BETTER OPTIONS New options for visualization, anchors and irrigation make arthroscopy more effective and efficient.

In arthroscopy, minimizing trauma to bone and soft tissue while ensuring a strong and resilient repair is key. It's a tall order, but improvements in arthroscopic equipment essentials — and new innovations like stem cell therapy — are expanding the possibilities of minimally invasive joint repair. Here are 4 game-changing innovations that promise to change the arthroscopic landscape.

1. Better imaging systems
After years of being the hot trend in the consumer market, 4K has finally hit the surgical world. Arthrex's new 4K video system is the first and only platform on the market to use the ultra-HD technology, which promises lifelike images. 4K offers 4 times the resolution and 4 times the color reproduction of standard HD, which means clearer, sharper images for your docs.

Marc Safran, MD, an orthopedic surgeon at Stanford Health Care in California and vice president of the International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine, has used the 4K system at the Stanford Medicine Outpatient Center, one of the few facilities currently with the technology. He says that the system's improved picture lets him see more detail during cases and, in turn, improve his efficiency.

"With 4K, it's an incremental step up," says Dr. Safran. "It definitely increases the definition and resolution of the joint you're looking at. You can achieve your goal more easily in surgery because you're seeing things with more detail."

While Arthrex is currently the only commercially available 4K system, other big-name manufacturers are planning to release their own systems later this year and in early 2016, says Jeffrey Dugas, MD, of Andrews Sports Medicine and Orthopaedic Center in Birmingham, Ala.

But that doesn't mean you have to run out and buy a new, pricey system right away. Dr. Dugas notes that while 4K is definitely a "nice improvement," there's limited research showing it offers any clinical advantages over standard HD. "Does it make you a better doctor? I don't know that it does," he says. "But, it does provide crisper imaging, which is especially nice when looking at anatomy such as cartilage."

IMPROVED OUTCOMES Jeffrey Dugas, MD, from the Andrews Sports Medicine and Orthopaedic Center in Alabama, is one of many surgeons using biologics.

Improved imaging isn't the only thing surgeons desire. EMR integration and the ability to record, annotate and send photos and video via e-mail are other sought-after features of the new arthroscopy systems, says Dr. Safran. That's become even more important as the government pushes more facilities to go paperless, adds Dr. Dugas. "Integration is very important," he says. "Being able to integrate with EMRs seamlessly and efficiently is a great bonus."

Finding a way to ensure docs get the high-tech features they want while you rein in costs is essential, says Greg DeConciliis, PA-C, CASC, administrator of Boston Out-Patient Surgical Suites in Waltham, Mass. He notes that in addition to an arthroscopy system's performance and cost, you also should evaluate the service agreement and ask vendors about bundling the purchase with other essentials, such as wands, shavers and burrs. "The more you package into the trial, the better you'll do cost-wise," he says.

2. Stronger, smaller anchor systems
Surgeons' desire for strong, minimally invasive anchor systems has created a slew of new options over the last few years, says Dr. Dugas. "We've gone from metal 2-prong and 4-prong anchors, to plastic, to absorbable, to hybrid, and now we're seeing soft, inert, all-suture anchors," he says.

The all-suture anchor system's tiny size is much less traumatizing to the bone and surrounding soft tissue than other larger metal or PEEK systems, yet it offers equivalent or better holding power, says Dr. Safran. "When you put in a metal screw, or even an absorbable screw, it tends to leave a gap in the tissue," he explains. "If you can get away with using a smaller device, and not pushing that large screw through the soft tissue, it's easier on the patient."

All-suture systems are especially useful for shoulder and hip procedures, says Dr. Dugas. He notes that for cases such as complicated rotator cuff repairs, where a surgeon may need 12 points of fixation, the small size of all-suture anchors lets surgeons place the numerous points in the joint more easily.

Plus, compared to bioabsorbable or metal options, these anchors don't react with the bone, leave behind soft deposits or cysts, or create gaping holes that can make revision surgery tough, says Dr. Dugas. These pluses can help offset the increased cost of the systems, which are now offered by most ortho manufacturers. "The benefit with these isn't necessarily speed, and definitely not price, but rather patient recovery," says Mr. DeConciliis.

Knotless anchors, another new option, may increase your surgeons' speed. These devices let surgeons fixate soft tissue to bone without the tedious task of tying suture knots. They are more expensive than other options, says Mr. DeConciliis, but can be worth it for some facilities. "If every minute saved in the OR is saving $15 to $20, you could come out on top financially," he says. "We haven't gone down that route yet, but I can see how it's beneficial."

3. Automated irrigation pumps
A good arthroscopy pump should irrigate the joint with enough saline to keep it open while minimizing bleeding and unwanted swelling in surrounding soft tissue, says Nady Hamid, MD, a shoulder and elbow orthopedic surgeon with OrthoCarolina in Charlotte, N.C. While old pump systems relied on gravity to insufflate the joint with fluid, new systems automate the process using pressure sensors that create a constant and predictable flow.

"The docs really like the ability to raise the pressure if there's bleeding that's getting in the way," says Mr. DeConciliis. "I think an automated pump is essential."

The latest pumps can determine when the outflow of the fluid is changing — for example, if a burr is in use and using suction — and modify the inflow accordingly to maintain pressure. Not only does this make the process more efficient, says Dr. Hamid, but it also can reduce the total amount of fluid used. This helps prevent swelling — important in shoulder cases — and may even speed up turnover times.

"We use fluid-preserving pumps now, so you don't have to infuse as much into the joint," he says. "During previous cases with older pumps, I would go through 10 bags of fluid. Now I only go through 4."

Though pumps have been improved, Dr. Dugas notes that many manufacturers are still working on fixing common pump problems, including clogged tubing and pressure sensor malfunctions, and will likely release new options in the near future. "If there's room for innovation in arthroscopy it's here," he says. "Pumps are a couple of generations behind video technology."

4. Biologics for better recoveries
The technology generating the most buzz in orthopedics, however, is biologics, says Dr. Dugas. Injecting platelet-rich plasma (PRP) and stem cells during surgery may help patients grow healthy cartilage following arthroscopy. The pricey procedure is becoming especially prevalent in surgical centers, notes Dr. Dugas.

PRP has been around longer than stem cells, says Dr. Safran. While some surgeons inject it during procedures such as ACL and rotator cuff repairs, it has shown more promise as an office-based treatment for chronic tendinopathy. Instead, PRP has taken a back seat to stem cell injections, which may hasten patient recovery and ward off repeat injuries.

At Dr. Dugas's center, surgeons use a special kit to remove a small amount of bone marrow from the patient at the start of the arthroscopic procedure. The marrow is spun in a centrifuge to separate the stem cells while the surgeon operates. At the end of the procedure, the doctor injects the stem cell concentration into the surgical site to help with recovery. "We've seen significantly improved results with our patients so far," says Dr. Dugas.

Though clinical research is limited, anecdotally, docs are excited by the outcomes. Dr. Dugas says he estimates more than 80% of patients who had stem cell injections during knee arthroscopy would get them again, and up to 90% of rotator cuff repairs — which typically have a 50% to 60% success rate — have seen positive results. "More and more surgeons are getting involved," he says. "We just don't know exactly where it fits in yet."

Although stem cell use is becoming more popular with both surgeons and patients, Mr. DeConciliis notes that reimbursement problems and high costs prevent more widespread use. Requiring up-front payment from patients for these alternative treatments can help, he says, at least until you work out reimbursement with your payors. "We've done a few more stem cells now," says Mr. DeConciliis. "You can bill for some of the codes associated with it, but it's challenging to do so, and it can be very cost-prohibitive."