Meniscal tears are one of the most common problems treated by orthopedic surgeons today. The meniscus plays an important role in knee stability and distribution of forces within the knee joint and therefore should be repaired whenever possible. Due to poor blood supply and challenging tear patterns, repairing a torn meniscus can be very challenging. Arthrex provides a multitude of options for treating the full spectrum of meniscal pathology, including meniscal repairs and transplants or arthroscopic resection.
Harnessing 20 years of excellence in designing arthroscopic hand instrumentation, Arthrex has engineered the next generation of instruments for diagnostic, resection, and extraction procedures. At just 2 mm in diameter, these small instruments are sharp, and engineered to efficiently resect meniscal tissue and other soft-tissue structures. Use the articulating, retractable NanoProbe hook probe for diagnostic procedures and atraumatically insert the NanoBiter, NanoScissor, and NanoGrasper instruments through tight joint spaces.

Knee

Procedure

Meniscal tears are one of the most common problems treated by orthopedic surgeons today. The meniscus plays an important role in knee stability and distribution of forces within the knee joint and, therefore, should be repaired whenever possible. Repairing a torn meniscus, with its poor blood supply and challenging tear patterns, can present quite a challenge. Arthrex provides a multitude of options for treating the full spectrum of meniscal pathology, including meniscal repairs and transplants or arthroscopic resection.
Harnessing more than 20 years of excellence in designing arthroscopic hand instrumentation, Arthrex has engineered the next generation of instruments for diagnostic, resection, and extraction procedures. At just 2 mm in diameter, these small instruments are sharp and engineered to efficiently resect meniscal tissue and other soft-tissue structures. Use the articulating, retractable NanoProbe hook probe for diagnostic procedures and atraumatically insert the NanoBiter, NanoScissor, and NanoGrasper instruments through tight joint spaces.

Foot and Ankle

Hand and Wrist

Imaging and Resection

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Human

Handheld Arthroscopy Instruments

video

Partial Meniscectomy

The surgeon begins by creating two portals or small incisions in the front of the knee. The arthroscope is inserted through one portal and a passport cannula is inserted through the other. The meniscal tear is identified and probed. If the tear cannot be repaired, the injured tissue is excised. Arthroscopic biters are introduced and the meniscal flap is trimmed. An arthroscopic shaver is placed inside the knee and debris is removed. The shaver is then used to smooth the edges of the meniscus, leaving behind stable, healthy tissue.

Arthroscopic Meniscectomy

Child (D)

Meniscal tears are one of the most common problems treated by orthopedic surgeons today. The meniscus plays an important role in knee stability and distribution of forces within the knee joint and therefore should be repaired whenever possible. Due to its poor blood supply and challenging tear patterns, repair of the torn meniscus can present quite a challenge. Arthrex provides a multitude of options for treating the full spectrum of meniscal pathology, including meniscal repairs and transplants or arthroscopic resection.
Harnessing 20 years of excellence in designing arthroscopic hand instrumentation, Arthrex has engineered the next generation of instruments for diagnostic, resection, and extraction procedures. At just 2 mm in diameter, these small instruments are sharp, and engineered to efficiently resect meniscal tissue and other soft-tissue structures. Use the articulating, retractable NanoProbe hook probe for diagnostic procedures and atraumatically insert the NanoBiter, NanoScissor, and NanoGrasper instruments through tight joint spaces.

Matt Daggett, DO, MBA (Kansas City, MO), describes his protocol for performing an incisionless diagnostic knee procedure and a meniscal debridement using the 1.9 mm NanoScope™ operative arthroscopy system with the 2.0 Nano instrumentation.

Nano Arthroscopy - Meniscal Debridement

Hi, my name is Doctor Matt Daggett. Today I'm going to introduce to you the nano arthroscopy kit. Both the diagnostic and therapeutic aspects. So the nano arthroscopy instrumentation allows us to traumatically perform these procedures, not just in a procedure room, but in standard or replacing traditional instrumentation. It provides a much less invasive option for some of these more simple arthroscopic procedures included in the kit. You have a tegaderm adhesive that can be utilized with the cannula to maintain accurate and stable placement of the cannula during the arthroscopic procedure. The spinal needle included in the kit has graduated markers demonstrating the depth for capsular penetration. The included switching stick also allows for atraumatic switching of arthroscopic portals as needed during the procedure. Here we have the 2.4 outflow suction cannula that allows us to remove any debris obtained during the procedure, whether through meniscal shaving, biting, or any other arthroscopic resection. Here we have the two millimeter nano arthroscopy shaver, which allows us to resect tissue in a very efficient manner in a very small size. Through the arthroscopic nano cannula, before the procedure starts, I'll often talk to the patient and ask the patient how much they want to be a part of this process. They can oftentimes visualize the nano arthroscopy tablet at the same time I am. So I'll see how much they feel comfortable seeing actually, the pathology that is in their knee and also being a part of the overall experience. So once the patient is comfortable in the supine position on the exam table, I will draw out the landmarks. And they're slightly different than traditional arthroscopic portals. First we're going to mark the inferior pole of the patella. And then we're going to mark the lateral And medial joint lines. This will give us constant feedback as far as where we're at in our positioning. I found that especially when the patient's awake, it is very important to understand where your surface landmarks are, as that will increase your efficiency during the procedure and improve the patient's comfort. Traditionally, the arthroscopic portals are a little different. We go right above the joint line, slightly one centimeter away from the patella tendon on the lateral side and on the medial side. You want to be just above the joint line as well. This will allow for easier access to the traditionally hard to reach areas within the knee. Here is our lateral arthroscopic portal. This is going to be our standard visualization portal. And here is the standard medial portal, which will be really the working portal for a lot of our arthroscopic procedures as we get to the therapeutic aspects of Pano arthroscopy. We also have other portals at our disposal. Traditionally, a posterior medial portal can be used and utilized during this procedure, as well as a standard superior lateral portal if you need to get better access to the to the Patellofemoral joint. So as I mentioned, the patient experience and comfort is really essential during these procedures. And so we want to make sure we get excellent local anesthesia before the patient starts the procedure. Oftentimes I will give them the following medication protocol. They will receive 400mg of Celebrex one hour before they come in for the procedure, as well as 600mg of neurontin one gram of Tylenol. And I also have them take an one gram of cephalexin orally just one hour before the procedure. So we really want to make sure we get excellent local cutaneous anesthesia. And so the first mixture we're going to use is a mixture of 1% lidocaine with epinephrine and half percent marcaine plane. This combination allows for some short term anesthetic, but it also decreases the amount of bleeding we're going to have at the injection sites, and really starts the process so that the patient gets more comfortable. Nanoscope now offers many options to address this pathology, seen at the time of diagnostic arthroscopy and through the utilization of either gravity pump or an inflow pump, and the other arthroscopic tools were able to really address this pathology in a minimally invasive manner. Now, in the conclusion of our diagnostic arthroscopy, if we identify intra-articular pathology that we believe can be addressed, we now have the equipment to be able to address these in a minimally invasive manner through the Nano Arthroscopy instrumentation kits. In addition, the stopcocks and inflows can accommodate for both a gravity pump and the standard arthroscopic pump system to allow more efficient fluid management options. Next, we're going to establish our working portal. We take the graduated spinal needle and we can insert that and visualize that upon entrance. The graduated lines on the spinal needle allow us to really identify the depth and appropriate cannula selection for the nano arthroscopy portal. As you can see we have these markings of seven, five, four, and three that give us the depth of trocar that we should utilize. And in this situation, we're going to be utilizing a three trocar cannula. Next step we'll remove the stylet insert the switching stick. And then we're going to back out the spinal needle. In some situations it's nice just to use the obturator first. This allows for some dilation of that portal. And then we back it off. And then we'll include the cannula with that. And it slides directly in without us having to make any incisions which I love. Now to prevent cannula fallout we will utilize these adhesive tegaderm which will really allow our cannula to stay in place. The tegaderm is placed over the cannula onto the surrounding skin. And secured. At this point, we'll make a small incision within the tegaderm itself to allow our instruments to work through. It's amazing that the only incision you make with this product is through the tegaderm, not the skin. Next, we're going to insert the Dynel probe as we insert it through the cannula. This will allow us to really better inspect tissue before we move on to addressing the pathology. The nano probe allows for varying degrees of depth of the probe itself, as the button on the outside allows for us to increase or decrease the amount of probe coming from the instrument. So after we've thoroughly probed, we can then insert the nano straight biter as needed, or other nano instrumentation that goes through the cannula and back into the knee. The efficiency of this two millimeter biter is surprising, even though it is quite smaller than standard arthroscopic instrumentation. It's because of its single use nature, very sharp and efficient. In the same amount of time, it would take you to do a partial meniscectomy with standard equipment. You can utilize this nano biter without any significant difference. With the cannula in place, we can now access inside the knee very efficiently as once the cannula is in place, we can change instrumentation without really causing a lot of damage to the knee itself. The two millimeter nano arthroscopy shaver really allows us to access these hard to reach areas a dramatically. The amazing thing about this technology is it really allows us to treat some of these common orthopedic conditions in a very minimally invasive manner. You can utilize two different methods of removing arthroscopic debris, either the arthroscopic shaver or this 2.4mm outflow cannula. This could be attached to either a syringe or suction tubing to remove arthroscopic debris. This is also a good way to drain the knee at the culmination of the procedure. Another instrument is the nano grasper, which allows us to grasp loose bodies or debris for removal. Once again, all going through the same cannula that you set up at the initial part of the procedure. Here we grab a loose body of cartilage debris floating within the knee. Another helpful tip is that we can utilize the cannula that's already in place, and place our inflow cannula with NanoScope within that, without making any other portal sites. And thus we've switched our visualization in a very efficient, patient friendly manner. Now we can use our upright percutaneously as well. This updater can really be beneficial in hard to reach meniscal pathology. The small size of this nanopowder still allows us to get very efficient resection of these hard to reach meniscal tears. A nice feature of this NanoScope medical grade console is the ability to capture video and annotate with VoiceOver real time during the procedure that you can share with the patient thereafter. One of the biggest things about the NanoScope is its ability to really improve and enhance the patient experience and recovery by educating the patient more about what their condition is, and then enhancing their recovery by using mainly local anesthesia and reducing the amount of general anesthesia. The recovery time of these procedures is significantly less than what's traditionally performed with standard arthroscopy. What's amazing is the recovery time is significantly less just in the short period thereafter surgery, because of that minimal general anesthetic that the patient is receiving compared to standard arthroscopic procedures prior to finishing the procedure, I will always aspirate any of the remaining fluid within the joint, and it really helps with the patient's discomfort. After the fluids are removed, we can take down the tegaderm and remove the cannula. What's amazing is after the procedure, we don't have any incisions to close with suture. At the end, we will apply these JumpStart bandages, which will protect the portal sites, but also help reduce the risk of any infection. The patient is then transferred to the recovery room, where their stay is minimal compared to traditional methods. As we have really minimized or eliminated the use of general anesthesia, it allows us to initiate physiotherapy very quickly after surgery and really hasten the patient's recovery process.

Spine

Orr Limpisvasti, MD (Los Angeles, CA), presents on the impact of the 1.9 mm NanoScope™ visualization system and the 2 mm Nano hand instruments on the future of minimally invasive arthroscopy.

Innovation: The Future of Minimally Invasive Surgery

I'm going to be speaking on the the future of minimally invasive surgery. My name is All-inside. I'm from Kerlan-jobe, just up the road, and I'm not really going to try to prognosticate the future here, but maybe just lend some directional things that are happening as it pertains to arthroscopy. So necessity is the mother of invention. It's sort of become a platitude for us at this point. Obviously, when this was coined, it was coined in a time of necessity. In around 400 B.C., the average human lived about 37 to 41 years. And currently, we're in a time of abundance. It takes a bigger push for us to want to innovate, to want to do something different. And that's why a course like this is really fun, because it sort of explores the edges of where we're going. But even 100 years ago, our arthroscopic forefathers here, you can see on the left there, Takagi, that's 1919. That's literally 100 years ago. Nordentoft 1912, they started to sort of push the limits and see what you can do with the scope. Well, before we had any sense of of what we would be doing today and just for context, to see how far ahead these guys were, the the innovations that were happening at that time, or the television set, household refrigerator and a ballpoint pen. So these guys are just light years ahead. But again, what is it that makes us want to innovate? I remember something that Frank Jobe taught me and told me as I was joining practice was that we have to keep changing what we do. You know, it's very counterintuitive to have someone who's an innovator tell you, okay, coming out of training, honing your skills, trying to perfect what you do now, start to unlearn it, start to change and transform what you do. And that was really something that's that's true even today. You know, he said there's no surgery that he did in his practice towards the end that he did when he started practice. And we're all sort of experiencing the same thing right now. So why is it so hard to change? Why is it so hard for us to change what we do? You know, you know, there's nothing permanent except change. But we've got this resistance. If you talk to any of the surgeons in this room about how they do rotator cuff repair ACL, we've got myself included. You've got this sort of visceral response of this is how I do it. This is how I like to do it. And, and I would just say, you know, at a meeting like this, it's great to, to kind of let go of that grip a little bit and think a little bit more clearly about where this is heading. You know, Steve Pressfield, in his great book called The War of Art, talked about this resistance, these internal hurdles that we create for ourselves that don't allow us to continue to evolve. And as the resistance pertains to arthroscopy, even some of the greats, I mean, these are legends, right? You see, some of the big heavy hitters say, hey, this is this is how I do it. I don't want to change. But, you know, and Charlie Rockwood called the arthroscope the tool of the devil. I mean, these guys had moved the dial so far in open shoulder surgery that that was where they found success. And it seems a little bit funny now that, you know, the question that they were asking was, why would you want to look through a keyhole? We can open the door wide open. So this is what the transformation looks like. On the left here, you've got sort of the early version of what we're doing and, and, you know, sort of looking at what's happening on the right side, how clear the picture is. Synergyrf 4K sort of where we're heading. Makes me a little bit embarrassed looking at this when I complain to my ex about how, you know, I got glare on the scope or the picture isn't that clear? You look at the guy on the left, he's happy as a clam, putting his eyeball on a scope. He's got his scope on the posterolateral part of the knee. He's got a clamp on the posterior medial part of the knee, and he's just probably thrilled to be able to see something and do something. But obviously there are numerous iterations that happen between these two pictures here. A lot of emotional labor went into continuing to transform and move the dial, but some things haven't changed. And that's what we need to think about, is how we're going to move things forward. Because what we've seen change in the last 20 years is what we're doing with the scope, as if the scope were a stable platform. But what you can see here, and this is more true in orthopedics actually, than other medical subspecialties, we have a fairly rigid scope. It's got a fixed angle. It's going to hover in the last 20, 30 years between about four and six millimeters in diameter. So, you know, Eric talked a little bit about the NanoScope coming out. This is kind of an interesting thing. That's going to be a little bit fun because it's going to push you to think. And it's sort of at base camp right now. There's a lot of great technology, the chip on chip technology that's come into this. And we'll talk a little bit about this. We've got a lab coming up that we can just do a quick demo to show everyone what it's capable of. So just take a look at the metric size comparison. So again going down from about 4 to 6mm in diameter to around that two millimeter size, that's a pretty big shift. It's much less invasive. And of course you don't want to just see you want to do so. There's instrumentation that's going to be coupled with that. That's also going to go down from about the four millimeter size down to the two millimeter size. And of course, yes, we're you know, we're skeptical scientists and surgeons here. But I would ask you to bracket your skepticism for a second, because as soon as you say needle scope, NanoScope small scope, you're thinking about the picture on the left. You know, we've all seen it. I'll put our put our hands on it. Seeing pictures coming into the office of what's out there right now. And the current scopes right now are about half the resolution of where the NanoScope is. And the NanoScope is going to continue to improve. And so the picture on the right there is about where we are right now at the NanoScope. And we'll, we'll show you that in a little bit. And of course, you don't want to just see you want to be able to do so. The disposable instruments that come with it, the arthroscopic cannulations that come with it, they're all sort of in that same size, that two, two millimeter size. And this, this slide here that that Eric showed earlier is really sort of the exciting thing. You know, the point isn't really these are the things that you should do with them. It's really more what is it going to work in your practice. What are the things that you want to do with it? For me, I can tell you I'm excited about having a second viewing portal in certain surgeries, shoulder surgeries, knee surgeries, maybe doing some second looks and some cartilage work. But there are people here that do small joint work. There are people here that want to do image guided injections. So we just heard a lot about doing injections for arthritis. Well, when we inject things into the knee, why not make it more precise. Why not put it into a into a specific structure under direct visualization. So this is the kind of case I just want to show real quickly. It's just a case I did last week. It's a college baseball player. Had to do a pasta repair on him. He failed non-operative management. This is sort of what it looks like where you're going to do percutaneous using the three nine knotless. So percutaneous, you place your anchor percutaneously place your sutures. And again it's all good and fine. We sort of come to perfect some of the techniques that we want to use. But all the little moves along the way, right. You're looking downstairs and you're going upstairs, you're going downstairs, you're going upstairs with something like the NanoScope. This whole process would be made much easier. So you can keep the scope, say, upstairs or downstairs, and actually work with a dual visualization. And here's another iteration for you to consider. Again. You can you can work through the same portal. You know, you got a passport cannula, but it's got a second parallel barrel if you would. So you can put the scope and the instrumentation in the same location for a lot of the surgeries that we do. So the paradigm shifts. Where is this sort of headed, you know, is a big shift from open to arthroscopic inpatient to outpatient sort of. The next step, again, is to see how minimally invasive we can be so that we're not actually having to to have our patients as down as much as possible, going from the operating room to maybe more procedure type setting eventually. And, you know, it seems like a stretch right now, but I don't imagine that it's not going to happen pretty soon. So we're just in the beginning here. This is the first step. I'd really encourage you all to to take a look at the NanoScope and should be coming out soon. So if you haven't had a chance to put your hands on it and take a look at it, Chris and Ryan, a bunch of other people are going to be around today to show you what that looks like, and I think we're going to do a quick lab demo. But as it as it pertains to the rest of this meeting, please do your best to to loosen that grip a little bit and think about where things may be heading. Thank you.

Meniscectomy

Arthroscopic Meniscectomy

Nano Meniscectomy