The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Wrist Arthroscopy with Sanj Kakar, part 2
Chuck and Chris are joined again by Sanj Kakar from the Mayo Clinic. Sanj is a high volume arthroscopist and luminary in the field. He is leading the way with contributions to the field and new ways of considering wrist pathology. If you missed episode 1, we would recommend a listen but each episode stands alone.
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Chuck, welcome to the upper hand podcast where Chuck and Chris talk hand surgery.
Chris Dy: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:Please subscribe wherever you get your podcasts, and thank
Chris Dy:you in advance for leaving a review and rating that helps us get the word out. You can email us at handpodcast@gmail.com so let's get to the episode. Oh, hey, Chris, hey, Chuck, how are you? I'm
Charles Goldfarb:really good today.
Chris Dy:Excellent. It looks like you are in the office, as is our special guest, also in the office. Our
Charles Goldfarb:special guest, Sanj Kakaar, is rejoining us by popular demand, because everyone loved the first episode on skatefa Luna, we wanted to take a deeper dive and talk a lot about technique, because Sanj is a luminary. He's going to teach us all today.
Chris Dy:Sanj, welcome back.
Sanj Kakar:It's good to be here Chuck and Chris and always happy to talk about anything in life, but especially wrist and arthroscopy. Yes,
Charles Goldfarb:I think Saj and I are both in the office. Chris, where are you?
Chris Dy:I'm at home. Fortunately, Saturday morning. Can't think of a better way than to spend it with you guys. I'm sure you're both doing your diligence and rounding and seeing patients and cleaning up cases from, uh, from your call,
Charles Goldfarb:I think. And I love Sanj's opinion when I round, which I try to do as little as possible, but when I do round, it's always enjoyable. It's just like coming in for a case in the middle of night. It's never the actual coming in and doing the case. It's sort of what happens after. But I got to hang out with one of our amazing residents, Jeremy Huckabee, who's just an amazing guy, and I learned things about him I didn't know. And it was, it was kind of fun,
Sanj Kakar:Chuck, I think you're rounding early like me, because you know that the soccer matches are going to kick off. You know, we're six hours behind the UK. So that's why you're you're rounding now. Don't let anyone believe anything else this.
Charles Goldfarb:This is true. And then I also have a business school final to finish this morning.
Chris Dy:You know, you know, Chuck, the residents are going to realize, those that are listening are gonna realize how out of touch you are. You know, rounding is just a novel, fun thing for you, and it's just day in, day out slog for them for years. So we're very lucky that we have residents and fellows that carry the load for sure,
Charles Goldfarb:very, very true. All right, let's not keep our listeners waiting too long. We have four or five points we want to cover with Sanj Over the next 40 minutes, and we'll start with something I know he feels passionately about, which is dry arthroscopy. So Sanj, give us a little background on how and why you started using dry arthrospy. Do you always use dry arthroscopy and what you think the benefits are?
Sanj Kakar:Yeah, it's a great, great question, Chuck, and I'm asked this a lot. You know, I trained here at Mayo, doing my fellowship with Dick Berger and Alan bishop, and were big wet arthroscopy proponents. So that's what I did in my, I would say, early part of my career, and it wasn't until my Bunnell fellowship where I had the opportunity to sort of go and see some of the luminaries around the world. And I would say, you don't need to have a named traveling fellowship to anybody out there who's interested to learn just, just go and visit people, be that nationally, internationally, just even across your town. It's amazing what you can learn from others. And it struck me that there were so many people doing dry arthroscopy, and this was like a real big sort of light bulb going off. And I remember Paco del Pinal at the hand society once talking about dry arthroscopy with distal radius fractures, and just talking to him about his sort of experience with this. And what have I seen now in my practice? Now 2025, basically, and moving forward, it allows me to do much more than I used to do. I used to always get frustrated with fluid in the joint, you get soft tissue extravasation. And as you know, Chuck and Chris, anytime you're doing arthroscopy is sometimes it's more sort of arthroscopic assisted, so you're making incision, so it's harder to find your soft tissue planes with all the soft tissue fluid. And then also, I was worried about disadractures, for example, in compartment syndrome, so I never did one wet, because I was worried about that. And then also, I just found that you can do much more dry than wet. You can make bigger portals so you can make you can put larger Shavers and burst your resection is much more efficient. You ask the question, do I always do dry? I would say 99.9% the two times that I don't is when I'm doing thermal shrinkage. And so you do need fluid in the joints. You don't get chondrolysis, and then also when you're doing washout. So those you know, you have, have to obviously flush out the joint, septic joint. And it's, it's ironic with with this flu, IV flu. Crisis. I'm not sure what's going on in your institution, but in our institution, that's been a big hit, especially on our sports medicine colleagues, who do a lot of wet arthroscopy, where we're told to sort of decrease our fluid use. So for me, in that way, it hasn't really been an issue.
Charles Goldfarb:Yeah, it's an interesting point. I would say I would maybe 25% now I'm doing dry arthroscopy, and it is a I'm just transitioning slowly, and I absolutely have started to see the benefit. I'm not completely convinced yet, but Chris, I know you don't do a ton of arthroscopy, but you definitely do scope. What are your thoughts? I
Chris Dy:haven't I haven't tried it yet. And now she was going to ask you a question is, why for you Chuck, what are the cases in which you've started to do it, and what's your rationale, so that people who are like me, kind of a general hand surgeon in that regard, of via, you know, doing scopes when I feel that they're appropriate, and kind of know, my sweet spot on what I can do and what I can't do. What are the reasons that you decided to take this jump into doing 25% of your cases with dry arthroscopy well.
Charles Goldfarb:One, in all seriousness, I do respect Sanj, and when someone like that says that it works for them, I I want to try it out. Two, I think the fluid, the lack of IV fluids, the crisis, so to speak, contributed to my interest in doing more of it. And it's just for certain risks, especially those where I know I'm doing an opening procedure, it just makes sense. And as long as I can visualize well, and I generally can, I like it, there's no doubt I like it. And so it's just, I feel like, if you know there are some risk arthros are very straightforward, and some for me remain a struggle, whether the wrist is tight, whether the humerus is short, and you just struggle to get things exactly like you need to. I tend to blame fluid or not fluid, so I don't want to bring the lack of fluid into it, but I do think it's going to be a slow transition towards dry arthroscopy for me, Sanja. Was it an evolution for you? Would you go cold turkey?
Sanj Kakar:No, I did go cold turkey, Chuck. And so I would say, I would say to people and and even just watching and training people at courses, what I would say to you is this, we're always taught put the needle in three, four portal and insufflate the joint, right? You don't want to do that. You want to stick the needle in. And the goal is to get the shaver in as quickly as possible, because there's some synovial fluid. There's bubbles in the joint. You can't see so I remember. So you don't want to start off doing, for example, a fracture case, right? So let's say you're doing a TCC debridement. Start off very simple, or a ganglia or something like that. So what I would say to my scrub tech is, I'm going to ask for fluid within 60 seconds, right? Your but your answer is, No, I'm not going to give it to you. And so I had to struggle a bit, a little. And so the key is, get your needle in, make your three four portal, and get your shaver in in the six hour, or the four, five portal, and then you take a 10 cc syringe, not a 20 CC, not a 30 CC, a 10 cc syringe. And usually I use a two millimeter shaver, and that's enough, enough suction power on the syringe to do an automatic washout. And, you know, we put this on videos, on handy, or on Anthology, so people can see how to technically do that. And then once you sort of lavage the joint, you leave the shaver on and you want to get rid of all the fluid. And then you can see, and so, for example, TFCC work, I always used to struggle to scope the D, R, U, J, you'd get underneath there, there'll be crab meat in your face. You can't see anything. Can you just pull the camera out and you just say, I'm not going to do this anymore. But if you do it dry, you can sort of see areas. You can see the phobia. I mean, that was a that was a thing for me in 2017 I'd never really seen the phobia before, and I didn't know what that looked like. And, you know, we're all well into practice there. So it's just sort of that evolution. But as you said, Chris, you know, you have to start simple and build up. And you'll you'll see, there's a couple of tricks. So you sometimes you get stuff on the lens of the camera and you can't see. So what are the tricks? So number one, well, the first thing that I do is I wipe the lens in the soft tissue, the bowler capsule, the TFCC, anything soft, not bony, and that usually clears your lens. If that doesn't happen, then I do the automatic washout technique. And if that doesn't happen, Chris, I know you're a big micro proponent, and so what we do is we want to be respectful of micro surgery. So we have the micro wipe, you know, that you use to wipe the needle, so we have that wet on the table, and we simply wipe the lens. And those little three tricks are all that you need to ensure that you can see with your camera.
Charles Goldfarb:So two, two comments and a question, and sorry, Chris, I beat you to it. Comment number one is, if there's a national shortage of micro wives, we know where they're going, Chris, they're all going to Rochester, Minnesota. But in all seriousness, comment number one, even if you don't believe in dry arthroscopy, stop insufflating the joint. I stopped that many, many years ago. It does nothing for you. It's vital for an elbow arthroscopy. It's a waste of time for the wrist. Insufflating the wrist joint does nothing. That's number one. Number two is. Essentially use a two millimeter shaver. I use a three millimeter shaver in most situations, just because I'm impatient. You may be more patient than I but I like the you know, size and power, etc. And then my question is, and we're already on a tangent, which is totally fine. Explain how you technically assess the phobia when you do a d a, quote, unquote, d r u j, arthroscopy, because, as I recall, you're not putting your portals necessarily in the D R, E, J, but correct me if I'm wrong,
Sanj Kakar:yeah. So, so technically, how to scope the d r u j, so it's a great question, Chuck, because the way I was taught was blind, right? You stick a needle in, and then you spread, and then you worry about, are you gouging the articular cartridge of the I'll be on the head, and you stick it in, you can't see any withdraw. So the way that I do this, number one, you need a smaller camera, right? So you use a 1.9 millimeter camera, so you have your camera in the three, four portal, and you put your needle underneath the middle of the TFCC, in the middle of the ulna head. What people tend to do is that they go to the words the ulna styloid. They took their two ulna and remember, then you're in the fovea and if there's a foveal injury, you're in scar tissue. So what I do is I slowly pronoun supinate. I feel the D, i, u, j, then I feel the on the styloid, and I put my needle in the middle of the on the head, underneath the TFCC, and I move the needle up and down, so I know 100% I'm in the right spot. Then you make a transverse incision or longitudinal, it doesn't matter, spread, spread, spread. And you pop into your scissors are underneath the TFCC. You move your scissors up and down. You have the camera in the three four portals. You know you're in the right spot. And then the system that I use has two cannulas. And so you simply now bring the second cannula in, you're underneath the TFCC, and then you put the camera in, and the first thing that you're going to see is white because you're adjacent to the bowler capsule. So I bring the camera back, and then I'm slowly pronoun supinating, and I'm looking for the sigmoid notch, because then I know exactly where I'm at. And then I'll move the camera towards the ulna side, and that's where you'll see the phobia. Now, sometimes the scar tissue, though, is you have to bring a shaver in, but I would say seven out of 10 times I'm clinically suspecting a foveal injury, the synovitis in that area. And then you can see the phobia. But to your point, you have to build up, like you showed in that, in this work that that you spearheaded, about the TFCC, right? The trampoline test, the hook test, you have to find out what your normal is for phobial attachments, because it's a gradation of injury, right? It's either torn or it's not torn. I don't think it's as black and white as that. It's gray. So there's partial injuries. There's near complete. So you have to scope as many as you can. And trust me, the first one you do, you're going to be frustrated. But again, it's just going through that. And I must stress, you have to, you can't do it with a regular 2.7 camera. It's too big. So
Chris Dy:the the 1.9 millimeter camera seems to be pretty essential for this. But I think that your your points. I want to dig in a little bit more about the experience with arthroscopy and Chuck. Maybe you could talk a little bit about two papers that you worked on, because I think they're very relevant and educational. The first being what Sanja alluded to with the how you evaluate the TFCC in terms of trampoline versus hook. So just for the general hand surgeon or a resident. Talk about how you do that. And then the second one is, can you talk a little bit about the the variability in in grading of some of these that's in some of the more recent work that you, that you guys have
Charles Goldfarb:worked on together? Yeah, I can super I can jump in super quick on that. So the first paper we did was a cadaver study looking at how does one diagnose a phobial tear? We certainly didn't come up with a concept of hook test, but we took cadavers without evidence of injury, we used a beaver blade through a minimally invasive approach to cut the foveal insertion, and then we repeated our arthroscopy. We started before cutting and then after cutting, and we demonstrated that the hook test was helpful. The hook test is not a simplistic yes or no test, either. It's become clear that people feel there are gradations to Sandra's point, gradations in the completeness of a tear, so to speak. And so the goal is, you know, the trampoline test is absolutely non specific, and it also is very operator dependent and tactile dependent. But the hook test, we thought maybe yes or no, but even that is vague. But the idea is that you go very olderly, and you take your probe and put it under the TFCC and try to lift up towards the traquitrum. And again, it's a sense of feel, but that's the gist behind it. And so what Sanj and I did, along with others, is we took 40 videos, and we rated our ability to assess, basically our Inter observer liability on TFCC tears. And suffice to say is we weren't very good, except for central tears, where we were really good. But that should not be we shouldn't pat ourselves. Look back too much for that, so that capture it. Sanj, yeah,
Sanj Kakar:yeah, absolutely. So. So for me, Chris, when I when I'm scoping a risk and I'm worried about the TFCC, I do four tests. I do the trampoline test, I do the the hook test, I do the suction test. We basically have the suction turn. You have the suction on shaver in sorry, you lift it off the TFCC, and you turn the suction on and off, and you see if that lifts up or down. And then the third one that I'll do is I'll always scope the diuj. I always tell our residents and fellows, right? You do a radio carpal joint arthroscopy, you look at the TFCC, and you also always go as far on as you can my mentor, Dick Berger, talked about the only tricoectal Split tear. And so there's always synovitis in that area if there's a tear. And so you have to debride that synovitis to see if there truly is a tear or not. And then I'll scope the D, I, E, J, after that. So those sort of four things in my mind are key when you're looking for the TFCC pathology, I want
Chris Dy:to ask one more question before we shift gears for the drej arthroscopy. How essential is that? Do you think to evaluation of TFCC lesions in general, in particular for fovea lesions, do you think that you gain a lot of information from that fourth test compared to the three others that you described.
Sanj Kakar:So I'll give you a study here, right? So you, and that's what I credit you and a lot of our friends in hand surgeries that we study our outcomes and and how our patients are doing. So we published a study, I think it was on 24 patients, and all of them had foveal injuries proved on arthroscopy and MRI was only accurate in 1/3 of those patients. And of those patients, about 75% had stable diu J's. So. So this dogma that we were taught that if you have a foveal injury is diuj, instability is simply not true. So when you see a patient in clinic and they're tender in the phobia, to me, it's a TFCC or on triquetral Split tear, until proven otherwise. So to your point, Chris, if I scope the radiocarbon joint, I see a big ut split tear, or I see a big peripheral TFCC tear. Then, then, no, I won't scope the dij. But you know, I remember sitting with Chuck. We were at the hand society, and I was saying to saying, Chuck, are you seeing these patients with central tears and a foveal tear at the same time? Because we were taught you have a central 10. You just debride them. Because, yeah, I'm seeing those as well. And so those patients, you know, you can simply lift the TFCC up and you can see a foveal injury. So again, you don't have to scope the Diag for that, for those cases, but I think as long as you have a high index of suspicion, that's when I think it's indicated.
Charles Goldfarb:I love that, and we're going to thank our sponsors here in a second. But I would say two things to listeners who are like, Oh my God, I don't think I'm ever scoping a wrist again. Number one, Sanja obviously has an immense experience, and I think his take homes are really important. Number two, I don't have quite as much faith in the suction test. I think it's important to do it. And if you have a guess, I would say a complete foveal tear, then you will see that TFCC elevate. It's not always again, as black and white as we would like. And the last thing in Sanj knows, and I've said this before, and others have said this to him, the LT split tear is, I guess, I would say, harder for some of us to appreciate than others, because of Sanj is influence I look forward every time, my guess is he diagnoses it more than I do. You
Chris Dy:trying to say it's controversial or maybe fake news?
Charles Goldfarb:No, I would never say alternative facts.
Sanj Kakar:There we go. Chris, be careful.
Chris Dy:Talk about talk about alternative facts before we move to our next topic, we should thank our sponsors. The overhand is sponsored by practicelink.com the most widely used position job search and career advancement resource.
Charles Goldfarb:But coming up position is hard. Finding the right job doesn't have to be joined. Practice link, for free today@www.practicelink.com backslash the upper hand. Alright, briefly. Sanj, so far, we're not good at being brief. Briefly, tell us about the Nano scope. I know, and I think full disclosure, you do 1.9
Chris Dy:millimeter Well, well, there are non
Charles Goldfarb:disposable 1.9 millimeter scopes, and there are disposable 1.9 millimeter scopes. And Sanjay, I do believe you work with Arthrex and and my understanding is the nanoscope is a zero degree scope, which takes a little getting used to. It is disposable, but explain how you use it, what diagnoses you use it for, and why you think it's super helpful. Yeah,
Sanj Kakar:no. Thanks for that question, and I appreciate Yeah, just for transparency and disclosure. I do have a consulting agreement with our threats and have worked on on this. What I what I would say to you with the nanoscope and. And Chris is, as you mentioned, there are traditional 1.9 millimeter scopes out there as well. So what the big sort of aha moment for me with the with the nanoscope, was the degree of flexibility. The typical 1.9 millimeter scopes are very short and rigid, and they're fragile. And I remember on the shelf we would ask for one, and they would always be broken or in the repair shop. And so the beauty of the 1.9 millimeter nano scope is that it's flexible, so it allows you to get into spaces where we would struggle with it first. So for example, the DI EJ, we've talked about, the MCP joint. I've never scoped the MCP joint, the stt, the CMC. It's allowed me to get into those smaller joints relatively a dramatically. You're right. It's a zero degree lens. So typically we're used to a 30 degree lens, so they do make a trocar, which has a degree of bend to give you that sort of flexibility, if you want. But for me, it's not just about the nanoscope chuck and Chris. It's about what that has given me in terms of arthroscopy. So my acronym for arthroscopy is first. When I think of first, I think of those indications for arthroscopy, fractures. We talked a little bit fusions. For example, you have a lunate cyst. How do you get into that lunate cyst in an arthroscopic way? You can do that going through the membranous portion of the LT or the SL and debride that and bone graft that. I think of fusions. I think of instabilities. TFCC, we've talked about, I think of R being repair or reconstruction scaffold, lunate, that has been a big game changer for me, and we've talked about that previously, about scaphalone instability and repairs. The other s, as I mentioned, is small joint arthroscopy yesterday we had a Bennett's fracture. And you know those Bennett fractures, you have those small, little fragments, and you think you sort of get it on K wire, you take in multiple fluoroscopic views. And yesterday we had one that was fragmented, and I just couldn't get it in a closed manner. But with arthroscopy, it allowed me to get in there, to breathe the hematoma and get that reduction. And the T in first is tunnel, so carpal tunnel, cubital tunnel, exercise induced compartment syndrome. These patients are usually young, bilateral, and traditional big forearm fasciotomies are kind of unsightly, but with arthroscopy, and it doesn't need to just be the nanoscope it could be with any camera, it allows you to do these sort of procedures in a more minimally invasive way. And so that's sort of been my Genesis on using nanoscope technology to allow me to address more than I could do before you
Chris Dy:really you know the Rochester spelling is different. So you spell first F, F, F, F, I R, R, S T, T, T. Is that correct? F,
Sanj Kakar:i, r, s, t, but there's several F,
Chris Dy:2r and four T's. But
Unknown:you can see there's so many. I've got so many ideas on how the F is. You started getting
Chris Dy:me going using the arthroscope as the nanoscope as an endoscope for the carpal tunnel. That's a whole different episode. I love
Charles Goldfarb:the comment about the fragility of the non disposable 1.9 scope. I I was doing a small joint arthroscopy, and to your point, small joint for me as MCPS typically. And we had a new SCRUB NURSE paired with an older scrub nurse, and I asked for the scope, and she handed me the scope, kind of like this, holding the barrel of the scope. By the time it got to me, it was totally useless. Like those scopes are really fragile, which is, which is, either you have to be really careful or have a good repair contract, or you just switch and use the disposables, which are not that price crazy. Let's briefly touch on TFCC repairs, specifically foveal repairs. And so a lot of us talk about ulnar tunnel, etc. You've described, and I'm curious if you still do it over the top technique for foveal repairs, what's your go to today for foveal repairs? Yes,
Sanj Kakar:it's a great question. And we used to do the ALMA tunnel technique, which is an outside to inside technique. But to your point, that can be technically challenging when you're putting that tunnel, it has to be in the right spot and and I do worry about tunnel fracture. You know when, when you see your trainees trying to make that tunnel multiple passes of the KY you do worry about that, and also you're limited in terms of the aperture of your tunnel, in terms of your suture passage. So the over the top technique is a relatively more straightforward technique, where you're literally coming from over the top and putting your suture through. So the difference is here is that you have your camera in the six hour portal, and you bring the needle through the three four portal, and you direct it through the TFCC, so you see exactly where you want to go through the TFCC, through the fovea and out the other side. So instead of being outside to inside, it's an inside to outside repair where you're putting a vertical mattress suture. The advantages are, it's it's quite. Cut. You don't need fluoro for it. You're not making big drill holes. So there is a degree of sort of flexibility when you put your repair in, where you if your stitch isn't quite perfect, you can put one either more bowler or more dorsal. And yeah, at this stage, we're doing that routinely, and I've definitely seen it's much quicker and it's easier for actually, the trainees to learn that technique.
Charles Goldfarb:I continue to use the ulnar tunnel, but I think a couple of your points are really important. First of all, thankfully, I've never seen a fracture. Hope I never do, but you're right. The key aspect is you're typically drilling a 3.0 millimeter pole. Once you put your K wire, you over drill through the ulna, starting just proximal to the Ole Miss dialyde, aiming for the fovea region. And then the spread of your sutures, because the goal is a horizontal mattress can be limited, and is technique dependent with trainees, absolutely. I you know, there are different ways to cheat with the ulnar tunnel. You know, you can go outside of the tunnel with one of your sutures. There's different ways to do it. But I think this concept is innovative that you describe and either be patient, you know, you got to learn a technique and be comfortable with it, but I think the goal is a nice spread in your sutures at the right location. So for example, this week, we had a dorsal radio, ulnar lunate tear and the volar aspect seemed to be intact, and so after debridement, we placed our suture dorsally, and we use the ulnar tunnel technique. But in some ways, I felt like we got a little lucky, because it went in the right spot. I think your technique may have provided more control.
Sanj Kakar:It's better to be lucky than good Chuck. But as you both are lucky, and good works well. But the other thing that I would also say is sometimes, in these chronic cases where the tissue quality isn't the best, right, I want to have a real wide spread of my sutures. And so, as you said, if you're cheating, I'd rather cheat on getting a good bite of the tissue, as opposed to being right, perfectly anatomic where you've got like, a two millimeter suture tissue bridge. And if you pull you can actually pull it out. And if that happens and that, then that's that's a hard one to salvage. What
Charles Goldfarb:percentage and you and I have talked offline about this, I think it's important for the listeners to understand this, because I think we see eye to eye on this, what percentage of your TFCC repairs are superficial, peripheral tears, rather than involving the phobia. So traditionally, if you read the textbooks, you'll read about either some type of suit, soft tissue, suture, anchor, TFC to capsule, or you'll read about using the ECU sub sheath in an outside in way to repair the 2c what percent of your repairs are those types versus a foveal repair?
Sanj Kakar:Yeah, I would say so, you know, we have great classifications in our in our literature, and we were taught the Palmer classification, but there's the at sea Lucchetti classification, which has really sort of opened my eyes to what we call this type three tear, which is where you pop the camera in, in the radio carpal joint. And the TFCC looks relatively pristine, but the problem is, like the iceberg concept, the problem is underneath the top, is in the fovea and and this is called that at sea, Luke type three injury, where the injury is in the foveal region. Now, as I mentioned, it doesn't have to be a gross disruption. There's no dij instability, but you get in there and there's partial fraying, there's partial tear, there's some synovitis. Now, what's normal, what's abnormal, as you've shown from your studies, Chuck, there's a high degree of subjectivity in that call, but I would say now I'm doing far more foveal repairs and typical, traditional peripheral tears. And we talked, and we talked a lot of our colleagues around the country, and they're still doing a lot of peripheral tears. But for me, I would say it's probably, I would say, I don't know, 80% phobial. I would say it's pretty high. And if I'm doing a peripheral it's more the ulnar ut split tear that I'm seeing, as opposed to the typical peripheral tear for
Chris Dy:a non sub specialist in this area, can you just use a foveal repair technique for everything?
Sanj Kakar:Well, I Yeah, cast aside, of course, no, I think you can. But there is also morbidity, right? If you're if you are drilling holes in bones, you know, it just takes one mishap, a fracture or something, I wouldn't advocate just go ahead and do a bone tunnel for everything. You know. That's like saying doing almost shortening osteotomy for every cell the animal side of wrist pain. So I think you have to have a degree of objectivity of when you're using that. But it's a good question.
Charles Goldfarb:I think this is important, and I think there will be people who disagree with this, but I'm going to say it relatively strongly, because that's how I feel about it. Today, it might change. Number one, if you have a split tear, you have to address it. As Sanj has said, the vast majority of what I do include faucial repairs, what I almost never do now. I almost never, and I don't remember the last time I did was the, what I would call the dorsal ulnar peripheral tear, and that is the ECU subsheet tear. 20 years ago, a private practice hand surgeon in St Louis came to the Shriners, and we used to talk, and he, you know, at that point, had a busy arthroscopy survey. He said, Look, I never repaired this. I'm like, What are you talking about? I always repair this. EC, sharp teeth. Technique is fantastic. He's like, What are you really doing? There's no instability. There may be some pain. If you debride that it'll heal. It took me 20 years to figure it out, but I think he's right, and I just don't do that repair almost ever anymore.
Sanj Kakar:Yeah, you know, it's funny. You say that about the UT split test in my mind, I always fix them. That's, you know, as my mentor showed me how to do it, and I always fix them. But I do know, you know, in my mind, I do think to myself, well, what happens if you simply debride them and you immobilize them? Do they heal and so that's, uh, you know, that's a thought that goes through my mind about that. And some people, I think, do they just debris them and they were mobilizing. Yeah,
Charles Goldfarb:just to be clear, I'm not saying I'm not talking about that tear. I'm talking about, okay, okay. I just want to be clear. I wasn't questioning that, even though I think it's a fair point. But I wasn't questioning that. Yeah,
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Charles Goldfarb:Chris gets excited when we talk anything nerve so he read like 90% of the copy for that. And so I get to close that with to learn more about this and other educational programs. Please visit nerve master, calm. Check fully surgical, driving innovation in nerve surgery. I'm
Chris Dy:so happy that you got three. I mean, you probably take those, those ad copy courses, right, those at the podcast studios to really deliver that last
Charles Goldfarb:line. You know, I'm working on the voice. I need to be a little more, more deep, probably to be, all right, Sanj, we have a few minutes left. We are grateful for your time. We don't want to monopolize it. So let's talk. SL, tears. I'm going to start with a simple question, not so simple, when do you open to address a scaffolding ligament injury? And when do you, and let's not get into the specifics yet, and when do you think about an arthroscopic approach? Yeah,
Sanj Kakar:so very, very quickly when I see a patient who's tender over the SL right, and the X rays are equivocal as well as the MRI. And just very quickly, when you're looking at the scans, I always look at the alignment of the scaphoid on the sagittal view, the lunate alignment on the coronal view and the axial view. See if it's a dorsal level or through and through injury. What I'll say to them is, I'm going to scope you, and we're going to go on the pathway of three ways. If it's arthritic, then we have to go down the arthritis pathway. Now that may be injections, that may be a partial denovation. What do you want to do if you are grossly unstable and I cannot get you arthroscopically, then we're coming back and doing a stage reconstruction. And in my hands, that's an SL 360 but I can honestly say, in the last three years, I've been able to always get the reduction with arthroscopic means and and I think there are, there are five sort of ligaments that we have to think about. We have to think about the DCSS, we have to think about the dorsal SL, we have to think about the vola SL. We have to think about the long radio lunate ligament. And we have to see think about the insertion of the DIC ligament on the Luna. Those are the five ligaments that you can address arthroscopically. The one that you can't is the stt ligament, and that a repair has been described by Nick Smith in Sydney and Australia, where it's a small, mini open incision to do those now, if I can get the reduction with sutures being passed through that way, plus or minus k wires, and that's what we're doing. And I have found that to be a very reproducible method to do it. The morbidity of doing those is relatively minimal. You're not making big drill holes in the in the carpus and and we've all done SL reconstructions where you've had a great reconstruction, the patient's doing well. You come back and they have a big X ray gap, but I think, but they're doing well. And I think with arthroscopy, you're stabilizing the carpet. You may not get rid of the gap completely, but they're stable, and they're and they're mobile. They're not stuck. They're not stuck in terms of scar tissue. And so that's sort of my algorithm for addressing the SL with the scope.
Charles Goldfarb:I love that this is a lot, and obviously we're not going to all our listeners, and likely Chris or I are not going to master this in the next few minutes. But what's the most common arthroscopic procedure you do for SL and obviously it has to be customized to the patient and the situation. But what's. The most common procedure you do?
Sanj Kakar:Yeah, so did one just yesterday, patient came in and was tender through and through. So I scoped them, and the vola SL was off as well as the dorsal and I put the volares capsular, desist suture, pulled it down, reduced the vola side and the dorsal side became more stable, and we were done. So I would say the vola side is where I'm going first, but I won't hesitate to do the others. But to your point, that's what I'm doing most often.
Charles Goldfarb:That's so interesting. And let's say you have an MRI that's equivocal. Do you have physical exam? Do you have a feeling about physical exam techniques to identify vulner pathology. In other words, is there a point tender area again? Can you talk about that? Yeah,
Sanj Kakar:so, so what they usually what I do is I'll palpate first over the fcr to make sure it's not fcr tendinitis. I'll then put my finger on the fcr and pull it only and go deep to that. Now, essentially, there's three issues there. There's either an occult volar ganglion, there's either an extrinsic injury, maybe radio Skipper caps, or long radio lunate ligament. Or, if you're pushing really deep, it's the volar SL, but those but the extrinsic ligaments, RSC, long radio lunate ligament, volar SL, even occult ganglion, you're either seeing well, occult ganglion you'll see on the MRI. The other three you may not and so those are the ones that you'll pop the camera in. And as I said yesterday, we popped it in, and there was a partial avulsion of the long radio lunate ligament off the distal radius proximately.
Charles Goldfarb:And this is great. And I think to listeners, this is not something you're typically going to learn on your hand rotation unless someone's really focused. I think that point tender area is under appreciated. And I love the how you stated that. So in the case you did yesterday, you did the volar capso Desis. And I don't want to say it's going to come out wrong, but is that all you did, in the sense you did, you try to do anything to have the long radio lunate heal back to bone?
Sanj Kakar:Yeah. So what? So what I did then is, for that one, then I took the shaver in because it was a partial injury, I'd say maybe 20 to 30% partial. The rest was on intact. I took a shaver and debrided the base of the radius and also the long radio lunate ligament. And then we described this, recently published in JHS, the Merlin technique, where you basically do an invocation long radio lunate ligament. Now, if there was a complete detachment of the long radio ligament off the radius, you were already bowler, because you made a bola radial portal, then you would put an anchor into the radius and then tie that ligament down to the radius.
Charles Goldfarb:Let's step back for one second if you have an MRI identified membranous tear. And for those who don't know the terminology, specifically, that's not dorsal, that's not volar. It's sort of the proximal aspect of the C MRI looks like his membranous a do your arthroscopy for a patient with radio sided pain, dorsal and volar seem to be intact, and he had this membranous tear. What do you do then? Is it just a simple debridement?
Sanj Kakar:Yeah, I'm not, I'm not fixing that. But truth be told, Chuck, if I'm seeing a memoryless tear, I mean, I'll debride it. But in my, in my sort of gut instinct, I'm thinking, Am I really addressing the problem here?
Charles Goldfarb:That that's what I was hoping you would say. I think that situations really rare where you just have memories, and I see op notes where people have just debrided the membrane is tear. And I'm always a little questioning is, was there really something else going on?
Sanj Kakar:Yeah, yeah. So
Chris Dy:he actually brings up a really good point. I wanted to ask both you, given that you are super specialized experts and nationally and internationally recognized for this area, what are the most common things that people don't treat appropriately or miss, or, you know, lead to issues down the line. With regards to SL,
Sanj Kakar:I think, honestly, it's the diagnosis, right? I think it's we were, we were taught, if the X rays are normal, get a stress view, and if the stress views are normal, there's not an SL problem, right? There's a lot of patients who have high grade instability. We publish a series on this, on patients with normal X rays, both at rest and stress views, and 40% had high grade geyser three or four instability. So I think that's the first one. I think getting the diagnosis correct. I think the second thing is coming in with a hammer as one treatment suits all and so, you know, when, when, when we were residents and fellows. It was a three ligament Tina thesis, right? And that was the one that was being done essentially, for most SLS, and I'm not knocking that operation, but my point is that it may be a border injury, maybe a dorsal injury, maybe through and through, there may be extrinsic ligament injuries as well. So you can't just have one approach to addressing the SL so I would say those are the two biggest sort of areas that I think, hopefully, that we can address for. For people that you can't think of it as a like an action potential. It's not all or nothing. Chris, so there you are. We got nerve in there for you, right? It has to be more of a rainbow approach. And how to address this,
Charles Goldfarb:I would close by offering this. When I was a resident, we were and Chris, you were in grade school. We were essentially witnessing a transformation from open rotator cuff repairs to many open rotator cuff repairs to all arthroscopic repairs. And that happened over a period of, I don't know how many years, six, 810, years, and I would say we're in the midst of that for SL and Sandra is leading the way, certainly amongst Americans. I think we may be behind some of our international colleagues, but I think in 10 years from now, the landscape is a look very different on how we approach these and you know, we have to do a lot of things. We have to communicate better on what we're doing to treat these arthroscopically. We have to really simplify techniques, and industry needs to partner with us to assist in that. And then we need to popularize these techniques. Because I do agree, there has been one big hammer, and I have been guilty, one big hammer to treat these injuries, and it needs to be much more refined than that.
Chris Dy:Thank you, both of you. That was That was fantastic. We I've learned a lot on this episode, and I think it's a really nice way to set the stage for the young folks who want to take this take this charge and lead us forward. So Sarge, always super fun to have you on. I'm sure we'll get listener feedback that we want to have you on again. So thank you for becoming our recurring guest for arthroscopy and wrist pain.
Sanj Kakar:Always a pleasure. Chuck and Chris, it's good to see you, and I love spending this time with you, and happy to come back and talk more about wrist and arthroscopy.
Charles Goldfarb:Awesome. Thank you so much. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to email us with topic suggestions and feedback. You can reach us at hand podcast@gmail.com
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Charles Goldfarb:Special, thanks to Peter Martin for the amazing music, and
Chris Dy:remember, keep the upper hand. Come back next time you
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good? Well, be sure to email us with topic suggestions and feedback. You can reach us. You.