Advances in Hip and Knee Arthroscopy

Reconstruction, restoration and repair have become more effective and reproducible for ortho facilities.

Innovations in hip and knee arthroscopy are transforming how orthopedic surgeons diagnose and treat joint injuries. With the arrival of ultra-high-definition imaging, wireless arthroscopy towers and smarter automated irrigation systems, a growing number of physicians are enjoying sharper visualization and greater precision inside the joint than ever before.

John Christoforetti, MD, FAAOS, is an orthopedic surgeon with The Centers for Advanced Orthopaedics, an alliance of more than 400 providers in the Washington, D.C. region that is one of the country’s largest independent groups of orthopedic surgeons. He says advancements such as OR suite integration of digital imaging technology with high definition and interactive imaging software have elevated the ability of orthopedic surgeons and their perioperative teams to perform.

“Clear visualization with detailed definition of the white spectrum cartilage and ligament allows increasingly precise interpretation and treatment of sports injuries,” says Dr. Christoforetti. “Holding on to old equipment in this arena can be like watching old family VHS tapes instead of streaming the latest shows.”

Hip labrum repair, reconstruction, capsule suturing and advanced bone reshaping procedures are safer and more efficient than ever thanks to modern tech. On the knee side, ACL repair or reconstruction, cartilage restoration and meniscal repair have become more reproducible, which increases the chance for great outcomes for every patient.

Technological advancements are not only improving surgical efficiency and outcomes but also helping patients recover more quickly than ever. As technology continues to evolve, the question becomes, “What’s next for minimally invasive joint repair?”

Here are some recent advancements that have made a big difference in arthroscopy cases for the knee and hip.

Ultra-high-def imaging

In hip arthroscopy, ultra-high-definition images allow detailed analysis of the quality of articular (surface) cartilage and guide interpretation of the presence of fatty infiltration within the hip labrum, which increases accuracy when identifying injuries.

“In the hip and the knee joints, the increased clarity also aids in identifying soft tissue planes during ligament repair or reconstruction,” says Dr. Christoforetti.

Derek Ochiai, MD, a board-certified arthroscopic hip surgeon and sports medicine expert in Arlington, Va., says ultra-high-definition video imaging was something he didn’t know he needed until he used it. While it hasn’t changed his approach per se, it has made him even more precise with where he places implants and how he resects bones.

“The images are so much clearer, which helps with having confidence that you have a really good handle on the pathology,” he says. “These images are also great for educational teaching of arthroscopy.” James B. Chen, MD, who specializes in knee and hip total joint replacement at DISC Surgery Center in Newport Beach, Calif., says high-def cameras allow surgeons to visualize anatomy with better clarity, simplifying previously complex arthroscopies.

“We can more precisely define structures,” he says. “For example, during knee arthroscopy, I can more accurately assess cartilage integrity and grading for cartilage damage. Additionally, difficult-to-access structures such as the posterior meniscus are more easily visualized and potentially repaired.”

Wireless innovations

New systems on the market, while not yet widely used, allow surgical teams to use cameras without plugging them in.

“Right now, when we do arthroscopic surgery, we have to take the camera and plug it into a tower. That’s a step in the process that takes a little time, and sometimes you have cables that could break or bend,” says Richard M. Wilk, MD, FAAOS, president of the Eastern Orthopaedic Association and clinical instructor at Harvard Medical School. “In an effort to make things more user-friendly, wireless technology is now in the realm of arthroscopic surgery.”

Wireless cameras and controls add an element of safety by reducing the need for cord management and electronic plug-in risks.

While Dr. Ochiai champions Bluetooth-enabled video cameras, which eliminate the need for a camera cord and light cord, he notes these systems still need a fluid pump, so it is still not completely “tubeless” — something he is hoping will come in time.

“A totally cordless system that is light and ergonomically workable for all arthroscopic joint surgeries could further increase efficiencies,” he says.

Wireless controls further improve accessibility and maneuverability when surgeons need to access difficult spaces in the hip or knee. Accessibility and visibility are particularly important for knee cases such as meniscal root repairs or meniscus transplants where precise placement is critical for successful outcomes. For hip arthroscopy, labral repairs can traditionally be difficult to grade and repair in some patients. Advancing technology is helping to improve the ease of these repairs.

“Traditional wired cameras, when combined with pump tubing, sutures and instruments, can cause clutter quickly and reduce maneuverability during procedures,” says Dr. Chen.

Streamlined scopes

The tools powering today’s minimally invasive hip and knee procedures are providing surgeons greater precision while sparing patients unnecessary incisions and trauma.

Flexible, angle-guided scopes now allow surgeons to access multiple viewing and work angles through a single entry point. In hip arthroscopy, for instance, what once required four or five incisions now can often be accomplished with just two or three.

By maximizing maneuverability within the joint, these streamlined scopes not only reduce the number of incisions and minimize tissue trauma, but also shorten recovery times and improve overall patient outcomes. For surgeons, the result is a clearer, more versatile view of the joint without the added burden of multiple access sites.

Automated pumps

Fluid management has become far more controllable thanks to “smart” pumps that automatically regulate flow and prevent excess fluid from leaking into surrounding tissues, says Dr. Chen. “Automated pumps can maintain intra-articular pressure to maintain visibility during the procedure that may happen with variations of pressure,” he says.

Automated pumps increase the consistency of the fluid flow and therefore reduce pressure variations that might lead to visual impairment from bleeding, says Dr. Christoforetti. They may also allow for reduced wastewater. Dr. Ochiai says automated irrigation pumps can also help with staffing, as manually managing pumps take personnel away from doing other important things. Some automated pumps today have remote controls, while others need to be manually adjusted.

“In the procedures I do, sometimes I may want the pressure to be higher or lower, so I’ll have my remote or have someone change it for me,” says Dr. Wilk.

On the horizon

FUTURE DAYS The elements of the latest arthroscopy systems respond to voice commands as the entire OR watches what the surgeon sees in real time.

Industry insiders predict more improvements for knee and hip arthroscopy and expect the advancements to come quickly as innovation in artificial intelligence (AI) continues.

For instance, Dr. Christoforetti believes adding multiview camera angles through integration of separate micro-camera video feeds would create a three-dimensional perspective, and that movement toward the use of augmented or virtual headsets will soon be upon us.

“AI and machine learning applied to live-camera-derived video technology will improve accuracy of diagnoses and track surgeons’ performance and patient outcomes,” he says. “Robotic-assisted limb positioners with voice or ocular movement cues to reduce the need for assistants in demand for advanced hip and knee procedures could be part of the solution. We may also see bio-cellular regenerative tissues matched for implantation with custom precision through arthroscopic surgery.”

Dr. Wilk has seen tremendous growth in technology such as robots helping with joint replacements and computer-based navigation systems that guide surgeons become mainstream in hip and knee replacement surgery. However, with arthroscopic hip surgery, the tech is still in research-and-development mode by numerous companies.

Dr. Ochiai believes breakthroughs in visualization systems will advance arthroscopic repair and reconstruction techniques.

“For arthroscopy itself, 3D visualization of the joint would be amazing,” he says. “In addition, use of augmented reality, where there is a CT or MRI projected overlay onto the arthroscopic image, would guide even more precision.”

Dr. Chen believes more minimally invasive procedures will be offered, especially as biologic options evolve. “The incorporation of augmented reality and AI-driven analytics will help further improve accessibility and performance with procedures,” he says. “At the same time, procedures will continue to evolve as we expand the capabilities of minimally invasive arthroscopic techniques that focus on restoration of normal anatomy.”

All these advancements will leverage the innate skills of the surgeons of tomorrow who were raised in the modern digital world. OSM