All right, awesome. Hopefully everybody can hear me. I'm Dr. Cleo Stafford. I'm the chair of the sports medicine community. I just want to thank everyone for showing up tonight. This evening, we're going to have our May community presentation. This is my son, Jackson, and he's going to be following along because it was too exciting for him to go to sleep, so he wanted to stay up and hear both of these talks. So hopefully everyone finds this thing pretty exciting. So tonight's topic is entitled, Ultrasound Interventions for Common Problems, Pushing the Limits for our Patients. Our first presenter is going to be Dr. Ricardo Coburg. He is a sports physiatrist currently practicing with the Andrews Sports Medicine Group in Birmingham, Alabama. He has a special interest in treating acute and chronic musculoskeletal injuries, including bone, joint, ligament, muscle, and tendon injuries. He performs various treatment modalities in a clinic that assists patients in their recovery from injury, among those being diagnostic musculoskeletal sonography, ultrasound-guided injections. Additionally, he has published several book chapters and peer-reviewed articles regarding the ultrasound-guided percutaneous soft tissue releases. And this evening, he will be speaking about the trigger finger and de Quervain's releases. Our second presenter is Dr. Walter Strussman. He's a sports physiatrist and the owner of Boston Sports and Biologics in Boston, Massachusetts. He has published peer-reviewed articles and book chapters on ultrasound-guided percutaneous surgical procedures, regenerative procedures, nerve hydrodyssection, and concussion management. He's a national leader in the field of regenerative medicine, serving as a board member for the Interventional Orthobiologic Foundation, and he's a member of the American Academy of PM&R Biologics Workgroup. Dr. Strussman will be speaking about percutaneous techniques to address Achilles and Hanglund's deformity. Without further ado, I will turn it forward to Dr. Ricardo Coburg. Thank you, Dr. Stafford, and thank you, APM&R, for having me. So I'm going to go ahead and share my screen here, so give me one second, and we'll get going. And so, all right, Dr. Stafford, can you confirm that y'all can see my presentation? We can see it. Great. So I'm going to be talking tonight about the ultrasound-guided ligament releases for the tendon pathologies in the hands and wrist. This has been an area of interest and research that I've been working with in the past eight years, and I'd like to share what I've learned throughout all these years with you tonight. So no conflict of interest, I am in Alabama, and so you always get the question, are you an Auburn fan or Alabama fan? Roll Tide. So we're going to cover tonight the trigger finger release, the decorvane release, and we've been exploring now how to do a six-dorsal compartment release for chronic extensor carpi ulnaris denosing tenosynovitis, which is similar to decorvane, except that it's on the ECU side. So just reviewing some basics of these tendinopathies. So for many years, the only option that we have for these chronic tendinopathies or stenosing tenosynovitis was doing the open surgical release. You had the trigger finger or decorvane or ECU. Success rate in the literature ranged from 60 to 90 percent, and it had a fairly significant complication rate. Typically, you would see better outcomes with trigger fingers, but the decorvane and the ECU are procedures that the hand surgeons are always going to be more careful about offering it because there's a higher likelihood that there could be tendon subluxation after the procedure is completed. And the main reason that happens is that for a surgeon to be able to see these tendons, they have to do the incision through the skin, but then they have to do a dissection of the integumentary system, as you can see on the bottom right side, that picture. And we believe that that is a major part of the reason why some patients may end up having tendon instability afterwards because they will make the incision afterwards through the extensor retinaculum, and they'll sew the skin back up, but the integumentary system connects the extensor retinaculum to the skin. And when you dissect all of that, then you lose the connection between those two layers, and so it's more likely for the tendon to eventually slip out from the extensor retinaculum and just get into that subdermal space. And so when we're doing our procedures, we do not dissect that tissue as extensively as an open technique would, and I believe that's one of the main reasons why we've never had any case of tendon subluxation with all the cases that we've done. Another major complication, and going back to the trigger finger, is that the hand tends to develop a lot of scar tissue hypertrophy. And so you will see a lot of patients that they had their trigger finger release, and afterwards they have a fairly significant prominent scar. In some cases, it even mimics Dupuytren's contracture. Now, you also have the neurovascular injury, risk of wound infection, inflection, contracture of a tendon, but those are less likely to happen. But aside from that, I think the biggest reason patients like to do the ultrasound-guided release techniques is that these techniques do not require wound care. They go home with a Band-Aid. It's a little puncture in the skin, and they go home with a Band-Aid for 24 hours. And so they don't have to worry about wound care. They don't have to worry about sutures or suture removal, and that means that they can get to work, they can get back to work a lot quicker. The average patient that has a tendon or an open surgical release from one of these tendinitis will be restricted from work. Especially if it's manual labor, they'll be restricted for six weeks. And in our case, we let the patient go back to sedentary duties the next day. They can perform light duty in three days, and then they can return to normal duty with no restrictions in two weeks. So I'm going to reveal a little bit about the history of percutaneous trigger finger releases, which came before the corven and ECU releases. In 1992, Gupta et al. described a palpation-guided percutaneous trigger finger release. And what they would do was advance a 20-page or an 18-page needle, and they would go down to where they felt like the A1 pulley was by palpation, and they would basically serrate the A1 pulley with a needle and fenestrate it and puncture holes through it. And then they would move the finger back and forth, flexion and extension, and try to see if there was any friction or if the tendon was grabbing the needle. And that's how they could tell how deep they were with the needle. And so looking at their outcomes, they had similar success rate to the open surgery, but they had a quicker recovery time because it was just a puncture in the skin. And so this procedure started catching some attention. And in addition, the complication rate was actually fairly low, 5 to 14 percent, as mainly the main complications were pain and incomplete releases. And the main reason that they would have incomplete release was because they had no visual confirmation that they had done a full incision through that A1 pulley. So then move on to the early 2000s. Ultrasound-guided techniques started becoming more prevalent, and researchers started exploring these techniques. And they looked at all the way from 22-gauge needle, 21, 20-gauge needles, fenestrations, to using a hook knife and using different instruments. And they were doing all these procedures under ultrasound guidance. So now they were able to provide visual confirmation of a complete release. Success rates reported ranging from 76 to 100 percent. Now, there was still a concern with all the techniques except the hook knife, which is a fairly large instrument. There was still a concern that the main procedure that was being performed was fenestration, which is basically like grating cheese. And so you would pass the needle multiple times through the A1 pulley until you eventually severed the A1 pulley, and then you would get a release. And in fact, that was the technique that I started performing 10 years ago when I started doing these procedures. I was using a 22-gauge needle, and I was finding that we had some cases that we were not getting the complete release. So I started brainstorming with my colleagues and talking at the academy meetings, trying to figure out ways that we could achieve an actual incision through the A1 pulley and move away from the fenestration technique. And we eventually ran into this instrument that we have there, which is a needle. It's an 18-gauge blade at the tip of an 18-gauge needle, and it's got a little opening fenestration near the tip, and so that's for irrigation. Technically, this was created as a filtration needle. So many of the physicians here tonight that do interventional spine will probably recognize this. The commercial name is no-corn needle. And so it was a filtration needle used to puncture vials and draw medication from vials and minimize the chance that you would get that corking, that small little piece of rubber that could get in the syringe and could potentially be injected into the epidural space. So we took that needle and started doing research and seeing if we could apply it to ultrasound-guided trigger finger release. And so we come to find out that the A1 pulley, when it hypertrophies, it's actually just about the size of the tip of that needle or blade, if we might call it. And so it was looking very promising, and so we decided to move forward and go from cadaver testing to pilot study with a patient, and then eventually did a series of patients and did our retrospective study and then a prospective study, which I'm going to be talking about tonight. And so the benefits of this technique is that now we're not only seeing the A1 pulley in live imaging with the ultrasound, but we're able to actually make a full incision through the A1 pulley and visualize the full incision, the full release. So we don't have to worry about fenestration or risk of a partial relief that could lead to recurrence of triggering. And then what we also found out throughout the years and the research is that there's really no report of a case of attendance subluxation or even scar hypertrophy after these procedures were performed using this instrument. And so we thought that that was a great advantage over the open surgical technique, aside from the fact that post-care is so much easier. So patient goes home with a bandaid, as I already mentioned, and they'll do their basic daily activities as soon as possible and they can get back to heavy lifting in a couple of weeks. So here are some videos that I want to show you all, because I always get this question. Can you show me how it's done? Can I see the technique described? And so on the top left corner, so where it says tendon catching before release, I have an oval, red oval that is showing the A1 pulley and you can see the hyperechoic A1 pulley. And then you see a nodule in the flexor, the digitorum superficialis part of the flexor tendon. And you can see the nodule getting hung up and stuck with the A1 pulley. So you can imagine that if you force it to bend, it'll slip under the A1 pulley and they'll get stuck in the flexion position. And so in these pictures, left is proximal, right is distal. And so left is metacarpal in the bottom and right is the proximal phalanx. And so, and then we move on to the next picture on the top right. And so here I'm anesthetizing the area. So I use three milliliters of lidocaine 1% with epinephrine. And I also get that question a lot, you know, is there risk of ischemia? And so we've done thousands of cases and we've not had anyone sustain ischemia. And the main reason is if you know your anatomy and you're proficient with controlling the needle, you should be able to anesthetize the skin at the puncture site, at the A1 pulley, over and under, and in the tendon sheath without letting any of the medication get to the digital nerves, which are going to be radial and ulnar to the tendon. So, but that's important. You need to be able to control this, these needles. And, you know, eventually you're going to be using a scalpel to make an incision. So you really need to be able to be proficient with using your, your hands to control the needle. And for that same reason, the fellows in training in our group seldomly get to try this procedure in the first, you know, six to nine months. It's really towards the end of their fellowship year. If they have been able to prove that they're proficient with basic ultrasound guided procedures and more advanced ultrasound guided procedures, such as doing nerve blocks and so forth, then I'll let them start performing the, this procedure, which is certainly a more advanced procedure with higher risk complications. But anyhow, getting back to this top right corner. So you can see the 25 gauge needle and it's inserted into the tendon sheath distal to the A1 pulley. And so as I'm injecting the medication, you see the medication extending or expanding the, the tendon sheath distal to the A1 pulley followed by proximal to the A1 pulley, both in the superficial aspect and the deep aspect. So that fluid that you see moving a little bit deeper as well, it's just expanding that, that tendon sheath and just kind of getting around that, that area. Now you see a hypoechoic and anechoic signal over the A1 pulley. So I also numb up that area because that soft tissue and, and you know, you got some of the fatty tissue and so forth is innervated. And if you do not anesthetize it, then it's going to hurt a lot. So then I go ahead and advance. I take that 18 gauge needle with the blade at the tip and I make a puncture incision in the distal aspect. So it's basically at the crease of the MCP joint and I go perpendicular to the skin. So I puncture down. Now, once I puncture the skin, I'll, I'll have the hand bolstered on with a little block under the hand with the edge at the MCP joint. And so I can hyperextend that MCP joint. And so then once I puncture the skin, I'll use my pinky finger to kind of hyperextend the, the finger. And then I, I take the needle and put it parallel to the tendon and parallel to the A1 pulley. And as you can see in that video, then I go ahead and make my incision right through that A1 pulley. Now I do have to say for those that have been doing this procedure and have questions about, you know, complications and so forth. So this video that you're seeing right now in the bottom right corner is a simple A1 pulley release. And that's not the case for most patients you're going to see. And that one, I was able to release it with a single pass and you can see the needle kind of pop. You're going to have a lot of cases where it's not just the A1 pulley that has hypertrophied and it's catching the tendon, but you also get this tenosynovitis and you get some scarring of the tendon sheath. And so, you know, as I started finding some cases that I required a little bit more of an extensive incision and irrigation, I discussed it with our hand surgeon. And she's the fellowship director for our hand fellowship program. And she told me that it's very common where they're going to have cases where they were not able to do a complete A1 pulley release. Sorry, they completed the A1 pulley release, but there was still some residual catching. And she was telling me that it's the tendon sheath that develops those adhesions and they would do a synovectomy. They would actually cut the tendon sheath open and then dissect that and irrigate it and release and get a full release of that tendon sheath adhesions as well. And so anyhow, it's just a comment for those of you that are trying this procedure. You make your incision through the A1 pulley. If you still feel like there's some catching, you may want to go into that tendon sheath a little bit more proximal or distal and find out if there's adhesions there or if you need to make an incision. And then you go ahead and irrigate the area with a little bit of saline. I typically, I have a syringe with three cc's of saline, but I typically end up using only about one to one and a half cc of saline. And then we have the end result in the bottom left corner where the tendon is not catching after the release. You see it fully flexing and extending and the nodule is going right where the A1 fully was and it's not catching. So this is the technique. Let's go ahead and talk about the studies and I'll show a few more pictures. So the first study we did, it was our first 50 patients. We were able to get 46 patients to agree to participate and so we collected the data. So it was a retrospective case series study. And of these patients, 100% of patients had the complete release with no recurrence of the mechanical symptoms. 0% of patients had complications perioperatively or post-operatively, including there was no ischemia, there was no nerve damage, there was no perfused bleeding, there was no significant pain after the procedure. And then 98% of patients had complete pain relief and symptom resolution with basically a 0 out of 10 pain. The average pain at final follow-up for all these patients was a 0.3 out of 10 and so basically, you know, you always have a few patients that may have a residual discomfort, which is expected with all the techniques really, even the open surgery techniques. So from this study, we concluded that the technique was safe and it provided full resolution for the trigger finger. And so then we moved on to doing a prospective study. But something that, you know, as we did this procedure, we realized that, you know, we had found a, you know, a procedure that was very effective, and that it was going to be important from an academic standpoint to describe the complete technique that we were doing or the factors that we were looking for to confirm that there was a complete release. So it's not just feeling and seeing that there's no catching. We went ahead and described three additional techniques that I use, and I still use to this day, to confirm that there has been a complete release. So the first technique is, both in long axis and short axis, you're going to irrigate the area with a saline. And you can see I still have that no-pore needle in that top left video, except that now I flipped it over. And so instead of having the scalpel pointing up, I'm having the scalpel pointing down. So that means that the fenestration that you originally saw is pointing down. So it's actually easier to irrigate down towards the tendon and into the tendon sheath. And so you can see the hypoechoic, sorry, the anechoic area where the ligament used to be, or that A1 pulley used to be. So now there's no A1 pulley right there at the head of the metacarpal and MCP joint. And then you do that short axis view, and you can see the hypoechoic edges of the A1 pulley, both on the left side of that oval and on the right side. The right side, you can see it kind of flip back down right about now, right there. And so you see that little white dot, hypoechoic dot, that comes in and into the anechoic defect where the incision was made. In addition, we do our dynamic test. So we bend and do flexion extension of the tendon, make sure there's no catching and the nodule is gliding smoothly. And then I do a manual test. And so I go ahead and get a sterile gauze. So I don't do it like that picture shows right there. But I get a sterile gauze, I put it right over the wound, and with sterile gloves, I fill my sterile gloves, I go ahead and do a full flexion of the tendon. And what's interesting is that there are cases where some of those adhesions from the stenosing tenosynovitis that get into the tendon sheath, you may actually feel like a little bit of a crepitance or even one last little kind of pop or crunch when you get to a full flexion. And then it goes away. And so those little bit of residual adhesions will eventually release. But this is really the best way to show the patient that you're done. And so every single patient that we do a release, they follow it up and they'll say, wow, I can bend my finger again. And so that's how you reassure them that the procedure has been completed. All right. So then I mentioned we did a retrospective study and we moved to our prospective case series study. And this one we had 79 fingers, 19 patients had multiple fingers. And so now we went to a more statistical statistically based data analysis, data collection with more objective numbers, using quick dash score, using numerical rating scale, the nurture score for pain. And so we follow the patient prospectively before and after the procedure up to a year and a half out. And in this case, in this case series, 100 percent of patients had complete release, no recurrence against zero percent complications, and then 97 percent complete pain symptom resolution. Again, we had that zero point two out of ten pain, similar to the other one, zero point three out of ten. Quick dash score was basically negligible residual deficits. And so conclusion, again, this was a very safe procedure and making a clarification. Yes, we did include thumbs. So both procedures, prospective and retrospective, had thumb releases. So there's been people that have expressed concern about the thumb because it's a little bit more technically challenging. But in the end, that it's all it is. It is just more technically challenging. And so if you are an advanced sonographer and you're proficient with controlling probe and controlling needles, you should be able to perform a trigger thumb release and you're just compensating for the slightly different angle that you got approached. Now, of course, you know, when we see these outcomes, you know, we we see a very promising technique that we could potentially apply to other pathologies. And so the next pathology that we looked at was the Corbin release. And so we went ahead and did our pilot study and then did our case series and publish our outcomes. And so with the Corbin release. So you're doing a very similar technique. It's very similar images. A few recommendations that I can give you. I always do a superficial radial nerve block about six inches proximal. Make sure that we provide patient comfort. Three milliliters, a lot of one percent, no epinephrine for the nerve block. But then I go to the skin right over the extensor retinaculum, the first dorsal compartment. And I'll put three cc's, a lot of cane with epinephrine mainly for bleeding, controlling bleeding for hemostasis. So I do my soft tissue and over and under the retinaculum. And then we advance the no core needle. Same technique as we do with the trigger finger. And so you can see in that picture on the left side, the thick retinaculum with the tendons in the bottom and then the needle going through it. This retinaculum tends to get thicker. So in many cases, I have to do something a little bit more like I describe it like you're cutting a steak with a steak knife. And, you know, basically you need to start just kind of working your way through. And that is exactly the same way that you would do an open surgery technique. So the surgeon will start making their incision and they're working their way down, making sure that they don't cut into the tendon. So there's really no difference with what you're doing to the open surgery technique on the retinaculum, except that in this case, we're leaving the integumentary system intact. So we're not dissecting the skin apart, which is what I believe is what causes the tendon instability and subluxation with the open surgery technique. Another concern that we typically get is little branches from superficial radial nerve that can go that can be severed. In all the procedures that we've done, we've never had anyone that has had residual paresthesia after the procedure. Once the numbing medication wears off, everyone has had their sensation back. And so, you know, you have the radial artery, you have more neurovascular structures in the area that you need to be able to recognize. And so in the end, same thing I tell our fellows, if you know your anatomy, you know how to do advanced ultrasound guided procedures, this is a very safe procedure that you can do. One last question that I get is what about the septum? About a third of patients with deforming tendinitis have a septated first dorsal compartment. And, you know, the surgeons, they've always have been taught to open up both tendon sheets. And what we found is that first, number one, you can actually identify with ultrasound, which of the two tendons is the one that is the most affected with tendinitis by doing color flow and seeing the anechoic signal and the color flow and so forth. And then second thing is that in most cases, if you release that retinaculum and you make an incision through that tendon sheet, even if there's a septum, we have not had anyone have a adverse event or even have a negative outcome because their tendon was septated or their dorsal compartment was septated. So that has not been a concern for me. I haven't seen it be a problem. And so moving on to the picture on the right side, so you see the superficial radial nerve and the retinaculum and the APV and APL and the radius below it. And so we have a before and after. So look at that retinaculum on the top page, the top image that's going over the two tendons. And then in the bottom image, you see the asterisk, which is the anechoic defect from the incision that was made right through that septum or sorry, that retinaculum. And in this case, I was able to do it right where the septum was. So here are the outcomes of our retrospective case series. Average follow up was two years, 100% complete release, no recurrence, 0% complications, no neurovascular injuries documented or reported two years out. And in this case, interestingly, everyone had 100% pain relief. And so, you know, in permanent function, they return to work, I do the same restrictions, just limit heavy lifting for two weeks. And then at that point, they can resume activities, or sorry, with no restriction. And they can do their basic ADL is basically the night of. So it's a quick return to activity. So then we move down this the last case I'm going to present. And so this was our most recent case. So naturally, you start thinking about other procedures that you can do. And so we had a patient that had a chronic extensor carpil narus stendocytina synovitis, and have felt conservative treatment for for a year. And the patient had had multiple cortisone shots, PRP injections, sprays, PT medications. When he came to us, he was three months out from the last cortisone injection that he had. And so we discussed this procedure as an experimental procedure. And that was going to be the same technique that we did for the first dorsal compartment deployment release. In this case, again, you got to go back to the anatomy and think about what are potential structures that you may injure. And so the dorsal ulnar cutaneous nerve is the main nerve you got to be careful with. So if you can find it, then you can make sure you stay away from it. And so we went ahead and did our release. And so we followed up with a patient closely for up to two years. And so two years out, patient still was reporting complete release, no complications, 100% resolution of symptoms, he returned to doing all his activities. And so what's interesting is after this procedure, I've been eager to get a case series going. But we see such few cases of these that we haven't really been able to to get a significant number of patients going for a study. So in conclusion, these ultrasound guided incisions, especially using that no cord needle, they show promising outcomes, they're safe and effective. You know, you can expect 97 to 100% improvement in symptoms. And I certainly would like the community to keep supporting the research on this and helping me out. And by all means, please reach out and you know, I mean, I have done 1000s of these. And I'm always more than happy to discuss if you're having complications, or running into problems, reach out to me. And so here's my information and my email there at the bottom. And we're happy to discuss further. Thank you so much, Dr. Colbert. That was an excellent presentation. For those who might have questions regarding this presentation, we're going to do at the end. But if you want to place them in the chat box, Dr. Colbert might be able to get to it while Dr. Sussman is doing his presentation. So next up, we'll have Dr. Sussman speaking about Achilles tendon pathology, and various ultrasound interventions to address it. Dr. Sussman's camera may not be working. So you may not be able to get on camera, but we should be able to hear him as he goes his presentation. Well, I appreciate the opportunity. You know, I'm going to talk about a couple different procedures for the Achilles. A lot of these translate to other areas of the body, though. These are my disclosures. We do have a textbook out there. Dr. Colbert actually wrote a chapter in here on some of these percutaneous releases that he just discussed. So that's a resource. I'm also involved with the Interventional Orthobiologics Foundation, which is Interventional Orthobiologics Foundation that runs courses on ultrasound guided techniques, cadaveric courses. So it allows some hands-on training for some of the techniques. And then I'm a consultant for Trice and Tenex. And so, you know, these techniques and the techniques Dr. Colbert is describing, you know, these really kind of aren't the traditional simple injections that most of us trained on or learned. And they're not quite the traditional surgical approaches either. And they kind of belong in their own category. And whether we're going to call it interventional orthopedics or minimally invasive ultrasound guided techniques or whatever term we decide, you know, cat's kind of out of the bag. You know, I mean, these are going to continue to grow because they offer faster recovery, you know, comparable outcomes, lower risk. And there are a lot of techniques that really have been described over the past 20, 25 years, as we've really understood that tendinopathy isn't an inflammatory condition, but it's degenerative. And we'll focus on these percutaneous or tenotomies under ultrasound guidance and using some of these different tools to achieve this. We're going to talk about Tenex because there's the most data on some of these ultrasonic debridement devices with this specific tool. And the way it works is you make a small incision because it's a fairly blunt device. You use ultrasound to guide it into the area of pathology. And it has a couple of different mechanisms of action. You know, one is it'll vibrate at this ultrasonic energy, which may help break apart any fibrinous disease tissue. It irrigates that area. So the outer sheath of this device will infuse the area with saline. And then there's an interlumen that has a vacuum component. So it'll vibrate, kind of this jackhammer kind of motion, and is a debridement tool. And then the primary mechanism is probably that it's stimulating bleeding. And just like with PRP or some of these other regenerative techniques, you know, getting blood to an area of injury and starting that healing cascade is really probably how these work. You know, tenatomies and ultrasound guidance have been studied throughout the body. There's data and studies on almost all these areas. And this is a study put out by Mike Berry at Ohio State, you know, a few years ago, showing what this Tenex device actually does. And you can see cavitation and absence of tissue in this cadaveric model. So it removes the diseased tissue. And then the hope is just like with wound care, you know, if you can remove the fibrinous scar tissue, diseased tissue, necrotic tissue, you know, hopefully you can start a healing process where you fill in with healthy tissue. So what's the evidence? This was a slide from a few years ago. I think that there's almost 90 articles now looking at the Tenex device specifically for this. And you can see, you know, throughout the body, you know, these are fairly impressive outcomes, you know, in the 80 to 90 percent range, which is about as good as we get with most of our orthopedic procedures. And we're going to talk a lot about Tenex because this is what I have the most experience with. But there is data on needle fenestration with just a 18-22 gauge needle. Endoscopic approaches. There's also other debridement devices like the Tenget. And then there's an Ocelot device, which also allows you to perform tenotomy in kind of a more mechanical nature. This is one of the earlier studies in literature. This is a study looking at the initial... Sorry to interrupt you. Your PowerPoint is not in full presentation mode. Let me see. What about here? Is that working for you, Cleo? We can see the slide. It's just not showing presenter mode. So we're just basically kind of seeing the description and everything. You may need to choose a different... When you do the share slide, choose a different screen. Yeah, if we can go to slide 11. I can't see the numbers. If you just tell me when to stop. Sorry, this one. This was perfect. Okay, perfect. Okay. So, you know, this is, you know, so the concept of a tenotomy, you know, isn't new. You know, this has been around for a long time. You know, this is a study of Mufuli's group in the UK, and they looked at 39 consecutive patients, and they were doing these in the late 80s, early 90s with an 11 blade. And here they made five incisions in the Achilles tendon, they moved that blade up and down, left and right, and they reported that 77% of patients had good or excellent outcomes. And within two weeks, they were able to jog. Next slide. This is the same group. You know, this is looking at a slightly larger group of patients. Again, you know, they reported in the 70% range, you know, good or excellent outcomes in these patients, fairly fast recovery. And you can see here on the left, this is kind of the approach, and they would come in with a scalpel, an 11 blade scalpel, make these percutaneous passes into the tendon, move the scalpel up and down, left and right, and just in an indiscriminate way traumatize the tendon. Next slide. McShane looked at this data, and he ended up kind of doing a similar procedure. This is for lateral epicondylitis, and he looked at consecutive patients with an 18 or 20 gauge needle, passing it parallel to the tendon, fenestrating the tissue until it was softened, which is kind of the definition of a tenotomy versus just making multiple passes until where you don't necessarily feel a tissue texture change. They looked at whether or not you added cortisone or not, and it didn't seem to make a big difference, and they reported even better outcomes. You know, 91% of patients in these studies reported good or excellent outcomes. Next slide. And you can do this endoscopically. So this is a more recent study. I think it was in 2018, and they looked at 24 tendons, consecutive patients where they went in with a carpal tunnel release device endoscopically and made vertical passes in the Achilles tendon. And when you look at patients who reported excellent results, 50 plus the patients who reported good results, you know, again, you're getting in that high 80% range in terms of outcomes. Next slide. And so, you know, there is a little difference between tenotomy and fenestration. And so, you know, typically fenestration, we're kind of making indiscriminate passes, peppering the tendon, whereas with the tenotomy, we're trying to braid the tendon until you feel softening of the tendon. And this study looked at if you change your technique, could you just make passes or do you do it until it softens and you combine it with PRP? And when you actually make enough passes to soften the tendon, people did better and they were less likely to require additional treatments. Next slide. And so the concept is pretty simple. You know, we see these acutely injured tendons, whether it's an acute injury or more degenerative. And some of these tendons will go through a healing cascade where it will resolve. And in most studies, you know, with the right therapy, with the right rehab program, 70% of patients will put resolution. But some of these patients will go on to create, you know, fibrinous scar tissue, degenerative changes within the tendon. Next slide. And so our understanding of tenotomy, tendon pathology is this continuum. You know, you have a normal tendon, you get this reactive injury, whether it's acute or chronic. And some of those patients will go back to normalize that tendon architecture, but some will go into this degenerative pathway where you start to see micro tears, disorganization, potentially calcifications within the tendon, hypervascularization, which shows up as hyperemia on ultrasound. Next slide. And so how we approach these, you know, it's probably different. You know, acute traumatic tendon injuries is a different pathology than these patients who have been dealing with this for years. And our treatments really have to adapt to where that patient is in this spectrum. Next slide. And so the concept with all these treatments, you know, whether it's a tenotomy or whether it's PRP is we're really taking a chronic degenerative tendon injury and we're converting into acute injury. And then hoping that it will go through the right healing process, you know, it's augmenting of rehab, you know, and supportive care after these procedures. Next slide. And the way this works, you know, when you look at animal models is that when you needle the tendon, you see an increase in cellularity. And in this rat model, you saw that these tendons would actually heal, you know, and this is the holy grail with what we're looking at with these minimally invasive treatments is how do we trigger a healing response where these tendons actually go through and resolve, they regenerate. Next slide. And the Tenex device specifically, you know, it creates this cavitation. This was a slide from earlier. And again, you know, trauma allows the body to react like this is a new injury and hopefully bring in the right supportive cells to heal it. Next slide. And so we're going to divide Achilles pathology right into two distinct pathologies, you know, mid substance Achilles tendinopathy or tendinitis and insertional Achilles tendinopathy are really very distinct disorders. Next slide. And next slide. So right now, you know, what we typically do, you know, for Achilles tendon pathology is conservative management. There's not a lot of data to support us. You know, most of us are prescribing this Alfredson protocol, you know, heavy, slow resistant training or eccentric training, you know, it does have some data to support it, anti-inflammatories. But, you know, patients who have ongoing pain, you know, three, six months down the road, you know, with these basic conservative measures are really looking for another alternative. Next slide. And in fact, 24 to 45% of patients with Achilles tendinopathy, mid substance Achilles tendinopathy will fail conservative management. In that case, often surgery is considered. But we don't really know what the ideal surgery is, you know, in most cases. Next slide. And when you look at the surgical literature, we've been doing a lot of different things for this. But most of these lack good evidence, lack level one data. And most of these procedures only have the level B or level C data to support them. Next slide. And so on the left, this is an open surgical debridement. And on the right is, this is what the 10X incisions look like. And so, you know, most patients, if they had the option, you know, with comparable outcomes, probably choose a procedure that's a little less invasive. Next slide. And the pathology, you know, when we look at this on ultrasound, you typically see this fusiform thickening of the tendon. And next slide. And when you actually challenge the tendon with saline, and there's a video, I'm going to start that. What you'll see is that the pathology isn't just, you know, thickening of the tendon. When you actually put fluid in there, what you'll see is that there's all these gaps and micro gaps where those fibers are no longer cross-linked. So we looked at that earlier slide where you get these micro tears within the tendon, you get these micro calcifications within the tendon. And that's exactly what we're seeing here. Next slide. And so the concept of the 10X tenotomy, you know, it's a surgical procedure. We can skip over actually the next slide and go, this is what a setup for 10X would look like. And then next slide. And so when we go in there, and this is a video of this too, so we can play that. What we're trying to do is we're trying to debride the tendon, remove those calcifications within the tendon. And we're trying to traumatize it to stimulate bleeding within the tendon to cause blood flow or bleeding, you know, and start that healing process, angiogenesis, and this healing cascade where we'll bring in type 1, type 3 collagen to fill in those gaps. The procedure is done with local anesthesia. So here you can see we're using anesthetic above the tendon. We're going to go through the tendon. Now we're going to anesthetize underneath the tendon, between the tendon and Kiger's fat pad. We use this skin wheel with some lidocaine with epinephrine to provide hemostasis. So when we make those stab incisions, it just makes the whole procedure cleaner. And again, the patient's awake. Here's the stab incision. So we're going to make the incision below, and then we're going to do another incision just above the tendon. And this allows us to get the 10X device in all aspects of the tendon that are degenerative. Now we come in with a 10X device. Again, it's fairly blunt, so you have to make those stab incisions to get it in. There's a foot pedal that will activate it. And when it's activated, you'll see this vibration throughout the screen. So that's that ultrasonic vibration. And we use ultrasonic energy to break up kidney stones. If you've ever had your teeth scaled within the past five years, you're using ultrasonic energy to break apart the plaque, but it doesn't damage your gum. And so we're using that to break apart any calcifications, any fibrous tissue, any inner product tissue in the tendon. And then at the same time, we're flushing it with saline. So we're debreeding the tendon. And now we're coming from the top. And again, we're making passes so we can touch every aspect of the tendon that may be degenerative. You'll feel crunchiness or a resistance to the tendon in areas that are pathologic. And this whole procedure takes less than five minutes. The patient's placed in a boot afterwards for about two weeks, and then we slowly ramp up their activity over a two to three month period. Next slide. And so this is our postoperative protocol. You know, this is more for reference than anything, but again, it's stair strips over the incisions. We avoid anything where they're submerging the wound until that closes. Typically, patients will get away with Tylenol or ice. We'll still prescribe metraminol for breakthrough pain. And then they're in a boot for two weeks versus most of the open surgical procedures where you're going to be immobilized in a boot for up to three months. And so within two weeks, we're starting that rehab process. Next slide. There are a couple complications that have been reported and we worry about, you know, infection and bleeding, you know, with any procedure. Sometimes this doesn't work, you know, so all the studies showed that, you know, in general, this works 80 to 90% of the time, but that's not 100%. And there have been cases of tendon rupture out there, but rare. Next slide. Now, insertional Achilles is a totally different pathology. And so just to get some terminology out of the way, you know, Hagelin deformity is when that posterior bump on the calcaneus is prominent. Hagelin syndrome is when you not only have the prominence, but you also have some tendon pathology or bursitis associated with it. And 25% of cases with insertional Achilles tenopathy have this bony pathology. Now this is different than an enthesiophyte or a spur at the insertion of the Achilles. You know, the Hagelin deformity is more proximal where that spur is typically at that insertion of the Achilles. Next slide. And as far as, you know, our exam, you know, it's pretty simple. You know, are they tender along the tendon? Are they tender anterior to the tendon where that retrocalcaneobursa sits, which may indicate that there's inflammation between that Hagelin protuberance and the tendon? Or are they tender when you push on the spur? And all of these can coexist, but it's helpful to kind of figure out exactly where the pain generator is. And if it's one or all three, that will change exactly, will change the procedure that we're going to consider for the patient. Sometimes it's hard for patients to localize the pain. We don't inject cortisone, but sometimes you can inject lidocaine or lidocaine and Toradol, um, into the retrocalcanea bursa to see if that's a source of pain or the retro Achilles bursa, which would be superficial to the enthesiophyte. Um, there's data look at, uh, radiographic findings and they tend not to have a predictive value on whether or not that Hagelin deforme is going to be symptomatic. Uh, next slide. In fact, there are different ways of, that have been described for measuring a Hagelin deformity. Um, so there's not even consistency or agreement in terms of which of these radiographic findings are clinically significant. Next slide. So these are a couple of our patients and you know, you can see it. There's a variety of pathology that can exist in this area. Uh, in the top left, this is, uh, an area of, uh, tendinopathy or interstitial tearing. So that dark area within the tendon, you have a little bit of fluid in that retrocalcaneal bursa, and then you have some prominence of that, the Hagelin, uh, prominent Hagelin deformity. Uh, at the top, right, there's an intratennis calcification as well as associated tendinopathic changes. Uh, in the bottom left, uh, this is a post-surgical patient who is still having persistent pain. Um, and this is what the enthesiophyte looks like. So in the bot, to the right side of that picture. Um, and then you can see the inflammation or post-surgical changes related to the Hagelin bump being trimmed away. Um, and then in the bottom right, you know, this is an intratennis calcification and this is an interesting, uh, area because one of the podiatrists locally, they injected cortisone. You can see erosion in the bone here as well, um, as the, the primary pathology. Next slide. And so, you know, Achilles tendinopathy and Hagelin syndrome, um, you know, these can extend upwards too, you know, so sometimes this can cause a linear split that travels upwards and looks like mid substance, uh, Achilles tendinopathy. You can see communication between the retrocalcaneobursa and Achilles or these delaminating tears. Um, and so all this pathology can overlap and, and, um, next slide. And traditionally the way we manage this is, is again, non-surgical, uh, anti-inflammatories, heel, left shoe modification, shockwave. Um, but 50% of these cases also fail, you know, and now we're looking at what do we do? And traditionally this has been surgery and there's open approaches. Uh, but the downside is that typically patients are mobilized for eight to 12 weeks. Um, and it often takes six months of rehab for them to normalize, uh, their activity, if not more. Uh, there are a number of different complications that have been reported with a surgical approach. Uh, endoscopic approaches, uh, potentially offer a faster recovery. Um, and that allows you to remove the Hagelin protuberance, uh, but it doesn't allow you to address any of the intratendinous pathology. Um, so not every candidate and not every patient is a candidate for the less invasive endoscopic approach. Uh, next slide. So this is, um, we can play this video. This is us performing this Hagelin resection, uh, using the, the Tenex bone device. Uh, this came out in 2019. So we've been using this for about five years and we make a pass through the tendon. This allows us to avoid any of the potential neurovascular complications, uh, that are reported if you come laterally. Um, and we make these slow passes up and down through the tendon. Um, and the device allows you to remove bone. Um, it's designed to do this. And, um, you can see, you know, as we make these passes, instead of that being a rounded, uh, bump that it's rocking into the tendon, every time the ankle dorsal flex, um, what we're doing is we're going to flatten that out and you can already see with two or three passes, you know, you've seen that flat line, uh, instead of that rounded, uh, architecture. Um, usually it takes about five to 10 minutes. That's the incision at the end of the procedure that gets covered with a Steri-Strip. Um, you know, again, minimizing some of the complications of infection, um, associated with, you know, some of the traditional surgical approaches. This will get covered with Tegaderm for about 24 hours because they'll ooze and weep. Um, again, we use a little lidocaine with epinephrine to minimize, um, the bleeding associated with the procedure. Um, and we put the patient in a boot for about two weeks, uh, similar to how we do with, uh, the mid substance procedure. Uh, sometimes if there's a lot of Achilles tendon, associated tendon tearing, you know, this will be coupled with a biologic injection. Uh, sometimes we'll mobilize the patient closer to four weeks. You know, if there's really significant tendon pathology associated with, uh, the, uh, the Haglund protuberance. Uh, next slide. We can go to the next one too. Um, so this is typically what this looks like after the procedure. So on the left, this is before we did the, the debridement and excision of the Haglund. Um, and to the right is, is you can see we, this removes bone and it removes that prominence that was rocking against the tendon. Uh, next slide. This is what it looks like in short axis. You can see we move left to right and there are these little, uh, grooves where we've passed the device. Uh, next slide. And our postoperative protocol, it's very similar. You know, usually it's stair strips to cover the incisions, uh, in the top, right, you can see it's post-op day one. You know, this is where we removed a spur lower down and we removed the Haglund protuberance a little higher up and 10 days in those incisions have healed. Uh, most patients again, get away with Tylenol and ice. Uh, we avoiding anti-inflammatory medications and we use tramadol for breakthrough pain, depending on how much tendon pathology, usually patients in a boot for about two to four weeks. And then we start that rehab protocol. Uh, next slide. And you know, you don't have to remove the very top of this protuberance to give patients relief. What you need to remove is you need to remove the part of the bone that rubs up against the tendon and causes the bursitis and, and, uh, degenerative changes. Next slide. And compared to the surgical, uh, approach in this endoscopic approach, you know, we remove a lot less bone, which again allows for faster recovery. Next slide. There's some debate in terms of how much bone we should remove. There's no clear cut guidelines. Uh, there's limited literature. Uh, this is a small study and an older study looking at 13 patients. Uh, they suggested that if we remove more bond bone, people, patients tend to do, um, better, but, but we haven't, we don't have any clear studies using these less, uh, invasive surgical devices. Next slide. So, uh, you know, in terms of diagnosing these, these can be subtle. Um, and, and again, like we talked about earlier, you know, these radiographic findings don't always correlate with, with symptoms. Um, and so what our practice is we'll remove bone and then we'll actually put the patient dorsiflexion, make sure that there's no bone contacting the tendon and maximum dorsiflexion. And that's kind of our indication, uh, to stop instead of, uh, an arbitrary radiographic, uh, uh, delineation of, of how much bone we should remove. Next slide. And so in general, the normal range for this Fowler's angle, which is what we're measuring here is between 44 and 69 degrees. And so this is a pre-Tenex bone patient that we just looked at earlier and their initial angle was 71 degrees. And just removing 10 degrees gets us in that normal range versus that open surgical approach that we looked at, where now you've over, uh, compensated, you've removed a lot of bone. In some cases, this results in other complications. We have a collegiate runner who had an open approach on one side where they removed a lot of bone similar to this. And she had repetitive stress fractures and stress reactions in her calcaneus. Um, and we did Tenex on our other side and, and faster recovery. And we haven't seen those same complications and she's remained asymptomatic. Uh, next slide. Um, this is, uh, again, you know, preoperative on the right and, and, uh, this Tenex calcaneoplasty, and you can see, you know, up to 1.5 years out, you know, you don't see any recurrence of the bursitis. You know, you see normalization of the tendon, uh, where those hypochloric changes. And we didn't do anything as far as augmenting. This was biologics. You know, some of the bleeding probably from this device, you know, may augment some of the tendon recovery. Uh, similar to how a PRP injection would, uh, next slide. And if we go back to that last one, sorry. Um, you know, this shows, you know, calcaneoplasty with Tenex versus an open calcaneoplasty. And again, you know, you're seeing, you know, normalization of the tendon versus, you know, on the right, you know, there's, there's a, there's a, there's a, there's a normalization of the tendon. And on the right, you know, there's still, you know, abnormality in the tendon. And this, this patient was still symptomatic, uh, even though you removed the bone. And so being able to finish straight or address the tendon pathology as well as remove the bone in the same procedure, you know, may potentially allow these patients, uh, an alternative to the traditional approach. Uh, next slide. Uh, again, these are, uh, more another patient, uh, showing, you know, the adequate removal of bone. This patient actually had an endoscopic, uh, resection before they even saw us. And so when you see that top right post-endoscopic resection x-ray, you can see that they removed that prominence, you know, so when they come in from a, uh, a top-down approach, they can remove the top of the deformity, but they're not removing the part of the Hagelin deformity that's really rubbing against the tendon. And when you see the picture just to the right of that, that's after 10 X, where we were able to come from distal proximal and shave off the part of the bone that's right up against the tendon. Next slide. Uh, like anything, there are complications. Um, you can have reformation of some of these spurs or these calcifications, uh, you know, bleeding, you know, something that you have to address. This is not my patient. This was a colleague's patient. You know, they didn't use lidocaine with epinephrine. This is probably why that's good idea when we're doing these procedures. Um, you know, you can have continued pain, you know, there's still a risk of tendon rupture. Um, so, you know, again, nothing we do is, is risk-free. Uh, next slide. Uh, the 10 X device can also get very hot, you know, if it's used inappropriately or, uh, it, it clogs, uh, which can happen even if you're using it in an appropriate manner. Um, and so you have to be conscious of that. You know, there's different things that you look for, uh, in terms of indication that the device will clog. It doesn't have a sensor that lets you know that it clogs. Um, if you need to get a thermal board, this is our protocol where you breathe the wound or where you work with the wound care clinic, um, and, and you dress them. And they tend to do well with appropriate wound care. Um, next slide. I think the big take home with how we're approaching it now is, you know, there's, there's multiple different reasons that in a social, it could have tended to bother people and, and really to address the underlying pathology instead of addressing everything, which is the typical open approach. And by addressing where the pain is coming from, we can do it in a less invasive way. Next slide. And again, this is showing, you know, an isolated calcification and to do an open approach for this, you know, which mobilized a patient for three months, you know, seems a little bit overkill, especially when we have these, these less invasive, minimally invasive tools at our disposal. Next slide. That's all I got for you guys. Thank you so much, Dr. Cussman. That's an excellent presentation. Um, now we will start a Q and a session. We have about, um, 10 to 12 minutes left. Um, for those that would like to ask a question, please go ahead and turn on your camera. Um, I see Jeremy Roberts, so give it a hand clap, not raising your hand. Um, but anyone who might want to ask a question, um, please go ahead and turn on your camera and your microphone and please ask away. I'll ask the first question. So Dr. Sussman, with regards to your Hagelin's deformity or section with the 10X bone device, I saw that you mentioned that you have your patients just in the boot for two to four weeks and weight bearing is tolerated. Was there any thoughts of having them not weight bearing with the first couple of days following the procedure to protect the tendon and what are your thoughts on that? Usually we're making a single pass for the tendon. So the only trauma to the tendon at that footprint is that single incision through the tendon. If you think about that Mufuli article, where they made five passes up and down with an 11 blade, they had people running within two weeks. So we may not even need to do two weeks in a boot. We haven't had any, you know, ruptures or any significant complications. So we will give patients crutches more for comfort, you know, than worry that they'll rupture the tendon in these cases. Awesome. Thank you. Dr. Kerberg, you know, you spoke extensively about trigger finger releases and Mufuli releases. Are there some mimickers of trigger fingers that can sometimes fool folks when considering this procedure? That's a great question. In fact, I do get a lot of patients that come in with what they believe it was a trigger finger and it's actually a Dupuytren's contracture. And so, you know, this procedure is not for Dupuytren's contracture. There have been some cases of early Dupuytren's contracture that also have trigger finger and we've gone ahead and done the release and they've done very well and haven't had any worsening of the Dupuytren's contracture afterward. But, you know, the telltale is when you're doing your flexion extension and you're feeling, you know, so I'll flexion extension, I'll have my finger just kind of feel it. I want to feel that nodule going under that A1 Mufuli compatible with, you know, trigger finger. If I'm not feeling anything and it's just big, thick cord on the hand, then, you know, it's probably more that Dupuytren's and they'd probably be better off with a collagenase injection or something like that, that would break the scar tissue. Awesome. Thank you. For both of you all, you know, since these are pretty advanced procedures, are there are certain patients that you would just kind of say no to from a potential complication rate such as, you know, someone with diabetes or a smoker or anything like that? Okay. First, David, in our clinic actually has worked the other way. So I've ended up doing procedures that the surgeon doesn't feel comfortable doing for different reasons. Be it they were in, you know, pepperine, you know, blood thinners, or they were had history of CRPS. And so she was just concerned that, you know, there would be a higher risk of doing an open release. And so she sent them to me. And so, I mean, we really haven't had any patients that I've turned away other than Dupuytren's contracture or trigger finger. For the decor veins, likely, I mean, it's going to be, you know, similar. I really haven't turned anyone away. But with the decor veins, I do tend to, you know, just kind of slow down a little bit by jumping to the procedure and maybe offer two injections instead of one. The trigger fingers, it's a one and done. If a cortisone injection doesn't get the nodule to go away, their pain may go away. But if the nodule doesn't go away and it's still locking, it's a matter of time they'll start having pain again and the nodule will get worse. So typically, my protocol for that, they come in, I do a cortisone injection, anti-inflammatory. In some cases, I'll give them a little night splint to wear at night to stretch it. I'll have them do prayer stretch. And if it doesn't significantly improve in the next, you know, two to four weeks, then we'll post them for doing the release. It's such an easy, simple procedure and minimal complication that it's worth it. The corvains will be more selective and will probably offer two to three cortisone shots in the span of a few months. Just kind of monitor them. But also, patients have to warm up a little bit more, I think, in that case. And so, yeah, those are my two cents about that. Thank you. Dr. Sussman. You know, the mid-substance ones, you know, if they failed three to six months of conservative management, you know, there's not a lot of contraindications to that procedure. You know, the insertional pathology, you know, if there's higher grade Achilles tendon tearing, you know, we'll often counsel patients that they have to like they have to augment this with something biologic, you know, to address the tendon pathology. Patients with extensive calcification, which you tend to see with patients with psoriatic arthritis, and it's not really calcification, it's more ossification, you know, those haven't done as well. Ossifications that occupy more than 50% of the insertional tendon, you know, those make me a little more nervous. We've still done some of those cases, but usually we're doing those with surgical backup, you know, so we'll have patients also get a surgical consultation, work with some of our colleagues just in case there's, you know, it doesn't work for them or there's, you know, that concern for rupture. And although that hasn't happened, you know, it's one of those things that we kind of do the work on the front end to make sure that, you know, they have a plan B, you know, if something did happen. But there are not a lot of contraindications, you know, in terms of, you know, who's a candidate or who isn't. You know, this is a surgical procedure, it's coded the same way as the surgeons are coding this. It's just done in a less invasive way. All right. Awesome. Well, I don't think we have any other questions in the audience. If those who may not want to open up the camera, you can put it in the chat, I can ask it. Otherwise, I'll go ahead and wrap things up. I don't see anything. Thank you all for coming. Thank you, Dr. Colbert and Dr. Sussman for providing us with such high level, high yield, excellent topics. And look forward to seeing you guys again on the community. Everyone have a great night. Thank you. Good night.

Dr. Cleo Stafford

ultrasound interventions

sports medicine

Dr. Coburg

ultrasound-guided procedures

trigger finger

De Quervain's releases

Dr. Strussman

percutaneous techniques

Tenex device

orthopedic conditions