What's New in Arthroscopy

After building what is now the Northwest Surgery Center in Indianapolis, the principals decided to equip it with autoclavable arthroscopic cameras rather than buy traditional cameras. They reasoned that the 10-minute autoclave cycle would provide very rapid turnover, save the expense of cold chemical sterilization, and allow the center to do more scopes without having to purchase extra camera systems. There was just one problem. Once the surgeons began using the scope, they realized that they hated the picture it provided, forcing them to ditch the autoclavable scopes, purchase six traditional cameras, and ramp up on their cold sterilization capability.

Their experience shows why, prior to purchasing expensive arthroscopic equipment, it can be helpful to seek the input of colleagues who have already used the devices. In this article, you'll find just that kind of advice. We asked decision-makers in outpatient surgery centers across the country to share their recent experiences with some of the newest arthroscopy systems and devices. It's our hope that this advice will help you more know-ledgeably assess new acquisitions for your center. One note: Please remember that our article only recounts anecdotal experiences. Although one center may be dissatisfied with a device, another may be perfectly happy with it.

Radiofrequence Energy Delivery Systems
One of the hottest but most controversial items on many wish lists is a radiofrequency energy delivery system. This device allows the surgeon to apply a controlled level of radiofrequency energy to stretched or slightly torn ligaments via various styles of arthroscopic wands, and the energy effectively shrinks the ligaments by altering type 1 collagen.

Currently, the most common application is capsular shrinkage for select patients with shoulder instability, although some clinics are also using the technology to shorten loose or partially torn ACLs or PCLs and treat ulno-carpal instability in the wrist. Reportedly, approximately 20 percent of ACL injuries involve ligaments that are relatively intact and may be candidates for this procedure.

The primary advantage of the ligament shrinkage procedure is dramatically reduced operating and immediate post-op recovery time. According to Thomas Knapp, MD, faculty member with the University of Southern California Sports Medicine Service and orthopedic surgeon with the Santa Monica Orthopedic Group, this technology has turned 23-hour holds into true outpatient procedures for properly selected patients. "Sixty- to seventy-five-minute manual shoulder reconstruction procedures that used to require a large incision and deep anesthesia with paralytics can, in some cases, be replaced with 15-minute procedures that require comparatively little anesthesia," says Dr. Knapp. This, he adds, translates into economy in the hands of a good surgeon. Although the wands can cost about $175 per procedure and are not reimbursable, Dr. Knapp believes the reduced anesthesia costs and the ability to perform more shoulder surgeries in a day may make up for this. "The only limiting factor is room turnover," he says.

Not everyone is so eager to jump on the thermal technology bandwagon, however. One ASC medical director, who performed capsular shrinkage but has reverted back to stitches and sutures for shoulder instabilities, noted that that the long-term safety and effectiveness of capsular shrinkage are simply unknown. In fact, says Stephen J. Snyder, MD, a specialist in arthroscopic shoulder reconstruction at the Southern California Orthopedic Institute in Van Nuys, thermal capsular shrinkage can cause severe complications for which there are few, if any, remedies - including transient or permanent axillary nerve damage, capsular necrosis, and capsular contracture, in which the ligaments become so tight they lose elast-icity and can tear from bone. "We need to be sure we know who will benefit and who is at risk for these serious problems," says Dr. Snyder. "Nobody knows what the bottom line is." For this reason, Santa Fe Orthopedics Medical Director Gerald McCann, MD, says he will wait another year before considering this purchase.

Other limitations of thermal ligament shrinkage, according to Dr. Knapp and others, include a steep learning curve, a narrow range of indications, and the need for a fairly lengthy, rigid postoperative rehabilitation protocol. "We're monitoring a biological response to treatment," notes an Oratec spokesman, "and patients respond at different rates." A primary difficulty is keeping patients down during rehab, as they may feel normal at two weeks post-op but usually need 12 to 16 weeks before they can safely return to athletic activity.

Bioabsorbables
Another new and somewhat controversial device is bioabsorbable implants.

Advocates say the biggest advantage is the ability to view the surgical repair on X-ray, MRI, or a CT-scan without any metal obstruction or scatter. This is useful for standard post-op evaluations and is especially important when the patient becomes symptomatic after surgery or returns with a related injury. According to Anthony L. Cruse, DO, director of the Southwest Orthopedic Ambulatory Surgery Center in Oklahoma City, bioabsorbable implants also obviate any need for implant removal, which he estimates is indicated in approximately 3 to 5 percent of all ligament fixation cases. "I also prefer bioabsorbable fixation when using a semitendinous hamstring graft for ACL reconstructions," he adds, "because the implants don't cut through the graft like metal screws can."

Others are not so sanguine about the products, citing:

- Product performance
Some centers have had bad luck with meniscal arrows and soft tissue anchors. "I have found meniscal arrows difficult to insert, and once inserted, they are not always secure," notes Robert Buly, MD, a hip arthroscopy specialist and Assistant Professor of Orthopedic Surgery at the New York City-based Hospital for Special Surgery/Cornell University Weill Medical College. James Horstman, MD, medical director of the Ft. Collins, Colo. Orthopaedic Center of the Rockies, says his center currently uses very few biodegradable anchors due to insufficient strength. "We're on the early side of the curve," he says. Shoulder specialist Dr. Snyder agrees, noting that he has only recently begun to use biodegradable anchors in select cases for glenoid procedures. "We're just now starting to see good quality biodegradable anchors," he notes.

Dr. Cruse, who uses Arthrex and Acufex bioabsorbables for both rotator cuff stabilizations and ACL repairs, contends that certain brands and designs of bioabsorbable meniscal arrows provide better fixation than others. And although he recognizes that a metal implant will take a lot more abuse going in, Dr. Knapp, who helped design bioabsorbable implants for shoulder repair, says surgical skill and experience are important factors. "There is a fairly steep learning curve," he says.

- Cost.
The cost of bioabsorbable implants can be 25 to 50 percent greater than that of their metal counterparts. Drs. Cruse and Knapp, who use a number of the devices, say volume discounts help ameliorate this problem. Dr. Knapp, who now uses primarily Arthrex and Acufex bioabsorbable implants, says his center also started a productive bidding war by simultaneously bringing several bioabsorbable implant makers into the facility. With this strategy, "you can rapidly get the price down to something reasonable," he says. "Our ACL screws now cost the same as the metal ACL screws we used to use."

Postop Pain Pumps/Catheters
Another significant trend in arthroscopy is the use of leave-in catheters or take-home pain pumps that automatically and continuously deliver local anesthetics directly into the surgical site for the first 48 post-op hours. The pumps are tamper resistant and feature sterile ????-??closed' integrated tubing for reducing contamination risk.

Centers who like them say patients are happier and make fewer post-op phone calls to the clinics, since the medication keeps patients comfortable while reducing or avoiding the sedative effects of systemic narcotics.

However, there are drawbacks. The first is cost. Jerry Mitchell, MD, medical director of the Van Nuys, Calif.-based Center for Orthopedic Surgery, notes that his center only uses pain pumps when their costs are reimbursed - either by the patient's insurer or the patient himself. "Some patients gladly pay for them out of pocket," he notes. At Santa Fe Orthopedics, Dr. McCann promotes a less expensive alternative to pain pumps for his shoulder and knee arthroscopy patients. He sends these patients home with an implanted catheter and butterfly needle securely taped to the exterior of the bandage or cast. "Besides allowing patients to self-administer 2 cc of a Toradol/marcaine mixture," says Dr. McCann, "it allows them to drain their own hematomas and collect the fluid into red-top laboratory tubes." According to Dr. McCann, some patients return for their day one visit with as many as eight filled tubes. Dr. McCann also notes that both patients and doctors can use the catheter/butterfly needle set-up to inject antibiotics into the site.

Another drawback is limited utility. The pumps may not help that much if you use a lot of pre-emptive analgesia. Although most users of the single-use pain pumps find them effective, Dr. Knapp says he found that the pain pump did not improve patient comfort in his experience. He performed a 50-patient, randomized comparison of pain scores after knee or shoulder arthroscopy and found no differences between patients who used a pain pump and those who did not. He notes, however, that he uses considerable pre-emptive analgesia and that his results may not be translatable given the wide variation in anesthesia and surgical protocols.

Anatomy-Specific Arthroscopy Systems
Two recent developments - high-resolution arthroscopy systems and anatomy-specific instrumentation - have opened the door for new arthroscopy applications in small or difficult-to-access areas such as the wrist, spine, and hip. Daniel J. Nagle, MD, Associate Professor of Clinical Orthopedic Surgery at Northwestern University Medical School, feels the devices can help build case volume provided that your surgeons are skilled. The applications include:

- Wrist.
There are numerous applications here, including diagnostic arthroscopy for the symptomatic patient who has no findings on standard X-ray; ????-??staging arthroscopy', which Dr. Nagle defines as cases of known pathology in which suspected concomitant conditions warrant arthroscopic assessment (i.e., ligament injury with arthritis); and surgical arthroscopy for treating conditions such as triangular fibrocartilage or scapholunate ligament tears, fixation of distal radius or scaphoid fractures, removal of loose bodies, and ganglionectomies.

- Spine.
Dr. McCann is now performing C-arm-assisted, arthroscopic percutaneous lumbar diskectomies on an outpatient basis using the holmium laser and specialized diskectomy instrumentation made by Dyonics.

- Hip.
Hip specialist Dr. Buly notes that, until two years ago, there was not one CPT code for hip arthroscopy; now, there are three. Buly presents three reasons for this. For one, hip injuries are less common than knee injuries. Hip arthroscopy is also technically difficult, and it can take 30 minutes just to position the fluoro-scopy unit and the patient. Lastly, he says, physicians are only now becoming aware of hip injuries. "Open MRI and other relatively low-resolution scans don't pick up hip pathologies," says Buly, "and many doctors are just not making the diag-nosis." Common hip injuries include labral tears (which cause locking of the hip), cartilage injuries, and degenerative processes in patients with dysplasia, osteoarthritis, or anatomic abnormalities.

Fairly recently, both Stryker Endoscopy and Dyonics developed extra-long, cannulated arthroscopic instruments that enable access into the hip. Buly says the cannulated instrumentation allows the surgeon to establish and verify portal placement with a long needle before actually creating the portal. "Proper portal placement is essential to a successful procedure," he says. Despite this beneficial advance, notes Buly, "there is definitely room for improvement" in terms of instrument design.

Other Advances
Several additional, recent advances appear to have helped some centers improve patient care.

- Osteochondral transfers.
Dr. Cruse says that osteochondral transfers - the ability to transplant an autogenous bone core capped with healthy hyaline cartilage from a non-weightbearing area of the femoral condyle to a diseased, weightbearing area - can effectively delay total knee replacement in the relatively young patient. Dr. Cruse says patients who qualify for this procedure (i.e., those with femoral chondral lesions that are too large to respond to microfracture yet are small and shallow enough to respond to the transfer), had few other options before this technique came along. Some primary concerns with osteochondral transfer include potential donor-site morbidity and accelerated mechanical erosion of the repaired articular surface due to incongruency.

- Modified anchors.
Precise suturing is an integral part of shoulder repair, and suture knots need to be buried beneath the articular surfaces to avoid further irritation and pathology. According to both Dr. Horstman and Dr. Snyder, soft tissue anchors that allow knot rotation into the joint represent an important development in the area of shoulder arthroscopy. Snyder cites the big-eyed anchor, which he says allows easier and more stable rotator cuff repairs, as a particularly important development.

The newest such device on the market is Mitek's Knotless Anchor. Dr. Horstman says the ability to eliminate suture knots altogether during Bankart shoulder repairs could be important. "Conceivably, this device could reduce surgery time by 10 to 15 percent, provided the procedure goes well" and the product performs to its promise, he says. "The problem with knots is the sutures get twisted around each other and they get in the way, and the surgeon can spend a lot of operative time trying to unravel knots." Dr. Snyder agrees that the idea is an innovative one, but notes that the ability to fine-tune suture knots using a standard arthroscopic knot tier and the big-eyed anchors is an extremely effective way to cinch tissues and ensure stable fixation.

See the Future
While increased efficiency, economy, and better patient care are the criteria for making purchasing decisions, one surgeon advises centers to remember to think holistically. Don't over-restrict your purchasing decisions, says Dr. Nagle, or you may find yourself unable to offer cutting-edge care. He says many arthroscopy devices are clearly useful, yet they offer benefits that are hard to quantify. "Sometimes we must go out on a limb and say: What is the potential here?"