OP0072 Comparative effectiveness of injection therapies in lateral epicondylitis: A systematic review and network meta-analysis of randomized controlled trials

Abstract

Background Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately several other injection therapies have become available. Objectives Using a systematic review and network meta-analysis, our objective was to assess the comparative effectiveness of different injection therapies used for pain reduction. Methods Structured literature searches in Medline, Embase, Cinahl, Web of Science, and the Cochrane Clinical Trials Database. Selected studies were randomized controlled trials comparing different injection therapies and/or placebo injections for lateral epicondylitis. Risk of bias was assessed in each of the included trials. The outcome measures were change in pain intensity at the end of the masked trial period (i.e., endpoint) and adverse events. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data. Following the arm-based network meta-analysis standardized mean differences (SMDs) were used as the effect size based on differences between means divided by the pooled standard deviation. Results Seventeen trials (1381 patients) allocating individuals to injection with glucocorticoid, botulinum toxin, platelet-rich plasma, autologous blood, hyaluronic acid, prolotherapy, polidocanol, glycosaminoglycan polysulfate, and/or placebo, fulfilled the inclusion criteria. Only 3 (18%) of the trials were judged to be at low risk of bias: one trial of glucocorticoid compared to platelet-rich plasma, and placebo-controlled trials of prolotherapy and polidocanol. Pooled results from all included studies showed that glucocorticoid injection (investigated in 12 treatment arms with 310 patients) was no more effective than placebo with respect to improvement in pain (SMD -0.04 [95% CI -0.45 to 0.35], P=0.81); Botulinum toxin injection (4 treatment arms with 130 patients) was statistically significant but clinically only marginally more effective than placebo (-0.50 [-0.91 to -0.08], P=0.023); whereas autologous blood injection investigated in three treatment arms with 96 patients (-1.43 [-2.15 to -0.71], P =0.001) and platelet-rich plasma with two treatment arms and 114 patients (-1.13 [-1.77 to -0.49], P =0.002) were both clearly more efficacious than placebo. Neither polidocanol (one treatment arm, 18 patients) nor glycosaminoglycan polysulfate (one treatment arm, 32 patients) were found to be superior to placebo, while prolotherapy (one treatment arm, 10 patients) and hyaluronic acid (one treatment arm, 165 patients) were both found to be much more efficacious than placebo (-2.71 [-4.60 to -0.82], P =0.009, and -5.58 [-6.35 to -4.82], P <0.0001 respectively). Conclusions Our study found that most trials that have assessed the value of injection therapy for lateral epicondylitis are at high risk of bias and that their results therefore need to be interpreted with caution. Further high quality trials are needed in this area. Disclosure of Interest None Declared

Does Nonsurgical Treatment Improve Longitudinal Outcomes of Lateral Epicondylitis Over No Treatment? A Meta-analysis

“…Our study was not designed to specifically focus on individual treatments that have, in many cases, been studied in only a small number of RCTs with at least 6 months followup. The comparative effectiveness of individual treatments was addressed in a recently published systematic review and meta-analysis comparing injection therapies for lateral epicondylitis [19]. Krogh et al reported benefits over placebo with autologous-blood, platelet-rich plasma, prolotherapy, and hyaluronic acid, but not corticosteroid, botulinum toxin, polidocanol, and glycosaminoglycan, although the number of RCTs available for inclusion was modest.…”

“…The methodologic quality of each included RCT was assessed using the 22-point Consolidated Standards Of Reporting Trials (CONSORT) checklist [34]. Studies were scored and classified as excellent (18)(19)(20)(21)(22), good (13)(14)(15)(16)(17), fair (8)(9)(10)(11)(12), or poor (B 7). A sensitivity analysis [22] was performed using only trials of excellent or good methodologic quality according to the CONSORT score.…”

“…The followup ranged from 6 months to 5 years, and 10 studies reported data for two intermediate-to long-term followup periods. The methodologic quality was excellent in 10 studies, good in four, and fair in eight, yielding a mean CONSORT score of 15.5 (range, [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. A funnel plot (Fig.…”

CORR Insights®: Does Nonsurgical Treatment Improve Longitudinal Outcomes of Lateral Epicondylitis Over No Treatment? A Meta-analysis

“…Finally, a large meta-analysis [3] showed that at final followup, there was limited difference with respect to change in pain intensity and adverse reactions at final followup after various injections. To further complicate matters, of the 17 trials evaluated in the study by Krogh et al [3], only two met the definitions established for studies displaying a low-risk of bias.…”

“…To further complicate matters, of the 17 trials evaluated in the study by Krogh et al [3], only two met the definitions established for studies displaying a low-risk of bias.…”