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Patients prefer In-Office Needle Arthroscopy (IONA) over traditional surgical arthroscopy
⁎Corresponding author: Gurjovan Sahi. jovan.sahi@mail.utoronto.ca
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Although exciting for surgeons and administrators, little is known about patients' perceptions of IONA. Level IV evidence shows that patients with claustrophobia or contra-indications to sedation prefer IONA to MRI for diagnostic purposes. However, no study to date has examined patients' preferences regarding IONA and traditional surgical arthroscopy. Therefore, this study was conceived with the purpose of gathering patients’ perspectives on IONA as an alternative to traditional surgical arthroscopy through semi-structured interviews. A secondary outcome was to determine the real-life financial impact with respect to profit and cost of introducing IONA at an academic mid-sized Canadian hospital.
All patients undergoing arthroscopic non-ligamentous knee surgery within a three-month period at a mid-sized academic hospital were approached for this study. A trained researcher conducted telephone interviews regarding patient experience with the entire surgical process, including diagnosis and treatment, suffering an injury, referral for MRI and sports surgeon, and booking arthroscopic surgery. Participants were provided information on IONA, including risks and benefits as an alternative to traditional arthroscopy, and were asked about their likelihood of choosing IONA as an alternative to their treatment pathway. Thematic and quantitative analysis was conducted based on interview results, with quantitative analysis conducted using a 5-point Likert scale. Financial analysis was conducted by observing the propensity to choose IONA via patients’ response to the 5-point Likert scale and then modeled for cost effectiveness.
Twenty-one patients were interviewed. The mean age was 32.3 (SD: 9.8) years old with 12 (57.1 %) females. Mean time from surgery to interview was 10.2 weeks (SD: 11.4). In general, patients’ perceptions of IONA were favorable. When asked how likely they would have been to opt for IONA over traditional arthroscopy, the mean response was “very likely” (4.10 [1.26]). The mean likelihood for males to select IONA was higher than females (4.78 versus 3.58). Common reasons for wanting IONA were to speed up the time between injury and surgery (n = 9), avoiding a general anesthetic/intubation and associated complications (n = 7), and avoiding the fear/anxiety of surgery (n = 6). Most patients listed the lack of primary data on the effectiveness, pain, revision rate, and PROMs as the primary hesitation (n = 6). Financial analysis revealed that IONA would reduce costs by $21,832.66 (p < 0.0001), resulting in an increase in profit of $21,468.80 (p < 0.0001).
The most significant finding in this study is that IONA may be preferable by patients in a publicly funded healthcare system with limitations to operating room access. Patients believe that IONA can accelerate the diagnosis and treatment of meniscal injuries, allowing patients to avoid surgery via the traditional route of the operating room. Furthermore, it is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy at a mid-sized Canadian institution.
Keywords
In-Office Needle Arthroscopy (IONA)
Patient perceptions
Cost-effectiveness
Healthcare efficiency
Meniscal tears
1 Introduction
The field of orthopaedic surgery continues to develop, with current advancements now aimed at less invasive, more efficient diagnostic and therapeutic measures for patients.1 In-Office Needle Arthroscopy (IONA) is a recent minimally invasive procedure that allows for both the diagnosis and resection of intra-articular knee pathologies, particularly meniscal tears, without the use of the traditional route of the operating room (OR).2 With a small-diameter arthroscope, IONA provides real-time visualization and potential therapeutic intervention of pathologies within an office setting. Compared to traditional methods of MRI and surgical arthroscopy, IONA also presents several benefits including reduced procedural time, avoidance of general anesthesia, and expedited recovery after procedure.2,3
IONA can serve patients in many clinical scenarios. The approach is primarily indicated in patients that require diagnostic evaluation of knee pathologies, especially when initial MRI suggest a likely irreparable meniscus tear. In patients with medial meniscus pathology, IONA is invaluable as it allows for an in-office meniscectomy, crucially avoiding a full surgical procedure in the OR.4 Additionally, IONA is beneficial for patients with contraindications to MRI, such as those with claustrophobia or metal implants, or those who prefer to avoid the risks and complications associated with general anesthesia.5,6
Current evidence suggests that IONA can offer comparable diagnostic accuracy to MRI, with improved accessibility and cost-effectiveness.7 In-office procedures, such as IONA, could be cost-effective alternatives by allowing for operating room diversion, according to financial analyses by Amin et al. (2019) and Abbas et al. (2023), maintaining high diagnostic accuracy, significantly reducing costs and improving profit margins compared to conventional surgical treatments5,8 (see Fig. 1 for proposed treatment pathway and diversion). IONA is an effective alternative that streamlines treatment processes and reduces OR resource demand,9 which can assist greatly in healthcare systems facing significant MRI delays, OR access limitations, COVID-19 backlogs, nursing shortages and limited OR time.8 IONA is also indicated in patients who would benefit from quicker treatment timelines, such as high performing athletes.10 IONA is especially transformative in patients experiencing considerable pain and functional limitations due to knee injuries, as it can significantly reduce the time from injury to intervention.3 Additionally, IONA provides shorter recovery times, which is substantial for active individuals eager for a rapid return to regular activities.11
Despite the substantial benefits, no studies to date have examined the long-term outcomes from IONA and patient preferences towards IONA. Current evidence instead analyzes the technical and economic aspects of IONA, creating a clear gap in the literature towards patient experiences and overall satisfaction.12 Determining patient preferences towards orthopaedic treatments is integral, as treatment decisions often involve comparing the benefits and risks of conservative and procedural approaches.13
As such, the primary objective of this study is to determine patient perceptions of IONA for diagnosing and treating certain knee pathologies as an alternative to the conventional approach of surgical arthroscopy. Through the use of semi-structured interviews, this study aims to define the reasons behind why patients may select or reject IONA. The secondary objective to this study will be to assess the financial impact of implementing IONA in a mid-sized academic Canadian hospital, with specific consideration to both cost-effectiveness and profitability.
2 Methods
2.1 Study design
This study utilized a prospective, mixed-methods cohort study design. The study was conducted at a mid-sized academic hospital in Canada. The study received ethical approval from the local institutional review board (IRB) (Certificate #829-2104-Ort-021). All patients who underwent arthroscopic non-ligamentous knee surgery over a three-month period were eligible for inclusion. Qualitative data collection was used for semi-structured interviews and quantitative data collection was used for financial modeling analysis.
2.2 Patient selection and recruitment
Recruitment of patients was conducted through the orthopaedic surgery department of a single sports medicine surgeon at the academic institution. Participants eligible for the study were identified from surgical logs. This included patients scheduled for arthroscopic non-ligamentous knee surgery (ie: partial meniscectomy), over the designated three-month period. Inclusion criteria was as follows: 1) adults aged 18 years and older who had undergone specified knee surgery and 2) fluent in English. Exclusion criteria was as follows: 1) had previously undergone ligamentous knee surgery and 2) had cognitive impairments that could impair their ability to provide informed consent or participate in an interview.
A trained research assistant approached potential participants post-operatively either during follow-up visits or via telephone. Informed consent was obtained from all participants before inclusion in the study.
2.3 Data collection
Semi-structured telephone interviews were conducted to gather detailed insights into patient experiences and preferences regarding IONA versus traditional surgical arthroscopy. The interviews were conducted by a single trained interviewer with expertise in qualitative research methods to ensure consistency in data collection. Each interview lasted between 15 and 60 min, depending on the depth of the responses provided by the participants (see Fig. 2).
Please see interview guide in Table 1. Interviews were audio-recorded and were transcribed verbatim for thematic analysis.
| Interview Questions Guide | |
| General Questions | Which side(s) were affected? |
| What is the nature of your work? | |
| How long was/were your knee(s) painful before you received treatment? | |
| Living with meniscus tear | What aspects of this disease bothered you the most? |
| In what ways, if any, did your disease impact you performing your usual activities? | |
| Tell me about your decision to seek treatment. | |
| What were your expectations of treatment? | |
| Treatment plan | Are you able to understand and weigh the advantages and disadvantages of IONA? |
| If eligible, would you consent to IONA? | |
| Do you feel that IONA is a safe alternative to traditional arthroscopy? | |
| If interested in undergoing IONA, why did you choose to undergo this procedure compared to a traditional knee arthroscopy? | |
| If you were presented with more than one treatment option for your condition, what factors would influence the decision to choose one treatment over another? | |
| Delays due to COVID | Did you experience any delays for treatment due to COVID-19? |
2.4 Data analysis
2.4.1 Financial analysis
Cost-effectiveness analysis was conducted using a well-established model by Abbas et al.8 to assess the financial impact of implementing IONA into a mid-sized academic hospital in Canada. Inputs into the financial model included direct costs (e.g., procedural costs, OR time, anesthesia) and indirect costs (e.g., time off work, rehabilitation costs) for both traditional surgical arthroscopy and IONA. Data for the model was obtained from the hospital's financial records, specifically the actual costs associated with knee arthroscopy procedures and projected costs for IONA.
Participants propensity to select IONA over surgical arthroscopy was recorded via Likert scale responses (ranging from 1 “certainly not” to 5 “certainly”). These responses were then incorporated into the cost-effectiveness model. To evaluate the robustness of the model, sensitivity analysis was conducted under varying assumptions, such as different rates of patient uptake and differing procedural costs.
2.4.2 Qualitative analysis
A framework approach was adopted in order to analyze interview transcripts in a thematic manner. Two independent researchers reviewed the transcripts to identify common themes and subthemes related to patient perceptions of IONA, barriers and facilitators to adoption, and perceived advantages and disadvantages compared to conventional surgical arthroscopy.
Qualitative data was coded manually to facilitate thematic analysis. Any discrepancies amongst the two researchers was resolved via discussion and consensus. Key themes were synthesized into a narrative summary, highlighting the range of patient experiences and preferences.
2.4.3 Quantitative analysis
Descriptive statistics was used to analyze quantitative data from the Likert responses, calculating means, standard deviations, confidence intervals and variability in patient preferences for IONA. Analysis of variance (ANOVA) was used to compare the mean likelihood of choosing IONA across different demographic groups (e.g., gender, age) and clinical characteristics (e.g., type of knee pathology).
To further assess the factors influencing patient choices, regression analyses were performed to explore the associations between demographic variables and Likert scale scores. Statistical significance was set at p < 0.05 for all analyses, which were conducted using R software.14
3 Results
3.1 Patient demographics and characteristics
A total of 21 patients participated in the study. All patients had undergone arthroscopic non-ligamentous knee surgery, specifically partial meniscectomy. Mean age of the participants was 32.3 years (SD: 9.8), ranging from 18 to 48 years. 12 (57.1 %) were female, and 9 (42.9 %) were male. The mean time from surgery to the interview was 10.2 weeks (SD: 11.4), and the mean time from injury to MRI was 14.7 weeks (SD: 21.1). The mean duration from the first general practitioner (GP) visit to orthopaedic consultation was 28.8 weeks (SD: 19.8), and the time from orthopaedic consultation to surgery was 8.1 weeks (SD: 6.7). All demographic results are displayed in Table 2.
| Characteristic | Value |
| Total Number of Participants | 21 |
| Mean Age (years) | 32.3 (SD: 9.8) |
| Age Range (years) | 18–48 |
| Gender Distribution | |
| - Male | 9 (42.9 %) |
| - Female | 12 (57.1 %) |
| Mean Time from Surgery to Interview (weeks) | 10.2 (SD: 11.4) |
| Mean Time from Injury to MRI (weeks) | 14.7 (SD: 21.1) |
| Mean Time from First GP Visit to Orthopaedic Consultation (weeks) | 28.8 (SD: 19.8) |
| Mean Time from Orthopaedic Consultation to Surgery (weeks) | 8.1 (SD: 6.7) |
3.2 Perceptions of IONA
Overall, patient perceptions of In-Office Needle Arthroscopy (IONA) were generally favorable. When asked about their likelihood of choosing IONA over traditional surgical arthroscopy, the mean response on a 5-point Likert scale was “very likely” (mean 4.10, SD 1.26). Males expressed a higher preference (mean 4.78) compared to females (mean 3.58) (p < 0.05) towards IONA.
3.3 Reasons for preferring IONA
Quicker Treatment Timelines - Nine patients (42.8 %) mentioned that IONA would expedite time between injury and treatment. Patients mentioned that IONA would reduce delays associated with MRI scheduling, GP referrals, orthopaedic consultations, and surgical bookings, leading to a faster overall treatment process.
Avoidance of General Anesthesia - Seven patients (33.3 %) preferred IONA as it allows for procedures to be performed under local anesthesia. Unlike local, general anesthesia can introduce potential risks and complications, including post-operative nausea, prolonged recovery time, and potential respiratory complications.
Reduced Anxiety and Fear of Surgery - Six patients (28.6 %) expressed that IONA would reduce the fear and anxiety associated with an OR setting.
Financial Considerations - Two patients (9.5 %) cited the potential for financial savings, including reduced time off work and decreased expenses towards rehabilitation and follow-up care.
Avoidance of Hospital Settings - Four patients (19.0 %) mentioned the desire to avoid hospital settings, particularly considering the COVID-19 pandemic, as a factor in their preference for IONA.
All reasons for preferring IONA are displayed in Table 3.
| Metric | Current State | Proposed State | Percentage Difference (%) | ||
| Mean | SD | Mean | SD | ||
| Revenue Total | $248,167.89 | $38,862.90 | $248,541.30 | $38,965.42 | −0.2 |
| OR meniscectomy/DA billing | $147,212.62 | $23,081.59 | $72,746.14 | $11,452.37 | 50.6 |
| OR repair billing | $100,955.27 | $15,793.66 | $82,038.03 | $12,851.18 | 18.7 |
| IONA meniscectomy/DA billing | NA | NA | $75,343.92 | $11,725.12 | NA |
| IONA revision billing | NA | NA | $18,413.21 | $2987.62 | NA |
| Expenses total | $280,975.19 | $43,995.11 | $259,989.95 | $40,866.08 | 7.5 |
| OR meniscectomy/DA costs | $152,369.75 | $23,890.18 | $75,294.57 | $11,853.56 | 50.6 |
| OR repair costs | $128,605.44 | $20,119.31 | $104,507.04 | $16,370.93 | 18.7 |
| IONA meniscectomy/DA costs | NA | NA | $45,590.27 | $7094.82 | NA |
| IONA revision costs | NA | NA | $34,598.07 | $5613.68 | NA |
| Profit | -$32,807.30 | $5133.35 | -$11,448.65 | $1933.00 | 65.1 |
| Profit margin | −13.22 % | −5 % | |||
3.4 Reasons against choosing IONA
Lack of Comprehensive Outcome Data - Seven patients (33.3 %) were hesitant to choose IONA due to concerns about the lack of long-term data on the effectiveness, pain management, revision rates, and patient-reported outcome measures (PROMs). Patients felt that further robust evidence was needed to fully endorse the procedure as a standard alternative to traditional arthroscopy.
Preference for Traditional Surgical Processes - Four patients (19.0 %) indicated a preference for the conventional surgical process involving general anesthesia, citing comfort with the familiar setting of the OR and the perceived safety of undergoing a well-established procedure.
Concerns About Novel Technology - Three patients (14.3 %) expressed apprehension about adopting a relatively new and unfamiliar technology. Their concerns were primarily related to the potential need for subsequent surgical intervention if IONA failed to fully address their pathology.
Fear of Needles and Being Awake During Procedure - Two patients (9.5 %) mentioned a fear of needles and a preference to be sedated during surgical procedures as reasons against choosing IONA. They were uncomfortable with the idea of being conscious during the procedure, despite its minimally invasive nature.
3.5 Financial impact analysis
The financial analysis revealed that implementing IONA could lead to substantial cost savings and increased profitability for the hospital. The study found that shifting from traditional surgical arthroscopy to IONA could reduce costs by $21,832.66 (p < 0.0001) and increase profit margins by $21,468.80 (p < 0.0001). These savings were primarily attributed to the reduced need for OR time, anesthesia costs, and the lower overall procedural costs associated with in-office settings.
The model projected that the adoption of IONA could lead to an 8.15 % decrease in total expenses, driven by a significant reduction in OR costs for both meniscectomy and repairs. Specifically, the cost for OR-based meniscectomy was reduced by 55.08 %, while OR costs for repairs decreased by 20 % when IONA was implemented as an alternative. Additionally, the cost savings were enhanced by reduced indirect costs, such as fewer days off work and decreased need for extended rehabilitation. See Table 4 for full breakdown of financial impact analysis.
| Reasons in Favour for IONA | Number of Patients |
| Speed up the time between injury and surgery (including time from injury to MRI, from GP referral to sports medicine consultation, and surgical consent to operation) | 9 |
| Avoiding a general anesthetic/intubation and associated complications | 7 |
| Avoiding the uncomfortable process of surgery (including being NPO, having cases bumped/rescheduled, fear/anxiety) | 6 |
| Avoiding hospitals during COVID surges | 4 |
| Financial savings from being off work/physiotherapy | 2 |
| Able to appreciate knee pathology and treatment real-time | 2 |
| Improved intra-articular visualization compared to MRI in the setting of prior hardware implantation | 1 |
4 Discussion
The most significant finding in this study is that In-Office Needle Arthroscopy (IONA) is perceived as a preferable alternative by patients in a publicly funded healthcare system, particularly in scenarios where there are limitations to operating room (OR) access. The study demonstrated that patients believe IONA can accelerate the diagnosis and treatment of meniscal injuries, potentially allowing them to avoid more invasive surgery in a traditional OR setting. This preference for IONA is particularly relevant given the current challenges faced by healthcare systems, such as increased wait times for elective procedures, COVID-19 backlogs, nursing shortages, and limited OR availability, all of which contribute to delays in patient care.15–18
Patients reported favorable perceptions towards IONA, with a mean likelihood score of 4.10 out of 5 for opting for this innovative approach over traditional arthroscopy. This inclination aligns with the findings of previous studies that highlight IONA's utility in providing a less invasive, patient-centered alternative that avoids general anesthesia, reduces procedural anxiety, and potentially shortens the time from diagnosis to treatment.2–4 The economic evaluation conducted in this study further emphasizes the cost-effectiveness of IONA, showing significant reductions in healthcare costs ($21,832.66) and increases in profit margins ($21,468.80), which demonstrates its economic viability within a mid-sized Canadian hospital setting.3
The main reasons behind patient preference for IONA included quicker diagnostic and therapeutic timelines, avoidance of general anesthesia, and prevention from a OR procedure thus providing a more comfortable and less intimidating surgical experience. These reasons are consistent with the growing emphasis on patient-centered care and shared decision-making in healthcare systems, such that patient values and preferences are prioritized in clinical decisions and treatments.19 IONA's ability to provide real-time visualization of knee pathology and treatment within an office-based setting aligns with patients' desire for greater involvement and understanding in their own medical care. Additionally, the COVID-19 pandemic has highlighted the importance of flexible and adaptable healthcare delivery systems. Many patients indicated a strong preference for avoiding hospital settings during COVID-19 surges and these instances IONA serves as a viable option in providing continuity of care that minimizes exposure to hospital environments. This preference is particularly relevant in situations where traditional surgical pathways are disrupted due to resource constraints, further highlighting the potential of IONA to fill critical gaps in care delivery. This has been successfully adopted in other orthopaedic practices, such as day-case arthroplasty, which has reduced hospital stay duration, minimized patient exposure to nosocomial infections, and enhanced resource efficiency.20
Financially, this study has crucially shown that the adoption of IONA as a diagnostic and therapeutic tool could result in significant cost savings and increased efficiency within the healthcare system. IONA's reduced need for operating room time, lower anesthesia-related costs, and shorter recovery times each contribute to its cost-effectiveness. Similar studies have demonstrated that other in-office procedures like IONA can also provide significant savings compared to traditional hospital-based interventions.8 The results from this present study supplement the existing literature providing a real-world financial analysis, showcasing IONA's potential to optimize resource allocation and enhance financial sustainability in publicly funded healthcare systems.3 Further, other minimally invasive techniques in outpatient settings, such as those used in carpal tunnel release, show the similar trend seen in IONA, with reduced costs and improved patient satisfaction.21
Though IONA holds much promise, there are some challenges associated with IONA. Patients have expressed concerns regarding the novelty of the procedure and the lack of extensive data surrounding long-term outcomes, pain management, revision rates, and patient-reported outcome measures (PROMs). Other barriers to the widespread adoption of IONA include logistical challenges related to equipment procurement, clinical setup, and training requirements for healthcare professionals. As such, continued research and data collection to validate the clinical efficacy and safety of IONA is crucial to gain further widespread acceptance among patients and healthcare practitioners.
There are several implications for future research based on the present study. As discussed above, this study provides a foundation for future work by identifying patient preferences and financial implications, but additional data from randomized controlled trials and larger, multi-center studies will be essential to better understand the clinical scenarios in which IONA could be most beneficial and to establish standardized protocols for its use. Additionally, the gender disparity observed in the likelihood toward selecting IONA–where males were more likely to opt for this approach compared to females–warrants further investigation to explore the underlying factors contributing to this difference and ensure equitable access to innovative treatment options for all patients.22 Studies should also explore the potential of IONA beyond knee pathology to other orthopaedic conditions including ankle impingement or shoulder injuries, thus broadening its scope and enhancing its utility as a versatile diagnostic and therapeutic tool in orthopaedic practice.
5 Conclusion
In conclusion, the findings of this study indicate that patient perceptions of IONA are favorable, with strong preferences for its use over traditional surgical arthroscopy in specific scenarios. IONA offers a promising alternative that aligns with the goals of modern healthcare delivery, by enhancing patient experience, reducing costs, and improving access to timely care. However, to fully appreciate its potential, ongoing research is necessary to address current limitations and to build a robust evidence base supporting its efficacy and safety. As healthcare continues to evolve, incorporating patient preferences and promoting shared decision-making will be essential to ensure the successful adoption of innovative technologies like IONA in clinical practice.
Patient consent statement
All patients signed an informed consent form and procedures were conducted according to the Declaration of Helsinki.
Ethical statement
This manuscript was produced without artificial intelligence software.
Ethical statement
This manuscript was produced without artificial intelligence software. The study received ethical approval from the local institutional review board (IRB) (Certificate #829-2104-Ort-021).
Funding statement
This study received funding support from Arthrex (Grant # IIRR 01259) to be utilized for the presentation and publication of this work. These funds were used for student researcher remuneration, software, and manuscript dissemination. Study sponsors were not involved in the design, conduction, or manuscript preparation of the study.
Author contribution statement
Gurjovan Sahi: Co-investigator, Data analysis, Ideation, Manuscript preparation.
Aazad Abbas: Co-investigator, Data analysis, Manuscript preparation.
Ajay Shah: Co-investigator, Data analysis, Manuscript preparation.
Johnathan R. Lex: Co-investigator, Data analysis, Manuscript Preparation.
Jihad Abouali: Co-investigator, Ideation, Manuscript preparation.
Jay Toor: Co-investigator, Ideation, Manuscript preparation.
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