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Orthopaedic Ultrasound

The use of ultrasound in orthopaedic surgery and sports medicine continues to evolve with ever increasing usage for both diagnostic and interventional purposes.

The benefits of ultrasound include the use of an imaging modality without the use of radiation and the ability to use real time analysis of structures in motion and in different positions.

Ultrasound uses high frequency sound waves to detect differences in tissue structure and evaluate different anatomic structures. These differences in echogenicity produce an anatomic picture and allow both anatomy and function to be evaluated. Unlike x-ray, ultrasound is poor at evaluating bony structures but is excellent at evaluating soft tissue structures such as muscles, tendons, and vascular structures. Ultrasound also allows the examination of patients with claustrophobia, and others who cannot undergo an MRI for various reasons.

Ultrasound in Orthopaedics

Orthopaedic Observations - A Matter of Medicine...
By Derek S. Shia, M.D.

The use of ultrasound in orthopaedic surgery and sports medicine continues to evolve with ever increasing usage for both diagnostic and interventional purposes. The benefits of ultrasound include the use of an imaging modality without the use of radiation and the ability to use real time analysis of structures in motion and in different positions.

Ultrasound uses high frequency sound waves to detect differences in tissue structure and evaluate different anatomic structures. These differences in echogenicity produce an anatomic picture and allow both anatomy and function to be evaluated. Unlike x-ray, ultrasound is poor at evaluating bony structures but is excellent at evaluating soft tissue structures such as muscles, tendons, and vascular structures. Ultrasound also allows the examination of patients with claustrophobia, and others who cannot undergo an MRI for various reasons.

Ultrasound for Diagnostic Purposes

Ultrasound has been a successful imaging modality used in standard practice in vascular surgery, cardiology and OBGYN for over 50 years. This success and experience has lead to the expansion of its use in orthopaedic surgery. Ultrasound has proved to be useful in detecting intra-articular problems such as joint effusions, tendon ruptures such as Achilles tendon tears and rotator cuff tears. Ultrasound is also excellent at evaluating tendinosis conditions such as tennis elbow and patellar tendonitis that results in abnormal vascularity and inflammation.

Ultrasound allows the evaluation of soft tissue pathology in the office and under physiologic conditions. In some conditions such as ulnar nerve subluxation, snapping triceps or biceps tendon dislocations there is a dynamic component that is not always captured with static modalities such as MRI. Ultrasound has the ability to image these problems with the joint in motion and in real time.

Ultrasound for Procedure Guidance

Ultrasound is now being used for needle guidance for more accurate placement of injections. Traditionally superficial injections have been done with anatomic landmarks and direct palpation to determine placement of injections. While this has been the accepted technique for these procedures, a closer look at various studies looking at the accuracy of needle placement without guidance demonstrates a less than perfect accuracy rate. Other types of procedures that have historically required x-ray exposure with fluoroscopy such as hip and glenohumeral injections can now also be done with ultrasound guidance.

The accuracy of different types of injections has been well studied and while some spaces and joints can be accurately injected without the use of ultrasound others require ultrasound or other imaging modalities for accurate placement.

Shoulder Injections

The accuracy of various shoulder injections including the acromioclavicular joint, glenohumeral joint, subacromial space and biceps tendon have been studied and demonstrate increased accuracy with imaging techniques. The AC joint is a superficial joint that is commonly injected with a direct palpation technique. A recent study published in JBJS British edition looked at the accuracy of AC joint injections performed by orthopedic surgeons and found that only 42% were accurately placed in the joint versus 100% with image intensification.

The accuracy of the injections into the subacromial space has also been studied and in a recent investigation examined the accuracy of three techniques without an imaging modality. This study demonstrated an accuracy of 56% for a posterior approach, 84% for an anterior approach and 92% for a lateral approach. Accuracy of biceps injections under palpation techniques has been shown to have an accuracy of 40% vs 87% with ultrasound guidance. The accuracy of these injections can be significantly improved with the use of ultrasound guidance.

Despite the fact that these studies may seem to underestimate the accuracy of these injections given the superficial locations of the AC joint, biceps tendon and subacromial space they do demonstrate that often injections may not always be in the correct positions. In addition, they also show that the accuracy of these injections can be significantly improved with the use of ultrasound guidance.

Knee injections

Accuracy of intra-articular knee injections without imaging guidance has been studied through various approaches and have demonstrated varying accuracy rates. With traditional techniques the accuracy with the use of an anterolateral approach is 71%, an anteromedial approach is 75%, and a superolateral approach is 93%. This accuracy can be improved to close to 100% with ultrasound.

The results of a recent systematic review of the current literature was published in the American Journal of Sports Medicine investigating various types of injections and is summarized in the table below.

SiteWithout imaging GuidanceWith Imaging Guidance
Acromioclavicular Joint45%100%
Subacromial Space63%100%
Biceps Tendon40%87%
Glenohumeral Joint79%95%
Knee79%99%

-AJSM 2011, JSES 2011

Injection Types

The type of injection may also influence the need for more accurate placement of the needle. Cortisone injections likely have the ability to diffuse through various tissues and produce an area affect. While this may be true with corticosteroids, other injections such as with hyaluronic acid or protein rich plasma (PRP) may not have the same local affect and misdirected injections can lead to more pain and less efficacy. Therefore these other injections are likely better performed with image guidance.

Additional Procedures

Barbotage is a technique used for the treatment of calcific tendonitis. This procedure requires the usage of ultrasound for the localization of the calcific nucleus and then irrigation of this mass to remove it. This has been shown in a randomized trial to show significant improvement over corticosteroid injections alone in terms of resolution of the calcific tendonitis and improvement of clinical symptoms.

Platelet Rich Plasma (PRP)

This involves the injection of platelet rich plasma into areas of pathology. This has demonstrated clinical improvement for several conditions that often are recalcitrant to other treatment modalities. Some of these conditions include chronic tendon conditions such as medial and lateral epicondylitis, patellar tendonitis, and Achilles tendonitis. The process begins by drawing blood from the patient. The blood is then centrifuged to concentrate growth factors into the supernatant fluid. This concentrated plasma can then be injected under ultrasound guidance into the pathological tissue. The PRP then releases various growth factors that aide in healing the involved tissue.

The use of ultrasound in our practice at the Orthopaedic Group advances our goal to continue to innovate and provide our patients with the best possible care.

Bibliographies

Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review. Am J Sports Med. 2011;39(3):656–662.

T Hashiushi, Journal of Shoulder and Elbow Surgery 2011, Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial de Witte PB, Am J Sports Med. 2013, Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and avage versus subacromial corticosteroids.

Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am. 2002;84A(9):1522–1527.
Partington PF, Broome GH. Diagnostic injection around the shoulder: hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg. 1998;7(2):147–150.

Sethi PM, Kingston S, Elattrache N. Accuracy of anterior intra-articular injection of the glenohumeral joint. Arthroscopy. 2005;21(1):77–80- Accuracy of intra-articular injection was 26%

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 Rheumatic Diseases 1997;56:59-63.- 42% accuracy rate.

Pichler W, Weinberg AM, Grechenig S, Tesch NP, Heidari N, Grechenig W. Intra-articular injection of the acromioclavicular joint. J Bone Joint Surg Br. 2009;91(12):1638–1640

Rutten MJ, Collins JM, Maresch BJ, Smeets JH, Janssen CM, Kiemeney LA, et al. Glenohumeral joint injection: a
comparative study of

© 2013 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

The Benefits of Orthopaedic Ultrasound

By Richard A. Bernstein, M.D

Over the last few years, the use of musculoskeletal ultrasound has gained increased popularity.  Ultrasound has been used for decades in many aspects of healthcare for its noninvasive nature and avoidance of exposure to ionized radiation.  Though the bony architecture is not visualized in detail, ultrasound provides incredible insight into the soft tissue structures of the musculoskeletal system.  Historically, musculoskeletal ultrasound has been primarily utilized by radiologists due to equipment costs.  As the technology evolved portable ultrasound has become a cost effective tool in Orthopaedic practice. Noninvasive musculoskeletal ultrasound allows a quick and immediate visualization of soft tissues.

Shoulder

In-office ultrasound allows visualization of partial and full-thickness rotator cuff tears, examination for calcific deposits within the shoulder and also allows for greater accuracy in injecting the specific areas around the shoulder.  Anatomic landmarks were relied on for years to inject the acromioclavicular joint, subacromial space and glenohumeral joints.  However, the advent of musculoskeletal ultrasound helps increase the reliability and accuracy of these injections.  Anatomic visualization of the rotator cuff may now also be done in the office setting.  It does not preclude the use of magnetic resonance imaging (MRI) for labral or other rotator cuff pathology, but ultrasound is a painless inexpensive test, now at our disposal.

Ultrasound-process-applying-gel-to-elbow-for-bernstein-article-(2).pngElbow

Similar to the shoulder, the use of ultrasound aids in the diagnosis of both medial and lateral epicondylitis and cubital tunnel syndrome.  The accuracy of intra-articular aspirations and injections has improved utilizing ultrasound technology.

Hand and Wrist

One of the greatest advantages of in-office ultrasound is the evaluation of hand and wrist soft tissue abnormalities.  The subcutaneous position of these abnormalities allows relatively easy access for diagnostic assessment.  Aneurysms and ganglia may be differentiated by color Doppler ultrasound. For example, a mass that is fluid filled may be a ganglia, whereas a solid mass may be a tumor. Most foreign bodies are non-radiopaque, but diagnostic ultrasound allows the visualization of small foreign bodies buried in the subcutaneous tissue. 

Ultrasound-Machine-for-Bernstein-article-wrist.pngThe differential diagnosis of radial wrist pain includes basal joint arthritis or deQuervains tenosynovitis of the first dorsal compartment.  Identifying the diagnosis clinically may be challenging. However, ultrasound of the first dorsal compartment may show tenosynovial inflammation and thickening of the first dorsal compartment which guides the differential diagnosis.  Thickening or enlargement of the first dorsal compartment may also be easily visualized on ultrasound. In an inflamed wrist, the addition of ultrasound may guide a corticosteroid injection into an inflamed sheath and improve its efficacy.

Superficial traumatic hand lacerations may affect the integrity of underlying tendons. Ultrasound may visualize the intact or lacerated flexor tendons thereby eliminating a need for surgical wound exploration. Foreign bodies may also be readily visualized in the office setting and thereby avoid expensive and time consuming testing.

Ultrasound-Machine-for-Bernstein-article.pngAnother advantage of diagnostic ultrasound is in the diagnosis of carpal tunnel syndrome.  Ultrasound allows for visualization of the median nerve in the wrist. Multiple studies have demonstrated that a median nerve cross sectional area greater than 10mm is consistent with carpal compression.  In hopes of avoiding useful though invasive, neuro-diagnostic testing, a faster painless noninvasive ultrasound may give significant information regarding the diagnosis of an entrapment neuropathy at the wrist.  Furthermore, aspiration and injection of the smaller joints of the hand and wrist are far more accurate with ultrasound guidance. This minimizes patient discomfort.

The rheumatology literature has also reported the beneficial use of ultrasound to identify early inflammatory arthritis. A patient may present with one inflamed finger joint but be found to have inflammatory synovitis of multiple digits by ultrasound, thereby warranting further serologic investigation.

In summary, the utility of musculoskeletal ultrasound is an incredible advantage to the physician and it is an even more important benefit to the patient as it allows for a definitive diagnosis and more effective, less painful treatment.