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.