26 May 2021
Our Department of Traumatology and Hand Surgery is now equipped with the highest quality arthroscopy tools thanks to dr. Balázs Patczai orthopaedic and traumatology expert and vice-director of the department. Not only has he brought the technology, he has also brought the methodology to Hungary. The 1.9 millimetre, somewhat flexible optics and the controls are smaller than a computer mouse, therefore it fits easily into the hand of a doctor. The device is officially called a nanoscope, or needle arthroscope, and it comes with a console that looks like a laptop: this is where the world within the joint and the ligaments is shown. I discussed the efficiency and future usability of this modern diagnostic and therapy tool with dr. Balázs Patczai.
written by Riza Schweier
- I see two buttons on the top of the arthroscope, what are those for?
- We can set what functions we want the camera to have on the console of the needle arthroscope: do we want pictures of video, that’s what the two buttons are for. This is important both for the safety of the patient and for documentation possibilities. With the recordings of a needle arthroscopy done at a clinic, we can help the definitive surgery preparations. The visuals from the camera are bought to the central unit by an optical system; this is also providing light to the inner workings.
- What can the console do?
- Consoles are a widely known concept in computer gaming, this is what we also use. This is a computer, perfected for the end user. It only has one button, and an inline connection for a single-use optical part, and there are multiple options for charging and data transfer. It provides a touchscreen where the patient can be registered, and it can also manage the interface of multiple doctors with special settings. An ankle- or foot surgeon can set fine-tune the device using pre-set panels.
This is different from previous technologies in that the optical unit is single-use and the console is highly transportable, opening the possibilities for examinations done at a doctor’s office. The philosophy of the development was to achieve the highest possible amount of data about joint damage and abnormalities with the least invasive method possible. The optics can be inserted through a needlemark, therefore the joint and joint functions are easy to examine during movement, even with local anaesthesia. Ligament stability, cartilage instabilities or movements would be difficult to prove or disprove with static MR or CT screenings. The system is therefore equipped with tools similarly thin to the optics: these could even be used for treating smaller injuries and deformities. We could move the meniscus in the knee joint, we could evaluate the stability of the ACL and damaged cartilage pieces, joint endothelia, growths and smaller cysts. There would be no need for a second surgery, because the equipment allows definitive treatment.
- Where does the needle go in the arthroscope?
- The inlines are called channels, one of these is where the camera goes for visualization, the others are for work. Tools used to work within the joints go through the latter. The diameter of the tools is only 1.9 millimetres compared to the previous 5 millimetres, which is important because we do not have to stitch the entry point after removing the trocars (casings for the work channels).
- So if a patient goes to such an examination, they will get two local anaesthesia shots in their knee, and then you will examine the damaged or deformed area with the needle arthroscope. If needed, you can even treat it on the spot, and then all that’s needed is a plaster on the entry point?
- Yes, this procedure causes no more damage than a joint injection.
- How big is the scar left by traditional surgeries?
- The size average of traditional arthroscopy tools is above the nanoscope, these have 4.5 millimetre optics, the work channels or trocars are also thichker, therefore they cause more damage – somewhere between 7 and 10 millimetres. With needle arthroscopy, this is only 2 millimetres. Insertion with the new technology does not even require a scalpel stab, the trocar opens the way towards the joint. After removing the needle, the tissues will touch again, there is no joint fluid leakage either. The joint capsules are barely damaged and the secondary damages are negligible compared to procedures done with traditional tools.
- How widely is this technology available?
- Barely, it only appeared in the United States at the end of 2019. Due to the pandemic in 2020, there were no outstanding successes, therefore the number of people who have this device is limited worldwide. I have completed this procedure in Hungary and in the middle-and far regions here in Pécs first.
- Why did you find bringing this technology home important?
- I am a curious person, drawn to new things, be that a wound treatment method or the use of new types of implants. My open-mindedness met one of my beloved areas, the treatment of ankle- and foot injuries. I have done many ankle arthroscopies, and the size of the entry points can have a huge effects, since the joint is narrow and small. This is a much lighter technology than its forbearers are, it is much more patient-friendly. Another advantage is that patients do not have to spend nights at the clinic; they can walk home right after the procedure. The pain is much less, they can even attend physiotherapy the very next day, and get back to their active life.
- Can we count on this becoming a common diagnostic and therapy tool in doctor’s offices?
- Yes, the possibilities are there, since the prices will also drop with time. With this device, diagnostics for upper and lower extremities will become available for many, including the peroneus tendons (these are around the outer part of the ankle) which could be treated in a minimally invasive way. This area is prone to inflammations and tearing of tendons, the presence of which could be proven with needle arthroscopy. The diagnostics of the hallux joint is very challenging, and this method would simplify that as well. The same can be said about the ankle joint, this is a small joint with a relatively small range of movement, and the semi-flexible, super thin optics make the diagnostics of the post-injury state much easier. The deformities of the upper jumping joint, membrane thickening and scarring could also be easier to treat in examination room circumstances. The removal of possible free bodies could also happen, and the so called frontal pinched injuries could also be treated easily.
I have done such an examination on a young woman doing sports. The metal tools implanted around the knee would have made an MR dangerous, and it would have provided too little information. However, we had to know what was inside the joint for a diagnosis. We surveyed the extent of the damage with needle arthroscopy, and we could also treat it during the same procedure. If this device enters common use, we could try and solve even more things.
- How many arthroscopies, procedures have you done with this method so far?
- We have worked for multiple days during dry trials with the Artrex company. Due to my serious experience with joint arthroscopies, especially in connection with ankle-, foot- and tendon injuries, I did not need a lot of preparation.
Getting to know the device is enough to provide confidence in completing surgeries with it. During the pandemic, the efforts of radiologist colleagues were concentrated on the pandemic, therefore the diagnostic possibilities were greatly reduced. We had over ten surgeries so far and we are still waiting for the licence to use the device in doctor’s offices. As clinical doctors, the development and implementation of these procedures is also our task.
- Do you have a lot of patients with joint damage?
- Yes, this is the largest part of extremity surgery. Our patients mostly have sports injuries, or have painful joint due to joint instability as they get on in age.
- How much does this cutting-edge device cost, and how can the intrinsic value be decided?
- The console itself is priced around the same as a higher-middle category car, but the hand device and the tools are not cheap as well. We intend to finance the costs of background research and the implementation of the new technology from the joint application of the Medical School and the Clinical Centre. The declarations about anaesthesia, surgery technique and use will all be a valuable basis for professional articles, and we hope that our workgroup will be able to publish these this year.
- Who are the members of the workgroup?
- I have invited dr. Róbert Almási, the expert of the Department of Anaesthesiology and Intensive Therapy, dr. Tibor Mintál knee specialist, leader of the Sports Medicine Department, and dr. Lóránd Kromek head physician for hand- and elbow surgery. We have already developed the scientific-professional project and the budget. We have the support of the director of our clinic, dr. Norbert WIegand, and the chairman of the Clinical Centre, dr. Andor Sebestyén, and we were able to being working.
We are planning publications for surgeries on each region, using the device in the everday life in the meantime (as much as our funding allows, of course). There will be boundaries, of course, since this is an expensive procedure. We have completed exact calculations about the cost of each traditional arthroscopy in a surgery room, compared to the cost of a needle arthroscopy; the former is naturally cheaper right now. We will only be able to draw exact economic conclusions after completing 40-50 procedures, because this requires serious examination for isolation, surgery time, staff, anaesthesia requirements and equipment sterilisation. Once we have this, we will know if the new technology is really more expensive than the traditional one.
- You have mentioned that you will become a national training centre after the initiative of Artrex.
- Yes, our clinic is the first NanoScope Centre, and we are proud of this title. We will endeavour to introduce this technology both in patient care and in the training of professionals and medical students. We aim to educate them on this new tool and the connected set of equipment. It is important to pass on this knowledge.