Arthroscopy might be the bread and butter of orthopedics, but there's nothing basic about today's advances in joint repairs. Here's a look at the latest in irrigation pumps, imaging, instrumentation and orthobiologics that your orthopedic surgeons would be pleased to see in your ORs.

1. Automated irrigation pumps

Sports medicine specialist Brett Owens, MD, was a surgeon in the Army for 11 years and currently operates at a hospital and several ASCs, including his physician-run surgery center. His most critical piece of equipment, the one item he asks for when he begins operating in new facilities, is a state-of the-art irrigation pump.

"Visualization is the critical aspect of arthroscopy," says Dr. Owens, a professor of orthopedic surgery at Brown University Alpert Medical School in Providence, R.I. "If you can't see, you can't perform surgery. Surgeons do fine with older pumps, but if they're struggling with visualization, a new pump can help."

He performs complex knee and shoulder procedures and has essentially eliminated tourniquet use and associated complications —post-op pain, DVT and post-op bleeding — by using a high-quality pump to maintain a bloodless field.

Surgeons must sustain constant pressure within the joint in order to maintain capsular integrity, but must also avoid fluid extravasation and "red out," which occurs when blood and fluid in the joint create an opaque cloud. "That's a frustrating scenario, which can be avoided by increasing the pressure and maintaining an adequate flow of fluid to clear blood from the field of vision," says Dr. Owens.

He says older pumps feature pressure-sensing transducers that read how much pressure is being generated within the pump line, but that reading doesn't always translate to the pressure within the joint. Newer pump systems are controlled by pressure and flow, and automatically adjust the amount of fluid delivered to the joint based on those 2 factors.

The latest pump systems are also integrated into arthroscopy shavers. If the pump doesn't "talk" and automatically adjust the intra-articular pressure when the shaver's suction is applied, the walls of the joint will collapse. Newer pump systems have inflow and outflow cannula integrated into shavers, so the pump will increase the flow of fluid to maintain joint pressure when the instruments are activated.

Setting up older gravity-based pumps is relatively easy; a fluid-filled bag is hung on a pole and gravity pulls fluid into the joint. The more pressure you need, the higher you hang the bag. Newer pump systems involve a slight learning curve with respect to connecting the pump tubing properly and prepping the system between cases, says Dr. Owens. However, he says, pump manufacturers have designed user-intuitive platforms to make set-up easier and faster. For example, newer pumps can be programmed to adjust the flow of fluid based on individual surgeon preferences during specific procedures.

High-end pump systems decrease the amount of fluid that's required to maintain a stable operative field. Instead of constantly pumping fluid into the joint, they maintain joint pressure with just the right amount. Less fluid spills out of the joint and into suction canisters or direct-to-drain fluid management systems, meaning your overall fluid waste management costs decrease.

Pump systems can often be obtained at no cost in exchange for purchasing the disposable tubing needed for each case, points out Dr. Owens. He says investing in a state-of-the-art pump is a "no-brainer" for reducing case times and shaving seconds off of room turnovers.

2. Ultra high-def imaging

Robert Morgan, MD, a sports medicine specialist at OrthoCarolina Concord (N.C.), says arthroscopy revolutionized joint injury diagnosis and treatment, and believes we'll look back in 10 years and realize 4K ultra high-definition imaging had the same game-changing impact.

"Orthopedics is all about restoring anatomy, and the better I can see anatomy, the better I can repair it," says Dr. Morgan, who adds that 4K imaging provides better resolution, brighter light and a wider spectrum of color, which lets him visualize anatomy and joint structure more clearly and operate with more precision and accuracy. Marshall Medical Centers in Guntersville and Boaz, Ala., recently added 4K imaging to its facilities' ORs. Orthopedic surgeon Joseph Kendra, MD, says the technology helps him discern between scar tissue and healthy tissue during shoulder and knee repairs. The brighter, more detailed imaging also allows for a safer and more efficient dissection, and lets him assess the integrity of tendons when deciding if they need to be repaired or removed. He says 4K imaging is most useful when he's operating in the shoulder joint, which contains various structures and textures.

Ultra high-def imaging helps Dr. Morgan see exactly where ACL bundles attach to the femur and insert into the tibia, so he can place guide pins more accurately when repairing the ligament bundles. It also lets him clearly see the amount of native tissue that remains on the femur and tibia where the ACL tore away from the bones. The improved visualization and lighting provided by 4K imaging help Dr. Morgan diagnose Ramp lesions of the medial meniscus and Kim's lesion, which is an incomplete labral tear in the shoulder that appears as a slight surface crack between the bony glenoid and the labrum.

"The superficial crack isn't as obvious with standard high-definition," says Dr. Morgan. "If you don't see it, you won't probe the area and can miss the injury entirely."

3. Improved instrumentation

Arthroscopy is being used for more applications as surgeons' skills improve and instrumentation, which is being designed for more precise and faster dissection, continues to advance. Eric Barp, DPM, an orthopedic surgeon who specializes in foot and ankle surgery at The Iowa Clinic in West Des Moines, says small joint arthroscopy has gained traction thanks to shavers and scopes that operate through incisions 2.7 mm and smaller.

He acknowledges the growing movement of treating fractures with surgery instead of with casts and says the latest arthroscopic instruments are helping to drive the trend. "We're able to reduce fractures through smaller incisions and use better visualization to assess the repair," says Dr. Barp. "That allows for better alignment of displaced intra-articular fractures and leads to better outcomes. Advanced arthroscopy also minimizes post-traumatic arthrosis because we're better able to debride intra-articular disease."

Smaller scopes and instrumentation also let surgeons operate much more efficiently, according to Dr. Barp, who says, "We can treat pathology arthroscopically that we wouldn't have attempted to address even 5 years ago."

4. Regenerative medicine

Orthobiologics involves using biological substances to help injuries heal faster. Dr. Morgan says the substances have an anabolic effect, which increases healing, and an anti-catabolic effect, which decreases factors that tear down cartilage and cause joint inflammation. There are two main types of orthobiologics in use today, according to Dr. Morgan:

• Platelet rich plasma injection (PRP) involves centrifuging blood taken from a patient to concentrate platelets to 5 to 12 times more than the normal concentrated volume before reinjecting the blood into damaged tissue. The platelets contain growth factors and cytokines, which proliferate and recruit cells that promote healing.
• Stem cell therapy involves harvesting stem cells from the patient's iliac crest and injecting them into a joint, tendon or ligament. The stem cells then substitute damaged cells within tissue. Dr. Morgan says studies involving second-look arthroscopy have shown that cartilage growth occurs in knees where stem cells have been injected, but it's unclear if the injected cells turned into new cartilage or simply acted as mediators to recruit cells that helped regenerate the cartilage.

The injections can be administered during adjunctive procedures in the OR during joint surgeries, or during in-office procedure injections for treating ailments such tennis elbow and knee arthritis.

There are barriers to more widespread use of orthobiologics, according to Dr. Morgan. He says insurers aren't currently paying for the treatments, so surgeons are forced to "sell" the new therapies in the clinic to patients who must be willing to pay out of pocket for the potential of improved post-op healing.

Surgical facilities must also pay more for the kits needed to harvest bone marrow and perform PRP injections. PRP kits cost between $150 and $200 and stem cell kits run $750 to $1,250, says Dr. Morgan.

PRP injections don't add much complexity to procedures; the anesthesia provider draws the needed blood as the patient is draped and put to sleep. Stem cell aspiration is more involved and takes up valuable OR time. Dr. Morgan says it can be profitable for multi-specialty facilities or orthopedic centers that specialize in lower reimbursed hand and pediatric procedures. He cautions, however, that adding the longer, more involved procedures might not be as financially beneficial for orthopedic centers already running at full capacity with money-making joint repairs.

Still, Dr. Morgan believes orthobiologics is poised to be the next big thing in joint repair. He says, "It's in its infancy now, but researchers are developing algorithms for determining which patients will benefit the most, when and where to perform the treatments, and how many injections are needed to promote healing." OSM