Cadmore media player playing video Open Latarjet - Dr Dipit Sahu (2)
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
Open Latarjet - Dr Dipit Sahu (2)
Description:
Open Latarjet - Dr Dipit Sahu (2)
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/d4dbdc40-ac43-4d71-969d-dcf4a16c2ec0/videoscrubberimages/Scrubber_1.jpg
Duration:
T01H11M12S
Embed URL:
https://stream.cadmore.media/player/d4dbdc40-ac43-4d71-969d-dcf4a16c2ec0
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/d4dbdc40-ac43-4d71-969d-dcf4a16c2ec0/Open Latarjet- Dr Dipit Sahu (2).mp4?sv=2019-02-02&sr=c&sig=zt7E4u5%2F5HIH11%2FcoOstiKVq1vHGix9sQAQQVFV%2FywA%3D&st=2024-11-21T17%3A58%3A09Z&se=2024-11-21T20%3A03%3A09Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DIPIT SAHU: Our second live case for two days, a 33-year-old left shoulder recurrent dislocation. First episode was two years back when he had a history of fall and over a period of time, over 2 years, he has got a total of 6 dislocations. So an examination, he has an positive apprehension test, no neurovascular deficit, and the patient has requires his over his overhead arm.
DIPIT SAHU: Our moment for this opportunity was, these were the x-rays and these are the MRI. OK. {INTERPOSING VOICES} Findings were suggestive of a Hill Sachs lesion measuring 2.5 centimeter transverse by 2 centimeter cranial caudal with a depression of 6.6 centimeter, there is an anterior inferior fill tear to inferior glenoid loss of 9%, and the glenoid track measurement is 1.9 centimeters, which is suggestive of engaging morphology.
DIPIT SAHU: The patient is planned for an open Latarjet procedure for anterior instability. OK can we go live? Are you able to see the screen? Summer let me switch around. Yea, are we live?
DIPIT SAHU: Hello? Yes. Yeah, because. Yeah, yeah, you can start. OK, so we've just made an incision here right from the coracoid downwards. This is a vertical incision. Can you see here we, I've just opened this skin and subcutaneous fat only.
DIPIT SAHU: We'll go to the delta vector group. Can you see the pectoralis here? Can you make it more specific? Brighter? Brighter? OK so let me just point out, this is the pectoralis. This is the fat. And here will be the deltoid. So this is a deltopectoral groove.
DIPIT SAHU: Is it sort of clear? I think. Maybe it's a bit brighter, right? We are good. We are good. OK so we'll just go on. I just would like to say this. Dr. Swati there with the brilliant anesthesia, and Dr. Lateef is assisting me.
DIPIT SAHU: And who else is assisting me? And the entire OT staff. Now we'll go on to the deltopectoral group OK? I'll just open the groove. {INAUDIBLE} Now it is exactly over your head. So you can either remove your head in that camera.
DIPIT SAHU: That'd be ideal. OK now that's better. OK can you see the groove? So this is the groove. Just opened up the groove here. OK? Now what I'll do is I'll open up, I'll keep on going and opening up the groove. OK? So this is putting my gill piece here.
DIPIT SAHU: Doing nothing, I'm just opening up the groove. So right now I'm on corocoid. What I'll do is I'll just put my small moments when it is coming. Kindly adjust the camera, you can zoom out slightly.
DIPIT SAHU: Yeah, yeah. Let's go ahead. OK OK. OK OK. Can you see something now? Just it's about. {INAUDIBLE}
DIPIT SAHU: So these are tributaries of the phallax. OK is my head coming in between? It's coming. I don't see that, you're assisting me. OK you can watch later. OK anyway, the camera is not adjusted quarter.
DIPIT SAHU: Can't see only. Once again, we'll adjust the camera. Camera, adjustable adjusted knee and surgical. Are just this. I just got on a.
DIPIT SAHU: I just got on. Thanks so we can see obviously only one thing and we just we are just adjusting the camera. Give us 2 minutes. Give us 2 minutes. We are adjusting the camera to this.
DIPIT SAHU: We just had to keep each other. Huh? Lined up? Light lights. A move for the. Let's move on to.
DIPIT SAHU: {INAUDIBLE} Slightly better now. Slightly better? No. OK. Good Where'd they go? Oh, subdural.
DIPIT SAHU: We'll have to. If there's anything at all. Collaterally if you can reject the rectangle. Neither the major. Barbara Luna.
DIPIT SAHU: Yes, I got. The lateral. OK? OK. How is it now? It is better now. OK. So this is the corocoid tip. Can you see this. Oh. No, it's OK.
DIPIT SAHU: Oh. So. OK, so this is the tip of the coracoid. OK OK, one second. It's got to. And we do this. OK now what I'll do is I'll just cut the slightly pectoral fascia.
DIPIT SAHU: We'll go lateral to the tendon and we'll cut the pectoral fascia here. OK so what we see now, this is the clavicle pectoralis fascia is cut. This is the conjoined tendon. Over here, we will see the c ligament. I'll just show you the anatomy. Forceps. OK.
DIPIT SAHU: Can you see this c ligament here? The through the retractable is coming into it. OK forceps. You know which retractor. OK OK. We are trying to show you a retracting, I'm trying to show you the c ligament. My forceps is underneath the c ligament.
DIPIT SAHU: OK so this is the c ligament. This is the coracoid. This is the. OK so we are showing you the correct acromion ligament. Ah, better now. OK? So, now. This is the c ligament OK? This is the conjoint tendon, pectoralis minus here. We can see it later on, but I'll just cut the ligament.
DIPIT SAHU: So c ligament. Now you can cut laterally or you can allow it completely as you wish, as for what you believe. But if you want to leave it, you can leave it in the suture in the end. I have just removed it. What I'll do is I'll also remove the CH3 ligament, which is underneath.
DIPIT SAHU: You don't see it very well, but I've just got it underneath the C ligament. OK so we've got the C ligament also. So now this part is clear. So we've got the c ligament. We'll go on to the pec minor now. Now, can you see the pec minor?
DIPIT SAHU: OK so what? What are they? Well, let that go. Yeah look a little like it. OK OK. Can you see the medial in this? Yes.OK. So this is the pec minor. You're seeing it for the last time.
DIPIT SAHU: Yes. So this pec minor is going to go off right off the bone. Repeat, will you make an effort to see the muscular fitness? I will not do it. If you want me, I can try. But mostly I've not been doing it. And with this strategy of not seeing what it is seeing, I know this is a controversy.
DIPIT SAHU: So we've sent our paper, it will be there. So if you do not see the muscular cutaneous, then your incidence of muscular or any neuropathy is 2% I have had one temporary, musculocutaneous palsy over a period of a couple of years, but we've analyzed a couple of last cases and just will be published in one or two months. But the incidence of nerve injuries, if you don't see is between 1 and 2% combining axillary and
DIPIT SAHU: musculocataneous both. So there have been papers published and some people do advocate. I think it's fine what you believe, I will not make an attempt. I will just remove all the pec minor here and I think look like they speak of this young audience, if you can indulge them just so that they understand where it lies.
DIPIT SAHU: It might be a very good teaching experience, if possible. Sure, of course. So this is the coracoid, the medial edge of coracoid, the medial edge, the subscap, sorry the pec minor has been removed and this is the under surface, this is the under surface of coracoid.
DIPIT SAHU: This is the tip of the coracoid. Can you see? This is the tip, this is the medial, medial part of the coracoid where the pec minor was attached. It's gone, now I'm going under, under the coracoid. OK, so I will clear off the adhesions and all the tissue underneath.
DIPIT SAHU: OK so I will make an attempt to show you the under surface. Now we will. I will just show you the under surface and the bend, both. {So how close we are to the neurovascularis?}. Yeah so neurovascular just underneath, but I'm going right off the bone, so I'm OK.
DIPIT SAHU: Now I don't know if you can see, I can see the bend of the coracoid also from here, so I've cleared out the tissues. This is the under surface of my periosteum, what is going on the under surface of the coracoid? OK? So this is the under surface. OK so I've cleared out the tissue, maybe it's a little dark, but I can see the bend of the coracoid here.
DIPIT SAHU: OK? Now, what I'll do is so I can see the bend of the coracoid also from here. Mop. What I'll do is I'll just push a mop underneath, so this will protect my brachial plexus when I'm doing the cutting. So this has gone underneath. So I put it underneath the coracoid here.
DIPIT SAHU: Anything visible? No. One second, I'll just show you. OK. Can you show this? So this is the medial. {INAUDIBLE} OK so, yes, so let me show you this.
DIPIT SAHU: So this is the medial part. Huh? OK. OK so this was the medial surface. This entire retractor. {INAUDIBLE}. One second. So, I'm thinking so.
DIPIT SAHU: Now I'll show you better. OK so. You pushed a mop underneath the surface here, so this was the medial part.
DIPIT SAHU: Beach chair {INAUDIBLE}.. Beach chair. Change will come from behind. I'll show you without my head. Beach chair?
DIPIT SAHU: And this. Yeah. So now you can see. This is fine. This is OK. So do you see this?
DIPIT SAHU: So this is the medial part. My periosteum is against the medial part of the medial edge or medial surface of the coracoid. This is OK? And there is a mop underneath, this is between the plexus and the coracoid. OK. OK? So, now I will take off the coracoid now.
DIPIT SAHU: OK? So what I'll do is, I'll go from medial to lateral and we'll cut the coracoid now. The special saw you having?
DIPIT SAHU: Special saw has done some special trick. OK? Oh, you know, stirred up and stirred.
DIPIT SAHU: So this has come off, OK? Now, usually it is around 2.5 centimeters, I'll show you. So this is, coracoid is off. What I'll do is now I'll take the arm again in abduction external rotation because there are some attachments always there, but it is coming in.
DIPIT SAHU: Can you see anything? {Yes. Yes}. {Coracoid ligament at the base}, yeah, the c ligament is still attached. Scissors please. So we'll cut it close to the biceps or sorry, close to the sub-scap.
DIPIT SAHU: It's. Yeah. Hold this. So no pec minor should be attached here.
DIPIT SAHU: Actually, if you still have pec minor, it can impinge on the brachial plexus. So we'd like to see no brachial, no pec minor attached on the coracoid, mop, and scissors. Just remove all the adhesions. And scissors. So there again.
DIPIT SAHU: Monopolies are just. Camera, just cutting a gap. OK? OK? Are you seeing anything? Yes or no?
DIPIT SAHU: Camera operator, just corona. That's there's still a lot of.
DIPIT SAHU: {INAUDIBLE} More. OK? You are willing to watch out like camera man is moving? {LAUGHTER} I'm not moving at all. Make it.
DIPIT SAHU: Anyway anything visible? Yeah OK. Yeah so what I'll do is I'll just put them up, up inside because it bleeds from the coracoid osteotomy site because then OK, so we'll come out, I'll just show you the preparation. Anyway, the coracoid is out and it mop hospital broad. Whole knife.
DIPIT SAHU: OK that was pretty stable. Whole knife, knife, knife, knife, knife we put on our knife. Can you just summarize what have you done till now? Yeah OK. So let me show you this.
DIPIT SAHU: So, see, this was a coracoid like this. OK I've averted it. The condyle tendon is still attached here. The pec minor is gone. This is the condyle tendon. This is the coracoid piece. I've inverted it. We'll show you the under surface forceps. So this is on the surface.
DIPIT SAHU: OK, pick this up. So this is on the surface. We are clearing it off. And this one. OK so I've cleared off the under surface. So this is the under surface that will go against the glenoid. So I'm just clearing off the tissues off of the under surface.
DIPIT SAHU: So this is under surface. Can you see? Very well on the surface. OK? This is the lateral, and this is the medial. This was the upper surface. Now this,
DIPIT SAHU: this is my preparation of the under surface because this will go against the glenoid. So you have to prepare this, take time to prepare it. What I'll do is I've removed all, so I've removed all the soft tissue here. Now what I'll do is I will do a little sawing over here. The bleeding wound. I will remove a bit of cortex. OK?
DIPIT SAHU: So this is the cortex that you want it to be removed. {That 90 degrees is very handy, sir isn't it?}
DIPIT SAHU: OK so this is the preparation done. This is under surface. Now, I made it flat, what I'll do is I'll make two holes here already. So we'll put a hole here, we'll put a hole here. So this is middle of the width. So this is the width? {Yes} so we'll put it in the middle of the width.
DIPIT SAHU: Two holes. OK this is the bone tail here. This is a bone tail here, it is in the middle. Two holes over. OK OK. So what I'll do now is, I will take my saw, sorry, I'll take my drill.
DIPIT SAHU: So cortisol screws are and one can suffice in this. Or I will put two screws like I always do. OK. OK. So this is one. So in the direction of those screws up and down additional that are not congruent.
DIPIT SAHU: So we are preparing the under surface. And the other one. What I meant to ask was, what are you doing for congruent strategy. The this is what I've done always. Yes, yes.
DIPIT SAHU: Two holes. You can see from the upper surface. OK so we have two holes. Yeah the one over here. And other hole. Approximate distances with the holes road, so between them is 1 centimeters, now, and it has to be in the middle of the width.
DIPIT SAHU: OK, now what I'll do is I'll just mark the holes here. So this is one hole, this is other hole. OK, so this is the inferior, this is the superior. Now, this distance I have to respect, this would be around 7 to 8 millimeters from the edge, so my corresponding hole will be from the glenoid edge around 8 millimeters.
DIPIT SAHU: I'd like to put either flush or up to 4 millimeter medial. So this surface will go, this surface will go against the glenoid. OK this will be. So there is a little bit of extra bone here, OK? I may remove it later on, but. we have expanded, coracoid here, if you see it going like this.
DIPIT SAHU: Now, this should not be lateral to the glenoid in any work. Never, ever be lateral. So we may actually be a little bit. So. I will butt it off right now only because this is a bit lateral.
DIPIT SAHU: We get. It's coming together. Cutting the lateral aspect like. Yeah I'm doing a little bit of carpentry here, but I have to get it in shape because this may be getting out.
DIPIT SAHU: But anyway, this is here. Now, what we'll do is we'll go to the sub-scap, right angle. OK so now we'll go to the sub-scap, I'll show you the sub-scap and the rest of the procedure. What we'll do is I'll put the hand in external rotation. OK, scissors please and close to the body and right angle to him.
DIPIT SAHU: OK. So let's show you the sub-scap. OK can you see the sub-scap? I'll show you even better. Now can you see the sub-scap? Ok, one second, Hold it out.
DIPIT SAHU: Yeah let's see. Let me put, this is the upper part of sub-scap. My exploded on the upper part of sub-scap in right angle. And where it is coming. You heard this. I show you the lower part. Let me just see first, then I'll show you, because even I can't see.
DIPIT SAHU: Yeah so these are the three sisters. I don't know if you can see. OK, I'll just try and point it out. The tip of my scissor is at the three sisters or the lower part of sub-scap. The tip of my scissors, so your three sisters is just below the scissor. OK, maybe you can't see, it's very deep down.
DIPIT SAHU: She says circumflex, which are at the lower part of the sub-scap. Can't see [INAUDIBLE} They can. [INAUDIBLE] We can decrease the brightness and redness [INAUDIBLE] don't do anything. OK three sisters.
DIPIT SAHU: Camera roll. You just saw it. OK clear? Hazy again. [INAUDIBLE] So by letting the Yeah now you see.
DIPIT SAHU: You see this black vessel? OK you see this? This is one of the three sisters. OK, got it. OK, so we've just made a bigger incision just to show you all this. Otherwise, I do it in a smaller incision. But this is a law of the three sisters. Anyway, we'll go out,
DIPIT SAHU: we'll go ahead. This was to just show you the lower part of the sub-scap. Now, what I'll do is, I will make a split. The upper 2/3 and lower 1/3 junction, which will be somewhere here. OK? This, see this? [INAUDIBLE] OK OK.
DIPIT SAHU: So what I'll do is we'll just make a split here, the corner. OK so this is the part of the sub-scap which I approximate idea lower one third upper two third or somewhere here. OK, very ballpark, but it is somewhere here. Got it? So this
DIPIT SAHU: I'll just split. Because suddenly we'll just split. So I'm just splitting the sub-scap and I will need some light now very soon because even I can't see anything now. OK anyway, we have split the sub-scap. Ok? What I'll do now is I will push this gauze piece inside,
DIPIT SAHU: this will make some space. And tied with a Y clip? Yeah so that I don't forget. OK, this is just my little idiosyncrasy. But anyway, we split the, we split the sub-scap, I put a little gauze inside just to show you, make some space and what I'll do now is I will split it a bit laterally also.
DIPIT SAHU: So maybe a bit more laterally, the split, so now this is split. Complete - can you see it? {Yes}. You see the white capsule? That is the capsule. {So what would be the length of the spread approximately?}. No, as much as required. Anyway,
DIPIT SAHU: the white is the capsule, the sub-scap is red, which is already split. Now what I'll do is I will just put one of the retractors here. Here? OK? OK, now I'll put another retractor and remove this, remove it, remove everything.
DIPIT SAHU: OK. OK. OK special? No, no. Just a normal Hohmann retractor. Just long. That's it. OK can you see the capsule now, white capsule [INAUDIBLE}.
DIPIT SAHU: [INAUDIBLE}. [INAUDIBLE] Can you see something? I'll take it off, very good. I will show you in a minute.
DIPIT SAHU: And then we should inside, inside. Thanks Arthur Inside, garnered. Can you see something now on air? Yes now he's moving.
DIPIT SAHU: Well, this is the capsule white, OK, resume opening. and this is a white capsule. The upper part of sub-scap has gone up, the lower part of sub-scap has gone down. This is a white capsule, which is washed you know. Now, maybe I'll be able to show you better if I wash it a bit. OK well, that case.
DIPIT SAHU: Ok yeah, let's start corona, because this will be done very soon. What is invisible. This, right? This is a capsule, sub-scap has gone up and down. I am just seeing the capsule in front.
DIPIT SAHU: [INAUDIBLE] OK, Manny. OK so question of the delegate, can we take that split slightly more and superior? One thing I'll just answer you to let me just do this, then I'll answer you. People go.
DIPIT SAHU: People grow.
DIPIT SAHU: OK Yeah. It's straight. Straight, nice. Yeah OK. Let me show you now. Yeah what was the question? Whether the split can be slightly more superior. So as superior you go, more external rotation may be restricted, but in Hyper laxpansion, you do go superior a bit.
DIPIT SAHU: OK is or disadvantage like advantage of that. So the more sub-scaps below the conjoined joint arthresis it, the bigger like this. So if you do a split as more superior than you may have chances of external rotation restriction. So classically it's upper two third, lower one third, wash like any cleaner, which is better.
DIPIT SAHU: No this is OK. This is all OK. There is no problem here. And two thirds, one third is best. OK so what are we seeing? We are seeing the glenoid, and,
DIPIT SAHU: let me just put one more retractor, then I'll show you everything. Hammer, please. Forceps.
DIPIT SAHU: [INAUDIBLE] Like this. Like this. So you need four retractors always, everything is in position. Can you see the glenoid now? Now I'll just show you what is where. So this is your 6 o'clock in here. Suction on.
DIPIT SAHU: I'll remove the capsular labrum. What six o'clock
DIPIT SAHU: is here. OK? This is sort of 9 o'clock, OK, 6 o'clock, 9 o'clock This retractor is in the gleno humeral joint. It's inside the joint. It's detracted the humeral head laterally and glenoid is medially. This is a medial retractor over here, which is the link retractor. This is just a Steinman pin over here.
DIPIT SAHU: And this is a Hohmann retractor normal, which is exposing that this is what you need to expose the medial unit, because here is where your coracoid will go. Now, what I'll do is I'll just remove this.
DIPIT SAHU: Posture don't ever, ever, ever. No course. I'm just removing the medial capsule of labral complex. 2 minutes. We'll just remove it. OK wash.
DIPIT SAHU: So this has gone. But you'll be able to see the bone better now. I'll start again. What we'll do is we'll just raise slightly, I won't remove any bone. We'll be just raising slightly there for the bone preparation.
DIPIT SAHU: So no bone loss will be done more. So no bone burring people have done bone burring earlier, but we won't be doing any we don't do any bone, more bone loss than what already there is. The only bony slivers.
DIPIT SAHU: OK so what I'll do is. I just show you this. Is it visible somewhere? But can you make it more clear? OK, one second. I'll make it better. Brother, let me make this clear.
DIPIT SAHU: Possible to decrease the brightness from your side? That includes. Yeah but I. So either they have are. OK. {INAUDIBLE}
DIPIT SAHU: OK OK. Lights now I need lights. I don't know if you can see the glenoid? [INAUDIBLE] [INAUDIBLE] [INAUDIBLE]
DIPIT SAHU: Wash.
DIPIT SAHU: Don't touch it. Things take a. I'll be back to do better. Slightly better for a light. This is better now. OK so now we have to show you the glenoid. So this is the glenoid edge. OK again.
DIPIT SAHU: So this is the glenoid edge. OK, so the 6 o'clock down here. OK. OK? This is the 3 o'clock. OK so this is the edge, this is the medial surface. Complete medial surface cushioning are all similar. OK, so this is the medial surface.
DIPIT SAHU: OK when we put the I've already done some jiggling or some slivers only. OK, only slivers, nothing else. Now this is the edge. Hall at 5 o'clock or sorry, this is a left shoulder, so we'll make it at 7 o'clock. OK we'll make it over here. OK we'll make one hole here, which should be 7 to 8 millimeters from the edge.
DIPIT SAHU: So somewhere here. So this will be done without any measurement, drill please. So this one is by just my experience and ballpark, because I know and we need the direction to be parallel. So I'll put it here. OK this is around 7 o'clock. OK, now I'll go.
DIPIT SAHU: {INAUDIBLE}. I've already made the hole. Now what? So now what I'll do is, I'll just bring out the, I'll bring out the coracoid. Here OK. Now, this is the starting screw.
DIPIT SAHU: 3.5 mm screw? This is my little screw. Open five.
DIPIT SAHU: So not. Later the second. So we take you? Yes what is the screw size? Do you measure or you don't measure a lot, actually. 70 to 70% of our time. It is 30 times.
DIPIT SAHU: Really? it can also be 35. It can be sometimes 25 slight individuals, but most of the time it will be 30. With washer, without washer? So we are using without washer here. So what I do is I've just put one screw and I can rotate as I want. And this is a bone, which is always obstructing sometimes, which I wanted to remove.
DIPIT SAHU: But anyway, we'll rotate it. Dipit, what's your take on fully threaded screws versus partially threaded screws? So I've been know, I'll be biased because I've used only partially threaded and have used maybe fully threaded once when I probably was in a soup.
DIPIT SAHU: And I had fractured the coracoid once, so I used it once fully threaded. Other than that, I think mostly it's partially threaded, especially. Fully threaded. Maybe OK, I don't know. What is your experience, sir? I always use fully threaded.
DIPIT SAHU: I don't know why I can't give you an answer, but I'm just not too confident, you know, because that coracoid in India is fairly soft so I'd rather have a purchase there. Yeah so I do the wash two finger technique. I don't over tighten them. Yeah two fingers. What we'll do also, I'll do that.
DIPIT SAHU: Exactly that two finger now is down. I'll just check where exactly it is. Saline, please. So we need to see the relation of the coracoid with glenoid. It is just flush.
DIPIT SAHU: I'll just show you how it is. But it is exactly flush. So it is exactly flush, if you can see. I don't know, I'll remove the soft tissue. But when I remove this soft tissue, you'll see that is just flush. I'll just show you in a minute. A knife, then?
DIPIT SAHU: The forceps. And let me just show you this. It is just flush.
DIPIT SAHU: Can you see anything? I don't know. A retractor. Change the light, it's a little dark, deep down there. OK, one second, let me show you this. [INAUDIBLE]
DIPIT SAHU: I can still rotate the coracoid as we want. Wherever we want. [INAUDIBLE] [INAUDIBLE] Scissors. Yeah.
DIPIT SAHU: So you want me to change it or this is OK. One second. Let me show you this. The grand durga. Oh, see, I can change it right now. I can change it later also, depending on what we feel, if we are happy or not. But the girls. OK, one second.
DIPIT SAHU: I just show them better soft tissue. So light underlines. Really? I'm going. Wash them up. Let me just show them better.
DIPIT SAHU: Scissors again. Can you see now? Yes. So this is the edge of the coracoid. This is the edge of the some of the glenoid here. Can you see this? This is the screw, this is the coracoid, this is the edge of the coracoid.
DIPIT SAHU: And this is the edge of the and there's some soft tissue here, but it's exactly flush. Saline wash again. OK, I'll show you better. Can you see the cartilage? Oh, one second.
DIPIT SAHU: The screwdriver, we can rotate. Did you see anything? Not of brightness, actually. Brightness otherwise, you know, brighter. You're rotating, rotating it more medially only two finger tightening. OK this is exactly flush.
DIPIT SAHU: Scissors. Again, so I'll just show you again. So, in this the language. And also the glue. Not actually. The screen.
DIPIT SAHU: How is this? Of better. But still is not visible lightning under. Can you just demonstrate with the artery. Forceps. Yeah. This is my knife, this is my scissors. Sorry this is a scissor, scissor.
DIPIT SAHU: This is a medial edge of the coracoid, this is the medial edge of the glenoid. OK so I'm just trying to see if it is flush or not. Well, this is the most important part, because if you do this lateral, then it's a problem. But as I can see, it is very flush to the edge. OK now see? Yeah can you see anything? I don't know.
DIPIT SAHU: It is very flush. Is it clear? Yes OK, so now I'll go on, I'll just put the other screw scissors, drill again. Always inferior screw first, inferior screw first and I'm committed. I can't change it. So what I'm doing is now I'll put the second screw and I'll see the articular surface.
DIPIT SAHU: I'm seeing the articular surface decline. Suction. So I'll directed parallel to the articular surface. OK so this is the articular surface. See this yellow? OK this the articular surface. This is my drill. Now I will just drill parallel. The place.
DIPIT SAHU: OK so I've just drilled it now I'll measure it. Let's see what it says. So what does it say? 30 so it is 30. So it's 70% 80% of time is 30. My screw is also 80/30. I always keep 230 ready. It may be 25 or 35 once or twice or maybe six months, but most commonly it's 30.
DIPIT SAHU: And because I'm using manual screws, so only multiples of 5. OK each. Correct so only two finger tightening because as Dr. Babulkah just said this, if you over tighten, it may break.
DIPIT SAHU: OK so. This is good. Only two finger tightening only. OK this is good. So I can't rotate more with two fingers. I'm only doing two fingers now.
DIPIT SAHU: Middle fingers either. Although this is only two finger technique, I will only try and rotate more. It's not going more well either one also. Sorry. OK. So this is tight enough. No more needed, and this is flush.
DIPIT SAHU: We don't need to do anything more, you can close the capsule if you want. I've done that in the past. Any other questions or we'll just go ahead. This is the gauze coming out because audience is asking you, what's your post-op imaging plan? Will do a epi X-ray right now and that's what we can do now.
DIPIT SAHU: Then we'll do anything else. We cannot do only AP x-ray. We can do right now, immediately. And then we are doing the CT scan after one year by rule in most of the patients, they are part of a study also. But actually you can be taken after one month when they are doing over head movements. So by two weeks you allow over head movements and then by one month we can take a actual view to see the direction of screws.
DIPIT SAHU: Right now it will be only anterior posterior x-rays. A quick see, I'm short by the side till as we move around. Yes do we have a CR arm on side? It was a shortcut. So all this is done, nothing else required. Any questions? Or I'll just go on to the other case.
DIPIT SAHU: I have one question regarding rehab. Rehab? We start movements tomorrow, active and assisted both for two weeks. They are in a sling after two weeks they are doing overhead exercises. Also, sling is for 10 to 14 days, two weeks because elbow flexion is normally allowed but not forceful.
DIPIT SAHU: But yeah, normally all shoulder elbow flexion, shoulder flexion, we start tomorrow. We start after one or two days and for pain control but after 24 to 48 hours and sling mostly is removed at two weeks. So in case there is a overhang after the second screw, do you recorticate it? And that is done by a burr, but we don't have a burr.
DIPIT SAHU: So I've never done it. So it should not be actually, there should not be overhang. You should not. I mean, that comes by practice, eventually you don't have it after a while, but there should be no overhang. So thanks Dipit for the great demonstration. I'll just remove this.
DIPIT SAHU: Thank you to my OT staff. Thank you anaesthetist Dr. Swati. You would like to know? Yeah you start the lecture, we'll be starting the scoping, I'll let when we're up and about. Thank you. Most creative.
DIPIT SAHU: The questions. [INAUDIBLE] In fact, I don't know of that occurrence or the correlation between the two, but in fact, somebody has an integrated capular. We actually do a pec minor tenotomy arthrotomy. I've just done it for my fellow three weeks back, you know.
DIPIT SAHU: No, no. If you have somebody with a poor posture and is not doing well, so you can do a pec minor arthrotomy in those very difficult periods and exceptional thing. But removing the pigment is more beneficial than it's the anemia of our therapists. So I don't think we can bring it to arm. Repairing that pec minor would create a tighter brachial plexus neuropathy issue.
DIPIT SAHU: So in the first series of laterjets is to repair the pec minor and had parts of numbness radiating pain. So it moved to the next lecture. But this you'll be speaking of. Sorry what?
DIPIT SAHU: We're going to come. It's that I think that in the past four administrations. I have about 60/70 patients between 80 and 87 exceptional patients not currently and they're not part of it was time that we were taught that the annual fatalities is as vertical as trauma.
DIPIT SAHU: Exceptionally you have that problem. We keep 6.5 lectures on the faculty, but I really have a six month term. The newer technologies are still work and 15% is not a problem. But if you can do a good anatomy and ensure that there is no cystic fibrosis here, then that will speak on the designs of the anatomic shoulders. Yeah, Thank you for having me here.
DIPIT SAHU: My topic is the design considerations for anatomic rolled shoulder arthroplasty. So for a modern anatomical storage shoulder, these are the principles that the prosthesis is designed on. It should be implanted in a patient who has an intact rotator cuff. Reconstruction of the tuberosity in a fracture case is a must, if possible, bone preservation of as much as bone preserved preservation the better, minimization of stress shielding, reduction of bone resection in a STEM prosthesis to improve fixation and simplifying the prosthesis designed for proximally humerus deformity.
DIPIT SAHU: So for the anatomical shoulder, these are our implant choices. Either it's a long stem, short stem now stem laces, resurfacing implants and for fracture stems for fracture cases to pass sutures for the tuberosity. On the glenoid side, before we make our choices, we need to be aware of this Walsh classification of for glenoid deformities post in arthritic cases.
DIPIT SAHU: We'll discuss about that. So let's take on resurfacing and for resurfacing and stemless designs, what was their ideology? The ideology is to preserve as much bone, revisions are easier and easier to take them out and also in special cases like where there is a plate put in which is going to be difficult to pass a stem or in proximal humerus deformities is where these implants really show their value.
DIPIT SAHU: So resurfacing was started by Copeland in 1979, the first implant placed in '86. It it has all the advantages of bone preservation, decreased bone loss, improved range of motion, it preserves humoral anatomy, and diaphysis is not disturbed. But there is a technical limitation. When you're resurfacing the humeral head, you're not taking a humeral head cut at all.
DIPIT SAHU: And you're just reaming the humeral head, taking away the cartilage. The downside of this is the problem that you have difficulty accessing the glenoid. So on the glenoid side, if you want to do a ream and run or place a glenoid prosthesis, that is difficult. But of late there are some modifications where you have angled reamers and it's still possible to do it. But most of the times with the resurfacing hemis, the only possibility it becomes difficult to do a total.
DIPIT SAHU: So why do a total shoulder at all, why not just a hemi-arthroplasty? It's because Copeland and Levy, they themselves published that patients who had a total shoulder replacement had better constant scores and better range of motion, reduced pain. But again, in 2010, they came up with, Copeland, came up with his technique of doing or his revised paper that he said that most of his total shoulders fail like the glenoid side failed, and which is why he now prefers to do just a hemi-arthroplasty.
DIPIT SAHU: But the most common cause of failure in a hemi-arthroplasty is painful erosion of the glenoid. And although this study, with a small sample size, said that the total shoulder had a greater failure rate, whereas a hemi-arthroplasty is almost 90% of the arthroplasties lasted through time. So what are the indications really when you do a total shoulder arthroplasty, when you have a concentric glenoid where we're putting in a hemi-arthroplasty, still going to give that glenoid concavity and reduced pain because of reduced wear on the glenoid side.
DIPIT SAHU: And a younger patient with avascular necrosis of the humeral head where the glenoid is not really affected. So these are your two patients. There are two indications where you consider a hemi-arthroplasty with a resurfacing, but doing a resurfacing is like parking a car in a tight space like this. It's challenging because if you go wrong, you can cause over stuffing where and which can lead to rotator cuff failures and cause of pain.
DIPIT SAHU: There are two ways of reducing this over stuffing or avoiding this over stuffing is use smaller head sizes of the two that you measure and avoiding varus. If your implant is in valgus, you're going to have over stuffing. So what was the reason of stemless coming in when resurfacing was so good? The reason for having a stemless is that you have better access to the glenoid and there is a good 3D finite study done on modeling saying that actually resurfacing causes less bone resorption than doing a hemi-arthroplasty.
DIPIT SAHU: So really comparing both of them are stemless wins because it has all the advantages of resurfacing. Why do, why do you now need a stem at all then in these patients? Because, when you do a stemless arthroplasty, you are reducing the amount of blood loss, reducing over time, and it's shown in published literature, as you see over here, that, you know, you're going to have a better range of motion and better function, reduce the licensee's rest, less stress shielding and all of those.
DIPIT SAHU: But there are some considerations. Do not throw your stemmed implants away because there are some considerations where there is severe osteoporosis, there is weak proximal humerus, proximal humerus metaphysis where your fixation can fail if you do a stemless arthroplasty. A simple thumb rule is that if your thumb can insert into the metaphyseal bone, then the bone is too weak.
DIPIT SAHU: You'll probably be better off putting in or putting in a STEM. So yeah, please keep your stems available.
Segment:0 .
DIPIT SAHU: Our second live case for two days, a 33-year-old left shoulder recurrent dislocation. First episode was two years back when he had a history of fall and over a period of time, over 2 years, he has got a total of 6 dislocations. So an examination, he has an positive apprehension test, no neurovascular deficit, and the patient has requires his over his overhead arm.
DIPIT SAHU: Our moment for this opportunity was, these were the x-rays and these are the MRI. OK. {INTERPOSING VOICES} Findings were suggestive of a Hill Sachs lesion measuring 2.5 centimeter transverse by 2 centimeter cranial caudal with a depression of 6.6 centimeter, there is an anterior inferior fill tear to inferior glenoid loss of 9%, and the glenoid track measurement is 1.9 centimeters, which is suggestive of engaging morphology.
DIPIT SAHU: The patient is planned for an open Latarjet procedure for anterior instability. OK can we go live? Are you able to see the screen? Summer let me switch around. Yea, are we live?
DIPIT SAHU: Hello? Yes. Yeah, because. Yeah, yeah, you can start. OK, so we've just made an incision here right from the coracoid downwards. This is a vertical incision. Can you see here we, I've just opened this skin and subcutaneous fat only.
DIPIT SAHU: We'll go to the delta vector group. Can you see the pectoralis here? Can you make it more specific? Brighter? Brighter? OK so let me just point out, this is the pectoralis. This is the fat. And here will be the deltoid. So this is a deltopectoral groove.
DIPIT SAHU: Is it sort of clear? I think. Maybe it's a bit brighter, right? We are good. We are good. OK so we'll just go on. I just would like to say this. Dr. Swati there with the brilliant anesthesia, and Dr. Lateef is assisting me.
DIPIT SAHU: And who else is assisting me? And the entire OT staff. Now we'll go on to the deltopectoral group OK? I'll just open the groove. {INAUDIBLE} Now it is exactly over your head. So you can either remove your head in that camera.
DIPIT SAHU: That'd be ideal. OK now that's better. OK can you see the groove? So this is the groove. Just opened up the groove here. OK? Now what I'll do is I'll open up, I'll keep on going and opening up the groove. OK? So this is putting my gill piece here.
DIPIT SAHU: Doing nothing, I'm just opening up the groove. So right now I'm on corocoid. What I'll do is I'll just put my small moments when it is coming. Kindly adjust the camera, you can zoom out slightly.
DIPIT SAHU: Yeah, yeah. Let's go ahead. OK OK. OK OK. Can you see something now? Just it's about. {INAUDIBLE}
DIPIT SAHU: So these are tributaries of the phallax. OK is my head coming in between? It's coming. I don't see that, you're assisting me. OK you can watch later. OK anyway, the camera is not adjusted quarter.
DIPIT SAHU: Can't see only. Once again, we'll adjust the camera. Camera, adjustable adjusted knee and surgical. Are just this. I just got on a.
DIPIT SAHU: I just got on. Thanks so we can see obviously only one thing and we just we are just adjusting the camera. Give us 2 minutes. Give us 2 minutes. We are adjusting the camera to this.
DIPIT SAHU: We just had to keep each other. Huh? Lined up? Light lights. A move for the. Let's move on to.
DIPIT SAHU: {INAUDIBLE} Slightly better now. Slightly better? No. OK. Good Where'd they go? Oh, subdural.
DIPIT SAHU: We'll have to. If there's anything at all. Collaterally if you can reject the rectangle. Neither the major. Barbara Luna.
DIPIT SAHU: Yes, I got. The lateral. OK? OK. How is it now? It is better now. OK. So this is the corocoid tip. Can you see this. Oh. No, it's OK.
DIPIT SAHU: Oh. So. OK, so this is the tip of the coracoid. OK OK, one second. It's got to. And we do this. OK now what I'll do is I'll just cut the slightly pectoral fascia.
DIPIT SAHU: We'll go lateral to the tendon and we'll cut the pectoral fascia here. OK so what we see now, this is the clavicle pectoralis fascia is cut. This is the conjoined tendon. Over here, we will see the c ligament. I'll just show you the anatomy. Forceps. OK.
DIPIT SAHU: Can you see this c ligament here? The through the retractable is coming into it. OK forceps. You know which retractor. OK OK. We are trying to show you a retracting, I'm trying to show you the c ligament. My forceps is underneath the c ligament.
DIPIT SAHU: OK so this is the c ligament. This is the coracoid. This is the. OK so we are showing you the correct acromion ligament. Ah, better now. OK? So, now. This is the c ligament OK? This is the conjoint tendon, pectoralis minus here. We can see it later on, but I'll just cut the ligament.
DIPIT SAHU: So c ligament. Now you can cut laterally or you can allow it completely as you wish, as for what you believe. But if you want to leave it, you can leave it in the suture in the end. I have just removed it. What I'll do is I'll also remove the CH3 ligament, which is underneath.
DIPIT SAHU: You don't see it very well, but I've just got it underneath the C ligament. OK so we've got the C ligament also. So now this part is clear. So we've got the c ligament. We'll go on to the pec minor now. Now, can you see the pec minor?
DIPIT SAHU: OK so what? What are they? Well, let that go. Yeah look a little like it. OK OK. Can you see the medial in this? Yes.OK. So this is the pec minor. You're seeing it for the last time.
DIPIT SAHU: Yes. So this pec minor is going to go off right off the bone. Repeat, will you make an effort to see the muscular fitness? I will not do it. If you want me, I can try. But mostly I've not been doing it. And with this strategy of not seeing what it is seeing, I know this is a controversy.
DIPIT SAHU: So we've sent our paper, it will be there. So if you do not see the muscular cutaneous, then your incidence of muscular or any neuropathy is 2% I have had one temporary, musculocutaneous palsy over a period of a couple of years, but we've analyzed a couple of last cases and just will be published in one or two months. But the incidence of nerve injuries, if you don't see is between 1 and 2% combining axillary and
DIPIT SAHU: musculocataneous both. So there have been papers published and some people do advocate. I think it's fine what you believe, I will not make an attempt. I will just remove all the pec minor here and I think look like they speak of this young audience, if you can indulge them just so that they understand where it lies.
DIPIT SAHU: It might be a very good teaching experience, if possible. Sure, of course. So this is the coracoid, the medial edge of coracoid, the medial edge, the subscap, sorry the pec minor has been removed and this is the under surface, this is the under surface of coracoid.
DIPIT SAHU: This is the tip of the coracoid. Can you see? This is the tip, this is the medial, medial part of the coracoid where the pec minor was attached. It's gone, now I'm going under, under the coracoid. OK, so I will clear off the adhesions and all the tissue underneath.
DIPIT SAHU: OK so I will make an attempt to show you the under surface. Now we will. I will just show you the under surface and the bend, both. {So how close we are to the neurovascularis?}. Yeah so neurovascular just underneath, but I'm going right off the bone, so I'm OK.
DIPIT SAHU: Now I don't know if you can see, I can see the bend of the coracoid also from here, so I've cleared out the tissues. This is the under surface of my periosteum, what is going on the under surface of the coracoid? OK? So this is the under surface. OK so I've cleared out the tissue, maybe it's a little dark, but I can see the bend of the coracoid here.
DIPIT SAHU: OK? Now, what I'll do is so I can see the bend of the coracoid also from here. Mop. What I'll do is I'll just push a mop underneath, so this will protect my brachial plexus when I'm doing the cutting. So this has gone underneath. So I put it underneath the coracoid here.
DIPIT SAHU: Anything visible? No. One second, I'll just show you. OK. Can you show this? So this is the medial. {INAUDIBLE} OK so, yes, so let me show you this.
DIPIT SAHU: So this is the medial part. Huh? OK. OK so this was the medial surface. This entire retractor. {INAUDIBLE}. One second. So, I'm thinking so.
DIPIT SAHU: Now I'll show you better. OK so. You pushed a mop underneath the surface here, so this was the medial part.
DIPIT SAHU: Beach chair {INAUDIBLE}.. Beach chair. Change will come from behind. I'll show you without my head. Beach chair?
DIPIT SAHU: And this. Yeah. So now you can see. This is fine. This is OK. So do you see this?
DIPIT SAHU: So this is the medial part. My periosteum is against the medial part of the medial edge or medial surface of the coracoid. This is OK? And there is a mop underneath, this is between the plexus and the coracoid. OK. OK? So, now I will take off the coracoid now.
DIPIT SAHU: OK? So what I'll do is, I'll go from medial to lateral and we'll cut the coracoid now. The special saw you having?
DIPIT SAHU: Special saw has done some special trick. OK? Oh, you know, stirred up and stirred.
DIPIT SAHU: So this has come off, OK? Now, usually it is around 2.5 centimeters, I'll show you. So this is, coracoid is off. What I'll do is now I'll take the arm again in abduction external rotation because there are some attachments always there, but it is coming in.
DIPIT SAHU: Can you see anything? {Yes. Yes}. {Coracoid ligament at the base}, yeah, the c ligament is still attached. Scissors please. So we'll cut it close to the biceps or sorry, close to the sub-scap.
DIPIT SAHU: It's. Yeah. Hold this. So no pec minor should be attached here.
DIPIT SAHU: Actually, if you still have pec minor, it can impinge on the brachial plexus. So we'd like to see no brachial, no pec minor attached on the coracoid, mop, and scissors. Just remove all the adhesions. And scissors. So there again.
DIPIT SAHU: Monopolies are just. Camera, just cutting a gap. OK? OK? Are you seeing anything? Yes or no?
DIPIT SAHU: Camera operator, just corona. That's there's still a lot of.
DIPIT SAHU: {INAUDIBLE} More. OK? You are willing to watch out like camera man is moving? {LAUGHTER} I'm not moving at all. Make it.
DIPIT SAHU: Anyway anything visible? Yeah OK. Yeah so what I'll do is I'll just put them up, up inside because it bleeds from the coracoid osteotomy site because then OK, so we'll come out, I'll just show you the preparation. Anyway, the coracoid is out and it mop hospital broad. Whole knife.
DIPIT SAHU: OK that was pretty stable. Whole knife, knife, knife, knife, knife we put on our knife. Can you just summarize what have you done till now? Yeah OK. So let me show you this.
DIPIT SAHU: So, see, this was a coracoid like this. OK I've averted it. The condyle tendon is still attached here. The pec minor is gone. This is the condyle tendon. This is the coracoid piece. I've inverted it. We'll show you the under surface forceps. So this is on the surface.
DIPIT SAHU: OK, pick this up. So this is on the surface. We are clearing it off. And this one. OK so I've cleared off the under surface. So this is the under surface that will go against the glenoid. So I'm just clearing off the tissues off of the under surface.
DIPIT SAHU: So this is under surface. Can you see? Very well on the surface. OK? This is the lateral, and this is the medial. This was the upper surface. Now this,
DIPIT SAHU: this is my preparation of the under surface because this will go against the glenoid. So you have to prepare this, take time to prepare it. What I'll do is I've removed all, so I've removed all the soft tissue here. Now what I'll do is I will do a little sawing over here. The bleeding wound. I will remove a bit of cortex. OK?
DIPIT SAHU: So this is the cortex that you want it to be removed. {That 90 degrees is very handy, sir isn't it?}
DIPIT SAHU: OK so this is the preparation done. This is under surface. Now, I made it flat, what I'll do is I'll make two holes here already. So we'll put a hole here, we'll put a hole here. So this is middle of the width. So this is the width? {Yes} so we'll put it in the middle of the width.
DIPIT SAHU: Two holes. OK this is the bone tail here. This is a bone tail here, it is in the middle. Two holes over. OK OK. So what I'll do now is, I will take my saw, sorry, I'll take my drill.
DIPIT SAHU: So cortisol screws are and one can suffice in this. Or I will put two screws like I always do. OK. OK. So this is one. So in the direction of those screws up and down additional that are not congruent.
DIPIT SAHU: So we are preparing the under surface. And the other one. What I meant to ask was, what are you doing for congruent strategy. The this is what I've done always. Yes, yes.
DIPIT SAHU: Two holes. You can see from the upper surface. OK so we have two holes. Yeah the one over here. And other hole. Approximate distances with the holes road, so between them is 1 centimeters, now, and it has to be in the middle of the width.
DIPIT SAHU: OK, now what I'll do is I'll just mark the holes here. So this is one hole, this is other hole. OK, so this is the inferior, this is the superior. Now, this distance I have to respect, this would be around 7 to 8 millimeters from the edge, so my corresponding hole will be from the glenoid edge around 8 millimeters.
DIPIT SAHU: I'd like to put either flush or up to 4 millimeter medial. So this surface will go, this surface will go against the glenoid. OK this will be. So there is a little bit of extra bone here, OK? I may remove it later on, but. we have expanded, coracoid here, if you see it going like this.
DIPIT SAHU: Now, this should not be lateral to the glenoid in any work. Never, ever be lateral. So we may actually be a little bit. So. I will butt it off right now only because this is a bit lateral.
DIPIT SAHU: We get. It's coming together. Cutting the lateral aspect like. Yeah I'm doing a little bit of carpentry here, but I have to get it in shape because this may be getting out.
DIPIT SAHU: But anyway, this is here. Now, what we'll do is we'll go to the sub-scap, right angle. OK so now we'll go to the sub-scap, I'll show you the sub-scap and the rest of the procedure. What we'll do is I'll put the hand in external rotation. OK, scissors please and close to the body and right angle to him.
DIPIT SAHU: OK. So let's show you the sub-scap. OK can you see the sub-scap? I'll show you even better. Now can you see the sub-scap? Ok, one second, Hold it out.
DIPIT SAHU: Yeah let's see. Let me put, this is the upper part of sub-scap. My exploded on the upper part of sub-scap in right angle. And where it is coming. You heard this. I show you the lower part. Let me just see first, then I'll show you, because even I can't see.
DIPIT SAHU: Yeah so these are the three sisters. I don't know if you can see. OK, I'll just try and point it out. The tip of my scissor is at the three sisters or the lower part of sub-scap. The tip of my scissors, so your three sisters is just below the scissor. OK, maybe you can't see, it's very deep down.
DIPIT SAHU: She says circumflex, which are at the lower part of the sub-scap. Can't see [INAUDIBLE} They can. [INAUDIBLE] We can decrease the brightness and redness [INAUDIBLE] don't do anything. OK three sisters.
DIPIT SAHU: Camera roll. You just saw it. OK clear? Hazy again. [INAUDIBLE] So by letting the Yeah now you see.
DIPIT SAHU: You see this black vessel? OK you see this? This is one of the three sisters. OK, got it. OK, so we've just made a bigger incision just to show you all this. Otherwise, I do it in a smaller incision. But this is a law of the three sisters. Anyway, we'll go out,
DIPIT SAHU: we'll go ahead. This was to just show you the lower part of the sub-scap. Now, what I'll do is, I will make a split. The upper 2/3 and lower 1/3 junction, which will be somewhere here. OK? This, see this? [INAUDIBLE] OK OK.
DIPIT SAHU: So what I'll do is we'll just make a split here, the corner. OK so this is the part of the sub-scap which I approximate idea lower one third upper two third or somewhere here. OK, very ballpark, but it is somewhere here. Got it? So this
DIPIT SAHU: I'll just split. Because suddenly we'll just split. So I'm just splitting the sub-scap and I will need some light now very soon because even I can't see anything now. OK anyway, we have split the sub-scap. Ok? What I'll do now is I will push this gauze piece inside,
DIPIT SAHU: this will make some space. And tied with a Y clip? Yeah so that I don't forget. OK, this is just my little idiosyncrasy. But anyway, we split the, we split the sub-scap, I put a little gauze inside just to show you, make some space and what I'll do now is I will split it a bit laterally also.
DIPIT SAHU: So maybe a bit more laterally, the split, so now this is split. Complete - can you see it? {Yes}. You see the white capsule? That is the capsule. {So what would be the length of the spread approximately?}. No, as much as required. Anyway,
DIPIT SAHU: the white is the capsule, the sub-scap is red, which is already split. Now what I'll do is I will just put one of the retractors here. Here? OK? OK, now I'll put another retractor and remove this, remove it, remove everything.
DIPIT SAHU: OK. OK. OK special? No, no. Just a normal Hohmann retractor. Just long. That's it. OK can you see the capsule now, white capsule [INAUDIBLE}.
DIPIT SAHU: [INAUDIBLE}. [INAUDIBLE] Can you see something? I'll take it off, very good. I will show you in a minute.
DIPIT SAHU: And then we should inside, inside. Thanks Arthur Inside, garnered. Can you see something now on air? Yes now he's moving.
DIPIT SAHU: Well, this is the capsule white, OK, resume opening. and this is a white capsule. The upper part of sub-scap has gone up, the lower part of sub-scap has gone down. This is a white capsule, which is washed you know. Now, maybe I'll be able to show you better if I wash it a bit. OK well, that case.
DIPIT SAHU: Ok yeah, let's start corona, because this will be done very soon. What is invisible. This, right? This is a capsule, sub-scap has gone up and down. I am just seeing the capsule in front.
DIPIT SAHU: [INAUDIBLE] OK, Manny. OK so question of the delegate, can we take that split slightly more and superior? One thing I'll just answer you to let me just do this, then I'll answer you. People go.
DIPIT SAHU: People grow.
DIPIT SAHU: OK Yeah. It's straight. Straight, nice. Yeah OK. Let me show you now. Yeah what was the question? Whether the split can be slightly more superior. So as superior you go, more external rotation may be restricted, but in Hyper laxpansion, you do go superior a bit.
DIPIT SAHU: OK is or disadvantage like advantage of that. So the more sub-scaps below the conjoined joint arthresis it, the bigger like this. So if you do a split as more superior than you may have chances of external rotation restriction. So classically it's upper two third, lower one third, wash like any cleaner, which is better.
DIPIT SAHU: No this is OK. This is all OK. There is no problem here. And two thirds, one third is best. OK so what are we seeing? We are seeing the glenoid, and,
DIPIT SAHU: let me just put one more retractor, then I'll show you everything. Hammer, please. Forceps.
DIPIT SAHU: [INAUDIBLE] Like this. Like this. So you need four retractors always, everything is in position. Can you see the glenoid now? Now I'll just show you what is where. So this is your 6 o'clock in here. Suction on.
DIPIT SAHU: I'll remove the capsular labrum. What six o'clock
DIPIT SAHU: is here. OK? This is sort of 9 o'clock, OK, 6 o'clock, 9 o'clock This retractor is in the gleno humeral joint. It's inside the joint. It's detracted the humeral head laterally and glenoid is medially. This is a medial retractor over here, which is the link retractor. This is just a Steinman pin over here.
DIPIT SAHU: And this is a Hohmann retractor normal, which is exposing that this is what you need to expose the medial unit, because here is where your coracoid will go. Now, what I'll do is I'll just remove this.
DIPIT SAHU: Posture don't ever, ever, ever. No course. I'm just removing the medial capsule of labral complex. 2 minutes. We'll just remove it. OK wash.
DIPIT SAHU: So this has gone. But you'll be able to see the bone better now. I'll start again. What we'll do is we'll just raise slightly, I won't remove any bone. We'll be just raising slightly there for the bone preparation.
DIPIT SAHU: So no bone loss will be done more. So no bone burring people have done bone burring earlier, but we won't be doing any we don't do any bone, more bone loss than what already there is. The only bony slivers.
DIPIT SAHU: OK so what I'll do is. I just show you this. Is it visible somewhere? But can you make it more clear? OK, one second. I'll make it better. Brother, let me make this clear.
DIPIT SAHU: Possible to decrease the brightness from your side? That includes. Yeah but I. So either they have are. OK. {INAUDIBLE}
DIPIT SAHU: OK OK. Lights now I need lights. I don't know if you can see the glenoid? [INAUDIBLE] [INAUDIBLE] [INAUDIBLE]
DIPIT SAHU: Wash.
DIPIT SAHU: Don't touch it. Things take a. I'll be back to do better. Slightly better for a light. This is better now. OK so now we have to show you the glenoid. So this is the glenoid edge. OK again.
DIPIT SAHU: So this is the glenoid edge. OK, so the 6 o'clock down here. OK. OK? This is the 3 o'clock. OK so this is the edge, this is the medial surface. Complete medial surface cushioning are all similar. OK, so this is the medial surface.
DIPIT SAHU: OK when we put the I've already done some jiggling or some slivers only. OK, only slivers, nothing else. Now this is the edge. Hall at 5 o'clock or sorry, this is a left shoulder, so we'll make it at 7 o'clock. OK we'll make it over here. OK we'll make one hole here, which should be 7 to 8 millimeters from the edge.
DIPIT SAHU: So somewhere here. So this will be done without any measurement, drill please. So this one is by just my experience and ballpark, because I know and we need the direction to be parallel. So I'll put it here. OK this is around 7 o'clock. OK, now I'll go.
DIPIT SAHU: {INAUDIBLE}. I've already made the hole. Now what? So now what I'll do is, I'll just bring out the, I'll bring out the coracoid. Here OK. Now, this is the starting screw.
DIPIT SAHU: 3.5 mm screw? This is my little screw. Open five.
DIPIT SAHU: So not. Later the second. So we take you? Yes what is the screw size? Do you measure or you don't measure a lot, actually. 70 to 70% of our time. It is 30 times.
DIPIT SAHU: Really? it can also be 35. It can be sometimes 25 slight individuals, but most of the time it will be 30. With washer, without washer? So we are using without washer here. So what I do is I've just put one screw and I can rotate as I want. And this is a bone, which is always obstructing sometimes, which I wanted to remove.
DIPIT SAHU: But anyway, we'll rotate it. Dipit, what's your take on fully threaded screws versus partially threaded screws? So I've been know, I'll be biased because I've used only partially threaded and have used maybe fully threaded once when I probably was in a soup.
DIPIT SAHU: And I had fractured the coracoid once, so I used it once fully threaded. Other than that, I think mostly it's partially threaded, especially. Fully threaded. Maybe OK, I don't know. What is your experience, sir? I always use fully threaded.
DIPIT SAHU: I don't know why I can't give you an answer, but I'm just not too confident, you know, because that coracoid in India is fairly soft so I'd rather have a purchase there. Yeah so I do the wash two finger technique. I don't over tighten them. Yeah two fingers. What we'll do also, I'll do that.
DIPIT SAHU: Exactly that two finger now is down. I'll just check where exactly it is. Saline, please. So we need to see the relation of the coracoid with glenoid. It is just flush.
DIPIT SAHU: I'll just show you how it is. But it is exactly flush. So it is exactly flush, if you can see. I don't know, I'll remove the soft tissue. But when I remove this soft tissue, you'll see that is just flush. I'll just show you in a minute. A knife, then?
DIPIT SAHU: The forceps. And let me just show you this. It is just flush.
DIPIT SAHU: Can you see anything? I don't know. A retractor. Change the light, it's a little dark, deep down there. OK, one second, let me show you this. [INAUDIBLE]
DIPIT SAHU: I can still rotate the coracoid as we want. Wherever we want. [INAUDIBLE] [INAUDIBLE] Scissors. Yeah.
DIPIT SAHU: So you want me to change it or this is OK. One second. Let me show you this. The grand durga. Oh, see, I can change it right now. I can change it later also, depending on what we feel, if we are happy or not. But the girls. OK, one second.
DIPIT SAHU: I just show them better soft tissue. So light underlines. Really? I'm going. Wash them up. Let me just show them better.
DIPIT SAHU: Scissors again. Can you see now? Yes. So this is the edge of the coracoid. This is the edge of the some of the glenoid here. Can you see this? This is the screw, this is the coracoid, this is the edge of the coracoid.
DIPIT SAHU: And this is the edge of the and there's some soft tissue here, but it's exactly flush. Saline wash again. OK, I'll show you better. Can you see the cartilage? Oh, one second.
DIPIT SAHU: The screwdriver, we can rotate. Did you see anything? Not of brightness, actually. Brightness otherwise, you know, brighter. You're rotating, rotating it more medially only two finger tightening. OK this is exactly flush.
DIPIT SAHU: Scissors. Again, so I'll just show you again. So, in this the language. And also the glue. Not actually. The screen.
DIPIT SAHU: How is this? Of better. But still is not visible lightning under. Can you just demonstrate with the artery. Forceps. Yeah. This is my knife, this is my scissors. Sorry this is a scissor, scissor.
DIPIT SAHU: This is a medial edge of the coracoid, this is the medial edge of the glenoid. OK so I'm just trying to see if it is flush or not. Well, this is the most important part, because if you do this lateral, then it's a problem. But as I can see, it is very flush to the edge. OK now see? Yeah can you see anything? I don't know.
DIPIT SAHU: It is very flush. Is it clear? Yes OK, so now I'll go on, I'll just put the other screw scissors, drill again. Always inferior screw first, inferior screw first and I'm committed. I can't change it. So what I'm doing is now I'll put the second screw and I'll see the articular surface.
DIPIT SAHU: I'm seeing the articular surface decline. Suction. So I'll directed parallel to the articular surface. OK so this is the articular surface. See this yellow? OK this the articular surface. This is my drill. Now I will just drill parallel. The place.
DIPIT SAHU: OK so I've just drilled it now I'll measure it. Let's see what it says. So what does it say? 30 so it is 30. So it's 70% 80% of time is 30. My screw is also 80/30. I always keep 230 ready. It may be 25 or 35 once or twice or maybe six months, but most commonly it's 30.
DIPIT SAHU: And because I'm using manual screws, so only multiples of 5. OK each. Correct so only two finger tightening because as Dr. Babulkah just said this, if you over tighten, it may break.
DIPIT SAHU: OK so. This is good. Only two finger tightening only. OK this is good. So I can't rotate more with two fingers. I'm only doing two fingers now.
DIPIT SAHU: Middle fingers either. Although this is only two finger technique, I will only try and rotate more. It's not going more well either one also. Sorry. OK. So this is tight enough. No more needed, and this is flush.
DIPIT SAHU: We don't need to do anything more, you can close the capsule if you want. I've done that in the past. Any other questions or we'll just go ahead. This is the gauze coming out because audience is asking you, what's your post-op imaging plan? Will do a epi X-ray right now and that's what we can do now.
DIPIT SAHU: Then we'll do anything else. We cannot do only AP x-ray. We can do right now, immediately. And then we are doing the CT scan after one year by rule in most of the patients, they are part of a study also. But actually you can be taken after one month when they are doing over head movements. So by two weeks you allow over head movements and then by one month we can take a actual view to see the direction of screws.
DIPIT SAHU: Right now it will be only anterior posterior x-rays. A quick see, I'm short by the side till as we move around. Yes do we have a CR arm on side? It was a shortcut. So all this is done, nothing else required. Any questions? Or I'll just go on to the other case.
DIPIT SAHU: I have one question regarding rehab. Rehab? We start movements tomorrow, active and assisted both for two weeks. They are in a sling after two weeks they are doing overhead exercises. Also, sling is for 10 to 14 days, two weeks because elbow flexion is normally allowed but not forceful.
DIPIT SAHU: But yeah, normally all shoulder elbow flexion, shoulder flexion, we start tomorrow. We start after one or two days and for pain control but after 24 to 48 hours and sling mostly is removed at two weeks. So in case there is a overhang after the second screw, do you recorticate it? And that is done by a burr, but we don't have a burr.
DIPIT SAHU: So I've never done it. So it should not be actually, there should not be overhang. You should not. I mean, that comes by practice, eventually you don't have it after a while, but there should be no overhang. So thanks Dipit for the great demonstration. I'll just remove this.
DIPIT SAHU: Thank you to my OT staff. Thank you anaesthetist Dr. Swati. You would like to know? Yeah you start the lecture, we'll be starting the scoping, I'll let when we're up and about. Thank you. Most creative.
DIPIT SAHU: The questions. [INAUDIBLE] In fact, I don't know of that occurrence or the correlation between the two, but in fact, somebody has an integrated capular. We actually do a pec minor tenotomy arthrotomy. I've just done it for my fellow three weeks back, you know.
DIPIT SAHU: No, no. If you have somebody with a poor posture and is not doing well, so you can do a pec minor arthrotomy in those very difficult periods and exceptional thing. But removing the pigment is more beneficial than it's the anemia of our therapists. So I don't think we can bring it to arm. Repairing that pec minor would create a tighter brachial plexus neuropathy issue.
DIPIT SAHU: So in the first series of laterjets is to repair the pec minor and had parts of numbness radiating pain. So it moved to the next lecture. But this you'll be speaking of. Sorry what?
DIPIT SAHU: We're going to come. It's that I think that in the past four administrations. I have about 60/70 patients between 80 and 87 exceptional patients not currently and they're not part of it was time that we were taught that the annual fatalities is as vertical as trauma.
DIPIT SAHU: Exceptionally you have that problem. We keep 6.5 lectures on the faculty, but I really have a six month term. The newer technologies are still work and 15% is not a problem. But if you can do a good anatomy and ensure that there is no cystic fibrosis here, then that will speak on the designs of the anatomic shoulders. Yeah, Thank you for having me here.
DIPIT SAHU: My topic is the design considerations for anatomic rolled shoulder arthroplasty. So for a modern anatomical storage shoulder, these are the principles that the prosthesis is designed on. It should be implanted in a patient who has an intact rotator cuff. Reconstruction of the tuberosity in a fracture case is a must, if possible, bone preservation of as much as bone preserved preservation the better, minimization of stress shielding, reduction of bone resection in a STEM prosthesis to improve fixation and simplifying the prosthesis designed for proximally humerus deformity.
DIPIT SAHU: So for the anatomical shoulder, these are our implant choices. Either it's a long stem, short stem now stem laces, resurfacing implants and for fracture stems for fracture cases to pass sutures for the tuberosity. On the glenoid side, before we make our choices, we need to be aware of this Walsh classification of for glenoid deformities post in arthritic cases.
DIPIT SAHU: We'll discuss about that. So let's take on resurfacing and for resurfacing and stemless designs, what was their ideology? The ideology is to preserve as much bone, revisions are easier and easier to take them out and also in special cases like where there is a plate put in which is going to be difficult to pass a stem or in proximal humerus deformities is where these implants really show their value.
DIPIT SAHU: So resurfacing was started by Copeland in 1979, the first implant placed in '86. It it has all the advantages of bone preservation, decreased bone loss, improved range of motion, it preserves humoral anatomy, and diaphysis is not disturbed. But there is a technical limitation. When you're resurfacing the humeral head, you're not taking a humeral head cut at all.
DIPIT SAHU: And you're just reaming the humeral head, taking away the cartilage. The downside of this is the problem that you have difficulty accessing the glenoid. So on the glenoid side, if you want to do a ream and run or place a glenoid prosthesis, that is difficult. But of late there are some modifications where you have angled reamers and it's still possible to do it. But most of the times with the resurfacing hemis, the only possibility it becomes difficult to do a total.
DIPIT SAHU: So why do a total shoulder at all, why not just a hemi-arthroplasty? It's because Copeland and Levy, they themselves published that patients who had a total shoulder replacement had better constant scores and better range of motion, reduced pain. But again, in 2010, they came up with, Copeland, came up with his technique of doing or his revised paper that he said that most of his total shoulders fail like the glenoid side failed, and which is why he now prefers to do just a hemi-arthroplasty.
DIPIT SAHU: But the most common cause of failure in a hemi-arthroplasty is painful erosion of the glenoid. And although this study, with a small sample size, said that the total shoulder had a greater failure rate, whereas a hemi-arthroplasty is almost 90% of the arthroplasties lasted through time. So what are the indications really when you do a total shoulder arthroplasty, when you have a concentric glenoid where we're putting in a hemi-arthroplasty, still going to give that glenoid concavity and reduced pain because of reduced wear on the glenoid side.
DIPIT SAHU: And a younger patient with avascular necrosis of the humeral head where the glenoid is not really affected. So these are your two patients. There are two indications where you consider a hemi-arthroplasty with a resurfacing, but doing a resurfacing is like parking a car in a tight space like this. It's challenging because if you go wrong, you can cause over stuffing where and which can lead to rotator cuff failures and cause of pain.
DIPIT SAHU: There are two ways of reducing this over stuffing or avoiding this over stuffing is use smaller head sizes of the two that you measure and avoiding varus. If your implant is in valgus, you're going to have over stuffing. So what was the reason of stemless coming in when resurfacing was so good? The reason for having a stemless is that you have better access to the glenoid and there is a good 3D finite study done on modeling saying that actually resurfacing causes less bone resorption than doing a hemi-arthroplasty.
DIPIT SAHU: So really comparing both of them are stemless wins because it has all the advantages of resurfacing. Why do, why do you now need a stem at all then in these patients? Because, when you do a stemless arthroplasty, you are reducing the amount of blood loss, reducing over time, and it's shown in published literature, as you see over here, that, you know, you're going to have a better range of motion and better function, reduce the licensee's rest, less stress shielding and all of those.
DIPIT SAHU: But there are some considerations. Do not throw your stemmed implants away because there are some considerations where there is severe osteoporosis, there is weak proximal humerus, proximal humerus metaphysis where your fixation can fail if you do a stemless arthroplasty. A simple thumb rule is that if your thumb can insert into the metaphyseal bone, then the bone is too weak.
DIPIT SAHU: You'll probably be better off putting in or putting in a STEM. So yeah, please keep your stems available.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode