Ultrasonic Percutaneous Tenotomy for the Treatment of Recalcitrant Triceps Tendinopathy

Abstract

Distal triceps injuries are uncommon, and are often managed non-operatively. Ultrasonic percutaneous tenotomy is a recently developed technique using a specialized device designed to microresect and debride tendinopathic tissue. The device is directed into the pathology tissue using ultrasound guidance. We describe the surgical technique for and present a series of patients with refractory partial triceps tendon tears treated with ultrasonic percutaneous tenontomy.

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Remedy Publications LLC.
Journal of Surgical Techniques and Procedures
2019 | Volume 3 | Issue 2 | Article 1028
1
Ultrasonic Percutaneous Tenotomy for the Treatment of
Recalcitrant Triceps Tendinopathy
OPEN ACCESS
*Correspondence:
Walter I Sussman, Department of
Physical Medicine and Rehabilitation,
Tufts University, Boston, MA 02111,
USA, Tel: (781) 573-1615; Fax: (781)
573-1691;
E-mail: walter.sussman@tufts.edu
Received Date: 14 Nov 2019
Accepted Date: 18 Dec 2019
Published Date: 23 Dec 2019
Citation:
Sussman WI, Fanuele J, Hackel JG.
Ultrasonic Percutaneous Tenotomy for
the Treatment of Recalcitrant Triceps
Tendinopathy. J Surg Tech Proced.
2019; 3(2): 1028.
Copyright © 2019 Walter I Sussman.
This is an open access article
distributed under the Creative
Commons Attribution License, which
permits unrestricted use, distribution,
and reproduction in any medium,
provided the original work is properly
cited.
Research Article
Published: 23 Dec, 2019
Abstract
Distal triceps injuries are uncommon, and are oen managed non-operatively. Ultrasonic
percutaneous tenotomy is a recently developed technique using a specialized device designed to
microresect and debride tendinopathic tissue. e device is directed into the pathology tissue using
ultrasound guidance. We describe the surgical technique for and present a series of patients with
refractory partial triceps tendon tears treated with ultrasonic percutaneous tenontomy.
Keywords: Triceps Tendinopathy; Triceps tear; Needle tenotomy; Tenex
Introduction
Distal triceps tendon injuries are uncommon, and oen the result of an isolated traumatic event
[1]. Injuries can occur from athletic injury, weight-training, local corticosteroid injections, anabolic
steroids, and complications of septic olecranon bursitis [1,2]. For complete distal triceps tendon
tears, management is almost uniformly surgical [3]. In the majority of cases, the tear is partial and
managed non-operatively [1]. When nonoperative management is unsuccessful, interventions can
be limited. Local corticosteroid injections are associated with triceps tendon rupture, and surgery is
associated with a prolonged recovery [4,5]. Regenerative procedures have become more common in
the last decade to augment the natural healing process in recalcitrant tendinopathy. e literature
on regenerative procedures for refractory triceps tendon pathology is limited, and to the authors’
knowledge, only 2 case reports have described regenerative procedures for recalcitrant triceps
tendon pathology [6,7]. Cheatham described the successful treatment of distal triceps tendinopathy
with platelet rich plasma, and Hall and Woodroe presented a case of recalcitrant calcic triceps
tendinopathy with ultrasonic percutaneous tenotomy [6]. In Hall and Woodroe’s case, there was a
small intra-substance partial thickness tear associated with the calcic tendinopathy [7]. In this case,
it is not clear if the improvement was due to treatment of the calcication, tendon tear or both [7].
Here we present four patients who underwent ultrasonic percutaneous tenotomy for the treatment
of refractory partial interstitial tear of the triceps tendon.
Material and Methods
Description of the procedure
e procedure was completed in an ambulatory surgical center under sterile conditions. e
patients were positioned supine, and the interstitial tear localized with ultrasound. A solution of
lidocaine 1% without epinephrine (2 ml) and ropivicaine 0.5% (2 ml) was injected around the
triceps tendon sheath and into the interstitial tear using a 25 gague 1.5” needle for anesthesia (Figure
1). A stab incision was made with an 11-blade scalpel through the skin wheal. e cutting power and
irrigation/aspiration setting of the hand-piece is set using the main console (Figure 2). e tip of the
Tenex hand-piece (Tenex Health, Lake Forest, California) was then introduced through the incision
and guided to the pathologic tissue using ultrasound guidance (Figure 3). e tip of the hand-piece
was activated by intermittently depressing the foot pedal. When the probe was activated the needle
would move at an ultrasonic frequency, and both irrigate and aspirate the diseased tendon. e tip
of the hand-piece was redirected and the probe activated fragmenting and removing pathologic
tissue (Figure 4). Multiple passes were made through the hypoechoic tendon to completely resection
of diseased tendon.
Postoperative care
e stab incision is closed with a steri-strip (3M, St. Paul, Minnesota) and covered with
Walter I Sussman1,2*, Jason Fanuele2 and Joshua G Hackel3
1Department of Physical Medicine and Rehabilitation, Tufts University, USA
2Department of Orthopedics, Orthopedic Care Physician Network, USA
3Department of Orthopedics, Andrews Institute, USA

Walter I Sussman, et al., Journal of Surgical Techniques and Procedures
Remedy Publications LLC. 2019 | Volume 3 | Issue 2 | Article 1028
2
Tegaderm (3M, St. Paul, Minnesota). e dressing is removed 5
to 7 days aer the procedure. One patient was placed in an elbow
T-Scope brace locked at 0 to 60º for 2 weeks and progressed to 0 to
90º for weeks 3 to 4 aer the procedure. ree patients were allowed
to return to normal activity without restrictions, and started a home
strengthening program at 2 weeks. All subjects had a progressive
rehabilitation program. No formal physical therapy was prescribed.
Patients were instructed to discontinue NSAIDs 1 week prior and 6
weeks post-procedure, and post-procedure pain was managed with
cryotherapy, acetaminophen and tramadol.
Results
Five patients diagnosed with partial interstitial tear of the distal
triceps tendon were treated with an ultrasonic percutaneous needle
tenotomy. All patients were diagnosed clinically, and with a diagnostic
ultrasound. Two patients (3 elbows) had concordant ultrasound and
MRI ndings. In 3 of the patients (4 elbows), the source of pain was
conrmed with an ultrasound-guided diagnostic anesthetic injection
(lidocaine 1%, 1.5 ml). e average age of the patients was 44.6 years
(range, 26 to 61 years), and included 3 male and 2 females (Table
1). Average follow-up was 64.2 weeks (range 24 to 112 weeks). One
patient (subject #3 in Table 1), elected to repeat the procedure at
72-weeks. e patient was pain free with daily activity, but reported
residual pain when doing push-ups. Aer the repeat procedure he
was able to return to push-ups and liing pain free.
Discussion
Ultrasonic percutaneous needle tenotomy is not a novel technique.
Case series have demonstrated improved pain and function with
ultrasonic percutaneous tenotomy for the treatment of chronic lateral
epicondylitis patella tendinopathy, and plantar fasciitis [8-13]. is
case series demonstrates that ultrasonic percutaneous tenotomy could
be an eective treatment for a chronic partial triceps tendon tears.
Traditionally, percutaneous needle tenotomy procedures involve
repeatedly fenestrating the aected tendon. e procedure disrupts
the degenerative tissue and encourages bleeding, which stimulates
a healing response. One limitation of a traditional percutaneous
needle tenotomy is that aer fenestrating and disrupting the aected
tendon the body must then remove the diseased tendinopathic
tissue. Ultrasonic percutaneous tenotomy is a dierent technology.
In addition to disrupting the aected tendon, the Tenex TX1 probe
has the ability to debride and remove pathologic tissue. e probe
oscillates at a high frequency emulsifying the pathologic tissue, and
continuously irrigates and aspirates the uid and debris through
the hollow 18-gauge needle. Removing the pathologic tendon was
previously only attainable by performing an open or arthroscopic
surgery. In an animal model, aer removing the pathologic tissue
with ultrasonic percutaneous tenotomy the evacuated space was
repopulated with mature and immature broblasts and the collagen
bers demonstrated a more normal alignment and ratio of type
Figure 1: Sonographic images from (A and C) a 26 year old female and (B
and C) 38 years old male long axis to the triceps showing 25 gauge needle
(open arrow) with the distal tip in the partial tear (arrows) anesthetizing the
tear. Representative sonographic images obtained using GE Logiq E, 12L-
RS Linear Array Transducer, 5 to 13 MHZ.
Figure 2: Tenex console with touch screen controlling the oscillation, or
“cutting power,” and aspiration of the hand piece. Cutting and aspiration
settings include high, medium and low settings.
Figure 3: The patient is positioned supine (A) with the shoulder abducted to
90º and the elbow exed over the table at 90º.
Figure 4: (A) The tip of the Tenex hand-piece (open arrows) directed into
hypoechoic tear (arrows). The redundant appearance of the needle from the
double lumen. (B) Close up of the Tenex hand-piece showing the double
lumen design. The inner most steel cannula oscillates when activated
debriding the targeted tissue and aspirating uid and pathologic tissue. The
outer most cannula allows outow of normal saline irrigating the pathologic
tissue.

Walter I Sussman, et al., Journal of Surgical Techniques and Procedures
Remedy Publications LLC. 2019 | Volume 3 | Issue 2 | Article 1028
3
I and III collagen [14]. In this series, the ultrasonic percutaneous
tenotomy was performed with sonographic guidance, targeting only
the abnormal appearing tissue and avoiding normal tendon. Patients
were allowed to return to normal activity as tolerated, and the arm was
not immobilized aer the procedure in the majority of the patients.
In contrast, open procedures usually require immobilization for 6
weeks and return to previous activity no earlier than 3 to 6 months.
In addition to a prolonged recovery, potential surgical complications
include exion contracture, olecranon bursitis and infection [3]. In
our series, one case was complicated by an olecranon bursitis, but the
swelling resolved spontaneously within one week (subject #3 in Table
1). e authors suspect that the uid used to irrigate the pathologic
tissue distending the bursal space. No other complications were
observed.
Limitations
ere are limitations to this report, including the limitations
inherent in a case study. e cases presented were performed at 2
separate institutions, and there may be slight variations to the
procedure post-procedure protocol with each contributing physician.
In addition, outcomes were dependent on patient self reported pain
scores and functional outcomes were not performed.
Conclusion
Partial triceps tendon tears are uncommon, and when
nonoperative management is unsuccessful, there is no consensus to
guide management. In recalcitrant cases, ultrasonic percutaneous
tenotomy may be an eective treatment to relieve pain.
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S. NoAge/sex Duration
symptoms Mechanism of
injury Pain scores (vas 0-10) 0, 2, 6, 12,
24, 52, 104 wks Complications Follow-up (wks)
1 61 F 6 mo None 4, 0, 0, 0, 1, 0 None 52
2 26 F 4 Yr MVA LT 8, 4, 0, 0, 0, 0 None 68
4 Yr MVA RT 8, 0, 0, 0, 0, 0 None 57
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5 46 M 2 Yr Lifting weights 7, 3, 4, n/a, n/a None 12
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F: Female; M: Male; mo: Month; wks: Weeks; yr: Year; MVA: Motor Vehicle Accident; n/a: Not Available
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