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In all but three scientific articles,10,37,40 outcomes were assessed by the surgical team itself, introducing a major source of bias. It allows you to bet on either team covering the spread. The endoscopic technique allows to visualize the joint, and the pathology of the ECRB, and to deal with concomitant pathologies. It can be performed as an office procedure, although it may not directly address the actual pathology of TE. The pathology can be approached by open, percutaneous and endoscopic routes. The open approach has seen a variety of procedures based on releasing, lengthening, excising and repairing the CEO, with occasional focus on the elbow joint to look for any obvious pathology. There were a variety of confounding factors within each study that made their statistical comparison challenging. This raises the question – If one procedure is so successful, why do we need to resort to such a wide variety of techniques? Nevertheless, the same could be said of several open techniques. We believe that this multiplicity of techniques stems from the relatively widespread lack of the aetio-pathogenesis for this condition. In the rest of the published articles, this process was flawed from the lack of one or more of the four criteria mentioned in the CMS.

Lack of satisfaction with one surgical technique stems from gross discrepancies between reported surgical success rates and personal clinical experiences. In a situation where surgical success rates are not conclusive, one relies on an approach that has the least morbidity or complication and failure rate, and early return to work. 52) showed the percutaneous technique to be more successful than the open technique in terms of DASH (disability of arm, shoulder and hand score) score and earlier return to activity. The open approach had a reported mean failure rate of 11.4% (031-81%41), with a reported mean complication rate of 10.6% (041-33%27). Commonly reported complications were wound haematoma (2), wound infection/abscess (7), scar disturbance (2), chronic pain (1), stiffness (5) and neurological problems (3). The mean time to return to work (pre-injury) was 6.6 weeks (2.619-20 weeks45). The percutaneous approach reported a mean failure rate of 8.7% (3.843-12.7%42), with a reported complication rate of 6.3%20. There were two reported wound haematomas with time to pain relief of 8.5 weeks (843-9 weeks20).

The reported average failure rate of the endoscopic approach was 8.3% (6.610-1046), with no reported complications. The open approach still remains the most common of the three, but there has been a recent increase in reports on percutaneous and endoscopic approaches. Comparing the CMS with year of publication gave an intra-class correlation coefficient score of 0.45. This indicates that the more recent scientific articles were not significantly better than the older studies. The intra-class correlation coefficient gave a score of 0.98. This indicates a high correlation between the CMS awarded to each scientific article by each independent marker. Moreover, it is also evident that there has been no improvement in CMS or the quality of our study designs over many years. The articles included in the present study used different methodologies, which account for a wide fluctuation in the CMS recorded. Our study also shows a generalized inadequacy in the methodological design of the studies that report these outcomes. Also, while analysing data for the present study we came across many studies detailing level 4 evidence.

While we acknowledge that evidence from these studies can be fraught with bias, we do believe that pooling data or comparing data from these studies can help us come up with clinically relevant conclusions. Through prospective studies we are able to avoid selection and investigator bias through rigid selection criteria, well documented pre-operative examination findings and regular post-operative assessments. Specifically, the differences are small and unclear in the variable of HMLD and distance covered, while they are possible/likely small in the AMP variable. A common finding during the present study was the variable but high success rate of virtually all types of surgical procedures for TE, coupled with a relatively low reported complication/failure rate. Also, the large number of reported modifications to each surgical technique shows a constant attempt by surgeons to improve surgical success rates, reduce complications, and make the procedure less technically demanding. We identified eight such scientific articles.21,28,48-53 On the other hand, centres in North America (and some in Europe) reported the more widely accepted Nirschl technique of excision of the damaged CEO origin or its variations. Three scientific articles38,39,64 reported a comparative study between the open and endoscopic technique. Most open procedures reported from Europe relied on the ‘release’ of the CEO.

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