Initial Experience of Office-based, Orthopaedic Surgeon Operated Ultrasonography of the Shoulder

OBJECTIVES: We present our initial experience of orthopaedic surgeon operated ultrasound examination as an extension of physical examination of the shoulder in our out-patient setting. MATERIALS AND METHODS: We retrieved information of all cases that underwent shoulder ultrasound examination in our out-patient clinic from June 2019 to Mar 2020. We reviewed the demography of the patients, their presenting symptoms and shoulder ultrasonographic findings. We also reviewed medical literature pertaining to accuracy of ultrasound detection of rotator cuff pathology, short learning curve for orthopaedic surgeons who are interested in acquiring proficiency in the use of ultrasound for shoulder examination, and increased accuracy of ultrasound guided therapeutic injections. RESULTS: We identified 90 patients who underwent out-patient clinic-based shoulder ultrasound examination. There were almost equally divided between males and females. Average age was 57 years. Pain was the most common chief complaint. We identified 12 different ultrasonographic pathologies in isolation or in combination. We describe the ultrasound findings in these pathologies. Most common ultrasonographic pathologies were subacromial-subdeltoid (SASD) bursitis and supraspinatus tendinitis or combination of both. Fifty-four ultrasound-guided therapeutic injections were performed. In our literature review we found overwhelming evidence for high accuracy for detection of rotator cuff pathology by orthopaedic surgeons, comparable to radiologists. There is also evidence of a shorter learning curve for orthopaedic surgeons interested in shoulder problems and for increased accuracy of therapeutic injections using ultrasound guide. CONCLUSION: We would like to encourage more orthopaedic surgeons to take up shoulder ultrasonography as part of their routine examination of shoulder problems and also consider integrating shoulder ultrasound training to the residency and fellowship training programs. The benefits to the patients include savings in time and money and also more accurate therapeutic injections when needed.

O rthopedic surgeon operated shoulder ultrasound as an extension of physical examination is gaining favour in Europe and the USA, but not so in Thailand.Ultrasonography of the rotator cuff was first presented at the American Institute of Ultrasound in Medicine (AIUM) in 1977. 1 Subsequently, Middleton et al. published a technique of ultrasonography of rotator cuff in 1984, 2 followed by ultrasonographic detection of rotator cuff tear in 1985. 3 Technological improvements in ultrasound machines and well-defined ultrasound examination protocols 4,5 has allowed for better accuracy in diagnosis and more widespread in-office use by different medical specialties. In spite of evidence of the accuracy of orthopaedic surgeon operated ultrasonographic diagnosis, and benefits of its in-office use, 6-8 many orthopaedic surgeons are hesitant to incorporate diagnostic ultrasound in their practice. 9 We recently acquired an ultrasound machine for our department and have been using it as an extension of physical examination for various musculoskeletal problems. In this report we focus on our experience in using ultrasonography for shoulder problems and through this report would like to encourage more orthopaedic surgeons to incorporate use of ultrasound in their practice.
The Bangkok Medical Journal Vol. 16

Material and Methods
Between June 2019 to March 2020 we performed 90 ultrasonographic shoulder examinations in our outpatient setting. All the ultrasonography was performed by the senior author (NB). The senior author had undergone a 2 days' hands-on musculoskeletal ultrasound training course and had been doing ultrasonographic examinations using borrowed ultrasound machines from other departments for about a year before we were able to acquire a machine for our department. Before each ultrasound examination a thorough clinical history and physical examination of the shoulder was done. Indication of an ultrasound examination included clinical suspicion or objective finding of pathology of rotator cuff. Every patient gave verbal consent for the ultrasound examination. Some patients had the ultrasound examination on more than one occasion. Shoulder ultrasonography was done following the technical guideline of the European Society of Musculoskeletal Radiology (ESSR), 10 using SONIMAGE HS1, Konica Minolta Inc., Japan and linear transducer frequency range 4-18 MHz.
The patient was seated comfortably on a stool facing the monitor of the ultrasound machine with the examiner standing behind him towards the side being examined. For examining the biceps tendon, the patient had his arm adducted against his body, his elbow flexed 90 degrees and forearm supinated on his ipsilateral thigh. The biceps tendon was examined in the long and short axis. In the same position the subscapularis tendon was examined in long axis and short axis. Passive external and internal rotation of shoulder was done to check integrity of subscapularis tendon and also to check for subcoracoid impingement and for dislocation of biceps tendon from bicipital groove. The patient was then asked to put his hand on the side being examined like putting it in the back pocket of his trousers so that the shoulder is in extension and internal rotation. The supraspinatus tendon was examined in this position in long and short axis. The subacromial-subdeltoid (SASD) bursa was also visualized in this position. Next, dynamic subacromial impingement was assessed by bringing the arm back to the first position and placing the probe superiorly in a coronal plane across the lateral edge of acromion and the supraspinatus tendon. The arm was then passively abducted and adducted to visualize gliding of supraspinatus tendon under the acromion process. The infraspinatus tendon was examined from the posterior by placing the probe just below the spinous process of the scapula and tracing the tendon laterally to its attachment to the greater tuberosity. It was also examined in long and short axes. Last of all the acromioclavicular (AC) joint was examined by placing the probe in line with the clavicle across the AC joint. While performing the examination the patient was also educated about the anatomy and any pathology detected was pointed out to him on the monitor. If it was deemed by the examiner that a therapeutic injection could benefit the patient, he was informed and given a choice to undergo the injection or to try another form of treatment first. If the patient preferred to take the injection, it was done right away under the ultrasound guide. All relevant ultrasound images were saved in the hospital's PACS (picture archiving and communications system) system, and a short written report was also made in the patient's file.

Results
Our patients consisted of 48 males and 42 females, whose ages ranged from 28 to 87 years, with a mean age of 57 years (Table 1). Ultrasound examination was done in 57 right side shoulders, 32 left-side shoulders and 1 on both shoulders. Pain was the most common chief complaint, sometimes accompanied with clicking, stiffness or weakness.  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23   36  55  37  52  35  53  45  52  37  33  35  35  63  67  50  56  77  58  57  73  87  65 Discomfort  Pain  Pain  Pain  Pain  Pain / weakness  Trauma / pain  Pain  Pain  Stiffness  Pain  Pain  Pain / stiffness  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain / weakness 24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62  63  64  65  66  67  68  69  70  71  72  73  74  75  76  77  78  79  80  81  82  83  84  85  86  87  88  89  90   42  57  73  34  43  50  77  36  63  40  47  40  73  50  82  48  55  40  57  71  69  51  63  48  80  38  70  73  55  73  80  34  79  30  47  70  80  74  37  72  70  54  65  73  49  77  28  49  53  37  71  42  67  61  64  44  61  74  46  82  73  55  66  51  70 64 63  6 w   Pain  Pain  Pain  Pain  Pain  Pain  Pain  Discomfort  Pain  Pain  Pain  Pain  Pain  Pain  Pain / stiffness  Pain  Pain  Pain  Pain  Pain / stiffness  Pain  Pain / weakness  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain / stiffness  Pain / clicking  Stiffness  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain  Pain / Instability  Pain  Pain  Pain  Pain  Pain  Pain  Pain / weakness  Pain / stiffness  Pain  Pain  Pain  Pain  Pain / stiffness  Pain / stiffness  Pain  Pain / Con  TI  TI  TI  Con  TI  TI  TI  TI  TI  TI both shoulders  TI  TI  TI  TI  Con  Con  Con  Con  Con  Con  TI  Con  TI  TI  TI  TI  TI  Con  Con  Con  TI  TI  Sur  TI  TI  Con  TI  TI  TI  TI  TI  TI  TI  Con  TI  Con  TI  Con  TI  Con  TI  Con  Con  TI  TI  TI  TI  Con  TI  Con  TI  TI   Case No  Age  Sex  Side  DOS  Main symptom  Diagnosis  Treatment The ultrasonography pathology detected is shown in Table  2. In 6 shoulders, no pathology was detected, and 111 pathologies were detected in the rest of 84 shoulders. In 27 shoulders, more than one pathology was detected. The most common pathologies detected were SASD bursitis and supraspinatus tendinitis. In 13 shoulders these two pathologies were detected in combination. SASD bursitis was detected by distension of fluid anechogenicity in the bursa (Figure 1). Supraspinatus tendinitis was detected by loss of normal fibrillar pattern of tendon with focal or diffuse hypoechogenicity. Calcification in tendons was detected by well-circumscribed hyperechogenicity ( Figure  2) or hyperechogenic arc with shadow ( Figure 3). Full thickness rotator cuff tear was seen as absence of supraspinatus tendon attached to the greater tuberosity. The torn tendon could be seen retracted medially if it was not hidden under the acromion process. The greater tuberosity is seen covered by bursal tissue and deltoid muscle ( Figures 4A,B), or by fluid anechogenicity replacing the tendon in the gap ( Figure 5). Sagging of peribursal fat and cortical irregularity of greater tuberosity could also be seen in both long and short axis ( Figures  4A,B). Partial thickness tear of rotator cuff is seen as hypoechoic or anechoic changes in the tendon ( Figure 6). Acromioclavicular joint arthritis shows up as effusion in the AC joint seen as ballooning out of joint capsule or geyser phenomenon (Figure 7). Biceps tendinitis was detected by loss of fibrillar pattern in the tendon and fluid anechogenicity around the tendon (Figures 8A, B). We were also able to detect 2 cases of cortical fracture of greater tuberosity causing persistent post-traumatic pain where x-rays were not able to detect any bone injuries (Figure 9). One case of biceps tendon dislocation was detected on seeing the biceps tendon on the lesser tuberosity and empty bicipital groove ( Figure 10). We performed 54 therapeutic injections under ultrasound guide including 34 injections into SASD bursa (Figure 11), 13 injections around calcific mass, 5 injections into AC joint and 2 injections into bicipital synovial membrane. In one case we were also able to demonstrate integrity of rotator cuff 3 months post arthroscopic rotator cuff repair ( Figure 12A,B).      Initial Experience of Office-based, Orthopaedic Surgeon Operated Ultrasonography of the Shoulder Figure 5A: Long axis of supraspinatus tendon demonstrating full thickness tear of the tendon.

Discussion
The first report on use of office-based ultrasound by orthopaedic surgeons for the purpose of diagnosing rotator cuff tear was by Roberts et al 11 in 1998. There have been several reports of orthopaedic surgeons performing office-based shoulder ultrasound [6][7][8][11][12][13][14][15][16][17][18] (Table 3). All of these reports have focused on the detection of rotator cuff tears. The mean sensitivity for the ability of an orthopaedic surgeon to detect a full-thickness rotator cuff tear with ultrasound was 92.4% (range 70%-100%). The mean sensitivity in detecting partial-thickness rotator cuff tear was 67% (range 7%-95%). The overall specificity in detecting a normal tendon was 89% (range 80%-100%). 9 In a meta-analysis on accuracy of ultrasound for rotator cuff tear, Smith et al 19   Surgeon-operated ultrasonography in a shoulder clinic can significantly reduce the time to treatment and the financial cost for patients with rotator cuff tear. 28 Several reports have shown benefits and accuracy of using ultrasound to evaluate postoperative rotator cuff healing. [29][30][31] There have also been cadaveric studies showing better accuracy of injections into acromioclavicular and glenohumeral joints using ultrasound guide compared with palpation or blind injections. [32][33][34]

Conclusion
Orthopedic surgeons use of ultrasound is gaining favour in Europe and America. It is still rare in Thailand where patients are more commonly referred to the radiology department. Ultrasonography is non-invasive, has virtually no side effects and allows the rotator cuff to be visualized dynamically during rotation and elevation of the shoulder. It is cost effective and time efficient and allows patients to see their own pathology, leading to better understanding of the pathology and a constructive discussion on the treatment options. Orthopaedic surgeons have the advantage of better knowledge of shoulder anatomy through surgical experience and understanding of shoulder problems through clinical examination, which may shorten their learning curve for ultrasound examination of the shoulder.
Our purpose in this report was to present our initial experience with incorporating musculoskeletal ultrasound examination as an extension of physical examination of the shoulder. There is a plethora of evidence of its accuracy and benefits as an office-based diagnostic and therapeutic use. With some training and practice an orthopaedic surgeon can become proficient in its use to the benefit of their patients. We would like to encourage more orthopaedic surgeons to take up shoulder ultrasonography as part of their routine examination of shoulder problems and also consider integrating shoulder ultrasound training to the residency and fellowship training programs.