2026 Volume 1 Issue 1 Pages 17-22
Arthroscopic techniques were first established in the early 20th century to provide alternative surgical treatment options for orthopedic pathologies. The discoveries and innovations of orthopedic pioneers provided the foundation for what is known today as the modern in-office needle arthroscope. The latest innovative optics in second-generation needle arthroscopes allow enhanced visualization of most joints and tendons and provide a visual platform that can facilitate a variety of surgical techniques. As a result, patients experience excellent clinical outcomes, along with increased satisfaction and greater cost-effectiveness when undergoing such procedures. The purpose of this review is to discuss the history, modern advancements, techniques, clinical outcomes, and cost-benefit analysis of in-office needle arthroscopy.
Figure 1
Example positioning for in-office anterior-posterior tibial tendon needle tendoscopy. The surgeon sits at the foot of the surgical bed with an assistant next to the viewing monitor. The assistant has provided permission to publish the image that was obtained.
The concept of arthroscopy was first established in 1912 by Danish surgeon Severin Nordentoft, who presented his novel trokart-endoscope at the Congress of the German Society of Surgeons in Berlin.1 Dr. Nordentoft promoted his device as a unique way to better visualize the anterior compartments of the knee.1 In 1918, Kenji Takagi advanced the arthroscope from Nordentoft’s original 5-mm design to his own 7.3-mm design.2 His final iterations were completed in 1920, when Dr. Takagi used saline solution as a medium to facilitate endoscopic images of the knee joint.2 The first person to use the arthroscopic technique on a larger scale was Eugen Bircher, who conducted approximately 60 endoscopic procedures of the knee between 1921 and 1926.3 In the United States, Phillip Kreuscher pioneered the arthroscopic approach in 1925 to diagnose and treat cartilage lesions of the menisci.4 Around the same time, Michael Burman highlighted the need for a light source and proper extremity positioning to optimize visualization.5 Not only did Dr. Burman perform his technique on cadavers, but he was also one of the first to apply the arthroscopic method on patients.5 An apprentice of Dr. Takagi, Masaki Watanabe, further advanced the development of the arthroscope. From 1951 to 1970, Dr. Watanabe developed various iterations, ultimately creating the No. 25 arthroscope with a 2-mm diameter sheath.6 The collective contributions of these pioneers laid the foundation of modern arthroscopic technology.
In the 1990s, the Optical Catheter System (Medical Dynamics, Englewood, USA) and the Needlescope (Smith & Nephew, USA) were the first two needle arthroscopes developed for clinical use.4,7 The diameters of these devices were 1.7 mm compared to traditional arthroscopes of 4.0 mm.8 The smaller diameter allowed procedures to be performed in an office setting, whereas traditional arthroscopic surgeries required an operating room.8 Furthermore, patients were able to remain awake during their surgeries with the use of local anesthetics. Needle arthroscopes not only allowed for in-office procedures, but orthopedic surgeons and rheumatologists also recognized the diagnostic value these methods provided. Compared to the diagnostic use of magnetic resonance imaging (MRI), needle arthroscopes could be used to accurately detect cartilage and synovial abnormalities.9
Despite advancements with needle arthroscopes, the novel technology and methods also had their limitations. Multiple studies assessed the use of an in-office needle arthroscopy in comparison to traditional arthroscopy for various knee pathologies. In a study of 47 patients with knee pathologies, Meister et al.10 found that the Optical Catheter System needle arthroscope was less accurate than traditional arthroscopy. Furthermore, the needle arthroscope was less accurate than MRI for diagnosing such lesions.10 Similarly, in a study of 50 patients, Denti et al.7 reported lower accuracy when using the Optical Catheter System needle arthroscopy to diagnose medial meniscus lesions compared to conventional arthroscopy. The authors also reported difficulty achieving adequate joint distension and hemostasis with the procedure.7 In 21 patients, Halbrecht et al.11 observed that MRI was superior in diagnosing subchondral lesions, medial cruciate ligament sprains, and bone contusions when compared to in-office needle arthroscopy. Due to the intricate surgical techniques at that time, the authors recommended that only surgeons with significant arthroscopic experience use the in-office needle arthroscope.11 Overall, the complexity of the procedure and suboptimal visualization compared to MRI prevented in-office needle arthroscopy from being universally adopted over traditional arthroscopy.
In recent times, the in-office needle arthroscope has advanced to improve visualization while maintaining a small needle size. The first modern needle arthroscope, VisionScope® (VisionScope Technologies, USA), was created for in-office diagnostic procedures.12 VisionScope has a 1.4 mm diameter with a 2 mm cannula, in addition to an 8 mm focal distance from the tip. This version of the needle arthroscope transmits images via a 1.5 mm fiber optic cable and provides a 75° field of view.
Complementary metal oxide semiconductors, or “chip-on-tip” technology, were later introduced to enhance imaging quality without the use of a glass tube or multiple lenses. One example is the mi-eye 3 needle arthroscope (Trice Medical USA), which uses a chip-on-tip camera for enhanced imaging resolution of 400 × 400 pixels.13 The mi-eye 3 needle arthroscope expanded the field of view from the previous 75° to 120°.13 Furthermore, both 0° and 25° viewing angle configurations are available for arthroscopic procedures.13 The handle of the needle arthroscope also includes an attached syringe to allow for intra-articular lavage.13
Another example of a chip-on-tip needle arthroscope is the NanoScopeTM (Arthrex, USA), originally developed in 2019 and upgraded to the NanoNeedle ScopeTM in 2022.14 Similar to the mi-eye 3, the NanoScopeTM provides 400 pixel resolution with a 120° field of view.14 The NanoScopeTM has a 1.9 mm diameter with viewing angles of either 0° or 10°. It also includes a 2.2 mm inflow sheath connected to an active fluid system, allowing for fluid flow without active syringe manipulation by the surgeon. In addition to the advanced fluid system, the NanoScopeTM comes with a set of nano-instruments including shavers, probes, biters, graspers, thermal ablators, and burrs.14 The collection of nano-instruments allows for expanded interventions during in-office procedures (Figure 1).
Example positioning for in-office anterior-posterior tibial tendon needle tendoscopy. The surgeon sits at the foot of the surgical bed with an assistant next to the viewing monitor. The assistant has provided permission to publish the image that was obtained.
A final modern needle arthroscope is the MIDASVu (IntraVu, Inc., USA), which also provides a 120° field of view. However, the MIDASVu needle arthroscope includes imaging resolution of 1,000 × 1,000 pixels.15 This version of the needle arthroscope is 1.4 mm in diameter with a cannula that provides a flush port.15 With regard to the viewing angle, a variant of the MIDASVu arthroscope, SideVu, creates a 30° rotating viewing angle to enhance visualization of complex anatomical areas.15
The novel development of in-office needle arthroscopy (IONA) has demonstrated promising results supporting its use in the surgical management of patients with foot and ankle pathologies.16-19 With regard to diagnostic management, the needle arthroscope can be more accurate than MRI.20 The 2 mm diameter of the needle allows for enhanced visualization and easier navigation of small spaces compared to larger diameter arthroscopic needles.21 Furthermore, the smaller needle minimizes iatrogenic damage and decreases overall costs associated with surgical procedures.21 Due to the nature of the procedure, local anesthesia is sufficient for intraoperative pain management, allowing patients to remain wide awake during their surgery. A variety of technique papers have been published on in-office needle procedures, not only outlining the steps to replicate such surgeries but also demonstrating high success rates, improved clinical outcomes, minimal complications, and reduced return-to-work and return-to-sport times (Figure 2).
Intraoperative image from an in-office posterior tibial tendon needle tendoscopy. The medial malleolus (left), shaver (top), and posterior tibial tendon (right) are all visible.
IONA has been found to provide benefit for patients undergoing procedures for the anterior foot and ankle. Colasanti et al.22 evaluated 31 patients who underwent IONA for anterior ankle impingement. All patients reported improvements in Foot and Ankle Outcomes Scale and Patient-Reported Outcome Measurement Information System scores. In addition, all patients returned to work at a median time of 1.98 days, and 96% were able to return to their previous level of sports at a mean time of 3.9 weeks (Figure 3).22 IONA has also been applied to investigate talar cartilage in patients who underwent autologous osteochondral transplantation or talar osteoperiostic grafting from the iliac crest for the treatment of osteochondral lesions of the talus. Walinga et al.23 found that, among 16 patients who underwent second-look needle arthroscopy of the anterior aspect of the ankle following either autologous osteochondral transplantation or talar osteoperiostic grafting from the iliac crest procedures, IONA was a safe and effective method to evaluate the state of reparative cartilage and associated osteochondral lesions of the talus. Additionally, IONA was efficient at resecting the soft and bony tissues causing anterior ankle impingement, which occurred in 87.5% of patients who underwent these surgeries.23
Intraoperative image from an in-office anterior ankle needle arthroscopy. The tibia (right), talus (bottom), and biter (center) are all visible.
For posterior ankle pathology, IONA is a less invasive technique that limits complications, improves cosmesis, allows for faster recovery, and increases patient satisfaction.24,25 Mercer et al.26 evaluated the use of IONA for the management of posterior ankle impingement in 12 patients with a mean follow-up time of 13.3 ± 2.9 months. The authors demonstrated excellent postoperative Foot and Ankle Outcomes Scale scores and a median return-to-work time of 3.4 ± 5.3 days.26 Furthermore, there was a 0% complication rate (Figure 4).26 In-office needle technology has also been used for the diagnosis and treatment of symptomatic tendons of the foot and ankle with in-office needle tendoscopy. Butler et al.27 assessed outcomes following the use of in-office needle tendoscopy for chronic Achilles tendinopathy and noted a success rate of 91.7%. There were excellent return-to-work and return-to-sport times, with 100% of patients returning to work at a mean time of 4.2 ± 1.2 days.27 Furthermore, patients returned to their previous level of sports at a mean time of 5.9 ± 2.6 weeks.27
Intraoperative image from an in-office Achilles needle tendoscopy. The Achilles tendon (bottom), inflamed paratenon (top), and shaver (center) are visible.
While IONA presents numerous benefits, its widespread adoption faces several practical challenges and inherent shortcomings. One of the primary limitations of IONA is the reduced field of view and limited instrumentation available with the smaller 1.9 mm 0° endoscope, making it difficult to perform more complex operative procedures. In addition, the technique has a significant learning curve, and a lack of surgical experience in IONA can lead to a higher risk of iatrogenic articular cartilage injuries, as demonstrated in cadaveric studies.28 Finally, while the wide-awake nature of the procedure is advantageous in most patients, some individuals may not want to watch their surgery and may experience discomfort with IONA.
In-office needle arthroscopy offers a compelling alternative for foot and ankle procedures compared to traditional arthroscopy due to two main advantages: patient satisfaction and cost-effectiveness.29-33 IONA procedures utilize the wide-awake local anesthesia no tourniquet (WALANT) technique, decreasing the length of hospital stay and improving both pain and anxiety in patients.29,30 Bilgetekin et al.29 conducted a retrospective study of 31 patients who underwent foot and ankle surgeries with WALANT, observing an average length of hospital stay of 8.3 ± 6.1 hours for all patients. Patients often prefer IONA procedures over traditional surgical arthroscopy due to substantial reductions in both anxiety and pain from the preoperative to postoperative period.30,34 Furthermore, MacNeill et al.30 found that WALANT patients reported a lower incidence of postoperative nausea and vomiting (5% rate) than patients who received general anesthesia (40% rate). As patients are wide-awake during the procedure, surgeons can obtain real-time patient feedback, ultimately enhancing patient understanding of the surgery (Figure 5).
Intraoperative image from an in-office four-compartment fasciotomy needle endoscopy. The fascia surrounds the lower leg compartment (bottom), and the biter (center) is visible.
In terms of cost-effectiveness, IONA provides notable savings for both commercial payers and patients. Unlike traditional arthroscopy, which is typically performed in the operating room, IONA can be conducted in the office setting. IONA procedures allow for cost reduction in operating room fees, anesthesia, and overall procedural charges.34 Sahi et al.34 found that switching from traditional arthroscopy to IONA for meniscectomies reduced overall costs by $21,832.66 and increased profits by $21,468.80. Additionally, Munn et al.35 demonstrated that IONA procedures produce 1/3 less non-recyclable waste compared to standard arthroscopic procedures. IONA presents a more accessible and efficient option for patients who need orthopedic procedures. However, since IONA is a relatively new approach to the surgical management of orthopedic pathologies, there is a lack of research on cost-benefit analysis for foot and ankle injuries specifically. Therefore, future research must be conducted to evaluate the cost-benefit analysis of IONA procedures for patients undergoing foot and ankle surgeries.
The development of the modern in-office needle arthroscope has enhanced both the diagnosis and treatment of foot and ankle pathologies. Recent iterations of in-office needle arthroscopes have improved visualization for surgeons during complex surgical procedures. Newly developed chip-on-tip technology and smaller instrumentation allow for effective and safe procedures to be conducted in the office setting. In addition, patients benefit from in-office needle arthroscopic surgeries through improved subjective outcome scores, faster return-to-work and return-to-sport times, increased satisfaction, and greater cost-effectiveness. As further advancements are made to the in-office needle arthroscope, including future studies evaluating long-term outcomes, IONA may eventually be applied across all subspecialties in the field of orthopedic surgery.
The authors report the following potential conflicts of interest or sources of funding: John G. Kennedy received support from Ms Tatiana Rybak and Mr. and Mrs. Michael J. Levitt. John G. Kennedy is a consultant for In2Bones and Arthrex®. No other authors receive support or funding.
Jared Rubin contributed to the substantial conception/design of the work, performed literature review, drafted the work, critically revised the work, prepared the manuscript, approved the final version for publication, and agreed to accountability for all aspects of the work. Alexander Tham contributed conception/design of work, performed literature review, drafted the work, critically revised the work, manuscript preparation, approved the final version for publication, and agreed to accountability of all aspects of work. Mark Pianka contributed to the performed literature review, drafted the work, critically revised the work, prepared the manuscript, approved the final version for publication, and agreed to accountability of all aspects of the work. Guillaume Robert contributed to drafting the work, critically revising the work, prepared the manuscript, approving final version for publication, and agreement for accountability of all aspects of the work. Anaelie Mainville contributed to drafting the work, critically revised the work, prepared manuscript, approving final version for publication, and agreement for accountability of all aspects of the work. Arianna Gianakos contributed to the interpretation of the review for work, revised the work for important intellectual content, final approval of the version for publication, and agreement to accountability of all aspects of the work. John Kennedy contributed to the interpretation of review for work, revising of the work for important intellectual content, final approval of the version for publication, and agreement to accountability of all aspects of the work.
John G. Kennedy and Arianna L. Gianakos are editors of Journal of Orthopaedic Foot and Ankle Science and on the journal’s Editorial Board. These authors were not involved in the editorial evaluation or decision to accept this article for publication at all.
None.
None.
None.
Informed consent was obtained from individuals pictured throughout this manuscript.
