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Editorial Commentary: Indications for Needle Arthroscopy as an Alternative to Magnetic Resonance Imaging: More to the Picture Than Meets the Eye

      Abstract

      Needle arthroscopy (using a 1- to 1.9-mm diameter arthroscope) is not new, and new interest is a result of the expense and inconvenience of magnetic resonance imaging (MRI), including time out of work, prolonged diagnostic dilemmas, and finite advanced imaging resources. Improvements in the image quality with the modern needle arthroscope have made it a viable option for use as a diagnostic tool in the operative setting, and eventually, if surgeons are able to create strict criteria for proper diagnostic use of the needle arthroscope, it may become an excellent tool for in-office use despite financial or legal hurdles. Specific clinical scenarios for use of an diagnostic needle arthroscopy instead of an MRI (and typically immediately followed by therapeutic arthroscopy in the same setting) include (1) a patient with a clinically obvious meniscus tear with a locked knee, (2) a patient with an outdated but previously positive MRI with recurrent injury such as a recurrent shoulder or patella dislocations, (3) a patient who is ineligible for an MRI such as those with pacemakers or spinal implants who have clear and obvious clinical findings to suggest intra-articular pathology, and (4) a patient who is over the age of 50 years with positive rotator cuff testing after a shoulder dislocation in which I have a high degree of suspicion of a rotator cuff tear. In the future, we envision using multiple needle arthroscopes to provide simultaneous views from different angles during surgery and giving ourselves a 360° view. I envision an operating room in the future with multiple small needle scopes in joint and multiple viewing monitors providing a new 3-dimensional world of arthroscopy.
      The concept of needle arthroscopy has been around for over 25 years. Ostendorf et al.
      • Ostendorf B.
      • Dann P.
      • Wedekind F.
      • et al.
      Miniarthroscopy of metacarpophalangeal joints in rheumatoid arthritis: Rating of diagnostic value in synovitis staging and efficiency of synovial biopsy.
      used miniarthroscopy with 1- to 1.9-mm arthroscopes to help diagnose rheumatoid arthritis in a cadaveric study. This was found to allow for grading of synovial alterations, chondromalacia, and bony alterations. Synovial biopsies were also performed to help stage the disease in the metacarpophalangeal joints. Using a 2-portal technique, this allowed for visualization of about 80% of the joint surface, thus giving wonderful insight in the disease. Later, this group found miniarthroscopy to correlate well with magnetic resonance imaging (MRI) findings associated with rheumatoid arthritis in a cohort of patients.
      • Ostendorf B.
      • Peters R.
      • Dann P.
      • et al.
      Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: Sensitive detection of morphologic changes in rheumatoid arthritis.
      Much attention has been given to needle arthroscopy recently, with a large surge in the literature after 2017. This newfound attention for mini or needle arthroscope has likely been driven by the ever expanding health care costs in our nation and more particularly the expense of MRI. Diagnostic modalities that could be used to offset the costs and time constraints of MRI usage in addition to traditional diagnostic arthroscopy have drawn the focus of providers, medical equipment companies, and health care systems. Improvements in the image quality with the modern needle arthroscope have made it a viable option for use as a diagnostic tool in the operative setting. Additionally, many providers have pushed the envelope in utilizing the needle arthroscope as an in-office diagnostic tool. Eventually, if the surgical community is able to create strict criteria for proper diagnostic use for the needle arthroscope, then this may be an excellent tool for in-office use. Widespread in-office use is likely unrealistic for the immediate future given many medicolegal hurdles that most providers would face, but if researchers continue to show evidence of the safety and efficacy of the technology, then many insurance providers may be drawn to this possible cheaper diagnostic option than MRI.
      I commend Wagner, Woodmass, Zimmer, Welp, Chang, Prete, Farley, and Warner
      • Wagner E.R.
      • Woodmass J.M.
      • Zimmer Z.R.
      • et al.
      Needle diagnostic arthroscopy and magnetic resonance imaging of the shoulder have comparable accuracy to surgical arthroscopy: A prospective clinical trial.
      for an excellent report, “Needle Diagnostic Arthroscopy and Magnetic Resonance Imaging of the Shoulder Have Comparable Accuracy to Surgical Arthroscopy: A Prospective Clinical Trial.” They provided excellent statistical analysis and showed a very high specificity to rule in pathology with needle arthroscopy compared to MRI. This article further strengthens my thought that needle arthroscopy will have a central role moving forward in our diagnosis and management of intra-articular pathology. My mentor, Dr Charles Giangarra, always instructed me, “If you do the correct procedure for the correct diagnosis you will be successful more than 90% of the time.” I have found this to be true in my practice, and obviously the heart of the issue is making the correct diagnosis, which is why the study above and the needle arthroscope gives us yet another tool at our disposal to correctly define pathology.
      This study follows several studies that have evaluated the efficacy of needle arthroscopy and standard arthroscopy with MRI.
      • Voigt J.D.
      • Mosier M.
      • Huber B.
      Diagnostic needle arthroscopy and the economics of improved diagnostic accuracy: A cost analysis.
      • Deirmengian C.A.
      • Dines J.S.
      • Vernace J.V.
      • Schwartz M.S.
      • Creighton R.A.
      • Gladstone J.N.
      Use of a small-bore needle arthroscope to diagnose intra-articular knee pathology: Comparison with magnetic resonance imaging.
      • Amin N.
      • McIntyre L.
      • Carter T.
      • Xerogeanes J.
      • Voigt J.
      Cost-effectiveness analysis of needle arthroscopy versus magnetic resonance imaging in the diagnosis and treatment of meniscal tears of the knee.
      • Cooper D.E.
      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.
      • Gill T.J.
      • 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.
      • Voigt J.D.
      • 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.
      • McMillan S.
      • Chhabra A.
      • Hassebrock J.D.
      • Ford E.
      • Amin N.H.
      Risks and complications associated with intra-articular arthroscopy of the knee and shoulder in an office setting.
      There is general agreement among the results that diagnostic arthroscopy with either standard or needle arthroscopy can save money. One large, prospective blinded, multicenter trial performed by Gill et al.
      • Gill T.J.
      • 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.
      compared accuracy and safety of diagnostic arthroscopy with MRI. The study enrolled 110 patients who underwent MRI and diagnostic arthroscopy using a VisionScope needle arthroscope followed by a standard arthroscopy. Their results concluded that in-office diagnostic arthroscopy was statistically equivalent to standard surgical diagnostic arthroscopy. They determined that in-office diagnostic imaging provides a more accurate picture and assessment of intra-articular pathology in the knee as well.
      In-office needle arthroscopy could potentially speed up the process of confirming and even treating a suspected diagnosis. The benefits of potential in-office use are numerous, including decreased time out of work, lower financial impact of prolonged diagnostic dilemmas, and a decreased burden upon our finite advanced imaging resources. Despite these possible positive impacts, I believe our focus should be on how to correctly use the needle arthroscopy in the outpatient operating room setting before focusing on in-office settings. As mentioned above, we have plenty of data to reveal the strength of the needle arthroscope as a diagnostic device, but I have focused recently on its use as a tool in the operating room. Over the past several years, we have published several techniques using the Nanoscope (Arthrex).
      • Lavender C.
      • Lycans D.
      • Sina Adil S.A.
      • Kopiec A.
      • Schmicker T.
      Incisionless partial medial meniscectomy.
      • Lavender C.
      • Lycans D.
      • Kopiec A.
      • Sayan A.
      Nanoscopic single-incision anterior labrum repair.
      • Lavender C.
      • Lycans D.
      • Sina Adil S.A.
      • Berdis G.
      Single-incision rotator cuff repair with a needle arthroscope.
      I prefer using the needle arthroscope in the operating room even as a diagnostic tool before making a final decision for treatment. This allows me to then address pathology in a single trip to the operating room if necessary, based upon my diagnostic findings. Once we have created a set of acceptable criteria for needle arthroscopy in the operating room, I hope that we can eventually have more widespread diagnostic use in the office setting. We must first delineate under which conditions this can be appropriately used in the office, which patients can tolerate such a procedure, and how we can safely carry out these procedures in a less controlled setting than the operating room.
      At this point, it is time to develop indications and our algorithms for when to use the needle arthroscope diagnostically in the operating room. In my current comfort level with needle arthroscopy, I prefer the use in the operating room because we have shown the ability to treat many conditions with this technology, yet still have the option to abort to a standard arthroscope if needed. My personal indications for the needle arthroscope diagnostically include any case in which I question the findings of the MRI or in select cases when a patient had a negative MRI with significant clinical findings who becomes frustrated by a lack of improvement with conservative management. There are specific clinical scenarios that I consider appropriate for use of a diagnostic needle arthroscope instead of an MRI: (1) a patient with a clinically obvious meniscus tear with a locked knee, (2) a patient with an outdated but previously positive MRI with recurrent injury such as a recurrent shoulder or patella dislocations, (3) a patient who is ineligible for an MRI such as those with pacemakers or spinal implants who have clear and obvious clinical findings to suggest intra-articular pathology, and (4) a patient who is over the age of 50 years with positive rotator cuff testing after a shoulder dislocation in which I have a high degree of suspicion of a rotator cuff tear. These are a few indications I propose would be starting points to use the needle arthroscope over MRI scans and would save cost to the patient. My rationale is this is at worst a needle stick that reveals no pathology but potentially has the benefit of allowing me to define pathology and treat it at the same time. Substantially more research will need to be done to validate my personal indications for needle arthroscopy, but I propose that the above indications represent a reasonable starting point that pose a minimally acceptable risk to select patients. My hope is that we will one day be able to provide more timely, cost-effective, and efficient care to our patients through more selective use of advanced imaging in favor of the needle arthroscope.
      My question moving forward is, how do we safely perform, correctly code, and correctly bill for an in-office needle arthroscope when there is a possibility of re-entering the joint in the operating room at a later time to perform necessary procedures? We need to develop ethical criteria for in-office use moving forward, but further research is needed to reveal the most appropriate diagnoses and patient populations that are best suited for in-office needle arthroscopy.
      I would like to take a final word to expound upon my vision for the future of needle arthroscopy. Up until this point, we have performed reconstructions and repair with the needle scope as a viewing scope. We have also worked on using the needle arthroscopes to provide simultaneous views from different angles during surgery and giving ourselves a 360° view. I envision an operating room in the future with multiple small needles in joint and multiple viewing monitors providing a new 3-dimensional world of arthroscopy. This will be a steep learning curve, but I have no doubt it will lead to more new and different minimally invasive techniques than we would have thought possible with less pain for our patients and improved outcomes. The recent publication by Wagner et al.
      • Wagner E.R.
      • Woodmass J.M.
      • Zimmer Z.R.
      • et al.
      Needle diagnostic arthroscopy and magnetic resonance imaging of the shoulder have comparable accuracy to surgical arthroscopy: A prospective clinical trial.
      is a tremendous advancement toward further validating the use of needle arthroscopy. Let us not forget that with these devices, there are innovative solutions beyond simple diagnostic use and the needle arthroscope. In other words, “there’s more to the picture than meets the eye”—Neil Young.

      Supplementary Data

      References

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