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Common Flexor Tendon Percutaneous Tenotomy

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Other Names

Anatomy of the common flexor tendon
Typical findings of the common flexor tendinosis. Left side shows normal fibrillar pattern. Right side is abnormal, showing loss of fibrillar pattern (arrowhead), diffuse thickening of the musculotendinous junction.[1]
  • Common Extensor Tendon Percutaneous Tenotomy
  • CET Tenotomy
  • Tenex

Background

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
  • Long axis, in plane technique is recommended
  • 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
The patient is prone, shoulder internally rotated, forearm pronated. Probe is in long axis with needle in plane.[1]
The patient is supine, shoulder flexed and externally rotated, elbow on pillow. Probe is in long axis, needle in plane.[1]
Long axis view of the tendon with needle in plane from distal to proximal.[1]
Out of plane view can be used to evaluate the entire width of the tendon.[1]

Procedure

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
    • Tendon is shorter, narrower compared to the common extensor tendon
    • Regions appear more like a musculotendinous junction
  • 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: Long Axis, In-Plane

  • Patient Position
    • Prone
    • Arm at patients side, arm internally rotated, forearm pronated (see picture)
  • Alternate position
    • Supine
    • Hand over head, elbow and forearm resting on pillow (see picture)
  • Probe Position, Needle Orientation
    • Long axis to the flexor tendon
    • Needle in plane, distal to proximal
  • Target
    • Common flexor tendon and myotendinous junction
  • Pearls and Pitfalls
    • Turning the probe to short-axis, out-of-plane technique can be used to ensure full width of the tendon is treated
    • Prone position allows for better visualization of the ulnar nerve and cubital tunnel
    • Consider treatment of the UCL, pronater teres origin for recalcitrant cases

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. ↑ 1.0 1.1 1.2 1.3 1.4 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
Created by:
John Kiel on 30 August 2023 13:39:39
Authors:
Last edited:
30 August 2023 14:16:58
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