Jump to content
We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Distal Biceps Tendon Percutaneous Tenotomy

From WikiSM


Other Names

Anatomy of the cubital fossa. Note the relationship between the distal biceps tendon, bursa, and the adjacent neurovascular structures.[1]
  • Distal Biceps Tendon Needle Tenotomy
  • Distal Biceps Tendon Percutaneous Tenotomy

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
  • Identify the regional neurovascular structures during pre-procedural ultrasound
  • 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
  • We highly encourage you to perform this procedure with ultrasound guidance

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

Patient positioning for anterior approach. Note transducer is in long axis with needle in plane.[1]
A) shows the short axis view of the biceps tendon and its relationship to the neurovascular structures. B) shows the view in long axis with an arrow representing the needle trajectory[1]
Anterior approach showing a distal to proximal needle trajectory[2]
Patient positioning for the posterior approach.[1]
Ultrasound view of the posterior approach with the arrow representing the needle trajectory[1]

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

  • Transducer: High Frequency, Linear
  • Identify
    • Distal biceps tendon
    • Proximal neurovscular structures
  • View
    • Anterior view great for short- and long-axis views but doesnt visualize most distal aspect of tendon well
    • Posterior view is best procedurally but provides limited diagnostic utility
    • Lateral and medial approaches provide excellent diagnostic information but are more limited procedurally because neurovascular structures are in the needle trajectory[3][4]
  • Common ultrasound findings for tendon:
    • Typical for tendinosis (hypoechogenicity, focal thickening, calcification, neovascularity, etc).
    • Important to distinguish from rupture as that would more likely benefit from surgical consultation

Technique: Long Axis, In-Plane

  • Patient Position
    • Supine
    • Arm extended at elbow, forearm supinated (see picture)
  • Probe Position, Needle Orientation
    • Long axis to the distal biceps tendon
    • Needle in plane, proximal to distal
  • Target
    • Distal biceps tendon
  • Pearls and Pitfalls
    • Safety and efficacy of procedure are poorly described
    • Identify neurovascular structures before you start
    • Anisotropy is common, use ample gel and consider a heel-toe maneuver
    • If you can not identify a safe path to the tendon, recommend posterior approach

Technique: Short Axis, In-Plane

  • Patient Position
    • Supine
    • Arm flexed at elbow, forearm hyperpronated (see picture)
  • Probe Position, Needle Orientation
    • Short axis to the distal biceps tendon
    • Needle in plane, radial to ulnar
  • Target
    • Distal biceps tendon
  • Pearls and Pitfalls
    • Safety and efficacy of procedure are poorly described
    • Posterior approach offers safest window to tendon but with less visualization
    • Identify the radial nerve during pre-procedural ultrasound

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.
  2. ↑ Sellon, Jacob L., Michael K. Wempe, and Jay Smith. "Sonographically guided distal biceps tendon injections: techniques and validation." Journal of Ultrasound in Medicine 33.8 (2014): 1461-1474.
  3. ↑ Kalume Brigido M, et al. Improved visualization of the radial insertion of the biceps tendon at ultrasound with a lateral approach. Eur Radiol. 2009;19(7):1817–1821
  4. ↑ Smith J, et al. Sonographic evaluation of the distal biceps tendon using a medial approach: the pronator window. J Ultrasound Med. 2010;29(5):861–865.
Created by:
John Kiel on 9 September 2023 14:45:04
Authors:
Last edited:
11 September 2023 12:39:31
Categories:
Retrieved from "https://wikism.org/w/index.php?title=Distal_Biceps_Tendon_Percutaneous_Tenotomy&oldid=20936"