Needle Arthroscopy: Current and Future Use in the Ankle.

Nine patients with mechanical or osteoarthritic knee pain present for more than 6 weeks were evaluated by clinical examination, needle arthroscopy, and standard arthroscopy. Each knee was assessed for patellofemoral cartilage disruption, cartilage abnormalities in the tibiofemoral joints, meniscal tears, and synovitis. Needle arthroscopy was performed immediately before standard arthroscopy in the operating room under local anesthesia. Six of the nine patients had magnetic resonance imaging (MRI) scans before the arthroscopic procedures. The clinical examination was 100% sensitive for the detection of patellofemoral disease, 62% sensitive for medial meniscal tears, and 14% sensitive for lateral meniscal tears. Visualization of the femoral-tibial joint was significantly better with standard arthroscopy than with needle arthroscopy (p = 0.002). Percent visualization with the needle arthroscope was higher for the patellofemoral and the medical tibiofemoral cartilage compared to the lateral tibiofemoral cartilage and menisci (p < 0.05). The needle arthroscope and MRI scan were equivalent to the standard arthroscope in the detection of patellofemoral cartilage disruption of any depth and in the detection of meniscal tears. However, the standard arthroscope was better in detecting cartilage abnormalities in the medial and lateral joint spaces (p < 0.05 and p < 0.01, respectively). The costs for diagnostic standard arthroscopy, needle arthroscopy, and MRI of the knee in an academic center are $3900, $1650, and $900, respectively. These data suggest that the majority of reversible causes of knee pain are diagnosed by physical examination. Therefore, after a complete history and physical examination, if the physician thinks that the patient has an internal derangement of the knee and that surgical intervention is needed, we suggest that the patient go directly to standard arthroscopy, which offers both confirmation and therapy. The MRI scan or needle arthroscopy should be considered only if, after a history and physical examination, the diagnosis of the knee pain is unclear.

Category: Trauma; Other Introduction/Purpose: Regional anesthesia has been increasingly used within orthopaedic surgery. It has been found to decrease opioid use and consumption and has been associated with decreased blood loss and clot formation in some lower extremity surgeries – specifically hip and knee arthroplasty surgery. General anesthesia is not without risks including malignant hyperthermia, laryngeal edema, vocal cord trauma, and delirium. This has led to increased utilization of regional anesthesia in foot and ankle surgery. However, there is a paucity of research that compares the postoperative outcomes in patients treated with regional compared to general anesthesia in these surgeries. We hypothesize the use of regional anesthesia in foot and ankle surgery leads to fewer short-term postoperative complications compared to general anesthesia. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006-2018 to identify patients undergoing foot and ankle surgery. Current Procedural Terminology (CPT) codes for all foot and ankle surgery were utilized to determine which participants to include in the analysis. The cohort was divided into patients who received regional anesthesia versus those who received general anesthesia, and comparisons were made on demographic characteristics, and comorbidities, using chi-squared and t-test analyses. Multivariate logistic regressions were performed to identify whether lack of regional anesthesia was an independent risk factor for infection, minor postoperative complications, and major postoperative complications. Major postoperative complications included any complication that had a long-term effect on someone’s life or led to reoperation, while minor postoperative complications included any event that needed medical intervention but did not impact a person’s health long-term. Results: Using the ACS-NSQIP database and CPT codes, there were 12,764 participants for regional anesthesia and 73,481 participants who had general anesthesia. Utilizing logistic regression, this study found that the absence of regional anesthesia was independently associated with an increased risk for minor complications in foot and ankle surgery (Odds Ratio (OR) 1.34, 95% Confidence Interval (CI) [1.25-1.44], p=0.00). The absence of regional anesthesia was not associated with increased risk of major complications in foot and ankle surgery (OR 1.04, CI [0.96-1.12], p=0.32). Patients who received regional anesthesia were older and had more comorbidities than those without regional anesthesia used which may be a reason for the findings for major complications. Conclusion: Regional anesthesia independently reduced the risk of minor postoperative complications up to 30-days following foot and ankle surgery in this study. Patients undergoing foot and ankle surgery may benefit from augmenting their anesthetic plan with regional anesthesia.

Background: As more patients undergo foot and ankle surgery, regional anesthesia's significance in postoperative treatment has grown. Anesthesiologists and pain specialists have adopted regional anesthesia in large numbers. Numerous techniques, such as nerve stimulation, anatomical markers, and ultrasonography, have been used to block the saphenous nerve. Objective: The present study aimed to assess the traditional anatomic landmark-guided approaches in lower limb surgery performed under regional anesthesia with ultrasound-guided ankle blocks in surgical anesthetic methods. Method: This randomized control study is carried out at the hospital. A total of 60 participants with scheduled foot and ankle surgery were randomly divided into two study groups (each n=30), Ultrasound-guided ankle block (USG) and anatomical landmark-guided ankle block (ALG). Results: Recruited participants had a mean age of 50.2± 14.02, with 39 (65%) male and 21( 35%) female. A total of 49 patients (82%) were able to undergo anesthesia successfully, with 26 (86.60%) of those patients belonging to the USG block group and 23 (76.60%) of those patients belonging to the ALG block group undergoing anesthesia successfully (p-value = &gt;0.999). Practical implication: This study will help to comprehend either ultrasound-guided ankle block or anatomical landmark-guided ankle block in foot surgeries give better results. Conclusion: The results of this research indicate that the success rates of the two procedures are statistically insignificantly different; however, the USG ankle block for surgical anesthesia performed under regional anesthetic had a greater success rate than the anatomic landmark-guided technique. Keywords: Foot surgery, USG ankle block, anesthesia, ALG Block, postoperative treatment

Application of nano arthroscopy in the office setting for the removal of an intra-articular loose osseous body not identified by magnetic resonance imaging: A case report

BACKGROUNDBedside needle arthroscopy of the ankle under local anesthesia has been proposed for intra-articular delivery of injectable agents. Accuracy and tolerability of this approach in the clinical setting–including patients with end-stage ankle pathology and/or a history of prior surgery–is not known.AIMTo assess clinical accuracy and tolerability of bedside needle arthroscopy as a delivery system for injectable agents into the tibiotalar joint.METHODSThis was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint. In our center, these injections are used as a last resort prior to extensive surgery. The primary outcome was injection accuracy, which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear arthroscopic view of the joint space. Secondary outcome measures included a patient-reported numeric rating scale (NRS, 0-10) of pain during the procedure and willingness of patients to return for the same procedure. NRS of ankle pain at rest and during walking was collected at baseline and at 2-wk follow-up. Complications were monitored from inclusion up to a 2-wk control visit.RESULTSWe performed 24 inspection-injections. Eleven (46%) participants were male, and mean age was 46.8 ± 14.5 years. Osteoarthritis was the indication for injection in 20 (83%) cases, of which 8 (33%) patients suffered from osteoarthritis Kellgren-Lawrence grade IV, and 10 (42%) patients from Kellgren-Lawrence grade III. An osteochondral defect was the indication for injection in 4 (17%) cases. A history of ankle surgery was present in 14 (58%) participants and a history of multiple ankle surgeries in 11 (46%) participants. It was possible to confirm accuracy in 21 (88%) procedures. The 3 (12%) participants where needle arthroscopy did not reach a clear view of the joint space all suffered from Kellgren-Lawrence grade IV osteoarthritis. Pain during the procedure was reported with a median of 1 [interquartile ranges (IQR): 0–2]. Willingness to return was 100%. Pain in rest decreased from a median NRS of 4 (IQR: 2–7) at baseline to a median of 3 (IQR: 1–5) at follow-up (P < 0.01). Pain during walking decreased from a median NRS of 8 (IQR: 6–9) to a median of 7 (IQR: 4–8) (P < 0.01). Infections or other complications were not encountered.CONCLUSIONClinical accuracy and tolerability of bedside needle arthroscopy of the ankle as a delivery system for injectable agents are excellent. Accuracy was 100% in patients without total ventral joint obliteration.

PurposeTo assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints.MethodsDuring a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded.ResultsEleven joints in 10 patients (four males, age range 35 – 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases.ConclusionsNeedle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

36 - Needle Arthroscopy of the Knee, Shoulder, and Hip

Category: Other Introduction/Purpose: Lower-extremity orthopaedic procedures may be performed under regional or general anaesthesia, or a combination of techniques. There is a growing body of evidence outlining benefits of regional anaesthesia, with meta-analyses of randomized controlled trials and registry data suggesting decreases in surgical site infections, thromboembolism, cardiopulmonary complications and length of stay associated with regional anaesthesia. In patients undergoing foot and ankle surgery specifically, the literature demonstrates decreased pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports increased use of regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict anaesthetic type in patients undergoing foot and ankle surgery. Methods: Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analyzed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used. Results: General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p &lt; 0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure ( &lt; 0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 ± 77 minutes, whereas patient provided with regional anaesthesia had a mean length of procedure 83 ± 64 minutes. Conclusion: With increasing evidence supporting use of regional anaesthesia, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure is a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be candidates for regional anaesthesia.

Knee needle arthroscopy (NA) represents a minimally invasive diagnostic and therapeutic approach for managing a variety of knee joint pathologies. This innovative technique, characterized by a thin, flexible, needle-like device, offers a less invasive alternative to conventional arthroscopy (CA), enabling outpatient procedures with reduced postoperative pain, faster recovery, and minimal scarring. This systematic review examines the current applications, diagnostic accuracy, clinical outcomes, and patient benefits of needle arthroscopy. Studies reveal that NA demonstrates comparable diagnostic efficacy to CA and superior accuracy to MRI for intra-articular knee pathology, particularly in meniscal injuries and anterior cruciate ligament assessments. NA facilitates real-time visualization and interventions under local anesthesia, promoting cost-efficiency and patient satisfaction. Despite its advantages, there are challenges such as limited visualization and technical proficiency. While NA emerges as a promising modality in knee diagnostics and treatment, further large-scale clinical trials are essential to validate its long-term efficacy, safety, and broader applications.

Suspected bacterial arthritis of a native joint requires urgent management to control potential life-threatening sepsis and limit cartilage damage. Diagnosing bacterial arthritis is often challenging and relies on diagnostic tests with low accuracy. A high threshold for surgery poses a risk of undertreatment, whereas a low threshold for surgery could lead to overtreatment with unnecessary invasive and costly procedures. Surgical lavage through arthroscopy or arthrotomy is generally considered standard treatment. Nowadays, needle arthroscopy provides an alternative and potentially less-invasive approach that can safely lower the surgical threshold. Needle arthroscopy can be performed directly upon presentation at the patient's bedside, as it is well tolerated under local anesthesia. Therefore, this Technical Note presents a stepwise guideline for performing standardized needle arthroscopic lavage in patients with (suspected) bacterial arthritis of the shoulder, elbow, wrist, knee, and ankle.

As more patients undergo foot and ankle surgery, regional anesthesia's significance in postoperative treatment has grown. Anesthesiologists and pain specialists have adopted regional anesthesia in large numbers. Numerous techniques, such as nerve stimulation, anatomical markers, and ultrasonography, have blocked the saphenous nerve. Objective: The present study aimed to assess the traditional anatomic landmark-guided approaches in lower limb surgery performed under regional anesthesia with ultrasound-guided ankle blocks in surgical anesthetic methods. Method: This randomized control study is carried out at the hospital. A total of 60 participants with scheduled foot and ankle surgery were randomly divided into two study groups (each n=30): Ultrasound-guided ankle block (USG) and anatomical landmark-guided ankle block (ALG). Results: Recruited participants had a mean age of 50.2± 14.02, with 39 (65%) male and 21 ( 35%) female. A total of 49 patients (82%) were able to undergo anesthesia successfully, with 26 (86.60%) of those patients belonging to the USG block group and 23 (76.60%) of those patients belonging to the ALG block group undergoing anesthesia successfully (p-value = &gt;0.999). Conclusion: The results of this research indicate that the success rates of the two procedures are statistically insignificantly different; however, the USG ankle block for surgical anesthesia performed under regional anesthetic had a greater success rate than the anatomic landmark-guided technique.

Anesthesia for ankle and foot surgery

SP19 Relevance of cutaneous nerve blocks

Bacterial (i.e., septic) arthritis requires prompt source control, including drainage of the infected synovial fluid, often through arthrocentesis (needle aspiration) or surgical intervention, in combination with antibiotics to prevent joint damage; however, when surgical intervention is required, conventional arthroscopy can lead to treatment delays and anesthesia-related complications. To overcome these delays, needle arthroscopy was recently developed to offer the possibility of 2-mm diameter arthroscopy lavage under local anesthesia. The purpose of this study was to prospectively evaluate bedside needle arthroscopy under local anesthesia to demonstrate its potential as an effective, minimally invasive alternative for timely diagnosis and joint lavage in patients with (suspected) native bacterial arthritis in a real-world clinical practice setting. Over a 30-month period, this prospective, double center cohort study included patients with either confirmed (positive synovial fluid culture) or highly suspected (≥ 2 local signs and ≥ 1 systemic sign) native joint bacterial arthritis. The primary outcome was the need for reoperation (conventional arthroscopy or arthrotomy) within 30 days. Bivariate analysis assessed differences in patient and treatment characteristics between successful and failed needle arthroscopic debridement. Forty-two patients (44 native joints) underwent needle arthroscopy. The mean age was 67 years (SD 16), the mean BMI was 26.8kg/m2 (SD 3.9), and 69% were male. The knee (n = 34, 77%) was the most commonly involved joint. Within 30 days, 14% (6/44; 95% CI 5-27%) required a reoperation (conventional arthroscopy or arthrotomy). Two parameters were identified as risk factors for failure of a single debridement: the baseline level of ESR (112mm/hr vs. 57mm/hr, p = 0.027) and purulent synovial fluid (67% vs. 11%; p = 0.011). No serious procedure-related complications were observed. A single bedside needle arthroscopy was effective in treating 86% of patients with confirmed or suspected native joint bacterial arthritis in a real-world practice, avoiding the need for general anesthesia or conventional surgery. This approach represents a safe and effective, minimally invasive alternative that can be rapidly implemented, enabling early joint lavage and potentially reducing the risk of secondary osteoarthritis. We pre-registered this trial on the Dutch Trial Register, later called CCMO (NTR 21076, CCMO NL78387.018.21).

Needle arthroscopy is an office-based technique allowing direct visualisation of the knee cavity and selective sampling of the synovial membrane. We performed needle arthroscopy in 150 patients with synovitis of the knee (1) to evaluate the diagnostic potential in early arthritis, (2) to perform therapeutic lavage in persistent inflammatory synovitis and (3) to assess the balance between technical feasibility, safety and patient comfort on the one hand, and the relevance of the obtained macro- and microscopic information for diagnosis and research purposes on the other. After disinfection of the leg and local anaesthesia of the skin and joint, a 1.8-2.7 mm needle arthroscope was introduced into the knee. Synovial fluid was aspirated and lavage of the joint cavity was performed to allow macroscopic evaluation of hyperaemia and hypertrophy of the synovial membrane. Biopsies were taken at inflamed sites, followed by another lavage to remove blood and debris. Needle arthroscopy of the knee is a simple and easy to perform technique made particularly attractive by the local anaesthesia and the ambulatory setting. It allows good macroscopic evaluation of synovial inflammation and selective sampling of the synovial membrane. Biopsies are suitable for RNA and DNA extraction, bacterial or lymphocyte culture, and cell isolation. Because samples were sometimes too small for representative histology, we switched from a 1.8 mm to a 2.7 mm biopsy forceps with good results. In nearly all cases the arthroscopy was well tolerated. Moreover, some patients reported relief of symptoms and even improvement of mobility after lavage of the inflamed joint. No major complications were noted. It was concluded that needle arthroscopy of the knee is a simple, safe and well-tolerated technique, with promising perspectives as a diagnostic, scientific and possibly therapeutic tool in rheumatic diseases.