ArticlePDF Available

Hand-Held Portable Versus Conventional Cart-Based Ultrasound in Musculoskeletal Imaging

Authors:

Abstract and Figures

Background Portable ultrasound machines are now common, used for point-of-care applications and needle guidance for percutaneous procedures; however, the effectiveness of portable ultrasound in evaluation of the musculoskeletal system has not been fully assessed. Purpose To prospectively evaluate the use of portable hand-held ultrasound in comparison with conventional cart-based ultrasound in evaluation of the musculoskeletal system. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods In this institutional review board–approved, prospective study, 100 consecutive patients with informed consent were imaged through use of both portable and cart-based ultrasound equipment using 12-5 MHz linear transducers. Agreement in ultrasound diagnosis was documented along with expected clinical changes in management if there was disagreement (definitely no, probably no, uncertain, probably yes, definitely yes). Imaging details of disagreement cases were recorded, and descriptive statistics were calculated. Results There were 42 male and 58 female patients (mean ± SD age, 53 ± 13 years) imaged over a time period of 20 months. Anatomic areas scanned were the shoulder (n = 30), elbow (n = 11), hand and wrist (n = 15), hip (n = 10), knee (n = 11), foot and ankle (n = 12), and others (n = 11). Scanning with conventional ultrasound revealed abnormality in 92% of patients. Agreement in diagnosis made between portable versus cart-based ultrasound was found in 65% of patients. In the 35% of patients with discordant results, the change in diagnosis resulted in no change in clinical management in 46%, probably no change in 29%, uncertain change in 14%, probable change in 11%, and definite change in 0%. The diagnoses changing management (4%; 4/100) included nondetection of a satellite nodule (n = 1), ganglion cyst (n = 1), hernia (n = 1), and underestimated tendon tear (n = 1). Conclusion When compared with conventional cart-based ultrasound, a musculoskeletal diagnosis using portable hand-held ultrasound was concordant or was discordant without clinical relevance in 96% (96/100) of patients. Knowledge of benefits and limitations of portable hand-held ultrasound will help determine areas where specific types of ultrasound equipment can be used.
Content may be subject to copyright.
Original Research
Hand-Held Portable Versus
Conventional Cart-Based Ultrasound
in Musculoskeletal Imaging
Anna L. Falkowski,*
†‡
MD, MHBA, Jon A. Jacobson,
MD, Michael T. Freehill,
§
MD,
and Vivek Kalia,
MD, MPH
Investigation performed at the University of Michigan, Ann Arbor, Michigan, USA
Background: Portable ultrasound machines are now common, used for point-of-care applications and needle guidance for
percutaneous procedures; however, the effectiveness of portable ultrasound in evaluation of the musculoskeletal system has not
been fully assessed.
Purpose: To prospectively evaluate the use of portable hand-held ultrasound in comparison with conventional cart-based
ultrasound in evaluation of the musculoskeletal system.
Study Design: Cohort study (diagnosis); Level of evidence, 2.
Methods: In this institutional review board–approved, prospective study, 100 consecutive patients with informed consent were
imaged through use of both portable and cart-based ultrasound equipment using 12-5 MHz linear transducers. Agreement in
ultrasound diagnosis was documented along with expected clinical changes in management if there was disagreement (definitely
no, probably no, uncertain, probably yes, definitely yes). Imaging details of disagreement cases were recorded, and descriptive
statistics were calculated.
Results: There were 42 male and 58 female patients (mean ±SD age, 53 ±13 years) imaged over a time period of 20 months.
Anatomic areas scanned were the shoulder (n ¼30), elbow (n ¼11), hand and wrist (n ¼15), hip (n ¼10), knee (n ¼11), foot and
ankle (n ¼12), and others (n ¼11). Scanning with conventional ultrasound revealed abnormality in 92% of patients. Agreement in
diagnosis made between portable versus cart-based ultrasound was found in 65% of patients. In the 35% of patients with dis-
cordant results, the change in diagnosis resulted in no change in clinical management in 46%, probably no change in 29%,
uncertain change in 14%, probable change in 11%, and definite change in 0%. The diagnoses changing management (4%; 4/100)
included nondetection of a satellite nodule (n ¼1), ganglion cyst (n ¼1), hernia (n ¼1), and underestimated tendon tear (n ¼1).
Conclusion: When compared with conventional cart-based ultrasound, a musculoskeletal diagnosis using portable hand-held
ultrasound was concordant or was discordant without clinical relevance in 96% (96/100) of patients. Knowledge of benefits and
limitations of portable hand-held ultrasound will help determine areas where specific types of ultrasound equipment can be used.
Keywords: diagnostic ultrasound; musculoskeletal ultrasound; portable ultrasound; cart-based ultrasound
Ultrasound has been shown to be an effective imaging
method in evaluation of the musculoskeletal system, such
as tendons, muscles, ligaments, and joints. Accurate diag-
nosis is important because musculoskeletal disorders
account for approximately $850 billion per year in health
care costs and lost wages in the United States.
13
Conven-
tional cart-based ultrasound equipment in this application
has been used, producing detailed high-resolution images;
however, the cost of such equipment (often >$100,000 US)
and lack of portability can be significant limitations. The
use of portable ultrasound units could overcome these lim-
itations, given that hand-held portable ultrasound units
cost approximately $2000 to $7000, and smaller hand-
held devices could further improve accessibility. Without
such barriers, hand-held ultrasound devices can potentially
have a positive effect in medical education
5,11,13,14
and
patient care, bringing ultrasound to classrooms, clinics,
sidelines of the playing field, the battle ground,
13
rural
locations, and countries with limited resources.
4,16
Portable ultrasound machines are now common, used for
point-of-care applications and needle guidance for percuta-
neous procedures.
2
More recently, ultrasound equipment
has been developed that includes hand-held devices, where
a transducer is connected to a tablet or phone to view
images.
4
Such equipment has been used in several applica-
tions, such as trauma, cardiorespiratory assessment, and
invasive procedures
4
; however, the effectiveness of portable
ultrasound in evaluation of the musculoskeletal system has
The Orthopaedic Journal of Sports Medicine, 8(2), 2325967119901017
DOI: 10.1177/2325967119901017
ªThe Author(s) 2020
1
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (https://creativecommons.org/
licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit SAGE’s website at
http://www.sagepub.com/journals-permissions.
not been fully assessed.
7,9,10,12
Thus, the purpose of this
study was to evaluate the use of a portable hand-held ultra-
sound device in the evaluation of the musculoskeletal sys-
tem compared with conventional cart-based ultrasound.
The hypothesis was that portable hand-held ultrasound
would be as effective as conventional cart-based
ultrasound.
METHODS
Institutional review board approval was obtained to
prospectively evaluate 100 consecutive patients (single-
center, evidence level 2 study) who underwent musculo-
skeletal ultrasound at an outpatient radiology clinic as part
of routine patient care.
15
Written informed consent was
obtained from all patients.
Ultrasound imaging was performed by 1 fellowship-
trained musculoskeletal radiologist (J.A.J.; 23 years of
experience in musculoskeletal ultrasound). Ultrasound
imaging was first performed by use of a portable hand-
held ultrasound device (Philips Lumify 12-5 MHz trans-
ducer; Nvidia 5 8.8-inch tablet) directed by the imaging
requisition and patient history, and the resulting diagnosis
was recorded. This was immediately followed with ultra-
sound imaging using a conventional cart-based ultrasound
unit (Philips Epiq 7G 12-5 MHz transducer), and a result-
ing diagnosis was also recorded. The 12-5 MHz transducer
was chosen rather than a higher frequency transducer to
allow direct comparison with the portable hand-held ultra-
sound unit (only a 12-5 MHz linear transducer was avail-
able for the portable ultrasound unit). Additionally, when
gray-scale abnormality was detected, color Doppler rather
than power Doppler was used on the cart-based ultrasound
unit, as power Doppler was not available on the portable
hand-held ultrasound unit. Ultrasound examinations were
focused to the area of concern, except for the shoulder,
which received a comprehensive evaluation.
Diagnoses from the portable hand-held and conventional
cart-based ultrasound units were later reviewed by the
radiologist who performed the ultrasound imaging in con-
sensus with a board-certified orthopaedic surgeon (M.T.F.).
Agreement between the portable and conventional ultra-
sound diagnoses was determined by consensus along with
expected changes in clinical management if disagreement
was present (definitely no, probably no, uncertain, probably
yes, definitely yes).
Descriptive statistics including mean, standard devia-
tion, range, and percentage were used to evaluate the data
of the consensus reading. Correlation was also made with
magnetic resonance imaging (MRI) and surgical results if
available, which were completed in some patients as part of
routine clinical care. The decision to obtain MRI or pursue
surgery was based on clinical judgment and may have been
influenced by the conventional cart-based ultrasound imag-
ing findings as part of routine patient care.
RESULTS
Demographics
The study group of 100 patients consisted of 42 male and 58
female patients with a mean ±SD age of 53 ±13 years
(range, 25-83 years). Anatomic areas scanned included
shoulder (n ¼30 patients), elbow (n ¼11 patients), hand
and wrist (n ¼15 patients), hip (n ¼10 patients), knee (n ¼
11 patients), foot and ankle (n ¼12 patients), and others (n
¼11 patients; neck, chest wall, abdominal wall, groin),
imaged over a time period of 20 months. The time interval
from the completion of patient scanning to retrospective
consensus review of results was 6 months.
Ultrasound Results
Scanning with the conventional cart-based ultrasound
machine revealed abnormality in 92%(92/100) of patients
*Address correspondence to Anna L. Falkowski, MD, MHBA, Department of Radiology, University of Michigan, 1500 East Medical Center Drive, Ann
Arbor, Michigan, 48103, USA (email: falkowski.anna@gmail.com) (Twitter: @AnnaFalkowskiMD).
Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.
Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland.
§
Department of Orthopaedic Surgery, University of Michigan, Domino’s Farms, MedSport, Ann Arbor, Michigan, USA.
Final revision submitted October 24, 2019; accepted November 1, 2019.
One or more of the authors has declared the following potential conflict of interest or source of funding: A.L.F. has received grants from the Research
Funds of the University of Basel, Swiss Society of Radiology, Gottfried und Julia Bangerter-Rhyner-Stiftung, and Freiwillige Akademische Gesellschaft Basel.
J.A.J. is on the advisory board for Philips Medical Imaging and has received speaking fees from Philips. M.T.F. has received research support from Smith &
Nephew, DJO, and RTI; speaking fees from Smith & Nephew; and consulting fees from Smith & Nephew. AOSSM checks author disclosures against the
Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating
thereto.
Ethical approval for this study was obtained from the University of Michigan Medical School Institutional Review Board (study No. HUM0013683).
TABLE 1
Primary Abnormalities Found on Conventional Cart-Based
Ultrasound Evaluation
Abnormality No. of Cases
Tendon abnormality 49
Mass or cyst 17
Joint degeneration 7
Bursal abnormality 6
Hernia (groin, abdominal wall) 5
Joint effusion 4
Plantar fasciopathy 3
Ulnar collateral ligament injury
(first metacarpophalangeal)
3
Inflammation or infection 3
Nerve abnormality 2
Dupuytren contracture 1
2Falkowski et al The Orthopaedic Journal of Sports Medicine
(Table 1). Comparison of portable hand-held and cart-based
ultrasound findings showed that results were concordant in
65%(65/100) (Figure 1) and discordant in 35%(35/100) of
patients. In the 35 patients with discordant results
(Table 2), the discrepancy in diagnosis resulted in no
change in clinical management in 46%(16/35) (Figure 2 and
Table 3), probably no change in 29%(10/35) (Table 4),
uncertain change in 14%(5/35) (Table 5), probable change
in 11%(4/35) (Figure 3 and Table 6), and definite change in
0%(0/35) of patients. The diagnoses changing management
included the following (Table 6): nondetection of a satellite
nodule of 2 mm associated with a superficial mass (1
patient), incorrect interpretation of a 5-mm ganglion cyst
as a possible solid mass (1 patient) (Figure 3), overlooked
direct inguinal and femoral hernias (1 patient), and misdi-
agnosis of partial gluteus medius tendon tear as tendinosis
(1 patient). Overall, the results from portable hand-held
ultrasound were concordant or discordant without clinical
relevance in 96%(96/100) of patients compared with those
from conventional cart-based ultrasound.
Regarding conventional color Doppler evaluation, 11
patients showed a discrepancy where increased flow or
hyperemia was present with conventional cart-based
ultrasound and not detected with the portable hand-
held ultrasound. These cases of discrepancy included the
following anatomic areas: elbow (n ¼6), Achilles tendon
(n ¼2), groin (n ¼1), shoulder (n ¼1), and shin (n ¼1).
They included abnormalities in the tendons (n ¼7),
masses or lymph nodes (n ¼3), and a bursa (n ¼1).
Tendon abnormality was diagnosed with conventional
cart-based ultrasound in 49%of patients (49/100); discre-
pancies were found in 12 patients when portable ultra-
sound was used: tendinosis was misdiagnosed as normal
tendon (n ¼3), underestimated (n ¼1), and overestimated
(n ¼1); tendon tears were overlooked (n ¼2), underesti-
mated (n ¼2), and overestimated (n ¼3). Overall, only 1 of
these discrepancies would have caused a probable change
in the clinical outcome, which involved the gluteus medius
tendon.
With regard to calcifications, in 2 of the 6 affected
patients, visibility was difficult when using the hand-held
portable ultrasound unit compared with the conventional
ultrasound unit in the rotator cuff (1 patient) and plantar
aponeurosis (1 patient). In both patients, the lesser visibility
did not change the patients’ clinical management because
the calcifications were not completely overlooked.
Figure 1. Findings for a 48-year-old man with full-thickness supraspinatus tear (concordant diagnoses). Images reveal tendon
defect (arrows) shown on (A, B) portable hand-held ultrasound, (C, D) conventional cart-based ultrasound, and (E, F) magnetic
resonance imaging. (A, C, E) Long axis of tendon. (B, D, F) Short axis of tendon. GT, greater tuberosity.
TABLE 2
Patients With Disagreement in Diagnosis Comparing
Hand-Held Portable Versus Conventional Cart-Based
Ultrasound and the Effect on Clinical Management
Influence
on Clinical
Management
No. (%)
of Patients Anatomic Area (No. of Patients)
Definitely no 16 (46) Shoulder (5), elbow (4), wrist/hand (1),
hip (1), knee (1), foot/ankle (2),
other (2)
Probably no 10 (29) Shoulder (6), elbow (1), wrist/hand (1),
other (2)
Uncertain 5 (14) Shoulder (1), elbow (1), wrist/hand (2),
other (1)
Probably yes 4 (11) Wrist/hand (2), hip (1), other (1)
Definitely yes 0 (0) None
The Orthopaedic Journal of Sports Medicine Portable Versus Cart-Based Ultrasound 3
In review of the medical records, 14%of patients (14/100)
had additional MRI evaluation where correlation confirmed
the cart-based conventional ultrasound diagnosis. Of these,
2 patients had surgery that confirmed the diagnosis of com-
plex ganglion cyst and lipoma. In the 7 patients with joint
degeneration on ultrasound, radiographs were present in 5
cases. In the 3 patients with inflammation or infection,
additional clinical history, clinical evaluation, and labora-
tory values confirmed the diagnoses of rheumatoid arthri-
tis, psoriasis, and abscess, respectively.
DISCUSSION
Although the use of portable hand-held ultrasound has
been described in general ultrasound applications, its use
in routine musculoskeletal applications has not been fully
assessed. Our study showed that the results from portable
hand-held ultrasound were concordant or were discordant
without clinical relevance in 96%(96/100) of patients com-
pared with conventional cart-based ultrasound.
Portable ultrasound was first developed for military pur-
poses to identify and diagnose serious injuries in the bat-
tlefield.
13
In clinical situations, portable ultrasound may be
of benefit when the transport of a patient to the ultrasound
department is not possible or the heavy conventional
ultrasound machine is less accessible to the patient. Such
point-of-care ultrasound applications may also include the
emergency department and the outpatient clinic, where an
urgent diagnosis may be important.
1,6
The lower cost of
such portable devices (approximately $2000-$7000) com-
pared with conventional machines (often >$100,000) cre-
ates another opportunity, especially for less economically
Figure 2. Findings for a 53-year-old man with common extensor tendinosis (discordant results due to differences in color Doppler
information with no change in clinical management). Images reveal severe tendinosis (arrows) shown on (A, B) portable hand-held
and (C, D) conventional cart-based ultrasound, appearing as increased signal on (E) intermediate-weighted fat saturation magnetic
resonance image. Note increased flow on color Doppler image of (D) conventional ultrasound compared with (B) the portable unit.
H, humerus; R, radial head; arrowhead, radial collateral ligament.
4Falkowski et al The Orthopaedic Journal of Sports Medicine
developed regions.
2,4
Portable ultrasound has also been
described in the field of medical education.
5,11,13,14
Common
applications for portable ultrasound include evaluation for
cardiac or abdominal abnormality.
5,14
The use of portable
ultrasound in the musculoskeletal system has been
described for foreign body removal
7,9
and rib fracture
assessment.
12
One study evaluated 10 shoulders and con-
cluded that abnormality could be identified
10
; however, a
comprehensive evaluation of routine musculoskeletal
applications has not been previously assessed.
Our study showed the utility of portable hand-held ultra-
sound in the evaluation of common musculoskeletal appli-
cations that is typical of an outpatient clinic. In our study
population, evaluation for tendon abnormality was the
most common application (49%, or 49/100). Of these 49
patients, the results were concordant in 76%(37/49) when
both portable and conventional ultrasound equipment were
used. In the remaining 12 patients, the most common dis-
crepancy was a change in severity of tendinosis, either
increasing or decreasing; however, the diagnosis provided
TABLE 3
Discrepancies in the Diagnosis: No Definite Change in Management
Anatomic Area Diagnosis on Portable Ultrasound
Additional or Changed Diagnosis on Conventional
Cart-Based Ultrasound
Shoulder Postoperative changes and no cuff tear Supraspinatus and infraspinatus muscle fatty
infiltration (additional diagnosis)
Shoulder Subacromial-subdeltoid bursal thickening and impingement Mild supraspinatus tendinosis (additional diagnosis)
Shoulder Subacromial-subdeltoid bursal thickening, tear, subluxation of the
long head of the biceps brachii tendon
Tendinosis of subscapularis and supraspinatus
(additional diagnosis)
Shoulder Partial bursal-sided tear of the supraspinatus tendon, fatty muscle
infiltration
Tendinosis of the subscapularis tendon (additional
diagnosis)
Shoulder Mild supraspinatus tendinosis, bursal thickening, joint effusion Moderate supraspinatus tendinosis (changed
diagnosis)
Elbow Severe common extensor tendinosis and partial tearing Flow on color Doppler imaging (additional diagnosis)
Elbow Moderate common extensor tendinosis Flow on color Doppler imaging (additional diagnosis)
Elbow Moderate common extensor tendinosis, interstitial tear Flow on color Doppler imaging (additional diagnosis)
Elbow Olecranon bursal distention Flow on color Doppler imaging (additional diagnosis)
Thumb Carpometacarpal osteoarthritis, remote injury of radial collateral
ligament
Ganglion cyst (additional diagnosis)
Abdominal wall Soft tissue nodule Postoperative changes (changed diagnosis)
Hamstring Moderate to severe tendinosis of conjoined semitendinosus and biceps
femoris tendons
Mild to moderate tendinosis (changed diagnosis)
Knee Joint effusion, osteoarthritis, abnormal lateral collateral ligament Synovial proliferation (additional diagnosis)
Calf Gastrocnemius and plantaris tear Normal plantaris (changed diagnosis)
Achilles tendon Severe tendinosis, interstitial tear Flow on color Doppler imaging, peritendinitis
(additional diagnosis)
Heel Plantar fasciopathy Calcification (additional diagnosis)
TABLE 4
Discrepancies in the Diagnosis: Probably No Change in Management
Anatomic Area Diagnosis on Portable Ultrasound
Additional or Changed Diagnosis on Conventional
Cart-Based Ultrasound
Shoulder Tendinosis supraspinatus tendon Interstitial tear of supraspinatus tendon (changed diagnosis)
Shoulder Focal full-thickness tear of supraspinatus tendon Overestimated tear size on portable ultrasound (changed diagnosis)
Shoulder Full-thickness tear of subscapularis, partial-
thickness tear of supraspinatus
Partial-thickness tear of subscapularis, full-thickness tear of
supraspinatus (changed diagnosis)
Shoulder Solid mass Flow on color Doppler imaging (additional diagnosis)
Shoulder Calcification Possible small tendon cleft (additional diagnosis)
Shoulder Biceps tendon split tear, subluxation, bursal
thickening
Partial-thickness tear of subscapularis tendon (additional diagnosis)
Elbow Moderate common extensor tendinosis, partial-
thickness tear
Flow on color Doppler imaging (additional diagnosis), no tear (changed
diagnosis)
Thumb Remote injury of ulnar collateral ligament, no
Stener lesion
Partial-thickness tear of ulnar collateral ligament, nondisplaced
avulsion fragment (additional diagnosis)
Abdominal wall Lipoma Size underestimated on portable ultrasound (changed diagnosis)
Leg Soft tissue mass Flow on color Doppler imaging (additional diagnosis)
The Orthopaedic Journal of Sports Medicine Portable Versus Cart-Based Ultrasound 5
by the conventional ultrasound would have changed clini-
cal management in only 1 patient (2%, or 1/49), in whom the
gluteus medius was involved. Importantly, there were no
changes in clinical outcome involving the shoulder, which
was the most common joint included in our study (30%,or
30/100). A previous study evaluated 10 shoulder cases via
portable ultrasound versus conventional ultrasound and
could identify abnormality in 70%to 80%of the cases
10
;
however, the authors did not investigate whether the incor-
rect diagnosis would have changed the clinical outcome.
Previous studies have also not evaluated the use of portable
ultrasound for other musculoskeletal applications beyond
the shoulder; our study included a relatively uniform dis-
tribution of cases outside of the shoulder, evaluating the
elbow (11/100), wrist and hand (15/100), hip (10/100), knee
(11/100), ankle and foot (12/100), and other miscellaneous
applications, such as the neck, chest wall, abdominal wall,
and groin (11/100).
In our study, there were 4 discrepant results that could
have potentially changed the clinical management (see
Table 3), which included 2 superficial (hand and finger) and
2 deep (groin and hip) pathologic findings. One case was an
overlooked superficial satellite nodule measuring 2 mm
adjacent to a solid mass of the palmar hand that could have
potentially influenced the surgical management. The sec-
ond case was a 5-mm ganglion cyst of the finger on conven-
tional cart-based ultrasound where the portable ultrasound
could not distinguish cyst versus solid, which may have
TABLE 5
Discrepancies in the Diagnosis: Uncertain About Change in Management
Anatomic Area Diagnosis on Portable Ultrasound
Additional or Changed Diagnosis on Conventional
Cart-Based Ultrasound
Shoulder Mild tendinosis, calcifications in subscapularis Calcifications in infraspinatus tendon (additional diagnosis)
Elbow Moderate common extensor tendinosis, interstitial tear Flow on color Doppler imaging (additional diagnosis)
Finger Probably ganglion cyst Definite ganglion cyst (changed diagnosis)
Thumb Carpometacarpal osteoarthritis Small cyst (additional diagnosis)
Groin Direct hernia Femoral hernia (additional diagnosis)
Figure 3. Findings for a 35-year-old woman with ganglion cyst (discordant results with probable change in clinical management).
(A) Image made on the portable hand-held unit reveals focal abnormality (arrow) appearing hypoechoic, raising concern for solid
mass. (B) On the image from the conventional cart-based unit, the abnormality appears anechoic consistent with cyst. Note
increased conspicuity of the posterior increased through transmission (arrowheads) in A compared with B. P, proximal phalanx;
T, flexor tendon.
TABLE 6
Discrepancies in the Diagnosis: Probable Change in Management
a
Anatomic Area Diagnosis on Portable Ultrasound Diagnosis on Conventional Cart-Based Ultrasound
Hand Single solid mass Solid mass with satellite nodules
Finger Differential diagnosis of hyperechoic or anechoic cyst
versus solid mass
Ganglion cyst
Groin Iliopsoas bursitis Iliopsoas bursitis
Additionally, direct inguinal hernia and femoral hernia
Hip Hydroxyapatite deposition disease of the medial gluteus
tendon, tendinosis of the gluteus minimus tendon
Hydroxyapatite deposition disease of the medial gluteus tendon
Missed partial-thickness tear of the gluteus medius tendon
a
Probable changes in management are indicated with italics.
6Falkowski et al The Orthopaedic Journal of Sports Medicine
resulted in an unnecessary biopsy or excision. The third
case involved the hip and groin; trochanteric bursal disten-
tion was identified, but the direct inguinal and femoral her-
nias were overlooked with the portable ultrasound unit. In
the fourth case, a partial tear of the gluteus medius tendon
at the greater trochanter was misdiagnosed as tendinosis.
The diagnosis of partial-thickness tear could have changed
management from percutaneous tenotomy or fenestration
to whole blood or platelet-rich plasma injection to minimize
risk of complete tendon tearing.
3,8
One limitation of the portable hand-held ultrasound unit
was the low sensitivity of the color Doppler compared with
cart-based ultrasound. Although we chose the low-flow set-
ting, there were 11 patients in whom the portable ultra-
sound did not reveal internal blood flow in tendons (n ¼7),
masses (n ¼3), and an olecranon bursa (n ¼1); however, the
additional finding of hyperemia when using the conven-
tional cart-based ultrasound machine did not significantly
change clinical management. Another limitation of the por-
table ultrasound equipment was difficulty in identifying
small calcifications in the rotator cuff (n ¼1) and plantar
aponeurosis (n ¼1), which also did not change clinical
management.
We acknowledge that our study has some limitations. We
did not directly assess the image quality of the 2 different
ultrasound techniques; however, the goal of our study was
to evaluate the clinical effect of diagnosis discordance using
a hand-held portable ultrasound unit. Second, imaging was
performed by only 1 observer without assessment of inter-
observer or intraobserver variability. Also, this observer
had significant experience in musculoskeletal ultrasound;
a study with multiple observers with different experience
would confirm generalization of our results. Another limi-
tation is that the images were obtained with the hand-held
portable examination performed first and interpreted in a
nonrandomized fashion not blinded toward the type of
ultrasound equipment used, which potentially introduced
bias. No statistical analysis (including power analysis) was
obtained. Also, the vast majority of patients did not have
additional imaging or surgical findings to correlate with
our results. An intrinsic limitation of the hand-held ultra-
sound machine is the lack of power Doppler and a linear
transducer with the highest frequency of 12-5 MHz; similar
settings and transducer frequency were used with the con-
ventional cart-based ultrasound unit to allow direct com-
parison. Although we determined overall concordance, we
were unable to determine concordances specific to each
joint given the low sample size.
CONCLUSION
In evaluation of the musculoskeletal system, our study
showed that the results from portable hand-held
ultrasound were concordant or were discordant without
clinical relevance in 96%(96/100) of patients compared
with conventional cart-based ultrasound. The most com-
mon joint evaluated was the shoulder, which showed no
clinically relevant discrepancies in diagnosis.
REFERENCES
1. Appropriate use criteria for handheld/pocket ultrasound devices. Ann
Emerg Med. 2018;72(4):e31-e33.
2. CADTH Rapid Response Reports. Portable Ultrasound Devices in the
Pre-Hospital Setting: A Review of Clinical and Cost-Effectiveness and
Guidelines. Ottawa, ON: Canadian Agency for Drugs and Technolo-
gies in Health; 2015.
3. Chiavaras MM, Jacobson JA. Ultrasound-guided tendon fenestration.
Semin Musculoskelet Radiol. 2013;17(1):85-90.
4. Epstein D, Petersiel N, Klein E, et al. Pocket-size point-of-care
ultrasound in rural Uganda—a unique opportunity “to see”, where
no imaging facilities are available. Travel Med Infect Dis. 2018;23:
87-93.
5. Galusko V, Khanji MY, Bodger O, Weston C, Chambers J, Ionescu A.
Hand-held ultrasound scanners in medical education: a systematic
review. J Cardiovasc Ultrasound. 2017;25(3):75-83.
6. Guermazi A, Hayashi D, Jarraya M, et al. Sports injuries at the Rio de
Janeiro 2016 Summer Olympics: use of diagnostic imaging services.
Radiology. 2018;287(3):922-932.
7. Holleyman RJ, Husaini H, Rankin KS. Image guided surgery for
removal of deep foreign bodies and soft tissue tumours using
portable ultrasonography. Ann R Coll Surg Engl. 2019;101(2):
136-137.
8. Jacobson JA, Rubin J, Yablon CM, Kim SM, Kalume-Brigido M, Para-
meswaran A. Ultrasound-guided fenestration of tendons about the hip
and pelvis: clinical outcomes. J Ultrasound Med. 2015;34(11):
2029-2035.
9. Kent MJ, Melton JT. Use of portable ultrasound for exploration and
removal of superficial foreign bodies. Ann R Coll Surg Engl. 2009;
91(4):344-345.
10. Lau BC, Motamedi D, Luke A. Use of pocket-sized ultrasound device
in the diagnosis of shoulder pathology. Clin J Sport Med. 2020;30(1):
20-24.
11. Maetani TH, Schwartz C, Ward RJ, Nissman DB. Enhancement of
musculoskeletal radiology resident education with the use of an indi-
vidual smart portable ultrasound device (iSPUD). Acad Radiol. 2018;
25(12):1659-1666.
12. Martin VT, Zeng L, Nzengue JC, Mao L, Huang J, Peng X. The use
of a portable ultrasound system in the surgical assessment of rib
fractures in an elderly patient. Ann Med Surg (Lond). 2018;36:
96-98.
13. McGahan JP, Pozniak MA, Cronan J, et al. Handheld ultrasound:
threat or opportunity? Appl Radiol. 2015;44(3):20-25.
14. Nielsen MB, Cantisani V, Sidhu PS, et al. The use of handheld ultra-
sound devices—an EFSUMB position paper. Ultraschall Med. 2019;
40(1):30-39.
15. Schweitzer ME. Evidence level. JMagnResonImaging. 2016;
43(3):543.
16. Shokoohi H, Raymond A, Fleming K, et al. Assessment of
point-of-care ultrasound training for clinical educators in Malawi,
Tanzania and Uganda. Ultrasound Med Biol. 2019;45(6):
1351-1357.
The Orthopaedic Journal of Sports Medicine Portable Versus Cart-Based Ultrasound 7
... Some studies have already shown the good applicability of HHUS devices for musculoskeletal ultrasound (MSUS) examinations, e.g., for hemarthrosis and local degenerative changes such as tendinopathies. [6][7][8][9]. However, the use of HHUS devices in rheumatology to systematically assess structural joint damage and inflammatory extent in inflammatory arthritis (IA) has not been evaluated to date. ...
... Despite a maximum frequency of 10 MHz, the HHUS device showed high accuracy in B mode in detecting pathological findings even for small joints, which are often affected in IA patients and for this reason are included in most established US-scoring systems for arthritis [23,24]. Some studies already evaluated the accuracy of HHUS devices for MSUS [6][7][8][9]. However, these studies only focused on the sensitivity assessment of degenerative changes without systematically evaluating pathologies found in IA, e.g., signs of erosions or synovitis. ...
... However, our study also revealed the absolute inadequacy of the PD mode of the Butterfly iQ device for detecting hypervascularisation in joints and periarticular structures. This limitation seems to be a general problem of HHUS devices at present, thus this shortcoming also applies to other portable devices [9]. Because PD mode has become an essential component of MSUS for assessing and monitoring acute inflammation [25][26][27], improvements in PD mode sensitivity are absolutely necessary to enable the use of HHUS devices in daily rheumatology practice. ...
Article
Full-text available
The purpose of this study was to assess the accuracy and performance of a new handheld ultrasound (HHUS) machine in comparison to a conventional cart-based sonographic machine in patients with inflammatory arthritis (IA). IA patients with at least one tender and swollen joint count were enrolled. US was performed on the clinically affected joints using a cart-based sonographic device (Samsung HS40) and a HHUS device (Butterfly iQ). One blinded reader scored all images for the presence of erosions, bony enlargement, synovial hypertrophy, joint effusion, bursitis, tenosynovitis, and enthesitis. Synovitis was graded (B mode and power Doppler (PD)) by the 4-level EULAR-OMERACT scale. To avoid bias by the blinded reader, we included 67 joints of two healthy volunteers in the evaluation. We calculated the overall concordance and the concordance by type of joint and pathological finding. We also measured the time required for the US examination per joint with both devices. Thirty-two patients (20 with RA, 10 with PsA, and one each with gout and SLE-associated arthritis) were included, and 186 joints were examined. The overall raw concordance in B mode was 97% (κappa 0.90, 95% CI (0.89, 0.94)). In B mode, no significant differences were found in relation to type of joint or pathological finding examined. The PD mode of the HHUS device did not detect any PD signal, whereas the cart-based device detected a PD signal in 61 joints (33%). The portable device did not offer any time savings compared to the cart-based device (47.0 versus 46.3 s). The HHUS device was accurate in the assessment of structural damage and inflammation in patients with IA, but only in the B mode. Significant improvements are still needed for HHUS to reliably demonstrate blood flow detection in PD mode.
Article
Full-text available
FULL TEXT: https://doi.org/10.2147/OARRR.S355140 Imaging has long been taking its place in the diagnosis, monitor, and prognosis of rheumatic diseases. It plays a vital role in the appraisal of treatment. Key progress in the clinical practice of rheumatology is the innovation of advanced imaging modalities; such as musculoskeletal ultrasound (MSUS), computerized tomography (CT) and magnetic resonance imaging (MRI). These modalities introduced a promising noninvasive method for visualizing bone and soft tissues to enable an improved diagnosis. The use of MSUS in rheumatology is considered a landmark in the evolution of the specialty and its ease of use and many applications in rheumatic diseases make it a forerunner instrument in the practice. The use of MSUS among rheumatologists must parallel the development rate of the excellence revealed in the specialty. Moreover, innovative interventional imaging in rheumatology (III-R) is gaining fame and key roles in the near future for a comprehensive management of rheumatic diseases with precision. This review article throws light on the emergence of these robust innovations that may reshape the guidelines and practice in rheumatology, in particular, efforts to enhance best practice during the coronavirus disease 2019 (COVID-19) pandemic are endorsed.
Article
Objectives: To compare medial meniscal extrusion on weight-bearing ultrasound (US) with supine US and magnetic resonance (MR) imaging correlating with meniscal pathology and reported symptoms. Methods: IRB approved study with informed consent. Patients obtaining routine knee MR imaging for suspected knee pathology were prospectively evaluated with supine and weight-bearing US of the medial meniscus. Meniscal extrusion was measured independently by two fellowship-trained musculoskeletal radiologists. Correlation was made to presence or absence of meniscal degeneration or tear on MR imaging, as well as reported symptoms. Statistical significance was calculated via intraclass correlation coefficient (ICC) and analysis of variance (ANOVA). Results: Ninety-nine knees from 95 subjects (50 males, 45 females; mean age 45 ± 15 years) were included. Mean medial meniscal extrusion measured at US for a normal meniscus (n = 36) was 0.8 mm when supine, increasing to 1.6 mm on weight-bearing. Mean meniscal extrusion in subjects with mucoid degeneration (n = 20) and those with meniscal tears (n = 43) was 1.6 mm, increasing to 2.3 mm with weight bearing. Inter-reader reliability showed ICC values of 0.853 to 0.940. There was a significant difference in medial meniscal extrusion comparing subjects with a normal medial meniscus at magnetic resonance imaging (MRI) and subjects with either meniscal degeneration or tear. There was no significant difference in degree of meniscal extrusion between subjects with meniscal degeneration or tear. There was trend of worsening symptoms and increasing functional limitations moving from normal meniscus to meniscal degeneration to meniscal tear. Conclusions: A normal meniscus shows lesser mobility between supine and upright position, than a pathologic meniscus. Both mucoid degeneration and meniscal tear demonstrate extrusion in the supine position, which increases with weight-bearing position.
Article
Musculoskeletal ultrasound (US) has many applications in the care of athletes. This article reviews the current literature and identifies research gaps regarding musculoskeletal US in the athletic training room setting to evaluate and manage soccer players. The best evidence for US in the training room setting is for diagnosis and prognosis of muscle injuries, where studies show that it is equivalent to other imaging modalities. US also has been used for injury risk prediction, although the data are mixed. Many applications of US are described in other sport settings and may have crossover applications to soccer.
Article
Full-text available
ACEP Policy regarding appropriate use recommendations for handheld ultrasound devices in emergency departments
Article
Full-text available
Introduction Portable ultrasound is a modality of medical ultrasonography that utilizes small and light devices, and is an established diagnostic method used in clinical settings such as Cardiology, Vascular Surgery, Radiology, Endocrinology, Pediatric and Obstetric & Gynecology. Presentation of cases We present a case report of 86-years old patient who underwent surgical rib fixation for multiple rib fractures followed by falling from standing height and our management experience. Discussion The use of portable ultrasound device in operation theatre demonstrates several advantages.We believe that Portable color doppler ultrasound system would be necessary in the management of rib fracture. Conclusion This study demonstrates that the portable ultrasound system is a valuable method of imaging in the assessment of rib fractures, and which can save time, economically affordable for many patients, and allow surgeons to make a minor incision in order to avoid complications such as infection, particularly in this group of vulnerable patients.
Article
Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013–2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.
Article
The miniaturization of ultrasound equipment in the form of tablet- or smartphone-sized ultrasound equipment is a result of the rapid evolution of technology and handheld ultrasound devices (HHUSD). This position paper of the European Federation of Societies in Ultrasound and Medicine (EFSUMB) assesses the current status of HHUSD in abdominal ultrasound, pediatric ultrasound, targeted echocardiography and heart ultrasound, and we will report position comments on the most common clinical applications. Also included is a SWOT (Strength - Weaknesses - Opportunities - Threats) analysis, the use for handheld devices for medical students, educational & training aspects, documentation, storage and safety considerations. © Georg Thieme Verlag KG Stuttgart · New York.
Article
Rationale and objectives: Many medical specialties have incorporated portable ultrasound into their educational curriculum. Our objective was to determine the utility of an individual smart portable ultrasound device (iSPUD) as an educational tool in resident and fellowship Musculoskeletal Radiology training. Materials and methods: After Institutional Review Board approval, volunteer radiology trainees were instructed to use the iSPUD (Philips Lumify ultrasound probe and Samsung Galaxy Tab S2 8 inch tablet), asked to identify 10 wrist structures with the iSPUD and completed a Likert scale-based, pretest survey. Trainees were then given the iSPUD for 3 days of independent scanning practice. Afterward, trainees were asked to identify the same 10 wrist structures with the iSPUD and to complete a Likert scale-based, post-test survey. Results: Twenty trainees volunteered to participate. Trainee performance on the 10-wrist structure identification test with the iSPUD resulted in a pretest mean number correct of 2.5 ± 2.16 and a post-test mean number correct of 9.85 ± 0.37 (p < 0.001). On the pretest survey, 68.42% (13/20) had never performed and 42.11% (8/20) had never interpreted a musculoskeletal ultrasound. On the post-test survey, 18/20 (94.74%) strongly agreed that access to an iSPUD would improve their ability to perform musculoskeletal ultrasound, improve ultrasound-guided interventional skills, and help them become better Radiologists. Conclusion: The use of an iSPUD as a tool in Musculoskeletal Radiology resident and fellow education can improve clinical ultrasound skills, build trainee technical confidence during diagnostic ultrasound procedures, and help trainees achieve their goal of becoming a competent Radiologist.
Article
Purpose To describe the occurrence of imaging-depicted sports-related stress injuries, fractures, and muscle and tendon disorders during the 2016 Summer Olympic Games in Rio de Janeiro, Brazil. Materials and Methods Data on radiologic examinations were collected and retrospectively analyzed centrally by two board-certified musculoskeletal radiologists (with a third musculoskeletal radiologist acting as an adjudicator in case of discrepancies). Descriptive data on all imaging examinations by using radiography, ultrasonography (US), and magnetic resonance (MR) imaging were collected and analyzed according to imaging modality, country of origin of the athletes, type of sport, and type and location of injury. Results There were 1101 injuries that occurred in 11 274 (9.8%) athletes. A total of 1015 radiologic examinations were performed, including 304 (30.0%) radiographic, 104 (10.2%) US, and 607 (59.8%) MR examinations. Excluding 10 athletes categorized as refugees, athletes from Africa had the highest utilization rate (14.8%, 148 of 1001). Athletes from Europe underwent the most examinations with 103 radiographic, 39 US, and 254 MR examinations. Gymnastics (artistic) had the highest percentage of athletes who underwent imaging (15.5%, 30 of 194). Athletics (track and field) had the most examinations (293, including 53 radiographic, 50 US, and 190 MR examinations). Conclusion The overall occurrence of imaging used to help diagnose sports-related injuries at the Rio de Janeiro 2016 Summer Olympics was 6.4% of athletes. In these cases, MR imaging comprised 60% of imaging utilization.©RSNA, 2018 Online supplemental material is available for this article.
Article
Objective: Musculoskeletal ultrasound imaging is increasingly being used for static and dynamic imaging of tendons, muscles, ligaments, and bones. New, hand-held, pocket-sized ultrasounds are more portable and affordable. The purpose of this study was to evaluate the feasibility of pocket-sized ultrasound to diagnose shoulder pathology. Design: Prospective cohort study. Setting: Tertiary Care Hospital. Methods: Ten consecutive patients (mean age 54; range 42-68 years) referred for a shoulder ultrasound for evaluation of shoulder pain were recruited. A diagnostic ultrasound was performed first with a pocket-sized ultrasound machine (VScan; General Electric, Northville, MI) and cine images saved for later review. Next, standard diagnostic ultrasound by a radiology technician specialized in musculoskeletal ultrasound was performed using (LOGIQ; General Electric, Northville, MI) ultrasound. The radiology report from the standard diagnostic ultrasound was used as the gold standard for diagnoses. Two independent evaluators, a musculoskeletal-trained radiologist and a sports-medicine-trained physician with over 8 years of experience with musculoskeletal ultrasound, reviewed the images from the pocket-sized ultrasound. Results: Nine of the studies were diagnosed with a pathologic entity during the standard diagnostic ultrasound and 1 was found to be normal. Diagnoses ranged from biceps tendinopathy, calcific tendonitis, and partial-articular-sided rotator cuff tear. Evaluator 1 correctly identified 7/10 diagnoses and evaluator 2 correctly identified 8/10 diagnoses. The evaluators also rated their confidence in diagnosis as 4.2/5 and the image quality as 3.7/4 from the pocket-sized ultrasound. Discussion: The findings from this study demonstrate that pocket-sized, hand-held ultrasound machines may be used to identify shoulder pathology.