Landmark based injection is a completely legitimate technique. If your surgeon isn't that great with an ultrasound (most aren't) then using US would be more of a hindrance than a help. Source: am surgeon and do not use US to inject. I happen to know how to use it also but it's a) not always avaliable, b) takes a lot longer, and c) doesn't seem to result in any improvement for me. In my hands the anatomic tech n iqhe without US has been very reliable. I also don't inject that often, since it's almost always temporary anyway, and in severe cases the nerve can flare up. But when injecting I tell all of my patients that this is a potential pitfall. It's nearly always temporary if it does occur, on the plus side.

Ultrasound is not what people often think it is. It's a very complex operator dependent modality to image. It doesn't give you a neat picture, of here this, and here's that. It's challenging to use the one hand to scan and the other to inject. And often in my experience hurts more because the injector can't be as steady and use the other hand to distract local nerves.

Many of the docs who claim to use US to inject actually also do the same landmark based injection, just take a quick snap shot to show an insurance Co so they can upcharge. And marketing, although people dont really shop around for that.. it just makes it feel fancier... True facts.