The sonographic community has the opportunity to take advantage of recent orthopedic surgeons’ interest in diagnostic ultrasound. Although much of the interest was prompted by the usefulness of guided injections, sonographers need to fully appreciate and understand the value of the information derived from an ultrasound study, which will ultimately lead the surgeon to better surgical decisions and better patient outcomes. Once you are a part of the orthopedic diagnostic team, you will be able to function as a specialist Physician Assistant member, adding a new dimension to the orthopedic practice and demonstrating the incredible value of diagnostic soft tissue imaging.
I am a Board-Certified Orthopedic Surgeon, with subspecialty in shoulder orthopedics including arthroscopy and open surgery. I incorporated diagnostic shoulder/MSK ultrasound as part of my office practice 20 years ago especially for evaluation of patients presenting with protracted shoulder pain (in addition to the traditional history and physical exam, and occasional MRI).
I have valued diagnostic shoulder imaging in my practice and determined that all Orthopedic Surgeons should be using ultrasound imaging as part of their usual diagnostic evaluation of patients (especially patients presenting with protracted painful shoulder problems affecting function). In addition, an ultrasound exam with normal findings may be more important than an ultrasound exam that finds some pathology.
I have concluded that the real-time ultrasound examination with comparison to the contralateral side available to the orthopedic surgeon, in most cases, is more valuable than the information obtained from the MRI (especially regarding soft tissue pathology, present or absent).
For example, compare the MRI detail of the supraspinatus with the ultrasound motion clip of the supraspinatus moving under the acromion (see the still MR image below and, at bottom of the page, the 1st video, which is the active ultrasound clip of the supraspinatus). MRI is accomplished with arms immobilized at one’s side, and does not benefit from the study being compared to the contralateral side. However, it produces a nice clear image. The ultrasound image in long axis can be a still image or a motion clip viewing the supraspinatus or infraspinatus moving under the acromion and the reaction causing impingement syndrome, spurs along the anterior lateral border of the acromion, dynamic sub acromial bursitis, or a rotator cuff tear, which may be attritional and similarly present on viewing the asymptomatic shoulder.
The Math
The following statistics help to identify the future vital need for the sonographer to become part of the team working with the surgeon in an orthopedic office practice (Orthopaedic Surgeon Quick Facts, www.aaos.org; 10 Interesting Statistics and Facts About Orthopedic Practice, www.beckersspine.com; Am J Orthop 2016;45(2):66-67; 20 Things to Know About Orthopedics, www.beckershospitalreview.com).
There are approximately 28,000 (2012) orthopedic surgeons in the US, 75% of whom are in private practice, and many are in group practices of 2 or more. The general orthopedic surgeon sees an average of 70-90 patients per week, of which an estimated 12% or more have shoulder problems. This equates to 10 orthopedic shoulder evaluations per week for 1 solo general orthopedic practice, and 20 for a 2-man group (in the same office). Ten to 20 patients (minimum) per week would then benefit from ultrasound imaging information, assisting the surgeon in making a surgical decision.
The following image identifies how important the cross axis image is, as well as describes the degree of rotator cuff injury and approximates the relative number of rotator cuff muscle tendon units that have been rendered dysfunctional.
Left, Close to the infraspinatus/supraspinatus interval and insertion site, many fibers are in harm’s way for tendon/fibril tearing. Center, The area for careful X-axis grid examination, looking for possible partial undersurface tearing, fibers losing their connection/attachment to the footplate. Right, Example of an X-axis grid examination of this full-thickness tendon tear, which should be accompanied by an x-axis measurement of the width/base of the triangular tear. Real time examination can help to identify the quality of the tissue, which may require repair. Usually, orthopedic surgeons pay more attention to the MRI reading and the coronal views (ultrasound long axis view). (See the 2nd video clip below for real-time imaging of the X-axis rotator cuff tear.) The X-axis view/measurement is the more important image. The wider the tear, the more tendon fibrils are affected and the more dysfunction to the rotator cuff area involved.
This need for diagnostic shoulder ultrasound information could be sufficient and important enough to support an entire career for an MSK sonographer. All the other valuable areas of MSK expertise that come with the MSK sonographer would be an extra bonus to the orthopedic office practice: helping with other ultrasound examinations, diagnosis, and surgical decisions.
Video clip 3 below is an MSK ultrasound examination for CTS identifying median nerve mobility or restriction within the tissue, questioning the presence of scar tissue restricting motion.
How have you used ultrasound in orthopedic surgery? What other areas of ultrasound are on the brink of emerging in a new field? Comment below or let us know on Twitter: @AIUM_Ultrasound.