A Guide to Ultrasound of the Shoulder, Part 3: Interventional and Procedural Uses
Ultrasound is an extremely useful diagnostic tool for physicians, but recent advances have found that ultrasound’s greatest utility is in interventional and procedural uses. Numerous studies have demonstrated a significant improvement in outcome and patient satisfaction when using ultrasound guidance for injections. Newer techniques are emerging to use ultrasound as an aid to surgery and interventional procedures. This allows the physician to use smaller incisions and less invasive methods, which are also easier to use for the practitioner and more cost-effective.
Ultrasound-Guided Procedures
Many injectable therapeutic options exist as interventions. Cortisone, hyaluronic acid, platelet-rich plasma (PRP), stem cells/bone marrow concentrate (BMC), amniotic fluid, prolotherapy, and saline are now commonly used.16-17 A meta-analysis of the literature assessing the accuracy of ultrasound-guided shoulder girdle injections vs a landmark-guided injection was done in 2015.18 It showed that for the acromioclavicular joint, accuracy was 93.6% vs 68.2% (P < .0001), based on single studies. The accuracy of ultrasound vs a landmark-guided injection was 65% vs 70% for the subacromial space (P > .05); 86.7% vs 26.7% for the biceps tendon sheath (P < .05); and 92.5% vs 72.5% for the glenohumeral joint (P = .025).18
With cortisone, injecting into muscle, ligament, or tendons could potentially harm the tissue or cause worsening of the disease process.19-20 With the advent of orthobiologics, injecting into these structures is now desirable, instead of a potential complication.19-20 Ultrasound has become even more important to the accurate delivery of these therapies to the disease locations. Multiple studies using leukocyte-poor PRP for osteoarthritis show significant differences in pain scores.21-23 Peerbooms and colleagues24,25 also showed that PRP reduced pain and increased function compared to cortisone injections for lateral epicondylitis in 1- and 2-year double-blind randomized controlled trials. Centeno and colleagues26 performed a prospective, multi-site registry study on 102 patients with symptomatic osteoarthritis and/or rotator cuff tears that were injected with bone marrow concentrate. There was a statistically significant improvement in Disabilities of the Arm, Shoulder and Hand (DASH) scores from 36.1 to 17.1 (P < .001) and numeric pain scores improved from 4.3 to 2.4 (P < .001).
By being able to see the pathology, like a hypoechoic region in a tendon, ligament, or muscle, the physician can reliably place the therapeutic agent into the precise location. Also, adjacent para-tendon or para-ligament injections allow for in-season athletes to get some relief from symptoms while allowing to return to play quickly; injections into muscle, ligament, or tendon can damage the structure and require days or weeks of rest, while para-tendon and para-ligament injections are far less painful.
Second-generation techniques have provided patients with great options that can help avoid surgery. Calcific tendonitis appears brightly hyperechoic on ultrasound and is easily identified. The physician can attempt to break up the calcium by fenestration or barbotage of the calcium. The same can be accomplished by injecting the density with PRP or stem cells. If the calcium is soft or “toothpaste-like,” the negative pressure will make it easy to aspirate it into the syringe. A 2-year, longitudinal prospective study of 121 patients demonstrated that visual analog score (VAS) pain scores and size of calcium significantly decreased with ultrasound-guided percutaneous needle lavage; 89% of patients were pain-free at 1-year follow-up.27 Moreover, a randomized controlled trial of 48 patients comparing needle lavage vs subacromial steroid injection showed statistically significant radiographic and clinically better outcomes with the needle lavage group at the 1-year mark.28
The Tenex procedure is a novel technique that uses ultrasonic energy to fenestrate diseased tendon tissue. It also can be used to break up calcific deposits. After the Tenex probe is guided to the diseased tendon/calcium, the TX-1 tip oscillates at the speed of sound, fenestrating/cutting through the tendon or calcium while lavaging the tendon with saline. Multiple prospective, noncontrolled studies done in common extensor, patellar, and rotator cuff tendinopathy have demonstrated good to excellent improvements in pain scores with the Tenex procedure.29-31
Ultrasound is extremely useful in the treatment of adhesive capsulitis.32 The posterior glenohumeral capsule can be distended using a large volume (60 cc) of saline to loosen adhesions in preparation for manipulation. Because the manipulation can be an extremely painful procedure, ultrasound can be used to perform an inter-scalene block for regional anesthesia prior to the procedure. In 2014, Park and colleagues33 performed a randomized prospective trial that showed that capsular distension followed by manipulation was more effective than cortisone injection alone for the treatment of adhesive capsulitis.Ultrasound guidance was found to be just as efficacious as fluoroscopy in a randomized controlled trial in 2014; the authors noted that ultrasound does not expose the patient or clinician to radiation and can be done in office.34
Currently, techniques to perform ultrasound-guided percutaneous tenotomies of the long head of the biceps tendon using hook blades are being studied.35
Ultrasound-Assisted Surgery
Ultrasound has been a boon to surgeons who perform minimally invasive procedures. It is far less cumbersome than classic fluoroscopy. Fluoroscopy requires the use of heavy lead aprons by the surgeons. Combining this with the impervious gowns and hot lights, the surgeons’ comfort level is severely sacrificed. When having to do many long surgeries in a row, this situation can take a toll on the surgeons’ endurance and strength. Improving the comfort of the surgeon is not the primary goal of surgery, but can significantly help our ability to do a better job.
