Original Research

US National Practice Patterns in Ambulatory Operative Management of Lateral Epicondylitis

Am J Orthop. 2015 December;44(12):E508-E512

References

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Results

A total of 30,311 ambulatory surgical procedures (95% CI, 27,292-33,330) or 10.44 per 100,000 capita were recorded by NSAS for the treatment of lateral epicondylitis in 2006 (Table 1). This represents a large increase in the total number of ambulatory procedures, from 21,852 in 1994 (95% CI, 19,981-23,722; 7.29/100,000) and 20,372 in 1996 (95% CI, 18,660-22,083; 6.73/100,000).

Between 1994 and 2006, the sex-adjusted rate of ambulatory surgery for lateral epicondylitis increased by 85% among females (7.74/100,000 to 14.31/100,000), whereas the rate decreased by 31% among males (8.07/100,000 to 5.59/100,000) (Table 1). The age-adjusted rate of ambulatory surgery for lateral epicondylitis increased among all age groups except the 30–39 years group (Table 2). The largest increase in age-adjusted rates was found for patients older than 50 years (275%) between 1994 and 2006.

During the study period, use of regional anesthesia nearly doubled, from 17% to 30%, whereas use of general anesthesia decreased, from 69% to 57% (Table 3). At all time points, the most common procedure performed for lateral epicondylitis in ambulatory surgery centers was division/release of the joint capsule of the elbow (Table 4). Private insurance remained the most common source of payment for all study years, ranging from 52% to 60% (Table 5). The Figure shows that, between 1994 and 2006, the proportion of surgeries performed in a freestanding ambulatory center increased.

Discussion

In this descriptive epidemiologic study, we used NSAS data to investigate trends in ambulatory surgery for lateral epicondylitis between 1994 and 2006.³² Our results showed that total number of procedures and the population-adjusted rate of procedures for lateral epicondylitis increased during the study period. The largest increase in age-adjusted rates of surgery for lateral epicondylitis was found among patients older than 50 years, whereas the highest age-adjusted rate of ambulatory surgery for lateral epicondylitis was found among patients between ages 40 and 49 years. These findings are similar to those of previous studies, which have shown that most patients with lateral epicondylitis present in the fourth and fifth decades of life.²² Prior reports have suggested that the incidence of lateral epicondylitis in men and women is equal.²² The present study found a change in sex-adjusted rates of ambulatory surgery for lateral epicondylitis between 1994 and 2006. Specifically, in 1994, surgery rates for men and women were similar (8.07/100,000 and 7.74/100,000), but in 2006 the sex-adjusted rate of surgery for lateral epicondylitis was almost 3 times higher for women than for men (14.31/100,000 vs 5.59/100,000).

We also found that the population-adjusted rate of lateral epicondylectomy increased drastically, from 0.4 per 100,000 in 1994 to 3.53 per 100,000 in 2006. Lateral epicondylectomy involves excision of the tip of the lateral epicondyle (typically, 0.5 cm) to produce a cancellous bone surface to which the edges of the débrided extensor tendon can be approximated without tension.²³ It is possible that the increased rate of lateral epicondylectomy reflects evidence-based practice changes during the study period,²⁷ though denervation was found more favorable than epicondylectomy in a recent study by Berry and colleagues.⁴⁰ Future studies should investigate whether rates of epicondylectomy have changed since 2006. In addition, the present study showed a correlation between the introduction of arthroscopic techniques for the treatment of lateral epicondylitis and the period when much research was being conducted on the topic.^24,25,28 As arthroscopic techniques improve, their rates are likely to continue to increase.

Our results also showed an increase in procedures performed in freestanding facilities. The rise in ambulatory surgical volume, speculated to result from more procedures being performed in freestanding facilities,³⁴ has been reported with knee and shoulder arthroscopy.⁴¹ In addition, though general anesthesia remained the most used technique, our results showed a shift toward peripheral nerve blocks. The increase in regional anesthesia, which has also been noted in joint arthroscopy, is thought to stem from the advent of nerve-localizing technology, such as nerve stimulation and ultrasound guidance.⁴¹ Peripheral nerve blocks are favorable on both economic and quality measures, are associated with fewer opioid-related side effects, and overall provide better analgesia in comparison with opioids, highlighting their importance in the ambulatory setting.⁴²

Although large, national databases are well suited to epidemiologic research,⁴³ our study had limitations. As with all databases, NSAS is subject to data entry errors and coding errors.^44,45 However, the database administrators corrected for this by using a multistage estimate procedure with weighting adjustments for no response and population-weighting ratio adjustments.³⁵ Another limitation of this study is its lack of clinical detail, as procedure codes are general and do not allow differentiation between specific patients. Because of the retrospective nature of the analysis and the heterogeneity of the data, assessment of specific surgeries for lateral epicondylitis was limited. Although a strength of using NSAS to perform epidemiologic analyses is its large sample size, this also sacrifices specificity in terms of clinical insight. The results of this study may influence investigations to distinguish differences between procedures used in the treatment of lateral epicondylitis. Furthermore, the results of this study are limited to ambulatory surgery practice patterns in the United States between 1996 and 2006. Last, our ability to perform economic analyses was limited, as data on total hospital cost were not recorded by the surveys.