True Transosseous Hybrid Rotator Cuff Repair

Speaker 1Perfect.

Speaker 1Awesome. Thank you so much for inviting me to discuss one of my passions. This, uh, topic is something I've explored a lot and spent a lot of personal time on.

Speaker 1And um I'm from Chattanooga, Tennessee, and we're gonna be talking about a true transosseous hybrid Rotator cuff repair.

Speaker 1And I have a relevant disclosure, I'm the founder of a company that makes a reusable transosseous tunneling device.

Speaker 1When we talk about our ideal repairs, uh, this is straight from Christian Gerber in the, in the 80s. We want uh uh ideal, we want initial fixation strength to resist ultimate cyclic failure. We want to prevent or reduce gap formation and uh adequately assess uh shear forces, but we also want to restore the footprint, which I think we're doing here. This is a transosseous repair.

Speaker 1Uh, we want to be able to have multiple fixation points to reduce these deformities, the bird beaks and the dog ears and have anatomy that's restored, and you need multiple fixation points to do that in addition to load share. We also, uh, I think need to be mindful of bone voids and surface area for healing and the biology that that imparts to the healing of the, of the repair.

Speaker 1There's been an anchor-induced failure mode recently, uh, caused by TOE type repairs, which causes a stress riser here medially and leads itself to an anchor-specific failure mode which is catastrophic called the type 2 failure. I think we need to be aware of that.

Speaker 1And that creates a revision scenario that's quite difficult in some cases, and we want to have good results and

Speaker 1Of course, but I'd like to introduce perhaps some new ideals. Uh, I think we should be looking at improved healing responses and, and the biological healing that can be quantified on MRI and the healing characteristics that we get.

Speaker 1We want to be able to utilize our patches and the biology that's probably the key to repair, but under the surgical cost ceiling because we can't just keep adding in these things. They're, they're too expensive and it's just not practical in most of our systems. We'd like to have improved vascularity which has been shown with uh uh uh transosseous repairs to be excellent.

Speaker 1We also wanna, uh, match the modulus, not exceed the modulus, and we want to restore the footprint and we've known for a long time that transosseous repairs are the best way to, to recapitulate the footprint.

Speaker 1And through this transosseous cirlage effect, we also want to be mindful of cost. We all have to have this optimization equation of, of time versus cost versus quality and implants and surface area and all these things and every cuff repair is a problem that we have to optimize. This concept of load sharing, I think is very important, so multiple fixation points, a set of pressure spikes.

Speaker 1It's going to be very important to redistribute the load mechanically.

Speaker 1I started into this topic, uh, with an interest in value as defined by the Harvard Business School as outcome over cost per episode. Many of you are in, uh, single-payer systems already and this has been a problem in, in the United States. We've been, we've managed to hide the cost problem through a very complicated third-party payer system. But we've definitely had technological convergence and commoditization of

Speaker 1Of implants, you know, an anchor is, is an anchor. They're commodities and, and, and something that can provide a non-inferior, it doesn't even have to be superior, just a non-inferior outcome and cost-effectiveness offers superior value. And we're in a prime zone for that and Shoulder. EA Codman, the, the, the person who, who repaired the first Rotator Cuff was measuring this, you know, even back in his early days, and, and talking about this got him actually kicked out of, of Mass General.

Speaker 1So this has been around for a while. Randelli, uh, and Castagna out of Italy introduced me to this Rotator cuff repair cycle, and we have transosseous. So there's a logical progression that, that, that progresses from transosseous open back to arthroscopic. This is the transosseous circlage effect. It's the best way to restore the footprint. We came to many open with anchors.

Speaker 1Uh,

Speaker 1Doing the same thing but adding a lot of hardware cost. And then when we came to the arthroscopic, uh, repair, we went to single row anchors, and this is where we, we had a lot of problems with the outcomes and an inferior repair and then we added extra anchors to recapitulate the transosseous repair, adding a lot of cost and adding a new failure mode as well. And where, where I'm, um, where I'm trying to work.

Speaker 2I think

Speaker 1I think we may need to mute, Doctor

Speaker 3Cotts, can you just mute, uh, Doctor Kovts? Would you, would you please,

Speaker 1yeah, thank you.

Speaker 1So, uh, you know, we're at the transosseous equivalent down here in the bottom left. And, uh, what I've worked on is this hybrid technique to try to step surgeons who are used to anchors, uh, into, uh, adopting transosseous tech techniques which have, uh, many advantages and to go fully transosseous arthroscopically again, uh, and come back to this, uh, same methodology with less cost and a lot of clinical and biological advantages.

Speaker 1Initially, when we went to arthroscopic techniques with single-row especially, they were uh disastrous failures in terms of outcomes. This has been shown with 90% or 80% failure here with these studies on the left and why they failed, whether you're a biologist or more of a biomechanics, uh, uh, Maven like uh Burkhart or, or, uh, like Snyder here, a biologist, biologic Approach, tension and biology on the left, um, is, is up for debate.

Speaker 1Um, but the solution that came to the fore offered by the industry was a biomechanical solution with the transosseous equivalent. We, we've just heard that discussed.

Speaker 1And uh these very smart authors came up with this, and this is a natural evolution, and they were comparing this to double row, not transosseous, uh, fully transosseous, it was double row anchors. And they, they say in their paper that they were exactly trying to recreate the traditional open transosseous cirlage effect. Um, and compared to double row, these anchors, uh, created more mean pressure over the footprint in the lab.

Speaker 1And they had a higher load to failure with no more gap formation. They had 400 Newtons or so versus 300 newtons or so. And in their paper, they state that 302 newtons is a theoretical force which we wish to achieve. That's the contraction of the superspinatus. So that's really all you need for healing.

Speaker 1And, um, the advantages that they list in their paper here talk about lower profile knots than double row, not relying on the torn tendon edge for fixation, reducing surgical time, placing anchors, uh, uh, um, eliminating some of the anchors from the healing zone, uh, load sharing, interconnecting fixation points, uh, lateral fixation, which is orthogonal to the force vector.

Speaker 1And I realized that all of these could be achieved with transosseous uh approaches actually. And so this is where we have stepped now into the hybrid technique, which I'm about to show you.

Speaker 1Um, we, we have known that the transosseous, many people here on this, uh, webinar might agree that the transosseous repair is the gold standard. The giants of cuff repair have done this forever. But there's a lot of interesting things coming out in the modern times about biology, biomechanics, Pain, revision considerations, and synergies with Other hard fixators that are quite interesting and sort of updating this technique, I would say for the modern era.

Speaker 1This was written up. This is a hybrid technique that was written up in 07 already with 400 or 500 Newtons. This is the first one I did arthroscopically and I just recapitulated this technique.

Speaker 1And again, your cuff repair methodology is an optimization of time, cost, fixation, usability, and what you can do in your hands and your system. But this was the first repair I did, just recapitulating what was already a strong construct, uh, in the, um, in the, in the uh literature using basically biomechanical rationale, just as the TOE repair had done.

Speaker 1Now, this is a slide on the right from the ES meeting in 2018 or so. And in the green box, you can see this is Brian Cole's slide from Rush showing that the transosseous equivalent with anchors has failure of 350 to 400 Newtons. And this paper from Bernie.

Speaker 1and Gus Mzaka, who are smart researchers, called the multi-suture technique, shows that using all suture, you can actually double that, 856 Newtons. So you won't, you won't have this shown to you by anchor companies. But this, they were ripping the surgical neck off the specimens with only suture.

Speaker 1And so this is my version of this arthroscopically using hybrid techniques. And so I think we can achieve this now arthroscopically. The biomechanics of transosseous is different than uh anchor points. And we don't have this. Funakashi has shown with finite element analysis that there's a stress riser and Sano has shown that that goes away with transossea versus these uh pressure spikes that cause type 2 failure.

Speaker 1You know, essentially peak loading right into the area where the tendon can't heal. And this is why you get some of these retears because it's exceeding, not matching the modulus. Scott Rodeo, one of the smartest researchers in the Business, has shown, among others, that

Speaker 1And uh S Sukumaran on this call has shown this as well, uh, that suture number determines the strength. It's not the anchors. And so now that we can put a lot of suture in arthroscopically and easily, uh, I think we're gonna be able to, uh, address this concern. I would, uh,

Speaker 1Implore a lot of the thought leaders on this webinar to think about moving the paradigm from rows to fixation points per surface area and number of sutures per fixation point. This is what was not controlled for in the original studies and it caused a lot of confusion. What's important is fixation points per surface area and number of sutures, not anchors.

Speaker 1And so using these principles, basic principle thought, we devised this uh true transosseous hybrid technique. And so this is a triple row if you, if that matters, uh, technique. You can see in the cartoon on the bottom left picture, uh, that has no anchor burden at the footprint, so it's only microfracturing, which is the only thing that's been shown to enhance healing actually biologically.

Speaker 1So you have Bone Marrow vents, you have improved surface area for healing, and you have better revision considerations because you don't have inert material in your healing zone that you have to work around. It's, it's triple row, but it's independent fixation. So you have knots fixing a, a transosseous Xbox and then you have an independent anchor backing it up. So you're not relying on that lateral row anchor like you are, for instance, with a knotless transosseous equivalent.

Speaker 1If you believe that there's problems with weak bone, you have bone augmentation, and if you're having trouble with tying knots or appropriate tension, that lateral row anchor allows you to, uh, tension the construct of the last, uh, step, re-tension it. And you have an improved cost per fixation point. So you see we're getting 5 fixation points here, but we could easily get 7 or even 9 if we wanted to expand this and put in more tunnels and just use 1.

Speaker 1Or two anchors as the surgeon wants.

Speaker 1And this is also a self-reinforcing construct. So the more force that's imparted orthogonal or perpendicular to the construct, the more it compresses that surface area. So this is the same principles that we have just been discussing are important for cup repair are all now being applied at a reduced cost or a better cost ratio. This is what it looks like arthroscopically. You would think there's 4 or 5 anchors in there, and there's no anchors in that, in that healing zone.

Speaker 1This is all transosseous with one anchor down laterally.

Speaker 1And this is my 14-month data of 143 patients. We had 4% retear. Uh, we had much less Pain, about 2 VAS points less, and you can see this is SOS data showing the reduced Pain when we changed to transosseous. We had a 40/40 point increase in the ASES score. So excellent outcomes. And interestingly,

Speaker 192% or 92 ASCS scores which matched perfectly uh Fabian Plaschel's study recently from Herbert Resch's data in 2019 JBJS. It was interesting, very high ASCAS scores from this technique. So I'll take you through it here with a live first-person video.

Speaker 1Here we're cleaning out the lateral gutter. Here's the transo device that I use through a small portal. We pop in through the subdeltoid fascia here. We've already made the medial tunnel just like you would for an anchor. We use it all to make a 2.9 millimeter tunnel here. We find that tunnel.

Speaker 1And place the uh transosseous device. It's quite stable. You see, I can let go of it, and the assistant deploys it within about 20 seconds. So that's how long it takes to make a transosseous tunnel. So I think we've solved the time and usability problem there. And now we're going to bring the suture, the shuttling suture out of the medial portal.

Speaker 1This is now our shuttling suture and we can shuttle tapes or sutures as the surgeon desires. I prefer the triplet, 3 sutures is the functional moiety of, of my repair constructs. Uh, it's a good balance. And here, we clip the suture to the COA in static mode inferiorly and in dynamic mode superiorly. So we let them slide superiorly and we don't let them slide inferiorly.

Speaker 1And this, and then we have topographic management. So what's happening on the outside of the patient is happening on the inside. And this is how we keep track of our sutures. Here is what the triplets look like from inside. You can see the monitor there. And then we're gonna exclude the inferior sutures with the cannula. So this makes a suture management set up exactly like anchors, and now you're just dealing with the superior suture. So it's very easy to pass your sutures in any manner you desire.

Speaker 1And here we're going to link the tunnels. So we talked about linked constructs. So we're linking the constructs. Some surgeons have concerns about knot tying, so we're gonna tie this outside the cannula. So it's a simple knot tying exercise outside the cannula here, square knot backed up with alternating post half hitches, and we're simply gonna tie those and pull them back in and manage those sutures from the top portal.

Speaker 1Next, we'll tie simple sutures. I use an SMC knot with the knot low and lateral. We keep the knots off the top of the tendon, mostly for cosmesis. Um, but that's a sli sliding, locking knot. Here, interestingly, you can put the knot stack where you wish to make the, uh, compression optimized and to make the make, um, the, uh, repair look nice and, and optimize compression. Can't do that with transosseous equivalent.

Speaker 1Uh, and then we're gonna secure the crossing sutures again by grasping the crossing sutures outside of the cannula, and we'll tie that knot again outside the cannula. Now, you could pull these in and go ahead and cut these sutures and you'd be done. That would be a transosseous Xbox. But what we're gonna do is, here's we're gonna reduce a little dog ear here using the cannula to make it look perfect.

Speaker 1And here we've left our tails long and we could be done here. You can see we're moving our repair site. It's got good sheer stability, excellent footprint reconstruction. And we're gonna take these, these tails that we've left and this is gonna give us a second chance to back up the construct independently within an anchor and also retention the construct in a knotless fashion.

Speaker 1So we're gonna bring this down in a self-reinforcing construct below the horizontal mattress limb. This is the triple row, and we're gonna put that in as you would any standard anchor, but it's just one anchor, and there's no anchors in the healing zone. So you see it's quite uh solid, and here it is from laterally.

Speaker 1Um, and we do that in about 15 minutes or so. It's time equivalent independent studies have shown that Lazarus and Black have shown that independently. So that's the repair, and these are the outcomes we get, we get, we're getting excellent outcomes with these patients with much less Pain.

Speaker 1And we had a webinar last night about this. Uh, the bone Pain, we think could be coming from anchors and the Bone Marrow edema, which has been shown to last for about 6 months. And, uh, we, we simply just don't get that with transosseous repairs. And there's level 1 data out of Italy showing decreased Pain.

Speaker 1And here's, here's an example of a cuff repair I did, and the radiologist read it as, uh, a normal cuff. So this is 6 months post-op, and the, the little white thing you're seeing there is a ferromagnetic artifact. So they, they can't even tell this cuff has been repaired. It's so natural in the healing. So I think that's very interesting. So there's a lot of interesting things to, to discuss Doctor Sanders.

Speaker 1OK, so we'll finish there. Thank you.