Two-millimetre diameter operative arthroscopy of the ankle is safe and effective

Wide-Awake Needle Arthroscopy of the Anterior Ankle: A Standardized Approach

Over the years, possibilities in ankle arthroscopy have evolved from diagnostic inspection to complex interventional procedures. Further innovation may come from needle arthroscopy, which has improved substantially in image quality in recent years and can now be used for interventional procedures as well. We here present a standardized approach to wide-awake needle arthroscopy of the anterior ankle under local anesthesia. As new needle arthroscopic procedures of the ankle arise, this approach serves to help ensure safe, uniform, and beneficial adoption of this emergent technique.

Comparison of needle and conventional arthroscopy for visualisation of predefined anatomical structures of the knee joint: a feasibility study in human cadavers and patients

BACKGROUND

In terms of the optics used for Knee arthroscopy, a large number of different endoscopes are currently available. However, the use of the 30° optics in knee arthroscopy has been established as the standard procedure for many years. As early as the 1990s, needle arthroscopy was occasionally used as a diagnostic tool. In addition to the development of conventional optics technology in terms of camera and resolution, needle arthroscopes are now available with chip-on-tip image sensor technology. To date, no study has compared the performance of this kind of needle arthroscopy versus standard arthroscopy in the clinical setting in terms of the visibility of anatomical landmarks. In this monocentric prospective feasibility study, our aim was to evaluate predefined anatomical landmarks of the knee joint using needle arthroscopy (0° optics) and conventional knee arthroscopy (30° optics) and compare their performance during knee surgery.

METHODS

Examinations were performed on eight cadavers and seven patients who required elective knee arthroscopy. Two surgeons independently performed the examinations on these 15 knee joints, so that we were able to compare a total of 30 examinations. The focus was on the anatomical landmarks that could be visualized during a conventional diagnostic knee arthroscopy procedure. The quality of visibility was evaluated using a questionnaire.

RESULTS

In summary, the average visibility for all the anatomic landmarks was rated 4.98/ 5 for the arthroscopy using 30° optics. For needle arthroscopy, an average score of 4.89/ 5 was obtained. Comparatively, the needle arthroscope showed slightly limited visibility of the retropatellar gliding surface in eight (4.5/ 5 vs. 5/ 5), medial rim of the patella in four (4.85/ 5 vs. 5/ 5), and suprapatellar recess in four (4.83/ 5 vs. 5/ 5) cases. Needle arthroscopy was slightly better at visualizing the posterior horn of the medial meniscus in four knee joints (4.9/ 5 vs. 4.85/ 5).

CONCLUSION

Needle arthroscopy is a promising technology with advantages in terms of minimally invasive access and good visibility of anatomical landmarks. However, it also highlights some limitations, particularly in cases with challenging anatomy or the need for a wide field of view.

Fifteen out of 16 elite athletes showed concomitant low-grade cartilage lesions of the ankle with unstable syndesmotic injuries: concerns from a prospective case series

Objectives

This study aimed to determine the incidence rate and characterise the location and severity of cartilage lesions in the ankle in elite athletes undergoing suture-button stabilisation for unstable distal syndesmotic injuries using needle arthroscopic examination. The feasibility and safety of ad hoc needle arthroscopy and its assisted interventions were also assessed.

Methods

This prospective case series included elite athletes undergoing surgical stabilisation between April 2021 and June 2023. Procedures involved suture button fixation and needle arthroscopy, conducted by a single ankle fellow-trained surgeon. Ankle cartilage lesions were graded using the Cheng and Ferkel classification and located using the nine-zone grid. The study followed the STROBE statement.

Results

This study included 16 elite athletes undergoing surgery for distal syndesmotic injuries, with 75% having acute and 25% chronic injuries. Cartilage lesions were prevalent (n=15/16, 94%), mainly at the talar dome (90%), and primarily scored as grade 1 (33%) or grade 2 (67%). Distal tibia cartilage damage occurred in 13% of cases. All patients were diagnosed with an instability of the syndesmosis confirmed through needle arthroscopy and were treated with a suture button (one or two buttons) fixation.

Conclusion

In 15/16 elite athletes with syndesmotic injuries, concomitant ankle cartilage lesions were identified through needle arthroscopy. In addition, most of the lesions were classified as grade 1 or 2, denoting superficial damage. Needle arthroscopic interventions proved feasible and safe for confirming syndesmotic instability and addressing intra-articular pathologies.

Comparison of different intraoperative reduction monitoring methods in a cadaveric intraarticular calcaneal fracture model: 3D scan vs arthroscopy vs nanoscopy

AIMS

Visualization of the subtalar joint surface in surgical management of calcaneal factures remains a big challenge and anatomic reduction of the articular surface is essential for a good clinical outcome. We hypothesize that video-assistance can provide superior fracture reduction compared to fluoroscopy and that nanoscopy (NSC) achieves more extensive visualization compared to fracturoscopy (FSC).

METHODS

Ten human cadaveric feet with artificially pre-fractured intraarticular calcaneal fractures with involvement of the posterior facet were treated via a minimal invasive subtalar approach. After initial control of reduction by 2D fluoroscopy, the reduction was further analyzed intraoperatively by FSC and NSC. 3D Scan served as gold standard control of reduction. Need of revision of reduction after the different visualization techniques was recorded and the extent of visualization of the subtalar joint surface in the medio-lateral dimension was compared for FSC and NSC. To quantify access and visualization of the medial and posterior facet, a depth gauge was used to measure from laterally at the clinically widest portion of the calcaneus targeted to the sustentaculum tali. The distance in millimetres was referred to the complete medio-lateral distance seen on paracoronal CT at the widest portion of the calcaneus.

RESULTS

Fracture analysis in preoperative CT-scans according to Sanders classification revealed four type IC, two IIA, three IIC and one IIIAC fractures. Mean visualization of the medial and posterior facet was significantly improved with NSC (30.4 ± 3.78 mm) compared to FSC (23.6 ± 6.17 mm) (p = 0.008). An imperfect reduction requiring revision was more often required with NSC compared to FSC. Insufficient reduction using video-assistance was found in two cases.

CONCLUSION

In order to optimize subtalar joint reduction and congruency, video-assisted techniques, especially NSC, provide superior visualization and thus can improve reduction in the surgical treatment of intraarticular calcaneal fractures.

Implantation of a Cushioning Injectable Implant Using Needle Arthroscopy in the Foot and Ankle and First Carpometacarpal Joint

Injectable implants constitute a newly developed treatment class in the battle against osteoarthritis. They consist of water-formulated supramolecular polymer, coming from a new class of resorbable biomedical materials, and are implanted in encapsulated joints in a liquid form, where they solidify to form a tough, elastic, and cushioning layer between the joint surfaces. To resort any effect, intra-articular delivery should be guaranteed, and the implant should be distributed throughout the entire joint space. Traditional implantation techniques do not seem to suffice for this new implant class, being either imprecise (traditional injection) or overly invasive (open procedures and traditional arthroscopic surgery). We describe a needle arthroscopic implantation technique to reap the benefits of both worlds, ensuring precise implant delivery while avoiding unnecessarily invasive procedures. This study depicts our needle arthroscopic technique for implantation of injectable implants in the ankle, first metatarsophalangeal joint, and first carpometacarpal joint.

Needle Arthroscopic Subchondroplasty With Adipose-Derived Stem Cell Augmentation for the Treatment of Osteochondral Lesions of the Talus

Needle arthroscopy has enjoyed a tremendous growth concerning the quality of intraoperative images due to technical innovation, resulting in innovative possibilities concerning concomitant minimally invasive procedures and treatment of osteochondral lesions of the talus (OLT). These lesions have increasingly been receiving scientific attention in the orthopaedic (sports) medicine field, and, as such, the quality of evidence-based treatment for them has developed substantially. Treatment of OLTs-and specifically subchondroplasty. OLTs may also be suitable for needle arthroscopic interventions. The purpose of the present technical note is, therefore, to present an all-arthroscopic needle arthroscopic technique, including subchondroplasty with adipose-derived stem cells augmentation for osteochondral lesions of the talus.

Needle arthroscopy of the elbow through an anterior transbrachial portal

Background

Current innovation in needle arthroscopy is improving the safety of anterior portals around the elbow. This study evaluated the proximity to the radial nerve, median nerve, and brachial artery on cadaveric specimens of an anterior portal used for elbow arthroscopy.

Methods

Ten fresh-frozen adult cadaveric extremities were used. After marking the cutaneous references, the NanoScope cannula was introduced just lateral to the biceps tendon, through the brachialis muscle and the anterior capsule. Elbow arthroscopy was performed. Dissection was then carefully performed on all specimens with the NanoScope cannula in place. The shortest distance from the cannula to the median nerve, radial nerve, and brachial artery was measured with a handheld sliding digital caliper.

Results

The cannula was an average of 12.92 mm away from the radial nerve, 22.27 mm from the median nerve, and 16.8 mm from the brachial artery. Needle arthroscopy performed through this portal allows complete visualization of the anterior compartment of the elbow, as well as direct visualization of the posterolateral compartment.

Conclusion

Needle arthroscopy of the elbow through an anterior transbrachialis portal is safe for the main neurovascular structures. In addition, this technique allows complete visualization of the anterior and posterolateral compartments of the elbow through the humerus-radius-ulna space.

Partial meniscectomy using needle arthroscopy associated with significantly less pain and improved patient reported outcomes at two weeks after surgery: A comparison to standard knee arthroscopy

Purpose

to compare immediate post-operative pain and patient-reported outcomes (PROs) after partial meniscectomy with needle (NA) vs. standard (SA) arthroscopy technique.

Methods

A retrospective review of a consecutive series of patients who underwent partial meniscectomy before and after adoption of a needle arthroscopic technique was performed. Meniscus repairs, root repairs, and those with ligamentous injuries were excluded. Total milligram morphine equivalents (MMEs) consumed, Visual analog scale (VAS) pain, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were compared pre-operatively and at 2 and 6-weeks postoperatively. Univariate analysis was used to compare results.

Results

Nineteen patients were in each group (NA: 10 females, SA: 11 females). Mean ± SD age (NA 42.8 ± 8.4 vs. SA 47.6 ± 10.4 years, p = 0.13) and body mass index (NA 31.4 ± 5.6 vs. SA 35.1 ± 5.4 m/kg2, p = 0.06) were not significantly different. Seventeen (89%) patients in both groups had medial meniscus tears of the posterior horn. Preoperative Outerbridge score was significantly greater in the SA group (3.4 vs. 1.8, p = 0.002); however, preoperative VAS pain (NA 6.1 ± 1.7 vs. SA 6.1 ± 1.8, p = 0.98) and KOOS pain (NA 44 ± 17% vs. SA 37 ± 12.5%, p = 0.20) were similar. Amount of arthroscopic fluid used was significantly greater in the SA vs. NA group (1.4 ± 0.7 vs. 0.5 ± 0.3 L, p < 0.0001), but tourniquet time was equivalent (NA 20 ± 6 vs.16 ± 6 min, p = 0.11). VAS pain scores (NA 1.0 ± 1.1 vs. SA 2.6 ± 1.5, p = 0.0014), KOOS pain (NA 79 ± 15% vs. 58 ± 19%, p = 0.0006), and Quality of Life (QOL) scores (NA 70 ± 22% vs. SA 43 ± 24%, p = 0.001) were significantly better at 2-weeks post-op in the N group. By 6 weeks post-op, all PROs including VAS pain and KOOS scores were similar between groups.

Conclusions

Adoption of a needle arthroscopic technique for partial meniscectomy was associated with significantly improved VAS and KOOS pain scores two-weeks post-operatively. Differences were not sustained at 6 weeks after surgery.

Level of evidence

III, Retrospective Comparison Study.

Needle Arthroscopic Inspection and Treatment of (Osteo)chondral Lesions of the Ankle in Unstable Syndesmotic Injuries Treated With Suture Button Fixation: A Standardized Approach

Both acute and chronic syndesmotic injuries are associated with (osteo)chondral lesions of the ankle in at least 1 out of 5 patients. Having a common denominator of an acute traumatic injury being external rotation and forced dorsiflexion, the injury of a combined unstable syndesmotic injury and a potentially present concomitant (osteo)chondral lesion to the ankle warrants a thorough diagnostic and interventional approach. Furthermore, early diagnosis may prevent further damage to the joint through lifestyle changes and increase the chances of successful conservative or surgical treatment, potentially reducing the progression toward end-stage osteoarthritis. Consequently, technological advances and financial considerations have led to the development of a minimally invasive needle arthroscopic inspection and treatment of concomitant (osteo)chondral injuries of the ankle in the combined treatment of unstable syndesmotic injuries with suture button fixation. The present Technical Note describes this innovative minimally invasive assessment and concomitant treatment technique.

Comparison of Visibility and Risk of Neurovascular Tissue Injury Between Portals in Needle Arthroscopy of the Anterior Ankle Joint: A Cadaveric Study

Background

For needle arthroscopy with 0° viewing, the visible range of intra-articular structures and the difference between portals remain unknown, as do the risks for neurovascular tissue at each portal.

Purpose

To clarify the visibility and safety of needle arthroscopy.

Study Design

Descriptive laboratory study.

Methods

Ten cadaveric ankle specimens were used. A needle arthroscope with a 1.9-mm diameter was inserted from 4 portals (anteromedial [AM], anterolateral [AL], medial midline [MM], and anterocentral [AC]). Visibility was assessed using a 15-point ankle arthroscopy checklist. In addition, the ankles were dissected to measure the distance between each portal and neurovascular tissues. The visibility of the ankle joint was compared between portals.

Results

The success rate of visibility in the deltoid ligament and the tip of the medial malleolus was 100% from the AM, MM, and AC portals and 10% from the AL portal, with significant differences between the portals (P < .01). The visibility success rates in the origin of the anterior talofibular ligament and the tip of the lateral malleolus were 20% for the AM portal, 90% for the MM and AC portals, and 100% for the AL portal, with significant differences between the portals (P < .01). All other points of the ankle joint were visualized from all the portals with a 100% success rate. The AC portal was in contact with the anterior neurovascular bundle in 4 of the 10 specimens.

Conclusion

When needle arthroscopy was performed from the AM or AL portal, the site opposite to the portal in the ankle joint was difficult to visualize. Conversely, most points of the ankle joint could be visualized from the MM and AC portals. Care should be taken when creating an AC portal because of its proximity to the anterior neurovascular bundle.

Clinical Relevance

The present study provides information regarding which portal should be selected to perform needle arthroscopy in the ankle joint, which will be beneficial for management of ankle injuries.

The role of outpatient needle arthroscopy in the diagnosis and management of musculoskeletal complaints: A systematic review of the Arthrex NanoScope

BACKGROUND

The aim was to review the literature regarding needle arthroscopy using the Arthrex NanoScope system and evaluate: (1) the diagnostic indications, utility, and efficacy compared to conventional methods, and (2) the therapeutic indications, safety, and reported outcomes.

METHODS

Searches of three databases (MEDLINE, Embase and PubMed) were conducted in November 2021 using MeSH terms: 'needle arthroscopy', 'human', 'in office arthroscopy', 'needle arthroscope', 'nanoscopic', 'surgery', 'nanoscope' and 'percutaneous arthroscopy'. The included studies were catalogued, quality-assessed using Methodological Index for Non-Randomised Studies (MINORS), and analysed using the Cochrane data collection templates for randomised control trials (RCT) and non-randomised control trials (non-RCT). The majority of studies were non-numerical and were examined using qualitative analysis.

RESULTS

The search yielded 314 studies, 22 of which were included for analysis. MINORS assessment was applicable to four studies. Mean MINORS was 10.7/16 with the most frequent limitations being lack of unbiased endpoint or sample size calculation. The level of evidence ranged from level IV-V. Diagnostic and therapeutic indications were described in relation to the: knee (n = 10); shoulder (n = 6); foot/ankle (n = 3); elbow (n = 2), and miscellaneous (n = 1).

CONCLUSIONS

Needle arthroscopy can augment the diagnostic process in patients presenting with musculoskeletal complaints, and may provide benefits in terms of diagnostic accuracy, cost efficiency, timeliness of investigation, and a visually impactful patient-centred consultation. Therapeutic interventions are reported by a small number of pioneer groups who report some benefits over conventional arthroscopy. The available literature remains small and of low quality, and more evidence is needed with regards to patient selection, efficacy, safety, and cost.

LEVEL OF EVIDENCE

Level V (based on the weakest study included in the Systematic Review).

Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study

Introduction

The objective of this investigation was to compare different techniques to improve visualization and reduction in tibial plateau fractures involving the central lateral segments.

Methods

Matched pairs of pre-fractured cadaveric tibial plateau fractures that include the central lateral segments were treated by either an anterolateral approach (supine) or PL approach (prone). Reduction was stepwise extended by additional fracturoscopy (FS), nanoscopy (NS) and lastly by epicondyle osteotomy (ECO). Reduction was analyzed by 3D scan and visualization of the lateral plateau was quantified.

Results

Ten specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were analyzed. Fracture steps involving the antero-latero-central (ALC) segment were insufficiently reduced after fluoroscopy using both approaches (AL 2.2 ± 1.2 mm vs PL 2.2 ± 1.0 mm, p 0.95). Additional NS and ECO achieved optimized fracture reduction in the ALC segment (NS AL 1.6 ± 1.3 mm vs PL 0.8 ± 0.9 mm, p 0.32). NS provided visualization of the entire lateral plateau (PL 102.9% ± 7.4, AL 108.8 ± 19.2%), while fracturoscopy only allowed visualization of the ALL segment and partially of PLL and ALC segments (PL 22.0 ± 23.4%, AL 29.7 ± 18.3%).

Conclusion

Optimized reduction of tibial head fractures with involvement of latero-central segments requires additional video-assisted reduction or extended approaches. Nanoscopy helps visualizing of the entire lateral plateau, when compared to fracturoscopy and may become a valuable reduction aid.

Needle arthroscopy in anatomical reconstruction of the lateral ankle: a report of three cases with a parallel comparison to the standard arthroscopy procedure

Purpose

This study evaluates the use of the needle arthroscopy in anatomical reconstruction of the lateral ankle. We hypothesized that the needle arthroscopy would allow anatomical reconstruction to be performed under arthroscopy.

Methods

Three patients underwent treatment of chronic ankle instability. The comparative procedure was performed in the following four steps: 1) anteromedial articular exploration (medial/lateral gutter/anterior chamber/syndesmosis); 2)creation of the talar tunnel via the anteromedial arthroscopic approach; 3) anterolateral fibular tunneling; and 4) positioning of the graft by the anteromedial arthroscopic approach.

For each of these steps, the planned procedure using the needle arthroscope was compared to the standard arthroscope. For each step, the planned procedure using the needle arthroscopy was compared to the standard arthroscope and the act was classified based on level of difficulty: facilitated, similar, complicated and impossible.

Results

The exploration of the medial and lateral gutter, the creation of the tunnel of the talus and graft positioning were not accomplished using the needle arthroscope. While the syndesmosis visualization was facilitated by the needle arthroscope in comparison to the standard arthroscope.

Conclusion

The anatomical reconstruction of the lateral ankle, using the needle arthroscopy-only approach, was impossible in all three cases, regarding: ankle joint exploration, creation of the tunnel of the talus and graft positioning. The needle arthroscope should not be considered as a "mini arthroscope" but as a new tool with which it is necessary to rethink procedures to take advantage of the benefits of this instrument.

Long head of the biceps intra-articular tenotomy using needle arthroscopy under local anesthesia: preliminary results and technical note

Purpose

Arthroscopic isolated biceps tenotomy is a procedure successfully performed in patients with degenerative rotator cuff tears which offers good clinical results. With this article, we describe the technique of biceps tenotomy with needle arthroscopy in local anesthesia and the results of first patients treated from 2018.

Methods

Thirteen patients with irreparable rotator cuff tear treated with arthroscopic needle biceps tenotomy under local anesthesia were included. Constant score and active/passive flexion were recorded preoperatively and at 3 months postoperatively.

Results

The average age of the patients was 71 ± 7 year old. All the patients were available for the follow-up. The Constant score significantly improved from pre- to postoperatively (44 ± 8.9 to 63.1 ± 14.2, p < 0.05). Active flexion improved from preoperatively 115 ± 24° to 145 ± 31° postoperatively (p < 0.05), while passive flexion did not significantly improve.

Conclusion

This technique can be safely performed in the elderly patient with irreparable rotator cuff tears and pain refractory to conservative measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00508-5.

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries.

DESIGN

A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions.

RESULTS

Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies.

CONCLUSIONS

This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome.

PROSPERO REGISTRATION NUMBER

CRD42020176641.

One in Three Patients With Chronic Lateral Ankle Instability Has a Cartilage Lesion

BACKGROUND

Chronic lateral ankle instability (CLAI) is associated with the presence or development of intra-articular pathologies such as chondral or osteochondral lesions, or (O)CLs. Currently, the incidence of (O)CLs in patients with CLAI is unknown.

PURPOSE

To determine the incidence of (O)CLs in patients with CLAI.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A literature search was conducted in the PubMed (MEDLINE), Embase (Ovid), and Cochrane databases for articles published from January 2000 until December 2020. Two authors independently screened the search results and conducted the quality assessment using the methodological index for non-randomized studies (MINORS) criteria. Clinical studies were included that reported findings on the presence of ankle (O)CLs based on pre- or intraoperative diagnostic measures in patients with CLAI (>6 months of symptoms). Patient and lesion characteristics were pooled using a simplified method. Lesion characteristics included localization and chondral and osteochondral involvement. The primary outcome was the incidence of (O)CLs in ankles with CLAI. A random-effects model with 95% CIs was used to analyze the primary outcome. The distribution of (O)CLs in the ankle joint was reported according to talar or tibial involvement, with medial and lateral divisions for talar involvement.

RESULTS

Twelve studies were included with 2145 patients and 2170 ankles with CLAI. The pooled incidence of (O)CLs in ankles with CLAI was 32.2% (95% CI, 22.7%-41.7%). Among all lesions, 43% were chondral and 57% were osteochondral. Among all (O)CLs, 85% were located on the talus and 17% on the distal tibia. Of the talar (O)CLs, 68% were located medially and 32% laterally.

CONCLUSION

(O)CLs were found in up to 32% of ankles with CLAI. The most common location was the talus (85%). Furthermore, most lesions were located on the medial talar dome (68%). These findings will aid physicians in the early recognition and treatment of ankle (O)CLs in the context of CLAI.

In-Office Needle Arthroscopy for the Treatment of Anterior Ankle Impingement Yields High Patient Satisfaction With High Rates of Return to Work and Sport

PURPOSE

To evaluate the clinical outcomes of in-office needle arthroscopy (IONA) for the treatment of anterior ankle impingement in the office setting and also evaluate patient experience of the IONA procedure.

METHODS

A prospectively collected database of 31 patients undergoing IONA for the treatment of anterior ankle impingement between January 2019 and January 2021 was retrospectively reviewed. Inclusion criteria for this study were patients ≥18 years of age, clinical history, physical examination, radiographic imaging, and magnetic resonance imaging findings consistent with anterior ankle impingement for which each patient underwent IONA and had a minimum of 12-month follow-up. Clinical outcomes were evaluated using the following methods preoperatively and at final follow-up: the Foot and Ankle Outcome Scores (FAOS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity domains. A 5-point Likert scale regarding patient satisfaction with their IONA procedure was evaluated at final follow-up. Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores.

RESULTS

In total, 31 patients were included in this study, including 18 male and 13 female, with a mean age of 41.7 ± 15.5 years (range, 17-69 years) and mean body mass index of 27.3 ± 5.7 (range, 19.37-41.5). The mean follow-up time was 15.5 ± 4.9 months. The mean postoperative FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life were 79.4 ± 11.9, 82.9 ± 15.3, 83.5 ± 15.4, 71.9 ± 18.5 and 64.3 ± 21.4 at final follow-up respectively. Minimal clinically important difference was achieved by 84% of patients for FAOS pain, 77% for FAOS symptoms, 75% for FAOS Quality of Life, 74% for FAOS sports, 65% for PROMIS Pain Interference, 61% for FAOS Activities of Daily Living, and 42% for PROMIS Pain Intensity. Lastly, 29 patients (94 %) expressed willingness to undergo the same procedure again.

CONCLUSIONS

The current study demonstrates that IONA treatment of anterior ankle impingement results in significant pain reduction, a low complication rate and excellent patient reported outcomes with high rates of return to work/sport. Additionally, IONA for anterior ankle impingement leads to high patient satisfaction with a significant willingness to undergo the same procedure again.

LEVEL OF EVIDENCE

IV, Case series study.

Editorial Commentary: In-Office Needle Ankle Arthroscopy May Be Better, Simpler, and Less Expensive

Orthopaedic surgeons have always been on the cutting edge of innovation in health care delivery and technology. In turn, the orthopaedic device industry has responded with new products that deliver better quality at competitive prices. Numerous examples of collaboration exist such as in outpatient joint replacement and minimally invasive orthopaedic procedures. In-office needle arthroscopy (IONA) for knees and ankles has been in existence since the 1990s but was hampered by poor image quality and a cumbersome-to-use technology. Now with improved technology for IONA, ankle IONA allows adequate visualization of all pertinent ankle joint structures, allowing reach of 96% of the talus surface and 85% of the tibia plafond, and may show greater accuracy than preoperative magnetic resonance imaging. The majority of cost of an arthroscopy episode of care may reside with the "facility" fee charged for the use of an operating room, personnel, and related equipment. Surgeons and their patients pay higher fees to use hospital or outpatient centers, sometimes with increased inefficiency or more adverse events. IONA may allow orthopaedic surgeons to deliver better services at a reduced cost for ankle arthroscopy.

Improved Clinical Outcomes and Patient Satisfaction of In-Office Needle Arthroscopy for the Treatment of Posterior Ankle Impingement

Purpose

To investigate the short-term clinical outcomes and satisfaction for the first set of patients at our institution receiving in-office needle arthroscopy (IONA) for the treatment of posterior ankle impingement syndrome (PAIS).

Methods

A retrospective cohort study was conducted to evaluate patients who underwent IONA for PAIS between January 2019 and January 2021. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and Patient-Reported Outcomes Measurement Information System Pain Interference, and Pain Intensity scores. Patient satisfaction was measured at the final follow-up visit with a 5-point Likert scale. The Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores.

Results

Ten patients (4 male and 6 female) with a mean age of 41.9 ± 15.5 years (range, 24-66 years) were included in the study. The mean follow-up time was 13.3 ± 2.9 months (range, 11-17 months). All mean preoperative FAOS scores demonstrated improvement after IONA, including FAOS symptoms (71.48 ± 10.3 to 80.3 ± 12.6), pain (69.3 ± 11.0 to 78.2 ± 13.9), activities of daily living (61.7 ± 8.8 to 77.93 ± 11.4), sports activities (55.6 ± 12.7 to 76.0 ± 13.6), and quality of life (46.6 ± 9.2 to 71.1 ± 12.1). There were 7 patients who participated in sports activities before the IONA procedure. Within this group, all patients returned to play at a median time of 4.1 weeks (range, 1-14 weeks). The median time to return to work was 3.4 ± 5.3 days. Patients reported an overall positive IONA experience with a mean rating scale of 9.5 ± 1.5 (range, 5-10).

Conclusions

The current study demonstrates that IONA treatment of PAIS results in significant pain reduction, a low complication rate, and excellent patient-reported outcomes. In addition, IONA for PAIS leads to high patient satisfaction with a significant willingness to undergo the same procedure again.

Level of Evidence

IV, therapeutic case series.

Minimally invasive arthroscopy of the knee using a new 2 mm device

Arthroscopy has been evolving over the last decades, whereas arthroscopic devices have not changed much. Smaller diameter arthroscopes would potentially reduce the intraoperative trauma for cartilage and soft tissues. Two‐millimeter‐diameter arthroscopy demonstrated very good visualization and reach of intraarticular structures—similar to knee arthroscopy using a standard arthroscopic system.

Can bedside needle arthroscopy of the ankle be an accurate option for intra-articular delivery of injectable agents?

BACKGROUND

Bedside needle arthroscopy of the ankle under local anesthesia has been proposed for intra-articular delivery of injectable agents. Accuracy and tolerability of this approach in the clinical setting–including patients with end-stage ankle pathology and/or a history of prior surgery–is not known.

AIM

To assess clinical accuracy and tolerability of bedside needle arthroscopy as a delivery system for injectable agents into the tibiotalar joint.

METHODS

This was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint. In our center, these injections are used as a last resort prior to extensive surgery. The primary outcome was injection accuracy, which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear arthroscopic view of the joint space. Secondary outcome measures included a patient-reported numeric rating scale (NRS, 0-10) of pain during the procedure and willingness of patients to return for the same procedure. NRS of ankle pain at rest and during walking was collected at baseline and at 2-wk follow-up. Complications were monitored from inclusion up to a 2-wk control visit.

RESULTS

We performed 24 inspection-injections. Eleven (46%) participants were male, and mean age was 46.8 ± 14.5 years. Osteoarthritis was the indication for injection in 20 (83%) cases, of which 8 (33%) patients suffered from osteoarthritis Kellgren-Lawrence grade IV, and 10 (42%) patients from Kellgren-Lawrence grade III. An osteochondral defect was the indication for injection in 4 (17%) cases. A history of ankle surgery was present in 14 (58%) participants and a history of multiple ankle surgeries in 11 (46%) participants. It was possible to confirm accuracy in 21 (88%) procedures. The 3 (12%) participants where needle arthroscopy did not reach a clear view of the joint space all suffered from Kellgren-Lawrence grade IV osteoarthritis. Pain during the procedure was reported with a median of 1 [interquartile ranges (IQR): 0–2]. Willingness to return was 100%. Pain in rest decreased from a median NRS of 4 (IQR: 2–7) at baseline to a median of 3 (IQR: 1–5) at follow-up (P < 0.01). Pain during walking decreased from a median NRS of 8 (IQR: 6–9) to a median of 7 (IQR: 4–8) (P < 0.01). Infections or other complications were not encountered.

CONCLUSION

Clinical accuracy and tolerability of bedside needle arthroscopy of the ankle as a delivery system for injectable agents are excellent. Accuracy was 100% in patients without total ventral joint obliteration.

Bacterial arthritis of native joints can be successfully managed with needle arthroscopy

PURPOSE

To assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints.

METHODS

During a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded.

RESULTS

Eleven joints in 10 patients (four males, age range 35 - 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases.

CONCLUSIONS

Needle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

Editorial Commentary: How Far Can the Arthroscope Reach in the Ankle Joint?

Surgical access to pathology of the talar dome (e.g., osteochondral lesions of the talus) can be limited because of the ankle joint congruity. When considering arthroscopic treatment, anterior arthroscopy with the ankle in plantar flexion or posterior arthroscopy with the ankle in dorsiflexion is used. The surgeon should carefully assess different clinical and radiologic aspects to plan the optimal operative approach. Meticulous physical examination, including ankle range of motion and possible palpation of a talar lesion, in combination with exact lesion localization on computed tomography or magnetic resonance imaging usually provide sufficient preoperative information. Most lesions with the anterior border localized on or anterior to the midline of the talus are accessible by anterior arthroscopy. In the case of preoperative doubt concerning the intraoperative accessibility, a computed tomography scan of the ankle in full plantarflexion is used to mirror arthroscopic reachability. Intraoperative surgical tricks to increase accessibility to the lesion may consist of an adjunct soft-tissue distraction device, reduction of the distal tibial rim, and treating the lesion from anteriorly to posteriorly, thereby gaining further exposure to the lesion throughout the procedure.

The ankle cartilage cascade: incremental cartilage damage in the ankle joint

Level of evidence Editorial, Level V.