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Ortho Ultrasound See Soft Tissue and Hard Money

Ortho Ultrasound See Soft Tissue and Hard Money. Benjamin 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

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Ortho Ultrasound See Soft Tissue and Hard Money

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  1. Ortho UltrasoundSee Soft Tissue and Hard Money Benjamin J. Ingram, MD Primary Care Sports Medicine Fellow Tri-Service Sports Medicine Fellowship Uniformed Services University Bethesda, MD

  2. Nothing to Disclose

  3. PubMed Literature Review • Dated March 13, 2011 • Limits Human, English, 5 years • 397 articles • 241 available at USU library

  4. American Journal Roentology • Dated March 13, 2011 • Ultrasound • Limit 5 years

  5. 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

  6. Top 10 Reasons • Everyone can Undergo Sonography • Pacemakers • Claustrophobic • Comfortable positioning • 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 • Sonography Allows Real-Time Dynamic Examination of the Patient • Impingement, snapping hip, peronealsubluxation, UCL tears with valgus stress Nazarian, The Top 10 Reasons Musculoskeletal Sonography Is An Important Complementary or Alternative Technique to MRI, AJR, 2008

  7. Top 10 Reasons • 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 • Sonography Can Effectively Image Patients with Surgical Hardware • Avoids MRI artifact • 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. Top 10 Reasons • 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 • Sonography is Better for Guiding Therapeutic Interventions • Needle Guidance to soft tissues • 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. Top 10 Reasons • 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. 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?)

  11. 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

  12. Useful for Diagnosis?

  13. 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.” Uh, Yeah…where do you find 5000+ folks with shoulder ultrasounds?... Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, EurRadiol, 2010

  14. 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, EurRadiol 2010

  15. 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, EurRadiol 2010

  16. Shoulder MRI vs US Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, EurRadiol 2010

  17. Shoulder MRI vs US Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, EurRadiol 2010

  18. Shoulder MRI vs US Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, EurRadiol 2010

  19. Shoulder MRI vs US Rutten, Detection of Rotator Cuff Tears: the Value of MRI following Ultrasound, EurRadiol 2010

  20. 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

  21. 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

  22. 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

  23. Shoulder MRI vs US Continued • Fancy Meta analysis Math de Jesus, Accuracy of MRI, MR arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: a Meta-Analysis, AJR 2009

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. Meniscal Tears • Ultrasound • 86.2% sensitive • 84.9% specific • 85.4% PPV • 91.8% NPV Park, The Value of Ultrasonography in the Detection of Meniscal Tears Diagnosed by Magnetic Resonance Imaging, Am J Phys Med and Rehab, 2008

  32. 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

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

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

  35. Accuracy How Good Are We Going Blind?

  36. 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

  37. 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

  38. Blind IA knee Jackson, Accuracy of Needle Placement into the Intra-Articular Space of the Knee, J Bone and Joint Surg, 2002

  39. MR ArthrographyContrast • 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

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

  41. 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 digitorumsuperficialis. • 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. 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

  43. US in Trigger Finger Injections IS= Intra-tendon sheath; IT= Inside Tendon; ST= Subcutaneous tissue Lee, Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections, J Ultrasound 2011

  44. 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 TraumatolArthrosc, 2007

  45. Four Different IA Knee sites Esenyel, Comparison of Four Different Intra-Articular Injection Sites in the Knee: A Cadaver study, Knee Surg Sports TraumatolArthrosc, 2007

  46. Are You Better Than These Guys? Maybe

  47. But maybe there are easy and more accurate ways to perform injections

  48. 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

  49. 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.

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

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