Name: Nano Arthroscopy in the Hand and Wrist
Uploaded: 2021-08-24T00:00:00Z
Channel: Arthrex
Description: Sanj Kakar, MD (Rochester, MN), discusses the most impactful nano arthroscopy cases of his practice.

Imaging and Resection

<p>Sanj Kakar, MD (Rochester, MN), discusses the most impactful nano arthroscopy cases of his practice.</p>

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VID1-002575-en-US | A | Nano Arthroscopy in the Hand and Wrist

Sanj Kakar

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Nano Arthroscopy in the Hand and Wrist

Hi, my name is Sanjay Kakkar. It's a privilege to be here today to talk to you about nano arthroscopy and hand and wrist surgery. I want to talk about my evolution in wrist arthroscopy. This was my mentor, Doctor Berger, who many years ago really was a big proponent in wrist arthroscopy. I was fortunate to be awarded the Bunnell Traveling Fellowship by the American Society for surgery of the hand. And really my theme for this was wrist arthroscopy and how we challenge dogma. Also, what we wanted to see is many of us use wet arthroscopy and fluid and how we do this dry. And this is where I think nano arthroscopy really has taken off. In doing dry arthroscopy, minimally invasive surgery in a safe and efficient way. So what did I learn? I really learned about Innovation pushing the envelope, doing new techniques. But how do we do these new techniques with older technology, which has large, more cumbersome, harder to get into tight spaces, which is really important for the hand and wrist. And so in terms of nano arthroscopy, when you think about the NanoScope, one of the real advantages is how small it is. It has an outer diameter of 2.2mm, and it really allows us to get into small spaces. For example, the Dr and digits, where beforehand we couldn't get in there. The NanoScope is also flexible, so it actually bends around the articular surfaces, which prevents iatrogenic cartilage injury. And also if you use the 1.9mm lenses in the past, they're very delicate. With nano arthroscopy, the lens is actually stronger, more robust, and as a result, less repair costs. So what's my evolution been. So we're going to go through some case examples. But in those people who like to do arthroscopy you can see a myriad of different indications. But some of you may not be an arthroscopic expert. And you're thinking, well, how can I use Nano to help our patients? Here you can see I've delineated other non arthroscopic roles for the use of nano arthroscopy. But to do this we have to have new tools that allow us to get into these spaces. So now if you look at the cannulas you can see the straight 2.2mm outer diameter cannula. But you also may want to use fluid and you use that 30 degree bend. Remember, the nano arthroscopy looks straight on where there's new tools that are being developed for this. For example, the high flow sheath cannula, which allows you to get more fluid if you want to do wet arthroscopy, but also has that 30 degree bend if you're used to traditional angle. In addition, what we've devised is the nano grip when you're using nano arthroscopy. Because it's more precise, we tend to hold it at the tip, but we're using the nano grip. This prevents you from telescoping out of the joint, and it gives you fine control without really squeezing the tip of the NanoScope so you can do longer cases more safely, more efficiently for your hands. So for me, when I'm thinking of hand and wrist, I think of nano arthroscopy first. And here's the acronym. And we'll go through what this means by first using nano arthroscopy. So when you think of F we can think of it for fusions. We can think of this for fractures. So one of the most common fractures that we treat are distal radius fractures. How can we use nano arthroscopy. Safer to get better articular reductions for our patient. So here's an example of a patient with a highly comminuted distal radius fracture. And when you look at the CT scan you can see there's diastasis at the sigmoid notch in the druj. And you also can see the articular incongruity. Now when you look at this axial view you can actually see that there's debris in the sigmoid notch. So how are we going to do this in a minimally invasive way without opening the wrist dorsally, causing soft tissue stripping. So here we're using the principles of dry arthroscopy for this radius fracture fixation. So the principles here are getting the best articular reduction you can. You can see I've put the plate on and I've held the plate proximally. But there's no fixation distally apart from K-wires. And so here you can see now the NanoScope is in the Z portal. And we're making a small stab incision. And the advantage of this is that we're doing this dry. Because if we were doing this wet one of the concerns is compartment syndrome with soft tissue extravasation. So here you can see we're using the automatic washout technique with technique with the two millimeters shaver, and all you need is 10 or 20 cc's. And you can see how by turning on the shaver, it's lavaging the joint. So there you see I've put ten cc's in. We'll put another ten cc's and eventually you start getting a picture. Now you can see we're debriding the joint and I can now see the articular reduction. Now this is a different patient but the same principle. So here you can see that there's callus in the articular surface. So we're debriding this under direct vision. Then I'm holding the reduction. And now with the Arthrex variable angle this radius plate that has locking guides in there. Now my assistant here is drilling away while I'm holding the reduction looking at it with the NanoScope. And we're getting the articular surface reduced. But here's the real advantage. You saw that that radial styloid was well reduced. But now I'm debriefing this. And now you can see actually I was off. I had a step off of at least five millimeters, which is not acceptable. Using nano we can disarticulate the fracture fragments, get the disimpaction corrected, and then fix this directly. We've reduced that step off. And here's the final post-operative x rays. So really I think for trauma in particular nano arthroscopy really is helping us. You don't have to be just for wrist fractures or carpal fractures. This could be tibial plateaus, tibial pylons anywhere where you want to see the articular surface. The advantage of this is it's a peel pack. None of the frustrations anymore about pulling in a big tower into the operating room, where the nurses aren't used to this. We've all been there. In fact. What? This is easy for the staff. They literally open the peel pack plug and you're ready to go. And this really is the nuance of nano arthroscopy for trauma. It makes my reductions better. It's better for our patients where we reduce step offs, as you saw in that patient where the fluoroscopic view wasn't bad. I was actually off in my reduction. And it allows us to also see other pathologies. And I'll show you an example of a scaphoid fracture where typically we may have missed these in the past. What does I stand for? I stands for instabilities or any way you want to inject. Let's say you want to inject into a joint and you want to see. Traditionally we use ultrasound, but what about using nano arthroscopy to see exactly where you want to go? I want to share a case here of a Deej instability case. And prior to nano arthroscopy, I thought D.J. arthroscopy was very difficult to do. It's a tiny space taking a 2.7mm lens, putting it into a small space. Really? You would scuff up the cartilage. So here's a patient who comes in, you can see has a nasty distal radius and ulna fracture that was highly displaced. Our orthopedic colleagues did a wonderful job reducing this and pinning it. And if you look at the articular reduction and the joint reduction, it actually looks pretty good. So I see the patient ten months later. And what he noticed is that in supination he basically had gross instability. And you can see from this video how he is D.J. is grossly unstable. So if you look at his MRI, the actual tfcc looks okay. And this is really where I've learned over the last few years how you have to trust your clinical examination and then use nano arthroscopy to allow you to detect pathology, because if you look at the MRI, read from world class MSK radiologists, they said the Tfcc is otherwise intact. So I think when you're treating especially ulnar wrist pain, it's important to have an algorithm in your mind. This is an algorithm that we use called the four leaf clover algorithm. And so in this patient bone looked good, cartilage looked good. The ECU was stable but clearly had a tfcc problem. So once I popped the NanoScope looking in the radiocarpal joint, the tfcc looks normal. Had a negative trampoline sign, had a negative hook test. So now what do you do? Basically, this is where the power of nano arthroscopy will help you. So in the pack you actually have two cannulas. And this is really advantageous to allow you to do for example tight space arthroscopy. So I've got the camera in the radiocarpal joint and I've put a needle underneath the tfcc so I know exactly where I'm in. And then the cannula then comes in. And so here you can see as we come, only we're underneath the tfcc. There it is. There's a foveal footprint where that tfcc should be backed down to bone. So now with the NanoScope in this tight space, I've put a needle in, I've developed a working portal, and then what I've done is brought in the curette to debris, the footprint to allow this tfcc to heal down to bone and then bring that two millimeter shaver, which is perfect for this, where you're debriding. Now you can see you can see everything perfectly. There's no need for fluid. There's no soft tissue extravasation. So as a result, the tissues don't blow up. And now what I've done is I've made a 0.0 62K wire, put a needle through the distal ulnar tunnel and through that fed a 200 FiberWire. Here's a foveal repair. I'm back in the radiocarpal joint. I've taken that probe and you can see how stable the tfcc is. So now when I look at this patient, this is in the operating room. And so what I've done is taken him released the traction and look how stable the dye is. Now this is markedly different to what it was a few minutes ago where I showed you how unstable that dye was. And this, you can see is the traction has been released. So there you've got instantaneous stability. And this is a patient three months post-op. So this is his normal side. And you can see the normal laxity of the drug. Now when I go to the side that we just repaired with the NanoScope he has good passive range of motion. And now you can see as good active and full range of motion. And now you'll see actually how stable is dry was. Remember how unstable he was initially. He's rock solid. What does R stand for in the acronym R stands for repair and Reconstruction. And you can see I've listed a myriad of different options here. But I want to show an example of a scapholunate ligament repair. So this is a patient that comes in with a non-displaced scaphoid fracture. And so it was non-displaced. You can see on the x ray and CT scan. So he elected non-operative treatment. So we place him into a cast. And he comes back three weeks later. And you can see there's some resorption at the fracture site. He wasn't very comfortable about this and said, you know, actually I want to get this fixed so I can move sooner rather than being in a cast. Asked. So here what we are showing you now is how you can use NanoScope, where traditionally you wouldn't have put a camera in to actually pick up additional pathologies at once upon a time we may have missed. We put the K-wires in. The reduction of the fracture looks good, but sometimes Flora can. You can be off. You can be more rotated. So I popped the NanoScope in where in the radial midcarpal portal. And you can see actually how stable that fracture site looks. So the reduction is good of the fracture. But look what else I saw. Now you can see I'm probing the cell. Look how it opens up. So this patient had a concomitant. You can see the dorsal cell is stable but he had a concomitant volar cell injury. And if I hadn't popped the NanoScope in I may have missed this injury. And so we've put the screw in the NanoScope picture there showing that the the reduction of the fracture looks good. But now we have to address that additional pathology that I wasn't suspecting. So here you can see the NanoScope in the ulnar midcarpal portal. I've taken a 200 FiberStick. And then what then what I'm basically doing now is taking a needle going radial and ulnar to the scapholunate ligament. This shows how the needle is being passed back and forth. And you can see under direct vision how that's going through the capsule. And remember precision matters. Accuracy matters because on the other side of this is an important structure the median nerve. So we're dealing in small millimeters of space. And this is what a nano arthroscopy will allow you to do. I'm pulling on that suture. Look how it reduces the scapholunate interval. So again this is where we're using the power of nano arthroscopy to help confirm our reduction and also detect additional pathology that we'll address at the same time. What does the S stand for. The S stands for small joint arthroscopy. I showed you an example of arthroscopy. But what about this case. So this is a patient that comes in to see me at a motor vehicle accident. Had a bad injury, soft tissue wise. Needed a skin graft but was complaining of MCP joint thumb pain. So initially treated the patient non-operatively with an With an injection got better, but the symptoms came back. And if you actually look at the x ray and the MRI, it doesn't look too bad. And the collateral ligaments are actually stable. So the read from the radiologist was that essentially the joint looked fine. So now what do you do. You can see the skin graft. So this is a patient I would be reluctant to make a big incision. So this is perfect for nano. It's a small incision. And you can see how we're holding the camera precisely to look into the joint. Here's our automatic washout technique that I talked about. So two millimeter shaver goes in. You can see the ten cc syringe attached to the NanoScope. And then we by turning on the shaver you see how it breathes the joint, how the plunger is being depressed. And this is the sort of moment for me as I came into the empi joint. Cartilage looks okay. But look at that post-traumatic arthritis right in the middle of the thumb metacarpal head. And this is somebody I would have missed without scoping that joint, and would have been much harder putting a 2.7mm scope in there. And now you can see the beauty of dry arthroscopy with minimally invasive incisions. We're just treating this with steri strips. No need for any sutures. And this is the patient several weeks later. A thumb motion. The injured side is her left hand. She has very good range of motion with minimal soft tissue injury. And you can see no skin wound healing problems. T stands for tunnel anywhere where you think of a tunnel, carpal tunnel, cubital tunnel, radial tunnel where you want to decompress a structure. Nano arthroscopy I think, will really help you. I want to share this case of an elite rower who actually comes with bilateral forearm flexor and extensor exercise induced compartment syndrome. So in the past, for example, this is a type of incision we would need. This is a long incision to decompress the whole flexor compartment. Now using nano arthroscopy we can do this safely minimally invasively. And I say safely because in this region there's going to be nerves that we have to decompress. So here you can see coming in, you can see we've lifted up the soft tissue envelope. And under direct vision very precisely we can release the superficial fascia. And so here you can see a complete release going essentially down the middle of the forearm. Well what about the nerve. There's the ulnar nerve. So it's critically important that we respect this and dissect around this safely. I've opened up the deep fascia and there you can see the ulnar nerve underneath you. So again releasing everything safely. So there's her incisions. And you can see these are much smaller than the traditional longitudinal incision. What about on the extensor side. You can see again a long incision which is rather unsightly. And a young lady remember it's bilateral forearms. And so here you can see through a smaller incision using the NanoScope. We're safely and efficiently dissecting the superficial fascia. And so here you can see a complete release. These are scars that she's healed and she's back to competing. So what have I learned over the last few years? This has been an exciting journey. It's made me better as a surgeon. It's allowed me to detect and treat more pathologies that previously I may have had difficulty taking care of. Also, our residents and fellows have enjoyed this. It's lighter for them. It's easier for them to navigate using the NanoScope. In addition, it's made me more efficient. In the operating room, there's less setup cost. For example, it's a peel pack. You literally open the pack and plug and play, and it's better for the nurses. They actually like doing these cases. In addition, the repair costs have decreased because I'm not breaking a 1.9mm lens anymore. So the NanoScope lens is more sturdy and more robust. So traditionally we've obviously evolved in orthopedics as in life. And so for me, when I think about nano arthroscopy, I think of first think about fractures and fusions, think about instabilities, injections, impaction, think about repair or reconstruction, think about small joint arthroscopy. And finally think about tunnels, carpal tunnel, cubital tunnel, radial tunnel. Really, the possibilities are endless. Thank you for your time.