Course: Inaugural NYU Langone Orthopedic Hospital Paul Lapidus Foot & Ankle Course: A Case Based Approach to the Management of Sports Injuries, Complex Deformities & Arthritis
Um, so I'm gonna talk a little bit about this needle arthroscopy. Um, these are my disclosures. Importantly, Arthrex makes the particular needle arthroscopy, um, component that I'm gonna be talking about today, so that is relevant. So this is what it is, um, it's chip on tip technology. Prior to probably 4 or 5 years ago, anytime we used in-office needle or needle arthroscopy, we're using refractory lenses. The picture was pretty poor. And so it really was a um almost gimmicky. We put it in, we'd use a little uh 20 cc syringe and we'd wash everything out and and convince ourselves that we could see something. And but this is revolutionized. This is the 1.9 millimeter tip. You can see it has an equivalence of um the regular um scope here in terms of um visual field and acuity. We're not talking about reinventing the wheel here. All we're doing is, and again we heard about it earlier on in in um. In the Lapidus talk, and, and my old boss, Walter Bone said the same thing, that that if he's teaching me something that I'm gonna be doing in a few years' time, then I'm doing the wrong thing. And so this was Nick Van Dyke's original article looking at the um posterior scoping. And all we've done is we've made it a little bit easier. It's the same procedure for the same indications. We're just using smaller instruments and now we can do it in an office setting with no anesthesia or with just local um analgesia. This was the original kit we set this up 4 years ago, and thanks to Arthrex and thanks to Lou and my other colleagues who um really sort of promoted this 4 years ago, we were the beta testing center at NYU in in actually in America, and this was the set that we got. This is all we needed for the office, and you can see here we have the camera, we have a couple of little bit of of um instruments, and then we have a a few other little bits and pieces. So we thought that, you know, you're gonna, this is gonna be a revolutionary technique or or way of doing something, but of course, you're only as good as your first infection. So we, we do dress up like we're real surgeons in, in the operating room, um, simply because I think for the 1st 1000 of these, we don't want any infections, so it's an abundance of caution to do that. And once again, the, the ability to see and do is important. Up to this, we have the ability to see. We could look in, we didn't see very well, but we could see into the joint. We had no ability to do anything within the joint, and now we're moving forward to doing more and more and more in there. So I think it provides not necessarily a new option, Mohammed, wherever you've gone, um, in terms of MRI, but it, it augments that. MRI won't give us the ability to test that cartilage, to probe the cartilage, to truly see what the quality of it is like. So of course, a lot of this work was done by our colleagues in AMC Amsterdam, and Gino Kirkoffs, Jordi Vega, John Carlson, and so forth. There's a growing, um, I think there's a almost a public perception. The people know our patients know a lot more now about pathology, they want to know a lot more about the treatments, and actually this system allows them to become involved in that. Um, as we evolve through it, the patients become more and more involved in their treatment, which is actually very good for outcomes. So we want to make sure also that it's safe and effective, and there have been plenty of studies to show that. This is one of the other points about this. Normally when we do ankle joints, uh, ankle scopes, we have to put them into traction. It's difficult to do, it's cumbersome, and even when we do it, we don't often get a huge amount of traction, and then we put it in a large scope, and you can see Jordi Vega again has got about um overall 31% of these. Joints will become damaged by estrogenic injury. That's enormous. So because we know that cartilage will never regenerate, and if we're going in there to do a cartilage procedure anyway, and why are we damaging it. So with these very small needle scopes, no need for traction and likelihood of damage is very small. So, as I said, the ability to see and I do, we can do the ankle, knee, shoulder. And with our resident colleagues, we've actually produced a series of papers and technique papers looking at the hand, wrist, elbow, and and so on and so forth, and I think we've pretty much captivated the market of this. This is, as I said, our setup in NYU. This is the posterior scope, the patient is looking at their phone, they're not writhing and acting up there, they're just looking at the phone um onto their broker or something to pay the bills. And uh and this is, so we have a small little screen. And um we have our nurse is uh handing me the instruments, and sometimes we have a resident or fellow, but we don't need it because it's always because it's very, very simple. We also um expanded down to West Palm. This is the first ever nano arthroscopy suite. You can see it's just a regular room with a big big screen TV and this was our first case, and this will be. Listening to these great uh experts on on on posterior tibial tendon um disorder today, there wasn't any room in that treatment algorithm for this. But these are in the old Myerson uh system or Johnson system that we were looking at, um, for a grade one, where the, where the patient can get up on their toes, they have pain and inflammation along the, uh, a son of ice along the posterior tibial tendon. This is what we use, we just simply do a sinorectomy, and we can do that in the office. This was an 80 year old lady, wanted to play tennis, didn't want the all-American operation. We did that down in West Palm. She got back to playing tennis. She actually fell asleep in this procedure. Uh, at least I thought at one point I thought she was dead, but she was just asleep, and then she woke up and everything was good. She got back playing tennis. So again, this is um just and and I'm so grateful that that I work in an institution where our residents and fellows are so involved with the innovation. One of the things that I learned here is that innovation is key in NYU and we've been really fortunate that we've really captured this this space. So you can see these are all the papers that have been published in large part by the residents and fellows, looking at nano arthroscopy, and then not just in the foot and ankle, in the knee, shoulder, and right now, elbow. Um, so I think this is, is a testament um to you guys. This is the first paper that we produced by uh Chris Coosanti and and other residents. Um, we looked at antraed impingement, which is very, very common. We see it a lot in athletes, and the most important part about this is the mean return to playtime was 3.9 weeks. So that's almost half of what it would be ordinarily if this was to be done in a main operating room with a standard scope. Mean return to work time is is 2 days, and that's terrific. So again, insurance companies are going to like this, um, because the cost of this is very, very low by comparison, uh, to bringing the patient to an operating room. But the most important part about this for us on this learning curve was, what was the patient's perception of this. Many patients, of course, would say, I don't want to look at it. Within in 2 minutes, they do want to look at it, because we'll have that human interest, what's going on in parts of our body we can't see or don't understand. So they looked at this, and then afterwards, and we tell them, you can do this, but you can't do that. They understand why, because I can get them to move their ankle and show, right, we've taken all that scar away. You can have much greater dorsiflexion now, um, but if you don't do that, all that scar tissue will come back. So one of the reasons many sports and athletes don't, don't get back to doing the things they want to do is fear of recreating the original injury and going through that whole process again. So when they see this, they become part of the treatment. Again, a similar patient or similar um study, this was just looking at 10 patients for um posterior impingement, 100% return to work, and mean return to work time at uh at 3 or 4 days, and again, getting back to work, getting back to sports around 5 weeks. This is um Achilles tenoscopy, which is a, you know, very difficult pathology to treat. We go through all the conservative uh paradigms, shock wave, PRP and so forth, and there's a small subset that don't do well from that. They don't necessarily want to have big surgery. This is a very useful thing, again, popularized by um our friends in in uh Nick Van Dyke, where he just simply goes in with a, with a shaver, and you go around and you probably denervate the paratenon on that increased neovascular response between the parainon and the tendon. And we just debride that, and then we'll use them a fully technique into the tendon uh to stimulate that. And again, you can see here, over 90% of these patients um did well and go back to their sports. This hasn't been published yet, but presented with 12 patients with perineal tenoscopy, um, 10 patients successful debridement and groove deepening, 2 patients had a large tear, and I will tell you that, um, one of these and, and James Calder, who works in London, looks after the Premiership, and, and I have really, we moved away from SPR repair, we do all of our groove deepenings. We don't think we need SPR repair, it's not the standard board answer. and um you you you probably should include that you need to do an SPR repair. We didn't, and I saw my first failure probably a couple of weeks ago, um, where we just did this in a football player or soccer player rather from from Boston, and, and it failed just when he was getting up on the table months later. So I think sometimes it it probably was me, I should have gone, I've improved the groove depth. Um, these are all oftentimes volumetric problems where we need to actually shave away some of that low lying muscle belly, um, so we don't necessarily need to go into the bone. I think you can. Um, increase the volume or the space available for the tendon by removing some of the muscle. It also allows this assessment and treatment of an ankle OCL. This is a previous oats. You can see the oats look great. All around the oats, the cartilage looks pretty grim. Um, and this is when we're using bio cartridges as an extracellular matrix for we use for small, um, uh, for small defects, we mix that with PRP in office. And again, the old adage that we had to have these people people non-weight bearing for 6 weeks, we don't do that. We, we weight bear them almost immediately because by contrast to the knee, the ankle is a very congruent joint, and all you're doing, there's not much sheer force going through this. It's mostly compressive loading through this, which actually stimulates um chondrocytes to regenerate. As I said, Mohammed, don't worry, we're not taking your job. We're simply using this to augment what MRI can't do at this time, and I think it's a useful adjunct for that. So everybody will always ask, when you come up with something innovative, well, that's it's gonna cost a lot of money and and Ken talked to about it earlier on. It costs more money, we're not going to be using it, insurance companies won't do it. We already know in the knee, it's around $1000 a saving. This is just the procedure. Forget about the the the cost of the um of the the operating room. The cost savings for Iona, um, are about just a little bit over that for for the ankle. So it is a cheaper thing. These are typically disposable. We're now gonna start making them where they're gonna have at least up to 3 uses. So again, that cost um will go down over time. There's a couple of cases. There's a 65 year old male, he had pain over the an aspect of his ankle joint, and a dorsi flexion, and he had lots of physiotherapy. Nobody could find out what was wrong with him. We went in, this is one of our first ones, we found all these sort of loose bodies sitting there, and when he, uh, when he dorsiflexed, they got trapped in there. We couldn't see those in MRI presumably they were 4 or 5 millimeter cuts. Um, but anyway, this was both diagnostic and therapeutic. The great thing about it is, there he is walking home, off to the bank. All right. Next one, posterior ankle impingement, 17 year old male tennis player, um, he was, his father was a very important person in this institution. He referred to us. He's a large steely lesion in the back. FHL teno synovitis wasn't settling down with conventional um conservative therapy, failed shock wave, and so forth. And this is him a couple of weeks um later, you can see that he is getting back to all the things. Again, remember, this patient didn't go to an operating room, didn't have general anesthesia, didn't go through all the risk of complications associated with that, had a simple procedure in the office where the patient was awake, with his father standing and looking at me, making sure I didn't make any mistakes. And you can get the patient to move their FHL up and down, you can see, and they can see how clear it is, and they buy in that they're better, and all they're doing from that point on is getting better. This is a case um that. You probably shouldn't do. Um, this is a 61 year old male. It was a patient of Doctor uh Walls and I, um, in multiple procedures up the road in that other institution. And, uh, and also down here where we put in a a knee an ankle replacement, uh, I think they tried to put in a knee replacement in HSS and his ankle didn't work. And uh so we we put in an ankle replacement here, and he just developed this awful a fibrosis. We didn't want to bring him back because he had all these steroid injections and all the rest so we didn't want to bring him back necessarily to the operating room. So we just looked inside um into the joint, and you can see um this massive arthro fibrosis that was getting sucked into the joint every time he tried to try to walk. And again, you have to be really careful not to scratch the poly or not to scratch the metal, and most importantly, obviously, to um to front load these people with antibiotics as well as postoperatively. Um, but he did well for for a particular, um, period of time, and then he came back and we had to do all sorts of other things. But again, it's a way of diagnosing, and then the patient truly understands. I can come out from a case and talk to the patient, and they won't know, they won't understand where I'm pointing to MRIs, but they do understand where they see themselves. Uh, this is anterior debridement, second look. Oftentimes after these oats grafts, they'll get a lot of hypertrophy of the capsule, and they get scarring at the front of the joint. And so we again, we can go in and we can remove that. You can see here it is, antramial impingement, lots of inflamed sinusitis, and we'd go in and we just simply resect that all the time, the patient wide awake and and seeing this. This is an FBI agent who came in and he had multiple surgeries all over the place and none of them worked, and he came in with us with pain over subtalar joint and perineal tendons, and we're able to um do a perineal tenoscopy. We were able to increase the space available for his tendons, um which we're subluxing. And we're able to take take care of that, and he's back out now fighting crime. This is an interesting case, and it really just the reason I put this up is it it just sort of underscores. That patients do not get pain from this procedure. They are local anesthetic, and it, it almost belies belief when you think that you're injecting or drilling into this is an AVN. We want to decompress the tibia, and then we want to add a biological adjunct. Patient came from out of state, she didn't have any insurance for out of state, so she didn't want to pay $40,000 for an operating room, but she was willing to pay for a procedure that was going to do the same thing in office as it would in an operating room. So this is where we're gonna drill the AVN and we're gonna add a biologic to there, so decompress and add the biologic. And you can see this is, um, you know, obviously this this picture is um Magnified, but this is a drill going into her tibia, and she's telling us about a horse farm in California. So I think this is something that that we we have to look at and and our vision for this, and this is the final one here, we don't just do, do ankles, we do knees and other joints. This is a 19 year old division one basketball player. He then oats, he had all sorts of other things done, and he was told he had to give up his um his career, he was going for the draft. And so he came into us and we found it was just all he needed with a partial menosectomy. He certainly has arthritic change. You can see his original oats there, but we removed the partial um this this torn piece of meniscus in office, and he's walking home and and and back doing all the things we want to do. So summary on this. Needle arthroscopy can facilitate not just the diagnosis, but we now have the ability to do is to uh see patients buy in and become really part of the team. That's really, really important now with patient education increasing. Um, we cannot just not only just look into the joints, we can also look into tendons, and we now have a whole bunch of of uh instruments that we can do the things that we used to do in an operating room, we can now do in our office. So many thanks indeed. Any questions? So I, I've a couple myself. um, so. One of the things that we're always trained in our minds is if you're going to do a surgical procedure, you've got to do it in the operating room because there's a risk of infection and all the rest. Have you had any infection problems when you do this in the office? No, so we, we've had no, uh, we've had no deep infections, um, and we've had less infection than than you would get typically in a, in an operating room setting strangely, I think because we're so fastidious about things, um, and also because the, the trauma to the soft tissue is so small. Um, we don't, we don't even put a suture in this. We put a Steri-Strip. It's a 1.9 millimeter scope, so you make a tiny, tiny nick. There's no, there's no spreading of the of the of the soft tissues. There's no trauma to the soft tissue. So the likelihood of any egress within is relatively small post-surgery. Um, so we've had one or two portal site, um, minor cellulitis events, um, but they've resolved within a day or two. So, I mean, I, you know, touch wood, it's Murphy's law as soon as I say this, in the next one we'll have a catastrophic infection, and that will happen, um, you know, happens to all of us, but, but to this point we haven't, and it is an abundance of caution, we do. Dress up like we're in, we're real surgeons. We do sterilize the whole area. Um, I think you probably don't need to do that, but until I've done 1000 of these without any major infection, I'll keep doing it. And then another thing is you get the pierces walking immediately. I mean, you can see them walking out the door. It, it really is an incredible thing, as opposed to myself. And I used to, after every scope, I would put them into a splint for two weeks, even if it was just a small 20 minute thing. Now I've progressed to using a soft dress and a walking boot. Part of the mindset was is that you can, because it's quite superficial in some people, you can get some persistent oozing. Have you noticed that at all with uh with getting these people moving immediately? Yeah, you will get oozing, um, simply because there is some fluid extravastation. Um, I don't mind that. It's, it's OK, but they, they come back in a couple of days later for a wound change and um and then they're just, wound change really means that any ABD dressing that we put in to absorb that is taken off and they're just given band-aids and off they go. Um, so, I think the old thing, we were always so worried about seromas and fistulas, and that's probably more academic than real. I, I can't imagine that anyone in this audience has ever seen, or it's probably less than 0.1%, any seromas or fistulas from ankle, um, ankle scopes. I think you're probably right. And just one final question from me again is um. I was really taken aback there of what you said. You allow these patients, where you've done an osteochondral surgery to weight bear immediately, and I, I, I think you're probably right, you know, maybe we're being overly cautious with certainly some of the smaller lesions where you do a sort of chondroplasty to take some of that subchondral bone and put the biocartilage in. But two quick questions. One, Cause I'm starting to maybe move away from using the fiber and glue to hold it because I do think it is in there. It is well packed in the recess, and there's a congruent joint, and if it's not off the shoulder and it's well aligned, it's, it's gonna stay there. It's not going to suddenly fall out of place because the joint will compress it down, so I think that's a good point about getting them weight-bearing early, but do use fiber and glue, and if you do get them weight-bearing, Do you put them into a boot and let them walk free, or do you let them walk free in sneakers? No, I think boot is should belongs down in Abu Ghraib. I think cam boots are overused and form of cruel and unusual punishment. I don't use cam boots because I think there's so many side effects to it. Um, you can use it a very, as a temporary thing, um, but I don't, um, use them. I, if I'm doing an osteochondral lesion, the patient will walk in a regular post-operative shoe just to to accommodate the bandage for a couple of days and then work in a in a sneaker afterwards. Um, you have to know your patient. I don't want them running the marathon the next day. I want them really more compressive loading, and I don't want them doing full. I don't want them on a treadmill or anything else like that until we know that it's seated in. For 2 weeks I'll get them into a gym and they can do elliptical and and they can do a bike. I don't use fiber and glue very often, um, sometimes I have to if it's not a fully contained lesion, and Dan Grande, you know, from who's current president of ICCRA, he talks about Fibrin, when you're putting in stem cells, or when you're putting in CBMA, which has a component of stem cells and secrettomes, it will push the the path of differentiation down the fibrous phenotype, if you have fibrin there. So it's better to try and avoid it or to use it very judiciously.
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