Dean Ziegler, MD
Published 9/9/2024
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Shafic Sraj, MD, MBA, FAAOS
Musculoskeletal ultrasound underwent a significant shift over the past decade due to enhancements in technology. These changes led to improved portability and higher resolution, which allowed the technology to be introduced into clinics and emergency rooms and adopted for quick and effective point-of-care assessments.
AAOS Now Editorial Board member Shafic Sraj, MD, MBA, FAAOS, sat down with Dean Ziegler, MD, a fellowship-trained shoulder and elbow surgeon at Blount Orthopaedic Associates in Milwaukee, Wisconsin, to discuss the value of point-of-care musculoskeletal ultrasound in orthopaedic practices. Dr. Ziegler is an expert in diagnostic and interventional use of office ultrasound and is a co-author of the recent two-volume textbook Musculoskeletal Ultrasound for the Orthopaedic Surgeon.
Dr. Sraj: When I was in training, ultrasound was rarely mentioned. We would only think about deep vein thrombosis or some fluid collection, and suddenly things exploded over the last few years. How has ultrasound been broadly implemented in orthopaedic practice?
Dr. Ziegler: I totally agree with you. I trained in the early 1990s, and there was some talk about ultrasound being used, especially in the shoulder, for diagnosis. Then I spent my fellowship in Seattle, where we pretty much focused on ultrasound, although it was performed mainly by the radiologists.
As I got into practice, I was able to incorporate ultrasound into my clinic, and I’ve been doing that for over 20 years now. But more recently, I think we’ve been doing a better job at getting into the training centers and allowing people to know that it’s certainly something that can be used every day in the clinic.
What is the value of point-of-care ultrasound for orthopaedic surgeons?
I see the value as really an extension of my physical exam. It’s sort of that advanced imaging that [orthopaedic surgeons] like to do. We obtain plain radiographs. We always get a good history and physical exam but then can add [ultrasound imaging] to any of the soft tissues we want to look at. We’ve looked at it as static imaging, but [ultrasound offers] dynamic imaging and even now functional imaging throughout the entire musculoskeletal system.
How can an orthopaedic surgeon who does not have formal training or just started practice start using ultrasound, and how can we incorporate ultrasound into our busy practices?
Number one, my feeling is, just get your hands on an ultrasound, and my co-author, Christopher M. Jobe, MD, and I have always talked about that. If you’re in training and residency or fellowship and there’s one available, try to use it as much as possible. Then if there’s ability to get machines into your clinic, start using them and looking at it.
The best person to do an ultrasound is a person who has a great 3D understanding of the structure being imaged. I think we as orthopaedic surgeons certainly have that, especially with our clinical and then surgical practice.
Then the other thing that’s really important is the ability to actually image with an ultrasound, which I have found to be very, very similar to imaging with arthroscopy. Those of us who do a lot of arthroscopy can certainly take that into the world of ultrasound as well.
How does ultrasound compare to MRI and CT scan? Are you suggesting that ultrasound is going to replace other advanced imaging modalities?
Certainly not. Number one, [ultrasound is] very convenient compared to [MRI and CT] because you can have it right in your office and you can perform it right away. It also offers that dynamic imaging, and it gives you automatic feedback with the patients. When you’re imaging over a structure that may be pathologic, they can respond to say, “Yeah, that’s where my pain is. That’s exactly what I’m feeling.”
However, it does have limitations. We can’t quite get inside the joint as much. Intra-articular pathology and other pathology within the bone is something that CT and MRI are always going to be valuable for.
Can you give us examples of cases where ultrasound made an immediate or highly impactful effect on how you were taking care of the patient? Something like a “wow” moment for you.
One of the greatest examples is the patient that comes in with calcific tendonitis and severe pain in their shoulder—inability to even move it, and way out of proportion to what you would think their symptoms ought to be. You can see those pathologies, pick them up on plain radiographs initially, but sometimes not even that. But then when you use ultrasound, you can see the large calcific nodule.
And if we’re able to [treat the patient] early enough in the disease process, we can actually aspirate a fair amount of the calcium out of the nodule, and people are immediately responsive to that. That’s something that is thrilling for us, but also for the patient as well.
What does it take to make sure that our performance during the ultrasound evaluation is accurate and, on top of that, properly compensated? Because it seems easy to get the machine. What happens next?
That’s a very good point. I think people have to be comfortable imaging and looking at the structures. I think it’s good to read as much as you can about it. Get a good book, read it to get an idea. You can go to different courses, instructional courses or specific courses, on ultrasound, and then get a real feel that you understand what you’re looking at.
You can compare it to findings on an MRI scan, certainly when a patient comes in with an MRI, and then you can image as well. Then more importantly, compare the ultrasound images with what you see when you take the patient to surgery.
The biggest thing for reimbursement has to be making sure that you hit all the points they’re looking for, for the different codes that you’re using. More importantly, talk to your coders to find out exactly what the payers are looking for, for the reimbursements.
A lot of people are now talking about ultrasound interventions and, more specifically, ultrasound-based surgery. What’s happening in that area?
That’s a good question. I have not quite ventured down the path of doing a lot of that.
But there is a good group of people, including Dr. Jobe, my co-author, who have ventured down the road of doing carpal tunnel releases with ultrasound. Again, it’s one of those somewhat office-based, somewhat procedure room–based procedures. It is a great way to see the release in vivo. I think it’s going to change as far as moving toward more minimally invasive type of procedures as we’re able to image with ultrasound.
What kind of future do you see regarding musculoskeletal imaging and our role educating future orthopaedic surgeons in that realm?
We need to get the ultrasound into the training centers, into residencies. There’s a lot of fellowships that are using it, and a lot of our fellows coming through look for that kind of training as something that they’d like to do.
Then, I think if we can get into the residencies and just have the residents have an opportunity to image, they’re going to find a great world of ways to look and evaluate the patients.
This interview has been edited for print.
Shafic Sraj, MD, MBA, FAAOS, is a hand surgeon and associate professor at West Virginia University in Morgantown, West Virginia. Dr. Sraj is a member of the AAOS Now Editorial Board.