Long-Term Experience with TO RCR in an Academic Center

Speaker 1With that, let's move along to uh Doctor Lazarus. Um,

Speaker 1Who, uh, has a very long-term experience with transosseous and, uh, has done a lot of studies clinically on transosseous techniques and can teach us all a lot about how this, uh, works in a, uh,

Speaker 1In a resident teaching situation and uh with complex techniques, so, uh.

Speaker 1Go ahead and take it away there, Doctor Ladder.

Speaker 2Can you hear and see me?

Speaker 1Yeah, looks great.

Speaker 2Wonderful. Well, first of all, Brett, thanks for inviting me for this webinar. Um, this is really great. Um, you asked me to talk about my experience at a large academic institution, which I am at, but, um, you also asked me to talk about the economics of this, uh, type of procedure, and I'm also a shareholder in a large private group. So, so the economics of this are not just, uh, academic for me, and so when I talk about that, it's not just an academic area of interest.

Speaker 2I have no disclosures relative to this device. I just like using it.

Speaker 2So, the 4 things that um Bra asked me to talk about is just a little bit of my experiences of technical pearls. Again, talk about the economics of uh transosseous, and I call anchorless Rotator cuff repair. Um, a word on the use of graphs and biologics and finally cortical augments.

Speaker 2So, when people talk about reasons to not tunnel, the big thing that comes up is suture management, and the suture management, it, it's, it's too painful to do. I've got a partner who, who always uses the F word before he, before he mentions tunneling. And actually, the suture management is the advantage of tunneling because it's in our control, and so we're not limited by anchor configuration. What I mean by that is

Speaker 2You have more ability to add points of fixation for the same amount of exposed tuberosity. We're not limited by having a 1 centimeter bridge between anchors or the number of sutures um within an anchor. You can come up with any configuration you want. That being said, you really need to have a plan in terms of suture sequencing, in terms of management. Um, I make, uh, use of colored hemostats, and, um, as I'll show you, varying different colors and types of sutures just to keep track of things.

Speaker 2So Gary Updegrove, who's one of our former fellows, put this together. It seems really complex, but in fact, and this is just a PowerPoint, he did it for himself, but he now shares it with all the fellows. So this is a 3 tunnel repair, and these are the 10 steps that, that, that you take by passing these sutures in this configuration. 10 steps later, you have a transosseous double row repair with multiple points of fixation. And again, it seems complex, but once you think of it in sequencing in those terms, it becomes very, very easy.

Speaker 2And so hopefully,

Speaker 2So I boiled this down to a 1 minute video. So this is a, uh, this is a tear that ended up being 4 tunnels. Um, and so the, then this will be a double row repair. We could talk about, um, if you want, whether or not you need a double row repair for, for this trans osseous technique. Um, but this is the uh tensor tunneler. I'll put a passing suture through.

Speaker 2And then you can pull anything you want through. And so I use tapes, and I use suture for the medial row. And so again, you can see the four tunnels with different tapes, different sutures, and then it simply becomes a Rotator cuff repair. And so you, you pass sutures. This is how I tie the horizontal mattresses, just bringing one limb from, from two consecutive tunnels out and tying them together with a non-sliding knot, you create a medial row and also a rip stitch for the lateral row sutures.

Speaker 2To to bridge across as I'm showing you here, without having that single point of fixation down to a single anchor. This is what I just did two weeks ago with my PA and this is 4 tunnels. Again, you get that spread of suture that Brett talked about earlier, so you don't dog here as much. You get the ripping effect of the tapes going over the horizontal mattress suture, and you get the, the, the, the footprint compression effect of a double row repair. So all the things we really want to do with cuff repair.

Speaker 2So, uh, several years ago, Eric Black, one of our fellows, did a retrospective study looking at my patients and cost, uh double row anchor versus transosseous. And what you can see here is, as you would expect, I don't know if you can see my cursor, but for the transosseous technique, the cost is the same. The, the cost remains stable regardless of the

Speaker 2size of the tear, but obviously, the larger the tear, the more anchors you use, the cost of the anchors goes up. And so for the large and massive tears, the, the, the cost difference becomes substantial. These were my first tunnels relative to uh already being very experienced with anchors, yet, yet the surgical time was the same. So it is not a procedure that takes longer.

Speaker 2Adam Seidel is now at the University of Colorado, then did a prospective study with us when he was one of our fellows. And again, the cost differences in this study was even greater. And so for large and massive tears, the cost difference was over $1000 per case, and uh that adds up.

Speaker 2And uh based upon simple Shoulder tests, the, the results were the same at, at 3 months, 6 months, and, and over a year. So the outcomes were the same cost dramatically less.

Speaker 2I don't know if um anyone has experience with constructing a bundled payment model, um, but we have done this and so we have constructed a bundled payment model for Rotator cuff repair. And this is the first step. The first step is looking at, at cost data per surgeon.

Speaker 2And and the reason that it is important is number one, insurance carriers are most interested in bundled payments when there's a large variation between cost per surgeon because they would rather we, we take the risk and they take the risk when there's that much variability.

Speaker 2Um, and number 2 is obviously, um, the more outlier surgeons you have, the more likely you are to break your bundle and, and lose money on the bundle payment. And so, I can't show you the absolute, uh, numbers, otherwise my, uh, CEO will kill me. Um, but, uh, this is Mia's baseline. This is our hospital. This is, by the way, up till last month.

Speaker 2So this is our hospital, our surgical specialty hospital, and these are the 4 busiest cuff surgeons. And what you find, so I'm 0 because I'm the lowest, and then these are the differences above me.

Speaker 2And so, what's really interesting is me and surgeon B do all the massive tears, do all the grafts, do all the revisions. The insurance carrier could care less, and our hospital administrator and our CEO could care less because it's all one bundle. And so the, the surgeon B happens to be a very good surgeon who's very cost effective. He's doing all these graph revisions and he, he's just $700 above me. It doesn't matter. They hate him.

Speaker 2Surgeon C does only the smallest tears. He only does single anchor tears. They love him. And then surgeon A is not going to be doing Rotator cuff repair very long at our hospital if he keeps doing this because he does not do all the revisions and he is uh $1400 on average above me per case, you know, despite the fact that I'm doing the more difficult ones. So, so, you know, if as, as we

Speaker 2Do more revisions, as we do more SCRs, things like that. All these things are included in the bundle and so you have to try and trim your cost somewhere and um Bob Tajin years ago published the, published a paper looking at the, the single best way that you can trim your cost of cuff repairs by lowering the cost of anchors. You're just not using them.

Speaker 2So a word about graph augmentation. I showed this video before, but the reason I like tunneling for graph augmentation is the procedure is no different. The steps are almost identical. Instead of tying the horizontal mattress uh like that, I actually pass it through the graph and then tie it. So, once you do that, you essentially have the medial side of the graph fixed down with the medial row of your Rotator Cuff.

Speaker 2And then you're just tying the tapes over the top. So it really um doesn't add any significant number of steps to what you're already doing, as opposed to um when I did these with anchors, it just, it seemed like they were, it's a different, completely different procedure than Rotator cuff repair. This seems to be the same thing, just adding a graph for reinforcement, um, for me primarily for revisions.

Speaker 2And then uh Brett mentioned SCR. SCR is limited by cost, and it's an extremely costly procedure. And so if you eliminate your lateral sided anchors, you can really, um, if we show some effectiveness of this down the lines, make it a cost effective procedure. And so yes, I use tunnels on the lateral side for all my SCRs as well.

Speaker 2So, you know, we hear a lot about the future biologics, Biologically active suture, you hear about this all the time and I always say to myself, well, does it really matter if the suture is attached to an anchor because the suture is not really exposed to the uh to the marrow. Uh, we hear about marrow stimulation either locally or

Speaker 2Moreystemically, medically, and again, I, you know, I would say, well, does it really matter if the marrow access to the undersurface of the Rotator Cuff is being uh obstructed by, by numerous anchors. And so, I think the tunneling really lends itself to these uh future biologic techniques.

Speaker 2Greg asked me to mention cortical augments probably because uh Grant Geragos, one of my former fellows, uh, insisted on writing this technique paper years ago. And so this was a, uh, device meant for open Surgery which we used for arthroscopic Surgery for tunneling.

Speaker 2Um, as Brett mentioned these, I've used generic augments, I've used specifically designed augments, polyethylene patches, 2.4 millimeter plates, but once I switched to tapes, um, I've not, cortical augmentation for me is a once.

Speaker 2Every Other year phenomenon these tapes just tend to not cut through bone and, and if you really focus on making the lateral aspect of your tunnel as far distal as possible by abducting the arm before you, before you seek the tunnel or, uh, you port a rare occurrence at this point.

Speaker 2OK.

Speaker 2All this great science.

Speaker 2Best reasons to tunnel and that's how I'm gonna end my talk. So best reason number one, we've all had these patients who want their, their Rotator Cuff repaired to be the hardest one you've ever done, and so they say, doc, how many anchors? You say, none.

Speaker 2Reason number 2, for the patient, we've all had these patients, right? That uh they're 6 months out from Surgery, you know the repair is good, but they're still having Pain. You send them for the MRI scan and because you didn't use anchors, there's so little artifact in the greater tuberosity. The official radiology reading is normal Shoulder, right? There's the tunnel. They don't even recognize that this patient's had cuff repair.

Speaker 2And then the most important reason is when you have that annoying partner who wants to impress you with their 8 anchor Rotator cuff repair and can't stop talking about it, you can say to them, anchors, anchors are so 2010.

Speaker 2Thank you.

Speaker 1A collaginous fibrile attached to the muscle architecture, you know, like the original tendon was. So I, I tend to be a, a double row guy which, which has been, uh, you know, a full foot if, assuming the tension's OK, uh, the, uh, you know, reconstitute the entire footprint, the surface area of the double row, you know, reconstruction has been linked with less retears. That would be my answer.

Speaker 1Yeah

Speaker 2I

Speaker 1would

Speaker 2agree

Speaker 1with,

Speaker 2I would, I would agree with that, but, you know, I, when I teach the, the residents and fellows, I, I always say cuff repair is a battle of tension versus coverage. And so if you can gain coverage without excessive tension, I think the literature would suggest at least for moderate, for, for a large and massive tears, integrity should be improved down the line. If you can't, then, then I think a single row more medialized repair is, is warranted.

Speaker 3And, and do you guys ever, I mean, you can do a transosseous technique and just not go as deep, right? Like to me you're doing the same thing as you're doing a middle row. Like you're, you're just not taking as much tendon laterally, right? I mean, it's, it's, it's, it's achieving the same thing, but you're still laying the tendon down, and I agree with you. I mean, it's just a matter of tension, and I understand the idea of a

Speaker 1single row, but yeah, when, when the tension's high.

Speaker 1Uh, one of the things I do is, like, often you'll have a chronic supra and acute infra. So infrado row, uh, the chronic supra that's under a lot of tension, do a tunnel, and then use arthroscopic Mason Allen sutures like Lafosse locking loops to essentially do a single row, and then you just tie the knot low and lateral. So it's a single row repair just without an anchor.