Percutaneous Ultrasound Guided Tenotomy Part 2: The Procedure
As a follow up to the review of evidence on percutaneous ultrasound guided tenotomy, the specifics of the procedure and options will be covered in the following post. As mentioned, tendinopathy is very commonly seen in sports medicine clinics and can be very challenging to treat. More than 20 million There are many patients that may still be symptomatic after multiple courses of physical therapy, soft tissue modalities and other treatment options. Other patients may be unwilling to go through the physical therapy programs associated with tendinopathy.
A 45 year old recreational golfer presents with right lateral elbow pain. She describes pain with gripping his club over the lateral elbow and has seen one other provider for this problem. She states he underwent an injection for this that seemed to help for about 2 months. After the pain returned, she started to research options and has questions about percutaneous ultrasound guided tenotomy. She read that there were certain providers that use ultrasound guidance. Which of the following is NOT an advantage of ultrasound guided injections when compared to palpation-guided injections?
A. Improved accuracy
B. Increased response rate
C. Reduced procedural pain
D. Smaller volume of fluid aspirated
Tenex Health, Inc., a privately held, U.S.-based medical technology company providing healthcare professionals with minimally invasive technologies to treat chronic pain in soft and hard tissue. The Tenex technology (particularly the TX1 system) was cleared by the FDA in 2011. The procedure is performed through a small skin incision and uses ultrasonic energy to break down and remove scar tissue in the damaged region, creating an acute inflammatory reaction and facilitating tendon healing. This is a similar theory of competing treatment options such as prolotherapy with the acute inflammatory reaction. For this reason, most providers recommend stopping any non-steroidal anti-inflammatory medications one week prior to the procedure and not continuing these for 1-6 weeks, depending on the provider.
The TX1 System delivers proprietary ultrasonic energy to debride, emulsify, and aspirate degenerated tissue through the pen-like ultrasonic handpiece. The TX1 Handpiece is activated through foot-pedal technology allowing for control throughout the procedure. The TX1 Handpiece has a length of 25.4 mm, a needle tip gauge of 19 and a sheath gauge of 11. It has indications for soft tissues only. It had indications such as medial and lateral epicondylosis, rotator cuff tendinopathy, patellar tendinopathy, Achilles tendinopathy, gluteal tendinopathy and plantar fasciitis.
The TX-Bone was the last of the handpieces to get approval in 2019. The indications for this include tendinopathy with calcifications, osteophyte or spur formation. This includes the rotator cuff, triceps, gluteal region, achilles insertion, plantar fascia and possibly exostosis. The length is 33.0 mm, the needle tip gauge is 15 and the sheath size is 11. It has a 650 % volume compared to the TX1 handpiece.
Many patients will need to undergo conservative measures for more than three months before getting the ultrasound guided tenotomy performed. This pain at this stage would less likely be a muscle strain or acute “tendonitis” and more likely be a more chronic condition. Many insurances do cover the procedure but all insurance carriers may have different reimbursement rates. The procedure is performed by specialists including orthopedic surgeons, podiatrists, sport medicine physicians, interventional radiologists, interventional pain specialists and physical medicine and rehabilitation physicians. The procedure does typically occur in a hospital or surgical suite, which may not be an option for some providers. Some hospitals have a procedural suite that would also be eligible for coverage. This can be done in an office setting, but reimbursement rates and work units are typically less and insurance coverage may differ.
The actual procedure and equipment is unique. An ultrasound is used throughout the procedure for guidance. There is a kit that is included with the handpiece. Local anesthesia is used and an 11 blade is used to make a roughly 5 mm incision at the site of insertion. More local anesthesia may then be used and the handpiece is then inserted into the target area. The surgical instrument emits ultrasonic energy at a specific wavelength that bounces off of healthy tissue, leaving it unharmed while debriding necrotic (dead) tendon tissue. This is done with control of a foot pedal and sterile water is injected and a small needle oscillates very quickly. The debrided tissue is aspirated simultaneously with a vacuum source tube attachment. It has been postulated that a specific frequency between 25 and 28 KHz is the frequency of oscillation most conducive to destruction of diseased tissue . The result is targeted débridement, in other words, emulsification and aspiration of diseased tendon tissue. The time with the needle inserted is usually less than ten minutes and usually three to five minutes. An adhesive bandage is then applied.
This is many times called the FAST technique, which stands for Focused Aspiration of Scar Tissue. Most patients undergo one procedure. General instructions include local over the counter medications including acetaminophen or cold compresses. Gentle range of motion exercises should be done over the first 48 hours. Most people can return to work over the next 1-10 days depending on the patient and procedure performed. It is recommended that no weight bearing activity is performed for at least two weeks with the affected area if possible. Physical therapy may be utilized and recovery time is normally 4-6 weeks.
In conclusion, percutaneous ultrasound guided tenotomy is an emerging treatment option for tendinopathies. There are currently many case studies and reports with decreased pain scores, quick recovery times and minimal risks. A recent study showed good sustainability at 7.5 years with epicondylosis . However, randomized controlled trials and larger studies are still needed. There are three different Microtips or handpieces that are currently FDA approved with the newest TX-Bone having both soft and hard tissue indications.
D is the correct answer. Percutaneous ultrasound guided tenotomy is a treatment option for lateral epicondylosis and requires use of ultrasound. The benefits of ultrasound guidance when performing injections include a larger volume of fluid aspirated, not a smaller volume. It has been shown that ultrasound guidance improves accuracy and response rate and reduced procedural pain has also been reported.
McNabb JW. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd ed. Philadelphia, PA: Lippincott. Williams & Wilkins; 2010.
- Burke, Christopher J., and Ronald S. Adler. “Ultrasound-guided percutaneous tendon treatments.” American Journal of Roentgenology 207.3 (2016): 495-506.
- Baker Jr, Champ L., and J. Ryan Mahoney. “Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy.” Orthopaedic Journal of Sports Medicine 8.3 (2020): 2325967120907868.
- Koh, Joyce, et al. “Ultrasound-guided Percutaneous Tenotomy Shows Sustained Clinical and Sonographic Outcomes for Recalcitrant Lateral Elbow Tendinopathy at 7.5 Years.” Orthopaedic Journal of Sports Medicine 8.7_suppl6 (2020): 2325967120S00420.