Needle Inserted Endoscopy For Management Of Tendon And Joint Disease

As specialists involved in managing the lower extremity, specifically the foot and ankle, we can appreciate the small area that we work in and the intolerances that the anatomy has to injury and disease. The pathology itself prompts the individual to seek medical care. During its management, the provider attempts to minimize further trauma by the treatment rendered. With improved technology and instrumentation, surgeons may employ more minimally invasive approaches in the care of these processes. The ability to visualize injured tissue in real-time through smaller portal incisions has been the cornerstone in the performance of endoscopic and arthroscopic care. Creating instrumentation and techniques to execute repair of injured tissue enhanced by direct visualization is a critical concept in the evolution of this approach.

Although it is in its infancy, a needle inserted endoscope to visualize joints in arthroscopy and tendons in tendoscopy is rapidly changing our management of orthopedic disorders. Benefits in my experience include the procedure setting, anesthesia required, minimal wound closure needs, expedited postoperative recoveries, and reduction of post-procedure pain requirements. I find many of these procedures can take place in an office setting under local anesthesia. Further direct imaging of pathology may have notable benefits compared to other forms of diagnostic studies including magnetic resonance imaging (MRI). Frequently, the procedure is shorter in duration, does not require the use of a claustrophobic chamber that may have relative contraindications including existing metals or pacemakers. It permits for a dynamic examination of anatomy versus only static images. Also, there is an appreciation of disease severity variations between advanced imaging and direct assessment. Previous studies in the orthopedic literature demonstrate the prevalence of abnormal MRI findings in asymptomatic patients. In a study by O’Neil and colleagues, the authors appreciated a 35 percent identification of peroneal pathology even though the patient was not symptomatic.¹ Similarly, Park and team concluded in their article that MRIs are vague in many cases when evaluating the peroneal tendons in patients with chronic ankle instability.²

Besides identified diagnostic advantages, there are treatment benefits to needle inserted endoscopy. This includes real-time administration of therapeutic agents directed to the site of injury. The 1.9 mm diameter of the arthroscope allows access to much smaller joints without inflicting more significant soft tissue trauma with larger diameter scopes or open incisions.

Practical Pearls For Needle Inserted Endoscopy: What You Should Know

Currently, we note there are two industry options in the performance of needle inserted endoscopy: the mi-eye 2™ (Trice Medical) and the NanoScope™ (Arthrex). Both are disposable systems. At present, the senior author has only used the NanoScope™ and will discuss its basic makeup and our experience with its use. The unit comes prepackaged sterile and the scope is a 1.9 mm diameter, zero-degree device. For arthroscopists accustomed to 30 and 70 degree endoscopes, there is some minor adjustment to the field of view.

The unit comes with the required cannula and trocar for insertion. The technique to facilitate entry into joints and tendon sheaths involves first placing a spinal needle and passing a thin wire through the needle. The surgeon then withdraws the needle and guides the cannula over the wire before its subsequent removal. Placement of the scope, attaching a fluid irrigant of choice to the cannula through gravity or pump and final hook up to the imaging device allows for anatomic visualization.

The small footprint of the unit and associated instrumentation facilitates its use in a myriad of conditions from traditional ankle disorders, peroneal, extensor and posterior tibial tendon repairs, management of osteochondritis dessicans and synovitis and in assisted fracture repair. Transport into the operatory theater can occur quickly and with little disturbance, particularly in more significant trauma cases where a fast intra-articular exam may be warranted.

One can devise many innovative treatments can be devised. The senior author recently employed this technique to manage chronic intrasheath peroneal instability. Discussion of endoscopic repair of the superior peroneal retinaculum exists in the literature.³ The procedure allows for direct examination of the tendons with a dynamic assessment of the instability. One can then place percutaneous suture anchors under endoscopic visualization in the posterior fibula for securing and repairing the retinaculum.

Final Thoughts

The ongoing changes in healthcare have driven the evolution of new technology and techniques to address patient demands of increased safety and faster recovery. Requirements for improved cost containment are moving care out of the hospital and surgery centers and back into office-based clinics. Needle-based endoscopy is at the forefront of this change. It will permit for readily available diagnostic and therapeutic care under local anesthesia, comfortably within an office setting. 

Dr. Theodoulou is a Fellow of the American College of Foot and Ankle Surgeons. He is Chief of the Division of Podiatric Surgery with the Cambridge Health Alliance and is an Instructor of Surgery at Harvard Medical School. 

Dr. Sikar is the outgoing Chief Podiatric Resident at Cambridge Health Alliance in Massachusetts.

1. O’Neil JT, Pedowitz DI, Kerbel YE, Codding JE, Zoga AC, Raikin SE. Peroneal tendon abnormalities on routine magnetic resonance imaging of the foot and ankle. Foot Ankle Int. 2016;37(7):743-747.

2. Park HJ, Cha SD, Kim HS, et al. Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clin Orthop Surg. 2010;2(4):237-243.

3. Theodoulou MH, Nodelman L. Endoscopic repair of a subluxing peroneal tendon complex. Foot Ankle Stud. 2017;1(1):1-4.