January 5, 2025 • 42 mins
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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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Charles Goldfarb (00:00):
Chuck, welcome to the upper hand podcast where
(00:07):
Chuck and Chris talk handsurgery.
Chris Dy (00:09):
We are two hand surgeons at Washington
University in St Louis, here totalk about all things hand
surgery related, from technicalto personal.
Charles Goldfarb (00:17):
Please subscribe wherever you get your
podcasts, and thank
Chris Dy (00:20):
you in advance for leaving a review and rating that
helps us get the word out. Youcan email us at
handpodcast@gmail.com so let'sget to the episode. Oh, hey,
Chris, hey, Chuck, how are you?
I'm
Charles Goldfarb (00:33):
really good today.
Chris Dy (00:35):
Excellent. It looks like you are in the office, as
is our special guest, also inthe office. Our
Charles Goldfarb (00:40):
special guest, Sanj Kakaar, is rejoining us by
popular demand, because everyoneloved the first episode on
skatefa Luna, we wanted to takea deeper dive and talk a lot
about technique, because Sanj isa luminary. He's going to teach
us all today.
Chris Dy (00:58):
Sanj, welcome back.
Sanj Kakar (01:00):
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 (01:08):
I think Saj and I are both in the office.
Chris, where are you?
Chris Dy (01:11):
I'm at home.
Fortunately, Saturday morning.
Can't think of a better way thanto spend it with you guys. I'm
sure you're both doing yourdiligence and rounding and
seeing patients and cleaning upcases from, uh, from your call,
Charles Goldfarb (01:24):
I think. And I love Sanj's opinion when I
round, which I try to do aslittle as possible, but when I
do round, it's always enjoyable.
It's just like coming in for acase in the middle of night.
It's never the actual coming inand doing the case. It's sort of
what happens after. But I got tohang out with one of our amazing
residents, Jeremy Huckabee,who's just an amazing guy, and I
learned things about him Ididn't know. And it was, it was
(01:45):
kind of fun,
Sanj Kakar (01:49):
Chuck, I think you're rounding early like me,
because you know that the soccermatches are going to kick off.
You know, we're six hours behindthe UK. So that's why you're
you're rounding now. Don't letanyone believe anything else
this.
Charles Goldfarb (02:01):
This is true.
And then I also have a businessschool final to finish this
morning.
Chris Dy (02:07):
You know, you know, Chuck, the residents are going
to realize, those that arelistening are gonna realize how
out of touch you are. You know,rounding is just a novel, fun
thing for you, and it's just dayin, day out slog for them for
years. So we're very lucky thatwe have residents and fellows
that carry the load for sure,
Charles Goldfarb (02:25):
very, very true. All right, let's not keep
our listeners waiting too long.
We have four or five points wewant to cover with Sanj Over the
next 40 minutes, and we'll startwith something I know he feels
passionately about, which is dryarthroscopy. So Sanj, give us a
little background on how and whyyou started using dry arthrospy.
Do you always use dryarthroscopy and what you think
(02:48):
the benefits are?
Sanj Kakar (02:52):
Yeah, it's a great, great question, Chuck, and I'm
asked this a lot. You know, Itrained here at Mayo, doing my
fellowship with Dick Berger andAlan bishop, and were big wet
arthroscopy proponents. Sothat'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 theopportunity to sort of go and
(03:13):
see some of the luminariesaround the world. And I would
say, you don't need to have anamed traveling fellowship to
anybody out there who'sinterested to learn just, just
go and visit people, be thatnationally, internationally,
just even across your town. It'samazing what you can learn from
others. And it struck me thatthere were so many people doing
dry arthroscopy, and this waslike a real big sort of light
(03:36):
bulb going off. And I rememberPaco del Pinal at the hand
society once talking about dryarthroscopy with distal radius
fractures, and just talking tohim about his sort of experience
with this. And what have I seennow in my practice? Now 2025,
basically, and moving forward,it allows me to do much more
(03:58):
than I used to do. I used toalways get frustrated with fluid
in the joint, you get softtissue extravasation. And as you
know, Chuck and Chris, anytimeyou're doing arthroscopy is
sometimes it's more sort ofarthroscopic assisted, so you're
making incision, so it's harderto find your soft tissue planes
with all the soft tissue fluid.
And then also, I was worriedabout disadractures, for
example, in compartmentsyndrome, so I never did one
(04:20):
wet, because I was worried aboutthat. And then also, I just
found that you can do much moredry than wet. You can make
bigger portals so you can makeyou can put larger Shavers and
burst your resection is muchmore efficient. You ask the
question, do I always do dry? Iwould say 99.9% the two times
that I don't is when I'm doingthermal shrinkage. And so you do
(04:43):
need fluid in the joints. Youdon'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 surewhat's going on in your
institution, but in ourinstitution, that's been a big
(05:05):
hit, especially on our sportsmedicine colleagues, who do a
lot of wet arthroscopy, wherewe're told to sort of decrease
our fluid use. So for me, inthat way, it hasn't really been
an issue.
Charles Goldfarb (05:16):
Yeah, it's an interesting point. I would say I
would maybe 25% now I'm doingdry arthroscopy, and it is a I'm
just transitioning slowly, and Iabsolutely have started to see
the benefit. I'm not completelyconvinced yet, but Chris, I know
you don't do a ton ofarthroscopy, but you definitely
do scope. What are yourthoughts? I
Chris Dy (05:37):
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 todo it, and what's your
rationale, so that people whoare like me, kind of a general
hand surgeon in that regard, ofvia, 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 Ican't do. What are the reasons
(05:58):
that you decided to take thisjump into doing 25% of your
cases with dry arthroscopy well.
Charles Goldfarb (06:02):
One, in all seriousness, I do respect Sanj,
and when someone like that saysthat it works for them, I I want
to try it out. Two, I think thefluid, the lack of IV fluids,
the crisis, so to speak,contributed to my interest in
doing more of it. And it's justfor certain risks, especially
those where I know I'm doing anopening procedure, it just makes
(06:25):
sense. And as long as I canvisualize well, and I generally
can, I like it, there's no doubtI like it. And so it's just, I
feel like, if you know there aresome risk arthros are very
straightforward, and some for meremain a struggle, whether the
wrist is tight, whether thehumerus is short, and you just
(06:48):
struggle to get things exactlylike you need to. I tend to
blame fluid or not fluid, so Idon't want to bring the lack of
fluid into it, but I do thinkit's going to be a slow
transition towards dryarthroscopy for me, Sanja. Was
it an evolution for you? Wouldyou go cold turkey?
Sanj Kakar (07:03):
No, I did go cold turkey, Chuck. And so I would
say, I would say to people andand even just watching and
training people at courses, whatI would say to you is this,
we're always taught put theneedle in three, four portal and
insufflate the joint, right? Youdon't want to do that. You want
to stick the needle in. And thegoal is to get the shaver in as
quickly as possible, becausethere's some synovial fluid.
(07:23):
There's bubbles in the joint.
You can't see so I remember. Soyou don't want to start off
doing, for example, a fracturecase, right? So let's say you're
doing a TCC debridement. Startoff very simple, or a ganglia or
something like that. So what Iwould say to my scrub tech is,
I'm going to ask for fluidwithin 60 seconds, right? Your
but your answer is, No, I'm notgoing to give it to you. And so
I had to struggle a bit, alittle. And so the key is, get
(07:44):
your needle in, make your threefour 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, nota 30 CC, a 10 cc syringe. And
usually I use a two millimetershaver, and that's enough,
enough suction power on thesyringe to do an automatic
washout. And, you know, we putthis on videos, on handy, or on
(08:05):
Anthology, so people can see howto technically do that. And then
once you sort of lavage thejoint, you leave the shaver on
and you want to get rid of allthe 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 getunderneath there, there'll be
crab meat in your face. Youcan't see anything. Can you just
(08:25):
pull the camera out and you justsay, 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, thatwas a that was a thing for me in
2017 I'd never really seen thephobia before, and I didn't know
what that looked like. And, youknow, we're all well into
practice there. So it's justsort of that evolution. But as
you said, Chris, you know, youhave to start simple and build
(08:47):
up. And you'll you'll see,there's a couple of tricks. So
you sometimes you get stuff onthe lens of the camera and you
can't see. So what are thetricks? So number one, well, the
first thing that I do is I wipethe 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 Ido the automatic washout
(09:10):
technique. And if that doesn'thappen, Chris, I know you're a
big micro proponent, and so whatwe do is we want to be
respectful of micro surgery. Sowe have the micro wipe, you
know, that you use to wipe theneedle, so we have that wet on
the table, and we simply wipethe lens. And those little three
tricks are all that you need toensure that you can see with
your camera.
Charles Goldfarb (09:29):
So two, two comments and a question, and
sorry, Chris, I beat you to it.
Comment number one is, ifthere's a national shortage of
micro wives, we know wherethey'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 insufflatingthe joint. I stopped that many,
many years ago. It does nothingfor you. It's vital for an elbow
(09:51):
arthroscopy. It's a waste oftime for the wrist. Insufflating
the wrist joint does nothing.
That's number one. Number twois. Essentially use a two
millimeter shaver. I use a threemillimeter shaver in most
situations, just because I'mimpatient. You may be more
patient than I but I like theyou know, size and power, etc.
(10:12):
And then my question is, andwe're already on a tangent,
which is totally fine. Explainhow you technically assess the
phobia when you do a d a, quote,unquote, d r u j, arthroscopy,
because, as I recall, you're notputting your portals necessarily
in the D R, E, J, but correct meif I'm wrong,
Sanj Kakar (10:33):
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? Youstick a needle in, and then you
spread, and then you worryabout, are you gouging the
articular cartridge of the I'llbe 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
(10:54):
camera, right? So you use a 1.9millimeter camera, so you have
your camera in the three, fourportal, and you put your needle
underneath the middle of theTFCC, in the middle of the ulna
head. What people tend to do isthat they go to the words the
ulna styloid. They took theirtwo ulna and remember, then
you're in the fovea and ifthere's a foveal injury, you're
in scar tissue. So what I do isI slowly pronoun supinate. I
(11:17):
feel the D, i, u, j, then I feelthe on the styloid, and I put my
needle in the middle of the onthe head, underneath the TFCC,
and I move the needle up anddown, so I know 100% I'm in the
right spot. Then you make atransverse incision or
longitudinal, it doesn't matter,spread, spread, spread. And you
pop into your scissors areunderneath the TFCC. You move
your scissors up and down. Youhave the camera in the three
(11:37):
four portals. You know you're inthe right spot. And then the
system that I use has twocannulas. And so you simply now
bring the second cannula in,you're underneath the TFCC, and
then you put the camera in, andthe first thing that you're
going to see is white becauseyou're adjacent to the bowler
capsule. So I bring the cameraback, and then I'm slowly
pronoun supinating, and I'mlooking for the sigmoid notch,
because then I know exactlywhere I'm at. And then I'll move
(11:59):
the camera towards the ulnaside, and that's where you'll
see the phobia. Now, sometimesthe scar tissue, though, is you
have to bring a shaver in, but Iwould say seven out of 10 times
I'm clinically suspecting afoveal injury, the synovitis in
that area. And then you can seethe phobia. But to your point,
you have to build up, like youshowed in that, in this work
(12:21):
that that you spearheaded, aboutthe TFCC, right? The trampoline
test, the hook test, you have tofind out what your normal is for
phobial attachments, becauseit's a gradation of injury,
right? It's either torn or it'snot torn. I don't think it's as
black and white as that. It'sgray. So there's partial
injuries. There's near complete.
(12:42):
So you have to scope as many asyou can. And trust me, the first
one you do, you're going to befrustrated. But again, it's just
going through that. And I muststress, you have to, you can't
do it with a regular 2.7 camera.
It's too big. So
Chris Dy (12:56):
the the 1.9 millimeter camera seems to be pretty
essential for this. But I thinkthat your your points. I want to
dig in a little bit more aboutthe experience with arthroscopy
and Chuck. Maybe you could talka little bit about two papers
that you worked on, because Ithink they're very relevant and
educational. The first beingwhat Sanja alluded to with the
how you evaluate the TFCC interms of trampoline versus hook.
(13:19):
So just for the general handsurgeon or a resident. Talk
about how you do that. And thenthe second one is, can you talk
a little bit about the thevariability in in grading of
some of these that's in some ofthe more recent work that you,
that you guys have
Charles Goldfarb (13:34):
worked on together? Yeah, I can super I
can jump in super quick on that.
So the first paper we did was acadaver study looking at how
does one diagnose a phobialtear? We certainly didn't come
up with a concept of hook test,but we took cadavers without
evidence of injury, we used abeaver blade through a minimally
invasive approach to cut thefoveal insertion, and then we
(13:54):
repeated our arthroscopy. Westarted before cutting and then
after cutting, and wedemonstrated that the hook test
was helpful. The hook test isnot a simplistic yes or no test,
either. It's become clear thatpeople feel there are gradations
to Sandra's point, gradations inthe completeness of a tear, so
to speak. And so the goal is,you know, the trampoline test is
(14:16):
absolutely non specific, and italso is very operator dependent
and tactile dependent. But thehook test, we thought maybe yes
or no, but even that is vague.
But the idea is that you go veryolderly, and you take your probe
and put it under the TFCC andtry to lift up towards the
(14:38):
traquitrum. And again, it's asense of feel, but that's the
gist behind it. And so what Sanjand I did, along with others, is
we took 40 videos, and we ratedour ability to assess, basically
our Inter observer liability onTFCC tears. And suffice to say
is we weren't very good, exceptfor central tears, where we were
(14:59):
really good. But that should notbe we shouldn't pat ourselves.
Look back too much for that, sothat capture it. Sanj, yeah,
Sanj Kakar (15:07):
yeah, absolutely.
So. So for me, Chris, when Iwhen I'm scoping a risk and I'm
worried about the TFCC, I dofour tests. I do the trampoline
test, I do the the hook test, Ido the suction test. We
basically have the suction turn.
You have the suction on shaverin sorry, you lift it off the
TFCC, and you turn the suctionon and off, and you see if that
lifts up or down. And then thethird one that I'll do is I'll
(15:29):
always scope the diuj. I alwaystell our residents and fellows,
right? You do a radio carpaljoint arthroscopy, you look at
the TFCC, and you also always goas far on as you can my mentor,
Dick Berger, talked about theonly tricoectal Split tear. And
so there's always synovitis inthat area if there's a tear. And
so you have to debride thatsynovitis to see if there truly
(15:51):
is a tear or not. And then I'llscope the D, I, E, J, after
that. So those sort of fourthings in my mind are key when
you're looking for the TFCCpathology, I want
Chris Dy (16:04):
to ask one more question before we shift gears
for the drej arthroscopy. Howessential is that? Do you think
to evaluation of TFCC lesions ingeneral, in particular for fovea
lesions, do you think that yougain a lot of information from
that fourth test compared to thethree others that you described.
Sanj Kakar (16:23):
So I'll give you a study here, right? So you, and
that's what I credit you and alot of our friends in hand
surgeries that we study ouroutcomes and and how our
patients are doing. So wepublished a study, I think it
was on 24 patients, and all ofthem had foveal injuries proved
on arthroscopy and MRI was onlyaccurate in 1/3 of those
(16:48):
patients. And of those patients,about 75% had stable diu J's.
So. So this dogma that we weretaught that if you have a foveal
injury is diuj, instability issimply not true. So when you see
a patient in clinic and they'retender in the phobia, to me,
it's a TFCC or on triquetralSplit tear, until proven
(17:09):
otherwise. So to your point,Chris, if I scope the
radiocarbon joint, I see a bigut split tear, or I see a big
peripheral TFCC tear. Then,then, no, I won't scope the dij.
But you know, I remember sittingwith Chuck. We were at the hand
society, and I was saying tosaying, Chuck, are you seeing
these patients with centraltears and a foveal tear at the
same time? Because we weretaught you have a central 10.
(17:31):
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 toscope the Diag for that, for
those cases, but I think as longas you have a high index of
suspicion, that's when I thinkit's indicated.
Charles Goldfarb (17:49):
I love that, and we're going to thank our
sponsors here in a second. But Iwould say two things to
listeners who are like, Oh myGod, I don't think I'm ever
scoping a wrist again. Numberone, Sanja obviously has an
immense experience, and I thinkhis take homes are really
important. Number two, I don'thave quite as much faith in the
suction test. I think it'simportant to do it. And if you
(18:12):
have a guess, I would say acomplete foveal tear, then you
will see that TFCC elevate. It'snot always again, as black and
white as we would like. And thelast thing in Sanj knows, and
I've said this before, andothers have said this to him,
the LT split tear is, I guess, Iwould say, harder for some of us
to appreciate than others,because of Sanj is influence I
(18:34):
look forward every time, myguess is he diagnoses it more
than I do. You
Chris Dy (18:39):
trying to say it's controversial or maybe fake
news?
Charles Goldfarb (18:43):
No, I would never say alternative facts.
Sanj Kakar (18:47):
There we go. Chris, be careful.
Chris Dy (18:52):
Talk about talk about alternative facts before we move
to our next topic, we shouldthank our sponsors. The overhand
is sponsored by practicelink.comthe most widely used position
job search and careeradvancement resource.
Charles Goldfarb (19:05):
But coming up position is hard. Finding the
right job doesn't have to bejoined. Practice link, for free
today@www.practicelink.combackslash the upper hand.
Alright, briefly. Sanj, so far,we're not good at being brief.
Briefly, tell us about the Nanoscope. I know, and I think full
disclosure, you do 1.9
Chris Dy (19:24):
millimeter Well, well, there are non
Charles Goldfarb (19:27):
disposable 1.9 millimeter scopes, and there are
disposable 1.9 millimeterscopes. And Sanjay, I do believe
you work with Arthrex and and myunderstanding is the nanoscope
is a zero degree scope, whichtakes a little getting used to.
It is disposable, but explainhow you use it, what diagnoses
you use it for, and why youthink it's super helpful. Yeah,
Sanj Kakar (19:48):
no. Thanks for that question, and I appreciate Yeah,
just for transparency anddisclosure. I do have a
consulting agreement with ourthreats and have worked on on
this. What I what I would say toyou with the nanoscope and. And
Chris is, as you mentioned,there are traditional 1.9
millimeter scopes out there aswell. So what the big sort of
aha moment for me with the withthe nanoscope, was the degree of
(20:10):
flexibility. The typical 1.9millimeter scopes are very short
and rigid, and they're fragile.
And I remember on the shelf wewould ask for one, and they
would always be broken or in therepair shop. And so the beauty
of the 1.9 millimeter nano scopeis that it's flexible, so it
allows you to get into spaceswhere we would struggle with it
first. So for example, the DIEJ, we've talked about, the MCP
(20:31):
joint. I've never scoped the MCPjoint, the stt, the CMC. It's
allowed me to get into thosesmaller joints relatively a
dramatically. You're right. It'sa 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 youthat sort of flexibility, if you
want. But for me, it's not justabout the nanoscope chuck and
(20:55):
Chris. It's about what that hasgiven me in terms of
arthroscopy. So my acronym forarthroscopy is first. When I
think of first, I think of thoseindications for arthroscopy,
fractures. We talked a littlebit fusions. For example, you
have a lunate cyst. How do youget into that lunate cyst in an
arthroscopic way? You can dothat going through the
(21:16):
membranous portion of the LT orthe 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 reconstructionscaffold, lunate, that has been
a big game changer for me, andwe've talked about that
previously, about scaphaloneinstability and repairs. The
(21:38):
other s, as I mentioned, issmall joint arthroscopy
yesterday we had a Bennett'sfracture. And you know those
Bennett fractures, you havethose small, little fragments,
and you think you sort of get iton K wire, you take in multiple
fluoroscopic views. Andyesterday we had one that was
fragmented, and I just couldn'tget it in a closed manner. But
with arthroscopy, it allowed meto get in there, to breathe the
hematoma and get that reduction.
And the T in first is tunnel, socarpal tunnel, cubital tunnel,
(22:02):
exercise induced compartmentsyndrome. These patients are
usually young, bilateral, andtraditional big forearm
fasciotomies are kind ofunsightly, but with arthroscopy,
and it doesn't need to just bethe nanoscope it could be with
any camera, it allows you to dothese sort of procedures in a
more minimally invasive way. Andso that's sort of been my
(22:23):
Genesis on using nanoscopetechnology to allow me to
address more than I could dobefore you
Chris Dy (22:31):
really you know the Rochester spelling is different.
So you spell first F, F, F, F, IR, R, S T, T, T. Is that
correct? F,
Sanj Kakar (22:42):
i, r, s, t, but there's several F,
Chris Dy (22:47):
2r and four T's. But
Unknown (22:49):
you can see there's so many. I've got so many ideas on
how the F is. You startedgetting
Chris Dy (22:53):
me going using the arthroscope as the nanoscope as
an endoscope for the carpaltunnel. That's a whole different
episode. I love
Charles Goldfarb (23:01):
the comment about the fragility of the non
disposable 1.9 scope. I I wasdoing a small joint arthroscopy,
and to your point, small jointfor me as MCPS typically. And we
had a new SCRUB NURSE pairedwith an older scrub nurse, and I
asked for the scope, and shehanded me the scope, kind of
like this, holding the barrel ofthe scope. By the time it got to
(23:22):
me, it was totally useless. Likethose scopes are really fragile,
which is, which is, either youhave to be really careful or
have a good repair contract, oryou just switch and use the
disposables, which are not thatprice crazy. Let's briefly touch
on TFCC repairs, specificallyfoveal repairs. And so a lot of
(23:44):
us talk about ulnar tunnel, etc.
You've described, and I'mcurious if you still do it over
the top technique for fovealrepairs, what's your go to today
for foveal repairs? Yes,
Sanj Kakar (23:57):
it's a great question. And we used to do the
ALMA tunnel technique, which isan outside to inside technique.
But to your point, that can betechnically challenging when
you're putting that tunnel, ithas to be in the right spot and
and I do worry about tunnelfracture. You know when, when
you see your trainees trying tomake that tunnel multiple passes
(24:18):
of the KY you do worry aboutthat, and also you're limited in
terms of the aperture of yourtunnel, in terms of your suture
passage. So the over the toptechnique is a relatively more
straightforward technique, whereyou're literally coming from
over the top and putting yoursuture through. So the
difference is here is that youhave your camera in the six hour
(24:40):
portal, and you bring the needlethrough the three four portal,
and you direct it through theTFCC, so you see exactly where
you want to go through the TFCC,through the fovea and out the
other side. So instead of beingoutside to inside, it's an
inside to outside repair whereyou're putting a vertical
mattress suture. The advantagesare, it's it's quite. Cut. You
don't need fluoro for it. You'renot making big drill holes. So
(25:03):
there is a degree of sort offlexibility when you put your
repair in, where you if yourstitch isn't quite perfect, you
can put one either more bowleror more dorsal. And yeah, at
this stage, we're doing thatroutinely, and I've definitely
seen it's much quicker and it'seasier for actually, the
trainees to learn thattechnique.
Charles Goldfarb (25:23):
I continue to use the ulnar tunnel, but I
think a couple of your pointsare really important. First of
all, thankfully, I've never seena fracture. Hope I never do, but
you're right. The key aspect isyou're typically drilling a 3.0
millimeter pole. Once you putyour K wire, you over drill
through the ulna, starting justproximal to the Ole Miss
dialyde, aiming for the fovearegion. And then the spread of
(25:46):
your sutures, because the goalis a horizontal mattress can be
limited, and is techniquedependent with trainees,
absolutely. I you know, thereare different ways to cheat with
the ulnar tunnel. You know, youcan go outside of the tunnel
with one of your sutures.
There's different ways to do it.
But I think this concept isinnovative that you describe and
either be patient, you know, yougot to learn a technique and be
(26:08):
comfortable with it, but I thinkthe goal is a nice spread in
your sutures at the rightlocation. So for example, this
week, we had a dorsal radio,ulnar lunate tear and the volar
aspect seemed to be intact, andso after debridement, we placed
our suture dorsally, and we usethe ulnar tunnel technique. But
(26:29):
in some ways, I felt like we gota little lucky, because it went
in the right spot. I think yourtechnique may have provided more
control.
Sanj Kakar (26:36):
It's better to be lucky than good Chuck. But as
you both are lucky, and goodworks well. But the other thing
that I would also say issometimes, in these chronic
cases where the tissue qualityisn't the best, right, I want to
have a real wide spread of mysutures. And so, as you said, if
you're cheating, I'd rathercheat on getting a good bite of
the tissue, as opposed to beingright, perfectly anatomic where
(26:59):
you've got like, a twomillimeter suture tissue bridge.
And if you pull you can actuallypull it out. And if that happens
and that, then that's that's ahard one to salvage. What
Charles Goldfarb (27:10):
percentage and you and I have talked offline
about this, I think it'simportant for the listeners to
understand this, because I thinkwe see eye to eye on this, what
percentage of your TFCC repairsare superficial, peripheral
tears, rather than involving thephobia. So traditionally, if you
read the textbooks, you'll readabout either some type of suit,
(27:32):
soft tissue, suture, anchor, TFCto capsule, or you'll read about
using the ECU sub sheath in anoutside in way to repair the 2c
what percent of your repairs arethose types versus a foveal
repair?
Sanj Kakar (27:44):
Yeah, I would say so, you know, we have great
classifications in our in ourliterature, and we were taught
the Palmer classification, butthere's the at sea Lucchetti
classification, which has reallysort of opened my eyes to what
we call this type three tear,which is where you pop the
camera in, in the radio carpaljoint. And the TFCC looks
(28:05):
relatively pristine, but theproblem is, like the iceberg
concept, the problem isunderneath the top, is in the
fovea and and this is calledthat at sea, Luke type three
injury, where the injury is inthe foveal region. Now, as I
mentioned, it doesn't have to bea gross disruption. There's no
dij instability, but you get inthere and there's partial
(28:25):
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 highdegree of subjectivity in that
call, but I would say now I'mdoing far more foveal repairs
and typical, traditionalperipheral tears. And we talked,
and we talked a lot of ourcolleagues around the country,
(28:45):
and they're still doing a lot ofperipheral tears. But for me, I
would say it's probably, I wouldsay, I don't know, 80% phobial.
I would say it's pretty high.
And if I'm doing a peripheralit's more the ulnar ut split
tear that I'm seeing, as opposedto the typical peripheral tear
for
Chris Dy (29:01):
a non sub specialist in this area, can you just use a
foveal repair technique foreverything?
Sanj Kakar (29:08):
Well, I Yeah, cast aside, of course, no, I think
you can. But there is alsomorbidity, 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 foreverything. You know. That's
(29:28):
like saying doing almostshortening osteotomy for every
cell the animal side of wristpain. So I think you have to
have a degree of objectivity ofwhen you're using that. But it's
a good question.
Charles Goldfarb (29:40):
I think this is important, and I think there
will be people who disagree withthis, but I'm going to say it
relatively strongly, becausethat's how I feel about it.
Today, it might change. Numberone, if you have a split tear,
you have to address it. As Sanjhas said, the vast majority of
what I do include faucialrepairs, what I almost never do
now. I almost never, and I don'tremember the last time I did was
(30:03):
the, what I would call thedorsal ulnar peripheral tear,
and that is the ECU subsheettear. 20 years ago, a private
practice hand surgeon in StLouis came to the Shriners, and
we used to talk, and he, youknow, at that point, had a busy
arthroscopy survey. He said,Look, I never repaired this. I'm
like, What are you talkingabout? I always repair this. EC,
sharp teeth. Technique isfantastic. He's like, What are
(30:25):
you really doing? There's noinstability. There may be some
pain. If you debride that it'llheal. It took me 20 years to
figure it out, but I think he'sright, and I just don't do that
repair almost ever anymore.
Sanj Kakar (30:37):
Yeah, you know, it's funny. You say that about the UT
split test in my mind, I alwaysfix them. That's, you know, as
my mentor showed me how to doit, and I always fix them. But I
do know, you know, in my mind, Ido think to myself, well, what
happens if you simply debridethem and you immobilize them? Do
they heal and so that's, uh, youknow, that's a thought that goes
through my mind about that. Andsome people, I think, do they
(30:59):
just debris them and they weremobilizing. Yeah,
Charles Goldfarb (31:01):
just to be clear, I'm not saying I'm not
talking about that tear. I'mtalking about, okay, okay. I
just want to be clear. I wasn'tquestioning that, even though I
think it's a fair point. But Iwasn't questioning that. Yeah,
Chris Dy (31:12):
so before we shift to our final topic, we did want to
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Charles Goldfarb (31:39):
Chris gets excited when we talk anything
nerve so he read like 90% of thecopy for that. And so I get to
close that with to learn moreabout this and other educational
programs. Please visit nervemaster, calm. Check fully
surgical, driving innovation innerve surgery. I'm
Chris Dy (31:55):
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 thatlast
Charles Goldfarb (32:03):
line. You know, I'm working on the voice.
I need to be a little more, moredeep, probably to be, all right,
Sanj, we have a few minutesleft. We are grateful for your
time. We don't want tomonopolize it. So let's talk.
SL, tears. I'm going to startwith a simple question, not so
simple, when do you open toaddress a scaffolding ligament
(32:25):
injury? And when do you, andlet's not get into the specifics
yet, and when do you think aboutan arthroscopic approach? Yeah,
Sanj Kakar (32:31):
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 veryquickly, when you're looking at
the scans, I always look at thealignment of the scaphoid on the
sagittal view, the lunatealignment on the coronal view
and the axial view. See if it'sa dorsal level or through and
(32:52):
through injury. What I'll say tothem is, I'm going to scope you,
and we're going to go on thepathway of three ways. If it's
arthritic, then we have to godown the arthritis pathway. Now
that may be injections, that maybe a partial denovation. What do
you want to do if you aregrossly unstable and I cannot
get you arthroscopically, thenwe're coming back and doing a
(33:14):
stage reconstruction. And in myhands, that's an SL 360 but I
can honestly say, in the lastthree years, I've been able to
always get the reduction witharthroscopic means and and I
think there are, there are fivesort of ligaments that we have
to think about. We have to thinkabout the DCSS, we have to think
about the dorsal SL, we have tothink about the vola SL. We have
(33:36):
to think about the long radiolunate ligament. And we have to
see think about the insertion ofthe DIC ligament on the Luna.
Those are the five ligamentsthat you can address
arthroscopically. The one thatyou can't is the stt ligament,
and that a repair has beendescribed by Nick Smith in
Sydney and Australia, where it'sa small, mini open incision to
do those now, if I can get thereduction with sutures being
(33:58):
passed through that way, plus orminus k wires, and that's what
we're doing. And I have foundthat to be a very reproducible
method to do it. The morbidityof doing those is relatively
minimal. You're not making bigdrill holes in the in the carpus
and and we've all done SLreconstructions where you've had
a great reconstruction, thepatient's doing well. You come
(34:19):
back and they have a big X raygap, but I think, but they're
doing well. And I think witharthroscopy, you're stabilizing
the carpet. You may not get ridof the gap completely, but
they're stable, and they're andthey're mobile. They're not
stuck. They're not stuck interms of scar tissue. And so
that's sort of my algorithm foraddressing the SL with the
scope.
Charles Goldfarb (34:38):
I love that this is a lot, and obviously
we're not going to all ourlisteners, and likely Chris or I
are not going to master this inthe next few minutes. But what's
the most common arthroscopicprocedure you do for SL and
obviously it has to becustomized to the patient and
the situation. But what's. Themost common procedure you do?
Sanj Kakar (35:02):
Yeah, so did one just yesterday, patient came in
and was tender through andthrough. So I scoped them, and
the vola SL was off as well asthe dorsal and I put the volares
capsular, desist suture, pulledit down, reduced the vola side
and the dorsal side became morestable, and we were done. So I
would say the vola side is whereI'm going first, but I won't
(35:24):
hesitate to do the others. Butto your point, that's what I'm
doing most often.
Charles Goldfarb (35:29):
That's so interesting. And let's say you
have an MRI that's equivocal. Doyou have physical exam? Do you
have a feeling about physicalexam techniques to identify
vulner pathology. In otherwords, is there a point tender
area again? Can you talk aboutthat? Yeah,
Sanj Kakar (35:47):
so, so what they usually what I do is I'll
palpate first over the fcr tomake sure it's not fcr
tendinitis. I'll then put myfinger on the fcr and pull it
only and go deep to that. Now,essentially, there's three
issues there. There's either anoccult volar ganglion, there's
either an extrinsic injury,maybe radio Skipper caps, or
long radio lunate ligament. Or,if you're pushing really deep,
(36:08):
it's the volar SL, but those butthe 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 maynot and so those are the ones
that you'll pop the camera in.
And as I said yesterday, wepopped it in, and there was a
partial avulsion of the longradio lunate ligament off the
distal radius proximately.
Charles Goldfarb (36:31):
And this is great. And I think to listeners,
this is not something you'retypically going to learn on your
hand rotation unless someone'sreally focused. I think that
point tender area is underappreciated. And I love the how
you stated that. So in the caseyou did yesterday, you did the
volar capso Desis. And I don'twant to say it's going to come
out wrong, but is that all youdid, in the sense you did, you
(36:53):
try to do anything to have thelong radio lunate heal back to
bone?
Sanj Kakar (36:57):
Yeah. So what? So what I did then is, for that
one, then I took the shaver inbecause it was a partial injury,
I'd say maybe 20 to 30% partial.
The rest was on intact. I took ashaver and debrided the base of
the radius and also the longradio lunate ligament. And then
we described this, recentlypublished in JHS, the Merlin
technique, where you basicallydo an invocation long radio
lunate ligament. Now, if therewas a complete detachment of the
(37:20):
long radio ligament off theradius, you were already bowler,
because you made a bola radialportal, then you would put an
anchor into the radius and thentie that ligament down to the
radius.
Charles Goldfarb (37:34):
Let's step back for one second if you have
an MRI identified membranoustear. And for those who don't
know the terminology,specifically, that's not dorsal,
that's not volar. It's sort ofthe proximal aspect of the C MRI
looks like his membranous a doyour arthroscopy for a patient
with radio sided pain, dorsaland volar seem to be intact, and
(37:55):
he had this membranous tear.
What do you do then? Is it justa simple debridement?
Sanj Kakar (38:00):
Yeah, I'm not, I'm not fixing that. But truth be
told, Chuck, if I'm seeing amemoryless tear, I mean, I'll
debride it. But in my, in mysort of gut instinct, I'm
thinking, Am I really addressingthe problem here?
Charles Goldfarb (38:12):
That that's what I was hoping you would say.
I think that situations reallyrare where you just have
memories, and I see op noteswhere people have just debrided
the membrane is tear. And I'malways a little questioning is,
was there really something elsegoing on?
Sanj Kakar (38:28):
Yeah, yeah. So
Chris Dy (38:30):
he actually brings up a really good point. I wanted to
ask both you, given that you aresuper specialized experts and
nationally and internationallyrecognized for this area, what
are the most common things thatpeople don't treat appropriately
or miss, or, you know, lead toissues down the line. With
regards to SL,
Sanj Kakar (38:51):
I think, honestly, it's the diagnosis, right? I
think it's we were, we weretaught, if the X rays are
normal, get a stress view, andif 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, onpatients with normal X rays,
(39:11):
both at rest and stress views,and 40% had high grade geyser
three or four instability. So Ithink that's the first one. I
think getting the diagnosiscorrect. I think the second
thing is coming in with a hammeras one treatment suits all and
so, you know, when, when, whenwe were residents and fellows.
(39:33):
It was a three ligament Tinathesis, right? And that was the
one that was being doneessentially, for most SLS, and
I'm not knocking that operation,but my point is that it may be a
border injury, maybe a dorsalinjury, maybe through and
through, there may be extrinsicligament injuries as well. So
you can't just have one approachto addressing the SL so I would
say those are the two biggestsort of areas that I think,
(39:56):
hopefully, that we can addressfor. For people that you can't
think of it as a like an actionpotential. It's not all or
nothing. Chris, so there youare. We got nerve in there for
you, right? It has to be more ofa rainbow approach. And how to
address this,
Charles Goldfarb (40:13):
I would close by offering this. When I was a
resident, we were and Chris, youwere in grade school. We were
essentially witnessing atransformation from open rotator
cuff repairs to many openrotator cuff repairs to all
arthroscopic repairs. And thathappened over a period of, I
(40:36):
don't know how many years, six,810, years, and I would say
we're in the midst of that forSL and Sandra is leading the
way, certainly amongstAmericans. I think we may be
behind some of our internationalcolleagues, but I think in 10
years from now, the landscape isa look very different on how we
(40:57):
approach these and you know, wehave to do a lot of things. We
have to communicate better onwhat we're doing to treat these
arthroscopically. We have toreally simplify techniques, and
industry needs to partner withus to assist in that. And then
we need to popularize thesetechniques. Because I do agree,
there has been one big hammer,and I have been guilty, one big
(41:18):
hammer to treat these injuries,and it needs to be much more
refined than that.
Chris Dy (41:25):
Thank you, both of you. That was That was
fantastic. We I've learned a loton this episode, and I think
it's a really nice way to setthe stage for the young folks
who want to take this take thischarge and lead us forward. So
Sarge, always super fun to haveyou on. I'm sure we'll get
listener feedback that we wantto have you on again. So thank
you for becoming our recurringguest for arthroscopy and wrist
(41:48):
pain.
Sanj Kakar (41:50):
Always a pleasure.
Chuck and Chris, it's good tosee you, and I love spending
this time with you, and happy tocome back and talk more about
wrist and arthroscopy.
Charles Goldfarb (42:00):
Awesome. Thank you so much. Hey, Chris, that
was fun. Let's do it again realsoon.
Chris Dy (42:05):
Sounds good. Well, be sure to email us with topic
suggestions and feedback. Youcan reach us at hand
podcast@gmail.com
Charles Goldfarb (42:12):
and remember please subscribe wherever you
get your podcast, and
Chris Dy (42:16):
be sure to leave a review that helps us get the
word out.
Charles Goldfarb (42:20):
Special, thanks to Peter Martin for the
amazing music, and
Chris Dy (42:23):
remember, keep the upper hand. Come back next time
you
Charles Goldfarb (42:44):
Hey, Chris, that was fun. Let's do it again
real soon.
Chris Dy (42:47):
Sounds good? Well, be sure to email us with topic
suggestions and feedback. Youcan reach us. You.
Chuck, welcome to the upper hand podcast where
(00:07):
Chuck and Chris talk handsurgery.
Chris Dy (00:09):
We are two hand surgeons at Washington
University in St Louis, here totalk about all things hand
surgery related, from technicalto personal.
Charles Goldfarb (00:17):
Please subscribe wherever you get your
podcasts, and thank
Chris Dy (00:20):
you in advance for leaving a review and rating that
helps us get the word out. Youcan email us at
handpodcast@gmail.com so let'sget to the episode. Oh, hey,
Chris, hey, Chuck, how are you?
I'm
Charles Goldfarb (00:33):
really good today.
Chris Dy (00:35):
Excellent. It looks like you are in the office, as
is our special guest, also inthe office. Our
Charles Goldfarb (00:40):
special guest, Sanj Kakaar, is rejoining us by
popular demand, because everyoneloved the first episode on
skatefa Luna, we wanted to takea deeper dive and talk a lot
about technique, because Sanj isa luminary. He's going to teach
us all today.
Chris Dy (00:58):
Sanj, welcome back.
Sanj Kakar (01:00):
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 (01:08):
I think Saj and I are both in the office.
Chris, where are you?
Chris Dy (01:11):
I'm at home.
Fortunately, Saturday morning.
Can't think of a better way thanto spend it with you guys. I'm
sure you're both doing yourdiligence and rounding and
seeing patients and cleaning upcases from, uh, from your call,
Charles Goldfarb (01:24):
I think. And I love Sanj's opinion when I
round, which I try to do aslittle as possible, but when I
do round, it's always enjoyable.
It's just like coming in for acase in the middle of night.
It's never the actual coming inand doing the case. It's sort of
what happens after. But I got tohang out with one of our amazing
residents, Jeremy Huckabee,who's just an amazing guy, and I
learned things about him Ididn't know. And it was, it was
(01:45):
kind of fun,
Sanj Kakar (01:49):
Chuck, I think you're rounding early like me,
because you know that the soccermatches are going to kick off.
You know, we're six hours behindthe UK. So that's why you're
you're rounding now. Don't letanyone believe anything else
this.
Charles Goldfarb (02:01):
This is true.
And then I also have a businessschool final to finish this
morning.
Chris Dy (02:07):
You know, you know, Chuck, the residents are going
to realize, those that arelistening are gonna realize how
out of touch you are. You know,rounding is just a novel, fun
thing for you, and it's just dayin, day out slog for them for
years. So we're very lucky thatwe have residents and fellows
that carry the load for sure,
Charles Goldfarb (02:25):
very, very true. All right, let's not keep
our listeners waiting too long.
We have four or five points wewant to cover with Sanj Over the
next 40 minutes, and we'll startwith something I know he feels
passionately about, which is dryarthroscopy. So Sanj, give us a
little background on how and whyyou started using dry arthrospy.
Do you always use dryarthroscopy and what you think
(02:48):
the benefits are?
Sanj Kakar (02:52):
Yeah, it's a great, great question, Chuck, and I'm
asked this a lot. You know, Itrained here at Mayo, doing my
fellowship with Dick Berger andAlan bishop, and were big wet
arthroscopy proponents. Sothat'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 theopportunity to sort of go and
(03:13):
see some of the luminariesaround the world. And I would
say, you don't need to have anamed traveling fellowship to
anybody out there who'sinterested to learn just, just
go and visit people, be thatnationally, internationally,
just even across your town. It'samazing what you can learn from
others. And it struck me thatthere were so many people doing
dry arthroscopy, and this waslike a real big sort of light
(03:36):
bulb going off. And I rememberPaco del Pinal at the hand
society once talking about dryarthroscopy with distal radius
fractures, and just talking tohim about his sort of experience
with this. And what have I seennow in my practice? Now 2025,
basically, and moving forward,it allows me to do much more
(03:58):
than I used to do. I used toalways get frustrated with fluid
in the joint, you get softtissue extravasation. And as you
know, Chuck and Chris, anytimeyou're doing arthroscopy is
sometimes it's more sort ofarthroscopic assisted, so you're
making incision, so it's harderto find your soft tissue planes
with all the soft tissue fluid.
And then also, I was worriedabout disadractures, for
example, in compartmentsyndrome, so I never did one
(04:20):
wet, because I was worried aboutthat. And then also, I just
found that you can do much moredry than wet. You can make
bigger portals so you can makeyou can put larger Shavers and
burst your resection is muchmore efficient. You ask the
question, do I always do dry? Iwould say 99.9% the two times
that I don't is when I'm doingthermal shrinkage. And so you do
(04:43):
need fluid in the joints. Youdon'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 surewhat's going on in your
institution, but in ourinstitution, that's been a big
(05:05):
hit, especially on our sportsmedicine colleagues, who do a
lot of wet arthroscopy, wherewe're told to sort of decrease
our fluid use. So for me, inthat way, it hasn't really been
an issue.
Charles Goldfarb (05:16):
Yeah, it's an interesting point. I would say I
would maybe 25% now I'm doingdry arthroscopy, and it is a I'm
just transitioning slowly, and Iabsolutely have started to see
the benefit. I'm not completelyconvinced yet, but Chris, I know
you don't do a ton ofarthroscopy, but you definitely
do scope. What are yourthoughts? I
Chris Dy (05:37):
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 todo it, and what's your
rationale, so that people whoare like me, kind of a general
hand surgeon in that regard, ofvia, 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 Ican't do. What are the reasons
(05:58):
that you decided to take thisjump into doing 25% of your
cases with dry arthroscopy well.
Charles Goldfarb (06:02):
One, in all seriousness, I do respect Sanj,
and when someone like that saysthat it works for them, I I want
to try it out. Two, I think thefluid, the lack of IV fluids,
the crisis, so to speak,contributed to my interest in
doing more of it. And it's justfor certain risks, especially
those where I know I'm doing anopening procedure, it just makes
(06:25):
sense. And as long as I canvisualize well, and I generally
can, I like it, there's no doubtI like it. And so it's just, I
feel like, if you know there aresome risk arthros are very
straightforward, and some for meremain a struggle, whether the
wrist is tight, whether thehumerus is short, and you just
(06:48):
struggle to get things exactlylike you need to. I tend to
blame fluid or not fluid, so Idon't want to bring the lack of
fluid into it, but I do thinkit's going to be a slow
transition towards dryarthroscopy for me, Sanja. Was
it an evolution for you? Wouldyou go cold turkey?
Sanj Kakar (07:03):
No, I did go cold turkey, Chuck. And so I would
say, I would say to people andand even just watching and
training people at courses, whatI would say to you is this,
we're always taught put theneedle in three, four portal and
insufflate the joint, right? Youdon't want to do that. You want
to stick the needle in. And thegoal is to get the shaver in as
quickly as possible, becausethere's some synovial fluid.
(07:23):
There's bubbles in the joint.
You can't see so I remember. Soyou don't want to start off
doing, for example, a fracturecase, right? So let's say you're
doing a TCC debridement. Startoff very simple, or a ganglia or
something like that. So what Iwould say to my scrub tech is,
I'm going to ask for fluidwithin 60 seconds, right? Your
but your answer is, No, I'm notgoing to give it to you. And so
I had to struggle a bit, alittle. And so the key is, get
(07:44):
your needle in, make your threefour 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, nota 30 CC, a 10 cc syringe. And
usually I use a two millimetershaver, and that's enough,
enough suction power on thesyringe to do an automatic
washout. And, you know, we putthis on videos, on handy, or on
(08:05):
Anthology, so people can see howto technically do that. And then
once you sort of lavage thejoint, you leave the shaver on
and you want to get rid of allthe 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 getunderneath there, there'll be
crab meat in your face. Youcan't see anything. Can you just
(08:25):
pull the camera out and you justsay, 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, thatwas a that was a thing for me in
2017 I'd never really seen thephobia before, and I didn't know
what that looked like. And, youknow, we're all well into
practice there. So it's justsort of that evolution. But as
you said, Chris, you know, youhave to start simple and build
(08:47):
up. And you'll you'll see,there's a couple of tricks. So
you sometimes you get stuff onthe lens of the camera and you
can't see. So what are thetricks? So number one, well, the
first thing that I do is I wipethe 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 Ido the automatic washout
(09:10):
technique. And if that doesn'thappen, Chris, I know you're a
big micro proponent, and so whatwe do is we want to be
respectful of micro surgery. Sowe have the micro wipe, you
know, that you use to wipe theneedle, so we have that wet on
the table, and we simply wipethe lens. And those little three
tricks are all that you need toensure that you can see with
your camera.
Charles Goldfarb (09:29):
So two, two comments and a question, and
sorry, Chris, I beat you to it.
Comment number one is, ifthere's a national shortage of
micro wives, we know wherethey'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 insufflatingthe joint. I stopped that many,
many years ago. It does nothingfor you. It's vital for an elbow
(09:51):
arthroscopy. It's a waste oftime for the wrist. Insufflating
the wrist joint does nothing.
That's number one. Number twois. Essentially use a two
millimeter shaver. I use a threemillimeter shaver in most
situations, just because I'mimpatient. You may be more
patient than I but I like theyou know, size and power, etc.
(10:12):
And then my question is, andwe're already on a tangent,
which is totally fine. Explainhow you technically assess the
phobia when you do a d a, quote,unquote, d r u j, arthroscopy,
because, as I recall, you're notputting your portals necessarily
in the D R, E, J, but correct meif I'm wrong,
Sanj Kakar (10:33):
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? Youstick a needle in, and then you
spread, and then you worryabout, are you gouging the
articular cartridge of the I'llbe 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
(10:54):
camera, right? So you use a 1.9millimeter camera, so you have
your camera in the three, fourportal, and you put your needle
underneath the middle of theTFCC, in the middle of the ulna
head. What people tend to do isthat they go to the words the
ulna styloid. They took theirtwo ulna and remember, then
you're in the fovea and ifthere's a foveal injury, you're
in scar tissue. So what I do isI slowly pronoun supinate. I
(11:17):
feel the D, i, u, j, then I feelthe on the styloid, and I put my
needle in the middle of the onthe head, underneath the TFCC,
and I move the needle up anddown, so I know 100% I'm in the
right spot. Then you make atransverse incision or
longitudinal, it doesn't matter,spread, spread, spread. And you
pop into your scissors areunderneath the TFCC. You move
your scissors up and down. Youhave the camera in the three
(11:37):
four portals. You know you're inthe right spot. And then the
system that I use has twocannulas. And so you simply now
bring the second cannula in,you're underneath the TFCC, and
then you put the camera in, andthe first thing that you're
going to see is white becauseyou're adjacent to the bowler
capsule. So I bring the cameraback, and then I'm slowly
pronoun supinating, and I'mlooking for the sigmoid notch,
because then I know exactlywhere I'm at. And then I'll move
(11:59):
the camera towards the ulnaside, and that's where you'll
see the phobia. Now, sometimesthe scar tissue, though, is you
have to bring a shaver in, but Iwould say seven out of 10 times
I'm clinically suspecting afoveal injury, the synovitis in
that area. And then you can seethe phobia. But to your point,
you have to build up, like youshowed in that, in this work
(12:21):
that that you spearheaded, aboutthe TFCC, right? The trampoline
test, the hook test, you have tofind out what your normal is for
phobial attachments, becauseit's a gradation of injury,
right? It's either torn or it'snot torn. I don't think it's as
black and white as that. It'sgray. So there's partial
injuries. There's near complete.
(12:42):
So you have to scope as many asyou can. And trust me, the first
one you do, you're going to befrustrated. But again, it's just
going through that. And I muststress, you have to, you can't
do it with a regular 2.7 camera.
It's too big. So
Chris Dy (12:56):
the the 1.9 millimeter camera seems to be pretty
essential for this. But I thinkthat your your points. I want to
dig in a little bit more aboutthe experience with arthroscopy
and Chuck. Maybe you could talka little bit about two papers
that you worked on, because Ithink they're very relevant and
educational. The first beingwhat Sanja alluded to with the
how you evaluate the TFCC interms of trampoline versus hook.
(13:19):
So just for the general handsurgeon or a resident. Talk
about how you do that. And thenthe second one is, can you talk
a little bit about the thevariability in in grading of
some of these that's in some ofthe more recent work that you,
that you guys have
Charles Goldfarb (13:34):
worked on together? Yeah, I can super I
can jump in super quick on that.
So the first paper we did was acadaver study looking at how
does one diagnose a phobialtear? We certainly didn't come
up with a concept of hook test,but we took cadavers without
evidence of injury, we used abeaver blade through a minimally
invasive approach to cut thefoveal insertion, and then we
(13:54):
repeated our arthroscopy. Westarted before cutting and then
after cutting, and wedemonstrated that the hook test
was helpful. The hook test isnot a simplistic yes or no test,
either. It's become clear thatpeople feel there are gradations
to Sandra's point, gradations inthe completeness of a tear, so
to speak. And so the goal is,you know, the trampoline test is
(14:16):
absolutely non specific, and italso is very operator dependent
and tactile dependent. But thehook test, we thought maybe yes
or no, but even that is vague.
But the idea is that you go veryolderly, and you take your probe
and put it under the TFCC andtry to lift up towards the
(14:38):
traquitrum. And again, it's asense of feel, but that's the
gist behind it. And so what Sanjand I did, along with others, is
we took 40 videos, and we ratedour ability to assess, basically
our Inter observer liability onTFCC tears. And suffice to say
is we weren't very good, exceptfor central tears, where we were
(14:59):
really good. But that should notbe we shouldn't pat ourselves.
Look back too much for that, sothat capture it. Sanj, yeah,
Sanj Kakar (15:07):
yeah, absolutely.
So. So for me, Chris, when Iwhen I'm scoping a risk and I'm
worried about the TFCC, I dofour tests. I do the trampoline
test, I do the the hook test, Ido the suction test. We
basically have the suction turn.
You have the suction on shaverin sorry, you lift it off the
TFCC, and you turn the suctionon and off, and you see if that
lifts up or down. And then thethird one that I'll do is I'll
(15:29):
always scope the diuj. I alwaystell our residents and fellows,
right? You do a radio carpaljoint arthroscopy, you look at
the TFCC, and you also always goas far on as you can my mentor,
Dick Berger, talked about theonly tricoectal Split tear. And
so there's always synovitis inthat area if there's a tear. And
so you have to debride thatsynovitis to see if there truly
(15:51):
is a tear or not. And then I'llscope the D, I, E, J, after
that. So those sort of fourthings in my mind are key when
you're looking for the TFCCpathology, I want
Chris Dy (16:04):
to ask one more question before we shift gears
for the drej arthroscopy. Howessential is that? Do you think
to evaluation of TFCC lesions ingeneral, in particular for fovea
lesions, do you think that yougain a lot of information from
that fourth test compared to thethree others that you described.
Sanj Kakar (16:23):
So I'll give you a study here, right? So you, and
that's what I credit you and alot of our friends in hand
surgeries that we study ouroutcomes and and how our
patients are doing. So wepublished a study, I think it
was on 24 patients, and all ofthem had foveal injuries proved
on arthroscopy and MRI was onlyaccurate in 1/3 of those
(16:48):
patients. And of those patients,about 75% had stable diu J's.
So. So this dogma that we weretaught that if you have a foveal
injury is diuj, instability issimply not true. So when you see
a patient in clinic and they'retender in the phobia, to me,
it's a TFCC or on triquetralSplit tear, until proven
(17:09):
otherwise. So to your point,Chris, if I scope the
radiocarbon joint, I see a bigut split tear, or I see a big
peripheral TFCC tear. Then,then, no, I won't scope the dij.
But you know, I remember sittingwith Chuck. We were at the hand
society, and I was saying tosaying, Chuck, are you seeing
these patients with centraltears and a foveal tear at the
same time? Because we weretaught you have a central 10.
(17:31):
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 toscope the Diag for that, for
those cases, but I think as longas you have a high index of
suspicion, that's when I thinkit's indicated.
Charles Goldfarb (17:49):
I love that, and we're going to thank our
sponsors here in a second. But Iwould say two things to
listeners who are like, Oh myGod, I don't think I'm ever
scoping a wrist again. Numberone, Sanja obviously has an
immense experience, and I thinkhis take homes are really
important. Number two, I don'thave quite as much faith in the
suction test. I think it'simportant to do it. And if you
(18:12):
have a guess, I would say acomplete foveal tear, then you
will see that TFCC elevate. It'snot always again, as black and
white as we would like. And thelast thing in Sanj knows, and
I've said this before, andothers have said this to him,
the LT split tear is, I guess, Iwould say, harder for some of us
to appreciate than others,because of Sanj is influence I
(18:34):
look forward every time, myguess is he diagnoses it more
than I do. You
Chris Dy (18:39):
trying to say it's controversial or maybe fake
news?
Charles Goldfarb (18:43):
No, I would never say alternative facts.
Sanj Kakar (18:47):
There we go. Chris, be careful.
Chris Dy (18:52):
Talk about talk about alternative facts before we move
to our next topic, we shouldthank our sponsors. The overhand
is sponsored by practicelink.comthe most widely used position
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Charles Goldfarb (19:05):
But coming up position is hard. Finding the
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today@www.practicelink.combackslash the upper hand.
Alright, briefly. Sanj, so far,we're not good at being brief.
Briefly, tell us about the Nanoscope. I know, and I think full
disclosure, you do 1.9
Chris Dy (19:24):
millimeter Well, well, there are non
Charles Goldfarb (19:27):
disposable 1.9 millimeter scopes, and there are
disposable 1.9 millimeterscopes. And Sanjay, I do believe
you work with Arthrex and and myunderstanding is the nanoscope
is a zero degree scope, whichtakes a little getting used to.
It is disposable, but explainhow you use it, what diagnoses
you use it for, and why youthink it's super helpful. Yeah,
Sanj Kakar (19:48):
no. Thanks for that question, and I appreciate Yeah,
just for transparency anddisclosure. I do have a
consulting agreement with ourthreats and have worked on on
this. What I what I would say toyou with the nanoscope and. And
Chris is, as you mentioned,there are traditional 1.9
millimeter scopes out there aswell. So what the big sort of
aha moment for me with the withthe nanoscope, was the degree of
(20:10):
flexibility. The typical 1.9millimeter scopes are very short
and rigid, and they're fragile.
And I remember on the shelf wewould ask for one, and they
would always be broken or in therepair shop. And so the beauty
of the 1.9 millimeter nano scopeis that it's flexible, so it
allows you to get into spaceswhere we would struggle with it
first. So for example, the DIEJ, we've talked about, the MCP
(20:31):
joint. I've never scoped the MCPjoint, the stt, the CMC. It's
allowed me to get into thosesmaller joints relatively a
dramatically. You're right. It'sa 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 youthat sort of flexibility, if you
want. But for me, it's not justabout the nanoscope chuck and
(20:55):
Chris. It's about what that hasgiven me in terms of
arthroscopy. So my acronym forarthroscopy is first. When I
think of first, I think of thoseindications for arthroscopy,
fractures. We talked a littlebit fusions. For example, you
have a lunate cyst. How do youget into that lunate cyst in an
arthroscopic way? You can dothat going through the
(21:16):
membranous portion of the LT orthe 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 reconstructionscaffold, lunate, that has been
a big game changer for me, andwe've talked about that
previously, about scaphaloneinstability and repairs. The
(21:38):
other s, as I mentioned, issmall joint arthroscopy
yesterday we had a Bennett'sfracture. And you know those
Bennett fractures, you havethose small, little fragments,
and you think you sort of get iton K wire, you take in multiple
fluoroscopic views. Andyesterday we had one that was
fragmented, and I just couldn'tget it in a closed manner. But
with arthroscopy, it allowed meto get in there, to breathe the
hematoma and get that reduction.
And the T in first is tunnel, socarpal tunnel, cubital tunnel,
(22:02):
exercise induced compartmentsyndrome. These patients are
usually young, bilateral, andtraditional big forearm
fasciotomies are kind ofunsightly, but with arthroscopy,
and it doesn't need to just bethe nanoscope it could be with
any camera, it allows you to dothese sort of procedures in a
more minimally invasive way. Andso that's sort of been my
(22:23):
Genesis on using nanoscopetechnology to allow me to
address more than I could dobefore you
Chris Dy (22:31):
really you know the Rochester spelling is different.
So you spell first F, F, F, F, IR, R, S T, T, T. Is that
correct? F,
Sanj Kakar (22:42):
i, r, s, t, but there's several F,
Chris Dy (22:47):
2r and four T's. But
Unknown (22:49):
you can see there's so many. I've got so many ideas on
how the F is. You startedgetting
Chris Dy (22:53):
me going using the arthroscope as the nanoscope as
an endoscope for the carpaltunnel. That's a whole different
episode. I love
Charles Goldfarb (23:01):
the comment about the fragility of the non
disposable 1.9 scope. I I wasdoing a small joint arthroscopy,
and to your point, small jointfor me as MCPS typically. And we
had a new SCRUB NURSE pairedwith an older scrub nurse, and I
asked for the scope, and shehanded me the scope, kind of
like this, holding the barrel ofthe scope. By the time it got to
(23:22):
me, it was totally useless. Likethose scopes are really fragile,
which is, which is, either youhave to be really careful or
have a good repair contract, oryou just switch and use the
disposables, which are not thatprice crazy. Let's briefly touch
on TFCC repairs, specificallyfoveal repairs. And so a lot of
(23:44):
us talk about ulnar tunnel, etc.
You've described, and I'mcurious if you still do it over
the top technique for fovealrepairs, what's your go to today
for foveal repairs? Yes,
Sanj Kakar (23:57):
it's a great question. And we used to do the
ALMA tunnel technique, which isan outside to inside technique.
But to your point, that can betechnically challenging when
you're putting that tunnel, ithas to be in the right spot and
and I do worry about tunnelfracture. You know when, when
you see your trainees trying tomake that tunnel multiple passes
(24:18):
of the KY you do worry aboutthat, and also you're limited in
terms of the aperture of yourtunnel, in terms of your suture
passage. So the over the toptechnique is a relatively more
straightforward technique, whereyou're literally coming from
over the top and putting yoursuture through. So the
difference is here is that youhave your camera in the six hour
(24:40):
portal, and you bring the needlethrough the three four portal,
and you direct it through theTFCC, so you see exactly where
you want to go through the TFCC,through the fovea and out the
other side. So instead of beingoutside to inside, it's an
inside to outside repair whereyou're putting a vertical
mattress suture. The advantagesare, it's it's quite. Cut. You
don't need fluoro for it. You'renot making big drill holes. So
(25:03):
there is a degree of sort offlexibility when you put your
repair in, where you if yourstitch isn't quite perfect, you
can put one either more bowleror more dorsal. And yeah, at
this stage, we're doing thatroutinely, and I've definitely
seen it's much quicker and it'seasier for actually, the
trainees to learn thattechnique.
Charles Goldfarb (25:23):
I continue to use the ulnar tunnel, but I
think a couple of your pointsare really important. First of
all, thankfully, I've never seena fracture. Hope I never do, but
you're right. The key aspect isyou're typically drilling a 3.0
millimeter pole. Once you putyour K wire, you over drill
through the ulna, starting justproximal to the Ole Miss
dialyde, aiming for the fovearegion. And then the spread of
(25:46):
your sutures, because the goalis a horizontal mattress can be
limited, and is techniquedependent with trainees,
absolutely. I you know, thereare different ways to cheat with
the ulnar tunnel. You know, youcan go outside of the tunnel
with one of your sutures.
There's different ways to do it.
But I think this concept isinnovative that you describe and
either be patient, you know, yougot to learn a technique and be
(26:08):
comfortable with it, but I thinkthe goal is a nice spread in
your sutures at the rightlocation. So for example, this
week, we had a dorsal radio,ulnar lunate tear and the volar
aspect seemed to be intact, andso after debridement, we placed
our suture dorsally, and we usethe ulnar tunnel technique. But
(26:29):
in some ways, I felt like we gota little lucky, because it went
in the right spot. I think yourtechnique may have provided more
control.
Sanj Kakar (26:36):
It's better to be lucky than good Chuck. But as
you both are lucky, and goodworks well. But the other thing
that I would also say issometimes, in these chronic
cases where the tissue qualityisn't the best, right, I want to
have a real wide spread of mysutures. And so, as you said, if
you're cheating, I'd rathercheat on getting a good bite of
the tissue, as opposed to beingright, perfectly anatomic where
(26:59):
you've got like, a twomillimeter suture tissue bridge.
And if you pull you can actuallypull it out. And if that happens
and that, then that's that's ahard one to salvage. What
Charles Goldfarb (27:10):
percentage and you and I have talked offline
about this, I think it'simportant for the listeners to
understand this, because I thinkwe see eye to eye on this, what
percentage of your TFCC repairsare superficial, peripheral
tears, rather than involving thephobia. So traditionally, if you
read the textbooks, you'll readabout either some type of suit,
(27:32):
soft tissue, suture, anchor, TFCto capsule, or you'll read about
using the ECU sub sheath in anoutside in way to repair the 2c
what percent of your repairs arethose types versus a foveal
repair?
Sanj Kakar (27:44):
Yeah, I would say so, you know, we have great
classifications in our in ourliterature, and we were taught
the Palmer classification, butthere's the at sea Lucchetti
classification, which has reallysort of opened my eyes to what
we call this type three tear,which is where you pop the
camera in, in the radio carpaljoint. And the TFCC looks
(28:05):
relatively pristine, but theproblem is, like the iceberg
concept, the problem isunderneath the top, is in the
fovea and and this is calledthat at sea, Luke type three
injury, where the injury is inthe foveal region. Now, as I
mentioned, it doesn't have to bea gross disruption. There's no
dij instability, but you get inthere and there's partial
(28:25):
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 highdegree of subjectivity in that
call, but I would say now I'mdoing far more foveal repairs
and typical, traditionalperipheral tears. And we talked,
and we talked a lot of ourcolleagues around the country,
(28:45):
and they're still doing a lot ofperipheral tears. But for me, I
would say it's probably, I wouldsay, I don't know, 80% phobial.
I would say it's pretty high.
And if I'm doing a peripheralit's more the ulnar ut split
tear that I'm seeing, as opposedto the typical peripheral tear
for
Chris Dy (29:01):
a non sub specialist in this area, can you just use a
foveal repair technique foreverything?
Sanj Kakar (29:08):
Well, I Yeah, cast aside, of course, no, I think
you can. But there is alsomorbidity, 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 foreverything. You know. That's
(29:28):
like saying doing almostshortening osteotomy for every
cell the animal side of wristpain. So I think you have to
have a degree of objectivity ofwhen you're using that. But it's
a good question.
Charles Goldfarb (29:40):
I think this is important, and I think there
will be people who disagree withthis, but I'm going to say it
relatively strongly, becausethat's how I feel about it.
Today, it might change. Numberone, if you have a split tear,
you have to address it. As Sanjhas said, the vast majority of
what I do include faucialrepairs, what I almost never do
now. I almost never, and I don'tremember the last time I did was
(30:03):
the, what I would call thedorsal ulnar peripheral tear,
and that is the ECU subsheettear. 20 years ago, a private
practice hand surgeon in StLouis came to the Shriners, and
we used to talk, and he, youknow, at that point, had a busy
arthroscopy survey. He said,Look, I never repaired this. I'm
like, What are you talkingabout? I always repair this. EC,
sharp teeth. Technique isfantastic. He's like, What are
(30:25):
you really doing? There's noinstability. There may be some
pain. If you debride that it'llheal. It took me 20 years to
figure it out, but I think he'sright, and I just don't do that
repair almost ever anymore.
Sanj Kakar (30:37):
Yeah, you know, it's funny. You say that about the UT
split test in my mind, I alwaysfix them. That's, you know, as
my mentor showed me how to doit, and I always fix them. But I
do know, you know, in my mind, Ido think to myself, well, what
happens if you simply debridethem and you immobilize them? Do
they heal and so that's, uh, youknow, that's a thought that goes
through my mind about that. Andsome people, I think, do they
(30:59):
just debris them and they weremobilizing. Yeah,
Charles Goldfarb (31:01):
just to be clear, I'm not saying I'm not
talking about that tear. I'mtalking about, okay, okay. I
just want to be clear. I wasn'tquestioning that, even though I
think it's a fair point. But Iwasn't questioning that. Yeah,
Chris Dy (31:12):
so before we shift to our final topic, we did want to
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Charles Goldfarb (31:39):
Chris gets excited when we talk anything
nerve so he read like 90% of thecopy for that. And so I get to
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Chris Dy (31:55):
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 thatlast
Charles Goldfarb (32:03):
line. You know, I'm working on the voice.
I need to be a little more, moredeep, probably to be, all right,
Sanj, we have a few minutesleft. We are grateful for your
time. We don't want tomonopolize it. So let's talk.
SL, tears. I'm going to startwith a simple question, not so
simple, when do you open toaddress a scaffolding ligament
(32:25):
injury? And when do you, andlet's not get into the specifics
yet, and when do you think aboutan arthroscopic approach? Yeah,
Sanj Kakar (32:31):
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 veryquickly, when you're looking at
the scans, I always look at thealignment of the scaphoid on the
sagittal view, the lunatealignment on the coronal view
and the axial view. See if it'sa dorsal level or through and
(32:52):
through injury. What I'll say tothem is, I'm going to scope you,
and we're going to go on thepathway of three ways. If it's
arthritic, then we have to godown the arthritis pathway. Now
that may be injections, that maybe a partial denovation. What do
you want to do if you aregrossly unstable and I cannot
get you arthroscopically, thenwe're coming back and doing a
(33:14):
stage reconstruction. And in myhands, that's an SL 360 but I
can honestly say, in the lastthree years, I've been able to
always get the reduction witharthroscopic means and and I
think there are, there are fivesort of ligaments that we have
to think about. We have to thinkabout the DCSS, we have to think
about the dorsal SL, we have tothink about the vola SL. We have
(33:36):
to think about the long radiolunate ligament. And we have to
see think about the insertion ofthe DIC ligament on the Luna.
Those are the five ligamentsthat you can address
arthroscopically. The one thatyou can't is the stt ligament,
and that a repair has beendescribed by Nick Smith in
Sydney and Australia, where it'sa small, mini open incision to
do those now, if I can get thereduction with sutures being
(33:58):
passed through that way, plus orminus k wires, and that's what
we're doing. And I have foundthat to be a very reproducible
method to do it. The morbidityof doing those is relatively
minimal. You're not making bigdrill holes in the in the carpus
and and we've all done SLreconstructions where you've had
a great reconstruction, thepatient's doing well. You come
(34:19):
back and they have a big X raygap, but I think, but they're
doing well. And I think witharthroscopy, you're stabilizing
the carpet. You may not get ridof the gap completely, but
they're stable, and they're andthey're mobile. They're not
stuck. They're not stuck interms of scar tissue. And so
that's sort of my algorithm foraddressing the SL with the
scope.
Charles Goldfarb (34:38):
I love that this is a lot, and obviously
we're not going to all ourlisteners, and likely Chris or I
are not going to master this inthe next few minutes. But what's
the most common arthroscopicprocedure you do for SL and
obviously it has to becustomized to the patient and
the situation. But what's. Themost common procedure you do?
Sanj Kakar (35:02):
Yeah, so did one just yesterday, patient came in
and was tender through andthrough. So I scoped them, and
the vola SL was off as well asthe dorsal and I put the volares
capsular, desist suture, pulledit down, reduced the vola side
and the dorsal side became morestable, and we were done. So I
would say the vola side is whereI'm going first, but I won't
(35:24):
hesitate to do the others. Butto your point, that's what I'm
doing most often.
Charles Goldfarb (35:29):
That's so interesting. And let's say you
have an MRI that's equivocal. Doyou have physical exam? Do you
have a feeling about physicalexam techniques to identify
vulner pathology. In otherwords, is there a point tender
area again? Can you talk aboutthat? Yeah,
Sanj Kakar (35:47):
so, so what they usually what I do is I'll
palpate first over the fcr tomake sure it's not fcr
tendinitis. I'll then put myfinger on the fcr and pull it
only and go deep to that. Now,essentially, there's three
issues there. There's either anoccult volar ganglion, there's
either an extrinsic injury,maybe radio Skipper caps, or
long radio lunate ligament. Or,if you're pushing really deep,
(36:08):
it's the volar SL, but those butthe 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 maynot and so those are the ones
that you'll pop the camera in.
And as I said yesterday, wepopped it in, and there was a
partial avulsion of the longradio lunate ligament off the
distal radius proximately.
Charles Goldfarb (36:31):
And this is great. And I think to listeners,
this is not something you'retypically going to learn on your
hand rotation unless someone'sreally focused. I think that
point tender area is underappreciated. And I love the how
you stated that. So in the caseyou did yesterday, you did the
volar capso Desis. And I don'twant to say it's going to come
out wrong, but is that all youdid, in the sense you did, you
(36:53):
try to do anything to have thelong radio lunate heal back to
bone?
Sanj Kakar (36:57):
Yeah. So what? So what I did then is, for that
one, then I took the shaver inbecause it was a partial injury,
I'd say maybe 20 to 30% partial.
The rest was on intact. I took ashaver and debrided the base of
the radius and also the longradio lunate ligament. And then
we described this, recentlypublished in JHS, the Merlin
technique, where you basicallydo an invocation long radio
lunate ligament. Now, if therewas a complete detachment of the
(37:20):
long radio ligament off theradius, you were already bowler,
because you made a bola radialportal, then you would put an
anchor into the radius and thentie that ligament down to the
radius.
Charles Goldfarb (37:34):
Let's step back for one second if you have
an MRI identified membranoustear. And for those who don't
know the terminology,specifically, that's not dorsal,
that's not volar. It's sort ofthe proximal aspect of the C MRI
looks like his membranous a doyour arthroscopy for a patient
with radio sided pain, dorsaland volar seem to be intact, and
(37:55):
he had this membranous tear.
What do you do then? Is it justa simple debridement?
Sanj Kakar (38:00):
Yeah, I'm not, I'm not fixing that. But truth be
told, Chuck, if I'm seeing amemoryless tear, I mean, I'll
debride it. But in my, in mysort of gut instinct, I'm
thinking, Am I really addressingthe problem here?
Charles Goldfarb (38:12):
That that's what I was hoping you would say.
I think that situations reallyrare where you just have
memories, and I see op noteswhere people have just debrided
the membrane is tear. And I'malways a little questioning is,
was there really something elsegoing on?
Sanj Kakar (38:28):
Yeah, yeah. So
Chris Dy (38:30):
he actually brings up a really good point. I wanted to
ask both you, given that you aresuper specialized experts and
nationally and internationallyrecognized for this area, what
are the most common things thatpeople don't treat appropriately
or miss, or, you know, lead toissues down the line. With
regards to SL,
Sanj Kakar (38:51):
I think, honestly, it's the diagnosis, right? I
think it's we were, we weretaught, if the X rays are
normal, get a stress view, andif 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, onpatients with normal X rays,
(39:11):
both at rest and stress views,and 40% had high grade geyser
three or four instability. So Ithink that's the first one. I
think getting the diagnosiscorrect. I think the second
thing is coming in with a hammeras one treatment suits all and
so, you know, when, when, whenwe were residents and fellows.
(39:33):
It was a three ligament Tinathesis, right? And that was the
one that was being doneessentially, for most SLS, and
I'm not knocking that operation,but my point is that it may be a
border injury, maybe a dorsalinjury, maybe through and
through, there may be extrinsicligament injuries as well. So
you can't just have one approachto addressing the SL so I would
say those are the two biggestsort of areas that I think,
(39:56):
hopefully, that we can addressfor. For people that you can't
think of it as a like an actionpotential. It's not all or
nothing. Chris, so there youare. We got nerve in there for
you, right? It has to be more ofa rainbow approach. And how to
address this,
Charles Goldfarb (40:13):
I would close by offering this. When I was a
resident, we were and Chris, youwere in grade school. We were
essentially witnessing atransformation from open rotator
cuff repairs to many openrotator cuff repairs to all
arthroscopic repairs. And thathappened over a period of, I
(40:36):
don't know how many years, six,810, years, and I would say
we're in the midst of that forSL and Sandra is leading the
way, certainly amongstAmericans. I think we may be
behind some of our internationalcolleagues, but I think in 10
years from now, the landscape isa look very different on how we
(40:57):
approach these and you know, wehave to do a lot of things. We
have to communicate better onwhat we're doing to treat these
arthroscopically. We have toreally simplify techniques, and
industry needs to partner withus to assist in that. And then
we need to popularize thesetechniques. Because I do agree,
there has been one big hammer,and I have been guilty, one big
(41:18):
hammer to treat these injuries,and it needs to be much more
refined than that.
Chris Dy (41:25):
Thank you, both of you. That was That was
fantastic. We I've learned a loton this episode, and I think
it's a really nice way to setthe stage for the young folks
who want to take this take thischarge and lead us forward. So
Sarge, always super fun to haveyou on. I'm sure we'll get
listener feedback that we wantto have you on again. So thank
you for becoming our recurringguest for arthroscopy and wrist
(41:48):
pain.
Sanj Kakar (41:50):
Always a pleasure.
Chuck and Chris, it's good tosee you, and I love spending
this time with you, and happy tocome back and talk more about
wrist and arthroscopy.
Charles Goldfarb (42:00):
Awesome. Thank you so much. Hey, Chris, that
was fun. Let's do it again realsoon.
Chris Dy (42:05):
Sounds good. Well, be sure to email us with topic
suggestions and feedback. Youcan reach us at hand
podcast@gmail.com
Charles Goldfarb (42:12):
and remember please subscribe wherever you
get your podcast, and
Chris Dy (42:16):
be sure to leave a review that helps us get the
word out.
Charles Goldfarb (42:20):
Special, thanks to Peter Martin for the
amazing music, and
Chris Dy (42:23):
remember, keep the upper hand. Come back next time
you
Charles Goldfarb (42:44):
Hey, Chris, that was fun. Let's do it again
real soon.
Chris Dy (42:47):
Sounds good? Well, be sure to email us with topic
suggestions and feedback. Youcan reach us. You.
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