Imaging and Resection

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Arthrex, ein Pionier in der Nanoarthroskopie, hat die nächste Generation entworfen – das NanoNeedle Scope. Dank seinem biegsamen Instrumentarium verleiht es Operateur:innen die Flexibilität, um Patient:innen besser behandeln zu können. Das NanoNeedle Scope ist eine Alternative zur MRT-Bildgebung und Second-Look-Arthroskopie und ermöglicht eine präzise, bildgeführte Darstellung von Injektionen.
Eigenschaften des NanoNeedle Scope:
<ul>
 <li>Drei verschiedene Längen (125, 180, 250&nbsp;mm) zur Optimierung der Nanoarthroskopie während unterschiedlichen Eingriffen.</li>
 <li>Das Design bietet dank der Chip-on-Tip-Technologie und ohne einen herkömmlichen Kamerakopf ein dynamisches, „echtes“ nadelähnliches Gefühl für präzises Manövrieren in allen Gelenkräumen</li>
 <li>Ergonomischer Kamera-Hub, ähnlich wie bei den SutureLasso-Produkten</li>
 <li>0° Blickrichtung, 120° Sichtfeld mit halbstarrem Design, sodass Operateur:innen die Kamerarichtung fühlen und steuern können</li>
 <li>Optimierte Positionierung der Kamera- und Videoaufnahmetasten auf dem Bildaufnahme-Dongle an einem leichten Kabel 1&nbsp;m vom NanoNeedle Scope entfernt, wodurch das Gewicht der Arthroskopieoptik verringert und ein präzises Greifen sowie eine präzise Handhabbarkeit ermöglicht werden</li>
</ul>

Vonda Wright, MD (Orlando, FL), shares the benefits of Nano arthroscopy technology for patient treatment.

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Human

Evolution From Traditional Arthroscopy to Nano Technology

Hi, I'm Doctor Vonda Wright, and today we're going to be talking about our evolution from traditional arthroscopy to the new nanotechnology. Any time we introduce something new into our surgical environment, we have to ask ourselves, why is it just a fancy new device, or can we really impact the care of our patients? When I think about nanotechnology, the first thought is does it increase patient safety? Will it allow me location flexibility? And how does it affect cost containment? When I introduced the idea of a new surgical approach to my patient in specific nanotechnology for their arthroscopy, I describe it to them as a procedure where I can fix their knee, take care of their meniscal pain with no incisions, with no narcotics, with no anesthesia, with limited or no need for physical therapy, and a promise that we will have rapid recovery back to life and activity. These are all whys Why's that? Encourage my patient and myself to push the needle into the new nanotechnology. So I wanted to share with you the critical pivots that I took over only a six week period to transition my oar from standard treatment of knee pathology with arthroscopy into NanoScope technology. It is a slow introduction, and it only took six weeks for both myself and the operating room to feel comfortable. So pivot number one was to introduce the NanoScope into the operating room. The first week I did this, we had both the NanoScope and all of our standard arthroscopy equipment in the room. Anesthesia remained general and both systems were open on the field. In the second pivot in the second week of this transition, it was a pivotal week for us because we eliminated all traditional arthroscopy equipment from the room. I had come to the knowledge that I needed to use the NanoScope high flow, 30 degree scope to reproduce my surgical procedure, and that was the only equipment open in the second pivot. Anesthesia was still general, but the room set up was only 1000 cc's of saline in a pressure bag. I replaced the traditional NanoScope 60 cc syringes because I found that it moved the view of my scope, but with 1000 cc bag on a simple tubing, I eliminated that problem. After the very important second pivot, the third pivot moved us in the forward direction. Here, in terms of equipment, I was still only using the NanoScope with the high flow sheath in the 30 degree angle. The pivot in number three that was so critical was that I went from general anesthesia to sedation with local anesthesia. In pivot three I Three I use ten CCS of 0.25 marcaine with epi into the subcutaneous tissue and intracapsular. Once that was set and numb, I then introduced 20 CCS of 0.25 marcaine intra-articular. And then we waited for that to set up in pivot number three. We again used only 1000 CCS of normal saline in a pressure bag. Patients tolerated this incredibly, and so I took the next leap to pivot number four, which is currently my standard of care, is to do NanoScope arthroscopy using high flow sheaths and a 30 degree scope, and an awake patient with only local anesthesia. For this, I found I wanted faster anesthesia, so I now use ten cc's of 1% lidocaine with epi in the subcutaneous and intracapsular space simply because it sets up faster. Then I put 20 CCS of 0.25 marcaine Intra-articular Lee. Again, we are only using normal saline in a pressure bag with this pivotal fourth pivot. My patients sometimes want to watch the procedure and are certainly recovering immediately. So how is this done? I wanted to go over with you the steps for implementing pivot for in the Or. You may use your usual prep and drape. Once that is complete, administer the local anesthesia Subcu Intracapsular and then finally Intra-articular. And then, while your scrub tech is setting up the equipment, the local anesthesia will set up my approach to making the points of entry, which is what we call the nanotechnology. Entry into the joint is to mark the tibial tuberosity. That helps me visualize where I am in the knee and the inferior pole of the patella. I then put a mark where the lateral point of entry will be very similarly to a standard portal. Through that I use the sharp tip high flow straight nano trocar into the anterior lateral position, and I simply gently pop it through the capsule and I leave it there anteriorly in the notch. I then exchange the sharp trocar for the blunt plastic tip, and either sweep across the notch or push it up into the suprapatellar space, which is my usual operation. I then exchanged the straight sheath for the curved high flow sheath over a simple wire. At this point in the suprapatellar pouch, I do my regular examination of the pouch. The medial gutter and finally sweeping down into the medial compartment. It's there under direct visualization that I again establish my medial point of entry, just as I would in traditional arthroscopy using first the straight sharp nano trocar with both sheaths in place, or removing the medial sheath and introducing biters, shavers ablator devices. I then treat the meniscus. I repeat this procedure for treatment and evaluation in the notch, and then in the lateral compartment by putting the knee in a figure four. When I am completely done with this procedure, which takes me anywhere from 15 to 20 minutes, I express the fluid and then I cover the points of entry with steri strips and a dressing. This is a simple overview of how I set up my tray. This is it. We don't need any big back table, only this simple array. Finally, I wanted to present to you a case that I did recently of a 32 year old bartender and recreational powerlifter with an acute onset of sharp stabbing posterior medial pain. He came to my office literally unable to bear weight because of this sharp pain, and we did an MRI and confirmed that he had not only a horizontal cleavage tear, but a piece that had flipped underneath the remaining meniscus. After talking him through the NanoScope technology and the reasons I use it, including why I would like for him to be awake during the procedure, we proceeded with a NanoScope awake debridement of the medial meniscus and plasty of his medial femoral condyle via two points of entry under local anesthesia. In this image, you see the two points of entry with my marking over the tibial tuberosity and mark over their inferior pole of the patella. They're barely visible to the patient in this series of pictures. You see my initial view with his damage to his medial femoral condyle and a hint in the back of his meniscus tear. The second photograph shows you his horizontal cleavage tear, and the third, the flipped piece of meniscus, which I had unflipped with a probe. And finally the picture shows you of the debridement I did with simple biters and shavers. This patient truly was awake and did not feel this procedure. He came back to my office two days after surgery with full range of motion, no effusion and a completely normal gait, and a couple days later sent me these pictures of him back in his powerlifting gym, having experienced a rapid recovery to recreation and work. Introducing nanotechnology into your practice and operating room or even your office procedure room is an exciting advance in arthroscopy. It takes careful planning, pivotal translations for not only your skill, but in the operating room and education of your patient on how they will remain safe and have rapid recovery. I hope this has helped you as you transition to this new technology.

Foot and Ankle

Knee

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Operative NanoNeedle Scope Surgery Using Local Anesthesia

Sanj Kakar, MD (Rochester, MN), provides an overview of the NanoNeedle arthroscopy portfolio.&nbsp;

Comprehensive NanoNeedle Arthroscopy Portfolio

Hi, it's Sanjay Kakkar here. It's a privilege to be here today to talk to you about the evolution of NanoScope technology. And you'll see the ergonomic evolution in what we're going to go through today. We've all learned the power of nano arthroscopy, for example, in hand and wrist I use the acronym first F stands for fractures and fusions. I is for instability, such as for example, Tfcc instability. Scapholunate R stands for the reduction. So now we can get anatomic articular reductions of our fractures. S is for small joint arthroscopy such as the thumb, the MCP joint and the Deej which were previously harder to do with traditional arthroscopy. And T stands for tunnels. So for example carpal tunnel and cubital tunnel. And how we can do this safer with this more ergonomic technology. A couple of the features I'd like to highlight today. First of all is the camera itself. You'll see what's missing is the actual gray handle. You can see now with this ergonomic evolution, how it's been designed such that it basically looks like a pencil you can still see on the on the left here you'll see the paddle. It says one meter cable that's attached to the nano needle. And we can still have the features of taking video or still photographs. So now if you look at the actual nano needle, what you'll see is there's some tactile function. You'll see that this is looking straight up. You can feel the ridge pattern here. And you'll actually see we still have the 1.9mm chip on the stick technology, which is flexible, which is what we need for those difficult areas to get to, such as the drudge when we're gripping this. So now, not only has there been an ergonomic evolution in terms of the camera, but also the cannulas itself. So if we look at the cannulas, what you'll see here, there's a screw in mechanism and this will be used for other procedures, for example where devices can be attached. For example, if we're deploying a FiberTak doing this nano through the NanoScope, you'll also see as we pull back, there's a little sort of paddle here. And this allows now a firm sort of click of the end obturator inside the cannula. So as we're putting it inside the Inside the wrist. As we're holding this, the actual obturator stays attached within the device. Now, what you'll also see is when we pull this out, you'll see that there's a ridge here. And this allows for the positive feel of when the nano needle actually engages within the actual cannula itself. And I'll show you that in a second. As you'll see, there's two cannulas. There's still the straight cannula out a diameter of 2.4mm. But also we have the 11 degree bend, because some surgeons like to have that ability to look at an angled view, which we've done traditionally with arthroscopy. This is now built into the nano needle system. In addition we have this working cannula. And what you'll see here is perfect for the hand and wrist in terms of its length. But you'll also see this sort of pattern here at the tip called this neural, which actually, once you're into the joint prevents the actual cannula from actually disengaging out of the joint. So one of those frustrations that we always have is the capsule preventing you going in and out of your working portal. But now you have this cannula that sits in there. And in addition, it's designed to be wide enough to allow. For example, your two millimeter nano shaver to go through there or the 2.8mm shaver or bur. So in this way, you basically have a system that allows you to do all your NanoScope debridement and procedures. What I want to show you is this latching mechanism. Now you'll see how the nano needle seamlessly integrates within the cannula and actually stays connected. So no more of this telescoping in and out of the actual cannula. So as I mentioned you have this paddle. So this comes straight out. We're in the joint. And then what we'll do is actually take the nano needle and you'll actually hear the click. Where it's engaged. And now you'll see when I'm trying to pull how it doesn't come apart. So now what we can do is seamlessly and safely position this within the wrist without the worry of the actual nano needle telescoping in and out of the cannula.

Matthew Daggett, DO, MBA (Kansas City, MO), introduces the next generation of surgical visualization using the NanoNeedle scope and provides a step-by-step guide to performing knee arthroscopy under local anesthesia.&nbsp;

Introduction to the NanoNeedle Scope and Knee Arthroscopy Local Protocol

Today we're going to discuss nano arthroscopy and some of the frequently asked questions we get regarding how to perform a traditional knee arthroscopy utilizing this new equipment. And what's really exciting is we have some new things to show today. First, we have the 125 millimeter nano needle. This is much more ergonomic and will be very friendly in your hands to be able to utilize and access those tight spaces. And then we also have some design changes to the high flow sheaths pictured here and here. Those will allow us good visualization, as well as a new ability to do some more exciting things within the joint with implants, etc. and we're just going to go over how we traditionally approach knee arthroscopy utilizing this new technology, and discuss some of the tips and tricks along the path that we've learned to be able to perform this procedure. While patients may just have local alone, needle arthroscopy for us as surgeons is really just an evolution in how we approach our surgical techniques. But the real revolution is in the patient experience. Patients can oftentimes be awake during these procedures, and it's really important you just focus on the overall patient experience and their comfort level during those time periods, while you're effectively treating their intra-articular pathology. Once you establish your portal placements and your portal placements are really dictated by your pathology, you have some flexibility given the small bore size of the nano needle, but you want to use oftentimes the angled cannula because that helps. And it's really important to have local anesthetic available during this. If the patient has pain as you're entering their knee joint, you can always just inject a little bit more local medication. This is really important, especially as you're going around the fat pad for insertion. As I'm doing this, I'm talking to the patient, making sure that their comfort level is at a high level and making sure they're as engaged as they want to be in the process. And it's really important to preoperatively identify if the patient wants to be a part of this and watch you do this surgery via the screen, or do they want to just kind of tune out for distraction? Either way, making sure that their comfort level is high is paramount to the success of the procedure. We're going to utilize the nano needle here. And the nano needle this 125mm. It comes in different sizes but is as excellent in its ability to not just visualize, but also in its ergonomics. And this just does kind of spin in and lock into the cannula. So I always inject more quarter percent marcaine into the joint prior to using the arthroscopic fluid. And that does two things. One, it helps you in visualization. It also helps you in in preparation in case the patient does experience some symptoms. So as we visualize the joint here utilizing the nano needle, we're going to look on the lateral compartment navigating the fat pad which in real life can be a challenge and is really important why you need that local anesthetic. So as we go through the joint we're going to utilize different tools. But you perform your diagnostic arthroscopy as you typically would. And patients really tolerate this well. As long as you have that initial skin to capsule well anesthetized, it allows you to perform a diagnostic arthroscopy as you traditionally would. And in regards to nano needle, I mean, think about the ergonomics of this design and the evolution that's occurred in such a short period of time in the last 4 or 5 years, with the advent of needle arthroscopy, from your usual large camera head and somewhat bulky end to this really nice, ergonomic, small design that allows for quick and easy navigation in the joint. It's really remarkable how different and how much more natural it feels. One other thing to point out with the needle arthroscopy and just our overall evolution and how we approach this, is you can come at pathology from different ways. And so oftentimes you'll have patients with very tight medial compartments. And while you can finish straight MCL, even then if you're trying to do a tough meniscus root repair or far posterior horn or ramp lesion, getting visualization of the posterior horn can be a challenge. So coming at this directly, because it is a zero degree scope from the medial portal, can be quite helpful in visualizing these posterior aspects of the anatomy and these medial compartments. From this angle, you can really easily see the patellofemoral joint and get really good visualization of how the patella is tracking and potentially other aspects of the patella that you have struggle visualizing for one reason or another. So now we're going to use the nano saber on a small joint shaver device. And that goes just in your regular Or arthroscopic portal. It's 2.8 by 11, and that longer shaver device really allows us to access as far back posteriorly as we need to without iatrogenically damaging the cartilage in a setting of meniscus pathology. Even on a local, you can address the meniscus any way you really need to, as long as you have extra local on board to make sure they're comfortable. I like using standard nano up biters to address meniscus pathology as need be, and they really don't feel this under local. And I think the quarter percent inside the joint really helps decrease any of the sensitivity they may have. And you can even get back to the really posterior elements and the and the red red white red red areas need be with minimal discomfort to the patient. I will say if you're going to perform meniscal repairs under local, make sure you anesthetize the area you're going to be repairing, as that really helps reduce the amount of pain the patient could have as you exit the capsule. So the nano saber really is incredibly efficient given its small size and doing these small mastectomies that you need. And you know, when initially it was launched, you're amazed at the ability to resect with such a small instrument so efficiently. So you can also do meniscus repair and other therapeutic treatments within the knee without just outside of just plasti meniscectomy removal of his body, etc. for demonstration purposes. Here we can also just do a meniscal repair. Even under local, the patient can tolerate a meniscal repair pretty well with the FiberStitch device, and as long as you inject extra CapsuleLink with local if you need to, their tolerance of pairs is actually pretty well. Overall, they don't have much pain and it's really just key. You have that conversation with them and what to expect. And then also just in sensitivity of how much pain they're having. So we're just going to cinch that down and complete our meniscal repair. So upon completion of the procedure, you definitely want to remove the remaining normal saline within the joint itself. And then one of the other advantages just to point out on this nano needle instrumentation is it's so lightweight and friendly, you can easily drop your hand and it stays within the joint. You don't have to worry about it falling out or iatrogenically causing any cartilage damage upon release. So it's really nice, especially if you have limited hands in the Or. Upon completion, as I said, make sure you remove the saline and then I inject a quarter percent Marcaine 1% white cocaine. Would that be from skin to capsule and then place steri strips and a Band-Aid over the incision portal sites? Transfer to PACU and usually in PACU. They're only there for a few minutes if they've had just a local procedure alone. Whether it's repair meniscectomy, removal of loose bodies, whatever you're doing within the knee joint. The NanoScope is an excellent tool, especially with the progression of these nano needles. It's going to be very exciting to see the progress over the coming months and years, as far as how we're going to be able to do things in a less invasive, safer way.

Hand and Wrist

Diagnostic NanoNeedle Scope Arthroscopy Using Local Anesthesia

Matthew Brant, DPM (Vineland, NJ), performs diagnostic subtalar and peroneal tendon arthroscopy using the NanoNeedle scope and Nano Sabre Shaver.&nbsp;

Diagnostic Subtalar and Peroneal Arthroscopy Using the NanoNeedle Scope and Nano Sabre Shaver

I'm Matt Brant out of reconstructive orthopedics in Sewell, new Jersey, and today we're going to be looking at arthroscopy of the subtalar joint and the peroneal tendons. All right. So I like to make two small portals right over the subtalar joint. I've marked out my fibula and kind of the superior aspect of the calcaneus. And I use a stat to open up into the capsule. So I can insert my nano needle to get into the subtalar joint. You have to triangulate through a fair amount of tissue, debride out some of that tissue, and then you can begin to visualize usually the aspect of the talus first, and then you can look up into the posterior facet as seen here. You can visualize some interosseous ligaments. And the nano saber allows me to debris out what tissue I need to while leaving the ligaments intact. So if you were evaluating a calcaneal fracture repair, you could look right in here and make sure that there's no step off in the posterior facet from medial to lateral. So I can use my instruments to open up a bit of that posterior facet and look up and through. And if you were to perform an arthroscopic arthrodesis, you can begin removing this cartilage. If you were evaluating your anatomic repair of your calcaneal fracture of the posterior facet, you can look right in here and evaluate for step off. And if you were to perform an arthroscopic arthrodesis, you can get your shaver right up into there and start removing cartilage. Now we're going to transition over to the peroneal tendons, where I'll make a small incision right over the tendons. Which I've palpated Just proximal to the fibula. I use this, I use a stat to get right into the sheath and I can insert the nano needle. So when I'm evaluating the peroneal tendons, I'll make a small incision right over the tendon. Use a little stat to get right into the tendon sheath. So I can just visualize a portion of the tendon so I can insert my nano needle into the sheath of the tendon, and I can visualize both peroneal tendons. Once I get into the sheath of the tendons, I can slide the needle up and through and evaluate both tendons. Rule out tear, look for synovitis, look for adhesions, and I can use my finger to kind of roll around a little bit of the tendons from the outside so I can get into different areas. And you can put the foot through a range of motion to see which tendon you're you're moving as well. And so we could insert the nano saber into a proximal incision along the sheath to and to breed out some of this, to breed the tendons arthroscopically and follow yourself along there. So we can remove synovitis, we can remove adhesions. We can inspect the tendon for interstitial tearing. It's nice in a situation like this to have the available extra afforded length of the nano saber. So we can slide it in along the sheath. And you'd really want to palpate out where the pain is in this patient to where you're going to make your portals above and below the nano needle and the nano saber. Allow me more precise maneuverability in small spaces such as the subtalar joint and the perineal tendons, which may not be possible with traditional arthroscopy.

Patient Rachel Schmitt and her surgeon, Matt Daggett, DO (Kansas City, MO), discuss how Nano technology impacted her surgical experience and recovery.

Nano Arthroscopy Patient Highlight: Rachel Schmitt

How many people go on day to day in pain. Mri shows nothing. Oh. You're fine. But when they physically go in and look inside your knee with a scope, there's a problem. There's the issue. We can fix it. My experience over the last few years with nanotechnology has been nothing short of transformative. It's changed the way I do everything. It's changed the way patients obtain their diagnosis. It's changed the way patients experience their care. I was awake for the entire surgery. Very quick, very painless and just amazing how much better I felt so quickly after.

Patient Dennis Seck and his surgeon, Matt Daggett, DO (Kansas City, MO), discuss how Nano technology impacted his surgical experience and recovery.

Nano Arthroscopy Patient Highlight: Dennis Seck

Playing some golf and tennis. I noticed a little more pain in my shoulder, but it got worse and worse, so I decided on doing surgery. It's almost like he was narrating the surgery, but he was actually talking to me and I was asking questions back and forth and it was wonderful. This is truly just social surgery. The patient's awake. They're a part of the experience. And being able to communicate with the patient while you're doing their procedure has truly been transformative. I absolutely had no pain. I had no scar. I couldn't even see where the entry point was. I'd say nanotechnology has changed everything I do, trying to do things in a less invasive way with less anesthesia. It's been absolutely amazing to be able to have that impact for patients. I would definitely recommend the surgery to any friend or family member for sure.

Spine

NanoScope™ Operative Arthroscopy System Scientific Updates

Nanoarthroskopiekameras

Child (D)

Bei der NanoScope-Bildgebungskonsole sind die neuesten Technologien in den Bereichen der 1&nbsp;mm Bildgebungssensoren, der LED-Beleuchtung, des Bildmanagements und der OP-Integration mit einer intuitiven, für den medizinischen Gebrauch zugelassenen Steuerungseinheit in Form eines Tablets mit Touchscreen kombiniert. Das System ist leicht transportierbar und kann sowohl im OP als Ersatz oder Ergänzung der herkömmlichen Arthroskopie als auch in neuen Bereichen wie dem Eingriffsraum oder der Arztpraxis eingesetzt werden. Die Netzwerkfähigkeiten des Systems erlauben die bidirektionale Kommunikation mit dem Netzwerk der Einrichtung und mit der Synergy iPad®-App.

Sanjeev Kakar, MD (Rochester, MN), discusses the advantages of dry wrist arthroscopy. Dr. Kakar also demonstrates diagnostic and operative uses of the NanoNeedle Scope System in the radiocarpal and midcarpal portals of the wrist.&nbsp;

NanoNeedle Scope Arthroscopy of the Wrist Using Dorsal Portals

Kevin D. Martin, DO (Columbus, OH), introduces the NanoNeedle scope, Nano Sabre Shaver, and ApolloRF® SJ50 probe. Dr. Martin explains how he uses the instruments to diagnose, evaluate, and treat foot and ankle injuries with minimally invasive arthroscopy. 
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The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

Using the NanoNeedle Scope in Minimally Invasive Arthroscopy 

Today we're going to be talking about the new, exciting nano needle. So nano needle. The advantages that we see compared to our previous nano is that it's very small. This is a 1.9mm camera. Other things that we're really excited about is now the junction between the NanoScope and the trocar will now snap and click into place, which will prevent some of that pistoning that was a problem on the previous generation. Second thing we're looking forward to is these small ridges. Here are the north cells. So the surgeon knows which way is up and which way is down, and gives them some proper orientation without looking compared to our previous scope. Other improvements. We've continued to use our pencil grip, so this will allow you to hold it again, making ergonomic motions much better and much smoother. And again, the clip on system is what really is making this system different and much improved from our previous system, where that camera will no longer piston and other devices, and Cannulas will be able to click on here and be able to adjust and allow the surgeon to continue working. We also have some new cannulas. These cannulas have a diamond pattern at the insertion here, which will help with some friction on the soft tissue, allowing these to stay in place as the surgeon is working. We have two different links a shorter one for a smaller joint versus a longer, depending on what joint you're going into and how much length you actually need. Another advantage of this is it's interchangeable with our whole entire nano system. It can easily work with our new saber shaver that can go directly in here and have a working portal, and it can also be used for our new nano small joint instruments. Things we're excited about. The new nano needle is the junction here that allows it to interact with the sheath and not piston. Second of all, the handle is much more lightweight. We've gotten rid of the redundant plastic and now made it very small and ergonomic. We also have these nice grips on the handle. These grips allow the surgeon to know north south and also the orientation when they're scoping. And you can see we've moved the plastic into this other control panel here. This control panel is about one meter away and allows the surgeon or an assistant to use the buttons to actually take the pictures and the camera. For the surgeon, these buttons are programable, so the surgeon can really dial in if they want this button to be the camera versus video, and this is adjustable per whatever the surgeons needs may be. For that case. One of the biggest advantages to the new nano needle is how the handle will now click into place. As you place it in, the surgeon can engage. And then a small turn. And now it's engaged and no longer comes apart. And our previous model, it was no lock in device. And this could easily piston during a case and become traction for the surgeon. But now with our new click in device, this is no longer an issue. The device goes in a small turn and it locks into place, giving the surgeon ultimate control. The other thing that's interesting about this is it's much smaller and ergonomic. Which will the surgeon be able to hold it in his hand in multiple different trajectories, either holding the handpiece or holding the pencil grip? Either one of these will allow the surgeon to adjust their hand grip for what's comfortable for them, given the joint they're scoping at that time. One of my favorite features about the new nano needle is how small it is, so it's easy to say it's 3.3, but when you hold it next to a 15 blade, that really allows you to judge, all you need is one simple poke hole. The nick and spread technique can be minimized, allowing decision to be to be very small and help your patients get back to activity sooner with much smaller incisions. So one simple stab. I like to hold my index finger and go right into the joint. Now the new nano needle comes in, snaps in in a small turn, and now it is connected to avoid any of that unwanted pistoning. And now the camera can be held like a pencil and allow the surgeon ultimate control. You're able to look around the joint very smoothly. Again, the pencil grip really allows the surgeon ultimate control and as you can see, my hand is rested. I'm resting on the ankle, and just having my muscles relaxed allows me more control and prevents surgeon fatigue over the long case. So once you're inside the joint, the shaver can come in very small. This is the new saber shaver, and what's nice is how small it is. So I'm able to negotiate inside the joint. You can see I have no friction in my joint. I really have very minimal distraction. And. But allowing me to be able to negotiate and move around freely, this is what really makes small joint arthroscopy nice. And the shaver has good has good control. It's small yet aggressive. So that's really what we're looking for is small and aggressive. Some of the larger shavers can be more aggressive. But again you also want to be safe inside these small joints. I teach residents in this small joint. Shaver has really been an improvement in safety. The other advantage of the small shaver is the handpiece. The handpiece is much smaller than the standard large handpiece, which really allows the surgeon to be able to do both simultaneously. Because having a small pencil grip in one hand and a large shaver in the other hand really does not make much sense. So by switching to the new, smaller, lightweight grip, it really allows that equal control and balanced approach that a surgeon is really looking for as they're going through a complex small joint. As you can see, it's very movable and agile. Inside this small joint you can see here. So now I want to talk about the Ss50. The ss50 is really nice in the nano profile because it's 3.3mm, which really allows it to complement the small size of the nano. As you can see, looking at the at the probe tip, it also has edge cutting. The edge cutting really allows the surgeon to have good control, as we're getting near soft tissues and be able to control that cut more than other ablators. The other issue about this is that it also has suction. So the suction really prevents the intra joint bubbles that can oftentimes obscure the view. So let's give it a try. So now looking at the intraoperatively inside the joint we can see that it's able to take these small pieces and actually use the side where I can actually be cauterizing while using the side and not endangering my articular surface or vital tissues, but yet allowing me to really gain visualization very nicely in a very safe, controlled manner. And as you can see, there's very few bubbles involved in this. The ablator is also the only one that has optimized suction. The suction allows for complete evacuation of fluid as I'm working, which allows for temperature regulation and for optimal viewing. Now, I know it's difficult to appreciate with the scope that I have here, but looking we are over the dome of the talus, looking at the posterior three quadrants without nano needle. This is not possible. And then with a slight bend in the SJ, we can actually get to the back of the joint and safely work in the back of the joint with this edge cutting, and not endanger our cartilage. This is not possible with a standard for. If you can see this visualization. This is the entire back of the joint, which I would challenge anyone to try to do this with a pro without causing iatrogenic injury. And you can see where I've just been. This cartilage is pristine, there is no grooves where I shoved my camera in. And again, we have very minimal distraction today. And that's what using nano needle really allows you to do is use minimal distraction, which can become a distraction inside your case and allow you to get to the back of the joint safely with no bubbles. And this is deep in the back. So nano needle also provides the ability to look deep into the medial gutter, allowing you to evaluate the deltoid. So if you suspect deltoid injury when you're doing your lateral ligament reconstruction, it allows you to look over here. Quickly examine your deltoid and see if there's a component to component to deltoid injury as part of your ankle instability. So I frequently use this to be able to assess not only the articular surface of the joint, but also our ligamentous structures medially and laterally as part of my standard InternalBrace protocol. So using the saber shaver really allows you to get in here and get the small joint. So in this case we have a redundant tissue in the syndesmosis. And I also use this to evaluate my Syndesmosis 10 to 15% of ankle instability will have a component to syndesmosis instability to it as well. So by using nano, I'm able to evaluate the Syndesmosis intraoperatively not only with a dynamic examination, but also direct visualization. There's plenty of literature out there showing us that direct visualization is much better than even our pre-operative fluoroscopic examination. And you can see the shaver really does a nice job of taking it down. And yet by moving it, I'm not getting into my articular cartilage, which really allows me to improve my visualization nicely, as you can see here. So now at this point, if I want to check out my syndesmosis, I could do a fibular translation test. We could stick a diagnostic probe in there and see if there's any instability. And again, with direct visualization, it really ensures that I'm making the proper diagnosis moving forward. Also, for my typical ankle instability, I'll stop right now and I'll do a Taylor tilt during the case. Watching this dynamic examination really again reiterates my diagnosis that I've made by watching this Taylor tilt, I can appreciate the ankles unstable and then complementing that with looking in the lateral gutter and seeing if I do have a patulous lateral capsule, thus indicating a repair of the lateral ligaments. Now we're viewing from the anterior lateral portal. So a slightly different topic, but when we're looking for our syndesmosis reduction, our trauma colleagues will often say they directly visualize their syndesmosis reduction. I would argue they do not. I would argue you need this view looking at the fibula, talus tibia. Getting this Mercedes sign right here. Truly ensuring your syndesmosis is reduced. So that's why nanoneedles can be so integral on our fracture cases and in trauma. Another advantage of nano needle is how small it is. Now we can easily pop into the perineal sheath and look into our perineal sheath and do a nice diagnostic examination of the perineal as we're here. Nano needle being so small, it allows me to travel up the sheath and actually get a dynamic exam where we can actually flex and extend the foot and watch the perineal tendons glide in their native position again without disrupting the retinaculum. And it really allows us to see, okay, there's an extra band of tissue in here. We should probably debride this back in a small maybe possibly a small tear right there. We can drive around the corner again, getting great visualization as we travel, and if there was a tear, we could simply pop in our scope proximally. Like right here, some scar tissue in the sheath and we can go down to and continue to follow the sheath and the brevis right there. So again, being able to check out the perineal minimally invasive is a very nice component. You already have the nano needle as part of your lateral ligament reconstruction. So why not pop it in and give it give it a quick look when you're here. So now we've flipped our patient. We're going to do some posterior ankle arthroscopy. We have the distal fibula down here and the medial malleolus right here. This is my area of my portal insertion. If I'm going to go in the subtalar joint. I'll use the level of the medial malleolus here to get the angle going into the posterior facet. If I'm going to go up into the ankle, then I want to choose a more distal portal orientation to the tip of the fibula. But this is basically your working distance of where you want your portals to be between this area right here. So for this demonstration we'll go into the joint the ankle joints. We'll make them a little bit more distal. Again just a small stab incision on each side. And that's all you need. When your posterior scope as you begin to establish visualization again this works really nice and is able to use a side cutting effect and really work the posterior subtalar joint, allowing good visualization and for careful, meticulous dissection. This will slowly take your time and be able to visualize the joint. And that's what it's all about. It's about safety and control. Now again, this is the is the Subtalar joint. This is a joint that's not really scoopable is what they tell us. But with nano needle, we can get in here. For all my Subtalar fusions and for my calcaneus fractures, I'm using nano needle for this reason. The 120 degree forward viewing is perfect for this, because you're never going to see this view with A40 scope. It's literally impossible to be able to see this far. Again, this was made possible by using the very small nano needle. So now again, visualizing posteriorly, with nano needle being so small, we can actually look at the lateral aspect of the subtalar joint and actually take it all the way anterior to the anterior subtalar joint, the posterior facet. This is not possible. Again, with the fluoroscope being able to see this gutter like this and retrieve loose bodies, or address any instability or evaluate instability. Right here is also very nice.

Matthew Brant, DPM (Sewell, NJ), performs diagnostic ankle arthroscopy using the NanoNeedle scope.&nbsp;

Diagnostic Ankle Arthroscopy Using the NanoNeedle Scope

Hi, my name is Matt Brant. I'm a reconstructive orthopedics in Sewell, new Jersey. And today we're going to be doing a diagnostic arthroscopy of the ankle. We're going to be using the nano needle today, which is a new design. It's still a 1.9mm scope but a little different in design. It's a little bit more versatile in that the buttons are detached. Still with video and picture capability. We're going to be using the 3.3 high flow sheath today one straight, one angled. And we have the option of a dull and a sharp obturator. And now we're going to transition over to the ankle. All right. So to make my portals I feel for the tibiotalar joint. I feel where the tibialis anterior tendon runs and stay just medial to that. And I'll insert a needle into the joint. And then I'll insufflate the joint with some saline. Remove the needle. Make my portal. And I'll use a stat to stat down into the capsule. So I like to first insert the obturator so that I can feel that I'm in the joint. Then remove that and place it into the trocar. So then I insert my obturator with the trocar into the joint. Remove the obturator and insert the nano needle until we can begin to see some cartilage and know that we're in the joint. And then I can direct the scope laterally to where I can feel it. And I'll make my second portal. And I'll just back my scope up out of the way so I can enter the joint. And I like to insert the blunt obturator reader first. So I know that I'm in the joint and I've triangulated. So then I can insert my nano saber. Shaver. Into the joint and begin debriding some of this synovitis from the anterior aspect of the joint. So I make sure to visualize the shaver at all times, so I'm not damaging any cartilage causing any iatrogenic defects. So I can open up the front of the joint and get a better view. So I can sweep the nano saber across the joint. I can piston it, I can rotate it. The nano saber is 2.8mm. Which allows me to move around the joint, see what I need to see, take out which tissue I need to remove. And I'll open up the joint laterally, removing some of the scar tissue. The nano shaver handpiece allows me to kind of choke up on the shaver and fine tune my movements around the joint so I can accomplish what I'm trying to accomplish. As compared to traditional larger shaver handles. We're looking in from the medial portal. Looking across the joint, you can see the anterior aspect of the tibia and our Taylor dome, and we can slide the nano needle across and evaluate into our lateral gutter. We can check out our syndesmosis which is right in here. She does not appear to have any instability. We would breed in through into here in our anterior talofibular ligament. If you were going to do an ArthroBrostrom, you'd insert your anchors here and here into the fibula, which is right here. And we can look into our down into our medial gutter. Way down in through there. She's got a little osteochondral defect right here on the medial dome. So if we were to treat this, we could use our scope in this portal. Then change our scope into the lateral portal and curette this microfracture that. Sometimes we'll use a heavier shaver on a braider and remove some portion of this anterior aspect of the tibia. If someone has an exostosis anteriorly or impingement syndrome, we can look down into the Taylor neck. Below the articular surface. So Then I can rotate and shift my scope into the lateral portal so I can get a better look at the medial side. To breed out any more. Tissue that I need to. Look over at the medial malleolus. So we can take a look at the lateral ankle and look into the area of the syndesmosis right here. This patient does have an effect on the lateral dome. If we were to stress the ankle rotate the foot externally this area here would note separation. And this patient is stable. In conclusion, the nano needle and the nano saber allow for increased versatility and control with increased ergonomics to maneuver through small joints of the foot and ankle, and allows me more precise control and maneuverability in my foot and ankle cases.

Sanjeev Kakar, MD (Rochester, MN), performs an arthroscopic volar scapholunate capsulodesis (stage 1 Garcia-Elias) using the NanoNeedle scope system.&nbsp;

Repair of a Stage 1 Volar SL Tear Using the NanoNeedle Scope

So we're going to do an arthroscopic volar capsulorhexis, just like the dorsal capsulorhexis, which is good for dorsal scapholunate ligament pathology. Sometimes you'll get into the wrist and you'll actually see that the volar side gap's more open than the dorsal side, or it's just a volar only tear. So how do you do this? Arthroscopically. So using the nano needle we're going to show you how to do this just in terms of orientation. We have the ulna and radial midcarpal portals. And we've also made an incision on the palmar side basically showing you the volar radial portal. And that's critical because we're actually going to be coming between the flexor carpi radialis and the median nerve and the flexor tendon. Okay. So the volar approach here, you've got the tendon and we have the median nerve as well as the flexor tendons towards the ulnar side. Now the Palmer cutaneous branch of the median nerve comes on the radio side of the median nerve and comes across your view. So it's important to understand where that is and either retract it only or radially. And this is the area that you want to see. You want to see this area here because this is where your needles are going to come Through, and you're going to be tying your suture down to the volar capsule in this area here. So when you first start off, make your volar FCR approach. And this will allow you to safely place that suture. Okay. So now we've got the camera in the ulnar mid carpal portal. And just a little word on terms of technique here. So I've taken an 18 gauge needle. You can take a spinal needle or a regular 18 gauge needle. And I've taken a 200 FiberStick. And what you'll see is that you have the actual ends of the FiberStick at the end of the needle. And this actually then is going to be passed for your repair. But if we look back, what you'll see at the end of the needle is that you actually have the loop of the 200 FiberStick, and that loop will be shuttled inside the joint. So in terms of orientation here we have the lunate and we have the capitate above us. And we can see the scapholunate instability. You can see the step off of the scaphoid and the lunate. So when we come in with the probe and you'll see the instability and the reducibility of the scaphoid and the lunate. If I pull back and push this down, you can see how it reduces. Now sometimes you'll come in there and there's a tear and there's volar instability. So how do we repair this. So first and foremost is we have to breed all this synovitis because this can act as a scar tether to prevent you from getting your reduction. So we're going to breed that first and then we'll do our repair. This is an important step for any sort of carpal pathology where you have to breed the scar tissue. You want to make sure that this is reducible, because if it's not reducible, if you're either doing an arthroscopic or even an open procedure, then your soft tissue reconstructions will not work. So you can see here we're debriding the scar. And now once we've debrided the scar, now we're going to do a capsular decease. So we're going to take this needle and we're going to come in in the radial midcarpal portal. And so now what I want to do is with the needle, I'm going to take a bite of the capsule on the radial Deal side of the scapholunate interval, then I'm going to pull back, and then I'm going to go on the ulnar side of the scapholunate interval. And by bringing this capsule together, it will allow us to do a volar SL capsule. So I'm going to go on the radial side, take a radial bite. And I'm going to push through the capsule. And on the volar side we've got the median nerve and the flexor tendons out of harm's way. So I'm going to push this through. And as I've come through I'm going to grab one limb of the 200 FiberStick. So we've grabbed one limb. And now I'm going to pull the stitch back and the needle out, but I'm going to stay within the midcarpal joint, because if I come out the midcarpal joint, I can get a soft tissue bridge. So I pull the needle back. And now I'm going to come on the and you can see the suture there. Now I'm going to take a bite of the ulnar capsule adjacent to the scapholunate interval and push this through. Okay, so now we've got both limbs on the volar side, and we've protected the neurovascular structures and the tendons. And now I simply just pull on both limbs of those sutures from the volar side. So we pull them. Pull them through. I'll take the needle out. And now you can see as I pull on that stitch, look at the scapholunate interval. Redeuce. There you see, it's off and it's reduced. Off, reduced. So here you can see by pulling on the stitch we're reducing the SL. And so now what we'll do is out of traction. We'll look on the palmar side ensure that the sutures are just through the capsule. And then we repair this down tying the knot down to capsule out of traction.

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