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Introduction and Objectives | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Introduction and Objectives | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRbrauncompletedinterventionalmedicalpercutaneousradiologyreviewerultrasonicultrasounduniversitywisconsin
Tendonosis | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Tendonosis | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017acuteangioAVIRcellschaptercollagencollagenousdegenerationdegenerativefibroblastfull videohealinghistologicallyhyperplasiainflammatoryinjurynormalphasetendontina
Pre-Procedure and Physical Exam | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Pre-Procedure and Physical Exam | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRbiggestchapterclinicdiagnosiselbowevaluatefull videohurts
MSK Ultrasound | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
MSK Ultrasound | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017atrophyAVIRaxialchapterdisruptionechogenicityfull videohumerushypoechoiclinearnormalpathologyprobestructurestendonultrasounduniformvascularity
Traditional Treatment Options for Tendinopathy | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Traditional Treatment Options for Tendinopathy | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRchapterdegenerativefull videoincisioninjectioninjectionsoticpatientsphysicalscarsteroidsteroidstendontherapytissue
When to Offer U/S Guided Percutaneous Tetonomy or Fasciotomy and Common Treatment Sites | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
When to Offer U/S Guided Percutaneous Tetonomy or Fasciotomy and Common Treatment Sites | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRchapterelbowfasciitisfull videohealingmedialpercutaneousphysicalproceduresteroidsymptomstendonultrasonic
Percutaneous Ultrasonic Tenotomy or Fasciotomy | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Percutaneous Ultrasonic Tenotomy or Fasciotomy | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017anestheticaspirateaspiratedAVIRcalibratedchapterdeliversdiseasedfrequencyfull videoincisionneedlenormalportionsalinescartendontissueultrasonicultrasoundvisualize
Technique | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Technique | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRbladechaptercomfortablefull videohypoechoicimageinchmaximalneedleoticpathologypatientpositionprobetendontissueultrasound
Lateral Epicondylitis | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Lateral Epicondylitis | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRcalcificationchapterfull videograypainprobesubstance
Achilles and Plantar Fascia  | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Achilles and Plantar Fascia | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017achillesapproachaspectAVIRaxialcalcaneuscalcificationchapterdiseasedfasciitisfashionfull videoheelhypoechoiclongitudinalmedialplantarportiontransverseview
Patellar Tendonosis and Post Procedure | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Patellar Tendonosis and Post Procedure | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017athletesAVIRcalcificcalciumchaptercufffasciitisfull videohypoechoicibuprofenlimbpatientsposteriorproceduresurgerytreatmentweeks
Orthotics and Post Procedure | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Orthotics and Post Procedure | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRchapterfasciitisfashionfootfull videogaithealingheelorthopedicpathologicphysicalsurgerytherapyweeks
Results | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Results | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
2017AVIRchaptercohortsfasciitisfull videoinitiallookedpatientspercutaneousplantarstudiessymptomaticultrasonicvalidated
Jumper's Knee and Publications | How to Guide: Percutaneous Ultrasonic Tenotomy / Fasciotomy
Transcript

our next presenter dr. Aaron Braun completed his medical education with the University of Nebraska he then completed a radiology residency with st. Joseph's Hospital in Phoenix Arizona and then went on to complete a vascular and interventional fellowship with Medical

College of Wisconsin dr. Braun currently works with radiology associates in Lincoln Nebraska and served as a clinical assistant professor at the University oh sorry but the University of Arizona's College of Medicine he's

heavily involved academically and serves on numerous committees at the society of interventional radiology and as a manuscript reviewer for its flagship journal the JV I are please welcome him to the podium good morning thinks that

have invited me to speak with you guys today so we're going to talk about percutaneous ultrasonic to not be in fasciotomy so I bet a lot of people in this room probably have this problem that have never heard about this

solution our goal today or just to understand the signs and symptoms of tendinosis understand what it looks like on ultrasound and then how to perform this procedure and then what you do afterwards so tendonitis and tendinosis

are two different things tendinitis is the acute inflammatory phase so right after the tendons injured and tendinosis is the chronically impaired healing so after you get the acute phase most people heal normally but a small subset

go on to what we call 10 enosis and that's when you have degeneration sorry degeneration of the collagenous matrix and then you get fibroblast proliferation and the big key here is there's lack of inflammatory cells or

you get angio fibrous I broke lastic hyperplasia say that a few times fast so this is what it looks like histologically um here on the Left we have a normal intact tendon you see the arrow pointing to some of the Tina sites

you have an acute injury and then you get inflammatory cells within the tendon and you're going to go one of two ways you're either going to go towards the degenerative chronic tendinopathy where you can see the disorganized collagen

and rare Tina sites or you can go after to a nice normal healing process so after the acute injury if you rest normally and you take time off you're probably going to go down the normal healing route and you're going to be

just fine but for most of us that's not really an option if you have a acute injury to your foot you still have to walk every day and you're going to go down this other pathway so when you see

a patient in clinic and you really have

to see these people in clinic this isn't a lot of our typical procedures with this kind of show up with the diagnosis you have to see these patients and evaluate them you really want to talk to them about how long this has been going

on the side of their pain where it's going to what makes it better what makes it worse and if they've had any prior treatments or surgery to that area on the physical exam kind of the biggest so ni are not taught traditionally how to

treat tendinosis or how to evaluate it so the biggest kind of rule of thumb is they can tell you with one finger where it hurts and they can point to it and you press down it hurts right there about 90 plus percent of the time you're

going to have a diagnosis of tendinosis but you want to get the range of motion test their strength sensation there's a couple specific tests for tennis elbow and golfers elbow that you can do as well so the other thing is msk

ultrasounds most radiologists in their training give very little ms Cal torso 90 I didn't have much so you kind of have to teach yourself this or go to a course but what a tendon looks like normally on ultrasound is it should look

just like it does on this screen just kind of let see if they can get the pointer to work here the green ok so here you'll see kind of linear sorry linear striations of alternating bands of echogenicity it's thin and uniform

and then this is what it looks like in axial but again a uniform thin structure a lot of people describe it looking like horsehair and also there's minimal vascularity within a normal tendon well when the tendon becomes inflamed or

kendra nautic you get this hypoechoic region that has some increased vascularity and you get disruption of that normal horse hair like architecture so there's internal architectural disruption and you get some increased

vascularity and that should be the area where you point where it hurts a lot of times to you can get an infeasible so here you can see this is the bone here and that's a little in fees of light that's coming out into the tendon and it

looks your regular one of the things you have to be careful for with msk ultrasound is you can get faked out very easily on curved structures a lot of our tendons aren't just straight linear structures a lot of them have curves to

it for example this is a rotator cuff tendon word inserts onto the humerus and with your ultrasound probe OOP you're not 90 degrees to the pathology you can get what's called a nice atrophy and you can be faked out so here that looks

pretty similar to what we saw in the last slide when it's hypoechoic you don't see the nice horse hair going through it one thing we'll notice those it doesn't really look thicken there compared to the other areas of the

tendon but then if you kind of rotate the ultrasound probe kind of heel to toe and put the pathology right 90 degrees directly down from the tendon that goes away and it looks very normal so don't be faked out and again you have to make

sure that the area you're seeing on ultrasound you see it in two planes to make sure its real and then the area that you're seeing on ultrasound correlates to the area that where the patients having pain so what do we do

for tendinopathy so these are the traditional treatment options and this is one of the reasons I get involved in this is there's just not a lot of really great options these are patients that are suffering that I've tried a lot of

different things and can't find any relief so the most common is rest so tell your patients to rest take it easy for a few weeks and if they're already in that chronic tena nautic stage where there's starting to form scar tissue and

degenerative tissue no matter how much you rest that's not going away you can try medications anti-inflammatories you'll hear a lot of patients getting steroid injections or now we're doing PRP or stem cell injections steroids

work for a limited period of time in your average patient that you're going to see is going to say well I got a steroid injection I felt great for three months and then it came back and then I got another steroid injection it was

good for a month and then it came back and then I got 12 days ago it didn't do anything and that's kind of your average story that you're going to hear in actually over time steroids week in the tendon you have an increased risk of

rupture with the tenant physical therapy is a good adjunct and lots of patients do well with physical therapy however again once you get that tendon otic tissue in there with physical therapy they have some techniques to try to

break it up to allow the tendon to move a little bit better but once that scar tissues in there it's not going to go away the defendant treatment is an actual open tenotomy or fasciotomy so essentially what they do is make a large

incision go in expose the tendon and shell out the scar tissue the recovery from that is very long and often six months or longer and most of these patients it's your pains a nuisance but it's not debilitating where you can do

your everyday life but these are marathoners these or weekend warriors people that want to get back to activities best so the other option now

is percutaneous ultrasonic to not a mere fasciotomy and so when do we talk to

patients about this or when do we offer it so the in the acute phase if you do physical therapy you rest there's a good chance that you can have normal healing if the symptoms have been around for over three months you form that scar

tissue and it's probably not going away with any of those methods so then we do an ultrasound in clinic and we correlated with the physical exam those things match up with the chronicity of the symptoms and they most of the

patients you're going to see have already failed not just one conservative measure but usually multiple but we do want them to at least try one conservative method before we offer them a procedure if they've had steroid

injections the steroid does stay around in the area for a while and it can impair the healing of the procedure so if they've had a steroid injection I usually advise them you know we're going to wait a couple of months before we

think about doing the procedure so where can we do this in the short answer is anywhere there's a tendon you can you can do this but these are the most common sites that we treat plantar fasciitis was probably the most common

in our practice we do a lot of Achilles tendon patellar tendon gluteus medius tendon hamstring tendon lateral elbow medial elbow rotator cuff for kind of those are all areas that we treat relatively commonly so this is what the

device looks like that we use its made by 10x health and it's called the TX microchip system but it's a image-guided minimally invasive foot therapy and you essentially visualize this under ultrasound I'll show you a lot of

examples of how we do this procedure but the microchip delivers ultrasonic energy which is specifically calibrated the tip of this instrument vibrates back and is the resonant frequency of scar tissue so essentially what it does is delivers this ultrasonic energy into the diseased portion of the tendon and scar tissue vibrates back and forth and actually breaks down into a fine dust and then

through the core of the needle it aspirates at the same time so you're actually removing the scar tissue the nice thing is normal tendon has a different resonant frequency so it's actually not affected by the microchip

so we're going in and selectively selecting out just the scar tissue and the normal tin the normal tendon is actually unaffected so whereas when you go in with an open surgery you have to go through subnormal 10 and you're going

to get some just by showing it out but this actually precision is calibrated for the scar tissue you can do it with only local anesthetic so we just numb up the patient a very tiny three millimeter incision to facilitate needle entry and

that's it takes about 20 minutes so can we see if we can get this video to play this is kind of a animated simulation of the procedure so you visualize the diseased area in the tenant with ultrasound make a small

incision and then this is the micro tip going in and this dark stuff is necrotic tissue within the healthy tendon this is a again kind of a pictorial but the outer portion of the sheets delivers saline which the broken down tissue will

actually kind of sit in the saline and then it's aspirated through the needle itself the Saline is nice because it allows you to aspirate the tissue but also cools the needle so you don't have thermal injury okay so technique so

depends on what you're treating how you're going to position the patient but mostly you want to position the patient in a way that's comfortable for the patient and comfortable for you so you're going to mark the site that

they're having maximal tenderness you're usually going to use a linear ultrasound probe and then you're going to position the pathology one of the limitations used to be with this device that the needle length is actually very short

it's about an inch and a half to an inch they've actually sent to come out with a longer probe that gives you more latitude but it used to be that you have to put the pathology almost right at the edge of the ultrasound because the

needle wouldn't reach all the way across the ultrasound screen but with the new technology that's been eliminated you're going to instill lidocaine to know them up this is what it looks like on ultrasound so the needle because it's a

hollow bore needle is it's somewhat blunt and to get to the tenon faccia is a little bit difficult so will actually pass our 11 blade or you can use like a 14-gauge needle through the tendon faccia in that kind of makes a pathway

for the 10x needle to go in so on the top image that's actually our 11 blade going into the diseased portion of the tendon which you can see the marketed by that hypoechoic architectural distortion and then the bottom image is the actual

TX handpiece going in and then once you're in the tendon otic tissue you activate the handpiece with foot pedal and debride the tissue so

this is an example of lateral epicondylitis or tennis elbow you can

again see the area of disease tendon once you see a few of these it becomes pretty easy to identify and so here you can actually see a little bit of micro calcification within the tenant it's at this little bright spot here and this

device can actually remove some of the calcification as well in the calcification releases substance P or pain substance and is law often the pain generator so I can get that calcium out of there you're going to have a good

result but again here we're going in with the 11 blade is the 10x probe going in and then this is what it looks like afterwards so after you go in and you activate the 10x probe your gonna have a go multiplication and you're going to

see this more of a gray area where it previously looked darker so for the

Achilles this is an axial an axial view of the Achilles you can see the denoted area of hypoechoic diseased tissue here is the 10 X Pro going in this is a

longitudinal view and you can actually see a little bit of calcification within that diseased portion with the plantar fascia again this is probably the most common of the tenon APPA these we went around the room there's probably ten

people in here that have plantar fasciitis it's a very common problem and so there's a couple of different ways you can approach the flutter fashion easier come from the medial aspect of the heel or you can come from the plant

or what I call the planter approaches from the plantar aspect this is what the pleasure of fashion looks like in longitudinal you'll see this this is what it should look like the whole way through but here's the diseased portion

again it's thickened you have that hypoechoic architectural distortion this is what that portion of the ten looks like in the transverse view and this is your calcaneus so this is the medial approach so on the axial view again our

11 blades coming in then we're treating the portion of the plantar fascia there from the side this is what it looks like after so before very dark after you get that nice kind of ISO a comic appearance so the platter approach here you're

coming from the toes towards the heel and again slender faccia the diseased portion of the plantar fascia the knife coming in treatment and then post treatment patellar tendinosis this is

you'll see this in a lot of athletes

particularly basketball players or track athletes will get this and kind of you're going to see a common theme here but I'm going through the different areas that we treat so again the hypoechoic the sword area the treatment

and what it looks like post treatment this is a rotator cuff treatment rotator cuff is technically probably the most difficult just because the curved surface the tendons a lot larger and there's a lot more going on in the

shoulder besides just the rotator cuff but here's an example of calcific tendinitis so you'll see this hyperechoic portion within the rotator cuff and then the posterior koushik shadowing that's a large chunk of

calcium that's within the tendon and there's some manipulations you can do on the setting of the machine to more accurately target calcium and we're going in removing the calcium and then hereafter you'll notice that it still

looks right there but that's actually a little bit of gas from the calcium removal and you'll notice you don't see any more shadowing there so the calcium is completely removed so post procedure this is really the advantage of this

procedures before you know we can take them to surgery they can have the surgery but it's going to be a good six months before they can go run and do anything that they're really hoping to do with this procedure we get them back

usually within six weeks to doing full marathons so after the procedure we don't have them there anyway to the affected limb for about 24 hours I heat really patients only need tylenol after this for painting there's only been a

very few number of patients were up thousand treatments now that we've done with us and only a handful of patients have needs anything more than tylenol for pain you want to avoid ibuprofen or naproxen because that's going to inhibit

the human response that we're trying to generate we put them in a brace depending on the limb usually for about two weeks for so for the plantar fasciitis of soft walking boot we tell them you can walk and do everything that

you would normally do but no running jumping anything like that for four weeks we call them two days after the procedure two weeks after the procedure and then we see them in clinic at four

weeks follow-up is there an example of

some of the orthotics that we use pretty basic stuff again the shoulder the elbow so initially we were not doing physical therapy but we try to kind of about we were coming up with our rehabilitation protocol with with the company

essentially because we were one of the first people to start doing this procedure there is no kind of rhyme or reason of what you do afterwards and so we've modeled it somewhat after the orthopedic surgery because that's what

we're doing right we're going in with an ultrasound and removing the scar tissue just like they were doing it open surgery except we're just doing it in a minimally invasive fashion so we started doing physical therapy actually now

sooner than four weeks and with the planner fasho what what you'll notice is patients will come back and they'll say well my foot doesn't hurt of my heel anymore but it now hurts kind of in my mid foot and what we realized is that

people's plantar fasciitis or actually have an abnormal gait they've adapted their gate to try to avoid stepping on their heel it's another stress in other parts of their foot now that their heel feels good they're actually feeling the

pain in their mid foot that they probably had before what was being overshadowed by the planter fashion so we actually send them to physical therapy for gait training or economy that's where we learn how to walk some

of the results most of the time so your average patient I tell them to expect to be 75 percent better four weeks and then over the next six months are going to start to feel one hundred percent better some patients I've had the healing

everybody heels as a different rate and you will see healing up to six that's been borne out in the pathologic studies but most of the time at four weeks they're feeling really good and then we tell them over the next two

weeks you can gradually build back up to dynamic activity running jumping into that nature so big question is does it

work so this is our experience this is currently a in review for JB I are and should hopefully be published soon but

so we looked at our first hundred patients with symptomatic plantar fasciitis for the first six months all these patients has bailed conservative therapy and they were all treated with the percutaneous ultrasonic fasciotomy

we looked at a validated scoring system for plantar fasciitis called the foot and ankle disability index or a t-score who looked at that at initial than 26 and 24 weeks after the procedure and so if higher on the y-axis is better you

can see this works very effectively our results were one hundred percent satisfaction in eighty eight percent of our patients so only a 12-percent failure rate which with anything in medicines extremely high this has been

validated with multiple other studies looking at different areas but there were relatively small cohorts there's a one of the initial studies of lateral epicondylitis looking at twenty patients and with this this is the bas scalar the

zero to ten pain score you can see that goes down at each time point this is looking at several different areas the elbow shoulder knee and achilles again the common theme is significant pain reduction when we do this procedure this

was this one was pretty interesting this looked at 18 colleges are 16 college athletes so these are high level performers with the patellar tendon which if you talk to an orthopedic surgeon is a nightmare if they have to

go in and shell out tissue from the patellar tendon it's a one of the largest or most load-bearing tendons in the body and it takes an extremely long time to recover so for college level athletes this is huge to be able to get

them back into six weeks back into their sport ninety-three percent revealed symptom resolution at three months and they were back to full activity meaning high level college athletics at six months these

are a whole bunch of other publications that have either been accepted or are submitted

yeah time for questions so my first question would be is this like readily available to msk nationwide that's being done or yeah so it's an interesting question because so I think everybody in this room probably agrees I ours are the right people to do this right this is an

ultrasound-guided procedure we're the experts an ultrasound-guided procedures so we should be doing this but the reality of the situation is most IRS have never thought about seeing somebody with plantar fasciitis or they don't

they don't come find us right so there's a lot of different disciplines that do this so it depends on your area in our area in Nebraska it's predominantly interventional radiology driven so but sports medicine physicians orthopedic

doctors are also doing this but it's one of the things that's hard to adapt for their specialties because they're not used to doing an ultrasound-guided procedure so a lot of them don't offer it because they don't they haven't done

it or they you know don't feel comfortable with ultrasound and there's no interventionalist doing it in their community so if you have an IR doc that's interested it is absolutely a hundred percent available they just need

to talk to the company it's a matter of getting the supplies in and they could start doing it tomorrow but it's FDA approved and readily available throughout and also this is something that would be used platelet-rich plasma

PRP before you would even get to this point well so that's kind of a ongoing debate there's the literature for PRP and stem cells is kind of all over the map on whether or not there's therapeutic benefit or not PRP is

currently not fda-approved and so it's primarily cash pay and so it's not reimbursed by most insurance companies so that's somewhat of a limitation but yes you could do that before this and see if they got good results there are a

lot of papers showing very promising results with stem cells and PRP in our practice now we've actually are doing adjunct we think that we're going to hopefully publish our results but we're actually doing stem cell injection into

the tendon about a week after we do the 10x procedure in our hypothesis is that's going to get people back activity even faster and so instead of the six weeks hopefully we can get them back at four weeks because they get a lot of

these people are athletes and they want to get back sooner so that's a long answer to that question share Eliza yes you can do it before and it wouldn't disqualify you from doing this but there's no definite treatment algorithm

that says PRP business or this than PRP hologram yeah and can I ask a question for the provocative bleed one do you think provocative blades are kind of going by the wayside because I've noticed with our dogs a lot of times you

know we want tagged or a CTA beforehand so we're not going in there kind of looking around for where's where's this going to be even though they think it may be here or not with CTA do you feel like provocative leads kind of something

that I know we're not seeing as much as we have banned in the past up till now do you think that's like a dying type of procedure I don't think I don't know that's a good question so the way that it was you studies are all negative hold

on sure and they're coming back two three four you know yeah over and over so I think it remains think the patient population of what you're using it in is changing this is not for every gee I believe that comes down that's right

okay thank you good morning I actually have a question for dr. Romano the ultra someone you were talking about wow that's really loud and I have a loud voice one's good okay all right there we go okay so you

were talking about the ultrasound procedure being prone with a full bladder and three to four hours do you use a Foley is that contraindicated when you're talking about areas of fibroid how is that be managed for patient

comfort well I mean you can so really you want to have that volume in the bladder I mean if the patient is uncomfortable the point of dissension which they are going to be regardless because you're instilling fluid in there

you can drain some but the whole purpose is to have a full bladder that uses a coup stick window and also to display structure so it's kind of a two-for-one so to speak and you can it still flip you can also remove through it as well

got it thank you and then dr. Brown I exposed to have a question for you as well do you have any information yet about what our retreatment rate may be considering this is a pretty new yeah so is yes the newer technologies the first

patients were treated in 2011 was the first US based treatment that was done the the treatment rates are extremely retreatment rates are extremely low I personally have only retreated one patient there's a lot of the studies

have shown that you have healing out to six months so we won't offer retreatment until at least six months and so then it really becomes a question of whether or not there's a residual scar tissue that maybe we didn't get all of it and in

that setting you you can retreat but the retreatment rate is less than five percent in the last scene rate is over 90 excellent and one last question reimbursement if they approved are you getting reimbursed for this yeah so this

this actually own you use the same codes as percutaneous tenotomy and so there's been a lot of studies on dry needling and some other techniques and so you're actually able to use pre-established codes and so it does get paid for and we

we have a pretty good setup now where we're not seeing any denials with this it's a standardized treatment but it's a because use the other codes it's actually like a well-established treatment okay well thank you are there

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