ULTRASOUND GUIDANCE: IMPROVED OUTCOMES?

26th Annual Update in Physical Medicine & Rehabilitation Zach Beresford, MD Assistant Professor University of Utah, University Orthopedic Center

Ultrasound guidance: Improved Outcomes?

•DISCLOSURES

None

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LEARNING OBJECTIVES

Very brief overview of Musculoskeletal Ultrasound

Ultrasound use in Interventional Procedures

Why talk about image guidance?

Does US guidance improve accuracy?

Does US guidance improve outcome?

Why talk about Musculoskeletal Ultrasound

Pubmed search for musculoskeletal ultrasound –> 1122 results since the year 2000

MSK US studies increased 316% from 2000 to 2009

MSK US procedures increased 717% over same time period (19,000 -> 158,000) Podiatrists – 51.5% of growth

Sharpe 2012

WHAT IS MUSCULOSKELETAL ULTRASOUND (MSK US)?

High frequency sound waves used to image soft tissues and bony surfaces

Higher resolution than MRI for superficial structures

MSK US

Advantages Safe

Dynamic and interactive Allows visualization of soft

tissues

Convenient

No radiation or contrast

Disadvantages Initial cost Limited field of view Operator-dependent quality

MSK US Uses

Diagnostic Tendon or ligament injury Similar sensitivity to MRI for RTC tears

Muscle strains and contusions Nerve entrapment Joint effusions

Interventional Joint, tendon, bursa - focus of this talk Axial procedures Neurotoxin guidance Nerve blocks

Do we need image guidance at all for interventional procedures?

Blind Injections are Inaccurate

Subacromial: ~ 70 % accurate

Partington 1998, Henkus 2006, Kang 2008

AC joint: ~40% Pichler 2009, Bisbinas 2006

Glenohumeral joint: 42% Eustace 1997

aafp.org

Blind Injections

Knee 66-80% accurate

Jones 1993, Jackson 2002

Ankle 81 % accurate

Heidari 2010

Aafp.org

Blind Injections: Unsafe depending on location

Hip (cadaver study)

Anterior approach – 60% accuracy, 27% contacted femoral nerve

Lateral approach – 80% accurate

Leopold 2001

Does Ultrasound Guidance Improve Accuracy?

YES!

Almost universally

US Guidance Superior to LMG

Superior accuracy to

landmark guided (LMG)

AC joint

Peck 2010, Sabeti-

Aschraf 2011

Glenohumeral

Rutten 2009

Subacromial Daley 2011

Bicep tendon sheath Hashiuchi 2011

Superior Accuracy with US Guidance

Hip Smith 2009

Knee Wiler 2010, Im 2009

Proximal tib-fib Smith 2010

Tibiotalar and Sinus Tarsi

Wisniewski 2010

…

Videos

ACCURACY

Experienced operators with equivalent accuracy using LMG in the knee

Novice operators with better accuracy using US

Curtiss 2011

Subacromial injection with same accuracy blind versus US guided (confirmed w MRI)

Rutten 2007

ACCURACY

US guidance superior to fluoroscopy Glenohumeral joint,

piriformis, subacromial

Better soft tissue visualization

Finnoff 2008, Rutten 2009,

Mathews

Finnoff 2008

Does Ultrasound Guidance Improve Outcome?

Does US Guidance Improve Outcome: Premise Injections have been shown to improve pain,

function, ROM in osteoarthritis, tendinopathy, bursitis

Blind injections often miss target, may be unsafe

Does US Guidance Improve Outcome?

Needle visualization confirms placement in joint or other targeted tissue

Should allow for accurate placement of specific targeted therapies – biologics, tenotomy

Should improve safety –> avoiding neurovascular structures, tendon, less needle trauma, ability to dilate/hydrodissect with local prior to injection

Better ability to see effusions to allow aspiration

Does US Guidance Improve Outcome?

More difficult to answer than accuracy question

Not a lot of large RCT’s

Inherent limitations in many studies – patients not really blinded (in most)

Not much long term follow up

What conditions have been looked at?

Joint pain

Bursitis

Inflammatory arthritis

Chronic tendinopathy

Calcific tendinitis

Different Procedures

Steroid and local anesthetic

Viscosupplementation

Platelet Rich Plasma (PRP)

Tenotomy

Needle aspiration and lavage

What outcomes have been measured?

Pain

Function and Disability

ROM

Procedural time and discomfort

Cost

OUTCOMES BY REGION/STRUCTURE

Shoulder

Knee

Hip

Multiple joints

Tendon

SHOULDER

“Painful shoulder”

Improved pain and function US guided versus blind subacromial steroid injection

Short term (6 week follow up) RCTs

Naredo 2004, Unucu 2009

Painful Shoulder

Improved ROM Unucu 2009

Less procedural pain and time Hashiuchi 2010

No difference in outcome blind versus US guided subacromial steroid injection for shoulder pain Panditaratne 2010

Shoulder

Bursitis (US confirmed)

Improved ROM with US guided steroid injection vs blind – 1 week follow up

Chen 2006

Less procedural time, less pain versus fluoroscopy guidance

Glenohumeral joint - Rutten 2009

Frozen Shoulder

Less pain, improved function and ROM with US guided steroid injection and 5 weekly sodium hyaluronate injections vs series of blind injections

6 week follow up Lee 2009

KNEE – US Guidance

Knee effusion - decreased procedural pain, increased amount of aspirate, better 2 week outcome with US guidance

Sibbit 2012

Less pain with procedure and decreased procedural time with US

Wiler 2010

Baker’s cyst – US drainage, steroid injection improves symptoms, cyst size

Di Sante 2010, Bandinelli 2011

HIP

Positive effect for US guided steroid injection versus baseline and age-matched control group

Walking pain, severity index, synovial hypertrophy improved at 1 and 3 months

Micu 2010

http://www.glasersportsmedicine.com

HIP

Pain and function improved with US guided steroid injection vs control group, saline injection, hyaluronate

Maintained up to 8 weeks

Greatest effect is early

Atchia 2011

MULTIPLE JOINTS: US guided steroid injection

Decreased pain, increased responder rate, decreased procedural pain, increased volume of aspirated fluid vs blind injection

Sibbit 2009

Improved accuracy, no improvement in clinical outcome vs blind injection

Cunnington 2010

Decreased Procedural Pain

WHY? Better control; direct needle away from

pain-sensitive structures Distraction effects Cooling effect of gel Pressure from transducer Ability to view images, interaction with

provider

CHRONIC TENDINOPATHY

Gluteus medius tendinopathy (“bursitis”)

Steroid injection blind versus fluoro guidance with equivalent outcomes

Cohen 2009

US-guided peritendinous steroid injection improved pain Labrosse 2010

ajronline.com

Does US guidance matter in the lateral hip?

Labrosse 2010

CHRONIC TENDINOPATHY

Chronic recalcitrant tendinopathy Multiple sites

Tenotomy improved VAS at 4 and 12 week follow up vs baseline

Housner 2009

Lateral epicondylosis: >90% of patients reported excellent or good results at 22 months

McShane 2008

CHRONIC TENDINOPATHY

Chronic Achilles tendinopathy

US guided Tenotomy survey: 75% 0f 63 patients reported good or excellent results

Avg. follow up 51 months

CHRONIC TENDINOPATHY

US guided PRP injection plus tenotomy

Improved function, decreased pain, improved US appearance of affected tendon

Multiple locations, mean follow up 14 months Finnoff 2011

CHRONIC TENDINOPATHY

US Guided PRP injection for chronic lateral epicondylitis

Trend towards improvement with PRP compared to whole blood injection for both pain and function

Improvement in pain at 6 weeks only significant difference Thanasas 2011

Figure 1. Pain visual analog scale score distribution (95% confidence interval). 0, no pain; 10, max pain. *Indicates significant difference between groups.

CALCIFIC TENDINITIS

Rotator cuff calcific tendinitis Fluoro guided needle fragment irrigation equivalent

results to burscoscopy (24 month follow up)

Maugars 2009

Improved pain, function, and ROM with US-guided percutaneous lavage and aspiration up to 1 year after procedure Serafini 2009 (vs control), del Cura 2007

del Cura 2007

COST

244 patients with inflammatory arthritis

Randomized to palpation vs US guidance

Improved pain, responder rate, therapeutic duration, decreased procedural pain

Overall 8% cost reduction per patient per year

Increased procedural cost for oupatients ($183) Sibbitt 2011

COST

Cost estimates dependent on reimbursement rates, reduced utilization of health care resources

Doesn’t take into account societal benefit

Goal is to deliver better clinical outcomes

CONCLUSIONS

Blind injections inaccurate

Data for improved accuracy with US guidance consistent

Data for efficacy less impressive, though safety alone may be incentive enough

Variable methodological quality Lack of large, blinded RCTs

Lack of long term outcome assessment

Different treatments

Different outcome assessments

ADANTAGES OF ULTRASOUND

Several options for needle guidance

Why not fluoroscopy, CT, MRI for guidance?

Better visualization of soft tissues

No radiation or contrast exposure

Portability

Ease of repeat exams

Expense (?)

Better patient experience

DOWNSIDES

Takes longer to perform than palpation-guided

Sibbitt reported 100% increase in procedure time

But less time than fluoroscopy

Increased procedure cost

Only a better value if duration of effect is sufficient

Limited field of view

Investment in equipment

Investment in training

QUESTIONS?

References

1. Atchia I, Kane D, Reed M, Isaacs J, Birrell F. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis Ann Rheum Dis 2011; 70(1): 110–116.

2. Bisbinas I, Belthur M, Said H, Green M, Learmonth DJ. Accuracy of needle placement in ACJ injections. Knee Surg Sports Traumatol Arthrosc 2006;14:762-765.

3. Buchbinder R, Green S, Youd J. Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews 2009. Issue 1. Art. No.: CD004016.

4. Chen MJL, Lew HL, Hsu TC, Tsai WC, Lin WC, Tang SFT, Lee YC, Hsu RCH, Chen CPC. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006; 85(1): 31–35.

5. Choudur H, Ellins M. Ultrasound-guided gadolinium joint injections for magnetic resonance arthrography. J Clinical Ultrasound 2011; 39(1): 6-11.

6. Cunnington J, Marshall N, Hide G, Bracewell C, Isaacs J, Platt, P, Kane D. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis & Rheumatism 2010; 62(7): 1862-69.

7. Davidson J and Jayaraman S. Guided interventions in musculoskeletal ultrasound: What’s the evidence? Clinical Radiology 2011; 66: 140-52.

8. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms Ann Rheum Dis 1997; 56(1); 59-63.

9. Finnoff, JT, Hurdle MFB, Smith J. Accuracy of ultrasound-guided versus fluoroscopically guided contrast-controlled piriformis injections. J Ultrasound Medicine 2008; 27(8): 1157-63.

10. Finnoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J. Accuracy of ultrasound-guided versus unguided pes anserinus bursa injections. PM&R 2010; 2(8): 732-39.

References

11. Galiano K, Obwegeser A, Walch C, Schatzer R, Ploner F, Gruber H. Ultrasound-Guided Versus Computed Tomography-Controlled Facet Joint Injections in the Lumbar Spine: A Prospective Randomized Clinical Trial. Reg Anesth Pain Med 2007; 32(4):317-322.

12. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis 2009; 68 (12):1843–49.

13. Henkus, H, Cobben, L, Coerkamp E, Nelissen R, van Arkel E. The Accuracy of Subacromial Injections: A Prospective Randomized Magnetic Resonance Imaging Study. Arthroscopy 2006; 22(3): 277-282.

14. Jackson, DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. JBoneJntSurg 2002; 84(9):1522-1527.

15. Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ 1993; 307(6915): 1329–30.

16. Kang MN, Rizio L, Prybicien M, Middlemas D, Blacksin M. The accuracy of subacromial corticosteroid injections: A comparison of multiple methods. J Shoulder Elow Surg 2008; 17(1S): 61-6.

17. KirkKL, Campbell JT, Guyton GP, Schon LC. Accuracy of posterior subtalar joint injection without fluoroscopy. Clin Orthop Relat Res 2008; 466(11):2856–2860.

18. Lambert RG, Hutchings EJ, Grace MG, et al. Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2007; 56(7): 2278 – 87.

19. Leopold SS, Battista V, Oliverio JA. Safety and efficacy of intraarticular hip injection using anatomic landmarks. Clin Orthop Rel Res 2001; 391:192–197.

20. Micu MC, Bogdan GD, Fodor D. Steroid injection for hip osteoarthritis: efficacy under ultrasound guidance. Rheumatology 2010; 49(8): 1490-4.

References

21. Naredo E, Cabero F, Beneyto P, Cruz A, Mondejar B, Uson J, Palop M, Crespo M. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004 Feb; 31(2): 308-314.

22. Partington PF, Broome GH. Diagnostic injection around the shoulder: Hit and miss? Acadaveris study of injection accuracy. J Shoulder Elbow Surg 1998. 7(2): 147-50.

23. Peck E, Lai JK, Pawlina W, Smith J. Accuracy of ultrasound-guided versus palpation-guided acromioclavicular joint injections: A cadaveric study. PM&R 2010; 2(9): 817-21.

24. Pichler W, Weinberg AM, Grechenig S, Tesch NP, Heidari N, Grechenig W. Intra-articular injection of the acromioclavicular joint. JBJS Br 2009; 91:1638-1640.

25. Pourbagher MA, Ozalay M, Pourbagher A. Accuracy and outcome of sonographically guided intra-articular sodium hyaluronate injections in patients with osteoarthritis of the hip. J Ultrasound Med 2005; 24(10): 1391–1395.

26. Robinson P, Keenan A, Conaghan P. Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis. Rheumatology 2007; 46(2): 285–291.

27. Rutten M, Collins J, Maresch B, Smeets J, Janssen C, Kiemeney L, Jager G. Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol 2009; 19(3): 722–30.

28. Saifuddin A, Abdus-Samee M, Mann C, Singh D, Angel JC. CT guided diagnostic foot injections. Clin Radiol 2005; 60: 191–195.

29. Sibbitt WL, Band PA, Chavez-Chiang NL, Delea SL, Norton HE, Bankhurst AD. A randomized controlled trial of the cost-effectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. J Rheumatology 2011; 38(2): 252-63.

References

30. Sibbitt W, Peisajovich A, Michael A, Park K, Sibbitt R, Band P, Bankhurst A. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol 2009; 36(9): 1892–902.

31. Smith J and Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: Part 1. Fundamentals. PM&R 2009; 1(1); 64-75.

32. Smith J and Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: Part 2. Clinical applications. PM&R 2009;1(2); 162-77.

33. Smith J, Finnoff JT, Henning PT, Turner NS. Accuracy of sonographically guided posterior subtalar joint injections. J Ultrasound Medicine 2009; 28(11): 1549-57.

34. Smith J, Hurdle MF, Weingarten TN. Accuracy of sonographically guided intra-articular injections in the native adult hip. J Ultrasound Medicine 2009; 28(3): 329-35.

35. Sofka CM, Saboeiro G, Adler R. Ultrasound-guided adult hip injections. J Vasc Interv Radiol 2005; 16(8): 1121-23.

36. Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database of Systematic Reviews 2009, Issue 4.

37. Wisniewski SJ, Smith J, Patterson DG, Carmichael SW, Pawlina W. Ultrasound-guided versus nonguided tibiotalar joint and sinus tarsi injections: a cadaveric study. PM&R 2010; 2(4): 277-81.

38. N. Heidari, W. Pichler, S. Grechenig, W. Grechenig, and A. M. Weinberg. Does the anteromedial or anterolateral approach alter the rate of joint puncture in injection of the ankle?: A CADAVER STUDY J Bone Joint Surg Br January 2010 92-B:176-178.

39. Panditaratne, N, Christopher Wilkinson, Clare Groves, and Muthusamy Chandramohan. Subacromial impingement syndrome: a prospective comparison of ultrasound-guided versus unguided injection techniques Ultrasound November 2010 18:176—181; published ahead of print 20 August 2010,