Percutaneous ultrasound-guided elbow flexor tenotomy: Cadaveric feasibility, learning curve, and procedure in two
Lucas Pouzenc1, Jules Descamps1, Claire Bastard1
1Department of Hand Surgery, Hôpital Saint-Antoine, Paris, France.
Background:
Spasticity is a common complication of central neurological disorders. It is observed in almost 25% of patients, depending on the initial neurologic injury. It can affect various anatomical regions of the human body, particularly the upper limb, progressing toward musculotendinous retraction. Therapeutic option may include tenotomy of the main elbow flexor muscles among which are the Biceps Brachii, Brachialis, and Brachioradialis. Currently, this procedure is performed through an open approach, requiring extreme caution due to the risk of vascular and nerve injury. In parallel, the growing development of ultrasound-guided procedures allows real-time visualization of anatomical structures, which may help reduce the risk of neurovascular injury. The objective was to evaluate the feasibility, accuracy and safety of real-time ultrasound-guided tenotomy of the main elbow flexor muscles on cadaveric specimens, to determine whether this minimally invasive approach could be applied to patients with spastic elbow contracture.
Methods:
Ultrasound-guided tenotomies of the elbow flexor muscles (Biceps Brachii, Brachialis, and Brachioradialis) were performed on 30 cadaveric specimens. For each procedure we visually measured and quantified the percentage of tendon sectioning achieved for each tendon, completion time, as well as any associated vascular or nerve injuries. To assess the feasibility of the procedure, we recorded the learning curve assessed in a resident, validated through the LC-CUSSUM method. In addition, the technique was applied in two patients with spastic elbow contracture as a preliminary exploratory clinical application.
Results:
The mean percentage of tendon section achieved was approximately 85% for the biceps brachii, 60% for the brachialis, and 51% for the brachioradialis. No injuries to the radial or median nerves were observed. Two injuries to the lateral cutaneous nerve of the forearm and one injury to the cephalic vein were recorded. Competency was considered achieved after 21 procedures for the biceps brachii and after 26 procedures for the brachioradialis. However, competency was not achieved for the brachialis tenotomy after 30 procedures. The procedure was also performed in two patients, resulting in gains of nearly 70° and 90° of passive range of motion, respectively.
Conclusion:
Ultrasound-guided tenotomy of the elbow flexor muscles may represent a minimally invasive option for the treatment of spastic elbow contractures. However, given the learning curve and the limited clinical data available, further studies are needed to confirm its safety, reproducibility, and clinical effectiveness.