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Rheumatology 2007 46(10):1583-1586; doi:10.1093/rheumatology/kem187
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© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

A modular, flexible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients with hip osteoarthritis

I. Atchia1,2, F. Birrell1,2 and D. Kane1,2

1Northumbria Healthcare NHS Trust, Northumberland and 2School of Clinical and Medical Sciences (Rheumatology), University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK.

Correspondence to: D. Kane, Department of Rheumatology, Adelaide and Meath Hospital (incorporating the National Children's Hospital), Tallaght, Dublin 24, Ireland. E-mail: david.kane{at}amnch.ie


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Acknowledgement
 References
 
Objective. This study sought to establish a model of training and an assessment of competency in musculoskeletal ultrasound (MSUS) diagnosis of hip synovitis and/or effusion and in MSUS-guided injection of the hip.

Methods. The ‘trainee’ (no previous experience in MSUS) was trained by an ‘expert’ [a rheumatologist who is a trainer on the European League Against Rheumatism (EULAR) MSUS course] using a modular approach focused on hip ultrasound only. This consisted of (i) a 1.5 h initial tutorial and practical demonstration and (ii) indirectly supervised non-continuous scanning of 40 hips over 5 h. Competency was assessed in three ways: (i) ability to obtain standard EULAR reference MSUS images of the hip of sufficient image quality, (ii) accuracy in diagnosis of synovitis or hip effusion by measurement of the anterior femur–capsule distance, and (iii) accuracy in ultrasound-guided hip aspiration and injection.

Results. After a period of scanning of 75 min (10 hips), the images obtained by the trainee were consistently graded as acceptable for routine clinical use. Next, blinded triplicate measurements of the anterior femur–capsule distance performed by the trainee and expert showed agreement regarding diagnosis of hip effusion (>7 mm thickness) in 16/17 cases of hip arthritis ({kappa} 0.876). The trainee performed 40 MSUS-guided hip injections (seven directly supervised followed by 33 indirectly supervised). After 10 consecutive MSUS-guided hip injections, the novice achieved a subsequent accuracy rate of 25/26 (96%) confirmed by radiographic localization of radiopaque contrast.

Conclusions. Using a modular approach, a learner-centred curriculum and a self-directed learning strategy with a minimum of direct supervision, a trainee achieved competence in MSUS diagnosis of hip effusion/synovitis and in MSUS-guided hip aspiration/injection.

KEY WORDS: Musculoskeletal ultrasound, Hip, Osteoarthritis, Training, Injection


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Supplementary data
 Acknowledgement
 References
 
Although aspiration and injection of synovial joints is a procedure that is commonly performed by rheumatologists and other musculoskeletal clinicians, the accuracy rate has been found to be surprisingly low even for superficial joints [1]. Hip aspiration and injection may be performed for diagnostic aspiration, for diagnostic local anaesthetic injection [2] and for therapeutic injection of corticosteroid and hyaluronic acid derivatives [3–5]. Due to a deep lying position, lack of bony landmarks to guide injection and closely associated neurovascular bundles, aspiration and injection of the hip is usually performed with imaging guidance. Fluoroscopy is widely available in hospital practice, but requires the availability of an adequately staffed location in the radiology department, the additional expense of a contrast agent and involves exposure to radiation.

Musculoskeletal ultrasound (MSUS) guidance is a reasonable alternative to fluoroscopic guidance for hip aspiration and injection [6–9]. The accuracy of MSUS-guided needle placement in both small and large joints is superior to needle placement using clinical examination alone for guidance [10, 11]. Additional advantages of MSUS-guided hip injection are its (i) safety, with no serious complications in one series of 358 adult hip injections [9], (ii) portability and (iii) lack of ionizing radiation.

A further advantage of ultrasound over fluoroscopy is that MSUS measurement of the distance between the neck of the femur and the anterior joint capsule is possible (see supplementary figure). By comparison with standard reference measurements of normal bone–capsule distance (BCD) [12–15], capsular distension due to the presence of synovitis/effusion can be detected, although the differentiation between synovitis and effusion is not usually achievable or necessary. A few studies of MSUS-guided injection of the hip in osteoarthritis have been published [4, 16, 17], but there is a lack of information about the training of the clinicians performing the injections. Recently, the Royal College of Radiologists (RCR) has made recommendations for non-radiologists training in ultrasound and, with regard to MSUS, has suggested a modular anatomical approach to training in MSUS may be appropriate to the training needs of rheumatologists [18]. In order to establish a training module for a trial of joint injection therapy in hip osteoarthritis, this study sought to demonstrate how to achieve competence in MSUS of the hip, MSUS detection of hip effusion and MSUS-guided aspiration and injection.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Supplementary data
 Acknowledgement
 References
 
The injections were performed as part of routine clinical care. Written informed consent for the procedure was obtained from all patients.

Training
The ‘trainee’ (I.A.), a rheumatologist trainee with a 1-yr experience clinical rheumatology as a registrar and who had no previous experience in MSUS, was trained by the ‘expert’ (D.K.), a rheumatologist with over 5 yr of practical MSUS experience who performs MSUS in his daily practice and who is a trainer on the British Society for Rheumatologists (BSR) and the European League Against Rheumatism (EULAR) courses. The training module consisted of an initial 1 h tutorial on the principles and safety of MSUS, illustrated by EULAR images of the hip [19], followed by a 30 min demonstration on a patient. This consisted of the expert teaching techniques about handling and movement of the transducer. The hip was scanned as previously described with the subject supine and the hip in 15–20% of external rotation before saving standard oblique and transverse images of the hip [19, 20].

Following this tutorial, the novice, using a portable MSUS system [Sonosite Titan®], scanned 40 hips in patients with OA on a non-continuous basis, totalling 5 h of active scanning over a period of 1 month. During this time, a logbook with details of the patients and scans were kept and the images obtained were saved for three 30 min meetings (at the end of weeks 1, 2 and 4) for the expert to review and assess.

Competency assessment
Following the initial training, competency was assessed in three different ways:

  1. Quality of standard MSUS images of the hip: The method described by Filippucci et al. [21] was used whereby the novice aimed to obtain images comparable to the ‘gold standard’ pictures on the EULAR website. The images were saved and then blindly scored by the expert from 0 (lowest quality) to 10 (highest quality), with a minimum score of 6 having been previously reported as acceptable for routine clinical use [21].
  2. Ability to diagnose joint effusion or synovitis: Once the trainee was consistently able to obtain images of acceptable quality, both novice and expert obtained triplicate measurements of the ultrasonographic BCD in 17 hips (seven cases of painful hip in patients with known OA and 10 asymptomatic hip joints in rheumatology ward inpatients) from which the mean was calculated. The observers were blinded to the other's results at the time of MSUS assessment. The intraobserver error (difference between the highest and lowest values divided by the mean and multiplied by 100) for both sets of measurements and the Intraclass Correlation Coefficient (ICC) of the two sets of mean measurements were calculated [22]. Diagnosis of joint effusion or synovitis was made according to established criteria [12, 15]. The interobserver agreement on diagnosis was assessed using Cohen's kappa statistic (unweighted kappa calculation using SPSS [22]).
  3. Accuracy of MSUS-guided hip injection by radiographic localization of contrast: MSUS-guided hip injections were performed—as clinically indicated—on a further set of 40 patients with hip symptoms, 26 with known OA requiring a therapeutic injection and 14 for diagnostic local anaesthetic injections [to confirm localization of source of hip pain prior to listing for Total Hip Replacement (THR)]. The hip injection was performed using a minor adaptation of the direct visualization technique [15]. Skin markings were made for the position of the transducer in the optimal anterior oblique view. The transducer was then removed and the field was sterilized. The skin was punctured with the spinal needle prior to replacing the transducer and visualizing the needle in real time. This technique ensured sterility and aided needle transducer alignment for the trainee.

In order to independently confirm intracapsular needle placement, Niopam® 300 (Bracco-Italy), a radiopaque contrast material (300 mmole iodine per ml), was added to the injection admixture. Initially, 1 ml of contrast was used but as the study progressed, we added 3 ml of contrast in order to ensure consistent radiographic localization. An anteroposterior (AP) radiograph of the hip was obtained within 30 min of the injection. Accuracy was confirmed when there was definite evidence of intracapsular infiltration of radiopaque contrast, best demonstrated as a band/rim opacity around the head of the femur on an AP radiograph of the hip (Fig. 1). The injection was deemed inaccurate otherwise. If contrast was not visualized on plain radiography, the injection was labelled as indeterminate.


Figure 1
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  		FIG. 1. Accuracy criteria based on post-injection X-rays. Injection is accurate when the contrast agent is localized within the capsule (A). Injection is indeterminate when the contrast agent is not visualized (B) and inaccurate if the contrast agent is localized outside the capsule (C).

 

   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Supplementary data
 Acknowledgement
 References
 
Quality of images
The trainee performed 5 h of scanning of the hip joint on a non-continuous basis and, following the scanning of 10 hips (75 min of active scanning time), was consistently obtaining images of the target standard.

Diagnosis of hip effusion/or synovitis
The mean of triplicate measurements taken on 17 hips by both observers demonstrated high interobserver agreement, with ICC of 0.93 (95% CI 0.83–0.98, P < 0.001) (supplementary table). There was disagreement regarding the presence or absence of BCD thickening in just one out of the 17 cases ({kappa} 0.876), a patient with anterior osteophytes which resulted in the ‘trainee’ and the ‘expert’ obtaining similar MSUS images but selecting different bony points for calibration of BCD.

Accuracy
Forty consecutive hip injections were performed by the trainee (Fig. 2). At the beginning of the study, the high rate of indeterminate localization of contrast was deemed to be due to either insufficient contrast volume or delay in obtaining a post-injection X-ray. From our experience, we found that delays of more than 1 h in having the image taken made it difficult to confirm accuracy and a minimum volume of 3 ml of contrast was required. The first seven injections were performed under direct supervision by the expert, with the other 33 performed independently with the expert available in the event of any difficulty. After the first 10 injections, only one of the next 26 was inaccurately placed (accuracy 96%), although a further four injections were indeterminate. In these four cases, the X-rays were out with the due time and therefore the accuracy had to be labelled as indeterminate. The one inaccurate hip injection (Case 23) was a lady with severe osteoarthritis and fixed flexion deformity of the hip which prevented clear, distinct images of the anterior capsule being obtained.


Figure 2
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  		FIG. 2. Accuracy outcome of the 40 injections performed by the trainee in chronological order.

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Supplementary data
 Acknowledgement
 References
 
This study demonstrates a successful protocol for training a novice in MSUS to become competent in MSUS diagnosis of hip effusion and/or synovitis and MSUS-guided hip injection using a modular approach, with reliance on self-directed learning complemented with timely supervision from the expert (Table 1). This protocol may be applied in future trials of injection therapy in hip arthritis. MSUS is relevant to rheumatology clinical practice [23–26], but factors that have limited its widespread use include the operator dependency of MSUS [20, 27] and the lack of both an established curriculum and consensus about the best teaching strategies [28]. The first interdisciplinary recommendations for rheumatologists performing MSUS [29] and guidelines produced by the RCR [18] include MSUS diagnosis of hip effusion/synovitis and MSUS-guided injection/aspiration of joints. The training strategy outlined here demonstrates that rheumatologists could potentially learn MSUS in modules, obtaining competency ‘region by region’ according to their clinical practice needs. While the hip requires mastery of fewer image planes than other joints, our experience is that trainees found hip ultrasound to be one of the more technically challenging joint regions [30]. In keeping with the RCR guidelines, this approach would be most successful if applied after an initial introductory theory and practical course such as those run by EULAR.


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  		TABLE 1. Model for training in interventional hip MSUS

 
This is the first study demonstrating competency in performing interventional MSUS of the hip joint based on accuracy of the injections performed by radiopaque contrast localization on plain radiography. A surprisingly short direct supervision time of 7 h total [1.5 h initial demonstration, 1.5 h reviews, 4 h supervising first 7 injections], plus unsupervised scanning of 5 h achieved an accuracy at the end of the training in this study as high as the accuracy rate described for MSUS-guided needle placement in other joints [10, 11]. As expected with any training, there is a learning curve, with a difference in accuracy at the start and end of the training period. Our data suggest that high accuracy can be achieved after only 10 injections, although this will vary depending on the technical abilities of trainees.

Operator dependency has often been perceived to be a limitation of MSUS, but few studies have assessed interobserver variability between sonographers. Two on hip MSUS have compared BCD measurement between (i) two rheumatologists (one expert and one novice) [31] and (ii) an experienced rheumatologist and radiologist [12], with correlation values of 0.89 and 0.94, respectively, comparable to our study although these two studies were based on normal subjects rather than our study which included OA subjects. Some caution should nevertheless be exercised in relying on BCD for diagnosis of hip synovitis/effusion. Indeed, there is some disagreement in the literature on BCD definitions of synovitis/effusion, with concerns about reliability of measurements. In our study, misdiagnosis of synovitis or effusion was minimized by ensuring the contra-lateral side was measured to look for a side difference of more than 1 mm. Also MSUS features other than BCD, such as shape of the capsule, have recently been advocated as being more sensitive in diagnosing synovitis/effusion [32].

There are potential limitations to a self-directed strategy for learning MSUS. Van Holsbeeck and Roemer have recently emphasized that learning MSUS of all regions to a high standard requires a lengthy practical experience and close interaction and supervision by an experienced teacher [33, 34]. We agree with this view that rheumatologists, with training limited to short courses in MSUS only, are unlikely to achieve a high level of competency across all procedures and all regions. Indeed, we have not demonstrated competency in MSUS diagnosis of other periarticular hip conditions such as iliopsoas bursitis, or tendinosis, but instead we report the first evidence of proven competencies in MSUS assessment of effusion/synovitis and guided injection of the hip—an area of MSUS likely to be of practical relevance to rheumatologists.

We have outlined a modular, flexible training strategy based around a learner centred curriculum: a strategy which is effective in achieving competence in MSUS-guided hip injection and aspiration. We feel this model is in line with the educational principles outlined by Brown et al. [35] about training in MSUS and we hope it is found useful by others seeking to develop competency in hip injection. When close and continuous expert supervision may be difficult, this strategy could be applied in a stepwise fashion by rheumatologists seeking to achieve overall competence in MSUS.

Formula


   Supplementary data
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
Acknowledgement
 References
 
Supplementary data are available at Rheumatology Online.


   Acknowledgement
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Acknowledgement
References
 
The work of D.K. is funded by the Arthritis Research Campaign. The fellowship of I.A. is funded by Northumbria Healthcare NHS Trust.

The authors are grateful for the support of Mr M. Reed, Mr P. Partington, Mr S. Jones and Mr I. Carluke from the Orthopaedics department at Wansbeck General Hospital.

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Acknowledgement
 References
 

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Submitted 21 March 2007; revised version accepted 7 June 2007.
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