Name:
Open Cuff Repair - Dr Pradip Nemade
Description:
Open Cuff Repair - Dr Pradip Nemade
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T00H55M50S
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https://cadmoreoriginalmedia.blob.core.windows.net/dda39588-4edf-4df8-af70-64e7aaf2c187/OPEN cuff repair- Dr Pradip Nemade.mp4?sv=2019-02-02&sr=c&sig=1U08jxP7r%2BeWytP9Xwn91hxIHRCHh7900cMzZD7wld8%3D&st=2024-05-10T21%3A09%3A44Z&se=2024-05-10T23%3A14%3A44Z&sp=r
Upload Date:
2024-03-30T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
PRADIP NEMADE/DIPIT SAHU: Only the acromion and a part of the clavicle. So what we are seeing here is anterior. [INTERPOSING VOICES] So what I'm writing here A is anterior. This is superior, this is inferior, and and this is posterior, 'P', you'll not be able to see probably you'll be seeing anteriorly and inferiorly.
PRADIP NEMADE/DIPIT SAHU: This is 'S'. Yeah, we can see that. And that is posterior. OK, and then that's the posterior angle of the acromion and that's the lateral border of the acromion. So we draw the acromion posterior border, then we see the clavicle here. So that's the clavicle over here. That's the anterior angle. Then this is the posterior 'V', then you part with it [?] See the anterior 'V' here, to join these two.
PRADIP NEMADE/DIPIT SAHU: This will be the AC joint, this will be the AC joint. So my incision is in line with the clavicle like this so this is the anterior of the acromion. So we take the incision almost somewhere over here till this much. This is anterior, I may go a little bit higher in this case because this is type 2 tear. This will be our line of the incision.
PRADIP NEMADE/DIPIT SAHU: On see if you see the bursa, bursa, the anterior, so there's a midline so the bursa will be somewhere over here. That would be the line of the bursa. Cut, scissor. Blue colours, I suggest. Any more questions on this before we start?
PRADIP NEMADE/DIPIT SAHU: No, carry on. And the [INAUDIBLE] suture [?] Right away. Do you infiltrate at all? Huh? Do you infiltrate before entering? No, I used to infiltrate in the past, nowadays, I just keep the solution ready and I use it inside to do the dissection.
PRADIP NEMADE/DIPIT SAHU: OK. [INTERPOSING VOICES] So I'm just waiting for the instruments. As soon as the instruments are in the theater, I will start. Cord resection then. Dr. Pradip, there's a question from the delegate. Can you show us the relation of the axillary nerve? Yeah so the axillary nerve will be, uh, so this is the posterior angle of the acromion, so you draw three fingers here from here and draw 4 to 5 fingers over here.
PRADIP NEMADE/DIPIT SAHU: It will be like this. So your incision is never going to go beyond that? No, no. It's never going to go there. [INTERPOSING VOICES] [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] Just taking a little bit time to getting the stuff here.
PRADIP NEMADE/DIPIT SAHU: And then as soon as we are ready, we'll start. Meantime, if we can discuss this. Hello? Yeah, we can hear you. Have we discussed the MRI? Yes. Yes, so it's a type 2 this, it's not a typical avulsion, kind of, probably this patient is having some impingement.
PRADIP NEMADE/DIPIT SAHU: So we are expecting some kind of tendon loss here. And there's a distal stump also, is there so it's going to be a little bit tricky. Yeah, I think we could see some lamellae of the tear and there is significant muscle atrophy of the supraspine. Yes, in the subscap look. OK but the MRI may be has a small subscapularis there. Yeah, and then there's a tissue around the biceps around the biceps, on the biceps.
PRADIP NEMADE/DIPIT SAHU: Also, Dipit has taken care, taken and made sure to give the tough one to me. Dr. Pradip, what's your plan? Yeah you just expose the cover, try to see what is the anatomy, and then we'll decide how to repair that. I don't have a fixed pattern, how to repair it. I do it once I see the tear. Most of the time in a simple I will use a [INAUDIBLE] otherwise I will do a suture bridge.
PRADIP NEMADE/DIPIT SAHU: So you are not going to do a transosseous, you are still going-? If my anchors are not holding. [INTERPOSING VOICES] [INAUDIBLE] OK. So shall I start now? Yes, please. [INTERPOSING VOICES] I, I, I stuck the I have and it got little bit crooked. It's not going to go as currently marked, little bit posteriorly because once when I applied, [INAUDIBLE] it got shifted a little bit.
PRADIP NEMADE/DIPIT SAHU: Dr. Pradip, we want to know what is your thinking about the biceps? What is your plan about the biceps in this case? Biceps? So we'll see it there again. I'm a little bit conservative about the biceps. If the biceps is looking good, I'll just leave it just like that. If it is inflamed, I will do it. You know, tenotomy in a soft tissue.
PRADIP NEMADE/DIPIT SAHU: Tenodesis. So tenodesis in soft tissue to the pectoralis. Pectoralis, yeah. That is all the available tissue. OK. Sometimes it not be, you know, again, sometimes it can be just a transfer [?] similar ligament also. OK. Do you believe in incorporating the biceps in your repair?
PRADIP NEMADE/DIPIT SAHU: Yes. Shall it be necessary, we do it, anterior edge [?] So first is to take the skin and the vertical skin so you can do it in a horizontal incision also if the tear is small and distinct [?] that is much more cosmetic incision than this vertical incision. But whenever you suspect that there can be some difficulty, then you can take vertical incision.
PRADIP NEMADE/DIPIT SAHU: OK, then you take the skins and cut till you you see biceps. Then you see a deltoid fascia. OK. Gelpi [?]. Gelpi [?] OK. They're deep, superficial. OK so You apply the Gelpi and [INAUDIBLE] once you see the deltoid fascia.
PRADIP NEMADE/DIPIT SAHU: The deltoid fascia, then you go on either side. Yeah - can we zoom in? Yeah. Thank you. Yeah. Yeah. Yeah. You undermine the incision. On all sides just to get the perspective.
PRADIP NEMADE/DIPIT SAHU: Utilize the entire skin incision. OK. I like to do this good, superficial hemostasis [?] because you don't want any blood to trickle down inside. So now we are exposed the deltoid fascia here.
PRADIP NEMADE/DIPIT SAHU: [INTERPOSING VOICES] Yeah, can you see it? So now what I am palpating here is the anterior edge of the acromion. So this is the anterior edge of the acromion. This is the anterior edge of the acromion. Can you see? Yes, yes. So right, it's right there.
PRADIP NEMADE/DIPIT SAHU: We're going to split the deltoid fascia in line with this fiber. So just a superficial cut onto the fibers. Once I'm touching the cautery, you can even see the fiber contracting. And then that also gives you the good orientation as to what is the direction. So can you see these fibers, the fascia? Yes. Yeah.
PRADIP NEMADE/DIPIT SAHU: No, no need, no need, no need, no need. So we don't need to retract distally, so we just need to go proximal. So as opposed to the perception that we need to go distally, it's not. We need to actually go proximally onto the acromion. So you, when your cautery touches the acromion, that is the point where you can, you know, that you are taken. We are going into the full depth of the deltoid.
PRADIP NEMADE/DIPIT SAHU: So now my cautery's touching the entire acromion. So here we just need to split the deltoid fascia. Then after that, we don't need to cut the cautery. Yes. On that in there, you just take the artery and just split it down completely. Yeah. And then you take the gauze piece [?] We'll take the fluid filled gauze piece [?]. Now, [INTERPOSING VOICES] [INTERPOSING VOICES] OK so, so we can see the bursa now.
PRADIP NEMADE/DIPIT SAHU: Can you see the bursa? Yeah, this is the bursa. [INTERPOSING VOICES] We need to change the angle of the camera. Yes. You need to come in front. That's what I'm saying. You learn better if you're on that side. Come. Yeah, that's what I'm saying.
PRADIP NEMADE/DIPIT SAHU: Come, come in front. Come in front. Over, over. OK, come in front. I'm just trying to get a good camera picture for you. Dr. Pradip, one question just in case you want to you have to extend your incision.
PRADIP NEMADE/DIPIT SAHU: You can extend it and convert it into proper deltoid split, complete anteriorly. So you will take off the deltoid from the acromion and then reattach it, right? From the anterior acromion? So you can take off from the lateral acromion if required. You can take off, not a problem. OK. OK. [INAUDIBLE] [INTERPOSING VOICES] OK, so while that is being done, we do the dissection with the [INAUDIBLE].
PRADIP NEMADE/DIPIT SAHU: So gauze piece to create this subdeltoid space. So my gauze, this is going in a subdeltoid space over [?] the bursa. So I will just push it completely inside, anteriorly and superiorly. And then I take it off. Next one. So that's how my subdeltoid space is created. OK. Next one. The camera angle is difficult to see, but we can appreciate what you are doing.
PRADIP NEMADE/DIPIT SAHU: So second one. Next one. Yeah, so. OK. So that's how I created the subdeltoid space. OK my finger is going now inside. Yeah. Yeah. Can they zoom out, please?
PRADIP NEMADE/DIPIT SAHU: Let's see if we can get otherwise, we'll change the camera position. Then we'll take off some deltoid fiber from the anterior aspect of the acromion, not the lateral aspect. I think if he positions the camera just a little bit more anteriorly, over your head, I think we can. Can you see now? It's better. Yeah. The position is going out over there.
PRADIP NEMADE/DIPIT SAHU: I think he needs to zoom out re-zoom into the incision. Yeah, now, can he zoom into the incision again? Can you zoom in now? Yes, OK. That's enough for me. Scissor, scissor [?] So they are shifting the camera.
PRADIP NEMADE/DIPIT SAHU: No problem. Any questions? Any questions from anybody? So the gauze is filled with adrenaline or just saline? You can fill with saline only. I fill here today with adrenaline, which I do regularly. But in case [INAUDIBLE] is just for the matter of dissection you need for lubrication.
PRADIP NEMADE/DIPIT SAHU: Yeah. [INAUDIBLE] [INTERPOSING VOICES] OK, so. Uh, Dr. Pradip, can you just enumerate some advantages of the open repair versus arthroscopic? So I did that in the morning. Hello? I'll do it again. This let's start from the physician [?] point of view and then [INAUDIBLE] for arthroscopic, I'll say what things work for me.
PRADIP NEMADE/DIPIT SAHU: OK, so first thing that I do, this inherited [?] position. So my cuff repair is not in so, whatever amount of tension or exertion [?] I get, that is maximum at the time of surgery. Now, the best view we could have ever imagined. That's amazing. Thank you. Now it's moved a little bit. I think I jinxed it.
PRADIP NEMADE/DIPIT SAHU: Yeah, OK. Can you bring it in the center? [INTERPOSING VOICES] Yeah, that's perfect. OK still. Is a little bit oblique. Can you take off this light? Can you take off this light?
PRADIP NEMADE/DIPIT SAHU: Actually from there light and now the camera in front. [INTERPOSING VOICES] Oh, that's perfect. I think we can see everything. OK, so now we can see the bursa. Yes. Yeah. So I'll take one advantage one by one as we go. So first thing to reach there in arthroscopy with our ten taken ten, 15 more minutes, we are there in five minutes.
PRADIP NEMADE/DIPIT SAHU: The second thing, I don't need to burn [?] this bursa. What I'm going to do is just cut this bursa. So can you see, I'm just cutting this bursa. I'll just cut this bursa. Take a gauze piece. Take a gauze piece and just wipe it anteriorly and posteriorly. Amazingly bloodless, I think that's an advantage over arthroscopic. Yeah, and then you can just swipe this bursa posteriorly and anteriorly So see, I'm swiping this bursa posteriorly and swiping this bursa anteriorly and I'm going to preserve the entire bursa.
PRADIP NEMADE/DIPIT SAHU: Not a single tissue of the bursa has been taken off. Can you see now? Your assistant's shoulder is coming into the camera. Yeah. Can you refocus, please? Yeah. Yeah. Perfect, thank you. And here [INTERPOSING VOICES] [INTERPOSING VOICES] The camera has moved again.
PRADIP NEMADE/DIPIT SAHU: And then the entire cautery [?] is right in front of me. The camera has moved. If we can zoom out and- zoom out a little bit. There, don't move so much. Have the camera still in the center. Yeah, go in.
PRADIP NEMADE/DIPIT SAHU: Yeah, now don't move. OK. [INTERPOSING VOICES] Shoulder is there or somebody. No, no, no. I'm just making space for my assistant.
PRADIP NEMADE/DIPIT SAHU: [INTERPOSING VOICES] OK, OK. Can you see now? Yes, this view is good. Still, it is not as good as I am seeing. But anyway, no problem. Well, this is OK. So the cautery [?] is right in front of me. Can you see?
PRADIP NEMADE/DIPIT SAHU: See, give me the grasper. [INAUDIBLE] Can you see now? Yes, yes. And cautery's right in front of your eyes. Yeah. [INTERPOSING VOICES] [INTERPOSING VOICES] [INAUDIBLE] [INAUDIBLE] I hope he's not standing on the table.
PRADIP NEMADE/DIPIT SAHU: [INAUDIBLE] That's perfect. This is OK? Yes it's perfect. Thank you. Yes, yes. [INAUDIBLE] [INTERPOSING VOICES] Excuse me.
PRADIP NEMADE/DIPIT SAHU: [INTERPOSING VOICES] [INTERPOSING VOICES] So can you see now? Yes yes. So I have not taken off any tissue, burnt any tissue, and I have entire cuff in my hand and I can see very easily to [inaudible] How the cautery reads.
PRADIP NEMADE/DIPIT SAHU: So it's a long longitudinal cut [?] here. It's probably because of the bursa and it's little bit laminated like here. So this lamina is going to come here and my cuff repair is done. Fabulous. Simple. The second thing which is advantageous here is I can clearly see that this anterior acromion can you see? Yes. Yeah, let me mark it with the marker for you.
PRADIP NEMADE/DIPIT SAHU: Mark on the system. So that is the sharp anterior edge of the acromion. Can you see this blue one now? OK, I'll leave the traction. And can you see now it is actually digging into the cuff. Yeah. So that is a direct demonstration of impingement. Can you see? So this patient is going to go in flexion.
PRADIP NEMADE/DIPIT SAHU: It's going to get impingement. So this patient 100% is going to require some acromial decompression. So the whole question of whether to do acromial decompression or subacromial decompression results, the same is really not the question for me. I don't even read the literature because I can directly demonstrate whether it is there. It is just required there or not required. So when you see that the cuff is sitting there, I know that I ought to do it.
PRADIP NEMADE/DIPIT SAHU: So I'm going to start with that cervical decompression. [INAUDIBLE] So it's actually the anterior acromial decompression. People say it is a subacromial decompression. It is actually anterior acromial decompression because I think that lecture must have been taken. But I'll just revise why we take [?] get that anteacromial [?] spot. It is actually the calcification of the CL [?] ligament.
PRADIP NEMADE/DIPIT SAHU: If you see the CL [?] ligament, the insertion, just like you get a calcaneus spot because of the detachment of plantar fascia here, because of detachment [?] of the CL [?] ligament there, we get this ossification. In routine, in normal patients, that tissue should be more flexible. CL [?] ligament, but now it is calcified. Now there is no excursion of the tissue there when you do all that activity and that's when you start digging into the greater tuberosity.
PRADIP NEMADE/DIPIT SAHU: So what you need to do is just take off this anterior edge. So what I am now doing is taking off the anterior edge. [INTERPOSING VOICES] So I'm just digging into the anterior edge and just taking off the sharp anterior border [?] of the chromium, just like what you do in arthroscopy. Yeah, yeah, we can do but the anterior needs to be taken off with the nebula. Once that has been done, suddenly my hooked acromion stop becoming a hook.
PRADIP NEMADE/DIPIT SAHU: Acromion has become flat [?]. Now next step, what I can do is- periosteum. Periosteum. Periosteum, sister, please. [INAUDIBLE] So what I'll do is just take off the periosteum of the subacromial space here underneath the acromion.
PRADIP NEMADE/DIPIT SAHU: So can you see I have taken of the- Somebody's blocking you. Yeah, can you see? I am limiting the periosteum [?] of the subacromial space, subacromial area. Fantastic. And then I'm just going to take off this bone here underneath the acromion, and the periosteum just remains there. Small osteum [?] sister, please.
PRADIP NEMADE/DIPIT SAHU: Yeah, hammer. OK. Take a sharp osteum, sharp osteum. I need a sharp osteum. Dr Pradip, do you ever worry about fracturing the acromion when you- No no, because I am not- I am going- I'm not going towards the thing.
PRADIP NEMADE/DIPIT SAHU: I'm just going underneath. So it has never occurred with me. If I don't do like this, then it can occur. But, you know, I turned everything into my vision. I'm just going to take a small chip off the underside of the Give me a nibbler [?]. Yeah, while that is being done, I can just take off this small plaque of the acromion there which I have taken off.
PRADIP NEMADE/DIPIT SAHU: We don't need to go all the way back. Because that portion of the acromion is normal. It is just the anterior portion, which is abnormal that we just need to take off. Then we need to take a rasp. We need to take a rasp and just even it out, just even out the surfaces, especially at the lateral margin.
PRADIP NEMADE/DIPIT SAHU: And we can see, I don't know whether you can see, but I think you can see that my periosteum is completely intact here. Yeah. And then we just rasp it out, just create that, clear that ledge over there, and suddenly I'll demonstrate. Nibbler, nibbler [?] Yeah. Rasp again. So the entire anterior boring tissue, which was, you know, snagging into the cuff, has been now cleared up and now I'm demonstrating the impingement again.
PRADIP NEMADE/DIPIT SAHU: See, now I am [INAUDIBLE] this is no longer digging into the cuff. Can you see this? I am pressing it against it but it's not digging into the cuff. You want it forward flexion. It is moving underneath. Can you see that? Yeah. OK. The second question that is asked whether you can manage the AC [?] joints.
PRADIP NEMADE/DIPIT SAHU: So this is a [inaudible] joint here. If if I increase my incision, I can directly go into a joint or if I just want to do a acromion clavicle co-planing [?] I can do here with the rasp. Here I'm putting a finger. It is co-planar already so I don't need to do anything with the AC joint. So next stop is to address the cavity [?] itself. So [INAUDIBLE] Just a probe.
PRADIP NEMADE/DIPIT SAHU: [INAUDIBLE] Yeah. So we can, we can examine the bicep, you know? Yeah. Yeah. So we can just examine the bicep tendon here. Can you see? Yes. It's looking healthy for me. They will need some fluid in the [INAUDIBLE] tendon [INAUDIBLE] Can you see this?
PRADIP NEMADE/DIPIT SAHU: Yes, very well. Yeah. So I'm just going to leave the bicep. I'm not going to do anything for the bicep. It is just an impingement, which causes a longitudinal split into the cuffs. So I just need to put one small anchor here and just repair it. Just next stop is to see whether they will laminate, take a 2% [?] I am just everting the cuff to see if there are any lamellae.
PRADIP NEMADE/DIPIT SAHU: And we can see a small lamella out there, could you scissor [?] that please? OK, so- Do you freshen the greater tuberosity? I will. I will, I will. First, I'm just assessing that here. So can you see the small lamella there? Yes. So you can see that lamella here.
PRADIP NEMADE/DIPIT SAHU: See? Yes. Very well. Yeah, so that we need to take a strategic pass suture passage so that my lamella comes over here. And then this part goes on the top of that. So that was seen on the MRI that, you know, that is kind of looking like a type 2 tear it introduces [?] interstitial separation.
PRADIP NEMADE/DIPIT SAHU: So that all can be corroborated here on the picture. Incoming. It is coming like this. And this part is going to go on the top of like this. So now I'm going to take off [INAUDIBLE] just small laterally. I just need to clear off, which is called a lateral [?] It's reverse subacromial decompression. So can you see the jump off [?] here? Yes. Yeah, take a nibbler.
PRADIP NEMADE/DIPIT SAHU: Yeah, also [inaudible] acromioplasty [?] So I'm just going to take off the smaller jump off here. OK. The delegates also we also want to see the subscap, if you can- Yeah, I'll show. So this is the subscap here. This is subscap, right in front of you. Yeah, perfect. Yeah. We have one question over here. Can you see?
PRADIP NEMADE/DIPIT SAHU: Yes, yes. The subscap actually zero repair subscap and supraspinatus [?]. When you've already done a great acromioplasty why do you really need to do a tuberoplasty [?] Tuberoplasty, we don't know what [INAUDIBLE] tuberoplasty, but small lateral edge, which is actually bone, which is extra bone, it is not a normal [?] bone. I'm not thinking of normal, but I'm just taking up the small lateral edge.
PRADIP NEMADE/DIPIT SAHU: Right, right. So then I use these rod retractors. Simple rod retractor, if you can see. It's designed by a very great surgeon whose name is Dr. Pradip Nemade. So he's great. I'm just joking. OK, so you can just use this rod retract and see underneath of the cuff if there's any tissue over here or there.
PRADIP NEMADE/DIPIT SAHU: They just it's a [INAUDIBLE] which is bent to my advantage. So I ergonomic handle to that. Can you zoom out? Fantastic. So, yeah, it's just a J straw [?] if you see, we can bend and you can just hold it to grip and then you can retract the cuff area you want to see underneath wherever you want.
PRADIP NEMADE/DIPIT SAHU: I can see the entire thing. I can even see the glenoid. I can see the bicep and cut here. Yeah, so, So Nikhil has given his a new name, it's called the pelican. So I'm going to start calling it the pelican now, henceforth. Pelican retractor. Good. OK, so we take one anchor now. One question from here, if at all you wanted to do a biceps tenodesis, would you?
PRADIP NEMADE/DIPIT SAHU: Where would you do it? In the groove? I got it right from- now two things. If I were to incorporate it into the cuff repair, then make sure the system. OK? Yeah. So what I do is suppose I want to do a bicep tenodesis. OK, that is [?] the bicep.
PRADIP NEMADE/DIPIT SAHU: So I'll just mark it first in lateral position. I'll mark the bicep and where I want to incorporate in the cuff repair here. Yeah. Like this. Once I have marked it. Mixture [?] Yeah. Once I have marked the normal position of the tendon without any tension. I'm just going to pull it and just distal to that I'll cut it.
PRADIP NEMADE/DIPIT SAHU: Fantastic, yeah. Got it? Yes. Sure. Anchor? OK. So I'm going to use a single anchor here because this is not a big tear [?]. So what I'm going to do, it is more of a longitudinal separation. So my.
PRADIP NEMADE/DIPIT SAHU: My cuff is coming somewhere around here like this. Cuff repair. So I'm going to center my anchor here or here. So what I'm going to do is just take off a little bit of cartilage because the underneath lamella is retracted. There's some tissue loss there. So what I'm going to do is I'm just going to take off around 4 to 5 millimeters of cartilage there.
PRADIP NEMADE/DIPIT SAHU: I'm going to treat my anchor a little bit more medially there because that lamella, there is some loss of tissue. So I'm going to, if I repair it under [inaudible] at a lateral position, then it will be under tension [?] I don't want that. So I'll just, with the scoop. Can you hear that sound? Of cartilage being taken out, around 4 to 5 millimeter of cartilage. And even if you see the MRI just below the GT [?] there are some cysts.
PRADIP NEMADE/DIPIT SAHU: So I don't I'm not I don't want to put my anchor in that [INAUDIBLE] cyst. So I've just taken off this 4 to 5 millimeter of the tissue there. So cartilage over there. Just clearing off the soft tissue, not taking off the bone. And once I have done that, my anchor is going to come there, radially. Great. So my anchor is going to come there at the cartilage margin.
PRADIP NEMADE/DIPIT SAHU: Yeah, so it's a screw-in anchor. So you want to hear you can see that it just went just like that. Yeah, so. Yeah. So it's just hard work, but I'll see whether I can get the hold [?], if I can get the hold and I'll go, go forward, I can convert it into transosseous anytime. So that's my anchor. I'm going to ask Nikhil to confirm the hole is there [?] because I'm biased.
PRADIP NEMADE/DIPIT SAHU: I may say that it is holding well and it might not be, so I'm just going to ask Nikhil, can you please check it within there and go look? Yeah. So Nikhil has given me the confirmation that we can go ahead with this anchor and that's what we are going to do, we're going to go ahead with this anchor now. So OK, Dr. Pradip, we have already concluded that you are great. We don't need any confirmation.
PRADIP NEMADE/DIPIT SAHU: I may be biased, you know "Oh, it's holding well," and then, you know, it just cut through. [INTERPOSING VOICES] [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] There was a 5.5 mm?
PRADIP NEMADE/DIPIT SAHU: Yeah yeah, 5.5 mm anchor. [INTERPOSING VOICES] OK so [INAUDIBLE] OK, so lamella [?] here I want to have, as I said, we want suture passage at a different location to the two lamellae are not holding [?] here so we need to take suture passage to different levels. Our view is obstructed. Thank you.
PRADIP NEMADE/DIPIT SAHU: Can you see here? Yeah. Hold there [?]. There. OK so what I am going to do is first get going through the interior lamella so that the interior lamella is just where my cuff is sitting. So that's my interior lamella first.
PRADIP NEMADE/DIPIT SAHU: Take it out completely altogether from that lamella. I don't know whether you can see this. Yes, we can, very well. Thank you. I just wanted a little smaller needle, but [INTERPOSING VOICES] My needle point, is it 220 [?] Anyway. [INAUDIBLE] OK.
PRADIP NEMADE/DIPIT SAHU: Then after that, interior lamella is done. I'm going to pass it to the superior lamella. So that's the superior lamella here. So it's going to come anteriorly here because the two lamellae are overlapping. So the same stitch- So you are repairing the interstitial tear with a [INAUDIBLE] clamp [?] Yeah, no, no, I'm not repairing.
PRADIP NEMADE/DIPIT SAHU: It's my suture. I don't have the material, so I'm using [INAUDIBLE] suture shuttle [?]. OK. Can we appreciate the musculotendinous junction just to know where you are passing your suture? So so my musculotendinous junction will be around two to three centimeters, much more medial still in the [?] tendon, two to three centimeters, much more medial.
PRADIP NEMADE/DIPIT SAHU: So this is my, so if I reduce this my lamella, can you see this now? When I'm pulling this, my lamella is getting reduced. I don't know whether you have that vantage point from there, but I can see that once I pull it, the lamella is getting shifted anteriorly. Yes. Yeah. Then we just make a loop of this white reel [?]. So in roll, in many of the places, you will not get Mayo needle or something like that.
PRADIP NEMADE/DIPIT SAHU: So you can always use this regular trolley [?]. So you are taking a vacule [?] and then you are just creating a trolley [?] and then you can use this. [INAUDIBLE] Yeah. Then we are past the suture. So this is a strategical suture passage. Second one. Now you can give me a scorpion, please.
PRADIP NEMADE/DIPIT SAHU: Yeah so- no, the other one. [INAUDIBLE] Yeah, yeah. So always I'll see where it comes, and then I pass it. I sometimes would even mark it though it is not required, so I'm just going to pass it just like that. OK, that's it.
PRADIP NEMADE/DIPIT SAHU: OK, I'm OK with that. OK, then the third one. The second one. Yeah. Yeah. Again, going through the lamella first. This is the first lamella. And then through the...
PRADIP NEMADE/DIPIT SAHU: I'll show you I don't know whether you are able to see, but there's not much to see in there. It is pretty basic, this thing that wherever the cuff is sitting you need to get it there. And then the last one is, at the last posterior-most margin. [INAUDIBLE] Yeah.
PRADIP NEMADE/DIPIT SAHU: I'm not happy with this suture, so I'm going to revise this [INAUDIBLE]. [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] Remove them [?]. OK? Suture [INAUDIBLE]. [INAUDIBLE] Yeah.
PRADIP NEMADE/DIPIT SAHU: Use this. So that is the outer lamella. Then the inner lamella. Hold it, reduce it. No. Yeah, and turn out a little bit [?]. Yeah, that's it. And then going to take off the suture from there.
PRADIP NEMADE/DIPIT SAHU: Yeah. So now I'm happy. So my suture passage is done. Can you see this? Just in a minute, try to pull this. Hello? The cuff is getting reduced. Can you see? Fabulous, yes.
PRADIP NEMADE/DIPIT SAHU: Yeah. So next thing is to create the tunnel, horizontal tunnel. So take a K-wire. Blade, then a blade just to take off this bursa. [INAUDIBLE] [INAUDIBLE] I'm just going to create a lateral anchor [?] just a little bit.
PRADIP NEMADE/DIPIT SAHU: So this technique people wanted to see. So just clearing off the bursa with the blade. Periosteum [INAUDIBLE]. Just swiping off the bursa, I'm not taking it off. Just swiping it off. And then, external rotate [?]. We palpate the bicep and lateral edge of the bicep through here. So that is a very strong bone here.
PRADIP NEMADE/DIPIT SAHU: OK. Yeah. So with a small K-wire, we make a- find a way to hold there [?]. So we make a small hole over there with a K-wire or [INAUDIBLE] anything or this, hammer. You make a small hole over there, on the anterior margin. And then we take the finer [?] [INAUDIBLE] bone.
PRADIP NEMADE/DIPIT SAHU: Hold them [?]. [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] [INTERPOSING VOICES] [INAUDIBLE] OK. So then we go through this hole.
PRADIP NEMADE/DIPIT SAHU: OK. So I think I missed my hole. [INAUDIBLE] Hammer. [INAUDIBLE] That hole is for your lateral [INAUDIBLE]? Yeah lateral, that is not- that is just a part [?]. Yeah, I got it. Yeah, just to pass the [INAUDIBLE] bone [?]. So I'm creating a horizontal tunnel in the T bone [?]. So the bone is so strong that the needle doesn't go there.
PRADIP NEMADE/DIPIT SAHU: [INAUDIBLE] Yeah. Yeah. OK. So that is there. They're going into a hole and they internally rotate a little bit. Yeah. And then I'm going to just take it off. Really little, little bit of force [?] there.
PRADIP NEMADE/DIPIT SAHU: Once it has been inserted, you need to see where it has come in. Yeah. Don't retract much [?]. I can just need to see but- What that is there, we just take off the thing. So that is how we are. Horizontal tunnel has been made, now this suture into the greater tuberosity the strong [INAUDIBLE] [INAUDIBLE] Can you see it is not cutting through.
PRADIP NEMADE/DIPIT SAHU: I'm holding it. And you see the humerus is moving. Yes. Yeah. So this is a very strong bone here. I'm literally applying little bit force to lift up. The humerus, it's not cutting through. So I'm happy with that bone quality there. If I'm not happy, I will go a little bit more distally. OK. Mayo [INAUDIBLE].
PRADIP NEMADE/DIPIT SAHU: So, so now we have these four sutures here. So the anterior suture goes posteriorly, the posterior sutures go anteriorly. So this suture, potentially [?] these sutures are coming posteriorly so, get the needle [?]. I generally use my own needle, but I don't have it. So I'm going to use the different technique today here. OK, hold it. Zoom out. Zoom in.
PRADIP NEMADE/DIPIT SAHU: [INAUDIBLE] Yeah. [INAUDIBLE] OK. So what I'm going to do is I'm just going to pass the needle through the suture. And then [INAUDIBLE] is just going to put the suture in the needle. So if- with my own needle, it is much easier.
PRADIP NEMADE/DIPIT SAHU: But we don't have it today here. Can you see this? Yeah. So that is- that suture has been connected to another suture. And then we put at a different location, we take another one. [INTERPOSING VOICES] Huh?
PRADIP NEMADE/DIPIT SAHU: What is? I don't know. Yeah, [INTERPOSING VOICES]. So can you see this now? Fabulous technique. Yeah, scissor [?]. Scissor. And this, we just cut off the [INAUDIBLE] needle, take off.
PRADIP NEMADE/DIPIT SAHU: Cut off the [INAUDIBLE] needle. We just take this posterior suture anteriorly. This one. Just leave it. Just leave it. [INAUDIBLE] Someone [INAUDIBLE]? Yeah. So we just take these two sutures from this one, this one, this one.
PRADIP NEMADE/DIPIT SAHU: OK, so we have got these posterior sutures anteriorly now, can you see this? Yes. Can you see? And my cuff is reduced. See? Fabulous. Yeah. And then we'll just need to tie it to the pillow suture here. So my white suture is going to go with white and my black sutures are Tiger sutures so we're going to go with the Tiger.
PRADIP NEMADE/DIPIT SAHU: Before that, I'm just going to tie the cuff tissue with a simple white reel [?]. So that it sits properly, get compressed properly, give me a white please, two zero [?]. So I'm in position to give the compression, but before that, I'm just going to tie with the white reel [?] two zero white [?]. So that available gap is closed.
PRADIP NEMADE/DIPIT SAHU: [INAUDIBLE] [INAUDIBLE] Can we start taking the next [INAUDIBLE] [INAUDIBLE] Are we breaking for lunch? Hello? Dipit? Hello? What exactly is the status of the next patient? Is he induced ? [INAUDIBLE] [INTERPOSING VOICES] I think so.
PRADIP NEMADE/DIPIT SAHU: The verdict is to induce so, so I'm just going to tie this cuff here with the simple [INAUDIBLE] Stitches [?]. Just a simple one-two stitch [?] so that, you know, it sits properly and then I can compress it uniformly. So did you do, like, a side to side or-? Yeah it's just a side to side. Yeah, it was more of a longitudinal split here, and the internal lamella was retracted so that we are repaired already.
PRADIP NEMADE/DIPIT SAHU: We are already going to take our sutures [?]. And then, I just need to provide a little bit compression now to the tissue. So it's already been repaired. Can you see with simple one-two [?] stitch? My cuff has already been repaired and I just need to tie it with the [INAUDIBLE] stitches, so I want him to step it [?]. [INAUDIBLE] Yeah.
PRADIP NEMADE/DIPIT SAHU: Yeah, step in. And another advantage [INAUDIBLE]. Another advantage is all these knots are not in the subacromial space. They're on the anterior-lateral aspect. Don't crush it. Yeah, so you use simple square knots. Sometimes you [INAUDIBLE]. [INAUDIBLE] No problem there.
PRADIP NEMADE/DIPIT SAHU: No problem. Step in. [INAUDIBLE] [INAUDIBLE] You can even use knot pusher [?] here if you want. Yeah. Here and catch again. Catch again. Yeah. So these knots you need to catch the second one also because you tend to become loose sometimes because the sutures are slippery.
PRADIP NEMADE/DIPIT SAHU: So the second one also needs to be cut later. So again, we put a knot. Nikhil will step it. I will put the reverse one to create a square knot, I will leave it. He will leave it and catch it again. And then I will use the third one. Ask him to leave. Then he will leave.
PRADIP NEMADE/DIPIT SAHU: Leave. Yeah. Blade. Bursa done [?]. [INAUDIBLE] I'm going to close the bursa here. So my bursa is there. [INAUDIBLE]. Yeah. So bursa which is slight [?] posteriorly is going to come all the way.
PRADIP NEMADE/DIPIT SAHU: So can we see the repair now? Yes, we can't see that. [INAUDIBLE] Our view is blocked a bit. Yeah. Can you see the repair now? Fantastic. And then now, widen [INAUDIBLE]. So the most important thing here, not the most important one. The important thing is that I can just simply close the bursa.
PRADIP NEMADE/DIPIT SAHU: Yeah. I can just simply close the bursa here. So all the bursal augmentation and all these things. Can you see? The bursa is back. Yes. So that's not possible without arthroscopic is it? Definitely not.
PRADIP NEMADE/DIPIT SAHU: Yeah. Nikhil is saying that after one year it will reform [?] back. But the other thing is we don't cut the bursa like this. Yeah, but you need to burn it. Little bit. Yeah. [INAUDIBLE] OK. Cut done. OK. So the most critical step here is now to get this deltoid closure here. OK? So that is the only thing which is a little bit tricky here.
PRADIP NEMADE/DIPIT SAHU: So that's why you need to just split, so if you see here, I just, they're going to split. That is not a worrisome factor [?]. What is a factor is this anterior of the acromion. So here you need to, [INAUDIBLE] please. Yeah. So you take this [?]. Can you see this? Yeah. Can you see this deltoid?
PRADIP NEMADE/DIPIT SAHU: So this is the anterior branch of the thoracoacromial artery. So you just need to take off, take the good fascia, bite here on one side and the good fascial bite, including [INAUDIBLE] just bite on the other side. And then, you pass two or three passes. Don't tie it off right now. Just get two or three bites like this.
PRADIP NEMADE/DIPIT SAHU: Sister, I want one number. You give me two zero. Anyway, [INAUDIBLE]. One more to the fascia. One more from the fascia here. Yeah. So three continuous bites you need to take, and then we'll tie. That's it.
PRADIP NEMADE/DIPIT SAHU: And suture [INAUDIBLE]. OK. The suture is too thick. I will change the suture because it's just- Cut it.
PRADIP NEMADE/DIPIT SAHU: Yeah. So they're one number [?]. Yeah, good. So if we need a biceps tenodesis to do a soft tissue tenodesis with the pectoralis major, you would take another incision or you can extend? No, no Don't need another-? Oh, no, no, no.
PRADIP NEMADE/DIPIT SAHU: Retract it. Or you can see below the subscap. Everything through the same incision, except rather than the SCR, where you need to make the individual portal. Yes. But there are separate kinds of devices available where you can even see the glenoid take that [INAUDIBLE] [INAUDIBLE] So these are the subacromial humeral depressors available. So if you put it here and spread it, you just depress the humerus.
PRADIP NEMADE/DIPIT SAHU: You can even see this thing I have even done in a case of an elderly, she had a cuff [INAUDIBLE] dislocation. And I could see a juicy labrum there. I'm going to do labral repair to this [?], through the cuff. I think the next live surgery will be that. Oh, I don't want. We all would want to see that. Yeah. Yeah. So that's it.
PRADIP NEMADE/DIPIT SAHU: Our steps into the deltoid has been closed. We may choose to close this or we may just leave that. The split does not matter. I just want to irrigate the wound and put some [INAUDIBLE] solution there just for the sake of completion of open surgery. And then we just need to close it up. Is that OK for you? Yes, absolutely.
PRADIP NEMADE/DIPIT SAHU: Brilliant, thank you so much. This, we may put a stitch here. Or we may just leave it there. Or we can just put one simple stitch. You make it look so easy. Yeah. Thank you. Thank you. So I thank Nikhil here, I thank [INAUDIBLE] here with me, a sister and the entire staff here of the [INAUDIBLE] hospital.
PRADIP NEMADE/DIPIT SAHU: And of course, [INAUDIBLE]. Thank you. We can go offline if you want now. Yeah delegates are asking a question, if you don't mind. Yeah. Yeah. [INAUDIBLE] [INAUDIBLE] The same technique where Dr. [INAUDIBLE] was using [INTERPOSING VOICES] was using the same technique.
PRADIP NEMADE/DIPIT SAHU: The same technique? I really don't know. I really don't know. I have never seen him, so I cannot comment. He might be using the same. Pradip sir, Dr. Coleman. Yeah? Excellent demonstration.
PRADIP NEMADE/DIPIT SAHU: Thank you. You have created a lot of doubts in minds of aspiring arthroscopy shoulder surgeons. [INAUDIBLE] Looks so simple. Excellent. Thank you. So with this technique, can this be called as a partial transosseous?
PRADIP NEMADE/DIPIT SAHU: I call it the combine transosseous anchor So there are other techniques- one technique some surgeon described [INAUDIBLE] transosseous, something, something, something. But this is completely different. The lateral row repair, which were lateral row. Actually, we are avoiding anchors there. Exactly. So it's a horizontal transosseous and it's not a- the typical all other transosseous tunnels describe a vertical along the line superior inferior.
PRADIP NEMADE/DIPIT SAHU: This is the only one where we describe enter the posterior transosseous tunnel. And the advantage is that it is a very strong bone of the humerus. It doesn't cut through. That is very true. [INAUDIBLE] [INAUDIBLE] [INTERPOSING VOICES] [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] Let me see again.
PRADIP NEMADE/DIPIT SAHU: [INAUDIBLE] Are we online, or-? Offline.