A Rare Complication of Percutaneous Ultrasonic Tenotomy in a 66-year-old Man with Calcific Achilles Tendinopathy: A Case Report

Case Diagnosis: Calcific Achilles Tendinopathy

Case Description or Program Description: A 66-year-old man presented with bilateral heel pain. Sonographic evaluation of his left Achilles’ tendon revealed significant calcifications throughout the region of the tendon insertion. Percutaneous ultrasonic tenotomy (PUT) was recommended to debride the calcifications. Approximately one minute into the procedure, smoke was noted arising from the incision. Skin exam showed an area of desquamation with surrounding non-blanchable erythema. The procedure was terminated. The patient was prescribed pain medications and he was referred to the burn clinic where he was subsequently diagnosed with a full thickness burn.

Setting: Outpatient Musculoskeletal Clinic

Assessment/Results: N/A

Discussion (relevance): PUT is utilized for a variety of conditions with satisfaction rates varying from 70-100%. PUT is considered a relatively safe procedure with adverse events occurring in 0-2.5%. There are reports of superficial wound infections, wound hypersensitivity, DVT, partial tearing and potential Achilles tendon rupture. This report describes a complication of PUT of a calcific Achilles’ tendon. The cause of the burn is indeterminant. The manufacturer posited that that the burn could have been caused by material between the needle and plastic sheath leading to decreased saline which created increased heat due to friction. There were no low flow alarms to suggest this occurred. Another potential explanation is that the needle and needle case came in to contact with each other which generated excessive friction due to the ultrasonic vibration. A previous case describing a corneal burn when using phacoemulsification for treatment of cataracts describes a similar mechanism. The density of the calcifications may have predisposed this individual to this adverse event. Even when considered to be safe and effective, it is important to understand and counsel patients regarding potential risks of interventional therapies.

Conclusions: This case describes the first known instance of a full thickness skin burn from PUT during treatment of calcific Achilles’ tendinopathy.