Hey, good morning, everyone. Welcome to Percutaneous Ultrasonic Tonotomy, otherwise known as PUT, Indications, Pitfalls and Best Practices. My name is Brian Lim. I'm your session moderator today. I'm a Clinical Associate Professor at the University of Washington, also the Fellowship Director of the PM&R Sports Medicine Program, joined by three wonderful faculty, which I'll introduce here in a second. I have no relevant financial disclosures. Here's our agenda today. We're going to go through some of the boring stuff, the indications and current evidence of Percutaneous Ultrasonic Tonotomy. Then I'm going to hand it over to Dr. Stephanie Peralt, talk about patient selection and pre-procedural considerations. Then we'll talk about procedure mechanics with Dr. Eric Latska, and then we'll wrap things up here with Charles Kenyon doing post-procedure care and rehabilitation. Just a brief review of tendinopathy, when we refer to the term tendinitis, we think of this more inflammatory and acute condition. This is in opposition to tendinosis, which is more of this chronic, degenerative, non-healing condition. What I have up here, I know this pointer works really well here, is a diagram by Jill Cook, who is a researcher out of Australia in tendinopathy. Just briefly going through tendinopathy and tendinosis, she proposes this to our three-stage progression, starting with normal tendon, with increased load, you get to this tendon reactive tendinopathy, and then with continued load, you get to tendon disrepair, and then degenerative tendinopathy. Histologically, what you might see on the slides here would be hypercellularity, loss of the normal architecture of the collagen fibers, and maybe a little bit of neovascularization. As you get on to more degenerative changes, you've got marked hypercellularity, neovascularization, and then loss of that fibular architecture. The key difference between tendinitis versus tendinosis is that in tendinosis, you have basically a lack of inflammatory cells. This is what it might look like on ultrasound. I've got a few pictures of basically hypochoic and thickened tendons with loss of fibular architecture. Up there at the top is a long axis of a patellar tendon, and then a short axis of a patellar tendon here. You may see some areas that are anechoic in nature, consistent with interstitial tearing. Down here on the left is common extensor tendinopathy of the elbow, so hypochoic thickening here, and on the right here is a side-by-side comparison of a symptomatic left plantar fascia compared to a right plantar fascia here. Here the symptomatic one has hypochoic thickening. These are treatments for tendinopathy here. This is just kind of a diagram showing that you can do load modification. We can do bracing orthotics. We can try things like medications, so that might include analgesics, topical, and oral. You could also try nitroglycerin patches. Here on the right, obviously, we love PT, so that includes eccentrics, manual therapy. Then down here at the bottom is basically interventional. Steroid injections, still kind of controversial, right? We're not used to inject steroids around a tendon. You could do a percutaneous needle tenotomy with an 18-gauge or 22-gauge needle, essentially a needle fenestration. You can inject PRP, prolotherapy, and then you can do things like shockwave therapy. This is one of my colleagues, Dr. Eric Chen, doing shockwave therapy here. Then lastly, we have procedures like percutaneous ultrasonic tenotomy. What is percutaneous ultrasonic tenotomy? It's basically a minimally invasive procedure using a device to help debride pathologic tendon or fascia. What is special about this device is it uses ultrasonic energy to oscillate this needle tip right here at a very high speed and frequency. What happens when that occurs is you get this jackhammer effect, so mechanical jackhammer effect on that pathologic tendon. You also get this effect called phacoemulsification effect, which is similar to cataract surgery. Because of that high ultrasonic energy, you essentially are softening the tissue. Now, there's continuous saline irrigation at the same time when this device is activated. The saline comes and it washes away that debrided tendon, and then inside the lumen of this device right here is basically a vacuum. You're basically irrigating and then vacuuming out that pathologic tissue. I like to, when I talk to patients, describe this as like cleaning your carpet. You're kind of washing it out and then vacuuming it back out. This was developed in collaboration with the Mayo Clinic and FDA cleared in 2013. Not to necessarily promote one company or device, but essentially the other brand name for this is Tenex, and the company is Trice Medical. Is this the same as Tenget? No, it's not. Tenget is using pressurized high velocity saline, which acts as more of a cutting water blade. This is also not an ocelot nano from Tendinova, which uses more of the staline steel Francine cutter. So each of these basically helps debride tendinopathy, but they do not use that ultrasonic energy that we have with percutaneous ultrasonic tenotomy. Treatment sites. These are the common treatment sites that you would have for anyone with tendinopathy. So lateral medial epicondyle tendons, rotator cuff tendons, patellar tendons, Achilles tendon, plantar fascia, gluteus medius and minimus tendons, and hamstring tendon, and we'll talk about each of these in detail. So here's kind of the more sort of boring stuff. Hopefully you guys have your coffee already here. Most of the data and studies are from looking at folks with lateral epicondylosis, and I just abbreviate that as CET. So there is a case series by Koh in 2013, basically 20 patients, average about one year of symptoms, had failed non-operative treatment. They had baseline ultrasound showing hypocoic thickening and scarring, and they looked at the VAS and the DASH, which is the disabilities in arm, shoulder, and hand, at three, six, and 12 months, and found that 19 to 20 of these patients had reduced tendon thickness and hypervascularity on ultrasound at six months. Now they did a follow-up study about four years later by Tseng, who looked at the same exact patients, and found that the VAS and DASH improvements were maintained, and none had needed any other treatments in that timeframe of the past four years, and all had maintained reduced tendon thickness and size of the hypocoic area on ultrasound. Small case series by Batista, just about seven patients. These patients had an average of close to about two years of symptoms, and they showed that when they performed percutaneous ultrasound tonotomy, their VAS scores went from 7.9 to 1.1, so a pretty dramatic drop there. Barnes study in 2015, this is Adam Mayo, and the co-author was Jay Smith here. Small case series, about 19 patients, which included both common extensor tendinopathy, but also medial epicondylitis, that six months of conservative treatment, and also ultrasound evidence of tendon thickening. They looked at the VAS, and this other outcome measure called the Mayo Elbow Performance Score, or MEPS, and they looked at six weeks, and they also evaluated this out to 12 months, so about a year. And here, the graphs basically show that the VAS improved from baseline to about six weeks most dramatically, and that improvement carried out to about 12 weeks. Similarly, the MEPS improved most dramatically at about six weeks, and they kind of leveled out at 12 weeks. This study here by Lavalle in 2021 was kind of a mixed retrospective and prospective cohort, and this study had 92 adults that underwent the procedure, including those with common extensor tendinopathy, but they also included folks with medial epicondylitis, Achilles tendinopathy, plantar fasciopathy, suprasthenitis tendinopathy, and essentially, and patellar tendinopathy, who had had these symptoms for about three months. They looked at the VAS and DASH outcome measures, and basically, the average mean VAS scores decreased from 7.3 to 1.37. Now, this study pooled all the different tendinopathies and fasciopathies together, right? So there isn't necessarily a specific breakdown of how the folks did with specifically common extensor tendinopathy of the elbow. This interesting study by Bode in 2019, which is a retrospective cohort, looked actually at PRP versus 10X, and it wasn't randomized because these folks, the study was done after these folks had had their treatment already, and the choice between whether or not they got PRP versus 10X was basically a combination of patient preference, as well as insurance coverage. But they looked at about 62 patients with both common extensor tendinopathy, as well as medial epicondylosis, who had had these symptoms for about three months, and their hypothesis was that the ultrasonic tenotomy would be inferior to PRP. The mean follow-up was about 17 months in the PRP group, 10 months in the ultrasonic tenotomy group here, and both groups actually improved in both their VAS and the DASH scores. So they found no statistical difference between the groups, suggesting essentially that percutaneous ultrasonic tenotomy could be just as good as PRP. Now, you could also do this potentially in post-surgical cases, right? So this was a study by Reed, or more of a case series by Reed, where he looked at two patients who had previously had open surgical release for chronic extensor tendinopathy, and at one year follow-up, they looked at the VAS and DASH scores, and in case one, the VAS improved from six to zero, all right, and then in case two, went from seven to zero. Obviously, these are our case series, but this suggests that you could potentially do this in people who have even had surgery. So from a medial epicondylosis standpoint, there are no standalone studies looking just at medial epicondylosis. Most of those are kind of mixed studies with lateral epicondylosis. We just mentioned the Bowdoin study in 2019, and then the Barnes study also looked at medial epicondylosis just at seven patients here, and with that study in the Barnes group, there wasn't a specific breakdown of how the people with medial epicondylosis did compared to lateral epicondylosis. What about rotator cuff tendinopathy, right? So there's no randomized controlled trials for rotator cuff tendinopathy here, but this small case series by Trivedi in 2024 looked at about 15 patients. Their average age was about 60 years old. They had an MRI and physical exam that confirmed that they had some degree of tendinopathy, partial tears. They excluded folks with full thickness rotator cuff tears, but they didn't describe how long these patients really had had symptoms before they underwent the procedure. At their six-month follow-up, they had 14 patients that they could really evaluate. One patient re-injured their shoulder, was considered a failure, so they didn't include them, but the majority of these patients had improvements in their shoulder pain and disability index by close to about 40 points, and they also interestingly did an MRI post the procedure and found that 11 had similar or, quote, improved MRI findings. They didn't break down who actually had improved findings out of the 11. And then we mentioned the study previously about Levale. In that mixed study, they only looked at one supraspinatus tendon. What about gluteus medius and minimus tendinopathy, right? So Baker in 2019 did a case series just of 29 patients that was confirmed that they had gluteus medius or minimus tendinopathy by MRI. They had tried non-surgical management for about four months, and it wasn't specified what that included, but it included some degree of injections, in quotes. And the follow-up was about three weeks, three months, and then the final follow-up ranged from about 18 to 30 months, and they looked at the VAS as well as the Harris-Hipps score, and you can see the VAS scores basically decreased from 5.86 on average to about 2.82. The Harris-Hipps scores improved as well, most dramatically at about three months. And three of the patients progressed to hip abductor tendon repair, so those considered failure from the procedure. There were no hamstring studies that I could find out there, so while we can do this on hamstrings, I didn't see any studies specifically. What about patellar tendinopathy? So this article by Ellen Trahe in 2013 was mainly a technique article, and it looked at about 16 patients with patellar tendinopathy. They didn't describe the duration of symptoms, but the ideal candidate had to have about six months of symptoms. There were no standard outcome measures reported, so we didn't know how they measured success, but they said 15 of 16 reported some level of improvement, and 10 of 16 returned to prior level of activity. The question is, though, is how long did it take for them to return to their level of activity? That wasn't described, and we also don't know to what level. Was it just to ADLs, or was it to sport? So we don't have that idea. Now this is another post-surgical case. This is by Nanos in 2015, and the co-author was Gerald Malanga on this. He was a 21-year-old college basketball player with proximal patellar tendinopathy, and they had done a ton of treatment. This included eccentrics, PT, bracing. They had reportedly undergone four ultrasound percutaneous needle tenotomies, so just like needle fenestration. They also went to paratenon hydrodissection, as well as a PRP injection, and they had also undergone arthroscopic right patellar tendon soft tissue debridement 11 months prior to having a percutaneous ultrasonic tenotomy. The intervention was the percutaneous ultrasonic tenotomy, but they also injected PRP in this case report here. This patient was able to return to sport after about five months, and about seven months after the procedure, they had no limitations whatsoever. The questions and confounders, they injected PRP with the percutaneous ultrasonic tenotomy, so was the PRP different? Did that have an effect? They also described a rehab protocol that followed after the procedure, so we don't know if maybe this rehab protocol was different than what the patient had had previously. What about Achilles insertional tendinopathy here? This study by Schimenti in 2019 was a retrospective case series. It looked at about 34 patients. They had an average of about one and a half years of pain prior to the treatment, and what was interesting is that they debrided not only the tendon and the paratenon, but if they saw a retrocalcaneal bursitis, they would go after that as well, and they would also go after calcifications, and they described primarily a distal to proximal approach. Their follow-up, they had mentioned a short-term follow-up and a long-term follow-up with these kind of average durations, and their outcome measure was the pain level with the AOFAS, which is the American Orthopedic Foot and Ankle Score, or SOCIETY, and they also looked at just overall patient satisfaction. The results were that the percentage of patients with moderate to daily pain decreased to 55% to 6%, and 70% of the patients were satisfied overall with their procedure. There's one superficial skin infection. This study of insertional tendinopathy for Achilles was done by Freed in 2019. This is a group of podiatrists, and the study overall wasn't really well done, but I just mentioned it here. It's 25 patients. They had failed an average of about 5.28 conservative treatments. They don't describe the approach, so was it long axis, short axis, distal to proximal, and then their outcome measures included the foot function index. They didn't take any foot function index scores prior to the procedure, and when they reported a percentage of improvement, they just mentioned this 8.53% of all patients, so really unclear what their outcome measure really meant and to take anything from this. For Achilles tendinopathy mid-portion specifically, so we talked about the insertional part, but for the mid-portion, there really isn't any dedicated case series or studies for the mid-portion, but there was an article here by Fick in 2021 who looked at a retrospective case series, performed 289 procedures, and this included 17 mid-portion Achilles tendons, average age of about 60 years old, and had symptoms for about three months. They did a distal to proximal approach, put people in a walking boot for one to two weeks, and then had them rest for about two weeks, and their outcome measures, they also used the AOFAS, and they also looked at patient satisfaction, and the majority of these cases, the pain decreased from a level AOFAS of two, which is moderate and daily pain, to a level of one in the short term. What about plantar fascia? So, RASDEN in 2018 looked at about 100 patients, so this is one of the studies that has a decent amount of folks here, who had four months of pain and at failure of at least one treatment. They don't really describe the treatments that they've had before, but failure of one treatment. And they looked at the foot ankle disability index pre-procedure and out to six months. And here you can see that basically the improvements were at least from a graph standpoint, pretty significant from baseline all the way out to about six months here in improvement. They noted no complications, so specifically no ruptures or infections. And at six months, 98% of patients would recommend this to a friend. All right, and then continuing on, we've got the fixed study in 2021, which we had previously discussed. 80 patients had plantar fascia within that study. And the majority of these folks showed some improvement. And then lastly here, we have a CRU study in 2024, which is actually a prospective cohort study. 67 patients who had three months of pain and they'd fail at least six weeks of other treatments. And they did a baseline ultrasound that was consistent with fasciopathy, greater than four millimeters of thickness. Use the TX device, it's a little bit longer here, and we'll talk about that in a little bit here. And they did two weeks of low impact exercises and found that the average VAS improved from 6.57 baseline to 0.8, so at 12 weeks. So pretty significant there. And 95% of patients were satisfied at about one year. So the key takeaways from all this kind of evidence is that most studies treated patients would fail non-operative treatment for at least three months. Most of these studies are low-level case series. We have an absence of randomized controlled trials. And then the most studies were done with common extensor tendinopathy of the elbow. And it's a treatment that's even possible after you've had surgery. So folks who have failed surgery could still be a candidate. And it's a relatively safe procedure with low complication rates. All right, that's all I got. Thanks, everyone. I'm gonna hand it off to Stephanie Perrault. Thank you. Hello everyone. My name is Stephanie Peral and I am going to be talking about patient selection for the 10-X procedure as well as pre-procedural considerations. I have no disclosures. This is the outline for my talk today. So starting with the clinical history, the ideal patient for 10-X is typically someone who has been experiencing symptoms of tendinopathy for greater than three months. The reason for this is somewhat twofold. One, you want to make sure that your patient has tried and failed all conservative treatments. And two, most of the studies, as Brian just mentioned in his talk, that have had successful outcomes have included patients who have been experiencing symptoms for at least three months. Now some of these conservative treatment options that your patients may have tried, rice obviously, Physical therapy, which really is that cornerstone of treatment for tendinopathy, we know that exercise has an effect on the tendon to not only change it mechanically, but to improve pain. However, this can take a long time, up to 12 weeks. And as most of us know, not all of our patients are the most compliant with going to PT and their home exercise program. So sometimes physical therapy fails. Bracing is also an option. However, there are not great braces for all tendinopathies. There is a counterforce strap, for instance, for the common extensor tendinopathy, but there really is not one for, say, gluteal tendinopathy or hamstring tendinopathy. There are various medications as well that you may recommend. Both oral and topical NSAIDs can help with pain, though NSAIDs may have a deleterious effect on the healing of tendon, so you may want to use these sparingly. Nitroglycerin is also a medication that has been shown to not only decrease pain related to tendinopathy, but also change the mechanical properties of a tendon. So this can be a very effective treatment option. However, there is a slightly higher side effect profile, in that a significant portion of patients may experience a headache and therefore may not tolerate the topical nitroglycerin. Iontophoresis is another method to deliver medication to tendons. Typically that would either be an NSAID or a topical corticosteroid. Studies looking at this, however, are limited to the body region, primarily the Achilles tendon. A patient may come to you who has also tried some other interventions prior to considering Tenex. This would include things like injections, with the two things being injected are steroids as well as platelet-rich plasma. However, we know that steroids are tenotoxic, meaning they have a negative effect on tendon cells, tendons, in that they reduce cell viability, cell proliferation, as well as collagen synthesis. All of this leads to reduced mechanical properties of the tendon, which thus increases the risk of tendon rupture. Therefore in a lot of musculoskeletal and sports medicine practices, there has been a large trend or move away from doing any injections into or around tendons with steroids. Platelet-rich plasma is an excellent option for injections for a tendinopathy. There have been numerous studies looking at PRP for tendons throughout the body, showing that they have a better effect and longer duration of improvement compared to steroids. However, the downside really of PRP is that it is not FDA approved, and so it is an out-of-pocket expense for the patient. The other part of the clinical history or workup that you would want to consider before 10X would be documentation of the tendinosis on some form of imaging. Now this could either be done on ultrasound or MRI. Since the 10X is done under ultrasound guidance, I personally like to look at the tendon with ultrasound first and characterize the tendon region that I am going to be treating. Moving on now to patient and device factors to consider prior to 10X. So the 10X comes with three micro-tip selections. And as Brian mentioned, these 10X micro-tips use optimized ultrasonic energy that precisely cuts out diseased tendon tissue, which is biomechanically different from healthy tissue. It then has this continuous saline irrigation, which not only cools the micro-tip, but it also helps to emulsify and then effectively remove that target tissue. So the three micro-tip offerings are the 10X1, 2, and 10X bone tip. The main difference between these is their length, the 10X1 being the shortest, the 10X2 tip is the longest at 1.7 inches, and the 10X bone tip is kind of an intermediate size. They also vary somewhat in the gauge of the actual tendon tip and then the sheath around them. So this is an important factor to consider, which micro-tip you are going to select to use based on the location of the tendon. Some tendons may be difficult to reach because they are covered by a lot of subcutaneous tissue, such as the gluteal region or the hamstring region. So if a patient has more subcutaneous tissue that could not be reached by a 10X micro-tip, then they obviously would not be a good candidate to select for this procedure. You may also pick the micro-tip based off of the tendon size that you're treating. So if it's a smaller tendon that's closer to neurovascular structures, you may opt for the 10X1 or 10X2 tip over the 10X bone tip. Another thing to consider is what are the other characteristics present in the tendinopathy that you are going to be treating? Is there emphysopathy present, calcification, is there a bone spur, and what about if there is a tear? So the various micro-tips operate at a different frequency. The 10X1 tip, which was the first iteration that they came out with, operates at the lowest frequency. The 10X2 is an intermediate frequency, and the 10X bone, as you can see, has the highest frequency. So if there is emphysopathy or calcification present within the tendon, you will likely want to select at least the 10X2 or possibly even the 10X bone tip so that you can also effectively treat that calcification in addition to the tendinopathy. If there is a larger bone spur present, such as a Hagelin deformity, then you may select to use the 10X bone tip, which operates at the highest frequency and better or more effectively be able to treat that bone spur. Lastly, if there is a tear, there really isn't any literature to say what the outcomes are if a large tear is present. If it is a high-grade tear, maybe you would opt for trying something like platelet-rich plasma over 10X because there is a potential possibility that doing 10X could further propagate that tear. If it's a smaller tear or interstitial tear, maybe you would then opt for the 10X1 or 10X2 tips, which operate at a lower frequency and thus may be less likely to further propagate that tear. Another thing to consider is what medications are your patients taking? The main ones that would be of concern prior to the 10X procedure are anti-inflammatories or anticoagulation medication. We know that anti-inflammatories inhibit platelet aggregation. And in a sense, the 10X procedure causes that tendon to bleed, which brings in platelets and aids in that overall healing process of the tendinopathy. Thus, if possible, it is generally recommended to have patients hold their anti-inflammatories or aspirin for at least one to two weeks prior to the procedure, as well as one to two weeks after the procedure. When it comes to anticoagulation, I was unable to find, again, any specific studies looking at holding anticoagulation and the risk benefit of that on the outcomes. My recommendation would be to clinically assess each individual patient. There are numerous scores out there that you can use to evaluate the patient's bleeding risk. The 10X procedure is done through just a small skin stab incision with an 11-blade scalpel. So generally bleeding isn't a huge risk, but it is possible. And lastly, it would never be wrong to reach out to the patient's either primary care physician or their cardiologist to get clearance to hold any of their anticoagulation prior to the procedure. Patients may also come to you wanting this 10X procedure, but having had a prior corticosteroid injection either into or near the tendon. So it's important to think about what would the optimal timing be to recommend the 10X procedure if they have had a corticosteroid injection. We know that corticosteroids have a varying duration from about 6 to 21 days. I wasn't able to find any specific studies looking at corticosteroid injections and outcomes as it relates to 10X. However, if we look to the orthopedic surgery literature, we know that corticosteroid injections within three months of a joint replacement and one month of an arthroscopic surgery increase the risk of infection postoperatively. So again, there's a lack of studies of what to do when it comes to 10X. However, if we kind of go by the guidelines in orthopedics, we would recommend a minimum of one month since 10X is a minimally invasive procedure, though it wouldn't also be wrong to wait three months on the more conservative side. Other considerations to talk to with your patient prior to 10X is their alcohol consumption and other substance use. Some studies suggest that there is a similar effect of alcohol on platelets as aspirin. Thus, if your patients can avoid consuming that prior to the procedure, that would be recommended. Same with tobacco and nicotine. They can increase the risk of thrombosis as well as change that morphology of platelets. So if they can discontinue the use of those prior to the procedure, that would be recommended. If a patient is immunocompromised, this still would generally be a safe procedure. Just make sure you have that conversation of a slightly increased risk of infection. If a patient has recent antibiotic use, generally safe, again, to perform it after they have completed their antibiotics, but you wouldn't want to do a minimally invasive procedure on someone who is still finishing a course of antibiotics for an infection. And lastly, low platelet state and if they've had a prior tendon repair surgery are just other considerations to think about. As Brian mentioned, there are a few studies that have looked at 10X still being effective after surgery. However, if there's been a tendon repair, say an Achilles tendon rupture, it'd just be important to make sure you would be able to identify where any of those sutures are that have previously been done in that surgery as you would want to avoid hitting those with the 10X tip. Insurance is kind of the last patient factor to consider. Again, this is an FDA approved procedure. However, it does still require insurance authorization. Even though it's covered by insurance, it's always important to counsel to your patients that this procedure is not free. There will likely be a portion of the procedure that they will have to pay for. And then worker's comp is another thing that has come up from time to time. In my personal experience, it has been very difficult to get worker's comp to approve and pay for this, but maybe some people have been more successful than me with this. Briefly, I'm just going to touch on some of the procedure logistics. So prior to the procedure, you will definitely want to counsel your patient on some risks that are possible. The main risks of 10X would be things like bleeding, bruising, infection, soft tissue injury. You may have a temporary increase in pain after the 10X procedure, though it's been my experience that most patients who have either had 10X and or PRP say that 10X is much less painful than PRP. And it's also possible that patients continue to experience symptoms after 10X. A few less common risks of this procedure would be tendon rupture, neurovascular compromise, skin burn because that microtip does heat up. So a protip is you can put the saline that irrigates that tip in the refrigerator to help keep that microtip cool. And then lastly, it is possible that that microtip could fracture off and get stuck or dislodged into the tendon that you're actually treating. However, even though there are risks, as with any procedure, overall the message that you should be telling to your patients is that 10X is a generally safe procedure. There is a retrospective study looking at 289 10X procedures and they found a very low complication rate of 0.7%. The two complications that were found were a wound infection and one of wound hypersensitivity. 10X can be performed in various locations. It is an outpatient procedure. There's no general anesthetic or anything, so patients will go home that same day. It is a sterile procedure, so you'll have a sterile setup. There are generally two locations where this procedure can be performed, either in the clinic or an office-based setting or in an ambulatory surgery center. This generally is going to be dictated by your own individual practice or institution for which you're working for. Where I practice at Overlake in Bellevue, Washington, we do it at the surgery center. Some of the other presenters I know do it in their office, so you would just have to work with your individual institution as far as where the procedure would be performed. As I mentioned, it's a sterile procedure, so sterile gloves. Some people wear surgical gowns, some don't. On the sterile tray, you'll likely want the items pictured here. A lot of these do come in the 10X box or kit that's provided, though you may want to supplement with some of your own items if you prefer them better, such as the probe cover and always, you know, extra sterile towels and that sort of thing. This is what the 10X setup looks like. So you have sterile saline with a pressure cuff, a foot pedal to operate the micro tip, the 10X micro tip, and then lastly the 10X console. So this is just looking at multiple studies of the use of 10X at various tendons throughout the body and as you can see, there is overall a very high percentage of success rate with patients experiencing improved pain and function following the 10X procedure. So in summary, you will want to select patients for 10X who have failed three months of conservative management and whose target tissue is reachable by one of the 10X micro tips. Recommend that your patients hold NSAIDs at least one week prior to as well as one to two weeks after the procedure. The procedure location will likely be determined by your own individual practice and that this is a highly effective and safe treatment option for your patients with chronic tendinopathy. And with that, I will pass it on to Eric. Hi everybody, I'll be talking about the procedural considerations for Tenex or percutaneous ultrasonic sonotomy. The main things we're going to focus on are patient positioning, use of anesthetics, procedural technique and then the risks and Stephanie did a great job talking about some of those already. But we'll focus on some of those particular risks and how they pertain to the specific tendons that we treat most commonly. So first thing to consider when it comes to the procedure is the positioning and first thing you should be focusing on is how can you avoid local neurovasculature. So this applies primarily to the common flexor tendon, when you're thinking about the ulnar nerve, hamstring, when you're thinking about the sciatic nerve, patellar tendon, there are some branches of the saphenous nerve that you may want to not approach from a lateral or sorry from a medial aspect and the Achilles with the sural nerve, plantar fascia with the medial calcaneal branches. So there are nerves to consider. Second is what is the depth of the tendon that we're looking at and where is the target tendinopathy? And is there a way to avoid the healthy tendon fibers and access those tendinopathic fibers without passing through the healthy tendon? Will you need more than one entry point? Most likely, sometimes with the glute medius and sometimes with the Achilles you will but for most tendons you can probably pick an entry point that can allow you to access all of the tendinopathic tissue. And then lastly, ergonomics. This is a procedure that can take a while especially if there's a bony debridement that you're doing. And so setting yourself up for success, trying to keep the procedure all in one plane. So here I just have an example of that on a glute medius where, you know, I'm behind the patient. I can access the tendon. I can see the probe, the device, and the image all in one line. Next is anesthesia. So first, pretty much for any tendon I'm doing, I'm doing LIDO with epi just to minimize local bleeding from that 11 blade incision. And then I'm using usually a 1 to 1 ratio of lidocaine and ropivacaine, 0.5. You can go higher than that ratio on the lidocaine side but I wouldn't go higher on the ropivacaine because then you'll start to, you know, have poor tolerance during the procedure. Other things you can do, you know, you can consider nerve blocks when they're appropriate. Pretty much the only nerve block I'm doing is a sometimes suprascapular nerve block but that's pretty rare. That's more for PRP injections. Or a tibial nerve block if I'm doing a Haglund's debridement. So if you're using the, some tips as Stephanie already alluded to is knowing the depth of your target. So one way you can do that is during the anesthetic, you know, use a 2 inch needle if you're planning to use a TX2 device. And if you're doing your anesthetic with a 2 inch needle, you'll know if you can reach your target. And if you're using a TX1, use a 1 inch needle. If you find out that you can't get there with the 1 inch needle, you might need to switch to a TX2 device. Technique wise, there's a few things to consider. Just a little bit about the cutting power and aspiration. I'm pretty much, and most people will use the moderate settings to start, moderate and moderate. The only reason to increase that cutting power and aspiration if you have some stubborn calcifications or enthesophytes that aren't coming out on that lower power. Now you can also turn off the cutting completely if your goal is to just aspirate, say after you've done a calcific tenotomy and you're worried about calcific particles in the subacromial bursa. Or if you're treating somebody who has CERVA and you're really trying to wash out all of the, all of that vaccine from their bursa. Those are two times that I often turn off the cutting completely. The scalpel stab incision, you should make that longitudinally with the tendon fibers or the muscle fibers that you're going to be passing through. That's one area where you could definitely, like if you went into Achilles in short axis or not longitudinally, you could do some damage before you even begin the procedure. The CPT code language for this, these tenotomies does require an incision. So we always document that an 11 blade is used to make an incision. I know there's some docs out there using just a large, larger gauge needle to kind of create a pathway. But if you just do that and you don't make an incision, you know, insurance could come back and say, hey, you didn't use a blade, you didn't make an incision. We're not going to, we want our money back. And then typically I don't find a need to use a large gauge needle to kind of create a tract for my device. Some people like to do that, but the device can get through pretty much any tissue pretty easily. And if you're just stuck on a fascia layer, just turn on the cutting power, step on your pedal and it'll go right through. This is probably the most debated thing that comes up and I'm sure nobody in here agrees. Should you be going in long axis or short axis to the tendon fibers? And this depends on where you trained, who you trained with, what tendon you're doing, where the location of pathology is. And just to kind of highlight the lack of agreement, you know, I trained under Troy Henning and Adam Portchou. So both of them trained at Mayo Clinic and they learned this from Jay Smith. Madera Call also trained at Mayo Clinic under Jay Smith. So these three people all trained from the same person doing Tenex with the guy who invented it and they do their procedures in different orientations. At my practice, Dr. Sussman is really, you know, focuses on going in long axis based on this one paper by Sanchez, which did show some horizontal tearing of the Achilles tendon after this was a surgical paper. And so I think when I can go in long axis, I will. But if it's going to involve me going through a lot of healthy tissue to get there, then maybe not. And I think a lot of people think that going in long axis, if you think of the fibers like the glute medius, if it's at a depth of, you know, two or three centimeters, by the time you get there in long, short axis, you're still, these fibers, just because you're going at it from above and not from behind, you're still going in through the fibers at the same angle. It's not a true long axis. It's not a true short axis. So I don't think that matters as much and there's definitely no paper showing that one way other than the Sanchez paper showing that this leads to any negative outcome. So I don't have a clear answer for that. I think when you can do long axis, do it. If there's a need to do short axis, it's appropriate. And for the first six years of my career, I did mostly short axis for most tendons and didn't have any negative effects. So using the device itself, you want to hold it like a pen so that you have that finger dexterity to make smaller motions. It does require some strength. So if you're doing a lot of these cases in a day, you might get, you know, some fatigue. We usually do on our 10X days like 10 to 12 cases in a day. And by the end of the day, my hand is kind of getting sore and cramping. So there are two different styles that I've seen of people and how they hold their probe. One is, you know, most people are always holding it like a pen, but some are just doing this repetitive kind of tapping back and forth technique. And that's what I see most people do. And then there's a few that do this kind of slower kind of scooping technique back and forth. Those are both fine. The one you want to avoid is just window washing. You don't want to go back and forth like this. You know, that's going to put pressure on the sides of the device, and especially with the TX2, you know, that pressure is going to cause it to break. And that's how your needle tip breaks off, and then you have to go in there, you know, fetching it out. Hopefully it's not too deep. When reading a bone, you want to take off, and this is not written about, I think, anywhere, but it's probably the most important pearl of the day. You want to take off one layer at a time. So you don't want to just go straight into the middle of the bone you're trying to debride, and that goes for large calcific deposits too. You want to go to the most superficial layer of that bone with your bevel pointed up and just shave it right off across the top. And then you can continue to do that and get deeper and deeper. That'll make it less likely that you core the bone and get a large chunk stuck in your needle tip. And we'll talk about that more with the Achilles. The foot pedal, you know, once you get to your target tissue, that's when you want to activate the device. If you can avoid activating it prior, that's probably better. When the device beeps, it gives you these three beeps. That tells you to, you know, take your foot off the pedal and let it clear, because it's sensing, you know, debrided tissue in the device that needs to clear. The cutting time depends on what study you look at and who's training you. Orthopedic surgical literature, a lot of their cases are showing cutting times of less than a minute, even just 20 to 30 seconds, which doesn't seem like enough. Most of the cases in the physiatry literature are between two and four minutes. And that gets higher if you're doing a bone debridement. Stephanie touched on some of these risks, so I won't belabor them. But focusing on the Hall study, which is one of the most recent and the largest, they looked at 655 procedures and showed an overall complication rate of 1.3%. So like she said, it's very safe. Some of the risks, or some of the complications, were a little unexpected. Four nerve injuries, two DVTs, and the DVTs are mostly with Achilles cases, because you're putting patients in a boot afterwards. So I do have patients take at least, you know, full-dose aspirin after the Achilles. They should be on something. If you want to put them on Blovinox or, you know, Afixaban, you could do that too. There is a very high rate of DVTs after surgical Achilles repairs. It's about 50%. So the fact that you're getting some DVTs with this debridement and a boot afterwards is not surprising. Otherwise, adhesive capsulitis, and Charlie might touch on this, you don't want to put people in a sling for too long, if at all. You want them doing early range of motion to avoid that potential risk. So for the rotator cuff, there's two different positions you could do this in. You could do it supine with the palm up, arm externally rotated positions on the symptomatic side, taking an angle from lateral to medial or from distal to proximal. The other way you could do it is sidelying in a modified crass position, if you need to expose more of that supraspinatus tendon. From a, like I said, the approach can be short axis, lateral to medial, or long axis distal to proximal. And then if you're performing a calcific tenotomy, you know, you can consider a post-procedure subacromial corticosteroid injection. Some people get flares from that debridement afterwards. Or you can just wash it out, you know, as I mentioned, turn the cutting device off and just wash out the bursa. This is, let's see if the video works. So that's a calcification. You can tell it's not fully calcified. There is a lot of posterior acoustic shadowing, but the way that the, you know, it almost moves and bends, it's not a fully solid calcification. Oftentimes, after you remove that calcification though, you'll see a tear because you've just hollowed out this area. Calcification on extensor tendons, again, two different positions. One can just be them supine, hand at the hip. The one I prefer, if you're, say if you're doing the left arm, hugging a pillow across the body, standing on the contralateral side, coming from across, so that that way you're in line with the tendon and you've got the ultrasound right in front of you. This is one that you can pretty much do distal to proximal, always in long axis with the fibers. Your main thing to worry about is the radial collateral ligament, you know, and that will be forming about the, from a third down, this portion of the tendon is likely radial collateral ligament. And if you can't tell that on your ultrasound device, hydrodissect the area, put some anesthetic in there. And so you can get a better sense for how deep you don't want to go with the 10X. Common flexor tendon. So this one, patient side-lying on their symptomatic side, arm extended off the table, and depending on your handedness, right or left, you can be above the arm or below so that you can just be, you know, going from, again, long axis to proximal. The thing about this is you really want to pay attention to that ulnar nerve. So I'll always do a full medial, like a diagnostic ultrasound before this, including looking at the ulnar nerve. The one thing you want to make sure you look at is that ulnar nerve in the groove in both full extension and full flexion, because if they happen to be, you know, one of the people that have asymptomatic ulnar subluxation, you don't want to find that out once you stick the 10X in to their nerve. So make sure they don't sublux, and if they do sublux, you keep them in more extension. Glute medius and minimus, three facets. So if you have medius and minimus tendinopathy, you're probably not going to be able to get to all of those facets with one approach. So most of the time, I'm taking two entry points, one a little more anterior to get the anterior and like the lateral facet, and then a separate one to get the posterior facet. You can do this from long axis or short axis, and like I said before, use that two-inch needle to know if you're going to get there. Injecting origin, there's a couple different ways to do this. I think the easiest one to conceptualize is going in on a patient who's prone, just from lateral to medial. But the safer one to do is from this position with them side-lying and the hip flexed. It increases the distance between the ischium and the sciatic nerve. And the more injectate you do, the more likely you'll have a sciatic nerve block. So, you know, if you're doing the right side and they're driving home, make sure they're not driving home if you're doing the right side. And if you're doing the left side, you know, make sure they know they might need crutches on the way out. And oftentimes, we're having patients have crutches either way for these hamstrings. Patellar tendons, this is one that does work well to go in short axis because a lot of times those superficial fibers are just fine and you may not want to pass through them. Patient supine, knees bent to put some tension on that tendon. You can go long axis though, especially if the tendinopathy is a little bit more diffuse. That short axis approach does allow one extra bonus though. You can do tendon scraping with the device afterwards and I'll show a video of tendon scraping at the Achilles later. So this is the Achilles tendon mid-substance. Patient supine, foot's off the table. Sorry, patient's prone, that's an error. Patient's prone, foot's off the table. You want it off the table a little bit so you can passively dorsiflex and see if any tears open up. Physician should be seated at the foot of the table, ultrasound on the ipsilateral side. This is one that I'm pretty much going in long axis all the time. It may require, it often requires two entry points because that mid-substance tendinopathy can be, you know, over a distance of five to six centimeters sometimes. And then your main caution is the serral nerve. So make sure you know where that is before you enter. And if you go in a short axis approach, let's see if any of these videos work. There we go. So this is, you know, the long axis approach for mid-substance, the bottom video's going too. The bottom video's showing tendon scraping afterwards. If you use a short axis approach, and I have the middle two videos, this is a short axis approach, 10X, and then we'll skip the last one. And then lastly, the Achilles tendon insertion. So most of these are going to involve some form of enthesopathy or a Haglund's. Again, same position though, foot off the table, patient prone, not supine. Same orientation, long axis, distal to proximal, especially if you're doing the Haglund's, you want to do it long axis, distal to proximal. The main thing here though to think about is the burn injury. So there is one reported case of a burn injury using the TX bone, and they theorized that it was because of decreased saline flow, which led to increased heat, or that the needle and sheath came into contact with each other. Now we've had a burn injury in our clinic, and there's a lot of good ways, I mean, once you know how this happens, I think it's easy to avoid. So as I mentioned before, don't stick the needle tip directly into the bone like you're seeing here in this, this is the same paper reporting this burn injury. So they're going, you know, right into the middle of that bone, start at the top and just shave it down layer by layer. So start there, then there, and then there. Now if the needle does clog, you're going to hear a change in the pitch of that needle. It's going to go from a lower pitch to a higher pitch. So knowing that you haven't turned the cutting power up and the pitch is now higher, that's your first clue. The second clue is the actual haziness of the bulb here. So if it clogs, you're going to start to get this hazy, yeah, a hazy color here as opposed to a clear. You're not going to be getting any irrigation going through that anymore. So pay attention to the bulb. And then the other thing you can do is you can take the device out and see if it's heating up too much. Interfascia, again, patient for this one, sideline on the symptomatic side, so you can, I usually take a medial approach. Just make sure you map out your medial calcaneal nerve branches first. Usually I'm going in short axis, and I think that's what Ryan Cruz's paper showed, even though he trained with Madera, who does this in long axis. So consider a tibial nerve block for these patients. Sometimes it can be a little hard to numb them up fully, especially if they have enthesophytes associated with this. And that's all. All right, I'll take us home then. So I'm Charlie Kenyon. I'm currently at the University of Washington. I'll be talking more on the back end, best practices in post-procedural care and rehabilitation. We are in the process of putting this into a formal publication, so we did kind of try to go through things systematically. The nice thing when you're following everybody up and there's only 20 some odd papers on the subject is that, you know, we can kind of review some of this stuff pretty quickly. All right, also no disclosures. So about four years ago now, Townsend and this group of people have passed through the NYPE, Columbia Cornell Fellowship, put out this paper on post-procedural protocols for PRP and tendinopathies. So we had that as a framework and then wanted to translate that into seeing how people in the literature were taking on, in these ultrasonic tenonomy cases, whether those reports were similar or different. So in this PRP paper, they ultimately looked at 84 studies meeting their inclusion criteria. Only 12% of those mentioned any weight-bearing protocols, 18 talking about orthoses, but that was up to 53% in the Achilles. Stretching commonly implemented within first two to seven days, and it was only about half of the papers that explicitly stated what their stretching protocols were. Similarly, about half the papers mentioned some sort of strengthening in two to three weeks. And then return to play was only objectively reported in about 42% of those PRP papers. Again, that timeline mostly being around four to six weeks. 20% reported NSAID restriction pre-procedure, like we've mentioned, and then a larger number mentioned 56% restricting NSAIDs post-procedure. So in our selection criteria, we're talking about adult human studies. They're undergoing ultrasound-guided vacuum-assisted tenonomy, so we did include any studies that had a TENGET device in this review. And these are, again, for the treatment of chronic tendinopathies or pasteopathies in either upper or lower extremity. Study designs. Basically, we wanted to see any original studies, so we didn't look at any reviews, just the trials, any cohort studies, case control studies, and case series. As we've seen, there aren't really any robust trials, so these are mostly case control or mostly cohort and case series type studies that we're looking at. In our initial search, we got down to 42 studies for a full-text review and only 23 studies that met our criteria. Some of the papers that have been mentioned already, while they look like they were well done, were more conference abstracts, so some papers that Dr. Lim mentioned may or may not be in this dataset. So of those, 21 were original protocols. We talked about the series from 20 patients from Singapore that had a one-year, three-year, and seven-year follow-up. So when we went through that, included that just as the 21 original protocols. Two cases, two papers looking at calcific rotator cuff tendinopathy, three Achilles studies, two looking at lateral hip, one being gluteal tendinopathy, one that was targeted more towards the IT band, two plantar fascia, and then two that were mixed between upper and lower extremity indications. So there's 17 of those that were case series, 15 original protocols, like we said, five cohort studies, average about 40 participants of those that were either case series or had a specific tenotomy arm, excuse me. Average age ranged from 22 to 67, average around 50, which I think is most people's experience of the demographic that tend to come through clinic. Pre-procedurally, like Stephanie mentioned, that the criteria in most of these studies were at least three months of persisting symptoms, multiple failed conservative measures, but some did include people who had been experiencing symptoms for well over three years. We talked a little bit about activation times. So most of the study is looking at the lateral elbow. Activation there was anywhere between 30 seconds to about three minutes. The study is looking at other areas, calcifectomy of the shoulder, insertion of Achilles tendon. Those got up to three plus minutes, the longest documented case was 19 minutes, 12 seconds. Looking at the commercial information from the bone device, the recommendation is to not be into bony tissue for more than 10 minutes and 15 minutes of total tissue. So I think largely we tend to see less calcific issues at the elbow, so I think that's maybe one reason why some of those lower extremities have longer cutting times. And also just want to highlight that largely these studies are looking at the TX1 device, which I think most peers tend not to use that just because of the shorter tip now. So there's a few who looked at TX2, only one explicitly talked about the bone, and at the elbow there was one Tangent study included as well. Pre-procedurally, this is only, NSAID restriction was only mentioned in two of the papers, anywhere from one to two weeks restricting pre-procedure. Post-procedurally, this was mentioned explicitly in seven of 21 protocols. No restriction in three of those, and then four that restricted NSAIDs explicitly afterwards. Three of those actually restrict that to six weeks, and then one study restricted anywhere from 10 to 14 days after the procedure. As we mentioned, one huge benefit of this procedure is that you're doing it under local anesthesia for the most part. Some people, depending on their setting, may use IV sedation at times. There were a few papers that didn't explicitly mention it, and the two papers that utilized a nerve block of what we went through were both at the plantar fascia with the tibial nerve block. Post-procedurally, as was widely variable, anywhere from over-the-counter medications. We mentioned there was one study of Cussive Tenopi that did do a cepachromial steroid injection afterwards. A couple studies that prescribed some tramadol afterwards. Clinically, for me, I end up doing most of these procedures on Fridays. So mostly because of that, and I just don't want somebody to be in a pain crisis and can't get a hold of me. I'll tend to prescribe a little bit of tramadol just so they have it on hand and have access just because I don't want them having to wait until Monday for us to get their symptoms back under control, but most people tend not to need it. Cryotherapy and ice. This was explicitly mentioned in seven studies. It was allowed or encouraged in six of those protocols. There was one protocol that recommended avoiding it for six weeks after the procedure. I included this. We touched on this as well. This is one of... a publicly available document from Ohio State. I just liked how they highlighted the tobacco and nicotine restriction. So I think one thing that we don't do commonly enough is, especially if we're getting into our interventional mindset, is really stepping back and trying to think about all the concomitant factors that might be driving these tendinopathies. So I think in the more education you can do at all times, again, about treatment alternatives, that metabolic factors, alcohol, tobacco influences, whether they have fluoroquinolone history or other medication side effects might be playing into this, I think are important things to consider. We looked at those barn studies. Just a good reminder in their protocol, in their after-visit summary, they're giving explicit instructions about who and when to call about any infection concerns, redness, bleeding, warmth. Post-procedurally, most commonly people are using some steri-strips, Tegaderm, some sort of gauze or non-adherent dressing, plus or minus some glue, but there was one paper that did use sutures. So more and more I'm leaning towards putting some compression wrap on folks. This is explicitly mentioned in eight of the protocols, and they went anywhere from two days to two weeks of having some compression on the area post-procedurally. Here's just a graphic for those of you who have not done this, what that looks like. So on the right is a picture of that stab incision. So again, it's an 11 blade, less than one centimeter wound. On the right is what it looks like when you have the steri-strips, gauze, and some Tegaderm over that. In terms of weight-bearing progressions, initial post-procedural activity restrictions, again, the nine original elbow protocols, kind of some common things that came out is considering some sort of offloading for comfort, whether that's a sling or one study utilized a wrist brace, which I actually think is not a bad idea, so you still have free range of motion of the elbow and shoulder, like Eric mentioned, avoiding any stiffness of other joints. Generally, people are encouraging gentle range of motion pretty quickly, even day of or next day, just to, again, avoid any post-procedural stiffness, keep things moving, avoid potential risks of DVTs and such. Some of the protocols are more explicit about weight-bearing precautions, some saying five pounds, some up to 10 pounds with elbow procedures for up to six weeks. Then again, using the wrist brace, especially for the common extensor tendon procedures, something I hadn't seen or considered, but something I might move into doing a little bit because I think it can make some good sense in the first couple days. Calcific rotator cuff tendinopathy, one protocol is more explicit than the others. Generally, just kind of think about mechanics, avoiding overhead lifting, excessive strain, and then progressive 10 pounds up to two weeks, and then restricting them under 20 pounds in those following four weeks, weeks two to six. The lateral hip, those precautions were a lot more liberal, so generally, people, weight bearers tolerated, you know, with some relative activity modifications over that first week and then generally progressing as tolerated. And the weight-bearing lower extremity tendons, I think this is where we all tend to get a little bit more nervous, so it was common to see weight-bearing precautions utilizing a boot or surgical shoe, especially over that first one to two-week period. For the plantar fascia of the Achilles tendon, the one patellar tendon study that did use a knee immobilizer set to 10 degrees of flexion and non-weight-bearing on crutches for one week, that study was a high-level athlete cohort, I believe from Japan, so I take some of that with a grain of salt. Formal physical therapy, again, why I range broadly, explicitly mentioned in 10 papers whether they did or did not encourage formal physical therapy, there was only four studies that formally recommended physical therapy, but say you're in a room with a physiatrist, you may already have strong feelings that therapy can be helpful, there is a piece of evidence that you can point to if you're trying to encourage people to engage. So this study was published in 2021, lateral elbow study. They told everybody to do PT, big surprise, some people didn't do the PT, some people were very compliant with it, so then they did a sub-analysis looking at those who did and didn't do physical therapy out to three years. The group that did not do the physical therapy did well, they had improvements in pain and function afterwards. The group that did PT, however, did better even out to that three-year follow-up, and that was of statistical significance. So smaller numbers, but if you feel like you need, if you want somebody to engage with physical therapy and need a little bit of evidence, there is something out there that you can point to. In terms of loading progressions, again, some variance here, just kind of pulling out the big picture stuff and what I do and train in my clinic, generally zero to two weeks having some activity modifications, progressing into daily activities pretty quickly, two to six weeks then starting to get into some light, mostly concentric loading, six plus weeks getting more aggressive eccentric loading, plyometrics, any return to higher-level activity progressions. Again, these other areas were pretty small. We talked about the rotator cuff progression, the cohort study that was done. The lateral hip, again, they weren't overly restricted in those studies. And then, again, in the weight-bearing tendons, I think this is where people tend to get a little bit more cautious, but similarly outside of the orthostasis use that we talked about before progressing through kind of zero to two, two to six, and then six weeks and beyond seems to be the most common trends. Return to support protocol is about a third of the papers that explicitly mention that. Generally starting to think about that somewhere within the first six to 12 weeks and the biggest thing there was think about your more advanced progressions in that kind of six to eight week window. And I think always good practice to be slow and progressive there, working with physical therapists and being clear with the patient about their criteria to advance to each stage. So this paper was mentioned before as well. I did my fellowship at Emory, so this tends to be essentially the structure and carbon copy of the instructions that I'm providing physical therapists and patients. Again, with that first few days, just kind of taking it easy, plus or minus using a sling. If you are going to choose to use a sling or other protective device to make sure they're coming out of that, doing some gentle range of motion, not getting too stiff. Then up to the two-week period, encouraging some more range of motion, getting them confident in their day-to-day activities. About two to six-week period, getting into low weight, high repetition work. If they work physical therapy, they may even start getting more aggressive on the soft tissue work at that time. And then as we're getting into that six-week and beyond time point, that's starting more eccentrics, you know, plyometrics and progressing as tolerated. Giving them some instructions, you know, as early as two weeks that a little bit of pain is okay. I think for me, a lot of the thing about restricting NSAIDs or being progressive is kind of resetting their mindset around how they manage pain. So saying like, you know, up to two to three points can be safe. We just want to make sure it's calming down. After activity is not having increased pain in the evening or the next day and progressing kind of with that mindset. And then at a three-month point, a very reasonable kind of step back and reassess where you're at with everything. Again, from this Ohio State website, their criteria for tests from one stage to the next is that they're not having reactive pain after a strength session for more than 24 hours. Commonly, people are following up at two, six, and twelve weeks. A reminder that we're billing this as a, you know, essentially a surgical procedure. So it does come with a global period of those first 90 days. Most commonly, as follows, the VAS, just pain scores for upper extremity dash, a very common outcome measure. And then the patella or Achilles, the associated VSA, VSIP scores. A common question that comes up is, should I track these outcomes with ultrasound? What does that mean? This is from that same paper that we mentioned earlier. So I think if you're going to choose to use an ultrasound at three months to look at structurally how things are looked, you need to be prepared that things may look worse than they did pre-procedurally. So left to right, it's talking about hypervascularity, tendinopathy, thickness, and any areas of hypocoic. So in about 20% of people, they either had increased hypervascularity or increased thickness at a three-month mark. You start to see pretty good resolutions at the six-month data point, and even, you know, further improvements at three years. But if you're going to take a look early, you should expect there's a strong chance that it may look worse. In terms of long-term outcomes, just wrapping up here quick, there's some scale issues here on the chart, but generally see potential for improvement up to even three years, but each of these time points is progressively longer. So around that three to six-month mark, that does start to level off a little bit, both in pain and function. A similar paper also showing some plateau from that three to six-month mark going up to 12 years with potential for ongoing improvements. Again, this paper showed that plateau point around four months, and plantar fascia is similarly around that 12-week time point there. We touched on the complications. They're real. You should be thorough in your counseling and know what to look out for in your expectations. Again, that overall rate in this largest study for these types of procedures we're talking about is 1.3% with potential for serious complications of nerve injury and things to counsel and be aware of, like the DVT, if you're going to restrict patient syringe motion. I want to thank our fabulous resident, Mika Sommer, for helping through some of this review, and thank you guys for attending today. Thank you, everyone. I think we're a little over our 1045 end time. If anyone wants to stay for questions, happy to field some questions for you guys. Some microphones out in the front. Yeah, go ahead. Should I just talk in here? Yeah, just go ahead. Okay. I do have a question about I've got a patient with a big old Haglund's coming up, so I've done some Achilles before and even some calcific. One time I worked on a Haglund's, but I only had the TX2, and man, I was wishing I had that TX bone tip, but this Haglund's is kind of on the books. I think I placed the order, you know, so I'm like, man, how much do I take out? It's a lot of bone shaving. I'm not a surgeon. How bloody is this thing going to get? Yeah. Do you guys want to answer it? So I usually tell patients we're not trying to take 100% of it. You know, we're trying to, I want to get 50% of it at least. If I can get more and they're doing well tolerating it, I got a good anesthetic block, I will take more. Usually I'm trying to gauge, you know, where's the tendinopathy? You know, how much tendinopathy is adjacent to this Haglund's? Is it diffusely all the way from medial to lateral? Is it mostly medial? And that way I can gauge, okay, am I going to focus more on the medial aspect of this Haglund's? It's usually not like the entire width of the calcaneus. When I make my entry point, I'm distal to it and I'm kind of just fanning from lateral. And then I shaved down in one plane, you know, as I said, like superficial, a little more deep, a little deeper. And then once I'm done with that plane, I fan or like I've turned my probe a little bit more medial and I do the same thing. I just start over again. And I just, you know, centimeter by centimeter move over as I'm going down. Yeah. If you'd kind of just go at it, like haphazardly, it doesn't work well and you're going to core the bone and you're going to need, and I definitely have an extra BTX bone device in the room because when you're doing a Haglund's, I don't, I think I go a little bit more slowly and gently than my partner does, but Walter breaks a machine or cores a bone probably 50% of the time. Now, 10X pays you. I go nice and easy. 10X will pay you. They'll, they aren't going to charge you for that second device. So you just keep that bone tip that broke or keep the device tip that broke and you give, put it in the box and let your rep know, and they'll reimburse you for the extra kit. Perfect. Thank you. Anyone else? Questions? Thanks. Yeah. Great talk guys. I'm Sushil from Canada. So we don't have 10X available right now in most provinces, but I just kind of a playing devil's advocate here. If there's not a lot of inferiority to PRP and I know I understand the out of pocket costs, but I'm sure co-pays are more than whatever, three to $800 of PRP costs. Why not just do the PRP? Yeah, I'd say it's been my experience at the University of Washington. A lot of insurers actually cover this pretty well, like at least in the United States. So even our Medicaid patients, you know, we are state insurance. They cover it pretty well. So a lot of times when it comes to PRP and our institution charges close to a thousand dollars for PRP, if it's going to be mainly covered by insurance, barring that they have like a high deductible plan, I'm actually moving towards 10X more than PRP, but it's a good point. And those Medicaid plans that we take mass health at my office and they have no deductible. So no deductible for those. Yeah. Yes. It can be better tolerated as well. A lot of patients find PRP into the tendon to be extremely painful, whereas 10X usually patients are good in a couple of days. Yeah, I think other considerations are going to be, we talked a little bit about, is there significant tearing where you might be worried about disrupting the tendon that might lead you towards choosing PRP or if you're doing a big bony debrisment, obviously that's not something you'll be able to get to with the PRP. Some of the, you know, you mentioned if you're doing like a long Achilles or getting the gluteal tendon, you're maybe limited just by the device and there's going to be some new technology probably coming out in the next year or so. But again, like it's shocking. You know, if you're going to get on your high horse, like, you know, there's 23 some studies looking at the 10X and, you know, that's covered. So, you know, on the insurance side, I don't know. And PRP, PRP for the Achilles is about the worst tendon you can do, you know, in terms of, no, in terms of outcomes, right? It's just the outcomes aren't as good as any other tendon in the body. So for this, I mean, mostly it's lateral elbow, right? So it's safe for lateral elbow. It's mostly soft tissue. You're not immobilizing them either way, but you think about this huge procedure you're setting up and you're going to an operating room or a procedure room and post-procedural visits. Yeah, right. I mean, those are the considerations here, right? Is that like all the setup time? I think we kind of touched about it, but at least in our institution, we do it in the clinic room and it takes probably a good half an hour just for them to open the box up for the kit, get the saline bag, get things set up, right? So that takes up so much time, you know, so it's, there are a host of other factors that go into, you know, should you do this procedure, the setup time and obviously the insurance, but for some folks, PRP takes just as long to get the blood, spin it down. It just depends on the mechanics of how you guys do it. And as mentioned by Stephanie here, it's also like, if you happen to do it in a ambulatory surgical center for 10X, then you have to book that time, maybe organically in some clinics with PRP. You have the PRP readily available in your clinic, so you can do a little bit more easily. So yeah. Yeah, the PRP in our clinic takes 60 minutes just to spin, so it's a 120 double spin system and 10X takes me less time. When I do 10X in the ASC, we book about 10 to 12 patients from 7 to noon and, you know, they'll take me on average about a half hour each one. So that, it's not that, you know, as long as it's the turnover and the efficiency and just getting used to it. No, I don't think that should be something that makes you shy away from the procedure. Yeah. Cool. Thanks so much. Hi guys. Great comment. Thank you. As you mentioned, there's not much literature on kind of what degree of tendon tearing is appropriate for the 10X procedure. I'm just interested in your personal experience. What is the largest partial thickness tear that you would be comfortable doing a 10X procedure? Are we talking 25%, 50%? I'd be interested in your thoughts. Usually anything over 50%. I'm telling them, you know, this, if we go in there and we're debriding the 50% that are left, that's going to, you know, be a higher risk of a full, complete rupture. So I usually hedge at 50%. Have I had a full rupture? No, but yeah, I tend, and if it is a high grade like that, you know, you maybe should be doing biologics either instead of, or in addition to 10X. So sometimes I'll go in and, you know, once I start, once the fluid starts aspirating that through that area, or you inject it with anesthetic, the tear is much larger than you expected. And then I let the patient know, Hey, we're like, we're doing the procedure today, but, you know, we, this is a larger tear than we thought. We might need to do a PRP injection down the road. And some patients opt to do that the same week. Others wait to see three or four months how they do, and then consider it later. Kind of dovetailing on that, the two, they're both lateral elbow papers, but the two papers that looked at the 10X plus some augmentation at the time procedure, one was with PRP, one was with a amniotic product, Waltz series, but they showed no statistical significant difference. But I think that some people are thinking about and interested in like, when does it make sense to augment that or follow it up down the line? Thank you. Don't do it on the same day, or you'll also get your insurance payment revoked. If you do a cash procedure on the same day as you're, you know, uh, billing your CPT code. So we usually do that a few days later if we're going to augment it. All right. Thanks everyone. Oh, I see. Yeah. You go low in this question. Well, I think mine kind of dovetailed on her question on the degree of tendinosis that you feel is safe. I'm part of my assignments at the VA. We're seeing these 70 year old guys with severe rotator cuff tendinosis. And you're like, well, do I really want to go in there with plow through this tendon? Because they're not candidates for rotator cuff repair. If it's not a full tear, if it's not a tear, I'd be fine. Like, even if it's just the worst looking tendon with multiple intrasubstance, partial tears all over the place, tons of neovessel infiltration, you know, calcifications, enthesopathy. I don't think, I think those are good candidates. Okay. Yeah. Sometimes it's about like what the alternatives are, right? So usually in that situation, we'll have them talk to a surgeon just so they've heard and understood options or what aren't options. But you know, at the rotator cuff or certainly at the gluteal tendons, like we have an excellent hip arthroscopist that will not touch a gluteal tendon. So sometimes we're just stuck if they want to do something and have been very frustrated with the years of PT. Yeah. And that's the same with like the Haglunds. I'll always have them go and talk to a surgeon. And most of them have already talked to a surgeon before they come to me for that because they know that surgery is about a year to recover. It's like a full Achilles rupture and repair. All right. Thanks everyone.

Percutaneous Ultrasonic Tenotomy

Tenex procedure

chronic tendinopathies

tendinitis

tendinosis

ultrasound imaging

neurovascular safety

anesthesia

rehabilitation

Platelet-Rich Plasma

minimally invasive

treatment protocols