Benjamin J. Ingram, MD Primary Care Sports Medicine Fellow Tri-Service Sports Medicine Fellowship...

ORTHO ULTRASOUNDSEE SOFT TISSUE AND HARD

MONEYBenjamin J. Ingram, MD

Primary Care Sports Medicine Fellow

Tri-Service Sports Medicine Fellowship

Uniformed Services University

Bethesda, MD

NOTHING TO DISCLOSE

PubMed Literature Review

Dated March 13, 2011 Limits Human, English, 5 years 397 articles 241 available at USU library

American Journal Roentology

Dated March 13, 2011 Ultrasound Limit 5 years

Ice Breaker Points

I am not an orthopedist

This is not an overview of all that ultrasound is capable of doing

Ultrasound is not a replacement for MRI

Top 10 Reasons

1. Everyone can Undergo Sonography• Pacemakers• Claustrophobic• Comfortable positioning

2. Sonography Can Resolve Finer Details Than MRI• 10MHZ probe resolution to 150μm• 1.5T scanner resolution to 469x469 μm• Tendon tears may be more visible on US than MRI

3. Sonography Allows Real-Time Dynamic Examination of the Patient

• Impingement, snapping hip, peroneal subluxation, UCL tears with valgus stress

Nazarian, The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI, AJR, 2008

Top 10 Reasons

4. The Ultrasound Probe Can Be Placed Exactly Where IT Hurts

• What of the asymptomatic rotator cuff tear?• Is it the ganglion in the knee that is the pain generator or the

semi-m insertion

5. Sonography Can Effectively Image Patients with Surgical Hardware

• Avoids MRI artifact

6. Doppler sonography Gives Important Physiologic Information

• Color Doppler- direction of flow• Power Doppler- presence of flow without direction but in much

smaller vesselsNazarian, The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI, AJR,

2008

Top 10 Reasons

7. Sonography is Better for Differentiating Fluid from Solid Material

• MRI may show a cystic mass that is amendable to percutaneous aspiration

• US reveals vascularity on color or power Doppler or filled with thick debris

8. Sonography is Better for Guiding Therapeutic Interventions

• Needle Guidance to soft tissues

9. Sonography Facilitates Bilateral Comparison• God Loves Symmetry• God Hates Straight Lines

Nazarian, The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI, AJR, 2008

Top 10 Reasons

10. Sonography has a More Flexible Field of View• MRI- Comprehensive field of view• US- Flexible field of view• Example: following the course of the radial nerve in

the arm to the point of pain at the arcade of Froshe

Nazarian, The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI, AJR, 2008

3 Key Questions to Answer

Useful for Diagnosis? Accuracy of Injections? Billing?

um, yeah…will this actually make me money or is this just cool academic stuff?

(Or worse yet, have the primary care guys latched onto this because they’re frustrated non surgeons who can’t ever fix anything?)

Also…

Many of These Studies Were Not Performed in the US.

The Markers at the Top of Those Slides Denote Country or State.

No other affiliations should be made between the study and the Marker

USEFUL FOR DIAGNOSIS?

Shoulder: MRI vs US

Retrospective review 5,216 patients with ultrasounds over 4 year

period “Based on the available literature, US is the

method of first choice in the detection of rotator cuff tears in our hospital. In the case of unequivocal findings or clinical doubt, additional MRI is requested.”

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol, 2010

Uh, Yeah…where do you find 5000+ folks with

shoulder ultrasounds?...

Shoulder: MRI vs US

5216 patients All of these had US

81 excluded for operation without MRI 275 later had MRI

80 of those with MRI had surgery 12 of those 80 were > 5 months between US and

MRI/surgery So, 68 remained with US/MRI/surgical findings to

compare

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol 2010

Shoulder: MRI vs US

3 Outcomes: Intact Cuff Partial Thickness Tears Full Thickness Tears

Results: 22 Full Thickness Tears 9 Partial Thickness Tears

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol 2010

Shoulder MRI vs US

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol 2010

Shoulder MRI vs US

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol 2010

Shoulder MRI vs US

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol 2010

Shoulder MRI vs US

Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, Eur Radiol 2010

Shoulder MRI vs US Continued

Meta-Analysis 1966-2007 Medline search

Rotator cuff Rotator cuff tear Magnetic resonance imaging Magnetic resonance MRI MR Magnetic resonance arthrography MR arthrography Ultrasound Ultrasonography Sonography US

1,195 articles to sort through

de Jesus, Accuracy of MRI, MR arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis, AJR 2009

Shoulder MRI vs US Continued

English Raw Data Studies interpreted by radiologists Data only published in one study

de Jesus, Accuracy of MRI, MR arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis, AJR 2009

Shoulder MRI vs US Continued

65 studies met inclusion 25 MRI only 5 MRI and MR arthrography 9 MR arthrography 1 MR arthrography and US 5 MRI and US 20 US only

de Jesus, Accuracy of MRI, MR arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis, AJR 2009

Shoulder MRI vs US Continued

de Jesus, Accuracy of MRI, MR arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis, AJR 2009

Fancy Meta analysis Math

Shoulder MRI vs US Continued

de Jesus, Accuracy of MRI, MR arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis, AJR 2009

US and Carpal Tunnel

44 wrists in 26 CTS patients proven on NCS

86 wrists in 43 asymptomatic volunteers

Average 9mm2 in

asymptomatic 14mm2 in CTS

Wiesler, The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome, J Hand Surg 2006

US and Carpal Tunnel

ULTRASOUND MANEUVERS

11mm2 correctly identified 40/44 CTS patients 91% sensitive 84% specific 74% PPV 95% NNV

Median Nerve Compression Test 87% sensitive 96% specific

Phalen’s 85% sensitive 96% specific

Wiesler, The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome, J Hand Surg 2006

US and Carpal Tunnel

ULTRASOUND NERVE CONDUCTION

Painless Cheap

You own the machine Quick

Measured at the level of the pisiform in this study

See other stuff Lipomas, hemangiomas,

hematomas, and anatomic anomalies.

Hurts Not Cheap

$500-800 (Google search) Not Quick

Only get electrical data

Wiesler, The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome, J Hand Surg 2006

Meniscal Tears

“prospective” study MRI: (gold standard)

27 knees in 22 patients with meniscal tears 14 knees in 14 normal volunteers

All received History Clinical Exam Ultrasound MRI

Park, The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging, Am J Phys Med and Rehab, 2008

Meniscal Tears

Park, The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging, Am J Phys Med and Rehab, 2008

Meniscal Tears

Park, The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging, Am J Phys Med and Rehab, 2008

Meniscal Tears

Park, The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging, Am J Phys Med and Rehab, 2008

Ultrasound 86.2% sensitive 84.9% specific 85.4% PPV 91.8% NPV

Meniscal Tears

Prospective study 35 patients with exam suggesting meniscal tear Ultrasound

By 1 Orthopaedic senior registrar and 1 senior superintendant radiographer

MRI By senior MSK radiologist blinded to US findings

Gold Standard Arthroscopy Senior orthopedic surgeon blinded to MRI and US

Shetty, Accuracy of Hand-Held Ultrasound Scanning in Detecting Meniscal Tears, J Bone and Joint Surg (Br), 2008

Meniscal Tears

Shetty, Accuracy of Hand-Held Ultrasound Scanning in Detecting Meniscal Tears, J Bone and Joint Surg (Br), 2008

Meniscal Tears

Shetty, Accuracy of Hand-Held Ultrasound Scanning in Detecting Meniscal Tears, J Bone and Joint Surg (Br), 2008

ACCURACYHow Good Are We Going Blind?

Blind Ant IA GH Joint

Unpublished material from the author on cadavers blind anterior approach 80% successful

41 patients scheduled for MR Single experienced operator single anterior procedure land mark guided

Needle was passed, a pop felt at the anterior capsule, 1cc of contrast was injected along with 1% lido.

Accuracy determined on fluoro 26.8% were intra-articular.

Sethi, Accuracy of Anterior Intra-Articular Injection of the Glenohumeral Joint, Arthroscopy, 2005

Blind IA knee

240 patients Single experienced operator 3 portals

Anteromedial Anterolatera Lateral midpatellar.

Single needle pass then contrast injected. Confirmed on Fluoro If missed on first past, failure reported.

Jackson, Accuracy of Needle Placement into the Intra-Articular Space of the Knee, J Bone and Joint Surg, 2002

Blind IA knee

Jackson, Accuracy of Needle Placement into the Intra-Articular Space of the Knee, J Bone and Joint Surg, 2002

MR Arthrography Contrast

Four centers Each radiologist did only one procedure in the

manner that they usually employ USa USp FLa FLp

Is the ultrasound better than fluoro? Or were the radiologists who did the ultrasound better?

Rutten, Glenohumeral Joint Injection: A Comparative Study of Ultrasound and Fluoroscopically Guided Techniques before MR arthrography, Euro Radiol, 2009

MR Arthrography Contrast

Rutten, Glenohumeral Joint Injection: A Comparative Study of Ultrasound and Fluoroscopically Guided Techniques before MR arthrography, Euro Radiol, 2009

US in Trigger Finger Injections

5 Cadavers, 40 fingers Skipped the thumbs

Hand Surgeon with 25 years experience vs. First Author, 6 years US experience

Blind Technique Through the skin, sheath and tendon, until bone reached With light pressure on the plunger, withdrawn until resistance

drops. This was deemed to be in the sheath.

US Guided Injected on long axis between the A1 pulley and the flexor

digitorum superficialis. Dissect the fingers and determine where the dye went.Lee, Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections, J Ultrasound 2011

US in Trigger Finger Injections

Effective optimal

Sheath only Suboptimal

Sheath and subcutaneous tissue

Dangerous Unsafe

In the tendon

Lee, Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections, J Ultrasound 2011

US in Trigger Finger Injections

Technique

Total Injections

IS ST IS+ST IT IT+IS

Blind 20 3 6 5 4 2

US Guided

20 14 4 2 0 0

Lee, Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections, J Ultrasound 2011

IS= Intra-tendon sheath; IT= Inside Tendon; ST= Subcutaneous tissue

Four Different IA Knee sites

78 Cadavers, 156 knees 39 Cadavers received AM and AL to both

knees 39 Cadavers received MMP and LMP to both

knees Needles advanced, Methylene blue injected

and needle left in place for dissection to site

Esenyel, Comparison of Four Different Intra-Articular Injection Sites in the Knee: A Cadaver study, Knee Surg Sports Traumatol Arthrosc, 2007

Four Different IA Knee sites

Esenyel, Comparison of Four Different Intra-Articular Injection Sites in the Knee: A Cadaver study, Knee Surg Sports Traumatol Arthrosc, 2007

ARE YOU BETTER THAN THESE GUYS?

Maybe

BUT MAYBE THERE ARE EASY AND MORE ACCURATE WAYS TO

PERFORM INJECTIONS

And who cares if it’s not where I meant for it to be?

Soft Tissue Damage Tendon Weakening Skin De-pigmentation with Corticosteroids Poor Images with Contrast Dye Neurovascular Damage from Needle Failed Procedure Need to Repeat the Procedure

With Blind Injections, You Kick It Up and Hope for the Best.

With Guided Injections, You Aim to Place Your Needle Where You Want it.

Injection Site Imaging

Systematic Literature Review

Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

Injection Site Imaging

Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

Injection Site Imaging

Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

Injection Site Imaging

Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

Injection Site Imaging

Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

Injection Site Imaging

Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

THIS IS MIGHTY FANCY STUFF HERE…

But How Will My Patients Tolerate This?

Clinical Outcomes with Image Guidance

PALPATION GUIDED SONOGRAPHIC GUIDED

74 patients 1 needle 2 syringes

traditional change over

74 patients “enhanced” with “one

handed control syringe”

Sibbitt, Does Sonographic Needle Guidance Affect the Clinical Outcome of Intra-Articular Injections?, J Rheum, 2009

Clinical Outcomes with Image Guidance

Sibbitt, Does Sonographic Needle Guidance Affect the Clinical Outcome of Intra-Articular Injections?, J Rheum, 2009

Clinical Outcomes with Image Guidance

Sibbitt, Does Sonographic Needle Guidance Affect the Clinical Outcome of Intra-Articular Injections?, J Rheum, 2009

Hip Visco-supplementation

25 years use in Europe 11 studies documenting use in the hip Safe May use fluoro to guide the needle, but… With Ultrasound it’s really easy to do

Mulvaney, A Review of the Visco-Supplementation for Osteoarthritis of the Hip and a Description of an Ultrasound-Guided Hip Injection Technique, Curr Sports Med Rep 2009

Hip Visco-supplementation

Mulvaney, A Review of the Visco-Supplementation for Osteoarthritis of the Hip and a Description of an Ultrasound-Guided Hip Injection Technique, Curr Sports Med Rep 2009

Hip Visco-supplementation

Mulvaney, A Review of the Visco-Supplementation for Osteoarthritis of the Hip and a Description of an Ultrasound-Guided Hip Injection Technique, Curr Sports Med Rep 2009

Hip Visco-supplementation

Mulvaney, A Review of the Visco-Supplementation for Osteoarthritis of the Hip and a Description of an Ultrasound-Guided Hip Injection Technique, Curr Sports Med Rep 2009

Military Disclaimer

Visco-Supplementation Approval Process See Patient Pick Joint to Inject Go To Room Open Drawer Pick Up Product Put Product In The Joint Oh, Forgot One Step Unlock The Drawer before opening

With Insurance Companies it’s not so easy

Does This Make Me Money?

48 year old single female, Owns lots of cats. Librarian by trade, works for DOD Knee pain that limits her ability to shelve books as

she has to climb up and down ladders to reach the top shelves.

You diagnose her with bilateral knee OA. The decision is made to pursue IA

Viscosupplementation into the knees.

Does This Make Me Money?

BLIND IMAGE GUIDED

CPT Code 20610 $66

CPT code 20610 $66

CPT code 76942 (-26) professional $33.92 (-TC) Technical $147.95

Total: 247.87

Based on Data from GE Healthcare Jan 2010 "Reimbursement Information for Diagnostic Musculoskeletal Ultrasound and Ultrasound Guided Procedures

Does This Make Me Money?

For Those Not Good in Math

$247 > $66

Does This Make Me Money?

That same 48 year old single female: Is impressed that you’re up on technology Here VAS was lower because you image guided She returns every 6 months for repeat injections ($) She refers all of her friends in the cat club ($) She tells everyone in the library about you ($)

References1. Daley E, Bajaj S, Bisson L, et al. Improving Injection Accuracy of the Elbow, Knee, Shoulder. Am J Sports Med 2011; 39: 656-662.

2. de Jesus J, Parker L, Frangos A, et al. Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis. AJR 2009; 192: 1701-1707.

3. Esenyel C, Demirhan M, Esenyel M et al. Comparison of Four Different Intra-Articular Injection Sites in the Knee: A Cadaver Study. Knee Surg Sports Traumatol Arthrosc 2007; 15: 573-577.

4. GE Healthcare Jan 2010 "Reimbursement Information for Diagnostic Musculoskeletal Ultrasound and Ultrasound Guided Procedures

5. Jackson D, Evans N, Thomas B. Accuracy of Needle Placement into the Intra-Articular Space of the Knee. J Bone and Joint Surg 2002; 84: 1522-1527.

6. Lee D, Han S, Park J, et al. Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections. J Ultrasound Med 2011; 30: 197-203.

7. Mulvaney S. A Review of the Visco-Supplementation for Osteoarthritis of the Hip and a Description of an Ultrasound-Guided Hip Injection Technique. Curr Sports Med Rep 2009; 8(6): 291-294.

8. Nazarian L. The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI. AJR 2008; 190: 1621-1626.

9. Park G, Kim J, Lee S, et al. The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging. Am J Phys Med Rehabil 2008; 87:14-20.

10. Rutten M, Spaaragaren G, Loon T, et al. Detection of Rotator Cuff Tears: the Value of MRI Following Ultrasound. Eur Radiol 2010; 20: 450-457.

11. Rutten M, Collins J, Maresch B, et al. Glenohumeral Joint Injection: a Comparative Study of Ultrasound and Fluoroscopically Guided Techniques Before MR Arthrography. Eur Radiol 2009; 19: 722-730.

12. Sethi P, Kingston S, Elattrache N. Accuracy of Anterior Intra-Articular Injection of the Glenohumeral Joint. Arthroscopy 2005; 21(1): 77-80.

13. Shetty A, Tindall A, James K. Accuracy of Hand-Held Ultrasound Scanning in Detecting Meniscal Tears, J Bone and Joint Surg [Br] 2008; 90-B: 1045-1048.

14. Sibbitt W, Peisajovich A, Michael A, et al. Does Sonographic Needle Guidance Affect the Clinical Outcome of Intra-Articular Injections?. J Rheum 2009; 36: 1892-1902.

15. Wiesler E, Chloros G, Cartwright M, et al. The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome. J Hand Surg 2006; 31(5): 726-732.