---
title: 'The Modern Transosseous Paradigm'
type: 'lesson'
url: 'https://doc.social/courses/transosseous-experts-webinar/the-modern-transosseous-paradigm'
course: 'Transosseous Experts Webinar'
course_url: 'https://doc.social/courses/transosseous-experts-webinar'
position: '2 of 6'
author: 'Brett Sanders'
transcript: 'yes'
---

# The Modern Transosseous Paradigm

## Summary

_This lesson is a recording without a written summary._

## Transcript

1,711 words · 10 min · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:08] Welcome to the, uh, Transoseous, uh, update, uh, for the modern-based era in 2020. We've got a great faculty here tonight, uh, ranging from, uh, thought leaders and scientists and academic, uh, guys to Private practice, uh, surgeons, and, uh, they all have their own unique perspective, and we hope to have a good discussion. Um, thank you for our, for your, for the attendees, for your, uh, time, uh, joining us, uh, tonight.
[0:34] Uh, in your busy life. I know it's hard, but hopefully we'll keep it, uh, dense, uh, information that's, uh, practical and good. Make sure that you're using the chat function if you want to ask questions, we'll try to get to them.
[0:45] And, uh, the purpose of this meeting is to, is to educate about new developments in this technique which has come back around. I believe this is one of the, um, first open discussions in, in really in North America since, you know, sort of the early 2000s when, um, when, uh, when the techniques started. We hopefully we'll dispel some myths and, and do some education, maybe talk about some future directions and there's a, there's a bunch of ways we can go with this in the future. OK.
[1:13] So, Brett Sanders, I'm, I'm in a Private practice group in, uh, Chattanooga, Tennessee, and I do have a relevant disclosure. I'm the founder and inventor of a, a transosseous repair device.
[1:24] Um, and we're, we're sponsoring this.
[1:27] This, this journey for me started with the problem of value, which we saw coming and fellowship. Uh, this was, this concept was, was, uh, brought about by Michael Porter at the, uh, Harvard Business School. It's defined as outcome over cost per episode. There's been a lot of theoretical discussion about this, but it's, it's had some trouble kind of getting into practice. In the States, this manifests as uh bundled payments, bundled joints have been around for a long time.
[1:52] Uh, our international colleagues will know that they're single-payer systems, so there's value, uh, propositions there. Simultaneously, we've had technological convergence and commoditization of anchors. So, basically, an anchor, uh, is an anchor and there's, at this phase, and there's really not much difference in them functionally. So, this is an opportunity. And at the beginning of this, I really felt that we had at least non-inferior outcome, if not superior, and, uh, definitely, we had a cost-effectiveness.
[2:20] With these, uh, techniques. EA Codman, you know, was the 1st 1st transosseous cuff repair, first cuff repair 100 years ago, the father of value-based Medicine and evidence-based Medicine. And, uh, um, he was measuring value, uh, with cuffs, and, uh, that didn't go so well for him in his time, but now his principles have come back. So, um, I'd like to introduce this concept of the Rotator cuff repair cycle, which I believe is, uh, uh, Casanna's, uh, concept, uh.
[2:50] And there's, there's basically a logical, uh, cycle back to transosseous techniques as they evolve. So, you know, we started with this transosseous, uh, repair, and this transosseous cirlage effect is extremely powerful at reproducing the footprint. And this is kind of what we're chasing basically.
[3:09] And then we went to transosseous, uh, mini open with or without augmentation. So you can do that with buttons, tapes, screws, plates, anchors. There's a bunch of ways to skin that cat. We can talk about that.
[3:20] Um, but we came to anchors, um, many open with anchors and, uh, the trans osseous equivalent. And then when we came into arthroscopic technique with single anchor repair, this is where we got stuck here. The, the failure rates, you know, clearly went up with Yamaguchi and, and Bishop's study, 90 and 80% failure rates at that time. And given these were, these were, these were double-loaded anchors and uh maybe triple would be better. We didn't really know about the Crimson Duvet at that phase.
[3:49] But, uh, it, it clearly worsened outcomes here. And that, we, and so we kept working and the industry kept chasing this transosseous cirlage effect. How can you do the same thing transosseously with anchors? So we added a couple 1000 more dollars of anchors and bone voids and inert material in the healing zone and overly stiff compression, decreasing vascularity, causing an, an induced failure mode, uh, bringing up a new failure mode, the type 2 failure, and, you know, that's kind of where we are now.
[4:19] And, and this is driven more by tech, you know, biomechanics and, and Technology and chasing the transosseous slage effect than it is by biologics or uh outcome. And, um, so, this is where I spent a lot of my original, uh, work on this, these hybrid techniques, trying to step surgeons into full arthroscopic techniques. So this allays a lot of their concerns and stepping into that sort of like mini open to arthroscopic.
[4:46] Until we can get people comfortable with arthroscopic transosseous techniques and then getting back to doing the, the whole thing without anchors.
[4:53] It's my position, uh, and belief now that, you know, transosseous cuff repair is the gold standard, is and was the gold standard, and we know that all the giants of Shoulder Surgery have, have used this technique for years. We, we definitely have a lot to talk about in terms of cost and value. Uh, the biology of the healing site is, is exceptional, and we've got access to stem cells. Uh, the biomechanics is, is basically the same or superior depending on what you read and who, who you talk to.
[5:20] Um, uh, the Pain is reduced, uh, uh, level one evidence on that, we can talk about.
[5:26] Um, and if you talk about biology and, and Pain, just, if you look at these, uh, look at the tendons on, on MRI, you get, you get this excellent healing response without the Sugaa 3 failures at the articular margin, and it's really a biologic, uh, repair. Uh, revision considerations are excellent. You don't have any anchor voids or hardware to, to, uh, miss, and you can do any technique you want. Outcomes have been excellent. Uh, there's, there's not a whole lot of studies, but there are long-term studies now.
[5:55] And it has synergy with all kinds of Other technologies. So there's a lot of ways to go with this. Historically, there's been a lot of people that have made a run at this, and I think that leads, lends it to its credence.
[6:08] I will call to your attention if you haven't read Kuroda in, in, uh, in Japan, you know, he's got a great, uh, 380 people, I believe, series with 94%, you know, healing rates and a really, uh, an interesting technique, but a, a great clinical series as well.
[6:23] Um,
[6:24] This is just a slide to show, this is from JBJS Dirk Singel, uh, pointing out that most technologies that we introduced don't have much difference and the things that we think are game-changers are really not, and when you look at them objectively, they're really, uh, because of ceiling effects, it's very, very difficult to show, you know, a true difference. So, I think this is kind of where anchors and tunnels are. It's kind of like down at the bottom right, locking and non-locking bolts and trauma. It's gonna be very hard to show a difference there, except on cost.
[6:54] Um, so, so what is the ideal repair? This is just principle-based thinking, mostly from Gerber. Uh, you want high initial fixation strength to resist ultimate cyclic failure. I think you can see those repairs have a, a, a capability of achieving that. We want to prevent gap formation and reduce shear forces as you can see the contour of the greater tuberosity there with these tapes in this massive three-tunnel tear. Here, we're reducing the shear force. But we also want to go a step further. We want, um,
[7:23] We want to reproduce the anatomy and this, uh, South Korean paper shows how when you get bird beaks and dog ears and, and your repairs, it's really because you're trying to repair, uh, you don't have enough, uh, fixation points. You're trying to repair a cuff that needs 6 anchors with 4 anchors, and that's why you get deformities.
[7:41] We want to, um, avoid these bone voids, um, through vision considerations. We want to be mindful of this medial stress riser, which is, uh, creating type 2 failures and causing tendon transsection which is a catastrophic failure mode.
[7:56] Um, of course, we want good outcomes and doc, we've got one of the experts here with two-year Ultrasound follow-up, he'll talk about. But I'd like to suggest some new ideals as well. So, um, I, I'd like to suggest that we should be paying attention to improved biological healing, uh, assessment on MRI's and perhaps Ultrasound with Doctor Cruz here. Um, we wanna be mindful of, uh, bringing in biology, and here's an SCR, uh, that we did.
[8:20] We wanna, we wanna use our patches and augments and biologics and reduce the cost ceiling for those. We want to improve the vascularity and there's, there's, uh, clear evidence on that with transosseous techniques by Ultrasound. Of course, we want to recapitulate the anatomy, uh, as we can easily, but we wanna avoid these, uh, pressure spikes and we want to increase our fixation point density.
[8:44] So, with that said, uh, I'll say after 8 years of, of going deep on these concepts, um, there's a couple of things I've learned about adoption. The, the things in red, safety, efficacy, theoretical concerns, biomechanics. This is what we talk about, and, and they're important, uh, but, but that's not typically what, what moves the needle on adoption. It's, uh, mostly, you know, I've found ease of use, familiarity.
[9:08] Incentive, payer mix, health system, but a lot of psychological factors as well, risk tolerance, dogma, um, and a lot of social aspects. So, I'd like to give a shout out to our Italian colleagues, Doctor Castania, and, uh, they're doing a lot of basic science for transosseous techniques out of Italy. They've been very open-minded on the science behind this and driving this as a worldwide grassroots phenomenon.

## In this course

- [Previous: Introduction to Tensor Surgical's Shoulder Repair System](https://doc.social/llms/courses/transosseous-experts-webinar/introduction-to-tensor-surgicals-shoulder-repair-system.md)
- [Next: Sustainable Aspects of TO Tunneling for RCR](https://doc.social/llms/courses/transosseous-experts-webinar/sustainable-aspects-of-to-tunneling-for-rcr.md)
- [All lessons: Transosseous Experts Webinar](https://doc.social/llms/courses/transosseous-experts-webinar.md)