Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Clinical and Sonographic Results at 90 Months

Background: In a study from our institution, ultrasonic percutaneous tenotomy of the brevis and the common extensor tendon for recalcitrant lateral elbow tendinopathy showed excellent safety profiles, high tolerability, efficiency, sustained pain relief, functional improvement, and sonographic evidence of tissue healing in 20 patients at 3 years’ follow-up. Purpose: To explore the long-term clinical and sonographic results of ultrasonic percutaneous tenotomy of the brevis and the common extensor tendon. Study Design: Case series; Level of evidence, 4. Methods: The same cohort of 20 patients was recalled after 7 years, and visual analog scale (VAS) for pain and Disabilities of the Arm, Shoulder and Hand (DASH) scores, need for secondary intervention, and overall satisfaction were assessed. They were also reassessed using ultrasound imaging of the brevis and the common extensor tendon to evaluate tendon hypervascularity, tendon thickness, and the progress or the recurrence of the hypoechoic scar tissue. Results: We successfully scored 19 patients and performed ultrasound on 16 patients with a median follow-up of 90 months (range, 86-102 months). There were no adverse outcomes and satisfaction remained at 100% (6 patients, satisfied; 13 patients, very satisfied). No patient developed a recurrence of symptoms and signs of lateral elbow tendinopathy, and therefore no secondary intervention was required. The improvement from baseline and early term scores was sustained ( P < .001 for all). At 90 months, there was a significant improvement in VAS scores and DASH–Compulsory scores compared with preprocedure scores and all follow-up times until 3 months. There was no difference in VAS scores and DASH–Compulsory scores at 90 months compared with 6 and 36 months. For DASH–Work scores, there was a significant improvement at 90 months compared with preprocedure scores, but there was no difference between DASH–Work scores at 90 months and scores at all other points of follow-up. At 90 months, hypervascularity remained resolved in 79% of patients, while all patients had reduced tendon swelling and sustained resolution or reduction of the hypoechoic lesion. Conclusion: At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy of the brevis and the common extensor tendon, previously shown to enhance recovery of lateral elbow tendinopathy, demonstrated good durability of pain relief and functional recovery that was previously achieved. This was accompanied by sustained sonographic tissue healing with no significant deterioration.

Sonographically Guided Percutaneous Sectioning of the Coracohumeral Ligament for the Treatment of Refractory Adhesive Capsulitis: Proof of Concept

Introduction Treatment options are limited for nonsurgical chronic refractory cases of adhesive capsulitis. We describe a novel percutaneous tenotomy technique for coracohumeral ligament interruption with cadaveric validation. Objective The objective of this study was to describe and validate a novel technique for percutaneous interruption of the coracohumeral ligament. Design Cadaveric study. Setting Academic tertiary care center. Methods Eight cadavers underwent ultrasound (US)-guided percutaneous incision of the coracohumeral (CHL) ligament. Performance of the procedure requires that the practitioner make oscillatory motions with a needle that uses ultrasound energy to cut through tissue. Each pass removes a pinhead-sized amount of tissue. The number of passes and the cutting time are recorded during the procedure. As a standard for this procedure does not exist, the authors created their own based on the preclinical information presented here. Postprocedure dissection was performed to assess the extent of CHL interruption and injury to surrounding tissue. Results The average resection time was seven minutes, requiring 500 passes. The technique described in this paper completely interrupted the CHL in all subjects. Cadaveric analysis demonstrated interruption of the CHL with respect to control shoulders requiring an average of seven minutes of cutting time and ∼500 micro-perforations. Conclusion US-guided percutaneous CHL ligament sectioning is possible with a commercially available ultrasonic probe.

Ultrasound-guided Percutaneous Tenotomy Shows Sustained Clinical and Sonographic Outcomes for Recalcitrant Lateral Elbow Tendinopathy at 7.5 Years

Objectives: In our previously published study, 20 patients who underwent ultrasound-guided percutaneous tenotomy for recalcitrant lateral elbow tendinopathy were followed up clinically and sonographically for 3 years, demonstrating sustained pain relief and functional improvement, with sonographic evidence of tissue healing. We aim to explore the long-term clinical and sonographic results of ultrasound-guided percutaneous tenotomy. Methods: The same cohort of patients were recalled at 7-8 years and assessed for visual analog scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) scores, need for secondary intervention, and overall satisfaction. They were also reassessed with ultrasound imaging to evaluate tendon hypervascularity, tendon thickness, and the progress or recurrence of the hypoechoic scar tissue. Results: We successfully scored 19 subjects and performed ultrasound on 16 subjects, with a follow up of 90 (median±standard deviation: 90±2.7; range: 86-94) months. Among them, one patient had subsequently undergone surgical fixation for an ipsilateral radial head fracture 6 years after ultrasound-guided percutaneous tenotomy, and was thus excluded from the study. There were no adverse outcomes and satisfaction remained at 100% (6 satisfied, 12 very satisfied). No patient developed a recurrence of lateral elbow tendinopathy, and therefore no secondary intervention was required. The improvement from baseline and early term scores was sustained as seen in figure 1. There was no significant change in VAS score (median±SD: 0±1.0; range: 0-4) at 7.5 years, compared to 3 years (0±0.9; 0-3) (p=1.000) or DASH-Compulsory score (0±4.51; 0-13.3) at 7.5 years compared to 3 years (0±0.644; 0-2) (p=0.627) or DASH-Work score (0±6.61; 0-25) at 7.5 years compared to 3 years (0±0; 0)(p=1.000), although there were isolated cases of increased DASH scores due to rotator cuff issues, as described by the patients, which were consistent with degeneration. DASH-Sports/performing arts had too few responses for analysis. At current, hypervascularity remained resolved in 13/16 (81%) subjects, 16/16 (100%) subjects had reduced tendon swelling, and 15/16 (94%) had sustained resolution or reduction of the hypoechoic lesion (Figure 2). Conclusion: At long term follow up, ultrasound-guided percutaneous tenotomy, previously shown to enhance recovery of lateral elbow tendinopathy, demonstrates good sustainability of pain relief and functional recovery that was previously achieved, accompanied with sonographic evidence of tissue healing at 7.5 years. [Figure: see text][Figure: see text]

Lengthening of Achilles Tendon from the Percutaneous Tenotomy Procedure in Ponseti’s Method

Background Talipes equinovarus is one of the common congenital disease of foot deformity of newborn. Initial treatment is often with the Ponseti method. Studies have demonstrated that radiographic measurements can be made with clubfoot. The purposes of this study were to document the amount of Achilles tendon lengthening obtained from PAT in Ponseti’s method and to analyze the factors that might impact on the amount of equinus correction. Methods This is a retrospective study carried out from 2002 to 2006. Sixteen feet of twelve children that received percutaneous Achilles tendon tenotomy (PAT) for the treatment of congenital clubfoot were included. Assessments before and after treatment were performed using Dimeglio system. The foot length from toe to heel at the time of PAT, the pre- and post-PAT ankle dorsiflexion and post-casting lateral view of foot were obtained. The Pearson correlation coefficient was used to establish relationships between pre-, post-PATT and post-casting Tibio-calcaneal angle (TCA) and Achilles tendon length(ATL).Results The TCA before, after PATT, and after casting were -9.3, 27.4 and 18.4degrees. The ATL before, after PATT, and after casting were 22.7, 31.3, and 28.3mm. The overall lengthening of Achilles tendon was 5.7% of the foot length. The pre-PATT TCA was correlated with post-PATT and post-casting TCA. The pre-PATT ATL was correlated with post-PATT ATL and post-casting ATL.Conclusion Post-PAT correction effect is negatively correlated with the pre-PAT severity of equinus. The comparison between post-PAT and post-casting TCA could be used to check the quality of casting in the Ponseti method.Level of Evidence: level IV

Outcome analysis of percutaneous tenotomy in chronic lateral epicondylitis elbow

<p class="abstract"><strong>Background:</strong> Lateral epicondylitis elbow is a self-limiting condition with an unclear pathology. Conservative therapy is treatment of choice in lateral epicondylitis elbow but chronic lateral epicondylitis elbow (&gt;6 month) is a condition difficult to treat. Percutaneous extensor tendon release can be a viable treatment option in such conditions.</p><p class="abstract"><strong>Methods:</strong> This prospective study was conducted in 2016 to 2017 at the Department of Orthopaedics Surgery in a tertiary care institute. 30 patients were treated by percutaneous tenotomy. The outcome was assessed at follow ups using numerical rating scale (NRS), disabilities of the arm, shoulder, and hand questionnaire (DASH) and Oxford scores.<strong></strong></p><p class="abstract"><strong>Results:</strong> 30 elbows were included in this study. They were managed by percutaneous method (PT; n=30). The mean age of patients was 41.74 years (range 26-67 years). Females were affected more than males in both groups (3:1). Dominant limb was involved in 86% of patients.73% of females were house wives exposed to household chores and manual activities while 40% of males were manual workers. Mean hospital stay was 35 minutes (range 20-43 minutes). Patients were followed up at 3 month and 6 month post intervention. NRS, DASH, Oxford score assessment showed that all the scores were significantly decreased (p&lt;0.05) at 3 month and 6 month in patients undergoing percutaneous tenotomy. </p><p class="abstract"><strong>Conclusions:</strong> Lateral epicondylitis &gt;6 month duration is difficult to treat. Percutaneous tenotomy is effective modality of treatment in such conditions.</p>