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Needle Tenotomy Main

From WikiSM

Other Names

  • Percutaneous Needle Tenotomy
  • Tenex
  • US-guided percutaneous needle tenotomy

Background

  • This is a summary page for percutaneous needle tenotomy (PNT) for tendinopathies

History
Epidemiology

Introduction

Illustration demonstrating mechanism of action of tenotomy.[1]

General Information

  • Widely accepted technique for the treatment of recalcitrant tendinopathies bounded by the limitations of the current literature

Definition

  • Involves repeatedly passing a needle under ultrasound guidance through a targeted area of tendinosis to disrupt the degenerative process
  • This includes scar tissue, encouraging localized bleeding, fibroblast proliferation, growth factory release, collage formation, and ultimately healing

Regenerative Medicine

  • Other percutaneous procedures to be considered include prolotherapy, autologous whole blood injections, autologous platelet rich plasma injections
  • These procedures are often performed in conjunction with tenotomy

Pre-Procedure Considerations

  • Consider the following labs
    • Coag panel
    • Leukocyte count and differential
    • Viral Markers (Hepatitis, HIV)

Procedure Locations

Upper Extremity

Lower Extremity

  • Adductor Tendon Needle Tenotomy
  • Gluteus Medius and Minimus Needle Tenotomy
  • Quadriceps Tendon Needle Tenotomy
  • Patellar Tendon Needle Tenotomy
  • Tibialis Posterior Needle Tenotomy
  • Tibialis Anterior Needle Tenotomy
  • Peroneus Tendon Needle Tenotomy
  • Proximal and Distal Hamstring Tendon Needle Tenotomy
  • Achilles Tendon Needle Tenotomy

Indications

  • Refractory tendinopathy that has failed less invasive procedures
    • Patient should have at least had a trial of medications and physical therapy

Patient Selection

  • Depends on clinical and radiological qualitative and quantitative assessments
  • Qualitative
    • Presence of pain, disability in the affeted tendon
  • Quantitative
    • VAS, disability scores
  • Qualitative ultrasound findings:
    • Intratendinous hypoechogenecity with or without a discrete tear
    • Intratendinous and/peritendinous color flow on Doppler
    • Presence or absence of underlying bony changes
  • Quantitative ultrasound findings:
    • Dimensions of the hypoechoic area of tendinosis
    • Measurement of the tear if present

Contraindications

  • Clinical signs of infection (cellulitis, abscess, bacteremia, etc)
  • Partial or full thickness tendon tear

General Procedure Technique

Image (a) and corresponding longitudinal ultrasound (US) of the lateral elbow (b) demonstrating relative position of needle and US probe during in plane technique of intervention in (a). The corresponding US image in (b) demonstrates whole length of needle trajectory and needle tip (small yellow arrows) in one plane.[1]
Longitudinal ultrasound demonstrate needle in the area of tendinosis with needle in hub up position (yellow arrow) for tenotomy of deep fibers in (a) and needle in hub down position (Red arrow) for tenotomy of superficial fibers in (b).[1]
Longitudinal ultrasound of the lateral elbow demonstrates area of tendinosis as hypoechoic area before percutaneous needle tenotomy (PNT) (area inside yellow circle) in (a) and after PNT (area inside yellow circle) in (b).[1]
  • Initial ultrasound evaluation
    • The affected tendon is carefully evaluated, typically using a high frequency linear transducer
    • The area of pathology is identified and marked
  • Sterile Prep
    • The skin is then thoroughly cleaned using aseptic technique
    • The ultrasound probe should have a sterile probe cover
    • Sterile gloves and equipment should be used
  • Technique
    • The preferred approach is tendon long axis, in-plane
    • Local anesthetic should be used to infiltrate the skin and subcutaneous tissue
    • The needle should be advanced into the tendon and generously anesthetized
    • Some recommend avoiding anesthetic in the tendon however patients may not tolerate the pain associated with this approach
  • Needle Tenotomy/ PNT
    • Once the needle is within the target tendon, gentle move the needle in and out in a conical manner
    • Attempt to cover all segments of the tendon
    • Be careful not to go outside the boundaries of the tendon
    • Consider abrading the bony margin with the needle tip of the tendinosis is near the bony attachment
    • Typically there are 15-20 passes or strokes with the needle
    • Another end point is lack of resistance with the needle
    • The hypoechoic area becomes isoechoic to the normal tendon
  • Completion
    • When complete, withdraw the needle and apply a gauze dressing
    • If bleeding occurs, apply compression until bleeding stops
  • Corticosteroids
    • Some prefer to inject corticosteroids following PNT on the same day
    • This is likely counterproductive as an anti-inflammatory corticosteroid contradicts the proinflammatory nature of PNT

Aftercare

  • Immediately post procedure
    • Avoid Strenuous exercise for 1 week post procedure
    • NSAIDS are contraindicated for 4-6 weeks
    • Limited use of Acetaminophen, Opioids should be considered for pain relief
  • Physical Therapy
    • Begin at approximately week 2
    • Preferably supervised by a sports medicine physician and/or physical therapist
    • One program uses 2 weeks of isometric strengthening, 2 weeks of concentric strengthening and finally 1 week of eccentric strengthening
  • Follow up imaging should be obtained at 6 weeks
  • Counsel patient about variable outcomes of procedure, may be adversely affected due to:
    • Chronicity of tendinosis
    • Presence of calcification
    • Disuse of muscle due to chronic tendinosis
    • Overuse of antagonist muscles
    • Strenuous exercise during the first few weeks after PNT
    • Poor compliance of post procedural rehabilitation
  • Need for reintervention
    • Patient should understand they may require a second treatment
    • This is typically done at 6 weeks if there is no significant clinical improvement

Complications

  • Post procedural Pain
  • Vasovagal Syncope
  • Burning Sensation
  • Swelling
  • Infection
  • Tendon Rupture

Literature

General

  • Singh et al, using PNT across all pathologies, showed a mean decrease in VAS from 8.02 to 3.16 after 6 weeks of PNT and rehabilitations[1]

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Singh, Dharmendra, et al. "Ultrasound-guided percutaneous needle tenotomy for tendinosis." Indian J Musculoskelet Radiol 2 (2020): 52.
Created by:
John Kiel on 31 August 2023 15:55:11
Authors:
Last edited:
21 September 2023 19:10:55
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