Ultrasound-Guided Percutaneous Tenotomy

1. Ultrasound-Guided
Percutaneous Tenotomy
Ade Wijaya, MD – April 2019

2. Prone to
Injury
Partial and complete
tendon tears
Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am 2013; 95 (17) 1620-1628

3. INJURY
(Internal tensile overload)
Acute event
Chronic repetitive
injury
loss of tendon architecture
abnormal tenocyte morphology
altered collagen fibril distribution
neovascularization
microtears
Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am 2013; 95 (17) 1620-1628

4. Tendinosis
• With advancing age and overuse, alterations in tendons predominantly take the form
of mucoid degeneration, termed tendinosis
• The term tendinopathy is a broader description that encompasses tendinosis,
tenosynovitis, and tendon tear
Jacobson JA, Kim SM, Brigido MK. Ultrasound-guided percutaneous tenotomy. InSeminars in musculoskeletal radiology 2016 Nov (Vol. 20, No. 05, pp. 414-421). Thieme Medical Publishers.

5. Ultrasound
Tendinosis:
- Abnormal tendon hypoechogenicity with possible tendon swelling but without
anechoic clefts or defects
- Hyperemia at color Doppler  hypervascularity
- Tendinosis may be associated with tendon tears that appear as defined hypoechoic
or anechoic areas of fiber discontinuity
Jacobson JA, Kim SM, Brigido MK. Ultrasound-guided percutaneous tenotomy. InSeminars in musculoskeletal radiology 2016 Nov (Vol. 20, No. 05, pp. 414-421). Thieme Medical Publishers.

6. Histology
• Eosinophilic and fibrillar degeneration
• Chondroid metaplasia
• Scarring
Buck FM, Grehn H, Hilbe M, Pfirrmann CW, Manzanell S, Hodler J. Magnetic resonance histologic correlation in rotator cuff tendons. J Magn Reson Imaging 2010; 32 (1) 165-172
Kjellin I, Ho CP, Cervilla V , et al. Alterations in the supraspinatus tendon at MR imaging: correlation with histopathologic findings in cadavers. Radiology 1991; 181 (3) 837-841

7. Tendon Treatments
• Initial: conservative treatments – physical therapy
• NSAIDs is not advised
• Corticosteroid injection, relieve pain in acute phase but worse at intermediate and
long term
• Prolotherapy, PRP, tendon scraping, tenotomy, hydrodissection, etc
Jacobson JA, Kim SM, Brigido MK. Ultrasound-guided percutaneous tenotomy. InSeminars in musculoskeletal radiology 2016 Nov (Vol. 20, No. 05, pp. 414-421). Thieme Medical Publishers.

8. Tenotomy
Definition: Passing a needle into a tendon to treat tendinosis or tendon tear
Synonim: fenestration, dry needling
•The goal of the procedure is to convert a chronic degenerative process into an acute
inflammatory condition that can proceed to tendon healing
•Bleeding that occurs during the process increases the concentration of growth factors
that can induce inflammation as the first step in tissue healing
•Ultrasound guided
Chiavaras MM, Jacobson JA. Ultrasound-guided tendon fenestration. Semin Musculoskelet Radiol 2013; 17 (1) 85-90
Jacobson JA, Rubin J, Yablon CM, Kim SM, Kalume-Brigido M, Parameswaran A. Ultrasound-guided fenestration of tendons about the hip and pelvis: clinical outcomes. J Ultrasound Med 2015; 34 (11) 2029-2035
McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. J Ultrasound Med 2006; 25 (10) 1281-1289

9. Tenotomy Technique
Considerations Prior to Procedure
1. Suspected tendon pathology should be confirmed with ultrasound or magnetic resonance
imaging.
2. The patient should be instructed to avoid aspirin or other medications that affect platelet
function for ∼ 7 to 10 days preceding the procedure
3. Ibuprofen should be avoided for 1 day before the procedure to ensure normal platelet
function.
4. Any medication that reduces inflammation should also be avoided prior to the procedure
to allow inflammation to occur as the initial step in tissue healing.
5. Depending on the tendon treated, immobilization may also be considered.
6. Informed consent should include potential risks to include infection, bleeding, allergic
reaction, tendon tear, injury to surrounding tissues, and ineffective treatment.
Godfrey EM, Godfrey AL, Perry DJ, Shaw AS. Don't be a clot: a radiologist's guide to haemostasis including novel antiplatelet and anticoagulant therapies. Clin Radiol 2011; 66 (8) 693-700
Goldenberg NA, Jacobson L, Manco-Johnson MJ. Brief communication: duration of platelet dysfunction after a 7-day course of Ibuprofen. Ann Intern Med 2005; 142 (7) 506-509
Foremny GB, Pretell-Mazzini J, Jose J, Subhawong TK. Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature. Skeletal Radiol 2015; 44 (5) 619-627

10. Tenotomy Technique
Marking Skin
Sterile Technique
Needle Size and Guidance (20G for hip and shoulder and 22G for more peripheral sites)
Needle Advancement
Tenotomy (20 to 50 passes)

11. Tenotomy Technique
Considerations After the Procedure
1. Any medication or action that reduces inflammation should be avoided for at least 7
days during this active inflammatory phase
2. The patient should be asked to reduce activity using the tendon
3. After 10 to 14 days postprocedure, physical activity may be increased gradually
4. Physical therapy may be considered as well.
5. If additional tenotomy treatments are considered, they should only be repeated at
least several months later if conservative and noninvasive treatments fail again.
Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am 2013; 95 (17) 1620-1628
Housner JA, Jacobson JA, Morag Y, Pujalte GG, Northway RM, Boon TA. Should ultrasound-guided needle fenestration be considered as a treatment option for recalcitrant patellar tendinopathy? A retrospective study of 47 cases. Clin J Sport Med
2010; 20 (6) 488-490

12. Contraindication
• Local infection
• Clotting disorder
Jacobson JA, Kim SM, Brigido MK. Ultrasound-guided percutaneous tenotomy. InSeminars in musculoskeletal radiology 2016 Nov (Vol. 20, No. 05, pp. 414-421). Thieme Medical Publishers.

13. ELBOW
KNEE
ANKLE

14. Summary
The use of ultrasound-guided percutaneous tenotomy (also known as fenestration or
dry needling) to convert a chronic degenerative tendon to an acute inflammatory
condition to promote healing was shown to be effective in many tendons in the body
Ultrasound-guided percutaneous tenotomy has been shown to be effective and safe
in the treatment of many tendons in the body