benjamin j. ingram, md primary care sports medicine fellow tri-service sports medicine fellowship...
TRANSCRIPT
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.