Value-Based Cuff Repair in Private Practice ASC

Speaker 1Why don't we move next to Doctor Brodigan. Doctor Brodigan is in Private practice in Ohio, and he's been a longtime tunneling expert and has taught many people how to utilize transosseous tunneling.

Speaker 1So we can benefit from his input here. Take it away, Brad.

Speaker 2Thanks, Brett.

Speaker 2So, Mark, that was a great talk. Uh, Uma's talk was very good as well, and Brett, your intro was, uh, fantastic. So there's not, not a whole lot of room here, but, um,

Speaker 2I come at this from a Private practice perspective. Uh, I have ownership in a Surgery center and, um, I'm definitely involved in cost containment and, and trying to, uh, reduce the amount of spend that we have per case because it affects our bottom line, uh, that, that definitely makes us a little bit more intimately involved in, in the cost per case. So I'll come at it more from the Private practice perspective and also

Speaker 2Um, I have been doing this for a, for a while. Um, my history with transosseous, uh, repair, um, you know, starts with, you know, just learning Rotator cuff repair as, as a resident at Akron City Hospital. I worked with Rob Bell who

Speaker 2I was just starting to transition to, uh, arthroscopic Rotator cuff repair with anchors. Uh, I did a Sports Medicine fellowship at the University of Kentucky and, and we did 99% knees and so there wasn't much going on for that year with regard to the Shoulder. Um, but in practice, I went and visited Gary Guardsman. He had, um, uh, like a weekend fellowship type of, um, offering and, um,

Speaker 2In, in a two-day clinic, um, that was very well organized. Um, he, he taught me how to do arthroscopic Rotator cuff repair. Um, it was really, really exceptionally well done and it makes me feel optimistic that anyone who would want to learn how to do this technique. Now, Gary taught me how to do it with anchors, but I feel the same methodology that Gary used to, to teach those of us who want to transition to arthroscopic Rotator Cuff, um,

Speaker 2Those same steps and techniques of teaching I think are applicable to this, uh, this methodology, and it, it can be that quick. I came back from a two-day clinic with Gary and just uh got right into it and I haven't looked back. Um,

Speaker 2From there, um, I was an arthro tunneler, uh, test site surgeon. Um, and we started off with a device that looked much, much like, um, the tensor device and that it was, it was a reusable device. It was heavy, it was sturdy, it, it felt great in your hands and then after, after the, uh, testing was over, they went to the disposable, um, and I've, I've been an arthro tunneler user, uh, since the beginning.

Speaker 2And uh according to Tournier, I was using the tunnler, um, I was 2nd place only to butch uh Christian as far as uh the use of, of the device. So I've, I've been doing this for a while using this type of technique.

Speaker 2Um, I started to use the tensor device and um there are some differences between the tensor device and the arthro tunneler. Um, the, the tensor device is far more sturdy in your hands. Uh, it's far more predictable with regard to the initial initial pass of the suture through the, the device to the eyelet. So it is, uh, more efficient in my operating room compared to the arthropeller. Both get the job done.

Speaker 2But uh the tensor device does have some advantages.

Speaker 2Uh, my experience from the Other side is that I had a Rotator cuff repair and a biceps tenodesis. It was done by Butch. Uh, I had it about a year and a half ago, so, uh, that meant I had to fly to Texas to have my Rotator Cuff done, uh, from Ohio, and it was well worth the trip. I can tell you. I, I've had a fantastic outcome and, uh, I'm a believer.

Speaker 2So

Speaker 2Why would we use this technique? I think everyone has touched on this. You know, the transosseous technique is the gold standard. Uh, you can use it open or arthroscopic for those of you who are still doing open cases, there's no, you know, there's no shame in that, but this technique is still applicable to that. Uh, the reduction in cost is dramatic and, you know, I'm intimately involved with looking at these numbers and

Speaker 2Um, a break-even point traditionally has, has always been discussed that like 1.5 anchors is the equivalent of using an arthro tunneler, uh, for many years and I've looked at it with, uh, the tensor device and it's between 1.5 and 2 anchors. So anytime you're, you know, and that's average anchor price. So, if you're looking at an average anchor price of, you know, anywhere from $250 to $325

Speaker 2Once you get beyond 1.5 to 2 anchors, you're spending more than on, than you would if you were using it, uh, the, the tensor methodology.

Speaker 2Um, the biologic advantages, I think are undersold, really. I think venting, uh, the greater tuberosity and having access to the Bone Marrow is a tremendous benefit with this technique. Uh, I don't think we talked about it enough, quite frankly. Um, it reduces the pressure head within the humeral head and, and my patients have far less Pain postoperatively than my, my partners who use anchors.

Speaker 2I think, uh, the reduction in Pain is from the venting and from the reduction of the pressure head.

Speaker 2Um, the, uh, marrow venting right into the site where you need the Bone Marrow is a, is just a tremendous advantage, and I've had actually, uh, I haven't looked at the numbers, but I am not afraid of repairing a smoker because of this technique. I don't have

Speaker 2Large failures at all, really, but I don't have large failures specifically with smokers. I try to get them to quit, but because of the biologic advantages, I think it actually overcomes some of the disadvantages of working on a smoker.

Speaker 2Um, the Other thing that, uh, as far as cost containment, if you're doing a biceps tenodesis in the same case, you don't need a separate anchor or fixation device, you can use, uh, the transosseous technique.

Speaker 2Um,

Speaker 2And uh the tensor device and uh versus the arthro tunneler. Again, I think it's a little bit more uh sturdy in your hands uh and much more predictable in that passage of the suture through the, the device. Um, once you pass it into place, it's, it, I haven't missed yet. Uh, the suture might drop once in a while, but, uh, I haven't missed actually getting, um, the pin to go right into the eyelet on every pass. So that's,

Speaker 2That's helpful because we don't want to pass through the, through the greater tuberosity any more than we have to.

Speaker 2I like simple sutures. Um, I don't like complex constructs or rip-stop sutures. Uh, Gary impressed upon me the fact that, uh, we want physiologic tension. He impressed upon me that we're soft tissue surgeons. There has to be some touch, some feel. Simple sutures with knot tying is all that's really required. If you need additional fixation, you use an additional suture.

Speaker 2Um, I don't think we need terribly complex patterns to get a good result. I think if you use simple sutures,

Speaker 2Um, you have, you leave the cuff in a position where it can find its own. So if it, if it is a little bit over tension, it can pull back just a little bit and find the appropriate tension for healing.

Speaker 2Um, if you use rip stops and you get, if, if you try to lock that thing down at time zero with maximum tension, you're set up for failure that way. Um, Gary liked to, he actually liked Ehebo for Rotator Cuff repairs. And I asked him why because we had better sutures at the time. And he said he liked the fact that if he was tying the knot too tight, it would, it would break.

Speaker 2So he'd never over tensioned the Rotator Cuff.

Speaker 2So, with some of the stiffer sutures that we use, I think we have to be really careful about how much tension we're using when we tie them down. I thought that was, that, that stuck with me for a long time and, you know, this picture of the Lilliputins holding down the, the giant with just simple ropes and ties. All they, all they had to do is add suture. So,

Speaker 2So, we've seen this, uh, slide before. This is, uh, one of, uh, Mark's slides and, and, um, you know, my repairs look much, uh, very similar to the repair that you see on the left. Um, I have used augments like, like, uh, Mark does, and, uh, the grommets that you see there on the, uh, lateral side of the repair. Um, I've used that. Uh, Tournier came out with, uh, a grommet technique and, uh, there was a question already in the chat room about what do you do with bad bone.

Speaker 2So what do I do with bad bone? I, I don't use grommets. I, I really don't. I use maybe a few more sutures and what I do is I make sure that I balance out the tension with each of those sutures as I'm tying so that I'm not overloading any individual suture. I use a physiologic tension with each suture and if I use multiple sutures with low tension,

Speaker 2or physiologic tension if, you know, is, is probably a better term, but lower tension for bad bone, then you're not gonna have a, a bony failure or a cutout.

Speaker 2I've been doing this for a while. I have not seen that problem in my patients, and I always check my lateral tunnel.

Speaker 2To make sure that I don't have cutout.

Speaker 2That's a checkpoint for me after, after I finish the fixation. I'll look at the cuff and then I'll put the scope in from the lateral side and I'll look directly into those, uh, those passage points to make sure that I don't have cut out.

Speaker 2So I thought I'd show you guys a case that I did yesterday. Uh, I took lots of pictures. So, uh, this is going to be, uh, a Rotator cuff repair and a, and a biceps tenodesis, and this is one method by which I do the, uh, tenodesis. There are a couple of methods. Uh, Brett has some really, uh, brilliant video, brilliant videos of, of his method using fixation that he, uh, does in the groove. I actually, uh, I'm going to fix this biceps to, uh, the tuberosity.

Speaker 2So this is, this is what uh I saw yesterday. Uh, I think all of us see this, uh, quite a bit. Um, one of the reasons I don't like uh screw fixation for biceps like this, um, is that with the biceps being a little beat up and frayed, sometimes, uh, during the passage of a screw, um, you traumatically transect through the biceps. So, uh, I'd much prefer to have suture fixation here. So, I'm just gonna breed the biceps a bit, debrid the Rotator Cuff.

Speaker 2Um, I'm looking at, uh, the foot, the footprint that I want to bring the cuff back to, uh, very directly here. So I'm gonna take advantage of that. I'm gonna create a little bit of exposed bone for my biceps to come back to in the cuff. And then I'm going to create my transosseous tunnel, um, while looking from the articular side of, of the tear.

Speaker 2And I've punched through the greater tuberosity to, to initiate my transosseous tunnel.

Speaker 2And you can see my transosseous tunnel. There's a little, there's a little bubble, um, there's a little fat coming up from the marrow.

Speaker 2And it's the tunnels ideally positioned.

Speaker 2Now, I'm going to um suture my biceps tendon and I, I wanna have a good suture um through the biceps tendon with a locking technique. And so after I pass it with um my night and all needle passer, I'm gonna make some passes around the biceps.

Speaker 2And uh create a locking stitch.

Speaker 2Then when I pull the biceps tendon back through the Rotator Cuff Tear, I'm gonna see where that biceps tendon is going to end up once I pass that suture through the transosseous tunnel. It's gonna get tucked in right there and my cuff repair is gonna come down around that.

Speaker 2From here I'm gonna go.

Speaker 2To the subacromial space. I've done my decompression of my distal clavicle excision and now I'm, I'm passing um my suture with, with a tensor device.

Speaker 2Um, now I'm passing my suture through the cuff.

Speaker 2I've got 3 sutures for my cuff repair.

Speaker 2And the knot that you see there is tied down on the lateral side. That was my bicep suture that I passed transosseously. I pulled the biceps into the repair site and tie it down with the lateral knot.

Speaker 2Uh, it was a small tear. I tried to peek in through the Rotator Cuff Tear to see the biceps parked in there. My, I can see my knot. It's parked exactly where I want it. It's right on top of my, uh, transosseous tunnel. I've got my Rotator Cuff sutures already passed. Those sutures are passed on the medial side of the biceps. So as I tie these sutures down, they'll provide additional fixation for the tenodesis as well.

Speaker 2So I'm just tying simple knots and this is a little uh nod to Gary, you know, the, um, I, I'm, I'm a believer in knot tying. I think it gives us the feel that we need to apply physiologic tension or the appropriate tension to our cuff repair.

Speaker 2Um, I know there's a, a need for knotless out there with some surgeons, but I'm a believer in knot tying, and I think, you know, the, the appropriate tension, you hold that on the post as you pass your knots is, is, is a field thing and, and something that you really need to try to pass on to those that you teach. But, uh, with a Revo knot where you're passing two, similar half hitches down on the same post, and then, uh, an alternating half hitch on the same post, and then finally, um,

Speaker 2Alternating half hitch on a switched post. So, I've switched the post by pass pointing and I need to maintain that pass point as I take that half hitch down, my knot's done. So, there were some questions about stack impingement or not impingement within the subacromial space. I really think that if you sequence 4 half hitches and you do it in the proper sequence and you get an alternating half hitch with an alternating post as your last half.

Speaker 2Pitch, you're gonna have a knot that looks like that. It's not gonna go anywhere. It's relatively small in profile and I really don't have an issue with stack impingement. I, maybe for six weeks, perhaps there's a little bit of creptence, but after that, there's not an issue with that.

Speaker 2So this is uh 3 sutures tying down the cuff.

Speaker 2And we're seeing Bone Marrow coming up. We're seeing some of the biology coming up right into the repair site.

Speaker 2And again, I always look from the lateral side to check my exit point from the bone and I think you can see the, the Rotator Cuff looks, uh, a little mounted up there because my, my biceps is captured underneath of that as well.

Speaker 2And the Other point to this is that the blood supply through the cuff comes from medial to lateral, and I've got plenty of room for the blood supply to come in from medial to lateral through the cuff tissue.

Speaker 2I don't have it closed off with a horizontal, uh, type of method or a rip stop. I'm, I'm not, I'm, I'm, you know, I'm sure Mark has, uh, numerous outcomes on, on his methodology and how it works. I'm, I'm just a believer that you can do this with simple suturing techniques. It certainly makes it a lot more simple for those transitioning to this technique and it does get the job done.

Speaker 2I had some additional um slides on cost, but we've already discussed that. Again, the break-even point typically has been about 1.5 anchors to 1.5 to, to 2 and uh

Speaker 2The cost is, is, uh, I believe, um, Brett, um, gave me a number of, um, $520 per kit depending on the number of cases that you do. Um, and again, anchors are somewhere in the neighborhood of $250 to $325 just as a, as an average, and those numbers fluctuate.

Speaker 2I can tell you if you have a rep who's opening boxes in the back of the room and you're, you're not terribly aware of what those boxes are, that can get really expensive and um

Speaker 2If, if we're gonna

Speaker 2Start really working toward um

Speaker 2Being organized for bundled payments and, and getting ready for direct contracting, which is, which is something that I'm very excited about. Um, I can, I can very aggressively go to an employer or to, um, uh, to a large group and discuss direct contracting for Rotator Cuff repairs as a carve-out and um I'm in the game because of the cost containment here and if you're part of a Surgery center or part of a group,

Speaker 2That is managing a hospital perhaps, um, this cost containment is going to be very, very meaningful. So I can do everything from a small Rotator cuff repair, uh, to a massive repair and my cost doesn't fluctuate except for maybe the need for additional suture. Now, with uh the tensor kit, you get 6 sutures. I can do a tenodesis and a cuff repair with that. Um, I can do a largely massive cuff repair with that. There's no issue.

Speaker 2So my cost is very much contained. If I need an additional suture, so be it. It's not that expensive. The cost containment is here, uh, the need for it is here and um we all have to be aware of that whether we're academic or private. Um, uh, the pressure, the downward pressures on Reimbursement are very, very significant.

Speaker 2I can tell you that the uh CMS Reimbursement for Total Knee Replacement at ambulance, Ambulatory Surgery Center should be a warning to all of us where um CMS would like to go with Reimbursement. Um, you know, private, the private pays are going to follow CMS in, in that payment model. That's

Speaker 2That's gonna be um really, really difficult on the bottom line. Um, that's been a dramatic reduction in our Reimbursement for Total Knee Replacement. So, uh, I know Aus is holding off on, on total hips, uh, following suit. They're not gonna have the total Hip Reimbursement follow, follow suit with total Knee and I don't blame them for that. I think the pushback is, is necessary, but, um,

Speaker 2The dramatic reduction in total mean Reimbursement should be a warning shot to all of us that we really need to be careful about our cost per case and um uh.

Speaker 2Not only do we get to stratify and maintain our cost per case very evenly with Rotator cuff repair using this technique, but we get all of the benefits of the fixation method and the biology and the reduction of Pain. It's, it's hard for me to understand and I know Brett and I have talked.

Speaker 2About this quite a bit. It's hard for me to understand why people haven't transitioned to this. There are just so many benefits and really no downside. I know that some are intimidated by the technique and, and they don't really feel like, you know, they were trained on anchors and anchors are easier and all of those things. I, I did a weekend fellowship with Gary Gartsman and I never looked back. I, and I know that um teaching Other surgeons using the same methods that Gary used, uh, is, is very doable.

Speaker 2So I will, I will stop there.

Speaker 1Great. Thanks, Brad. Uh, a lot of good insights there, uh, from, uh, from Private practice and, uh, we, we appreciate your input.