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#Livesurgery with Dr.Badia - Rotator Cuff Repair and Distal Clavicle Resection
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#Livesurgery with Dr.Badia - Rotator Cuff Repair and Distal Clavicle Resection
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Upload Date:
2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
Hello, Dr Badia here, # live surgery Tuesday Where, as promised, we're doing another shouder [inaudible] The gentleman who had a traumatic injury a work injury. Had a mild separation of the clavicle. Ac joint separation. But he's had continued pain there and then an MRI also revealed what I just found is a small rotator cuff tear.
So he's got no labral tear today. We did a big massive labral repair. And the guy who came down from Delray Beach or something. But this looks pretty good. No arthritis like this. So this looks better than mine. And he's older than me. But now I'm going to swivel the light source the other way.
And there's a hole. So we didn't see it initially because I had to clean up, ao we are going to do a most likely a rotator cuff repair. If so, we'll need a slotted cannula for that. So I'm just going to tighten up some of these tissues a little bit, all right. [inaudible] So I'm going to mark, sometimes I like to mark just to give me an orientation.
So [inaudible] in the joint. For those of you that are viewing followers and Fellows, please comment where you are viewing from. And feel free to ask any questions in the comments section. And I'm allowed to ask them questions. Everyone try to get stuck in something.
Yes. Dr. Badia will ask you questions, Fellows. We had a case like that, a wrist case where I said, you know, I've got a poll. I had to it was a very difficult problem. And I said, what would you people do? And we discussed it. That's the way medicine should be right? None of us know all the answers.
OK so there's the, there's the, my kids know that. I don't know all the answers. [inaudible] I have two teenagers. OK. So before I go [inaudible] to take care of the joint.
So now I'm in the joint. So this is radio frequency, which I'm a fan of. I think it helps reduce the inflammation. A lot of this grey tissue, this can be a skin irritant. You have a little bit of a frozen shoulder here, so I'm actually going to release that. And then.
And then. And then I cleaned up the edges. See this capsule right there? Right at the bottom. Let's get a better look at it. Right here. And this sort of red that's a sign of an early adhesive capsulitis or people know it as frozen shoulder.
So that will help them. OK hello, Dr. Castillo. Thank you for joining our lives. Please let us know where you are watching us from. [Spanish] Dr. Sergio Castillo.
I'll go to try to get Dr. Drew to have this on my surgery. What do you think of that? Oh, that would be so much fun. Great audience. I will tell you, it will not be a fun conversation. You're going to talk about, insurance, problems of health care delivery that we face constantly. I have a guy here right now who had an injury with his dog.
The dog. The dog is blind. How do you like that? So the dog ran into him, a 60 pounds dog and hyper flexed his thumb, tore ligaments. So on one visit I examined him. We did fluoroscopy. We actually did an MRI because it was sort of iffy. And sure enough, the MRI shows it.
And they're currently battling with the insurance company right now. So I'm wondering why the heck they pay their premiums. Right OK, let's. And for the layperson that is watching, Dr Badia, if you could explain what's going on right now. Sure so this is inside the shoulder joint, the glenohumeral joint, the humerus, the head, the head of the upper arm bone.
This is the shoulder joint. This is the glenoid. It looks very nice, actually. No arthritis or anything. See, the cartilage looks nice and white. The last patient we did was younger than this guy, but he had an injury and he had lost the cartilage. Now, the MRI that we have done pre-op showed a rotator cuff tear and there it is.
So the rotator cuff, you can look up stuff like that on my website. Drbadia.com, we have some stuff that explains for you can see. So we're going to have to fix that little hole. And I marked it with this suture. The other thing he has is a collarbone separation. And we're going to shave down the collarbone, which will help with the pain.
So we're ready now to go and look above because you can actually see he has a little step off. All right. That's his that's his arthritic collarbone. He's got a bump there. So we're going to go in there and just shaving it down will help with the pain. All right. So so now we're going to go outside of the joint, outside of the drive.
We're going to go slide back and above the rotator cuff, and underneath the acromion, which is this little bone here. And we're going to see that rotator cuff tear from above and we're going to see that [inaudible] OK so there's a little needle. [inaudible] Please. Nice.
You've got a hole called portals. They're not really incisions. Once we close them on the wrist, I don't even put a stitch in the shoulder. I do put a little stitch. And traditionally, is this procedure done open? Well, traditionally, some years ago. But at this point in time and in 2020, somethings most clinicians will do that, most orthopedic surgeons, certainly if they are shoulder specialists will do this arthroscopically.
[inaudible] I'm not it's not a criticism. It's just that it's more painful and the reality is you see better arthroscopically it's called, people call it keyhole surgery but to do it open I wouldn't be able to look all the way in there very easily. Oh, Yeah. I can see the tear already.
Look at the edge of it. So it doesn't look that fresh, that new. So it's probably what we call an acute on chronic. He's, you know an older gentleman and probably had a small cut there already degenerative tear. He's got some impingement here. This is the acromion. So I'm going to shave this down in a bit. [Spanish] The suit is not my size.
So bunny suit looks great. We often have visitors, which is great for me because I get to continue learning. I'm not. I'm not at the University of Miami or anything like that. So my interaction is with our visiting Fellows and colleagues.
OK so let's get a slotted cannula, pick a yellow slotted canula and have it ready. OK switching to the first. So we're going to I'm doing bearing down the ball. We want to create a bleeding surface. So let's get a burr in this case also, because for the clavicle, it's easier.
OK can you explain why you were trying to create bleeding? For healing. All healing occurs with blood and platelets, right? That's why we use it. Just a little while ago, I injected somebody with platelet rich plasma. So healing comes from platelets. So if we can get the little micro bleeding you see there, that'll create healing because we want to reattach that tendon to the bone and you'll see how we do that.
It's a bigger tear than I thought. You can get really fooled sometimes looking from below. I'm going to document that. OK actually, well, OK, we'll use it and then I'll come back. Dr. Badia, I have a question from your colleague, Dr. Lincoln Vargus. Do you use another viewing portal for an infraspinatus repair?
Rarely sometimes I'll make a posterolateral portal or I'll move the scope to the front. But that's pretty rare. Just like the wrist I've gotten accustomed to use in my working portal. [inaudible] [inaudible] So this is a clear plastic disposable cannula, basically.
OK we have a question, Dr. Badia, is it normal to have both a rotator cuff and AC joint injuries at the same time? Yeah in older patients, Yes. I agree. That's a great question. Not not in younger patients, but he's older. And all I can tell you is my definition of older changes every year.
All right. So what I'm going to see here talked about the blood. So he's got a pretty good quality bone for an older guy. So I'm just going to spare a little bit and then we're going to need this anyway for the collarbone. So I decided just use it.
OK let's have regular shaver. The only question will be how many anchors? And it's looking like it might be a two anchor repair. I'll know in the moment. So we also clean up the other surface site to create a little bit of bleeding in the cup although you can see the cup doesn't bleed a lot.
That's the problem. That's that's why sometimes repairs fail. But surprisingly, you know, you could do very well even if the cup is not very vascular. You can see the blood coming up now from the bones and. got a lot of bursitis here still so I'm cleaning that out. And also if I can see better.
Plus, please. What is the recovery like for this patient after the procedure? About three weeks in a sling because I don't want him to really be elevated, moving his arm too much. So, you know, he'll be able he can use a computer, but he's not going to be able to, you know, fix his hair, which I can tell you in his case, not a big issue, but.
But it's a little bit of a surprise, some of the ladies. But, you know, because they can't reach up and touch your head. Actually, we had the last scope we just did was a lady came down from the West. I'm going to distribute the forces on this.
So I am going to use two anchors, so let's go ahead and open to [inaudible] please. Did this patient try anything prior to surgery to prevent surgery, or was this his first idea for treatment? Usually if it's a work injury, they send them to these kind of general clinics. And honestly, most of the times they go directly to the therapy.
I mean, in many times that's OK. But in this case, this ends up hurting the patient more. And it's really a waste of money and time. We have to be responsible. You know, if you have a tear like this, you know, therapy doesn't close the repaired tear. But this is, you know, our health care system. Unfortunately, it's we have this obsession with, you know, having sort of the generalist, see, first thinking that they're saving money.
But we don't realize you actually spend more money because ultimately it comes to this. So let's just do this from the beginning. Can you give an example of a shoulder diagnosis that would get better with therapy? Yeah, a mild bursitis. And you take some anti-inflammatories, you do some rotator cuff strengthening.
They'll get better sometimes in the injection. I don't inject cortisone as much, but PRP would work very well there. You can have a very small labral tear. You can have I had a separation and I treated it conservatively. The reality is I regret that, because took a long time. But anyway, you know, there's a decision to make.
So but sure. I mean, you know, people have pain all the time. Bicep tendinitis, that's one of the most common causes. Do you have your anchor ready and the second suture ready?
OK so this is how. Rather than opening it, passing the suture, this little device, this is called the scorpion. A picture there please.
The quality of tissues here on the edges is terrible. So I've got to go way in to find. Good call. I'm going to need the roller. Is it the fraying around the cuff that lets you know? I can't think of anything right now.
You go that way. And then give me the before that the kingfisher please.
See that. You don't want you always want it in this orientation. When we got these sutures out to the front. [inaudible] So this is our last pass.
Now we're passing suture through the edge of this torn tear, so you can see it very clearly here. Again, the quality of cuff is not very good, so I want to make sure I really go back and grab better quality tissue. We had a question about the quality of the cuff. Do you know because of the frame or what lets you know? THis is degenerate. This is what happens to all of us, right?
We get, you know, we get older and our tissues just, you know, are not the same, just the reality. Right so we're going to repair first the back here. So I'm going to take. I need to take the roller, please. I'm going to take. We're going to cross the stitches. Hold this, please.
We will pull this suture out. Some I'm going to take the back one. And that's about it. Take this out. Hold this here.
That one. OK and we have anchor. We need to. OK do we have a little clamp? OK so so this is what we call the suture management and rotator cuff repair.
And now we're going to make a little hole where the anchor is going to go. It's in. So there you go.
Your left hand. Making a little hole. We don't have to tap it. Just push on like that. [inaudible] Now, you really got to be really precise. OK OK.
Hold it up again. Constantly adjusting to keep that same image. OK like that. [inaudible] Well we're still seeing the effects of COVID.
My usual assistant. I wonder if these things are ever going to go away. Or, more importantly, our reaction to it. OK looks good. Hold it there. No, there. There, you just got to push him a little bit right here.
Where exactly are the anchors going Doctor Badia? Into the humeral head, what we call the greater tuberosity. That's where the supraspinatus is attaches and the intraspinatus.
[inaudible] So now I'm going to cut the excess. suture. It's doing a great job. Perfect. OK, good. OK, so these are knotless anchors. So you see, look look at how there's no longer a hole.
So now we distributed the forces, roller please. [inaudible] Perfect. Now we're going to go and get the front of the front two sutures, and I'm going to go find them. There it is. Now do you always use double roll technique or is there another one you fancy more doing?
This is not a double row, this is simply two anchors on a lateral row because there's no tension on this repair. There's not a massive tear. It was a bit smaller when you just had one anchor but due to the degenerative nature, I figured we'd distribute the forces. Now I'm going to externally rotate a little bit to show us where we're going to put the [inaudible] anchor.
OK so we're going to put it. So now, now you can hold it like that. Yep you're going to go in a little farther. You're going to try to keep that. Hello, Dr. Haggard.
Thank you for joining our live. [inaudible] [inaudible] [Spanish] So this is the anterior.
Anterior. So patients are always worried about anchors, they like, they think this is, we call it an anchor because it holds right, but it's bioabsorbable, this will not, this goes in the bone, it stays there. Some some people still like to use metal. That's fine. There's really no problem with these.
But these do absorb and it takes actually takes a few years. But there is no problem with this. For some reason, I find patients often have that concern. I'm looking to the name. So I'm going to I'm going to come up with a different name. Yeah names. Vocabulary is important.
OK. Shaver, please. So now we've got crossing sutures and I look what a nice repair that is. See, there's no, can't see it. And then we're going to go looking for the end of the clavicle, which is what everybody's waiting for.
But OK. So the anchors are in there. I think the pictures that you saw, the patient very important that patients understand why they can't lift their arm because the only thing holding this is these sutures.
So if the patient was to lift their arm, which weighs, you know, a good 20 pounds, 25 pounds, that's a lot of stress on this repair. But over the course of the course of the next three to four weeks, they'll start to heal. And we could start gently to move them. And now we're going to start, let's get our ref, we're going to start looking for the... I need a little more pressure.
OK, it's easier. Have you ever done this procedure on athletes? Oh, sure. And can they return back to their sport after a procedure like this? Absolutely one of the beauties of arthroscopy is doing stuff, minimally invasive. So I'm going to outline.
So this is the bone called the acromion above. So this is hard bone. Finally, a ligament. So I'm going to remove some of this because that will give the patient more, more space. [Spanish] We're we're going to go hunt for the collarbone.
Sometimes it's easier than others to find. We need a spinal needle for that because we're going to put the needle actually in the joints and that'll help mark it for us. We're seeing them already, I think. So the reason I draw out the anatomy, you see, I drew under the collarbone there, and pressing down on it.
I'm not. OK so it's even a little farther in. [Spanish] The Northeast of.
Oh I've just hit. [inaudible] Give me a flush in a moment. Thank you for writing that in English. A big hug, my friend.
Yep Yeah. Dr. Raul is one of the great educators in the region. He organizes, he's organized a number of meetings in his beautiful city, seaside, and much like Miami.
Are you getting out of town? Too much traffic. Can you explain what you're doing with the radio frequency? Yeah, I'm, I'm cleaning out all this soft tissue so that localize the AC joint.
When I press on the joint, see there. There it is. And now I'm seeing the answer now. I think the spinal, I'm going to put the needle in the joint and that will help me to determine how and where. So so that's the clavicle.
But there it is. Well, there it is. You guys just witness something unseen. We've never seen that in the OR before. I have. OK, hold this here. So actually, I'm going.
[inaudible] There's different ways. I like to go really into. Here is the blade. Do this at home, kids. OK all right. And now I'm going to take it out.
She's got it ready for me. Thank you. Clamp. All right, now I'm going to take the shaver. Now, it's I'm kind of cheating here. This is a nice. Once I've got enough space. OK go ahead.
So surgery's going to be done in a few minutes, but we're inside the AC joint. All right, so all of this sort of tissue is. You have to, its caused pain. What we're doing is we're going to create a nice space. You're going to see the end of the collarbone in a minute. We will see our little burn in the moment.
I'm just creating a space now. Now I mean, you could touch down on the collarbone. There you go. See, that's the [inaudible] So I'm going to clean this up. Dr. Philippe June. Dr. Philip June.
So we showed a we showed a before surgery, showed a video of one of those sort of fitness competitors, kind of a combination of almost like female bodybuilding and, you know, very, very pretty girl. And these competitions they had. But she had this ugly bump on her shoulder that you can see. And its a cyst. So I was afraid if I did it arthroscopically, I wouldn't be able to I might not get the bump out because she had some she had pain, but she also had that ugly bump.
I decided I did it open. And I did a very small incision, kind of a little plastic surgery type closure. OK, let's get the burr now. You could put your finger over it and it goes. OK so there's the end of the collarbone. So this is not there's a decent space excision just to end just the end of the collarbone, which is painful.
Just before you guys tuned in, Dr. Badia did a rotator cuff repair with two anchors. After we're done with live surgery, I'll post the whole video. But here's the end of, here's the end of the collarbone. You see there is loss of cartilage. You see that and then all this tissue so we're going to clean all that out.
And I. You use a burr. Give me a little bit. You mentioned, Dr. Badia, that this is common in weightlifters. Yeah in his case, he had a separation, he says now. But if you lift weights and you find that doing push ups or bench pressing typically hurts, that is that you may have something called osteolysis of the clavicle that don't move the moves.
[inaudible] So often the clavicle means the collarbone just becomes kind of arthritic and some of it actually kind of almost melts away. It's, you know, it's a cause of shoulder pain in athletes. You're flush. We're almost done.
We're not. you know, the burr allows us to remove a lot of bone very quickly. I don't even normally use it, but. OK let's have a shaver now. And press down on the clavicle.
Now I can get in there easily because there's a space. So if you have an arthritic joint, as long as both sides of the joint are not touching each other generally the pain is gone. So when I do a shoulder replacement, I do, usually I do a, means I replace the humeral head because I don't believe that you need to put the sock in necessarily. Sometimes you do but.
If you're basically. So your eliminate that rubbing, you're resecting of piece of the clavicle. Yeah, just the end of it. You'll be able to see it better.
Does the patient have any limitations as far as how much they will be able to lift after a procedure like this long term, or will they be able to return? I guess you guys haven't seen my post where I'm on. I'm on South Beach and I'm doing whatever I want. I come in. Look, you know, when I decided to have surgery, I told the story.
But it is when a little old lady has to help me with my overhead bag. I mean, I literally could not and couldn't throw my kids in the pool, you know? All dads do that. I think that's our chromosome. Chromosome it says you have to throw your kids in the pool. Right and I could not, you know, pick up the little rugrats and people when I tell you.
But now look at all this space. When we got in there first, you didn't have this space so you could drive a truck through here. Being for some patients, the thought of having to resect, remove a piece of a bone that may be essential is what's scary. My question to those persons is, you know, do you know anybody who's had an appendectomy, your appendix, you can live perfectly well without your appendix.
I mean there are, you talk to reconstructive micro surgeons. My partner and I have done some of that myself. And there are spare parts in the body. So OK. So that looks good. Yes let's go back. So the end of your clavicle is something you can live without.
You cannot live without love. You had to save that one for February. Christmas is coming. Dr. Rodrigo Cardoso, Thank you for joining. Ooh let me get this. See this little, little prominence of bone here, guys.
Right here. We're going to get that. You know what we can use lot the chamber. Yeah, that should be enough. And then. And then we are. Then we'll be done. We're going to inject, we have PRP, right?
Yes so we don't do live surgery Tuesday dvery Tuesday. We've been doing every other Tuesday. Dr. Badia will be in New York next week, correct? Yeah yeah, we're, we might. Might be a case I might be doing. I'm not sure. So anybody listening? I see some patients in New York.
We do surgery in a small outpatient center there. So good. You can reach me just through Drbadia.com, and I'm happy to help. But a lot of my international patients say they might have business to do in New York. And I said, you know, let's give them that option. Besides I'm a New Yorker at heart, so I have a little place there.
OK, so so this is an acromion blast You guys see it? So I'm just removing a little bone, because now that the rotator cuff is fixed, every time they lift up their arms, you don't want it. Or if you don't want it crashing up against the spine. So we just removed a little bit of that under the surface. Since we get this bleeder, we're done, we'll put the needles to put the needle for the PRP underneath the cuff between the cuff and the bone.
Once we. Get those, the fluid out, then we'll inject it. Who's going to watch the US Iran game? Poll from our watchers? Who's winning that game? Iran's pretty good. I just came back from Qatar. Iran's pretty good.
Please don't make this political. Who are you rooting for Dr. B? Oh, man, I am. I am as American as Apple pie and. I'm a Cuban American, but I am a proud American, so I am rooting for US. If the US doesn't, then everyone knows I'm going for Spain.
And Spain is pretty strong this year. Yeah OK. So we've done, we did the acromion, we did the distal clavicle resection. Actually, that bump is looking smaller already. There's the rotator cuff repair right here. OK, get this out. Great two in one.
So here's a needle. So what I'm going to do is put the needle underneath the repair. So that when you inject the plasma, then we're flooding that area with this platelet rich plasma. [inaudible] Any questions [Spanish] Where's our anesthesiologist?
Yep he's rooting for US too. You know, with your culture there's always a limit. Let me get my phone, please. Which pocket is it in? Don't answer spam. All you spammers are listening, all you Instagram trolls going. Let me tell you right now that when you spam somebody like myself.
Dr. McDowell. Right we're in the surgery, right? It's not cool. All right, this is the problem, because it could be somebody in need. Hey, Gigi from the office said Carmen is watching. Is it his step mom, Gigi? I think that's what she meant.
Oh, Wow. [Spanish] Hi, Carmen. [Spanish] Yes your stepmom. Wow oh, my So we're onto the question before, you know post op.
He's going to go into a sling and we'll start moving on in about three weeks. You're going to want to get some early healing in a cup. Doctor Divanshu, you join towards the end of the live. I know you always have great questions. We are just finishing up, but we'll post a recording for you to watch in the next few minutes. We should have a tell Instagram that you guys want to see some open surgery and if you don't want to watch it, then don't click on it. Like me.
You know what? I don't like to watch all those movies, like, sort of like, so that we can watch people being tortured right and surgery where we're helping somebody, that Instagram says that is too graphic. Graphic it really is an unbelievable all yours whenever I see them top of mind all say they're all covered, right?
Yeah you know, I don't necessarily mean recovered. It's just that you're actually restricting us. Yeah yeah, they are. And that's the problem. So it's the reason why we decided to go with an arthroscopic procedure. But we love to show you guys open procedures. The open. Why are we doing that?
It's kind of like nudity, its natural. Let's get nude. Everybody get ready for this. I'm going to get in trouble for... Instagram won't ban that, that's allowed. So here's a magic juice. All right. So I do a lot.
I did an injection today on a patient who without, you know, possibly being able to avoid surgery. But in this case, I'm putting it right where we did the repair. And that's going to give it some extra oomph that Dr. Devonshu says that he's interested in open procedures. We will have our next live surgery in the next two weeks. Maybe we can plan ahead and do it on YouTube.
For those who want to watch an open procedure, [inaudible] to know, you know, you don't want to watch or interact that's cool. The cocktail was a PRP injection. What's that? They asked what was the content in the cocktail you just injected I said, it's PRP, platelet rich plasma. When we put the IV in and the nurse in the holding area before we did the block.
Get a little sedation for the block. This block by the way, we use a medication called exporel. It is amazing. I know because I had a big knee surgery. My tibia was cut. That's correct. [inaudible] I watched the animation, that animation, photographic.
And I can tell you I never had pain. It was unbelievable. I had I felt this weird, like my leg felt like wood and I would knock on it. And it was very strange. But I remember thinking, I'm glad I don't feel it. And, you know, a couple of days. Hello, Dr. Badia from Bolivia. [Spanish] I'm assuming that's physiotherapy or physical therapy.
Extracorporeal shock wave therapy. That is where you stimulate blood flow by almost like how they remove kidney stones. The problem is, the literature I read about it is very popular in Latin America. And, you know, I think it works. Obviously, you can do it, but the literature just shows a lot of recurrence. So for tennis elbow, it's used a lot abroad, I don't think as much in the US.
And I just, you know, some people obviously it works, but I, it just hasn't been my... There's a question for you about the PRP. Don't you think that it isn't useful post arthroscopic because it would be flushed out? No, that's a good question. That's why I do it at the end when I close the portals. And no, I don't think it's flushed out. You just have to have to close the portals and just make sure that you've got the excess fluid out.
It's a good question. Thank you, guys for watching. Any questions that come up, you can definitely comment and we'll get back to you guys. All right. Thank you. Bye bye.
Segment:0 .
Hello, Dr Badia here, # live surgery Tuesday Where, as promised, we're doing another shouder [inaudible] The gentleman who had a traumatic injury a work injury. Had a mild separation of the clavicle. Ac joint separation. But he's had continued pain there and then an MRI also revealed what I just found is a small rotator cuff tear.
So he's got no labral tear today. We did a big massive labral repair. And the guy who came down from Delray Beach or something. But this looks pretty good. No arthritis like this. So this looks better than mine. And he's older than me. But now I'm going to swivel the light source the other way.
And there's a hole. So we didn't see it initially because I had to clean up, ao we are going to do a most likely a rotator cuff repair. If so, we'll need a slotted cannula for that. So I'm just going to tighten up some of these tissues a little bit, all right. [inaudible] So I'm going to mark, sometimes I like to mark just to give me an orientation.
So [inaudible] in the joint. For those of you that are viewing followers and Fellows, please comment where you are viewing from. And feel free to ask any questions in the comments section. And I'm allowed to ask them questions. Everyone try to get stuck in something.
Yes. Dr. Badia will ask you questions, Fellows. We had a case like that, a wrist case where I said, you know, I've got a poll. I had to it was a very difficult problem. And I said, what would you people do? And we discussed it. That's the way medicine should be right? None of us know all the answers.
OK so there's the, there's the, my kids know that. I don't know all the answers. [inaudible] I have two teenagers. OK. So before I go [inaudible] to take care of the joint.
So now I'm in the joint. So this is radio frequency, which I'm a fan of. I think it helps reduce the inflammation. A lot of this grey tissue, this can be a skin irritant. You have a little bit of a frozen shoulder here, so I'm actually going to release that. And then.
And then. And then I cleaned up the edges. See this capsule right there? Right at the bottom. Let's get a better look at it. Right here. And this sort of red that's a sign of an early adhesive capsulitis or people know it as frozen shoulder.
So that will help them. OK hello, Dr. Castillo. Thank you for joining our lives. Please let us know where you are watching us from. [Spanish] Dr. Sergio Castillo.
I'll go to try to get Dr. Drew to have this on my surgery. What do you think of that? Oh, that would be so much fun. Great audience. I will tell you, it will not be a fun conversation. You're going to talk about, insurance, problems of health care delivery that we face constantly. I have a guy here right now who had an injury with his dog.
The dog. The dog is blind. How do you like that? So the dog ran into him, a 60 pounds dog and hyper flexed his thumb, tore ligaments. So on one visit I examined him. We did fluoroscopy. We actually did an MRI because it was sort of iffy. And sure enough, the MRI shows it.
And they're currently battling with the insurance company right now. So I'm wondering why the heck they pay their premiums. Right OK, let's. And for the layperson that is watching, Dr Badia, if you could explain what's going on right now. Sure so this is inside the shoulder joint, the glenohumeral joint, the humerus, the head, the head of the upper arm bone.
This is the shoulder joint. This is the glenoid. It looks very nice, actually. No arthritis or anything. See, the cartilage looks nice and white. The last patient we did was younger than this guy, but he had an injury and he had lost the cartilage. Now, the MRI that we have done pre-op showed a rotator cuff tear and there it is.
So the rotator cuff, you can look up stuff like that on my website. Drbadia.com, we have some stuff that explains for you can see. So we're going to have to fix that little hole. And I marked it with this suture. The other thing he has is a collarbone separation. And we're going to shave down the collarbone, which will help with the pain.
So we're ready now to go and look above because you can actually see he has a little step off. All right. That's his that's his arthritic collarbone. He's got a bump there. So we're going to go in there and just shaving it down will help with the pain. All right. So so now we're going to go outside of the joint, outside of the drive.
We're going to go slide back and above the rotator cuff, and underneath the acromion, which is this little bone here. And we're going to see that rotator cuff tear from above and we're going to see that [inaudible] OK so there's a little needle. [inaudible] Please. Nice.
You've got a hole called portals. They're not really incisions. Once we close them on the wrist, I don't even put a stitch in the shoulder. I do put a little stitch. And traditionally, is this procedure done open? Well, traditionally, some years ago. But at this point in time and in 2020, somethings most clinicians will do that, most orthopedic surgeons, certainly if they are shoulder specialists will do this arthroscopically.
[inaudible] I'm not it's not a criticism. It's just that it's more painful and the reality is you see better arthroscopically it's called, people call it keyhole surgery but to do it open I wouldn't be able to look all the way in there very easily. Oh, Yeah. I can see the tear already.
Look at the edge of it. So it doesn't look that fresh, that new. So it's probably what we call an acute on chronic. He's, you know an older gentleman and probably had a small cut there already degenerative tear. He's got some impingement here. This is the acromion. So I'm going to shave this down in a bit. [Spanish] The suit is not my size.
So bunny suit looks great. We often have visitors, which is great for me because I get to continue learning. I'm not. I'm not at the University of Miami or anything like that. So my interaction is with our visiting Fellows and colleagues.
OK so let's get a slotted cannula, pick a yellow slotted canula and have it ready. OK switching to the first. So we're going to I'm doing bearing down the ball. We want to create a bleeding surface. So let's get a burr in this case also, because for the clavicle, it's easier.
OK can you explain why you were trying to create bleeding? For healing. All healing occurs with blood and platelets, right? That's why we use it. Just a little while ago, I injected somebody with platelet rich plasma. So healing comes from platelets. So if we can get the little micro bleeding you see there, that'll create healing because we want to reattach that tendon to the bone and you'll see how we do that.
It's a bigger tear than I thought. You can get really fooled sometimes looking from below. I'm going to document that. OK actually, well, OK, we'll use it and then I'll come back. Dr. Badia, I have a question from your colleague, Dr. Lincoln Vargus. Do you use another viewing portal for an infraspinatus repair?
Rarely sometimes I'll make a posterolateral portal or I'll move the scope to the front. But that's pretty rare. Just like the wrist I've gotten accustomed to use in my working portal. [inaudible] [inaudible] So this is a clear plastic disposable cannula, basically.
OK we have a question, Dr. Badia, is it normal to have both a rotator cuff and AC joint injuries at the same time? Yeah in older patients, Yes. I agree. That's a great question. Not not in younger patients, but he's older. And all I can tell you is my definition of older changes every year.
All right. So what I'm going to see here talked about the blood. So he's got a pretty good quality bone for an older guy. So I'm just going to spare a little bit and then we're going to need this anyway for the collarbone. So I decided just use it.
OK let's have regular shaver. The only question will be how many anchors? And it's looking like it might be a two anchor repair. I'll know in the moment. So we also clean up the other surface site to create a little bit of bleeding in the cup although you can see the cup doesn't bleed a lot.
That's the problem. That's that's why sometimes repairs fail. But surprisingly, you know, you could do very well even if the cup is not very vascular. You can see the blood coming up now from the bones and. got a lot of bursitis here still so I'm cleaning that out. And also if I can see better.
Plus, please. What is the recovery like for this patient after the procedure? About three weeks in a sling because I don't want him to really be elevated, moving his arm too much. So, you know, he'll be able he can use a computer, but he's not going to be able to, you know, fix his hair, which I can tell you in his case, not a big issue, but.
But it's a little bit of a surprise, some of the ladies. But, you know, because they can't reach up and touch your head. Actually, we had the last scope we just did was a lady came down from the West. I'm going to distribute the forces on this.
So I am going to use two anchors, so let's go ahead and open to [inaudible] please. Did this patient try anything prior to surgery to prevent surgery, or was this his first idea for treatment? Usually if it's a work injury, they send them to these kind of general clinics. And honestly, most of the times they go directly to the therapy.
I mean, in many times that's OK. But in this case, this ends up hurting the patient more. And it's really a waste of money and time. We have to be responsible. You know, if you have a tear like this, you know, therapy doesn't close the repaired tear. But this is, you know, our health care system. Unfortunately, it's we have this obsession with, you know, having sort of the generalist, see, first thinking that they're saving money.
But we don't realize you actually spend more money because ultimately it comes to this. So let's just do this from the beginning. Can you give an example of a shoulder diagnosis that would get better with therapy? Yeah, a mild bursitis. And you take some anti-inflammatories, you do some rotator cuff strengthening.
They'll get better sometimes in the injection. I don't inject cortisone as much, but PRP would work very well there. You can have a very small labral tear. You can have I had a separation and I treated it conservatively. The reality is I regret that, because took a long time. But anyway, you know, there's a decision to make.
So but sure. I mean, you know, people have pain all the time. Bicep tendinitis, that's one of the most common causes. Do you have your anchor ready and the second suture ready?
OK so this is how. Rather than opening it, passing the suture, this little device, this is called the scorpion. A picture there please.
The quality of tissues here on the edges is terrible. So I've got to go way in to find. Good call. I'm going to need the roller. Is it the fraying around the cuff that lets you know? I can't think of anything right now.
You go that way. And then give me the before that the kingfisher please.
See that. You don't want you always want it in this orientation. When we got these sutures out to the front. [inaudible] So this is our last pass.
Now we're passing suture through the edge of this torn tear, so you can see it very clearly here. Again, the quality of cuff is not very good, so I want to make sure I really go back and grab better quality tissue. We had a question about the quality of the cuff. Do you know because of the frame or what lets you know? THis is degenerate. This is what happens to all of us, right?
We get, you know, we get older and our tissues just, you know, are not the same, just the reality. Right so we're going to repair first the back here. So I'm going to take. I need to take the roller, please. I'm going to take. We're going to cross the stitches. Hold this, please.
We will pull this suture out. Some I'm going to take the back one. And that's about it. Take this out. Hold this here.
That one. OK and we have anchor. We need to. OK do we have a little clamp? OK so so this is what we call the suture management and rotator cuff repair.
And now we're going to make a little hole where the anchor is going to go. It's in. So there you go.
Your left hand. Making a little hole. We don't have to tap it. Just push on like that. [inaudible] Now, you really got to be really precise. OK OK.
Hold it up again. Constantly adjusting to keep that same image. OK like that. [inaudible] Well we're still seeing the effects of COVID.
My usual assistant. I wonder if these things are ever going to go away. Or, more importantly, our reaction to it. OK looks good. Hold it there. No, there. There, you just got to push him a little bit right here.
Where exactly are the anchors going Doctor Badia? Into the humeral head, what we call the greater tuberosity. That's where the supraspinatus is attaches and the intraspinatus.
[inaudible] So now I'm going to cut the excess. suture. It's doing a great job. Perfect. OK, good. OK, so these are knotless anchors. So you see, look look at how there's no longer a hole.
So now we distributed the forces, roller please. [inaudible] Perfect. Now we're going to go and get the front of the front two sutures, and I'm going to go find them. There it is. Now do you always use double roll technique or is there another one you fancy more doing?
This is not a double row, this is simply two anchors on a lateral row because there's no tension on this repair. There's not a massive tear. It was a bit smaller when you just had one anchor but due to the degenerative nature, I figured we'd distribute the forces. Now I'm going to externally rotate a little bit to show us where we're going to put the [inaudible] anchor.
OK so we're going to put it. So now, now you can hold it like that. Yep you're going to go in a little farther. You're going to try to keep that. Hello, Dr. Haggard.
Thank you for joining our live. [inaudible] [inaudible] [Spanish] So this is the anterior.
Anterior. So patients are always worried about anchors, they like, they think this is, we call it an anchor because it holds right, but it's bioabsorbable, this will not, this goes in the bone, it stays there. Some some people still like to use metal. That's fine. There's really no problem with these.
But these do absorb and it takes actually takes a few years. But there is no problem with this. For some reason, I find patients often have that concern. I'm looking to the name. So I'm going to I'm going to come up with a different name. Yeah names. Vocabulary is important.
OK. Shaver, please. So now we've got crossing sutures and I look what a nice repair that is. See, there's no, can't see it. And then we're going to go looking for the end of the clavicle, which is what everybody's waiting for.
But OK. So the anchors are in there. I think the pictures that you saw, the patient very important that patients understand why they can't lift their arm because the only thing holding this is these sutures.
So if the patient was to lift their arm, which weighs, you know, a good 20 pounds, 25 pounds, that's a lot of stress on this repair. But over the course of the course of the next three to four weeks, they'll start to heal. And we could start gently to move them. And now we're going to start, let's get our ref, we're going to start looking for the... I need a little more pressure.
OK, it's easier. Have you ever done this procedure on athletes? Oh, sure. And can they return back to their sport after a procedure like this? Absolutely one of the beauties of arthroscopy is doing stuff, minimally invasive. So I'm going to outline.
So this is the bone called the acromion above. So this is hard bone. Finally, a ligament. So I'm going to remove some of this because that will give the patient more, more space. [Spanish] We're we're going to go hunt for the collarbone.
Sometimes it's easier than others to find. We need a spinal needle for that because we're going to put the needle actually in the joints and that'll help mark it for us. We're seeing them already, I think. So the reason I draw out the anatomy, you see, I drew under the collarbone there, and pressing down on it.
I'm not. OK so it's even a little farther in. [Spanish] The Northeast of.
Oh I've just hit. [inaudible] Give me a flush in a moment. Thank you for writing that in English. A big hug, my friend.
Yep Yeah. Dr. Raul is one of the great educators in the region. He organizes, he's organized a number of meetings in his beautiful city, seaside, and much like Miami.
Are you getting out of town? Too much traffic. Can you explain what you're doing with the radio frequency? Yeah, I'm, I'm cleaning out all this soft tissue so that localize the AC joint.
When I press on the joint, see there. There it is. And now I'm seeing the answer now. I think the spinal, I'm going to put the needle in the joint and that will help me to determine how and where. So so that's the clavicle.
But there it is. Well, there it is. You guys just witness something unseen. We've never seen that in the OR before. I have. OK, hold this here. So actually, I'm going.
[inaudible] There's different ways. I like to go really into. Here is the blade. Do this at home, kids. OK all right. And now I'm going to take it out.
She's got it ready for me. Thank you. Clamp. All right, now I'm going to take the shaver. Now, it's I'm kind of cheating here. This is a nice. Once I've got enough space. OK go ahead.
So surgery's going to be done in a few minutes, but we're inside the AC joint. All right, so all of this sort of tissue is. You have to, its caused pain. What we're doing is we're going to create a nice space. You're going to see the end of the collarbone in a minute. We will see our little burn in the moment.
I'm just creating a space now. Now I mean, you could touch down on the collarbone. There you go. See, that's the [inaudible] So I'm going to clean this up. Dr. Philippe June. Dr. Philip June.
So we showed a we showed a before surgery, showed a video of one of those sort of fitness competitors, kind of a combination of almost like female bodybuilding and, you know, very, very pretty girl. And these competitions they had. But she had this ugly bump on her shoulder that you can see. And its a cyst. So I was afraid if I did it arthroscopically, I wouldn't be able to I might not get the bump out because she had some she had pain, but she also had that ugly bump.
I decided I did it open. And I did a very small incision, kind of a little plastic surgery type closure. OK, let's get the burr now. You could put your finger over it and it goes. OK so there's the end of the collarbone. So this is not there's a decent space excision just to end just the end of the collarbone, which is painful.
Just before you guys tuned in, Dr. Badia did a rotator cuff repair with two anchors. After we're done with live surgery, I'll post the whole video. But here's the end of, here's the end of the collarbone. You see there is loss of cartilage. You see that and then all this tissue so we're going to clean all that out.
And I. You use a burr. Give me a little bit. You mentioned, Dr. Badia, that this is common in weightlifters. Yeah in his case, he had a separation, he says now. But if you lift weights and you find that doing push ups or bench pressing typically hurts, that is that you may have something called osteolysis of the clavicle that don't move the moves.
[inaudible] So often the clavicle means the collarbone just becomes kind of arthritic and some of it actually kind of almost melts away. It's, you know, it's a cause of shoulder pain in athletes. You're flush. We're almost done.
We're not. you know, the burr allows us to remove a lot of bone very quickly. I don't even normally use it, but. OK let's have a shaver now. And press down on the clavicle.
Now I can get in there easily because there's a space. So if you have an arthritic joint, as long as both sides of the joint are not touching each other generally the pain is gone. So when I do a shoulder replacement, I do, usually I do a, means I replace the humeral head because I don't believe that you need to put the sock in necessarily. Sometimes you do but.
If you're basically. So your eliminate that rubbing, you're resecting of piece of the clavicle. Yeah, just the end of it. You'll be able to see it better.
Does the patient have any limitations as far as how much they will be able to lift after a procedure like this long term, or will they be able to return? I guess you guys haven't seen my post where I'm on. I'm on South Beach and I'm doing whatever I want. I come in. Look, you know, when I decided to have surgery, I told the story.
But it is when a little old lady has to help me with my overhead bag. I mean, I literally could not and couldn't throw my kids in the pool, you know? All dads do that. I think that's our chromosome. Chromosome it says you have to throw your kids in the pool. Right and I could not, you know, pick up the little rugrats and people when I tell you.
But now look at all this space. When we got in there first, you didn't have this space so you could drive a truck through here. Being for some patients, the thought of having to resect, remove a piece of a bone that may be essential is what's scary. My question to those persons is, you know, do you know anybody who's had an appendectomy, your appendix, you can live perfectly well without your appendix.
I mean there are, you talk to reconstructive micro surgeons. My partner and I have done some of that myself. And there are spare parts in the body. So OK. So that looks good. Yes let's go back. So the end of your clavicle is something you can live without.
You cannot live without love. You had to save that one for February. Christmas is coming. Dr. Rodrigo Cardoso, Thank you for joining. Ooh let me get this. See this little, little prominence of bone here, guys.
Right here. We're going to get that. You know what we can use lot the chamber. Yeah, that should be enough. And then. And then we are. Then we'll be done. We're going to inject, we have PRP, right?
Yes so we don't do live surgery Tuesday dvery Tuesday. We've been doing every other Tuesday. Dr. Badia will be in New York next week, correct? Yeah yeah, we're, we might. Might be a case I might be doing. I'm not sure. So anybody listening? I see some patients in New York.
We do surgery in a small outpatient center there. So good. You can reach me just through Drbadia.com, and I'm happy to help. But a lot of my international patients say they might have business to do in New York. And I said, you know, let's give them that option. Besides I'm a New Yorker at heart, so I have a little place there.
OK, so so this is an acromion blast You guys see it? So I'm just removing a little bone, because now that the rotator cuff is fixed, every time they lift up their arms, you don't want it. Or if you don't want it crashing up against the spine. So we just removed a little bit of that under the surface. Since we get this bleeder, we're done, we'll put the needles to put the needle for the PRP underneath the cuff between the cuff and the bone.
Once we. Get those, the fluid out, then we'll inject it. Who's going to watch the US Iran game? Poll from our watchers? Who's winning that game? Iran's pretty good. I just came back from Qatar. Iran's pretty good.
Please don't make this political. Who are you rooting for Dr. B? Oh, man, I am. I am as American as Apple pie and. I'm a Cuban American, but I am a proud American, so I am rooting for US. If the US doesn't, then everyone knows I'm going for Spain.
And Spain is pretty strong this year. Yeah OK. So we've done, we did the acromion, we did the distal clavicle resection. Actually, that bump is looking smaller already. There's the rotator cuff repair right here. OK, get this out. Great two in one.
So here's a needle. So what I'm going to do is put the needle underneath the repair. So that when you inject the plasma, then we're flooding that area with this platelet rich plasma. [inaudible] Any questions [Spanish] Where's our anesthesiologist?
Yep he's rooting for US too. You know, with your culture there's always a limit. Let me get my phone, please. Which pocket is it in? Don't answer spam. All you spammers are listening, all you Instagram trolls going. Let me tell you right now that when you spam somebody like myself.
Dr. McDowell. Right we're in the surgery, right? It's not cool. All right, this is the problem, because it could be somebody in need. Hey, Gigi from the office said Carmen is watching. Is it his step mom, Gigi? I think that's what she meant.
Oh, Wow. [Spanish] Hi, Carmen. [Spanish] Yes your stepmom. Wow oh, my So we're onto the question before, you know post op.
He's going to go into a sling and we'll start moving on in about three weeks. You're going to want to get some early healing in a cup. Doctor Divanshu, you join towards the end of the live. I know you always have great questions. We are just finishing up, but we'll post a recording for you to watch in the next few minutes. We should have a tell Instagram that you guys want to see some open surgery and if you don't want to watch it, then don't click on it. Like me.
You know what? I don't like to watch all those movies, like, sort of like, so that we can watch people being tortured right and surgery where we're helping somebody, that Instagram says that is too graphic. Graphic it really is an unbelievable all yours whenever I see them top of mind all say they're all covered, right?
Yeah you know, I don't necessarily mean recovered. It's just that you're actually restricting us. Yeah yeah, they are. And that's the problem. So it's the reason why we decided to go with an arthroscopic procedure. But we love to show you guys open procedures. The open. Why are we doing that?
It's kind of like nudity, its natural. Let's get nude. Everybody get ready for this. I'm going to get in trouble for... Instagram won't ban that, that's allowed. So here's a magic juice. All right. So I do a lot.
I did an injection today on a patient who without, you know, possibly being able to avoid surgery. But in this case, I'm putting it right where we did the repair. And that's going to give it some extra oomph that Dr. Devonshu says that he's interested in open procedures. We will have our next live surgery in the next two weeks. Maybe we can plan ahead and do it on YouTube.
For those who want to watch an open procedure, [inaudible] to know, you know, you don't want to watch or interact that's cool. The cocktail was a PRP injection. What's that? They asked what was the content in the cocktail you just injected I said, it's PRP, platelet rich plasma. When we put the IV in and the nurse in the holding area before we did the block.
Get a little sedation for the block. This block by the way, we use a medication called exporel. It is amazing. I know because I had a big knee surgery. My tibia was cut. That's correct. [inaudible] I watched the animation, that animation, photographic.
And I can tell you I never had pain. It was unbelievable. I had I felt this weird, like my leg felt like wood and I would knock on it. And it was very strange. But I remember thinking, I'm glad I don't feel it. And, you know, a couple of days. Hello, Dr. Badia from Bolivia. [Spanish] I'm assuming that's physiotherapy or physical therapy.
Extracorporeal shock wave therapy. That is where you stimulate blood flow by almost like how they remove kidney stones. The problem is, the literature I read about it is very popular in Latin America. And, you know, I think it works. Obviously, you can do it, but the literature just shows a lot of recurrence. So for tennis elbow, it's used a lot abroad, I don't think as much in the US.
And I just, you know, some people obviously it works, but I, it just hasn't been my... There's a question for you about the PRP. Don't you think that it isn't useful post arthroscopic because it would be flushed out? No, that's a good question. That's why I do it at the end when I close the portals. And no, I don't think it's flushed out. You just have to have to close the portals and just make sure that you've got the excess fluid out.
It's a good question. Thank you, guys for watching. Any questions that come up, you can definitely comment and we'll get back to you guys. All right. Thank you. Bye bye.
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