In-Office $450 MRI Alternative; “First-in-the-NFL” Ankle Study; No “July Effect” for Orthopedic Training?
Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, December 21st, 2016
In-Office Arthroscope for Knees, Shoulders!
A method to save time, money, and reduce stress on the patient…what could it be? A new handheld imaging system from Trice Medical called Mi-eye 2 which costs about as much as a cell phone and is fully reimbursed by Medicare and private payers.
The image quality is clear enough that, says Dr. James Gladstone at Mount Sinai in New York City, it can give MRIs a run for their money.
James N. Gladstone, M.D. is co-chief of the Sports Medicine Service at The Mount Sinai Hospital, and associate professor of Orthopaedic Surgery, in the Department of Orthopaedics at the Icahn School of Medicine at Mount Sinai. He specializes in sports medicine, arthroscopic surgery, and knee and shoulder reconstructive surgery and told OTW, “The Mi-eye 2, the second generation of this tool, is essentially an in-office arthroscope for use on knees and shoulders. (In theory, it can be used on any joint because it is tiny.) The doctor numbs the area and inserts the 14-gauge needle to puncture the skin and the joint capsule. Once in the joint he deploys a lever, which pushes out the scope that contains a digital camera. The scope has a port through which one can inject saline to help visualize the environment.”
“It is very exciting to be able to do all of this during an office visit.”
“The Mi-eye 2 has increased resolution and a better viewing angle (now 120 degrees) such that when you are looking at anything in the joint it’s very similar to what you see in the operating room.”
“Everything is housed in one unit with a USB cable that connects to a tablet-sized screen. If you are suspicious of something in the office, you can administer lidocaine to the knee or shoulder and 10 minutes later insert the scope. The patient can come to the office and leave with a definitive diagnosis.”
“The probes for the Mi-eye 2 are $450 while an MRI can be close to $2,000. We are still defining what the Mi-eye 2 is good for and how it should be used. Just today I had a patient with an osteochondral plug that someone put in two years ago, but he was still in pain. He had an MRI and the area didn’t look like it had healed well. The Mi-eye 2 gave me more of a definitive look at the surface of the cartilage. I could clearly see that it had not healed. So for this patient the next step is a major procedure. We did, however, avoid a formal arthroscopy with time out of work…not to mention anesthesia. And an ability to plan the definitive procedure at the time of the office visit.”
“You have to learn where it fits in your practice. As you use it more, you will understand where it can be helpful. It sure beats the logistics surrounding an MRI, such as having your office staff tied up on the phone getting authorization, then scheduling the appointment for an MRI, and having to tell the patient to come back on a different day to review results. This is the wave of the future as far as injury diagnosis goes.”
When pivoting and tackling in the National Football League (NFL), players need to have their ankles in tip-top shape. Sometimes, however, these athletes have limited range of motion (ROM) and pain as a result of a dorsal impaction syndrome, aka, anterior ankle impingement.
James Bradley, M.D. is team orthopedic surgeon for the Pittsburgh Steelers. He is a past president of the National Football League Physicians Society, is currently chairman of the NFL’s Medical Research Peer Review Committee and serves on the NFL Injury and Safety Panel Committee. Dr. Bradley told OTW, “My colleagues and I have just completed a ‘first-in-the-NFL study,’ namely an investigation on 28 ankles with dorsal impaction syndrome in NFL players from one team.”
“Over years of playing sports, the distal tibia and talar neck suffer from repeated lifting, making it difficult for players to break on the ball in the normal fashion. At the end of a typical season, we have to perform surgery through two portals and remove all of the tibial spurs and do a partial synovectomy, followed by rehabilitation.”
“For this study I worked with Christopher McCrum, M.D. and Sonia Ruef, M.A., A.T.C. to review the results of 28 ankle arthroscopies (26 patients) that I performed over a 23 year period. Each patient had undergone an arthroscopic debridement of the pathologic soft tissue, and an arthroscopic debridement of tibial and talar osteophytes in the anterior ankle.”
“We found a significant reduction in pain as measured by the American Orthopedic Foot and Ankle Score. Thus, the procedure is reproducible and can help these individuals get back to play at a high level.”
“All of the athletes returned to play at the same level within an average of 67 days, and only two players reported residual pain (which resolved at the last follow-up). In addition, there was a significant increase in active ankle dorsiflexion when comparing preoperative motion and postoperative motion at the time of return to play.”
“Our findings indicate that arthroscopic debridement for anterior ankle impingement is a reliable method of relieving pain and restoring ROM in professional football players.”
Study: Perhaps There is No “July Effect”
New work from Rush University Medical Center in Chicago is upending traditional thought about orthopedic training. When summer rolls around each year, in orthopedic training programs, most senior surgeons are gearing up for a new crop of young surgeons in need of training. Anthony A. Romeo, M.D. is director of the Section of Shoulder and Elbow at “Rush.”
Dr. Romeo told OTW, “Every year during the month of July, there is a transition in the orthopaedic training programs where younger and presumably less experienced residents and fellows are promoted to their next year of training. This transition is recognized by the faculty, and typically measures such as increased supervision or less autonomy for the new class of residents and fellows occurs at this time.”
“However, there is speculation that the less experienced trainees at the beginning of their new year may be associated with an increased risk of complications and poorer outcomes for our surgical patients. This has been referred to as the ‘The July Effect,’ and has been reported and sensationalized by influential, high-profile, national news organizations with little scientific support.”
“There are three key points from our work, which was initiated by our residents, and completed by lead author and resident, Allison Rao. We selected total shoulder arthroplasty patients as our study group. We used the American College of Surgeons National Surgical Quality Improvement Program database to look at the results of 1,591 patients.”
“Our goal was to identify any relationship between adverse events in this patient group and the involvement of residents or fellows in their surgical care. One, the involvement of residents and fellows during the first academic quarter had no effect on serious adverse outcomes or events. Two, the lack of a relationship between adverse events and the beginning of the new training year suggests that there is an effective balance between the duty and responsibilities necessary to provide consistent care for patients and the desire to train and educate residents and fellows.
Three, scheduling total shoulder arthroplasty procedures at teaching institutions during the first academic quarter appears to be safe for the patients and does not affect their expected outcomes.”
“On a personal basis, what is most interesting to me after more than 20 years at an academic teaching institution, with responsibilities to both resident and fellow education, is that the lack of an association between adverse events and the onset of the new academic year suggests an appropriate balance between education and patient care. In other words, this analysis would suggest that the most important part of our professional responsibilities, which is to deliver the best care possible to our patients, is not affected by the fact [that] the new and less experienced residents and fellows are integrated into the patient care pathway in the first academic quarter. The supervising physicians are making appropriate adjustments to resident and fellow autonomy so that it does not impact patient outcomes. This process is in effect throughout the entire year, but is most pertinent at the beginning of every academic year.”
“Future work will include the analysis of the impact of resident and fellow participation in other areas of orthopaedic surgery.”
“We recognize that resident and fellow education is a process, and that it is valuable to have real time feedback in terms of the level of technical skill and intellectual prowess of the residents and fellows working with us to care for our patients. We also recognize that the process is not uniform, with some trainees exhibiting expertise at earlier or later time frames than their peers. Therefore, we are working to develop and institute programs such as surgical simulation, as well as technical proficiency analysis, in our training programs.”
“All airline pilots are not equal in their expertise or experience, yet safely transport millions of passengers every day. Programs have been developed to establish a baseline of safety and competence which leads to the trust of the people whose lives they are responsible for. As academic surgeons, we need to develop programs that establish a safe and competent level of patient and surgical care in each an every one of our residents and fellows that is combined with our own ability to adjust our supervision with their level of competence.”