Cost-Benefit Analysis of Ultrasonography in the Hand Clinic

Efficacy of Diagnostic In-Office Shoulder Ultrasound in the Surgical Treatment of Full-Thickness Rotator Cuff Tears

Background

Early surgical management of full-thickness traumatic rotator cuff tears (RCTs) may optimize functional outcomes, prioritizing timely diagnoses. Ultrasound and magnetic resonance imaging (MRI) are highly sensitive and specific modalities for RCT diagnosis, yet MRI remains the gold standard diagnostic tool despite increased costs and potential delays in care. Ultrasound can provide same-day diagnosis, thus possibly expediting care.

Hypothesis

The use of diagnostic shoulder ultrasound alone in the orthopaedic surgeon's office could increase the efficiency of diagnosis and care of traumatic full-thickness RCTs compared with MRI.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective chart review of patients with full-thickness traumatic RCT diagnosed via ultrasound or MRI who subsequently underwent rotator cuff repair with 1 of 2 ultrasound-trained surgeons between January 1, 2014, and December 31, 2019, was performed. Inclusion criteria included patients ≥18 years old, documentation of a first-time traumatic event, and the patient's desire to have immediate surgical management. Revision surgeries, long-term shoulder instability, and nontraumatic injuries were excluded. Basic demographic data were collected, and the number of preoperative office visits and the timing from initial evaluation to diagnosis and surgery were calculated for the ultrasound and the MRI cohorts. A power analysis of 0.8 with an alpha of .05 required 38 patients per group.

Results

Overall, 133 patients were diagnosed via MRI compared with 76 via ultrasound. Besides body mass index, there were no significant differences in demographic variables or insurance status. Compared with the MRI cohort, patients in the ultrasound cohort received their diagnosis almost 2 weeks faster (P < .0001), were scheduled for surgery almost 3 weeks faster (P < .0001), and underwent surgery 2 weeks faster after initial evaluation (P < .0001) while requiring nearly half as many clinical visits (P < .0001). Regression analysis confirmed that ultrasound significantly reduced time to imaging, scheduling, and surgery after initial evaluation while requiring fewer clinical visits (P < .05).

Conclusion

The study findings indicated that ultrasound was a time-saving alternative diagnostic modality for traumatic RCT compared with MRI without compromising standard of care. These results were achieved independent of patient insurance status, disability index, or other demographic variables.

Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice

BACKGROUND

 Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices.

METHODS

 We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks.

RESULTS

 US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity.

CONCLUSION

 Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.

Assessment of Motor Function in Peripheral Nerve Injury and Recovery

Introduction

Peripheral nerve injuries can be difficult to diagnose, treat, and monitor given their highly variable presentation. When the status of nerves is not accurately assessed, treatment may be delayed or overlooked and can result in lasting functional deficits. As our understanding of nerve repair and generation evolves, so will tools for evaluating both the functional and morphological status of peripheral nerves.

Objective

There is currently no single article which provides a detailed, comprehensive view of the literature comparing the clinical utility of various assessment modalities. Furthermore, there is no consensus on the optimal assessment algorithm for peripheral nerve injuries.

Methods

We performed a literature review using a comprehensive combination of keywords and search algorithm. The search was focused on clinical data regarding the assessment of peripheral nerves Results: This review may help to determine the appropriate tools that are currently available for monitoring nerve function both pre and postoperatively. Additionally, the review demonstrates possible roles and areas of improvement for each tool used to assess motor function.

Conclusion

As surgeons work to improve treatments for peripheral nerve injury and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.