Is In-office Needle Arthroscopy Worth Another Look?

In 2015, knee pain was the ninth most common reason for ambulatory medical office visits in the United States, accounting for 1.6 percent of such visits. Evaluation of a patient who presents with knee pain begins with a focused history and physical exam. If radiographs are nonrevealing, advanced imaging, such as MRI, often is required to arrive at a diagnosis and develop a treatment plan. Although MRI remains a standard of care in the workup of suspected intra-articular knee injuries, it does have limitations.

MRI is instrumental in the diagnosis of intra-articular knee pathology; however, acute anterior cruciate ligament and meniscal injury may be missed in one in 14 and one in 10 individuals, respectively. A greater number of these injuries may be missed in patients who have previously undergone a knee operation, have metallic implants near the knee joint, or have injuries to multiple structures. In addition, MRI remains limited in its ability to definitively diagnose or quantify cartilage injuries, even with 3T scanners. Although special sequences such as T1rho appear to be valuable for musculoskeletal imaging, they are not yet commonly available. Given these and other limitations, diagnostic arthroscopy remains the gold standard in the diagnosis of intra-articular knee injuries.

Over the past three decades, a new imaging modality, in-office needle arthroscopy, has emerged as a tool to aid in the diagnosis of intra-articular pathology. The technique was first described by Jeffrey Halbrecht, MD, in 1992. His study demonstrated that needle arthroscopy’s accuracy was superior to that of MRI in the diagnosis of articular cartilage and meniscal pathology, although it had limitations in diagnosing ligamentous injuries.

Technical considerations

Currently, two needle arthroscopy systems are available for use in the United States: mi-eye 2 (Trice Medical) and VisionScope® imaging system (VisionScope Technologies). Both systems utilize a portable, high-definition viewing screen for visualization and a zero-degree-angle handheld arthroscope with integrated light source and camera. The scope, available in various lengths, offers a 120-degree field of view.

The procedure, performed after standard sterile skin preparation, involves injecting local anesthetic subcutaneously at the portal sites and within the knee joint. In contrast to diagnostic arthroscopy, which utilizes continuous inflow and outflow of fluid to distend and flush the joint, inflow during needle arthroscopy is provided via small bursts of fluid without continuous irrigation. The fluid injected as inflow is later aspirated through the same syringe. At the conclusion of the procedure, a compressive wrap can be placed over the knee. Pending the results of the needle arthroscopy, the patient is either permitted to ambulate normally or is placed on a modified weight bearing status.

Needle arthroscopy can present technical challenges for orthopaedic surgeons. Arthroscopists who are accustomed to operating a standard 30- and 70-degree arthroscope may find that the zero-degree-angle scope presents a significant learning curve. Modification of the standard arthroscopic portals often is necessary. Visualization also may be affected by the smaller diameter needle arthroscope and the lack of continuous inflow and outflow.


Fig. 1 Anikar Chhabra, MD, MS, performs an in-office needle arthroscopy with the mi-eye 2™ system with the patient in supine position.
Courtesy of Anikar Chhabra, MD, MS


Fig. 2 Arthroscopic imaging from the mi-eye 2™ system demonstrates (A) an acute retear of the medial meniscus in a patient with a history of multiple meniscectomies, and (B) the medial compartment of the knee with chondral defect on the medial femoral condyle.
Courtesy of Anikar Chhabra, MD, MS

Patient experience

In-office needle arthroscopy offers many distinct advantages to both clinicians and patients. The procedure is performed in a standard clinic examination room with the patient seated on a reclining chair or lying prone on an examination table (Fig. 1). Anesthesia is provided by local injection, avoiding the potential complications of general anesthesia. The procedure is performed in 15 minutes or less, and a diagnosis may be obtained in real time. Needle arthroscopy gives the physician the ability to review captured images and video with the patient immediately following the procedure.

In Dr. Halbrecht’s study, 100 percent of the patients (n = 20) preferred in-office needle arthroscopy to MRI because they were able to participate in the visualization of their pathology and it facilitated immediate diagnosis. Comparatively, obtaining an MRI, receiving the results, and following up with an orthopaedic surgeon to create a treatment plan may take several weeks to months. Furthermore, the out-of-pocket costs incurred by patients are significantly less for needle arthroscopy compared to MRI. Lastly, needle arthroscopy also can be used as an adjunct to correlate MRI findings, which can (1) lower the risk of complications, (2) allow patients to feel empowered in their own care, and (3) limit the actual surgical procedure to only one surgery, whereas before a surgeon may have preferred a staged arthroscopic procedure with an initial diagnostic arthroscopy in the operating room (OR).

Although rare, complications can occur with needle arthroscopy. Like diagnostic arthroscopy, patients may be exposed to infection, hemarthrosis, and damage to intra-articular structures. Overall, the safety profile has been shown to compare favorably to that of diagnostic arthroscopy, given the smaller entry portals and lower number of portal sites used with needle arthroscopy.

Diagnostic capability

Needle arthroscopy is especially useful in the diagnosis of intra-articular surface pathology and provides a dynamic assessment of patellofemoral and tibiofemoral joint motion. In a 2018 prospective,
blinded, multicenter clinical trial by Gill et al., in-office needle arthroscopy was found to have comparable accuracy, sensitivity, and specificity to diagnostic arthroscopy when evaluating meniscal, chondral, and patellofemoral joint pathology. Both arthroscopic modalities were found to be more accurate than MRI for those specific locations. MRI provides a volumetric view of the joint that cannot be obtained by arthroscopy, which more accurately assesses the surface pathology and thus remains critical when considering certain conditions, including but not limited to osteonecrosis, subchondral insufficiency fractures, osteochondral lesions, and intratendinous partial ligament tears (Fig. 2).

In cartilage repair surgery, lesion size often determines the surgical intervention performed. Preoperative MRI has been shown to significantly underestimate the size of cartilage defect in most patients. Needle arthroscopy can aid orthopaedic surgeons by more accurately measuring the size of defect, which is instrumental in the preoperative planning phase, especially when allograft is needed. Needle arthroscopy may be exceptionally valuable in the postoperative setting as well. In patients with persistent pain following a previous knee operation, MRI interpretation is limited by post-surgical signal change and scatter due to metallic implants. In patients who have undergone meniscal repair/replacement or cartilage repair/replacement, needle arthroscopy may be used as a “second look” to assess healing status, effectively eliminating or significantly decreasing the need to return to the OR for diagnostic arthroscopy.

Needle arthroscopy could serve a useful role in evaluating pathology in patients when history, physical exam, and imaging are not in concordance and a direct view of the joint is the best way to diagnose and treat. It would also benefit the subset of patients with knee pain who have absolute contraindications to MRI, including those with permanent implants, such as pacemakers; intracranial devices; certain vascular clips; intraocular metallic foreign body; obesity; and claustrophobia.

Following the procedure, injection of corticosteroid, biologics, and other products may be performed under direct visualization to ensure accurate intra-articular placement. Currently, instruments are being developed to aid providers in performing simple procedures during in-office arthroscopy and could contribute to greater cost savings and patient satisfaction.

Economic impact

In 2010, 50 percent of arthroscopic procedures were performed to address medial or lateral cartilage and meniscal pathology. Given the difficulty of diagnosing chondral and meniscal injury on MRI, equivocal findings may lead to unnecessary diagnostic arthroscopy to obtain definitive diagnoses. A 2014 study by Voigt et al., examined the impact needle arthroscopy could have on the U.S. healthcare system. They determined that needle arthroscopy used in place of MRI resulted in net cost savings of $115 million to $177 million in patients presenting with medial meniscal pathology. For patients presenting with lateral meniscal pathology, needle arthroscopy cost the healthcare system an additional $14 million to $97 million; however, this was due to increased accuracy of diagnoses, thus leading to additional costs secondary to appropriate surgical management.

Cost savings may be incurred at the patient level as well. McMillan et al., determined that compared to MRI of the knee, needle arthroscopy provided an average cost saving of $418 when performed in the outpatient setting and $961 when performed in the hospital setting.

In addition to the direct monetary benefits of needle arthroscopy, indirect quality-of-life benefits may be acquired. Needle arthroscopy may limit underdiagnosis of injury severity and therefore lead to earlier intervention with less time and money spent on conservative treatment. Obtaining immediate diagnoses could expedite initiation of treatment plans and eliminate follow-up visits needed to review MRI results.

Conclusion

In summary, in-office needle arthroscopy is a safe, cost-effective, and powerful tool to visualize intra-articular surface pathology of the knee in real time and rapidly establish a diagnosis. It can serve as an important modality in the surgeon’s toolbox to accurately diagnose and treat patients while minimizing patient costs and increasing patient satisfaction. Still, patient selection remains important to determining appropriate clinical situations to utilize needle arthroscopy.

Chad W. Parkes, MD; Ayoosh Pareek, MD; Anikar Chhabra, MD, MS; and Aaron J. Krych, MD, are with the Department of Orthopaedic Surgery at the Mayo Clinic in Rochester, Minn. Dr. Parkes can be reached at
parkes.chad@mayo.edu.

 

References:

  1. Rui P, Okeyode T: National Ambulatory Medical Care Survey: 2015 State and National Summary Tables. Available at: http://www.cdc.gov/nchs/ahcd/ahcd_ products.htm. Accessed November 2, 2018.
  2. Phelan N, Rowland P, Galvin R, et al: A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee. Knee Surg Sports Traumatol Arthrosc 2016;24:1525-39.
  3. Crawford R, Walley G, Bridgman S, et al: Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 2007;84:523.
  4. Nouri N, Bouaziz MC, Riahi H, et al: Traumatic meniscus and cruciate ligament tears in young patients: a comparison of 3T versus 1.5T MRI. J Belg Soc Radiol 2017;101:14.
  5. Halbrecht JL, Jackson DW: Office arthroscopy: a diagnostic alternative. Arthroscopy 1992;8:320-6.
  6. Patel KA, Hartigan DE, Makovicka JL, et al: Diagnostic evaluation of the knee in the office setting using small-bore needle arthroscopy. Arthrosc Tech 2018;7:e17-e21.
  7. Deirmengian CA, Dines JS, Vernace JV, et al: Use of a small-bore needle arthroscope to diagnose intra-articular knee pathology: comparison with magnetic resonance imaging. Am J Orthop 2018;47(2).
  8. Gill TJ, Safran M, Mandelbaum B, et al: A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical diagnostic arthroscopy. Arthroscopy 2018;34:2429-35.
  9. Szachnowski P, Wei N, Arnold WJ, et al: Complications of office-based arthroscopy of the knee. J Rheumatol 1995;22:1722-5.
  10. Gomoll AH, Yoshioka H, Watanabe A, et al: Preoperative management of cartilage defects by MRI underestimates lesion size. Cartilage 2011;2:389-93.
  11. Campbell AB, Knopp MV, Kolovich GP, et al: Preoperative MRI underestimates articular cartilage defect size compared with findings at arthroscopic knee surgery. Am J Sports Med 2013;41:590-5.
  12. McMillan S, Schwartz M, Jennings B, et al: In-office diagnostic needle arthroscopy: understanding the potential value for the US healthcare system. Am J Orthop 2017;46:252-6.
  13. Voigt JD, Mosier M, Huber B: Diagnostic needle arthroscopy and the economics of improved diagnostic accuracy: a cost analysis. Appl Health Econ Health Policy 2014;12:523-35.

 

Is in-office needle arthroscopy the triumph of technology over reason?

The ability to perform in-office needle arthroscopy for the evaluation of knee pathology has existed since the early 1990s. Although the major selling point for in-office needle arthroscopy is increased diagnostic accuracy of knee pathology, a complete physical examination performed by a trained healthcare provider, coupled with a thorough history, has been found to be diagnostically valid for anterior cruciate ligament, posterior cruciate ligament, and meniscal injuries, as well as cartilage lesions. Therefore, assuming adequate evaluation is performed, needle arthroscopy should add little clarity to the diagnostic picture.

Needle arthroscopy also is purported to decrease the need for MRI in the evaluation of knee pathology, but needle arthroscopy cannot adequately assess extra-articular pathology such as subchondral edema/fractures, ligament injuries, and tendinopathy. Thus, the clinical scenario where needle arthroscopy would add to diagnostic capability is limited to patients with meniscus or articular cartilage lesions where the history and physical examination were equivocal and the examiner was absolutely certain that the source of pain was extra-articular.

As the patient-physician relationship obligates adherence to the principles of benevolence and nonmaleficence, the benefits of any intervention must outweigh the inherent risks of the procedure. The risk of septic arthritis after arthrocentesis is low—less than 0.01 percent of all injections—but the capsular violation coupled with the iatrogenic effusion can stimulate arthrogenic quadriceps inhibition and exacerbate knee dysfunction.

Furthermore, needle arthroscopy proponents point to its value in the post-surgical setting as a way to take a “second look.” However, given the lack of value in arthroscopic knee surgery in the presence of preexisting degenerative changes, the only clear indication for post-surgical arthroscopy is the presence of mechanical symptoms that are nonresponsive to appropriate nonoperative treatment. Thus, the indication for surgical intervention in this case would be determined by the patient’s history. Needle arthroscopy would only add an unnecessary invasive intervention—especially because the zero-degree viewing angle requires a significant learning curve, even for arthroscopists.

In summary, although in-office needle arthroscopy may indeed be a safe and cost-effective evaluation tool, it is still an invasive procedure not without risk to the patient. At its current state of evolution, the potential benefits derived by needle arthroscopy are too limited to justify the risks.
Anthony E. Johnson, MD, is the Diversity Advisory Board liaison for AAOS Now. He is the orthopaedic residency program director at Dell Medical School at the University of Texas, Austin.

References:

  1. Décary S, Ouellet P, Vendittoli PA, et al: Diagnostic validity of physical examination tests for common knee disorders: an overview of systematic reviews and meta-analysis. Phys Ther Sport 2017;23:143-55.
  2. Palmieri-Smith RM, Kreinbrink J, Ashton-Miller JA, et al: Quadriceps inhibition induced by an experimental knee joint effusion affects knee joint mechanics during a single-legged drop landing. Am J Sports Med 2007;35:1269-75.
  3. Brignardello-Petersen R, Guyatt GH, Buchbinder R, et al: Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open 2017;7:e016114.

Advertisements


Advertisement