December 20, 2020
evidence for ultrasound guided needle tenotomy cover

Evidence for Ultrasound Guided Needle Tenotomy

Tendinopathy is commonly seen in sports medicine clinics and involves multiple joints including the elbow, foot/ankle, gluteal musculature, and shoulder. At the microscopic level, degenerated tenocytes lead to mucoid degeneration within the tendon (2). The prevalence of chronic tendinopathy led to the creation of the Tenex procedure in 2011. Percutaneous ultrasonic tenotomy is indicated for recalcitrant tendinopathy (2). The Tenex device uses ultrasonic vibration of a needle to remove the necrotic tissue found in tendinopathy (1). Using a 19g needle, the 28kHz oscillation will irrigate the tendon with saline to assist in debriding the tendinopathy (1).

Case Question

Which of the following ultrasound findings is seen in lateral epicondylitis?

A) Hyperechoic tendon suggests tendinopathy
B) Calcifications at the tendon insertion
C) Lack of new blood vessel formation
D) Hypoechoic fluid collection within the subcutaneous tissue above the tendon

Tenex Needle Demonstration
Image 1: Example of Tenex Needle (1)

Evidence

Recently published in Skeletal Radiology in their January 2021 edition, was a retrospective study looking at the use of Tenex-1 for treatment of chronic epicondylitis verse surgical tenotomy (1). The patients enrolled in the study filled out a QuickDASH survey to help gauge their pain score. Preprocedurally, the tenotomy group scored a 56 +/- 8.4 and 3 months after the procedure scored a 21 +/- 7.6 (1). This was similar to the surgical group who preoperatively scored a 56 and 3 months after the procedure scored a 16 (1). The outcomes between the two groups were also similar at 12 months (1). The cutting time was in line with previous studies at 105s (1).
Hypoechoic Tissue Within the Common Extensor Origin
Image 2: Hypoechoic Tissue Within the Common Extensor Origin (1)
Ultrasonic tenotomy has also been used in the treatment of calcific tendonitis. Recently published in the Journal of Primary Care & Community Health, a sports medicine clinic looked at the treatment of calcific tendonitis with an ultrasonic tenotomy and debridement using the Tenex TX2 and TXBone tip (3). They found that all 8 patients treated with the ultrasonic tenotomy had statistically significant reductions in their pain scores (3).
Calcific Tendonitis on Ultrasound
Image 3: Calcific Tendonitis on Ultrasound (3)
One of the leading causes of trochanteric bursitis is gluteal tendinopathy. Outside of physical therapy and either PRP or corticosteroid injection into the trochanteric bursa, treatment options are limited. As a result, a study published in the Orthopaedic Journal of Sports Medicine looked at the treatment of gluteal tendinopathy with the Tenex TX System. The provider identified the hypoechoic area within the gluteus medius insertion or within the gluteus minimus tendon insertion. Then, after ultrasound guided insertion of the needle into the hypoechoic area, the tendon was pulsed with ultrasound energy and there was continuous irrigation and debridement (4). They found that there were improvements in patients visual analog scale up to 18 months after the procedure (4).
Gluteal Tendon Tenex Procedure
Image 4: Gluteal Tendon Tenex Procedure (4)
Chronic patella tendonitis is also commonly seen in sports medicine clinics. There is a case study published in the Journal of Injury, Function, and Rehabilitation of a collegiate athlete successfully treated with the Tenex 1 probe. They think that their patient responded better to the Tenex procedure then PRP and surgical debridement because the Tenex procedure was able to precisely remove the calcifications within the tendon (5).
Patella Tendon Injection with Tenex
Image 5: Patella Tendon Injection with Tenex (5)

Achilles tendinopathy is another area in which ultrasonic tenotomy has been used as a treatment modality. A study in the Journal of the American Institute of Ultrasound in Medicine evaluated complications following an ultrasonic tenotomy for patients with insertional achilles tendinopathy. Side effects seen were superficial wound infection, hematoma, scarring, DVT, and recurrence of pain (6). They did find that performing an ultrasound tenotomy verse an open achilles debridement saved the institution $18,000 (6). Based on a review of the data for Achilles tendinopathy and percutaneous tentomy, there is a lack of evidence regarding long term outcomes with the procedure (10).

 

Further evidence looking at the use of the Tenex device for chronic elbow tendinopathy was published in the Journal of Shoulder and Elbow Surgery. The study looked at the treatment of both medial and lateral epicondylitis with the Tenex 1 system (7). They found that preprocedure VAS scores averaged to 6.4 and following the procedure at 12 months the VAS score was 0.7 (7).

 

Another common treatment for epicondylitis is Platelet Rich Plasma injections. As a result, a study was performed that compared a group of patients with epicondylitis and randomized them to receive either a PRP injection for epicondylitis or a Tenex procedure (9). PRP injections deliver growth factor to the tendon to stimulate angiogenesis and tendon remodeling (10). The study found that both PRP and tenotomy had statistically significant improvements in their pain scores post procedure (9). Since both procedures led to improvement in pain, it is up to the physician to choose which to use. In a patient who cannot afford the out-of-pocket price of PRP, a tenotomy may be preferred since most procedures are covered by insurance after a prior authorization. A recent review in Sports Health found five studies looking at the value of percutaneous ultrasound tenotomy for epicondylitis and found that the procedure led to significant improvements in VAS and DASH subscores (10).

Conclusion

Percutaneous ultrasonic tenotomy is an emerging treatment for chronic tendinosis. Patient’s should still be treated with activity modification, bracing, NSAIDs, and PT. However, patients that fail first line measures and/or corticosteroid injection or PRP injection should be considered for tenotomy due to its price advantage compared to surgery.

Case Answer

Correct Answer is B calcifications at the tendon insertion. Tendinopathy on ultrasound can be seen with hypoechoicity within the tendon, calcifications within the tendon origin, neovascularization, and tendon thickening.

 

Seng, Chusheng, et al. “Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years.” The American Journal of Sports Medicine, vol. 44, no. 2, Feb. 2016, pp. 504–10. PubMed,

References

  1. Altahawi, Faysal, et al. “Percutaneous Ultrasonic Tenotomy with the TX-1 Device versus Surgical Tenotomy for the Treatment of Common Extensor Tendinosis.” Skeletal Radiology, vol. 50, no. 1, Jan. 2021, pp. 115–24. PubMed, doi:10.1007/s00256-020-03540-7.
  2. Peck, Evan, et al. “Advanced Ultrasound-Guided Interventions for Tendinopathy.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, Aug. 2016, pp. 733–48. PubMed, doi:10.1016/j.pmr.2016.04.008.
  3. Erickson, Jacob L., and Andrew R. Jagim. “Ultrasonic Tenotomy and Debridement for Calcific Tendinopathy of the Shoulder: A Pilot Case Series.” Journal of Primary Care & Community Health, vol. 11, Oct. 2020. PubMed Central, doi:10.1177/2150132720964665.
  4. Baker, Champ L., and J. Ryan Mahoney. “Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy.” Orthopaedic Journal of Sports Medicine, vol. 8, no. 3, Mar. 2020, p. 2325967120907868. PubMed, doi:10.1177/2325967120907868.
  5. Nanos, Katherine N., and Gerard A. Malanga. “Treatment of Patellar Tendinopathy Refractory to Surgical Management Using Percutaneous Ultrasonic Tenotomy and Platelet-Rich Plasma Injection: A Case Presentation.” PM & R: The Journal of Injury, Function, and Rehabilitation, vol. 7, no. 12, Dec. 2015, pp. 1300–05. PubMed, doi:10.1016/j.pmrj.2015.06.439.
  6. Chimenti, Ruth L., et al. “Percutaneous Ultrasonic Tenotomy Reduces Insertional Achilles Tendinopathy Pain With High Patient Satisfaction and a Low Complication Rate.” Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, vol. 38, no. 6, June 2019, pp. 1629–35. PubMed, doi:10.1002/jum.14835.
  7. Baria, Michael R., et al. “Percutaneous Ultrasonic Tenotomy Effectively Debrides Tendons of the Extensor Mechanism of the Knee: A Technical Note.” The Knee, vol. 27, no. 3, June 2020, pp. 649–55. PubMed, doi:10.1016/j.knee.2020.04.010.
  8. Barnes, Darryl E., et al. “Percutaneous Ultrasonic Tenotomy for Chronic Elbow Tendinosis: A Prospective Study.” Journal of Shoulder and Elbow Surgery, vol. 24, no. 1, Jan. 2015, pp. 67–73. PubMed, doi:10.1016/j.jse.2014.07.017
  9. Boden, Allison L., et al. “Platelet-Rich Plasma versus Tenex in the Treatment of Medial and Lateral Epicondylitis.” Journal of Shoulder and Elbow Surgery, vol. 28, no. 1, Jan. 2019, pp. 112–19. PubMed, doi:10.1016/j.jse.2018.08.032.
  10. Seng, Chusheng, et al. “Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years.” The American Journal of Sports Medicine, vol. 44, no. 2, Feb. 2016, pp. 504–10. PubMed, doi:10.1177/0363546515612758.
  11. Vajapey, Sravya, et al. “Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review.” Sports Health, Nov. 2020, p. 1941738120951764. PubMed, doi:10.1177/1941738120951764.

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