Wide-awake needle arthroscopy is a minimally invasive surgical procedure whereby surgeons can diagnose and treat certain orthopedic injuries and conditions while the patient is fully awake. The procedure may be performed in an operating room, a procedure room, or even in a doctor’s office. In-office needle arthroscopy (IONA) has been gaining attention as a way to treat the same conditions that were once reserved for the operating room.

In-office needle arthroscopy has been available since the 1990s. At the time, it was primarily used for diagnostic purposes. However, its use was limited due to poor image quality. Recent advancements in camera and device technology have substantially improved image quality, improving diagnostic accuracy. Additionally, a number of surgical tools designed specifically for the procedure are available.

These developments allow doctors to use wide-awake needle arthroscopy not only to diagnose but also treat some joint conditions. Previously, these conditions would have required traditional arthroscopy, a more invasive procedure that is typically performed in an operating room with the patient under general or regional anesthesia.

Arthroscopy is a minimally invasive surgical procedure used to visually examine the inside of a joint and treat joint issues. It is often used to evaluate and treat problems in the knee, shoulder, elbow, ankle, hip, and wrist.

Arthroscopy may be performed for a number of reasons, including to evaluate the cause of joint pain and other issues, assess the health of a joint (for instance, after an injury), and treat a number of joint problems. Arthroscopic procedures include repairing ligament, tendon, and cartilage tears; removing loose bodies (tiny pieces of cartilage or bone); and removing damaged cartilage from the joint, among others.

During a traditional arthroscopic procedure, a surgeon makes one or more small incisions (approximately 2 to 3 mm wide) on the skin above the affected joint. Next, the surgeon inserts an arthroscope equipped with a tiny light and camera into the incision to examine the inside of the joint. The camera transmits images to a monitor, allowing the surgeon to examine the joint and make a diagnosis. If treatment is needed, the surgeon repairs or corrects the issue arthroscopically during a single arthroscopic procedure.

Traditional arthroscopy is usually performed as an outpatient procedure in a hospital or surgery center. It can be performed using different types of anesthesia:

• Local anesthesia: A local anesthetic is injected into the joint to numb it, ensuring there is no pain. The patient remains awake during the procedure.
• Regional anesthesia: An anesthetic is injected near nerves to numb a specific area of the body. Spinals and epidurals are types of regional anesthesia. Patients may be awake when regional anesthesia is used, though a sedative may be administered to help them relax, feel drowsy, or sleep. Risks and side effects include headache, stuffy nose, hoarseness, collapsed lung (pneumothorax), and injection of the anesthetic into a vein.
• General anesthesia: Anesthesia is injected into a vein, causing the patient to lose consciousness. A breathing tube may be necessary. Side effects of general anesthesia can include nausea, vomiting, sore throat, confusion after the procedure, muscle aches, and cognitive dysfunction, among other side effects and complications.

Wide-awake needle arthroscopy is an alternative to traditional arthroscopy. Like traditional arthroscopy, it is used to visually assess, diagnose, and treat joint issues. The procedure uses a local anesthetic to numb the affected joint and is performed while the patient is awake. It can be performed in a doctor’s office.

In wide-awake needle arthroscopy, a small “needle arthroscope”—a needle-sized tube equipped with a light and camera—is inserted through a tiny incision on the affected joint. The doctor then uses the arthroscope to visually examine the joint and, if necessary, provide treatment using small surgical instruments.

Compared to traditional arthroscopy, wide-wake needle arthroscopy offers several advantages, including:

• Less invasive: The needle arthroscope is around 1.9 mm in diameter, significantly smaller than the arthroscope used in traditional arthroscopy, which typically measures around 4 mm in diameter. The smaller size of the needle arthroscope allows for smaller incisions than those used during traditional arthroscopy.
• No regional or general anesthesia: Because regional and general anesthesia are not used, patients avoid their associated risks and side effects.
• Shorter recovery time: Wide-awake needle arthroscopy typically involves a shorter recovery time.
• Potentially reduces time between diagnosis and treatment: Because wide-awake needle arthroscopy can diagnose and treat joint issues in a single procedure, during a single appointment, it can reduce the time between diagnosis and treatment. In contrast, traditional arthroscopy may involve multiple appointments for an initial evaluation, imaging tests, follow-up with the surgeon to discuss the treatment plan, and finally, arthroscopy to treat the joint issue.

Wide-awake needle arthroscopy may be used to evaluate, diagnose, and treat a number of joint injuries and conditions, including:

Shoulder:

• Evaluation and diagnosis: Rotator cuff tears, labral tears (tear of the labrum, cartilage that lines the rim of the joint), shoulder impingement (when a tendon rubs against bone or tissue in the joint).
• Treatment: Debridement (removal of damaged, infected, or dead tissue from the joint, for example, after an infection), rotator cuff repair, labral repair, biceps tenotomy (a procedure in which the biceps tendon is released, or cut, and detached from the humerus (the upper arm bone)).

Wrist:

• Evaluation and diagnosis: Carpal tunnel syndrome, triangular fibrocartilage complex (TFCC) tears (TFCC is an area of cartilage in the wrist).
• Treatment: Debridement, TFCC repair, wrist fracture fixation (using pins, screws, plates, or other implants to hold the bones in place while they heal).

Knee:

• Evaluation and diagnosis: Meniscus tears, ligament tears, cartilage and bone damage, synovial inflammation (swelling of the synovial membrane, a layer of tissue that lines the joint).
• Treatment: Meniscus repair, partial meniscectomy (when a surgeon removes the damaged portion of the meniscus), debridement.

Ankle:

• Evaluation and diagnosis: Bone and cartilage damage, ankle impingement (pinching or compression of soft tissues such as ligaments between ankle bones), ligament injuries.
• Treatment: Debridement, bone marrow stimulation (making small holes in the bone to stimulate formation of new cartilage), removal of loose bodies (fragments of cartilage, bone, and/or cartilage and bone), resection of Os (removal of extra bone that can cause impingement), FHL tenosynovectomy (removal of the sheath—connective tissue that covers a tendon—of the flexor hallucis longus (FHL) tendon in people with an inflamed FHL tendon), tendoscopy (using a needle arthroscope to visually evaluate and, if necessary, treat tendon conditions and issues).

Foot:

• Evaluation and diagnosis: Cartilage and bone damage.
• Treatment: Debridement.

Elbow:

• Evaluation and diagnosis: Cartilage and bone damage, identifying the presence of loose bodies.
• Treatment: Loose body removal, bone fracture fixation, osteocapsular arthroplasty (a procedure that involves reshaping the bones, removing loose bodies, and making an incision in the capsule that surrounds the joint to improve elbow movement).

Hip:

• Evaluation and diagnosis: Labral tears (when the labrum, a ring of tough tissue that cushions and stabilizes the hip, tears or detaches from the underlying bone), femoroacetabular impingement (when one or both bones of the hip joint are shaped irregularly, causing them to rub against one another).
• Treatment: Labral repair, debridement.

Wide-awake needle arthroscopy may also be used in other cases as well, including:

• Septic arthritis treatment: Septic arthritis is a condition in which a joint is infected by bacteria, virus, or a fungus, resulting in inflammation and pain. Treatment involves using the needle arthroscope to wash out the joint with saline (known as lavage) or to remove fluid from the joint (known as arthrocentesis).
• Second-look arthroscopy: Wide-awake needle arthroscopy may be used to evaluate a joint after a previous procedure.

At the start of the procedure, a surgeon will position you on an examination table. The position in which you are placed depends on which joint the procedure will be performed. For example, for a knee procedure, you may hang your knee off the examination table, or the provider may place a bolster under your knee to hold it in a bent position. For an ankle procedure, you may be told to hang your leg off the table, whereas for a shoulder procedure, you may be seated in a position that allows the surgeon easy access to your shoulder.

If you wish to observe the procedure, you may be able to watch on a monitor or you may be provided with a mirror that allows you to see the monitor.

The surgeon will then determine where to make skin incisions on the affected joint. A local anesthetic, typically lidocaine, is injected into the incision sites. After 5 to 10 minutes, when the skin is numb, the surgeon injects a local anesthetic, usually a mixture of lidocaine and bupivacaine, into the joints at the incision sites. The surgeon will make small incisions on the skin, then insert the needle arthroscope through the incisions to examine the inside of the joint and treat the injury or conditions, if necessary.

At the end of the procedure, the incisions are closed, usually with adhesive strips.

After the procedure, patients may experience mild pain and may have restrictions on weight-bearing depending on the procedure.

Because wide-awake needle arthroscopy is less invasive than traditional arthroscopy, recovery may be quicker, and patients can often return to walking and work sooner. Additionally, patients do not require a lot of pain medication, including opioids. In some cases, no pain medication is necessary.

While wide-awake needle arthroscopy is a safe procedure, certain complications are possible, including:

• Infection
• Bleeding
• Fainting
• Need for additional surgery

“There has been increased attention in the orthopaedic community focusing on the benefits of more minimally invasive surgeries to help reduce postoperative complications and expedite recovery,” says Yale Medicine orthopaedic surgeon Arianna Gianakos, DO. “At Yale, we offer needle arthroscopy procedures and are the first institution in Connecticut to offer this procedure in the ankle joint in a wide-awake setting, reducing the need for general anesthesia and its associated adverse effects. Needle arthroscopy can be utilized in the treatment and management of various conditions, including tendon injuries, ankle joint injuries, small joint injuries, and in multiple areas of the body. While this procedure may not be indicated for everyone, Yale is at the forefront of new minimally invasive technologies in order to provide the best care for patients.”