Year-end is traditionally a time to indulge in both reflection and prognostication. This year, rather than just looking back at these past 12 months, we’ve gone back a full decade to 2010. That’s when we first introduced the needleoscopy modality and our NeedleView® arthroscope for use in equines…and we’re proud that the pioneering veterinarians who were early adopters are still using it today.
The benefits that distinguished NeedleView upon its introduction are the same ones responsible for its rise to prominence as the tool of choice for standing diagnostic arthroscopy.
NeedleView Benefits for the Horse and the Owner
- Because scoping with NeedleView is minimally-invasive, recovery is faster. The scope has an outer diameter of only 1.2 millimeters. Accordingly, the site of the scope portal rarely requires sutures, is “healed and sealed” at a microscopic level within 48 hours, and the horse can resume normal exercise after 4-5 days of bandaging.
- Because scoping with NeedleView can be done with the horse standing, it’s less risky. The NeedleView scope is the size of an 18-gauge needle. This allows the joint to be scoped with just a local block and sedation…avoiding all the attendant risks of general anesthesia.
- Because scoping with NeedleView can be done in the field and with the horse standing, it’s less expensive. Practitioners can perform diagnostic stifle exams with the NeedleView anywhere it’s possible to achieve and maintain sterility of the operative site. This can include not just your practice/facility, but even a barn or wash rack as well. Other diagnostic imaging approaches such as x-ray, CT, and MRI can require travel to special facilities. Not only can the travel be expensive, but so can the tests and the necessary general anesthesia–often $3,000 or more when all is said and done–and these imaging approaches can still leave you without a conclusive diagnosis.
NeedleView Benefits for the Practitioner
- Because scoping with NeedleView requires no general anesthesia, no operating room or ventilator is needed. NeedleView opens up a way for practitioners who see a lot of lameness but have more basic facilities to diagnose these cases.
- Because scoping with NeedleView has a short, comfortable learning curve, it’s accessible for general practitioners. The standing stifle diagnostic procedure with NeedleView is easy to learn, and a practitioner needn’t be a surgeon or specialist to be able to use the tool effectively. As long as the practitioner is comfortable with joint anatomy and knowledgeable about how to be in a joint without damaging cartilage, he or she can learn the standing stifle diagnostic procedure in a wetlab or weekend workshop.
- Because scoping with NeedleView provides a definitive diagnosis, it simplifies the treatment decision for practitioners and clients alike. NeedleView helps practitioners give clients the information they need to make good decisions about how to proceed with an injured horse. For example, if a horse has been treated with IRAP and doesn’t seem to be responding, NeedleView® provides a look to see what’s going on. Or if a horse has a meniscal tear, NeedleView® can help give the owner the information to decide to proceed with surgery, debride to speed healing, or–if the injury is so severe that the horse is still likely to be only 50/50 a year out–maybe not opt for the “Cadillac” level of treatment.
In this issue of Biovision Veterinary Endoscopy’s Views newsletter, we’re exploring how NeedleView has been used since its introduction. We’ll also peek into the future to see what’s on the horizon for this still-exciting and innovative tool.
Audio clips from current clinical users and researchers regarding NeedleView:
- Dr. Miller on NeedleView's ease of use and utility in his practice
- Dr. Pérez-Nogués on why NeedleView is a preferred diagnostic tool
- Dr. Bonilla on NeedleView as a tool for evaluating paranasal sinuses
- Dr. Bonilla on NeedleView compared to other imaging modalities
Jump to Individual Interviews
You may use the following links to jump to a specific section or simply scroll to continue.
NeedleView Then and Now:
- David Frisbie, DVM, PhD, DACVS, DACVSMR
- Josh Zacharias, DVM, MS, DACVS, DACVSMR
- Shane Miller, DVM, MS, DACVS, DACVSMR
The Future of NeedleView:
NeedleView Then and Now: David Frisbie, DVM, PhD, DACVS, DACVSMR
Any discussion of NeedleView’s history must start with Dr. David Frisbie. Dr. Frisbie is a professor of equine surgery at Colorado State University (CSU) College of Veterinary Medicine and Biosciences. As Dr. Frisbie recalls, “As Biovision moved into arthroscopy [in 2010], a colleague suggested that I be recruited to evaluate and develop potential equine applications for the NeedleView scope. We knew we could probably find applications and develop techniques. I met with Biovision’s president John Small and we came up with a plan to look at NeedleView in the field and see where the technology could make the biggest impact. Then we would conduct research and publish for solid science.”
The stifle was the logical best first place to look for applications, Frisbie noted at the time, because:
- Stifle problems account for an estimated 40% or more of injuries in sport horses.
- Definitive diagnosis of slight to moderate stifle pathology was limited.
- Many practitioners are uncomfortable performing diagnostic anesthesia of the stifle.
- Many lesions (particularly soft tissue lesions) go undetected with radiography.
- Use of ultrasonography to examine cruciate ligaments remained difficult because of the orientation and deep anatomic location of these structures.
- CT using contrast arthrography had been used to image the stifle, but limitations existed to its availability and the availability of MRI.
The outcome of that research was the development and refinement of the standing stifle diagnostic arthroscopy procedure as described in “Diagnostic stifle joint arthroscopy using a needle arthroscope in standing horses,” Vet Surg. 2014 Jan;43(1):12-8. doi: 10.1111/j.1532-950X.2013.12068.x. Epub 2013 Oct 31.
In the study, Frisbie and his colleagues were able to confirm that the 18-gauge NeedleView arthroscope could be used to perform complete diagnostic examination of the three compartments of the stifle joint in standing horses. Further, they found that in some areas of the joint where space was limited, the small diameter of the scope was an advantage despite the smaller field of view.
In a 2014 video in which he demonstrated the standing stifle diagnostic exam, Dr. Frisbie noted, "The scope that we're using is the size of an 18-gauge needle. So when we go to treat a stifle joint, we use an 18-gauge needle. So we're really using the same size arthroscope as we do needle to treat them. So, i.e., it's very non-invasive. And as you can see, you know, it's, it's just like prepping it to treat or block a joint except you leave the needle in for four or five minutes as you're looking around to see what kind of a lesion that you have. So it's novel from another standpoint, in that the stifle is a very difficult place to image…meaning we can take x-rays of it [but] they're not horribly sensitive and not necessarily very specific for specific disease processes. Ultrasound helps us a little bit, but it misses a lot of the subtle things that keep our elite athletes from performing at their peak. We can go in and we can put local anesthetic in the joint and those horses go sound; we can treat them and they go sound for a couple of weeks, but then they return with this low-grade lameness. And up until now we've never been able to really look in there without doing, you know, general anesthesia and 'a big surgery.' So this [NeedleView] allows us like in this horse to go in and look around and say, 'Look, there's a little bit of damage probably from a meniscal tear that is not accessible surgically. But we can treat it with other methods like stem cells.'”
"The scope that we're using is the size of an 18-gauge needle. So when we go to treat a stifle joint, we use an 18-gauge needle. So we're really using the same size arthroscope as we do needle to treat them. So, i.e., it's very non-invasive. And as you can see, you know, it's, it's just like prepping it to treat or block a joint except you leave the needle in for four or five minutes as you're looking around to see what kind of a lesion that you have. So it's novel from another standpoint, in that the stifle is a very difficult place to image…meaning we can take x-rays of it [but] they're not horribly sensitive and not necessarily very specific for specific disease processes. Ultrasound helps us a little bit, but it misses a lot of the subtle things that keep our elite athletes from performing at their peak. We can go in and we can put local anesthetic in the joint and those horses go sound; we can treat them and they go sound for a couple of weeks, but then they return with this low-grade lameness. And up until now we've never been able to really look in there without doing, you know, general anesthesia and 'a big surgery.' So this [NeedleView] allows us like in this horse to go in and look around and say, 'Look, there's a little bit of damage probably from a meniscal tear that is not accessible surgically. But we can treat it with other methods like stem cells.'” –Dr. David Frisbie, Colorado State University College of Veterinary Medicine and Biosciences (Fort Collins, CO)
Click to hear this clip from Dr. Frisbie
Upon the 5-year anniversary of NeedleView in 2015, Dr. Frisbie said, “We’ve pretty much established what NeedleView can do, and our experience will stand in any arena. We’ve used it to diagnose meniscal tears and lesions, cartilage damage, cruciate ligament tears and lesions, floating joint fragments, and subchondral bone cysts.”
We spoke with Dr. Frisbie recently to ask how his use of NeedleView has evolved in the intervening years. Following are excerpts from that interview.
Biovision (BV): When you spoke of first exploring potential applications for NeedleView a decade ago, you remarked about the limitations of various imaging modalities when it came to diagnosing stifle injuries. Do those limitations still exist? Have any of those modalities surpassed NeedleView as a diagnostic tool?
David Frisbie (DF): In the last decade, there's been a lot more people trained in all of those modalities. So a decade ago, there weren't that many people that were really that skilled -- especially at stifles – so just the overall awareness and ability to do those things in the field has improved, there's no doubt about it. Likewise, the number of MRIs that are capable of handling a horse have increased, as have the number of MRIs with high field magnets. The quality of the imagery is certainly getting better, there's more of it out there, and people are better trained. Really, even with all those things said, it's not decreased the usefulness of the scope -- the definitive diagnosis can be had with the needle scope.
BV: How has your use of NeedleView evolved over the last 10 years?
DF: It's evolved some. Most of the things that I do are related to the stifle, so in some respects I’m not the greatest litmus test [of evolving use]. But certainly we've scoped navicular bursas (which are really quite interesting), fetlocks front and back, and carpuses. We've also done a lot of experimental work or research scoping hocks with synovitis. With the size of the NeedleView being so much smaller [than a standard arthroscope], it's easier to move around with that smaller scope in the navicular bursa, because it is such a limited space. So I can actually see myself doing some navicular bursa arthroscopy using the needle scope preferentially because of that.
"...we've scoped navicular bursas (which are really quite interesting), fetlocks front and back, and carpuses. We've also done a lot of experimental work or research scoping hocks with synovitis. With the size of the NeedleView being so much smaller [than a standard arthroscope], it's easier to move around with that smaller scope in the navicular bursa, because it is such a limited space. So I can actually see myself doing some navicular bursa arthroscopy using the needle scope preferentially because of that." –Dr. David Frisbie, Colorado State University College of Veterinary Medicine and Biosciences (Fort Collins, CO)
DF (continued): When I was over in Sweden [demonstrating and training] they enjoyed the stifle piece, but they were even more keen about scoping the carpus. And I got feedback subsequent to it saying that was the thing that was a bit of a game changer for those guys, especially in those Standardbred horses. Again, the carpus is an area where the cartilage is thin so you can't really ultrasound very well and you don’t really know on x-ray, so there's no imaging modality that's going to give it to you. But when you stick the [needle] scope in there, it really almost instantaneously tells you if you've got a fair bit of cartilage damage.
BV: Have you done much with the NeedleView and regenerative medicine?
DF: Quite a bit, actually. When we're scoping the stifles with the needle scope, about half of the horses go on to surgery and about half just get regenerative medicine. It’s economically really quite friendly to the consumer [to use the NeedleView for evaluation vs. arthroscopy under general anesthesia] because now you've got $1,000 in to make the diagnosis instead of two to three times that, easily, for a diagnostic arthroscopy under general anesthesia. And you don't have the risk [of general anesthesia]. Now you can put that delta [difference] into the regenerative therapy instead of spending $2,000 to $3,000 on the arthroscopy only to learn that it was diagnostic in its benefit and you're going to do stem cells anyway.
BV: Any closing thoughts about NeedleView on its 10-year anniversary?
DF: You know, the Biovision scope was the first to be described, it's been used the longest, and it certainly has had unique adaptations -- specifically the cannula -- to be better suited for use in horses. Those are all things that I think are unique pieces.
"You know, the Biovision scope was the first to be described, it's been used the longest, and it certainly has had unique adaptations—specifically the cannula—to be better suited for use in horses. Those are all things that I think are unique pieces." –Dr. David Frisbie, Colorado State University College of Veterinary Medicine and Biosciences (Fort Collins, CO)
NeedleView Then and Now: Josh Zacharias, DVM, MS, DACVS, DACVSMR
Dr. Josh Zacharias is another surgeon who can proudly claim status as one of the earliest adopters of NeedleView. Dr. Zacharias is a large animal surgeon and clinician with Countryside Large Animal Veterinary Services, PLLC in Greeley, Colorado. His main interests are equine lameness and all aspects of large animal surgery. A referral practice, Countryside draws clients not only from Colorado but also from Kansas, Nebraska, Wyoming, Utah, New Mexico, Texas, and Oklahoma.
As guest editor of the newsletter issue commemorating NeedleView’s first five years, Dr. Zacharias recounted his first exposure to the technology, saying, “I first encountered the NeedleView scope at the American College of Veterinary Surgeons (ACVS) Surgery Summit in Seattle, Washington, in 2010, where Biovision was an exhibitor. I met John Small, the company’s president, and immediately was intrigued and excited by the potential of this new diagnostic tool. We got our hands on one in 2012 and began using it as a way to definitively diagnose stifle disease without the expense and risk of general anesthesia and surgery.” As Dr. Zacharias noted, “NeedleView piqued my interest because it’s been my experience that it’s easy for private practitioners to get comfortable–and rusty–doing what they’ve always done. My goal is to always be learning and growing,” and needle arthroscopy provided that opportunity.
The standing stifle procedure developed by Dr. Frisbie “became our ‘bread and butter’ in regard to the NeedleView,” said Dr. Zacharias. He added, “The system easily paid for itself. Keep in mind, our practice is in Colorado State University’s ‘back yard,’ and we’re not all that far from Littleton Equine Medical Center. But with the NeedleView, we can compete with an academic institution and a large practice and more than hold our own treating Western performance horses.”
“…with the NeedleView, we can compete with an academic institution and a large practice and more than hold our own treating Western performance horses.”–Dr. Josh Zacharias, Countryside Large Animal Veterinary Services (Greeley, CO)
We had a chance to catch up with Dr. Zacharias, and he reports that not much has changed for him in regard to his opinion or use of NeedleView since 2015. He sees that as a good thing, though, because it means he has a “workhorse” of a diagnostic tool he can rely on to provide definitive diagnoses quickly and affordably, while additional uses—such as for examination of septic joints and as an aid to their lavage—just make the tool even more valuable and versatile.
NeedleView Then and Now: Shane Miller, DVM, MS, DACVS, DACVSMR
Rounding out our stable (pun intended) of early NeedleView adopters still using the technology today is Dr. Shane Miller of Comstock Equine Hospital in Reno, Nevada and Great Basin Equine Medicine and Surgery in Gardnerville, Nevada. Dr. Miller's professional interests lie in orthopedic and soft tissue surgeries with an emphasis in arthroscopy, laparoscopy, and regenerative medicine. He also has a large clinical interest in lameness and performance horse medicine. He has written articles in Veterinary Surgery Journal, Equine Veterinary Journal, Journal of the American Veterinary Medical Association, and many lay journals. Dr. Miller has also presented numerous surgical and lameness topics both nationally and internationally
Dr. Miller purchased his NeedleView system in 2012 and it quickly proved its value helping him perform the many stifle diagnostics needed due to his practice’s population and caseload. And the tool soon proved its versatility. In a 2016 interview, Dr. Miller told us, “I also use it for exploration in areas like the tendon sheath, coffin, fetlock, and carpus. In addition, I use it in paranasal sinuses to help with diagnosis of masses and undetermined infections. One location that I really like its use is in the navicular bursa because of its small diameter. This is helpful in lameness diagnostics when localized to the bursa (via MRI results) or when there has been penetration of a foreign object and subsequent septic bursitis.”
Building on NeedleView’s utility, Dr. Miller developed an additional use in horses that present with septic arthritis. As he noted in 2016, “The typical approach is to lay the horse down with general anesthesia and use a standard 4mm arthroscope to lavage or flush the joint.” In the recent interview he added, “With the NeedleView, with the horse either standing sedated or under general anesthesia, I can flush the joint or sheath and it’s less labor intensive than an arthroscopic flush. Even if there is a lot of debris, we can still use instrumentation to help clear and remove using the NeedleView.”
When we reached out to Dr. Miller for this 10-year anniversary newsletter issue, we found that he has added yet another procedure to his NeedleView repertoire: bursoscopy. “I use it a lot for septic joints, especially for horses that step on nails and have septic navicular bursitis. I like using needle arthroscopy in that location for bursoscopy to take a peek in there. Again, it's much smaller diameter with less iatrogenic trauma. I can get a good evaluation inside the bursa in that location and a great lavage.”
Now, some eight years after first acquiring NeedleView for his practice, the tool is still in regular use four to five times a month, says Dr. Miller. And for good reason: “I really like the system. It's super easy to use. You can see in the areas where you typically can't with a larger scope, and so I can get in some areas that I usually wouldn't be able to. So in that regard, just based on size alone, it allows us to see other aspects of the joint that you typically can't. I mean, other than that, it's, you know, the portability and ease of use, especially if you're used to doing arthroscopy. It's really simple.”
“I really like the system. It's super easy to use. You can see in the areas where you typically can't with a larger scope, and so I can get in some areas that I usually wouldn't be able to. So in that regard, just based on size alone, it allows us to see other aspects of the joint that you typically can't. I mean, other than that, it's, you know, the portability and ease of use, especially if you're used to doing arthroscopy. It's really simple.”–Dr. Shane Miller, Comstock Equine Hospital (Reno, NV)
Click to hear this clip from Dr. Miller
Now let’s peer into the future to see what’s on the horizon for NeedleView® as we talk with researchers who are pushing the boundaries of the technology and exploring novel applications.
The Future of NeedleView: Marcos Pérez-Nogués, LV, MSc, DACVS-LA
We’re excited to introduce you to Dr. Marcos Pérez-Nogués of the University of California-Davis. Dr. Pérez-Nogués obtained his veterinary degree from the School of Veterinary Medicine of Complutense University in Madrid, Spain. He then completed a 1.5-year equine internship at the School of Veterinary Medicine of Complutense University along with a master's degree in Veterinary Research. Dr. Pérez-Nogués then completed two equine surgery internships in private practice: Milton Equine Hospital in Ontario, Canada, and Hagyard Equine Medical Institute in Lexington, Kentucky. Upon completion of these internships, he joined and completed the equine surgery residency program at UC Davis. A Diplomate of the America College of Veterinary Surgeons, Dr. Pérez-Nogués is currently an equine surgeon with the UC Davis Veterinary Medical Teaching Hospital.
Dr. Pérez-Nogués is one of the researchers eager to expand the use of NeedleView technology to–for lack of a better phrase–“go where no scope has gone before.” His recent area of research interest focused on equine caudal cervical articular process joints. Disorders of this area have been linked to spinal cord compression resulting in severe clinical signs such as ataxia, lameness, and weakness.
In Dr. Pérez-Nogués’s words, “The population of geriatric and retired horses, or simply late in their career that we see in our practice has increased. Mostly horses that have had a very good jumping, eventing, racing or other demanding physical activity usually develop some degree of arthritis problems. So we see like, almost ‘maintenance’ horses all the time…we will be checking them all the time because of arthritis.” He continued, “We see a lot of arthritis in the neck, too. And these horses with arthritis in the joints that we started scoping, they're very difficult to treat and assess because [of limitations in] the tools that we have now--the diagnostic imaging techniques that we have for horses. We have the radiology which is not that great; you can see that there's arthritis, but you cannot see the whole picture of what this arthritis is causing [in the spinal cord]. And then when we do an ultrasound of the neck, we just see the surface of the bone. And now they're developing some CT equipment that can fit a horse or do it standing. But we don't have it here [in our practice] yet. We're trying to get it. So the only diagnostic tools that we have is x-ray and ultrasound and they're not good enough."
“We see a lot of arthritis in the neck, too. And these horses with arthritis in the joints that we started scoping, they're very difficult to treat and assess because [of limitations in] the tools that we have now--the diagnostic imaging techniques that we have for horses. We have the radiology which is not that great; you can see that there's arthritis, but you cannot see the whole picture of what this arthritis is causing [in the spinal cord]. And then when we do an ultrasound of the neck, we just see the surface of the bone. And now they're developing some CT equipment that can fit a horse or do it standing. But we don't have it here [in our practice] yet. We're trying to get it. So the only diagnostic tools that we have is x-ray and ultrasound and they're not good enough.”–Dr. Marcos Pérez-Nogués, University of California-Davis
Click to hear this clip from Dr. Perez-Nogues
Others have tried to access these joints with standard arthroscopes. “There have been two or three cases published…people in Europe that tried [this procedure] with a big scope. They had to do a big surgery and cut very deep. Everything is really deep and if you damage something there, it’s going to be a big issue. So the needle scope comes in very handy.”
So Dr. Pérez-Nogués turned to needle arthroscopy. He particularly likes the insertion method available to him with NeedleView. “We’ve tried different needle scopes over the years, too, and I think the [NeedleView] insertion method with the trocar and the cannula separated from the camera is really good. It’s nice. It’s easy.”
“We’ve tried different needle scopes over the years, too, and I think the [NeedleView] insertion method with the trocar and the cannula separated from the camera is really good. It’s nice. It’s easy.”–Dr. Marcos Pérez-Nogués, University of California-Davis
For his prospective experimental case series, Dr. Pérez-Nogués selected six adult horses. Leaving them standing and sedated in stocks (check out a video snippet here), he placed the trocar and cannula assembly under ultrasound guidance without joint distention and then introduced the NeedleView. He explored bilateral C5-6 vertebral articular process joints in three of the horses; in the other three, he examined bilateral C6-7 joints. As he reports in his paper “Evaluation of the caudal cervical articular process joints by using a needle arthroscope in standing horses,”:
- All 12 articular process joints were successfully explored.
- Entering the joint on the first attempt was achieved in 10 of 12 joints.
- A craniodorsal approach for arthroscope insertion allowed evaluation of the most cranial aspect of the articular cartilage surface.
As for limitations, he reported, “Triangulation with a spinal needle was determined to be difficult and resulted in a limited space for movement.”
He concluded that needle arthroscopy of the caudal cervical facet joints can be performed safely and efficiently in standing sedated horses. The clinical significance, then, is that “Standing cervical articular process needle arthroscopy is a minimal morbidity technique with the potential to be an advantageous technique for the diagnosis and treatment of cervical articular process pathology.”
As exciting as these findings are, Dr. Pérez-Nogués acknowledges they’re not yet sufficient to convince some of the vets who refer horses to the UC Davis Veterinary Medical Teaching Hospital. “The technique is very good, but it's still not very accepted by our ref vets,” he said. “Even though we lower the price [to perform the exam] and everything, the ref vet’s still ‘Well, we may have problems.’ It’s not usually a routine technique yet. So they are still backing up on sending horses that are more or less neurologic or ataxic with this problem to be scoped. And we still cannot say, ‘Oh, we're going to diagnose your horse with this technique’ yet.”
Being able to use the NeedleView to get definitive diagnoses in this tricky area is what’s next on the research horizon for Dr. Pérez-Nogués. He notes, “It's a little bit early for us to say [we can do] that. Now what we have to do is [scope] the horses with problems and then correlate what we can see.” His next step is to look for such correlations in cadaver horses that have already died of the disease or that were euthanized because of the progression of the disease. “So far, I just have one horse that I've done. But yeah, I’m kind of hunting those cases down to see what we can learn.”
Dr. Pérez-Nogués sees great things ahead for NeedleView. “I think the biggest advantage of this technique mainly is not [just] doing the horse standing but accessing joints that we've never routinely done…some joints that we’ve never been able to easily access without trouble: neck, hip, shoulder, etc.”
And that – “joints we’ve never been able to easily access without trouble” – leads to our final interview in this 10-year NeedleView anniversary issue…
The Future of NeedleView: Alvaro Garcia Bonilla, DMV, MSc, DACVS
We’re not aware of anybody recently who has stuck NeedleView in so many new joints—and then published about the experiences—as Dr. Alvaro Garcia Bonilla, Assistant Professor of Equine Surgery at Université de Montréal in Saint-Hyacinthe, Quebec, Canada.
Dr. Bonilla received his DMV from the Universidad de Cordoba in Spain and completed two internships in medicine and equine surgery at the Universitat Autonoma de Barcelona in Spain and a private practice in Spain. Then, he moved to North America where he completed an internship at Milton Equine Hospital in Canada and an orthopedic fellowship at University of Pennsylvania. During his equine surgery residency at The Ohio State University, he earned his Master’s of Science and followed the residency with a one-year term as a Clinical Instructor in Equine Surgery and Emergency. After experience as an equine surgeon with the Université de Montréal, Charles Sturt University, and the University of Bristol, Dr. Bonilla joined the Université de Montréal as an Assistant Professor of Equine Surgery in 2016. A Diplomate of the American College of Veterinary Surgeons, Dr. Bonilla regularly conducts and publishes scholarly research focused on expanding the clinical applications of minimally-invasive approaches such as endoscopy and needle arthroscopy in equine diagnostics and treatment.
One of Dr. Bonilla’s first forays into research with NeedleView was his 2020 paper titled “Validation of a 2-mm videoendoscope for the evaluation of the paranasal sinuses with a minimally invasive technique” (Vet. Surg. 2020 Jun;49 Suppl 1:O60-O70). Using the NeedleView camera in conjunction with a 2mm flexible endoscope for standing, conscious evaluation of the paranasal sinus, he concluded, “Minimally invasive sinoscopy was readily performed without relevant complications in standing horses. A thorough evaluation of most sinus structures was obtained only using the frontal and the rostral maxillary portals."
When we asked him recently about the 2020 study, Dr. Bonilla noted, “Yes, it requires knowledge of the anatomy of the paranasal sinuses to do it, but once you have the knowledge, it doesn't require a lot of technical skills. So I think this is a procedure which is much simpler to perform. It’s very beneficial not only for a specialist; I think even practitioners could do it. Of course, it should be practitioners with good training and good knowledge of the anatomy of the paranasal sinuses and the pathologies. But it's a simple technique. It's very minimally invasive. The traditional technique makes around a 10-millimeter hole through the head. This one, we make it with a needle—two millimeters. You put the scope [in], look inside, and you have an idea about what is going on. And you can, in some locations, escape the need for advanced imaging, either because you don't need it or maybe because you don't have the money or the access to it.”
“That technique [evaluation of the paranasal sinuses with the NeedleView camera and a flexible endoscope]…yes, it requires knowledge of the anatomy of the paranasal sinuses to do it, but once you have the knowledge, it doesn’t require a lot of technical skills. So I think this is a procedure which is much simpler to perform…You put the scope [in], look inside, and you have an idea about what is going on.”–Dr. Alvaro Bonilla, Université de Montréal
Click to hear this clip from Dr. Bonilla
That experience sparked a desire in Dr. Bonilla to exploit the unique advantages of NeedleView as a tool for diagnostic arthroscopy. We spoke to Dr. Bonilla recently in preparation for this newsletter issue. Following are excerpts from that interview.
Biovision (BV): From your perspective, how do you feel about this as a tool? And what sort of implications do you see it having?
Alvaro Bonilla (AB): So to me, the needle scope is a very valuable tool. And I think in the future, or progressively, we're going to give it a little bit of more therapeutic application, but the potential and the current use for me and others is diagnostics. So to me, it's a diagnostic or an alternative diagnostic tool. Many of us, when we work in academia, we have CT, we have MRI, we have a lot of toys…but many people [outside academia] are left still with radiography and ultrasound to get their diagnosis. It's not that we need the needle scope for every case, but in selected cases, radiography and ultrasound don't give us a definitive diagnosis. And we need to go beyond that. And that's specifically why it was created for the stifle. So the way I see it, we have kind of two limitations for diagnostics in horses. On one side is that advanced imaging: CT and MRI are cost prohibitive for many, and it's not accessible to many people. And the other limitation is that even if it is accessible, there are certain regions in the horse, especially the upper limb--like the shoulder [or] the stifle--where you pretty much cannot do any advanced imaging. So there are still, in our field, certain limitations regarding traditional diagnostics, and that's where the needle scope is a valuable tool…having another diagnostic tool that can help you to get a diagnosis more precisely when you don't have it with basic imaging.
“So there are still, in our field, certain limitations regarding traditional diagnostics, and that’s where the needle scope is a valuable tool…having another diagnostic tool that can help you to get a diagnosis more precisely when you don’t have it with basic imaging.” –Dr. Alvaro Bonilla, Université de Montréal
BV: Can you talk a little bit about NeedleView and the information that you get from it versus something like an MRI or a CT or an X ray? How much of an advantage is that?
AB: It's a great advantage. So arthroscopy remains the gold standard to diagnose multiple pathologies. MRI progressively is getting better and better for diagnosis of cartilage lesions. But [with] some of them, our eyes are better than others and some sequences are better than others. Many times you need to put the horse under general anesthesia to get an appropriate diagnosis. So it's always an advantage to be able to put your eyes inside a joint to look at the cartilage, look at the soft tissues within the joint, to look at some fragments that you may be suspicious of or that may be silent on other imaging modalities.
And, you know, surgeons…sometimes we are a little simplistic, so having our eyes on something and being able to see it really helps us to determine exactly what's going on. So that's for sure a value.
“It's a great advantage. So arthroscopy remains the gold standard to diagnose multiple pathologies. MRI progressively is getting better and better for diagnosis of cartilage lesions. But [with] some of them, our eyes are better than others and some sequences are better than others. Many times you need to put the horse under general anesthesia to get an appropriate diagnosis. So it's always an advantage to be able to put your eyes inside a joint to look at the cartilage, look at the soft tissues within the joint, to look at some fragments that you may be suspicious of or that may be silent on other imaging modalities.”–Dr. Alvaro Bonilla, Université de Montréal
Click to hear this clip from Dr. Bonilla
Dr. Bonilla has since gone on to co-author four more papers involving NeedleView in just this year alone. We provide a brief overview of each study below, along with links to the published papers. (Note: journal subscription is required to view the full content.)
Diagnostic needle arthroscopy of the tarsocrural joint in standing sedated horses. Kadic DTN, Bonilla AG. Vet Surg. 2020 Apr;49(3):445-454. doi: 10.1111/vsu.13375. Epub 2020 Jan 13.
In this experimental study, Dr. Bonilla and his coauthors used cadaveric hind limbs in Phase 1 and six healthy horses in Phase 2, examining each tarsocrural joint (TCj) with the NeedleView scope and the use of a custom-made splint and base to maintain joint flexion during the procedure. As reported in the paper, “Thorough evaluation of the dorsal intra-articular structures of the TCj via dorsomedial and dorsolateral approaches was possible in both phases. The procedure was feasible, quickly performed, and well tolerated by all horses. Complications consisted of moderate movement (2/6 horses) and hemarthrosis (3/6 horses).” Dr. Bonilla and his coauthors concluded that “Diagnostic standing needle arthroscopy of the TCj allowed thorough evaluation of the dorsal aspect of the joint while avoiding the cost and risks associated with general anesthesia,” and “Needle arthroscopy of the TCj offers an alternative diagnostic tool when traditional imaging techniques (radiography and ultrasonography) are unrewarding or nondiagnostic.”
Diagnostic tenoscopy of the carpal sheath with a needle arthroscope in standing sedated horses. Miagkoff L, Bonilla AG. Vet Surg. 2020 Jun;49 Suppl 1:O38-O44. doi: 10.1111/vsu.13381. Epub 2020 Jan 25.
Dr. Bonilla and his coauthors took a similar approach with this experimental study, again choosing to use six cadaveric limbs (forelimbs this time) in Phase 1 and six healthy horses in Phase 2. In Phase 1, the researchers performed carpal sheath tenoscopy with NeedleView using both the 65mm and 100mm scopes. This was followed by tenoscopy with a 4-mm arthroscope through a standard proximolateral approach. In Phase 2, they performed unilateral standing carpal sheath tenoscopy in six healthy sedated horses with the 65mm NeedleView scope, maintaining the limbs in flexion with a custom-made splint and base. As reported in the paper, “Visibility at the most distal aspect of the sheath was absent for the needle arthroscopes vs a standard arthroscope. The maneuverability with a 65-mm needle arthroscope was excellent and allowed exhaustive visualization of the proximal region of the carpal sheath in cadaveric limbs and standing horses (six of six). However, visualization of the intertendinous recess was partial in most horses (four of six) vs cadavers (complete in six of six) because of remaining flexor tendon tension in standing horses. No major complications were encountered.” The researchers concluded, “Standing carpal sheath tenoscopy allowed a safe and thorough evaluation of most structures in the proximal region of the sheath and offers an alternative diagnostic technique,” and “Horses with unrewarding results after traditional imaging or that require an accurate diagnosis before treatment may benefit from this alternative procedure.”
Needle arthroscopy of the radiocarpal and middle carpal joints in standing sedated horses. Kadic DTN, Miagkoff L, Bonilla AG. Vet Surg. 2020 Jul;49(5):894-904. doi: 10.1111/vsu.13430. Epub 2020 Apr 25. PMID: 32333682
Replicating the methods of the preceding two studies, Dr. Bonilla and his coauthors used NeedleView in cadaveric forelimbs as well as in healthy sedated standing horses to evaluate the radiocarpal and middle carpal joints. In Phase 1 (cadaveric), they were able to thoroughly evaluate the dorsal and palmar recesses of both joints with NeedleView. In phase 2 (standing sedated healthy horses), “…joint evaluation was also thorough but only dorsal approaches were performed. All horses underwent radiocarpal joint arthroscopy, whereas the middle carpal joint was evaluated in only three of six horses because of limb movement.” The researchers noted, “The technique was quickly performed and well tolerated by all horses. Complications included moderate movement, mild iatrogenic cartilage damage, and mild hemarthrosis.” They concluded, “Standing needle arthroscopy allowed thorough evaluation of the dorsal aspect of both joints, although only three of six middle carpal joints were assessed because of movement limitations,” and “The proposed technique offers an alternative diagnostic tool for radiographically silent intra-articular lesions of the carpus while initially avoiding the cost and risks associated with general anesthesia. Arthroscopy of a single joint is recommended to minimize risks associated with movement during the procedure.”
Diagnostic needle arthroscopy of the scapulohumeral joint in standing sedated horses. Pouyet M, Bonilla AG. Vet Surg. 2020 Oct 19. doi: 10.1111/vsu.13529. Online ahead of print.
In his most recent and arguably most ambitious study with the technology, Dr. Bonilla and his coauthors sought to describe the technique for using NeedleView to perform diagnostic standing scapulohumeral joint needle arthroscopy in horses. Using eight cadaveric thoracic limbs in Phase 1, they assessed the feasibility of the technique by using a craniolateral arthroscopic approach, performing an evaluation of the visible structures of the scapulohumeral joint with both the needle scope and a 4-mm arthroscope. In Phase 2, they performed the technique in six healthy sedated standing horses. As reported in the paper, “In phase 1, joint evaluation was similar between arthroscopes and allowed complete evaluation of approximately the lateral half of the humeral head and the lateral glenoid rim. In phase 2, all joints were successfully accessed, and fluid extravasation was mild. Arthroscopic visualization was complete for the centrolateral aspect of the joint in all horses and either complete (3/6) or partial (3/6) for the craniolateral and caudolateral structures, respectively. The procedure was rapidly performed and well tolerated, and no postoperative complications occurred.” The researchers concluded “The described technique was simple and allowed direct inspection of the scapulohumeral joint. Nonetheless, the standing nature of the technique prevents evaluation of the medial aspect of the humeral head and most of the glenoid cavity.” They added, “Needle arthroscopy of the scapulohumeral joint is feasible in horses and offers a diagnostic technique that may improve the surgeon's diagnostic ability for certain shoulder pathologies.”
BONUS: Watch Dr. Bonilla's AAEP Presentation on Standing Diagnostic Arthroscopy Beyond the Stifle
Watch Dr. Bonilla’s presentation – “How to Perform Standing Needle Arthroscopy Beyond the Stifle” – on demand via the American Association of Equine Practitioners’ 2020 Virtual Convention. To watch Dr. Bonilla's session, you must be registered for the convention. Once you have your login credentials, you will be able to access his presentation by using this link: https://aaep.digitellinc.com/aaep/sessions/5156/view. Dr. Bonilla’s presentation is available now and will remain accessible through June 30, 2021.
Thanks for Reading!
It has been our pleasure to bring you this “look back and look forward” to commemorate the 10-year anniversary of NeedleView’s introduction for equine use. We hope you’ve enjoyed it and that it has set the wheels turning in your mind as to the value this versatile diagnostic tool could have for you in your practice.
To See NeedleView in Action…
We miss being able to demonstrate NeedleView at conferences and conduct continuing education wetlabs with the technology. You can still see the tool in action by checking out some of our featured videos:
This is a Perfect Time to Add NeedleView to Your Diagnostic Toolbox
Now is a perfect time to add NeedleView to your diagnostic toolbox so you can begin offering minimally-invasive standing joint diagnostics in the new year. Favorable financing offers are available, and your purchase may qualify for special tax treatment. Contact us at 303-225-0960 Monday-Friday between 9:00 a.m. and 5:00 p.m. Mountain time or send an email to .