With the advent of the NanoScope, more procedures can be minimally invasive as well as using the NanoScope to enhance your surgery. In a multiligamentous knee reconstruction surgery, visualization of the posterior portion of the tibia is critical to the case for PCL reconstruction. Risks associated with multiligamentous knee reconstruction include iatrogenic vascular injury, iatrogenic nerve injury (saphenous nerve), compartment syndrome, tourniquet complications, wound problems, complex regional pain syndrome, deep vein thrombosis, loss of motion, and persistent laxity7Manske R.C. Hosseinzadeh P. Giangarra C.E. Multiple ligament knee injury: Complications.

North Am J Sports Phys Ther. 2008; 3: 226-233

. For visualization, a PM portal can be made; however, there is a danger if making an incision in the medial capsule, which could lead to damage of surrounding neurovascular structures. The obturator used with a standard scope to enter into the joint could also lead to iatrogenic cartilage injury off of the medial femoral condyle posteriorly if you are not perfect with your technique. The NanoScope uses a spinal needle for localization of your portal, followed by a nitinol wire, a small cannula, and then the NanoScope is entered into the joint. This allows for controlled entrance into the joint without causing an iatrogenic injury to the femoral condyle. Once you place this scope, you then have 2 views of the knee, one being with your standard scope anteriorly and then your NanoScope looking from posteromedial. If you do not want to make a posteromedial portal to visualize the poster aspect of the knee, some people use a 70° scope. Even with this extra angle, there are limitations when looking from the anterior knee portals, and you will actually have blind spots to some portions of the posterior compartment of the knee.8Arthroscopic assessment of the posterior compartments of the knee via the intercondylar notch: The arthroscopist's field of view.

Arthroscopy. 1993; 9: 284-290

The visualization of the tibia is important for tunnel placement as poor tunnel placement is one of the most common causes of PCL reconstruction failure. A tibial tunnel that is too proximal will lead to a vertical graft and decreasing the ability for the PCL to resist posteriorly translated forces.There are several pearls to our technique that make it more streamlined for the surgeon. Removing tissue posteriorly that would block the nanoscopic view is very important as this will enhance your visualization (Table 1). This technique also allows simultaneous viewing. A disadvantage to this technique is that it is technically challenging given that you have to have multiple assistants in the operating room helping you since you are using 2 cameras at once (Table 2). One should not hesitate to make the standard portal if necessary.

Table 1Pearls and Pitfalls of Nanoscopic-Assisted ACL-PCL Reconstruction

PearlsPitfalls

Table 2Advantages and Disadvantages of Nanoscopic-Assisted ACL-PCL Reconstruction

AdvantagesDisadvantages

Limitations to the technique include being technically demanding and there is a learning curve. Working with a 0° NanoScope has its challenges in the back of the knee which is why your needle placement initially is so important. Another limitation is the added cost versus an open PM portal. However, if you are able to gain that access, it yields for a more comprehensive surgery.

The use of a minimally invasive NanoScope during an ACL-PCL reconstruction has significant advantages with regards to visualization of the posterior tibia when preparing and drilling your PCL tunnel. We believe that this is an attractive technique that may be used as the years progress.