Fig. 1 Common foot and ankle arthroscopic procedures performed in the OR with the needle arthroscope.
Courtesy of Arianna L. Gianakos, DO, and John G. Kennedy, MD

AAOS Now

Published 12/20/2023
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Arianna L. Gianakos DO; John G. Kennedy, MD

Advancing Techniques in Foot and Ankle Arthroscopy: Adopt Needle Arthroscopy in Various Sites of Care

Minimally invasive foot and ankle surgery continues to evolve, particularly in athletic injuries. Needle scope technology now allows surgeons to perform arthroscopic procedures through even less invasive approaches. The needle scope utilizes a 1.9 mm arthroscope with a 2.2 mm inflow/outflow sheath, with programmable buttons for image and video capture. It contains a chip-on-tip technology, which affords better visualization than the standard fiberoptic systems. With this smaller size and diameter, procedures can now be less invasive, resulting in less scar tissue formation, lower risk of complications, lower risk of morbidity, and quicker recovery. In addition, less instrumentation and equipment are required—only a console, camera handpiece, and inflow from either a syringe with normal saline or a fluid pump. Therefore, this technology has the potential to make ankle and tendon scopes less invasive and more accessible.

Previous studies have demonstrated iatrogenic articular chondral injuries during ankle arthroscopy utilizing the 4.0 mm scope. Vega et al. reported an overall iatrogenic chondral injury rate of 31 percent with larger arthroscopes in the ankle joint. The needle scope is not only much smaller in diameter but also semirigid and therefore more flexible, allowing surgeons the ability to navigate the joint with a lower risk of chondral injury.

Fig. 1 Common foot and ankle arthroscopic procedures performed in the OR with the needle arthroscope.
Courtesy of Arianna L. Gianakos, DO, and John G. Kennedy, MD
Fig. 2 Foot and ankle arthroscopic interventions commonly performed in the office or procedure room setting.
Courtesy of Arianna L. Gianakos, DO, and John G. Kennedy, MD

The ability to utilize smaller instrumentation during arthroscopy allows for expanded indications in diagnostic modalities and in both treatment and follow-up arthroscopic procedures. There have been developments in micro-instruments to accompany the use of the needle scope, although 2.9 shavers/burrs are still often utilized. Procedures that were once done with general anesthesia in the OR can now be performed under local anesthesia in the procedure room or office setting. Diagnostic capabilities may also become better and more cost-effective than MRI. The needle scope can be used in various joints, including the ankle, knee, shoulder, hand, wrist, elbow, and so on. Fig. 1 lists the current types of foot and ankle arthroscopy procedures that can be performed in the OR setting with a nanoscope, and Fig. 2 lists procedures that can be done under local anesthesia in the procedure room or office setting.

Moving surgeries from the OR to an office setting can reduce overall hospital costs with decreased needs for OR equipment and staff. In addition, patients can undergo procedures with local anesthesia, reducing the need for regional or general anesthesia and thereby eliminating many of the associated risks and adverse effects. Although in-office needle arthroscopy (IONA) is still in its infancy, previous studies have demonstrated good clinical outcomes and return to work and sport following these procedures. Colasanti et al. and Mercer et al. demonstrated that patients were able to return to sport 2 to 3 weeks faster after IONA for the treatment of anteromedial and posterior ankle impingement compared with standard arthroscopic procedures on the same pathology.

IONA or procedure room needle arthroscopy procedures streamline the experience for patients, saving time and possible anesthesia side effects. Furthermore, patients are able to interact in real time with surgeons, becoming part of the treatment process and thereby having the ability to better understand their surgery and their recovery. This psychological difference may result in a quicker recovery both physically and mentally, as the patient feels more prepared and directly involved in their own care.

Limitations of needle arthroscopy include the learning curve when performing a procedure in a wide-awake setting. Indications for performing surgery in the office setting must be understood, as more progressed injuries may require open intervention or longer surgery times; therefore, the office setting may not be conducive in such situations. In addition, although hemostasis is achieved with the inflow combined with utilization of normal saline with epinephrine, visualization may be impaired, making some interventions difficult to perform. Lastly, at this time, CPT codes have not yet been established in the office setting, but this will change as demand and utilization increase.

Needle arthroscopy technology can facilitate the diagnosis of intra-articular pathology and is a useful minimally invasive approach in the treatment of various foot and ankle injuries. The technology is still evolving, but procedures that once could be performed only in an OR under general anesthesia are now starting to be performed in procedure rooms and office sites under local anesthesia. The simplicity of the procedure allows for patients to observe their own condition and therefore better understand treatment and rehabilitation protocols. The patients “buy in” and therefore become part of the team. This type of technology can become the future of arthroscopic intervention.

Arianna L. Gianakos, DO, is an orthopaedic surgeon specializing in sports-related injuries of the foot and ankle in the Department of Orthopaedics and Rehabilitation at Yale School of Medicine in New Haven, Conn.

John G. Kennedy, MD, FRCS, is a professor of orthopaedic surgery at NYU Grossman School of Medicine and chief of the Division of Foot and Ankle Surgery at NYU Langone Health in New York City.

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