Applications of Muskuloskeletal Ultrasound · Applications •Diagnostic Ultrasound –Can be used...

22

Applications of Muskuloskeletal Ultrasound

Kush Patel, MDBone and Joint Center, UPMC Pinnacle

3

Objectives

• discuss basics of ultrasound, indications, and common applications

• discuss common pathophysiologic findings seen on ultrasound

• demonstration of shoulder ultrasound

UPMC LIFE CHANGING MEDICINE

4

Disclosure Statement

Nothing to dislose.


5

Ultrasound Basics

• Physics – Sound waves are transmitted in arrays– 2D picture of plane beneath probe– Tissue properties determine the

behavior of the sound waves which is then created into an image.

– Different probes produce different images• Higher Frequency = more resolution

but less penetration• Lower frequency = less resolution but

deeper penetration


6

Terminology

– Anechoic: Black (i.e., no reflection)

– Hypoechoic: Dark, relative to the surrounding structures (i.e., less reflection)

– Isoechoic: Same shade of gray as another structure

– Hyperechoic: Bright, relative to the surrounding structures (i.e., high reflection

hyperechoic

Echogenicity

isoechoic

(anechoic) I

hypoechoic

Hyperechoic: Bone, ligament, dura, nerves

lsoechoic: Muscles

Hypoechoic: lntrathecal space, CSF, blood, fluids


7

Terminology

Anisotropy: Artifactual hypoechoic/anechoic appearance from oblique angle so that sound waves are reflected away from transducer (false-positive interpretation)

Posterior Acoustic Shadowing: hypoechoic/anechoic region deep to an area of high attenuation (i.e., bone or calcium)

Jacobson, J. A. (2013). Fundamentals of musculoskeletal ultrasound. Philadelphia, PA: Elsevier/Saunders.

FIGURE 1- 3 @ Transducer movements. A, Heel-toe maneuver. B, Toggle maneuver. (Mo .. .

UPMC ~.:!NGING MEDICINE

8

Applications

• Diagnostic Ultrasound– Can be used as an adjunct to the physical exam– Done at bedside– Sideline Emergency Assessment

• Interventional Ultrasound – allows accurate needle placement– Diagnostic or Therapeutic injections– Advanced Procedures


9

Common Findings on Diagnostic Exam

• Tendons - Tendinopathy, Calcifications, partial tears, full thickness tears

• Ganglion cysts, hematoma, joint effusion

• Arthritic changes


10

Tendinopathy


Madden, Christopher C. Netter's Sports Medicine. Elsevier, 2018.

8. ::.e\·ere tend no:sis or the co·1mon ex·c NL1lc the.· c.omµldc.· lo~!: ul 1il, i1IJ1 c.·<.hl)I<.· ! ,l,'f()•.-1· .i ..

UPMC ~.:NGING MEDICINE

11

Calcific Tendinapthy



12

Partial Thickness Tear


D

UPMC ~~NGING MEDICINE

13

Full Thickness Tear


J

UPMC ~::NGING MEDICINE

14

Dynamic Testing

• Impingement Syndrome

• Elbow– Ulnar nerve instability

– UCL tear

• Long Head Biceps subluxation

Beggs I, et al. Musculoskeletal Ultrasound Technical Guidelines I. Shoulder. European Society of Musculoskeletal Radiology. 2010


15

Beggs I, et al. Musculoskeletal Ultrasound Technical Guidelines II. Elbow. European Society of Musculoskeletal Radiology. 2010 UPMC LIFE

CHANGING MEDICINE

16

Interventional Applications

● Needle guidance for Injections

○ Corticosteroid injections

○ Percutaneus Needle Tenotomy

○ Percutaneus Ultrasonic Tenotomy

○ Platelet-Rich-Plasma

● Advanced Procedures

○ Radiofrequency Ablation of Genicular Nerves for Knee Pain

○ Percutaneus Ultrasound Guided Carpal Tunnel Release

Madden, Christopher C. Netter's Sports Medicine. Elsevier, 2018.


17

Corticosteroid injections

Is most effective when combined with other treatment modalities

Can be effective to decrease pain and inflammation

Relatively safe with only rare side effects.

Early studies in animal models showed possibility of increased cartilage destruction but other studies show no significant cartilage degradation with even multiple injections UPMC LIFE

CHANGING MEDICINE

18

Palpation vs. US Guided Injections

Hall M. Curr Sports med Rep. 2013 Sep-Oct;12(5):296-303. doi: 10.1097/01.CSMR.0000434103.32478.36.

Table. Accuracy ranges for selected peripheral joint injections.

Joint Palpation (Cadaver) Palpation (Clinical) US Guided (Cadaver) US Guided (Clinical)

Glenohumeral 50% to 96% (10, 15, 18- 20) 10% to 100% (7- 9, 11- 14, 16, 17) 93% (20) 97% to 100% (21 - 23)

Acromioclavicular 40% to 72% (24-28)

Elbow

Wrist

Hip

Knee

Tibiotalar

Subtalar

60% to 80% (51 - 54)

55 % to 100% (64,65)

78% to 100% (7,43,72- 74)

68% to 100% (72,75- 78)

39% to 50% (29,30)

38 % to 100% (7,41 - 43)

25% to 97% (7,41,43)

51 % to 78% (51 - 54)

40% to 100% (7,41,42,58- 63)

67 % to 77% (7,43,72- 74)

90% to 100% (24,27 ,28) 100% (31)

97% (55- 57, 107)

100% (65)

91 % to 100% (41,42)

79% to 94% (42,44)

100% (55- 57, 107)

75 % to 100% (22,58,66- 68)

90% to 100% (72,75- 78)


19

Percutaneus Needle Tenotomy/Fenestration

Aim is to restart the healing response

Agure 1. Images from a 64-)ear-Old man with duonc: n<;,t lateral elboN pas, mting his abffily to play tennis. Al1Er lrealmenl the palielrt ll!CDll0"ed fully witlm 12 weelcs ard remained asymptomalic: 4 )ears later. A, Loocjtudml soricx,arn of the lateral elxMr shoM lhic:kening and hetm,geneity of the CIT (arr<MIS) consistent with tencslosis, with intrastbstanc:e tears !asterisk>, calc:ffic:alions (;irrCM'head), .-xi marked irregularity of the lateral epic:ondyle (0_ B, An 18--gauge nee<le has been advanced into the tendon substance. The tip of the needle was subsequently used to fenestrate the tendoo, brealc up the calcifications, .-xi abrade the bony margin. C. The needle is SOOM1 breamg off an enthesiophyte (arrow) from the lateral epic:ondyle. D, The needle is then inserted into the tendon from a supenor to inferior awcach, which malces ii easier to place the needle tangential to the plane of the lateral epic:ondyle. The bony irregularity was swsequently abraded with the needle Up.

A B

C D

J Ultrasound Med 2006; 25:1281- 1289 1283 UPMC ~::NGING

MEDICINE

20

McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. J Ultrasound Med 2006;25(10):1281–9.

Sonographically Guided Percutaneous Needle Tenotomy for Treatment of Common Extensor Tendinosis in the Elbow

John M. Mcshane, MD, Levon N. Nazarian, MD, Marc I. Harwood, MD

Objective. Chronic tendinosis of the common extensor tendon of the lateral elbow can be a diffJCult problem to treat. We report our experience with sonographically guided percutaneous needle tenotomy to relieve pain and improve function in patients with this condition. Methods. We performed sonographically guided perrutaneous needle tenotomy on 58 consecutive patients who had persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle W"5 advanced into the common extensor tendon, and the tip of the nee

dle W"5 used to repeatedly fenestrate the tendinotic tissue. Cakifications. if present. were mechanically fragmented. and the adjacent bony surface of the apex and face of the epicondyle were abraded. Finally, the fenestrated tendon was infiltrated with a solution containing corticosteroid mixed w ith bupivacaine. After the procedure, patients were instructed to perform passive stretches and to undergo physical therapy. During a subsequent telephone interview, patients answered questions about

their experience, their functioning level, and their perceptions of procedure outcome. Results. Fiftyfe,e (95%) of 58 patients were contacted by telephone and agreed to participate in the study. Thirtyfe,e (63.6%) of 55 responclents reported excellent outcomes, 16.4% good, 7.3% fair, and 12.7% poor. The average follow-up time from the date of the procedure to the date of the interview was 28 months (range, 17-44 months). No adverse events were reported; 85.5% stated that they would refer a friend or close relatiive for the procedure. Condusions. Sonographically guided percutaneous nee

dle tenotomy for lateral elbow tendinosis is a safe, effectiive, and viable alternatiive for patients in whom all other nonsurgical treatments failed. Key words: common extensor tendon; elbow; needle; sonography; tennis elbow; tendinosis.

UPMC ~::!HGING MEDICINE

21

McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med 2008;27(8):1137–44.

Sonographically Guided Percutaneous Needle Tenotomy for Treatment of Common Extensor Tendinosis in the Elbow Is a Corticosteroid Necessary?

John M. McShane, MD, Vinil N. Shah, MD, Levon N. Nazarian, MD

Objective. Chronic refractory common extensor tendinosis of the lateral elbow has been shown to respond to sonographical~ guided percutaneous needle tenotomy (PND followed by corticosteroid injection. In this ana~. we attempted to determine whether the corticosteroid is a necessary component of the procedure. Methods. We performed PNT on 57 consecutive patients (age range, 34-61 years) with persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle was advanced into the tendon, and the tip of the needle was used to fenestrate the tendinotic tissue, break up any calcifications, and abrade the adjacent bone. After the procedure, patients undeiwent a specified physk:al therapy protocol. During a subsequent telephone interview, patients answered quesfons about their symptoms, the level of functioning, and per· ceptions of the procedure outcome. Results. Of the 52 patients who agreed to participate in the study, 30 (57.7%) reported excellent outcomes, 18 (34.6%) good, 1 (1.9%) fair, and 3 (5.8%) poor. The average follow-up time from the date of the procedure to the telephone interview was 22 months (range, 7-38 months). No adverse events were reported, and 90% stated that they would refer a friend or dose relative for the procedure. Condu.sions. Sonographical~ guided PNT for refractory lateral elbow tendinosis is an effective procedure, and subsequent corticosteroid injection is not necessary. Key words: common extensor tendon; elbow; needle; sonography; tendinosis; tennis elbow.

Table 3. Responses to Questionnaire Regarding the 52 Treated Elbows

Task None M ild Dlfflcul~ Level, n (%)

Moderate Unable NA

Turning a doorknob 49 (94.2) 2 (3.8) 0(0) 1 (1.9) 0 (0) Carrying a bag of groceries 41 (78.8) 10(19.2) 0(0) 1 (1.9) 0(0) Lifting a rup or glass to mouth 49 (94.2) 1 (1.9) 0(0) 1 (1.9) 1 (1.9) Opernng a jar 39 (75) 8(15.4) 1 (1.9) 2 (3.8) 2 (3.8) Wringing a washcloth 42 (80.8) 9(17.3) 0(0) 1 (1.9) 0(0) Vacuuming 39 (75) 6 (11.5) 0(0) 2(3.8) 5 (9.6) Unloading a dishwasher 48 (92.3) 1 (1.9) 0(0) 1 (1.9) 2 (3.8) Performing a usual job 37 (71.2) 10(19.2) 1 (1.9) 1 (1.9) 3 (5.8) Recreallon or sports actMbes 25 (48.1) 18(34.6) 2 (3.8) 2 (3.8) 2 (3.8)

Palients were asked to rate the degree of d1ff1CUlty In performing specific tasks over the past week. NA indicates not applicable.

UPMC ~\:NGING MEDICINE

22

Housner JA, Jacobson JA, Morag Y, et al. Should ultrasound-guided needle fenestration be considered as a treatment option for recalcitrant patellar tendinopathy? A retrospective study of 47 cases. Clin J Sport Med 2010;20(6):488–90.

Shoulld Ultrasound-Guid,ed Needle Fenestration Be Considered as a Treatment Option for Recalcitrant Patellar

Tendinopathy? A Retrospective Study of 47 Cases Jeffrey A. Housne,; MD, ''f Jon A. Jacobson, MD,/ Yoav Morag, MD,/ George Guntar A. Pujalte, MD, f

Rebecca M. Northway. MD.§ and Tracy A. Boon, AAS, RDMS, RVT/

Objectiw: To repon the retrospcc1ive resul1< ofultrasoun<l,.guided needle fooeruation for the treatment of rooilcitmnt patellar tendinopao,y.

Design : Reuospective follow-up srudy.

Setting: Unive rsity outpatient sports medicine dinie.

Patien ts: Forty-seven patellar tendons in 32 patients (26 men and 6 women; mean •ge, 26 year,,) with recalcitr.lnt patellar tcndinopathy. DiagMsis made via hisiory. physical examination, and sonov,1phie examination.

lnten ·entioo: Ultrosound-guided needle fenestmtion o.fte,- failure of conservati,e mrut3gement.

Maio Outcome Measures: Pre-1reatmen1 and 4-week clinical follow-up detenninotion offilnctionlll octivity score. Phone follow-up determination or best achie,able te,el of acti, ity and satisfaction score of the procedure.

Results: Avemge tune to follow-up wos 45 months. Se\'Cnty-fl'o pen:ent of pati..,1< reported exeellent or good results when questioned regarding retum U> activity. Thenty~ight percent of patients were unable to return to their desired activity level. Six patient1 subsequenlly undetv.-ent surgical lreatrnent. One a1hle1e underwent surgery"' repair a patellar tendon ruprure that oocurred 6 weeks aller the procedure. Eigh,y-0ne percent of patient< reported exeellc,,t or good satisfaction scores.

Conclusions: Ultra.sound-guided needle fenestmtion wamu11< fur.

ther in, e:<tigation for the treatn>ent of re<:alei1r.1nt patellar tendinopa~1y. UPMC LIFE CHANGING MEDICINE

23

Jacobson JA, Rubin J, Yablon CM, et al. Ultrasound-guided fenestration of tendons about the hip and pelvis: clinical outcomes. J Ultrasound Med 2015; 34(11):2029–35

Ultrasound-Guided Fenestration of Tendons About the Hip and Pelvis Clinical Outcomes

Jon A. Jacobson, MD,Josl,ua Rubi11, MD, Corrie M. Yablo11, MD, Sung Moon J(jn,, MD, Monica Kalume-Brigido, AID, Aishwarya Paramcswaran, MS

Objedives- Percutaneous ultrasound-guided needle fenestrabon has been used to treat tendinopathy of the elbow, knee, and ankle with promising results.. The purpose of this study was to evah1.1te the clinical outcome of ultrasound-guided fenestration of tendons

about the hip and pelvis.

M,thod!- After Institutional ~view Boord approval, a retrospective search of imaging

reports from January I, 2005, to June 30, 2011, was completed to identify patients treated with ultrasound-guided tendon fenestration about the hip or pelvis. Subsequent clinic notes wen, n,trospectively reviewed to determine wht>ther the patient showed

marked improvement, some improvement, no change, or worsemng symptoms.

Results- The study group consisted of 22 tendons in 21 patients with an average age

of SS.8 years (range, 26. 7-77.0 years). The treated tendons included 11 gluteus medius (9 tendmosis and 2 partial tears), 2 gluteus minimus (both tendinosis), 8 hamstring (6 tt>ndinosis and 2 partial tears), and I tensor fascia latae (tendino,is). The average

interval to clmical follow-up was 70 days (range, 7-81 3 days). There was marked in1provement in 45.5'16 ( 10 of22), some improvt>n1enl in 36.4'16 (8 of22), no change in symptoms in 9. J'J(, (2of22), and worsenings-ymptomsin 9, J'J(, (2 of22). There were

no patient variables ( age, chronicity of symptoms, sex, tendon, tendinosis versus tear, prior physical therapy, and prior corticosteroid injection) that wen, significantly differt>nl

between patients who improved and those who dKI not. There were no cases of a subsequent tendon tear or inkction.

Corn:lu.siom-Clinical foOow-up after ultrasound-guided fenestration of the gluteus

med.ms, gluteus mirumus, proximal hamstnng, and tensor fascia latae tendons showed that 82% of patients had improvement in their symptoms.

Figure 1. Images from a 71-year-ofd wooianwith gluleus medius lendi· nosis and fenestration. A. Sonograrn in a long-axis orienlation to the gluleus medius show,ig alnormal hypoed1oic erugement of the gfuleus mecfnJS tendon (arrows)al the supemposlerior lacel of the greater Uochanter (GTI. B. Twenty- needa, (arrov.tleads) during fenestration (lelt side of image is cephaladl.


24

Percutaneus Ultrasonic TenotomyBased off opthalmology procedure for removal of cataracts via ultrasonic energy

Tenex Tx Procedure

https://youtu.be/OLV5xad5lKk


https://youtu.be/OLV5xad5lKk

25Peck E., Jelsing E., and Onishi K. Phys Med Rehabil Clin N Am 27 (2016) 733–748

67 total cases. Improvement in pain and functional scores were noted as early as 1 week and as late as 2 months postprocedure, with no reported complications.

Table 1 Oinical studies of PUT

Average Duration Authorlsl. Year Dia11nosis Treated of S~ml!!oms (mo) Samele Size Outcome Measurements Results

Elattraclie & Morrey. 26 Patellar tendinopathy Not reported 16 Return to previous level of play Approximately 63% of subjects 2013 returned to previous level

with >93"- verbalizfog some i m rove me nt.

Koh et al.27 2013 Common extensor 13 20 VAS, DASH. sonographic VAS improvement at week 1. tendinopathy appearance of tendon, patient with progre~ive improvement

satisfaction. complications over 12 mo. DASH improved at 3, 6. and 12 mo postprocedure. At least 85% of tendons showed improved morphologic characteristics at 6 mo postprocedure; 95% of patients verbalfaed satisfaction.

Barnes et al,:ia 2015 Common extensor and At least 6 12 (CEn; VAS, QuickOASH. MEPS, VAS improvement at week 6, common flexor/pronator 7 (CFPT) complic.ations with progressive improvement tendinopathy over 12 mo. QuiciDASH and

MEPS stayed improved for 12mo.

Patel. 29 2015 Plantar fasciopathy 19 12 AOFAS Average AOFAS impro\'ed from 30 to 88. All subjects were pain-free by 24 mo.

Al I studies noted are c.ase series. Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale; CET, elbow common extensor tend inopathy; CFPT, elbow common

flexor/pronator tendinopathy; DASH, Disabilities of the Arm. Shoulder, and Hand Score; MEPS, Mayo Elbow Performance Score; QuidDASH, shortened version of DASH score.


26

Platelet-Rich-Plasma (PRP)

Deposit blood products that aid in the healing response


27

Stem Cell InjectionsHematopoietic •• Red blood

stem cells (HSCs) -· cells

/

~ cells

•K ·"· Platelets ,t"~ a

ASPIRATE BONE MARROW INJECT INTO DISEASED AREA

28

Demonstration


29

Advantages

• Available at bedside and generated in real time– Can examine site of injury and discuss injury with patient during exam

• Excellent visualization of superficial structures• No radiation exposure• Lower Cost (compared to MRI)• Can test Dynamic motion and compare to ipsilateral side

– Shoulder - Biceps Instability, Impingement view– Elbow - Ulnar nerve subluxation

• Accurate needle placement– Helps avoid nerve or intravascular puncture


30

Disadvantages

• User-Dependent modality

• Anisotropy

• Cannot penetrate bone– Only surface of bone can be seen

• Difficult to see deeper structures– shoulder or hip labrum

– ACL/PCL, meniscusUPMC LIFE

CHANGING MEDICINE

31

References

• Ayhan E, Kesmezacar H, Akgun I. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop. 2014;5(3):351–361. Published 2014 Jul 18. doi:10.5312/wjo.v5.i3.351

• Beggs I, et al. Musculoskeletal Ultrasound Technical Guidelines I. Shoulder. European Society of Musculoskeletal Radiology. 2010 • Beggs I, et al. Musculoskeletal Ultrasound Technical Guidelines II. Elbow. European Society of Musculoskeletal Radiology. 2010 • Berkoff DJ, English J, Theodoro D. Sports medicine ultrasound (US) beyond the musculoskeletal system: use in the abdomen, solid organs, lung, heart

and eye. British Journal of Sports Medicine 2015;49:161-165.• Hall M. Curr Sports med Rep. 2013 Sep-Oct;12(5):296-303. doi: 10.1097/01.CSMR.0000434103.32478.36.• Housner JA, Jacobson JA, Morag Y, et al. Should ultrasound-guided needle fenestration be considered as a treatment option for recalcitrant patellar

tendinopathy? A retrospective study of 47 cases. Clin J Sport Med 2010;20(6):488–90.• Jacobson, J. A. (2013). Fundamentals of musculoskeletal ultrasound. Philadelphia, PA: Elsevier/Saunders.• Jacobson JA, Rubin J, Yablon CM, et al. Ultrasound-guided fenestration of tendons about the hip and pelvis: clinical outcomes. J Ultrasound Med

2015; 34(11):2029–35• Madden, Christopher C. Netter's Sports Medicine. Elsevier, 2018.• McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the

elbow. J Ultrasound Med 2006;25(10):1281–9.• McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the

elbow: is a corticosteroid necessary? J Ultrasound Med 2008;27(8):1137–44.• Peck E., Jelsing E., and Onishi K. Phys Med Rehabil Clin N Am 27 (2016) 733–748• Petrover D, Silvera J, De Baere T, Vigan M, Hakimé A. Percutaneous Ultrasound-Guided Carpal Tunnel Release: Study Upon Clinical Efficacy and

Safety. Cardiovasc Intervent Radiol. 2016;40(4):568–575. doi:10.1007/s00270-016-1545-5


3232UPMC LIFE

CHANGING MEDICINE

3333UPMC LIFE

CHANGING MEDICINE

Applications of Muskuloskeletal Ultrasound · Applications •Diagnostic Ultrasound –Can be used...

Documents

Transcript of Applications of Muskuloskeletal Ultrasound · Applications •Diagnostic Ultrasound –Can be used...