder arthroplasty (mean ages of 47 years,²³ 55 years,²⁴ 60 years,¹⁰ and 62 years²⁵). On the other hand, the continued existence of an age gap between RA and non-RA patients undergoing shoulder arthroplasty may be the result of several possible phenomena. First, this may reflect issues with patient access to and coverage of expensive biologic antirheumatic medication that would otherwise mitigate disease progression. For instance, the out-of-pocket expense for biologic medication through Medicaid and Medicare is substantial,²⁶which has direct implications on over two-thirds of our RA cohort. Second, it may be skewed by the proportion of RA patients who have previously been or continue to be poorly managed, enabling disease progression to end-stage arthropathy at a younger age. Ultimately, further investigation is needed to determine the reasons for this continued age disparity.

In comparing RA and non-RA patients undergoing shoulder arthroplasty, we did not find a significant difference in the overall nor the individual rates of early adverse events. This finding appears to be unique, as similar studies pertaining to total knee arthroplasty (TKA) demonstrated a significantly higher incidence of postoperative pneumonia and bleeding requiring transfusion among RA patients as compared with non-RA patients.²⁷ In patients with RA being treated with biologic medication and undergoing shoulder arthroplasty, the frequent concern in the postoperative period is the integrity of the wound and the potential for infection.²⁸ In this study, we did not find a significant difference in the rate of early infection, and although the difference in the rate of early wound dehiscence approached significance, it did not meet the threshold of 0.05 (P = .09). This finding is in keeping with the aforementioned NIS study pertaining to TKA, and we believe that it likely reflects the short duration of follow-up for patients in both studies. Given the nature of the database we utilized, we were only privy to complications that arose during the inpatient hospital stay, and it is likely that the clear majority of patients who develop a postoperative infection or wound dehiscence do so in the postoperative setting following discharge. A second concern regarding postoperative wound complications is the management of biologic medication in the perioperative period, which we cannot determine using this database. Despite all these limitations specific to this database, a past systematic review of reverse TSA in RA patients found a low rate of deep infection after reverse TSA in RA patients (3.3%),¹⁷ which was not higher than that after shoulder arthroplasty performed in non-RA patients.

A final demonstration from this study is that the hospital length of stay was significantly longer for RA patients than non-RA patients undergoing shoulder arthroplasty; however, given that the difference was only 0.1 days, and there was no significant difference in hospitalization cost, we are inclined to believe that statistical significance may not translate into clinical significance in this scenario. Ultimately, we do believe that length of stay is an important consideration in the current healthcare system, and given our finding that shoulder arthroplasty in the RA patient is safe in the early postoperative period, that a prolonged postoperative hospitalization is not warranted on the sole basis of a patient’s history of RA.

As with all studies using data from a search of an administrative database, such as the NIS database, this study has limitations. First, this type of research is limited by the reliability of both diagnosis and procedural coding. Although the NIS database has demonstrated high reliability,³ it is still possible that events may have been miscoded. Second, the tracking period for adverse events is limited to the inpatient hospital stay, which may be too short to detect certain postoperative complications. As such, the rates we report are likely underestimates of the true incidence of these complications, but this is true for both the RA and non-RA populations. Third, the comparisons we draw between RA and non-RA patients are limited to the scope of the NIS database and the available data; as such, we could not draw comparisons between preoperative disease stage, intraoperative findings, and postoperative course following hospital discharge. Lastly, our data are limited to a distinct period between 2002 and 2011 and may not reflect current practice. Ultimately, our findings may underestimate current trends in shoulder arthroplasty utilization among RA patients, particularly for the reverse TSA.

CONCLUSION

In this study, we found that the utilization of shoulder arthroplasty in patients with RA increased significantly from 2002 to 2011, largely related to a rise in the utilization of TSA. Similarly, we observed a rise in the proportion of RA patients undergoing shoulder arthroplasty with a corresponding diagnosis of rotator cuff disease, and we believe the increased utilization of shoulder arthroplasty among RA patients resulted from management of both end-stage inflammatory arthropathy and rotator cuff disease. Although we did not find a significant difference between RA and non-RA patients in the rates of early adverse events and overall hospitalization costs following shoulder arthroplasty, length of stay was significantly longer among RA patients; however, the absolute difference does not appear to be clinically significant.

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Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Dr. Leroux is an Assistant Professor, University of Toronto, Toronto, Ontario. Dr. Basques and Dr. Saltzman are Residents, Dr. Nicholson and Dr. Romeo are Professors, and Dr. Verma is an Assistant Professor, Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois.

Address correspondence to: Bryan M. Saltzman, MD, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 (tel, 312-243-4244; fax, 312-942-1517; email, bryan.m.saltzman@gmail.com).

Timothy S. Leroux, MD Bryce A. Basques, MD Bryan M. Saltzman, MD Gregory P. Nicholson, MD Anthony A. Romeo, MD Nikhil N. Verma, MD . Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost. Am J Orthop. June 19, 2018

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Original Research

Author(s)

Timothy S. Leroux, MD

Bryce A. Basques, MD

Bryan M. Saltzman, MD

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

Author(s)

Timothy S. Leroux, MD

Bryce A. Basques, MD

Bryan M. Saltzman, MD

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

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ajo_-_shoulder_arthroplasty_in_patients_with_rheumatoid_arthritis_a_population-based_study_examining_utilization_adverse_events_length_of_stay_and_cost_-_2018-06-20.pdf

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ajo_-_shoulder_arthroplasty_in_patients_with_rheumatoid_arthritis_a_population-based_study_examining_utilization_adverse_events_length_of_stay_and_cost_-_2018-06-20.pdf

ABSTRACT

Continue to: It has been suggested...

METHODS

Appendix A. ICD-9-CM Codes Corresponding to Postoperative Adverse Events

Event	*ICD-9-CM*
Acute kidney injury	584.5-584.9
Cardiac arrest	427.41, 427.5
Thromboembolic event	453.2-453.4, 453.82-453.86, 415.1
Myocardial Infarction	410.00-410.92
Peripheral nerve injury	953.0-953.9 954.0-954.9, 955.0-955.9, 956.0-956.9
Pneumonia	480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 484.1-484.8, 485, 486
Sepsis	038.0-038.9, 112.5, 785.52, 995.91, 995.92
Stroke	430, 432, 433.01-434.91, 997.02
Surgical site infection	998.51, 998.59, 996.67
Urinary tract infection	599
Wound dehiscence	998.30-998.33

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESULTS

Table 2. The Annual Utilization of Shoulder Arthroplasty Among Patients with a Diagnosis of Rheumatoid Arthritis.

Proportion of RA patients
Year	Overall Rate of Shoulder Arthroplasty^a	HA	Anatomic TSA	Reverse TSA
2002	0.39	0.23	0.16	0
2003	0.37	0.19	0.18	0
2004	0.46	0.25	0.21	0
2005	0.46	0.21	0.25	0
2006	0.47	0.20	0.27	0
2007	0.55	0.22	0.33	0
2008	0.47	0.17	0.30	0
2009	0.50	0.15	0.35	0
2010	0.58	0.15	0.37	0.06
2011	0.58	0.12	0.23	0.23
Absolute number of RA patients
2002	1295	768	527	0
2003	1247	650	597	0
2004	1667	906	761	0
2005	1722	776	946	0
2006	1847	794	1053	0
2007	2249	910	1339	0
2008	2194	799	1395	0
2009	2407	724	1683	0
2010	2869	722	1857	290
2011	3193	649	1261	1283

^aRate determined as number of RA patients undergoing shoulder arthroplasty compared to the number of patients with an RA diagnosis in the stated calendar year.

Abbreviations: HA, hemiarthroplasty; RA, rheumatoid arthritis; TSA, total shoulder arthroplasty.

Continue to: Among patients with RA...

Table 3. A Comparison of Early Adverse Events, Length of Stay, and Cost Between Patients With and Without Rheumatoid Arthritis (RA) Undergoing Shoulder Arthroplasty

Comparison of Early Adverse Event Rates
	Non-RA Patients	RA Patients	Multivariate Logistic Regression
	Non-RA Patients	RA Patients	Odds Ratio	P-Value
Overall adverse event rate	3.02%	3.12%	1.0	0.83
Specific adverse event rate
Death	0.08%	0.05%	0.9	0.91
Acute kidney injury	0.85%	0.66%	0.9	0.59
Cardiac arrest	0.05%	0.05%	1.3	0.70
Thromboembolic event	0.01%	0.00%	-	-
Myocardial Infarction	0.22%	0.06%	0.4	0.17
Peripheral nerve injury	0.08%	0.11%	1.5	0.45
Pneumonia	0.47%	0.38%	0.9	0.70
Sepsis	0.08%	0.08%	1.3	0.62
Stroke	0.07%	0.05%	0.9	0.93
Surgical site infection	0.09%	0.13%	1.4	0.52
Urinary tract infection	1.44%	1.80%	1.1	0.46
Wound dehiscence	0.01%	0.05%	3.6	0.09
Comparison of Length of Stay and Hospital Charges
	Non-RA Patients (percent)	RA Patients (percent)	Multivariate Linear Regression
	Non-RA Patients (percent)	RA Patients (percent)	Beta	P-Value
Length of stay^a	2.3±2.0	2.4±1.6	+0.1	0.002
Hospitalization cost^b	14,826±8,336	14,787±7,625	+93	0.59

^aReported in days. ^bReported in 2011 US dollars, adjusted for inflation.

DISCUSSION

Continue to: In this study, we observed...

CONCLUSION

ABSTRACT

Continue to: It has been suggested...

METHODS

Appendix A. ICD-9-CM Codes Corresponding to Postoperative Adverse Events

Event	*ICD-9-CM*
Acute kidney injury	584.5-584.9
Cardiac arrest	427.41, 427.5
Thromboembolic event	453.2-453.4, 453.82-453.86, 415.1
Myocardial Infarction	410.00-410.92
Peripheral nerve injury	953.0-953.9 954.0-954.9, 955.0-955.9, 956.0-956.9
Pneumonia	480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 484.1-484.8, 485, 486
Sepsis	038.0-038.9, 112.5, 785.52, 995.91, 995.92
Stroke	430, 432, 433.01-434.91, 997.02
Surgical site infection	998.51, 998.59, 996.67
Urinary tract infection	599
Wound dehiscence	998.30-998.33

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESULTS

Table 2. The Annual Utilization of Shoulder Arthroplasty Among Patients with a Diagnosis of Rheumatoid Arthritis.

Proportion of RA patients
Year	Overall Rate of Shoulder Arthroplasty^a	HA	Anatomic TSA	Reverse TSA
2002	0.39	0.23	0.16	0
2003	0.37	0.19	0.18	0
2004	0.46	0.25	0.21	0
2005	0.46	0.21	0.25	0
2006	0.47	0.20	0.27	0
2007	0.55	0.22	0.33	0
2008	0.47	0.17	0.30	0
2009	0.50	0.15	0.35	0
2010	0.58	0.15	0.37	0.06
2011	0.58	0.12	0.23	0.23
Absolute number of RA patients
2002	1295	768	527	0
2003	1247	650	597	0
2004	1667	906	761	0
2005	1722	776	946	0
2006	1847	794	1053	0
2007	2249	910	1339	0
2008	2194	799	1395	0
2009	2407	724	1683	0
2010	2869	722	1857	290
2011	3193	649	1261	1283

^aRate determined as number of RA patients undergoing shoulder arthroplasty compared to the number of patients with an RA diagnosis in the stated calendar year.

Abbreviations: HA, hemiarthroplasty; RA, rheumatoid arthritis; TSA, total shoulder arthroplasty.

Continue to: Among patients with RA...

Table 3. A Comparison of Early Adverse Events, Length of Stay, and Cost Between Patients With and Without Rheumatoid Arthritis (RA) Undergoing Shoulder Arthroplasty

Comparison of Early Adverse Event Rates
	Non-RA Patients	RA Patients	Multivariate Logistic Regression
	Non-RA Patients	RA Patients	Odds Ratio	P-Value
Overall adverse event rate	3.02%	3.12%	1.0	0.83
Specific adverse event rate
Death	0.08%	0.05%	0.9	0.91
Acute kidney injury	0.85%	0.66%	0.9	0.59
Cardiac arrest	0.05%	0.05%	1.3	0.70
Thromboembolic event	0.01%	0.00%	-	-
Myocardial Infarction	0.22%	0.06%	0.4	0.17
Peripheral nerve injury	0.08%	0.11%	1.5	0.45
Pneumonia	0.47%	0.38%	0.9	0.70
Sepsis	0.08%	0.08%	1.3	0.62
Stroke	0.07%	0.05%	0.9	0.93
Surgical site infection	0.09%	0.13%	1.4	0.52
Urinary tract infection	1.44%	1.80%	1.1	0.46
Wound dehiscence	0.01%	0.05%	3.6	0.09
Comparison of Length of Stay and Hospital Charges
	Non-RA Patients (percent)	RA Patients (percent)	Multivariate Linear Regression
	Non-RA Patients (percent)	RA Patients (percent)	Beta	P-Value
Length of stay^a	2.3±2.0	2.4±1.6	+0.1	0.002
Hospitalization cost^b	14,826±8,336	14,787±7,625	+93	0.59

^aReported in days. ^bReported in 2011 US dollars, adjusted for inflation.

DISCUSSION

Continue to: In this study, we observed...

CONCLUSION

References

Mertelsmann-Voss C, Lyman S, Pan TJ, Goodman SM, Figgie MP, Mandl LA. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014;66(6):1432-1439. doi:10.1002/art.38384.
Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis. 2010;69(5):868-871. doi:10.1136/ard.2009.112474.
HCUP Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality; 2002-2011.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004.
Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109-1118. doi:10.1097/MLR.0b013e31825f64d0.
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5.
Weiss RJ, Ehlin A, Montgomery SM, Wick MC, Stark A, Wretenberg P. Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatol Oxf. 2008 ;47(4):491-494. doi. 10.1093/rheumatology/ken009.
Jämsen E, Virta LJ, Hakala M, Kauppi MJ, Malmivaara A, Lehto MU. The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010. Acta Orthop. 2013;84(4):331-337. doi:10.3109/17453674.2013.810519.
Jain A, Stein BE, Skolasky RL, Jones LC, Hungerford MW. Total joint arthroplasty in patients with rheumatoid arthritis: a United States experience from 1992 through 2005. J Arthroplasty. 2012;27(6):881-888. doi:10.1016/j.arth.2011.12.027.
Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH, Sperling JW. Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. J Shoulder Elbow Surg. 2014;23(6):791-799. doi:10.1016/j.jse.2013.09.016.
Collins DN, Harryman DT, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am. 2004;86–A(11):2489-2496. doi:10.2106/00004623-200411000-00020.
Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res. 2006;448:28-32. doi:10.1097/01.blo.0000224007.25636.85.
Rozing PM, Nagels J, Rozing MP. Prognostic factors in arthroplasty in the rheumatoid shoulder. HSS J. 2011;7(1):29-36. doi:10.1007/s11420-010-9172-1.
Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg. 2007;16(6):683-690. doi:10.1016/j.jse.2007.02.135.
Khan A, Bunker TD, Kitson JB. Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study. J Bone Joint Surg Br. 2009;91(12):1594-1600. doi:10.1302/0301-620X.91B12.22139.
Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88(8):1742-1747. doi:10.2106/JBJS.E.00851.
Gee ECA, Hanson EK, Saithna A. Reverse shoulder arthroplasty in rheumatoid arthritis: A systematic review. Open Orthop J. 2015;9:237-245. doi:10.2174/1874325001509010237.
Holcomb JO, Hebert DJ, Mighell MA, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg. 2010;19(7):1076-1084. doi:10.1016/j.jse.2009.11.049.
Postacchini R, Carbone S, Canero G, Ripani M, Postacchini F. Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review. Int Orthop. 2016;40(5):965-973. doi:10.1007/s00264-015-2916-2.
Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg. 2001;10(1):17-22. doi:10.1067/mse.2001.110515.
American Medical Association. American Medical Association Web site. www.ama-assn.org/ama. Accessed January 15, 2016.
Smith AM, Sperling JW, Cofield RH. Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg. 2005;87(8):1782-1787. doi:10.2106/JBJS.D.02452.
Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br. 2009;91(9):1197-1200. doi:10.1302/0301-620X.91B9.22035.
Geervliet PC, Somford MP, Winia P, van den Bekerom MP. Long-term results of shoulder hemiarthroplasty in patients with rheumatoid arthritis. Orthopedics. 2015;38(1):e38-e42. doi:10.3928/01477447-20150105-58.
Hettrich CM, Weldon E III, Boorman RS, Parsons M IV, Matsen FA III. Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg. 2004;86–A(7):1446-1451.
Yazdany J, Dudley RA, Chen R, Lin GA, Tseng CW. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-1480. doi:10.1002/art.39079.
Jauregui JJ, Kapadia BH, Dixit A, et al. Thirty-day complications in rheumatoid patients following total knee arthroplasty. Clin Rheumatol. 2016;35(3):595-600. doi:10.1007/s10067-015-3037-4.
Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br. 2002;84(8):1121-1125. doi:10.1302/0301-620X.84B8.0841121

References

Mertelsmann-Voss C, Lyman S, Pan TJ, Goodman SM, Figgie MP, Mandl LA. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014;66(6):1432-1439. doi:10.1002/art.38384.
Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis. 2010;69(5):868-871. doi:10.1136/ard.2009.112474.
HCUP Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality; 2002-2011.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004.
Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109-1118. doi:10.1097/MLR.0b013e31825f64d0.
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5.
Weiss RJ, Ehlin A, Montgomery SM, Wick MC, Stark A, Wretenberg P. Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatol Oxf. 2008 ;47(4):491-494. doi. 10.1093/rheumatology/ken009.
Jämsen E, Virta LJ, Hakala M, Kauppi MJ, Malmivaara A, Lehto MU. The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010. Acta Orthop. 2013;84(4):331-337. doi:10.3109/17453674.2013.810519.
Jain A, Stein BE, Skolasky RL, Jones LC, Hungerford MW. Total joint arthroplasty in patients with rheumatoid arthritis: a United States experience from 1992 through 2005. J Arthroplasty. 2012;27(6):881-888. doi:10.1016/j.arth.2011.12.027.
Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH, Sperling JW. Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. J Shoulder Elbow Surg. 2014;23(6):791-799. doi:10.1016/j.jse.2013.09.016.
Collins DN, Harryman DT, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am. 2004;86–A(11):2489-2496. doi:10.2106/00004623-200411000-00020.
Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res. 2006;448:28-32. doi:10.1097/01.blo.0000224007.25636.85.
Rozing PM, Nagels J, Rozing MP. Prognostic factors in arthroplasty in the rheumatoid shoulder. HSS J. 2011;7(1):29-36. doi:10.1007/s11420-010-9172-1.
Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg. 2007;16(6):683-690. doi:10.1016/j.jse.2007.02.135.
Khan A, Bunker TD, Kitson JB. Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study. J Bone Joint Surg Br. 2009;91(12):1594-1600. doi:10.1302/0301-620X.91B12.22139.
Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88(8):1742-1747. doi:10.2106/JBJS.E.00851.
Gee ECA, Hanson EK, Saithna A. Reverse shoulder arthroplasty in rheumatoid arthritis: A systematic review. Open Orthop J. 2015;9:237-245. doi:10.2174/1874325001509010237.
Holcomb JO, Hebert DJ, Mighell MA, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg. 2010;19(7):1076-1084. doi:10.1016/j.jse.2009.11.049.
Postacchini R, Carbone S, Canero G, Ripani M, Postacchini F. Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review. Int Orthop. 2016;40(5):965-973. doi:10.1007/s00264-015-2916-2.
Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg. 2001;10(1):17-22. doi:10.1067/mse.2001.110515.
American Medical Association. American Medical Association Web site. www.ama-assn.org/ama. Accessed January 15, 2016.
Smith AM, Sperling JW, Cofield RH. Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg. 2005;87(8):1782-1787. doi:10.2106/JBJS.D.02452.
Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br. 2009;91(9):1197-1200. doi:10.1302/0301-620X.91B9.22035.
Geervliet PC, Somford MP, Winia P, van den Bekerom MP. Long-term results of shoulder hemiarthroplasty in patients with rheumatoid arthritis. Orthopedics. 2015;38(1):e38-e42. doi:10.3928/01477447-20150105-58.
Hettrich CM, Weldon E III, Boorman RS, Parsons M IV, Matsen FA III. Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg. 2004;86–A(7):1446-1451.
Yazdany J, Dudley RA, Chen R, Lin GA, Tseng CW. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-1480. doi:10.1002/art.39079.
Jauregui JJ, Kapadia BH, Dixit A, et al. Thirty-day complications in rheumatoid patients following total knee arthroplasty. Clin Rheumatol. 2016;35(3):595-600. doi:10.1007/s10067-015-3037-4.
Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br. 2002;84(8):1121-1125. doi:10.1302/0301-620X.84B8.0841121

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

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There was a significant increase in the utilization of shoulder arthroplasty in RA patients, particularly TSA.
There was a significant increase in the number of RA patients who underwent shoulder arthroplasty with a diagnosis of rotator cuff disease.
There were no significant differences in adverse events or mean hospitalization costs between RA and non-RA patients.
Non-RA patients had a significantly shorter length of stay.
The utilization of shoulder arthroplasty in patients with RA significantly increased from 2002 to 2011, which may partly reflect a trend toward management of rotator cuff disease with arthroplasty rather than repair.

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Open vs Percutaneous vs Arthroscopic Surgical Treatment of Lateral Epicondylitis: An Updated Systematic Review

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Open vs Percutaneous vs Arthroscopic Surgical Treatment of Lateral Epicondylitis: An Updated Systematic Review

Author(s)

Andrew J. Riff, MD

Bryan M. Saltzman, MD

Gregory Cvetanovich, MD

Jonathan M. Frank, MD

Mohamad R. Hemu, BS

Robert W. Wysocki, MD

ABSTRACT

This study was performed to compare outcomes of open, arthroscopic, and percutaneous surgical techniques for lateral epicondylitis. We searched PubMed (MEDLINE) for literature published between January 1, 2004 and May 23, 2015 using these key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). Meta-analyses were performed for outcomes reported in 3 studies using 2-sample and 2-proportion Z-tests. Thirty-five studies including 1640 elbows (1055 open, 401 arthroscopic, 184 percutaneous) met the inclusion criteria. There were no differences between groups regarding duration to return to work, complication rate, or patient satisfaction. A greater proportion of patients were pain free in the open group than in the arthroscopic group (70% vs 60%). Despite the absence of a difference among techniques regarding return to work and subjective function, we recommend open débridement as the technique most likely to achieve a pain-free outcome.

Continue to: Lateral epicondylitis affects...

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

Case series/cohort studies reporting the results of isolated arthroscopic, percutaneous, or open surgical treatment for lateral epicondylitis.
Comparison studies reporting the results of any combination of arthroscopic vs percutaneous versus open surgical treatment for lateral epicondylitis.

Anatomic studies: 11
Systematic reviews: 1
Review articles: 45
Case series/cohort studies reporting the results of isolated arthroscopic, percutaneous, or open surgical treatment for lateral epicondylitis.
Comparison studies reporting the results of any combination of arthroscopic vs percutaneous versus open surgical treatment for lateral epicondylitis.Technique articles: 3
Imaging studies: 6
Case reports: 7
Basic science articles: 2
Erratum to previous studies: 1
Studies in non-English languages: 7
Letters to Editor/Author replies: 2
Surveys to surgeons: 1
Studies assessing other etiologies of elbow pain different from lateral epicondylitis: 7
Studies about available online information on the term lateral epicondylitis: 2
Therapeutic studies on lateral ulnar collateral ligament. reconstruction: 2
Therapeutic studies on injection treatments for lateral epicondylitis: 10
Therapeutic studies on radial shock wave therapy for lateral epicondylitis: 6
Therapeutic studies for radial tunnel syndrome: 1
Technique not addressing extensor origin: 1
Studies evaluating rehabilitation/exercises for musculoskeletal injuries: 3
Studies that were included in the Lo and Safran² systematic review of the literature: 2

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.

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Data from all studies were pooled and descriptive statistics were reported as weighted mean ± weighted standard deviation for continuous variables and frequency with percentage for categorical variables. A meta-analysis was performed for all outcome measures that were reported in 3 or more studies within a specific treatment cohort. Data were analyzed using 2-sample and 2-proportion Z-tests. Results were considered statistically significant at P < .05.

RESULTS

LITERATURE RESEARCH

Using the aforementioned search strategy, 154 studies were identified. Following application of the inclusion and exclusion criteria, 35 studies were included in the analysis (Figure 1). One study compared open and percutaneous techniques, and another compared arthroscopic and percutaneous techniques, rendering a total of 19 studies examining open surgical techniques for treatment of lateral epicondylitis,^3-21 12 studies examining arthroscopic techniques,^14,22-32 and 6 studies reporting percutaneous surgical treatment of lateral epicondylitis^29,33-37 (Table 2). There was1 level I study (3%), 6 level III studies (17%), and 28 level IV studies (80%).

Table 2. Study Demographic Data for Open, Arthroscopic, and Percutaneous Lateral Epicondylectomy

	Open	Arthroscopic	Percutaneous	Total
Number of studies	19	12	6	35
Level of evidence
I	1 (5%)	0	0	1 (3%)
II	0	0	0	0
III	3 (16%)	4 (33%)	1 (17%)	6 (17%)
IV	15 (79%)	8 (67%)	5 (83%)	28 (80%)
US: International	8:12	3:9	1:5	12:24
Journals of publication
AJSM	3	1	1	5
JSES	2	2	1	5
Arthroscopy	2	2	0	3
KSSTA	1	2	0	3
CORR	0	2	0	2
JHS	0	1	0	1
JOS	1	1	0	2
AJO	2	0	0	2
Other	8	1	4	12

Abbreviations: AJO, The American Journal of Orthopedics; AJSM, American Journal of Sports Medicine; Arthroscopy, The Journal of Arthroscopy and Related Surgery; CORR, Clinical Orthopaedics & Related Research; JHS, Journal of Hand Surgery; JOS, Journal of Orthopaedic Surgery; JSES, Journal of Shoulder and Elbow Surgery; KSSTA, Knee Surgery, Sports Traumatology, and Arthroscopy.

SUBJECT DEMOGRAPHICS

The 35 included studies comprised 1579 patients and 1640 elbows. Among these, 1055 (64%) elbows underwent open (O), 401 (25%) underwent arthroscopic (A), and 184 (11%) underwent percutaneous (P) treatment. The average age was 45.7 years, 47% of the patients were male, 43% were laborers, 31% had worker’s compensation claims, and the dominant extremity was involved in 62% of patients. The percutaneous cohort was older than the open cohort (P = 46.9, O = 45.4, A = 45.8; P = .036). The duration of symptoms was shorter in the percutaneous cohort than in the other 2 groups and shorter in the arthroscopic cohort than in the open cohort (P = 8 months, O = 23 months, A = 18 months; P < .001). There were no significant differences between groups regarding gender, occupation, worker’s compensation status, or involvement of the dominant extremity (Table 3).

Table 3. Subject Demographics for Open, Arthroscopic, and Percutaneous Groups

	Open	Arthroscopic	Percutaneous
Subjects (N)	999	397	183
Elbows (N)	1055	401	184
Elbows with follow-up (%)	915 (87%)	350 (87%)	181 (98%)
Males (%)	427 (47%)	173 (49%)	78 (43%)
Females (%)	488 (53%)	177 (51%)	103 (57%)
Mean age (years)	45.4	45.8	46.9
Dominant elbow (%)	70%	69%	53%
Laborer (%)	56%	53%	48%
Work comp (%)	36%	30%	NR
Symptoms to operation (months)	23	18	8
Min. symptoms to operation (months)	6	6	3
Mean follow-up (months)	60	44	11

MATA-ANALYSIS CLINICAL OUTCOMES

Clinical outcome results were pooled for all studies reporting the same outcome measure for the same technique (open, arthroscopic, or percutaneous). A meta-analysis was performed for all outcome measures that were reported in a minimum of 3 studies utilizing the same surgical technique (Table 4).

PAIN RELIEF

Thirteen open studies,^{3,5,7,8,11-16,18,19,21} 7 arthroscopic studies^{14,22-24,26,27,31} and 0 percutaneous studies reported the proportion of patients who were pain free at final follow-up. The proportion of patients who were pain free following open débridement was greater than that in the arthroscopic cohort (O = 70%, A = 60%; P = .009) (Table 4).

Continue to: Subjective improvement and satisfaction...

SUBJECTIVE IMPROVEMENT AND SATISFACTION

Nine open studies, 6 arthroscopic studies, and 1 percutaneous study reported the proportion of patients who felt that their condition had been improved as a result of surgery. There was no difference in the proportion of patients who experienced improvement between the open and arthroscopic cohorts. Four open studies,^3,11,12 5 arthroscopic studies,^{22,26,28,29,32} and 2 percutaneous studies^29,36 reported the proportion of patients who were satisfied or partially satisfied with the results of the procedure. There was no difference between the open and arthroscopic groups in the proportion of patients who were satisfied or partially satisfied (Table 4).

RETURN TO WORK

The duration to return to work following surgery was reported in 5 open studies,^4,5,10,13,14 9 arthroscopic studies,^14,23-29,32 and 2 percutaneous studies.^29,36 There was no statistically significant difference between the open and arthroscopic groups with regard to duration to return to work (O = 6.5 weeks, A = 6 weeks; P = .601). The percutaneous technique could not be included in the meta-analysis due to the presence of only 2 studies, but the pooled mean duration to return to work in these 2 studies was 5.5 weeks (Table 4).

GRIP STRENGTH

Postoperative grip strength was reported in 2 open studies,^10,19 4 arthroscopic studies,^28,30,32 and 2 percutaneous studies.^35-36 A meta-analysis could not be performed on all the groups due to the presence of only 2 open and 2 percutaneous studies reporting grip strength. The pooled averages were O = 38.3 kg, A = 34.8 kg, and P = 27.1 kg (Table 4).

DASH SCORE

The postoperative DASH score was reported in 4 open studies,^{4,15,17,19,20} 5 arthroscopic studies,^28-31 and 3 percutaneous studies.^29,33,36 At final follow-up, the mean DASH score was higher in the arthroscopic group than in the open and percutaneous groups (A = 12.8, O = 19.5, P = 25.3; P < .001 for both comparisons), and the mean DASH score was significantly higher in the open group than in the percutaneous group (P = .029). The reporting of DASH scores in the early postoperative period was not sufficiently consistent to allow us to test our hypothesis that there would be early differences in function between groups (Table 4).

VAS PAIN SCORE

Postoperative VAS pain scores were reported in 11 open studies,^{6,8-10,12,15,19-21} 8 arthroscopic studies,^24-26,29-32 and 5 percutaneous studies.^29,33,35-37 At final follow-up, there was a lower mean VAS score in the arthroscopic group than in the open and percutaneous groups (A = 1.1, O = 1.9, and P = 2.5; P < .001 for both comparisons) and a lower mean VAS score in the open group than in the percutaneous group (P = .002) (Table 4). Reporting of VAS scores in the early postoperative period in the included studies wan not sufficiently consistent to allow us to test our hypothesis that there would be early differences in pain between groups.

COMPLICATIONS

The complication rate was reported in 15 open studies, 10 arthroscopic studies, and 3 percutaneous studies. There was no difference in the complication rate between the open and arthroscopic techniques (O = 2.4%, A = 1.9%; P = .629) (Table 4). Complications noted in the open cohort included superficial wound infection (6), hematoma (5), synovial fistula (2), seroma (2), and posterior interosseous nerve palsy (1). Complications noted in the arthroscopic cohort included superficial infection (3), hematoma (1), and transient paresthesia (1). Of note, there were no complications in the percutaneous group.

Continue to: Discussion...

DISCUSSION

The primary purpose of this review was to determine if definitive evidence suggests that any 1 of open, percutaneous, or arthroscopic surgical treatment is superior to the other 2 for relieving pain, improving functionality, restoring strength, or accelerating return to work. The most striking finding of this study was a significantly higher proportion of patients who were pain free at final follow-up in the open group than in the arthroscopic group (70% vs 60%, P = .009) (Table 4). At final follow-up, there were no significant differences between groups regarding duration to return to work, proportion who were improved, proportion who were satisfied or partially satisfied, and complication rate. Average VAS and DASH scores at final follow-up were lower in the arthroscopic group than in the open and percutaneous groups (Figure 2). However, although the difference between mean DASH scores in the arthroscopic and open groups (6.7 points) was statistically significant, it is likely not clinically significant, as the minimal clinically important difference (MCID) for the DASH score is 10 points, as demonstrated by Sorensen and colleagues.³⁸ Although it has not been specifically defined for lateral epicondylitis, the MCID for VAS pain has been reported in the literature to range from 1.0 to 1.4.^39-40 Therefore, as for the DASH score, the difference witnessed between the open and arthroscopic groups (0.8) is likely not clinically significant. Of note, the differences between values for arthroscopic and percutaneous techniques are greater than the MCID.

Postoperative clinical outcomes following surgery for lateral epicondylitis

In light of a recent increase in the prevalence of surgical intervention for lateral epicondylitis, many authors have promoted arthroscopic and percutaneous techniques as alternatives to traditional open débridement with the goal of achieving the same results with decreased morbidity and accelerated return to work. Given the increased proportion of patients who were pain free at final follow-up in the open cohort, it is our contention that open release/débridement of the common extensor/ECRB origin allows the surgeon to fully appreciate the extent of tendinotic tissue that is contributing to the patient’s symptoms and to address the pathology in its entirety. Other authors have also questioned whether the full extent of extra-articular tendinosis can be accurately identified arthroscopically. Cummins⁴¹ demonstrated, in a series of 18 patients who underwent arthroscopic ECRB débridement, that 6 patients had residual tendinosis upon open evaluation and 10 had residual tendinosis on histologic assessment. Additionally, in the same series, residual tendinopathy was associated with poorer clinical outcomes.

The improved visualization associated with an open technique comes at minimal expense, as the incision was only 1.5 cm to 5 cm in 13 of 15 papers reporting incision length.^{3,4,6,8-11,13,15,18-20} This increased exposure may not translate into increased morbidity, as there was no increase in the duration to return to work nor the complication rate. As a result of the extensive instrumentation necessary for arthroscopic techniques, open techniques also appear to be less expensive. Analyses in the literature have suggested increased expenditures associated with arthroscopic treatment ranging from 23%⁴² to 100%⁴³ greater than those of open treatment.

Although obvious, it should be noted that a percutaneous tenotomy does not permit assessment of the extent of pathologic tendinosis. As a result of an inability to visualize and débride pathologic tissue, percutaneous tenotomy rendered inferior outcomes to open and arthroscopic techniques in terms of both postoperative VAS pain score and DASH score. Nonetheless, it is a relatively rapid and simple technique and resulted in zero complications in 184 elbows. Overall, percutaneous tenotomy appears to be an inferior technique to open and arthroscopic techniques in terms of achieving complete pain relief and optimal functional recovery; however, it may be useful in those who wish to avoid a more invasive intervention.

LIMITATIONS

The most significant limitation of this study was the heterogeneity in the techniques utilized in each group. Among the 19 papers in the open cohort, 11 used techniques aimed at lengthening or release of the extensor origin, 7 performed débridement of tendinotic tissue at the ECRB origin, and 1 compared these approaches. Exposures ranged from 1.5 cm to 8 cm in length, 3 techniques added tendon repair following débridement, and 2 utilized a radiofrequency device.

Among the 12 papers in the arthroscopic cohort, 8 performed arthroscopic (inside-out) débridement of the tendinotic tissue at the ECRB origin, 3 performed arthroscopic release of the ECRB tendon, and 1 performed endoscopic ECRB release in an outside-in fashion. Four techniques added posterior synovial plica excision and 4 added decortication of the lateral epicondyle débridement or release. Some authors advocate for arthroscopic intervention on the grounds that it permits evaluation and correction of other intra-articular pathology. With this in mind, some authors have suggested that a synovial fold (plica) adjacent to the radiocapitellar joint may contribute to lateral elbow pain.^27,44 Nevertheless, in the only comparative trial in the literature, Rhyou and Kim³⁰ demonstrated that excision of posterior synovial fold failed to enhance pain relief or function in a retrospective cohort study comparing arthroscopic débridement with and without plica excision.

Continue to: Some authors advocate...

Some authors advocate decorticating the non-articular, lateral epicondyle with a shaver to stimulate bleeding and promote a healing response. However, 1 study in our review compared arthroscopic ECRB release with and without decortication and found that decortication significantly increased pain up to 4 weeks postoperatively, increased duration to return to work, and did not improve the ultimate clinical result.²⁵ Of note, others have used a similar rationale to advocate drilling the lateral epicondyle when utilizing an open technique. However, Dunn and colleagues⁸ note that they have modified the Nirschl technique to eliminate drilling because they feel it increases postoperative pain and may damage the extensor digitorum communis origin.

Among the 6 papers in the percutaneous tenotomy cohort, 2 performed tenotomy with a hypodermic needle, 2 with a scalpel through a limited incision (0.5 cm-1 cm), 1 using a TX1 tissue removal system (Tenex Health), and 1 with a percutaneous radiofrequency probe. In 3 techniques, ultrasound was used to direct the tenotomy.

The quality of this review is also limited by the studies included for analysis, as with any systematic review. Because 28 of the 35 included studies were classified as evidence level IV, the likelihood of methodological bias is increased. The majority of studies contained ≥1 demonstrable biases, including selection, detection, attrition biases, or a combination. Selection bias is prevalent among predominantly level IV studies, in which the authors have selected their preferred surgical technique. There was heterogeneity in the reporting of preoperative variables and the outcome measures that were utilized. Scoring systems, such as the Nirschl Tennis Elbow Score and the Mayo Elbow Performance Index, would have been valuable in comparing the groups had they been more consistently reported. The heterogeneity in clinical outcome tools and the lack of reported outcome variance or standard deviations prevented a formal meta-analysis of some of these outcome measures. Due to inconsistent reporting, we were also unable to test our hypothesis that there would be less pain and improved function in the arthroscopic and/or percutaneous cohorts in the early postoperative period compared to the open cohort due to the less invasive techniques used. Although the differences in DASH and VAS scores at final follow-up likely did not meet the MCID threshold, these differences may have been greater and more clinically relevant in the early postoperative period.

CONCLUSION

We hypothesized that the arthroscopic and percutaneous groups would experience accelerated return to work and reduced pain in the early postoperative period but no difference in ultimate pain, functional outcome, or subjective satisfaction. There is no difference between open, arthroscopic, and percutaneous surgical treatment for lateral epicondylitis regarding return to work and subjective satisfaction; however, open treatment led to a greater percentage of patients being pain free at final follow-up. While arthroscopic treatment led to better pain and functional scores at final follow-up, the absolute differences were quite small and likely not clinically significant. In light of the available evidence, we recommend open débridement as the best means of minimizing cost and achieving a pain-free outcome in the long term. For future investigators, it would be useful to perform a randomized clinical study directly comparing open, arthroscopic, and percutaneous techniques, including assessment of pain and functional scores in the early postoperative period, and to further evaluate differences in cost among the various techniques.

This paper will be judged for the Resident Writer’s Award.

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Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Dr. Riff is an Attending, Indiana University, Bloomington, Indiana. He was a resident at the time the article was written. Dr. Saltzman is a Resident and Dr. Wysocki is Assistant Professor, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois. Dr. Frank is an Attending Surgeon, Los Angeles, California. Mr. Hemu is a Medical Student, Rosalind Franklin University of Medicine and Science, Chicago, Illinois.

Andrew J. Riff, MD Bryan M. Saltzman, MD Gregory Cvetanovich, MD Jonathan M. Frank, MD Mohamad R. Hemu, BS Robert W. Wysocki, MD . Open vs Percutaneous vs Arthroscopic Surgical Treatment of Lateral Epicondylitis: An Updated Systematic Review. Am J Orthop. June 11, 2018

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Andrew J. Riff, MD

Bryan M. Saltzman, MD

Gregory Cvetanovich, MD

Jonathan M. Frank, MD

Mohamad R. Hemu, BS

Robert W. Wysocki, MD

Author(s)

Andrew J. Riff, MD

Bryan M. Saltzman, MD

Gregory Cvetanovich, MD

Jonathan M. Frank, MD

Mohamad R. Hemu, BS

Robert W. Wysocki, MD

Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Article PDF

ajo_-_open_vs_percutaneous_vs_arthroscopic_surgical_treatment_of_lateral_epicondylitis_an_updated_systematic_review_-_2019-03-28.pdf

Article PDF

ajo_-_open_vs_percutaneous_vs_arthroscopic_surgical_treatment_of_lateral_epicondylitis_an_updated_systematic_review_-_2019-03-28.pdf

ABSTRACT

Continue to: Lateral epicondylitis affects...

METHODS

SEARCH STRATEGY AND STUDY SELECTION

Table 1. Inclusion and Exclusion Criteria for the Analyzed Studies

Inclusion Criteria

Exclusion Criteria

Case series/cohort studies reporting the results of isolated arthroscopic, percutaneous, or open surgical treatment for lateral epicondylitis.
Comparison studies reporting the results of any combination of arthroscopic vs percutaneous versus open surgical treatment for lateral epicondylitis.

Anatomic studies: 11
Systematic reviews: 1
Review articles: 45
Case series/cohort studies reporting the results of isolated arthroscopic, percutaneous, or open surgical treatment for lateral epicondylitis.
Comparison studies reporting the results of any combination of arthroscopic vs percutaneous versus open surgical treatment for lateral epicondylitis.Technique articles: 3
Imaging studies: 6
Case reports: 7
Basic science articles: 2
Erratum to previous studies: 1
Studies in non-English languages: 7
Letters to Editor/Author replies: 2
Surveys to surgeons: 1
Studies assessing other etiologies of elbow pain different from lateral epicondylitis: 7
Studies about available online information on the term lateral epicondylitis: 2
Therapeutic studies on lateral ulnar collateral ligament. reconstruction: 2
Therapeutic studies on injection treatments for lateral epicondylitis: 10
Therapeutic studies on radial shock wave therapy for lateral epicondylitis: 6
Therapeutic studies for radial tunnel syndrome: 1
Technique not addressing extensor origin: 1
Studies evaluating rehabilitation/exercises for musculoskeletal injuries: 3
Studies that were included in the Lo and Safran² systematic review of the literature: 2

DATA EXTRACTION AND ANALYSIS

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESULTS

LITERATURE RESEARCH

Table 2. Study Demographic Data for Open, Arthroscopic, and Percutaneous Lateral Epicondylectomy

	Open	Arthroscopic	Percutaneous	Total
Number of studies	19	12	6	35
Level of evidence
I	1 (5%)	0	0	1 (3%)
II	0	0	0	0
III	3 (16%)	4 (33%)	1 (17%)	6 (17%)
IV	15 (79%)	8 (67%)	5 (83%)	28 (80%)
US: International	8:12	3:9	1:5	12:24
Journals of publication
AJSM	3	1	1	5
JSES	2	2	1	5
Arthroscopy	2	2	0	3
KSSTA	1	2	0	3
CORR	0	2	0	2
JHS	0	1	0	1
JOS	1	1	0	2
AJO	2	0	0	2
Other	8	1	4	12

SUBJECT DEMOGRAPHICS

Table 3. Subject Demographics for Open, Arthroscopic, and Percutaneous Groups

	Open	Arthroscopic	Percutaneous
Subjects (N)	999	397	183
Elbows (N)	1055	401	184
Elbows with follow-up (%)	915 (87%)	350 (87%)	181 (98%)
Males (%)	427 (47%)	173 (49%)	78 (43%)
Females (%)	488 (53%)	177 (51%)	103 (57%)
Mean age (years)	45.4	45.8	46.9
Dominant elbow (%)	70%	69%	53%
Laborer (%)	56%	53%	48%
Work comp (%)	36%	30%	NR
Symptoms to operation (months)	23	18	8
Min. symptoms to operation (months)	6	6	3
Mean follow-up (months)	60	44	11

MATA-ANALYSIS CLINICAL OUTCOMES

PAIN RELIEF

Continue to: Subjective improvement and satisfaction...

SUBJECTIVE IMPROVEMENT AND SATISFACTION

RETURN TO WORK

GRIP STRENGTH

DASH SCORE

VAS PAIN SCORE

COMPLICATIONS

Continue to: Discussion...

DISCUSSION

LIMITATIONS

Continue to: Some authors advocate...

CONCLUSION

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Continue to: Lateral epicondylitis affects...

METHODS

SEARCH STRATEGY AND STUDY SELECTION

Table 1. Inclusion and Exclusion Criteria for the Analyzed Studies

Inclusion Criteria

Exclusion Criteria

Case series/cohort studies reporting the results of isolated arthroscopic, percutaneous, or open surgical treatment for lateral epicondylitis.
Comparison studies reporting the results of any combination of arthroscopic vs percutaneous versus open surgical treatment for lateral epicondylitis.

Anatomic studies: 11
Systematic reviews: 1
Review articles: 45
Case series/cohort studies reporting the results of isolated arthroscopic, percutaneous, or open surgical treatment for lateral epicondylitis.
Comparison studies reporting the results of any combination of arthroscopic vs percutaneous versus open surgical treatment for lateral epicondylitis.Technique articles: 3
Imaging studies: 6
Case reports: 7
Basic science articles: 2
Erratum to previous studies: 1
Studies in non-English languages: 7
Letters to Editor/Author replies: 2
Surveys to surgeons: 1
Studies assessing other etiologies of elbow pain different from lateral epicondylitis: 7
Studies about available online information on the term lateral epicondylitis: 2
Therapeutic studies on lateral ulnar collateral ligament. reconstruction: 2
Therapeutic studies on injection treatments for lateral epicondylitis: 10
Therapeutic studies on radial shock wave therapy for lateral epicondylitis: 6
Therapeutic studies for radial tunnel syndrome: 1
Technique not addressing extensor origin: 1
Studies evaluating rehabilitation/exercises for musculoskeletal injuries: 3
Studies that were included in the Lo and Safran² systematic review of the literature: 2

DATA EXTRACTION AND ANALYSIS

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESULTS

LITERATURE RESEARCH

Table 2. Study Demographic Data for Open, Arthroscopic, and Percutaneous Lateral Epicondylectomy

	Open	Arthroscopic	Percutaneous	Total
Number of studies	19	12	6	35
Level of evidence
I	1 (5%)	0	0	1 (3%)
II	0	0	0	0
III	3 (16%)	4 (33%)	1 (17%)	6 (17%)
IV	15 (79%)	8 (67%)	5 (83%)	28 (80%)
US: International	8:12	3:9	1:5	12:24
Journals of publication
AJSM	3	1	1	5
JSES	2	2	1	5
Arthroscopy	2	2	0	3
KSSTA	1	2	0	3
CORR	0	2	0	2
JHS	0	1	0	1
JOS	1	1	0	2
AJO	2	0	0	2
Other	8	1	4	12

SUBJECT DEMOGRAPHICS

Table 3. Subject Demographics for Open, Arthroscopic, and Percutaneous Groups

	Open	Arthroscopic	Percutaneous
Subjects (N)	999	397	183
Elbows (N)	1055	401	184
Elbows with follow-up (%)	915 (87%)	350 (87%)	181 (98%)
Males (%)	427 (47%)	173 (49%)	78 (43%)
Females (%)	488 (53%)	177 (51%)	103 (57%)
Mean age (years)	45.4	45.8	46.9
Dominant elbow (%)	70%	69%	53%
Laborer (%)	56%	53%	48%
Work comp (%)	36%	30%	NR
Symptoms to operation (months)	23	18	8
Min. symptoms to operation (months)	6	6	3
Mean follow-up (months)	60	44	11

MATA-ANALYSIS CLINICAL OUTCOMES

PAIN RELIEF

Continue to: Subjective improvement and satisfaction...

SUBJECTIVE IMPROVEMENT AND SATISFACTION

RETURN TO WORK

GRIP STRENGTH

DASH SCORE

VAS PAIN SCORE

COMPLICATIONS

Continue to: Discussion...

DISCUSSION

LIMITATIONS

Continue to: Some authors advocate...

CONCLUSION

This paper will be judged for the Resident Writer’s Award.

References

Sanders TL Jr, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015;43(5):1066-1071. doi:10.1177/0363546514568087.
Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res. 2007;463:98-106. doi:10.1097/BLO.0b013e3181483dc4.
Balk ML, Hagberg WC, Buterbaugh GA, Imbriglia JE. Outcome of surgery for lateral epicondylitis (tennis elbow): effect of worker’s compensation. Am J Orthop. 2005;34(3):122-126; discussion 126.
Barth J, Mahieu P, Hollevoet N. Extensor tendon and fascia sectioning of extensors at the musculotendinous unit in lateral epicondylitis. Acta Orthop Belg. 2013;79(3):266-270.
Bigorre N, Raimbeau G, Fouque PA, Cast YS, Rabarin F, Cesari B. Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: is outcome influenced by the occupational disease compensation aspect? Orthop Traumatol Surg Res. 2011;97(2):159-163. doi:10.1016/j.otsr.2010.11.007.
Cho BK, Kim YM, Kim DS, et al. Mini-open muscle resection procedure under local anesthesia for lateral and medial epicondylitis. Clin Orthop Surg. 2009;1(3):123-127. doi:10.4055/cios.2009.1.3.123.
Coleman B, Quinlan JF, Matheson JA. Surgical treatment for lateral epicondylitis: a long-term follow-up of results. J Shoulder Elbow Surg. 2010;19(3):363-367. doi:10.1016/j.jse.2009.09.008.
Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 2008;36(2):261-266. doi:10.1177/0363546507308932.
Manon-Matos Y, Oron A, Wolff TW. Combined common extensor and supinator aponeurotomy for the treatment of lateral epicondylitis. Tech Hand Up Extrem Surg. 2013;17(3):179-181. doi:10.1097/BTH.0b013e31829e0eeb.
Meknas K, Odden-Miland A, Mercer JB, Castillejo M, Johansen O. Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis. Am J Sports Med. 2008;36(10):1960-1965. doi:10.1177/0363546508318045.
Pruzansky ME, Gantsoudes GD, Watters N. Late surgical results of reattachment to bone in repair of chronic lateral epicondylitis. Am J Orthop. 2009;38(6):295-299.
Rayan F, Rao V Sr, Purushothamdas S, Mukundan C, Shafqat SO. Common extensor origin release in recalcitrant lateral epicondylitis – role justified? J Orthop Surg Res. 2010;5:31. doi:10.1186/1749-799X-5-31.
Reddy VR, Satheesan KS, Bayliss N. Outcome of Boyd-McLeod procedure for recalcitrant lateral epicondylitis of elbow. Rheumatol Int. 2011;31(8):1081-1084. doi:10.1007/s00296-010-1450-1.
Rubenthaler F, Wiese M, Senge A, Keller L, Wittenberg RH. Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis. Arthroscopy. 2005;21(6):684-690. doi:10.1016/j.arthro.2005.03.017.
Ruch DS, Orr SB, Richard MJ, Leversedge FJ, Mithani SK, Laino DK. A comparison of debridement with and without anconeus muscle flap for treatment of refractory lateral epicondylitis. J Shoulder Elbow Surg. 2015;24(2):236-241. doi:10.1016/j.jse.2014.09.035.
Siddiqui MA, Koh J, Kua J, Cheung T, Chang P. Functional outcome assessment after open tennis elbow release: what are the predictor parameters? Singapore Med J. 2011;52(2):73-76.
Solheim E, Hegna J, Øyen J. Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):1023-1027. doi:10.1007/s00167-011-1477-1.
Svernlöv B, Adolfsson L. Outcome of release of the lateral extensor muscle origin for epicondylitis. Scand J Plast Reconstr Surg Hand Surg. 2006;40(3):161-165. doi:10.1080/02844310500491492.
Tasto JP, Cummings J, Medlock V, Hardesty R, Amiel D. Microtenotomy using a radiofrequency probe to treat lateral epicondylitis. Arthroscopy. 2005;21(7):851-860. doi:10.1016/j.arthro.2005.03.019.
Thornton SJ, Rogers JR, Prickett WD, Dunn WR, Allen AA, Hannafin JA. Treatment of recalcitrant lateral epicondylitis with suture anchor repair. Am J Sports Med. 2005;33(10):1558-1564. doi:10.1177/0363546505276758.
Wang AW, Erak S. Fractional lengthening of forearm extensors for resistant lateral epicondylitis. ANZ J Surg. 2007;77(11):981-984. doi:10.1111/j.1445-2197.2007.04294.x.
Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008;36(2):254-260. doi:10.1177/0363546507311599.
Grewal R, MacDermid JC, Shah P, King GJ. Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis. J Hand Surg Am. 2009;34(5):849-857. doi:10.1016/j.jhsa.2009.02.006.
Jerosch J, Schunck J. Arthroscopic treatment of lateral epicondylitis: indication, technique and early results. Knee Surg Sports Traumatol Arthrosc. 2006;14(4):379-382. doi:10.1007/s00167-005-0662-5.
Kim JW, Chun CH, Shim DM, et al. Arthroscopic treatment of lateral epicondylitis: comparison of the outcome of ECRB release with and without decortication. Knee Surg Sports Traumatol Arthrosc. 2011;19(7):1178-1183. doi:10.1007/s00167-011-1507-z.
Lattermann C, Romeo AA, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(5):651-656. doi:10.1016/j.jse.2010.02.008.
Mullett H, Sprague M, Brown G, Hausman M. Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies. Clin Orthop Relat Res. 2005;439:123-128. doi:10.1097/01.blo.0000176143.08886.fe.
Oki G, Iba K, Sasaki K, Yamashita T, Wada T. Time to functional recovery after arthroscopic surgery for tennis elbow. J Shoulder Elbow Surg. 2014;23(10):1527-1531. doi:10.1016/j.jse.2014.05.010.
Othman AM. Arthroscopic versus percutaneous release of common extensor origin for treatment of chronic tennis elbow. Arch Orthop Trauma Surg. 2011;131(3):383-388. doi:10.1007/s00402-011-1260-2.
Rhyou IH, Kim KW. Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow? Clin Orthop Relat Res. 2013;471(1):284-290. doi:10.1007/s11999-012-2585-z.
Wada T, Moriya T, Iba K, et al. Functional outcomes after arthroscopic treatment of lateral epicondylitis. J Orthop Sci. 2009;14(2):167-174. doi:10.1007/s00776-008-1304-9.
Yoon JP, Chung SW, Yi JH, et al. Prognostic factors of arthroscopic extensor carpi radialis brevis release for lateral epicondylitis. Arthroscopy. 2015;31(7):1232-1237. doi:10.1016/j.arthro.2015.02.006.
Barnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. J Shoulder Elbow Surg. 2015;24(1):67-73. doi:10.1016/j.jse.2014.07.017.
Kaleli T, Ozturk C, Temiz A, Tirelioglu O. Surgical treatment of tennis elbow: percutaneous release of the common extensor origin. Acta Orthop Belg. 2004;70(2):131-133.
Lin MT, Chou LW, Chen HS, Kao MJ. Percutaneous soft tissue release for treating chronic recurrent myofascial pain associated with lateral epicondylitis: 6 case studies. Evid Based Complement Alternat Med. 2012;2012:142941. doi:10.1155/2012/142941.
Lin CL, Lee JS, Su WR, Kuo LC, Tai TW, Jou IM. Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis. Am J Sports Med. 2011;39(11):2429-2435. doi:10.1177/0363546511417096.
Zhu J, Hu B, Xing C, Li J. Ultrasound-guided, minimally invasive, percutaneous needle puncture treatment for tennis elbow. Adv Ther. 2008;25(10):1031-1036. doi:10.1007/s12325-008-0099-6.
Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-related outcomes instruments. J Hand Surg Am. 2013;38(4):641-649. doi:10.1016/j.jhsa.2012.12.032.
Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J. 2001;18(3):205-207. doi:10.1136/emj.18.3.205.
Tashjian RZ, Deloach J, Porucznik CA, Powell AP. Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg. 2009;18(6):927-932. doi:10.1016/j.jse.2009.03.021.
Cummins CA. Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes. Am J Sports Med. 2006;34(9):1486-1491. doi:10.1177/0363546506288016.
Stapleton TR, Baker CL. Arthroscopic treatment of lateral epicondylitis: a clinical study. Arthroscopy. 1996;1:365-366.
Hastings H. Open treatment for lateral tennis elbow good for certain indications. Orthop Today. 2009;2:1-2.
Duparc F, Putz R, Michot C, Muller JM, Fréger P. The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat. 2002;24(5):302-307. doi:10.1007/s00276-002-0055-0.

References

Sanders TL Jr, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015;43(5):1066-1071. doi:10.1177/0363546514568087.
Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res. 2007;463:98-106. doi:10.1097/BLO.0b013e3181483dc4.
Balk ML, Hagberg WC, Buterbaugh GA, Imbriglia JE. Outcome of surgery for lateral epicondylitis (tennis elbow): effect of worker’s compensation. Am J Orthop. 2005;34(3):122-126; discussion 126.
Barth J, Mahieu P, Hollevoet N. Extensor tendon and fascia sectioning of extensors at the musculotendinous unit in lateral epicondylitis. Acta Orthop Belg. 2013;79(3):266-270.
Bigorre N, Raimbeau G, Fouque PA, Cast YS, Rabarin F, Cesari B. Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: is outcome influenced by the occupational disease compensation aspect? Orthop Traumatol Surg Res. 2011;97(2):159-163. doi:10.1016/j.otsr.2010.11.007.
Cho BK, Kim YM, Kim DS, et al. Mini-open muscle resection procedure under local anesthesia for lateral and medial epicondylitis. Clin Orthop Surg. 2009;1(3):123-127. doi:10.4055/cios.2009.1.3.123.
Coleman B, Quinlan JF, Matheson JA. Surgical treatment for lateral epicondylitis: a long-term follow-up of results. J Shoulder Elbow Surg. 2010;19(3):363-367. doi:10.1016/j.jse.2009.09.008.
Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 2008;36(2):261-266. doi:10.1177/0363546507308932.
Manon-Matos Y, Oron A, Wolff TW. Combined common extensor and supinator aponeurotomy for the treatment of lateral epicondylitis. Tech Hand Up Extrem Surg. 2013;17(3):179-181. doi:10.1097/BTH.0b013e31829e0eeb.
Meknas K, Odden-Miland A, Mercer JB, Castillejo M, Johansen O. Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis. Am J Sports Med. 2008;36(10):1960-1965. doi:10.1177/0363546508318045.
Pruzansky ME, Gantsoudes GD, Watters N. Late surgical results of reattachment to bone in repair of chronic lateral epicondylitis. Am J Orthop. 2009;38(6):295-299.
Rayan F, Rao V Sr, Purushothamdas S, Mukundan C, Shafqat SO. Common extensor origin release in recalcitrant lateral epicondylitis – role justified? J Orthop Surg Res. 2010;5:31. doi:10.1186/1749-799X-5-31.
Reddy VR, Satheesan KS, Bayliss N. Outcome of Boyd-McLeod procedure for recalcitrant lateral epicondylitis of elbow. Rheumatol Int. 2011;31(8):1081-1084. doi:10.1007/s00296-010-1450-1.
Rubenthaler F, Wiese M, Senge A, Keller L, Wittenberg RH. Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis. Arthroscopy. 2005;21(6):684-690. doi:10.1016/j.arthro.2005.03.017.
Ruch DS, Orr SB, Richard MJ, Leversedge FJ, Mithani SK, Laino DK. A comparison of debridement with and without anconeus muscle flap for treatment of refractory lateral epicondylitis. J Shoulder Elbow Surg. 2015;24(2):236-241. doi:10.1016/j.jse.2014.09.035.
Siddiqui MA, Koh J, Kua J, Cheung T, Chang P. Functional outcome assessment after open tennis elbow release: what are the predictor parameters? Singapore Med J. 2011;52(2):73-76.
Solheim E, Hegna J, Øyen J. Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):1023-1027. doi:10.1007/s00167-011-1477-1.
Svernlöv B, Adolfsson L. Outcome of release of the lateral extensor muscle origin for epicondylitis. Scand J Plast Reconstr Surg Hand Surg. 2006;40(3):161-165. doi:10.1080/02844310500491492.
Tasto JP, Cummings J, Medlock V, Hardesty R, Amiel D. Microtenotomy using a radiofrequency probe to treat lateral epicondylitis. Arthroscopy. 2005;21(7):851-860. doi:10.1016/j.arthro.2005.03.019.
Thornton SJ, Rogers JR, Prickett WD, Dunn WR, Allen AA, Hannafin JA. Treatment of recalcitrant lateral epicondylitis with suture anchor repair. Am J Sports Med. 2005;33(10):1558-1564. doi:10.1177/0363546505276758.
Wang AW, Erak S. Fractional lengthening of forearm extensors for resistant lateral epicondylitis. ANZ J Surg. 2007;77(11):981-984. doi:10.1111/j.1445-2197.2007.04294.x.
Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008;36(2):254-260. doi:10.1177/0363546507311599.
Grewal R, MacDermid JC, Shah P, King GJ. Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis. J Hand Surg Am. 2009;34(5):849-857. doi:10.1016/j.jhsa.2009.02.006.
Jerosch J, Schunck J. Arthroscopic treatment of lateral epicondylitis: indication, technique and early results. Knee Surg Sports Traumatol Arthrosc. 2006;14(4):379-382. doi:10.1007/s00167-005-0662-5.
Kim JW, Chun CH, Shim DM, et al. Arthroscopic treatment of lateral epicondylitis: comparison of the outcome of ECRB release with and without decortication. Knee Surg Sports Traumatol Arthrosc. 2011;19(7):1178-1183. doi:10.1007/s00167-011-1507-z.
Lattermann C, Romeo AA, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(5):651-656. doi:10.1016/j.jse.2010.02.008.
Mullett H, Sprague M, Brown G, Hausman M. Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies. Clin Orthop Relat Res. 2005;439:123-128. doi:10.1097/01.blo.0000176143.08886.fe.
Oki G, Iba K, Sasaki K, Yamashita T, Wada T. Time to functional recovery after arthroscopic surgery for tennis elbow. J Shoulder Elbow Surg. 2014;23(10):1527-1531. doi:10.1016/j.jse.2014.05.010.
Othman AM. Arthroscopic versus percutaneous release of common extensor origin for treatment of chronic tennis elbow. Arch Orthop Trauma Surg. 2011;131(3):383-388. doi:10.1007/s00402-011-1260-2.
Rhyou IH, Kim KW. Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow? Clin Orthop Relat Res. 2013;471(1):284-290. doi:10.1007/s11999-012-2585-z.
Wada T, Moriya T, Iba K, et al. Functional outcomes after arthroscopic treatment of lateral epicondylitis. J Orthop Sci. 2009;14(2):167-174. doi:10.1007/s00776-008-1304-9.
Yoon JP, Chung SW, Yi JH, et al. Prognostic factors of arthroscopic extensor carpi radialis brevis release for lateral epicondylitis. Arthroscopy. 2015;31(7):1232-1237. doi:10.1016/j.arthro.2015.02.006.
Barnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. J Shoulder Elbow Surg. 2015;24(1):67-73. doi:10.1016/j.jse.2014.07.017.
Kaleli T, Ozturk C, Temiz A, Tirelioglu O. Surgical treatment of tennis elbow: percutaneous release of the common extensor origin. Acta Orthop Belg. 2004;70(2):131-133.
Lin MT, Chou LW, Chen HS, Kao MJ. Percutaneous soft tissue release for treating chronic recurrent myofascial pain associated with lateral epicondylitis: 6 case studies. Evid Based Complement Alternat Med. 2012;2012:142941. doi:10.1155/2012/142941.
Lin CL, Lee JS, Su WR, Kuo LC, Tai TW, Jou IM. Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis. Am J Sports Med. 2011;39(11):2429-2435. doi:10.1177/0363546511417096.
Zhu J, Hu B, Xing C, Li J. Ultrasound-guided, minimally invasive, percutaneous needle puncture treatment for tennis elbow. Adv Ther. 2008;25(10):1031-1036. doi:10.1007/s12325-008-0099-6.
Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-related outcomes instruments. J Hand Surg Am. 2013;38(4):641-649. doi:10.1016/j.jhsa.2012.12.032.
Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J. 2001;18(3):205-207. doi:10.1136/emj.18.3.205.
Tashjian RZ, Deloach J, Porucznik CA, Powell AP. Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg. 2009;18(6):927-932. doi:10.1016/j.jse.2009.03.021.
Cummins CA. Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes. Am J Sports Med. 2006;34(9):1486-1491. doi:10.1177/0363546506288016.
Stapleton TR, Baker CL. Arthroscopic treatment of lateral epicondylitis: a clinical study. Arthroscopy. 1996;1:365-366.
Hastings H. Open treatment for lateral tennis elbow good for certain indications. Orthop Today. 2009;2:1-2.
Duparc F, Putz R, Michot C, Muller JM, Fréger P. The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat. 2002;24(5):302-307. doi:10.1007/s00276-002-0055-0.

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Open vs Percutaneous vs Arthroscopic Surgical Treatment of Lateral Epicondylitis: An Updated Systematic Review

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TAKE-HOME POINTS

While favorable results have been reported for open, arthroscopic, and percutaneous surgical techniques, there is no current consensus regarding the optimal technique for lateral epicondylitis.
There is no difference between open, arthroscopic, and percutaneous surgical treatment for lateral epicondylitis regarding return to work and subjective satisfaction.
Open treatment led to a greater percentage of patients being pain free at final follow-up.
While arthroscopic treatment led to better pain and functional scores at final follow-up, the absolute differences were quite small and likely not clinically significant.
We recommend open débridement as the best means of minimizing cost and achieving a pain-free outcome in the long-term.

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A Systematic Review of 21 Tibial Tubercle Osteotomy Studies and More Than 1000 Knees: Indications, Clinical Outcomes, Complications, and Reoperations

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Author(s)

Bryan M. Saltzman, MD

Allison Rao, MD

Brandon J. Erickson, MD

Gregory L. Cvetanovich, MD

David Levy, MD

Bernard R. Bach, Jr, MD

Brian J. Cole, MD, MBA

Take-Home Points

TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects.
Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.
TTO was most commonly performed for isolated patellar instability in the presence of knee pain.
Young women with prior surgery on the affected knee made up the primary patient population for this procedure.
While TTO significantly improves knee pain and clinical outcome scores, >1 in 5 patients required reoperation for hardware removal.

Patellofemoral pain and patellofemoral instability are common orthopedic problems. Studies have found that 30% of patients 13 to 19 years old have patellofemoral pain and that 29 in 100,000 patients 10 to 17 years old have patellofemoral instability.^1-3 The reported rate of recurrence after nonoperative management of patellofemoral instability is 33%.⁴ Tibial tubercle osteotomy (TTO), first described by Hauser⁵ in 1938, is an effective treatment option for many patellofemoral disorders.

TTO indications include patellofemoral maltracking or malalignment, patellar instability, patellofemoral arthritis, and focal patellofemoral chondral defects.⁶ With TTO, the goal is to move the tibial tubercle in a direction that will either improve patellar tracking or offload the medial or lateral patellar facet to improve pain and function.^7,8 This action typically involves anterior, medial, lateral, or distal translation of the tibial tubercle, as posteriorization can lead to increased contact forces across the patellofemoral joint, resulting in accelerated patellofemoral wear and increased pain.⁹

We systematically reviewed the TTO literature to identify indications, clinical outcomes, complications, and reoperations. We hypothesized that the overall complication rate and the overall reoperation rate would both be <10%.

Clinical Evaluation of Patellofemoral Pathology

Patients with patellofemoral pain often report anterior knee pain, which typically begins gradually and is often activity related. Several symptoms may be present: pain with prolonged sitting with knees bent; pain on rising from a seated position; pain or crepitus with climbing stairs; and pain during repetitive activity such as running, squatting, or jumping. Location, duration, and onset of symptoms should be elicited. Patellofemoral instability can be described as dislocation events or subluxation events; number of events, mechanisms of injury, and resulting need for reduction should be documented. As age, sex, body mass index, and physical fitness are relevant to risk of recurrence, the physician should ask about general ligamentous laxity, other joint dislocations, and prior surgical intervention. Swelling or mechanical symptoms may indicate patellofemoral joint pathology.^6,10

Physical examination of patients with patellofemoral pathology begins with assessment for overall limb alignment (including resting position of patella and corresponding quadriceps angle [Q-angle]), generalized ligamentous laxity (including hypermobile joints, evaluated with Brighton criteria), overall peri-knee muscle tone and strength, effusion, and gait pattern.

Knee and hip range of motion should be documented. Apprehension (Figure 1) and lack of a firm endpoint on placement of a lateralizing moment on the patella suggest prior dislocation or subluxation. Patella and surrounding anatomy must be palpated for location and severity of tenderness. Finally, patellar tilt, height, mobility, and dynamic tracking, including J-sign, are pertinent to evaluation. The J-sign for patellar tracking is positive when the patella deviates laterally as the knee moves from flexion into extension. Examination of the asymptomatic contralateral side is essential for comparison. Plain radiographs are important first-line imaging. Computed tomography or magnetic resonance imaging can be used to measure tibial tubercle-trochlear groove (TT-TG) distance. TT-TG distance of >15 mm is abnormal, and >20 mm indicates TTO is required. Advanced imaging is additionally valuable in assessing for chondral injury or trochlear dysplasia.^6,10

Common TTO Procedures

TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects. Essentially, the patella is translated to offload the affected areas. Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.

Lateralization or anterolateralization may be pertinent to revision if an osteotomy direction results in overcorrection of tuberosity position. Anteriorization (Figures 2A-2C) does not have a role in patellofemoral instability, but can unload areas of excessive patellar chondral force concentration at the central or proximal patella by increasing the angle between the patellar and quadriceps tendons and thereby decreasing the joint reaction forces.

Straight medialization (Figures 3A, 3B) offloads lateral patellar chondral injury and may decrease lateral instability.

Distalization (Figures 4A-4C) can correct for patella alta in the setting of patellar instability and allows earlier engagement of the patella in the trochlea to increase osseous restraint to lateral translation.⁶

Anteromedialization (Figure 5) is indicated in patients with a normal proximal and medial patellar chondral surface and a laterally positioned patella leading to alteration of the contact area in the trochlear groove and resulting pain, lateral patellar or trochlear chondral disease, or instability. Osteotomy angle can provide varied medialization through consistent slope and anteriorization. For example, a 60° slope osteotomy provides 9 mm of medialization with 15 mm of anteriorization.⁶The procedure, similar to the additional TTO operations, begins with a lateral parapatellar incision that is extended distal to the tibial tubercle and anterior over the crest. The soft tissues around the tubercle are released to allow mobilization.

Variable osteotomy jigs allow for different slope cuts for more medialization or anteriorization, based on preoperative findings. The osteotomy cuts are started with a thin oscillating blade (Figure 6) and finished with an osteotome.

The tubercle fragment (Figure 7) is shifted and provisionally fixed with a Kirschner wire before being drilled and fixated with two 4.5-mm countersunk cortical screws (Figures 8, 9A-9B).

Locally harvested corticocancellous bone can help anteriorize the tubercle block. Osteotomy specifics allow for corresponding anatomical translations of the TTO to address the preoperative pathology.

Methods

Search Strategy and Data Collection

We searched the PubMed (Medline) database for all English-language TTO studies published between database inception and April 9, 2015. After PROSPERO registration, and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we used the algorithm (“tibial” AND “tubercle” AND “osteotomy”) NOT (“total” AND “knee” AND “arthroplasty”) to search the literature. Inclusion criteria included level I-IV studies on TTO indications, operative findings, and outcomes. Exclusion criteria were non-English studies, unpublished studies, level V evidence, letters to the editor, editorials, review articles, basic science articles, technique articles, revision procedures, articles without clinical outcomes, and conference proceeding abstracts. Studies that reported on duplicate populations were included only with the most recent available clinical outcomes. All abstracts were reviewed in duplicate by Dr. Levy and Dr. Rao and assessed with respect to the criteria outlined. Then the same authors performed full-text reviews of eligible studies before including these studies in the systematic review.

They also manually checked the references in study articles to identify additional studies for possible inclusion in the review. A standardized form created by the authors at the start of the review was used to extract data (Table 1).

Assessment of Study Quality

The quality of each TTO study in the review was assessed with a modified Coleman methodology score (MCMS), which ranges from 0 to 100. A study with an MCMS of <55 points is considered a poor-quality study.¹¹

Data Synthesis and Statistical Analysis

Given that most of the included studies were level IV, a formal meta-analysis was not indicated. In this article, we report categorical data as frequencies with percentages and preoperative and postoperative continuous data as means (SDs), with weighted means based on number of patients in each study, where applicable. We used 2-tailed t tests for comparisons made with the free Meta-Analysis Calculator and Grapher (http://www.healthstrategy.com/meta/meta.pl ). Statistical significance was set at P < .05.

Results

Search Results and Included Studies

Twenty-one studies (976 patients, 1055 knees) were included in the analysis (Figure 10; Table 2).^12-32 These studies were published between 1986 and 2013. There were 18 level IV studies (85.7%), 3 level III studies (14%), and no level I or II studies. Better quality studies had a mean (SD) MCMS of 19.8 (8.2), well under the 55-point cutoff. In the 16 studies that reported sex, women accounted for 69% of the population. Weighted mean (SD) age was 27.68 (10.45) years (range, 12-77 years) (18 studies reporting).

Only 1 study provided preoperative body mass index (27 kg/m2). There were 55.35% of patients who had prior surgery on the affected knee (6 studies reporting).

Preoperative Data

Preoperative pathologic, radiographic, and clinical scoring data were scarcely reported and nonuniform (Table 2). The most common pathology treated with TTO was isolated patellofemoral instability (746/1055 patients, 70.7%). The other pathologies addressed were isolated patellofemoral osteoarthritis/chondromalacia patellae (143, 13.6%), patellofemoral instability with patella alta (61, 5.8%), patellofemoral instability with patellofemoral osteoarthritis (45, 4.3%), isolated patella baja (41, 3.9%), isolated patella alta (19, 1.8%), and patellofemoral osteoarthritis with patella baja (2, 0.2%). Five hundred fifty-five patients (53%) had a preoperative complaint that included knee pain, and 809 (77%) reported preoperative patellar laxity or instability events. The imaging data reported were Q-angle, Insall-Salvati ratio, Caton-Deschamps index, Blackburne-Peel ratio, Outerbridge osteoarthritis grade, and TT-TG distance. Preoperative clinical scoring data most prominently included a visual analog scale (VAS) score of 70.50 (4 studies reporting), a Lysholm score of 59.19 (5 studies), and a Kujala score of 41.16 (4 studies). Shelbourne-Trumper and Cox-Insall scores were reported in 1 and 2 studies, respectively.

Operative Characteristics

Of the 21 studies, 12 reported only on patients who had TTO performed in isolation; in the other 9 studies, cohorts included patients who underwent concurrent procedures. In the 17 studies (856 patients) that listed numbers of patients who underwent specific concomitant procedures, 715 patients (83.5%) underwent an isolated TTO procedure, and the other 141 (16.5%) underwent either concomitant lateral femoral trochleoplasty, arthroscopic drilling of chondral lesions, patellar shaving chondroplasty, partial meniscectomy or concomitant meniscal repair, intra-articular loose body removal, and/or lateral release with or without medial plication.

Twenty studies reported specifics on the intraoperative direction of the tibial bone block osteotomy (Table 3). In most cases (50.8%), anteromedial translation (anteromedialization) was performed; anteriorization was performed in 18.7% of cases, medialization in 9.6%, medial and distal translation in 7.2%, a “triple” (anteriorization, medialization, proximalization) in 6%, isolated distalization in 2.8%, and proximalization in 1.6%. The remaining 2.8% of procedure specifics were not identified.

Postoperative Data

Table 4 lists the overall cohort’s postoperative radiographic, clinical outcome scoring, and complications data. Fifteen studies reported follow-up of >2 years. As with the preoperative data, radiographic and clinical scoring data were relatively nonuniform; some numeric data, however, should be highlighted. Statistical analysis allowed for comparison of preoperative-postoperative VAS, Lysholm, and Kujala scores, each of which was significantly higher after surgery (P < .001). Seven studies reported an overall clinical outcome rating, with the cumulative majority of patients reporting good (37.9%) or excellent (39.2%) results.

There was a cumulative total of 79 complications (8% of cohort): 17 recurrent patellar dislocations (1.9%), 4 recurrent patellar subluxations (0.4%), 10 wound complications (1.0%), 2 intraoperative complications (0.2%), 14 tibial tubercle fractures (1.3%), 19 proximal tibia fractures (1.8%), 4 cases of anterior knee pain (0.4%), 4 cases of neuropraxia (0.4%), and 5 infections (0.5%). Of note, 219 knees (21%) required reoperation, but 170 (16.3%) of these were for painful hardware removal. Sixteen knees (1.5%) required revision TTO, 1 (0.1%) required subsequent high tibial osteotomy, 2 (0.2%) underwent patellofemoral arthroplasty for advanced arthritic changes, and 5 (0.5%) underwent total knee arthroplasty for advanced arthritic changes.

Studies With TTO Performed in Isolation

Twelve studies reported outcomes of isolated TTO procedures. In the 638 patients who underwent isolated TTO, the pathologies addressed were instability/laxity (429 patients, 67%), patellofemoral osteoarthritis (74, 12%), patella alta with instability (61, 10%), patellofemoral osteoarthritis with instability (31, 5%), patella baja (24, 4%), and patella alta (19, 3%). Pain was a preoperative issue in 289 (45%) of these patients and instability in 472 (74%).

Only 2.8% of patients experienced postoperative patellar dislocation events. Of the 12 studies, 2 reported VAS scores (34-point weighted mean improvement, 65 points before surgery to 31 after surgery), 3 reported Lysholm scores (30-point improvement, from 60 to 90), and 2 reported Kujala scores (21-point improvement, from 46 to 67).

Complication rates for this isolated-TTO pooled cohort of patients were 1.2% for revision TTOs, 0.5% for wound complications, 0.8% for tibial tubercle fractures, and 1.9% for proximal tibia fractures. In total, 16% of patients required hardware removal after surgery.

Discussion

This study found that TTO improved patient pain and clinical outcome scores despite having a high (16%) rate of reoperation for painful hardware in patients with preoperative pain or instability, or with patellofemoral osteoarthritis or aberrant patellar anatomy. This reoperation rate and the overall complication rate both exceeded our hypothesized 10% cumulative rate. However, <1% of patients required conversion to a definitive end-stage surgery (patellofemoral arthroplasty or total knee arthroplasty) by final follow-up, and the rates of comorbidities (anterior knee pain, wound infection, recurrent patellar subluxation/dislocation, tibial fracture) were relatively low.

Patellofemoral disorders are common in the general population and a frequent primary complaint on presentation to orthopedic offices. Having a thorough understanding of knee joint biomechanics is imperative when trying to determine whether surgery is appropriate for these complaints and how to proceed. Extensor mechanism abnormalities, including high lateral force vectors (or larger TT-TG distances) and excessive patellar tilt, can affect alignment and increase the risk for patellofemoral dislocations, patellofemoral anterior- based knee pains, and chondral lesions. Patella alta, an elevated patella, risks increased contact stresses between the patella and the trochlear groove³³ and decreases the osseous constraints that inhibit dislocation of the patella with physiologic flexion of the joint.³⁴ With TTO, the change in tuberosity position can alter angles in the extensor mechanism and thereby decrease joint reaction forces and patellofemoral contact area forces.^35,36

Although its use began as an option for combating patellar instability events in patients with predisposed patellofemoral kinematics,⁵ TTO has evolved in its therapeutic uses to include offloading patellar and trochlear focal chondral lesions and slowing progression of patellofemoral arthritis. Multiple iterations and modifications of the procedure have involved distal and medial transfer of the tibial tuberosity, medialization alone, concurrent anterior and medial elevation of the tuberosity, and proximal or distal transfers, depending on the pathology being corrected. Although TTO is highly versatile in treating multiple patellofemoral joint pathologies, this study found that its primary indication continues to be patellar instability, with anteromedialization as the most common direction of tubercle transfer in support of the medial structures providing the medial force vector that keeps the patella in place. These medial structures include the medial patellofemoral ligament, the vastus medialis obliquus, the medial patellotibial ligament, and the medial retinaculum.

Also notable was the relatively high rate of reoperation after TTO. However, >75% of reoperations were performed to remove painful hardware, and the need for reoperation seemed to have no effect on the statistically significant overall preoperative-to-postoperative improvement in VAS, Lysholm, and Kujala scores. Rates of definitive surgery for end-stage patellofemoral changes, including patellofemoral arthroplasty and total knee arthroplasty, were quite low at the weighted mean follow-up of several years after surgery, suggesting a role for TTO in avoiding arthroplasty. Although the infection rate was <1%, the rate of tibial tubercle or proximal tibia fractures was a cumulative 3.1%. Patients should be counseled on this complication risk, as treatment can require cast immobilization and weight-bearing limitations.²⁴

The 69% proportion of women in the overall cohort and the mean (SD) age of 27.68 (10.45) years highlight the primary patient population that undergoes TTO. Compared with men, young women are more likely to have aberrant patellofemoral biomechanics, owing to their native anatomy, including their relatively larger Q-angle and TT-TG distance and thus increased lateral translational force vectors on the patella.³⁷ In addition, more than half of patients who are having TTO underwent previous surgery on the affected knee—an indication that TTO is still not universally considered first-line in addressing patellofemoral pathology.

Limitations of the Analysis

The limitations of this analysis derive from the limitations of the included studies, which were mostly retrospective case series with relatively short follow-up. The low MCMS (<55) of all 21 studies highlights their low quality as well. These studies showed considerable heterogeneity in their reporting of specific preoperative, intraoperative, and postoperative radiographic, physical examination, and clinical outcome scores, which may be indicative of the relatively low rate of use of TTO, a procedure originally described decades ago. These studies also showed ample heterogeneity in the specific radiographic parameters or outcome scales they used to present their data. We were therefore limited in our ability to cohesively summarize and provide cumulative data points from the patients as a unified cohort. There was substantial variety in the procedures performed, surgical techniques used, concomitant pathologies addressed at time of surgery, and diagnoses treated—indicating a performance bias. This additionally precluded any significant meta-analysis within the patient cohort. A higher quality study, a randomized controlled trial, is needed to answer more definitively and completely the questions we left unanswered, including the effect on radiographic parameters, additional clinical outcomes, and patient satisfaction.

Conclusion

TTO is most commonly performed for isolated patellar instability in the presence of knee pain. Other pathologies addressed are patellofemoral osteoarthritis, and patella alta and patella baja with and without associated knee pain. TTO significantly improves knee pain and clinical outcome scores, though 21% of patients (>1 in 5) require reoperation for hardware removal. Young women with prior surgery on the affected knee are the primary patient population.

References

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11. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports. 2000;10(1):2-11.

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16. Drexler M, Dwyer T, Marmor M, Sternheim A, Cameron HU, Cameron JC. The treatment of acquired patella baja with proximalize the tibial tuberosity. Knee Surg Sports Traumatol Arthrosc. 2013;21(11):2578-2583.

17. Eager MR, Bader DA, Kelly JD 4th, Moyer RA. Delayed fracture of the tibia following anteromedialization osteotomy of the tibial tubercle: a report of 5 cases. Am J Sports Med. 2004;32(4):1041-1048.

18. Ebinger TP, Boezaart A, Albright JP. Modifications of the Fulkerson osteotomy: a pilot study assessment of a novel technique of dynamic intraoperative determination of the adequacy of tubercle transfer. Iowa Orthop J. 2007;27:61-64.

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22. Jack CM, Rajaratnam SS, Khan HO, Keast-Butler O, Butler-Manuel PA, Heatley FW. The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: a five-year prospective study. Bone Joint Res. 2012;1(8):167-173.

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Read more about A Systematic Review of 21 Tibial Tubercle Osteotomy Studies and More Than 1000 Knees: Indications, Clinical Outcomes, Complications, and Reoperations

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Author(s)

Bryan M. Saltzman, MD

Allison Rao, MD

Brandon J. Erickson, MD

Gregory L. Cvetanovich, MD

David Levy, MD

Bernard R. Bach, Jr, MD

Brian J. Cole, MD, MBA

Author(s)

Bryan M. Saltzman, MD

Allison Rao, MD

Brandon J. Erickson, MD

Gregory L. Cvetanovich, MD

David Levy, MD

Bernard R. Bach, Jr, MD

Brian J. Cole, MD, MBA

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Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

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Take-Home Points

TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects.
Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.
TTO was most commonly performed for isolated patellar instability in the presence of knee pain.
Young women with prior surgery on the affected knee made up the primary patient population for this procedure.
While TTO significantly improves knee pain and clinical outcome scores, >1 in 5 patients required reoperation for hardware removal.

Clinical Evaluation of Patellofemoral Pathology

Common TTO Procedures

Straight medialization (Figures 3A, 3B) offloads lateral patellar chondral injury and may decrease lateral instability.

The tubercle fragment (Figure 7) is shifted and provisionally fixed with a Kirschner wire before being drilled and fixated with two 4.5-mm countersunk cortical screws (Figures 8, 9A-9B).

Locally harvested corticocancellous bone can help anteriorize the tubercle block. Osteotomy specifics allow for corresponding anatomical translations of the TTO to address the preoperative pathology.

Methods

Search Strategy and Data Collection

Assessment of Study Quality

Data Synthesis and Statistical Analysis

Results

Search Results and Included Studies

Only 1 study provided preoperative body mass index (27 kg/m2). There were 55.35% of patients who had prior surgery on the affected knee (6 studies reporting).

Preoperative Data

Operative Characteristics

Postoperative Data

Studies With TTO Performed in Isolation

Discussion

Limitations of the Analysis

Conclusion

Take-Home Points

TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects.
Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.
TTO was most commonly performed for isolated patellar instability in the presence of knee pain.
Young women with prior surgery on the affected knee made up the primary patient population for this procedure.
While TTO significantly improves knee pain and clinical outcome scores, >1 in 5 patients required reoperation for hardware removal.