Abstract
Objectives
To compare percutaneous ultrasound-guided needle tenotomy (PUNT) to alternative treatments for chronic tendinopathy.
Materials and methods
A systematic literature search was performed with the following combination of keywords: ultrasound-guided, percutaneous, needling, tenotomy, Tenex, tendinopathy, and fasciotomy. Original studies comparing PUNT to alternative treatments for chronic tendinopathy were included in this systematic review.
Results
Twelve (n = 12) studies with 481 subjects were included. Two (2/12) articles compared PUNT to surgical tenotomy and concluded that PUNT provides the same outcomes as surgical tenotomy. Six (6/12) studies compared PUNT to platelet-rich plasma (PRP) injections, and two of them found both treatment modalities effective with no significant between-group differences. Three trials claimed that PUNT followed by PRP injections showed superior clinical outcomes compared to PUNT alone. However, the difference at long-term follow-up was statistically significant only in one of them. One study found PUNT superior to PUNT + PRP injection at short-term follow-up, although there were no between-group differences at long-term follow-up. Four (4/12) studies compared PUNT to steroid injection (SI) and showed that SI causes fast (2 weeks) but temporary pain relief, PUNT results in persistent but relatively slower improvement to SI, and the combined procedure has a more rapid and steady reduction in symptoms.
Conclusion
PUNT is an effective treatment technique for chronic tendinopathy and should be considered when non-invasive treatments have failed. Effects of PRP and SI are transient and dissipate over time and do not contribute to long-term outcome.
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References
Morrey BF. 60 - Percutaneous ultrasound tenotomy treatment of epicondylitis. In: Morrey BF, Sanchez-Sotelo J, Morrey ME, editors. Morrey's the elbow and its disorders. 5th ed. Philadelphia: Elsevier; 2018. p. 582–7. https://doi.org/10.1016/B978-0-323-34169-1.00060-7.
Coleman B, Khan K, Maffulli N, Cook J, Wark J. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports. 2000;10(1):2–11 (Review article).
Testa V, Capasso G, Benazzo F, Maffulli N. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc. 2002;34(4):573–80.
Chimenti RL, Stover DW, Fick BS, Hall MM. Percutaneous ultrasonic tenotomy reduces insertional Achilles tendinopathy pain with high patient satisfaction and a low complication rate. J Ultrasound Med: Off J Am Inst Ultrasound Med. 2019;38(6):1629–35.
Elattrache NS, Morrey BF. Percutaneous ultrasonic tenotomy as a treatment for chronic patellar tendinopathy-jumper’s knee. Oper Tech Orthop. 2013;23(2):98–103.
Boden AL, Scott MT, Dalwadi PP, Mautner K, Mason RA, Gottschalk MB. Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis. J Shoulder Elbow Surg. 2019;28(1):112–9.
McMullen C, Liem B. Efficacy of percutaneous ultrasonic ablation of soft tissue (Tenex) in tendinopathy and fasciopathy. Curr Phys Med Rehabil Rep. 2018;6(2):156–60.
Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of percutaneous ultrasonic tenotomy for tendinopathies: a systematic review. Sports health. 2021;13(3):258–64.
Peers KH, Lysens RJ. Patellar tendinopathy in athletes. Sports Med. 2005;35(1):71–87.
McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med. 2008;27(8):1137–44.
de Jonge S, de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011;39(8):1623–30.
Fitzpatrick J, Bulsara M, Zheng MH. The effectiveness of platelet-rich plasma in the treatment of tendinopathy: a meta-analysis of randomized controlled clinical trials. Am J Sports Med. 2017;45(1):226–33.
Stoychev V, Finestone AS, Kalichman L. Dry needling as a treatment modality for tendinopathy: a narrative review. Curr Rev Musculoskelet Med. 2020;13(1):133–40.
Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–54.
Patel MM. A novel treatment for refractory plantar fasciitis. Am J Orthop (Belle Mead NJ). 2015;44(3):107–10.
Goldin M, Malanga GA. Tendinopathy: a review of the pathophysiology and evidence for treatment. Phys Sportsmed. 2013;41(3):36–49.
Koh KH, Ahn JH, Kim SM, Yoo JC. Treatment of biceps tendon lesions in the setting of rotator cuff tears: prospective cohort study of tenotomy versus tenodesis. Am J Sports Med. 2010;38(8):1584–90.
Maffulli N, Testa V, Capasso G, Bifulco G, Binfield PM. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle-and long-distance runners. Am J Sports Med. 1997;25(6):835–40.
Walch G, Edwards TB, Boulahia A, Nové-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005;14(3):238–46.
Jamali AA, Afshar P, Abrams RA, Lieber RL. Skeletal muscle response to tenotomy. Muscle Nerve: Off J Am Assoc Electrodiagnostic Med. 2000;23(6):851–62.
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):1281–9.
Shalaby M, Almekinders LC. Patellar tendinitis: the significance of magnetic resonance imaging findings. Am J Sports Med. 1999;27(3):345–9.
McCarthy E, Hegazi TM, Zoga AC, Morrison WB, Meyers WC, Poor AE, et al. Ultrasound-guided interventions for core and hip injuries in athletes. Radiol Clin North Am. 2016;54(5):875–92.
Chiavaras MM, Jacobson JA, Carlos R, Maida E, Bentley T, Simunovic N, et al. IMpact of Platelet Rich plasma OVer alternative therapies in patients with lateral Epicondylitis (IMPROVE): protocol for a multicenter randomized controlled study: a multicenter, randomized trial comparing autologous platelet-rich plasma, autologous whole blood, dry needle tendon fenestration, and physical therapy exercises alone on pain and quality of life in patients with lateral epicondylitis. Acad Radiol. 2014;21(9):1144–55.
Abat F, Alfredson H, Campos J, Planells G, Torras J, Madruga-Parera M, Rodriguez-Baeza A. Ultrasound-guided versus blind interventions in patellar tendon lesions: a cadaveric study. Skelet Radiol. 2021;50(5):967–72. https://doi.org/10.1007/s00256-020-03635-1.
Vahedifard F, Raissi G, Ahadi T, Forogh AA. Ultrasound-guided intervention for chronic abdominal wall pain; overlooked but curative approach. J Clin Images Med Case Rep. 2022;3(5):1836.
Vahedifard F, Malinowski M, Chakravarthy K. Mechanism of action of radiofrequency ablation. In: Deer TR, Azeem N, editors. Essentials of radiofrequency ablation of the spine and joints. Cham: Springer International Publishing; 2021. p. 7–29. https://doi.org/10.1007/978-3-030-78032-6_2.
Suzuki T, Iwamoto T, Matsumura N, Nakamura M, Matsumoto M, Sato K. Percutaneous tendon needling without ultrasonography for lateral epicondylitis. Keio J Med. 2020;69(2):37–42.
Mattie R, Wong J, McCormick Z, Yu S, Saltychev M, Laimi K. Percutaneous needle tenotomy for the treatment of lateral epicondylitis: a systematic review of the literature. PM&R. 2017;9(6):603–11.
Koh J, Png MA, Howe TS, Lee B, Morrey B, Mohan BAFC. Ultrasound-guided percutaneous tenotomy shows sustained clinical and sonographic outcomes for recalcitrant lateral elbow tendinopathy at 7.5 years. Orthop J Sports Med. 2020;8(7_suppl6):2325967120S00420.
Lavallee M, Bush C. Ultrasound-guided percutaneous tenotomy and its associated pain reduction and functionality outcomes in nonelite active adults. Am J Phys Med Rehabil. 2021;100(4):349–53.
Kirschner JS, Cheng J, Hurwitz N, Santiago K, Lin E, Beatty N, Kingsbury D, Wendel I, Milani C. Ultrasound‐guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet‐rich plasma injection for the treatment of chronic tendinosis: a randomized controlled trial. PM&R. 2021;13(12):1340–9.
Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil. 2013;27(2):113–22.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group* P. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.
Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6.
Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med. 2011;45(5):407–10.
Altahawi F, Li X, Demarest B, Forney MC. Percutaneous ultrasonic tenotomy with the TX-1 device versus surgical tenotomy for the treatment of common extensor tendinosis. Skelet Radiol. 2021;50(1):115–24.
Stenhouse G, Sookur P, Watson M. Do blood growth factors offer additional benefit in refractory lateral epicondylitis? A prospective, randomized pilot trial of dry needling as a stand-alone procedure versus dry needling and autologous conditioned plasma. Skeletal Radiol. 2013;42(11):1515–20.
Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014;42(3):610–8.
Jacobson JA, Yablon CM, Henning PT, Kazmers IS, Urquhart A, Hallstrom B, et al. Greater trochanteric pain syndrome: percutaneous tendon fenestration versus platelet-rich plasma injection for treatment of gluteal tendinosis. J Ultrasound Med: Off J Am Inst Ultrasound Med. 2016;35(11):2413–20.
Ferrero G, Fabbro E, Muda A, Sconfienza L, Silvestri E. One-year survey of two different ultrasound (US)-guided percutaneous treatments of lateral epicondylitis: results of a randomised controlled trial. Insights Imaging. 2011;2(S1):S165.
Sconfienza L, Ferrero G, Orlandi D, Fabbro E. One year outcome of ultrasound guided percutaneous treatment of plantar fasciitis: a randomised controlled trial. Cardiovasc Interv Radiol. 2011;34:538.
Stomp W, Krabben A, van der Heijde D, Bloem J, Huizinga T. 19th Annual Scientific Meeting of the European Society of Musculoskeletal Radiology (ESSR), Innsbruck, Austria-June 28–30, 2012. Skeletal Radiol. 2012;41:871–86.
Fabbro E, Sconfienza L, Ferrero G, Orlandi D, Lacelli F, Serafini G, et al., editors. One year outcome of ultrasound (US)-guided percutaneous treatment of Achilles tendinopathy: results of a randomized controlled trial. European Congress of Radiology-ECR. 2012. https://doi.org/10.1594/ecr2012/C-1850.
Pomerantz ML. Complications of lateral epicondylar release. Orthop Clin North Am. 2016;47(2):445–69.
Chiavaras MM, Jacobson JA, editors. Ultrasound-guided tendon fenestration. Semin Musculoskelet Radiol. 2013. Thieme Medical Publishers.
Mirzayan R, McCrum C, Butler RK, Alluri RK. Risk factors and complications following arthroscopic tenotomy of the long head of the biceps tendon. Orthop J Sports Med. 2020;8(2):2325967120904361.
Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthrosc: J Arthrosc Relat Surg. 2006;22(8):907. e1-.e4.
Assendelft WJ, Hay EM, Adshead R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic overview. Br J Gen Pract. 1996;46(405):209.
Lewis M, Hay EM, Paterson SM, Croft P. Local steroid injections for tennis elbow: does the pain get worse before it gets better?: results from a randomized controlled trial. Clin J Pain. 2005;21(4):330–4.
Ford LT, DeBender JO. Tendon rupture after local steroid injection. South Med J. 1979;72(7):827–30. https://doi.org/10.1097/00007611-197907000-00019.
Chechick A, Amit Y, Israeli A, Horoszowski H. Recurrent rupture of the achilles tendon induced by corticosteroid injection. Br J Sports Med. 1982;16(2):89.
Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15(5):E370.
MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology. 2009;252(3):647–61.
Ahmad Z, Brooks R, Kang S-N, Weaver H, Nunney I, Tytherleigh-Strong G, et al. The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis. Arthrosc: J Arthrosc Relat Surg. 2013;29(11):1851–62.
de Vos R-J, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952–6.
Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463–71.
Bell KJ, Fulcher ML, Rowlands DS, Kerse N. Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial. BMJ (Clinical research ed). 2013; 346.
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Shomal Zadeh, F., Shafiei, M., Hosseini, N. et al. The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review. Skeletal Radiol 52, 875–888 (2023). https://doi.org/10.1007/s00256-022-04140-3
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DOI: https://doi.org/10.1007/s00256-022-04140-3