Diagnostic and Therapeutic Elbow Arthroscopy 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.

Arthroscopic Hip Labral Repair Using Needle Arthroscopic Visualization

Hip arthroscopy has become increasingly popular in recent years and continues to grow as techniques and understanding of hip arthroscopy evolve. Needle hip arthroscopy is emerging as a technique that can offer potential advantages compared with a traditional arthroscope. These benefits include a higher degree field of view, lower profile design for easier maneuverability, decreased arthroscopic fluid, and potentially decreased postoperative pain and swelling. We herein present and describe a technique of needle hip arthroscopy as a viable option in the treatment of hip pathology.

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.

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).

Evaluation of a small-bore needle arthroscope for diagnosis and treatment of medial coronoid disease in dogs: a pilot study with short-term assessment

CASE HISTORY

Dogs (n = 15) that were presented to a single veterinary teaching hospital with elbow dysplasia-associated lameness between September 2021 and May 2022, and were determined to require arthroscopy based on imaging results, were prospectively recruited into the study. The median duration of lameness was 4 (min 1, max 24) months.

CLINICAL FINDINGS

Various breeds were represented with a median body weight of 31.6 (min 15, max 46.4) kg and median age at presentation of 14 (min 8, max 83) months. Results of imaging modalities (CT) were consistent with medial coronoid disease with fissured or fragmented medial coronoid process in all dogs.

ARTHROSCOPIC FINDINGS

Feasibility of the needle arthroscopy (NA) procedure was firstly assessed in a preliminary cadaveric study in forelimbs (n = 10) collected from 10 adult dogs euthanised for reasons unrelated to the study. Elbow exploration was performed through a medial approach beginning with NA (1.9 mm 0° angle scope) followed by standard arthroscopy (SA; 2.4 mm 30° angle scope). The quality and extent of visualisation (scored through the number of anatomical structures visualised) were recorded and statistically compared. As the cadaver study indicated that NA allowed safe inspection of all structures in medial/caudal compartments, this procedure was then used in the dogs requiring treatment. In the clinical setting, elbow exploration was successful in all dogs and the treatment (removal of osteochondral fragments) was performed without requiring conversion into SA. One month after surgery, all dogs had an improvement in their lameness score (0-5) and 12/15 dogs were no longer lame. There was a reduction in Canine Orthopaedic Index scores measured a median of 99 (min 47, max 180) days after surgery (24 (IQR 19.5-31.5)) compared to the pre-operative period (49 (IQR 46.5-57); p < 0.001).

CLINICAL RELEVANCE

Needle arthroscopy-assisted removal of osteochondral fragments was performed in all dogs with satisfactory short-term clinical outcome. NA is a feasible technique for diagnosis and lesion assessment in dogs with a fissured or fragmented coronoid process. Larger clinical studies with longer follow-up are necessary to validate the NanoScope operative arthroscopy system as an alternative strategy to SA for video-assisted treatment of medial coronoid disease.

Small-Bore Needle Arthroscopic Extensor Carpi Radialis Brevis Release Results in Improved Outcomes at One Year Postoperatively

Purpose

To evaluate outcomes of patients who underwent small-bore needle arthroscopic extensor carpi radialis brevis (ECRB) release for the management of recalcitrant lateral epicondylitis.

Methods

Patients who underwent elbow evaluation and ECRB release using a small-bore needle arthroscopy system were included in this study Thirteen patients were included. Quick Disabilities of the Arm Shoulder and Hand and Single Assessment Numerical Evaluation scores, as well as overall satisfaction scores, were collected. A 2-tailed paired t-test was conducted to assess the statistical significance of the differences observed between preoperative and 1-year postoperative scores with significance set at P < .05.

Results

There was a statistically significant improvement in both outcome measures (P < .001) and a 92.3% satisfaction rate with no significant complications at a minimum 1-year follow-up.

Conclusions

Patients with recalcitrant lateral epicondylitis treated with ECRB release using needle arthroscopy demonstrated significantly improved Quick Disabilities of the Arm Shoulder and Hand and Single Assessment Numerical Evaluation scores postoperatively, without complications.

Level of Evidence

IV, retrospective case series.

Evaluation of Osteochondral Allograft Transplant Using In-Office Needle Arthroscopy

In-office needle arthroscopy (IONA) has been available in various iterations for decades. Studies have described it as comparable if not superior to magnetic resonance imaging for identifying intra-articular pathology with associated cost savings per patient. A new IONA system has been brought to market with a modernized user interface and disposable handpieces offering the opportunity to address intra-articular pathology. This article outlines the use of this IONA system for the postoperative evaluation of an osteochondral allograft transplant.

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.

Concurrent Needle and Standard Arthroscopy for Posterior Cruciate Ligament Reconstruction

Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure, particularly with respect to tibial footprint debridement and tibial tunnel placement, where iatrogenic damage to anatomic structures is a well reported complication and incorrect tunnel placement can have functional implications. Preparation of the tibial component often involves switching between 30° and 70° arthroscopes and frequent portal swapping and reorientation, which can be inefficient and time-consuming. As the technology and picture resolution of needle arthroscopy has improved, its clinical application has widened. This manuscript describes the use of needle arthroscopy-assisted arthroscopic PCL reconstruction for optimal visualization of the PCL tibial footprint using an accessory posterolateral portal, while obviating the need of both 30° and 70° arthroscopes.

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.

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.

Nanoscopic Distal Clavicle Resection

Acromioclavicular joint pathology such as osteoarthritis has historically been treated with either an open or arthroscopic distal clavicle resection. Over the years the trend has been toward more minimally invasive treatment options with the arthroscope. In this article we highlight the use of the nanoscope to visualize the resection which can be performed through a small percutaneous incision. The advantages of this technique include the use of smaller portals, which should lead to improved earlier outcomes, and less iatrogenic damage to the shoulder.

Arthroscopically Assisted Fixation of Terrible Triad Variant Injuries of the Elbow With Small-Bore Needle Arthroscopy

The range of diagnostic and therapeutic applications of needle arthroscopy (NA) continue to expand due to advances in image quality and resolution. Minimally invasive techniques can be augmented by the smaller camera size and reduced fluid use made possible by NA. Small-bore arthroscopy presents opportunities for use in smaller joints, such as the elbow, where applications of standard arthroscopic equipment may be limited by small anatomic spaces and fluid extravasation. In this Technical Note, we present our technique for NA-assisted treatment of terrible triad injuries, specifically in the setting of an intact radial head. The technique describes a stepwise approach to arthroscopically aided fixation of the coronoid process, followed by open reconstruction of the lateral collateral ligament complex.