Percutaneous Ultrasonic Tenotomy of the Common Extensor
Tendon Origin
Kile R. Skrobacki, Shawn D. Felton, Jason C. Craddock,
Florida Gulf Coast University, Department of Rehabilitation Sciences, Fort Myers, FL USA
Abstract Introduction Treatment Results
Discussion and Summary
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In conclusion, the TX1 procedure has demonstrated over multiple times
successful in treating lateral epicondylitis or tennis elbow. Clinicians will not
recommend this option unless the condition remains chronic and the
conservative treatments fail. Trying non-operative treatments for greater
than three months is recommended before considering the TX1 procedure
(Seng et al., 2016). Studies would show that the majority of tennis elbow
symptoms reduce within 12 months, so the patient should continue to try
conservative treatment until this time. If and when these treatments fail, the
TX1 procedure is recommended over arthroscopic surgery. Arthroscopic
surgery does have more operational risks when compared to the TX1
treatment. Cummins (2006) argued, “It is unclear whether arthroscopy is
effective in identifying and removing the degenerative portion of the
extensor tendon origin.” The TX1 treatment is an outpatient procedure and
can be done in a clinical setting as well as an ambulatory setting. In both of
these cases the patient will leave after the surgery and be able to use their
arm like normal after the first week post operation. The patient will be
limited in lifting and pulling with this arm but will have access to it. The TX1
procedure is a safe and effective procedure for the treatment of lateral
epicondylitis or tennis elbow, and should be recommended for chronic
symptoms that fail conservative treatment.
The Tenex ultrasonic percutaneous tenotomy of lateral epicondylitis has
shown to be 95% effective with treatment outcomes. Studies would show
that excellent short-term results with long-term durability have been
produced by the Tenex procedure (Luk, Tsang, & Leung, 2014). “Recent
data suggests that the prevalence of lateral epicondylopathy in the
general population is approximately 1.0% to 1.3% in men and 1.1% to
4.0% in women” (Papa, 2012). While the majority of cases usually resolve
within 12 to 24 months with conservative treatment, the Tenex procedure
has been proven to relieve symptoms when conservative treatment fails
(Jariwala, Dorman, Bruce, & Rickhuss, 2012). After following up with the
patient during the post procedure visits, the patient was experiencing
satisfactory results with no complaints and sustained improvements. The
patient returned to work under no restrictions after 4 weeks of light duty.
As this procedure is becoming more popular and has shown to have
more responsive results, athletes can look to this treatment when
conservative treatment fails. When compared to surgical intervention,
Tenex can be a faster road to recovery for athletes getting them back into
their sport. Even though this procedure’s outcome does correlate with
other case studies, this study focused on one patient, so the outcome and
results should be considered.
Ultrasonic percutaneous tenotomy is a procedure used to treat lateral
epicondylitis of the humerus or tennis elbow. The machine, which is used to
perform this procedure, is classified as a Tenex machine (TX1). This
treatment can be used after conservative treatment has failed. Tenotomy of
the common extensor tendon is minimally invasive and has a much shorter
recovery time than other surgical interventions. Koh et al. stated (2013),
“Chronic tendinopathy of the common extensor origin of the elbow
(commonly termed tennis elbow) affects 2% to 3% of the population, with a
tendency toward an economically active population between 40 to 50 years
of age.” This common overuse injury can take up to 24 months to heal, and
in some cases last for longer periods of time. When a patient is experiencing
these symptoms, they can miss work due to pain or doctor visits. “Up to 30%
can have prolonged absence from work for 11 to 12 weeks, which can
occasionally extend up to a year or even result in occupational changes”
(Koh et al., 2013). There are many conservative treatments for this pathology.
Some of the treatments are NSAIDs, physiotherapy, bracing, shock wave
therapy, laser therapy, ultrasound therapy, and injections: Corticosteroid,
platelet-rich plasma, autologous blood, botulinum toxin, sodium hyaluronate,
glycosaminoglycan polysulfate (Sayegh & Strauch, 2015). After these more
conservative treatments have failed, either arthroscopic debridement,
tendon release, or ultrasonic percutaneous tenotomy is advised.
Arthroscopic debridement or tendon releases are more invasive than
percutaneous tenotomy and have greater operational risks. They also can
have a longer recovery period lasting up to a year. Percutaneous tenotomy
has been proven to heal patients with this chronic condition. About 10% to
15% of the patients experiencing the symptoms of chronic elbow tendinitis
will not obtain results from conservative treatments and therefore will be
surgical candidates (Barnes, Beckley, & Smith, 2015).
Background: Patient was a 54 year-old (162.5cm and 53.9kg) female. The
patient’s activity level was low. She reported to the orthopedic clinic complaining
of chronic pain on the lateral aspect of her right elbow that has lasted for 1 year in
duration. The patient denied any specific mechanism. Initial evaluation revealed
no obvious deformities, or signs of trauma. She was point tender over the lateral
aspect of the epicondyle of the humerus and proximal forearm. Patient had full
ROM, wrist flexion, extension, supination, pronation, radial deviation, and ulnar
deviation. Limited strength of the right arm compared bilaterally, wrist extension
4/5, handgrip 4/5, and supination 4/5. Orthopedic clinical examination continued
with the following: Tennis Elbow test (+), Mill’s test (+), Varus stress test (-),
Valgus stress test (-), Tinels sign (-), Pinch grip test (-). Differential Diagnosis:
Lateral Epicondylitis, tendinopathy, tenosynovitis, tendinitis, syndesmosis, radial
ulnar stress fracture, extensor carpi radialis (ECR) strain, and Extensor digitorum
strain. Treatment: Patient began conservative treatment with prescription
NSAID’s, formal physical therapy, and home exercise program with no significant
relief. Patient underwent evaluation with X-Ray and Ultrasound imaging. X-ray
was normal, Musculoskeletal Ultrasound revealed hypoechoic area with signs of
fluid accumulation and inflammation over the common extensor tendon origin.
Patient underwent percutaneous ultrasonic tenotomy (Tenex, Tx1) as a treatment
for lateral epicondylitis (Tennis Elbow). The Tx1 procedure is a sonographically
guided percutaneous tenotomy and debridement technique that uses ultrasonic
energy to produce low-amplitude, high frequency longitudinal oscillations of an
18-gauge hollow-tip needle. Following the Tenex procedure, the patient
underwent 6 weeks of rehabilitation. Patient returned to ADL’s without any
complaints. Uniqueness: Lateral epicondylitis is a common injury in the general
population. Research suggested that up to 3% of the population develops lateral
epicondylitis lasting 12 to 24 months in duration. The average age to develop
lateral epicondylitis is 35 to 55 years old. The most common mechanism is
overuse. It has recently been seen less in tennis players possibly due to the
lighter tennis rackets. This particular case report examined the recovery and
outcome from percutaneous ultrasonic tenotomy of the common extensor tendon
origin under local anesthesia following the unsuccessful use of conservative
treatment. When compared to surgical procedures, Tenex is minimally invasive
and has minimal to no operative risks. The Tenex recovery period is also shorter
in duration. Studies would indicate that 95% of patients that received the Tenex
treatment were satisfied and feeling better after the first week of recovery.
Conclusions: This case study followed the outcome and recovery process of a
patient that was diagnosed with lateral epicondilitis and tendinopathy. The study
looks at the minimally invasive percutaneous ultrasonic tenotomy, Tenex, Tx1,
procedures effectiveness and recovery rate. Conservative treatment failed making
the patient a candidate for the procedure. After following up with the patient during
the post procedure visits, the patient was experiencing satisfactory results with no
complaints and sustained improvements. The patient returned to work under no
restrictions after 4 weeks of light duty. As this procedure is becoming more
popular and has shown to have more responsive results, athletes can look to this
treatment when conservative treatment fails. When compared to surgical
intervention, Tenex can be a faster road to recovery for athletes getting them back
into their sport. Even though this procedure’s outcome does correlate with other
case studies, this study focused on one patient, so the outcome and results
should be considered.
The Tenex procedure was performed under the guidance and assistance of
ultrasonography. Ultrasound allowed the clinician to perform the procedure
accurately viewing the tenotomy that is taking place under the skin in real time.
This imaging can also be used to provide the clinician and patient with
evidence and documentation of the procedure. The patient was scanned using
ultrasound or magnetic resonance imaging prior to the tenotomy procedure to
look for evidence of calcification or necrotic tissue. “An MRI usually shows
increased signal density indicating edema and degeneration at ECRB
insertion” (Jariwala, Dorman, Bruce, & Rickhuss, 2012). The clinician can
locate this tissue by ways of ultrasound looking for hypoechoic areas or signs
of calcification near or on the site of symptoms. After the decision was made to
have the TX1 treatment, the patient obtained a surgery date. Barnes, Beckley,
and Smith (2015) stated, “The TX1 technique is a novel sonographically
guided percutaneous tenotomy and debridement technique that uses
ultrasonic energy to produce low-amplitude, high-frequency longitudinal
oscillations of an 18-gauge hollow-tip needle.” During the date of surgery, the
patient reported to the site of operation and begun the pre operative protocol.
Her arm was cleansed and sterilized for the procedure. The patient was long
sitting slightly declined with their shoulder abducted, arm placed on a flat
surface, and elbow flexed 60 degrees. She was then covered with sterile
drapes with the appropriate elbow exposed. The doctor rescanned the site
using a draped sterile ultrasound 12-3 MHz transducer and marked on the
elbow where the finding of the damaged tissue was. Once the elbow was
marked, local anesthesia of 1% lidocaine 3ml was used to numb the patient’s
arm. The patient was experiencing twilight anesthesia under mild sedation.
The doctor begun by cutting a small incision into the elbow 1.5cm away from
the site of damaged tendon. Barnes, Beckley, and Smith (2015) stated, “A
number 11 scalpel blade was used to make a 4-mm stab incision through the
skin, subcutaneous tissue, and into the tendon, in plane with the forearm and
just distal to the epicondyle.” The doctor then took the handheld device that
performs the debridement and tenotomy and inserted it at an angle appropriate
to reach the site of damaged tendon. Viewable under the ultrasound probe,
“ultrasonic energy rapidly oscillates the hollow 18-gauge tip of the TX1 to
emulsify tissue, which is subsequently removed by an inflow-outflow fluid
circuit” (Barnes, Beckley, & Smith, 2015). In order for the handheld device to
become active, the doctor steps onto a pedal that activates the irrigation,
oscillation, and aspiration. While the doctor was stepping onto the pedal, he
also moved the handheld device in an up and downward motion to allow for
the tip of the needle to puncture tiny micro tears into the damaged tendon. This
is also helping the device emulsify the damaged tendon and draw it out of the
elbow by aspiration. The amount of time that the device was active was
recorded onto the Tenex machine in seconds. There are three speeds; slow,
medium, and fast oscillation, irrigation, and aspiration. For however damaged
or calcified the tendon is, the faster the speed should be to debride the area.
Studies would show, the average ultrasonic energy time ranges from 25 to 63
seconds, and total procedure time is completed in less then 15 minutes
(Barnes, Beckley, & Smith, 2015). This particular patient received a total
procedure time of 43 seconds. After the delivery of the treatment, the
hypoechoic area on the ultrasound became hyperechoic, filling the dark areas
on the screen with micro bubbles. “These microbubbles manifested as
hyperechoic speckling, which were conspicuous on ultrasound, and therefore
served as a marker for treatment of a specific region” (Barnes, Beckley, &
Smith, 2015). With help from viewing this on the ultrasound screen, as well as
the feeling of the tissue becoming more consistent, the doctor made the
decision to end the treatment. The handheld device was removed from the
tissue and the area was wiped clean of blood. The small incision was then
covered with sterri strips and an inclusive bandage. The patient received an
ace bandage wrap and a sling to protect her arm through the first few days
post operation. This was an outpatient procedure and the patient returned
home that day after the treatment. She was given NSAIDs and instructed to ice
the elbow as needed to help reduce swelling and pain. She was also instructed
to leave the bandage on until her first visit that was one-week post procedure.
During this first post op visit, the bandage was taken off, but the sterri strips
remained over the incision. The patient was then instructed to not use the sling
and ace wrap and shower normally, leaving the sterri strips to fall off on their
own. After the first post op week, the patient was instructed to return to her
normal life functions minimizing the use of the treated arm.