Cover Story

Diagnostic potential of ultrasound not yet fully realized

Low reimbursement rates for ultrasound may deter orthopedic surgeons from use.

Since its first recorded description in the literature, musculoskeletal ultrasonography has been shown to be beneficial for diagnosis and treatment in orthopedics by providing focused, real-time assessment of soft-tissue vascularity through a non-contrast Doppler scan and in less time than MRI. Its portability, low cost, and use to guide injections and as an educational tool were highlighted by sources for this Cover Story as some advantages of ultrasonography.

Scott P. Steinmann, MD, professor of orthopedic surgery at Mayo Clinic and Orthopedics Today Editorial Board Member, said use of musculoskeletal ultrasonography in academic and private practices has increased in the past 5 years. However, this year Xinning Li, MD, and colleagues reported there is underutilization of ultrasonography compared with MRI, CT and plain radiography.

“Physicians, in general, have been educated with the thought that MRI is the end all, be all, to give us the answer to what the problem is,” Dean W. Ziegler, MD, of Blount Orthopaedic Associates, told Orthopedics Today.

Dean W. Ziegler, MD
Dean W. Ziegler, MD, said diagnostic ultrasonography can be readily incorporated into an orthopedic practice and utilized for the effective and efficient evaluation and management of musculoskeletal disorders.

Source: Darren S. Nabor, MD

Advantages over MRI

But, ultrasonography appears to have some advantages over other types of imaging. It provides a safer option for patients by using high-frequency sound waves compared with fluoroscopy and CT, Steinmann noted.

Ultrasonography has also been shown to have no deleterious effects, according to Theodore T. Miller, MD, FACR, chief of the division of ultrasound in the department of radiology and imaging at Hospital for Special Surgery and professor of radiology at Weill Medical College of Cornell University.

“The risk of any ultrasound guided procedure would be the same as any other time you are sticking a needle into somebody,” Miller said. “You always have to do it with a sterile technique so that you do not introduce an infection to the patient.”

Theodore T. Miller, MD, FACR
Theodore T. Miller

MRI machines are easy to access, however the static images they produce, and the possibility of false negatives, may lead physicians to a misdiagnosis, according to Ziegler.

Furthermore, the static images from MRI and MR arthrography do not provide functional assessment of an injury, which makes it difficult to thoroughly evaluate professional baseball players with ulnar collateral injuries, for example, Michael G. Ciccotti, MD, chief of sports medicine at Rothman Institute and Thomas Jefferson University, said.

In the early 2000s, Ciccotti and his colleagues began to develop a technique to evaluate a professional baseball player’s risk for injury using ultrasound.

“We can maneuver or move the elbow into different positions and we could put stress on it. This simulates what might happen while throwing a ball and we can then correlate what we see injury wise in the ligament to actually how stable or unstable the ligament is with stress under ultrasound,” Ciccotti, who is also head team physician for the Philadelphia Phillies, said.

A physical exam and dynamic ultrasound in conjunction with MRI may help with diagnosis of some conditions that may not be obvious from MRI alone, according to Anthony J. Scillia, MD, of the New Jersey Orthopaedic Institute and clinical associate professor at Seton Hall University.

“I think maybe we could have less utilization of MRI in the early stages, but I do not think we should get to the point where we are not supporting the use of MRI, especially prior to surgery or in refractory cases,” Scillia told Orthopedics Today.

Sources said when injections are needed, ultrasonography can be helpful even though orthopedic surgeons are trained to perform blind injections.

“With ultrasound guidance you can be assured you are putting the cortisone and anesthetic where you want it to be,” Miller said.

Areas of interest

Ultrasound can be used to image any soft tissues, however Scillia noted the hip and shoulder are the areas that stand to benefit most, especially in instances of snapping hip syndrome or biceps instability.

Anthony J. Scillia, MD
Anthony J. Scillia

The knee joint may not benefit from ultrasound as a diagnostic tool or when it is used to inject a small volume of hyaluronic acid (HA), according to Hussein A. Elkousy, MD, of the Fondren Orthopedic Group.

“I do not need an ultrasound to give an intra-articular injection of the knee,” Elkousy said. “The only exception to that rule is if I am giving 5 mL of the hyaluronic acid, which is a viscous substance. If I give it to [patients] without ultrasound into the anterolateral portal of their knee, it hurts them quite a bit, so ultrasound helps me put it through the superior-lateral portal.”

Ultrasound use may be restricted in various joints because it cannot “see” through bone, according to Ciccotti.

“Ultrasonographers have to be creative in how they image structures where there is a lot of bony constraint,” Ciccotti said. “Elbows are straightforward. The shoulder is a little bit more complicated for some of the deeper structures, but the rotator cuff can be visualized well.”

Increased accuracy

An argument in favor of using dynamic ultrasound prior to injection is it will reveal the patient’s pathology to the orthopedic surgeon, which may help with more accurate diagnosis and treatment, according to Scillia.

“Physically, you are increasing the accuracy, so you know for diagnostic purposes what pathologic structure you are anesthetizing. Then, for a clinical treatment, in theory, if you are more accurate you should have better clinical outcomes,” Scillia said.

Ziegler said orthopedists can integrate ultrasound into their practice as an extension of the patient’s physical exam. Ultrasound-guided injections are also beneficial for patients who take anticoagulants since patients do not have to discontinue their blood-thinning medicines for the exam. In addition, it helps keep the injection away from any sensitive sites around the area of interest.

“You see your needle, you can see your target, you can see the thing you want to stay away from, which might be ... a vessel, it might be a nerve, and so you can avoid those structures on your way down to the area of interest,” Miller told Orthopedics Today.

Elkousy noted ultrasound is helpful when performing differential injections and barbotage to break up calcification.

Hussein A. Elkousy, MD
Hussein A. Elkousy

“In the shoulder, if you have adhesive capsulitis and undergo injection into the glenohumeral joint, ultrasound helps you do that without sending [the patient] to radiology to have a fluoroscopic-guided injection,” Elkousy said.

In addition to its role in nonoperative treatment, ultrasound can be used in the OR when a surgeon needs to decide about an incision, Ziegler said.

Use as an educational tool

Not only can ultrasound add diagnostic and diagnostic injection-type treatments to an orthopedist’s armamentarium, but it can help educate residents and fellows on the anatomy, according to Scillia.

Elkousy said, “We have a fellowship and ... one of the components of it is I teach our fellows, if they desire, how to use ultrasound. I think it is helpful and it gives you a perspective on anatomy. It helps you understand MRIs better.”

Ciccotti said learning about ultrasound as a diagnostic tool for musculoskeletal injuries is essential.

“For medical professionals in training, we feel it is important they be aware of its applications, understand the basic principles of its use and be able to interpret these imaging studies in a basic way while subspecialists, like radiologists and ultrasonography radiologists, are going to be focused on all aspects of its use. We believe it is an important part of the evaluation process for many musculoskeletal injuries,” Ciccotti said.

Dynamic ultrasound can also help patients learn about their pathology and become engaged in their treatment and care, Ziegler said.

“[Patients] become an active participant because they can look, they can see. You go over an area where there is pathology and it is painful, [and] they can say that is where it hurts, and I can say that is where the problem is,” he said.

Michael G. Ciccotti, MD
Michael G. Ciccotti

Orthopedists’ use of ultrasound

Orthopedic surgeons may not be as comfortable as other medical professionals when using ultrasound in practice. Mainly used by nonoperative musculoskeletal physicians, doctors in the ED and interventional radiologists, orthopedists are in the minority when it comes to using ultrasound.

“We, as orthopedic surgeons, should certainly be doing [ultrasound], but I do think that the nonoperative musculoskeletal [specialist], whether it is primary care, sports medicine people or physiatrists ... are the ones that are probably using it the most for management of musculoskeletal disorders,” Ziegler said.

Orthopedic surgeons may find performing ultrasound is like arthroscopy, he said.

“I look at [ultrasound] as extremely close to doing arthroscopy because you are looking at a screen, you are moving your hand, you are either rotating the probe or moving the orientation of the probe just like you would the arthroscope or moving the anatomic structure,” Ziegler said. “So, people who do a lot of arthroscopy I think can easily take to using ultrasound and then the same thing with injections because they are used for triangulating with arthroscopy.”

For orthopedic surgeons who want to incorporate ultrasound in their practice, he recommends reading about the technique or watching an instructional video before practicing on “anyone and anything you can.”

“Get a feel for the technique and realize how intuitive it is for you, especially if you do a lot of arthroscopy,” Ziegler said.

Ultrasound findings can be compared with MRI or surgical findings, Ziegler noted, and a machine can be borrowed from a representative for a few weeks if the orthopedist does not have one of his or her own.

“If you have further questions, get in touch with one of us who uses ultrasound regularly,” he said.

Team-based approach

Several sources said ultrasound should be used in a team approach. Orthopedists at Scillia’s institution rely on primary care sports medicine physicians to do diagnostic dynamic ultrasound, as well as ultrasound-guided injections for patients with core muscle injury or sports hernia.

After examining a patient, surgeons and non-surgical clinicians at Hospital for Special Surgery “may send the patient directly to ultrasound for a guided procedure or may ask [radiology colleagues] to help them with a diagnosis by scanning to see what anatomic structure corresponds to the patient’s pain,” Miller said.

However, he said, not all orthopedic surgeons have access to those resources. If the orthopedic surgeon has such access, “I think that is great, use them,” Miller said. “But on the other hand, nature abhors a vacuum, so if you are in private practice in a small community and you do not have access to someone with that kind of expertise, you are going to try to do it on your own.”

Factors to consider

Orthopedic surgeons interested in performing ultrasound should consider the time it takes to learn and perform ultrasound in the clinic, which includes “the time it would take to be trained and feel proficient about the use of ultrasound and then the time in the clinic to do it,” Ziegler said.

The cost to own or lease an ultrasound machine is another consideration. Although inexpensive ultrasound units are now available, units range in price from $30,000 to $35,000. Couple that with a low reimbursement rate and the return on investment is a financial negative, sources noted.

“I bought my ultrasound unit over 10 years ago for $35,000 and because reimbursement was good it paid for itself in a few years,” Elkousy said. “But if it breaks, I will probably not continue doing ultrasound because if I paid $35,000 for a machine it will take me 10 years for a return on investment, so it is not helpful.”

Reimbursement amounts depend on the type of insurance and they vary around the country, according to Steinmann.

Ultrasound graphic

“Medicare, Medicaid pay for [ultrasound], but Medicare rates vary for parts of the country,” Steinmann said. “In the private practice, private insurance payers do tend to cover the injection, but rates depend on the insurance company.”

Elkousy believes the reduced reimbursement may be because ultrasound has been abused by non-orthopedists.

“I think [non-orthopedists] have been using it for things they do not need ultrasound for,” Elkousy said. “For example, [in] injections of knees, routinely it should not be used. I do not need it for a cortisone injection in the knee.”

Furthermore, it should not be used for one of five HA knee injections, but because a lot of physicians used ultrasound for that, the reimbursement was cut substantially, according to Elkousy.

Ultrasound regulations

If any regulations are placed on who can use ultrasound as way of reducing abuse of the technology, Elkousy believes this, combined with low reimbursement, would decrease utilization of ultrasound even more. Currently, the American College of Radiology has placed some credentialing on the use of ultrasound, but not from a musculoskeletal point of view, Miller noted.

“They are typically done for obstetrics and GYN and body imaging, ... looking at the liver, looking at the kidneys, looking at the spleen. But as far as I know, there is no regulation or regulatory body looking at musculoskeletal ultrasound,” Miller said.

Despite the possible misuse and abuse of ultrasound, Steinmann said the procedure is safe and he does not believe regulations need to be placed on who performs it.

“Everybody that I know that is facile at ultrasound has gone to a course, just like any other procedure,” Steinmann said. “I know of nobody who just went and bought a machine and just started doing it.” – by Casey Tingle

Disclosures: Ciccotti, Elkousy, Miller, Scillia, Steinmann and Ziegler report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “Does dynamic ultrasound help surgeons assess postoperative rotator cuff healing better than other imaging modalities?

Since its first recorded description in the literature, musculoskeletal ultrasonography has been shown to be beneficial for diagnosis and treatment in orthopedics by providing focused, real-time assessment of soft-tissue vascularity through a non-contrast Doppler scan and in less time than MRI. Its portability, low cost, and use to guide injections and as an educational tool were highlighted by sources for this Cover Story as some advantages of ultrasonography.

Scott P. Steinmann, MD, professor of orthopedic surgery at Mayo Clinic and Orthopedics Today Editorial Board Member, said use of musculoskeletal ultrasonography in academic and private practices has increased in the past 5 years. However, this year Xinning Li, MD, and colleagues reported there is underutilization of ultrasonography compared with MRI, CT and plain radiography.

“Physicians, in general, have been educated with the thought that MRI is the end all, be all, to give us the answer to what the problem is,” Dean W. Ziegler, MD, of Blount Orthopaedic Associates, told Orthopedics Today.

Dean W. Ziegler, MD
Dean W. Ziegler, MD, said diagnostic ultrasonography can be readily incorporated into an orthopedic practice and utilized for the effective and efficient evaluation and management of musculoskeletal disorders.

Source: Darren S. Nabor, MD

Advantages over MRI

But, ultrasonography appears to have some advantages over other types of imaging. It provides a safer option for patients by using high-frequency sound waves compared with fluoroscopy and CT, Steinmann noted.

Ultrasonography has also been shown to have no deleterious effects, according to Theodore T. Miller, MD, FACR, chief of the division of ultrasound in the department of radiology and imaging at Hospital for Special Surgery and professor of radiology at Weill Medical College of Cornell University.

“The risk of any ultrasound guided procedure would be the same as any other time you are sticking a needle into somebody,” Miller said. “You always have to do it with a sterile technique so that you do not introduce an infection to the patient.”

Theodore T. Miller, MD, FACR
Theodore T. Miller

MRI machines are easy to access, however the static images they produce, and the possibility of false negatives, may lead physicians to a misdiagnosis, according to Ziegler.

Furthermore, the static images from MRI and MR arthrography do not provide functional assessment of an injury, which makes it difficult to thoroughly evaluate professional baseball players with ulnar collateral injuries, for example, Michael G. Ciccotti, MD, chief of sports medicine at Rothman Institute and Thomas Jefferson University, said.

In the early 2000s, Ciccotti and his colleagues began to develop a technique to evaluate a professional baseball player’s risk for injury using ultrasound.

PAGE BREAK

“We can maneuver or move the elbow into different positions and we could put stress on it. This simulates what might happen while throwing a ball and we can then correlate what we see injury wise in the ligament to actually how stable or unstable the ligament is with stress under ultrasound,” Ciccotti, who is also head team physician for the Philadelphia Phillies, said.

A physical exam and dynamic ultrasound in conjunction with MRI may help with diagnosis of some conditions that may not be obvious from MRI alone, according to Anthony J. Scillia, MD, of the New Jersey Orthopaedic Institute and clinical associate professor at Seton Hall University.

“I think maybe we could have less utilization of MRI in the early stages, but I do not think we should get to the point where we are not supporting the use of MRI, especially prior to surgery or in refractory cases,” Scillia told Orthopedics Today.

Sources said when injections are needed, ultrasonography can be helpful even though orthopedic surgeons are trained to perform blind injections.

“With ultrasound guidance you can be assured you are putting the cortisone and anesthetic where you want it to be,” Miller said.

Areas of interest

Ultrasound can be used to image any soft tissues, however Scillia noted the hip and shoulder are the areas that stand to benefit most, especially in instances of snapping hip syndrome or biceps instability.

Anthony J. Scillia, MD
Anthony J. Scillia

The knee joint may not benefit from ultrasound as a diagnostic tool or when it is used to inject a small volume of hyaluronic acid (HA), according to Hussein A. Elkousy, MD, of the Fondren Orthopedic Group.

“I do not need an ultrasound to give an intra-articular injection of the knee,” Elkousy said. “The only exception to that rule is if I am giving 5 mL of the hyaluronic acid, which is a viscous substance. If I give it to [patients] without ultrasound into the anterolateral portal of their knee, it hurts them quite a bit, so ultrasound helps me put it through the superior-lateral portal.”

Ultrasound use may be restricted in various joints because it cannot “see” through bone, according to Ciccotti.

“Ultrasonographers have to be creative in how they image structures where there is a lot of bony constraint,” Ciccotti said. “Elbows are straightforward. The shoulder is a little bit more complicated for some of the deeper structures, but the rotator cuff can be visualized well.”

PAGE BREAK

Increased accuracy

An argument in favor of using dynamic ultrasound prior to injection is it will reveal the patient’s pathology to the orthopedic surgeon, which may help with more accurate diagnosis and treatment, according to Scillia.

“Physically, you are increasing the accuracy, so you know for diagnostic purposes what pathologic structure you are anesthetizing. Then, for a clinical treatment, in theory, if you are more accurate you should have better clinical outcomes,” Scillia said.

Ziegler said orthopedists can integrate ultrasound into their practice as an extension of the patient’s physical exam. Ultrasound-guided injections are also beneficial for patients who take anticoagulants since patients do not have to discontinue their blood-thinning medicines for the exam. In addition, it helps keep the injection away from any sensitive sites around the area of interest.

“You see your needle, you can see your target, you can see the thing you want to stay away from, which might be ... a vessel, it might be a nerve, and so you can avoid those structures on your way down to the area of interest,” Miller told Orthopedics Today.

Elkousy noted ultrasound is helpful when performing differential injections and barbotage to break up calcification.

Hussein A. Elkousy, MD
Hussein A. Elkousy

“In the shoulder, if you have adhesive capsulitis and undergo injection into the glenohumeral joint, ultrasound helps you do that without sending [the patient] to radiology to have a fluoroscopic-guided injection,” Elkousy said.

In addition to its role in nonoperative treatment, ultrasound can be used in the OR when a surgeon needs to decide about an incision, Ziegler said.

Use as an educational tool

Not only can ultrasound add diagnostic and diagnostic injection-type treatments to an orthopedist’s armamentarium, but it can help educate residents and fellows on the anatomy, according to Scillia.

Elkousy said, “We have a fellowship and ... one of the components of it is I teach our fellows, if they desire, how to use ultrasound. I think it is helpful and it gives you a perspective on anatomy. It helps you understand MRIs better.”

Ciccotti said learning about ultrasound as a diagnostic tool for musculoskeletal injuries is essential.

“For medical professionals in training, we feel it is important they be aware of its applications, understand the basic principles of its use and be able to interpret these imaging studies in a basic way while subspecialists, like radiologists and ultrasonography radiologists, are going to be focused on all aspects of its use. We believe it is an important part of the evaluation process for many musculoskeletal injuries,” Ciccotti said.

PAGE BREAK

Dynamic ultrasound can also help patients learn about their pathology and become engaged in their treatment and care, Ziegler said.

“[Patients] become an active participant because they can look, they can see. You go over an area where there is pathology and it is painful, [and] they can say that is where it hurts, and I can say that is where the problem is,” he said.

Michael G. Ciccotti, MD
Michael G. Ciccotti

Orthopedists’ use of ultrasound

Orthopedic surgeons may not be as comfortable as other medical professionals when using ultrasound in practice. Mainly used by nonoperative musculoskeletal physicians, doctors in the ED and interventional radiologists, orthopedists are in the minority when it comes to using ultrasound.

“We, as orthopedic surgeons, should certainly be doing [ultrasound], but I do think that the nonoperative musculoskeletal [specialist], whether it is primary care, sports medicine people or physiatrists ... are the ones that are probably using it the most for management of musculoskeletal disorders,” Ziegler said.

Orthopedic surgeons may find performing ultrasound is like arthroscopy, he said.

“I look at [ultrasound] as extremely close to doing arthroscopy because you are looking at a screen, you are moving your hand, you are either rotating the probe or moving the orientation of the probe just like you would the arthroscope or moving the anatomic structure,” Ziegler said. “So, people who do a lot of arthroscopy I think can easily take to using ultrasound and then the same thing with injections because they are used for triangulating with arthroscopy.”

For orthopedic surgeons who want to incorporate ultrasound in their practice, he recommends reading about the technique or watching an instructional video before practicing on “anyone and anything you can.”

“Get a feel for the technique and realize how intuitive it is for you, especially if you do a lot of arthroscopy,” Ziegler said.

Ultrasound findings can be compared with MRI or surgical findings, Ziegler noted, and a machine can be borrowed from a representative for a few weeks if the orthopedist does not have one of his or her own.

“If you have further questions, get in touch with one of us who uses ultrasound regularly,” he said.

Team-based approach

Several sources said ultrasound should be used in a team approach. Orthopedists at Scillia’s institution rely on primary care sports medicine physicians to do diagnostic dynamic ultrasound, as well as ultrasound-guided injections for patients with core muscle injury or sports hernia.

After examining a patient, surgeons and non-surgical clinicians at Hospital for Special Surgery “may send the patient directly to ultrasound for a guided procedure or may ask [radiology colleagues] to help them with a diagnosis by scanning to see what anatomic structure corresponds to the patient’s pain,” Miller said.

PAGE BREAK

However, he said, not all orthopedic surgeons have access to those resources. If the orthopedic surgeon has such access, “I think that is great, use them,” Miller said. “But on the other hand, nature abhors a vacuum, so if you are in private practice in a small community and you do not have access to someone with that kind of expertise, you are going to try to do it on your own.”

Factors to consider

Orthopedic surgeons interested in performing ultrasound should consider the time it takes to learn and perform ultrasound in the clinic, which includes “the time it would take to be trained and feel proficient about the use of ultrasound and then the time in the clinic to do it,” Ziegler said.

The cost to own or lease an ultrasound machine is another consideration. Although inexpensive ultrasound units are now available, units range in price from $30,000 to $35,000. Couple that with a low reimbursement rate and the return on investment is a financial negative, sources noted.

“I bought my ultrasound unit over 10 years ago for $35,000 and because reimbursement was good it paid for itself in a few years,” Elkousy said. “But if it breaks, I will probably not continue doing ultrasound because if I paid $35,000 for a machine it will take me 10 years for a return on investment, so it is not helpful.”

Reimbursement amounts depend on the type of insurance and they vary around the country, according to Steinmann.

Ultrasound graphic

“Medicare, Medicaid pay for [ultrasound], but Medicare rates vary for parts of the country,” Steinmann said. “In the private practice, private insurance payers do tend to cover the injection, but rates depend on the insurance company.”

Elkousy believes the reduced reimbursement may be because ultrasound has been abused by non-orthopedists.

“I think [non-orthopedists] have been using it for things they do not need ultrasound for,” Elkousy said. “For example, [in] injections of knees, routinely it should not be used. I do not need it for a cortisone injection in the knee.”

Furthermore, it should not be used for one of five HA knee injections, but because a lot of physicians used ultrasound for that, the reimbursement was cut substantially, according to Elkousy.

Ultrasound regulations

If any regulations are placed on who can use ultrasound as way of reducing abuse of the technology, Elkousy believes this, combined with low reimbursement, would decrease utilization of ultrasound even more. Currently, the American College of Radiology has placed some credentialing on the use of ultrasound, but not from a musculoskeletal point of view, Miller noted.

PAGE BREAK

“They are typically done for obstetrics and GYN and body imaging, ... looking at the liver, looking at the kidneys, looking at the spleen. But as far as I know, there is no regulation or regulatory body looking at musculoskeletal ultrasound,” Miller said.

Despite the possible misuse and abuse of ultrasound, Steinmann said the procedure is safe and he does not believe regulations need to be placed on who performs it.

“Everybody that I know that is facile at ultrasound has gone to a course, just like any other procedure,” Steinmann said. “I know of nobody who just went and bought a machine and just started doing it.” – by Casey Tingle

Disclosures: Ciccotti, Elkousy, Miller, Scillia, Steinmann and Ziegler report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “Does dynamic ultrasound help surgeons assess postoperative rotator cuff healing better than other imaging modalities?