Round Table: In-office needle arthroscopy has potential to transform outpatient care
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Moderator
- Andrew R. Hsu, MD
- Orange, California
- Rachel M. Frank, MD
- Aurora, Colorado
- John G. Kennedy, MD, MCh,
- MMSc, FFSEM, FRCS (Orth)
- New York, New York
- David A. Kulber, MD, FACS
- Los Angeles, California
Minimally invasive procedures have flourished within orthopedic surgery during the past few decades as surgeons have continually sought out faster recovery times and improved clinical outcomes.
Modern arthroscopy using a 4-mm camera has revolutionized orthopedics by significantly reducing local soft tissue trauma compared with traditional open techniques, thus allowing earlier mobilization with decreased pain. Advancements in large-joint arthroscopy have spread to distal extremities where procedures involving ankle and wrist joint arthroscopy using a 2.7-mm camera are now commonplace with even smaller joint arthroscopy of the toes and fingers being performed along with tendoscopy.
In-office needle arthroscopy (IONA) has been available since the 1990s, but it was previously limited due to issues including poor image quality and lack of instrumentation to perform procedures other than diagnostic evaluations. Recent advancements have led to the creation of newer IONA equipment and techniques, such as nano arthroscopy (NanoScope, Arthrex), in which a disposable semi-rigid 1.9-mm camera kit attached to a tablet control unit can be used alongside small shavers, burrs and 2-mm instruments to perform a growing number of procedures in-office under local anesthesia. With improved image resolution, field of view, wider variety of instruments and easier logistical setup, IONA now represents a next frontier for minimally invasive surgery that has the potential to transform outpatient care.
For this Healio Round Table, three experts representing foot and ankle, hand and sports medicine, discussed their experiences with IONA, answer the most common questions about the technology and share their vision of the future for IONA.
Andrew R. Hsu, MD
Moderator
Foot and ankle perspective
Andrew R. Hsu, MD: What are the pros and cons of IONA?
John G. Kennedy, MD, MCh, MMSc, FFSEM, FRCS (Orth): IONA allows me the ability to see certain intra-articular pathologies, as well as tendon pathologies, and with better-quality optics and with new smaller instruments, we now also can do as well as see. In our first clinical outcomes paper using IONA for anterior ankle impingement, we found the ability of patients to see their pathology was a significant factor in their recovery. Patients felt they were part of the team and had a better understanding of the pathology and rehabilitation compared with those treated with traditional surgery.
The obvious pros are in-office utility, so less time and less cost, and because of the smaller soft tissue trauma, consequently faster return to play times. The current cons are the lack of, but evolving, instrumentation to provide a broader portfolio of procedures.
As with all new innovations, there is a reticence on some traditional arthroscopic surgeons to adopt IONA for fear of a requirement to need to open or change the procedure to a more complex procedure which would need transfer to an OR. Defining procedures that IONA works best will ameliorate these concerns in the future.
In addition, the facility fee is not reimbursed in many of these cases if truly performed in-office and therefore revenues can be reduced. This can be offset by the relative speed of the procedure and the reduction in expensive equipment required for a traditional scope.
Hsu: What are the most useful indications for IONA in foot and ankle?
Kennedy: We started with anterior ankle impingement and posterior ankle impingement with os trigonum resection. We have now expanded to small talar osteochondral lesion (OCL) treatments, lateral ligament stabilization techniques, as well as tendoscopy of the Achilles, peroneal tendons and posterior tibial tendon. Small cheilectomies for hallux rigidus are now becoming more common with the ability of the patient to walk right off the table following the procedure. IONA also allows for visualization of direct delivery of a biologic in intra-articular and/or tendon pathologies.
Hsu: What is the best way to effectively set up IONA for those who are not doing it yet?
Kennedy: Learn from our mistakes. Visit us or contact those who are doing it. You need to have a good nurse and a good company vendor who can have what you need available. The dynamic between the team and surgeon is always visible to the patient. The setup of the equipment is straight forward and dependent on the body part.
Hsu: Where do you see the technology and techniques moving in the future of foot and ankle?
Kennedy: I believe visiting your surgeon will be like visiting your dentist. You’ll walk in and have the procedure done and walk out for many pathologies. We are at the spear tip of a new wave of diagnosis and treatment of many pathologies. This will grow as instruments get smaller and chip-on-tip optics technology advances further. Standard arthroscopy will still be needed in an OR for larger cases that have concomitant surgical pathology. Similarly, IONA can be used as an adjunct to MRI but will not replace it for evaluation of pathology.
Hand perspective
Hsu: What are the pros and cons of IONA?
David A. Kulber, MD, FACS: IONA has many advantages for both the patient and treating physician. First, it obviates the need to go to a surgery center, which is more costly and time-consuming. As local anesthesia is usually sufficient for pain control, the patient does not need additional anesthesia. The patient can also view the arthroscopic pathology in real time. IONA is often more comfortable and convenient and cost-effective for both the patient and the physician.
Hsu: What are the most useful indications for IONA in hand surgery?
Kulber: Basilar joint arthritis is one of the most common problems in hand surgery that causes significant pain and disability for patients. The trend is for a more minimally invasive strategy in the treatment of arthritis, especially in the younger and more active population. IONA is easy to perform in the thumb CMC joint and adjunct treatments, such as synovectomy, coblation and fat grafting, all which have proven to have a positive effect on thumb arthritis can be performed at the same time.
Hsu: What is the best way to effectively set up IONA for those who are not doing it yet?
Kulber: There is a definite learning curve of using IONA in the thumb joint and other joints of the hand. First, using it in a simulation facility would help familiarize the physician with the portals and angles needed to successfully address the joints in the hand. The next step would be the physician going to the OR with the patient under anesthesia until the physician is comfortable enough to move to the office setting.
Hsu: Where do you see the technology and techniques moving in the future of hand surgery?
Kulber: As the devices become smaller and more minimally invasive, arthritis in the hand will be treated in a more minimally invasive way with less risk and complications. This will be done in combination with regenerative technology, such as adipose-derived stem cells and platelet-rich plasma, and joint resurfacing procedures.
Sports medicine perspective
Hsu: What are the pros and cons of IONA?
Rachel M. Frank, MD: In brief, the advantages include the following: the ability to get a point-of-care diagnosis, which is helpful for both surgeon and patient; improved patient satisfaction as they leave the office knowing the next step vs. waiting for MRI scheduling/results; and a low-risk procedure that is no more painful than a steroid injection. Of course, no procedure is perfect, and so the potential disadvantages include the cost of the disposable supplies and the potential for disruption to traditional office flow and efficiency.
Hsu: What are the most useful indications for IONA in sports medicine?
Frank: The most useful indications for IONA in sports medicine include the following: diagnostic arthroscopy for cartilage injuries (to stage for future cartilage repair/restoration); diagnostic arthroscopy for meniscus tears, especially after prior repair or prior tear as MRIs have inherent challenging in interpreting tear patterns in the setting of prior surgery; and “second-look” arthroscopy after prior cartilage/meniscus surgery and/or ligament reconstruction surgery when indicated. MRI findings in the postoperative setting can be difficult to interpret and direct visualization via IONA is ideal.
Hsu: What is the best way to effectively set up IONA for those who are not doing it yet?
Frank: This depends on the office environment. If I am seeing 60 to 70 patients in typical day, a single IONA procedure in the middle of the morning or afternoon might be less ideal. In this scenario, we prefer to do to the procedures at the beginning of the day, the middle of the day or at the end of the day.
For those not doing it yet, I suggest the following strategies. First, consider doing the procedure in the OR first with the patient under anesthesia, so you can get a feel for the equipment and setup. At a minimum, practice in the lab. Then, consider doing the procedure again in the OR, but with the patient wide-awake, essentially replicating what the office-setting would be like, with the ability to administer anesthesia and/or convert to a traditional scope if the surgeon or patient become uncomfortable. When doing this in the office, I suggest booking your first procedure at the beginning of the day with extra time.
Do a dry run before (ie, the morning of the procedure and before the patient gets there) and simulate the procedure, so anything you might have forgotten or not thought of (ie, where the monitor goes, whether it plugs in, etc.) can be modified prior to the actual procedure. Make sure to have all needed items (ie, local anesthesia, prep materials, etc.) ready to go. Have your room set up so when the patient comes in, everything is ready.
Hsu: Where do you see the technology and techniques moving in the future of sports medicine?
Frank: The technology behind IONA is evolving rapidly, and it is an exciting time to be able to use this technology and help improve our ability to diagnose and treat patients. With smaller cameras and instruments, I think we will be able to do more procedures in the office setting, improving the patient experience and improving access to care. In addition, I believe we will be able to accomplish our tasks in the OR with better accuracy and precision, potentially viewing from multiple vantage points with multiple cameras and/or performing single-portal arthroscopy, making our procedures more minimally invasive.
Questions on cost, as well as efficiency, remain. It will be important for all of us to continue to collect and report on clinical outcomes and cost-effectiveness of these procedures in the office setting, procedure room setting and OR setting.
For more information:
Rachel M. Frank, MD, is an associate professor of orthopedic surgery, and director of the Joint Preservation Program, department of orthopedic surgery at the University of Colorado School of Medicine. She can be reached at: rachel.frank@cuanschutz.edu.
Andrew R. Hsu, MD, is an associate clinical professor of orthopaedic surgery, chief, division of foot & ankle surgery at the department of orthopedic surgery, University of California Irvine Medical Center. He can be reached at: hsuar@hs.uci.edu.
John G. Kennedy, MD, MCh, MMSc, FFSEM, FRCS (Orth), is a professor of orthopedic surgery, and chief of the division of foot and ankle surgery, department of orthopedic surgery, at NYU Langone Health. He can be reached at john.kennedy@nyulangone.org.
David A. Kulber, MD, FACS, is a professor of surgery at Cedars Sinai Medical Center and USC Keck School of Medicine, and director of hand and upper extremity surgery, program director of the Marilyn and Jeffrey Katzenberg Hand fellowship, department of orthopedic surgery at Cedars Sinai Medical Center, and the director of the Plastic Surgery Center of Excellence at Cedars Sinai Medical Center. He can be reached at david.kulber@cshs.org.
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