Advances in Hip and Knee Arthroscopy

Technological advancements allow surgeons to perform arthroscopic procedures in ways they couldn’t attempt 10 years ago, according to Brian Bjerke, MD, an orthopedic surgeon at Twin Cities Orthopedics in Edina, Minn., and team physician for the NFL’s Minnesota Vikings. Among the improvements he cites are minimally invasive techniques, which lead to less tissue damage and less time to post-op ambulation for patients, factors that result in faster, easier recoveries and more efficient surgical care.

• Ultra-high-def imaging. A better visualization of the operating site is obviously always a benefit. Dr. Getelman notes that standard high-definition imaging is the minimum acceptable standard, although that standard continues to rise, with 4K or ultra-high-def video providing even better resolution and a clearer picture. Imaging upgrades can be pricey — and must include all components of the imaging chain, from the monitor to the arthroscope camera — so facilities must weigh the cost of the equipment versus the benefits it provides in orthopedics.

• Wireless automation. Dr. Bjerke says arthroscopy towers with wireless controls of automated irrigation pumps make procedures more efficient for the entire surgical team by freeing up time for the nursing staff to handle other tasks. They also mean fewer cords and chances of equipment tangling which generally makes life easier for everyone. There’s also a lessened risk of contamination.

On the other hand, Dr. Getelman notes that if the technology isn’t working or the OR staff is unfamiliar with it, delays can occur as someone from the team tries to troubleshoot an issue. He added that automated irrigation pump control can improve surgical visualization without manual control.

“However, surgeons often use visual cues to adjust pump settings based on their experience and judgment,” he says. “There is potential for improvement as this technology continues to advance and machine learning becomes more mainstream in more ORs.”

• Better fixation. Dr. Getelman says the development of the suture anchors, suture passing devices and new knotless options make it easier to attach tendons and ligaments to bones. “We’ve seen marked technical advancements that have altered the scope of practice, allowing for more procedures to be done, and done well arthroscopically,” he adds.

• Improved instrumentation. Newer arthroscopes are smaller and stronger and have sharper business ends. Automated irrigation pumps adjust the amount of fluid delivered to the joint to maintain fluid equilibrium, which ensures distention pressure remains consistent and gives surgeons room to move within the joint.

“Careful control of irrigation pressure is needed to achieve excellent visualization while limiting swelling in the joint,” says Dr. Getelman. “Appropriate surgical portal positioning is also key to successful arthroscopy.”

The latest instrumentation is also often more durable, according to Dr. Bjerke. “Generally, the better the technology, the better the quality,” he says. “But you always have to stay a little bit ahead. You can’t rely on old equipment forever. It’s going break down and then you’re going to have frustrations in the operating room from everybody.”

It’s clear that innovation and arthroscopy will continue to be intertwined, notes Dr. Getelman. In particular, he cites the increased role of disposable technology. “Surgical leaders must take into account costs associated with reprocessing, repairing and sterilizing reusable instrumentation,” he says. “As disposable options become more available and affordable, we might see an increase in their use moving forward.”

In an ideal world, surgical facilities could buy whatever new technology they wanted as soon as it was released. In reality, the cost of acquiring the latest platforms, as well as the time and energy spent learning how to use it, means facilities must be much more strategic about what technology they incorporate and when. Some of the factors that go into that evaluation are the reliability and service of the manufacturer, how well the devices have worked for other facilities, and an analysis of the cost versus the potential clinical benefits to the surgical team and patients.

“If you’re going to get new equipment, it’s important that you make sure you get good service with it,” says Dr. Bjerke. “When it breaks down, you want to have a good service agreement in place.” He adds that once you incorporate new technology, you’ll likely be making updates to it every five to 10 years, which should be factored into your purchase analysis.

Dr. Getelman suggests reaching out to other facilities that have used the technology you’re considering adding for a real-life perspective on its benefits. “Visit and talk with the surgeons, staff and administrators,” he says. “Ask the important questions, observe the technology in use and inquire if the upgrade in technology accomplished the goals they had in mind.”

Surgeons at Stanford Health Care are performing the osteochondral autologous transfer system (OATS) procedure, which involves taking cartilage plugs from one part of the knee and using them to repair damaged cartilage on the other side of the joint. Cartilage is limited in the knee, so the plugs must be 10mm wide or less, notes a report in Stanford Health Care Now.

Marc Safran, MD, chief of sports medicine at Stanford (Calif.) Health Care, addresses this limitation of the OATS procedure by transplanting patellar cartilage from a cadaver, an approach that fills the defective area of the knee with a single, smooth piece of donor cartilage that can be sized appropriately. “What’s going to be key with the older population is to prevent the diseases of aging,” Dr. Safran told Stanford Health Care Now. “To me, that’s the Holy Grail. Everyone is looking to solve or prevent arthritis.”

Dr. Safran and his colleagues are studying the effect excessive motion of the femoral head within the acetabulum has on hip microinstability with the aim of improving outcomes of hip arthroscopy, according to Stanford Health Care Now. The outlet says he’s also championing the creation of the North American hip arthroscopy registry, which would collect patient data such as BMI and procedure type with the aim of analyzing hip arthroscopy outcomes and learning more about the limitations of the procedures. His goal is to collect data from about 8,000 patients each year and capture reliable data over the next few years.

The benefits of emerging arthroscopic procedures are clear, but no change happens without some hurdles along the way. For surgeons, there can be a steep learning curve involved in adopting arthroscopic techniques and technologies. “The biggest challenge for a lot of newer surgeons is getting the experience and the repetitions they need, and performing arthroscopic procedures until they become second nature,” says Dr. Bjerke. “Different types of cases can be challenging from a technical standpoint.”

Dr. Getelman agrees that arthroscopic procedures are technically demanding. “Arthroscopy is a learned skill that takes years of practice to perfect,” he says. He adds that efforts to achieve arthroscopy success begin when the patient is first evaluated in the clinic — a comprehensive patient history, detailed physical examination and clear imaging allow surgeons to make the correct diagnosis and address the underlying pathology of the patient’s condition.

Different types of cases can be challenging from a technical standpoint.
— Dr. Brian Bjerke

“Understanding the subtleties is the foundation to achieving successful outcomes,” said Dr. Getelman. “Surgeons must then anticipate and plan the surgical steps and have all necessary equipment available. The superior surgeon will be methodical and efficient in their approach using reproducible and deliberate steps to treat each source of pathology.”

Dr. Urse believes quality pre-op imaging shows clear views of both femoral heads in the hip and provides a good view of the alignment of the sacrum and the top of the pubic symphysis. “Surgeons can notice abnormal or well-formed sockets to determine if hips are dysplastic,” he says. “It allows us to find out why the patient is experiencing joint pain.”

In the OR, applying the proper amount of traction to the patient’s leg during hip arthroplasty is key to achieving excellent outcomes. Patients are most often placed in the supine or lateral position, says Dr. Urse. Most surgeons perform the procedure with the patient in the supine position with traction applying pressure to the upper medial thigh to get lateral displacement. Slight abduction and a bit of flexion relaxes the capsules, according to Dr. Urse. “Traction is the key to surgery. It lets you open the joint to get the views you need to perform the procedure,” he explains. “As Dr. Jim Glick, an early pioneer of arthroscopic techniques said, ‘Inadequate traction is the root of all evil in hip arthroscopy.’”

Dr. Getelman says surgeons still need to be prepared to convert arthroscopic procedures to open surgery when the minimally invasive approach isn’t feasible for medical or technical reasons and cautions against surgeons becoming too reliant one way of performing surgery. “Arthroscopic techniques can be a great positive, but it can be a negative if that’s the only way you know how to repair a joint,” he says. “Surgeons must learn the basics and the fundamentals of the surgery in order to take full advantage of technology as a tool to improve it.”

Dr. Bjerke believes high-tech arthroscopy procedures should be seen as a complement to a surgeon’s existing skillset — a way to perform complex techniques in a safer or less invasive way. He adds that it’s easy for surgeons, especially younger ones who have always had these options, to get too reliant on the technology.

“Surgeons do things they’re comfortable with and they get into a routine, which is good. You want to be able to do things well and repeat them,” he says. “But not being able to perform a specific surgery because a certain supply or instrument isn’t available is a red flag, indicating surgeons need to expand their repertoire and knowledge of what else is available.”

That education needs to be included for other surgical staff, too. In many cases, if something goes wrong, it’s the nursing staff or surgical techs who must troubleshoot the equipment. The surgical centers where Dr. Bjerke operates have the representatives from arthroscopy device manufacturers train the surgical staff on how the equipment works and how to optimize its performance.

 “It’s technology; things can fail or break so the teaching part is extremely important,” he says. “It should be a priority when you’re getting new equipment to make sure you take the time to do that upfront rather than rely on on-the-job training.”

Like most things in surgery, that understanding comes from learning by doing. “Reputation and experience play important factors — the more you do, the more you know and the better surgeon you become,” says Dr. Bjerke. OSM