Integrating Needle Arthroscopy into Your Daily Practice

Hello, my name is Sean McMillan. I'm an orthopedic surgeon based out of Cherry Hill, New Jersey, and I'm gonna speak to you a little bit today about moving Needle arthroscopy into your practice in the office and the benefits that I see in my experience over the last 5 or 6 years with doing this.

My disclosures for this, uh, I am a paid consultant with Trice Medical, and I do have some compensation tied to royalties. However, this talk is really, uh, on my behalf. There's no financial implication tied to this.

Some of the goals today, I wanna provide some information for you about who the right candidate might be for this, and then for you to be able to use this in the right patient to gain clarity of information heading into Surgery because it'll help some of your pre-surgical planning. I'm gonna present some data about the outcomes from Needle arthroscopy so far, and I'll share my experience on how it's helped retain patient capture. And then lastly, I'm gonna touch on some of the advances over the last 18 months for Needle arthroscopy and the billing component as well.

Historical reference, we know Needle arthroscopy has been around for almost 30 years and, you know, in our own Practices, 1 out of every 10 patients uh get an MRI when you, when you think about this yearly. So, when we translate that into what we're good at doing, Knee scopes, in particularly in the operating room, there's more than 2 million done a year, so we know how to scope a Knee.

And when someone says to me they want to get into using Needle arthroscopy, unless you're purely a Shoulder guy or purely a Foot and ankle guy, I think the home run is working in the Knee just because of the muscle memory, then expanding our scope of practice into the Shoulder, Hip, Knee, uh, ankles, etc.

When you look at sort of the national database of, of Research that's out there, 120 articles have been written in PubMed looking at Needle arthroscopy. So, certainly, the interest is growing. And now it's a matter of finding a place to integrate this into our practice. There's several platforms that are out there, certainly in the last 5 years, there's been a rebirth and, and an interest where I can think of 4 or 5 different companies that have some sort of Needle arthroscopy platform. Really, it's a matter of finding the one that fits best into your hands and your, your comfort level.

Again, perfection is a roadblock to progress. So if you're waiting for the perfect system to come out, you're gonna keep waiting while your, your, your competition and your partners sort of steal away some of your patients. And the old adage, if it ain't broke, don't fix it doesn't hold true anymore, particularly in an arthroscopy, because our patients are demanding more and more. They want instant answers, they don't want to wait, they want to be fixed today, and in the current climate of COVID, we wanna make sure we offer them options that keep them in our office and keep them safe.

Getting started, really this is about for you identifying the right patients and knowing what you can and can't see when you do a Needle arthroscopy. So certainly the easiest candidate is someone who can't get an MRI for various reasons, claustrophobia, pacemakers, uh, obesity, you know, these are sort of the homerun patients. But really once you get comfortable, the things that I like to do are, are thinking about patients that had previous Surgery and you wanna get a second look. Too many times we've gotten MRIs after a patient had a previous metastectomy or some Other procedure done.

In the MRI, you know, cannot rule in or rule out a new tear, so that's usually, you know, you know, pretty frustrating. And second, looks at cartilage in particular. Looking back at a microfracture, a meniscal transplant, those are all different ways that we can evaluate in the office in a much better way because what we're good at is, is arthroscopy. So we know with our own eyes if something looks healthy or doesn't look healthy, and that really is much better in my hands than an MRI.

What it won't show you though are things in the Knee like subchondral Bone Marrow edema. If you're doing a revision ACL and you gotta look at the tunnel widening, it won't show you that. And in the Shoulder, the supacromial space still isn't a great spot for it, so you're gonna miss some of your bone spurs. You won't really be able to evaluate tendon atrophy or paralabral cysts, but otherwise, it really gives you a nice sort of uh addition to your patients. And if you have a patient who maybe had an MRI that was inconclusive, this is a great way to plan before you get to the operating room.

So for me, the indications, I, I mentioned Knee is a home run for me, so meniscal Pathology, loose bodies, cartilage evaluations, those are all things that I really think are important in the Shoulder, great way to look at labral instability. If I have a patient that maybe had a dislocation and I wanna see, you know, how much bone is really left to that glenoid, I can really get an idea in the office if, if I use them in the appropriate manner to make sure that I'm gonna do the right procedure, whether it's soft tissue or maybe a bone block procedure.

But second looks for me in particular, I mentioned the cartilage. That's the home run, that is the one place where I think it's important.

There's a patient of mine who underwent a meniscucal transplant, about 18 months prior, was having some symptoms of, of, of Pain and some instability. Uh, we did the Needle arthroscopy. The meniscus itself was OK. The cartilage, he had a couple of flaps that were there. Uh, and again, this allowed me to sort of plan appropriately and take him to the operating room to do the right procedure.

And again, if you ask me that one home run area, that double jeopardy sort of uh bonus question, it's gonna be cartilage every time. This is the best place for a launching point for getting yourself comfortable and it leads itself to evaluate the, the meniscus, the ACL and Other sort of Pathology is much better.

I'll give you a case presentation. This was a 40-year-old individual, part of the United States Air Force, who had an I'm sorry, medial opening wedge HCO done 7 years ago. They were having increased instability, Pain, and swelling over the last 9 months. They failed bracing, viscosupplementation, and Other modalities, and came to me. And when I saw this X-ray, there's no way you're gonna be able to get a really good MRI to evaluate what that cartilage looks like or the meniscus inside the Knee. So we have to do an in-officek Needle arthroscopy.

And again, here was the MRI that he had done previously and, and even with metal subtraction, it's tough to really glean, you know, what's going on with that cartilage. Is, is it a big unstable flap? Is there some subchondral bone edema there? You know, what's really gonna happen with that flap? And I didn't wanna have to plan, you know, once I got into the operating room, I want to know ahead of time.

So again, viewing in the medial side of his Knee, uh, I was able to see that that 7 millimeter cold lesion on the MRI was actually about 2 centimeters by 1 centimeter when I measured it. So really getting a chance to look at that meniscus and that cartilage defect helped me change my algorithms from something that might have been just a simple chondroplasty to maybe doing some sort of bone plug procedure. And again, looking back at that cartilage, you really get a chance to evaluate the unstable nature of those edges because they propagate much bigger than what the MRI tends to show us.

Another scenario, 44-year-old avid runner, 13 months of Pain after stepping off of a curb, um, and, and really just didn't get better with all the conservative modalities. You can see here on the MRI that you've got sort of these lesions and some edema of the cartilage on the medial side. Um, when I got inside his Knee, I was able to use a probe and I was able to see one, the cartilage is unstable, but two, I can actually measure how big that defect is, and, and again, the MRI undersizes by almost 50%.

So when you're able to see the edges medial to lateral and front to back, uh, you can really see how much of a bigger lesion you have there. And again, this changes the decision from maybe a simple chondroplasty to maybe doing some sort of, uh, biouni or, or bio bone plug. It's gonna help with again, Other institutions, uh, of pre-op planning, particularly with cartilage work. And again, you think about Patella instability, you always have these concerns about what the cartilage looks like, whether or not there's, the bone's unstable, if it needs a screw or not.

So again, I'll, I'll look at these and here's viewing from a superiorlateral sort of position. I'm, I'm able to see the cartilage and the instability of the cartilage and some of the defects that are there. And again, this changes my algorithm, but then I can also look at tracking and I can see again if I push the kneecap over with my

My thumb, uh, in the office, you know, do I get better tracking or not? So I can see how shallow the trochlear groove is. I can evaluate the plan for my cartilage, and I can also see my tracking correction, you know, how much do I need to correct this patient, uh, so I'm not just relying on the simple numbers from my CAT scan or my MRI.

But you know, now that we've been able to sort of look at some of the clarity and information this can provide you, you know, it lends itself to planning. This was a really perplexing case that, that we had, uh, we had a 25-year-old patient who had a previous ACLPCL reconstruction done about 5 years ago. Uh, the treating surgeon at that time chose to use allograft for, for both ligaments. Um, and she was someone who was previously running marathons, uh, as recently as about a year ago, but over the last sort of 12 months had increasing complaints of instability.

So, the MRIs have been negative. Um, so again, I looked at her, so first thing I see is when I'm looking at this, the ACL, which is 5 years old, has not incorporated, still shiny like the date was put in, no incorporation, but when I put her into a figure 4, and I use a little bit of fluid there, you can see the ACL really didn't incorporate or sort of stretched out of that femoral wall. Uh, it's not holding the way it should. It's incompetent. So even though she had a good Laman test, uh, the, the ACL stretched out and was, in my mind, incompetent.

So again, comparing the two, here's your MRI again, looking at the ACL. Um, it looks OK on that and the radiologist called it OK, but when I put her to the figure 4 dynamically in the office, I could see that this ACL is incompetent on the wall. And really, you know, that's sort of to me is, is, is information I wouldn't have gleaned otherwise and help me plan appropriately.

So again, thinking about this again, the Patient experience. this gal came to me, she thought she was, you know, maybe crazy. She saw two Other doctors who told her the ACL was fine on the MRI, needed more Physical therapy, um, and it just wasn't something that was, you know, meshing and jiving. So I was able to give her an experience that, uh, you know, little or no Pain in a couple of minutes, give her information that she was looking for.

So the retention of patients that undergo this is important and I mentioned earlier the capture rate. So looking at Needle arthroscopy, we went back and looked at this retrospectively. The 1st 300 patients that we did needle scopes on in the office, uh, and we found that, uh, of these, only 9 patients chose not to follow up after the Needle arthroscopy.

So what that means is after I did the Needle Scope, uh, hopefully to confirm their Pathology and set them up for Surgery, I was able to offer them something that led to a benefit to them, whether it was non-surgical modalities in the form of injections or biologic or, or therapy, for reassurance of what the Pathology was, or I was able to confirm their Pathology as, as needing surgical intervention and take them forward into the operating room.

When we compare that to a typical MRI that's ordered in, in my practice, we ordered the MRI. The patient, you know, is told, we'll contact you with the authorization number and then after that, you're supposed to, you know, give us a buzz to come back and we'll, we'll bring you back in. We found that of all the MRIs we're ordering in that time frame, we had about a 74% follow-up rate. And, and of the ones that did follow up, 37% of those MRIs are not done within our health system. So the idea of keeping all those patients, you know, in and, and thinking that every MRI is gonna get done at your institution.

Um, it is wrong. And furthermore, 26% of the patients who we ordered an MRI on, never got the MRI done or never came back for whatever reason. Either it was too costly and they just didn't have anyone to speak to.

They got the MRI done, but we couldn't get them back in soon enough, so they maybe went somewhere else. Uh, there's different variations of why and we're still trying to drill this down. But I can tell you, you know, keeping another 25% of your patients and, and giving them a service that maybe leads to, you know, treatment for them that, with a positive outcome or Surgery for you and, and your practice, uh, sustainability, that's important. So I think it's something that, that can't be underestimated.

So looking at this nationally, and I know there's certainly outliers, when you think about uh the retention rate of getting an MRI, the turnaround time from the time a patient is seen, getting the X-ray, the physical examination, the MRI, bringing them back.

For the MRI and then ultimately deciding upon a, a surgical or non-surgical route. You know, that takes time and, and really by offering them a Needle Scope, we're able to do this in, in one visit or, or maybe two and save roughly about 2.5 weeks of time for the, for the patient, and, and that's huge. We think about kids that wanna get back to sports or people that just can't be out of work, uh, it's really important to sort of, uh, think about what you're doing for them.

The next question simply has to be, does it work? And, and the answer is, you know, it does. Uh, and once you've trained on it like everything else, and, and you've learned sort of the ins and outs, I, I think there's a really big benefit for the patients. So this was a paper that was written by Carl Dimension as well as uh Doctor Gladstone and Josh, uh, Josh Stein's looking at 106 patients. It was a multi-center study, and they looked at sort of surgical arthroscopy versus MRI versus Needle arthroscopy in the office.

What they found was the accuracy versus surgical arthroscopy was 91.5% for the Needle arthroscopy, whereas 61% for the MRI. So we've always said that arthroscopy itself is the gold standard for looking at intra-articular Pathology, and that holds true. Using the Needle Scope and recording and documenting what you see is much more sensitive and inaccurate than an MRI and we've known this forever.

Looking at this further, the MRI versus the Needle Scope, the discrepancies, again, there was a lot of false negatives on the MRI, uh, and the discrepancies also led to about 17% overcall on the MRIs, meaning, you know, they saw something that maybe wasn't there.

Cannot rule out a tear or undercal a cartilage defect uh uh on the femoral condyle. Looking specifically at the meniscus though, the sensitivity and specificity, again, looking and comparing this from Needle arthroscopy to the MRI was a higher sensitivity and specificity on both with the Needle arthroscopy versus the MRI. So again, trusting yourself, taking the time to make sure you evaluate the joint fully will lead to a better outcome and certainly should not lead to, uh, you know, false information.

The next thing we get asked a lot about is, you know, again, cost. This is a level 2 study that was done by Tom Gill, uh, and Doctor Rex looking at again, patients that were blinded and comparing MRI, Needle Scope, and traditional scope. What they found was it was a safe and effective tool. It led to real-time information and Cost Savings.

When you think about that Cost Savings, uh, uh, myself as well as a couple of Other, uh, colleagues were able to look at the Cost Savings by using a Needle arthroscopy in the US. We broke this down retrospectively in the five regions of the country, looking at the Northeast, the Mid-Atlantic, the Southeast, the Midwest, and the West Coast. And we analyzed, you know, the payments of Needle arthroscopy versus MRI. And we looked at this at both free-standing MRI suites as well as hospital MRI suites and looked at the cost associated.

What we found was the average Reimbursement for commercial insurances looking at uh the knees and the shoulders was about $630 for the Knee and about $500 for the Shoulder. When you looked at what it was for an MRI, the Outpatient cost of an MRI was roughly about $1000 and in the hospital it's almost $1600. These are for nonarthrograms, looking at a minimum, um, I'm sorry, a Tesla 1.5 image.

So again, the Cost Savings that was there and realized, you're saving almost $400 for the Knee and almost $500 for the Shoulder, uh, when you look at a freestanding facility. And when you look at a patient who has to go to an MRI, uh, get an MRI done at the hospital, it's about $1000 in Cost Savings for the patient in the healthcare system. So again, using this is cost-effective for both the system, the patient, as well as your practice.

And when you think about uh a lot of these groups that are out there, ACOs that are, you know, looking for doctors to partner with for Cost Savings to keep healthcare down, and it leads to a positive outcome and in their bottom line later on, this is a great way to sort of network with your, your family physicians in the area, to let them know that you have an option that can provide Cost Savings for them and for their patients.

Doctor X and, uh, Doctor Voigt, uh, excuse me, uh, Doctor Voight and, uh, Doctor Huber rather had looked at this study again in a different manner, looking at their own patients, and they found that there was an estimated $115 million at a minimum that was done when looking at just the medial meniscus alone, and this was sort of calculated by figuring out.

The missed Pathology, the delay in treatment, the time missed from work while being injured or for appointments or for follow-up, and undue treatment that was given. Maybe someone had a large, uh, meniscal tear that was flipped to put them through 6 weeks of therapy, you know, it was undue, not needed, and perhaps we ought to go ahead and treat them better.

So the last thing that's asking me a lot of times is, well, is it safe? And we were able to get published some data, myself and a couple of colleagues looking at, you know, the risks and complications associated with Needle arthroscopy in the Knee and the Shoulder, and we found that along with major complications, we had zero in the form of infections. We had 0 chondrotoxicities. We have 1 patient had to go to the ER.

Urgent care. That was over 1400 patients that were analyzed there. And, and that one patient that went to the ER uh was mine, to be fair. Uh, he was on Plavix, uh, he just continued to sort of ooze out of his, out of his portal, so he went there and they put a little Dermabond on him and, and he was fine.

Minor complications were actually on par with those of routine injections in the office. So we had about a 1.9 vasovagal rate. Uh, we had about 1.4% of the patients where what we saw was inconclusive or didn't match what we thought we would find. So we had to get further imaging, uh, to look for either Bone Marrow edema or maybe to evaluate the bone as a whole for instability in the Shoulder, and Pain in more than 24 hours was less than 1%.

If you do this right and you numb the patient's skin in the capsule appropriately, it doesn't hurt. It's very similar to going to the dentist. You'll feel pressure but not Pain. So our conclusion was that the In-Office Needle arthroscopy is a safe, uh, uh, modality to offer your patients with complication rates similar to or better than office-based injections. So we know that this is something that we can offer our patients and we know it's gonna be safe.

Some of the Other impediments we've heard over the last couple of years has simply been, you know, it's not easy to do. And we've heard that and we've addressed it. So we've created a Knee post as well as a Shoulder distractor to mimic the operating room. If you go back and look at some of the earlier sort of technique papers from just 5 years ago, the patients were static. Either they were laying flat, supine, and we didn't move the Knee around, or we put a a bump under the Knee to make the Knee go to 30 degrees.

We realized we couldn't see all the Pathology, but by making the Knee In-Office Needle arthroscopy similar to Surgery, using Knee posts, using Shoulder distractors, it allows us to have the muscle memory that we need. We can embarrass and valgus the joint, however, we need to, to get into the tight compartments, and really, it's been a game changer for us.

And what that's done is it's opened up the door now for some treatment options and using nano instruments, uh, and again, there's all these small instruments that are available now for use either in the operating room or in the office that can allow for treatment of the meniscus in the form of biting, in the form of shaving or removing a loose body.

I myself have been able to perform a couple In-Office Knee meniscectomies on patients that did not want to go to the operating room during the Pandemic, uh, and we were able to get really good success. Actually, their quads did not shut down because you're using such a low amount of fluid, uh, inside the Knee joint. They did not require physical.

Therapy and all, um, all the patients are able to walk out of the office not using crutches. Uh, so again, small instruments, small, uh, visualization allows for treatment of patients, which I think will lead to better outcomes and we're looking at this through some papers that will be coming out down the road shortly.

So, workflow has always been a concern. You know, people don't wanna get jammed up in the office. They're worried about falling behind and particularly post-COVID where you're limited to the number of people you can see in the office. Time, time is very, uh, an important factor. And, uh, within the Journal of Orthopedic uh Experience and Innovation, I was able to write an article specifically looking at the workflow, and this is something that's available online that you can do. And again, the title of this was adopting.

An office Needle arthroscopy without wrecking your office flow. And I think looking at this picture here, the, the setup is important, looking at the rolling cart that has all of my instruments ready to go. Uh, again, this is simply, uh, syringes, uh, the cold spray, bandages, uh, wraps, as well as having the, uh, the, the, the Tablet and the distractors all on this cart makes me to have the ability to have portability, bringing this from room to room and set up right away for a patient.

And sort of the crux of this was looking at patients for both scheduled and unscheduled cases.

Ideally, if you have a patient that you can bring back at, at lunchtime or at the end of the day, that's a scheduled patient, um, or even the next day, you have all the time that you need to perform this. But unscheduled cases are people that you're in the office setting and you see them and you, you know they have a meniscal tear, you know they have something going on. Your exam and your history tells you this. You just wanna confirm it so we can get them set up for Surgery without the need to send them out for the MRI. That's pretty much undue and maybe more costly.

So, unscheduled patients are the ones that sort of have the opportunity to either be, uh, you know, a home run or they can wreck your office flow. So, in the, the crux of the paper that we discussed was really understanding your workflow and working with your team, your, your MA, your Surgery schedulers to really develop a way to, uh, make this efficient.

So again, the first thing is simply having this work table cart available. So again, I have all the syringes that I need. I have a couple of the needle scopes on the bottom shelf ready to go. They, they're in their box typically. And then I'll have the Tablet and I'll have the poster distractor on the second level. So my MA can wheel us into any room and we can go ahead and perform the Needle arthroscopy if we choose to.

So, let, let's take a scenario. In my clinic, I typically run 3 rooms. Um, let's say the patient in room 1, is someone that I think, uh, you know, has a Knee scope, uh, excuse me, a meniscal tear that would benefit from a Needle arthroscopy. So what I'll do is I'll walk out and I'll come to my MA and I'll say, you know, Mrs. Jones in room 1, I wanna do a Needle Scope on her. What she'll do or he'll do, uh, in the MA, they'll actually run the benefits quickly over the phone or they may know already, looking at the insurance that it does not need prior authorization.

While they're doing that, I'm gonna head to room 2 to see my next patient, and once that sort of information that the MA was looking for has been obtained, they'll head back or he'll head back to the clinic. If they're approved and it can be done now, they'll give them a consent form. They'll make sure that they get changed in the shorts, and they'll begin setting up uh the uh Knee distractor, getting the Tablet ready to go, putting the patient information in, and again, making sure that we open up, uh, what we need our syringes and our sterile saline for Injection.

While that's happening, I'm finishing room two and I'll come back to room one. I'll say to Mrs. Jones, all right, we're all set, and while we're doing, uh, that conversation, I'll sign the consent and then I'll anesthetize the skin in the capsule. My typical cocktail is I use about 10 to 15 cc's of 1% lidocaine plain mixed with 0.5% Marcaine plain. If I have a patient who takes an aspirin a day or maybe he's on a blood thinner, I'll change that 0.25% Marcaine plain to 0.5% Marcaine with epinephrine, so that'll again minimize some of the bleeding.

But that numbing process, because I've already had the discussion before I left the room initially, that takes about a minute or two to, to perform. And while I'm waiting for that patient to get numb, I'm gonna go back uh uh to room 3 in a second. While I'm doing this, so the MA is bringing a new patient into room 2 to backfill. So once this patient's numb, the MA has brought a new patient in room 2, and then I'm gonna go over down to room 3.

So while room 1 is getting numb, I'll do my examination or whatever it might be in room 3. And once I complete room 3, I'm gonna circle back to room 1 to perform my Needle Scope. But when you actually add up all the time that it takes to get this ready, you're only adding a couple of minutes in increments because it's sort of the symphony of people moving back and forth, uh, and getting things done.

So I've come out of room 3. I performed my Needle Scope and I can tell you once I'm comfortable, a, a Needle Scope in the Knee or the Shoulder takes under 5 minutes for me to do, to document, uh, 3 compartments in the Knee or document the intratricular portion of the joint in the Shoulder. So, when I'm done with that, I'm gonna go ahead and explain to my patient, showing them on the Tablet, their Pathology while the MA, the Orthotech, puts a dressing on them.

At this point, we'll make a decision what the next steps might be, whether it's Surgery or therapy or whatever it might be, and I'll exit, go back and see the patient in room two, and the MA or the ortho tech will bring the patient to the Surgery schedule or to the checkout desk. So we, we studied this and timed it, and the average time added to your entire encounter with the patient in room one is about 9 to 10 minutes. So I was able to still see two Other patients. I'm not sitting in the room the whole time doing all of this. I'm working, my staff's working.

Behind me. And again, getting this workflow is important because I've now garnered a Surgery. The patient's gonna book today. They know what's going on. I've given the patient a positive experience which they'll share with a colleague or a friend hopefully, and we saved time and, and money to the healthcare system. The billing and coding is real. Uh, you can bill for a, a new patient visit or an established patient visit depending on what it might be. Your diagnosis code is gonna be internal derangement, and you can add a modifier 59 for the decision to perform a surgical procedure.

Um, depending on if you're gonna inject a cortisone or a biologic, you can go ahead and add the 20,610, uh, large joint Injection code, and then from there, once you performed your procedure, you're gonna use a diagnostic arthroscopy code for the Knee, the Shoulder, the Hip. Um, the ankle is the only one without a true diagnostic code that's available right now. And then you can add a modifier 57 or 58 when it's time to go to Surgery.

What's important to realize is you will get paid 100% on the Surgery after doing a Needle arthroscopy. And the reason for that is there's place of service. So again, if you're doing this in the office at time 0, there's a modifier uh which is place of service for modifier 11.

From there, when you take the patient using the modifier 58 over to the uh operating room at the Surgery center or the hospital, you'll use again different modifiers for point of service and this leads to a 100% Reimbursement on the initial code, both in the office as well as in the operating room. So you don't need to worry about getting your fees cut, which I know has always been a concern.

You wanna make sure your office notes are, are, are, are solid. You wanna make sure you documented the Pathology, the pertinent imaging that's been done previously, your assessment and why you think that the patient has the Pathology, and then when you document your procedure note for the In-Office Needle arthroscopy, you wanna make sure that they were consented, document the

Anesthesia that was used, document you did a full diagnostic evaluation and actually performed that. You don't wanna just say you looked in the medial compartment, saw a medial meniscal tear, and you popped out because if you get to the operating room, and they also have a lateral meniscal tear, um, you're gonna bill for that and you're gonna get some pushback from the insurance companies in some instances.

So you wanna again give an updated assessment and plan after the procedure has been performed. And again, I would not document the length of time that the procedure took because again, this is something that the patient's been with you for, uh, you know, the, the full half hour perhaps. Uh, so again, I think just uh like in regular Surgery, we don't talk about length of time. I don't think that's necessarily needed.

But closing thoughts, you know, in my, uh, my practice, in my hands, and the, the residents and fellows that we train, Needle arthroscopy is the future and I think it's safe, it's cost-effective. Uh, the literature does bear out that it's, uh, has a high sensitivity and specificity, and it can provide a rapid answer for you. The advances in Technology have been incredible over the last 18 months or so, and now we have the option of giving patients treatment in the office if so desired or in using this in a minimally invasive way to lead to better outcomes in the operating room.

So I think, you know, when you think about things and ask the questions that fit into your practice, it may not have in the past, but I think, you know, now is the time to reassess this because it's gonna be something where the guy down the street will begin doing it soon, and you don't wanna be the person who lost a patient because of this opportunity down the road. So that, I thank you for your time. I, I thank you for your, your listening. And again, I encourage you to try this out. I'm always available um as a resource if you have any questions, uh, and I'm happy to present on this further. Thank you.