Afshin Arianjam, MD, Sports Medicine & Joint Reconstruction, Department of Orthopaedic Surgery, Pomona Valley Hospital Medical Center
Orthopaedic surgery continues to be a subspecialty that benefits from advances in new technology. As we look at the broad category of patient care, much of the advances in orthopaedics seem to be focused on operative treatment. However, it is also important to highlight advances that help elucidate diagnosis. One such advancement in the field of surgical optics is the advent of needle-based diagnostic arthroscopy, mi-eye 2 (Trice Medical), which can be performed in the office setting. Previously, in the presence of metal hardware, prior surgery, or uncertain radiographic or CT/ MRI findings, the surgeon had to debate whether to discover pathology at time of surgery, or to resume nonoperative care without a definitive diagnosis. With the ability to use a 2.2 mm needle to evaluate the knee or shoulder joint prior to any ultimate surgical treatment, orthopaedic surgeons are now able to reach a definitive diagnosis as part of their clinical decision making more quickly.
In a traditional practice, it may take four total visits including the office consultation, a separate day to get an MRI, returning to discuss the MRI results, and finally a separate day for any potential surgical intervention. With needle arthroscopy, the consultation and definitive diagnosis can happen in one day, and the patient would then have surgery on their second visit. This cuts the time from initial diagnosis to treatment by half. A recent publication in the Journal of Arthroscopy has also demonstrated that needle arthroscopy may be more accurate in diagnosis of structural pathology in the knee such as meniscus tears and cartilage lesions when compared to a traditional MRI. In joint reconstruction, it may help a surgeon gain confidence in determining whether to perform a partial versus total knee replacement by being able to evaluate all three compartments of the knee prior to surgical intervention. After knee or shoulder reconstruction, needle arthroscopy can be used to evaluate polyethylene wear, hardware loosening, or failure.
In addition to being helpful for the knee, needle arthroscopy can be advantageous in the shoulder. For decades, patients with claustrophobia had to settle for suboptimal studies produced by open MRIs which may not ultimately answer the clinical question that remains. In my office, needle arthroscopy is performed with little patient discomfort. In the case of previous hardware, needle arthroscopy can also be very helpful. For example, consider a patient with a previously repaired proximal humerus fracture that has difficulty with active motion. It is imperative to know whether there is a rotator cuff tear in that setting. Unfortunately, the patient’s shoulder contains a metal plate with multiple screws, and it is often difficult to evaluate this type of injury with an MRI given the artifact that would be produced. Conversely, obtaining a CT arthrogram maybe inaccurate and still present challenges in establishing a diagnosis of a rotator cuff tear. Furthermore, the dose of radiation emitted during a CT scan could be avoided with a needle arthroscopy. Though ultrasound has helped in the setting of diagnosing rotator cuff tears, it is still highly subjective and user dependent. By being able to directly visualize pathology with a needle arthroscope, the surgeon can be confident in obtaining a 100 percent definitive diagnosis.
In addition to being helpful during diagnosis, needle arthroscopy can also be used for treatment. For example, in the setting of adhesive capsulitis of the shoulder, needle arthroscopy can be used in order to inject the shoulder capsule in order to break the adhesive tissue which limits shoulder motion. These are just among a few of the examples that I have had the privilege of utilizing in my practice. As with any new technology, there are also limitations. Needle arthroscopy presents a reasonable learning curve and should not be used in the setting of an infection. My initial experience has been very positive, and as I continue to use this technology in my practice, I find new instances where I can solve difficult clinical scenarios. As I look ahead, I remain optimistic about our future as orthopaedic surgeons and incorporating new technologies that can help improve our patients’ quality of life.
Hesham Abboud, MD, PhD, Director of the Multiple Sclerosis and Neuroimmunology Program and staff neurologist at the Parkinson’s and Movement Disorder Center at University Hospitals of Cleveland, Case Western Reserve University School of Medicine