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Ultrasonic energy helps perform fasciotomy and surgical tenotomy for tendinosis, fasciosis
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Tendinosis is a common condition affecting roughly 10 million people per year. This tendon injury, also called chronic tendonitis, is often the result of overuse activities, which cause microtears of collagen fibers within a tendon. These microtears can propagate a cycle of degenerative changes leading to tendinosis.
Histologically, the tissue demonstrates angiofibroblastic hyperplasia, disorganization of collagen fibers, and neovascularization without inflammatory cells. The collagen fibers of the tendon are replaced with mucoid ground substance or calcification. In addition, many researchers have shown that the damaged collagen in tendinosis is primarily replaced with type III collagen and not the normal type I collagen in healthy tendons. These changes lead to a tendon that is unable to sustain normal tensile load. The tendon is believed to emit signals that chemo-attract certain elements that cause pain that affects the tendon in question, such as substance P, a neurotransmitter.
Clinical presentation and diagnosis
Patients with tendinosis often present with a history of repetitive activities prior to the development of pain over the tendon. There are a variety of presentations depending on the location of the tendon injury.
The diagnosis of tendinosis is made by history and physical exam, and can be confirmed with imaging. A musculoskeletal ultrasound will reveal hypo-echoic enlargement of the involved tendon with or without disruption of tendon fibers. Using the Doppler function available with most ultrasound devices, neovascularization can be visualized, which may provide further confirmation of tendinosis.
Nirschl and colleagues developed a useful staging system for tendinosis. Stage 1 describes the initial injury and inflammatory response, which can set up the rest of the cascade leading to tendinosis. With stage 2, the angiofibroblastic hyperplasia described earlier is seen. A tendon that fails and ruptures is at stage 3. After a rupture, the tendon may form calcifications or a soft matrix, which characterizes stage 4 of Nirschl’s staging system.
Indications
Traditional management of tendinosis involves physical therapy, ice, NSAIDs, bracing/immobilization and possibly corticosteroid injections. Stretching and strengthening, particularly eccentric exercises, are an essential part of nonsurgical management. NSAIDs are not recommended since this problem is noninflammatory and therefore inhibiting inflammatory cells is counterintuitive. However, these medications can be effective simply as an analgesic. A counterbalance strap can restrict tendon movement and improve symptoms. Immobilizing the patient with lower extremity disease in a boot can be helpful.
Corticosteroid injections have also been shown to be helpful at reducing pain, however corticosteroids have the potential to cause further tendon tissue degeneration and increase the risk of recurrence.
The goal of treatment is to control pain, restore function (flexibility, strength and endurance), and restore normal anatomy (remove neovascularization and return the normal collagen ratios). About 90% of patients will be treated effectively with these non-surgical options.
If conservative treatment fails, then the patient is typically offered surgery and, in most cases, it would involve a variation of an open tendon debridement. Cummins showed up to 50% of patients still had tendinopathy of the affected tendon following surgical debridement and were likely to have recurrence of symptoms. A lengthy postoperative period with rehabilitation is expected.
To date, physicians have had difficulty treating tendinosis. There are many treatment options which suggest no single outstanding option is available. However, within the last year an FDA-approved technology has become available to treat tendinosis and fasciosis. The FAST procedure — meaning fasciotomy and surgical tenotomy — is an innovative new treatment option for tendinosis and fasciosis. If the tendon or fascia is located at an accessible tissue depth, the ultrasonic probe used with the procedure can relieve pain and dysfunction by releasing and removing the degenerative portion of the tendon.
The minimally invasive FAST procedure treats and addresses the plantar fascia similar to the traditional open fasciotomy. It has been successful in the treatment of lateral and medial epicondylosis, plantar fasciosis, patellar tendinosis, quadriceps tendinosis and Achilles tendinosis.
The technology has been in use in the United States just over 1 year. A prospective study of 20 patients, published in the American Journal of Sports Medicine, revealed 19 of the patients were satisfied they had the procedure at 1-year surveillance. To date, in more than 2,500 uses, there have been no complications requiring medical attention or additional treatment.
Procedural description
Using ultrasound guidance, the FAST procedure removes degenerative tendon tissue without damaging surrounding healthy tissue. The device used for the procedure is the TX1 Tissue Removal System (Tenex Health; Lake Forest, Calif.) and it is available as a disposable kit that includes lidocaine, a syringe, the microtip, a #11 scalpel, ultrasound gel and a probe cover. The hand piece or microtip is attached to a central console via a sterile water intake and output tubing.
This procedure requires local anesthesia only. The area to be treated is prepped and draped in the usual sterile fashion as is typically done in a procedure room for any procedure performed under local anesthesia (Figure 1).
Figure 1. Local anesthesia is used starting with a skin wheel creating a tract down to the degenerative area or in this case, down to the plantar fascia identified on ultrasound.
Images: Hackel JG
An ultrasound examination is performed to identify the degenerative area of the tendon to be treated. Once that area is identified, a small incision or puncture is made in the skin to enable easier passage of the microtip hand piece.
Plantar fasciosis is treated with the FAST procedure by transecting and removing a portion of the medial plantar fascia origin, similar to what is done with the traditional open surgical technique (Figure 2).
Figure 2. The #11 blade provided in the disposable kit is used to make a stab incision, which is for introduction of the microtip.
When treating lateral epicondylosis with this surgical technique, the small needle-like device is passed down to the degenerative tissue under ultrasound guidance. The device is activated and it releases the diseased tendon attachment and aspirates the degenerative tissue by repeated passages through the degenerative area. Cutting time averages 60 seconds and the entire procedure may take 15 minutes or less from the time the patient is brought into the procedure room until departure (Figures 3 and 4).
Figure 3. The surgeon introduces the microtip handpiece into the lateral elbow down to the degenerative tissue that was identified on ultrasound.
At the completion of the procedure, the incision is closed with a small adhesive bandage (Figure 5).
Figure 4. In this photo, the handpiece is introduced to the medial foot and guided via ultrasound down to the medial aspect of the plantar fascia origin.
Immediately after the procedure the patient can return home. If patients have discomfort, they can take over-the-counter pain relievers for this. Patients should be instructed to limit heavy strain or weightlifting that involves the affected tendon for 1 week to 2 weeks; however, there is no need for any formal physical therapy in most cases.
Figure 5. At the end of the procedure, Steri (3M;
St. Paul, Minn.) strips are applied to the skin to
close the small incision.
Patients can expect to return to normal activities without pain in about 4 weeks to 6 weeks.
The use of ultrasonic energy to tenotomize diseased tissue reliably can treat tendinosis and fasciosis and result in excellent patient satisfaction. To date, minimal complications have been reported and there have been no problems that required additional medical attention. This procedure is less invasive, less painful and less expensive than surgical debridement with little to no requirement for post-procedure rehabilitation or physical therapy.
References:
Khan KM. Sports Med.1999;27: 399.
Khan KM. BMJ. 2002;doi:10.1136/bmj.324.7338.626.
Koh JSB. Am J Sports Med. 2013;doi:10.1177/0363546512470625.
Kraushaar B. J Bone Joint Surg. 1999;81-A: 2.
Maffulli N. Am J Sports Med. 2000;28:4.
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Disclosures: Hackel is a medical advisory board member for Tenex. Williams has no relevant financial disclosures.