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

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.

The Role of Needle Arthroscopy in the Assessment and Treatment of Ankle Sprains

Lateral ankle ligament complex injuries are most commonly managed nonoperatively. If no improvements have been made following conservative management, surgical intervention is warranted. Concerns have been raised regarding complication rates following open and traditional arthroscopic anatomical repair. In-office needle arthroscopic anterior talo-fibular ligament repair provides a minimally invasive arthroscopic approach to the diagnosis and treatment of chronic lateral ankle instability. The limited soft tissue trauma facilitates rapid return to daily and sporting activities making this an attractive alternative approach to lateral ankle ligament complex 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).

Moving orthopaedic procedures out of the operating theatre:Outpatient needle arthroscopy can reduce cost & waste, and increase inpatient capacity compared to conventional knee arthroscopy

BACKGROUND

Needle arthroscopy (NA) is an emerging technique that could streamline pathways, facilitate timely care, and reduce service burden. The primary aim was to assess the practical and economic viability of an outpatient NA service. Secondary aims were to assess the relative costs and benefits compared to a conventional arthroscopy (CA) service.

METHODS

This service feasibility study was conducted between 2021-2022 in a high-volume national treatment centre. A NA pathway was established for patients with chronic soft tissue pathology or early degenerative knee disease. The pathway was evaluated in terms of: i) cost; ii) efficiency, and iii) waste production, and an assessment was conducted of the patient-related and service-related effects.

RESULTS

The cost of the NA pathway was £1555.20 per patient, compared to £2,351.53 for CA. Time to management was 45 days for NA versus 180 days for CA. The NA pathway involved two hospital attendances, whereas CA required a minimum of three. NA cases produced 1.4 kg of non-recyclable waste compared to 5.0 kg produced by CA. For every two cases managed by NA instead of CA, capacity for one additional obligate-inpatient procedure was created.

CONCLUSIONS

The NA pathway offers a technically and economically viable approach for the management of refractory knee symptoms in the context of chronic soft tissue or early degenerative disease. NA placed less demand on hospital resources, produced two-thirds less non-recyclable waste, and is amenable to a one-stop clinic approach. Clinical studies focused on objective and patient-reported outcome measures are required to assess clinical efficacy.

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.

Needle Arthroscopy for Bacterial Arthritis of a Native Joint: Surgical Technique for the Shoulder, Elbow, Wrist, Knee, and Ankle Under Local Anesthesia

Suspected bacterial arthritis of a native joint requires urgent management to control potential life-threatening sepsis and limit cartilage damage. Diagnosing bacterial arthritis is often challenging and relies on diagnostic tests with low accuracy. A high threshold for surgery poses a risk of undertreatment, whereas a low threshold for surgery could lead to overtreatment with unnecessary invasive and costly procedures. Surgical lavage through arthroscopy or arthrotomy is generally considered standard treatment. Nowadays, needle arthroscopy provides an alternative and potentially less-invasive approach that can safely lower the surgical threshold. Needle arthroscopy can be performed directly upon presentation at the patient's bedside, as it is well tolerated under local anesthesia. Therefore, this Technical Note presents a stepwise guideline for performing standardized needle arthroscopic lavage in patients with (suspected) bacterial arthritis of the shoulder, elbow, wrist, knee, and ankle.

In-office needle arthroscopic assessment after primary ACL repair: short-term results in 15 patients

Purpose

In-office needle arthroscopy has been reported as a diagnostic tool for different knee pathologies. In addition, ACL repair has seen a resurgence with the advent of innovative orthopedic devices. The aim of this study was to assess clinical, radiological, and in-office needle arthroscopic findings in 15 adult patients who underwent acute (within 14 days from injury) anterior cruciate ligament (ACL) repair.

Methods

Fifteen patients voluntarily participated in the study. A second-look arthroscopy was performed with an in-office needle arthroscopy at an average of 7.2 months after the primary repair. The parameters included in the investigation were the continuity of the anatomical footprint of the repaired ACL, subjective assessment of the ACL tension with the probe, and synovial coverage of the ACL. All patients had a Magnetic Resonance Imaging (MRI) at 6 months after repair and an arthrometric evaluation with the KT-1000. Clinical evaluation with the scores, Tegner Lysholm Knee Scoring Scale (TLKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) was performed at the final follow-up of 2 years. Moreover, a correlation between the characteristics of ACL appearance at the time of the second look in-office needle arthroscopy, MRI and KT-1000 was performed.

Results

The mean TLKSS was 97.86, the mean KOOS was 98.08 and the mean subjective IKDC was 96.71. The objective IKDC was A in 10 patients and B in 5 patients. ACL healing was graded as A in 11 patients and B in 4 patients. Synovial coverage was graded as good in 10 patients and fair in 5 while MRI assessment showed a type I ACL in 10 patients, type II in 4 patients and type III in 1 patient.

Conclusion

In-office needle arthroscopy is a reliable tool to assess the condition of a repaired ACL. In addition, ACL repair performed in acute proximal tears demonstrated excellent clinical results.

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.

Needle arthroscopy for exploration of the elbow joint: a case series of six dogs with preliminary cadaveric study

CASE HISTORY

Dogs (n = 6) suffering from elbow-associated lameness for a median of 3.5 (min 2, max 12) months duration requiring arthroscopic exploration according to imaging results were prospectively included in this study.

CLINICAL FINDINGS

Dogs that met the inclusion criteria were of various breeds with a median body weight of 18 (min 13.2, max 34.5) kg and median age at presentation of 11 (min 6, max 96) months.

RESULTS

of imaging modalities (radiographs and/or CT) were consistent with developmental elbow disease in all of the dogs.

ARTHROSCOPIC FINDINGS

Feasibility of the needle arthroscopy procedure was first assessed in a preliminary cadaveric study. Disease-free cadaveric forelimbs (n = 12) were collected from adult dogs (n = 6) euthanised for reasons unrelated to the present study. Elbow exploration was performed, beginning with needle arthroscopy (1 mm, 0° angle scope) followed by standard arthroscopy (2.4 mm, 30° angle scope) through a medial approach. The ease of introduction, range of motion and the quality of visualisation were assessed subjectively and presence of iatrogenic introduction lesions and extent of field of vision (assessed by the number of anatomical structures visualised) were scored and statistically compared. Needle arthroscopy allowed inspection of all structures at risk for medial/caudal compartment disease in all joints considering the occasional need for multiple portals. In the clinical setting, elbow exploration was found to be similar to that in cadaver joints in 4/6 dogs. The lower quality of vision provided by needle arthroscopy was a limitation of the technique, and 2/6 clinical cases required conversion to standard arthroscopy for full visualisation of the joint. No introduction lesions were noted with needle arthroscopy in either the cadaveric or clinical studies.

CONCLUSIONS AND CLINICAL RELEVANCE

Needle arthroscopy allowed safe visualisation of all the structures of the medial and caudal compartment in disease-free cadaveric elbows, suggesting that needle arthroscopy is an appropriate technique for diagnosis and assessment of lesions of developmental elbow disease. However, the low quality of vision provided by the 1 mm scope, and the small diameter of the sleeve, which limited fluid inflow, combined with fragility of the device were major drawbacks that prevented consistent full exploration of the joint and detailed lesion assessment in clinical situations. Improvement of the device is thus necessary before use of the technique in clinical practice can be recommended.

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.

Comparison of needle arthroscopy, traditional arthroscopy, and computed tomography for the evaluation of medial coronoid disease in the canine elbow

OBJECTIVE

To evaluate the diagnostic value of still images of needle arthroscopy (SNAR), still images of traditional arthroscopy (STAR), and computed tomography (CT) to diagnose medial coronoid process (MCP) pathology.

STUDY DESIGN

Prospective clinical trial.

ANIMALS

Dogs (n = 17) presented for evaluation of elbow dysplasia.

METHODS

For each case, two SNAR and STAR images of the MCP were reviewed independently and in random order by three board-certified surgeons. Computed tomographic images were reviewed by one board-certified radiologist. Reviewers were blinded to surgical and clinical findings. Surgical findings from real-time TAR with palpation were used as the gold standard. Receiver operating characteristic (ROC) curves and concordance statistics tests for the diagnostic accuracy of MCP fissure, MCP fragment, medial compartment condition, and cartilage score were calculated.

RESULTS

Images of 27 elbows joints were reviewed. For MCP fissure detection, areas under the ROC curves for CT (0.84), STAR (0.73), and SNAR (0.57) did not differ. For the detection of MCP fragment, STAR had a larger area under the ROC curve (0.93) compared with SNAR (0.74, P = .015) and CT (0.54, P < .001). Still images of TAR and SNAR had comparable concordance for cartilage score (0.80 and 0.77, respectively) and medial compartment pathology (0.80 and 0.73, respectively).

CONCLUSION

Still images of NAR, STAR, and CT had similar diagnostic value to identify MCP fissures. Still images of TAR was superior to SNAR and CT to identify MCP fragments.

CLINICAL SIGNIFICANCE

The diagnostic accuracy of SNAR varied on the basis of the coronoid lesion being evaluated.