Cover Story

Time to take another look at second-look knee arthroscopy

Second-look knee arthroscopy may prove therapeutic for symptomatic patients.

Historically, second-look arthroscopy has been used to assess healing in the knee joint postoperatively for research and non-research purposes. However, due to some of its risks and complications, as well as recent advances that have yielded better imaging of tissue and structures, orthopedic surgeons have looked for good alternatives to follow-up knee arthroscopy.

On the other hand, sources for this Cover Story discussed new in-office arthroscopy technology to get a less-invasive second-look at a cartilage or meniscal repair, for example. These techniques may mitigate undergoing a subsequent OR visit and some of the associated risks.

“Second-look arthroscopy, or diagnostic arthroscopy, if you will, which is a [broader] term, was historically performed in a setting where we did not know or needed to confirm a diagnosis in the absence of high-quality MRI to otherwise guide our decision-making,” Brian J. Cole, MD, MBA, associate chairman of the department of orthopedics at Midwest Orthopaedics at Rush, told Orthopedics Today. “But frankly, taking a history, performing a physical and maybe obtaining an X-ray or MRI may obviate the need for second-look arthroscopy in many instances simply for the purposes of obtaining a diagnosis.”

Sources said second-look arthroscopy is not standardized in the United States but is performed on a case-by-case or one-off basis. Robert G. Marx, MD, professor of orthopedic surgery at Hospital for Special Surgery and Weill Cornell Medical College, noted patients who are symptom-free after surgery should not be subjected to second-look arthroscopy as it may cause complications that may not have occurred otherwise.

Nicholas A. Sgaglione, MD
Nicholas A. Sgaglione, MD, said second-look arthroscopy can be valuable when used during removal of hardware placed to fix intra-articular or chondral fractures.

Source: C. Sgaglione

“If I do an operation on someone and they are symptom-free, I may be interested to see what is going on, but I will not subject that patient to another operation, the risks of surgery and the recovery, because I do not feel it is in their best interest unless they have been enrolled and consented to a research protocol where it would have stated ahead of time that was part of the deal,” Marx said.

Cole does not perform diagnostic second-look arthroscopy, but only uses second-look arthroscopy when the patient is symptomatic. During medically indicated second-look, patients may realize a therapeutic benefit. He told Orthopedics Today this tends to occur in patients who underwent cartilage repair in conjunction with meniscal transplants or osteochondral allografting.

“True second-look arthroscopy in the setting of cartilage transplantation can actually be a therapeutic procedure when associated with limited debridement of a previous cartilage transplant,” Cole said.

“If I am going to take someone to surgery, it is because I want to look and determine what I can do. Hopefully I can do something relevant and productive at that time. If not, then it helps me plan for the future,” Cole said. “Unfortunately, our meniscal allograft [cases] with other cartilage procedures, such as osteochondral allografts, not uncommonly go back for second-look up to one-third of the time because of symptoms.”

Brian J. Cole, MD, MBA
Brian J. Cole

John M. Tokish, MD, Orthopedics Today Section Editor for Arthroscopy, said second-look arthroscopy in patients after osteoarticular transfer, juvenile cartilage transplant or microfracture can give the surgeon and patient “a clear sense of how that cartilage is maturing and allows them to evaluate the stiffness of it and even take biopsies of it and evaluate the scene of the junction between the normal cartilage and where [the transfer or transplant] was done.”

Any regenerative efforts performed on the cartilage and meniscus also can be evaluated for effectiveness through second-look arthroscopy, he said.

“Before we, as a society, go down a road where we invest in many of these technologies, I think it is incumbent upon us to prove the structural outcomes and the biologic outcomes of these [new devices exceed] what we currently offer. In-office or diagnostic arthroscopy, second-look arthroscopy can be a valuable adjunct tool in evaluating the effectiveness of these regenerative technologies,” Tokish said.

Nicholas A. Sgaglione, MD, professor and department chair at Northwell Health Orthopedics, said second-look arthroscopy provides the most value when it is used after removal of hardware placed to fix intra-articular or chondral fractures.

“The value would be perhaps in removing intra-articular hardware in cases of fixation of osteochondritis dissecans (OCD) where you fix a fragment in the knee of an adolescent with a screw. At the time you need to remove it, you would do a second-look arthroscopy for removal of the hardware before the patient would be allowed to fully return to functional activities. At the same time, you would be able to assess healing of the OCD lesion or fragment,” Sgaglione, who is an Orthopedics Today Editorial Board Member, said.

The timing of second-look arthroscopy to evaluate treatment progress depends on the expected time of tissue maturation and biological healing, according to Sgaglione.

“In cases of OCD healing, it may be 3 months,” he told Orthopedics Today. “In cases of meniscus repair, it may be 4 to 6 months. In cases of cartilage biorestoration, it may be 6 to 12 months.”

Related risks, complications

Second-look arthroscopy does not tend to be particularly invasive. Research by Patel and colleagues into second-look arthroscopy published in Arthroscopy Techniques showed it had 30-day readmission and reoperation rates of 0.64% and 0.40%, respectively.

John M. Tokish, MD
John M. Tokish

Risks with anesthesia, infection, thromboembolic disease, as well as the lost wages and time at work and extended recovery that patients must endure after second-look arthroscopy done in the OR all must be considered, Sgaglione said.

“I do not think [second-look arthroscopy is] something that will become commonplace for any of the common procedures we do because of those logistical challenges and the small, but not zero risk, of going back to the operating room or going back inside the knee,” Tokish told Orthopedics Today.

Another downside to second-look arthroscopy, he said, is patients undergo a short postoperative rehabilitation period right after the postoperative rehabilitation period that occurred after the primary surgery.

“Whenever you place fluid in the knee it will cause a reflex shut down of the quad[riceps] musculature. That is fairly well demonstrated in the literature,” he said. “So, patients cannot necessarily go back to aggressive sports or activity that afternoon, but generally, because there has been fluid placed in the knee and no real procedure is done, the rehabilitation is accelerated. Most patients are back to near full activity as soon as the wounds heal, which happens sometimes around 7 to 10 days.”

Benefits of in-office arthroscopy

New products are on the market, such as Mi-Eye 2 (Trice Medical) and VisionScope (VisionScope Technologies LLC) that allow surgeons to perform second-look arthroscopy in the office. They eliminate the need to take patients back to the OR and make the procedure less invasive, Tokish said.

The FDA-cleared, hand-held Mi-Eye 2 arthroscope, which consists of a needle, camera and integrated light source, can be used to illuminate and visualize the inside of the knee joint in-office for diagnostic and operative arthroscopy in conjunction with a high-definition tablet.

VisionScope, which is FDA-cleared, can produce still and motion pictures of articular cavities when used with a light source, camera and handpiece.

“There are several companies now that have developed in-office arthroscopy systems to where, through an injection or a port the size of a large needle, we can do the second-looks, if you will, right inside the office, which is a tremendous step forward,” Tokish said. “As the technology of the systems gets better, it may become a super valuable tool to [improve] our ability to evaluate cartilage surfaces, menisci.”

In-office arthroscopy can benefit patients who cannot undergo MRI for medical reasons or who are claustrophobic, Patel and colleagues noted. It is “a less expensive, more readily available way to visualize the previous repair” vs. diagnostic arthroscopy, they wrote.

In-office arthroscopy, however, is not immune to complications, according to Tokish, who noted patients still have a small risk for infection.

One downside of in-office arthroscopy is “visualization is not as clear as a true operative diagnostic arthroscopy,” Patel and colleagues wrote.

Arthroscopy vs high-quality imaging

Bert R. Mandelbaum, MD
Bert R. Mandelbaum

For many orthopedic surgeons, MRI, which is completely noninvasive, seems to be a better option to assess the knee after primary arthroscopy, according to Bert R. Mandelbaum, MD, orthopedic surgeon and co-chair of medical affairs at Cedars-Sinai and Kerlan-Jobe Institute in Los Angeles.

“When you have MRI and some of the [higher] technological MRIs where we can look at specific questions, the MRI could be helpful in that regard,” Mandelbaum told Orthopedics Today.

MRI avoids the need to evaluate a treatment invasively, he said.

Better MRI technology with newer sequences result in more detailed images, and may provide visuals of “gross structures and imaging characteristics” that second-look may not be able to capture, Tokish said.

However, compared to a second look via an arthroscope or equivalent in-office technology, even the latest MRI technology does now show the surgeon the type of tissue seen. Furthermore, surgeons who use MRI alone cannot palpate or tactilely evaluate the stiffness and structure of a construct in the knee, Tokish said.

Histological information

“Especially with the new advent of regenerative technology, sometimes we want a little biopsy or a little sample of that because it is important to us to exactly, histologically know what is going on. You can get that from second-look arthroscopy with minimally invasive techniques, but you cannot get that from imaging or MRI,” Tokish said.

He said not all MRI is the same. MRI results at a major academic university may differ from results “from a local for-profit, private practice MRI suite,” which makes a difference.

Insurance coverage

Payment for second-look arthroscopy is another issue. Surgeons must justify to the insurance company why they performed a second arthroscopy, especially in a patient who is asymptomatic.

“For cartilage evaluation, in the asymptomatic patient, that can be a difficult thing to get insurance to cover. But, in patients who are struggling or not doing well, then it becomes a good diagnostic tool that generally insurance companies will cover,” Tokish said. “But, it oftentimes does take some peer-to-peer discussion between the operating surgeon and the insurance company to justify.”

reimbursement graphic

Second-look arthroscopy for hardware removal is an indication for which Sgaglione has seen favorable approval from insurance companies.

“If we are doing [second-look arthroscopy] for removal of hardware, our ability to look while we are actually carrying out a procedure that is indicated, meaning the metal or the screws have to come out, would be supported,” Sgaglione said. “If we are just looking for the sake of recording information to more objectively evaluate outcomes, they would not support that.”

In terms of cost, second-look arthroscopy “is similar to regular, diagnostic arthroscopy,” but that depends on the patient’s case and insurance, Tokish noted.

Research benefits

Although many arthroscopy surgeons may not use second-look arthroscopy to assess healing progress in asymptomatic patients, sources told Orthopedics Today taking a second, arthroscopic look at the knee joint may be helpful in the research setting.

“Second-look arthroscopy for the sake of simply looking at something may not be a high-demand situation any longer other than for research purposes,” Cole said.

Robert G. Marx, MD
Robert G. Marx

It can help researchers who are performing new procedures in patients see “what is happening in their knee or in their joint,” Marx noted.

“[It] may be part of the research protocol that the patient is subjected to a second-look largely for research purposes, so you can learn from that person’s experience and perhaps even biopsy a small piece of the regenerative or new tissue or see otherwise what is happening,” Marx said. “But, that would be something that is specified ahead of time and ethically the patient would have the right, of course, to opt out.”

In studies being submitted to the FDA, follow-up arthroscopy can be of benefit based on the trial’s focus and what investigators hope to show, Tokish said.

“[Sponsors] going through the regulatory process would submit to the FDA applications that include second-look arthroscopy with a primary endpoint being the structural integrity ... of a graft. ... Now, they focus mainly on pain and function and those are secondary outcome variables,” Cole said.

Marx noted the information obtained from second-look arthroscopy for research purposes must still be weighed against the patient’s infection risk and anesthesia time.

“There is also recovery time, time off work [and] economic consequences,” Marx said. – by Casey Tingle

Disclosures: Sgaglione reports he receives royalties from Wolters-Kluwer and consulting fees from Zimmer Biomet. Cole, Marx, Mandelbaum and Tokish report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “In today’s health care environment, should second-look knee arthroscopy be reevaluated as a clinical practice?

Historically, second-look arthroscopy has been used to assess healing in the knee joint postoperatively for research and non-research purposes. However, due to some of its risks and complications, as well as recent advances that have yielded better imaging of tissue and structures, orthopedic surgeons have looked for good alternatives to follow-up knee arthroscopy.

On the other hand, sources for this Cover Story discussed new in-office arthroscopy technology to get a less-invasive second-look at a cartilage or meniscal repair, for example. These techniques may mitigate undergoing a subsequent OR visit and some of the associated risks.

“Second-look arthroscopy, or diagnostic arthroscopy, if you will, which is a [broader] term, was historically performed in a setting where we did not know or needed to confirm a diagnosis in the absence of high-quality MRI to otherwise guide our decision-making,” Brian J. Cole, MD, MBA, associate chairman of the department of orthopedics at Midwest Orthopaedics at Rush, told Orthopedics Today. “But frankly, taking a history, performing a physical and maybe obtaining an X-ray or MRI may obviate the need for second-look arthroscopy in many instances simply for the purposes of obtaining a diagnosis.”

Sources said second-look arthroscopy is not standardized in the United States but is performed on a case-by-case or one-off basis. Robert G. Marx, MD, professor of orthopedic surgery at Hospital for Special Surgery and Weill Cornell Medical College, noted patients who are symptom-free after surgery should not be subjected to second-look arthroscopy as it may cause complications that may not have occurred otherwise.

Nicholas A. Sgaglione, MD
Nicholas A. Sgaglione, MD, said second-look arthroscopy can be valuable when used during removal of hardware placed to fix intra-articular or chondral fractures.

Source: C. Sgaglione

“If I do an operation on someone and they are symptom-free, I may be interested to see what is going on, but I will not subject that patient to another operation, the risks of surgery and the recovery, because I do not feel it is in their best interest unless they have been enrolled and consented to a research protocol where it would have stated ahead of time that was part of the deal,” Marx said.

Cole does not perform diagnostic second-look arthroscopy, but only uses second-look arthroscopy when the patient is symptomatic. During medically indicated second-look, patients may realize a therapeutic benefit. He told Orthopedics Today this tends to occur in patients who underwent cartilage repair in conjunction with meniscal transplants or osteochondral allografting.

PAGE BREAK

“True second-look arthroscopy in the setting of cartilage transplantation can actually be a therapeutic procedure when associated with limited debridement of a previous cartilage transplant,” Cole said.

“If I am going to take someone to surgery, it is because I want to look and determine what I can do. Hopefully I can do something relevant and productive at that time. If not, then it helps me plan for the future,” Cole said. “Unfortunately, our meniscal allograft [cases] with other cartilage procedures, such as osteochondral allografts, not uncommonly go back for second-look up to one-third of the time because of symptoms.”

Brian J. Cole, MD, MBA
Brian J. Cole

John M. Tokish, MD, Orthopedics Today Section Editor for Arthroscopy, said second-look arthroscopy in patients after osteoarticular transfer, juvenile cartilage transplant or microfracture can give the surgeon and patient “a clear sense of how that cartilage is maturing and allows them to evaluate the stiffness of it and even take biopsies of it and evaluate the scene of the junction between the normal cartilage and where [the transfer or transplant] was done.”

Any regenerative efforts performed on the cartilage and meniscus also can be evaluated for effectiveness through second-look arthroscopy, he said.

“Before we, as a society, go down a road where we invest in many of these technologies, I think it is incumbent upon us to prove the structural outcomes and the biologic outcomes of these [new devices exceed] what we currently offer. In-office or diagnostic arthroscopy, second-look arthroscopy can be a valuable adjunct tool in evaluating the effectiveness of these regenerative technologies,” Tokish said.

Nicholas A. Sgaglione, MD, professor and department chair at Northwell Health Orthopedics, said second-look arthroscopy provides the most value when it is used after removal of hardware placed to fix intra-articular or chondral fractures.

“The value would be perhaps in removing intra-articular hardware in cases of fixation of osteochondritis dissecans (OCD) where you fix a fragment in the knee of an adolescent with a screw. At the time you need to remove it, you would do a second-look arthroscopy for removal of the hardware before the patient would be allowed to fully return to functional activities. At the same time, you would be able to assess healing of the OCD lesion or fragment,” Sgaglione, who is an Orthopedics Today Editorial Board Member, said.

The timing of second-look arthroscopy to evaluate treatment progress depends on the expected time of tissue maturation and biological healing, according to Sgaglione.

PAGE BREAK

“In cases of OCD healing, it may be 3 months,” he told Orthopedics Today. “In cases of meniscus repair, it may be 4 to 6 months. In cases of cartilage biorestoration, it may be 6 to 12 months.”

Related risks, complications

Second-look arthroscopy does not tend to be particularly invasive. Research by Patel and colleagues into second-look arthroscopy published in Arthroscopy Techniques showed it had 30-day readmission and reoperation rates of 0.64% and 0.40%, respectively.

John M. Tokish, MD
John M. Tokish

Risks with anesthesia, infection, thromboembolic disease, as well as the lost wages and time at work and extended recovery that patients must endure after second-look arthroscopy done in the OR all must be considered, Sgaglione said.

“I do not think [second-look arthroscopy is] something that will become commonplace for any of the common procedures we do because of those logistical challenges and the small, but not zero risk, of going back to the operating room or going back inside the knee,” Tokish told Orthopedics Today.

Another downside to second-look arthroscopy, he said, is patients undergo a short postoperative rehabilitation period right after the postoperative rehabilitation period that occurred after the primary surgery.

“Whenever you place fluid in the knee it will cause a reflex shut down of the quad[riceps] musculature. That is fairly well demonstrated in the literature,” he said. “So, patients cannot necessarily go back to aggressive sports or activity that afternoon, but generally, because there has been fluid placed in the knee and no real procedure is done, the rehabilitation is accelerated. Most patients are back to near full activity as soon as the wounds heal, which happens sometimes around 7 to 10 days.”

Benefits of in-office arthroscopy

New products are on the market, such as Mi-Eye 2 (Trice Medical) and VisionScope (VisionScope Technologies LLC) that allow surgeons to perform second-look arthroscopy in the office. They eliminate the need to take patients back to the OR and make the procedure less invasive, Tokish said.

The FDA-cleared, hand-held Mi-Eye 2 arthroscope, which consists of a needle, camera and integrated light source, can be used to illuminate and visualize the inside of the knee joint in-office for diagnostic and operative arthroscopy in conjunction with a high-definition tablet.

VisionScope, which is FDA-cleared, can produce still and motion pictures of articular cavities when used with a light source, camera and handpiece.

“There are several companies now that have developed in-office arthroscopy systems to where, through an injection or a port the size of a large needle, we can do the second-looks, if you will, right inside the office, which is a tremendous step forward,” Tokish said. “As the technology of the systems gets better, it may become a super valuable tool to [improve] our ability to evaluate cartilage surfaces, menisci.”

PAGE BREAK

In-office arthroscopy can benefit patients who cannot undergo MRI for medical reasons or who are claustrophobic, Patel and colleagues noted. It is “a less expensive, more readily available way to visualize the previous repair” vs. diagnostic arthroscopy, they wrote.

In-office arthroscopy, however, is not immune to complications, according to Tokish, who noted patients still have a small risk for infection.

One downside of in-office arthroscopy is “visualization is not as clear as a true operative diagnostic arthroscopy,” Patel and colleagues wrote.

Arthroscopy vs high-quality imaging

Bert R. Mandelbaum, MD
Bert R. Mandelbaum

For many orthopedic surgeons, MRI, which is completely noninvasive, seems to be a better option to assess the knee after primary arthroscopy, according to Bert R. Mandelbaum, MD, orthopedic surgeon and co-chair of medical affairs at Cedars-Sinai and Kerlan-Jobe Institute in Los Angeles.

“When you have MRI and some of the [higher] technological MRIs where we can look at specific questions, the MRI could be helpful in that regard,” Mandelbaum told Orthopedics Today.

MRI avoids the need to evaluate a treatment invasively, he said.

Better MRI technology with newer sequences result in more detailed images, and may provide visuals of “gross structures and imaging characteristics” that second-look may not be able to capture, Tokish said.

However, compared to a second look via an arthroscope or equivalent in-office technology, even the latest MRI technology does now show the surgeon the type of tissue seen. Furthermore, surgeons who use MRI alone cannot palpate or tactilely evaluate the stiffness and structure of a construct in the knee, Tokish said.

Histological information

“Especially with the new advent of regenerative technology, sometimes we want a little biopsy or a little sample of that because it is important to us to exactly, histologically know what is going on. You can get that from second-look arthroscopy with minimally invasive techniques, but you cannot get that from imaging or MRI,” Tokish said.

He said not all MRI is the same. MRI results at a major academic university may differ from results “from a local for-profit, private practice MRI suite,” which makes a difference.

Insurance coverage

Payment for second-look arthroscopy is another issue. Surgeons must justify to the insurance company why they performed a second arthroscopy, especially in a patient who is asymptomatic.

“For cartilage evaluation, in the asymptomatic patient, that can be a difficult thing to get insurance to cover. But, in patients who are struggling or not doing well, then it becomes a good diagnostic tool that generally insurance companies will cover,” Tokish said. “But, it oftentimes does take some peer-to-peer discussion between the operating surgeon and the insurance company to justify.”

reimbursement graphic

PAGE BREAK

Second-look arthroscopy for hardware removal is an indication for which Sgaglione has seen favorable approval from insurance companies.

“If we are doing [second-look arthroscopy] for removal of hardware, our ability to look while we are actually carrying out a procedure that is indicated, meaning the metal or the screws have to come out, would be supported,” Sgaglione said. “If we are just looking for the sake of recording information to more objectively evaluate outcomes, they would not support that.”

In terms of cost, second-look arthroscopy “is similar to regular, diagnostic arthroscopy,” but that depends on the patient’s case and insurance, Tokish noted.

Research benefits

Although many arthroscopy surgeons may not use second-look arthroscopy to assess healing progress in asymptomatic patients, sources told Orthopedics Today taking a second, arthroscopic look at the knee joint may be helpful in the research setting.

“Second-look arthroscopy for the sake of simply looking at something may not be a high-demand situation any longer other than for research purposes,” Cole said.

Robert G. Marx, MD
Robert G. Marx

It can help researchers who are performing new procedures in patients see “what is happening in their knee or in their joint,” Marx noted.

“[It] may be part of the research protocol that the patient is subjected to a second-look largely for research purposes, so you can learn from that person’s experience and perhaps even biopsy a small piece of the regenerative or new tissue or see otherwise what is happening,” Marx said. “But, that would be something that is specified ahead of time and ethically the patient would have the right, of course, to opt out.”

In studies being submitted to the FDA, follow-up arthroscopy can be of benefit based on the trial’s focus and what investigators hope to show, Tokish said.

“[Sponsors] going through the regulatory process would submit to the FDA applications that include second-look arthroscopy with a primary endpoint being the structural integrity ... of a graft. ... Now, they focus mainly on pain and function and those are secondary outcome variables,” Cole said.

Marx noted the information obtained from second-look arthroscopy for research purposes must still be weighed against the patient’s infection risk and anesthesia time.

“There is also recovery time, time off work [and] economic consequences,” Marx said. – by Casey Tingle

Disclosures: Sgaglione reports he receives royalties from Wolters-Kluwer and consulting fees from Zimmer Biomet. Cole, Marx, Mandelbaum and Tokish report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “In today’s health care environment, should second-look knee arthroscopy be reevaluated as a clinical practice?