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Name:
Arthroscopic Double Row Cuff Repair - Dr Ashish Babhulkar
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Arthroscopic Double Row Cuff Repair - Dr Ashish Babhulkar
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DR ASHISH BABHULKAR/DIPIT SAHU: Yeah. Hi.
DR ASHISH BABHULKAR/DIPIT SAHU: Can you hear me? One, two, three. Soundcheck? {INAUDIBLE} {INAUDIBLE}
DR ASHISH BABHULKAR/DIPIT SAHU: Welcome, sir. Yes hello, Dr. Can you hear me? Abhishek? Yeah. Hello, sir. Hey good morning. Can you hear me? Yeah, I can hear you.
DR ASHISH BABHULKAR/DIPIT SAHU: Yeah do you have an outside view? Yeah, there is outside view. Yeah and you can see the shoulder, the presentation is done? So you know the history? Right. Yeah, so we're doing a small rotator cuff tear in the 62-year-old chap, and we're doing this in the beach chair position and can someone switch off all your mobiles, please?
DR ASHISH BABHULKAR/DIPIT SAHU: So these are my markings. This is my posterior viewing portal. I take it a little high and lateral as opposed to the conventional 2 centimeter which is what is convention. Yeah. This is my suboptimal viewing portal, this will be my intervention portal, the five yard. And there's an additional anterior portal. That's all I need for a rotator cuff repair.
DR ASHISH BABHULKAR/DIPIT SAHU: So let's start from time zero. So I expect the tear to be, present as a rim tear on the sub-acromial side, I expect that the gleno humeral joint would be normal and the articular surface of the cuff should be intact and we will be able to appreciate the tear once we go sub-acromially. OK.
DR ASHISH BABHULKAR/DIPIT SAHU: OK so the initial entry point and yes, on the rotator cuff, you take this entry or is it different for this particular case? No, no, no. This is my standard entry for all the subacromial work, including subacromial including supra-scapular nerve, including rotator cuff repair except for a full blown sup-scap tear. If I'm doing a
DR ASHISH BABHULKAR/DIPIT SAHU: type 1 or type 2 or type 3 tear sub-scap, I would still stick to the same except for one additional portal but if I'm doing a type 4 sub-scap out of the box, then I'll have some more additional adventurous portals. Yep. So let's do a diagnostic scope first. Can we just drop the brightness a little down and so, here we are looking at the glenoid joint.
DR ASHISH BABHULKAR/DIPIT SAHU: Do you have an inside picture now? Yeah, inside picture is small, so can we shift? Stop the pictures, make the inside monitor picture larger and outside one, it can go small. Yes. Yeah. OK, so here we are. This is our lighthouse longer biceps right there.
DR ASHISH BABHULKAR/DIPIT SAHU: Now you see the arthroscopic view. Arthroscopic, not the outside view. Yeah, the monitor view. We're. Yeah. Yeah, Yeah. Perfect. So this is the biceps anchored, significantly worn out. There is some degenerative change. I don't think this is a traumatic slap.
DR ASHISH BABHULKAR/DIPIT SAHU: I'm going to ignore that for sure. These glenoid looks in good health. This is the anterior labrum, middle labrum, inferior labrum going into the X-ray pouch. Not much of inflammation, which is a good sign because that could be a precursor of frozen shoulder. So although his range of movements, only 90, 90 rotations are quite well preserved. And then this is the sub-scap.
DR ASHISH BABHULKAR/DIPIT SAHU: And you could appreciate that the sub-scap has the image wrapped around it. So it's a thin, transparent gel that's your sub-scap and that's your insertion of the sub-scap. There's a little bit fraying on the insertion, but I wouldn't call it a tear tear, but there's a lot of fraying within the injured shell. There's some inflammation in the rotator interval so this is just the early onset of adhesive capabilities that he's going to experience.
DR ASHISH BABHULKAR/DIPIT SAHU: But whenever you see an injured shell, which is visible, oblique, it means that the sub-scap anatomy is normal. That if you don't see the injured shell then you can imagine that the sub-scap is probably torn and injury migrated medially. So and then coming in next door to the sub-scap, its immediate neighbor is the longer of biceps. So here on the longer of biceps, you can see that there's a lot of inflammation there, typical
DR ASHISH BABHULKAR/DIPIT SAHU: and that is what incites the pain. So thinning of the biceps and you can see the pulley is pretty disrupted, you don't see a formal pulley here. So biceps has lost this pulley, so that would provoke as a biceps pain here. And then we're coming in just lateral to the biceps, a lot of inflammation here. And this is the rotator cuff.
DR ASHISH BABHULKAR/DIPIT SAHU: And you can see a paint lesion here, and there is a small rent here. There's a small wrinkle. Never assess the tear from the glenohumeral joint because the tear is rather overwhelming when see when we move in sub-achromially. So don't take your decision of one anchor signal repaired based on your glenohumeral joint. So I'm just coming in with my portal here and this would be portal that matches with the tear anatomy, just taking,
DR ASHISH BABHULKAR/DIPIT SAHU: and it's exactly in the fire line that I had marked. But I did rather have my knee dictate the portal rather than do a pre-judged portal like as you were doing a knee arthroscopy from outside right now so that it is easier to go back from sub-achromial space. Is it so? Probably but I won't mark it. In this case, there's going to be a fairly small tear.
DR ASHISH BABHULKAR/DIPIT SAHU: So sometimes you could put your whistle inside whilst you change your viewing portal. So you just come in there. This looks like some inflammation within the sub-achromial joint because the moment I made that portal, everything started bleeding.
DR ASHISH BABHULKAR/DIPIT SAHU: So the outside camera also needs to be adjusted because we can't be showing the wrong outside camera. Zoom out and show the portals. Yeah no, no, no. Zoom out, zoom out, zoom out, zoom out and focus where my hand is, zoom out.
DR ASHISH BABHULKAR/DIPIT SAHU: {INAUDBLE} You need to show this area here. The map. So that has to be transmitted. That is not. This is something else that, which is the third camera there? That is too zoomed out. It's too zoomed out.
DR ASHISH BABHULKAR/DIPIT SAHU: He's right, he's showing the right stuff, it's not getting transmitted. OK, OK. Yeah, that's perfect. Yes, OK. Just clearing up the stuff now. I'm a very consistent advocate of biceps tenotomy in such inflammatory tears, especially when the biceps is
DR ASHISH BABHULKAR/DIPIT SAHU: inflamed, degenerated and damaged. And so we are going to start with the biceps tenotomy. It's not an all absolute, but exceptionally I would leave the biceps in place. So the normal that I would do a tenotomy for all my rotated tears. I'm just taking the opportunity of cleaning up all the scar tissue there, we created tissue there. And at the same time, since I'm there, I'm preparing this footprint.
DR ASHISH BABHULKAR/DIPIT SAHU: Probably it looks like a modest tear maybe about 20 anti-posterial, not retracted medially. Probably would deserve a triple loaded single medial suture anchor. But I'm just thinking to myself loudly so that the team prepares that anchor. But I will not take it on the table yet because you could end up having a surprise once you go in there.
DR ASHISH BABHULKAR/DIPIT SAHU: OK don't mess up in the rotator interval because that's the tissue that usually bleeds coming with my arrest. And just because we know how the thought process goes, that is very important indeed. Indeed so if you know the vascular anatomy of the shoulder, then you should know where not to take the shaver in, because once it starts bleeding, then it can get a little messy. So those are certain areas that you want to avoid and that keeps the surgery as clean as possible.
DR ASHISH BABHULKAR/DIPIT SAHU: Can you specify the areas which we were like using the shaver? OK so if this is inflamed and if these encapsulate this, then be very careful here, largely safe here, and try not to get in there. So just coming up here, about a centimeter from here is a suprascapular nerve. So here what I'm using is just quagmore, not cutting more. So I don't want the current to be transmitted to the supra-scapula nerve because we want to worship the suprascapular nerve.
DR ASHISH BABHULKAR/DIPIT SAHU: So this is the area. Often you will see a lot of inflammatory changes here. And in the rotator intertwined biceps, the one thing before you cut the biceps you want to do is just go in there and see that's the inflammatory area. So we'll just whack those because that just points the feel. Good morning, Sir, Saturn here.
DR ASHISH BABHULKAR/DIPIT SAHU: How much is your pump pressure and how do you manage that? So it's about 35 and very low, I'm very conservative on the pump and I'm happy to do the surgery without the pump elsewhere. And so your blood pressure, how much would you prefer? Well, that's my team, Doctor Babhulkar and team have kept it at around 165. We have an agreement between them that they will keep it below 90 and then that works,
DR ASHISH BABHULKAR/DIPIT SAHU: that's the A-team. So your entire success of surgery? I told Doctor that it depends entirely on the anesthetist, so you need to be on the good side. OK. So what I'm doing here is that I'm signing, pulling the biceps in. You can do this better with a hook probe and once you pull it in, you will see that the inflammatory, see that inflammatory change there very well, that is in the groove and not visible to most of the biceps, where pattern inflammation will be in the groove, in the bicepular group under the transverse ligament.
DR ASHISH BABHULKAR/DIPIT SAHU: So you need to pull it out, pull it in, check that you know that this is damaged. If it's pristine and there's no wear and tear, then I'm happy for this to be left in position, but as I said, I would do that in a young athletic male, which is not the common norm. You are dealing with 62 year olds, degenerative tendons. These are question from the delegates audience that whether you do biceps tenotomy in all your cases or how do you treat that?
DR ASHISH BABHULKAR/DIPIT SAHU: I, I don't get along with the biceps. So my. Thumb rule is, do a tenotomy for the biceps as far as possible. And if the patient flip side, then sorry, even the patient on the younger side of the spectrum played less than 40. I would do a biceps tenodesis between 50 and 60, I'm equivocal. It depends on its physiological age, whether it is athletic, doing gym stuff and all that.
DR ASHISH BABHULKAR/DIPIT SAHU: But for that to retain the biceps, I need the biceps to be healthy. No vascularity, no inflammation, and the tears should not be in the vicinity, the pulley should be intact. If your pulley is gone, then you're asking for trouble. And this is what, what level do you know? This is your I do it arthroscopic in the groove.
DR ASHISH BABHULKAR/DIPIT SAHU: Haven't regretted doing that, there are many ways to skin the cat. And so I don't like the effect major technique because one, it is takes time consuming. Number two, you want to open their incision? We prefer an all arthroscopic. And number three, there is a small incidence of humeral fractures. When you do that, pec major level 10.
DR ASHISH BABHULKAR/DIPIT SAHU: tendonisis. Right, so we have in the sub-humeral joint fairly clean some inflammatory tissue here. So we're going to just, this is more important from the vascular anatomy point of view. So most of you should. There's an article in JBJS about the vascular anatomy of the sub-acromial joint, what they read that to tell you the areas to avoid.
DR ASHISH BABHULKAR/DIPIT SAHU: There are variations, but 90% of times it's a fairly consistent pattern that will follow. So you can see that this is the area, which is just the, see the ligament here? Right in front and that's your only marker in the sub-acromial joint that will tell you that you are in the sub-acromial. Otherwise, you can get lost, especially if this is full of bursitis, inflammation and you can place it up here.
DR ASHISH BABHULKAR/DIPIT SAHU: You can see this is the only focal area of frame. The rest of the seam ligament looks fairly pristine, clean, neat. Let's clear this up, there's some inflammation. So just to take you one step back. Do you feel any change when you cut the biceps, or do you see any significant difference in your technique of cutting the biceps with the meniscus biter or if you do it with the RF?
DR ASHISH BABHULKAR/DIPIT SAHU: So I am very frugal with the use of the RF. I do it very rarely. Sometimes I'm lazy, and the skin knife. I mean, the skin knife that I use, I use an 11 number knife. I go in the vicinity and when nobody is looking, I just quickly cut the biceps with the skin knife. But that's just to add variable to whole thing, I would always almost use a duckbill or a biter.
DR ASHISH BABHULKAR/DIPIT SAHU: There are certain companies done by the duckbill which are very small in mouth. And then what happens is they take a bite and the bite drops into the joint. I don't like that debris in the joint because that incites inflammation. So you want a large size duckbill which will go and swallow the entire biceps and you don't cut it completely because then the fragment gets dropped into the joint.
DR ASHISH BABHULKAR/DIPIT SAHU: So you do it, one third, one third, one third, and keep completing the test slowly. So, Nicilia, one question about tenotomy what percentage of your patients come back and tell you that they've noticed barbwire deformity and how many are actually bothered by it? So if you can't sell them well in advance, then they can anticipate it maybe three out of hundred, honestly, the ones who are very elderly, but you have to make a distinction between other surgeons.
DR ASHISH BABHULKAR/DIPIT SAHU: Me, if I have a sub-scap tear in association with my supra stem I will always do a bicep tenodesis with the sub-scap. So my sub-scap repair mandates that I do a sub-scap repair and a biceps tenodesis within that same anchor because the anatomy, native anatomy of the sub-scap and supra and biceps is very close to each other. And the sub-scap has a running affair with the biceps, whenever the sub-scap tears, the biceps will elope with it.
DR ASHISH BABHULKAR/DIPIT SAHU: And that's why whenever the sub-scap is damaged, you can take it for sure that the biceps is unstable and it's more likely to dislocate or undergo popeye sign. But even if I do a tenotomy in this situation, the sub-scap is intact. I'm presuming the intra-trabecular ligament is intact. It'll go in slide and sit there, it will not go down.
DR ASHISH BABHULKAR/DIPIT SAHU: So it finds its own home position. If you are a little worried, then you can do a cauliflower tenotomy. Yes so thought process when you have a small sub-scap tear associated with a biceps inflammation like so, would you do a tenodesis and repair the sub-scap in the same anchor or do you use different anchors for both? Good question.
DR ASHISH BABHULKAR/DIPIT SAHU: Type two I would do it in the same anchor. I have a cruciate technique not so distressed where one suture goes into the biceps and the rest will go into the, three will go into the sub-scap. That holds true for type II and type III. If I have a type four, then I'm going to do an extra articular out of the box where I would do a tenodesis on two anchors for the sub-scap so at least seven sutures in the sub-scap and one for the biceps.
DR ASHISH BABHULKAR/DIPIT SAHU: So, so no double rows for the sub-scap in your hands? In type 4 and type 5 occasionally, not always. The sub-scap anatomy is a little different from the supraaspinatus. If you see the supraspinatus it has a footprint, which is very broad, and it's almost rectangular. If you go back and see the sub-scap's anatomy, it's like a wedge.
DR ASHISH BABHULKAR/DIPIT SAHU: It's broad on the top and narrow on the bottom. So I don't think a double row is going to add much value. So I need to ensure that the bicep is not inflamed. I have a position there to put my anchor in and then I would do an additional but I don't see a huge value addition in doing a double row for a subscap. But I would reserve that only for a type 4 or a type 5.
DR ASHISH BABHULKAR/DIPIT SAHU: So I was trying to show you this c ligament as you come up the c ligament, when you can see frame here only in the anterolateral part. That's the part where there's been gone . So this is impingement and that impingement happened because of a weak cuff. But the c ligament is not at fault so there's no point taking the c ligament down. It just tells me that this patient has a recurrent impingement.
DR ASHISH BABHULKAR/DIPIT SAHU: And if at all, I'm compared to osteoplasty, I would do it only of this area, which is the anterior and lateral acromion. There is no point doing an acromioplast medially or posteriorally because that area is not involved. But the threshold for problems is very, very high. Again, I do them very infrequently. So do you ever wander upon the critical angle and for latero acromiopathy or I mean, is that something we should be doing routinely?
DR ASHISH BABHULKAR/DIPIT SAHU: Actually, good question. We started doing it, we got excited with the standard of the paper and we started measuring all those. And then there are at least four different counter papers that in New Zealand population the critical ankle does not correlate with cuff tear as such, but it does restrict my anchor passage and my portals are suboptimal when I'm doing the cuff repair.
DR ASHISH BABHULKAR/DIPIT SAHU: So in such situation then I find that my acromion is impeding my access for a vertical 70 degree angle, then I will do a lateral acromioplasty. So we noted down pre operatively, my fellows do their angles and warn me that there is a chance that I might need to do it. But I let my arthroscopic picture decide whether I need to do it or not. So it's not based on a pre-op plan.
DR ASHISH BABHULKAR/DIPIT SAHU: Noted. Yeah. So the areas to be avoided coming in there, So this is the c ligament. You go and give it to the c ligament. I'm going to have to take a portal there. There's a branch from solar canal, bleeds viciously, so do be careful around that area, certainly this area.
DR ASHISH BABHULKAR/DIPIT SAHU: If the c joint is involved, then this is the area underneath the incision that can have significant bleeders. And then coming in here, this is going to be the spine of the scapular. I'm going to show that to you in a minute, and that area, when I do the release. But I'm compelled to do the release because in my patients, it's obligatory for me to do a decompression at the spine,
DR ASHISH BABHULKAR/DIPIT SAHU: we'll talk about that later, so I need to go down. But if you're not compelled to do a spinal glenoid decompression in your cases, then you can safely avoid. This is the area where there's maximum bleeding. And then the last level of bleeding is posteriorly. But that's related to not vasculature, that's related to chronic inflammation,
DR ASHISH BABHULKAR/DIPIT SAHU: so if a patient doesn't have vision, then that should be a OK position to go to. So I'm going to be brave and start using my shaver. It's the shaver that inside bleeding because it sucks tissues and creates the mess like this. Now this is the bursa. It's a small tear, so I don't like taking out bursa. The bursa has the largest concentration of the MSCs and the stem cells.
DR ASHISH BABHULKAR/DIPIT SAHU: Plus it brings in very healthy vascular tissue for the repair. So unless it's a massive tear where I need a better visualization, my sutures and anchor are going to be compromised. I would only then do an extensive bursectomy. But here, as long as I can see my vessels coming in, I have my anatomy fairly clear. I will do a very limited bursectomy here, this one.
DR ASHISH BABHULKAR/DIPIT SAHU: OK? and this is the nature of our tear OK? So I think this is a tear that deserves a single triple loaded anchor as I said, this must be about 20 mm and kilo posteriorly and partly five mm protracted. This is typical remnant tear, very little here. You can see in the glenoid joint it's a complete tear. So we're going to ask. Today we will demonstrate to you and also to anchor the iconic speed.
DR ASHISH BABHULKAR/DIPIT SAHU: The reason it's called speed is will be evident to you and we'll use that for 1 medial anchor, the iconic speed and then the omega up here. So we need to prepare our position for the omega. We are doing good for time, we are just about 20 minutes in and I'll need another 15, 20 minutes to finish this case. One question about the greater tuberosity preparation. You are very aggressive in taking down all the remnant of the tendon from there and make it and making it a bleeding surface.
DR ASHISH BABHULKAR/DIPIT SAHU: No, no, no. Because this surface is fairly tenuous, osteoporotic, I just do a dusting and my dusting is actually very stable. Never, ever use a burr. That's pretty much OK. Sometimes there's a layer of leathery tissue there. So then you might want to use your RF to clear the tissue because the shaver doesn't take soft tissue as well.
DR ASHISH BABHULKAR/DIPIT SAHU: And this is as much as I would do if you are going to use like if you're using all suture here, you want your cortex to be intact. Irrelevant. The all suture makes such a small hole. It's a 2.3 anchor. No pilot hole, no drill. So it's going to be just straight forward and it'll have a much better hole. Actually, if I mess around.
DR ASHISH BABHULKAR/DIPIT SAHU: Let's see. You must, whatever happens, keep the cortical margin in. But I think the one metric that prevents an anchor pull out is your direction angle of attack. And that is not the conventional Orthodox angle. That is 40, 45 degrees that was advocated by Burkhart. It should be as vertical as possible, and that's the point I was trying to make, that if you have a lateral acromial spot or a down sloping acromion, then you will not be able to go into that.
DR ASHISH BABHULKAR/DIPIT SAHU: You're going in a sloping angle and it's been proven. Burkhart has done some fantastic studies to show that the dead man's angle is irrelevant, it should be as vertical as possible. Now it is inconceivable that either of us can do a 90 degree insertion because of the way the equipment comes in the way. If you can get a 70 degree angle, then that will ensure that your anchor has the strongest hold possible for the pull out.
DR ASHISH BABHULKAR/DIPIT SAHU: So can you explain what you're doing now? Right so let's wait for this to clear up with some caution. Give me a wash. So this is what I do. The brightness is too high. Can somebody drop the brightness? Can I do it from my end? Yeah, yeah. That's much better,
DR ASHISH BABHULKAR/DIPIT SAHU: thank you. This is the acromium. Just for reference sake. This is the anterior column and you can see the c ligament. This is all the c ligament. This is the area that got worn out. So that's the anterolateral part. And we still need some better water fluid control. Let me make an anterior portal, that will help.
DR ASHISH BABHULKAR/DIPIT SAHU: Give me a minute. I'll just improve the visualization so that when you go into the bursa or is it still 35? Come again? Do you increase the pump pressure when you go into the bursa or is it still 35? I don't like to, it's still 35, I've not changed that
DR ASHISH BABHULKAR/DIPIT SAHU: and I rarely do. These things happen, the bleeding will eventually cease. What happens with increasing the pump pressure is it creates a huge soft tissue swelling eventually, and if you finish your surgery in 40 minutes flat, hopefully that's the plan today
DR ASHISH BABHULKAR/DIPIT SAHU: then we should be on a home run. But if you delay surgery and one and one and a 1/2 hours later, the entire tissue starts swelling and it closes on you, and then that creates a problem, so I don't see a flow there. I need a flow. Yeah. Yeah. So I'm just putting a cannula anteriorly. Again, don't do that too often, but that's going to improve, improve our flow.
DR ASHISH BABHULKAR/DIPIT SAHU: I just seem to be focused as well. Yeah, that's better. Yeah, that's much better. So as I saying, the c ligament coming in here and that's the anterolateral acriment is the lateral margin of the domain you're moving medially. There's a lot of debris here, all this debris is unwanted. It's not.
DR ASHISH BABHULKAR/DIPIT SAHU: So I'm following that into the spine of the scapula OK? And this is the spine of scapular. At some point, I'm going to have to remove the soft tissue for you to be able to visualize. And I stick to bone, you find bone and stick to bone. Don't digress, because that's very important. I mean, just lift my light source up a little, just here. So you're running down the entire spine of the scapula.
DR ASHISH BABHULKAR/DIPIT SAHU: OK can I have a shaver? I'll do a little risky maneuver, keep this in your hand. There's a debris there. So we are doing the decompression of the spinal glenoid notch for the supra scapular nerve, I do that for all my cuff cases. This is the area that bleeds I'm just
DR ASHISH BABHULKAR/DIPIT SAHU: doing minimum there and then coming in like this. Yeah, so just follow the acromium and go down and you see a lot of debris here. The entire spine of the scapula is like the bow of a ship it's broad in the top and narrow at the bottom. So your job is to go all the way down to the apex. OK. One question here regarding this, your rationale behind doing this for all cuff cases.
DR ASHISH BABHULKAR/DIPIT SAHU: OK. Good question. Again, the point is this , let me finish this anotomy and I'll come back to it. Let me, you can see that it's bottoming out. There's going down into the apex and following it down. And if you can see the apex there, then that means that you have arrived to the bottom of the huge debris hill.
DR ASHISH BABHULKAR/DIPIT SAHU: And this is what unnerves me, because this actually compresses the spinal glenoid ligament, compresses the suprascapular nerve. OK. Here we are. So this here posteriorly is the exit of the spinal glenoid notch and this here is the entry and that's still tight.
DR ASHISH BABHULKAR/DIPIT SAHU: If you can see the spinal column and can you see that it's closed completely. Yeah, yes. I'll show you again. This it's never so full of debris. This is intact, It's closed here. The entry point is closed. So it's a tight canal.
DR ASHISH BABHULKAR/DIPIT SAHU: I have opened it posterior so if you can see here posterior has gone open. Few little remnants are there, so my job is to open the entry and exit so be very gentle. Now, you see on the right side of the screen is full of fat and that fat is next to the nerve. The fat protects the nerve, so you don't want to go laterally.
DR ASHISH BABHULKAR/DIPIT SAHU: So I have just opened the entry portal here completely, that's it. So it's fairly thick spinal glenoid ligament here and then just complete the same posteriorly. Yeah and I've opened it posteriorly as well. OK. Now, so this probably applies to only 2% or 5% of the population and but there is no means of knowing which patient has a suprascapular glenoid
DR ASHISH BABHULKAR/DIPIT SAHU: compression and which patient does not. Now imagine a patient who has a spinal glenoid compression, which is a very true fact, and it's known and probably it's been under compression for various reasons for a long time. That's my outside portal. Coming in it's fairly vertical, you can see that and that's coming at an angle of almost 70 degrees because we are doing a single anchor we will go in the medial at the junction of the cartilage.
DR ASHISH BABHULKAR/DIPIT SAHU: Hand and footprint right there. OK? So that patient is going to have progressive wasting of his infra spinal rotator cuff, and then eventually he'll have a small trauma. We record the trauma and we dictate that he has a rotator cuff tearing, end up repairing the rotator cuff without realizing that there's a inherent supra scapular nerve policy, which has not been detected. In the presence of a cuff tear
DR ASHISH BABHULKAR/DIPIT SAHU: it is going to be very difficult to do an EMG to prove that there is a supra scapular neuropathy, and most surgeons are now aware of this, so they are not going to subject the patient of a rotator cuff tear for a EMG. And that patient is the one that's not going to do well. And although structurally, you do your MRI's and stenography and you're going to see that structure is intact, it is not innervated and it goes up progressive wasting.
DR ASHISH BABHULKAR/DIPIT SAHU: So those are the patients I'm targeting. So I would just spend five minutes doing this. What you're seeing now is iconic speed, so you don't need a punch. It just goes in directly. It's an all suture 2.3mm anchor, this one is triple loaded, hopefully and just goes in and goes all the way. There's a marker there that that's the stop and I'll go in there.
DR ASHISH BABHULKAR/DIPIT SAHU: Perfect. Babhulkar Sir, is that the same approach you take for a spinal glenoid knot decompression, or do you do it through the slap? No so I used to do it to the slap, but that's a indirect way of doing it. But there there's a very impressive parallel system. My colleague is just yanking it to ensure that the knot is set ii is very important, to ensure that this anchor is synced because you want to pick up all the slack put in.
DR ASHISH BABHULKAR/DIPIT SAHU: And then. Yes so I have switched over the last four or five years picking after Jinjiang who showed me that we should do this sub acromially so from the sub-acromial side, I split the RAF between the supra and and infra and then identified the swiss I must confess, I can't do this for all these parallel places that I see because you need an impressive system, like a dumbbell system that moves from the subacromial to the transverse capital notch.
DR ASHISH BABHULKAR/DIPIT SAHU: So those are the ones. So the smaller sister still do them from the glenohumeral joint along with the slap postural repair. So I'm going to identify, there three different colours here so I'll take one pair here, park it into the lateral portal and then I'm going to give you an indirect her coming in from the front
DR ASHISH BABHULKAR/DIPIT SAHU: like so. And then we started the anterior edge of the tear, you want to go a little close to the rotator cuff cable. That dictates your tension and that dictates your success of surgery. Because if you don't restore the original leg tension relationship, then. OK? Yeah. Then it will remain a loose repair, a non repair because it's important to
DR ASHISH BABHULKAR/DIPIT SAHU: put in the exact trigger there. So just checked which one, the anterior one has to come in there so my colleague just checked, which suture I've got to deploy and then just retrieve it through. And I think the pump pressure needs to go up a little. Just a little woozy. So do you use on scorpion like suture retrieval devices?
DR ASHISH BABHULKAR/DIPIT SAHU: I have, I have two other devices with me. I have a first class and an elite one, but I don't use it too frequently, certainly not for the smaller tears because the corners are not amenable, it's too small for the whole thing to go through and if it's a double layered tear, then I'm going to prefer this, this is my go to device.
DR ASHISH BABHULKAR/DIPIT SAHU: So which statistic of 90% of the cases, I would do the indirect suture surgeon. Yeah it's much better now, I think the flow is good, this is working well. {INAUDIBLE} What has happened is both the bottles are finished off at the same time.
DR ASHISH BABHULKAR/DIPIT SAHU: That's right. So now I use the left indirect suture shuttle for the first two sutures and for the rest, now I'm going to switch to the right. So first, I'll get my, I always keep the colored sutures for the corners, and I use the white ones in the center because the white ones tend to get masked and then you can't see them in the corners
DR ASHISH BABHULKAR/DIPIT SAHU: so always keep the colored ones in the periphery and now I'm going to come with the right from posterior viewing portal, which was the gleno humeral viewing portal. Just come in there nicely, and then keep them right about the same table at the same time and a half equidistant. So you want them equidistant so that I'm just going there at the junction of the tendon and cuff.
DR ASHISH BABHULKAR/DIPIT SAHU: OK? Now the advantage here is I can actually visualize which part of the opinion, which part of the cuff is coming through. Yeah so if I've got the middle most part, which is close to the cable, then I'm OK and happy with it otherwise I can just change it there.
DR ASHISH BABHULKAR/DIPIT SAHU: Sometimes the suture shuttle misses the inferior layer when you're doing a double layer tear. So with this suture shuttle, I can stay there and still swing it through another loop and get it to that inferior level. You can't do that with the direct devices because then once it's passed in, it's impossible to see whether it has factored in both the layers or not. Having said that, I'm not against them.
DR ASHISH BABHULKAR/DIPIT SAHU: They are quicker on a day that I have a bigger tear. I need a bigger tear to be able to use the direct devices, Coming in here again, equidistant, there's a white here which is again, see, I was mentioning that the white is, see? It's very difficult to see the white. That's why I keep it in the center. And you'll end up taking a bite just there. So you want stitches for all?
DR ASHISH BABHULKAR/DIPIT SAHU: Sorry, come again? Mattress here. Mattress for all. Mattress for all. Because a mattress for all. Because I'm a person who advocates double rows and a mattress for all will sit very nicely with the, the double row technique because that mimics the grand fossa as widely as possible.
DR ASHISH BABHULKAR/DIPIT SAHU: And that remains our gold standard, the Transocean equivalent. These devices, these mini tapes. They look more like tapes. These are tapes. So you can get the iconic speed with sutures or you can get them with tapes. And so we've been provided tapes, so I don't ask for it, I'm not a big fan of the tapes, but it's an option that we. So,
DR ASHISH BABHULKAR/DIPIT SAHU: the tapes were not them. So yes, yes, I will knot them, I don't like, not tying the middle row because then we have invested everything into our lateral row and the one that fails is the lateral row. The one that fails is the lateral row and when the lateral row fails, your entire concept is gone. So today, if my lateral row fails because of the osteoporotic bone, repeat, we are about 10/12 minutes away
DR ASHISH BABHULKAR/DIPIT SAHU: then I'm still invested in the medial side, so I have no stress. The program rehab recovery will be identical. Yes, sir. Yeah and now I've done five of the six sutures, now I'm going to switch over and give me the yellow again. So I go back to the left, so I used the right for the central
DR ASHISH BABHULKAR/DIPIT SAHU: three sutures and then I come back and there's a method in this madness, I'll show you. As I was coming. OK. So previously I took them here, this time instead of going in that direction because I'm dealing with a lateral leaf that I want to factor in as laterally, I'm going to dive this way.
DR ASHISH BABHULKAR/DIPIT SAHU: So this is the right one. It's got a light intensity. We increase slightly because the picture is slightly darker. Let me do that. Thank you so much. It's my end. Increased sir. I'm doing it
DR ASHISH BABHULKAR/DIPIT SAHU: I'm doing it. Yeah is that better now? Yes, sir. Much better. Thank you. Yeah so, as I was saying, instead of going from here to here, this is the left turn. So I just dive like this and so I can factor in again equidistant and get a nice bad bite on the lateral reef and just comes out here.
DR ASHISH BABHULKAR/DIPIT SAHU: Here it's important to have a look and ensure that you've got the entire cuff, not a small part of it. So this device allows me to do all that. So it's a much more judicious approach. I know. I know that I've taken the entire width of that and then when you look from here, that's all our in session done.
DR ASHISH BABHULKAR/DIPIT SAHU: It's an equal distance, nice little star configuration so happy with this. Now, unless the situation demands I start from a posterior to anterior time order. So this is our posterior suture. That's why I keep blue posteriorly and then I have to search for my whites, somewhere here and these will be tied first.
DR ASHISH BABHULKAR/DIPIT SAHU: So I tried my central ones first. OK? Yeah. It's important to ensure that you see you're not coming in and that can be a challenge. Sometimes if the bursa has not been taken down, if the bursa has not been taken down initially in the presence of the sutures, removing the bursa now is precarious,
DR ASHISH BABHULKAR/DIPIT SAHU: and it can damage the sutures as well. It's been done, so we don't want to do that. So the white coming in this is central. The reason I do the central sutures first is because that's the most mobile part of the tear kingdom and that's the one that you want to bring over the footprint and ensure that it sits there.
DR ASHISH BABHULKAR/DIPIT SAHU: That will basically pull the whole cuff to your? Correct, correct. Can we take the omega for the lateral row on the table? The single omega. Perfect - tender, duncan's loop.
DR ASHISH BABHULKAR/DIPIT SAHU: OK so we've seen the knot coming in laterally and that means we are going Sometimes a knot stays high and the knot pressure comes through so that's not a good situation. OK, so that's done with this. Then we come to the posterior one, which is the blue. Yep.
DR ASHISH BABHULKAR/DIPIT SAHU: OK. We just facilitate to ensure that the blues are just coming in to the view and then gently. Yeah? OK. Again, ensure that your sutures are. And then alternative half inches.
DR ASHISH BABHULKAR/DIPIT SAHU: The tapes are impressive and they probably prevent a lot of cheese cutting. They do increase the size of the knot and sometimes when your instrument is coming in, they can get damaged because they are much broader in the portal. So now I'm going to park my blue suture in the higher portal, anchor portal.
DR ASHISH BABHULKAR/DIPIT SAHU: So I've got four sutures in the anchor portal. Welcome back. In and then come and find my anterior suture here. So there's a pain, pressure. Someone and then. So I've had some feedback from my Fellows that there sometimes struggle with the lateral row anchor.
DR ASHISH BABHULKAR/DIPIT SAHU: I think there's great merit in having the lateral row anchor because the retreats are far, far superior. I'm not too worried about the strain and the configuration because naturally the double row is going to be a far more stronger construct than the single row. So do your views on using the cannulas? So I never use the cannulas. My cannula goes in only when the anchor goes in and when I retrieve the suture, then I take off the cannulas.
DR ASHISH BABHULKAR/DIPIT SAHU: They impede my progress. They obscure the flow, and the callunas tend to direct you into one particular direction. This is free flowing. So I use the cannulas for the Bankart repair, that's for sure, because I can afford to get all my sutures. It up. But if your portals are clean and the direction is clean, then you don't need them because this is a free flow.
DR ASHISH BABHULKAR/DIPIT SAHU: So you've got a medial row here done, now we are going to prepare for a lateral row. I just, need to make a little bit of revision. I could use two lateral rows, but it's a bit of an overkill today. It's a much smaller tear; just clear up this little band, which is always a consistent band here.
DR ASHISH BABHULKAR/DIPIT SAHU: And then you want to orient the lateral anchor in such a manner that all the sutures are under rotation. Slight internal rotation for me. Right? OK. If you look at this part, you could draw this line straight. It's going to come in line with the wide suture so that's the central suture. So this is X marks the spot. That is where I want to be.
DR ASHISH BABHULKAR/DIPIT SAHU: Let's have a cannula. I'll use the cannula now because I don't want my deltoid getting involved inside my repair when I pick my sutures. I so. So, Dr. Komal, I have one question. Yes, come on. We prefer to do a microfracture on a GT.
DR ASHISH BABHULKAR/DIPIT SAHU: What are the chances? So I have used the Crimson duet technique. Previously, we actually did a study to see the improvement on the vascular. We are studying the vascularity on ultrasound studies postoperatively and did that impact our repair? Number one, we abandoned the study because we saw no difference at all.
DR ASHISH BABHULKAR/DIPIT SAHU: Number two, it's going to be very difficult to prove that the repair rates are far better with that because our repair rates are extremely low. Maybe for a 10/15mm tear, it's almost less than 1% in this. If you hire when you're dealing with [one second] larger tears. Still, I would do that sometimes when I see a very closed one, one switches off.
DR ASHISH BABHULKAR/DIPIT SAHU: Sometimes we're dealing with a very sclerotic, very see that you have done a shaving of the GT preparation and you find out that it's very dense, there is no potential bleeding, I would just arbitrarily do that. We only anecdotal. Not sure it helps. OK so this is a new generation anchor that I want to introduce to you.
DR ASHISH BABHULKAR/DIPIT SAHU: This is the Omega, and it comes in two different forms. There are several plusses here. So this is a direct punch. You don't need to use a punch to get this in and this is like a wedge with a barb, but it just goes in there. I mean. I mean, how many tapes have you packed in that?
DR ASHISH BABHULKAR/DIPIT SAHU: Six very comfortably, six and now sometimes you struggle to find your point of insertion but because the sutures are there, they lead us to this, and then the screw comes over it and now don't push the screw. My colleague is just going to just tension the repair. Not too much. Just enough, somebody can give a heads up to
DR ASHISH BABHULKAR/DIPIT SAHU: repeat that he is on in 10 minutes time. He needs a spoiler alert. And then you are so you're number one because the tapes are there. There is no chance of losing the pilot hole. Number two, you've got dual fixation here in a soft sclerotic bone, your initial wedge and the screw that locks over it. Less likely that you lose the lateral row.
DR ASHISH BABHULKAR/DIPIT SAHU: And so it comes in and configuration where it's pre-packed with two different implants. So most of the tension is taken by the medial row and there's lateral buttress that edge down to the bone. No, so the basic job of the lateral anchor is number one to create a maximum contact area so that the entire footprint is covered, by a medial row you will have the inside contact, but the lateral leaf will be floating and not in contact with the bone.
DR ASHISH BABHULKAR/DIPIT SAHU: The more that the tissue is going to contact with raw bone, the better the chances of healing. Do you get that? So that is the role for the double row. So this is our repair and when you move it through, not a problem. [Question do you always do double row? In all your cases?] 99%, yes. But if I'm dealing with a very, very small tear, open tear, fine tear, I personally don't operate fine tears, all the tears less than 10 mm are sent on a conservative program.
DR ASHISH BABHULKAR/DIPIT SAHU: So accidentally, if I come into a slap tear with a fine tear, then that will be a small single medial row anchor So you can see this is plastered down, you can barely see the tear. There is no dog here because the sutures are equidistant to each other so the tension is equal. So we can see that it's sitting in perfectly well, and when you move it, it moves asymmetrically with the tendon.
DR ASHISH BABHULKAR/DIPIT SAHU: We'll just do one last quick look on the glenoid, gleno humeral side. [INAUDIBLE]. [INAUDIBLE]. Thank you. That's we are about 45 minutes into surgery, five minutes more than what we wanted for. So we come back in the glenoral joint and have a look at how does that sit, because that will dictate how well.
DR ASHISH BABHULKAR/DIPIT SAHU: So that's pretty anatomical because you can't see any of the greater tuberosity. Can you see the red marking there? [YYES} So those vascular stops at the rotator cuff cable, that means that cable is very close and the crescent is matching to the footprint, which means that this has been tensioned anatomically. It's not too loose, it's not too tight and you can see a nice tension there,
DR ASHISH BABHULKAR/DIPIT SAHU: it's as if the tear was not there, it's clustered in beautifully and that's that effect you will see only on with double row. You'll never see that with a single, single row, it'll be lax limb. It will never have the same taut effect that you see here. And you can move it through as much as you can and you can see there is no micro movement at all. So I think I'm happy with this,
DR ASHISH BABHULKAR/DIPIT SAHU: hopefully you'll agree with me. Before I close, must thank the anesthesia team, has to be a operating team doctor. Fantastic we get a very nice blood pressure control doctor Ajib who assisted us and we know this has been our loyalty brother. Thank you very much. Thank you very much. Thank you. So we are shifting to the road. So give us 10 minutes for the trolley and the AV equipment to go across.
DR ASHISH BABHULKAR/DIPIT SAHU: I'll join you downstairs in a minute. So there's one question from the delegate on if to assess pre operatively that we can manage this tear, cuff tear in a single medial row or double and pre operatively after seeing the MRI. I would always start it off,
DR ASHISH BABHULKAR/DIPIT SAHU: I would always give them a stronger. Right so. So we'll go back to the lectures, now, because this will further suggest.
DR ASHISH BABHULKAR/DIPIT SAHU: Those will be speaking on the designs in reverse shoulder from Medicare and the veterans. So just ask, very basic, just ask this question because we have to clear our doubts.
DR ASHISH BABHULKAR/DIPIT SAHU: OK so yeah, so I asked the same question and there are different ways of doing it. Some people prefer it differently, some people do it differently. Most of us, we do the same thing, we just shave off as a little bit of it, we don't want to take away bone from that area because that's the main stronghold that anchor is going to hold.
DR ASHISH BABHULKAR/DIPIT SAHU: So if you use a bore to take away a lot of that bone, you are corticating that area and probably your fix might get compromised on the end. Yeah so rasping micro fractures, all that are known to sort of you know technically promote healing, but there is no real study that shows one is better than the other. Yes before constructing anything to debride the tear, to debride the tuberosity and all of those things, because once you put your anchor in, then you're going to entangle your suture.
DR ASHISH BABHULKAR/DIPIT SAHU: I'm just going to give a slightly opposite and controversial use. There's a paper. So when you talk about tendon to bone healing, normally tendon ends into sharpest fibers and they go into the bone, not to do anything at all. So when you take off the cortical bone, you're actually exposing the subchondral bone and that is not how tendon inserts into the bone in the normal human body.
DR ASHISH BABHULKAR/DIPIT SAHU: So there is a point of view, which is that just don't take anything off the scar tissue and buttress the tendon. The sharpest fibers still form and the downside is the localization of your medial position is slightly under the age of the target is not. So if you can extend into what you see, what you can actually do.
DR ASHISH BABHULKAR/DIPIT SAHU: So as soon as more relevant to the traditional double row where the medial row anchor goes medially and the lateral anchor goes on the edge of the deposit. But with this type of technique, when you go down on the bone that's quite strong, it's like a cortical matter. Lateral row anchor is very difficult to dislodge. So, sorry. My question is not to the procedure it's basic to the basic science.
DR ASHISH BABHULKAR/DIPIT SAHU: The cause of the tear is probably degenerative usually which we encounter in supra-spinator tears and we are going to repair that. And the basic pathology is degeneration because that supply is not there. So putting an anchor and fusing it out there, I just want this is just curiosity in inquisition. Does good healing take place by that if we do open or arthroscopic or whatever repair we take, does healing take place, is difference from is.
DR ASHISH BABHULKAR/DIPIT SAHU: If you go to the conservative approach or is better with the operative approach, what's your take on it, what's your experience on it, that counts the most? If you do MRI's on all elderlies, you will find almost 50% of them have degenerative cuff tears {15 or 50?} but most of them are not symptomatic. So you want to operate the ones that are symptomatic and the ones that are symptomatic,
DR ASHISH BABHULKAR/DIPIT SAHU: if you operate them, most of them do get better, so it depends upon obviously the size of the tear, the amount of degeneration and all of those things. But more, I think symptomatic ones once operated and repaired, well, they definitely improve in my own experience as well. So yes, so when you assess the patient's pre operatively and we don't know very often that science is incorrect.
DR ASHISH BABHULKAR/DIPIT SAHU: Yes so I'll answer that question. {INTERPOSING VOICES} This is your question. Yes so I'll answer your question first. So see, eventually, what we want is a patient who has a symptomatic shoulder. Everything's pain, stiffness and weakness. So these are things you assess pre operatively. I sir said that this patient was probably in early stages of capsulitis or stiffness.
DR ASHISH BABHULKAR/DIPIT SAHU: You wait till the stiffness resolves, then comes pain and weakness. So if weakness is the main symptom, then yes, you would want the tear to come back anatomically. If pain is the main symptom, some of them, you know, can take. And if somebody is going to play.
DR ASHISH BABHULKAR/DIPIT SAHU: Before but we. [VOICES FADE}
Segment:0 .
DR ASHISH BABHULKAR/DIPIT SAHU: Yeah. Hi.
DR ASHISH BABHULKAR/DIPIT SAHU: Can you hear me? One, two, three. Soundcheck? {INAUDIBLE} {INAUDIBLE}
DR ASHISH BABHULKAR/DIPIT SAHU: Welcome, sir. Yes hello, Dr. Can you hear me? Abhishek? Yeah. Hello, sir. Hey good morning. Can you hear me? Yeah, I can hear you.
DR ASHISH BABHULKAR/DIPIT SAHU: Yeah do you have an outside view? Yeah, there is outside view. Yeah and you can see the shoulder, the presentation is done? So you know the history? Right. Yeah, so we're doing a small rotator cuff tear in the 62-year-old chap, and we're doing this in the beach chair position and can someone switch off all your mobiles, please?
DR ASHISH BABHULKAR/DIPIT SAHU: So these are my markings. This is my posterior viewing portal. I take it a little high and lateral as opposed to the conventional 2 centimeter which is what is convention. Yeah. This is my suboptimal viewing portal, this will be my intervention portal, the five yard. And there's an additional anterior portal. That's all I need for a rotator cuff repair.
DR ASHISH BABHULKAR/DIPIT SAHU: So let's start from time zero. So I expect the tear to be, present as a rim tear on the sub-acromial side, I expect that the gleno humeral joint would be normal and the articular surface of the cuff should be intact and we will be able to appreciate the tear once we go sub-acromially. OK.
DR ASHISH BABHULKAR/DIPIT SAHU: OK so the initial entry point and yes, on the rotator cuff, you take this entry or is it different for this particular case? No, no, no. This is my standard entry for all the subacromial work, including subacromial including supra-scapular nerve, including rotator cuff repair except for a full blown sup-scap tear. If I'm doing a
DR ASHISH BABHULKAR/DIPIT SAHU: type 1 or type 2 or type 3 tear sub-scap, I would still stick to the same except for one additional portal but if I'm doing a type 4 sub-scap out of the box, then I'll have some more additional adventurous portals. Yep. So let's do a diagnostic scope first. Can we just drop the brightness a little down and so, here we are looking at the glenoid joint.
DR ASHISH BABHULKAR/DIPIT SAHU: Do you have an inside picture now? Yeah, inside picture is small, so can we shift? Stop the pictures, make the inside monitor picture larger and outside one, it can go small. Yes. Yeah. OK, so here we are. This is our lighthouse longer biceps right there.
DR ASHISH BABHULKAR/DIPIT SAHU: Now you see the arthroscopic view. Arthroscopic, not the outside view. Yeah, the monitor view. We're. Yeah. Yeah, Yeah. Perfect. So this is the biceps anchored, significantly worn out. There is some degenerative change. I don't think this is a traumatic slap.
DR ASHISH BABHULKAR/DIPIT SAHU: I'm going to ignore that for sure. These glenoid looks in good health. This is the anterior labrum, middle labrum, inferior labrum going into the X-ray pouch. Not much of inflammation, which is a good sign because that could be a precursor of frozen shoulder. So although his range of movements, only 90, 90 rotations are quite well preserved. And then this is the sub-scap.
DR ASHISH BABHULKAR/DIPIT SAHU: And you could appreciate that the sub-scap has the image wrapped around it. So it's a thin, transparent gel that's your sub-scap and that's your insertion of the sub-scap. There's a little bit fraying on the insertion, but I wouldn't call it a tear tear, but there's a lot of fraying within the injured shell. There's some inflammation in the rotator interval so this is just the early onset of adhesive capabilities that he's going to experience.
DR ASHISH BABHULKAR/DIPIT SAHU: But whenever you see an injured shell, which is visible, oblique, it means that the sub-scap anatomy is normal. That if you don't see the injured shell then you can imagine that the sub-scap is probably torn and injury migrated medially. So and then coming in next door to the sub-scap, its immediate neighbor is the longer of biceps. So here on the longer of biceps, you can see that there's a lot of inflammation there, typical
DR ASHISH BABHULKAR/DIPIT SAHU: and that is what incites the pain. So thinning of the biceps and you can see the pulley is pretty disrupted, you don't see a formal pulley here. So biceps has lost this pulley, so that would provoke as a biceps pain here. And then we're coming in just lateral to the biceps, a lot of inflammation here. And this is the rotator cuff.
DR ASHISH BABHULKAR/DIPIT SAHU: And you can see a paint lesion here, and there is a small rent here. There's a small wrinkle. Never assess the tear from the glenohumeral joint because the tear is rather overwhelming when see when we move in sub-achromially. So don't take your decision of one anchor signal repaired based on your glenohumeral joint. So I'm just coming in with my portal here and this would be portal that matches with the tear anatomy, just taking,
DR ASHISH BABHULKAR/DIPIT SAHU: and it's exactly in the fire line that I had marked. But I did rather have my knee dictate the portal rather than do a pre-judged portal like as you were doing a knee arthroscopy from outside right now so that it is easier to go back from sub-achromial space. Is it so? Probably but I won't mark it. In this case, there's going to be a fairly small tear.
DR ASHISH BABHULKAR/DIPIT SAHU: So sometimes you could put your whistle inside whilst you change your viewing portal. So you just come in there. This looks like some inflammation within the sub-achromial joint because the moment I made that portal, everything started bleeding.
DR ASHISH BABHULKAR/DIPIT SAHU: So the outside camera also needs to be adjusted because we can't be showing the wrong outside camera. Zoom out and show the portals. Yeah no, no, no. Zoom out, zoom out, zoom out, zoom out and focus where my hand is, zoom out.
DR ASHISH BABHULKAR/DIPIT SAHU: {INAUDBLE} You need to show this area here. The map. So that has to be transmitted. That is not. This is something else that, which is the third camera there? That is too zoomed out. It's too zoomed out.
DR ASHISH BABHULKAR/DIPIT SAHU: He's right, he's showing the right stuff, it's not getting transmitted. OK, OK. Yeah, that's perfect. Yes, OK. Just clearing up the stuff now. I'm a very consistent advocate of biceps tenotomy in such inflammatory tears, especially when the biceps is
DR ASHISH BABHULKAR/DIPIT SAHU: inflamed, degenerated and damaged. And so we are going to start with the biceps tenotomy. It's not an all absolute, but exceptionally I would leave the biceps in place. So the normal that I would do a tenotomy for all my rotated tears. I'm just taking the opportunity of cleaning up all the scar tissue there, we created tissue there. And at the same time, since I'm there, I'm preparing this footprint.
DR ASHISH BABHULKAR/DIPIT SAHU: Probably it looks like a modest tear maybe about 20 anti-posterial, not retracted medially. Probably would deserve a triple loaded single medial suture anchor. But I'm just thinking to myself loudly so that the team prepares that anchor. But I will not take it on the table yet because you could end up having a surprise once you go in there.
DR ASHISH BABHULKAR/DIPIT SAHU: OK don't mess up in the rotator interval because that's the tissue that usually bleeds coming with my arrest. And just because we know how the thought process goes, that is very important indeed. Indeed so if you know the vascular anatomy of the shoulder, then you should know where not to take the shaver in, because once it starts bleeding, then it can get a little messy. So those are certain areas that you want to avoid and that keeps the surgery as clean as possible.
DR ASHISH BABHULKAR/DIPIT SAHU: Can you specify the areas which we were like using the shaver? OK so if this is inflamed and if these encapsulate this, then be very careful here, largely safe here, and try not to get in there. So just coming up here, about a centimeter from here is a suprascapular nerve. So here what I'm using is just quagmore, not cutting more. So I don't want the current to be transmitted to the supra-scapula nerve because we want to worship the suprascapular nerve.
DR ASHISH BABHULKAR/DIPIT SAHU: So this is the area. Often you will see a lot of inflammatory changes here. And in the rotator intertwined biceps, the one thing before you cut the biceps you want to do is just go in there and see that's the inflammatory area. So we'll just whack those because that just points the feel. Good morning, Sir, Saturn here.
DR ASHISH BABHULKAR/DIPIT SAHU: How much is your pump pressure and how do you manage that? So it's about 35 and very low, I'm very conservative on the pump and I'm happy to do the surgery without the pump elsewhere. And so your blood pressure, how much would you prefer? Well, that's my team, Doctor Babhulkar and team have kept it at around 165. We have an agreement between them that they will keep it below 90 and then that works,
DR ASHISH BABHULKAR/DIPIT SAHU: that's the A-team. So your entire success of surgery? I told Doctor that it depends entirely on the anesthetist, so you need to be on the good side. OK. So what I'm doing here is that I'm signing, pulling the biceps in. You can do this better with a hook probe and once you pull it in, you will see that the inflammatory, see that inflammatory change there very well, that is in the groove and not visible to most of the biceps, where pattern inflammation will be in the groove, in the bicepular group under the transverse ligament.
DR ASHISH BABHULKAR/DIPIT SAHU: So you need to pull it out, pull it in, check that you know that this is damaged. If it's pristine and there's no wear and tear, then I'm happy for this to be left in position, but as I said, I would do that in a young athletic male, which is not the common norm. You are dealing with 62 year olds, degenerative tendons. These are question from the delegates audience that whether you do biceps tenotomy in all your cases or how do you treat that?
DR ASHISH BABHULKAR/DIPIT SAHU: I, I don't get along with the biceps. So my. Thumb rule is, do a tenotomy for the biceps as far as possible. And if the patient flip side, then sorry, even the patient on the younger side of the spectrum played less than 40. I would do a biceps tenodesis between 50 and 60, I'm equivocal. It depends on its physiological age, whether it is athletic, doing gym stuff and all that.
DR ASHISH BABHULKAR/DIPIT SAHU: But for that to retain the biceps, I need the biceps to be healthy. No vascularity, no inflammation, and the tears should not be in the vicinity, the pulley should be intact. If your pulley is gone, then you're asking for trouble. And this is what, what level do you know? This is your I do it arthroscopic in the groove.
DR ASHISH BABHULKAR/DIPIT SAHU: Haven't regretted doing that, there are many ways to skin the cat. And so I don't like the effect major technique because one, it is takes time consuming. Number two, you want to open their incision? We prefer an all arthroscopic. And number three, there is a small incidence of humeral fractures. When you do that, pec major level 10.
DR ASHISH BABHULKAR/DIPIT SAHU: tendonisis. Right, so we have in the sub-humeral joint fairly clean some inflammatory tissue here. So we're going to just, this is more important from the vascular anatomy point of view. So most of you should. There's an article in JBJS about the vascular anatomy of the sub-acromial joint, what they read that to tell you the areas to avoid.
DR ASHISH BABHULKAR/DIPIT SAHU: There are variations, but 90% of times it's a fairly consistent pattern that will follow. So you can see that this is the area, which is just the, see the ligament here? Right in front and that's your only marker in the sub-acromial joint that will tell you that you are in the sub-acromial. Otherwise, you can get lost, especially if this is full of bursitis, inflammation and you can place it up here.
DR ASHISH BABHULKAR/DIPIT SAHU: You can see this is the only focal area of frame. The rest of the seam ligament looks fairly pristine, clean, neat. Let's clear this up, there's some inflammation. So just to take you one step back. Do you feel any change when you cut the biceps, or do you see any significant difference in your technique of cutting the biceps with the meniscus biter or if you do it with the RF?
DR ASHISH BABHULKAR/DIPIT SAHU: So I am very frugal with the use of the RF. I do it very rarely. Sometimes I'm lazy, and the skin knife. I mean, the skin knife that I use, I use an 11 number knife. I go in the vicinity and when nobody is looking, I just quickly cut the biceps with the skin knife. But that's just to add variable to whole thing, I would always almost use a duckbill or a biter.
DR ASHISH BABHULKAR/DIPIT SAHU: There are certain companies done by the duckbill which are very small in mouth. And then what happens is they take a bite and the bite drops into the joint. I don't like that debris in the joint because that incites inflammation. So you want a large size duckbill which will go and swallow the entire biceps and you don't cut it completely because then the fragment gets dropped into the joint.
DR ASHISH BABHULKAR/DIPIT SAHU: So you do it, one third, one third, one third, and keep completing the test slowly. So, Nicilia, one question about tenotomy what percentage of your patients come back and tell you that they've noticed barbwire deformity and how many are actually bothered by it? So if you can't sell them well in advance, then they can anticipate it maybe three out of hundred, honestly, the ones who are very elderly, but you have to make a distinction between other surgeons.
DR ASHISH BABHULKAR/DIPIT SAHU: Me, if I have a sub-scap tear in association with my supra stem I will always do a bicep tenodesis with the sub-scap. So my sub-scap repair mandates that I do a sub-scap repair and a biceps tenodesis within that same anchor because the anatomy, native anatomy of the sub-scap and supra and biceps is very close to each other. And the sub-scap has a running affair with the biceps, whenever the sub-scap tears, the biceps will elope with it.
DR ASHISH BABHULKAR/DIPIT SAHU: And that's why whenever the sub-scap is damaged, you can take it for sure that the biceps is unstable and it's more likely to dislocate or undergo popeye sign. But even if I do a tenotomy in this situation, the sub-scap is intact. I'm presuming the intra-trabecular ligament is intact. It'll go in slide and sit there, it will not go down.
DR ASHISH BABHULKAR/DIPIT SAHU: So it finds its own home position. If you are a little worried, then you can do a cauliflower tenotomy. Yes so thought process when you have a small sub-scap tear associated with a biceps inflammation like so, would you do a tenodesis and repair the sub-scap in the same anchor or do you use different anchors for both? Good question.
DR ASHISH BABHULKAR/DIPIT SAHU: Type two I would do it in the same anchor. I have a cruciate technique not so distressed where one suture goes into the biceps and the rest will go into the, three will go into the sub-scap. That holds true for type II and type III. If I have a type four, then I'm going to do an extra articular out of the box where I would do a tenodesis on two anchors for the sub-scap so at least seven sutures in the sub-scap and one for the biceps.
DR ASHISH BABHULKAR/DIPIT SAHU: So, so no double rows for the sub-scap in your hands? In type 4 and type 5 occasionally, not always. The sub-scap anatomy is a little different from the supraaspinatus. If you see the supraspinatus it has a footprint, which is very broad, and it's almost rectangular. If you go back and see the sub-scap's anatomy, it's like a wedge.
DR ASHISH BABHULKAR/DIPIT SAHU: It's broad on the top and narrow on the bottom. So I don't think a double row is going to add much value. So I need to ensure that the bicep is not inflamed. I have a position there to put my anchor in and then I would do an additional but I don't see a huge value addition in doing a double row for a subscap. But I would reserve that only for a type 4 or a type 5.
DR ASHISH BABHULKAR/DIPIT SAHU: So I was trying to show you this c ligament as you come up the c ligament, when you can see frame here only in the anterolateral part. That's the part where there's been gone . So this is impingement and that impingement happened because of a weak cuff. But the c ligament is not at fault so there's no point taking the c ligament down. It just tells me that this patient has a recurrent impingement.
DR ASHISH BABHULKAR/DIPIT SAHU: And if at all, I'm compared to osteoplasty, I would do it only of this area, which is the anterior and lateral acromion. There is no point doing an acromioplast medially or posteriorally because that area is not involved. But the threshold for problems is very, very high. Again, I do them very infrequently. So do you ever wander upon the critical angle and for latero acromiopathy or I mean, is that something we should be doing routinely?
DR ASHISH BABHULKAR/DIPIT SAHU: Actually, good question. We started doing it, we got excited with the standard of the paper and we started measuring all those. And then there are at least four different counter papers that in New Zealand population the critical ankle does not correlate with cuff tear as such, but it does restrict my anchor passage and my portals are suboptimal when I'm doing the cuff repair.
DR ASHISH BABHULKAR/DIPIT SAHU: So in such situation then I find that my acromion is impeding my access for a vertical 70 degree angle, then I will do a lateral acromioplasty. So we noted down pre operatively, my fellows do their angles and warn me that there is a chance that I might need to do it. But I let my arthroscopic picture decide whether I need to do it or not. So it's not based on a pre-op plan.
DR ASHISH BABHULKAR/DIPIT SAHU: Noted. Yeah. So the areas to be avoided coming in there, So this is the c ligament. You go and give it to the c ligament. I'm going to have to take a portal there. There's a branch from solar canal, bleeds viciously, so do be careful around that area, certainly this area.
DR ASHISH BABHULKAR/DIPIT SAHU: If the c joint is involved, then this is the area underneath the incision that can have significant bleeders. And then coming in here, this is going to be the spine of the scapular. I'm going to show that to you in a minute, and that area, when I do the release. But I'm compelled to do the release because in my patients, it's obligatory for me to do a decompression at the spine,
DR ASHISH BABHULKAR/DIPIT SAHU: we'll talk about that later, so I need to go down. But if you're not compelled to do a spinal glenoid decompression in your cases, then you can safely avoid. This is the area where there's maximum bleeding. And then the last level of bleeding is posteriorly. But that's related to not vasculature, that's related to chronic inflammation,
DR ASHISH BABHULKAR/DIPIT SAHU: so if a patient doesn't have vision, then that should be a OK position to go to. So I'm going to be brave and start using my shaver. It's the shaver that inside bleeding because it sucks tissues and creates the mess like this. Now this is the bursa. It's a small tear, so I don't like taking out bursa. The bursa has the largest concentration of the MSCs and the stem cells.
DR ASHISH BABHULKAR/DIPIT SAHU: Plus it brings in very healthy vascular tissue for the repair. So unless it's a massive tear where I need a better visualization, my sutures and anchor are going to be compromised. I would only then do an extensive bursectomy. But here, as long as I can see my vessels coming in, I have my anatomy fairly clear. I will do a very limited bursectomy here, this one.
DR ASHISH BABHULKAR/DIPIT SAHU: OK? and this is the nature of our tear OK? So I think this is a tear that deserves a single triple loaded anchor as I said, this must be about 20 mm and kilo posteriorly and partly five mm protracted. This is typical remnant tear, very little here. You can see in the glenoid joint it's a complete tear. So we're going to ask. Today we will demonstrate to you and also to anchor the iconic speed.
DR ASHISH BABHULKAR/DIPIT SAHU: The reason it's called speed is will be evident to you and we'll use that for 1 medial anchor, the iconic speed and then the omega up here. So we need to prepare our position for the omega. We are doing good for time, we are just about 20 minutes in and I'll need another 15, 20 minutes to finish this case. One question about the greater tuberosity preparation. You are very aggressive in taking down all the remnant of the tendon from there and make it and making it a bleeding surface.
DR ASHISH BABHULKAR/DIPIT SAHU: No, no, no. Because this surface is fairly tenuous, osteoporotic, I just do a dusting and my dusting is actually very stable. Never, ever use a burr. That's pretty much OK. Sometimes there's a layer of leathery tissue there. So then you might want to use your RF to clear the tissue because the shaver doesn't take soft tissue as well.
DR ASHISH BABHULKAR/DIPIT SAHU: And this is as much as I would do if you are going to use like if you're using all suture here, you want your cortex to be intact. Irrelevant. The all suture makes such a small hole. It's a 2.3 anchor. No pilot hole, no drill. So it's going to be just straight forward and it'll have a much better hole. Actually, if I mess around.
DR ASHISH BABHULKAR/DIPIT SAHU: Let's see. You must, whatever happens, keep the cortical margin in. But I think the one metric that prevents an anchor pull out is your direction angle of attack. And that is not the conventional Orthodox angle. That is 40, 45 degrees that was advocated by Burkhart. It should be as vertical as possible, and that's the point I was trying to make, that if you have a lateral acromial spot or a down sloping acromion, then you will not be able to go into that.
DR ASHISH BABHULKAR/DIPIT SAHU: You're going in a sloping angle and it's been proven. Burkhart has done some fantastic studies to show that the dead man's angle is irrelevant, it should be as vertical as possible. Now it is inconceivable that either of us can do a 90 degree insertion because of the way the equipment comes in the way. If you can get a 70 degree angle, then that will ensure that your anchor has the strongest hold possible for the pull out.
DR ASHISH BABHULKAR/DIPIT SAHU: So can you explain what you're doing now? Right so let's wait for this to clear up with some caution. Give me a wash. So this is what I do. The brightness is too high. Can somebody drop the brightness? Can I do it from my end? Yeah, yeah. That's much better,
DR ASHISH BABHULKAR/DIPIT SAHU: thank you. This is the acromium. Just for reference sake. This is the anterior column and you can see the c ligament. This is all the c ligament. This is the area that got worn out. So that's the anterolateral part. And we still need some better water fluid control. Let me make an anterior portal, that will help.
DR ASHISH BABHULKAR/DIPIT SAHU: Give me a minute. I'll just improve the visualization so that when you go into the bursa or is it still 35? Come again? Do you increase the pump pressure when you go into the bursa or is it still 35? I don't like to, it's still 35, I've not changed that
DR ASHISH BABHULKAR/DIPIT SAHU: and I rarely do. These things happen, the bleeding will eventually cease. What happens with increasing the pump pressure is it creates a huge soft tissue swelling eventually, and if you finish your surgery in 40 minutes flat, hopefully that's the plan today
DR ASHISH BABHULKAR/DIPIT SAHU: then we should be on a home run. But if you delay surgery and one and one and a 1/2 hours later, the entire tissue starts swelling and it closes on you, and then that creates a problem, so I don't see a flow there. I need a flow. Yeah. Yeah. So I'm just putting a cannula anteriorly. Again, don't do that too often, but that's going to improve, improve our flow.
DR ASHISH BABHULKAR/DIPIT SAHU: I just seem to be focused as well. Yeah, that's better. Yeah, that's much better. So as I saying, the c ligament coming in here and that's the anterolateral acriment is the lateral margin of the domain you're moving medially. There's a lot of debris here, all this debris is unwanted. It's not.
DR ASHISH BABHULKAR/DIPIT SAHU: So I'm following that into the spine of the scapula OK? And this is the spine of scapular. At some point, I'm going to have to remove the soft tissue for you to be able to visualize. And I stick to bone, you find bone and stick to bone. Don't digress, because that's very important. I mean, just lift my light source up a little, just here. So you're running down the entire spine of the scapula.
DR ASHISH BABHULKAR/DIPIT SAHU: OK can I have a shaver? I'll do a little risky maneuver, keep this in your hand. There's a debris there. So we are doing the decompression of the spinal glenoid notch for the supra scapular nerve, I do that for all my cuff cases. This is the area that bleeds I'm just
DR ASHISH BABHULKAR/DIPIT SAHU: doing minimum there and then coming in like this. Yeah, so just follow the acromium and go down and you see a lot of debris here. The entire spine of the scapula is like the bow of a ship it's broad in the top and narrow at the bottom. So your job is to go all the way down to the apex. OK. One question here regarding this, your rationale behind doing this for all cuff cases.
DR ASHISH BABHULKAR/DIPIT SAHU: OK. Good question. Again, the point is this , let me finish this anotomy and I'll come back to it. Let me, you can see that it's bottoming out. There's going down into the apex and following it down. And if you can see the apex there, then that means that you have arrived to the bottom of the huge debris hill.
DR ASHISH BABHULKAR/DIPIT SAHU: And this is what unnerves me, because this actually compresses the spinal glenoid ligament, compresses the suprascapular nerve. OK. Here we are. So this here posteriorly is the exit of the spinal glenoid notch and this here is the entry and that's still tight.
DR ASHISH BABHULKAR/DIPIT SAHU: If you can see the spinal column and can you see that it's closed completely. Yeah, yes. I'll show you again. This it's never so full of debris. This is intact, It's closed here. The entry point is closed. So it's a tight canal.
DR ASHISH BABHULKAR/DIPIT SAHU: I have opened it posterior so if you can see here posterior has gone open. Few little remnants are there, so my job is to open the entry and exit so be very gentle. Now, you see on the right side of the screen is full of fat and that fat is next to the nerve. The fat protects the nerve, so you don't want to go laterally.
DR ASHISH BABHULKAR/DIPIT SAHU: So I have just opened the entry portal here completely, that's it. So it's fairly thick spinal glenoid ligament here and then just complete the same posteriorly. Yeah and I've opened it posteriorly as well. OK. Now, so this probably applies to only 2% or 5% of the population and but there is no means of knowing which patient has a suprascapular glenoid
DR ASHISH BABHULKAR/DIPIT SAHU: compression and which patient does not. Now imagine a patient who has a spinal glenoid compression, which is a very true fact, and it's known and probably it's been under compression for various reasons for a long time. That's my outside portal. Coming in it's fairly vertical, you can see that and that's coming at an angle of almost 70 degrees because we are doing a single anchor we will go in the medial at the junction of the cartilage.
DR ASHISH BABHULKAR/DIPIT SAHU: Hand and footprint right there. OK? So that patient is going to have progressive wasting of his infra spinal rotator cuff, and then eventually he'll have a small trauma. We record the trauma and we dictate that he has a rotator cuff tearing, end up repairing the rotator cuff without realizing that there's a inherent supra scapular nerve policy, which has not been detected. In the presence of a cuff tear
DR ASHISH BABHULKAR/DIPIT SAHU: it is going to be very difficult to do an EMG to prove that there is a supra scapular neuropathy, and most surgeons are now aware of this, so they are not going to subject the patient of a rotator cuff tear for a EMG. And that patient is the one that's not going to do well. And although structurally, you do your MRI's and stenography and you're going to see that structure is intact, it is not innervated and it goes up progressive wasting.
DR ASHISH BABHULKAR/DIPIT SAHU: So those are the patients I'm targeting. So I would just spend five minutes doing this. What you're seeing now is iconic speed, so you don't need a punch. It just goes in directly. It's an all suture 2.3mm anchor, this one is triple loaded, hopefully and just goes in and goes all the way. There's a marker there that that's the stop and I'll go in there.
DR ASHISH BABHULKAR/DIPIT SAHU: Perfect. Babhulkar Sir, is that the same approach you take for a spinal glenoid knot decompression, or do you do it through the slap? No so I used to do it to the slap, but that's a indirect way of doing it. But there there's a very impressive parallel system. My colleague is just yanking it to ensure that the knot is set ii is very important, to ensure that this anchor is synced because you want to pick up all the slack put in.
DR ASHISH BABHULKAR/DIPIT SAHU: And then. Yes so I have switched over the last four or five years picking after Jinjiang who showed me that we should do this sub acromially so from the sub-acromial side, I split the RAF between the supra and and infra and then identified the swiss I must confess, I can't do this for all these parallel places that I see because you need an impressive system, like a dumbbell system that moves from the subacromial to the transverse capital notch.
DR ASHISH BABHULKAR/DIPIT SAHU: So those are the ones. So the smaller sister still do them from the glenohumeral joint along with the slap postural repair. So I'm going to identify, there three different colours here so I'll take one pair here, park it into the lateral portal and then I'm going to give you an indirect her coming in from the front
DR ASHISH BABHULKAR/DIPIT SAHU: like so. And then we started the anterior edge of the tear, you want to go a little close to the rotator cuff cable. That dictates your tension and that dictates your success of surgery. Because if you don't restore the original leg tension relationship, then. OK? Yeah. Then it will remain a loose repair, a non repair because it's important to
DR ASHISH BABHULKAR/DIPIT SAHU: put in the exact trigger there. So just checked which one, the anterior one has to come in there so my colleague just checked, which suture I've got to deploy and then just retrieve it through. And I think the pump pressure needs to go up a little. Just a little woozy. So do you use on scorpion like suture retrieval devices?
DR ASHISH BABHULKAR/DIPIT SAHU: I have, I have two other devices with me. I have a first class and an elite one, but I don't use it too frequently, certainly not for the smaller tears because the corners are not amenable, it's too small for the whole thing to go through and if it's a double layered tear, then I'm going to prefer this, this is my go to device.
DR ASHISH BABHULKAR/DIPIT SAHU: So which statistic of 90% of the cases, I would do the indirect suture surgeon. Yeah it's much better now, I think the flow is good, this is working well. {INAUDIBLE} What has happened is both the bottles are finished off at the same time.
DR ASHISH BABHULKAR/DIPIT SAHU: That's right. So now I use the left indirect suture shuttle for the first two sutures and for the rest, now I'm going to switch to the right. So first, I'll get my, I always keep the colored sutures for the corners, and I use the white ones in the center because the white ones tend to get masked and then you can't see them in the corners
DR ASHISH BABHULKAR/DIPIT SAHU: so always keep the colored ones in the periphery and now I'm going to come with the right from posterior viewing portal, which was the gleno humeral viewing portal. Just come in there nicely, and then keep them right about the same table at the same time and a half equidistant. So you want them equidistant so that I'm just going there at the junction of the tendon and cuff.
DR ASHISH BABHULKAR/DIPIT SAHU: OK? Now the advantage here is I can actually visualize which part of the opinion, which part of the cuff is coming through. Yeah so if I've got the middle most part, which is close to the cable, then I'm OK and happy with it otherwise I can just change it there.
DR ASHISH BABHULKAR/DIPIT SAHU: Sometimes the suture shuttle misses the inferior layer when you're doing a double layer tear. So with this suture shuttle, I can stay there and still swing it through another loop and get it to that inferior level. You can't do that with the direct devices because then once it's passed in, it's impossible to see whether it has factored in both the layers or not. Having said that, I'm not against them.
DR ASHISH BABHULKAR/DIPIT SAHU: They are quicker on a day that I have a bigger tear. I need a bigger tear to be able to use the direct devices, Coming in here again, equidistant, there's a white here which is again, see, I was mentioning that the white is, see? It's very difficult to see the white. That's why I keep it in the center. And you'll end up taking a bite just there. So you want stitches for all?
DR ASHISH BABHULKAR/DIPIT SAHU: Sorry, come again? Mattress here. Mattress for all. Mattress for all. Because a mattress for all. Because I'm a person who advocates double rows and a mattress for all will sit very nicely with the, the double row technique because that mimics the grand fossa as widely as possible.
DR ASHISH BABHULKAR/DIPIT SAHU: And that remains our gold standard, the Transocean equivalent. These devices, these mini tapes. They look more like tapes. These are tapes. So you can get the iconic speed with sutures or you can get them with tapes. And so we've been provided tapes, so I don't ask for it, I'm not a big fan of the tapes, but it's an option that we. So,
DR ASHISH BABHULKAR/DIPIT SAHU: the tapes were not them. So yes, yes, I will knot them, I don't like, not tying the middle row because then we have invested everything into our lateral row and the one that fails is the lateral row. The one that fails is the lateral row and when the lateral row fails, your entire concept is gone. So today, if my lateral row fails because of the osteoporotic bone, repeat, we are about 10/12 minutes away
DR ASHISH BABHULKAR/DIPIT SAHU: then I'm still invested in the medial side, so I have no stress. The program rehab recovery will be identical. Yes, sir. Yeah and now I've done five of the six sutures, now I'm going to switch over and give me the yellow again. So I go back to the left, so I used the right for the central
DR ASHISH BABHULKAR/DIPIT SAHU: three sutures and then I come back and there's a method in this madness, I'll show you. As I was coming. OK. So previously I took them here, this time instead of going in that direction because I'm dealing with a lateral leaf that I want to factor in as laterally, I'm going to dive this way.
DR ASHISH BABHULKAR/DIPIT SAHU: So this is the right one. It's got a light intensity. We increase slightly because the picture is slightly darker. Let me do that. Thank you so much. It's my end. Increased sir. I'm doing it
DR ASHISH BABHULKAR/DIPIT SAHU: I'm doing it. Yeah is that better now? Yes, sir. Much better. Thank you. Yeah so, as I was saying, instead of going from here to here, this is the left turn. So I just dive like this and so I can factor in again equidistant and get a nice bad bite on the lateral reef and just comes out here.
DR ASHISH BABHULKAR/DIPIT SAHU: Here it's important to have a look and ensure that you've got the entire cuff, not a small part of it. So this device allows me to do all that. So it's a much more judicious approach. I know. I know that I've taken the entire width of that and then when you look from here, that's all our in session done.
DR ASHISH BABHULKAR/DIPIT SAHU: It's an equal distance, nice little star configuration so happy with this. Now, unless the situation demands I start from a posterior to anterior time order. So this is our posterior suture. That's why I keep blue posteriorly and then I have to search for my whites, somewhere here and these will be tied first.
DR ASHISH BABHULKAR/DIPIT SAHU: So I tried my central ones first. OK? Yeah. It's important to ensure that you see you're not coming in and that can be a challenge. Sometimes if the bursa has not been taken down, if the bursa has not been taken down initially in the presence of the sutures, removing the bursa now is precarious,
DR ASHISH BABHULKAR/DIPIT SAHU: and it can damage the sutures as well. It's been done, so we don't want to do that. So the white coming in this is central. The reason I do the central sutures first is because that's the most mobile part of the tear kingdom and that's the one that you want to bring over the footprint and ensure that it sits there.
DR ASHISH BABHULKAR/DIPIT SAHU: That will basically pull the whole cuff to your? Correct, correct. Can we take the omega for the lateral row on the table? The single omega. Perfect - tender, duncan's loop.
DR ASHISH BABHULKAR/DIPIT SAHU: OK so we've seen the knot coming in laterally and that means we are going Sometimes a knot stays high and the knot pressure comes through so that's not a good situation. OK, so that's done with this. Then we come to the posterior one, which is the blue. Yep.
DR ASHISH BABHULKAR/DIPIT SAHU: OK. We just facilitate to ensure that the blues are just coming in to the view and then gently. Yeah? OK. Again, ensure that your sutures are. And then alternative half inches.
DR ASHISH BABHULKAR/DIPIT SAHU: The tapes are impressive and they probably prevent a lot of cheese cutting. They do increase the size of the knot and sometimes when your instrument is coming in, they can get damaged because they are much broader in the portal. So now I'm going to park my blue suture in the higher portal, anchor portal.
DR ASHISH BABHULKAR/DIPIT SAHU: So I've got four sutures in the anchor portal. Welcome back. In and then come and find my anterior suture here. So there's a pain, pressure. Someone and then. So I've had some feedback from my Fellows that there sometimes struggle with the lateral row anchor.
DR ASHISH BABHULKAR/DIPIT SAHU: I think there's great merit in having the lateral row anchor because the retreats are far, far superior. I'm not too worried about the strain and the configuration because naturally the double row is going to be a far more stronger construct than the single row. So do your views on using the cannulas? So I never use the cannulas. My cannula goes in only when the anchor goes in and when I retrieve the suture, then I take off the cannulas.
DR ASHISH BABHULKAR/DIPIT SAHU: They impede my progress. They obscure the flow, and the callunas tend to direct you into one particular direction. This is free flowing. So I use the cannulas for the Bankart repair, that's for sure, because I can afford to get all my sutures. It up. But if your portals are clean and the direction is clean, then you don't need them because this is a free flow.
DR ASHISH BABHULKAR/DIPIT SAHU: So you've got a medial row here done, now we are going to prepare for a lateral row. I just, need to make a little bit of revision. I could use two lateral rows, but it's a bit of an overkill today. It's a much smaller tear; just clear up this little band, which is always a consistent band here.
DR ASHISH BABHULKAR/DIPIT SAHU: And then you want to orient the lateral anchor in such a manner that all the sutures are under rotation. Slight internal rotation for me. Right? OK. If you look at this part, you could draw this line straight. It's going to come in line with the wide suture so that's the central suture. So this is X marks the spot. That is where I want to be.
DR ASHISH BABHULKAR/DIPIT SAHU: Let's have a cannula. I'll use the cannula now because I don't want my deltoid getting involved inside my repair when I pick my sutures. I so. So, Dr. Komal, I have one question. Yes, come on. We prefer to do a microfracture on a GT.
DR ASHISH BABHULKAR/DIPIT SAHU: What are the chances? So I have used the Crimson duet technique. Previously, we actually did a study to see the improvement on the vascular. We are studying the vascularity on ultrasound studies postoperatively and did that impact our repair? Number one, we abandoned the study because we saw no difference at all.
DR ASHISH BABHULKAR/DIPIT SAHU: Number two, it's going to be very difficult to prove that the repair rates are far better with that because our repair rates are extremely low. Maybe for a 10/15mm tear, it's almost less than 1% in this. If you hire when you're dealing with [one second] larger tears. Still, I would do that sometimes when I see a very closed one, one switches off.
DR ASHISH BABHULKAR/DIPIT SAHU: Sometimes we're dealing with a very sclerotic, very see that you have done a shaving of the GT preparation and you find out that it's very dense, there is no potential bleeding, I would just arbitrarily do that. We only anecdotal. Not sure it helps. OK so this is a new generation anchor that I want to introduce to you.
DR ASHISH BABHULKAR/DIPIT SAHU: This is the Omega, and it comes in two different forms. There are several plusses here. So this is a direct punch. You don't need to use a punch to get this in and this is like a wedge with a barb, but it just goes in there. I mean. I mean, how many tapes have you packed in that?
DR ASHISH BABHULKAR/DIPIT SAHU: Six very comfortably, six and now sometimes you struggle to find your point of insertion but because the sutures are there, they lead us to this, and then the screw comes over it and now don't push the screw. My colleague is just going to just tension the repair. Not too much. Just enough, somebody can give a heads up to
DR ASHISH BABHULKAR/DIPIT SAHU: repeat that he is on in 10 minutes time. He needs a spoiler alert. And then you are so you're number one because the tapes are there. There is no chance of losing the pilot hole. Number two, you've got dual fixation here in a soft sclerotic bone, your initial wedge and the screw that locks over it. Less likely that you lose the lateral row.
DR ASHISH BABHULKAR/DIPIT SAHU: And so it comes in and configuration where it's pre-packed with two different implants. So most of the tension is taken by the medial row and there's lateral buttress that edge down to the bone. No, so the basic job of the lateral anchor is number one to create a maximum contact area so that the entire footprint is covered, by a medial row you will have the inside contact, but the lateral leaf will be floating and not in contact with the bone.
DR ASHISH BABHULKAR/DIPIT SAHU: The more that the tissue is going to contact with raw bone, the better the chances of healing. Do you get that? So that is the role for the double row. So this is our repair and when you move it through, not a problem. [Question do you always do double row? In all your cases?] 99%, yes. But if I'm dealing with a very, very small tear, open tear, fine tear, I personally don't operate fine tears, all the tears less than 10 mm are sent on a conservative program.
DR ASHISH BABHULKAR/DIPIT SAHU: So accidentally, if I come into a slap tear with a fine tear, then that will be a small single medial row anchor So you can see this is plastered down, you can barely see the tear. There is no dog here because the sutures are equidistant to each other so the tension is equal. So we can see that it's sitting in perfectly well, and when you move it, it moves asymmetrically with the tendon.
DR ASHISH BABHULKAR/DIPIT SAHU: We'll just do one last quick look on the glenoid, gleno humeral side. [INAUDIBLE]. [INAUDIBLE]. Thank you. That's we are about 45 minutes into surgery, five minutes more than what we wanted for. So we come back in the glenoral joint and have a look at how does that sit, because that will dictate how well.
DR ASHISH BABHULKAR/DIPIT SAHU: So that's pretty anatomical because you can't see any of the greater tuberosity. Can you see the red marking there? [YYES} So those vascular stops at the rotator cuff cable, that means that cable is very close and the crescent is matching to the footprint, which means that this has been tensioned anatomically. It's not too loose, it's not too tight and you can see a nice tension there,
DR ASHISH BABHULKAR/DIPIT SAHU: it's as if the tear was not there, it's clustered in beautifully and that's that effect you will see only on with double row. You'll never see that with a single, single row, it'll be lax limb. It will never have the same taut effect that you see here. And you can move it through as much as you can and you can see there is no micro movement at all. So I think I'm happy with this,
DR ASHISH BABHULKAR/DIPIT SAHU: hopefully you'll agree with me. Before I close, must thank the anesthesia team, has to be a operating team doctor. Fantastic we get a very nice blood pressure control doctor Ajib who assisted us and we know this has been our loyalty brother. Thank you very much. Thank you very much. Thank you. So we are shifting to the road. So give us 10 minutes for the trolley and the AV equipment to go across.
DR ASHISH BABHULKAR/DIPIT SAHU: I'll join you downstairs in a minute. So there's one question from the delegate on if to assess pre operatively that we can manage this tear, cuff tear in a single medial row or double and pre operatively after seeing the MRI. I would always start it off,
DR ASHISH BABHULKAR/DIPIT SAHU: I would always give them a stronger. Right so. So we'll go back to the lectures, now, because this will further suggest.
DR ASHISH BABHULKAR/DIPIT SAHU: Those will be speaking on the designs in reverse shoulder from Medicare and the veterans. So just ask, very basic, just ask this question because we have to clear our doubts.
DR ASHISH BABHULKAR/DIPIT SAHU: OK so yeah, so I asked the same question and there are different ways of doing it. Some people prefer it differently, some people do it differently. Most of us, we do the same thing, we just shave off as a little bit of it, we don't want to take away bone from that area because that's the main stronghold that anchor is going to hold.
DR ASHISH BABHULKAR/DIPIT SAHU: So if you use a bore to take away a lot of that bone, you are corticating that area and probably your fix might get compromised on the end. Yeah so rasping micro fractures, all that are known to sort of you know technically promote healing, but there is no real study that shows one is better than the other. Yes before constructing anything to debride the tear, to debride the tuberosity and all of those things, because once you put your anchor in, then you're going to entangle your suture.
DR ASHISH BABHULKAR/DIPIT SAHU: I'm just going to give a slightly opposite and controversial use. There's a paper. So when you talk about tendon to bone healing, normally tendon ends into sharpest fibers and they go into the bone, not to do anything at all. So when you take off the cortical bone, you're actually exposing the subchondral bone and that is not how tendon inserts into the bone in the normal human body.
DR ASHISH BABHULKAR/DIPIT SAHU: So there is a point of view, which is that just don't take anything off the scar tissue and buttress the tendon. The sharpest fibers still form and the downside is the localization of your medial position is slightly under the age of the target is not. So if you can extend into what you see, what you can actually do.
DR ASHISH BABHULKAR/DIPIT SAHU: So as soon as more relevant to the traditional double row where the medial row anchor goes medially and the lateral anchor goes on the edge of the deposit. But with this type of technique, when you go down on the bone that's quite strong, it's like a cortical matter. Lateral row anchor is very difficult to dislodge. So, sorry. My question is not to the procedure it's basic to the basic science.
DR ASHISH BABHULKAR/DIPIT SAHU: The cause of the tear is probably degenerative usually which we encounter in supra-spinator tears and we are going to repair that. And the basic pathology is degeneration because that supply is not there. So putting an anchor and fusing it out there, I just want this is just curiosity in inquisition. Does good healing take place by that if we do open or arthroscopic or whatever repair we take, does healing take place, is difference from is.
DR ASHISH BABHULKAR/DIPIT SAHU: If you go to the conservative approach or is better with the operative approach, what's your take on it, what's your experience on it, that counts the most? If you do MRI's on all elderlies, you will find almost 50% of them have degenerative cuff tears {15 or 50?} but most of them are not symptomatic. So you want to operate the ones that are symptomatic and the ones that are symptomatic,
DR ASHISH BABHULKAR/DIPIT SAHU: if you operate them, most of them do get better, so it depends upon obviously the size of the tear, the amount of degeneration and all of those things. But more, I think symptomatic ones once operated and repaired, well, they definitely improve in my own experience as well. So yes, so when you assess the patient's pre operatively and we don't know very often that science is incorrect.
DR ASHISH BABHULKAR/DIPIT SAHU: Yes so I'll answer that question. {INTERPOSING VOICES} This is your question. Yes so I'll answer your question first. So see, eventually, what we want is a patient who has a symptomatic shoulder. Everything's pain, stiffness and weakness. So these are things you assess pre operatively. I sir said that this patient was probably in early stages of capsulitis or stiffness.
DR ASHISH BABHULKAR/DIPIT SAHU: You wait till the stiffness resolves, then comes pain and weakness. So if weakness is the main symptom, then yes, you would want the tear to come back anatomically. If pain is the main symptom, some of them, you know, can take. And if somebody is going to play.
DR ASHISH BABHULKAR/DIPIT SAHU: Before but we. [VOICES FADE}
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