The SL Ligament with Sanj Kakar

Chuck and Chris welcome Sanj Kakar, MD from the Mayo Clinic to discuss the SL ligament.  We discuss Sanj's path to his current role and his approach to the SL ligament including diagnosis and treatment.  

We refer to
Scapholunate Instability: Diagnosis and Management e Anatomy, Kinematics, and Clinical Assessment. Part I Lauren E. Wessel, MD,* Scott W. Wolfe, MD† 2023 (also part 2)

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Transcript

Charles Goldfarb: 0:00

Chuck, welcome to the upper hand podcast, where Chuck and Chris talk hand surgery.

Chris Dy: 0:09

We are two hand surgeons at Washington University in St Louis, here to talk about all things hand surgery related from technical to personal.

Charles Goldfarb: 0:17

Please subscribe wherever you get your podcasts,

Chris Dy: 0:20

and thank you in advance for leaving a review and a rating that helps us get the word out. You can email us at handpodcast@gmail.com so let's get to the episode.

Charles Goldfarb: 0:30

Oh, hey, Chris,

Chris Dy: 0:31

hey, Chuck. How are you?

Charles Goldfarb: 0:32

I'm fantastic. How are you?

Chris Dy: 0:35

I'm good. I'm here in the office on the weekend. What could be better?

Charles Goldfarb: 0:39

I see your office in the background, it looks nice and neat. Yeah,

Chris Dy: 0:43

it's, you know, there have been some, there's been some shuffling in our department space, and I'm excited that you have now given me a window office. So thank you for that. All of Dr Nunley's stuff is still in the drawer, apparently, so I'll have to sort that out. But I see him with some frequency, so I'll talk to him about whether he wants his old ID badges.

Charles Goldfarb: 1:00

I think he probably wants you to deliver his stuff to him. Is what I think I am. All out of sorts, almost beyond description, because it's now been one week since I've had my computer. Wow, I'm on a loaner. It is. I'm one who lives on my computer. And it's really, it's really making me crazy.

Chris Dy: 1:21

What happened to your computer? Well, Chris, I was

Charles Goldfarb: 1:26

at the hospital, and I had my bag, and somehow some water got spilled in my bag, and I didn't recognize it initially, and didn't recognize how much water got spilled in my bag. And then after I got done with surgery, I had a book in there that was waterlogged, and the computer was a little wet. I thought it would dry out in 24 hours. I took off the back, which probably I shouldn't have done, but everything online said, do that to dry it out. And now it's with the computer gods, hopefully making it right. Are

Chris Dy: 1:56

you supposed to put like, if an iPhone gets wetter, supposed to put it like a like rice, like uncooked rice, and just dry it out.

Charles Goldfarb: 2:02

You are not supposed to do that. That is like, apparently, that's the rumor mill or whatever. But don't do that. Well.

Chris Dy: 2:10

I'm hoping that our esteemed guest will have some advice, both on how to dry out your computer and in how to to, you know, maybe fix or reconstruct SL ligaments. But why don't you introduce our friend who's joining us? I'm sorry here about your computer, first off, but thank

Charles Goldfarb: 2:26

you. Thank you for your sympathy. Yeah, it's a really special day. We have an amazing guest. Sanjkara is joining us from the Mayo Clinic. It's kind of like the Ohio State, you know,

Chris Dy: 2:37

actually, it's, I've, I've been told that is the world famous Mayo Clinic. I apologize. Mayo Clinic.

Charles Goldfarb: 2:44

Anyways, Sanj is a friend for a long time. He is a football fan, and that's the soccer variety, although his team, Liverpool, is heading in the wrong direction, and we're really super excited about his joining and teaching us and bantering with us. So Sanj, welcome

Sanj Kakar: 3:03

Chuck, Chris. It's a real honor to be here. Finally, I've heard and seen so much about this wonderful podcast. I have the loops retainer that I think Chris kindly gave me. I think I took a few of those, and I love the fluorescent color. And if I'm if I'm a little bit distracted, you're right. We're 10 minutes into the new season, and so I, I'll be keeping an eye on the score, but hopefully we'll do better than your team this year. Chuck, how's the How's the water bottle? So Chuck was our visiting professor for our fellowship graduation, so we got him a water bottle and some socks to highlight to the world his soccer aficionado. Yes,

Charles Goldfarb: 3:46

well, you know, you know, have to be a little honest with you, I do love Chelsea, and I still follow them. I don't think my soccer and I may annoy many people on the call, but you're not born an English Premier team fan, if you are a United States citizen the way that you were born, a Liverpool fan. And so we can our allegiances aren't quite so tight, and when my team sucks, I consider cheering for another team. So I don't know where I am. I love Chelsea. I'm grateful for the water bottle and socks, but it's I thought I should say the fandom is not the same. You probably know that. Yeah,

Unknown: 4:25

it was a for me. It's family here, the Liverpool Football Club right there, as you can see in the in the background.

Chris Dy: 4:32

Well, Sanj, thank you for mentioning those, those loop croakies, because we actually need to order more, because that is the most requested item I've ever encountered, more than anything else. And saj, I'm going to try to bring you a coveted Limited Edition upper hand coffee mug. Actually found one the other day in my house, still in the plastic wrap. Somehow, my parents have two of them at their house. I don't know how that happened, but we will try to get you the mug. Great. Rob gray is one of our friends. He. Been on the pod before, and he sent us a picture of him with Dr Orbe, also another recent podcast guest who drinking out of the mug. So we'll try to get you one of those.

Unknown: 5:10

Yeah, that'd be great. Rob's a great guy. He was one of our fellows, and what an amazing human being. Yeah,

Chris Dy: 5:16

he is super fantastic. And look forward to seeing everybody pretty soon at the hand society, which isn't gonna be coming up in your backyard in Minneapolis. But Sanj, before we jump into the topic, I'd love to know a little bit more about your path and where you trained along the way. Clearly, your Texas accent is strong, so tell us a little bit about you and when you knew you wanted to be a hand surgeon.

Unknown: 5:38

Yeah, so it's an interesting question. So, you know, so I was born and raised in London and went to medical school. And medical school there is five years. And so after our first two years, you go into clinicals. But my best friends wanted to spend one more year and get a Bachelor of Science degree. And so I had a passion for anatomy, and it was a funny route. And so I met Professor McGraw that who was big into flex attendant healing at the time, and my modules did not line up with the project that we were doing. So he said, Do orthopedics, and I have to profess. I didn't even know what orthopedics meant. I saw the word peed in there. Wasn't really interested in children. And I said, No, this is not for me. And so I obviously have to look at, look at what it was. And so during that, actually met dr gelberman at the British Society for Surgery the hand, because he, as you know, is a thought leader in Flex attendant healing. And so I meant, met him and really inspired me about the thoughts of academics in the United States. And then my mentor there in London were Professor mcgrowther and Professor George Bentley. And so what I did, I asked him, Where should I go? And they said, You need to go to Boston. And I said, Well, do you know anybody in Boston go? No, we don't, but you need to go to Boston. That's where orthopedics is coming out from. So I literally wrote to everybody in the editorial board of jbjs. And back then, Chris, you probably weren't conceived at the time, but you had to send faxes. And so I sent faxes. I know

Chris Dy: 7:15

what a fax is, yeah. And I have said some faxes in the past,

Unknown: 7:20

and and I thought the United States was like England. I thought I could go to Boston and then to LA and then to St Louis and then be back in Boston at the same day. Had no idea how big the United States was, so I drew a ring around Boston, and then I basically, literally packed my bags and visited people from Boston, New York, Philadelphia, who answered the facts. Not everybody did. And I remember one day I was with this person called Andy Rosenberg, who's a bone pathologist at Mass General, and he's looking at me, and he said, Why are you here? And so I want to do academic orthopedics. And he said, Oh, I'm a bone pathologist. I just happened to be on the editorial board of jbgs. And he said there's somebody called Tom Einhorn who was the chair of orthopedics at Boston University at the time, giving Grand Rounds. And it's amazing how fate happens. I didn't plan to meet this person. He said, Just go and see him. So as Dr Einhorn was coming off the podium, leaving the auditorium, I gave him my CV and and then I went back to my hotel, and sure enough, he had called my mentors back in London invited me to come to visit him the next day, and then the rest is history. That's insane. It is. It's kind of it's kind of weird, and it's sort of my MO now, for other people who want to try and come over and that you had to try and take a risk, it didn't plan this. And so he said, I can bring you over, but I can't pay you. I can bring you over and you can do research for me in the lab for one year. So I went home, moved home with my parents, saved, I think I did the USMLE in about seven months because I didn't have those exams. And then came a came over and just loved it. And met him and Paul tornetta, who really sort of took me under their wing, and then I was fortunate to match there, and then did my residency there. And, yeah, it's funny how life turns out.

Charles Goldfarb: 9:12

Wow. That is, that is something I think, you know, not a lot of those of us in medicine would call ourselves risk takers. You mean some of the appeal as I talk to my children about kind of life choices and job paths, and, you know, my my daughters are younger, or in, you know, in college, and they're little jealous of my son, who's on the medical path, because it feels like his his course is just plotted out safely and still with choices, but very safe, and your story is not that,

Unknown: 9:42

yeah, I think there's an element of risk to it. But, you know, it was, I told my parents, because they had no I was a PGY for when I left London, and they had no idea, go, why are you going over? You have to start over again. I had to set the TOEFL, which is the Test of English as a foreign language, to come to the US. They did not believe. My birth typical passport at the time. And yeah, I said it was short term pain for long term gain.

Chris Dy: 10:07

You had to take the TOEFL coming from the UK. I did. I did.

Unknown: 10:12

Failed it because my mind was drifting. And they asked very specific questions. Like, you know, Chuck Goldfarb went to Starbucks and ordered A, B, C, or D or E, and so you have to actually listen to pass

Chris Dy: 10:25

it. That's so American to make somebody from the country where our language originally take the Test of English as a foreign language. Anyway, can you That's amazing. And we talked a little bit about your mentor, Dr tornetta, did you have any other mentors along the way? And you know, what did they teach you? Is there anything particular that lessons they imparted upon you? Oh,

Unknown: 10:48

sure, Chris. You know, mentors evolve over time. I mean, when I was in Boston, honestly, when I was going through residency, the it was the choice between. Was between spine and hand, and I was flip flopping between both and my hand mentors in Boston, Andy Stein, Eric Tolo, Alice Hunter, George casperian, I think Max Sung and Steve margles really took me under their wing and actually opened the open my eyes, I mean, to get a letter from Eric Tolo. He said, Look Out of respect. Can you go to my alma mater, where I my fellowship. And so I came to Mayo. And if you've not been here before, I remember taking the shuttle bus, and it's an hour and a half of cornfields, and I'm like, you know, born and raised in London, I'm in Boston. Like, where have you sent me? And I'm texting him on the phone, like, and he goes, Just wait, just wait till you get there. So, you know, it's funny how mentors evolve. And so I think for me, my mentors in Boston were crucial for me in England. Actually, they were, they were my most influential. I mentioned George Bentley and and Professor McGraw that, but there was two others far saddad And Andy Williams. They're based basically hip and knee surgeons, and I didn't look like the typical orthopedic surgeon in London at the time, and they really took me under their wing and sort of guided me through through the process. And I'm always grateful to them every time I go home to London. You know, I always try and look out for them. I think when I came to Mayo, my current partners have been amazing. Then, and you learn from them over time. Dick Berger was very influential to me at the time, but then you meet others, and so, you know, for example, Dr stern and sites I met just at meetings. I'd never trained with them. I'd heard about them and and how influential work they were to others, and they just took time out of their day just to get to know me as a human being, and I'm always grateful for that. But then, you know, there's other people, you know, I served under Jim Chang in council, learned so much from him, really did. I mean, what an influential person he's been previously and to me, and then people like Marty Boyer, Jennifer Wolf, Tamar Rosenthal and Scott Cozen, but that's just, you know, domestically, I think I've learned a lot from people overseas. And my banal I think really was eye opening for me, because I got to see other people really challenging dogma and pushing thoughts that I didn't even know was was possible. I remember a story with PC Ho. He had a course in arthroscopy course in Hong Kong, and I remember sitting in the audience watching them about scaphoid non unions. And I thought we had scaphoid non union sus, you know, medial femoral condyle baskerized bone grafting, and I saw him doing things through the scope that I'd even need knew were possible. You know, I had great mentors in the US, Dick Berger, I mean, he's a forefather of arthroscopy. And that really sort of was a flip in my mind about the fact of seeing others outside of your bubble and then challenging that dogmatic aspect. So these mentors, I probably left out some, and I apologize for that, but these have been critical in my thought processes. You know, previously and hopefully moving forward, I think it's

Chris Dy: 14:17

really easy to get caught in an echo chamber if you choose to select, surround yourself with people that have the same training in the same thought process. And you know, I think that's amazing, that your banal Scholarship, which is awarded by the hand society, to the elite in hand surgery, to travel and see, you know, to go to places of your choosing. That's incredible. You have that opportunity. I wanted to get a little bit into our the meat of our discussion. But before we do that, we do have to acknowledge our sponsor. The upper hand is sponsored by practicelink.com you know, the practice link is great at sponsoring people for finding finding positions. I was asked by a former fellow if I could do this copy in my sleep without showing it as. I don't know, but here's the copy practice. The upper hand is sponsored by practice link, becoming a physician is hard. Finding a job doesn't have to be visit practice link@practicelink.com I think that's it, but I'm

Charles Goldfarb: 15:13

practicelink.com, backslash the upper hand, there

Chris Dy: 15:16

you go. Almost got it, almost got it. Almost

Charles Goldfarb: 15:21

Yeah, it sounds the mentor discussion was super interesting, and obviously we could talk all day the briefly, I guess. How did the wrist and maybe it was Dick burger, excuse me, maybe it was Dick burgers influence. How did the risk become so important to you and your practice and, you know, I guess that is interesting to me, and in arthroscopy itself. And then we do want to dive into talking about the topic of the day, which is SL, ligament pathology.

Unknown: 15:53

Yes, it's a great question. Chuck. It's funny when I came here on staff, right? I did everything. And there was an area that that nobody was doing, which was tumor. And so I remember speaking to Dick Berger at the time, because he was the division chair, and he said, you know, dive into tumor. I found great mentors in Peter Jepsen, Pete Murray and Ed Athanasian. And I loved it. I love taking care of those patients, but, but as a fellow, the risk always fascinated me, because we know so much and we know so little. And the irony of all of this is, during residency, I really didn't do much arthroscopy whatsoever. I didn't even know you could put a camera in the wrist and just watching somebody as elegant as Dick. And Dick was an amazing arthroscopist, even better human being, and an amazing artist, and he could sketch these things out. And you know, it was just being here, being surrounded by my partners as a strong legacy of wrist at Mayo, with Dobbins and lynche and Cooney and so I think just from that aspect, that's where the passion really came from. And at the time, there was somebody, as you everybody knows, well, was Mark Garcia Elias. And I remember listening to Mark's talks. He was so eloquent. His dissections were so perfect. And it was just something that sparked in my, in my, in my mind. But at the time, you know, as a junior faculty, everyone was doing it, and it was hard to try and carve out that area. But I remember, you know, Chris mentioned the banal, and what an amazing opportunity that was. And for the banal, as you know, you have to put a theme. And I wrote it, my first one about tumor. And somebody came up to me, it may have been Marty, I'm not sure. And he said, are you really passionate about tumor? Is that what you want to do for the next 20 to 30 years? And it wasn't, you know, and he just said, Look, just stick to your passion, and you'll see what will happen. And the rest is history. I love that.

Charles Goldfarb: 17:50

I love that. And that's right. I mean, there's so many lessons from what you said, but finding your passion. You know, passion may be hand surgery, but hopefully it's a little more than that. It's easy for us to say in academics, where we're both blessed to have wonderful partners that can, you know, take on other parts of the hand practice. But like you, I've been lucky to find my passion and narrow things down a little bit. Let's maybe we'll kick this off. We'll just briefly present a case, no images, just a theoretical case of a 32 year old executive who is racing on his bicycle. We have a race in St Louis called Race for the Cure, which has raised an incredible amount of money for cancer research.

Chris Dy: 18:33

I thought, I thought you were going to talk about the naked bike parade, which was a couple of weeks ago. But, yeah, that's fine. That's fine. No worries. Race for the Cure is a better one. Yeah.

Charles Goldfarb: 18:40

Well, you there again, Chris, do we kind of keep you naked? I

Chris Dy: 18:44

heard about it from a patient. I heard about it.

Charles Goldfarb: 18:50

So you're on the bike at this really nice event that raises money, and unfortunately, go flying over the handlebars and the executive lands on his outstretch his outstretched, dominant right wrist, and he has immediate pain. He you know, it hurts a lot. It swells. Immediately he was able to get back on the bike finish the race, and about a week later, his wrist is still hurting. He comes in, you get an x ray, and he has what, for all the world, appears to be a scapegoat ligament injury. There is the three millimeters of diastasis between the scaphoid and the lunate. And the scaphoid is a bit flexed. The Escape fluid angle is about 60 degrees, and so he comes in you examine him. Why don't you, if you wouldn't mind, give us a couple of tips on how you do a physical exam if you're worried about scape ligament pathology and sort of the thoughts that initially go through your head.

Unknown: 19:49

Sure, no thanks for that sort of setup. Well, the main thing we'll talk about the exam first, right? So for me, anything about the risk, the beauty of the. Risk is, I think 95% of the diagnosis and the history and the physical exam, I think imaging we use to sort of rule in or rule out pathology, but I don't sort of hang my hat on it, so I think so, just like finding the three four portal, right? I find list is tubercle just come distal to it, and there's a soft spot right there. And essentially, if a patient's tender in that area, there's four diagnoses in my mind. I mean, obviously there's a traumatic case, but sometimes you see patients come in with chronic history of wrist pain. So it's either an occult ganglion, it's a scaffold lunate ligament injury, it's either some form of sort of scaphoid impaction or or wrist impingement. So those are the four things that go through my mind. On the on the physical exam, we use the sort of the shift test. I don't know how much stock I put into that test, unless they maybe have some pain, but the clunking that your so called talked about, I don't often see maybe pain with it, but not the clunking. And so typically I get, yeah,

Charles Goldfarb: 20:53

can I interrupt? It's a really interesting point, because I also find the Watson skateboard shift test to be potentially helpful, but it not very specific and not very sensitive. And for those who haven't read about it, and we will use our video, you know, this is a test where you start in ulnar deviation and slight extension, and you manipulate the wrist from that position to a position of slight flexion and radial deviation, while putting pressure on the skateboard tuberosity to theoretically prevent the scapegoat from flexing, with the theory that when you move to radial deviation, the scaphoid has to flex and you get a pop and pain dorsally. If the test is positive, I hope that was helpful. It may not have been, but your point is right. I don't put a whole lot of stock in that test, either, Chris, I don't know if you have thoughts about it, or you use it regularly. I

Chris Dy: 21:44

use it all the time. I very carefully document whether the Watson test is positive or negative for pain, shift or clunk, because I think that the Watson positive negative gets thrown around. And there are two physical exam moves that I teach every resident or fellow when I have the chance. It's the Watson test and testing for ulnar nerve stability. Because nobody knows how to actually do those tests when they come to clinic, except if they've rotated with Chuck. But you know, I feel like those are two tests that oftentimes are not appropriately performed, and I didn't know how to do them until I really sat down and read the papers. But you know, the Watson paper itself, and then really thought about the scaffolding, what you're trying to do with that maneuver. So oftentimes I will see it's it can produce some pain, it can have some shifting, but the full on clunk when you release your thumb. I very rarely see, and

Unknown: 22:34

I'm going to give a shout out to Bill Kleinman. There's a video on handy, which, if people know is a digital platform from the hand side, he's got a wonderful physical examination video on there. And it's funny, we're talking about that. And maybe Chuck and Chris, we can collectively work on this together. But there's, in my mind, there's a sign that when they come in, sometimes patients will say it feels like it's going through and through from the dorsal to the vole. I call it like C sign that you're putting your fingers there, and I haven't proven it yet, and maybe you can guide us how to do it, and we can do it together. But I think that when they say that to me, it's a through and through injury. It's dorsal to volatile. And I found that in clinic and enough times now where patients will point dorsally and volatile and say, pain's not just awful. It goes through and through. And you know when you scope them, it is a through and through injury. But so those are the clinical signs that I use. And then typically I get an x ray bilateral risks, because, as Chuck in this case you mentioned, is three millimeter gap. But as you know, there's subset of populations of three millimeter gap on the other side as well. So you have to correlate one with the other. We here we get actually, EC Ho has a nice trick actually on the X rays, because typically when you get an AP X ray, you get an oblique gram through the scape, Luna interval you're not looking at perpendicular. So he recommends putting your ring and small finger and making a fist, and that actually bumps up the wrist. And so now typically I use his little trick of that gives you a colinear, perpendicular view through the scaffolding intervals. I get that and I get a stress view. Now we were always taught about X rays, and sometimes you can have dynamic scaffolding instability. But when I first started in practice, they would tender over the SL they would have a normal stress view, and the x and the MRI would be so, so. And then now, what do I do with these and and where I found that when, when you scope these patients, just under half, like 41% with normal X rays and tendon over this had Geisler three or four or high grade instability. So I just don't hang my hat just on the X ray. It has to be with the clinical findings. When I look at the MRI, there's a couple of points I look at. I go through the axial view and the sagittal views more important than the coronal views, because in the axial views, you can look at it as dorsal if it's vol. Solar if it's through and through. The sagittal views, for me, are helpful for looking at carpal alignment. So you talked about scaphoid flexion. Also, there could be scaphoid dorsal subluxation. And also the lunate. Is it extended on the sagittal view, or is it only translocated in the coronal view? And I think we're learning more and more now about these dorsal extrinsic ligaments, the disease they will call secondary or critical stabilizers, for example, the DIC ligament, or the long radio lunate ligament or the stt. My point is that an SL injury isn't just an SL injury. There's other things going on, and maybe dogmatically we were taught, just address the SL and you'll be fine, as we know, that's not the case. And I think there's great work coming out of New York, out of Australia, just really teaching us about those other ligaments. So I wanted

Chris Dy: 25:51

to know a little bit more. I mean, you, you said so much in that last statement that I think people want to know more about. And I guess, what do you mean by stress? For you, because I've seen a couple different descriptions of how to get a stress view. I get a stress view. And then are you getting an arthrogram when you do an MRI? And then I want to talk a little bit more about, you know, an SL is not an SL. We can talk about that afterwards. But let's talk about what a stress view is and whether you get an arthrogram.

Unknown: 26:14

Yeah, great point. So, there's many stress views, right? And I think, I think Steve Lee in New York showed the pencil grip view was, was, was the one to get. We typically get the clench fist view. So true. Pa, with the the ring and small finger lying flat on the cassette will give you the first of all, the orthogonal view. And then and then grip. And that said, the sort of the clench fist view that we get here. We do not get an MRI, MRI arthrogram as it just MRI 3t I found that geographical variation on the arthrograms that are performed, but we typically just get a standard MRI.

Charles Goldfarb: 26:55

I like that. Yeah, we I typically, I stopped doing arthrograms A while back for a number of reasons. I do think it provides they typically provide additional information, but they're not always easy. Patients don't love them, and I don't know the information we get is all that transformative. So I agree with that. I'm gonna have to look into the extended index and middle finger. I'm very curious about what that can do for us. So back to Chris's question. Talk to us a little bit, and I know you have a soccer game to watch and Chris has a case to do, but talk to us a little bit about which. Talk to us a little, very basically, about the scaffolding ligament itself and what is most critical for you and the key accessory, or critical ligaments, as you call them, supporting the scaphoid as well, and the principle that it's more than a SL ligament,

Unknown: 27:51

yeah, so we would, we were taught, right? So the SL ligaments are C shaped ligament, dorsal, membranous, vola, the dorsal being the strongest, and the vola being weaker than the dorsal, the membrane has been the weakest. And I think historically, because of that, everyone pine to the dorsal SL it's the strongest. But it never made sense to me. It's like a door coming off the hinges. If you fix it dorsally, what it's going to gap open volatly If the volar structures are injured. So that's so that's number one, but number two these dorsal or critical, these sorry critical stabilizers, that of the dorsal INTERCAL ligament, dorsally, the long radio lunate ligament, bola Lee and the stt ligament. All of this complex may or may not get injured. You know, it's a spectrum of injury, and I think if you look at it critically, when we've been doing these bigger open repairs, like, what are we repairing? We're probably repairing the SL and maybe tacking down the dorsal into carpal ligament, but we're neglecting the others. And so I think now through arthroscopy, and that's what's really sort of inspiring and challenging here, is I think we're learning things that have always been there, but we just didn't know about them. And so now, I mean, there's many times when I'm scoping these patients, I'm critically looking at all of these ligaments. So what am I looking at? I'm looking at the SL, I'm looking at the insertion of the DIC, which you can get an idea on the saddle views, and the MRI, but I confirm it arthroscopically. I'm looking at the long radio lunate ligament. I'm looking at the stt ligament, and sort of going through that algorithmically about which ones are injured and which one should we repair. Because sometimes you go in there and the bowler SL is open, so you fix it volarly, and you're done. You don't need to touch the dorsal SL. And so I think we haven't figured it out yet, but we're on our pathway to doing it. There was a good article recently by Scott Wolf. There's two, two articles, in general hand surgery, where he goes through this sort of ligament classification on which ones are injured. I don't think we've perfected which had to fix them all yet, but, but we're getting there. And so for me, when I'm seeing a patient, I have an acronym in my mind, because in the operating room it's hard to have all these tables. So my acronym is scarce, right? So S is for the secondary or critical stabilizers. The C is the cartilage. Is it arthritic or not? If it's arthritic, you're not going to do anything, irrespective of the acuity of the injury. A is the alignment of the scaphoid on the sagittal view. Is it dorsally translated or not? Because that's a different beast. Is the Luna extended on the sagittal or is it ulna translocation? Again, that's different. The R is reducibility. Can I easily reduce the carpus? Because if I can't, any form of soft tissue reconstruction probably won't work. C is the chronicity? Is it acute or chronic? You painted an acute case, but we see many chronic cases that still can be repaired an easy extent to the injury. Is it dorsal? Is it vola? Is it through and through what other ligaments are injured? And I think you have to package that all together to then be able to treat those and for me, I mean, it'd be good to hear chuck you and Chris's thoughts. For me, the quality of the secondary stabilizers, the reducibility, the extent of the injury and the location of the injury. For me, I can only detect arthroscopically, and so I make that final decision of how I'm going to treat these patients once I've done the scope, wow. I feel

Chris Dy: 31:25

like you just dropped the mic, like you just that was so much knowledge right there. I mean, that was like Steph Curry at the end of Team USA team against France. I mean, that was

Unknown: 31:33

amazing. More like Steven Gerrard scoring the winner in the FA Cup Final, right?

Chris Dy: 31:38

That that tip, whatever that was. So I want to ask you some more questions about you know, how you assess those ligaments arthroscopically, and how you talk to patients about it. But before we do that, I did want to let our listeners know to mark their calendars for October, 25 and 26 for checkpoint surgicals. Next category, course, upper extremity nerve distress. What a title strategies for surgical management. Join the course faculty, Dr Fraser levers edge and Dr David Brogan, we know those guys in Denver as they review management strategies for commonly encountered challenging nerve injuries and conditions affecting the upper extremities. To learn

Charles Goldfarb: 32:17

more about this and other educational programs, please visit nervemaster.com checkpoint, surgical driving innovation and nerve surgery. So yeah, so talk to us again briefly about how you place your scope to make determinations, and I'll get the ones that aren't obvious. I hope the long radio lunate, the vola SL and the stt joint, which could include the DIC as well. Sort of, how do you assess those four areas arthroscopically?

Unknown: 32:54

Okay, so, great question. So the long radionate ligament is assessed through the radiocarpal portal. So cameras in the three, four portal probes coming in through the 6r and sometimes you can see it stretched out. Sometimes you can see it's actually coming off, partially injured, off the off the radius. So you're using your probe, and you're sort of trying to understand the natural tension of these, as you've shown chuck with the TFCC, there's a high degree of observer variability in this. And so we're learning, right? So this is a new sort of concept. So that's how we assess the long radio lunate ligament mid carpal arthroscopy. So one pearl to the listeners, some I always found getting in the mid carpal joint challenging, really hard. And so a little pearl is that typically, the dorsal on the structure, on the on the wrist that's most readily palpable is the triquetram. So just find the triquetram. Just go distal and radial to that, and that's the soft point for the mid carpal ulna portal. So always, always, always make the middle carpal ulna portal first, because if they have subtle degrees of scaffolding instability, the scaphoid flexes and loses distally, and it's harder to get it. And we were taught that the portal comes in like horizontally, invariably, you're really dropping your hand to get in there. So I always make that on the mid carpal portal first easily to find, and then I make the radial mid carpool. Then I put the probe in, and then I'm setting the probe, putting it volatly To look at the volar SL, looking at dorsally as well. And then I'll drop my eyes, and I'll look at the DIC insertion on the dorsum of the lunate. And I will take a probe and pull that off. Christoph mathlin also talked about the DCSS, which is the insertion of the capsule, essentially down onto the dorsum of the carpus, which you can assess dorsal from the radiocarpal or midcarp or joint. I tend to find it easy, easier to do from the mid carpal joint, and then the stt. So I've got an idea of the stt from the MRI preoperatively in the sagittal view. And then what I'll do is I'll pop the camera in the. Radio mid carpal portal. You hug the scaphoid radially, and you follow that up, and you'll drop into the stt joint. It's harder to feel that arthroscopically looking at those ligaments, because it's a very tight space, but I'll have a high index of suspicion if there's dorsal subluxation of the scaphoid and it flexes, has it rotated out of the stt and Nick Smith in Sydney Australia is really sort of highlighted the importance of that.

Charles Goldfarb: 35:28

That's amazing. That's that's a lot and, and I think for it's probably a little daunting for some of our younger listeners to hear all that, I would say that that's incredible, and it highlights the complexity of the pathology we're discussing in a way that I'll be honest, many people don't approach it in a similar way. There is a concept that I have my treatment for SL pathology, excuse me, it's an open exploration and repair or internal brace or whatever. And yes, maybe there's a role for those procedures, but I think increasingly we're starting to understand that it's far more complex, and you need to really understand the pathology to have a chance, just to have a chance to get the to realign these patients. So that's that's great, and maybe what I'll do is just outline in this particular case, because we really want to know how you are going to surgically address it. And we could talk for hours about the different variables, but let's say there is a complete SL tear, so dorsal and volar, and don't really worry too much about membranous. And we'll say it includes a tear of the DIC and the stt capsule is questionable after arthroscopy. So you're doing dry arthroscopy, which also for the listeners who don't do dry arthroscopy, it does make the actual scope part less influential for your open procedure. If you're doing a not dry arthroscopy, then you have to deal with a lot of water, but you're not dealing with that. So you've done your scope, you've come to the conclusion, what next?

Unknown: 37:05

Yeah, so, so Chuck, I'm using it because to your listeners, as you say, right? They may, they may think, Well, you know, it takes me a long time to even get in the wrist, and then I have to look at all these ligaments. So how do you do this in two hours? So my algorithm, in 2024 right? Is, and then I'll get back to your patient is, I will say to the patient, we're going to do one of three things, in general, for scaphalenic pathology, I'm going to scope you, and if you're arthritic, right, we're going to treat this as an arthritic risk. And so the options are doing a partial denovation At the same time, or we're going to start, you know, treating it with injections, blah, blah, blah, nurse you along. That's option one. Option two is, I'm going to scope you, and if I find that you have these ligament injury that on this case, then I'm going to fix you arthroscopically at the same time, plus or minus pinning. If I find that I get in there, and what I'm trying to do arthroscopically, I cannot get it reduced, but you have a reducible, reconstructible problem, then we're coming back another day, we're closing up, and we're going to talk about open procedures. Because open procedures we can talk on, as you said, we can talk hours on this there is, there is morbidity associated with that procedure, and I think patients really need to understand that. And I think it's like when you're going in and say, I could do Plan A, B, C, D or E, you're not you're not getting anything into your brain. And so I think for me, that's how I really sort of treat these patients going into the operating room. And also, you can plan your surgical day, because if you're scoping, and then you're going to open, and then you're going to do a big reconstruction, that's a two to three hour operation right there. And when you have multiple other cases going on, or two rooms, it's hard to sort of logistically plan it. So back to your patient. So let

Charles Goldfarb: 38:47

me, let me, let me interrupt for one second. I would just say that's really important, especially for the younger surgeons, you know. And Chris and I talk a lot about flow and a day and efficiencies and and we also, we don't talk a lot about coming back. And I encounter that for the exact scenario you discuss, I encountered for elbow pathology, OCDs, for example, whether you're gonna do a micro fracture or an oats and so we shouldn't be afraid of coming back, even though no one wants to do that, patient or physician. But there is a place for it, and as the complexity of the injury goes up. Patients have to understand that may be the right thing.

Unknown: 39:25

And Chuck to your point, when I went overseas, I would see that all the time. You know, if patient was having a decision between scapegoat excision for corn and fusion or PRC, the surgeon pop the camera and take pictures, stop, come back another day. And I was like, wow, you can do this. And he goes, why wouldn't you do this? It's more informed decision for the patient. So you know, it's, it's, it's learning from others, right for what we could do today. So to your point, so that to that patient, it's acute scope the patient, there's no arthritis. It's reproducible. So for me, voli, I'm repairing this as many ways to describe this, it's. Inside Out or outside in of doing a vola scaphalone, eight arthroscopic repair dorsally. I think Christoph Matt Lewin has really popularized the repair of this DCSS, which I, which I do, and when the DIC has come off, the Luna mark, Ross and Greg cousins have popularized a procedure called the radical, where you're popping an anchor in the dorsal aspect of the lunate and tying the ligament complex down. And I don't hesitate to pin if I cannot reduce it like if I put the sutures in, there's days you'll put the sutures in. And I was a skeptic, trust me, I did not. I did the DCSS procedure that Christoph mathlin described, didn't see anything. He was very skeptical. Saw him on the banal and he just said, Get your camera ready. Literally watched this. He put the sutra in, pulled on a three zero, PDS, and it reduced, and immediately became from a doubter to a believer. And so technically, I was doing something wrong. And so that's why I think, as you and Chris have said, going to see others, seeing how they do it is huge. I just technically couldn't get it from just reading a paper. And so now, if you put the sutures in and it reduces, which most will, especially in the scenario that you've done that you described, then we're done. But if I'm pulling the suture and it sort of gets there, but it's not perfect, then I won't hesitate to pin them to SL one skate for capita. I cut the pins under the skin, leave them in the car for six to eight weeks, and then take the pins out. And I, knock on wood, I haven't, I haven't regretted that sort of algorithm approach.

Chris Dy: 41:34

So Sandra, that's amazing. I mean, listening to you and Chuck talk about this is like listening to a master class. So for a not expert in this area, I have two questions before we bring it to a close. One, is there anything you can do on your pre op assessment that can tell you whether the scaffold deformity, for lack of better term, whether it's diastasis, sl angulation, lunate, dorsiflexion? Is there anything you can do to tell whether it's reducible before you're in the OR, and two is, is the SL really repairable?

Unknown: 42:06

Yeah, these are great questions. So what you can do preoperatively, you can either get live fluoro, or what we have here is we just get Motion series where they're taking sort of flexion, extension views. And all I'm watching there is seeing, does the lunate reduce in its position. Does it move? Because sometimes it will. And then the case that Chuck presented, which was cute, it should, but sometimes it doesn't. But that doesn't necessarily mean that you can't repair them, because when you get in the or through the scope, you can debride all that scar tissue, and you can make something that was partially or irreducible reducible. Number two, to your point. I think with these repairs, these are more arthroscopic catalyst DCS, you're not actually repairing the ligament, like when you're doing the bowler SL, repair, you don't actually see the bowler SL, you're you're repairing the radioscape for capitate, which is attached to the scaphoid, and the long radio lunate ligament, which is attached to the lunate. And you're essentially bringing them together. And as you bring them together in an acute scenario, you're bringing that SL ligament together to repair. So I don't think you're actually technically repairing the ligament. You're you're repairing the capsule back down to its insertion

Chris Dy: 43:12

and allowing the SL to re approximate, yeah,

Unknown: 43:15

wow.

Chris Dy: 43:16

That's bomb. I love that. Thank you for joining us. I will have to have you back to talk about all the open procedures and reconstruction, because there's so much to unpack here. And Chuck be excited. I picked an SL article for journal club on Monday for you, just for you, I saw that. I

Charles Goldfarb: 43:31

am excited, Sanj, to put you on the spot a little bit. I'd love to include in our show notes a couple of resources for the listeners, whether that's a couple of key articles that you really find transformative. Don't have to be 2024 by any stretch, and maybe a handy video or two, and we can certainly link the Kleinman video, just so people have a few resources, if you don't mind, that would be super helpful for us.

Unknown: 43:58

Yeah, I think so. I think the articles to read right now the two series articles by Scott Wolf, I think, in the last year in the Journal of hand surgery, these were review articles, which goes through the anatomy and biomechanics and then the ligament type of injury, I think on hand e we talked about Bill kleiman's video. I actually also put a physical exam video on there as well. And I think in terms of arthroscopy, there are several videos on wrist arthroscopy, just first of all, understanding how to do this on hand e so I would probably watch those wrist arthroscopy videos first sort of shout out to the hand Society meeting coming up in September. We're doing an arthroscopy course, which is partnered by Iwas, which is the International wrist arthroscopy society, where we'll be basically taking an A to Z approach through all of wrist arthroscopy. So it's a one day Tuesday pre course, and I would just urge people to come and just even learn how to. Scope, because we're not really taught how to scope. There's a few centers yours included, that really teach it, but most people aren't really doing much of this because we were never, you know, Chuck, Chris, we were never taught this when we were training. So we're learning this as faculty trying to sort of inspire the next generation. So that's probably what I would say right now, love it, love it.

Charles Goldfarb: 45:22

Thank you. Good luck to Liverpool this morning, and hope your weekend is excellent.

Unknown: 45:29

Chuck, Chris, thank you so much. Really, really enjoyed this. What is it about? 50 minutes discussion just flew by. I mean, you two are just amazing at this sort of yin and yang approach. And I know this is a deliberate way. It doesn't happen by happenstance, but thank you so much. I really enjoyed it.

Chris Dy: 45:46

I'm glad it came across that way. All right, thank you, son. Really appreciate it.

Unknown: 45:51

Take care, boys.

Charles Goldfarb: 45:52

Thank you. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy: 45:56

Sounds good. Well, be sure to email us with topic suggestions and feedback. You can reach us at handpodcast@gmail.com

Charles Goldfarb: 46:03

and remember, please subscribe wherever you get your podcast,

Chris Dy: 46:07

and be sure to leave a review that helps us get the word out. Special,

Charles Goldfarb: 46:11

thanks to Peter Martin for the amazing music, and remember,

Chris Dy: 46:15

keep the upper hand come back next time you