Ultrasound-guided injection is more precise, less painful

Orthopaedic surgeon’s design helps patients with sports, arthritis and overuse injuries.

(December 2011) A Yale Medical Group orthopaedic surgeon is the first doctor in the country to offer a new technique for the treatment of patients with bone, joint and tendon disease—an integrated ultrasound-guided way to inject medication to the exact site of pain.

Yale Medical Group orthopaedic surgeon John S. Reach, Jr, MSc, MD, who co-designed a special device that combines the ultrasound with the injection, says it allows him to pinpoint the exact location of the pain with exquisite precision. This increases the accuracy of treatment and allows him to use a more slender, less painful needle, making the process of getting a pain injection much more tolerable for patients.

He described the process for WTNH ABC News 8 at Yale Medical Group’s new Guilford Shoreline Orthopaedic Surgery Office.

Dr. Reach says the technique will improve treatment for many patients suffering from sports, arthritis, nerve and overuse injuries. It can even cure some patients by reducing inflammation to such a point that they can avoid surgery for their problem in the future, he adds.

Ultrasound guided injections: wtnh.com

‘Virtual syringe’ in real time

The new device, called Navigator DS, was approved by the FDA this past fall. It is a portable, laptop system with an ultrasound transducer and monitor, attached to a needle about the thickness of a human hair. Dr. Reach collaborated on the design with an Atlanta company called Carticept.

Using the device, Dr. Reach can deliver medication to difficult-to-reach tissue with the touch of a button. He uses the imaging screen to guide an injection of medication, until he can hit the precise point of inflammation, and use more pressure than he could deploying a syringe. He tracks progress watching a “virtual syringe” in real time on the monitor.

“With the help of ultrasound imaging, I can guide the needle and deliver medications exactly where I want it to be. The technique allows me to decrease the pain right at the point of inflammation: diagnostically allowing the patient to test-drive any future surgery on that joint, while at the same time improving the patients immediate level of function” says Dr. Reach, who is using the technique for patients at Yale Medical Group’s new Shoreline Orthopaedic Surgery Office in Guilford.

“There are big benefits to using image guidance with a smaller needle. Smaller needles simply hurt less than bigger needles,” he says, adding that the larger needles can be trying for a patient when the doctor is basically just trying to relieve their pain.

Accuracy of ultrasound

In a 2007 study presented at the American Academy of Orthopaedic Surgeons and published in Foot & Ankle International, Dr. Reach and his colleagues at Duke demonstrated 100 percent accuracy with ultrasound guided injections in the small joints and tendon sheaths of the foot and ankle.

Blind unguided local anesthetic and steroid shots are far less accurate—studies have shown blind injections to be only 80 percent accurate in the knee, which is a very large joint, and only 30 percent in the shoulder. “In my specialty (orthopaedic foot and ankle surgery), we treat over 28 bones and 38 joints. This new system give us the ability to precisely place medications accurately and painlessly into these tiny joints without resorting to higher expense MRI or the potential harm of ionizing radiation with CTs,” Dr. Reach says.

Indeed, doctors have used CT and MRI to guide injections, but radiation and expense make those methods difficult for patients, doctors and staff, and those techniques require the addition of iodine based contrast agents and cannot quickly capture the real-time motion of the needle.

Implications for the future

Dr. Reach had been using a “bridge” system that used a traditional ultrasound machine to guide injections, but that required several people to handle different parts of the procedure. “I wanted to put the two things together, to have the syringe attached to the ultrasound system,” he says. He and Mary Badon, MD, MBA, presented a study this past summer at the AOFAS Annual Meeting that showed more than $650 million savings in Medicare dollars when musculoskeletal ultrasound is used in place of less accurate tests and treatments.

Dr. Reach believes the new device has significant implications for doctors in non-orthopaedic specialties, including anesthesia and rheumatology. “Very rarely in medicine do we have a new technology that improves patient care while decreasing overall health care costs,” he says.