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Percutaneous Ultrasound Tenotomy Treatment of Epicondylitis
Introduction
Over the last several years one of the most significant changes in the practice of managing epicondylar tendinopathy has been the introduction of ultrasound (US)-guided treatment. This in turn prompted the development of a percutaneous ultrasonic treatment of the pathology, which has the simplicity of a cortisone injection but the effectiveness of a surgical procedure, without the cost or morbidity.
Rationale
US-guided intervention for musculoskeletal conditions appears to have been first described by Crass and Karl in 1982. It was first described to direct a percutaneous patella tenotomy as early as 1999, with subsequent application to other tendinopathies. The concept of the use of ultrasonic energy to cut or ablate and remove pathologic tissue was first utilized for the treatment of cataracts in the early 1980s. Today, this is the standard of treatment for most cataracts. The same technology has now been applied to the management of chronic refractory tendinopathy (TenexHealth, Lake Forest, CA).
Indications
As indicated in prior chapters our definition of a chronic refractory tendinopathy has been recently clarified ( Fig. 60.1 ). If symptoms persist for 6 months, which occurs in 20% of those with epicondylitis, the mean time for nonsurgical resolution averages about 24 additional months. Furthermore, a recurrence requiring additional physician intervention occurs in about 15% of patients. Hence a patient who has had symptoms for approximately 6 months, and has failed nonoperative management with traditional treatment modalities, is a candidate for this procedure. Patients who are not improving and in whom the pain is interfering with their daily activity, sleep, or employment, are considered candidates for earlier intervention.
Contraindications
There are no absolute contraindications. When the process is improving with eccentric exercises, rest, and splinting etc., and when the symptoms are more of a nuisance that can be tolerated, the intervention is deferred. Patients on anticoagulation have been treated, but adequate compression is applied after the procedure.
Preoperative Assessment
The key is to identify the site of localized tenderness and to mark this site. Note the position of elbow flexion, and reproduce this angle when imaging and treating. Medially, assess for a subluxing ulnar nerve. If this is present, the elbow is treated in extension.
Ultrasound Imaging
Tendinopathic tissue appears as a hypoechoic signal often with an element of edema on US examination. One blinded study documented US examination to provide a sensitivity of 90%, specificity of 89%, and diagnostic accuracy of 94%. Secondary features of pathology include calcific deposits and an irregularity of the epicondyle at the site of involvement, and often an enthesophyte is present at the origin of the extensor carpi radialis brevis. The diagnostic study of the epicondyle is straightforward as the radial head is readily identified laterally ( Fig. 60.2 ), as is the steep slope of the medial epicondyle ( Fig. 60.3 ). While the normal tendon appears more homogeneous and uniform in appearance, tendinopathic tissue exhibits a “hypoechoic” image that generates a black defect in the tendon with ultrasonic imaging. However, the possibility of a hypoechoic artifact can occur due to lack of proper orientation or contact of the sensor. The rule is that an artifact can make a normal structure appear abnormal, but it cannot make an abnormal tendon appear normal.
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