Question: In patients who require surgery for the treatment of
tennis elbow, how do the open formal release and the percutaneous tenotomy
procedures compare with regard to functional outcome?
Design: Randomized (unclear allocation concealment), unblinded
controlled trial with 1-year follow-up.
Setting: A hospital in Manchester, England, United Kingdom.
Patients: 45 patients (mean age, 45 y; 51% women) with tennis elbow
(47 elbows) who had received conservative treatment, including 2 injections of
80 mg of hydrocortisone and modification of activity, for 12 months. Follow-up
was 100%.
Intervention: Patients were allocated to open (n = 22) or
percutaneous (n = 23) surgery. The open procedure involved making a 7-cm
incision over the common extensor origin, reflecting the extensor carpi
radialis longus to expose the origin of the extensor carpi radialis brevis,
and removing the damaged portion of the tendon. The percutaneous technique
involved making a 1-cm incision over the mid-point of the lateral epicondyle,
dividing the common extensor origin with small artery forceps, flexing the
wrist to complete the defect and allow a 1-cm gap to be created at the common
extensor origin, and palpating the gap. Patients in both groups had a bandage
applied for 7 days and then began physiotherapy.
Main outcome measures: Change in score on the American Academy of
Orthopaedic Surgeons' Disabilities of the Arm, Shoulder and Hand (DASH)
questionnaire; time to return to work; and patient satisfaction.
Main results: At 1 year postoperatively, patients in the
percutaneous technique group had greater improvement than those in the open
group in the basic normalized DASH score and the sport function section of the
DASH score; groups did not significantly differ on the DASH high-performance
work score (Table). Patients in
the percutaneous group returned to work sooner than those in the open group
(Table) and were more satisfied
with the results (p = 0.012).
Conclusions: In patients who required surgery because of tennis
elbow, percutaneous tenotomy led to greater improvements in function, quicker
return to work, and greater patient satisfaction than did the formal open
release.
Prior to this high-quality randomized trial by Dunkow and colleagues,
favorable outcomes following percutaneous techniques for tennis elbow were
reported mainly in small case series constituting level-IV
evidence1-4.
As recently as 2002, the Cochrane Collaboration suggested that no evidence
existed to either support or discourage the use of surgical interventions for
lateral elbow pain and that patients undergoing surgical procedures for
lateral elbow pain should do so in the knowledge that it is an unproven
treatment modality for this
condition5.
The internal validity of the study by Dunkow and colleagues was enhanced by
clear inclusion criteria, use of a single surgeon, and strict control of
presurgical and postsurgical management. This study used the self-reported
DASH questionnaire, but whether or not the participants or evaluators were
blind to treatment (a possible source of bias) was unclear.
Both groups in this study made dramatic improvements between their
preoperative and postoperative DASH scores. The percutaneous group, however,
had greater improvement in DASH scores and patient satisfaction, and shorter
time to return to work. Because the minimally important difference in the DASH
score has been reported to be 10 to 15
points6,7,
the clinical importance of the difference of 3 points in favor of percutaneous
release is uncertain and must be considered by the surgeon weighing the risks
and benefits of each surgical technique. Furthermore, only one patient in the
current study (open group) had a compensation claim.
This study provides a benchmark to which future randomized trials should be
compared. Recent reports of favorable outcomes following arthroscopic release
of tennis elbow will require future randomized trials to compare these 2
options.
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