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Name:
Arthroscopic Bankart Repair - Dr Nikhil Gokhale
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Arthroscopic Bankart Repair - Dr Nikhil Gokhale
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
NIKHIL GOKHALE: Hello.
DIPIT SAHU: Hi Nikhil yes, you are. Go ahead.
NIKHIL GOKHALE: Hi yes. So good morning, everyone. So this is a soft-tissue Bankart repair we are doing in a 25-year-old chap. He's a kabaddi player.
NIKHIL GOKHALE: He has his first dislocation about four years ago while playing kabaddi. The last one was about 2 and 1/2 months back while swimming. He's had no slip dislocations. He has a Beighton score of 0 by nine, so no laxity as such. We've done imaging. I don't know if Dr. [inaudible] has shown you the images. He's got a soft tissue Bankart, minimal bone loss on the anterior glenoid and Hill-Sachs, which is shallow and measures about 11 in width.
NIKHIL GOKHALE: So I have with me Dr. Abhishek Jaroli and Dr. Saurabh who are going to give me a hand and Dr. Ganesh is our anesthetist so the patient is under GA in beach-chair position. We've given a [INAUDIBLE] block that helps reduce the pain and reactionary bleeding. I also give them tranexamic acid, something I picked up from arthroplasty people and we've applied gentle traction on the arm just to balance it.
NIKHIL GOKHALE: I took the liberty to start making the initial posterior portal and one of the working portals whilst waiting. Am I audible? Hello? Any questions so far? You're very well audible. Yes. So let me just take you through a round of diagnostic arthroscopy. So on the right side of the screen, So the patient is in beach-chair position.
NIKHIL GOKHALE: That's how I do my shoulder arthroscopy. So the glenohumeral joint will always look vertical. On the right side of your screen is the flat glenoid. On the left side is the humeral head. On top here what you see is the biceps tendon. So that's called a lighthouse of the shoulder. In the beginning, whenever you get lost while doing arthroscopy, just look for this and then try to find this triangle.
NIKHIL GOKHALE: We call it the horizon. Once you see this triangle, you'll know where you are and you can reference off it and move around. If you go in slightly deeper, This, this band here, that's the upper margin of the subscapularis muscle. Now, because this last dislocation was just a couple of months ago, there's still some capsulitis, but clinically has got full range of movement.
NIKHIL GOKHALE: Now if you see anteriorly, there is deficiency of the labrum all the way from about there one o'clock position. And somewhere around here six o'clock position, you start seeing the labrum again. Yeah, can you see that?
NIKHIL GOKHALE: But the posterior [?] labrum is intact. Yeah that's the posterior [?] labrum there, and the anterior labrum is stone [?]. Now it doesn't have much in the way of glenoid bone loss, but there is a Hill-Sachs defect. So carrying on with the diagnostic round, this transverse band you see in the front, is the subscapularis.
NIKHIL GOKHALE: This triangle in between is the rotator interval. Yeah, so between the subscap and the anterior margin of the supraspinatus is the rotator interval. And therein lies the biceps tendon. If you keep coming back from the biceps, this tendon here is the tendon of the supraspinatus, which is intact. If you come further behind, that's a tendon of the infraspinatus. Now here, you start seeing some bone loss.
NIKHIL GOKHALE: Can you see that? Hello? Yes, yes, you can see bone loss. Yeah. Now, the normal anatomic bare [?] spot is also in this region. And sometimes one can get confused as to whether it is a Hill-Sachs lesion or a normal anatomic bare spot. And the way to tell is that if you see the Hill-Sachs, there will be an abrupt ending between the cartilage and the subchondral bone.
NIKHIL GOKHALE: Whereas if you look at the bare spot, it's more of a gradual transition from cartilage to bone. So if you keep going back, you come into the inferior pouch. That's the inferior glenohumeral [?] ligament. Yeah? Yes. I'm going back into the shoulder that's the glenohumeral joint.
NIKHIL GOKHALE: So the next thing we're going to do is we are going to establish the interval portal. I've already made the superior viewing portal. Can I have a needle please? So the anterior inferior portal will try to make it just skirting the subscap, I'm coming down.
NIKHIL GOKHALE: I want to be slightly more inferior than that. So somewhere there. Yeah? So normally how much space do you want between the two portals, anterior portals? So normally I put a cannula in here and I really don't always put a cannula in the superior lateral portal because I view from here and then I use it to shuttle sutures directly from the cuff.
NIKHIL GOKHALE: But yes, we need at least a centimeter, centimeter and a half of gap. Also, what one can do to prevent crowding is use a larger cannula in the front and maybe a smaller cannula there at the back. So you are demonstrating outside-in technique, which is the laid out technique that you can use for this portal as well, right?
NIKHIL GOKHALE: Yes yes, you can use the internal technique as well. But to be honest, I have never really used it. I've always used the outside-in technique. So I'm trying to keep my blade away from the subscap to prevent any iatrogenic damage. The subscap. And try not to rotate the blade inside because these are flimsy blades, they can sometimes break and then it's a disaster.
NIKHIL GOKHALE: Can I have a [INAUDIBLE] please? So I'm making the skin incision slightly longer at this point because my 8.5 mm cannula needs to go in from here. So everyone is aware of the inside-out technique also, all the delegates? Yes? So with the inside-out technique, you basically, what you do is you just drive your posterior [INTERPOSING VOICES] drive it forward.
NIKHIL GOKHALE: So they're just touching the subscap tendon and then bring the scope out and pass everything the rod through which comes out to the skin. So that is the- it's a relatively easier and safer way of starting to do [INAUDIBLE]. You're starting out with the arthroscopy that is a safer, easier, more reliable way of doing a [INAUDIBLE] especially the one that he's showing right now, The green cannula with the dilator please.
NIKHIL GOKHALE: [INTERPOSING VOICES] Yes, yes. All the portals are in the [INAUDIBLE]. That's why externally we are taking the portals to make sure there is adequate space we don't want there to be any [?] crowding of the tendon. [?] It depends on what you're used to but school [?] is more strict [?] around here.
NIKHIL GOKHALE: So I've got my 8.5 mm cannula in. [INAUDIBLE] please. I'm going to pull out the cannula and, just pull it out, yeah. Thank you. And it is looking directly all the way down. OK so if [INAUDIBLE] please. So when I eventually pass my anchors. Can I just distract the joint slightly?
NIKHIL GOKHALE: So I've got a shot right up till there. Almost five o'clock position. Is that OK? Yes. OK. Right so, when you think of doing an arthroscopic Bankart surgery, you think of it in three steps. First is establishing your portals. So that is the viewing portal, ah sorry that is the working portal.
NIKHIL GOKHALE: There is where I'll put my scope. If you see there's adequate space in between, so I don't expect any crowding to happen. So portals are done. Next is to find the actual Bankart lesion. Now, if you see in the front, there's absolutely no tissue there. Yeah? And this is what generally happens. The tissue lies somewhere around the corner in the front.
NIKHIL GOKHALE: That is perhaps some capsule where it's very difficult to look at it from this position, so we are now going to switch to this portal here. That all right? It looks like an ulcer [?] lesion. Yes, yes. But even on the scan, I didn't see any labrum because probably because it's subluxation [?] or dislocated seven, eight times. His entire labrum is degenerate.
NIKHIL GOKHALE: Anyway I will shift our scope to the superior viewing portal so that can come behind us. So everyone knows that [INAUDIBLE], I'll say is where the labrum sort of dislocates and heals medially to the glenoid instead of being at the edge, it moves medially. Sometimes it is detached in certain areas, but in some areas it is attached to the medial side or medially to the- [INTERPOSING VOICES] Yeah, sure.
NIKHIL GOKHALE: I mean, sometimes we see patients who are dislocated 20, 30 times, 50 times. So it all depends on how loose the shoulder is. But it depends. You have to assess it's not only that you have to first assess the bone loss. You can [?] see the quality of the tissue, things like that.
NIKHIL GOKHALE: So the planning for a Bankart is not when you are doing the surgery, it is before the surgery, it's preoperative, the plan. Right? So, Nikhil, we have a question here. The delegates want to know whether in multiple dislocators you will just do a Bankart or how will you plan your surgery in multiple dislocators? So I think more than the number of dislocations, I think a couple of things are important.
NIKHIL GOKHALE: One is whether theyre dislocating in sleep or not. Second is whether they have soft-tissue laxity or not. And third is what the imaging shows. Now, this person hasn't really dislocated in his sleep, is not really, uh, doesn't have much in the way of laxity. When we did imaging and, one sec, let me just clear this up, we've also done a CT for him. The CT doesn't show much in the way of bone loss.
NIKHIL GOKHALE: There's hardly, perhaps 5% bone loss. So I don't really think that he needs any bony procedure. I don't really decide that interop, my planning is all done preoperatively. I know some people like to do a diagnostic scope and then decide whether they're going to go ahead with the soft-tissue or bony procedure. Also the size of his- so the first thing I look at in imaging is the amount of bone loss.
NIKHIL GOKHALE: If it is more than 15%, I would be worried. If it is more than 20%, definitely I would offer them a bony procedure. 15 to 20%, as everyone knows,is slightly of a gray zone. Also depends on the individual patient characteristics. The next thing- Nikhil, let me stop you. Now you're talking about the glenoid bone loss, but do you have [?] combined bone loss also or just the glenoid loss? Yes so the first thing I look at is glenoid bone loss.
NIKHIL GOKHALE: Then I look at whether the Hill-Sachs lesion is engaging or not. So if the patient has a 20% bone loss, then I would just offer them a Latarjet. If there is no significant bone loss, the next thing I look at is whether the Hill-Sachs is engaging or not. So you can see the Hill-Sachs over here. So that is rather on track or not. So what I've realized after doing a lot of calculations is that for the Hill-Sachs to be off track, you know, if the width of the Hill-Sachs is more than 20, then it is more likely to be off track.
NIKHIL GOKHALE: So only if the width of the Hill-Sachs, as per [INAUDIBLE] reported is more than 15, then I actually do those calculations. His MRI has reported a Hill-Sachs width of around 11. Also it's quite shallow so I don't really think that he's going to need any posterior procedure like a remplissage. So it's more than the depth of the Hill-Sachs. It's where it is. If it is more medial [INTERPOSING VOICES] width of the engaging rather than the depth of the inside. [?] So that is more important.
NIKHIL GOKHALE: Also, you can do glenoid tracking, which is offered by some of the ligaments. I'm not sure where you practice, whether they do the glenoid tracking, but that can be done and that can give you a more accurate sort of understanding of the combined bone loss. So now I'm going to start elevating the capsule. Are you able to see the labrum there?
NIKHIL GOKHALE: Some tissue. Perhaps this is all stuck medially, so it's very diff- yeah, perhaps this is the labrum. Can you see that? That which I'm rolling in? Yeah, yeah. Gone all medially. So it's a classic ulcer [?]. Yeah yeah, we will start calibrating it and see what happens.
NIKHIL GOKHALE: [INTERPOSING VOICES] Yeah, tap tap tap [?] [INAUDIBLE] because we know that [INAUDIBLE] [INAUDIBLE] Let's focus on that. [INTERPOSING VOICES] [INAUDIBLE] So I'm getting some tissue, which looks like labral tissue, or generally when you liberate [?] all the way, you start to see some kind of bleeding there.
NIKHIL GOKHALE: [INTERPOSING VOICES] Tap tap tap, please. Once or twice please [?] Now I think we are around four thirty, five o'clock position.
NIKHIL GOKHALE: All the way, all the way. Keep going. Keep going. And you suddenly feel it give way. That's when you know that it's completely elevated. Am I audible? Yes yes, go ahead. Just not getting any feedback. Surgeon? Yeah. So we have a question here from the delegate.
NIKHIL GOKHALE: They are asking is, if the tissue is very flimsy, Yeah? And you're not able to see adequate labrum anterior- how would you proceed then? So generally when you see from this portal, even if the tissue on top here is flimsy, you'll see that the [INAUDIBLE] has gone down and stuck somewhere behind. So in that case, you can liberate the tissue and try to tuck it up at least up to two thirty, three o'clock position. Hammer [?] please.
NIKHIL GOKHALE: If there is absolutely no tissue, then I'm afraid the only option is to abandon the surgery and convert it into a - can you retract, [INAUDIBLE] around please - into a bony procedure at a later date. So you would prefer to do a bony instead of doing just a capsular shift? Do you consider doing a capsular shift like anterior as well as posterior and then interval closure? [INAUDIBLE] or remplissage [?]. So, see I thought the question was if there is no capsule.
NIKHIL GOKHALE: So of course, if there is capsular tissue, then yes, that would be an option to create sort of a new labrum. Right, right. By just rolling it up and creating a bumper to give some sort of a suction cup effect. Yeah. But yes if there's absolutely no capsular tissue, see now we are going almost up to five, five thirty position. Yeah, and from there the labrum is sort of intact. Yeah? Yes.
NIKHIL GOKHALE: [INTERPOSING VOICES] Hammer please. [INAUDIBLE] all the way down to continue via incisions [?] Sorry? I didn't catch the question. The question was, they wanted to ask, what does exactly 'liberate' mean. Liberate means? [INTERPOSING VOICES] Yes, yes. And how much do you release?
NIKHIL GOKHALE: Yes, yes. So if you see initially you weren't really seeing much, but now you can see this white tissue. Yeah so that was the tissue, which is a part of the labrum periosteum capsule complex, which had migrated medially and stuck to the neck of the glenoid. And how much to liberate is till you start seeing the fibers of the subscapsule.
NIKHIL GOKHALE: You see that hole there? Yes, yes. So that is our extent of liberation. So when that hole extends all throughout, that is when we know that we have completely liberated the tissue and then it starts floating [?] nicely. Can you tap, tap, tap, please? Yeah. So also in these ulcer [?] lesions, when you liberate or release the whole tissue the labrum comes back and sits at the edge of the glenoid.
NIKHIL GOKHALE: So, you know, that is an adequate [INAUDIBLE] Yes, yes. So this is tissue [INAUDIBLE] site of periosteum. [?] Yes, yes, it is. Just like, you know, while doing a hemiarthroplasty, you take off the extraosseous [?] from the bone. That is exactly what we're doing. So some people have seen some people using like a mallet in order to release it very close- Yeah we are using a mallet.
NIKHIL GOKHALE: So my colleague is hammering it. As I would say, tap tap tap. Not just a hand movement, but you also use fine strokes of that mallet. You can also use a 20 degree turbo wand [?], which is exactly the shape of a - tap, tap, tap - periosteal elevator, [?] but has a radio [?] frequency at the top that helps to reduce bleeding as well. Tap, tap, tap.
NIKHIL GOKHALE: See that is Subscap is slightly more somewhere here. This is going to be And sometimes when we think of something as an extension of [?] [INAUDIBLE] [INAUDIBLE] All of it. Yeah. So I can feel the tissue liberating.
NIKHIL GOKHALE: Can you see that white band coming out? I'm sorry? Can you see that white band which is- Yes, yes, we can see. Gradually. Think it's going down. Traction, slight traction.
NIKHIL GOKHALE: Yeah, [INAUDIBLE] [INTERPOSING VOICES] Yes so a ligament tissue [?] is the one that the hammer- Can you show us the medial glenohumeral ligament? Delegates want to see whether the [INTERPOSING VOICES] It's usually the one that crosses the subscap. Yes, yes. So... it's gone back slightly.
NIKHIL GOKHALE: So it's seen better from the posterior portal. Yes. Can you see this band? One second. Is this the biceps? Yeah. So this, this band of tissue. Yeah, this band of tissue going from here.
NIKHIL GOKHALE: Yeah, can you see that? That is the medial interior [?] ligament attaching to the glenoid. Yeah, so it's going from the glenoid up to the humeral head. Also if you see the head is not really central as it is subluxing. Slightly anteriorly, not much. Right. Slightly. And there's not much in the way of bone loss. Otherwise you see those pear-shaped, inverted, pear-shaped-
NIKHIL GOKHALE: So that is you can also see the bare spot of the glenoid. So, yeah, this is the best part of the glenoid that's the embryological center, so-called. And what they say is it is the center between the anterior and posterior axis, although there are studies which have shown that the anterior- inferior distance is slightly less as compared to the posterior-inferior. So it's not exactly the center, but I think if you're looking at it, then a few millimeters is very difficult to really make out, isn't it?
NIKHIL GOKHALE: Traction. Thank you. I think there is some region somewhere around here. Tap, tap, tap please. I can feel some fiber, can we open Yeah, yeah. Yeah. So whenever that blood comes, it means that we've
NIKHIL GOKHALE: drawn [?] adequately. Yeah. Hammer, please. OK. Yeah, OK. See, now the capsule is starting to show. Can I have a suture manipulator please?
NIKHIL GOKHALE: Can you see that? Yes. So now this is going to come and sit here. OK? Yeah. Yes. Let's prepare the the bed [?] Now, this tissue here. We need to rasp [?] it and make sure that
NIKHIL GOKHALE: Your arm, please [?] One second, I think my cannula has come out. Rasp please. [?] Can you hold the cannula please?
NIKHIL GOKHALE: OK. I'm assuming everyone has started doing a few shorter [INAUDIBLE] to preserve the digits. Yes so that is the rasp. It's a very sharp instrument and its only function is to operate the bone so that we get a good healing surface. OK? We start from somewhere there. Hammer, please.
NIKHIL GOKHALE: Yeah. Tap tap tap. Tap. OK. Hammer please. It can be challenging if you have not done it in the past. The main reason is - hammer please - how much bleeding [?] in the knee. If you've done knee arthroscopy, you're not worried about doing the shoulder. You have to be worried about [INAUDIBLE] So I think actually personally I feel that doing knee arthroscopy is more difficult. The shoulder is a round joint, right?
NIKHIL GOKHALE: So eventually your instruments will triangulate if you try to put them into the center of the cavity. But it is more like a disk. Plus, it's a tighter joint to actually dissect it as much. No, no, Nikhil I was telling them about the bleeding. If once you start getting bleeding, if you are a beginner, it can be quite daunting.
NIKHIL GOKHALE: Yes, yes. OK, OK. That can put you off completely off shoulder. So if you are starting out, you have to be a little patient and may take some time in order to do your first entire case arthroscopy. So what do you guys do for instability? [INAUDIBLE] Are you reopen this? Open?
NIKHIL GOKHALE: [INAUDIBLE] OK, now I understand. I think that is the best way of starting your arthroscopy is to have someone who has a little bit of experience, who is helping you out, and then gradually you can take over more and more steps in the surgery. Yeah I think mentorship is very important, especially while doing surgery.
NIKHIL GOKHALE: Get some traction. Just going around the edge there. I think I've abraded enough, gotten enough scar tissue out. Do you use like a shaver or some? Yes, I'm going to use a shaver next.
NIKHIL GOKHALE: Attach the suction on the shape of this [?] Thank you. Yeah, can you give me the foot pedal? So you just shave off all these adhesions and scar tissue.
NIKHIL GOKHALE: Suctions [INAUDIBLE]. OK.
NIKHIL GOKHALE: I've just kept the suction on very minimal outflow. I don't want the entire thing to collapse. Just want to take the soft tissue out which I think I've done. Yeah. Can you see that raw surface now? Yes. So that's the bed.
NIKHIL GOKHALE: That's what you want to repair. Can you see that? Yes, we can. There's a little bleeding, Bankart [?] bleeding also. Yes, yes, we want that. Because we want some biology to come in and chip in. So all the way up to almost five thirty, six.
NIKHIL GOKHALE: o'clock, yeah? Yeah. Vertical [?] capsule. So I'm going to switch back to the posterior portal now. [INAUDIBLE] What anchor placement do you use the scope, in the post? Yes, I use the scope in the posterior portal. It's just how I'm used to viewing things while putting anchors.
NIKHIL GOKHALE: Also, the fact that if one has to pull up the superior edge of the labrum at any point, then the anterior super [?] portal comes in handy. Sure. Do you like, in the setup, do you like to use like a lateral traction, that dual traction that some of these companies have. Have you used-
NIKHIL GOKHALE: No, I have never used that, I mean, I would like to. I've never used it, to be honest. We have recently acquired the spider. Can you put the suction in, please? Spider? Yes, the Smith and Nephew spider and attachment.
NIKHIL GOKHALE: But you have to start using it regularly OK. One sec, one sec. So it's nicely bleeding, now you see that labrum, which was initially not visible. It's nicely seen. This this whole tissue. I think my green cannula is out. Hold this. Can I have the [INAUDIBLE], please?
NIKHIL GOKHALE: I'm just going to reposition the cannula. Yes. Thank you. And now Saurabh is going to make sure that the cannula doesn't come out again.
NIKHIL GOKHALE: OK. Hold on [?] Green angular [?] OK. So we've prepared our bed. Pick up [INAUDIBLE], please.
NIKHIL GOKHALE: That's the labrum which we want to repair. It's... yeah? So it's coming up nicely. I think I might have to hold it in traction even while taking sutures. Yeah. I think it's deficient somewhere here, but it's coming up nicely with the [INAUDIBLE]. OK. Grasp through the superior portals. [?]
NIKHIL GOKHALE: That's what I want. [?] Grasp them. Where the scope was. Yes, exactly. We can hold it up and then take a stitch [?] through there here in [INAUDIBLE]
NIKHIL GOKHALE: Some traction [?] Looking all right but the more I look at it, it seems to be lesser and lesser. So if you could just hold it up there, please. I think once we start putting sutures, it will start coming up nicely.
NIKHIL GOKHALE: Can I have the [INAUDIBLE] guide? [INAUDIBLE] guide? What kind of anchor configuration do you use? So I use at least three single loaded all suture anchors. Single loaded. Yes, yes, single load. So just don't let it all-
NIKHIL GOKHALE: Relax. And we're using Iconix. All suture anchors, some traction. This is a nice curved guide. Just hold the cannula. Can you see this on the outside screen? Yes, yes. So that allows us to get a good angle onto the surface of the glenoid.
NIKHIL GOKHALE: For the first, for the lowermost anchor? Yes, yes. And obviously you will be using the straighter ones for the- Yes, the latter ones. So... Where, where is the placement? This is the most important anchor. Yes, so I tried to place it around five o'clock. So this is six. I feel this is somewhere around five o'clock. Also, I try to be slightly onto the surface of the glenoid, then the edge.
NIKHIL GOKHALE: So maybe about a millimeter of tissue there. Are you happy with that placement? Yeah it looks good. Yeah? Drill, please. Nikhil, just stop- So there are a lot of controversies of how much cartilage to remove. You remove a bit? I don't remove any cartilage, no.
NIKHIL GOKHALE: So, you don't want the healing on the edge, because Dr. Sanjay Desai just published a randomized controlled trial. Yes. In arthroscopy journal. And he said you remove four or five mm of the cartilage on the edge because you want the healing between the labrum and the edge. Yes. Right? So that is one concept.
NIKHIL GOKHALE: Yes. You just want it on the glenoid, the healing. Yes. Remove just a bit, but you don't remove at all? Or you would do a little bit of, uh- So I don't remove, whatever abrasion I did with the shaver, that's it. See, the thing is that if you think of bone loss, I mean, I may be wrong, this is just my thinking. Evidence is always superior.
NIKHIL GOKHALE: But if you think of bone loss, the average size for a dentist and - hammer hammer hammer - the average width of the glenoid is about 25 to 28 mm. So every 1 millimeter is about 3% bone loss. So I don't really know if causing that heterogenic [?] bone loss was a good thing or a bad thing. So technically, it's not about [?] taking the bone off [INTERPOSING VOICES] so that there is more surface area for healing.
NIKHIL GOKHALE: Yes, for healing. Maybe I should change, but I've never done that. Yeah yeah, very few people do it. People do it. Pull the two threads please. This- here. That's it, that's it. That's it that's it. OK, so I've got my first site of the whole thing [?]
NIKHIL GOKHALE: OK. It started to draw the cannula slightly. OK. [INAUDIBLE] So I'm just going to take one suture out from here.
NIKHIL GOKHALE: One can go to cannula here, but, to be honest as somebody rightly said in the beginning, it was crowding. Can you hold the others please? Causes crowding. Yeah. Pull on one. Yeah. Hold it, yeah. Hold it there, hold it. Let go. Can you load the first pass?
NIKHIL GOKHALE: So I use a scorpion-like device to go down there and get a bite. [INAUDIBLE] Suture manipulator. I think it's a matter of personal preference more than anything else. Mr L [?] speaking with Dr. Babulkar [?], sir, and what he said was that he takes a bite of the inferior capsule from the posterior board using a laser-like device, which was something- I think there are a lot of people do that, they take a double-loaded suture.
NIKHIL GOKHALE: Yes, yes. In this position. And one of the stitches they use through the posterior portal, the other suture, they use the anterior portal. So you get a wider area and good fixation that way as well. Yes, but it is, I think, more of a personal preference. Yes, absolutely. And this technique works pretty well. Yes. Can you just hold this suture please, under some tension.
NIKHIL GOKHALE: Let go. Let go, please. So I'm just going to try and grab that piece of cartilage and bring it up the labrum as much as possible. You think I can get it up to almost there, two o'clock position?
NIKHIL GOKHALE: Can you hold on to this, please? Tightly. It's not, it's not a locking device. Try to lift it up. I left [?] the other one, the orange. Sorry. Can you load that suture onto this please? And you use a simple configuration, not [INAUDIBLE] simple configuration.
NIKHIL GOKHALE: Can you hold that thread down, please? Thank you. That's our scorpion-like device. Can you distract the joint slightly please? We're going to go as low as possible, there.
NIKHIL GOKHALE: Open up the jaws. Yeah. We are somewhere around five o'clock. I'll try to go lower if possible. [INAUDIBLE] come out. Can you just pull it back towards me? Towards me? Thank you.
NIKHIL GOKHALE: It's got a slight look [?]- can I have a suture manipulator please? [INAUDIBLE] There's one more.
NIKHIL GOKHALE: [INAUDIBLE] [INAUDIBLE] So we've got a slight tangle here. And we are going to try and get this out in front of the loop. There.
NIKHIL GOKHALE: Just hold the posterior thread please. Yeah. OK. All right? So if when, if and when we tie this, this labrum is going to come. Hold it there. Very nice,iIt's forming a bump. Yeah. So now I'm going to request Saudabh to come back. And hold all the scope. One second. Suture [INAUDIBLE] please, Parakh [?] [INAUDIBLE].
NIKHIL GOKHALE: We can get that other suture out. Coming up please. So for tying the knot, I use a simple Duncan loop knot. And it works very well. This is the suture in the front, so I'll make sure that this is my post, and my knot is around this suture rather than this one.
NIKHIL GOKHALE: Yeah. I need to make sure that the sutures are sliding, which they are. Which knot do you use? A Duncan loop. Duncan. Yes, so can you just focus? Yeah. Can you see what I'm doing on that? Yes, we can see.
NIKHIL GOKHALE: Can everyone see that? See the knot [?] Yes, yes. So hold us up. I'll have [?] this. Sir our training, [INAUDIBLE] So as to make sure that you choose the appropriate suture for the post because you want the knot to be on the opposite side on the front, not on the face of the glenoid.
NIKHIL GOKHALE: Angler [?]. Yeah? Yes, we can see that. So we want them not to be there so that it stays away from the joint surface. You see the labrum coming up. I think because he's recently had a acute dislocation,
NIKHIL GOKHALE: his labrum is slightly frayed. I'm going to tighten it more. Right. Strung [?] out nicely. Yeah, can you see that bumper? Yes, we can. OK, hold on. And then I just hit four [?] half inches [?] on top, secure the knot.
NIKHIL GOKHALE: Pass pointing [?] Any questions from the delegates so far? Any questions?
NIKHIL GOKHALE: So do you use like three anchors every time you use the anchors? At least. At least three anchors. OK. At least three anchors. [INAUDIBLE] And if sometimes you can see a tear extending posteriorly, how many anchors would you put posterior?
NIKHIL GOKHALE: So it would depend on the size of the tear, obviously, but then at least one anchor around seven, eight o'clock position. OK. And a single loaded or double loaded? So I would put single loaded. To be honest, I don't have much experience with double loaded anchors. I've used them a few times. I just, I'm worried that putting both the stitches under a lot of tension might sometimes unload the anchor.
NIKHIL GOKHALE: It has happened to me once. After that, I just stopped. I mean, if you need if I need, I can use two single loaded rather than one double loaded. OK. This is an Indigenous suture cutting device, which I don't know if any of you have seen. Can you see this? Yes. It's a modified disc [?].
NIKHIL GOKHALE: So which company means this? So it's a local Indian company. Hip Surgical. OK. but it does the job also, if you see, it ensures that about two to three mm of thread remains in front because that's the thickness of this. Right. So, moving on. Can I have the grasper [?] again, please?
NIKHIL GOKHALE: All this tissue. [INAUDIBLE] The tissue quality doesn't look great in that area.
NIKHIL GOKHALE: Yeah, not good at all. Yeah. Somewhere. But even that doesn't have much of you know, this capsule is completely... So in this case, then would you still put, like, three anchors. Yes at least three. You have some tissue there. OK. Can I have the drill, please?
NIKHIL GOKHALE: With the- Same, we'll just [?] 1 by 4 [?] Second one will go... I'll try to put three, obviously. OK. Yeah. Drill [?] please.
NIKHIL GOKHALE: Is this still the curved one or-? Yes this is the curved one, this is still the curved one [INAUDIBLE]. Anchor, please.
NIKHIL GOKHALE: Hammer. Hold on to the sutures. OK, thank you.
NIKHIL GOKHALE: Can I have the left side bird beak, please? And so we'll to try and retrieve one suture with a bird beak now. Try going as low as possible. It's difficult to use bird beak in the lowermost uh, anchor, but here you should- Why not use the scorpion once again?
NIKHIL GOKHALE: I can use the scorpion, it's just, so, the bird when you use the bird beak, you don't really have to do suture shuttling so much. So you save one step. That's the only reason. The quality of the tissue is not great. Why not just go a little more inferior with the scar? Yeah, I could do that. Suture manipulator.
NIKHIL GOKHALE: Hold the other one please. Take the [INAUDIBLE] Can you load it?
NIKHIL GOKHALE: One second. Short on time [?] go as deep as possible, as you said. Time [?] to grab the tissue there.
NIKHIL GOKHALE: So we've got some tissue there. It's forming some sort of a bumper. But then again, it is quite precarious, isn't it? Yes, yes, it looks precarious. So when you get a stitch like this, would you then rather use like a mattress configuration and use the other stitch to put it more medially while use this stitch as for it as a fraction stitch?
NIKHIL GOKHALE: To be honest, I don't think there is much tissue here. If you see here this subscapularis, it looks like the capsule is torn in that there is no capsule there. OK so I think this is as medial as you can get. [INAUDIBLE] Is the suture not-?
NIKHIL GOKHALE: [INTERPOSING VOICES] After putting this anchor I'll reassess. See where we are in terms of remnant of the labrum. We're getting some sort of a bumper there, but it's definitely not ideal.
NIKHIL GOKHALE: The quality of the tissue is not great, not at all. But I think the four o'clock to five o'clock position, that is the most important thing. Yes, that has been well taken care of. So really actually from one o'clock to three o'clock, it doesn't really matter if you repair that or not.
NIKHIL GOKHALE: Suture manipulator [?] please. Starting through some of the tissues. Very [INAUDIBLE] Yes.
NIKHIL GOKHALE: Shall we induce the next case? Have you taken the case in? Next case. Get here. Yes. Do you want to? Sorry? Yes Nikhil, you were saying something? Well, I was just asking my anesthetist if they have started inducing the next case because they'll need some time.
NIKHIL GOKHALE: So I don't know if any of this issue is worth its salt. [?] There's something there. I think we should be able to get this tissue up as well. You see that? Yes, yes. Looks very flimsy, though. Yes, yes. But something is better than nothing, I guess.
NIKHIL GOKHALE: I think we will be able to get this up and put another anchor, one anchor at least. OK. OK. Let's go back to putting our third anchor. How much space do you keep between the two anchors? So about a centimeter. Straight, again, straight back [?]
NIKHIL GOKHALE: With these smaller anchors, it will just allow you to put more anchors if needed, because the size of these anchors is [INAUDIBLE] 1.4 [INTERPOSING VOICES]. So the anchor would be somewhere around... here. One second, hold this. So we've got space upstairs. We might actually end up putting four anchors if we find tissue.
NIKHIL GOKHALE: Let's see. Yeah? Four anchors? Yes, if we find tissue, because- Let's see. Yeah? Anchor please.
NIKHIL GOKHALE: So literature says at least three anchors is what is necessary. Some others recommend at least four. Right. But I guess by and large, consensus is that three is good enough. So our water has run out, and you just pull up, yeah? OK. Take that. And the cannula. [INAUDIBLE]
NIKHIL GOKHALE: Huh? [INAUDIBLE] Suture manipulator. So there was a question from the delegate here. They want to know that the device that you use for taking the bite, that's through pass [?], what is the depth of the bite that you get from that with that device?
NIKHIL GOKHALE: So first pass, the two of them, this first pass, SD was only used for cuff. So you get about a centimeter of tissue in this. Can you see? And the other one, the orange one is a first pass, meaning it's meant for the labrum. Right. And it is about 2 to 3 mm less. So it's like a younger sibling of this suture busting device. Right, OK.
NIKHIL GOKHALE: [INAUDIBLE] Suture manipulator. [INAUDIBLE] cannula. Can I get any tissue out here? Very flimsy.
NIKHIL GOKHALE: All that [?] capsule released. Let's see.
NIKHIL GOKHALE: There is quite flimsy tissue around here. We'll just try to get at least this bit. It's already got the whole [?] [INAUDIBLE] More beak there.
NIKHIL GOKHALE: Try and take as much tissue as possible from the medial side. So you would like to include the capsule that is beyond the tear as well? Yes, but I don't know how much of it is going to be probably. Yeah. I had another question here. Sometimes if that tissue is really bad, would you, like, take a bite of the subscap? Yes, I've done that.
NIKHIL GOKHALE: And so, to be honest, the first time I did that, it was inadvertent. And I called up my fellowship boss and discussed it with him. And he told me that people used to do that in the olden days. Right. Something which is unheard of. And, yeah so but then I would restrict their external rotation for a few weeks. OK. That's mainly the capsule.
NIKHIL GOKHALE: Not got much in the way of... Can you just hold the other one, please? But that's mainly capsule I've not got much in the way of labrum. On there. [INAUDIBLE] I'll try one more time to see if I can get any labrum as well. Why not do the other [INAUDIBLE] suture, since you already have some tissue in this one?
NIKHIL GOKHALE: Yeah. [INAUDIBLE] But even then it's very final [?]
NIKHIL GOKHALE: Yeah. Hardly any tissue. Sorry? There's hardly any tissue left. Absolutely but, as you rightly said, it's better to include at least whatever we can. Right. Some fissure [?] here.
NIKHIL GOKHALE: Let's see if we can get back. I don't think I'm going to get much in the way of any substantial tissue here. I don't want to keep digging and damaging the labrum.
NIKHIL GOKHALE: [INAUDIBLE] I don't know if I can take a bite of this tissue just to recreate some
NIKHIL GOKHALE: labrum in the front. Can you give me the suture manipulator please? Thank you. No that tissue is really, really, really thin.
NIKHIL GOKHALE: Even this tissue is quite, quite fragile [?] Just try to take this down and stitch it downstairs. Can I have the [INAUDIBLE] Watch they're even [?]
NIKHIL GOKHALE: Put up some tissue there. I don't think I'm going to be able to get any more tissue.
NIKHIL GOKHALE: Let's go back. [INTERPOSING VOICES] [INAUDIBLE] Hold this there please. [INTERPOSING VOICES]
NIKHIL GOKHALE: Even the tissue quality here, the remnant capsule is quite thin. Yeah. Do you guys ever include this bit in the repair? Has anyone done that? It's like the Buford complex, isn't it? Yeah, it's a Buford. Yeah. Yeah. This will be glenohumeral ligament, it is attaching to the top. Hold the lever. [?]
NIKHIL GOKHALE: Yes, yes. I think I'm going to use this tool. Why not use that? Because there is a lack of tissue. Yes, at least some sort of tissue. There is a nice paper which says that there's not much of a difference in terms of getting stiffness, postoperative. So I'm just going to use the-
NIKHIL GOKHALE: Hold the other one please. Come back, please. [INAUDIBLE] Unusual. Yeah I think that is going to give a good- Yeah. Keep sewing [?]
NIKHIL GOKHALE: Thank you. You're doing fine. We just have to end that. Now that's quite a nice integration [?] there. Yes so, integration [?] effect, anterior capsule sort of-
NIKHIL GOKHALE: Yes, yes. And now I think I'm a little bit more optimistic of putting another anchor. I think- What do you think, three's enough? I think three should be enough. I think because you've sort of bunched up the capsule there. [INAUDIBLE] anchor. Yes, yes, yes. So I think I'll go a little slow with this mobilization
NIKHIL GOKHALE: postoperatively. Right. Let it all heal up. Do you have a normal postop protocol that you follow? I just give them something for comfort. Tell them to avoid external rotation beyond 45 degrees for six weeks. OK. Start active [?] assisted movements whenever pain allows. Anybody does anything different?
NIKHIL GOKHALE: If it [?] was top [?] protocol. Labral tear repairs. I think you said correctly, I just use a sling for about six weeks and avoid any heavy activity. But day to day activity, I would allow them to do it immediately, as soon as the pain allows them to do it. What's not to be done for at least two to three months?
NIKHIL GOKHALE: Sports-specific training. Three months, yeah. Yes, I think full-fledged contact sport six months. Sew it [?] So when you [INAUDIBLE] it means what? Sorry? You said that you want to go slow in this particular patient, so-
NIKHIL GOKHALE: Yes so I'll not really start active assisted movements. I'd suspend a lot of [?] movements for three to four weeks. OK. Gradually start active assisted movements. So keep him in the sling as much as possible for four weeks or so. Four to six weeks. Yes, yes. Just because of the quality of his tissues. Right. I'm [INAUDIBLE]
NIKHIL GOKHALE: Yes. Any more questions from the delegates? Yes, I think we have one question. Do you want to-? Yes go for it. If we are seeing such poor quality tissue or fraying of tissue on table [?] Yeah? Is it better to [INAUDIBLE] to convert this patient into Bankart [?] or we should do such [INAUDIBLE]?
NIKHIL GOKHALE: Yes see, the thing is, we are already here now, so let's repair whatever we can. And of course, if he starts dislocating again, then the next thing to do would be a Laterjet. Because we're not losing anything by doing this repair. Yes, his tissues are [INAUDIBLE], but I think we've got, you know, at least some sort of capsular tightening. My scope is not going down now. The drive-thru [?] sign is negative.
NIKHIL GOKHALE: So hopefully they should all start up and he should be all right. Got some sort of a bumper there. [INTERPOSING VOICES] Sorry? Have you ever [INAUDIBLE] [INAUDIBLE] I can't hear you, sorry.
NIKHIL GOKHALE: Can you hear me? Hello? Can you use the mic? That's what- Hello? Am I audible? Ask the question again.
NIKHIL GOKHALE: So, Nikhil, can you hear us now? Yes, now I can. Yes. OK. So the question is, have you ever converted a surgery that you started out arthroscopic and then converted into Latarjet, and what was your threshold? No, I've never, never had to do that. So almost always it's a preop decision.
NIKHIL GOKHALE: Yes, yes. How about the others? Anyone else had to convert it? So, so I think there are two things. One is, you know, you go in, do a diagnostic scoping, and then decide whether you're going to do a Bankart, soft tissue repair or Latarjet process. You go in thinking, doing, thinking that you're going to do a Bankart, but because of soft tissue, you convert into Latarjet.
NIKHIL GOKHALE: Right. I've never had to do the latter and I never used the prior because it's a preop decision, whether it's a bony procedure a or soft tissue procedure. Right. So also in your clinical experience, when patients have these kind of like poor tissue, how have they fared postoperatively? So, I mean, to be honest - like, have they redislocated? - one patient who's had such poor tissue and he's about six months postop and is not really reconstructed [?] yet.
NIKHIL GOKHALE: So - Has he resumed all activities? Yes, yes, yes. He's resumed all activities. He's slightly on the stiffer side, but I'm telling him not to stretch much. But gradually they all stretch out. They start using the shoulder. No apprehension? No, no.
NIKHIL GOKHALE: He's not apprehensive yet. OK, thanks. Yeah, any other questions? Do we have any other questions? If not, then we'll go on to the next surgery. Right. Is that all right?
NIKHIL GOKHALE: Yes, yes. Thank you very much. OK. You got an excellent demonstration. I just wish that the tissue quality was better. Thank you so much. Thank you. We always wish for that, right? Yes, but especially in a demo case. All right,
NIKHIL GOKHALE: thank you so much. [INAUDIBLE] [INTERPOSING VOICES]
Segment:0 .
NIKHIL GOKHALE: Hello.
DIPIT SAHU: Hi Nikhil yes, you are. Go ahead.
NIKHIL GOKHALE: Hi yes. So good morning, everyone. So this is a soft-tissue Bankart repair we are doing in a 25-year-old chap. He's a kabaddi player.
NIKHIL GOKHALE: He has his first dislocation about four years ago while playing kabaddi. The last one was about 2 and 1/2 months back while swimming. He's had no slip dislocations. He has a Beighton score of 0 by nine, so no laxity as such. We've done imaging. I don't know if Dr. [inaudible] has shown you the images. He's got a soft tissue Bankart, minimal bone loss on the anterior glenoid and Hill-Sachs, which is shallow and measures about 11 in width.
NIKHIL GOKHALE: So I have with me Dr. Abhishek Jaroli and Dr. Saurabh who are going to give me a hand and Dr. Ganesh is our anesthetist so the patient is under GA in beach-chair position. We've given a [INAUDIBLE] block that helps reduce the pain and reactionary bleeding. I also give them tranexamic acid, something I picked up from arthroplasty people and we've applied gentle traction on the arm just to balance it.
NIKHIL GOKHALE: I took the liberty to start making the initial posterior portal and one of the working portals whilst waiting. Am I audible? Hello? Any questions so far? You're very well audible. Yes. So let me just take you through a round of diagnostic arthroscopy. So on the right side of the screen, So the patient is in beach-chair position.
NIKHIL GOKHALE: That's how I do my shoulder arthroscopy. So the glenohumeral joint will always look vertical. On the right side of your screen is the flat glenoid. On the left side is the humeral head. On top here what you see is the biceps tendon. So that's called a lighthouse of the shoulder. In the beginning, whenever you get lost while doing arthroscopy, just look for this and then try to find this triangle.
NIKHIL GOKHALE: We call it the horizon. Once you see this triangle, you'll know where you are and you can reference off it and move around. If you go in slightly deeper, This, this band here, that's the upper margin of the subscapularis muscle. Now, because this last dislocation was just a couple of months ago, there's still some capsulitis, but clinically has got full range of movement.
NIKHIL GOKHALE: Now if you see anteriorly, there is deficiency of the labrum all the way from about there one o'clock position. And somewhere around here six o'clock position, you start seeing the labrum again. Yeah, can you see that?
NIKHIL GOKHALE: But the posterior [?] labrum is intact. Yeah that's the posterior [?] labrum there, and the anterior labrum is stone [?]. Now it doesn't have much in the way of glenoid bone loss, but there is a Hill-Sachs defect. So carrying on with the diagnostic round, this transverse band you see in the front, is the subscapularis.
NIKHIL GOKHALE: This triangle in between is the rotator interval. Yeah, so between the subscap and the anterior margin of the supraspinatus is the rotator interval. And therein lies the biceps tendon. If you keep coming back from the biceps, this tendon here is the tendon of the supraspinatus, which is intact. If you come further behind, that's a tendon of the infraspinatus. Now here, you start seeing some bone loss.
NIKHIL GOKHALE: Can you see that? Hello? Yes, yes, you can see bone loss. Yeah. Now, the normal anatomic bare [?] spot is also in this region. And sometimes one can get confused as to whether it is a Hill-Sachs lesion or a normal anatomic bare spot. And the way to tell is that if you see the Hill-Sachs, there will be an abrupt ending between the cartilage and the subchondral bone.
NIKHIL GOKHALE: Whereas if you look at the bare spot, it's more of a gradual transition from cartilage to bone. So if you keep going back, you come into the inferior pouch. That's the inferior glenohumeral [?] ligament. Yeah? Yes. I'm going back into the shoulder that's the glenohumeral joint.
NIKHIL GOKHALE: So the next thing we're going to do is we are going to establish the interval portal. I've already made the superior viewing portal. Can I have a needle please? So the anterior inferior portal will try to make it just skirting the subscap, I'm coming down.
NIKHIL GOKHALE: I want to be slightly more inferior than that. So somewhere there. Yeah? So normally how much space do you want between the two portals, anterior portals? So normally I put a cannula in here and I really don't always put a cannula in the superior lateral portal because I view from here and then I use it to shuttle sutures directly from the cuff.
NIKHIL GOKHALE: But yes, we need at least a centimeter, centimeter and a half of gap. Also, what one can do to prevent crowding is use a larger cannula in the front and maybe a smaller cannula there at the back. So you are demonstrating outside-in technique, which is the laid out technique that you can use for this portal as well, right?
NIKHIL GOKHALE: Yes yes, you can use the internal technique as well. But to be honest, I have never really used it. I've always used the outside-in technique. So I'm trying to keep my blade away from the subscap to prevent any iatrogenic damage. The subscap. And try not to rotate the blade inside because these are flimsy blades, they can sometimes break and then it's a disaster.
NIKHIL GOKHALE: Can I have a [INAUDIBLE] please? So I'm making the skin incision slightly longer at this point because my 8.5 mm cannula needs to go in from here. So everyone is aware of the inside-out technique also, all the delegates? Yes? So with the inside-out technique, you basically, what you do is you just drive your posterior [INTERPOSING VOICES] drive it forward.
NIKHIL GOKHALE: So they're just touching the subscap tendon and then bring the scope out and pass everything the rod through which comes out to the skin. So that is the- it's a relatively easier and safer way of starting to do [INAUDIBLE]. You're starting out with the arthroscopy that is a safer, easier, more reliable way of doing a [INAUDIBLE] especially the one that he's showing right now, The green cannula with the dilator please.
NIKHIL GOKHALE: [INTERPOSING VOICES] Yes, yes. All the portals are in the [INAUDIBLE]. That's why externally we are taking the portals to make sure there is adequate space we don't want there to be any [?] crowding of the tendon. [?] It depends on what you're used to but school [?] is more strict [?] around here.
NIKHIL GOKHALE: So I've got my 8.5 mm cannula in. [INAUDIBLE] please. I'm going to pull out the cannula and, just pull it out, yeah. Thank you. And it is looking directly all the way down. OK so if [INAUDIBLE] please. So when I eventually pass my anchors. Can I just distract the joint slightly?
NIKHIL GOKHALE: So I've got a shot right up till there. Almost five o'clock position. Is that OK? Yes. OK. Right so, when you think of doing an arthroscopic Bankart surgery, you think of it in three steps. First is establishing your portals. So that is the viewing portal, ah sorry that is the working portal.
NIKHIL GOKHALE: There is where I'll put my scope. If you see there's adequate space in between, so I don't expect any crowding to happen. So portals are done. Next is to find the actual Bankart lesion. Now, if you see in the front, there's absolutely no tissue there. Yeah? And this is what generally happens. The tissue lies somewhere around the corner in the front.
NIKHIL GOKHALE: That is perhaps some capsule where it's very difficult to look at it from this position, so we are now going to switch to this portal here. That all right? It looks like an ulcer [?] lesion. Yes, yes. But even on the scan, I didn't see any labrum because probably because it's subluxation [?] or dislocated seven, eight times. His entire labrum is degenerate.
NIKHIL GOKHALE: Anyway I will shift our scope to the superior viewing portal so that can come behind us. So everyone knows that [INAUDIBLE], I'll say is where the labrum sort of dislocates and heals medially to the glenoid instead of being at the edge, it moves medially. Sometimes it is detached in certain areas, but in some areas it is attached to the medial side or medially to the- [INTERPOSING VOICES] Yeah, sure.
NIKHIL GOKHALE: I mean, sometimes we see patients who are dislocated 20, 30 times, 50 times. So it all depends on how loose the shoulder is. But it depends. You have to assess it's not only that you have to first assess the bone loss. You can [?] see the quality of the tissue, things like that.
NIKHIL GOKHALE: So the planning for a Bankart is not when you are doing the surgery, it is before the surgery, it's preoperative, the plan. Right? So, Nikhil, we have a question here. The delegates want to know whether in multiple dislocators you will just do a Bankart or how will you plan your surgery in multiple dislocators? So I think more than the number of dislocations, I think a couple of things are important.
NIKHIL GOKHALE: One is whether theyre dislocating in sleep or not. Second is whether they have soft-tissue laxity or not. And third is what the imaging shows. Now, this person hasn't really dislocated in his sleep, is not really, uh, doesn't have much in the way of laxity. When we did imaging and, one sec, let me just clear this up, we've also done a CT for him. The CT doesn't show much in the way of bone loss.
NIKHIL GOKHALE: There's hardly, perhaps 5% bone loss. So I don't really think that he needs any bony procedure. I don't really decide that interop, my planning is all done preoperatively. I know some people like to do a diagnostic scope and then decide whether they're going to go ahead with the soft-tissue or bony procedure. Also the size of his- so the first thing I look at in imaging is the amount of bone loss.
NIKHIL GOKHALE: If it is more than 15%, I would be worried. If it is more than 20%, definitely I would offer them a bony procedure. 15 to 20%, as everyone knows,is slightly of a gray zone. Also depends on the individual patient characteristics. The next thing- Nikhil, let me stop you. Now you're talking about the glenoid bone loss, but do you have [?] combined bone loss also or just the glenoid loss? Yes so the first thing I look at is glenoid bone loss.
NIKHIL GOKHALE: Then I look at whether the Hill-Sachs lesion is engaging or not. So if the patient has a 20% bone loss, then I would just offer them a Latarjet. If there is no significant bone loss, the next thing I look at is whether the Hill-Sachs is engaging or not. So you can see the Hill-Sachs over here. So that is rather on track or not. So what I've realized after doing a lot of calculations is that for the Hill-Sachs to be off track, you know, if the width of the Hill-Sachs is more than 20, then it is more likely to be off track.
NIKHIL GOKHALE: So only if the width of the Hill-Sachs, as per [INAUDIBLE] reported is more than 15, then I actually do those calculations. His MRI has reported a Hill-Sachs width of around 11. Also it's quite shallow so I don't really think that he's going to need any posterior procedure like a remplissage. So it's more than the depth of the Hill-Sachs. It's where it is. If it is more medial [INTERPOSING VOICES] width of the engaging rather than the depth of the inside. [?] So that is more important.
NIKHIL GOKHALE: Also, you can do glenoid tracking, which is offered by some of the ligaments. I'm not sure where you practice, whether they do the glenoid tracking, but that can be done and that can give you a more accurate sort of understanding of the combined bone loss. So now I'm going to start elevating the capsule. Are you able to see the labrum there?
NIKHIL GOKHALE: Some tissue. Perhaps this is all stuck medially, so it's very diff- yeah, perhaps this is the labrum. Can you see that? That which I'm rolling in? Yeah, yeah. Gone all medially. So it's a classic ulcer [?]. Yeah yeah, we will start calibrating it and see what happens.
NIKHIL GOKHALE: [INTERPOSING VOICES] Yeah, tap tap tap [?] [INAUDIBLE] because we know that [INAUDIBLE] [INAUDIBLE] Let's focus on that. [INTERPOSING VOICES] [INAUDIBLE] So I'm getting some tissue, which looks like labral tissue, or generally when you liberate [?] all the way, you start to see some kind of bleeding there.
NIKHIL GOKHALE: [INTERPOSING VOICES] Tap tap tap, please. Once or twice please [?] Now I think we are around four thirty, five o'clock position.
NIKHIL GOKHALE: All the way, all the way. Keep going. Keep going. And you suddenly feel it give way. That's when you know that it's completely elevated. Am I audible? Yes yes, go ahead. Just not getting any feedback. Surgeon? Yeah. So we have a question here from the delegate.
NIKHIL GOKHALE: They are asking is, if the tissue is very flimsy, Yeah? And you're not able to see adequate labrum anterior- how would you proceed then? So generally when you see from this portal, even if the tissue on top here is flimsy, you'll see that the [INAUDIBLE] has gone down and stuck somewhere behind. So in that case, you can liberate the tissue and try to tuck it up at least up to two thirty, three o'clock position. Hammer [?] please.
NIKHIL GOKHALE: If there is absolutely no tissue, then I'm afraid the only option is to abandon the surgery and convert it into a - can you retract, [INAUDIBLE] around please - into a bony procedure at a later date. So you would prefer to do a bony instead of doing just a capsular shift? Do you consider doing a capsular shift like anterior as well as posterior and then interval closure? [INAUDIBLE] or remplissage [?]. So, see I thought the question was if there is no capsule.
NIKHIL GOKHALE: So of course, if there is capsular tissue, then yes, that would be an option to create sort of a new labrum. Right, right. By just rolling it up and creating a bumper to give some sort of a suction cup effect. Yeah. But yes if there's absolutely no capsular tissue, see now we are going almost up to five, five thirty position. Yeah, and from there the labrum is sort of intact. Yeah? Yes.
NIKHIL GOKHALE: [INTERPOSING VOICES] Hammer please. [INAUDIBLE] all the way down to continue via incisions [?] Sorry? I didn't catch the question. The question was, they wanted to ask, what does exactly 'liberate' mean. Liberate means? [INTERPOSING VOICES] Yes, yes. And how much do you release?
NIKHIL GOKHALE: Yes, yes. So if you see initially you weren't really seeing much, but now you can see this white tissue. Yeah so that was the tissue, which is a part of the labrum periosteum capsule complex, which had migrated medially and stuck to the neck of the glenoid. And how much to liberate is till you start seeing the fibers of the subscapsule.
NIKHIL GOKHALE: You see that hole there? Yes, yes. So that is our extent of liberation. So when that hole extends all throughout, that is when we know that we have completely liberated the tissue and then it starts floating [?] nicely. Can you tap, tap, tap, please? Yeah. So also in these ulcer [?] lesions, when you liberate or release the whole tissue the labrum comes back and sits at the edge of the glenoid.
NIKHIL GOKHALE: So, you know, that is an adequate [INAUDIBLE] Yes, yes. So this is tissue [INAUDIBLE] site of periosteum. [?] Yes, yes, it is. Just like, you know, while doing a hemiarthroplasty, you take off the extraosseous [?] from the bone. That is exactly what we're doing. So some people have seen some people using like a mallet in order to release it very close- Yeah we are using a mallet.
NIKHIL GOKHALE: So my colleague is hammering it. As I would say, tap tap tap. Not just a hand movement, but you also use fine strokes of that mallet. You can also use a 20 degree turbo wand [?], which is exactly the shape of a - tap, tap, tap - periosteal elevator, [?] but has a radio [?] frequency at the top that helps to reduce bleeding as well. Tap, tap, tap.
NIKHIL GOKHALE: See that is Subscap is slightly more somewhere here. This is going to be And sometimes when we think of something as an extension of [?] [INAUDIBLE] [INAUDIBLE] All of it. Yeah. So I can feel the tissue liberating.
NIKHIL GOKHALE: Can you see that white band coming out? I'm sorry? Can you see that white band which is- Yes, yes, we can see. Gradually. Think it's going down. Traction, slight traction.
NIKHIL GOKHALE: Yeah, [INAUDIBLE] [INTERPOSING VOICES] Yes so a ligament tissue [?] is the one that the hammer- Can you show us the medial glenohumeral ligament? Delegates want to see whether the [INTERPOSING VOICES] It's usually the one that crosses the subscap. Yes, yes. So... it's gone back slightly.
NIKHIL GOKHALE: So it's seen better from the posterior portal. Yes. Can you see this band? One second. Is this the biceps? Yeah. So this, this band of tissue. Yeah, this band of tissue going from here.
NIKHIL GOKHALE: Yeah, can you see that? That is the medial interior [?] ligament attaching to the glenoid. Yeah, so it's going from the glenoid up to the humeral head. Also if you see the head is not really central as it is subluxing. Slightly anteriorly, not much. Right. Slightly. And there's not much in the way of bone loss. Otherwise you see those pear-shaped, inverted, pear-shaped-
NIKHIL GOKHALE: So that is you can also see the bare spot of the glenoid. So, yeah, this is the best part of the glenoid that's the embryological center, so-called. And what they say is it is the center between the anterior and posterior axis, although there are studies which have shown that the anterior- inferior distance is slightly less as compared to the posterior-inferior. So it's not exactly the center, but I think if you're looking at it, then a few millimeters is very difficult to really make out, isn't it?
NIKHIL GOKHALE: Traction. Thank you. I think there is some region somewhere around here. Tap, tap, tap please. I can feel some fiber, can we open Yeah, yeah. Yeah. So whenever that blood comes, it means that we've
NIKHIL GOKHALE: drawn [?] adequately. Yeah. Hammer, please. OK. Yeah, OK. See, now the capsule is starting to show. Can I have a suture manipulator please?
NIKHIL GOKHALE: Can you see that? Yes. So now this is going to come and sit here. OK? Yeah. Yes. Let's prepare the the bed [?] Now, this tissue here. We need to rasp [?] it and make sure that
NIKHIL GOKHALE: Your arm, please [?] One second, I think my cannula has come out. Rasp please. [?] Can you hold the cannula please?
NIKHIL GOKHALE: OK. I'm assuming everyone has started doing a few shorter [INAUDIBLE] to preserve the digits. Yes so that is the rasp. It's a very sharp instrument and its only function is to operate the bone so that we get a good healing surface. OK? We start from somewhere there. Hammer, please.
NIKHIL GOKHALE: Yeah. Tap tap tap. Tap. OK. Hammer please. It can be challenging if you have not done it in the past. The main reason is - hammer please - how much bleeding [?] in the knee. If you've done knee arthroscopy, you're not worried about doing the shoulder. You have to be worried about [INAUDIBLE] So I think actually personally I feel that doing knee arthroscopy is more difficult. The shoulder is a round joint, right?
NIKHIL GOKHALE: So eventually your instruments will triangulate if you try to put them into the center of the cavity. But it is more like a disk. Plus, it's a tighter joint to actually dissect it as much. No, no, Nikhil I was telling them about the bleeding. If once you start getting bleeding, if you are a beginner, it can be quite daunting.
NIKHIL GOKHALE: Yes, yes. OK, OK. That can put you off completely off shoulder. So if you are starting out, you have to be a little patient and may take some time in order to do your first entire case arthroscopy. So what do you guys do for instability? [INAUDIBLE] Are you reopen this? Open?
NIKHIL GOKHALE: [INAUDIBLE] OK, now I understand. I think that is the best way of starting your arthroscopy is to have someone who has a little bit of experience, who is helping you out, and then gradually you can take over more and more steps in the surgery. Yeah I think mentorship is very important, especially while doing surgery.
NIKHIL GOKHALE: Get some traction. Just going around the edge there. I think I've abraded enough, gotten enough scar tissue out. Do you use like a shaver or some? Yes, I'm going to use a shaver next.
NIKHIL GOKHALE: Attach the suction on the shape of this [?] Thank you. Yeah, can you give me the foot pedal? So you just shave off all these adhesions and scar tissue.
NIKHIL GOKHALE: Suctions [INAUDIBLE]. OK.
NIKHIL GOKHALE: I've just kept the suction on very minimal outflow. I don't want the entire thing to collapse. Just want to take the soft tissue out which I think I've done. Yeah. Can you see that raw surface now? Yes. So that's the bed.
NIKHIL GOKHALE: That's what you want to repair. Can you see that? Yes, we can. There's a little bleeding, Bankart [?] bleeding also. Yes, yes, we want that. Because we want some biology to come in and chip in. So all the way up to almost five thirty, six.
NIKHIL GOKHALE: o'clock, yeah? Yeah. Vertical [?] capsule. So I'm going to switch back to the posterior portal now. [INAUDIBLE] What anchor placement do you use the scope, in the post? Yes, I use the scope in the posterior portal. It's just how I'm used to viewing things while putting anchors.
NIKHIL GOKHALE: Also, the fact that if one has to pull up the superior edge of the labrum at any point, then the anterior super [?] portal comes in handy. Sure. Do you like, in the setup, do you like to use like a lateral traction, that dual traction that some of these companies have. Have you used-
NIKHIL GOKHALE: No, I have never used that, I mean, I would like to. I've never used it, to be honest. We have recently acquired the spider. Can you put the suction in, please? Spider? Yes, the Smith and Nephew spider and attachment.
NIKHIL GOKHALE: But you have to start using it regularly OK. One sec, one sec. So it's nicely bleeding, now you see that labrum, which was initially not visible. It's nicely seen. This this whole tissue. I think my green cannula is out. Hold this. Can I have the [INAUDIBLE], please?
NIKHIL GOKHALE: I'm just going to reposition the cannula. Yes. Thank you. And now Saurabh is going to make sure that the cannula doesn't come out again.
NIKHIL GOKHALE: OK. Hold on [?] Green angular [?] OK. So we've prepared our bed. Pick up [INAUDIBLE], please.
NIKHIL GOKHALE: That's the labrum which we want to repair. It's... yeah? So it's coming up nicely. I think I might have to hold it in traction even while taking sutures. Yeah. I think it's deficient somewhere here, but it's coming up nicely with the [INAUDIBLE]. OK. Grasp through the superior portals. [?]
NIKHIL GOKHALE: That's what I want. [?] Grasp them. Where the scope was. Yes, exactly. We can hold it up and then take a stitch [?] through there here in [INAUDIBLE]
NIKHIL GOKHALE: Some traction [?] Looking all right but the more I look at it, it seems to be lesser and lesser. So if you could just hold it up there, please. I think once we start putting sutures, it will start coming up nicely.
NIKHIL GOKHALE: Can I have the [INAUDIBLE] guide? [INAUDIBLE] guide? What kind of anchor configuration do you use? So I use at least three single loaded all suture anchors. Single loaded. Yes, yes, single load. So just don't let it all-
NIKHIL GOKHALE: Relax. And we're using Iconix. All suture anchors, some traction. This is a nice curved guide. Just hold the cannula. Can you see this on the outside screen? Yes, yes. So that allows us to get a good angle onto the surface of the glenoid.
NIKHIL GOKHALE: For the first, for the lowermost anchor? Yes, yes. And obviously you will be using the straighter ones for the- Yes, the latter ones. So... Where, where is the placement? This is the most important anchor. Yes, so I tried to place it around five o'clock. So this is six. I feel this is somewhere around five o'clock. Also, I try to be slightly onto the surface of the glenoid, then the edge.
NIKHIL GOKHALE: So maybe about a millimeter of tissue there. Are you happy with that placement? Yeah it looks good. Yeah? Drill, please. Nikhil, just stop- So there are a lot of controversies of how much cartilage to remove. You remove a bit? I don't remove any cartilage, no.
NIKHIL GOKHALE: So, you don't want the healing on the edge, because Dr. Sanjay Desai just published a randomized controlled trial. Yes. In arthroscopy journal. And he said you remove four or five mm of the cartilage on the edge because you want the healing between the labrum and the edge. Yes. Right? So that is one concept.
NIKHIL GOKHALE: Yes. You just want it on the glenoid, the healing. Yes. Remove just a bit, but you don't remove at all? Or you would do a little bit of, uh- So I don't remove, whatever abrasion I did with the shaver, that's it. See, the thing is that if you think of bone loss, I mean, I may be wrong, this is just my thinking. Evidence is always superior.
NIKHIL GOKHALE: But if you think of bone loss, the average size for a dentist and - hammer hammer hammer - the average width of the glenoid is about 25 to 28 mm. So every 1 millimeter is about 3% bone loss. So I don't really know if causing that heterogenic [?] bone loss was a good thing or a bad thing. So technically, it's not about [?] taking the bone off [INTERPOSING VOICES] so that there is more surface area for healing.
NIKHIL GOKHALE: Yes, for healing. Maybe I should change, but I've never done that. Yeah yeah, very few people do it. People do it. Pull the two threads please. This- here. That's it, that's it. That's it that's it. OK, so I've got my first site of the whole thing [?]
NIKHIL GOKHALE: OK. It started to draw the cannula slightly. OK. [INAUDIBLE] So I'm just going to take one suture out from here.
NIKHIL GOKHALE: One can go to cannula here, but, to be honest as somebody rightly said in the beginning, it was crowding. Can you hold the others please? Causes crowding. Yeah. Pull on one. Yeah. Hold it, yeah. Hold it there, hold it. Let go. Can you load the first pass?
NIKHIL GOKHALE: So I use a scorpion-like device to go down there and get a bite. [INAUDIBLE] Suture manipulator. I think it's a matter of personal preference more than anything else. Mr L [?] speaking with Dr. Babulkar [?], sir, and what he said was that he takes a bite of the inferior capsule from the posterior board using a laser-like device, which was something- I think there are a lot of people do that, they take a double-loaded suture.
NIKHIL GOKHALE: Yes, yes. In this position. And one of the stitches they use through the posterior portal, the other suture, they use the anterior portal. So you get a wider area and good fixation that way as well. Yes, but it is, I think, more of a personal preference. Yes, absolutely. And this technique works pretty well. Yes. Can you just hold this suture please, under some tension.
NIKHIL GOKHALE: Let go. Let go, please. So I'm just going to try and grab that piece of cartilage and bring it up the labrum as much as possible. You think I can get it up to almost there, two o'clock position?
NIKHIL GOKHALE: Can you hold on to this, please? Tightly. It's not, it's not a locking device. Try to lift it up. I left [?] the other one, the orange. Sorry. Can you load that suture onto this please? And you use a simple configuration, not [INAUDIBLE] simple configuration.
NIKHIL GOKHALE: Can you hold that thread down, please? Thank you. That's our scorpion-like device. Can you distract the joint slightly please? We're going to go as low as possible, there.
NIKHIL GOKHALE: Open up the jaws. Yeah. We are somewhere around five o'clock. I'll try to go lower if possible. [INAUDIBLE] come out. Can you just pull it back towards me? Towards me? Thank you.
NIKHIL GOKHALE: It's got a slight look [?]- can I have a suture manipulator please? [INAUDIBLE] There's one more.
NIKHIL GOKHALE: [INAUDIBLE] [INAUDIBLE] So we've got a slight tangle here. And we are going to try and get this out in front of the loop. There.
NIKHIL GOKHALE: Just hold the posterior thread please. Yeah. OK. All right? So if when, if and when we tie this, this labrum is going to come. Hold it there. Very nice,iIt's forming a bump. Yeah. So now I'm going to request Saudabh to come back. And hold all the scope. One second. Suture [INAUDIBLE] please, Parakh [?] [INAUDIBLE].
NIKHIL GOKHALE: We can get that other suture out. Coming up please. So for tying the knot, I use a simple Duncan loop knot. And it works very well. This is the suture in the front, so I'll make sure that this is my post, and my knot is around this suture rather than this one.
NIKHIL GOKHALE: Yeah. I need to make sure that the sutures are sliding, which they are. Which knot do you use? A Duncan loop. Duncan. Yes, so can you just focus? Yeah. Can you see what I'm doing on that? Yes, we can see.
NIKHIL GOKHALE: Can everyone see that? See the knot [?] Yes, yes. So hold us up. I'll have [?] this. Sir our training, [INAUDIBLE] So as to make sure that you choose the appropriate suture for the post because you want the knot to be on the opposite side on the front, not on the face of the glenoid.
NIKHIL GOKHALE: Angler [?]. Yeah? Yes, we can see that. So we want them not to be there so that it stays away from the joint surface. You see the labrum coming up. I think because he's recently had a acute dislocation,
NIKHIL GOKHALE: his labrum is slightly frayed. I'm going to tighten it more. Right. Strung [?] out nicely. Yeah, can you see that bumper? Yes, we can. OK, hold on. And then I just hit four [?] half inches [?] on top, secure the knot.
NIKHIL GOKHALE: Pass pointing [?] Any questions from the delegates so far? Any questions?
NIKHIL GOKHALE: So do you use like three anchors every time you use the anchors? At least. At least three anchors. OK. At least three anchors. [INAUDIBLE] And if sometimes you can see a tear extending posteriorly, how many anchors would you put posterior?
NIKHIL GOKHALE: So it would depend on the size of the tear, obviously, but then at least one anchor around seven, eight o'clock position. OK. And a single loaded or double loaded? So I would put single loaded. To be honest, I don't have much experience with double loaded anchors. I've used them a few times. I just, I'm worried that putting both the stitches under a lot of tension might sometimes unload the anchor.
NIKHIL GOKHALE: It has happened to me once. After that, I just stopped. I mean, if you need if I need, I can use two single loaded rather than one double loaded. OK. This is an Indigenous suture cutting device, which I don't know if any of you have seen. Can you see this? Yes. It's a modified disc [?].
NIKHIL GOKHALE: So which company means this? So it's a local Indian company. Hip Surgical. OK. but it does the job also, if you see, it ensures that about two to three mm of thread remains in front because that's the thickness of this. Right. So, moving on. Can I have the grasper [?] again, please?
NIKHIL GOKHALE: All this tissue. [INAUDIBLE] The tissue quality doesn't look great in that area.
NIKHIL GOKHALE: Yeah, not good at all. Yeah. Somewhere. But even that doesn't have much of you know, this capsule is completely... So in this case, then would you still put, like, three anchors. Yes at least three. You have some tissue there. OK. Can I have the drill, please?
NIKHIL GOKHALE: With the- Same, we'll just [?] 1 by 4 [?] Second one will go... I'll try to put three, obviously. OK. Yeah. Drill [?] please.
NIKHIL GOKHALE: Is this still the curved one or-? Yes this is the curved one, this is still the curved one [INAUDIBLE]. Anchor, please.
NIKHIL GOKHALE: Hammer. Hold on to the sutures. OK, thank you.
NIKHIL GOKHALE: Can I have the left side bird beak, please? And so we'll to try and retrieve one suture with a bird beak now. Try going as low as possible. It's difficult to use bird beak in the lowermost uh, anchor, but here you should- Why not use the scorpion once again?
NIKHIL GOKHALE: I can use the scorpion, it's just, so, the bird when you use the bird beak, you don't really have to do suture shuttling so much. So you save one step. That's the only reason. The quality of the tissue is not great. Why not just go a little more inferior with the scar? Yeah, I could do that. Suture manipulator.
NIKHIL GOKHALE: Hold the other one please. Take the [INAUDIBLE] Can you load it?
NIKHIL GOKHALE: One second. Short on time [?] go as deep as possible, as you said. Time [?] to grab the tissue there.
NIKHIL GOKHALE: So we've got some tissue there. It's forming some sort of a bumper. But then again, it is quite precarious, isn't it? Yes, yes, it looks precarious. So when you get a stitch like this, would you then rather use like a mattress configuration and use the other stitch to put it more medially while use this stitch as for it as a fraction stitch?
NIKHIL GOKHALE: To be honest, I don't think there is much tissue here. If you see here this subscapularis, it looks like the capsule is torn in that there is no capsule there. OK so I think this is as medial as you can get. [INAUDIBLE] Is the suture not-?
NIKHIL GOKHALE: [INTERPOSING VOICES] After putting this anchor I'll reassess. See where we are in terms of remnant of the labrum. We're getting some sort of a bumper there, but it's definitely not ideal.
NIKHIL GOKHALE: The quality of the tissue is not great, not at all. But I think the four o'clock to five o'clock position, that is the most important thing. Yes, that has been well taken care of. So really actually from one o'clock to three o'clock, it doesn't really matter if you repair that or not.
NIKHIL GOKHALE: Suture manipulator [?] please. Starting through some of the tissues. Very [INAUDIBLE] Yes.
NIKHIL GOKHALE: Shall we induce the next case? Have you taken the case in? Next case. Get here. Yes. Do you want to? Sorry? Yes Nikhil, you were saying something? Well, I was just asking my anesthetist if they have started inducing the next case because they'll need some time.
NIKHIL GOKHALE: So I don't know if any of this issue is worth its salt. [?] There's something there. I think we should be able to get this tissue up as well. You see that? Yes, yes. Looks very flimsy, though. Yes, yes. But something is better than nothing, I guess.
NIKHIL GOKHALE: I think we will be able to get this up and put another anchor, one anchor at least. OK. OK. Let's go back to putting our third anchor. How much space do you keep between the two anchors? So about a centimeter. Straight, again, straight back [?]
NIKHIL GOKHALE: With these smaller anchors, it will just allow you to put more anchors if needed, because the size of these anchors is [INAUDIBLE] 1.4 [INTERPOSING VOICES]. So the anchor would be somewhere around... here. One second, hold this. So we've got space upstairs. We might actually end up putting four anchors if we find tissue.
NIKHIL GOKHALE: Let's see. Yeah? Four anchors? Yes, if we find tissue, because- Let's see. Yeah? Anchor please.
NIKHIL GOKHALE: So literature says at least three anchors is what is necessary. Some others recommend at least four. Right. But I guess by and large, consensus is that three is good enough. So our water has run out, and you just pull up, yeah? OK. Take that. And the cannula. [INAUDIBLE]
NIKHIL GOKHALE: Huh? [INAUDIBLE] Suture manipulator. So there was a question from the delegate here. They want to know that the device that you use for taking the bite, that's through pass [?], what is the depth of the bite that you get from that with that device?
NIKHIL GOKHALE: So first pass, the two of them, this first pass, SD was only used for cuff. So you get about a centimeter of tissue in this. Can you see? And the other one, the orange one is a first pass, meaning it's meant for the labrum. Right. And it is about 2 to 3 mm less. So it's like a younger sibling of this suture busting device. Right, OK.
NIKHIL GOKHALE: [INAUDIBLE] Suture manipulator. [INAUDIBLE] cannula. Can I get any tissue out here? Very flimsy.
NIKHIL GOKHALE: All that [?] capsule released. Let's see.
NIKHIL GOKHALE: There is quite flimsy tissue around here. We'll just try to get at least this bit. It's already got the whole [?] [INAUDIBLE] More beak there.
NIKHIL GOKHALE: Try and take as much tissue as possible from the medial side. So you would like to include the capsule that is beyond the tear as well? Yes, but I don't know how much of it is going to be probably. Yeah. I had another question here. Sometimes if that tissue is really bad, would you, like, take a bite of the subscap? Yes, I've done that.
NIKHIL GOKHALE: And so, to be honest, the first time I did that, it was inadvertent. And I called up my fellowship boss and discussed it with him. And he told me that people used to do that in the olden days. Right. Something which is unheard of. And, yeah so but then I would restrict their external rotation for a few weeks. OK. That's mainly the capsule.
NIKHIL GOKHALE: Not got much in the way of... Can you just hold the other one, please? But that's mainly capsule I've not got much in the way of labrum. On there. [INAUDIBLE] I'll try one more time to see if I can get any labrum as well. Why not do the other [INAUDIBLE] suture, since you already have some tissue in this one?
NIKHIL GOKHALE: Yeah. [INAUDIBLE] But even then it's very final [?]
NIKHIL GOKHALE: Yeah. Hardly any tissue. Sorry? There's hardly any tissue left. Absolutely but, as you rightly said, it's better to include at least whatever we can. Right. Some fissure [?] here.
NIKHIL GOKHALE: Let's see if we can get back. I don't think I'm going to get much in the way of any substantial tissue here. I don't want to keep digging and damaging the labrum.
NIKHIL GOKHALE: [INAUDIBLE] I don't know if I can take a bite of this tissue just to recreate some
NIKHIL GOKHALE: labrum in the front. Can you give me the suture manipulator please? Thank you. No that tissue is really, really, really thin.
NIKHIL GOKHALE: Even this tissue is quite, quite fragile [?] Just try to take this down and stitch it downstairs. Can I have the [INAUDIBLE] Watch they're even [?]
NIKHIL GOKHALE: Put up some tissue there. I don't think I'm going to be able to get any more tissue.
NIKHIL GOKHALE: Let's go back. [INTERPOSING VOICES] [INAUDIBLE] Hold this there please. [INTERPOSING VOICES]
NIKHIL GOKHALE: Even the tissue quality here, the remnant capsule is quite thin. Yeah. Do you guys ever include this bit in the repair? Has anyone done that? It's like the Buford complex, isn't it? Yeah, it's a Buford. Yeah. Yeah. This will be glenohumeral ligament, it is attaching to the top. Hold the lever. [?]
NIKHIL GOKHALE: Yes, yes. I think I'm going to use this tool. Why not use that? Because there is a lack of tissue. Yes, at least some sort of tissue. There is a nice paper which says that there's not much of a difference in terms of getting stiffness, postoperative. So I'm just going to use the-
NIKHIL GOKHALE: Hold the other one please. Come back, please. [INAUDIBLE] Unusual. Yeah I think that is going to give a good- Yeah. Keep sewing [?]
NIKHIL GOKHALE: Thank you. You're doing fine. We just have to end that. Now that's quite a nice integration [?] there. Yes so, integration [?] effect, anterior capsule sort of-
NIKHIL GOKHALE: Yes, yes. And now I think I'm a little bit more optimistic of putting another anchor. I think- What do you think, three's enough? I think three should be enough. I think because you've sort of bunched up the capsule there. [INAUDIBLE] anchor. Yes, yes, yes. So I think I'll go a little slow with this mobilization
NIKHIL GOKHALE: postoperatively. Right. Let it all heal up. Do you have a normal postop protocol that you follow? I just give them something for comfort. Tell them to avoid external rotation beyond 45 degrees for six weeks. OK. Start active [?] assisted movements whenever pain allows. Anybody does anything different?
NIKHIL GOKHALE: If it [?] was top [?] protocol. Labral tear repairs. I think you said correctly, I just use a sling for about six weeks and avoid any heavy activity. But day to day activity, I would allow them to do it immediately, as soon as the pain allows them to do it. What's not to be done for at least two to three months?
NIKHIL GOKHALE: Sports-specific training. Three months, yeah. Yes, I think full-fledged contact sport six months. Sew it [?] So when you [INAUDIBLE] it means what? Sorry? You said that you want to go slow in this particular patient, so-
NIKHIL GOKHALE: Yes so I'll not really start active assisted movements. I'd suspend a lot of [?] movements for three to four weeks. OK. Gradually start active assisted movements. So keep him in the sling as much as possible for four weeks or so. Four to six weeks. Yes, yes. Just because of the quality of his tissues. Right. I'm [INAUDIBLE]
NIKHIL GOKHALE: Yes. Any more questions from the delegates? Yes, I think we have one question. Do you want to-? Yes go for it. If we are seeing such poor quality tissue or fraying of tissue on table [?] Yeah? Is it better to [INAUDIBLE] to convert this patient into Bankart [?] or we should do such [INAUDIBLE]?
NIKHIL GOKHALE: Yes see, the thing is, we are already here now, so let's repair whatever we can. And of course, if he starts dislocating again, then the next thing to do would be a Laterjet. Because we're not losing anything by doing this repair. Yes, his tissues are [INAUDIBLE], but I think we've got, you know, at least some sort of capsular tightening. My scope is not going down now. The drive-thru [?] sign is negative.
NIKHIL GOKHALE: So hopefully they should all start up and he should be all right. Got some sort of a bumper there. [INTERPOSING VOICES] Sorry? Have you ever [INAUDIBLE] [INAUDIBLE] I can't hear you, sorry.
NIKHIL GOKHALE: Can you hear me? Hello? Can you use the mic? That's what- Hello? Am I audible? Ask the question again.
NIKHIL GOKHALE: So, Nikhil, can you hear us now? Yes, now I can. Yes. OK. So the question is, have you ever converted a surgery that you started out arthroscopic and then converted into Latarjet, and what was your threshold? No, I've never, never had to do that. So almost always it's a preop decision.
NIKHIL GOKHALE: Yes, yes. How about the others? Anyone else had to convert it? So, so I think there are two things. One is, you know, you go in, do a diagnostic scoping, and then decide whether you're going to do a Bankart, soft tissue repair or Latarjet process. You go in thinking, doing, thinking that you're going to do a Bankart, but because of soft tissue, you convert into Latarjet.
NIKHIL GOKHALE: Right. I've never had to do the latter and I never used the prior because it's a preop decision, whether it's a bony procedure a or soft tissue procedure. Right. So also in your clinical experience, when patients have these kind of like poor tissue, how have they fared postoperatively? So, I mean, to be honest - like, have they redislocated? - one patient who's had such poor tissue and he's about six months postop and is not really reconstructed [?] yet.
NIKHIL GOKHALE: So - Has he resumed all activities? Yes, yes, yes. He's resumed all activities. He's slightly on the stiffer side, but I'm telling him not to stretch much. But gradually they all stretch out. They start using the shoulder. No apprehension? No, no.
NIKHIL GOKHALE: He's not apprehensive yet. OK, thanks. Yeah, any other questions? Do we have any other questions? If not, then we'll go on to the next surgery. Right. Is that all right?
NIKHIL GOKHALE: Yes, yes. Thank you very much. OK. You got an excellent demonstration. I just wish that the tissue quality was better. Thank you so much. Thank you. We always wish for that, right? Yes, but especially in a demo case. All right,
NIKHIL GOKHALE: thank you so much. [INAUDIBLE] [INTERPOSING VOICES]
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