Technological advances, economic factors and convenience may be contributing to a resurgence of interest for in-office diagnostic arthroscopy.1 Although this modality is gaining traction in the orthopedic community, it is important to consider the benefits and costs of in-office diagnostic arthroscopy procedures. In a 2018 commentary, Cooper reminded us that in-office arthroscopy has had significant criticism and abuse over the years.2
In no way am I promoting in-office surgery. Instead, I wish to stress that in-office diagnostic arthroscopy is simply another modality that we all should have available to us. For me personally, diagnostic arthroscopy is simply like a diagnostic injection or a stress exam. It gives the patient and I instant information without going to the operating room or ordering magnetic resonance imaging (MRI).
Diagnostic arthroscopy is frankly fun for patients. The soldier patients that I see love watching the procedure. It is very rewarding to be able to show patients their pathology when previous providers or tests suggested nothing was wrong. After 27 years, I put more stock in my diagnostic injection than MRIs when it comes to being able to predict pathology. We all order MRIs but realistically, their value for predicting true intra-articular pathology is poor and this is backed up with a plethora of research.
A Closer Look At The Benefits Of In-Office Diagnostic Arthroscopy
Newer research suggests that in-office arthroscopy is far more cost-effective than MRI for diagnosing intra-articular pathology. Amin and colleagues compared these options for meniscal tears in the knee, and saw not only improved diagnosis but significant cost reduction in performing in-office diagnostic arthroscopy.3
Over the years, I have had my share of patients who have all the clinical findings of an intra-articular issue but there were negative findings with imaging. Far too often, insurance companies see a normal MRI report and conclude that there is no further need for treatment or workup. We all know independent medical examiners (IMEs) are less likely to delve into the depth of chronic intra-articular pain with normal X-rays and MRI. Additionally, in some cases, it often takes a bit more to convince a patient that the problem is intra-articular versus extra-articular. Proving that a soldier actually has a problem can often be a career-saving event. On many occasions, I have stopped a medical discharge by using diagnostic arthroscopy.
One can say the same for an athlete with an unexplained clicking in a joint. Far too often, athletes will opt for an injection but we all know that no injection will fix a cartilage injury. Even with a positive diagnostic injection, it is not always easy to convince a patient that there is all this synovitis in his or her joint. Even when you show some examples of arthroscopic pictures, not all patients can make the leap. At least with my patient base, seeing is believing. Thus, diagnostic arthroscopy can play a role.
We have all had patients with no concrete explanation for their pain and a constant joint effusion. For those cases, I find diagnostic arthroscopy an easy and simple one-portal technique to confirm whether the joint is normal or abnormal. More times than I can count, a positive diagnostic injection followed by a diagnostic arthroscopy yielded a vast array of pathology ranging from synovitis, scar tissue, cartilage flaps and loose bodies to hematoma, gouty crystals, degenerative joint disease (DJD) and even pigmented villonodular synovitis (PVNS) (see first photo to right). Then there are some cases when you see unexpected pathology like a full-thickness cartilage flap or a significant meniscoid lesion (see second and third photos to the right).
Pertinent Considerations And Caveats With Diagnostic Arthroscopy
Diagnostic arthroscopy, along with in-office arthroscopy, does not just apply to the foot and ankle, but to multiple orthopedic joints as well as the temporomandibular joint (TMJ). Let us be clear though. Not every joint is safe or comfortable to address arthroscopically in the office. I personally restrict diagnostic arthroscopy for the foot and ankle to only the ankle and the first MPJ. However, now that we have needle scopes which are significantly smaller than a standard 2.7/2.9 mm scope, one could conceivably expand the indications for diagnostic arthroscopy to all joints. If you can get an 18-gauge needle into a joint, you can get the scope into the joint.
Unfortunately, some joints are simply harder to get into because portals can be variable. Just imagine how fun it is for patients during diagnostic or therapeutic injections of other joints like the subtalar or calcaneocuboid. It is no picnic to find the best portals even with C-arm fluoroscopic assistance for many joints. The medial ankle and the dorsomedial aspect of the first MPJ are pretty much slam dunks. The goal is to get in without significant anesthesia and limit the amount of time within the joint. My office is not really equipped for conscious sedation or ankle blocks. However, if you have access to these options in your practice setting, then you could conceivably scope any joint you desire.
For me and my clinic, the one-portal technique is simple to do after performing a diagnostic injection. The area is already numb and the arthroscopic camera system is not much bigger than an 18-gauge needle.
Get in and get out. You are not there to find everything. Residents often spend too much time trying to do the Ferkel 21-point inspection.4 It is okay to simply show the patient that he or she has a completely fibrosed joint, which necessitates a formal debridement. If you need to assess a cartilaginous lesion, the needle scopes are long enough to find this lesion without much effort. Again, your goal is to not only show that the patient needs surgery but to better assess the need for cartilage repair (see fourth photo to right) as lesions can take on a wide range in appearance and size.
Years ago at Fort Bragg, we utilized in-office arthroscopy as a diagnostic tool for assessing intra-articular pathology. We used a standard 2.9 mm scope using a one-portal technique to simply confirm pathology. We have all experienced the perils of an MRI that does not show the true clinical picture. Many of us have cases in which the intent is to surgically fix a cartilage lesion only to find the lesion is perfectly healed. In other cases, we thought we had a simple procedure ahead but instead find a completely delaminated cartilage fragment and wished a biologic product were available.
I had a resident who thought every patient needed an osteochondral autograft transfer system (OATS) or mosaicplasty. Doesn’t every resident think every osteochondral lesion of the talus needs a medial malleolar osteotomy and allograft transplantation plugs? After performing a medial malleolar osteotomy and finding intact cartilage in a procedure, I adopted a diagnostic arthroscopy protocol. Regardless, imaging occasionally fools all of us. In a prospective multicenter study out of Denmark assessing the accuracy between MRI and arthroscopy, Gill and colleagues concluded that “in-office diagnostic imaging provides a safe, accurate, real-time, minimally invasive diagnostic modality to evaluate intra-articular pathology without the need for surgical diagnostic arthroscopy or high-cost imaging.”5
Additionally, the use of in-office arthroscopy is an excellent option for performing second looks. In a 2019 column “Assessing Post-Op Outcomes With Cartilage Repair In Athletes” in Podiatry Today, I stressed the importance of second looks.6 In my population, I have no real issues convincing soldiers of this need but convincing the average patient may be a hard sell. Utilizing in-office arthroscopy for a second look is a powerful tool for educating patients (see fifth image to right). As I have discussed in previous columns, this is not just for assessing cartilage healing but the degree of scarring as well.
A Closer Look At Advances In Diagnostic Arthroscopy
One needs to understand the evolution of in-office and diagnostic arthroscopy. Years ago, we simply used a 2.9 mm small joint scope and standard scope tower in a minor surgery room and employed a one-portal technique for the first MPJ and ankle. This was possibly ahead of the curve. Our Army and Navy residents at Womack Army Medical Center performed diagnostic arthroscopy regularly.
Years later, Biomet came out with the first needle scope system called the InnerVue™. I used it for a few years while I was in Minnesota. I was very happy with image quality and even happier that the system had disposable parts and was only 1.9 mm. The tower was simple and the equipment was simple to set up and use. Unfortunately, the system started to become abused and eventually the system was recalled. In my observation, this recall was not because of the product but more due to surgeons abusing it. One cannot resterilize something that is disposable. All of the major arthroscopy/endoscopy companies now have needle scopes but there are very few systems that are actually focused on in-office procedures for orthopedic and podiatric uses. Many instead focus on the oral/maxillofacial community for scoping temporomandibular joints in the office.
Today, we have two systems making the rounds in the orthopedic community. Arthrex has come out with the NanoScope™, which is a two mm scope, and IntraVu Medical came out with the MIDAScope, which is a 1.4 mm system. Both systems have state-of-the-art image quality. In either case, both systems adapt to an in-office or minor surgery setting. In a 2020 cadaver study, Stornebrink and coworkers found two mm arthroscopy safe for the ankle.7 Did we really need a study to show that ankle arthroscopy is a safe procedure for the ankle?
Arthrex, unlike IntraVu Medical, promotes its system for both diagnostic and therapeutic surgeries. My focus in this column is purely the use of needle scopes for diagnostic purposes. Although both systems are fully capable, why use a needle scope when you can use a real scope and shaver?
One can couple the NanoScope with a laptop, tablet or traditional scope tower. The image quality is excellent and the system is clearly geared for operative multi-portal arthroscopy either in-office or in the operating room. The kits are very well-organized and complete so you have everything you need to perform an extensive debridement, and not just a one-portal scope. The Arthrex website highlights numerous videos on the NanoScope. At our facility, we hope to see the Nanoscope as an adjunct to numerous surgeries. One use highlighted in the Arthrex videos is utilizing the NanoScope during ankle fractures or Brostrom procedures to reduce fluid extravasation. In our practice, we also see a benefit in exploring tendon sheaths prior to a formal open procedure.
The aforementioned MIDAScope comes with a portable monitor. Image quality is excellent. Despite its small size, the needle scope is very stiff. The length is perfect for any foot or ankle and multiple specialties currently use the MIDAScope for the temporomandibular joint, knee, shoulder and wrist. The system is simple, cost-effective and truly suited to in-office use by podiatrists and orthopedists.
Emphasizing The Potential Cost Savings Of In-Office Diagnostic Arthroscopy
Many in private practice worry about the cost as well as insurance coverage. Adding a diagnostic scope as a precursor to a formal scope sounds expensive. However, if it eliminates the need for an MRI, it not only saves money but may result in avoiding the need for surgery altogether.
We forget how many diagnostic scopes are performed nationally that find zero pathology. In a 2014 study looking at in-office diagnostic arthroscopy for the knee and shoulder, Voigt and colleagues saw a significant cost savings with the use of this procedure.8 They concluded, using data from the United States, that in-office diagnostic arthroscopy was able to “shorten the diagnostic odyssey for patients and in some cases eliminate the need for unnecessary outpatient arthroscopy procedures.”8 They surmised that in 2012 dollars, there was a potential savings of 151 million dollars for the knee and 59 million dollars for the shoulder.8
In-office diagnostic arthroscopy is an excellent and safe modality. It is important to emphasize appropriate patient selection since this is a purely local anesthetic procedure. I do recommend avoiding patients who illustrate signs of needle phobia.
From a practical standpoint, the procedure should be no more than 20 minutes. Ensure proper sterile technique with a one-portal technique, minimal draping and standard preparation of the site. As with any technique, there will be a learning curve. The hard part is understanding that the focal lengths of these smaller cameras are much shorter. Accordingly, you will have to put the scope closer to what you are visualizing. You cannot do what you are accustomed to doing with a 4.0 mm scope. You will have to push the needle scope throughout the joint to maximize clarity. Again, that is why long, thin scopes like those offered with the NanoScope and MIDAScope are so adept at visualizing any size joint.
Dr. Spitalny is a staff podiatrist at the General Leonard Wood Army Community Hospital in Ft. Leonard Wood, MO, and adjunct faculty with the DePaul Podiatric Surgical Residency Program in St. Louis.
1. McIntyre LF. Editorial commentary: what you see is what you get - is in-office needle arthroscopy ready for prime time? Arthroscopy. 2019;35(9):2722-2723.
2. Cooper DE. Editorial commentary: the desire to take a look: surgeons and patients must weigh the benefits and costs of in-office needle arthroscopy versus magnetic resonance imaging. Arthroscopy. 2018;34(8):2436-2437.
3. Amin N, McIntyre L, Carter T, Xerogeanes J, Voight J. Cost-effectiveness analysis of needle arthroscopy versus magnetic resonance imaging in the diagnosis and treatment of meniscal tears of the knee. Arthroscopy. 2019;35(2):554-562.
4. Ferkel RD. Arthroscopic Surgery: The Foot and Ankle. Philadelphia: Lippincott-Raven;1996:112-114.
5. Gill TJ, Safran M, Mandelbaum B, Huber B, Gambardella R, Xerogeanes J. 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(8):2429-2435.
6. Spitalny AD, Staples B, Patel J. Assessing post-op outcomes with cartilage repair in athletes. Podiatry Today. 2019;32(2):56-60.
7. Stornebrink T, Altink JN, Appelt D, Wijdicks C, Stufkens SAS, Kerkhoffs GMMJ. Two-millimetre diameter operative arthroscopy of the ankle is safe and effective. Knee Surg Sports Traumatol Arthrosc. 2020. Available at: https://link.springer.com/article/10.1007/s00167-020-05889-7 . Accessed May 22, 2020.
8. Voigt JD, Mosier M, Huber B. In-office diagnostic arthroscopy for knee and shoulder intra-articular injuries its potential impact on cost savings in the United States. BMC Health Serv Res. 2014;14:203.