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Benjamin J. Ingram, MD Primary Care Sports Medicine Fellow Tri-Service Sports Medicine Fellowship Uniformed Services University Bethesda, MD.

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Presentation on theme: "Benjamin J. Ingram, MD Primary Care Sports Medicine Fellow Tri-Service Sports Medicine Fellowship Uniformed Services University Bethesda, MD."— Presentation transcript:

1 Benjamin J. Ingram, MD Primary Care Sports Medicine Fellow Tri-Service Sports Medicine Fellowship Uniformed Services University Bethesda, MD

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

4 Dated March 13, 2011 Ultrasound Limit 5 years

5 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

6 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

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

8 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

9 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

10 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 theyre frustrated non surgeons who cant ever fix anything?)

11 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

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13 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 folks with shoulder ultrasounds?...

14 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

15 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

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20 Meta-Analysis 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

21 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

22 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

23 Fancy Meta analysis Math

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

25 44 wrists in 26 CTS patients proven on NCS 86 wrists in 43 asymptomatic volunteers Average 9mm 2 in asymptomatic 14mm 2 in CTS Wiesler, The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome, J Hand Surg 2006

26 ULTRASOUNDMANEUVERS 11mm 2 correctly identified 40/44 CTS patients 91% sensitive 84% specific 74% PPV 95% NNV Median Nerve Compression Test 87% sensitive 96% specific Phalens 85% sensitive 96% specific Wiesler, The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome, J Hand Surg 2006

27 ULTRASOUNDNERVE 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 $ (Google search) Not Quick Only get electrical data Wiesler, The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome, J Hand Surg 2006

28 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

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

32 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

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35 How Good Are We Going Blind?

36 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

37 240 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

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39 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

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41 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

42 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

43 Techniq ue Total Injection s ISSTIS+STITIT+IS Blind US Guided 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

44 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

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46 Maybe

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48 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

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50 Systematic Literature Review Daley, Improving Injection Accuracy of the Elbow, Knee, Shoulder, Am J Sports Med 2011

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56 But How Will My Patients Tolerate This?

57 PALPATION GUIDEDSONOGRAPHIC 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

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60 25 years use in Europe 11 studies documenting use in the hip Safe May use fluoro to guide the needle, but… With Ultrasound its 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

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64 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 its not so easy

65 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.

66 BLINDIMAGE GUIDED CPT Code $66 CPT code $66 CPT code (-26) professional $33.92 (-TC) Technical $ Total: Based on Data from GE Healthcare Jan 2010 "Reimbursement Information for Diagnostic Musculoskeletal Ultrasound and Ultrasound Guided Procedures

67 For Those Not Good in Math $247 > $66

68 That same 48 year old single female: Is impressed that youre 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 ($)

69 1. Daley E, Bajaj S, Bisson L, et al. Improving Injection Accuracy of the Elbow, Knee, Shoulder. Am J Sports Med 2011; 39: 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: 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: 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: Lee D, Han S, Park J, et al. Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections. J Ultrasound Med 2011; 30: 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): Nazarian L. The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI. AJR 2008; 190: 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: Rutten M, Spaaragaren G, Loon T, et al. Detection of Rotator Cuff Tears: the Value of MRI Following Ultrasound. Eur Radiol 2010; 20: 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: Sethi P, Kingston S, Elattrache N. Accuracy of Anterior Intra-Articular Injection of the Glenohumeral Joint. Arthroscopy 2005; 21(1): 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: Sibbitt W, Peisajovich A, Michael A, et al. Does Sonographic Needle Guidance Affect the Clinical Outcome of Intra- Articular Injections?. J Rheum 2009; 36: Wiesler E, Chloros G, Cartwright M, et al. The Use of Diagnostic Ultrasound in Carpal Tunnel Syndrome. J Hand Surg 2006; 31(5):


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