Diagnostic Evaluation of the Knee in the Office Setting Using Small-Bore Needle Arthroscopy

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.

In-Office Needle Arthroscopy: Indications, Surgical Techniques, Tips, and Tricks

In-office needle arthroscopy (IONA) has gained increased attention as a minimally invasive alternative to standard arthroscopy performed in the operating room (OR) setting. IONA uses instrumentation that is markedly smaller in size and diameter making arthroscopy less invasive. Less OR equipment and less OR staff are required resulting in procedures that may be more accessible and less expensive. IONA is typically performed using local intra-articular blocks, thereby reducing the need for regional anesthesia or general anesthesia along with its associated risks. Using a clinic setting rather than an OR reduces the cost and increases the efficiency of the procedure. This article will present the indications for IONA in upper and lower extremity injuries and will describe the best practice office setup. Technical pearls and pitfalls will also be discussed.

In-Office Needle Arthroscopy with Meniscal Repair for Meniscal Lesions of the Knee

Meniscal injuries are a common cause of knee pain and are often an indication for knee arthroscopy, the most common orthopedic surgical procedure in the United States. In-office needle arthroscopy (IONA) is a described technique with the ability to diagnose and treat meniscal injuries in the office. IONA allows for diagnosis and treatment at a significantly deceased cost, with both quicker patient recovery, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office needle arthroscopy for meniscal injuries of the knee, including the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Nano-Arthroscopy of the Shoulder with Acromioplasty

Subacromial decompression with acromioplasty is among the most commonly performed shoulder procedures. The advantages of in-office nano-arthroscopy include the capability of diagnosing and treating subacromial impingement, swifter patient recovery, improved cost-effectiveness, and superior patient satisfaction. The purpose of this technical report is to describe our technique for performing in-office nano-arthroscopy for subacromial decompression (subacromial bursectomy and acromioplasty), with a particular focus on appropriate indications, providing sufficient local anesthesia, optimizing visualization, and discussing the advantages of the in-office setting compared to the operating room.

In-Office Needle Arthroscopic Synovial Biopsy Is an Effective Diagnostic Tool in Patients With Inflammatory Arthritis

Purpose

To assess the utility, safety, and accuracy of in-office needle arthroscopic (IONA) synovial biopsy as a diagnostic tool during treatment of drug-resistant monoarticular inflammatory arthritis of the knee.

Methods

Consecutive patients diagnosed with rheumatoid or psoriatic arthritis with treatment-resistant monoarticular knee involvement who underwent in-office needle arthroscopic synovial biopsy were considered for inclusion. The exclusion criteria were any current malignancies or infection. All patients underwent systematic physical and laboratory examination. IONA was undertaken to inspect the macroscopic appearance of the joint, choose the biopsy site, and classify synovial inflammation. Once collected, synovial tissue specimens were examined histologically using the Krenn scoring system.

Results

In total, 12 patients (9 male and 3 female, median age 57 [interquartile range {IQR} 8] years, median disease duration 156 [IQR 201] months) affected by psoriatic arthritis (n = 6) or rheumatoid arthritis (n = 6) were included in this study. Median operating time was 12 (IQR 11) minutes. Three biopsies per patient were collected. The success rate of specimen collection was 97%, the median postoperative 0-10 visual analog scale pain score was 2 (IQR 3), and only one minor complication occurred.

Conclusions

Knee IONA with synovial biopsy is an effective and well-tolerated procedure that can help clinicians formulate specific treatment strategies in patients with refractory pain in the setting of rheumatoid and psoriatic arthritis.

Level of Evidence

IV, Therapeutic case series.

In-Office Diagnostic Needle Arthroscopy Using the NanoScope™ Arthroscopy System

Diagnostic needle arthroscopy performed in office is a safe and cost-effective method for accurate evaluation of intra-articular pathology, improving clinical decision making. This minimally invasive approach is an effective alternative to traditional diagnostic techniques of diagnostic surgical arthroscopy and magnetic resonance imaging (MRI). Needle arthroscopy is considered low-risk, with an extremely low complication rate when performed with appropriate technique and indications. The purpose of this article is to describe an approach to an in-office diagnostic procedure using a needle arthroscopy system.

In-Office Needle Arthroscopy for Anterior Ankle Impingement

Anterior ankle impingement is a common cause of chronic ankle pain characterized by altered joint mechanics with considerable deficits in range of motion. The benefits of in-office nano arthroscopy (IONA) include the ability to diagnosis and treat anterior ankle impingement, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office nano arthroscopy for anterior ankle impingement, with special consideration of the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Needle Arthroscopy Can Evaluate Meniscus Tear Repair Healing as an Alternative to Magnetic Resonance Imaging

PURPOSE

To assess the healing of horizontal cleavage tears of the meniscus 1 year after surgical repair and to determine what modality is best to determine healing.

METHODS

Patients were prospectively followed for 12 months after surgical meniscus repair using a circumferential compression stitch. Inclusion criteria were preoperative magnetic resonance imaging (MRI) evidence of horizontal cleavage tear, age between 18 and 50 years, and no concomitant anterior cruciate ligament reconstruction. Patients were excluded if they were >50 years old, had a meniscus tear pattern other than horizontal cleavage tear, and underwent concomitant ligament reconstruction. MRIs were performed 1-year postoperatively for evaluation of repair healing. Preoperative and postoperative MRIs of tears were evaluated blindly by a musculoskeletal radiologist. In-office needle arthroscopy was performed at 6 months post-operatively.

RESULTS

Eight patients were included and had surgery between March 2016 and November 2017. There were 4 medial and 4 lateral meniscus tears. No patients had recurrence of preoperative symptoms or evidence of retear. Six repairs evaluated by in-office needle (at 5.9 months postsurgery) arthroscopy demonstrated complete healing. Seven of the 8 patients had grade III changes on preoperative MRI, and 1 patient had grade IIc changes. On postoperative MRI, 5 of 7 patients had grade III changes, 1 patient had IIc changes, and 1 had IIb changes. There was no significant difference in the proportion of patients with grade III changes preoperatively compared with postoperatively (P = .57). One of 8 patients with preoperative MRIs demonstrated extrusion where no patients demonstrate postoperative MRI evidence of extrusion (P = .47).

CONCLUSIONS

Horizontal cleavage meniscal tears repaired with a circumferential compression stitch demonstrate healing on in-office needle arthroscopy 6 months after surgery. No evidence of incomplete or failed healing was found. MRI at 1 year after surgery demonstrated residual tear evidence for all patients.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Accuracy of magnetic resonance imaging in predicting anterior cruciate ligament tear location and tear degree

Purpose

The purpose of this study is to evaluate the reliability of magnetic resonance imaging (MRI) in predicting the location of ACL tears in preoperative planning for anterior cruciate ligament (ACL) repair.

Methods

Thirty-four patients who underwent ACL repair were retrospectively analyzed to compare intraoperative arthroscopic findings with preoperative MRIs.

Results

For identifying type I tears, the sensitivity of MRI was 9.0% and the accuracy of MRI was 8.8%. There was moderate interrater agreement between MRI findings for tear location and tear degree.

Conclusion

MRI alone may not necessarily be accurate in identifying which ACL tears are amenable to repair.

Study design

Retrospective case series; Level of Evidence: IV.

Comparison of classic and needle arthroscopy to diagnose canine medial shoulder instability: 31 cases

This retrospective study compared surgery time, anesthesia time, and costs recorded with classic arthroscopy or needle arthroscopy when diagnosing canine medial shoulder instability. Signalment, examination findings, diagnostics, anesthesia time, surgery time, treatment, invoices, and complications were reported. All cases (classic arthroscopy, 14 cases; needle arthroscopy, 17 cases) were diagnosed with medial shoulder instability. Anesthesia times, surgery times, and invoices were statistically compared for classic and needle arthroscopy (P < 0.05). No significant differences were reported for surgery time (P = 0.13) but existed for anesthesia time (35 minutes shorter with needle arthroscopy; P < 0.0001) and invoice (38% lower with needle arthroscopy; P < 0.0001). No complications were recorded by the time of last direct follow-up, which was at a mean of 12.4 weeks after surgery. Needle arthroscopy offers an alternative, safe technique to reliably diagnose canine medial shoulder instability. Shorter anesthesia times and lower costs to the client may be advantages of needle over classic arthroscopy.

In-Office Biceps Tenotomy with Needle Arthroscopy: A Feasibility Study

Isolated pathology of the long head of the biceps is an indication for biceps tenotomy. To date, needle arthroscopy allows a direct diagnosis of shoulder lesion. We aimed to evaluate the technical feasibility of an in-office biceps isolated tenotomy by needle arthroscopy. Advantages were found in the fast-track process and the high rate of satisfaction in our selected patients. It was also a way to correct the diagnosis of torn biceps missed by the imaging. However, performing this procedure requires previous experience in conventional arthroscopy and should not be performed on anxious patients. Further studies will be necessary to confirm the reproducibility of this promising method, which could be a valuable alternative to heavy in-operating room process.

Percutaneous Anterior Cruciate Ligament Repair With Needle Arthroscopy and Biological Augmentation

Recent advancements in orthopaedic devices have instilled a renewed interest in repair of the anterior cruciate ligament. Biological augmentation of the repair has also recently been investigated with the hopes of improving repair outcomes and improving biological healing. The advent of needle arthroscopy allows for potentially decreased recovery times and potentially reduced complication rates compared with traditional arthroscopy. The purpose of this article is to present a percutaneous technique to repair the anterior cruciate ligament with suture tape augmentation while also augmenting with the biological byproducts from the native effusion using needle arthroscopy.

Deep Learning for US Image Quality Assessment Based on Femoral Cartilage Boundary Detection in Autonomous Knee Arthroscopy

Knee arthroscopy is a complex minimally invasive surgery that can cause unintended injuries to femoral cartilage or postoperative complications, or both. Autonomous robotic systems using real-time volumetric ultrasound (US) imaging guidance hold potential for reducing significantly these issues and for improving patient outcomes. To enable the robotic system to navigate autonomously in the knee joint, the imaging system should provide the robot with a real-time comprehensive map of the surgical site. To this end, the first step is automatic image quality assessment, to ensure that the boundaries of the relevant knee structures are defined well enough to be detected, outlined, and then tracked. In this article, a recently developed one-class classifier deep learning algorithm was used to discriminate among the US images acquired in a simulated surgical scenario on which the femoral cartilage either could or could not be outlined. A total of 38 656 2-D US images were extracted from 151 3-D US volumes, collected from six volunteers, and were labeled as "1" or as "0" when an expert was or was not able to outline the cartilage on the image, respectively. The algorithm was evaluated using the expert labels as ground truth with a fivefold cross validation, where each fold was trained and tested on average with 15 640 and 6246 labeled images, respectively. The algorithm reached a mean accuracy of 78.4% ± 5.0, mean specificity of 72.5% ± 9.4, mean sensitivity of 82.8% ± 5.8, and mean area under the curve of 85% ± 4.4. In addition, interobserver and intraobserver tests involving two experts were performed on an image subset of 1536 2-D US images. Percent agreement values of 0.89 and 0.93 were achieved between two experts (i.e., interobserver) and by each expert (i.e., intraobserver), respectively. These results show the feasibility of the first essential step in the development of automatic US image acquisition and interpretation systems for autonomous robotic knee arthroscopy.

Diagnostic and Therapeutic Shoulder Arthroscopy Using a Small-Bore Needle Arthroscope

As resolution and image quality improve, several potential advantages make needle arthroscopy (NA) appealing for broader therapeutic applications in the operating room. Smaller camera size and weight allow for a minimally invasive approach with smaller incisions than standard arthroscopy and decreased use of arthroscopic fluid. Differences in the technology, such as a 0° optic and less rigid instrumentation, necessitate a modified technique to accommodate thorough diagnostic arthroscopy as well as modified approaches to therapeutic procedures. This article introduces our preferred approach to diagnostic arthroscopy of the glenohumeral joint and subacromial space with needle arthroscopy and small-bore instruments. This technique could increase efficiency and decrease operative time with certain arthroscopic procedures, and it may improve patient outcomes.

Partial Medial Meniscectomy Using Needle Arthroscopy and a Standardized Local Anesthetic Protocol

Needle arthroscopic procedures of the knee offer potential advantages over standard arthroscopic procedures. The small size of the instruments allows for surgery without the use of a scalpel or suture, potentially decreased recovery times, and potentially reduced complication rates compared with traditional arthroscopy. In some patients, the procedure can be performed without the use of either general anesthesia or sedation. The purpose of this article is to provide a standardized technique guide for needle arthroscopic partial medial meniscectomy under local anesthesia.

Diagnostic Needle Arthroscopy and Partial Medial Meniscectomy Using Small Bore Needle Arthroscopy

As resolution and image quality improve, several potential advantages make needle arthroscopy (NA) appealing for broader therapeutic applications in the operating room. The smaller camera size and weight allow for a minimally invasive approach with smaller incisions than standard arthroscopy and decreased arthroscopic fluid use. Differences in the technology, such as a 0-degree optic and less rigid instrumentation necessitate a novel technique to accommodate thorough diagnostic arthroscopy as well as new approaches to therapeutic procedures. This manuscript introduces our preferred approach to diagnostic arthroscopy and partial medial meniscectomy with NA and small-bore instruments. The minimally invasive nature of this technology may decrease postoperative pain and improve return of comfort and function.

Office-Based Needle Arthroscopy: A Standardized Diagnostic Approach to the Shoulder

In-office needle arthroscopy offers the potential advantage of reduced injury to intervention time, without the need for advanced imaging. It is particularly appropriate for those with contraindications to advanced imaging and also may reduce the risk of incorrect diagnoses in those situations in which imaging is associated with low sensitivity/specificity. The purpose of this article is to provide a standardized diagnostic approach to needle arthroscopy of the shoulder.

Evaluation of the caudal cervical articular process joints by using a needle arthroscope in standing horses

OBJECTIVE

To determine the safety and efficacy of caudal cervical articular process joint arthroscopy by using needle arthroscopy in standing sedated horses.

STUDY DESIGN

Prospective experimental case series.

ANIMALS

Six adult horses.

METHODS

Three horses underwent exploration of bilateral C5-6 vertebral articular process joints and three bilateral C6-7 articular process joints by using a 1.2 × 65-mm needle arthroscope under standing sedation. The 16-gauge arthroscopic trocar and canula assembly was inserted in the desired articular process joint under ultrasonographic guidance without distention of the joint.

RESULTS

All 12 articular process joints were successfully explored. Entering the joint on the first attempt was achieved in 10 of 12 joints. A craniodorsal approach for arthroscope insertion allowed evaluation of the most cranial aspect of the articular cartilage surface. Triangulation with a spinal needle was determined to be difficult and resulted in a limited space for movement.

CONCLUSION

Needle arthroscopy of the caudal cervical facet joints was performed safely and efficiently in standing sedated horses.

CLINICAL SIGNIFICANCE

Standing cervical articular process needle arthroscopy is a minimal morbidity technique with the potential to be an advantageous technique for the diagnosis and treatment of cervical articular process pathology.

In-Office Needle Arthroscopy: A Systematic Review of Indications and Clinical Utility

PURPOSE

This review explores the current literature regarding both the clinical indications and utility of minimally invasive in-office needle arthroscopy (IONA) relative to conventional imaging modalities.

METHODS

In compliance with R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched in July 2018, in addition to the conference abstract databases of 5 prominent meetings between 2013 and 2018, for studies using IONA for diagnostic purposes. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Among 932 conference abstracts and 369 studies identified, 11 publications involving 404 patients (395 knees and 9 shoulders) were included, with 9 clinical studies and 2 cost analyses. The median Methodological Index for Non-Randomized Studies (MINORS) score was 9 for noncomparative and 23 for comparative studies. Among the 9 clinical studies, IONA had a superior sensitivity, specificity, positive predictive value, and negative predictive value to magnetic resonance imaging (MRI) in the evaluation of knee osteoarthritis, anterior cruciate ligament insufficiency, and meniscal tears. IONA was comparable or inferior to MRI in the same parameters for the diagnosis of osteochondral defects and rotator cuff tears. In the 2 cost analyses, IONA had lower costs when used in place of MRI for treatment algorithms involving medial meniscal tears and rotator cuff tears but not lateral meniscal tears.

CONCLUSIONS

IONA holds potential for cost savings and improved diagnostic accuracy relative to MRI, primarily for intra-articular meniscal, ligamentous, and chondral defects of the knee. However, its current indications for use in other joints are limited to rotator cuff tears in the shoulder, making its diagnostic value in other joints much more limited. The current quality and breadth of evidence are significantly lacking, with numerous practical shortcomings. To improve acceptance of IONA, priority should be placed on establishing defined protocols, indications, contraindications, and patient perspectives for the procedure.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.