1

Advantages of office based U/SDaniel Day DO FAOASM

OMED 2019 10/27 1:30pm

2

AGENDAUS Technical ReviewUS Office DiagnosticsUS Guided InjectionsUS Business PlanUS Resources

WHY ULTRASOUND

• BENEFITS• High resolution• Point of care imaging• Scan whole area (no slices)• Lacks Radiation• Compare limbs• Inexpensive• No real contra-indications• Improves anatomy knowledge

3

WHY ULTRASOUND

• BENEFITS• No metal artifact• Extension of physical exam• Sono-palpation• Dynamic testing/imaging• Practical and rapid• Real time procedures• Patient education!• Patient satisfaction!

4

WHY ULTRASOUND

• Limitations• Operator-dependent

• Hand-eye coordination• Long training period

• Can be time consuming• Limited field of view• Incomplete evaluation of

bones/joints

5

TERMINOLOGY

6

HYPERECHOICBright signal

ISOECHOICNormal Signal

HYPOECHOICLow Signal

ANECHOICAbsent Signal

TERMINOLOGY

• Anistropy• Occurs at 3-8 degrees

angulation• Greater Density =

increased Anistropy• Ligament > Tendon >

Muscle > Nerve

7

MUSCLE

• Echogenicity – Mixed• Echotexture –• Transverse - Starry night• Longitudinal - Pennate or feather like

8

TENDON

• Echogenicity – Hyperechoic• Echotexture –• Transverse – Broom end• Longitudinal - Fibrillar

9

LIGAMENT

• Echogenicity – Hyperechoic• Echotexture –• Transverse – Broom end• Longitudinal - Fibrillar

10

CARTILAGE/BONE/JOINT

• Bone• Echogenicity –

Hyperechoic• Posterior acoustic

shadowing

• Cartilage • Echogenicity -

Anechoic

11

NERVE

• Echogenicity – Mixed• Hyperechoic Epineurium

• Echotexture –• Transverse - Honeycomb• Longitudinal - Fascicular

12

CASES - SHOULDER

• Bicep tendon

13

CASES - SHOULDER

• Supraspinatus

14

CASES - SHOULDER

• AC Joint

15

SHOULDER - CASES

16

SHOULDER - CASES

• Smith et al – Diagnostic accuracy of ultrasound for rotator cuff tears• 6066 shoulders• Partial tears – 84% Sensitive, 89% specific• Full thickness – 96% Sensitive, 93% Specific• However inexperienced technicians lowered Sensitivity/Specificity

17

SHOULDER - CASES

• Supraspinatus • Longitudinal axis Short axis

18

TEAR

HYALINE CARTILAGE CORTICALIRREGULARITY

THICKENED BURSA

ARTICULAR SURFACE PARTIAL TEAR

SHOULDER - CASES

• Supraspinatus• Longitudinal axis Short axis

19

HYALINE CARTILAGE

TEAR

BURSA SURFACE

NO CORTICALIRREGULARITY

BURSAL SURFACE PARTIAL TEAR

SHOULDER - CASES

• SUPRASPINATUS

20

TENDINOSIS – NO TEAR

THICKENINGTHICKENED BURSA

NO CORTICALIRREGULARITY

SHOULDER - CASES

• SUPRASPINATUS

21

CALCIFIC TENDINOSIS

CALCIFIC DENSITY

ANISOTROPY

SHOULDER - CASES

• BICEP TENDON• Short axis Longitudinal axis

22

HYPOECHOIC ENLARGEMENT

FLUID DISTENSTION

BICEP TENDINOSIS

CASES – ELBOW/WRIST

• Lateral Epicondyle

23

RADIAL COLLATERAL LIGAMENT

COMMON EXT TENDON

TENDINOSISW/PARTIAL TEAR

CORTICAL IRREGULARITY

CASES – ELBOW/WRIST

• POSTERIOR ELBOW

24

TRAUMATIC OLECRANON BURSITIS

HETEROGENEOUS DISTENSION

NEEDLE

CASES – ELBOW/WRIST

• FINGER • DORSAL WRIST

25

THICKENED HYPOECHOICA1 PULLEY

MCP

TRIGGER FINGERANECHOIC CYST

GANGLION CYST

CASES - HIP

• HIP JOINT

26

OA

EFFUSION

IRREGULAR CONTOUR

LABRAL TEAR

PARALABRAL CYST

TEAR –ANECHOIC

CLEFT

CASES - HIP

• LATERAL HIP• Short axis

27

IT BAND TRACT

GLUT MEDGLUT MIN

CASES - HIP

• LATERAL HIP• Longitudinal axis

28

ANTERIOR FACET

GLUT MIN

LATERAL FACET

GLUT MED

LOSS OF FIBRILLAR PATTERNHYPOECHOIC

TENDINOSIS

CASES - KNEE

• KNEE - ANTERIOR

29

EFFUSION

CASES - KNEE

• KNEE - ANTERIOR

30

TENDINOSISPATELLAR TENDON

HOFFAS

CASES - KNEE

• KNEE - MEDIAL

31

MENISCUS

MCL

TEAR TEAR WITH CYST

JOINT SPACE NARROWING WITH EXTRUSION

MENISCUSPATHOLOGY

CASES - ANKLE

• ANTERIOR ANKLE

32

HYALINE CARTILAGEEFFUSION

FAT PADDISPLACED

EFFUSION

CASES - ANKLE

• ACHILLES

33

TENDINOPATHY

HYPOECHOICTHICKENED

TEAR

CASES - INJECTION

U/S Guided• 100%• 92-95%• 100%• 87%• 97%• 95%• 100%• 90%

Landmark• 72%• 72-79%• 44%• 27%• ---• 78%• 85%• 35%

34

• Subacromial• GH• AC• Bicep• Hip• Knee• Tibiotalar• Subtalar

Statistic examples

STUDIES ALSO SHOW IMPROVED OUTCOMES

CASES - INJECTION

• Improves accuracy• Improves outcomes• Diagnostic and therapeutic purposes• Cortisone• Visco• Prolotherapy• Biologics• Needling/tenotomy

35

CASES - INJECTION

• BICEP TENDON

36

CASES - INJECTION

• GLENOHUMERAL

37

CASES - INJECTION

• SUPRASPINATUS CALCIFIC TENDINITIS

38

CASES - INJECTION

• HIP

39

CASES - TENOTOMY

40

BUSINESS PLAN• Direct Value

• Increase reimbursement• Add diagnostic testing• Enhanced injection options• Practice expansion

• Indirect Value • Master Anatomy• Faster diagnostics• Decrease health care cost• Decrease patient cost• Improved outcomes• Increased patient satisfaction

41

BUSINESS PLANEXPENSES• Training costs – dependent…

• Fellowship• Mentor based• Courses• Online resources• Textbooks, DVDs

• Accreditation – Currently not required• www.AIUM.org – practice based• www.ARDMS.org – individual (RMSK)

• Exam - ~$600• 150 MSK studies• Maintaence – 30hrs/3yrs

EXPENSES• Equipment • Machine 20k-100k+

• Lease to own options• Service cost ~1000/yr

• Supplies • Needle, gel, sterile gel, sterile

transducer cover

• Time• Experience dependent• Clinic flow dependent

42

BUSINESS PLANREIMBURSEMENT• CPT Codes• Diagnostic

• 76882 – Limited• 76881 –Complete

• Injection• 76942 – US guided needle

placement• Use with non bundled codes

• Joint injection codes - Bundled• 20604• 20606• 20611

REIMBURSEMENT• Payer example• Evaluate payer mix• AMSSM example (76942)

• Medicare 25% - $54.77• Medicaid 15% - $84.63• Commercial 60% - $127.14

• Average - $102.66

• RVU example• 20610 – 0.79• 20611 – 1.1• 76942 – 0.67

43

BUSINESS PLAN

• Math, math and more math• Calculate Expenses vs Income• Add up reimbursement of each U/S guided injection and subtract from

expense• (U/S Large Joint – Landmark large joint)(x/month)• ($30)(5/day)(5days/week)(4weeks/month) – 3k/month - expenses• Add in tendon codes• Add in diagnostic codes

44

DOCUMENTATION - DIAGNOSTIC

• Patients name• Facility information• Date of Ultrasound• Image Orientation• Doctor name• ICD 10 code

• Procedures and materials –Description of the study• Findings• Potential limitations• Clinical issues• Comparison studies/reports• Impression – specific dx,

differential, recommended follow up

45

DOCUMENTATION

46

DOCUMENTATION

• AMSSM• Scanning

protocols

47

DOCUMENTATION

48

DOCUMENTATION

• Injection technique

49

https://www.orthopedicshoulder.com/radiology-imaging/msk-ultrasound/

RESOURCES

GETTING STARTED/EDUCATION• www.amssm.org/sportsultrasound.php

GETTING STARTED/EDUCATION• www.aium.org

50

RESOURCES

ONLINE• AMSSM• 35 Free modules/videos!• Scanning protocols• Business plan• Accreditation/certification FAQ• Articles

51

RESOURCES

ONLINE• AIUM• Practice Parameter Articles/PDF

• US guided procedures• Documentation• Performing MSK exam

52

RESOURCES

TEXT/REFERENCE

53

RESOURCES

ONLINE• European society of

musculoskeletal radiology (ESSR)• https://www.essr.org/subcommi

ttees/ultrasound/• Scanning protocols• Shoulder, elbow, wrist, hip, knee,

ankle

• Articles/CME/Webinars

54

RESOURCES

ONLINE• www.ultrasoundcases.info

55

RESOURCES

CME/Courses

56

ULTRA-FANTASIC

1. We are Osteopaths 2. We have great exam skills3. Can utilize U/S to confirm Dx4. Treatment measures to help patient

• OMT• Diagnostic/therapeutic injections• Percutaneous tendon debridement• Prolo/PRP/BMC

57

REFERENCES• Bianchi S, Martinoli C. Shoulder. In: Ultrasound of the Musculoskeletal System. New York: Springer, 2007: 190 – 235.

• Jon A. Jacobson MD. Fundamentals of Musculoskeletal Ultrasound: Expert Consult-Online and Print, 2e Jon A. Jacobson MD (Nov 21, 2012)

• https://www.ultrasoundcases.info/

• www.amssm.org

• 1: Adelman S, Fishman P. Use of portable ultrasound machine for outpatient orthopedic diagnosis: an implementation study. Perm J. 2013 Summer;17(3):18-22. doi: 10.7812/TPP/12-128. PubMed PMID: 24355886; PubMed Central PMCID: PMC3783087.

• 2: Amoo-Achampong K, Nwachukwu BU, McCormick F. An orthopedist's guide to shoulder ultrasound: a systematic review of examination protocols. Phys Sportsmed. 2016 Nov;44(4):407-416. Epub 2016 Aug 22. PubMed PMID: 27548649.

• 3: Apard T. Ultrasonography for the orthopaedic surgeon. Orthop Traumatol Surg Res. 2019 Feb;105(1S):S7-S14. doi: 10.1016/j.otsr.2018.04.027. Epub 2018 Jul 7. Review. PubMed PMID: 29990601.

• 4: Balog TP, Rhodehouse BB, Turner EK, Slevin JM, Bush LA, Grassbaugh JA, Marchant BG. Accuracy of Ultrasound-Guided Intra-articular Hip Injections. Performed in the Orthopedic Clinic. Orthopedics. 2017 Mar 1;40(2):96-100. doi: 10.3928/01477447-20161213-03. Epub 2016 Dec 20. PubMed PMID: 27992639.

• 5: Berkoff DJ, English J, Theodoro D. Sports medicine ultrasound (US) beyond the musculoskeletal system: use in the abdomen, solid organs, lung, heart and eye. Br J Sports Med. 2015 Feb;49(3):161-5. doi: 10.1136/bjsports-2014-094238. Epub 2014 Nov 10. Review. PubMed PMID: 25385167.

• 6: Bianchi S, Martinoli C, Gaignot C, De Gautard R, Meyer JM. Ultrasound of the ankle: anatomy of the tendons, bursae, and ligaments. Semin Musculoskelet Radiol. 2005 Sep;9(3):243-59. Review. PubMed PMID: 16247724.

• 7: Blankstein A. Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope. World J Orthop. 2011 Feb 18;2(2):13-24. doi: 10.5312/wjo.v2.i2.13. PubMed PMID: 22474631; PubMed Central PMCID: PMC3302037.

• 8: Bureau NJ, Ziegler D. Economics of Musculoskeletal Ultrasound. Curr Radiol Rep. 2016;4:44. Epub 2016 Jun 20. Review. PubMed PMID: 27398265; PubMed CentralPMCID: PMC4914528.

• 9: Chiu CH, Chen P, Chen AC, Hsu KY, Chang SS, Chan YS, Chen YJ. Shoulder ultrasonography performed by orthopedic surgeons increases efficiency in diagnosis of rotator cuff tears. J Orthop Surg Res. 2017 Apr 20;12(1):63. doi: 10.1186/s13018-017-0565-4. PubMed PMID: 28427416; PubMed Central PMCID:PMC5399436.

• 10: Coris EE, Pescasio M, Zwygart K, Gonzalez E, Farrar T, Bryan S, Konin J, McElroy T. Office-based ultrasound in sports medicine practice. Clin J Sport Med. 2011 Jan;21(1):57-61. doi: 10.1097/JSM.0b013e31820758aa. PubMed PMID: 21200172.

• 11: Day M, Phil M, McCormack RA, Nayyar S, Jazrawi L. Physician Training Ultrasound and Accuracy of Diagnosis in Rotator Cuff Tears. Bull Hosp Jt Dis (2013). 2016 Sep;74(3):207-11. PubMed PMID: 27620544.

• 12: de Brito Vieira WH, Aguiar KA, da Silva KM, Canela PM, da Silva FS, Abreu BJ. Overview of ultrasound usage trends in orthopedic and sports physiotherapy. Crit. Ultrasound J. 2012 May 28;4(1):11. doi: 10.1186/2036-7902-4-11. PubMed PMID: 22871050; PubMed Central PMCID: PMC3439362.

• 13: Dukes C, Melton T, Turner E, Jackson A, Grassbaugh J, Slevin J, Arrington ED, Eichinger JK. Three-Year Analysis of Value and Utilization After Development of an Ultrasound-Based Orthopedic Injection Clinic. Mil Med. 2017 Sep;182(9):e1965-e1968. doi: 10.7205/MILMED-D-17-00028. PubMed PMID: 28885963.

58

REFERENCES• 14: Fukushima Y, Ray J, Kraus E, Syrop IP, Fredericson M. A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries. J Ultrasound Med. 2018

Oct;37(10):2297-2307. doi: 10.1002/jum.14588. Epub 2018 Apr 14. Review. PubMed PMID: 29655254.

• 15: Grasu BL, Wolock BS, Sedgley MD, Murphy MS. Principles of Billing for Diagnostic Ultrasound in the Office and Operating Room. J Hand Surg Am. 2019 Jan;44(1):55-59. doi: 10.1016/j.jhsa.2018.03.034. Epub 2018 May 8. Review. PubMed PMID: 29751979.

• 16: Iannotti JP, Ciccone J, Buss DD, Visotsky JL, Mascha E, Cotman K, Rawool NM. Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am. 2005 Jun;87(6):1305-11. PubMed PMID:15930541.

• 17: Li X, Yi PH, Curry EJ, Murakami AM. Ultrasonography as a Diagnostic, Therapeutic, and Research Tool in Orthopaedic Surgery. J Am Acad Orthop Surg. 2018 Mar 15;26(6):187-196. doi: 10.5435/JAAOS-D-16-00221. Review. PubMed PMID: 29517623.

• 18: O'Neill W. The physician-owned imaging center. Orthop Clin North Am. 2008 Jan;39(1):37-48, vi. PubMed PMID: 18061768.

• 19: Ok JH, Kim YS, Kim JM, Yoo TW. Learning curve of office-based ultrasonography for rotator cuff tendons tears. Knee Surg Sports Traumatol Arthrosc. 2013 Jul;21(7):1593-7. doi: 10.1007/s00167-012-2105-4. Epub2012 Jun 27. PubMed PMID: 22735978.

• 20: Plomb-Holmes C, Clavert P, Kolo F, Tay E, Lädermann A; French Arthroscopic Society. An orthopaedic surgeon's guide to ultrasound imaging of the healthy, pathological and postoperative shoulder. OrthopTraumatol Surg Res. 2018 Dec;104(8S):S219-S232. doi: 10.1016/j.otsr.2018.07.011. Epub 2018 Aug 11. Review. PubMed PMID: 30107274.

• 21: Seagger R, Bunker T, Hamer P. Surgeon-operated ultrasonography in a one-stop shoulder clinic. Ann R Coll Surg Engl. 2011 Oct;93(7):528-31.doi10.1308/147870811X13137608454939. PubMed PMID: 22004635; PubMed Central PMCID: PMC3604922.

• 22: Thomason K, Cooke PH. The use of surgeon-performed ultrasound assessment in a foot and ankle clinic. Foot Ankle Surg. 2012 Sep;18(3):213-5. doi: 10.1016/j.fas.2011.12.002. Epub 2012 Jan 10. PubMed PMID: 22857966.

• 23: Wilson DJ, Scully WF, Rawlings JM. Evolving Role of Ultrasound in Therapeutic Injections of the Upper Extremity. Orthopedics. 2015 Nov;38(11):e1017-24. doi: 10.3928/01477447-20151020-11. PubMed PMID: 26558666.

• 24: Yim ES, Corrado G. Ultrasound in athletes: emerging techniques in point-of-care practice. Curr Sports Med Rep. 2012 Nov-Dec;11(6):298-303. doi: 10.1249/JSR.0b013e318272c89b. Review. PubMed PMID: 23147017.

• 25: Ziegler DW. Orthopedic perspectives of musculoskeletal ultrasound. Phys Med Rehabil Clin N Am. 2010 Aug;21(3):631-44. doi: 10.1016/j.pmr.2010.05.003. Review. PubMed PMID: 20797553.

• 26: Ziegler DW. The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders. J Shoulder Elbow Surg. 2004 May-Jun;13(3):291-7. PubMed PMID: 15111899.

59

THANK YOU!

60