Name: First International Shoulder Planet Indo-Brazil Webinar - Rotator Cuff Healing Biology
Uploaded: 2024-05-31T00:00:00.0000000
Duration: T02H19M20S
Description: First International Shoulder Planet Indo-Brazil Webinar - Rotator Cuff Healing Biology

Name: First International Shoulder Planet Indo-Brazil Webinar - Rotator Cuff Healing Biology

Description: First International Shoulder Planet Indo-Brazil Webinar - Rotator Cuff Healing Biology

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Upload Date: 2024-05-31T00:00:00.0000000

Transcript: Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinksi from Shoulder Planet here from the city of Sao Paulo, Brazil. In this video, I have the honor to present to all of you the first international Shoulder Planet Indo-Brazil webinar. This webinar was a fantastic event that was only possible because of the outstanding efforts of our good friends
Dr. Neeraj Bijlani and Dr. Ashok Shyam, both from OrthoTV and I am very happy to present to you. We had big stalwarts of the shoulders scenario in this event. Dr. Ildeu Almeida, ex-president of Brazilian shoulder and Elbow Society and still two fantastic shoulder surgeons from India. Dr. Shirish Pathak from the city of Pune. And Dr. Sanjay Trivedi from the city of Ahmedabad.
It was a 2 and 1/2 outstanding discussion on biological healing of rotator cuff, with lovely lectures, principles, methods and discussions. So I hope you like it, and let's see the video. So welcome to this first India, Brazil collaboration webinar, and good morning to everybody in Brazil and good afternoon, everybody in India. We are here together to see this webinar on the geopolitics of healing and how to improve it.
This is a disclaimer from the author. We would like to thank all our faculty for sharing their knowledge and expertise, especially in this challenging time. We wish all our audience healthy and safe day ahead, and we hope these webinars add value to your time. These webinars are dependent on a lot of technology and expertise, which might be unstable at times, so please bear with us for any issues of technology.
So Thanks for attending this webinar again. Audio Dr. Sergio. So can I. Can I speak? Yes, sir. OK my friend. So it's a pleasure to have all of you here. I'm Dr. Sergio Rowinski, shoulder and elbow surgeon from Brazil, from Shoulder Planet show. Their planet is my international personal project and shoulder and elbow.
International medicine and surgical education. It's a pleasure to be here. This is one of the biggest achievements I have ever done with my project, and I am very thankful for Ortho TV for giving us this wonderful opportunity, which is something very special to me. None of them would have happened without the tremendous help of two special people, Dr. Ashok Shyam
He doesn't need any introductions nor doctor needs who have been doing that tremendous, nice work for all of us with not only we for TV, but with all of these webinars. As Dr. Ashok has told in these difficult times that we are all passing through. We have today here a constellation of big stars, and I am very happy to have them all. So first of all, I would like to introduce to all of you guys, my good friend, Dr. Almeida.
Dr. Almeida is a very good friend of mine. He's not only my colleague, I consider him my friend, my good friend. He was the president of our Brazilian here, Brazilian shoulder and Elbow Society in 2019. And so he's the ex-president of the Brazilian shoulder and elbow on societies and still. Besides, he was one of the organizers of the international shoulder and elbow Congress last year in 2019.
So it's an honor to have him here. He lives in a city which is called Belo Horizonte, which is 500 kilometers from Sao Paulo. It's a very big city, and he's not only a wonderful surgeon, but a very good academic. So it's a pleasure to have him here and a big honor. Still, we have here my good friend Dr. Shirish from Pune, star ward from the Indian shoulder scenario. Everybody knows him and still Dr. Sanjay Trivedi from the city of Ahmedabad.
One thing that I haven't mentioned is just that Dr. Ildeu. It's not only a shoulder and elbow guy for more than 25 years. I guess I'm something like that. But he spent two years when he started his shoulder practice a long time ago with Doctor Angus Wallace, which is one of the biggest shoulder guys in planet Earth nowadays is the biggest shoulder guy in the UK, and he spent two years with him living in Edinburgh, in the UK, us.
Excuse me, Nottingham, Nottingham. I'm sorry, I'm sorry. So he has a very big, I would say, experience not only in Brazil, but also abroad. So this is his introduction. So now this is what we are going to follow with all of the help of Doctor Ashok and Doctor Nitesh we will have now. So this is a meeting, a very nice meeting about the biology of rotator cuff healing, which we have been paying attention to a lot in the last years.
A lot of attention has been given in the last 20 years about the biomechanics role and a lot of new sutures and suture techniques. But biology is very important too, and we have been seeing a lot of papers about it. Last week, Doctor Hillsdale organized at the lovely event here in Brazil about biology of the calf healing and we are continuing this. I am very happy about that.
So this is the sequence. Doctor ideal is presenting a lecture about 20-25 minutes. He has all of the time. He wishes, of course, about a lot of aspects of the biology of the rotator cuff healing and how to improve it. And also, Doctor Shirish is going to show a lot of tips with all of his experience. So we are about to have a sequence, I guess 40 or 45 minutes of beautiful explanations and then I hope we have a lot of time to talk.
So I'm very happy to be here. It's an honor. It's a very happy moment in my life. And Doctor Ildeu, it's not only a pleasure to have you here, but now the microphone is all yours. Thank you very much for the invitation. It's a great honor to be here with you. And I'm going to talk a little bit about the healing process of rotator cuff after the repair, and now I'm going to share my personal information.
Thank you. OK, it's all right. Yeah OK. Yes Yeah. Yeah just a second, please. So I'm going to talk a little bit about the healing process regarding the rotator cuff repair.
I work at three different hospitals in Brazil. Felicia Rocho, La Cruz and Orizonti And this is the team that works with me. And I have nothing to declare regarding the conflict of interest. I work as a consultant for Johnson Johnson, but mainly for arthroplasty, shoulder, arthroplasty. And I have elbow, arthroplasty, a prosthesis, a Brazilian elbow prosthesis being developed.
And last year we have published a book about shoulder and elbow fractures here in Brazil. Well, when we talk about the healing processes we have to take in consideration the local and the systemic factors, the pre and the post op aspects. Specifically about the systemic factors we have to take in consideration alcohol, obesity, smoking, cholesterol, diabetes, hypertension, immune biological aspects, genetic and age.
When we talk about alcohol, you know that we have more massive tears in the long term. Alcohol intake is a very significant risk factor for recurrence and severity of the rotator cuff tear in men and in women as well. So the obesity increases the occurrence and the severity of the rotator cuff tear, and it's very well established that smoking is a great problem. And nicotine reduces this MMP 9 expression in thinner sites.
What is MMP nine? It's an enzyme that involved in the extracellular matrix degradation. So the elasticity modulus of the tendon is changed after years of smoking. So there is no point in stop smoking before the surgery because the damage is already done. OK, and the risk factor for tearing propagation is well established by age 80.
Cholesterol does the same in the elasticity models of the tendon. And diabetes is something that we have to pay attention. In the past, we didn't look for about this, these aspects which just indicate the operation and perform it. Now we know that we need to control the glycemia after the operation. Otherwise, the healing process will be a problem. OK, so.
Hypertension increases 2 times the chance of large tears and four times the chance of massive tears. And this is an aspect that we can't control this immune or biological factors, and we know that these participates in the mechanism of fatty degeneration. So some patients have a tendency of developing fatty degeneration more than others. And unfortunately, we can't control that.
Age is a problem as well. If we understand that the longer term goes at the age of 40 in the jungle is a mode animal and has its rotator cuff degenerated. And now we are achieving 100 years and our DNA is 97% identical to it. So we are going to have rotator cuff tear in between 40 to 100 years.
So what can we do biologically to improve tendon quality and try to avoid this problem? So that's the next lecture, ok? And Fukuda has defined five different parts of the tendons, and he showed us that in a. It's a very well tendon. But when we achieve middle age, this standard is swollen, homogenous, so we have a degeneration already in the middle age.
So these systemic factors are very difficult to control, but some local factors we can try to control. So we have to talk about tire size, muscle tendon, bone quality and bone morphology. Regarding to your size, we have to analyze it in both plans, coronel and sagittal, and we use patch classification and Cofield/Bateman's classification, and we understand if we are going to treat a small tear, we have a chance of 94% of healing.
But if we are going to treat a big or a massive tear, the literature shows us that the chance of failure is as high as 97% These number 2.2 centimeter is very important to remember. When we consider the tear in a sagittal plan, if you have a tear higher than greater than 2.2 centimeters, you are going to have only 49% of healing.
But if the tear is less than 2 centimeters you are going to have 72% of healing. So when the tear is greater than 2 centimeters it almost is always involving this infrastructure. So this is something that we have to remember when we have an MRI in front of us regarding the retraction, the tendon retraction. The tender retraction is not always due to the muscle that pose it, it's due to the tendon bone reminiscent because some tears are in the middle of the tendon.
They are not only abortions. So in this case, the tendon is short. And then when we are going to repair it, if you repair it in the proper footprint, you are going to be overtaken. So in these situations, it's better to repair it a little bit more. I know that Dr. Kapinski likes to do these repairs a little bit immediately, and this is a reason for that to restore the proper tension.
The tendon resorption is a occurs as well in the board of these because of the necrosis, so this is a problem that we have to consider during operation. If we have a retraction greater than 2 centimeters. We are going to have only 47% of healing. And if it's less than two centimeters it's seventy six percent, so it's higher. So we have to talk to our patients and explain them the chance of success of our procedures.
So regarding the coronal plane? Well we pay attention during the MRI about muscle and about tendons, but we have to pay attention about muscular tendons junction these concepts. We sometimes forget if we have the musculature and dinos junction lateral to the glenoid. We are going to have a great chance of healing. But if it's medial to the glenoid, you have a high chance of failure.
So that's another criteria to use it. Well, but muscle atrophy and fatty degeneration is very used for a long time now. Then we use the classification, and if we have type 1 or type two, we have a 75% chance of healing. But for five types three or four, we have only 41% of healing.
And talking about muscle atrophy, you have to calculate the muscle occupation in the not super supraspinatus fossa. If we have less than 43% of muscle occupation, we will have a high rate of retail. So we have lots of criterias to use to understand the chance of success of our procedures. Well, they have done quality when we talk about tendon quality.
We have to pay attention about the elimination because the elimination is related to prognosis, is related to chronicity and the tendon is thinner than before. So when we have a look at the tendon during a task, we try to understand the quality of the tendon. Is it a reliable? Well, this paper shows us that there is no correlation between macroscopic and microscopic findings or arthroscopic findings related to the tendon healing.
So we simply can't predict if our tendon is going to heal properly. Based on our arthroscopy. And how to understand how to identify the elimination. Doing an arthroscopy could be the majority of the surgeons do not change from the posterior portal should the lateral portal in the adequate way to see to identify the elimination is using the lateral portal.
It's a gold standard, so we need to change our practice. And before doing the repair, we have to change the scope from the posterior part or to the lateral portal and then go back to the posterior part and start doing the procedure. OK this paper analyze it 1,043 patients, and they said that there is a determination is not an independent fracture. It might be related to other factors like osteoporosis, chronicity, tendon retraction as well.
And can we predict bone healing based on bone morphology? This is something that I understand that we can do using the critical shoulder and go the critical shoulder angle is the third image on the right. OK if you calculate the critical shoulder angle. And if it's greater than 38 degrees, it means that you can't predict.
You can tell to the patient if the patient does not have a rotator cuff tear that the chance of having a rotator cuff tear in the future is greater than if the critical shoulder angle is less than 38 degrees. So if you have a critical shoulder angle of 32 degrees, for example, the chance is of developing arthritis, not rotator cuff tear.
And it's related to her feeling if you have a greater critical shoulder and go above 38 degrees, you have less chance of healing. So what we can do during the procedure trying to avoid this healing, this impact on healing process, you can do a lateral acromioplasty so as described by Christian Gerber, trying to avoid impingement after the operation.
Bone quality is related to two complications. So if you have a chronic tear, you might have a greater chance of anchor pullout, so you have to talk to the patients or to change our technique, increasing increasing the strength, the bone stress some guys they use May to matriculate or some guys change from anchors to transocean's suture.
Well, this is an interesting paper, and they try to create an index for curve healing, and they use it some criteria as a size of the tear retraction of the tendon go clear classification, bone quality and work activity. So you have 15 points, and if you have less than four points, you have a great chance of healing.
But if you have more than five points, you have a great chance of complications. And we know based on what we have spoken before that we have lots of other criteria should take in consideration. But this index is established and it's something that we can use it. Now we have to talk a bit about preoperative aspects.
Per operative aspects, so we're going to talk a little bit about techniques, but I'm not going to talk about the biology of it because this is the next presentation to choose the technique, we have to dominate the principles. So we have lots of options. You can do transosseous suture arthroscopic or open. You can do suture bridge, double or single row, but you need to know the basic concepts and the basic concepts.
They were established since 1984 by Christian Gerber to 2016 by King, and they took in consideration rigidity, stress instability, tension, gap, contact pressure and we are going to talk a little bit about these techniques. So what kind of surgical strategies do we have to reconstruct the rotator cuff tear? So we have various construct configurations, and we have many factors that contribute to a structural integrity of the repair.
This includes repaired rotator cuff and footprint motion. So what kind of mobility we have after our repair increase? Standard footprints, contact area pressure. So And what kind of procedure we are doing in what kind of pressure we have between the tendon to the bone and increasing the tissue quality tendon to bone. In this case, we can use biological.
Her issue is to increase the bond quality and the tender quality. Well, let's talk about single roll, which is the most used procedure in the world, but it's less expensive, it's less demanding and but we have just 67% of cover covering the footprint using a single roll. But the functional results are not bad. They are similar to double roll.
So that's the procedure I do. The majority of the cases. In some specific cases, it's better to do a double role in the double roll technique. You increase the footprint, the contact, the footprint area covered, but you're not increased that much, the contact between the tendon and the bone. So to do that, you can do a suture bridge technique.
So the pressure between the contact area between the two and the bone is greater. But it might compromise vascularity so you can have all the best things from one procedure. Well, if I'm going to have my rotator cuff repaired, I would prefer to have these right X-ray after the operation than the left one. So trust also suture is an option.
And Alex castagna has described it. This procedure in on his book using this guy's LCA guys or shoulder guides to do a truss also as your suture. Well, after doing the procedure, we have to pay attention about some aspects. Otherwise we are going to have failure. And I just use a non-steroidal anti-inflammatory drugs in the first two or three days to control pain.
Because I like to do a multimodal control of the pain. If we use non-steroidal inflammatory drugs for more than three, four, four days, we are going to have a bad effect on the healing process. Regarding rehabilitation, we can choose from an early passive motion protocol to delay the range of motion protocol. And here I have some doubts because some people say if you perform a delayed protocol, you are going to have more stiffness.
I'm not sure about that. I think that the stiff shoulder stiffness is more related to other aspects of the patient much more than the time that you use for a mobilization. So sometimes we do an early passive motion protocol and the patient becomes stiff anyway. So I think the sensibility, the pain control, the psychological aspects of the treatment, much order, the reaction, the biological response from the body to the procedure is another aspect should be considered as well.
But this paper talk a lot about that stiffness is a complication that you can treat, but non-healing is a failure, and it's a major problem. So that's something for us to discuss. OK well, immobilization, most of the surgeons tell to the patients to keep this link for six, 5 to six weeks after the procedure. But the literature tells us that we, if we use for weeks, is OK.
There is no support for using more than four weeks. But after the procedure, if the patient is an old patient, the bone quality is poor. The tendon is very thin. We we try to use this link for more than four weeks. The majority of the cases and the abductions link is another thing that it might be OK for reducing pain, but there is no support for using a reduction in lean regarding the healing process.
It does not. It's not proven that the improves the healing process, so that's something that should be discussed as well. Well, I'm very open to the questions in the end of the presentations, and thank you very much for the opportunity. Hello yes, so, my friend. Are you there?
Are you listening to me? Yes, very much indeed. OK, good. So see, I'm very happy because you mentioned a lot of stuff that we can discuss a lot of things. This is going to be not only good for us, but very good for the audience, which doesn't have. So much. I would say experience with all of the things that I noted, a lot of things that we can discuss is going to be very nice.
And now Dr. Shirish is going to talk about his experience with enhancing the biology has a lot of experience, of course. So let's hear it. And then we can start a nice discussion not only between us, but obviously with the audience. So sharing the screen is all yours. So, Joe, can you hear me well? Yes, yes, very good.
First of all, I would like to thank my friend Sergio from Brazil for involving me in this first Indo Brazil webinar. I'm very happy. Uh, and also our two TV team, doctor Ashok and Nita on the OrthoTV, so I think whatever Dr. Ildeu has already mentioned, whatever I'm going to talk is in continuity with what we have discussed.
So let me start with my presentation. So enhancing biology of arthroscopic of repair. How do I do it? So as we know, rotator cuff disease is prevalent in the aging population and is the most common cause of shoulder pain and disability. What are the indications for the cuff repair by and large, a full thickness there with severe pain and disability week abduction, which is not responding to conservative treatment and the person who is active irrespective of his age?
I would take into consideration the physiological age. I think he becomes a suitable candidate for cuff repair after adequate counseling. The surgical goal of cuff repair is to create a low tension, stable repair construct, which is strong enough to sustain build biologic takes over. Now I'm going to show you a video. This is a, I would say, a large rotator cuff tear u-shaped involving supine spine.
You can see glenoid and retractable. Quite reparable, the footprint is almost covered fully. Now, in second video, you can see I'm create I have created a nice footprint. I've done a microfracture to create more growth factors at the footprint for better biology and healing. And then my anchor construct with double row repair with transocean's equivalent.
This is the final picture. OK, now my question is if I ask you whether this repair is going to heal and give a good functional outcome, will you be able to answer? I think it is very difficult because it is not only the arthroscopic procedure, but there are so many factors which are playing a role and which will effectively give a better biological healing at the rotator cuff.
And in first lecture, we have listen, there are so many patient factors, local factors, their pattern factors. So one by one, I'm going to go through that. So if at all, if this repair heals, we need to ask ourselves why this has healed. And if it does not heal, we have to ask ourselves why it has not healed. I think we always see microscopically the rotator cuff, and we are very proud that we repair them anatomically as far as possible.
But at the same time as a surgeon, we should or need to know some basic science. First, we should know what is microscopic anatomy of tendon and tendon bone junction. What happens at the cellular level when tendon tears, water freezes of tendon, biological healing? What are the factors which affect biological healing, which stimulate or inhibit biological healing, and last which is very clinically relevant, is how to improve biology.
So what option do we have at our hands so that we can effectively improve the biology? Now let us start with the histology of the tendon. So as we all know, the extracellular matrix of a tendon 85% is collagen. Rest is non collagen protein, which includes proteoglycans and GAGS. It's very important to understand it is primarily a type I collection.
95% is type I collagen, and the cells are called tenocytes or fibroblasts, and there are certain cells, which are around the tendon tendon sheet cells. So both have important role in laying down the color. Now, tendon bone junction, we have to understand the different parts of muscle, tendon and how it inserts onto the bone. It is very relevant when you do or arthroscopic cuff repair.
Now we know my tendon a junction is the weakest link, but we have to take a look how it inserts. So we have a tendon. Then we have a fibrous cartilage, then a calcified fibrous cartilage. And then the bone. So this transition is very important. And when we repair tendon, we hope that this sort of architecture will be reproduced or it will eventually get remodeled to this sort of anatomy to give the best possible result near anatomy.
Now what are phases of rotator cuff healing? I think this is very relevant because it is going to dictate not only your technique, but also your post-operative rehab protocol and the restriction of activity and how to go about increasing activity and eventually the strengthening. So the first step is inflammatory, which which is there for about 5 to seven days, then is the stage of repair, which is roughly up to three months.
And the last stage, stage of remodeling, where you gain the maximal tensile strength, which happens roughly about three months. And it goes on for a few weeks more. So now it is very important to understand. The first is inflammation. Second is a repair. There, a type 3 collagen is being produced, which is not the right collagen for the tendon.
But remodeling is a stage where this type III collagen is going to get converted into type I by a cellular cascade, which is very important. So if you are able to achieve a type 1 collagen in a nicely healed tendon at the end, then that's going to give you the best outcome, best functional outcome and strength. So I would like to go through a few steps because I thought it is very important as a surgeon to understand what is happening.
So if there is an acute rotator cuff tear, then what happens at the cellular level? So an inflammatory phase, which is roughly first to one be the injured tissue, is going to release the cytokines. These cytokines causes neutrophil attraction and mobilization. These neutrophils, they release interleukin 1 B and tumor necrosis factor alpha, which are the primary inflammatory cytokines, and they activate nuclear factor Kappa b, which leads to the process of apoptosis in musculotendinous units.
So this happens precisely if you leave that there without repair or if you just ignore it, leave it, then this apoptosis is going to lead to further loss, further tissue damage, muscle atrophy and eventually fat infiltration. But if we repair it or if it is a partial tear which has got potential to heal, then probably it will go to the second stage, which is of stage of repair, where musculotendinous units now wheels will start anti-inflammatory effect and they will start regenerative process, where they will create pro fibrotic factors from extracellular matrix and now multiple growth factors like transforming growth factors.
IGF. These are all platelet growth derived factors, many of them, and they act synergistically. They clear the dead tissue and stimulate regeneration. And now, in the later part of this inflammation and start of the repair macrophages, they come in action and angiogenesis and fibroblast activity starts, which primarily secrete collagen type III.
So we have to understand from the basic science that the Reformation of normal tendon bone attachment takes at least 24 weeks based on histological analysis. So the strength of rotator tendon repair is very low in the animal model when measured in first six weeks, and I think it will corroborate in human model as well. So now we have to understand coming back to the same question that tendon, which we have repaired.
Is it going to heal? Is it going to repair? So we have to look into the literature. So if you see there's so much literature telling us about overall healing rates and this healing rates, as rightly mentioned, they vary from 60% to 90% And for large, they're even they have reported healing rate less than 10% also. So we have to understand most of our repairs are not actually getting healed, which range from 10% to 30% and maybe even more.
So it is very clear that the healing is very less than we thought previously, and then it ignited controversy, whether open arthroscopy, whether a single row double row, whether a suture configuration, whether type of anchor, whether the post-op rehab protocol, which is playing an important role and leading to less biology and more reiterates.
So does healing really matter? That is another question. Whatever you have repaired, if it heals well, then it has been proven in literature. Healed intact rotator cuff is going to give you a far better functional and clinical outcome and strength as compared to the one which is partly healed or not at all healed. So the problem here, I think, is the poor biological healing.
So we have to look into the factors. So I would go quickly through this because most of these factors have been already covered, so I would like to divide them as patient factors, surgeon factors and of course, the rehab protocol and then miscellaneous factors. So patient factors. So these are all patient factors, which tells me before surgery that this candidate is a candidate where there is a poor biology.
So increased age, uncontrolled diabetic, uncontrolled hypercholesterolemia, use of recurrent and sell for a pretty long time. The smoker osteoporotic vitamin D deficient patient. These are the patients who are poor biologic patient for me. So I'm going to be a little careful and counsel them and try to correct the correct factors, whatever possible, to give a better biologic.
Now, the pattern so acute versus chronic, it has been proven in literature that if you repair them early, the healing rates are far superior because as you have seen the process of biological healing, if you intervene at a repair stage, then it is going to complement the healing process by giving anatomically repaired tendon. Again, the size grade of retraction, tendon loss, fatty atrophy, everything plays a very important role already discussed.
So I will skip this reference because they have been already covered, only to mention that if the age advances, the percentage of cuff healing is going to go down. And if the tear size goes up again, the healing rates are going to drop. This is the bottom line. Osteoporosis, again, is an independent risk factor, and as you correctly mentioned in earlier lecture, if there is a back out of the suture anchor before it by the biologically heals well, there is going to be high rate of failure leading to bad results.
So we have to be very careful while choosing our patient. If we have osteoporotic patients, then you should be ready with alternative option of suture anchor or alternative suture repair techniques. So just similar to the scoring system, what Doctor Ildeu mentioned, I would classify my cuff tear scenario in three groups favorable, unfavorable and hopeless group. So favorable is a younger patient.
Less than 65 smaller tear typically traumatic ones who present early minimally retracted with good muscle bulk good to clear one or max two. These are good, good, biologically good result. Unfavorable is more than 65 large stains. Great to retraction tendon loss and grade 3 or 4 grade 3 year poor biology. Relatively and this is the last group where I would not repair the cuff tear.
Rather, I would look for other options if they is more than 70 with grade four retraction osteoporotic bone. I may think in terms of reverse shoulder of the plastic or just leave them alone, but the good rehab. Non-surgical, take me does it make a difference in the healing? I think yes, if fixation is unable to handle the post-op, PLOS biology just cannot compensate. So we have to make the best environment, best situation for the cuff to heal and the cuff to be biomechanical is strong enough to heal the biological bones, develop between the tendon and the bone.
So again, surgeons higher the level of expertise, ability to understand the tear pattern, mobilization techniques, repair techniques properly than single roll and a properly done double row and most importantly, the augmentation of pilots. I think each and every point in this slide is far better by love. Two you can see the biology is something different, which is like holy grail, which I'm going to add later.
No, it starts from the selection of patient and step by step with your every surgical step. So I would summarize, if you do your mechanical job correctly, then you are trying to improve the biology. So you have a correct suture strain, multiple suture, correct suture configuration, adequate number of sutures, anchor right technique, nicely prepared bone footprint would suffer from decompression microfracture. You can do this irrespective of whether you are doing single double.
Because some tears will dictate to do a single road repair. So never mind, you can do whatever technique you want to follow, but follow this and you will give a very good mechanical construct leading to best biology possible. We all know that a lot of biomechanical data on a cadaver lab study that double repair gives a better fixation to direct contact between tendon and both increased load to failure, less gap formation and increased cyclic load to failure.
So I think that has led to a better initial stent fixation and better results with newer double repair techniques. So to summarize, I think it appears that there is definitely a structural benefit of structural healing when you do a double fixation as opposed to single excision. This is more applicable for tests, which are more than three centuries.
Now we are talking about the healing the functional outcome may be. Not so much different, but if you see the healing patterns, I think with double row, it is definitely better if you're doing a medium sized, low tension, single repair. Don't forget to open up the channels on the lateral part of the footprint, which has been popularized by Professor Schneider, which is, he calls it a Crimson blue wave where it gives a bone marrow veins to create more growth factors super clot formation leading to better biological healing.
Now, coming to the post-op rehab protocol, I think this has been already covered, so there is a lot of conflicting evidence early versus delayed. So recent JBJS review concludes that there is no difference in retail, even if you start early mobilization. But it is very important to understand can't apply the same rules for all patients. It has to be individualized decision when you are dealing with large and massive cup cuff tears.
It is better to give time for biology to take place and better healing than being hurry to get early range of movement, so go slow. If it is a large or massive tear. Now, there are a lot of options in market available to augment the biology. So we would divide them into three types you know, inductive teno- conductive and teno-productive. So let us go one by one.
So what is teno conductive? So these are nothing but scaffolds. So there are scaffolds available commercially. There are three types xenografts made from porcine or dermal or mucosal patches. In India, very few are available, and exorbitant cost is the problem of using them then allograft. There are certain graft jackets, human dermal patches and synthetic grafts, so gore-tex patches.
So these are scaffolds which will definitely help you, and they have a limited role in large, retracted cuff days to augment the biology. No second group is not productive. Now this is a whole or two biologics, which is coming up silly, we don't have very good evidence to use them, but we definitely know that they are proving beneficial day by day.
So there are two types of cells adult and embryonic stem cells. The adult stem cells are primarily multipotent mesenchymal stem cells. You can harvest them from bone marrow or adipose tissue, and there are placenta derived pluripotent stem cells, so they have capacity to transform themselves to any type of tissue. So here, if you use these mesenchymal stem cells and give them the right environment, then they probably will differentiate into a rotator cuff tissue, giving a better biology and a better heal.
And the last is the inductive. So I think these are nothing but the all growth factors, cytokines. So what we studied or discussed during the repair phase. These are all cytokines. They're produced by a body as a response to create repair. But if they're available at your hand, then probably can add them during repair and hope to have a better biology because they play important role in migration, proliferation and differentiation.
And a single growth factor is not going to help you, but multiple growth factors. They act synergistically and give you best results. So there are transforming growth factors. Bone morphogenesis protein 12 so there are plenty of them available. Now, the last group, which I'm going to discuss is the platelet rich plasma. The best way to get autologous growth factors in a better concentration is the platelet rich plasma, so platelets can give you a lot of growth factor TGF B PDGF, vegf, egf, IGF c, you can go to the long form Insulin growth factor is vascular endothelial growth factors, plenty of them.
So a simple technique of centrifuge using them and separating plasma platelet leukocyte and RBC can help you to get the concentrate of these growth factors, which are which has got a small high. Them at right timing, then probably they are going to help you in. So there are four types of PRP available in the market, so there is again debate going on leukocyte, rich and leukocyte tour the plasma and fibrin pure AARP.
So it's still debatable, but there is some benefit proven in the literature. A lot of animal studies and few trials on human subjects also claim good results. So let us go one by one. So you have two types of PRP. One is leukocyte rich and one is leukocyte poor leukocyte rich is where you want to induce inflammation, like where you want to do like colitis.
You can use leukocyte. Rich while poor is something which you would like to use for cuff repair, where you want to primarily give regeneration. And TRF is the platelet rich fibrin, if you add calcium. And if you activate the platelets, then eventually it is going to form a thrombin and leading to a platelet rich fibrin matrix. So the advantage is it because it forms like a matrix membrane, so you can put it wherever you want, like a patch.
So it has been used effectively in the rotator cuff repairs and meniscus repair. So instead of injecting, you can actually place it and incorporate in sutures to give a better biological augmentation. So this is the current recommendation for use of platelet rich plasma. But we know for specifically cuff repair, there is lack of data.
Still, it is, I would say, experimental. Now, the recommendation for biologic therapy in rotator cuff is the PRP has not been shown to improve healing rates or, you know, reducing it. But they have said it definitely has got some adjuvant role in reduction of pain and there has been some benefit in small to medium sized stared in high risk patients where that biology is poor and biological patches augments with growth factors implanted on them.
They have definitely some role as dermal patches in large and massive rotator cuffs. So this is what current guidelines in 2018 and 19 tells us. So just to summarize biological augmentation strategies, so at one hand, you have scaffolds. At one hand, you have cells like bone marrow cells, mesenchymal cells, and then you have bioactive molecules like platelet derived growth factors.
So now you would ask me whether I use them in my practice. Unfortunately, I use them in few of my patients. But still, there is no current evidence and it adds a lot of cost. But what I do is I utilize the local anatomy local procedure to give this growth factor. So it has been proven that if you do a chromium plasticity, then it. Gives you a lot of growth factors like platelet derived growth factors and plenty of them, and there is a study where Peter Randelli did and he took two CCs of fluid from subacromial space after doing a chromioplasty and compared with another group where he was not done and they found the concentration of growth factors was too high, like a PRP in patient where you have done a thorough acromioplasty.
So I make it a point that I may not do a formal acromioplasty for all of my patients, but majority of them I do a thorough, tuberoplasty on greater tuberosity side and a thorough or judicious acromion, plus D on a chromium side to create these growth factors which help in biological healing of my patients. So in summary, I would say to optimize biology, it will start right from selecting right cases.
The early repair, if possible, to double repair, augment your repair with fracture, go judicious acromioplasty which is going to give you a free local PRP. Ask patients to stop smoking, at least in perioperative period. It will to some extent help you with biological healing. Don't use nonsteroidal anti-inflammatory medication for a very long time. You can use these medications as and when required.
We solely rely on in the skeleton blocks and patches in immediate post-op period. And of course, you have to have individualized physio protocol to prevent repair because of too much aggressive physical therapy in early post-operative period. Thank you. Thank you for your patience and listening.
Hello yes, I do. OK, so see, folks, that was a lovely presentation showing a lot of things. I made a lot of notes. We could be discussing this for the whole day. But I think we can do a nice discussion now. I have a lot of things to mention. And obviously, everybody can say whatever they wish. But I think that we must pay a lot of attention with the audience.
We have beginners, not experienced surgeons as all of us are. And Dr. Ashok was telling me about some basic things that people were asking. We have basically three questions. The PRP was already answered about by you series, but we can discuss. But there is two questions that I would like to start with. And the first one is very basic.
I'm going to reply and then a second one, I'm going to give my feelings because as Dr. Ildeu mentioned, I have a good experience with that as all of us. But I'm going to mention, and then I would like to know what you guys think about and we can discuss this. So the first one is there is a very basic question is about which are the MRI findings that can predict a worse respond, worse outcome.
So this is a very basic one. But I think we must mention to the audience, which is when the lesion is retracted or I would say immediately to the glenoid, this is a very bad predictor sign. Or, as Dr. Ildeu has mentioned, after 2.5 or centimeters. This is something that would lead to a worse outcome in spite of the fact that I have a lot of experience with big tears, and I'm going to comment upon that as we discuss.
And of course, the good classification. As all of us know, when you have more than 50 percent, that would say lead to a less not to mandatorily a bad outcome, but we are less we can less expect, I would say, a quite predictable good outcome. This is quite, I would say, mentioned in literature, but the second one is about the tension.
So someone was asking, how do you do? How do you manage to get a tension free and how do you decide it intraoperative? So this is very easy to me because I use it all of the time as all of us, but I'm going to talk a little bit about this with medicalization. What you must do is to do a lot of releases and then to pick up the tendon and to pull it and to see how much does it cover the footprint.
And as long as it doesn't cover, you don't have to fight with it. But rather than that to achieve a tension free repair, which is something that I decide I would say with my eyes microscopically, and if I have a doubt, I do the realization of the footprint. So what have been seen over these years, and Snyder said, is that as long as you do attention free and I decided with my eyes microscopically after some time, the scar will cover all of the footprint and I have four cases in my life so far.
I show it each to Dr. Ildeu five days ago, six in which when you do an MRI one year after the surgery, the footprint is covered. So as long as you do a tension free, which you decide microscopically with or without medical realization, it will heal. So my decision is absolutely with my eyes. And after a lot of releases, and if I have a doubt, I don't spend a minute, I'm talking about big tears, of course, in me realizing the footprint.
So I would like to know you guys, if you think the same. And if not, how do you, I would say, interpret attention free repair operatively and this is very important for the audience. So now I opened the mic. Dr. Ildeu, how do you manage to would say, decide what is a tension free or a repair with tension operatively?
Yes, regarding tension, I think we have to talk a little bit about the basic concept, which is the rotator cuff cables. We have the anterior cable, which is the superior border of service cap and the cortical ligament. And we have the posterior table, which is a little bit more posterior, inferior.
So the anterior cable and the cable serial cable, which is in between infraspinatus and tear, is minor. So we have some balance, so we do not need to cover the humeral head completely in chronic and in massive tears. So if we have this balance achieved after the operation, so we might have improve the function and decrease the pain.
So first of all, as I said, we need to put the actual scope on the lateral portal. And we have to feel the elasticity of the tendon and the quality of the tendon if it's a good quality or bad quality. It's not related to healing, but it's related to detention and where you are going to put your stitch. This sometimes when you have an MRI with a massive tear after a small trauma, an old patient at home.
So some tears are chronic ones and others are acute ones. So you have to pay attention not to try to repair the old and chronic tears because the patient, the patient was very good with that tear and very adaptable and very adapted, adapted. So you just have to reconstruct the acute one, if possible, you do the chronic one. But there is no point in trying to put it over tension.
So you have to feel the tension is something difficult to explain by using words you have. This is something that during your practice and with another surgeons, you will balance the tendons and see the proper place to put the sticks. But there's just one thing, just one thing. So you give you have the same feeling that I have, and I'm very happy with it. But see, I this is something that I see case by case with my eyes.
There is not I would say a [inaudible], so I think that you do the same. It's a matter of feeling in every case. How much can you pull? And you say at some point, that's enough. That's the d-max. I can pull it and you can fix it. I would say, let me use the expression in situ, and that's it.
I guess that that's exactly what you do. And it's a feeling I would say interop in every case. Yes, I think we have to pay attention about the release, the amount of release we perform because during the posterior superior release, we have the suprascapular nerve. So I don't know how do you do the release if you use the shaver for that or if you use the bone bone?
Yes are telescopic. Periodically, our elevator is exactly so. I had at least two cases of suprascapular nerve damage doing a very big release. Yes so they the French guys. They say that some degeneration of the curve is related to the retraction of the rotator cuff.
And compromising the suprascapular nerve. So doing a balance, you are going to decompress the slippery suprascapular nerve. And this is I want you to comment about because many few people know in the audience this is what Lefors calls as the shoulder carpal tunnel syndrome. Yes so but one little glitch that you says is that when you pull down, when you would say when you fix the tendon, you would be releasing the nerve as a carpal tunnel syndrome, Lefors
He talks about it, but and I guess that you feel the same. Yes, there is something else I would like to add, which is the traumatic tears, because we say that the retraction is a poor prognosis aspect, but in the traumatic tears, if the patient is a very strong guy, sometimes you have a lot of retraction. But during the operation, you see that it's very easy to bring the tendon to the proper place, so you have to take it in consideration before the surgery.
Yeah so see, you mentioned something that I really care about and I'm going to comment my way and I would like to know how she thinks about it. And Dr. Sanjay, you told me, how do I do releases, huh? So you see, so above the cuff, I go with a lateral cut tary because there is much bleeding on the bursal side. So if you go with the shaver, it bleeds a lot and you take a lot of time to stop the bleeding. So I do with electrical tary radial frequency device.
I don't care about the nerve because the nerve is below the tendon, but I care too much about damaging the scapular. And so I go with the pediosteal elevator, but no more than, I would say, centimeter medial to the superior board of glenoid. And I have a lot of fear of damaging the scapular nerve, and so far, hopefully I had not problems with that. But so I would like to ask Sanjay and Shirish, how do you do your releases and how much do you fear damaging the scapula?
This is a very important question that Dr. Ildeu has mentioned, and especially for beginners, they must understand that you cannot be very aggressive. You must go with care, especially regarding the suprascapular nerve when doing releases. Sanjay, what do you think about it and Shirish, please? Yeah Dr Almeida and Shirish is excellent overview of the healing process and the factors affecting the healing for the rotator cuff.
You haven't left anything untouched, but only one thing for the beginners. We need to understand there are today's keyword is low tension repair, and that is the buzzword in today's 2020 era. So very aptly asked by one of our listeners that how to measure the tension now before coming to that. When you enter into the subacromial space at first, when you look at the cuff without any vasectomy or anything, there would be a great deal of tension in the cuff.
When you try to catch and hold and, you know, try to bring it to the footprint, you need to understand the tear patterns also to assess the tension in the cuff and you need to grab from a cuff tissue and bring it to the footprint to the posterior footprint. You need to get hold of the center portion and try to bring it there. So once you are able to identify and/or reverse a seemingly high tension, irreparable cuff would become extremely low tension, repairable cuff.
So then you need to understand. Secondly, once you're done that, you must assess the tension before the release it after the release because there is going to be a huge difference in these two stages. So what I do typically I put a humeral ligament or anterior release is very important. I do that. And then I pay my attention.
I bring my attention to the spine of the scapular. And when I raise the bursa from the spine of the scapular without damaging any of the muscle, fiber or tissue, or no, I'm able to get a great deal of excursion of the cuff, you know, laterally because it is attached there. Yeah, just a second. I'm sorry to interrupt you, but just for the audience to understand that, as Berger said, the cuff it doesn't come from medial to lateral, but from posterior medial to enteral lateral.
So what you have said is absolutely I would say, I agree because I see this all of the time. You doesn't come, you didn't. You doesn't pull the especially the posterior part of the posterior superior curve, just lateral but lateral anterior anteriorly. Because the cuff doesn't go from lateral to me from medial to lateral, but from postural medial to enteral lateral. But still, Sanjay, how much do you fear damaging the suprascapular nerve when doing the releases?
Because this question from. You deal with a key point, right? So you've got to be extremely cautious to not go beyond your spine of the scapular. Once you make it bare. You do not go medial to that as placed in the anterior just anterior to the spine of the scapular. That is where you might end up with the trouble, and you don't need to release that part.
Once you, it is your bursa from the spine of the scapular. Most of your release is achieved as far as the center portion of the curve is concerned. And sometimes apparently you shave. There is a postural posterior there and you can bring it anteriorly and naturally very easily to quantify the tension into the cuff here. There has been papers quantifying the appropriate tension in the cuff repair, and if I can share my screen, I can just, you know.
Show you this paper in which. They have. Now, now this is a Korean paper, it is a retrospective study, and they have defined this tension that what they did. They check the integrity of cuff at the end of 24 months by MRI. So they decide they define that greater. They define your true intention is too much tension.
And this has been published in the arthroscopy in November 2020. So this is a fairly recent. So 20 Newton is the, you know, cut off tension limit less than that. You're good enough. More than there, it is bad for the cuff you know. Yes, more than that, it will be in danger. That's exactly what I feel.
That's a lovely explanation, but I would like to finish to give his thoughts about it. Yeah, I think most of the points are covered. But why doing arthroscopy? What I would do, typically, is put attraction suture. In the village of the town of tendon, and after every release, I would check how much mobilization I have achieved. I don't want to overdo it.
I don't want to undergo it. Second, when I do my cuff repairs, my arm is almost by side. I do it in lateral position. I release the vertical traction, so am is almost by side. So that it opens up some space very well. So when arm is almost by side, maybe 10 50 degrees of abduction, and if I do a low tension repair, which is very easy to get it to footprint.
If there is a tendon loss, I don't try to pull it too much to cover. The whole footprint. Yes the consideration of the last part of the tendon and then I don't mind me realizing it and repair it. That's how rough judgment of the tensioning, I do it, and I agree, I really see it in a really, for sure, who mobilized the anterior leaflet posteriorly I don't do interval release between super and and intraspinatus because I think it's a conjoined tendon.
I want to maintain the integrity, and I would use a blunt perio stimulator, as you rightly said, so that there is no chance of damaging scapular. Now Yes, so this is something I would like to mention, because there are, I would say, blunt blunt instruments like the pediosteal elevator, but some, some they are, I would say, more sharp, like an arthroscopic osteotomy.
And you shall not use it, of course, just as blunt. But see many questions. They are coming. I would just mention that I don't do a posterior interval of slides and a interval slides. There is a question coming about it. I would. I would. Just to look
I think we don't have to talk too much about it. So many things to discuss, but any of you guys like to do posterior or anterior interval slides because the answer is I don't do it, but Shirish doesn't do it. So that's right. You do you have any concerns because I don't do it. Yes, I would like to say something about the post-operative recovery of strength.
You might have some patients that do recover the abduction strength but do not recover the external rotation ones. And we say that that's because the interesting part to this poor prognosis muscle. But I believe that some of these cases is that because we have damage the scapular parts of the nerve that goes through the infrastructure. So the problem is that we do not study this problem properly.
We do not ask the lateral biography for these cases. So we simply do not have the diagnosis done. And I think that we should pay attention about these cases a little bit more. Yeah, OK. So another thing that is coming, I think that we have a lot of things to discuss, but I want to give attention to the audience.
The thing is, Dr. Ildeu talked about the critical shoulder angle, and some things are very clear in my mind and some not, of course. So the thing is, what I learned with the critical shoulder angle is that and we should not only do an until inferior acromioplasty, but also alerted our acromioplasty. And I have been doing this for about three or four years.
So far, so good because I care a lot about not only the number of the critical shoulder angle, but the idea of down sloping downs, the downward sloping of the acromion. According to that paper, Gerber said that the insertion of the deltoid is not only lateral in the lateral border of the bone of acromium, but also superior. You don't have to detach the deltoid, but not detaching it.
I pay a lot of attention to down sloping and to do a lot that our acromioplasty and not only anterior and and also, as she said, we have to think about the biological, the biological aspects, which is the blood coming from the acromioplasty. So my question is to all of you panelists, and this is a beautiful one. Do you care about lateral acromioplasty?
I think this is good for beginners. And also, how much do you care about the critical shoulder angle? Because I know, but I don't know what to do with in my practice. So I think this is a good question. You deal any concerns about how much the critical shoulder angle I would say have and how can you apply it in your practice? Because I know it, but it doesn't change.
So much to me besides the idea of the lateral acromioplasty. How do you use it in your practice? I think this is a nice discussion. And I would like to listen to the other panelists. I think we have changed the way of analyzing the acromium shape after and before the critical shoulder angle. We use it to use the Bigliani classification. You see, for 20 years and now we know that the critical shoulder angle, I understand it's more important than the Bigliani classification because the lateral aspect of the acromium regarding the position of the curve is more important for the tears, then the curve of anterior curve of it.
OK, so we know that when we do a. If your acromioplasty if you perform an MRI one year after, you are going to have the cortical acromion ligament intact again. So the problem is that the impingement is not inferior. In this case, the critical shoulder NJR angle is open. The impingement is lateral. So you have to individualize your acromioplasty.
That's the question, and I am extremely happy to hear from Dr. Pathak that the growth factors and the biological is increased by doing an economic class because I believe that for many years. But I didn't have a literature support to say that, and now I have. Thank you very much. Well, that's good.
So, Sanjay, how the critical shoulder angle has changed your practice. And what do you think about lateral acromioplasty? I absorbed that idea for many years. I'm happy with that. What do you think about that and more? Thanks, Sanjay, for this question. My thought process has been, you know, slightly different about this.
The effect of the acromion on the impingement acquired bursal type rotator cuff, and I always thought whether it is the effect of the loss of biomechanics of the shoulder forward elevation and ejection because of the tear or it is the effect of the acromion itself, there has not been a lot of struggle in my mind to understand that clearly the classification consider this is a cause of the problem with the shoulder.
Slowly, it became evident that it is being overplayed and how we would not. We don't know if this is the cause or a consequence. We checked. Yeah, and this is the old discussion, Dr. Ildeu. He was talking about that the chicken and the egg and the chicken and the egg who came first but still deal critical shoulder angle is a new kid around the block, reinventing the theory of Giuliani's little sloping acromion.
I am just keeping an eye on it. I'm just noticing it, but I am not applied it into my management yet. I still continue doing only interlateral sloping acromion. In my outlet view, I have continued flattening that area and not touching the lateral side of the acromion, and I'm waiting for solid evidence, the high-power study telling me that it reduces the retail rate.
And then, you know, I in kind of, you know, I don't guess on the early worms, I just try to play for a couple of years and see how it feels. And then fold. I am kind of a follower of that philosophy. OK Yeah. Shirish why wider concerns about this? This discussion? This nice new, new idea.
Relatively new idea. Yeah so I think in 2017, we had a SHIN Congress in Mumbai, India, and Christian Gerber did a presentation and it was something new and it was quite exciting to learn about this new angle and everything. But I agree I'm exactly in sync with Sanjay. I started observing them, but I have not changed my surgical technique. OK OK, so different points of view, but that's part of the game, but there's a question that I'm going to ask Shirish.
It's coming from the audience about what is your experience with patches and scaffolds? My is none. And we were in international Congress of shoulder and elbow surgery seven months last year, which was organized, also bought by UJO And there was a presentation about that. And someone from Canada, I guess, was telling that the results were very disappointing.
The J graph and all of the other ones, because the scaffolds, they cannot reproduce real biology for tendon in growth. So my perception is that they are quite frustrating, but I have absolutely no experience. Have you done some? Do you have any good results? And Dr. Ildeu and Sanjay, what are your thoughts about scaffolds?
So in my practice, I have never used them for two reasons. As I said, they are not available. The one which is available is porcine and it is very costly. So there are some religious reasons where people are not very keen to go ahead with this sort of patches. But one of my senior colleagues from UK, Doctor Modi. He has done a very large series of graft jacket and he keeps coming to India.
And he has presented his work and the results are very promising. He has done more than 200 cases where the results are good with long term follow up. So but I think with the newer options available slowly and the cost constraint, I think still it has not picked up so much in India, so no great experience with that. Yeah, me too, Sanjay.
Any thoughts? Well, I concur with the series in India. We haven't got any graft jackets. My exposure since 2009, when I visited the USA in prominent doctor bucket and he was using this VRRP into the, you know, to augment the healing in the repair in 2009. And this is 2000 2020 still on VRRP front.
Also, we have no conclusive evidence that whether it works or not, whether it works significantly, what kind of work, what combination, and there are theories. It is a work in the right direction, but it is not reached to a point where we can conclusively come to an agreement. So all this in our current evolution in the healing augmentation is going in the right direction, but it's not yet there.
That is my feeling right now. OK doctor. Doctor he did want to comment something about that. Yes, I understand that dispatch. They do as conduction aspect and we have to increase biologically do injecting the PRP or now doing the acromioplasty. So here we have our Switzerland one, a patch which costs $2,000.
It's a 4 plus centimeters. So it's very expensive and we are not allowed here in our state in Brazil, miniaturized to do the PRP at the moment because we have. So many commercial issues involving it that it's prohibited at the moment. So now we have to wait a little bit more to do these kind of procedures, unfortunately. OK OK, good.
So another thing that is coming, and I think that, well, that's something that I was thinking about. I have I would say an interesting question to Shirish, which is he was talking about the microfractures and the idea of [inaudible] talk about Steven Snyder. But I was thinking about something I already do some fractures or perforations where when we put some anchors, we know that and we don't have much bleeding because the ankle is in place, but there is still some blood coming.
But my question, I think it's a very interesting one. How much would you be afraid of having a greater to velocity fracture, doing fractures and the other perforations with when putting anchors? So when I do my fracture, my idea is first step, what I would do is I will check the osteoporosis. I would open the scar and check how strong is the bone?
OK, if I find it quite osteoporotic my typical sequences, I would never take away the cortical bone at the junction of the cartilage because there is the area where I want to put my ankles. I would prefer anchors which are open architectural type, which will allow a lot of bone marrow to come out and bone in growth as well. So finish at ankles and whenever I do microfracture the lateral half of the footprint there I concentrate primarily and I make sure that I don't go too deep.
I would make a perforation of about five at a distance from each other, and I won't go beyond five deep. And I would avoid areas closer to the anchor because I don't want to make the anchor. This way, by compromising the ball around, you don't have a pull out of the anchor, of course. Yes, absolutely.
And if I find bones too weak, then just the plastic is good enough, it is going to open a lot of channels. OK, and which instrument do you use to do the fracture? Because I couldn't understand. No, the same car with which I make a hole for 5.5 anchor. The tape of that same instrument, I use it to create a.
How and what is the biggest number you would do? Two or one or three? I would be afraid of doing more than one. And to create a fragility situation on greater tuberosity and having a fracture because see an intraoperative fracture of greater tuberosity, it would be a very complicated issue. I never had it, and I pray that I never have it in future.
But having said that, how many perforations? Let's see that you are. You are three to four. OK, I guess that doctor you there you are, raising your hand to say something about it. Yeah OK. You have a comment and a question for Dr. Pathak. I like to do the perforations. I use the operator of 1.5 millimeters that we use for small anchors, for instability and we perform one perforation a.
It just. Sometimes we do not need to use the hammer because the tuberosity is so soft, we're just perforated by hand, and I have a quick question about how much do you debride, the greater tuberosity because I found a paper telling that we do not have to remove everything all the reminiscent of the tendon because some parts of the tendon might induce the healing process and stimulate the healing process or the undifferentiated cells to turn themselves.
And saying that the biological issue, I would like Doctor Pathak to say if there is any point of this is true that if you keep some parts of the tendons, parts of it around the tuberosity. If it increases the biology or not, you believe that we have to remove everything and perforate the tuberosity. No most of the times I try to do a double row transosseous, yes Very good.
And in those cases, I try to clear of all soft tissues from the footprint and do extensive tuberoplasty. I would say in the little part, make perforations and do a double repair. So I don't rely on the tendon tissue. But I would take a close look because that is going to tell me the tendon loss, but I don't try to preserve them.
But he has the anterior and posterior cable. I would definitely incorporate when I do the repair. I just want to make a comment, I think that everybody should listen to it carefully because I've been thinking about it too much. The most beautiful paper I saw, the most beautiful lecture I saw in international Congress last year was from a Japanese guy because he made he divided some patients in 3 scenarios.
The first one are full tuberoplasty with a bony bed. The second one, he didn't do nothing, and he left the remaining tendon and the cartilage. Not not only the tendon. And the other one, he made a small debridement. And after it was in and after one year, something like that, he made. He came back. He picked that small piece of the tendon, and he sent these to histology.
A beautiful paper. A lot of difficult to do this. But in Japan, I guess the patient accepted to do a second look only for, I would say, scientific reasons. And when he did the histological analysis, the quality of the scar was better in the cases in which he left some cartilage and some tendon in the insertion.
So that would maybe change our minds not to do a full tuberoplasty, but still have some cartilage over there together with some tendon. So that would be a new idea, and I have been thinking about it. It's new, and there was a guy from Chicago saying that considering this idea, he would do an integrator tuberosity a healing zone and a fixation zone. So in some parts, he would leave the tendon and in the other one, he would see the wall bone to have a better idea of the purchase of the anchor.
This is something very new. I guess the Dr. Ildeu was thinking about it, but you see, this Japanese idea is, I'm really thinking about it. How much do I shall leave the native tendon of this insertion? And how much do I must care about it to leave some cartilage over there, to leave some tendon or to take it all? Because the old idea is to take it all as she was telling us.
But have you been changing your mind? You deal about this because I have the sensation. You are changing your mind. I'm trying to change, but I have the doubts and that Japanese paper, but no more papers I have seen. What can you clarify something about it? Doctor, you there? When, if and if someone wants to talk? I think that this is very interesting to discuss.
I have changed a little bit. The way of doing the cleaning the tuberosity because in the past I used the soft tissue shaver first and then I used a little bit of the bone shaver. And now I just use the soft tissue once and you're doing that. Some tendons, part of the tendon, remains attached to the tuberosity, but just small parts of it because I like to have contact between the tendon and the bone.
That's it. OK, Sanjay wants to talk about it. Um, my two penny worth is this that if it is a young patient post traumatic period, there is a stump at the tuberosity. I would leave it there and do a single repair with two tendon remnants, microfracture and just leave that everything to just gel on its own.
But otherwise, in a degenerative kind of situation where there is hypo muscularity at the, you know, this watershed area of the degenerated fear, I would need a good, you know, biology coming from the greater diversity and hence I would not really leave anything there. So I haven't come across that paper, which you are talking about your ok? You an interesting read.
No, no. It's very it's very nice. But the thing is that you are trusting as we have trusted for years in a word, which is blood. You trust him. Yeah but the thing is that maybe it's not only blood, but the remaining stump plays a bigger role that we were thinking about. This is something that we really should think about.
But just changing a little because I want to give attention to the audience someone is asking, I have I have absolutely no response if you I guess, I guess Dr. Ildeu has more experience about it. If you do some laser and ultrasound in the beginning of the physiotherapy. Do you think that these devices of these tools can increase the biology of the tendon?
I have absolutely no idea, but they come in this question from the audience. The question. Mm-hmm Well, we are talking about resources to increase healing process, mechanical or thermal or biological. So if we have a good young guy, I think we don't need that because the biological response is very good.
We are going to have the inflammatory phase. OK, and we are going to have the healing process done without problems. But if we have a chronic 10-year-old guy, I think we can use some of these resources, like ultrasound or laser to increase the inflammatory response because these patients, sometimes they do not have this big response. So that's my I don't have a paper or to confirm this is something I feel based on my experience.
Sanjay, any thoughts? Um, for the bone healing ultrasonic waves has been tried, but for tendon healing, I don't think anything other than, you know, blood which is inside and the repair side works. Yeah Shirish, no, not for healing, but sometimes certain patients have too much of pain, so we use tense trance transcutaneous electrical stimulation to relieve pain and to avoid, you know, high dosage of anti-inflammatories.
OK, because we're a doctor, Dr. Ildeu was talking about something very interesting, because this is something that I face. I think that we can discuss this. The thing is, Burkhardt said that in big tears, you will have much less pain than in small tears post-operatively. The problem is that especially in women with small tears, I've been having a lot of cases of post operative stiffness.
And the thing is, as Ildeu has said, stiffness, stiffness. I can manage failure. I cannot manage. But the problem is that I had some cases last year about CRP complex regional pain syndrome, reflex sympathetic dystrophy, which they give me a lot of work. So I know how to manage that because I do a lot of fractures.
But and then I have to enter with gabapentin brand preg goblin C vitamin B12 complexes. And it gives me a lot of difficulties. So the thing is, how do you manage? How do you manage to avoid stiffness? It's a difficult question and crops, which is a bad issue. I know how to manage, but when it comes, it's a mess.
There is. In my experience, I am not doing partial thickness tear for young ladies anymore, repair for young ladies because I had the same situation of frozen shoulder after these repairs because I think that the biological response is too high in these patients.
Sometimes they go very well doing a conservative management conservative treatment. So saying that I try to identify the risk factors for a frozen shoulder before the surgery and if I have a lady 50 or 55 years old, very anxious, very diabetic, patient. Patients with metabolic problems of thyroid or other problems.
And patients that needs medication. Central medications for sleeping in these patients, they are more tend to have frozen shoulder after surgery. So in this case, I talked to the patient and I try to use some painkillers before the operation two days before the operation. It's like a preemptive analgesia. So after the operation, I try to do a multimodal protocol using not only anti-inflammatory drugs, non-steroidal inflammatory drugs for five days.
Not more than that. Not to interfere in the healing process. And I use some different kind of drugs as well, like you told us that you use for treating the complication. So I think that when I start seeing that the patient is having too much pain after the surgery, I have no problem doing a suprascapular nerve block straight away.
So that's the way I try and I stop doing the rehabilitation regarding movements because I keep the patient comfort in this link. And I the protocol for rehabilitation is just for pain in the beginning. So I just start moving the arm after having the pain controlled. This is very important, and my experience with super scapular nerve blocks is very big, I'm very happy with that 13 years doing that.
Dr. Ildeu seems to do it all, so it's very good for frozen shoulder. I know it's a big discussion and for as reflex sympathetic dystrophy. But how do you what your experience, Dr. Sanjay and Shirish on dealing with pain in stiffness and CRP? Do you have it? Yes or no? And what do you think about suprascapular nerve blocks?
I'm Uh, the thing is, Doctor. This is a very nice discussion. We have something like more 30 minutes to discuss as long as we wish. I would like to keep here all day because it's a lot of things. But the thing is we still have 30 minutes. So I think this is very important because it's not the success.
As we have discussed, it is not what I do operatively is what I do preoperatively intraoperative and post operatively. So it's not only about how to conduct a post-op rehabilitation, but in identifying post-op problems and how to manage that. You all know that I am absolutely in the right way of thinking, so please finish. And then, Sanjay, your experience with complex regional pain.
How do you manage that? Medications, super scapula, nerve blocks. I think this is a very productive discussion, please. Yeah so so you mean it's a post-op case with ICD, right? Yes so I think first of all, while selecting patients for repair, I would be very selective if someone who has a partial or articulate diabetic, hypothyroid patient and, you know, very apprehensive about the result.
I would prefer to avoid this kind of patient because I this sort of patient would give a lot of trouble in post-operative period, if at all. If we decide, then I would always go ahead with the down in a partial rotator cuff tears. I would not do a tendon as repair, so I'm more comfortable taking a complete the tear and do a proper repair because the part of the tendon, which is still microscopically intact, it has been shown in literature.
The histologically it is abnormal, so better to get rid of that tissue. Those in those patients, I would be, as I said, individualized post-op rehab protocol. I would be a little aggressive in early post-op period. I would start early passive range of movement early depending hangs, most importantly, external rotation exercise. I would start from day one.
Yes, I use periscapular blocks and transdermal patches in such patient pregabalin gabapentin, they are of great help in treating them. And you have to counsel them that this is going to be all right and it is going to take at least six to eight months. That's what I tell them on day one and in two of my patients, I have taken help of my colleague, who is a pain specialist and have done some stellate ganglion blockers and everything.
And I think you have to just buy time, you know, for six months. By the time you know, the natural history also know for sure. Another thing that I'm very serious. Dr. Ildeu, I want you to comment, Sanjay. You see this kind of patients, especially young, middle aged ladies. It happens a little bit more. There is literature about it, but I think I'm very serious that you must spend time talking to them.
Talk, talk, talk. You must give her emotional attention because these kind of patients, they need more psycho emotional attention. It's difficult to find literature about it. It's very easy to see in the office. So it's medication and emotional support. I'm very serious. I don't know if you have this patients in India.
I have a lot and yes, and I'm and I'm going to be very serious. I think that in that age, they have these ladies, they have problems because I'm very serious. The kids, they are leaving home. So the motherhood is not so strong, to feel her emotions every day. And then you see, sometimes I'm very serious. The marriage is a little bit wasted.
All of these things, they play a role and I make some jokes with my residents. When they get older, they have grandkids and then the mind gets better because they can feel their emotions in a different way. I'm very serious because I see this when they have grand grand grandkids. It goes better. OK it's a personal 15 year perception, but I talk a lot, a lot with them to give them emotional support.
I think this is very important in this kind of patient in this kind of post op. Doctor, you do. Do you have any concerns about giving them? I would say some emotional comfort. I'm very serious about this. I'm serious. What do you think about it then, Sanjay, in this specific kind of patient?
Go, please. No, no, you can go, Sanjay. OK so, sir, you these are very difficult cases which you are talking about. So during the clinics, I tend to keep my radar really, really up for this and I try to console them as far as possible. But once again, here I get caught in this. So when this is a pastoral or partial articular care and I take the challenge to make them little happier counselling, counseling and counselling, so that is very important.
And then during this surgery, I take care of bursa more aggressively. Wherever I see red, I just go and clear it out. I release their capsule proactively so that whatever effect of the secondary stiffness is there, I get ahead of that. Then I use inter-school any block with, if possible, with the catheter so that for a couple of days, that patient is pain free.
And then I use this opioid patches by introducing patches. And along with that, I add a little bit of anti-depressant and then, you know, keep them very close. You call them frequently for follow up and give them enough time. Are to your brain. But in the end, say at the end of six to seven months, you've got a bad day are better. And one thing I do at the beginning, I charge them double.
Oh, that's very good. That's fantastic. You know, I'm very happy to know that all of these 50, 60-year-old ladies with emotional weakness, I would say they are not only in Brazil, they happen in India. I'm very happy about it. Shirish any concerns about this? I would say this middle aged ladies, which these emotional allow me to use the word not weakness, but characteristic.
Do you pay more attention to them? Post-operatively, you know they I love it. The expression Sanjay. Use it, they chew your brain so they chew my brain to and they chew my heart because they are emotionally demanding. So how do you manage that? Cherish, honor. I would say on a regular practice because I want to know that you suffer as much as I do.
I should confess now I'm practicing for last 12 years, but still this sort of patient wait when they come to my turn. Still, patience, because you know that next 20-25 minutes are gone and you have to keep talking to them. But I think it's very important. I always call their close relatives, especially if she's an elderly lady. I would call her daughter-in-law.
And you have to make sure that daughter-in-law understands that she she's not a malingerer. It's a real problem. She's suffering because from outside, they feel that she just making some fuss. So I make sure that every family member understand this problem, and together we have to find a solution. And I think this few detailed counseling sessions are good enough, and you have to just make sure that they don't feel that you are trying to avoid them.
Now that I tell them that either you come early in my outpatient hours or you come last so that I can give you more time. So I have a couple of and if you convince them that I'm going to get all right, they are OK. OK yeah, OK. Sometimes my physical therapists, they say they make a joke that these ladies, they don't need so much physiotherapy, but they need psychotherapy.
So it's another way of seeing this. But there is a nice question coming. There is a wonderful shoulder surgeon in the state where Dr. Ildeu lives, Minas Gerais is Dr. Morta He lives in a City College juiz de fora. He's a very good friend of mine, outstanding surgeon, and he's asking me a question here in WhatsApp because he deals a lot with athletes.
And I don't deal with athletes. It's very uncommon. He's asking me if you think differently when you are dealing with pesta lesions in athletes and not in ordinary patients. You see, I have a way of thinking of pasta for non-athletes. My experience with athletes is very small. Dr. Morta, he has a big experience, and I would like you to know, do you think differently to deal with pasta lesions in high demand in patients from an athletic point of practice would like us to talk about it, please?
Doctor, you there? Can you start? Well, based on the papers, I can say that I like to perform the complete delusion to have 100% repair in these cases because the biological aspect of the healing process is stronger when compared when you do a partial repair.
That's the way I like to do it. I don't have too experience to athletes, but regarding these partial articular tears, I feel more confident doing 100% repair because I can't control the tension and I can control the exact part where I'm going to reinsert the tendon. That's my experience. OK so my feeling is the same because Burkhardt says that in partial tears, you must take all of the bad tissue from a, I would say, microscopic point of view.
But what you do has said is absolutely as my feelings that the biological potential in this patient is very high because they say they are younger and then they have good biology. And the thing is, so I really think that, but what is your experience? You do? And then the others with athletes because my is so small?
What is our experience and acting like that operatively? How do you see them six months, eight months, one year after surgery in sports activity? Do they really get better? You know, the question is that these shoulders, they are not young anymore, because these guys, they have a high demanding activity, so sometimes in a patient of 25 or 30 years old, we have a 60 or 70 years old shoulder, so they have to understand the limits of it.
So I talk too much about them, about the limits of the treatment and how can we improve biologically. And the protocols of post-operative are a little bit different because they have different phases to cover because it depending on the sports that they are involved, it's like tennis, like volleyball, like soccer.
We need to do some specific post-operative protocols to put these guys at the same level that before surgery. So it's not easy and sometimes you have to do more than one operation in these guys. That's the problem. OK, and then and then I'm going to do a very interesting question. When you have a 30-year-old boy with a serious stutter that needs surgery, you know that the problem is not exactly impingement, but intrinsic tendon degeneration.
OK having said that, would you still do an acromioplasty even as move just to have some bleeding upon the repair? I guess you will say yes, but it's still a nice question. I think in this case, sometimes you can do injection into the tendon into that the entire substance of the tendon, because do we just in acromioplasty?
Probably the cells are not going to achieve the part of the tendon, which is degenerated. So I like to open a little bit longitudinally the tendon and to create a path to use the shaver and divide it a little bit. And in this way, after that, I do a suture over the top to close the tendon. That's the way I do it. OK Sanjay, your experience with past lesions in athletes to Dr. Morta, who is very interested in this topic and shirish, because my experience is very small, so my experience is also very small.
But in athletes, in younger athletes, I tend to really, you know, beat them conservatively. And when I operate, I do a completion of their repair, good vasectomy and rehab, early mobilization, and I need to tell them that your post-operative level in the performance is not going to be improved or amazing. You will have to understand that it's up to him.
I guess shift owners to him to use this surgery as his advantage and bring the best out of him. And, you know, adapt to this new issue and re-educate and then perform. That is my strategy. But very small volume in a my style of practice in these cases. Ah Shirish.
You are muted. Oh, no, no, no, no, no. I have treated a few of them, so I think when you are dealing a throwing athlete, it's a throw shoulder. So we can just look at the past legion alone. I would make sure that all components are well taken care of. Looking at the scapular dyskinesia, the deficit, I would put them on a good supervised program where we would stretch out his posterior capsule, put them on good scapular rehab, strengthening programs, sports specific training and most of them, they get better.
Now I would divide these athletes into two groups, one who is still continuing to play at whatever level, state level or national level. I'm very reluctant to touch them because the return to sports after surgery in the worldwide literature, the person is very less. But someone who has played for a lot of years and now he's out of the game, out of the team because of this injury.
Then these are the patients where after adequate rehab trial, if they are not getting better, then I would counsel them that yes, we can try our best, but I'm not sure. But at least you should be able to get back to sport may not be at the same level, but you should be there. And then we are well informed consent. We try our best and few of our patients. They still manage to get back to the same level.
What was their pre injury? But still, the chances of having recurrent pain and getting back to the clinic is very high. No and so what are you saying? And it's very clear for you, me but and all of the panelists, but I'm talking to the audience. We must be very honest with these patients in a way that I'm going to try my best, but I cannot promise you that you will come back or you will come back.
I would say relatively, but not in a competitive level. And you see the problem is that you are getting old is not me. The surgeon is, you are. You are getting old. And this is very important. But the thing is, we have to pay a lot of attention in scapular dyskinesia because this is important in everybody, especially in athletes, because they are high, high demanding. But that is then one thing that I want to question, because it's very difficult to me and and I want to see if you suffer as I do.
The thing is, I pay a lot of attention in scapula, dyskinesia, post-operatively. It's very important, especially if I am acting with Ric relatives', middle aged sport people in the gym, these cases I can handle well. The problem is that in all patients, especially in obese ladies, and they have spine forces in English kyphosis, it's very difficult to work with the scapula, even if you operate the shoulders.
They are the curves. They are low demandingness patients. But I have a lot of difficulty in, I would say, treating scapular dyskinesias in all patients, especially in obese ladies with kyphosis. Do you have these same difficulties and how do you try to improve it? Post-operatively after a curve repair? I think this is a difficult question, but a practical one, Dr. Ildeu.
How do you suffer? Do you suffer too? Well, I think we have to pay attention about the origin of the pain in this case because some of these ladies, they have pain on the AC joint because of the position of the scapular regarding the rest of the body. So the protection of the scapular increases the pressure over the AC joint.
And the external sternoclavicular joint as well. So some of these ladies, they have what we call. How can I say it in english? Is the minor over tension? OK just a second. And you will continue now is the back minor over tension leaving to myofascial pain. This is what you want to mention. Myofascial pain?
Yes Yeah. So I think the key point in this case is to perform a proper strengthening of the scapular muscles and stretching the back minor impact major muscles and sometimes even the surface capillaries. So it's difficult because these ladies, they are lazy and they do not they don't like to do some exercises daily. So simply, they do not do the treatment properly.
So in this case, it's difficult and we sometimes we indicate the surgery trying to compensate. Conservative treatment that was not done in a proper way in trying to do using surgery. And this is not a good thing to do because they are going to complicate, I think this we have to try to treat cons Yes.
And as Sanjay has said, and after surgery, if they are not fully OK, they are going to chew your brain. I love it. The expression Sanjay, OK, because they feel my doing, but I say my brain and my heart. But still, Sanjay about scapula, the scapular part of rehabilitation, old ladies, obese when you operate the curves.
They are low demandingness. I have. So much difficulty to work this part. Physiotherapy in both of scenario. Your thoughts about it? How do you deal with that? So the one thing is that I commence these exercises before the surgery. The scapular stabilization exercises.
So they are familiar with these exercises once I operate. And as soon as you know, they are out of anesthesia and they are comfortable, say, for five hours after the surgery, they start at least brisk breathing exercises. And I put them on those table slides and, you know, just elbow exercises. And then in the next phase, when I mobilize them passively to control the scapula, I ask them at home the supine exercises they lie down and the scapular are touching the bed, and then they do passive exercises.
And that educates that scapular and their muscles to do really, you know, act rhythmically so to avoid this sitting position shrugging or of what you call tic movements. I want them to do passive exercises in initial six to eight weeks. If it's a big tear in a lying down position. That is my trick. OK we are finishing just in a second, but here is, do we want to make final comments because you didn't answer?
I just want to hear your thoughts and then we will finish. Finish any thought about this? Yeah so I think you have to make patients aware about the scapular issues and we have a good rehab team. So where we advised post-operatively, few supervised sessions and we sort of tell patients that surgery is only 50 percent, 50% is a proper rehabilitation and if you do it, then you'll get the good result.
And I think most of the patients follow that rehab protocols, and we have very good results with supervisory protocol, early post-op period. And then sequentially, they come in two weeks, eventually four weeks later for a follow up visit with physiotherapy. And we make it sure that we work on the scapular very well right from day one. OK, so see, my friends, it was a lovely discussion, but we have to finish because Doctor Ashok has a lot of webinars to run before my final statements.
Doctor Ildeu, do you want to make any final comments, Sanjay? We have one or two minutes for everyone to speak if you wish, of course. Doctor, you deal with any final statements. Feel feel free. My friend. Thanks first of all, I would like to thank OrthoTV, I would like to thank Shoulder Planet.
That's my motto here. And lots of Brazilian guys, they are asking for one. OK please be aware of it. Yeah, maybe one. Oh Yes. I'm going to send you. I promise. And I really I'm really happy and honored to be part of this discussion.
And Thanks for the opportunity. And Sergio, you have. Brazilian shoulder surgery, and I would like to congratulate you and your relationship between India and Brazil, you have established a channel of communication and this is very important for both countries. So congratulations for all of you.
Thank you. OK OK, thank you very much. I'm very I am very happy about it, Sanjay. If you want to say something, the microphone is yours, right? So you right? It is my privilege to interact like this freely without constraint of time. Speaking our mind and heart to our discussion on this OrthoTV facilitated webinar on your Shoulder Planet platform.
Thank you very much for making me part of it and fellow participants for their participation and listening to me very patiently. OK, thank you. Shirish, you want to say something to thank you. Thank you. Thank you, Sergio. Sanjay and Dr. Ildeu, thank you very much. It was a fantastic academic feast.
OK, so see this one. One, to be very honest, this one of the most beautiful moments of all of my India and I would say the award that started 10 years ago. I'm very thankful. Like my Indian friends do, they do like this? So I must thank you a lot. Doctor Ashok, it's a pleasure to be here. I thank you too much.
OrthoTV. The formal and very brotherhood that we are establishing. I hope that we can continue these, these projects, and I'm very happy that in a very spontaneous way. Doctor Ashok, he mentioned this as an Indo Brazil event because this is not my event. This is an Indo Brazil event. I think we have to join forces to be stronger together to use the internet.
I'm very happy about it. And as long as we can, I hope we can do in future more events like this connecting Brazil with not only with India, but with people from other countries. I think that this is the spirit. I'm very happy about it. Doctor Ashok, if you want to say something to finish it, I'm going to be delighted, my good friend.
Oh, I think it was a really great event. We were joined by around, I think 900 to 1,000 people joined us online and was the thing. The discussion was very lively and a lot of things about the biology of our city and how the purkis. A lot of concepts were clear, especially with the discussion amongst the panelists. So it was a really good webinar and had a lot of academic value to the viewers.
And like I said, it's in the Brazilian venture and we should look in ahead in doing this regularly as much as possible for both of us. And we involve more people into it so that we can share knowledge across continents and across the world. So, OK, just the final statements that I am very proud to say that if, if, if we can do another one, I am delighted and just for people to know that I have invited one of the most important persons nowadays of the world shoulder scenario, which is our good friend, Doctor Osborne, which is not only a good friend of Doctor Rodeo and of me, Doctor Ildeu helping me in the invitation.
I thank publicly Doctor Ildeu to invite Dr. Watson, who was not only ex-president of Brazilian Orthopedic Society but Brazilian shoulder and elbow society, and he's now the president of International board of shoulder and Elbow Society. He's a very important guy, very proactive, very, very clever man, very intelligent, and he has already accepted the invitation as long as we can do a second event.
So I am super proud of saying that and we have other guys to invite of very important people from. I would say abroad, I don't have the yes, but we are trying. Doctor Hillsdale is giving me super support on that. So the thing is, I just want this to be the start of a new, I would say, digital relation between Brazil and India. I'm very proud of that and very happy, and I hope to see you guys soon as long as we can.
Of course, in a second event, as long as OrthoTV give us the opportunity, I guess we will have and deep and see and the biggest responsible for all of these journeys, Doctor Ashok, Doctor Neeraj, they are extremely active and thank you from the bottom of my heart, my good friends. I think neither coordinated all of them, and he can end the meeting with OK. Go ahead.
OK yeah, yeah, so we will definitely do it on a regular basis. We will coordinate again. We will keep that group on. So that it'll be very easy for us to coordinate. So with this, we end our meeting, feel that we end our first Brazilian shoulder meeting today. Thank you very much and.
So, my friends, I hope you'll like it. So please don't forget. Subscribe give your thumbs up. Leave your comment and see you in the next video, as Dr. Sergio always says. Never stop flying. See all my good friends.

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