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Common Extensor Tendon Percutaneous Tenotomy

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Other Names

  • Common Extensor Tendon Percutaneous Tenotomy
  • CET Tenotomy
  • Tenex

Background

Illustration of the 4 muscles of the common extensor tendon[1]

Key Points

  • Percutaneous needle tenotomy involves repeatedly fenestrating the diseased tendon under ultrasound with the goal of promoting a healing response
  • An 18-20 gauge 1.5 inch needle is ideal for the procedure
  • Be sure to council the patient on increased pain following the procedure

Anatomy

Palpation vs Ultrasound Guidance

  • To date, there are no studies comparing ultrasound-guided and palpation-guided approaches

Indications


Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Tendon tear or rupture
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Needle tenotomy of the common extensor tendon showing (a) probe and needle position and (b) length and trajector of needle in-plane.[2]
Percutaneous tenotomy with the "Tenex TX-1". The needle is positioned within the common extensor tendon just distal to the osseous footplate (asterisk). The device has a blunt, 18-g tip (a, small arrows) and larger irrigation sheath more proximally (a, large arrows). When activated, the device creates a snow storm-like artifact due to the ultrasonic vibration of the tip (b)[3]

Equipment

  • Sterile prep (including chloraprep, chlorhexadine, iodine, etc)
  • Ultrasound with sterile probe cover
  • Gloves
  • Needle
    • Local anesthesia: typically 21-25 gauge, 1.5 inch
    • Tenotomy: 18-20 gauge, 1.5 to 3 inch needle
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid/ injectate

Ultrasound Findings

  • Best visualized with high frequency linear probe
  • Common ultrasound findings include:
    • Enthesophyte at the apex of the epicondyle
    • Thickened, heterogenous common extensor tendon
    • Interstitial tearing (often not seen sonographically)
    • Increased flow on color doppler

Technique

  • Patient Position
    • The patient is supine or seated
    • Elbow in resting position, flexed to approximately 90°
  • Probe Position and Needle Orientation
    • Long axis to the CET
    • Needle is in plane, distal to proximal
  • Target
    • Target is the origin of the CET
    • Emphasis on areas that appear tendinotic on US
  • Pearls and Pitfalls
    • Small amounts of fluid can be injected into the tendon to ensure adequate distribution
    • Needle is repeatedly passed form superficial to deep, distal to proximal
    • The periosteum should be diffusely abraded
    • There is no max/minimum number of fenestrations; the goal is to fenestrate all abnormal tendon
    • The needle should glide through the tendon easily at the end
    • The decision to inject corticosteroids is controversial and generally not recommended

Aftercare

  • Council patient on increased pain immediately following the procedure

Complications

  • Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycmia
  • Nerve or blood vessel injury
  • Tendon rupture
    • Frequency unknown

See Also


References

  1. Image courtesy of orthobullets, "Tennis Elbow"
  2. Singh, Dharmendra, et al. "Ultrasound-guided percutaneous needle tenotomy for tendinosis." Indian J Musculoskelet Radiol 2 (2020): 52.
  3. Altahawi, Faysal, et al. "Percutaneous ultrasonic tenotomy with the TX-1 device versus surgical tenotomy for the treatment of common extensor tendinosis." Skeletal Radiology 50 (2021): 115-124.
Created by:
John Kiel on 19 April 2023 14:19:36
Authors:
Last edited:
30 August 2023 13:47:00
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