In-office needle arthroscopy (IONA) has gained increased attention as a minimally invasive alternative to standard arthroscopy performed in the operating room (OR) setting. IONA affords surgeons the opportunity to diagnose and treat upper and lower extremity injuries under local anesthesia in the office setting avoiding the negative effects associated with either general anesthesia or spinal/epidural anesthesia.

Needle arthroscopy has been used for many years but has always been plagued by inadequate visualization when compared with standard arthroscopy and the lack of small instruments to perform any intra-articular procedure. More recently, the introduction of chip-on-tip technology has facilitated excellent visual optics, and the introduction of downscaled small instruments has allowed intra-articular procedures to be performed with ease.

Using instruments that are markedly smaller in size and diameter allows surgical intervention to be less invasive. Moving surgeries from the OR setting to an office setting can reduce the burden on limited OR resources, with the need for less OR equipment and less OR staff, making it more accessible and thereby decreasing overall costs. Reducing the need for regional anesthesia or general anesthesia by using local intra-articular blocks eliminates many of the concerns and possible risks of anesthesia (ie, postoperative nausea, vomiting, and need for preoperative clearance). Using a clinic setting rather than an OR reduces the cost and increases the efficiency of the procedure. The growing trend of using IONA has shifted many procedures away from the standard OR environment to an office setting. The effect on the patients' outcomes, by being able to see their pathology in real time and by being able to see what was being done to address this, allowing them to be directly involved in their own care, has benefits downstream in expectation of outcome and compliance with postoperative regimens that have been seen in several studies.1,2 This article will present the indications for IONA in upper and lower extremity injuries and will describe the best practice office setup. Technical pearls and pitfalls will also be discussed.

Indications/Contraindications (Shoulder, Wrist, Knee, and Ankle)

IONA can be used as both a diagnostic modality and a therapeutic intervention. While MRI remains the benchmark for preoperative diagnosis of soft-tissue pathology, MRI is not without contraindications and limitations. Patients often must undergo multiple office visits before an MRI, completion of an MRI, and review of the results with the surgeon, which then is finally followed by definitive intervention. This process results in an extended length of time from the initial visit to treatment. In addition, limited resources can cause strain on the healthcare system further delaying intervention.3 IONA offers an alternative diagnostic modality providing more detailed and accurate diagnostic assessment and can help address these delays in care.4 Therefore, IONA can be indicated as an adjunct to physical examination and imaging as a diagnostic modality in the shoulder, wrist, knee, and ankle joints. While there may be delays in IONA including scheduling and insurance authorization, IONA still does afford the opportunity to diagnose and treat in real time, which can expedite management.

IONA can also be used in the management of a variety of upper and lower extremity conditions. Table 1 provides an overview of the various indications in the shoulder, wrist, knee, and ankle and foot.

Table 1 - In office needle arthroscopy Indications Body Part Arthroscopic Intervention Indication Shoulder Shoulder arthroscopic débridement
Biceps tenotomy Rotator cuff tear
Shoulder impingement
Biceps tendinitis Wrist Wrist arthroscopic débridement TFCC tear Knee Knee arthroscopic débridement, removal of loose body, partial meniscectomy, meniscal repair Loose body
Meniscus tear
OCL Ankle Anterior ankle arthroscopic débridement, bone marrow stimulation, removal of loose body
Posterior ankle arthroscopic débridement, resection of Os, FHL tenosynovectomy, removal of loose body
Subtalar arthroscopic débridement, bone marrow stimulation
Peroneal tendoscopy +/− groove deepening
Posterior tibial tendoscopy +/− groove deepening
Achilles tendoscopy with débridement Anterior ankle impingement
OCL
Loose body
Posterior ankle impingement
Os trigonum
FHL tenosynovitis
Loose body
OCL
Peroneal tenosynovitis, stenosis, subluxation
Posterior tibial tendinopathy
Achilles tendon degenerative changes, tendinopathy, hypertrophy Foot Talonavicular (TN) arthroscopic débridement
1st MTP joint arthroscopic débridement
Lesser MTP arthroscopic débridement TN chondral injury, OCL
1st MTP OCL, stage 1 hallux rigidus ALL joints Second look arthroscopy
Septic arthritis

FHL = flexor hallucis longus, MTP = metatarsophalangeal, OCL = osteochondral lesion, TFCC = triangular fibrocartilage complex

In-Office Procedure Equipment and Setup (Shoulder, Wrist, Knee, and Ankle)

The procedure room is set up similar to the OR setting (Figure 1). An examination table is used as the patient bed, and the patient is prepped with chlorhexidine gluconate mixed with isopropyl alcohol and draped in a normal sterile fashion. The surgeon can use an arthroscopy pump with inflow consisting of 1 L of 0.9% normal saline mixed with 5 cc of epinephrine to promote hemostasis. Alternatively, fluid through a syringe connected to the handpiece may also be beneficial and can be used based on surgeon preference. The needle arthroscopy set comprises the needle scope, obturators, and cannulas. The surgeon can select additional instrumentation that typically can be provided by a peel pack depending on the intervention. Local anesthesia is often a mixture of lidocaine and bupivacaine and can vary depending on the surgical site and the procedure being performed. Typically, one nurse assists as a scrub technician while another staff member assists in opening any additional equipment during the procedure, although this is not required.

Figure 1:

Images demonstrating the in-office room setup

Patient Positioning and Technical Considerations

The patient is positioned on the examination table similar to the positioning in the OR setting with the surgical side exposed and on the side of the monitor (Figure 2, A–D). The arthroscopy portal sites are identified, cleaned with alcohol, and injected with 10 cc of 1% lidocaine into each portal. Using a sterile technique, the extremity is prepped using a solution of chlorhexidine gluconate mixed with isopropyl alcohol and draped.1,2 After 5 to 10 minutes, 20 cc of 1% lidocaine and 0.5% bupivacaine in a 1:1 ratio is injected through the portal sites into the joint. An 11 blade is used to make portal stab incisions. The standard OR procedure is then performed. Portal incisions are closed using adhesive wound closure strips (Steri-Strip; 3M), and the extremity is dressed in a dry sterile dressing.1 The postoperative course will vary based on injury and intervention. Typically, IONA procedures afford patients early mobilization and range of motion with quicker return to work and day-to-day activities.1,2,5 The pearls and pitfalls are summarized in Table 2.

Figure 2:

A, Images demonstrating the IONA anterior and posterior ankle setup. B, Image demonstrating the IONA knee setup. C, Image demonstrating the IONA shoulder setup. D, Image demonstrating the IONA wrist setup. IONA = in-office needle arthroscopy

Table 2 - Pearls and Pitfalls Body Site Technical Pearl Pitfalls Shoulder Ensure the patient is seated comfortably but so that the surgeon has easy access to the shoulder, with the ability for the arm to be manipulated
The elbow and hand are not sterile so that an assistant can help manipulate the arm during the procedure Vasovagal syncope is a reported complication of peripheral injections around the shoulder7 Knee Hang the knee off the side or front of the bed or place a bump under the knee to allow opening of the joint space
Rest the hanging leg on the thigh so that the patient feels that the leg is supported Ankle When performing an anterior ankle scope, hang the foot off the edge of the bed to allow gravity to open the joint space General IONA uses a 0° scope
Allow for 5-10 min for the anesthetic to take effect before starting the procedure. Be sure to inject the portal sites and the joint
Have a sterile anesthetic available on the field in case the patient requires additional pain control during the procedure
Have pillows available to support the patient as they sit/lay on the table
Use the lavage or increase fluid pressure temporarily if there is impaired visualization because of bleeding. Using an ablator may be useful in these cases Patients on anticoagulant and antiplatelet medications are at increased risk of bleeding during the procedure

IONA = in-office needle arthroscopy

Complications

While there has been little reported on complications after IONA, the risks are similar to those of an injection into the joint.6 As with any procedure, superficial and deep infection can occur postoperatively, and therefore, patients are typically prescribed 24 hours of a prophylactic antibiotic postoperatively. Bleeding and vasovagal syncope have also been reported, although rare.7 Finally, there is always a risk of the need for additional surgery if additional pathology is diagnosed in the IONA setting or if the pathology cannot be addressed arthroscopically. Of note, McMillan et al. reported no major complications and a minimal risk of minor complications among 1419 cases for IONA of the shoulders and knees.6

Discussion

In-office needle arthroscopy offers a minimally invasive treatment alternative offering several advantages in comparison with the standard OR arthroscopy procedure. From the patient perspective, IONA allows individuals to be more involved in their own care. Patients have the ability to interact with the surgeon, asking questions in real time about their pathology and the intervention that is being performed. This provides patients with insight into their condition enhancing their understanding of their postoperative course and rehabilitation after the procedure. In addition, patients do not have to spend time in the preoperative holding unit or post-anesthesia care unit and, therefore, do not feel that they are “sick” or “injured” in the hospital setting. The ability to use local anesthesia avoids the adverse effects associated with either general or epidural anesthesia.

IONA does not require the large equipment necessary for standard OR arthroscopy procedures and can be performed in a small clinic room, using a computer console and disposable instruments.8 In addition, IONA can be used for both diagnostic and therapeutic modalities. Previous studies have demonstrated that IONA is equivalent in efficiency and accuracy to surgical arthroscopy and may be superior in diagnostic accuracy compared with MRI in certain pathologies.4,9–11 In addition, IONA affords surgeons the ability to address and treat pathology at the same time as diagnosis, thereby reducing time to diagnosis and management, expediting patients' recovery.

Recent studies have demonstrated good clinical outcomes and patient satisfaction after IONA, particularly in the foot and ankle setting. Colasanti et al. reported statistically significant improvements in pain scores with a mean return to work of 1.98 days and a 96% return-to-sports rate after IONA for anterior ankle impingement. Of note, 94% of patients expressed that they were willing to undergo the same procedure again.1 Similarly, Mercer et al.2 reported 100% return to work and sport at 3.4 days and 4.8 weeks, respectively, in patients who underwent IONA for posterior ankle impingement. IONA has been used for biopsy in the knee affording good macroscopic evaluation and selective sampling of synovial tissue. Baeten et al12 reported that in nearly all 150 patients who underwent IONA for knee biopsy, IONA was well tolerated, with patients reporting relief of symptoms and improvement of mobility with no major complications. IONA has recently gained increased attention for its use in the setting of bacterial arthritis of native joints. Stornebrink et al. evaluated seven joints (wrist, ankle, knee, and shoulder) treated with bedside arthroscopic lavage under local anesthesia for bacterial arthritis and reported that all patients tolerated the procedure without conversion to general or spinal anesthesia. Only one patient required a second arthroscopic lavage, and no additional surgical interventions were required for the management of the other six patients.13 Eliminating the need for conventional surgery, need for general/spinal anesthesia, and delay in care with surgery scheduling and preanesthesia testing in the hospital setting not only affords better care for patients but also reduces overall healthcare costs.13,14

Limitations

While the technique of IONA is comparable with standard arthroscopic procedures, it is not without limitations. IONA uses a 0° scope, and therefore, the surgeon must become familiar with this technical difference when compared with a standard scope. Previous surgery may also increase difficulty of using small instruments through previous scars. Finally, it is also important to indicate patients who can tolerate being awake during the procedure with the understanding that IONA may identify certain pathologies requiring the OR setting, and therefore, the patient may undergo a second intervention.

In-Office Needle Arthroscopy Cost Analysis

Previous cost-analysis studies have demonstrated more than a $150 million per year in savings to the healthcare system using IONA over MRI and have reported an average cost savings of $418 and $961 compared with independent facility and hospital-based MRI in patients with meniscus injury.9,15,16 Gill et al4 performed a prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of IONA when compared with MRI and demonstrated that IONA can provide a more detailed and accurate diagnostic assessment of intra-articular pathology. In addition, IONA in place of MRI may allow for a shorter diagnostic process, better patient understanding of their condition, and higher patient satisfaction scores.1,7 Therefore, IONA can be indicated as an adjunct to physical examination and imaging as a diagnostic modality in the shoulder, wrist, knee, and ankle joints. Future studies evaluating the cost comparisons of IONA versus standard OR arthroscopy are needed to better assess cost savings.

Summary

IONA is a minimally invasive alternative to standard arthroscopy using instrumentation that is markedly smaller in size and diameter making arthroscopy less invasive. IONA reduces the need for regional anesthesia or general anesthesia along with its associated risks. In addition, the utilization of a clinic setting rather than an OR reduces the cost and increases the efficiency of the procedure. This article reviewed the current indications for IONA in upper and lower extremity injuries and presented methods for best practice office setup.

Acknowledgment

Thank you to James Butler for assisting in obtaining figure images.

References 1. Colasanti CA, Mercer NP, Garcia JV, Kerkhoffs GMMJ, Kennedy JG: In-office needle arthroscopy for the treatment of anterior ankle impingement yields high patient satisfaction with high rates of return to work and sport. Arthroscopy 2022;38:1302-1311. 2. Mercer NP, Samsonov AP, Dankert JF, et al.: Improved clinical outcomes and patient satisfaction of in-office needle arthroscopy for the treatment of posterior ankle impingement. Arthrosc Sports Med Rehabil 2022;4:e629-e638. 3. Zhang K, Crum RJ, Samuelsson K, Cadet E, Ayeni OR, de Sa D: In-office needle arthroscopy: A systematic review of indications and clinical utility. Arthroscopy 2019;35:2709-2721. 4. 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;34:2429-2435. 5. Annibaldi A, Monaco E, Daggett M, et al.: In-office needle arthroscopic assessment after primary ACL repair: Short-term results in 15 patients. J Exp Orthop 2022;9:89. 6. McMillan S, Chhabra A, Hassebrock JD, Ford E, Amin NH: Risks and complications associated with intra-articular arthroscopy of the knee and shoulder in an office setting. Orthop J Sports Med 2019;7:2325967119869846. 7. Daggett MC, Stepanovich B, Geraghty B, Meyers A, Whetstone J, Saithna A: Office-based needle arthroscopy: A standardized diagnostic approach to the shoulder. Arthrosc Tech 2020;9:e521-e525. 8. Trang G, Del Sol SR, Jenkins S, et al.: Evaluation of osteochondral allograft transplant using in-office needle arthroscopy. Arthrosc Tech 2022;11:e2243-e2248. 9. 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. 10. Bradsell H, Lencioni A, Shinsako K, Frank RM: In-office diagnostic needle arthroscopy using the NanoScope arthroscopy system. Arthrosc Tech 2022;11:e1923-e1927. 11. DiBartola AC, Rogers A, Kurzweil P, Knopp MV, Flanigan DC: In-office needle arthroscopy can evaluate meniscus tear repair healing as an alternative to magnetic resonance imaging. Arthrosc Sports Med Rehabil 2021;3:e1755-e1760. 12. Baeten D, Van den Bosch F, Elewaut D, Stuer A, Veys EM, De Keyser F: Needle arthroscopy of the knee with synovial biopsy sampling: Technical experience in 150 patients. Clin Rheumatol 1999;18:434-441. 13. Stornebrink T, Janssen SJ, Kievit AJ, et al.: Bacterial arthritis of native joints can be successfully managed with needle arthroscopy. J Exp Orthop 2021;8:67. 14. Van Demark RE, Becker HA, Anderson MC, Smith VJS: Wide-awake anesthesia in the in-office procedure room: Lessons learned. Hand 2018;13:481-485. 15. McMillan S, Schwartz M, Jennings B, Faucett S, Owens T, Ford E: In-office diagnostic needle arthroscopy: Understanding the potential value for the US healthcare system. Am J Orthop (Belle Mead NJ) 2017;46:252-256. 16. Patel KA, Hartigan DE, Makovicka JL, Dulle DL III, Chhabra A: Diagnostic evaluation of the knee in the office setting using small-bore needle arthroscopy. Arthrosc Tech 2018;7:e17-e21.