Clinical Review

Quality and Quantity of the Elbow Arthroscopy Literature: A Systematic Review and Meta-Analysis

Am J Orthop. 2016 July;45(5):E290-E298

References

1. Khanchandani P. Elbow arthroscopy: review of the literature and case reports. Case Rep Orthop. 2012;2012:478214.

2. Dodson CC, Nho SJ, Williams RJ 3rd, Altchek DW. Elbow arthroscopy. J Am Acad Orthop Surg. 2008;16(10):574-585.

3. Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique. J Bone Joint Surg Am. 2008;90(suppl 2 Pt 1):47-62.

4. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am. 2001;83-A(1):25-34.

5. Rajeev A, Pooley J. Lateral compartment cartilage changes and lateral elbow pain. Acta Orthop Belg. 2009;75(1):37-40.

6. Miyake J, Shimada K, Oka K, et al. Arthroscopic debridement in the treatment of patients with osteoarthritis of the elbow, based on computer simulation. Bone Joint J. 2014;96-B(2):237-241.

7. Babaqi AA, Kotb MM, Said HG, AbdelHamid MM, ElKady HA, ElAssal MA. Short-term evaluation of arthroscopic management of tennis elbow; including resection of radio-capitellar capsular complex. J Orthop. 2014;11(2):82-86.

8. Gay DM, Raphael BS, Weiland AJ. Revision arthroscopic contracture release in the elbow resulting in an ulnar nerve transection: a case report. J Bone Joint Surg Am. 2010;92(5):1246-1249.

9. Haapaniemi T, Berggren M, Adolfsson L. Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture. Arthroscopy. 1999;15(7):784-787.

10. Yeoh KM, King GJ, Faber KJ, Glazebrook MA, Athwal GS. Evidence-based indications for elbow arthroscopy. Arthroscopy. 2012;28(2):272-282.

11. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. BMJ. 2009;339:b2700.

12. PROSPERO. International Prospective Register of Ongoing Systematic Reviews. The University of York CfRaDP-Iprosr-v. 2013 [cited 2014]. http://www.crd.york.ac.uk/PROSPERO/. Accessed March 17, 2016.

13. Oxford Centre for Evidence-Based Medicine - levels of evidence (March 2009). Centre for Evidence-Based Medicine Web site. http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed July 6, 2016.

14. Cowan J, Lozano-Calderόn S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.

15. Jones GS, Savoie FH 3rd. Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow. Arthroscopy. 1993;9(3):277-283.

16. O’Brien MJ, Lee Murphy R, Savoie FH 3rd. A preliminary report of acute and subacute arthroscopic repair of the radial ulnohumeral ligament after elbow dislocation in the high-demand patient. Arthroscopy. 2014;30(6):679-687.

17. 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.

18. Jerosch J, Schunck J. Arthroscopic treatment of lateral epicondylitis: indication, technique and early results. Knee Surg Sports Traumatol Arthrosc. 2006;14(4):379-382.

19. Tijssen M, van Cingel R, van Melick N, de Visser E. Patient-Reported Outcome questionnaires for hip arthroscopy: a systematic review of the psychometric evidence. BMC Musculoskelet Disord. 2011;12:117.

Discussion

Elbow arthroscopy is an evolving surgical procedure that is used to treat intra- and extra-articular pathologies of the elbow. Outcomes of elbow arthroscopy for certain conditions have generally been reported as good, with improvements seen in pain, functional scores, and range of motion.^6,15-17 The authors’ hypotheses were mostly confirmed in that the average age of patients undergoing elbow arthroscopy was <40 years, release/débridement was one of the most common indications (along with lateral epicondylitis and OCD), and the general evidence for elbow arthroscopy was poor. Also, there were almost no differences between continents/countries related to patient indications, preoperative imaging, anesthesia choice, indications, postoperative protocols, and outcomes (although the number of studies that reported outcomes was low and could have skewed the results), with the exception of a higher number of preoperative MRI scans in Asia. Some of the notable findings of this study included: 1) the number of studies published on elbow arthroscopy is significantly increasing with time, despite a lack of improvement in the level of evidence; 2) the majority of studies on elbow arthroscopy do not report a surgical outcome score; and 3) the number of reported cases for the 3 most common indications significantly increased over time (OCD, P = .005; lateral epicondylitis, P = .044; release and débridement, P = .042) but did not differ between regions (P > .05 in all cases).

The indications for elbow arthroscopy have grown dramatically in the past 2 decades to include both intra- and extra-articular pathologies.¹⁸ Despite this increase in the number of indications for elbow arthroscopy, the study did not find a significant difference between countries/continents in the indications each used for elbow arthroscopy patients. There was a trend towards an increase in OCD cases in all continents, especially Asia (Figure 4), with time. Interestingly, while not statistically significant, there was variation among countries for surgical indications. In North America, removal of loose bodies accounts for 18% of patients, while in Europe this accounted for only 9% and in Asia for 1%. Post-traumatic stiffness was the indication for elbow arthroscopy in Europe in 19% of patients vs 7% in North America and 10% in Asia. In Asia, OCD accounts for 40% of arthroscopies, 7% in Europe, and 14% in North America (Figure 4) (Table 3).

This study demonstrated that the mean increase in elbow extension gained after surgery in North America was significantly greater when compared with studies from Asia, but the gain in flexion, pronation, and supination was similar across continents. The underlying cause of this difference in improvement in elbow extension between nations is unclear, although differences in diagnosis could account for some variation. This study did not examine differences in rehabilitation protocols, and certainly, it is plausible that protocol variations by country could account for some discrepancy. Furthermore, differences in functional needs may vary by continent and could have driven this result.

This study found no routine reporting of outcome scores by elbow arthroscopy studies from any continent, and that when outcome scores are reported, there is substantial inconsistency with regard to the actual scoring system used. No continent reported outcome scores in more than 40% of the studies published from that area, and the variation of outcome scores used, even from a single region, was large. This makes comparing clinical outcomes between studies difficult, even when performing identical procedures for identical indications, because there is no standardized method of reporting outcomes. To allow comparison of studies and generalizability of the results to different populations, a more standardized approach to outcome reporting needs to be instituted in the elbow arthroscopy literature. To date, there is no standardized score that has been validated for reporting clinical outcomes after elbow arthroscopy.19 Hence, it is not surprising that there were 16 different outcome scores reported throughout the 112 studies analyzed in this review, with the most frequent score, the MEPS, reported in a total of 10 studies. As medicine moves towards pay scales that are based on patient outcomes, it will become more important to define a clear outcome score that can be used to assess these patients, and reliably report scores. This will allow comparison of patients across nations to determine the best surgical treatment for different clinical problems. A validation study comparing these outcome scores to determine which score best summarizes the patient’s level of pain and function after surgery would be beneficial, because this could identify 1 score that could be standardized to allow comparison among reported outcomes.

Limitations

This study had several limitations. Despite having 2 authors search independently for studies, some studies could have been missed during the search process, introducing possible selection bias. Including only published studies could have introduced publication bias. Numerous studies did not report all the variables the authors examined. This could have skewed some results, and had additional variables been reported, could have altered the data to show significant differences in some measured variables. Because this study did not compare outcome measures for varying pathologies, conclusions cannot be drawn on the best treatment options for different indications. Case reports could have lowered the MCMS score and the average in studies reporting outcomes. Furthermore, the poor quality of the underlying data used in this study could limit the validity/generalizability of the results because this is a systematic review, and its level of evidence is only as high as the studies it includes. Because the primary aim was to report on demographics, this study did not examine concomitant pathology at the time of surgery or rehabilitation protocols.

Conclusion

The quantity, but not the quality, of arthroscopic elbow publications has significantly increased over time. Most patients undergo elbow arthroscopy for lateral epicondylitis, OCD, and release and débridement. Pathology and indications do not appear to differ geographically with more men undergoing elbow arthroscopy than women.