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Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis
  1. Wei Dong1,
  2. Hans Goost2,
  3. Xiang-Bo Lin3,
  4. Christof Burger4,
  5. Christian Paul5,
  6. Zeng-Li Wang1,
  7. Fan-Lin Kong1,
  8. Kristian Welle4,
  9. Zhi-Chao Jiang6,
  10. Koroush Kabir4
  1. 1Department of Orthopedic and Trauma Surgery, Central Hospital of PetroChina, Langfang, China
  2. 2Department of Orthopedic and Trauma Surgery, Hospital Wermelskirchen, Wermelskirchen, Germany
  3. 3Department of Orthopedic and Trauma Surgery, Rizhao People's Hospital, Rizhao, China
  4. 4Department of Orthopedic and Trauma Surgery, University Hospital Bonn, Bonn, Germany
  5. 5Department of Orthopedic and Trauma Surgery, Evangelic Wald-Krankenhaus, Bonn, Germany
  6. 6Department of Fundamental Science, North China Institute of Aerospace Engineering, Langfang, China
  1. Correspondence to Dr Koroush Kabir, Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, Bonn 53127, Germany; koroush.kabir{at}


Background There are many injection therapies for lateral epicondylalgia but there has been no previous comprehensive comparison, based on the Bayesian method.

Methods The MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for appropriate literature. The outcome measurement was the pain score. Direct comparisons were performed using the pairwise meta-analysis, and network meta-analysis, based on a Bayesian model, was used to calculate the results of all of the potentially possible comparisons and rank probabilities. A sensitivity analysis was performed by excluding low-quality studies. The inconsistency of the model was assessed by means of the node-splitting method. Metaregression was used to assess the relationship between the sample size and the treatment effect.

Results All of the injection treatments showed a trend towards better effects than placebo. Additionally, the peppering technique did not add additional benefits when combined with other treatments. No significant changes were observed by excluding low-quality studies in the sensitivity analysis. No significant inconsistencies were found according to the inconsistency analysis, and metaregression revealed that the sample size was not associated with the treatment effects.

Conclusions Some commonly used injection therapies can be considered treatment candidates for lateral epicondylalgia, such as botulinum toxin, platelet-rich plasma and autologous blood injection, but corticosteroid is not recommended. Hyaluronate injection and prolotherapy might be more effective, but their superiority must be confirmed by more research. The peppering technique is not helpful in injection therapies.

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