What is interventional orthopedics?
Interventional Orthopedics
Interventional orthopedics is an emerging field that endeavors to bridge the gap between non-operative orthopedics (sports medicine, interventional spine, and pain medicine) and surgery and offers a variety of efficacious, alternative interventions to surgery for patients who have not responded to conservative therapies instead of simply evaluating whether musculoskeletal injuries are severe enough for surgery or not (Williams 20).
Ultrasonography plays an integral role in the field of interventional orthopedics and complements the traditional history and physical exam allowing the interventionist to make a more accurate diagnosis at the bedside and allowing for a wider range of treatments that more accurately target specific pathology.
A 2009 study by Sibbet et al demonstrated that using ultrasound guidance resulted in 43.0% reduction in procedural pain, 58.5% reduction in absolute pain scores at the 2-week outcome, 75% reduction in significant pain, 25.6% increase in the responder rate, 62.0% reduction in the nonresponder rate, increased detection of effusion by 200% and volume of aspirated fluid by 337% compared to non-imaged guided procedures.
Additionally, ultrasonography has been shown to reduce healthcare costs, reduce time to diagnosis, and improve the safety of interventions in various circumstances (Sibbett et al 2011, Smallwood et al 2018). A 2008 study by Parker et al demonstrated that nearly 30% of the musculoskeletal diagnoses for which MRIs were ordered could have been made by ultrasound and would have saved more than 6.9 billion dollars between 2006 and 2020 when substituted appropriately for MRI. So why isn’t ultrasound used more often?
Unfortunately, clinical practices are on average 15 years behind current evidence-based practice (Melnyk et al 2021) and many orthopedic and primary care offices not trained in ultrasonography or regenerative techniques and utilize non-image-guided, chondrotoxic steroids injections, as the main intervention before deciding on surgery or not (Seshadri et al 2009, Nakazawa et al 2002, Wyles et al 2015).
The fact is, over 90% of all musculoskeletal injuries do not require surgery and a review of eligible member claims data in 2022 by Sword Health found that 36% of musculoskeletal surgeries were unnecessary, costing the workforce 90 billion dollars; 80% of which were undergone without attempting conservative care and alternative options first.
Furthermore, multiple studies have demonstrated many surgeries such as arthroscopic meniscectomies, debridement for arthritis, and subacromial decompression for rotator cuff impingement have little evidence of efficacy for long-term benefit when compared to conservative therapies, yet continue to be performed and contribute to low-value care and high healthcare costs (Louw et al 2017, Katz et al 2020, Thorlund et al 2015, Karjalainen et al 2019). A 2022 systematic review and meta-analysis by Skou et al in the Journal of Orthopedic Sports Therapy concluded that the low certainty of evidence does not support recommending surgery over non-surgical interventions for most musculoskeletal conditions.
At TSARO, we utilize state-of-the-art technologies, evidence-based literature, and the latest cutting-edge techniques in the field to deliver high-value musculoskeletal care for treating tendinopathies, osteoarthritis, neuropathies, and other conditions to delay or avoid the need for surgery and help patient’s return to activities sooner than the traditional treatments.
References
Williams, C, Sussman, W, Pitts, J. (2023). Atlas of Interventional Orthopedics Procedures. Elsevier.
Sibbitt WL Jr, Peisajovich A, Michael AA, Park KS, Sibbitt RR, Band PA, Bankhurst AD. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009 Sep;36(9):1892-902. doi: 10.3899/jrheum.090013. Epub 2009 Jul 31. PMID: 19648304.
Smallwood N, Dachsel M. Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine? Clin Med (Lond). 2018 Jun;18(3):219-224. doi: 10.7861/clinmedicine.18-3-219. PMID: 29858431; PMCID: PMC6334078.
Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5(3):182–188. doi: 10.1016/j.jacr.2007.07.016.
Melnyk, B. M. The Current Research to Evidence-Based Practice Time Gap Is Now 15 Instead of 17 Years: Urgent Action Is Needed. Worldviews Evid Based Nurs 18, 318-319 (2021). https://doi.org:10.1111/wvn.12546
Seshadri V, Coyle C.H, Chu C.R. Lidocaine potentiates the chondrotoxicity of methylprednisolone. Arthroscopy . 2009;25(4):337–347.
Nakazawa F, Matsuno H, Yudoh K, Watanabe Y, Katayama R, Kimura T. Corticosteroid treatment induces chondrocyte apoptosis in an experimental arthritis model and in chondrocyte cultures. Clin Exp Rheumatol . 2002;20(6):773–781.
Wyles C.C, Houdek M.T, Wyles S.P, Wagner E.R, Behfar A, Sierra R.J. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res . 2015;473(3):1155–1164.
The MSK Money Pit: $10 Million Wasted Every Hour on Low-Value Musculoskeletal Care in the U.S. Sword Health. (2023, July). https://edge-content-cdn.swordhealth.com/Predict_white_paper_Sword_branded_876dcdb939/Predict_white_paper_Sword_branded_876dcdb939.pdf
Louw A, Diener I, Fernandez-de-Las-Penas C, Puentedura E.J. Sham surgery in orthopedics: a systematic review of the literature. Pain Med . 2017;18(4):736–750.
Katz J.N, Shrestha S, Losina E, et al. Five-year outcome of operative and nonoperative management of meniscal tear in persons older than forty-five years. Arthritis Rheumatol . 2020;72(2):273–281.
Thorlund J.B, Juhl C.B, Roos E.M, Lohmander L.S. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ . 2015;350:h2747.
Karjalainen T.V, Jain N.B, Page C.M, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev . 2019;1:Cd005619.
Skou ST, Poulsen E, Bricca A, Dideriksen M, Lohmander LS, Roos EM, Juhl CB. Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2022 Jun;52(6):312-344. doi: 10.2519/jospt.2022.11075. PMID: 35647883.
