SURGEON'S PREFERENCE Paul Rud, MD, wants to work with clear images and effective irrigation pumps.

Like tablets and smartphones, today's new and improved arthroscopy equipment will seem old and outdated in a few months when the next innovation comes along. "The technology has evolved greatly over the past couple years," says Greg DeConciliis, PA-C, CASC, administrator of the Boston Out-Patient Surgical Suites in Waltham, Mass. He's currently shopping for a new platform that promises better visualization and interconnectivity with electronic recordkeeping. He's not at a loss for options, thanks to the latest offerings.

1. Clear images
What do surgeons want in arthroscopy systems? "It's not complicated," says Sandy Berreth, RN, MS, CASC, administrator of the Brainerd Lakes Surgery Center in Baxter, Minn., a small but busy multi-specialty facility that hosts a high volume of ortho cases. "They want clear, detailed images that present true-to-life colors when they're performing procedures, and clear pictures to share with patients and their families afterward."

In the last decade, images generated by arthroscopy systems have evolved from good (standard definition) to great (high definition). Ms. Berreth remembers adjusting the green and blue tints on old monitors, trying to capture the best and most accurate picture.

"High definition gives surgeons the clarity and detail they want," she says. "The images are so true-to-life, you feel like you can reach out and touch them."

One of her docs, orthopedic surgeon Paul Rud, MD, says color contrast and clarity is slightly more important than color accuracy. During knee procedures, for example, color contrast lets him identify where cartilage stops and the meniscus begins.

2. Prime pumps
The irrigation pump's performance is critical in maintaining adequate flow rate and distention pressure in the joint, says Dr. Rud. Those issues are perhaps less important during routine knee procedures, but are a definite must during shoulder scopes. "When you're in the sarcoma bursa, you need to turn up the pump pressure as soon as bleeding starts in order to clear the field," he explains.

He says maintaining distention pressure isn't as difficult when using a shaver because the diameter of the suction apparatus tends to be smaller. If you're using a burr and open up the suction, however, the joint can be quickly sucked dry and distention lost. Suddenly you've got a lot of bleeding to deal with.

Bleeding limits a surgeon's view of the joint, which interrupts the entire procedure. "You're no longer proceeding with the case, you're trying to get your visualization back," says Dr. Rud. "It can turn a 20-minute procedure into an hour-long surgery."

Maintaining a stable operative site also lets surgeons operate more aggressively and quickly. "Being able to see what you're doing is obviously a critical element of surgery," says Dr. Rud. "If you're not sure what you're looking at because you're dealing with a cloud of blood, you're certainly less likely to start burring away bone."

Most of Dr. Rud's younger partners like to use hand controls to operate pumps, but he still prefers the tactile feel of using a foot pedal to regulate pressure levels. A system that has both options available would be a versatile platform to add.

Automatic pumps can sense when distention pressure is dropping and adjust accordingly, including recognizing when burrs and shavers are in use. Dr. Rud likes the idea of a pump working, along with a few manual adjustments, to help maintain distention pressure.

Different pump manufacturers have different recommended pressure levels. "You're always concerned with setting pressure too high, which can cause extravasation of the tissue and swell the joint," says Dr. Rud. He typically starts a knee scope at 40mmHg and keeps it there more than 95% of the time. He starts shoulders with the pressure set at 50 or 60mmHg, increasing it as needed if bleeding issues arise.

3. Interconnectivity
"Picture quality is definitely important to our docs, but now interconnectivity is, too," says Mr. Deconciliis. "Physicians want arthroscopy images to integrate with EMRs. They want to e-mail pictures to patients or back to their practices."

Don't ignore the administrative and financial burdens of paper charting. Mr. DeConciliis says systems that integrate with electronic recordkeeping save tremendous amounts of time and money by eliminating printing costs. Instead of printing pictures to put in patients' paper charts or to give to surgeons, the systems automatically and seamlessly generate and store the images.

One company offers the entire arthroscopy platform — light source, camera, digital data capture device — in a single space-saving box that sends images to cloud-based servers. That's a valuable design.

4. Sales and service
"The nuances between the available systems are difficult to define, because they're all very good," says Ms. Berreth. "You have to decide based on a company's reputation and responsiveness."

Trial all components of a company's system: pumps, burrs, shavers, radiofrequency and thermal ablation wands. Opt for multiple-use, not single-use, tubing to realize cost savings. The ergonomics of the handpieces and autoclavability of the devices should factor into your decision-making process.

COMFORT ZONE The right arthroscopy platform lets surgeons operate more aggressively.

You can buy systems up front or work on creative purchasing methods: fee-for-disposables agreement, bundling into a cost-per-case fee, financing or loaner contract, says Mr. DeConciliis.

Negotiating price is key, but so is finding the right service contract. "Working with a single company that can service every part of a system is a lot easier than having to work with several vendors to keep things online," says Mr. DeConciliis.

Ms. Berreth agrees. She says cameras get dropped and light cords get abused, so the company you work with must have excellent customer service that provides fast repair and replacements when systems break down. "If problems or concerns arise, we can have a rep on the phone immediately, or on site in a matter of hours."

Mr. DeConcillis' surgeons are currently trialing 4 systems. He has an attractive offer in his back pocket from a company with excellent technology, but without a proven track record in customer service. "That factor alone is holding us back, even though they're giving us a great deal," he says. "So now we're also considering the company with great service and the next best deal, and working on bringing down the price."

Like any capital purchase, your decision will often boil down to finances, and differentiating between surgeons' needs and wants. Do they really need a new platform to achieve better patient outcomes? "If they tell me the system will contribute to healthy, happy patients who feel good about the procedures they undergo, then OK, I'll get it for them," says Ms. Berreth.