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Controversies in Surgical Management of Recalcitrant Enthesopathy of the Extensor Carpi Radialis Brevis
THE HAND SURGERY LANDSCAPE
Controversies in Surgical Management of Recalcitrant Enthesopathy of the Extensor Carpi Radialis Brevis Bonnie P. Gregory, MD,* Robert W. Wysocki, MD,* Mark S. Cohen, MD* Enthesopathy of the extensor carpi radialis brevis, often referred to as “tennis elbow,” is common and responds to nonsurgical treatment in 80% to 90% of patients within 1 year. For those who proceed with surgery, much remains unclear regarding the ideal treatment. This paper discusses controversies in surgical management of extensor carpi radialis brevis enthesopathy including clinical outcomes of open versus arthroscopic techniques, the relevance of concomitant pathology addressed arthroscopically, and avenues for assessing comparative cost data. (J Hand Surg Am. 2016;41(8):856e859. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Key words Enthesopathy, extensor carpi radialis brevis, lateral epicondylitis, tennis elbow.
E
NTHESOPATHY OF THE EXTENSOR carpi radialis brevis (ECRB), often referred to as “tennis elbow,” is a common condition affecting the elbow with a prevalence of 1% to 3% of the general population and up to 7% of manual laborers. Patients generally initially undergo some combination of nonsurgical treatments including nonsteroidal antiinflammatory medication, bracing, physical therapy comprising common extensor stretches and modalities such as ultrasound and iontophoresis, and injectables such as corticosteroid or platelet-rich plasma, all of which have mixed results. A consistent finding in prospective studies of ECRB enthesopathy is that 80% to 90% of patients experience improvement within a year of enrollment no matter the treatment. However, with many patients
From the *Department of Orthopaedics, Rush University Medical Center, Chicago, IL. Received for publication June 24, 2016; accepted in revised form June 24, 2016. R.W.W. is co-investigator and principal investigator respectively on an NIH R01 grant and an American Foundation of Hand Surgery Grant studying tendinopathy and lateral epicondylitis. Corresponding author: Bonnie P. Gregory, MD, Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St, Ste 400, Chicago, IL 60612; e-mail: [email protected]. 0363-5023/16/4108-0009$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.06.010
856
r
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
having months of symptoms before enrollment, it stands to reason that symptoms can persist for greater than 1 year yet still resolve without surgery. It is estimated that between 4% and 11% of patients eventually undergo surgery. However, much controversy exists regarding the optimal surgical intervention, either debridement of the origin of the ECRB through a small open exposure or using an arthroscope. EVIDENCE FOR AN OPEN TECHNIQUE In a retrospective review of 88 elbows treated with open release, Solheim et al1 found QuickDASH scores of <20, which they categorized as excellent, in 72.5% of patients, and between 20 and 40, which they categorized as good, in another 9% at an average of 4 years after surgery. They reported no complications. They also identified several factors that weakly correlated with residual symptoms including a high level of baseline symptoms, the acute occurrence of symptoms, long duration of symptoms, female gender, and young age. Arm dominance, workers’ compensation, and a strenuous job were not correlated with residual symptoms. Nirschl and Pettrone2 retrospectively reviewed 1,213 cases of ECRB enthesopathy, of which 82 patients (88 elbows) chose an open surgical treatment.
CONTROVERSIES IN MANAGEMENT OF ECRB ENTHESOPATHY
After an average of 28 months after surgery, 75% of elbows had excellent results characterized as full return to activity with no pain, and another 10% had good results characterized as full return to activity with occasional mild pain. Coleman et al3 reviewed 149 elbows an average of 10 years (range, 1.5e17 years) after open surgery. Two patients developed a synovial fistula, but the others were rated excellent (86%) or good (9%). Grip strength was equal to the opposite side at follow-up. One hundred and seventeen patients (85%) returned to work within 6 weeks of surgery.
patient had a greater than 10-degree difference in range of motion and grip strength averaged 91% of the unaffected side at follow-up. All patients returned to work at an average of 5 3 weeks after surgery. CONCOMITANT PATHOLOGY ADDRESSED ARTHROSCOPICALLY A proposed advantage of arthroscopic treatment is the ability to address other intra-articular pathology found intraoperatively. Several studies have provided such data. Grewal et al4 noted 58% of elbows with intra-articular pathology, of which 60% were identified as synovitis, 20% osteophytes, and 20% chondromalacia of the radial head. Szabo et al7 reported that 18 of 41 (44%) elbows treated in their series had concomitant intra-articular pathology addressed at the time of surgery. These pathologies consisted of plicae (78%), loose bodies (11%), and posterolateral ligamentous insufficiency (11%). In the study referenced above, Baker and Baker4 found intra-articular pathology in 63% elbows, of which 71% were identified as synovitis, 14% were loose bodies, 9% were valgus extension overload, and 3% were degenerative joint disease. Owens et al8 reported synovitis or osteophytes in 3 of 16 (18.8%) of their cases. Latterman et al5 addressed intra-articular pathology in 31% of patients, of which 90% were synovitis and 10% were a loose body.
EVIDENCE FOR ARTHROSCOPIC TECHNIQUE Grewal et al4 reviewed a cohort of 36 patients who underwent arthroscopic treatment of ECRB enthesopathy. At an average of 42 months after surgery, 30 patients (83%) rated themselves improved: 14 asymptomatic, 16 better or much better, 5 the same, and 1 worse. However, there were only 61% good to excellent results based on Mayo Elbow Performance Index (MEPI). There was a significant improvement in grip strength of 27% after surgery. The average time off work was 18 weeks, with workers’ compensation patients taking an average of 24 weeks and noncompensation patients taking an average of 10 weeks to return to work. In a retrospective review of 40 patients (30 of whom were available at final follow-up), Baker and Baker5 reviewed satisfaction, functional outcomes, and pain scores at an average of 130 months. There were no complications or re-operations in this group. They found that the average pain score at rest was 0 out of 10, 1.0 (0e5) with activities of daily living, and 1.9 (0e9) with work or strenuous activities. Twenty-six patients (87%) said that they were satisfied with the surgery, and 28 patients (93%) said that they would have the surgery again. The mean MEPI functional score was 11.7; however, only functional scores were assessed and no breakdown was made between outcome groups into categories of excellent, good, and so on. Latterman et al6 retrospectively reviewed 36 patients treated with arthroscopic debridement of the ECRB. Complications included 1 patient who experienced transient forearm paresthesiae that resolved 2 weeks postoperatively. At a mean follow-up of 3.5 years, the mean functional MEPI score was 11.1; however, the results did not include the other components of the MEPI and was not broken down into outcome groups. Mean visual analog scale pain scores significantly improved from 8.5 to 1.9. No J Hand Surg Am.
857
COMPARATIVE DATA Solheim et al9 assessed 305 elbows in a retrospective comparative case series, comparing open versus arthroscopic release of the ECRB. At 4-year followup, they reported greater improvement in QuickDASH scores for the arthroscopy group (11.6) compared with the open group (17.8). In addition, they reported a significantly higher number of excellent outcomes in patients treated arthroscopically (78% vs 67%). No differences were identified in complications or failures between the 2 groups. In a retrospective comparison of 108 patients treated with open, arthroscopic, or percutaneous techniques, Szabo et al7 found no differences in visual analog scale scores, recurrences, or failures of treatment between the 3 treatment methods. However, this study may have been underpowered to detect a difference if one was present, based on the low rate of occurrence of outcomes like “failure” reported in some other studies. r
Vol. 41, August 2016
858
CONTROVERSIES IN MANAGEMENT OF ECRB ENTHESOPATHY
Finally, a retrospective cohort study of 87 patients by Peart et al10 compared long-term outcomes of open versus arthroscopic treatment. Sixty-nine percent of patients treated with open ECRB release and 72% of those treated arthroscopically had good or excellent results. There were no significant differences identified in outcomes between the 2 groups, but the arthroscopic group had a more rapid return to work (1.7 vs 2.5 months) and used less postoperative physical therapy (11% vs 24% of patients, respectively).
case series, many promoting a given technique. The comparative studies are also retrospective and subject to selection bias. A Cochrane review completed in 201113 was unable to recommend for or against any operative treatment based on the paucity of high-quality studies. In addition, outcome measures were noted to vary widely amongst the series, with few using objective outcome tools. Thus, neither open nor arthroscopic treatment has demonstrated an overall clinical benefit. Ideally, a prospective, randomized controlled trial comparing specific surgical techniques with special attention to objective outcomes measures would be helpful. Most powerful would be a trial that used the same incisions but randomized to open versus arthroscopic treatment. Though difficult to undertake, a sham-surgery controlled trial also could be helpful in determining the outcomes of surgical intervention. The proposed benefit of arthroscopy for assessing concomitant pathology is a controversial one. As we discussed above, arthroscopic series report such pathology in 18% to 58% of patients; however, in the vast majority (60% to 90%), these were synovitis conditions and it is unclear what criteria were used to establish this as a true diagnosis, and to what degree the synovectomy portion of the procedure truly affected outcome compared with treatment of the enthesopathy. We would recommend that for any patient with mechanical symptoms and evidence of loose bodies, or clear clinical evidence of symptomatic valgus extension overload or osteoarthritis, arthroscopy can have a clear advantage. Fortunately, these conditions should be easily discernable from ECRB enthesopathy clinically and, in our experience, are quite uncommon concomitant clinical problems. Given the current environment of health care cost containment and the potential for increased direct surgical cost of arthroscopic compared with open debridement, a thorough cost analysis would be an important next step as well. Although one could potentially use some methodology used in the studies of the rotator cuff cited above as a template, it is important to be aware that there is significant variability in quality amongst cost analysis studies. A comprehensive study should include not only direct costs of surgery and postoperative ancillary services but also factor in indirect costs or cost savings associated with return to work times and rates of revision or need for further treatment that would incur future cost. A decision analysis model that uses expected cost as the utility measure could be an effective way to approach this question.
COMPARATIVE COST DATA There is a paucity of literature addressing the cost effectiveness of arthroscopic versus open surgical treatment of enthesopathy of the ECRB, or any condition of the elbow for that matter (contracture release, osteoarthritis debridement, etc.). Although the differences have not been studied, a potential advantage of arthroscopy for ECRB enthesopathy is a faster return to work or fewer outpatient physiotherapy sessions from a less invasive technique. The main disadvantage of arthroscopic treatment would be increased surgical cost (operating room time, instruments, etc.). The rotator cuff repair literature has begun to address cost effectiveness in ways that could be used for future evaluation of tennis elbow treatment. A recent study by Carr et al11 evaluated open versus arthroscopic rotator cuff repair and found that although the surgical cost of arthroscopic versus open repair was significantly more, there was no difference in the cost of treatment or outcomes at 2-year followup. This point is worthy of additional emphasis, as surgical cost is only one aspect of the total cost in managing a condition from start to finish. A more expensive surgery can become cost efficient if it allows for faster return to gainful employment, or less utilization of postoperative resources such as physiotherapy. Another study by Adla et al12 showed an increase in direct surgical cost of arthroscopic repair, with similar clinical outcomes at a year. In an effort to more accurately calculate the direct economic cost of arthroscopic rotator cuff repair, Narvy et al13 used the time-driven activity-based costing algorithm to determine that an arthroscopic rotator cuff repair has a direct cost of $5,904.21, with consumables (ie, suture anchors) making up a significant portion of operating room costs. FUTURE DIRECTIONS The evidence regarding operative treatment of enthesopathy of the ECRB consists largely of retrospective J Hand Surg Am.
r
Vol. 41, August 2016
CONTROVERSIES IN MANAGEMENT OF ECRB ENTHESOPATHY
We believe that the results of open and arthroscopic release are comparable and the decision can be left to the discretion of a well-informed patient. For the small subset of patients with additional symptomatic diagnoses within the elbow, we favor an arthroscopic technique. Further pursuit of standardized high-quality comparative clinical series and detailed cost data that take into account all drivers of cost will be critical to properly assess the superiority of open versus arthroscopic treatment.
5. Baker CL, Baker CL. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008;36(2): 254e260. 6. Latterman C, Romeo A, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(5):651e656. 7. Szabo SJ, Savoie FH III, Field LD, Ramsey JR, Hosemann CD. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg. 2006;15(6): 721e727. 8. Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy. 2001;17(6):582e587. 9. Solheim E, Hegna J, Øyen J. Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows. Arthroscopy. 2013;29(5):854e859. 10. Peart R, Strickler S, Schweitzer K. Lateral epicondylitis: a comparative study of open and arthroscopic lateral release. Am J Orthop (Belle Mead NJ). 2004;33(11):565e567. 11. Carr A, Cooper C, Campbell M, et al. Clinical effectiveness and costeffectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial]. Health Technol Assess. 2015;19(80):1e248. 12. Adla D, Rowsell M, Pandley R. Cost-effectiveness of open versus arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2010;19(2): 258e261. 13. Narvy SJ, Ahluwalia A, Vangsness CT. Analysis of direct costs of outpatient arthroscopic rotator cuff repair. Am J Orthop. 2016;45(1): E7eE11.
REFERENCES 1. 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):1023e1027. 2. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg. 1979;61(6A):832e839. 3. Coleman B, Quinlan J, Matheson J. Surgical treatment for lateral epicondylitis: a long-term follow-up of results. J Shoulder Elbow Surg. 2010;19(3):363e367. 4. Grewal R, MacDermid JC, Shah P, King GJW. Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis. J Hand Surg Am. 2014;34(5):849e857.
J Hand Surg Am.
859
r
Vol. 41, August 2016
Controversies in Surgical Management of Recalcitrant Enthesopathy of the Extensor Carpi Radialis Brevis Bonnie P. Gregory, MD,* Robert W. Wysocki, MD,* Mark S. Cohen, MD* Enthesopathy of the extensor carpi radialis brevis, often referred to as “tennis elbow,” is common and responds to nonsurgical treatment in 80% to 90% of patients within 1 year. For those who proceed with surgery, much remains unclear regarding the ideal treatment. This paper discusses controversies in surgical management of extensor carpi radialis brevis enthesopathy including clinical outcomes of open versus arthroscopic techniques, the relevance of concomitant pathology addressed arthroscopically, and avenues for assessing comparative cost data. (J Hand Surg Am. 2016;41(8):856e859. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Key words Enthesopathy, extensor carpi radialis brevis, lateral epicondylitis, tennis elbow.
E
NTHESOPATHY OF THE EXTENSOR carpi radialis brevis (ECRB), often referred to as “tennis elbow,” is a common condition affecting the elbow with a prevalence of 1% to 3% of the general population and up to 7% of manual laborers. Patients generally initially undergo some combination of nonsurgical treatments including nonsteroidal antiinflammatory medication, bracing, physical therapy comprising common extensor stretches and modalities such as ultrasound and iontophoresis, and injectables such as corticosteroid or platelet-rich plasma, all of which have mixed results. A consistent finding in prospective studies of ECRB enthesopathy is that 80% to 90% of patients experience improvement within a year of enrollment no matter the treatment. However, with many patients
From the *Department of Orthopaedics, Rush University Medical Center, Chicago, IL. Received for publication June 24, 2016; accepted in revised form June 24, 2016. R.W.W. is co-investigator and principal investigator respectively on an NIH R01 grant and an American Foundation of Hand Surgery Grant studying tendinopathy and lateral epicondylitis. Corresponding author: Bonnie P. Gregory, MD, Department of Orthopaedics, Rush University Medical Center, 1611 W. Harrison St, Ste 400, Chicago, IL 60612; e-mail: [email protected]. 0363-5023/16/4108-0009$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.06.010
856
r
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
having months of symptoms before enrollment, it stands to reason that symptoms can persist for greater than 1 year yet still resolve without surgery. It is estimated that between 4% and 11% of patients eventually undergo surgery. However, much controversy exists regarding the optimal surgical intervention, either debridement of the origin of the ECRB through a small open exposure or using an arthroscope. EVIDENCE FOR AN OPEN TECHNIQUE In a retrospective review of 88 elbows treated with open release, Solheim et al1 found QuickDASH scores of <20, which they categorized as excellent, in 72.5% of patients, and between 20 and 40, which they categorized as good, in another 9% at an average of 4 years after surgery. They reported no complications. They also identified several factors that weakly correlated with residual symptoms including a high level of baseline symptoms, the acute occurrence of symptoms, long duration of symptoms, female gender, and young age. Arm dominance, workers’ compensation, and a strenuous job were not correlated with residual symptoms. Nirschl and Pettrone2 retrospectively reviewed 1,213 cases of ECRB enthesopathy, of which 82 patients (88 elbows) chose an open surgical treatment.
CONTROVERSIES IN MANAGEMENT OF ECRB ENTHESOPATHY
After an average of 28 months after surgery, 75% of elbows had excellent results characterized as full return to activity with no pain, and another 10% had good results characterized as full return to activity with occasional mild pain. Coleman et al3 reviewed 149 elbows an average of 10 years (range, 1.5e17 years) after open surgery. Two patients developed a synovial fistula, but the others were rated excellent (86%) or good (9%). Grip strength was equal to the opposite side at follow-up. One hundred and seventeen patients (85%) returned to work within 6 weeks of surgery.
patient had a greater than 10-degree difference in range of motion and grip strength averaged 91% of the unaffected side at follow-up. All patients returned to work at an average of 5 3 weeks after surgery. CONCOMITANT PATHOLOGY ADDRESSED ARTHROSCOPICALLY A proposed advantage of arthroscopic treatment is the ability to address other intra-articular pathology found intraoperatively. Several studies have provided such data. Grewal et al4 noted 58% of elbows with intra-articular pathology, of which 60% were identified as synovitis, 20% osteophytes, and 20% chondromalacia of the radial head. Szabo et al7 reported that 18 of 41 (44%) elbows treated in their series had concomitant intra-articular pathology addressed at the time of surgery. These pathologies consisted of plicae (78%), loose bodies (11%), and posterolateral ligamentous insufficiency (11%). In the study referenced above, Baker and Baker4 found intra-articular pathology in 63% elbows, of which 71% were identified as synovitis, 14% were loose bodies, 9% were valgus extension overload, and 3% were degenerative joint disease. Owens et al8 reported synovitis or osteophytes in 3 of 16 (18.8%) of their cases. Latterman et al5 addressed intra-articular pathology in 31% of patients, of which 90% were synovitis and 10% were a loose body.
EVIDENCE FOR ARTHROSCOPIC TECHNIQUE Grewal et al4 reviewed a cohort of 36 patients who underwent arthroscopic treatment of ECRB enthesopathy. At an average of 42 months after surgery, 30 patients (83%) rated themselves improved: 14 asymptomatic, 16 better or much better, 5 the same, and 1 worse. However, there were only 61% good to excellent results based on Mayo Elbow Performance Index (MEPI). There was a significant improvement in grip strength of 27% after surgery. The average time off work was 18 weeks, with workers’ compensation patients taking an average of 24 weeks and noncompensation patients taking an average of 10 weeks to return to work. In a retrospective review of 40 patients (30 of whom were available at final follow-up), Baker and Baker5 reviewed satisfaction, functional outcomes, and pain scores at an average of 130 months. There were no complications or re-operations in this group. They found that the average pain score at rest was 0 out of 10, 1.0 (0e5) with activities of daily living, and 1.9 (0e9) with work or strenuous activities. Twenty-six patients (87%) said that they were satisfied with the surgery, and 28 patients (93%) said that they would have the surgery again. The mean MEPI functional score was 11.7; however, only functional scores were assessed and no breakdown was made between outcome groups into categories of excellent, good, and so on. Latterman et al6 retrospectively reviewed 36 patients treated with arthroscopic debridement of the ECRB. Complications included 1 patient who experienced transient forearm paresthesiae that resolved 2 weeks postoperatively. At a mean follow-up of 3.5 years, the mean functional MEPI score was 11.1; however, the results did not include the other components of the MEPI and was not broken down into outcome groups. Mean visual analog scale pain scores significantly improved from 8.5 to 1.9. No J Hand Surg Am.
857
COMPARATIVE DATA Solheim et al9 assessed 305 elbows in a retrospective comparative case series, comparing open versus arthroscopic release of the ECRB. At 4-year followup, they reported greater improvement in QuickDASH scores for the arthroscopy group (11.6) compared with the open group (17.8). In addition, they reported a significantly higher number of excellent outcomes in patients treated arthroscopically (78% vs 67%). No differences were identified in complications or failures between the 2 groups. In a retrospective comparison of 108 patients treated with open, arthroscopic, or percutaneous techniques, Szabo et al7 found no differences in visual analog scale scores, recurrences, or failures of treatment between the 3 treatment methods. However, this study may have been underpowered to detect a difference if one was present, based on the low rate of occurrence of outcomes like “failure” reported in some other studies. r
Vol. 41, August 2016
858
CONTROVERSIES IN MANAGEMENT OF ECRB ENTHESOPATHY
Finally, a retrospective cohort study of 87 patients by Peart et al10 compared long-term outcomes of open versus arthroscopic treatment. Sixty-nine percent of patients treated with open ECRB release and 72% of those treated arthroscopically had good or excellent results. There were no significant differences identified in outcomes between the 2 groups, but the arthroscopic group had a more rapid return to work (1.7 vs 2.5 months) and used less postoperative physical therapy (11% vs 24% of patients, respectively).
case series, many promoting a given technique. The comparative studies are also retrospective and subject to selection bias. A Cochrane review completed in 201113 was unable to recommend for or against any operative treatment based on the paucity of high-quality studies. In addition, outcome measures were noted to vary widely amongst the series, with few using objective outcome tools. Thus, neither open nor arthroscopic treatment has demonstrated an overall clinical benefit. Ideally, a prospective, randomized controlled trial comparing specific surgical techniques with special attention to objective outcomes measures would be helpful. Most powerful would be a trial that used the same incisions but randomized to open versus arthroscopic treatment. Though difficult to undertake, a sham-surgery controlled trial also could be helpful in determining the outcomes of surgical intervention. The proposed benefit of arthroscopy for assessing concomitant pathology is a controversial one. As we discussed above, arthroscopic series report such pathology in 18% to 58% of patients; however, in the vast majority (60% to 90%), these were synovitis conditions and it is unclear what criteria were used to establish this as a true diagnosis, and to what degree the synovectomy portion of the procedure truly affected outcome compared with treatment of the enthesopathy. We would recommend that for any patient with mechanical symptoms and evidence of loose bodies, or clear clinical evidence of symptomatic valgus extension overload or osteoarthritis, arthroscopy can have a clear advantage. Fortunately, these conditions should be easily discernable from ECRB enthesopathy clinically and, in our experience, are quite uncommon concomitant clinical problems. Given the current environment of health care cost containment and the potential for increased direct surgical cost of arthroscopic compared with open debridement, a thorough cost analysis would be an important next step as well. Although one could potentially use some methodology used in the studies of the rotator cuff cited above as a template, it is important to be aware that there is significant variability in quality amongst cost analysis studies. A comprehensive study should include not only direct costs of surgery and postoperative ancillary services but also factor in indirect costs or cost savings associated with return to work times and rates of revision or need for further treatment that would incur future cost. A decision analysis model that uses expected cost as the utility measure could be an effective way to approach this question.
COMPARATIVE COST DATA There is a paucity of literature addressing the cost effectiveness of arthroscopic versus open surgical treatment of enthesopathy of the ECRB, or any condition of the elbow for that matter (contracture release, osteoarthritis debridement, etc.). Although the differences have not been studied, a potential advantage of arthroscopy for ECRB enthesopathy is a faster return to work or fewer outpatient physiotherapy sessions from a less invasive technique. The main disadvantage of arthroscopic treatment would be increased surgical cost (operating room time, instruments, etc.). The rotator cuff repair literature has begun to address cost effectiveness in ways that could be used for future evaluation of tennis elbow treatment. A recent study by Carr et al11 evaluated open versus arthroscopic rotator cuff repair and found that although the surgical cost of arthroscopic versus open repair was significantly more, there was no difference in the cost of treatment or outcomes at 2-year followup. This point is worthy of additional emphasis, as surgical cost is only one aspect of the total cost in managing a condition from start to finish. A more expensive surgery can become cost efficient if it allows for faster return to gainful employment, or less utilization of postoperative resources such as physiotherapy. Another study by Adla et al12 showed an increase in direct surgical cost of arthroscopic repair, with similar clinical outcomes at a year. In an effort to more accurately calculate the direct economic cost of arthroscopic rotator cuff repair, Narvy et al13 used the time-driven activity-based costing algorithm to determine that an arthroscopic rotator cuff repair has a direct cost of $5,904.21, with consumables (ie, suture anchors) making up a significant portion of operating room costs. FUTURE DIRECTIONS The evidence regarding operative treatment of enthesopathy of the ECRB consists largely of retrospective J Hand Surg Am.
r
Vol. 41, August 2016
CONTROVERSIES IN MANAGEMENT OF ECRB ENTHESOPATHY
We believe that the results of open and arthroscopic release are comparable and the decision can be left to the discretion of a well-informed patient. For the small subset of patients with additional symptomatic diagnoses within the elbow, we favor an arthroscopic technique. Further pursuit of standardized high-quality comparative clinical series and detailed cost data that take into account all drivers of cost will be critical to properly assess the superiority of open versus arthroscopic treatment.
5. Baker CL, Baker CL. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008;36(2): 254e260. 6. Latterman C, Romeo A, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(5):651e656. 7. Szabo SJ, Savoie FH III, Field LD, Ramsey JR, Hosemann CD. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg. 2006;15(6): 721e727. 8. Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy. 2001;17(6):582e587. 9. Solheim E, Hegna J, Øyen J. Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows. Arthroscopy. 2013;29(5):854e859. 10. Peart R, Strickler S, Schweitzer K. Lateral epicondylitis: a comparative study of open and arthroscopic lateral release. Am J Orthop (Belle Mead NJ). 2004;33(11):565e567. 11. Carr A, Cooper C, Campbell M, et al. Clinical effectiveness and costeffectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial]. Health Technol Assess. 2015;19(80):1e248. 12. Adla D, Rowsell M, Pandley R. Cost-effectiveness of open versus arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2010;19(2): 258e261. 13. Narvy SJ, Ahluwalia A, Vangsness CT. Analysis of direct costs of outpatient arthroscopic rotator cuff repair. Am J Orthop. 2016;45(1): E7eE11.
REFERENCES 1. 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):1023e1027. 2. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg. 1979;61(6A):832e839. 3. Coleman B, Quinlan J, Matheson J. Surgical treatment for lateral epicondylitis: a long-term follow-up of results. J Shoulder Elbow Surg. 2010;19(3):363e367. 4. Grewal R, MacDermid JC, Shah P, King GJW. Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis. J Hand Surg Am. 2014;34(5):849e857.
J Hand Surg Am.
859
r
Vol. 41, August 2016