Percutaneous Ultrasound Tenotomy

A NEW TECHNIQUE TO TREAT TENDINOPATHY

Tendonitis is a common term used to describe pain caused by tendon irritation around a joint. It is usually associated with overuse and is aggravated with activity. It is very common, impairing over 20 million people a year in the US and it impacts individuals of all ages, backgrounds, and activity levels. It affects all major joints, from shoulders to ankles and every joint in between. Symptoms can range from mild discomfort to debilitating pain and can cause a significant socioeconomic burden with the loss of work and productivity.

What’s causing your pain?

Researchers once considered tendon pain to be an inflammatory process, thus the term tendonitis was often used when diagnosing the condition. However, it has now been established that symptoms are associated with tendon degeneration rather than inflammation. Repetitive microtrauma causes changes to the tendon on a cellular level, which impede its ability to remodel into normal healthy tissue. The diseased tendon can be identified using MRI or diagnostic ultrasound in combination with a physical exam.

How can the pain be treated?

Initial treatment for tendinopathy is a combination of various conservative measures including: rest, ice, stretching, strengthening, bracing, nonsteroidal anti-inflammatory medications, and corticosteroid injections. While most symptoms do improve with nonsurgical treatment, a significant number do not. For example, up to 15% of elbow and 25% of Achilles tendinopathy cases fail to improve with conservative treatment. Traditionally for those patients, the only remaining option was surgical intervention to remove the diseased tendon. While successful, the surgery comes with inherent risks as well as prolonged recovery time.

New advances in treatment

A new minimally invasive option to surgery is percutaneous ultrasound tenotomy (PUT), which uses 2 types of ultrasound—diagnostic and therapeutic. Advances in diagnostic ultrasound technology have lead to an expanded role in orthopaedics. It is now possible to easily identify diseased tendon with small handheld ultrasound machines. The affected portion of tendon is typically enlarged and hypoechoic (darker than normal). A trained physician can recognize the dark areas that represent partial tearing or chronic degeneration of the tendon. After locating the diseased tissue, the ultrasound can be used to precisely and accurately guide treatment to the intended area.

Therapeutic ultrasound, such as with the TenexTM system, can eliminate a diseased tendon using an ultrasonic “jack-hammer” effect. As the damaged tissue is cut, it is removed through continuous irrigation and suction. By using this technology and live ultrasound guidance, the surgeon can precisely remove the diseased tendon tissue while sparing healthy tissue (Fig). Multiple studies have demonstrated that this technique is a safe and effective treatment for tendinopathy that has failed conservative treatment.

Because PUT is still a relatively new technology, its uses are still being developed; however, almost all areas of the body that develop tendonitis can be treated using this method. The Hughston Clinic is currently involved in a prospective study for gluteal (hip) tendonitis.

How is the TenexTM procedure done?

Before the procedure, the physician presses over the area of concern to locate the point of maximal tenderness. This gives the physician an idea of where the diseased tendon is located. Next, the doctor sterilizes and drapes the area with sterile towels. Using a sterile technique, the physician again confirms the point of maximal tenderness and “numbs up” the area with a local anesthetic. Using the diagnostic ultrasound, the physician locates the damaged tissue and makes a small sub-centimeter incision. Finally, the diagnostic ultrasound guides the therapeutic probe to the exact location and targets only that area, so healthy tissue is not damaged. The procedure removes the damaged and degenerated tendon tissue in minutes. After the procedure, the wound is covered with a dry sterile bandage. Often, a compression wrap is applied to help reduce swelling.

What happens after the procedure?

Since the procedure is done as outpatient, you will go home that same day. Your incision is small, and there are no stitches, but you must not submerge the wound in water for about a week to give it time to close. You will leave the surgical center or doctor’s office with instructions to follow until you return for your follow-up visit.

Some swelling, bruising, and soreness are expected after the procedure. You can ice the area for 20 minutes every few hours to help with swelling, and take acetaminophen for pain. Depending on what area is treated, you should take it easy for the first few weeks with no excessive lifting or strenuous activity. Most patients experience full recovery in 6 weeks.

Does it really work?

The PUT procedure is noninvasive and safe, and very few patients have any complications at all. Many complications associated with surgery are related to anesthesia and long surgical times; however, because this procedure uses local anesthetics and it only takes minutes to complete, complications are rare. Most patients are pain free within weeks after the procedure and back to full activity in a quarter of the time when compared to other traditional surgical procedures.

Author: M. Canaan Prater, DO and J. Ryan Mahoney, DO

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 4, Fall 2017.