Needle Arthroscopy of the Knee, Shoulder, and Hip

Needle Arthroscopy—Background

Arthroscopy is a surgical procedure in which a video imaging device is placed into a joint to allow visualization and assessment of the joint space. With additional instrumentation, surgery can be performed without making large incisions or a large dissection to open up the joint. Masaki Watanabe, a Japanese surgeon, is generally credited with being the first to use arthroscopy for knee evaluation and surgery in the late 1950s. In 1964, Robert W. Jackson met Watanabe in Japan and brought this revolutionary surgical technique back to North America.

Arthroscopy provides a magnified direct view of intra-articular anatomy with minimal potential complications and is the gold standard for intra-articular joint evaluation. Arthroscopy is used to guide surgical intervention for most intra-articular orthopedic pathology. Orthopedic surgeons in the United States receive 4 years of residency training on arthroscopic surgical procedures. In 2013, the average orthopedic surgery resident completed over 300 diagnostic and surgical arthroscopy procedures prior to graduation. The Arthroscopy Association of North America (AANA) requires a minimum of 50 arthroscopic procedures a year for active membership. To obtain the sports medicine subspecialty certification from the American Board of Orthopedic Surgery, a 1-year sports medicine surgical fellowship and a minimum of 75 arthroscopies must be completed in the year prior to application. Despite significant arthroscopic surgery training at the resident and fellowship levels, even experienced arthroscopists will experience a learning curve when using needle arthroscopy in the office under local anesthesia.

Traditionally, large-joint arthroscopy has been performed with an arthroscope 4 mm in diameter and 30 or 70 degrees of visual offset. Technologic advances have led to the introduction of small-diameter disposable needle arthroscopes that can be used in the office setting under local anesthesia. Imaging can be done on a portable tablet and even combined with diagnostic ultrasound imaging on the same tablet. Instrumentation has been further refined to allow for surgical procedures to be done in an operating room or procedure room with the disposable needle arthroscope as the only imaging modality. These advances have lowered the per-procedure instrument cost of diagnostic arthroscopy to as little as $500.

With the advent of needle arthroscopy, the number of physicians interested in using diagnostic joint arthroscopy has increased, largely because hospital surgical privileges, residency training, and surgical malpractice insurance are currently not required. Physicians who have shown interest in needle arthroscopy include physiatrists, rheumatologists, and interventional radiologists. In the office, needle arthroscopy is used both for diagnosis and as a delivery system for injecting intra-articular structures or the joint itself. As a result, there is an increased demand for postdoctoral needle arthroscopy training for nonsurgeons and for needle arthroscopy protocols that promote the safe and effective evaluation of joint pathology. In-office needle arthroscopy has been evaluated over more than 1400 cases and found to pose lower surgical risks than traditional arthroscopy.

We recommend that physicians in specialties where training and scope of practice do not include arthroscopic surgical procedures get advice from their state medical licensing boards and national board certifying organizations for any requirements and consensus on the use of needle arthroscopy in their specialties. Clinicians using needle arthroscopy should make sure that they have malpractice coverage for surgical procedures, both for their own protection and their patients’ protection.

In-office needle arthroscopy has a diagnostic accuracy equivalent to that of magnetic resonance imaging (MRI) or traditional arthroscopy when used to evaluate intra-articular nonligamentous pathology. In-office needle arthroscopy used as a diagnostic tool also involves potential financial savings compared with MRI and traditional arthroscopy.

Patient evaluation—including history, physical, and relevant imaging—is always done prior to considering needle arthroscopy. Often an in-office needle arthroscopy substitutes for an MRI scan, especially if the primary clinical concern is an intra-articular derangement. We do not feel that ordering an MRI scan prior to needle arthroscopy is routinely necessary unless there is clinical concern for intraosseous, subchondral, popliteal, or extracapsular pathology. We do obtain plain radiographs prior to needle arthroscopy to evaluate joint alignment and stability as well as bony anatomy and pathology.

Our review of needle arthroscopy indications and techniques is agnostic with regard to any particular needle arthroscopy system.

Indications for Needle Arthroscopy

Common indications for using needle arthroscopy in the knee:

1.

Diagnosing meniscal tears
2.

Diagnosing chondral pathology
3.

Diagnosing anterior and posterior cruciate ligament pathology
4.

Evaluating prior intra-articular procedures
5.

Guiding intra-articular injections.
6.

Identifying loose bodies
7.

Diagnosing patellofemoral tracking abnormalities
8.

Staging osteoarthritis of the knee joint
9.

Patients unable to get an MRI scan

Common indications for using needle arthroscopy in the shoulder:

1.

Diagnosing labral pathology
2.

Diagnosing articular-sided rotator cuff pathology
3.

Diagnosing superior labrum, biceps tendon anchor pathology (SLAP lesions)
4.

Diagnosing humeral head and glenoid bone loss
5.

Evaluating prior intra-articular procedures
6.

Guiding intra-articular injections
7.

Identifying loose bodies
8.

Staging osteoarthritis of the glenohumeral joint
9.

Patients unable to get an MRI scan

Common indications for using needle arthroscopy in the hip:

1.

Diagnosing labral pathology
2.

Diagnosing femoroacetabular impingement and CAM lesions
3.

Diagnosis hip joint synovitis
4.

Staging osteoarthritis of the hip joint
5.

Guiding intra-articular injections
6.

Evaluating prior intra-articular procedures
7.

Diagnosing loose bodies
8.

Patients unable to get an MRI scan

Needle Arthroscopy Technique

Preparation

Clinicians should obtain preoperative informed consent prior to initiating needle arthroscopy. We typically do not give pre- or post-procedure antibiotics because there are no significant data suggesting that the extremely low infection rates associated with needle arthroscopy would be lowered further with antibiotic medications. If a patient is on anticoagulation, the clinician should decide on its appropriate management prior to the procedure. In our practice, we do not alter the patient’s anticoagulation regimen since the bore of the arthroscope is not significantly larger than the bore of a 14- to 18-gauge needle. We do not typically give patients preoperative pain medications or benzodiazepines, although that may be a consideration in some clinical situations. Prior to beginning the procedure, we follow the Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.

The surgical site is always isolated and draped, and sterile technique is observed. The skin is prepped with an effective surgical prep such as povidone-iodine (Betadine) or chlorhexidine. Procedural anesthesia is usually obtained with a choice of lidocaine 1% to 2% and/or bupivacaine (Marcaine) 0.25%. The addition of epinephrine may be considered, depending on physician preference. Other local anesthetics can also be considered based on physician preference. It is important to wait 3 to 5 minutes after injecting the local anesthetic into the portal sites before proceeding with the arthroscopy. Under local anesthesia, the physician has 10 to 15 minutes of procedure time to evaluate the joint.

With all needle arthroscopy systems, normal saline is used to distend the joint. The volume of saline needed for needle arthroscopy is significantly less than the volume used in standard arthroscopy. Usually no more than 30 to 50 mL of normal saline is used in the joint. The normal saline can be injected using multiple small 10- to 30-mL syringes or with a larger bag of normal saline attached to the arthroscope with intravenous tubing and a three-way stopcock. While the joint is being injected, the inflow of saline can also be used as a diagnostic tool to see whether structures such as the labrum or meniscus are stable.