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A subset of tendinopathy appears to become chronic and nonresponsive to conservative treatments such as activity modification and exercise-based rehabilitation.
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Ultrasound-guided needle tenotomy is a simple office-based procedure that has been shown effective at multiple tendon locations throughout the body.
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Ultrasound-guided tenotomy and debridement with the Tenex Health TX System provides a less-invasive and cost-effective option for chronic tendinopathy compared to traditional surgical management.
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An in-depth understanding of the regional anatomy and the ability to obtain optimal ultrasound images of the region are essential prerequisites of either procedure.
Introduction
Tendinopathy is a clinical condition characterized by pain and dysfunction related to mechanical loading of a tendon. While often self-limited and responsive to conservative measures, such as activity modification and exercised-based rehabilitation, a subset of patients goes on to develop chronic and recalcitrant symptoms. While the optimal treatment for this group remains poorly defined in the literature, minimally invasive ultrasound-guided mechanical treatments have shown favorable results. In this chapter we review ultrasound-guided needle tenotomy and ultrasound-guided tenotomy and debridement with the Tenex Health TX System. Procedural technique, post-procedure care and rehabilitation, and patient selection are discussed.
Pathology
The term “tendinopathy” includes a wide array of potential histopathology involving the tendon and its paratenon or sheath. Chronic tendon pain is felt to predominately represent a condition characterized histologically as mucoid collagen degeneration with other variable features such as collagen disorganization, fibrocartilaginous metaplasia, calcification, and neovascularity. These changes are often referred to as tendinosis. Although primarily an overuse and degenerative process with an absence of acute inflammatory infiltrate, inflammatory mediators are present. Clinically, tendinopathy is characterized by pain and dysfunction with mechanical loading of a tendon and can lead to significant time loss from sport and work. While the optimal treatment for this group remains poorly defined in the literature, minimally invasive ultrasound-guided mechanical treatments have shown favorable results.
Treatment Options
Ultrasound-guided percutaneous needle tenotomy was first described in the early 1980s as a nonsurgical treatment option for common extensor tendinopathy. Subsequent studies have reported favorable outcomes across multiple tendon locations. The basic principle of the procedure is to stimulate a healing response within a region of disorganized nonhealing tendon tissue via local acute trauma produced by multiple needle fenestrations . ,
Despite early encouraging outcomes with simple needle fenestration, there are inherent limitations with this technique. The Tenex Health TX system (Tenex Health, Lake Forest, CA) is an ultrasonic cutting instrument designed to focally debride and remove pathologic tissue from tendons allowing for both a true tenotomy and debridement. The rationale is that when the pathologic tissue is removed, a chronic degenerative process is converted to an acute process, introducing inflammatory growth factors and promoting tendon healing. Recent advances in the technology now allow for removal of hard calcifications and bone. Early clinical experience has been favorable, even for challenging locations such as the Achilles insertion. The procedure is safely performed in a clinical setting under local anesthesia, which reduces cost significantly compared to an open or endoscopic tenotomy. Furthermore, the minimally invasive nature allows for less post-procedure pain and faster recovery than traditional surgical approaches.
Techniques
A pre-procedural ultrasound should be performed to confirm pathology amendable to treatment and to identify local structures at risk such as nerves and blood vessels. Ergonomics for both patient and physician should be considered. Nuances in treatment of each individual tendon location are outside the scope of this chapter. An in-depth understanding of the regional anatomy and the ability to obtain optimal ultrasound images of the region are essential prerequisites of either procedure.
While there may be variance in clinical practice, we have found that ultrasound-guided needle tenotomy and ultrasound-guided tenotomy and debridement are safely and effectively performed in an outpatient setting under local or regional anesthesia. We recommend a sterile technique including a sterile ultrasound transducer cover and sterile acoustic coupling gel. Our local anesthetic preference is a 50:50 mixture of 1% lidocaine without epinephrine and 0.5% ropivacaine. Between 4 and 10 mL should provide adequate anesthesia in most cases. This can be titrated to patient comfort using the lowest effective dose.
Ultrasound-Guided Needle Tenotomy/Fenestration
After anesthesia is obtained, a large-gauge needle (typically 18 to 20 G) is advanced with live ultrasound guidance to the area of pathology, and multiple fenestrations are made through the pathologic tissue. Whenever possible, fenestrations should be made parallel to tendon fibers in order to avoid unnecessary trauma to surrounding normal tissue. While determining the necessary amount of tissue fenestration is subjective, a change in tissue resistance to the needle will be appreciated as adequate fenestration is achieved.
Ultrasound-Guided Tenotomy and Debridement With the TX System
Once anesthesia is achieved, a #11 blade is used to make a 5-mm skin incision and create a tract to the tendon or fascia being treated ( Fig. 26.1A ). We prefer to perform the incision under live ultrasound guidance to maximize safety. The incision should always be performed in line with the tendon or fascia to avoid iatrogenic horizontal fiber laceration. Occasionally, more than one incision/entry site is required to effectively address the full extent of the pathologic tissue.
