»» Good afternoon, I'm John Andrew Grotting with Synergy Orthopedics in San Diego, California. And I'll be presenting on our experience with, can 2mm diameter operative arthroscopy predict appropriate surgical management of intraarticular shoulder pathology more accurately than MRI? I'd like to thank my co-authors. I have no disclosures and those of my co-authors are available online. So when it comes to shoulder, MRI can leave some uncertainty, especially when it comes to borderline shoulder pathology like partial thickness rotator cuff tear. Ultimately the length of immobilization and the likely length of rehab is one of the questions that our patients value the most. And between a rotator cuff repair and rotator cuff debridement, there's a pretty significant difference. To that end, needle arthroscopy has been developed to allow direct inspection of some of the pathologic tissue to make better decisions with regard to that. MacMillan et al. had demonstrated this could be done safely in office for both knee and shoulder. And Wagner et al. had shown some promising results for this diagnostically within the shoulder using the beach chair position. Now we know we can do this. The question is, what could be the diagnostic patient benefit and if we should do it? So our question was, our objective was to compare the diagnostic and procedure-predictive accuracy of a 2-millimeter arthroscopy of the shoulder using an Arthrex nanoscope with a 1.5 Tesla MRI. And the gold standard for us was the 4-millimeter surgical arthroscopy. So the study was an IRB-approved prospective blinded single-centered trial. We had 30 patients who were already scheduled for surgery who had undergone an MRI of the shoulder. On the day of surgery under general anesthesia, a 2-millimeter needle arthroscopy was performed from a single posterior viewing portal in the lateral position and a full standardized evaluation was performed and recorded. Following that, a 4-millimeter scope was used to perform and record the gold standard comparison and an evaluation followed by a surgical procedure which is indicated by the evaluation. Both videos and MR images were then de-identified and blindly reviewed by two Sports Medicine Fellowship-trained surgeons using a standardized evaluation rubric. We then compared diagnostic agreement as well as the most appropriate treatment recommendations in the form of CPT codes between the diagnostic modalities of the 2-millimeter and the MRI. For diagnostic agreement, kappa values and p-values are outlined in red for all anatomic structures on the right there. What we found is there's a trend towards higher kappa coefficients in the 2-millimeter versus the MRI in all rotator cuff diagnostic categories. When considering the predictive ability of the 2-millimeter arthroscope to determine whether or not a patient will undergo arthroscopic rotator cuff repair defined here as 29827 CPT code, the 2-millimeter was equally sensitive to MRI to rule it out but at a higher positive predictive value as compared to MRI. Then when you compile all CPT codes for arthroscopy of the shoulder, the agreement, the 2-millimeter demonstrated a higher kappa coefficient compared to MRI. So just to show you some of the video from our study to kind of show what we're looking at here, on the left obviously we have the MRI. And reviewers had not indicated 29827 rotator cuff repair for that. And looking at the amount of footprint that was exposed using the 2-millimeter scope, for the 2-millimeter scope they did indicate 29827. And then ultimately a rotator cuff repair was performed using the 4-millimeter scope. Now there's some important limitations to our study obviously. We tried to make this a real-world study with 1.5 tesla oftentimes being what we're able to use. But a 3 tesla would have been more accurate if we were able to have access to that for all of our patients. We did not include other imaging modalities which may have improved accuracy like MR arthrography or ultrasound. And the patient was obviously awake, which limits our ability, it was obviously asleep versus the ideal patient would be awake in office to do this and it may alter the accuracy of this. Finally the glenohumeral joint was the only joint that we looked in. We didn't look in the subacromial space with the 2-millimeter and these patients had already been indicated for surgery so there's some selection bias apparent here. So for conclusion, the 2-millimeter arthroscopy demonstrated to us that it was pretty effective in both anatomic structures as well as surgical decision-making and could in the future with more studies be a potential alternative to MRI in the appropriate patients. But certainly I think further study is needed to see this actually borne out in awake patients. So thank you.

John Andrew Grotting

Synergy Orthopedics

San Diego

2mm needle arthroscopy

1.5 Tesla MRI