Opioid Sparing Techniques for Sports Medicine

Speaker 1More people will be joining.

Speaker 1Uh, I'm just gonna start a little bit now. Uh, tonight we'll be talking about opioid sparing techniques for Sports Medicine and Shoulder procedures. Uh, the authors were Par Kanddar and Paul Seti. Paul is here tonight to discuss the articles. Uh, I'll be letting people in as, as they come in.

Speaker 1I do want to say that this was an extraordinarily popular article, 835 views, uh, which puts it in really the top 10 to 15% of articles in our journal. Um, this should give you a perspective, the average journal in, uh, JBJS or Journal of Arthroplasty gets around 65 to 120 views.

Speaker 1So this is a very, very popular and very well read, uh, article, beautifully written, I have to say, uh, and was unanimous choice by the board, uh, the review board that reviewed it, and everyone wanted to review it. Uh, the Journal, as you know, publishes articles on a regular basis. This is what we published today by Brian Kelly at HSS, and we do that, um.

Speaker 1For people who want to submit, you just go to 4, sorry, you just go to 4 authors.

Speaker 1And click on submit a manuscript. We do have some advertisements here from some companies, um, you just submit a manuscript and it's just that simple.

Speaker 1And if you would look at this, you'd see that in the 2 years we've been in.

Speaker 1Publication Business, over 100,000 page views and almost 50,000 unique visitors, which is particularly good. So, I'm gonna stop the share.

Speaker 1And I'm gonna go on to uh Paul. Paul, uh, I'm gonna start off a little bit right now and really pretty much say, what was the

Speaker 1Reason for you kind of to begin to look at this issue when you first got started looking at this issue of changing the way you look at Pain in rotated in Sports Medicine procedures.

Speaker 2Well, I think I, first of all, congratulations on the journal and and hitting the 100,000 number. Uh, and I'm even more impressed. I didn't realize that metric of how many, how few people will review or read an article that I submit to JBJS. So, I, I'm really excited about that. Um,

Speaker 2My, my motivation to, to sort of start this, I guess, has a lot of, a, a, a lot of beginning factors. The first thing is that Rotator Cuff Surgery, historically, and that's an important statement, hurts a lot. And I didn't go into Spine Surgery because I didn't want to have tons of Pain post-operatively and have to follow patients and realize that they, they were

Speaker 2Struggling. But as it turns out, uh, the, the, the Rotator Cuff surgeries that I did when I first started practice, and perhaps there's a Learning curve, but 18 years ago, hurt a lot, a lot. They'd come in at post-op day 7 or 10 and tell me that this was a miserable experience. And that experience stayed miserable for 6 weeks, sometimes, if not 3 months in certain patients.

Speaker 2So I, I, I recognized that I had a problem or whatever I was doing, getting ahead of the Pain, giving them Pain Pain medications preemptively, that wasn't really an effective strategy. And at the same moment, I'm operating on a lot of vulnerable people, vulnerable people, meaning young athletes who've had their identity stripped because of taking, being taken out of sport, vis would be their labrum or ACL. And now, now I've got this conundrum of I need to treat Pain. The world has taught me that.

Speaker 2Pain is a vital sign and I must stay ahead of it. And I'm over narcotizing these patients. In comes the recognition that, that actually, these opiate medications are, are not just solving problems, they're creating problems and killing people. And I'd read in the newspaper every day about another youth in my community that died, right? It didn't make sense. And I felt really good that that wasn't me. I never gave Pain medication for anyone Other than Surgery or a bad Fracture. I was really responsible.

Speaker 2But as it turns out, 20% of patients after Rotator Cuff Surgery on Pain medication at 6 months out. As it turns out, many of these kids who who've gone down dark pathways started out with appropriately prescribed medications that subsequently became diverted and were part of the problem.

Speaker 2So I guess it's a long preamble as to, I had a problem with, with controlling Pain. I had a resource that really wasn't appropriate, and I have a vulnerable population. So, the, the world was begging me to do something differently, and I, I just had to, it took me a couple of years to figure that out.

Speaker 1So, a lot of, what is, what right now are the

Speaker 1Base tools that you use. What, what are the building blocks of the Pain management tools that you are currently using in, in all your Sports Medicine procedures? What are, what are sort of each of the different items, and then we'll talk about how to, how you're using them and how you're protocolling them.

Speaker 2So each of the items are really important. I think that any one item in isolation probably isn't sufficient or may not work as well as the sort of cumulative process. So, so part one is fortuitously, I live in a community where patients are educated.

Speaker 2And come in with certain expectations. But I go on further and I go into education. I think that education is the first pillar, recognizing one, that these medications are dangerous, but 2, a little Pain is OK. Pillar 2 is gonna be um pillar 2.

Speaker 2Pillar 2 is, uh, is, is the requirement for preoperative, preventive analgesia. Pillar 3 is for intraoperative medications that are gonna mitigate and reduce the Pain, and that's where a medication like Exbrel will play play into a role. And pillar 4 is again appropriate modalities, ice.

Speaker 2PT, postoperative anti-inflammatory medication, and again, postoperative reinforcement that we don't need to rely back or fall back on a stronger Pain medication. So I think it's all of those things together, and one in isolation, I don't know is, is

Speaker 2adequate.

Speaker 1So what is, first of all, let's talk about education for a second. Who does the education in your office?

Speaker 1How does it get done? And are you educated now about Pain, what to expect, what, what is the whole thing?

Speaker 2So education is gonna get done and reinforced by all of us, right? It'll get, it'll get done by myself, it'll get done by my PA who's gonna help me in the pre-op, and then everyone who's on my team, including my coordinator, knows that we really want to rely less on the, on the opiate medication. And I'm not this nihilist where I say, no, you can't have it, or I don't say, gosh, it, it is the wrong thing. I'll kind of challenge.

Speaker 2especially with the athletes. I'm like, look, we'll give you some, but you're a pretty good athlete, you're not gonna need this, or you're pretty tough. I could tell, you know, you're, you're not gonna succumb. I, I'll bet that, you know, the guys on your team didn't need it, you won't either. Uh, we also have made a video, right? And, and we, it's a video where, where it's 2.5 minutes, they'll get played at the pre-op visit, and then we'll push it to the patient the night of their Surgery. So there's lots of reinforcement of this idea.

Speaker 2Uh, there, there are two different studies, uh, one from Rothman Institute, looking at shoulders specifically, where Luke Austin demonstrated that education alone reduced the opiate consumption by 25%. So, uh, he did another study where they put the prescription in a sealed envelope and said, only break this if you need it. Um, and once again, patients just don't break it. If you, if you set a challenge or make it exciting for them, it becomes very, they get engaged.

Speaker 1So I'm gonna share a uh just a screen from the article. Current opioids.

Speaker 1Prescribing habits are inconsistent, 5-fold range from 12 to 60 pills. What do you think is going on there?

Speaker 2Well,

Speaker 2Uh, uh, a lot of things. Michael Redler, who's on this call, may remember, we were at dinner, um, uh, in New Haven, and I went around the room and I asked people, after a simple Knee arthroscopy, how many pills do you give? And Michael was one of the last ones actually to respond. And I, I was getting a lot of 40s, 40s, 40s, 40s. And then there was a couple of 20s, and then there were some comments, and Mike's like, none, I give none, you don't need it for that.

Speaker 2So in, in that example, example, we had 0 to 40. And why, why is there such a variation? Really, knowledge on how to do this is passed down. It's passed down from resident to the chief resident or whatever you'd learned to do, and formal education about how to prescribe and treat Pain postoperatively has really been relegated to a secondary component of, of surgeon education. Um, so as a consequence, we, we don't have those standards.

Speaker 1So, in the um in the issue here in in your article.

Speaker 1Uh, I'm gonna bring this up right now. Sorry, it's taking a second.

Speaker 1Uh, there we go.

Speaker 1There we go. All right, um.

Speaker 1You point out the education in the article, OK. But now in looking at all the Shoulder Operations, the Rotator cuff repair, the labrums, the total shoulders, there's gotta be a range of how many opioids in each of those. I mean, I've got to imagine the total Shoulder reverse Shoulder has gotta be more painful than a Rotator Cuff.

Speaker 2So I love that you said that. Um, it's the exact opposite, right? As it turns out, and, and that's, by the way, my patients believe that, uh, Other subspecialties believe it, but Shoulder replacement is a very low hanging fruit. These are older patients who have a lot of Pain, who've learned to manage their Pain, and postoperatively, it's kind of like a Hip Replacement. You get rid of that, that bone on bone Pain, and yes, you can be sore, but it, it's a different level of

Speaker 2Soreness. So, really, what we have to do is challenge ourselves and ask us how many are needed. You're, you're right, there has to be a range, and patients are gonna have comorbidities. So patients with, with depression and patients with anxiety or a previous history of opiate medication use, like that's gonna be a challenging group, and we're gonna have to fight through that in a very different way. But the generally opiate naive, and I mean opiate naive, not having medications for the last 3 months or so, the opiate naive patients, we needed to create guidelines, and that's what

Speaker 2We set out to do about 5 years ago. Uh, and, and we, and we pressed ourselves, uh, you know, I, when, when, when Xper came out, I had a pesky, pesky rep who was telling, you gotta try this, Paul, you have to try and use this. And I said, look, I don't, it's not gonna work with my arthroscopy. I can't inject it arthroscopically. And she said to me, well, you better figure it out. Like, this is, this is a good idea, and you're missing an opportunity to treat people really well. So I credit Laura Wing with sort of.

Speaker 2Pressuring me down the, the pathway of trying to understand how to use alternate medications in the, in the setting of arthroscopy. But we asked ourselves, I, so the first group of studies we did were retrospective studies, where we went back and looked at how many they, they took. And a lot of those retrospective studies didn't want to get published because, you know, look, anyone could do a lookback, there could be recall bias, there could be all sorts of things leftover. But once we gained a range that we saw people were taking retrospectively,

Speaker 2Then we went ahead and did the prospective randomized studies. And prospectively, we said, look, we're going to limit to this many pills. And, and we, and then we did pill counts, and we were really aggressive, so there was no recall bias. And we found that, you know, when we gave 25 pills, they needed a few, they, they didn't use them all. Now, we give 15 pills, they don't use them all. But really, I think that that's my magic number, 5 to 15 for a Shoulder procedure, right? For um

Speaker 2For a total Shoulder, for a reverse Shoulder, for a Rotator Cuff, and for a labrum, and Rotator Cuff, for at least in my experience, is, is the most consistently painful outside of perhaps, you know, Shoulder Fracture, which is also uh a painful procedure.

Speaker 1When did you start using interscaling nerve blocks routinely?

Speaker 2So,

Speaker 2Interscaling nerve blocks have been a normal part of, of what I've done since I've entered practice, I guess 18 years ago now. Uh, I can't believe I, that's 18 years. That's, that's been a blink. Uh, what I really loved about the interscaling nerve block is that we had a reduced need for anesthesia. Patients were less, less, you know, less drowsy, less nauseated. They felt good. They were able to go home the same day from Surgery. But there was this thing called rebound Pain. And rebound Pain was when the nerve block.

Speaker 2wore off somewhere at 234 in the morning. Their Pain came screaming back and, and it didn't go to a 6 or a 7, but it went to a spinal tap. It went to an 11, right? And it went to an 11 in a way that patients had a really hard time catching up, and they would routinely call the office. They would, some would go back to the emergency room. And if you're thinking about like the quality of their surgical event or the, or the episode of care and the cost of care, if they go back to the emergency room, you've just, you know, you've completely just pooped in the boat on that one. So.

Speaker 2So, this rebound Pain was a real challenge to respond to rebound Pain, take 2, take 2 narcotic pills the minute you get home and take them every 4 hours. And now they were constipated, and they burned through 10 pills before they may have even needed them.

Speaker 1So

Speaker 1You know, it, we just uh pub uh submitted a publication on Joint replacement readmissions, sorry, revisits to the ED.

Speaker 1OK, have you noticed since you started the protocol.

Speaker 1That you published in the journal, a decrease in either calls to the office or admissions, oh sorry, ED visits, a variety of things like that.

Speaker 2So we, we, we tracked that, right? Um, and that's, that's an important part of, of what we have to figure out. So, uh, call reduction after ACL Surgery, there was a mean of 3 calls, uh, over a 2-week period for these patients, right? So that's still a, a it's a relatively small number. And we, unfortunately, couldn't sort of discern whether that was a call about PT range of motion, but the Pain calls are very, very few. Uh, visit to the emergency room, you know, I, I, I've gotten to the point now.

Speaker 2But if a patient actually comes in and tells me that they had Pain after Surgery, I'm actually surprised. And you know, Pain and disproportionate. Uh, if someone goes to the emergency room after, afterwards, I'm really worried that something untoward has happened. I, I, it would be not, not a one or two standard deviation outlier, but much more than that. So, uh, it, it, it really, uh, it, it's changed everything. But maybe to the point where I, now I'm, I'm more annoyed with, when I have Pain than, than sort of compassionate as I should be.

Speaker 1So what has, what has been the advantage for you, in your, in your experience of the use of liposomal bivvicaine in the interscaling blocks? Have you've seen it cause, cause there you wrote in the article that there was some equivocal data but most positive. What's been your experience in using that in interscaling block?

Speaker 2So, we initially started using a field block, a blocker we would just inject it. And I was actually injecting into the suprascapular nerve uh distribution and the axillary nerve distribution. And the field block, let me just be honest, and our Pain scores are, you know, reflected. The field block is not as effective as an interscaling nerve block. The Pain scores in the pack you were a 3 or a 4, which are tolerable.

Speaker 2As opposed to a 0 or a 1. So the field block was good, but it wasn't, it's not as good as an intra scaly nerve block. And we didn't have FDA clearance for it, right? But now, I, I, I use a small volume. I, I, I use 10 ccs. Uh, my anesthesiologist does it. I don't have to think about it. It's actually there preemptively. So if I believe in any sort of preemptive analgesia, it's done for me. Um, and going back to this rebound idea, rebound Pain is gone.

Speaker 2The, the, since it's slowly sort of trickles off, it's got a much longer effect, and we see it, we see it last pretty consistently to 48 hours, not always 72, but consistently to 42, 48. Um, I, we just don't see that rebound. They're not coming back and saying, oh my gosh, this has been transformational. So, in and of itself, it's solved for that, that major problem. The Other thing is that

Speaker 2They, they, if we look at all the studies, whether they're the our ACL study that we just presented at the academy this year or our Rotator Cuff or our total Shoulder study, you look at the area under the curve and look at their Pain scores, and the total amount of opiate is reduced by nearly, near, nearly 50%. So they, they don't, they don't need as much, and they get to ride in first class like you and uh like you and, and, and, and Reddler, sorry.

Speaker 1Yeah.

Speaker 1Yeah, I wouldn't expect him riding in first bus either. That's why I would have paused.

Speaker 1You know, those Connecticut guys, you know, you don't know that, you don't know that. Um, there was a, a question that came through to me privately on the chat, which was, um, what about all the Other things such as, you know, the Tylenol, the, the NSAIDs, the gabapentin, you know, when did you start using those was, did you notice it?

Speaker 1Have you, have you done a study to remove those from the

Speaker 1From the whole protocol,

Speaker 2that's a great question. And I, and I think the first response to the question, at least if I can since, since I have the mic, I can answer, I think. I'm like a politician, I can say what I want. Um, the, the first response is that I, I think those things are absolutely necessary. And if it's just the same as education, if you don't have an appropriate multimodal Approach towards this, then, then you're in trouble. So, let's talk about.

Speaker 2Each one of those three medications in a slightly granular way, the acetaminophen, the non-steroidal, and the gabapentin. Well, I'll go with the one, that the lowest hanging one, right? The gabapentin. Gabapentin has been debated back and forth in the joint literature. Does it help? Does it not help? Does 300 mg HS I'll never reach a therapeutic effect of medication, and it's just doesn't make sense from a pharmacologic medical standpoint.

Speaker 2That said, it works. It outright works. It gets you, you know, the anesthesiologists, when I started using it, they're like, your patients may be drowsy at night, and I said to them,

Speaker 2They can sleep at night. That's OK. Um, so, it can cause some drowsiness, but not at that small dose. So we've really been thrilled with it. And in fact, when patients do have more Pain or their complaint is that they are having some difficulty sleeping, cause, uh, it's not, you know, of course, some people are gonna have a little hard time.

Speaker 2And others we'll refill their gabapentin before refill anything else, and the gabapentin at night can really be helpful if I have to go to BID, and I can go to BID very easily. So, uh, we've, we've looked at the literature once again, lots of debate back and forth. Low dose seems to be very effective. The next 10,

Speaker 3say a question. I will say Paul.

Speaker 3Gabapentin.

Speaker 2Oh, OK. No, no, no worries. That's just something in the background. So the next

Speaker 1question, no, no, no, uh, uh, Neil just said he, he, gabapentin, I thought was useful, right, Neil? Yeah,

Speaker 3well, the gabapentin is a major piece of pharmacology. It's controlling a lot that's going on.

Speaker 3It's not surprising.

Speaker 3Uh, it's, uh, uh, work, and it's also an enormous adoption outside of its Primary just because of its, uh, power.

Speaker 2So, I mean, very helpful. Look, for some, for, for someone who sort of is a firsthand, I think that, that's helpful. The, the, the next sort of medication, non-steroidal. Well, in, in tendon healing Surgery and some ACL and Rotator Cuff or, you know, surgeries where we're worried about healing, there's some kickback or concern about using non-steroidal. Well, as it turns out, there's no study that shows that if you have non-steroidal use for between 3 and 5 days post-surgically, that you're gonna have

Speaker 2Have a, uh, a long-term effect. And that's actually been looked at in longitudinal, animal and human studies in Rotator Cuff, as opposed to the continuous for six weeks, which may be a problem. So, if we consider the 1st 3 to 5 days, and really it's 3 for most studies, the 1st 3 to 5 days is the window where you need to get Pain control. If you can get Pain control, then, uh, you'll, the patient will in perpetuity have a better experience. So that's where the non-steroidals are great. And as, and as orthopedic surgeons, we

Speaker 2I know that non-steroidals are great for bone and musculoskeletal Pain. So, that'll be a very consistent part of what I use in that, in that period of time. After 3 days or 5 days, I think a lot of patients' stomachs can get upset anyway. So I'm happy to get it off of my elderly patients, and I'm also happy to get it off in someone with a massive cuff tear that I'm worried about. But that really helps a lot. And finally, the acetaminophen, you know, just because it's over the counter, doesn't mean it doesn't work. And we're gonna use consistent.

Speaker 2Constantly, uh, 1000 mg TID for the 1st 5 days. And once again, if we really blast them with the medications and stagger the anti-inflammatory, the non-steroidal, and the Tylenol, so that the peaks and troughs don't hit at the same time, we've been really, really effective in helping the patients. Um, so, those are the three sort of stall, stalwart medications that I use for any Surgery that's very painful. I don't use the gabapentin, for example, and, um,

Speaker 2And a Knee arthroscopy, I think that's probably overkill. Uh, I avoid the gabapentin in the kids who are under 15 or 16, just because I don't know that I have enough collective experience with that medication. Um, and then, and then, you know, going to the nerve block, right? The nerve block is, is just, it's just about an always. Um, it's just about an always, and it's an interscaling nerve block. You guys will be interested, uh, for my ACLs, uh, and I haven't published this yet, but this is coming.

Speaker 2We have routinely used an adductor block, right? We've gone away from the femoral nerve block just like everyone else, whether it's Hip or Hip, or rather total Knee or Knee uh arthroscopy because we want the femoral nerve to come back fast enough. But I found that the adductor block, even, even with Experel, isn't always enough. Um, and then I was doing some local field infiltration, but once again, there's a

Speaker 2A lot of sort of time, effort, remember to technique with that. Now, I've added, instead of that, uh, a, a superior and a lateral geniculate block. And those are field blocks, right? And those are blocks that you as a surgeon do at the end of the case, 3 finger breadths above the Patella, you come down the bone, just come off, and you, you load, you know, you field block 10.

Speaker 2there, and you come in laterally, right where your guide pin might come out in an ACL or where you might make your, your secondary incision to insert something and you field block it there. And that, when you add that field block to an adductor block, you get really comprehensive coverage of the Knee, at least arthroscopically and perhaps don't know to go, need to go to something more sophisticated like an iPAC.

Speaker 1It's great. I, I'm gonna take exactly a 3 minute break cause we have a sponsor for this session, which I have to respect. All right, I'm just gonna play a short movie. We have the pleasure of this sponsorship by uh Gate Science, uh, a new company, and I'm just gonna play this.

Speaker 4Gate Science,

Speaker 4safely silencing Pain.

Speaker 4Pain after Orthopedic Surgery is severe in the first few days and can persist for weeks.

Speaker 4Following discharge after orthopedic surgeries, such as total joint and Rotator Cuff procedures, opioids become the cornerstone of Pain management. Each year in the US, 2.4 million post-surgical patients become opioid dependent.

Speaker 4Two gates control Pain transmission from the periphery, the molecular gate and the synaptic gate.

Speaker 4Pain is transmitted through afference that synapse onto secondary neurons in the dorsal horn, which in turn carry the signal to higher centers.

Speaker 4The molecular gate closes with pharmacologic blockade of the sodium channel, commonly used with nerve block.

Speaker 4The synaptic gate closes with neuromodulation, pulsed-electal stimulation, commonly used for treatment of chronic Pain.

Speaker 4Both gates can be closed with a single lead positioned next to the nerve trunk.

Speaker 4The relay system is the first to combine pharmacologic blockade and neuromodulation in one multimodal device. An Injection port delivers analgesic to induce Primary nerve block.

Speaker 4Relay's wireless integrated pulse generator provides neuromodulation via two electrodes at the distal end of the lead.

Speaker 4There's a 2nd Injection port for treatment of breakthrough Pain following discharge.

Speaker 4Relay fits into existing workflow, and clinical deployment is as simple as performing a single shot block.

Speaker 4Prior to Surgery, relay is positioned next to the target nerve and delivers Primary nerve block.

Speaker 4Surgery proceeds with relay in place outside of the surgical field.

Speaker 4After Surgery, neuromodulation is activated.

Speaker 4Following discharge, the patient is in control. Instead of reaching for an opioid pill, the patient adjusts pulse intensity up or down via an app on their smartphone.

Speaker 4Relay can be used for up to 30 days.

Speaker 1OK.

Speaker 1So, um, screen share has stopped. OK. Do you, can you hear me OK?

Speaker 1Yep. All right, good deal, good deal. So that's another that was an example of another type of concept of, of nerve blocks, um, and you know that we're not going to switch to that topic, but let's talk a little bit about patient compliance, Paul, uh, with your protocol.

Speaker 1Have you felt, you know, I have a lot of problems in the South Bronx. We, we, we don't have a lot of patient compliance, you know, with, with, with our Protocols, and, and it's, there's a lot of substitute of opioids because of.

Speaker 1The lack of trust of thinking that Tylenol or um Advil is is good enough. What happens in your practice?

Speaker 2Look, that's a really fair question. And in fact, the first submission that we sent to the, to the Journal of arthroscopy came back like that's great. A bunch, a bunch of patients in Greenwich, Connecticut can do better. How is that generalizable to the rest of the population?

Speaker 2Um, so we actually redid the study and we included a group from Oregon and a group from South Florida. Uh, so, look, compliance is a huge deal. And, and if the patient doesn't buy in from the get-go, you're gonna, it's gonna be an uphill fight. Uh, and, and that's why the buy-in has to be so consistent from, from me to PA to nurse, to every single person. Initially, when we started doing Shoulder replacements as Outpatient

Speaker 2Patients would be amazing. The patient will be set. They want to be an Outpatient Shoulder replacement. They get there and the, and the pre-op nurse is like, look, you should definitely stay. Your insurance will cover this. Why wouldn't you stay? You should, it'll be better for you. So, every single *** in my armor has been exposed uh in one way or another as I, as I sort of tread through this career. Uh, and that was another one of them that I really had to, to work through. Um.

Speaker 2But, but I, I am a little privileged, uh, at times with, with patients who are more likely to listen. But of course, I've got my share of non-compliance. I mean, most non-compliant ones are some of the, uh, in my lax bros who are just gonna smoke instead of take any medications. And like, that could open up a whole another discussion of is that a reasonable and effective, uh, non-opiate analgesic, uh, that I don't know, I know the answer to, but needs to be figured out.

Speaker 1So, let me ask you a little bit about surgical technique.

Speaker 1And whether or not you feel that surgical time, how much fluid you use, it's all about Rotator Cuff specifically, OK, Rotator Cuff specific.

Speaker 1How much do you feel that the surgical technique and the surgeon factor plays into post-operative Pain?

Speaker 1A lot of people don't like to talk about it, but, you know.

Speaker 1So,

Speaker 2I,

Speaker 2I don't know the true answer to that. Of course, I wanna believe that I'm efficient and I handle the soft tissues very effectively and I, and, and all of those things that, that I, I may do are, are reasonable. But having been all around the world and watched people operate, I think most orthopedic surgeons are, are pretty darn, I mean, it, it's rarefied error already, and I don't wanna be arrogant and say that, but they're very reasonable, well

Speaker 2Trained groups. So, I think that most of us can have the same guidelines and it's interesting. Our, our trading Protocols are very, very similar. So I have the privilege of working with fellows now, and the fellows come back from, you know, from Colorado, Steadman Hawkins, and, and, and they're like, look, you guys are really doing all the same stuff everywhere. Um, and they've trained in major residency programs. So, yes, I, I wanna believe that good surgical techniques.

Speaker 2is going to play a role in that, but I think that it's just sort of like, you know, when someone comes in and needs a Revision surgery and you think that you're just gonna do a better job right away. Well, you know, ask yourself for sure, are, are you sure you're gonna do a better job, or are you just gonna do the same thing over and have that patient doomed to another problem? Uh,

Speaker 3uh, so what, what do you think this plays into this plays into the discussion we had.

Speaker 3Uh, last week, and actually a question that Michael last week, uh,

Speaker 3How much of Pain control is actually attributable to

Speaker 3Surgical tetanus and how much of it is attributable to patient type.

Speaker 3I think uh it's something we have to get after, if we're going to actually address this question in a meaningful way, and maybe it's all about.

Speaker 3Uh

Speaker 3Uh,

Speaker 3How old are you sir?

Speaker 2You, you know, Ira, could you repeat the question for everyone because yeah,

Speaker 1how much was, uh, related to a surgeon technique or patient type.

Speaker 1Yeah.

Speaker 2I, I, I mean, look, patient type and patient's expectations preoperatively are gonna dictate how they do postoperatively and, and some of their comorbidities, whether they have severe anxiety, depression, or, or Other issues, um, are, are gonna, are gonna play a role in how they perceive and function with Pain.

Speaker 2So I, I believe that those are all factors, but those are factors that, that we don't necessarily control for because depressed patients are gonna still tear their Rotator Cuff and anxious patients are still gonna have problems. So I think that we have to learn uh strategies on how to help those patients.

Speaker 1You know, I, uh

Speaker 1We, I, I gave a lecture recently at the National Kaiser meeting and uh I zoomed in, um.

Speaker 1Andy Wickline, who is a real specialist in Opioid Free Joint replacement Surgery.

Speaker 1And he said that the number one.

Speaker 1Complication of Surgery is anxiety, patient anxiety. What do you think?

Speaker 1And he felt that education was the number one reason way to get rid of that anxiety.

Speaker 3So I, I,

Speaker 2I, I, I, I don't know that. I, I'd love to see Andy's data on it, but of course, that the anxious patient struggles more, and those are the ones you have to just dive in with care and call them every Other day and just, you know, really help them through the experience. And they're the ones who love you and endear themselves the most to you.

Speaker 2A lot of work on, on both ends, patient and surgeon. But, but yeah, I think, look, it's got to be scary having a surgeon, right? It's got to be scary to go through something you don't know what to do with and how to manage. But uh nonetheless, it's part of the, it's part of the job.

Speaker 1Let me ask you a a side question. You are in a very active Private practice.

Speaker 1Um, you are, uh, in it, I know this because I live nearby extraordinary high quality Private practice. How do you get the time to do the Research?

Speaker 2You know, it's, uh, I, I, I'm not, when I was in college, I had to run gels and look at chicken livers and do all these sort of hoops to get into medical school that I didn't really enjoy. These are problems, you know, you asked me the question from the very, very beginning, like, well, how do I, how do I get into this? And it was a problem I thought I had. It was a problem I was facing. So, I enjoy solving for problems that, that I face clinically. And that's, uh, if you look at any of the Research I've done, you know, 80% of it's gonna revolve around like how to

Speaker 2Fix the subscapularity is better after a Shoulder replacement. How to do something, um, and if you read between the lines, clearly, you're gonna read that, like, gosh, it's something that I struggled with, right? It's something that didn't make sense to me as a surgeon that I wanted to try and contribute to, uh, to some slightly better answer on.

Speaker 1I get it. Where do you think, well, I got two questions. First of all,

Speaker 1We still have an opioid problem. Not everybody's doing your protocol. Uh, we know 925 people or so read your article, so we know, uh, at least some of them will, will follow this. What do you think are the surgeon barriers to adopting this full force surgeon barrier?

Speaker 2I, I think the first barrier is that many surgeons in large Practices.

Speaker 2may not even know about some of these inbound phone calls. They don't wanna be bothered with that as a part of their life or a part of their practice. So, it, it'll, it'll be a, it'll, it'll be a nurse or a PA who sort of has historical training and wants to appease the patient. Uh, and that's the first barrier. The second barrier is it's not that important to them. The surgeon is thinking, gosh, they have to identify who needs Surgery, do a good job at their Surgery, and that

Speaker 2Post-operative part, like, look, there's some education. We didn't want to get them behind on Pain. Um, and we're still breaking, we're breaking knowledge gaps that, that we were trained in a certain way. We were trained that if we neglected to treat Pain, that fifth vital sign, that we were just as remiss as the cardiologist who didn't talk to the patient about angina. So, you've got to change practice patterns. If I told you, Ira, I think you do a, you do an anterior or posterior Hip.

Speaker 1I do a uh answer.

Speaker 2So if I said you have to go, uh, it's a little trickier, right? But if I said you can only go posterior right now, you're like, well, I'd say, no, I, the date is out. You gotta go posterior exclusively, but, well, I, I don't know. I, I've got a long history of doing a reasonable job. So, um, I don't think any of, any, very few surgeons walk around Doctor Death style and they're doing things nefariously. They believe that they're doing a good job, so it's hard to change.

Speaker 1What do you

Speaker 3think I have, uh, I have another question about barriers.

Speaker 3Uh,

Speaker 3To what extent is the disconnect between the anesthesiologist and the surgeon?

Speaker 3Impeding Pain management.

Speaker 1OK, I, the question is, if people didn't hear well, um, what is the

Speaker 1Disconnect between anesthesiologists and the surgeons in the, in the area of Pain management.

Speaker 2I mean, I can have fun and make the orthopedic surgeons laugh and like the anesthesiologist doesn't see the patient after they discharge him ever and it's all our problem, right? They just gotta do their job. But, you know, at the end of the day, look, they're, they're, we're all aligned, and I think that if you can align your anesthesia team, like I fortunately did, um, they really work towards the same goals as you. That said, when we first marched down this pathway, when I asked all

Speaker 2My anesthesiologist, what's in an interskeletal nerve block? I had 6 different answers and I had no idea. I had no idea at all that some people put clonidine, some people put Decadron, some people use 10, some people use 15, and the consistency of the Approach and exactly where they put the block, that was different across the board. It's sort of like how each of us would have done some, you know, some Surgery that would allowed variation.

Speaker 2So, I, I think now we're working towards the same goals, uh, and, and as we push more towards an Outpatient presence, really, our anesthesia team wants to engage with us and see that our patients do just as well in the follow-up. Uh, but, but of course, there can be some, there can be some thought differences on how we Approach the same problem. And those are healthy thought differences to help challenge us and, and to push us forward with different perspectives on the same issue.

Speaker 5Hey Ira, can I ask, uh, or like a thanks. So Paul, you, you continue to be an incredibly elegant speaker no matter what you speak about, and, and your message is, is spot on. A, a couple things I, I wanted to touch base with, you know, it's interesting in terms of the anti-inflammatories. We always used to try and do Celebrex because it wouldn't cause bleeding and Surgery, but the reality is, is that, um,

Speaker 5Most of the insurances may require, you know, some pre-authorization or deny as well. So we've actually gone to meloxicam as our anti-inflammatory cause you don't have to get the pre-certification, and that works pretty well. I, I think that your message regarding the patient education is key. I think that you're convincing the patient that this works great ahead of time is key.

Speaker 5And, and I think that what we know is, is that the patient's personality and their anxiety ahead of time may be a big factor in terms of our success. You know, it, it's interesting in terms of the concept of using uh Expiril as your inter scaling block.

Speaker 5I have patients that after 20 minutes freak out.

Speaker 5When they can't feel their arm.

Speaker 5And they can't feel their hand, and no matter how much you've talked about it ahead of time, they're saying.

Speaker 5When is this gonna wear off, and so a little my hesitancy to going towards, and I use Xel for all my ACLs and for Other procedures.

Speaker 5But a little my hesitancy with shoulders is that same patient freaking out. Now it's 48 to 72 hours where they think they have no arm attached to them. Do you, do, do you, do you find that? And, and if so, how do you deal with

Speaker 5it?

Speaker 2So that's definitely, definitely a real thing, um, and thank you, Michael, for the nice compliment, but it's definitely a real thing, and it's not just the patient anxiety. I did a, a complex revision of a reverse Shoulder replacement last week.

Speaker 2And I had to do a lot of work. And, and the next day, I talked to the patient. He's like, everything's great. I can't really bend my elbow or wiggle my fingers. I'm like, oh, don't worry, that's just your nerve block. And I call him, you know, the next morning, he's like, no, it's still not working. And, you know, at that point, I, um, I, I, I, I need to take anti-anxiety medications. And, you know, look, fortuitously, it wore off. So, that, that anxiety level can go both ways. Um, that said, to me, I, I think it's a 1 in 10 or 1 in 20. I talk him through the.

Speaker 2The Exper motor block doesn't last much longer. So, it's a longer sensory than motor block. So it isn't as bad, but it, it could be a good day. And you're right, there is that group of patients and um I do my very best and, and, you know, most of them end up tolerating it, but you're right, it's a hiccup. But it's a hiccup the same because even if I don't use an exal nerve block, we'll use a, uh, an interscalar nerve block with, with Decadron in it, which will still go 12 to 14 hours.

Speaker 5Is it anesthesiologist dependent how long the motor versus the sensory block

Speaker 5lasts?

Speaker 2I don't think I know the, the, the correct answer to that question. Um, you know, everything we can, there, there, look, there's certain anesthesiologists who, you know, each of us love to work with. They, you know, they make your day smoother and better. You never have any issues. No one ever gets thumb numbness afterwards. None of it, right? But uh, I, I don't know that I've, I've uncovered or figured that answer out.

Speaker 1I wanna make a comment that uh Marty Nichols commented, uh, and thank you Marty for this, that a lot of leading edge ASCs for that he has seen for total joints have incorporated the anesthesiologist in the post-op Pain management as well, not just.

Speaker 1In the OR and we may see that. I mean, I think we may see that in the future that we pass on post-op Pain management.

Speaker 1Uh, to a

Speaker 1To a group run by the anesthesiologist to take it through the 3rd or 4th day. I mean, it's a surgeon's dream sometimes, I guess.

Speaker 2I mean, I mean, look, we had it at one point when there was Pain services, right? When they, when, when the anesthesiologists were getting reimbursed for Pain services. So if we turn around and look at the bundle and part of our bundle, if we're gonna share a part of the pie or the risk with our anesthesia team, and we, we engage them in helping with the post.

Speaker 2For Pain management, I think it could be useful, but it's just, it's one of those scary levers or controls that I wanna be careful to help manage as a surgeon because if there's something impending like a compartment, I, I don't want anyone to ignore or blow off the small little minutia that might, that, that I could, that could be important triggers to me. So, it, it's, it'd be great, but it's something I'd wanna really trust, it's a lot of trust there.

Speaker 1So this is your protocol now. Oh, so Neil, question again.

Speaker 3Yeah, I agree, uh, but, uh, the level of attention that could be given with the appropriate focus in that circumstance might help you out, and it might not be all you thinking about.

Speaker 2Well, and, and you're right, Neil, as, and, and as we develop new technologies that can help us for more than, you know, 3 to 5 days, and as, as we look at what gate's gonna bring to the world, I think that, that, that's where we're, we're gonna need the team of, of surgeon and anesthetists to really sort of shepherd us through the entire experience. And that might be the next, the next gate, or if it were transition to, to how we effectively manage 30 days of, of Pain post-surgically.

Speaker 1So,

Speaker 1Where is, if you could try to put your crystal hands on the crystal ball, what's the next world of Pain management? Where, where does that go?

Speaker 2Uh, was it Neil's Bo who said, uh, you know, I'm not very good at predictions, especially when they're about the future. Uh, so that's, that's me. I, I don't, I don't know that right answer, but look, I, I think that we're gonna get to a point, um, surgically where, where we either have enough robotic interface.

Speaker 2or enough minimally enough interface that we can minimize the trauma to the tissues. I think we're gonna simultaneously, somehow harness the biology of healing so that we can expedite these things. Um, and then you're gonna add in the next generation of, of how to modify your Pain response, whether that's gonna be controlling the nerves.

Speaker 2At the efferent and afferent level, we're coming up with more super tentorial mechanisms on how to eradicate or tell your brain to shut off those Pain strategies. So, I think that our kids who end up being surgeons will look at what we did as barbarism, uh, and, and we've got, there's only upside. It really will be Star Trek type, you know, where you're holding little monitors over people and figuring this out. And I don't think it's that far off.

Speaker 3And I do think the super temporal is the next big.

Speaker 3Understanding, and you can do great things in the peripheral nervous system, but you really have to start understanding.

Speaker 1I agree, you know. Um, so let me ask you a practice Marketing question related to that, OK, because, uh, I always say there's 6 things that motivate all orthopedic surgeons. It's doing the right thing, making money, Marketing at practice, covering your ass, power and glory, and going home. Those are the 6 things that every orthopedic surgeon has some variant of.

Speaker 3Have you noticed?

Speaker 1What?

Speaker 3What was number 5?

Speaker 1I forgot number 5. Yeah, they're all number 5. So, in market, have you noticed, Paul, since you have been

Speaker 1Decreasing the Pain more as word got out.

Speaker 1That you're the pain-free Shoulder guy.

Speaker 2No, that, that stays with a guy called Scott Sigm in Massachusetts. I have not quite got the title yet.

Speaker 1Um.

Speaker 1No, I look, look, I, no, I don't mean opioid sparing. I mean, patients telling Other patients, I had a good experience.

Speaker 2Yeah, look, that's how, uh, whether good or bad, I think that's how most surgical Practices develop, uh, at least in, in Private practice.

Speaker 2Especially where, where we are in proximity to a big city where there's no shortage of surgeons. Uh, Patients don't just flow into you, uh, referred by a sequence of, of orthopedic surgeons who don't want to do the case or internists. It's really word of mouth from surgeons, I mean, from patients and, and how they've done well.

Speaker 1So I have another question from uh from Marty. Is there a point that total Pain relief post-op could become detrimental to an outcome? For example, could a patient become active too quick, because they have, they're so pain-free.

Speaker 2Shit, when we get there, I'll be so happy, right? Yeah, I guess, I guess too much of a good thing, but um.

Speaker 2You know, look, I'll take that, that, that would be a good problem to have. Right, right,

Speaker 1they really have to convince them. I know that. But Paul, I'll, I'll,

Speaker 5Ira's question to you, and I'll, I'll, I'll send it back again. I, I think that as time goes on.

Speaker 5You don't choose your practice, your practice chooses you, and if you have this reputation of being able to do this great Shoulder Surgery with minimal discomfort, you're gonna get a patient, a bunch of patients flowing in, and, and I give minimal no narcotics from anything I do, and I, and I was talking about with my MA. I think that my

Speaker 5The calls up for a refill for the 5 or 7 or 9 oxycodone 5 mg tablets that I give for a Rotator cuff repair is in the single digits.

Speaker 5But I think that one of the things that we need to think about in that situation.

Speaker 5Is it because we're doing such great, minimally invasive, reasonably pain-free Surgery, or patients who need a lot of Pain medication just aren't coming to us cause they know you're not gonna have a Pain Medicine.

Speaker 2Yeah, look, that, that, that's, people are gonna select us, and I think they're absolutely gonna find, find people who historically may have been Pain, Pain pill mills, uh.

Speaker 2Whether good or bad, you know, and I don't know if legislation is the answer on how we should solve this, but it's made it a lot harder. And, and, in a bad way, patients who suffer from chronic Pain have a, have a very different battle to get into here. Thomas Evely, I see you on the horn. Thomas is a surgeon in Alabama. Thomas, how does this, this Pain stuff transpire? How does it play out in a different population in Alabama, much to what Mike and I are alluding to.

Speaker 6Yeah.

Speaker 6Yeah, that, that, that was gonna be my question to you is, cause I, I have a, uh, not a small proportion of patients that are on chronic narcotics when they, when they come to me. And, uh, one of the things, you know, I'm only a couple of months in. One of the mistakes, uh, I have learned from quickly is identifying those patients and making sure I recognize going in, uh, the, the ones that are on chronic narcotics before Surgery. Uh, cause that's a, uh, it's a daily battle for me. Uh,

Speaker 6Calling in for, for refills. I'm not as, uh as slick as uh Doctor Sey on my Rotator Cuff. So they, they take me a little longer. So I, like my, my post-op patients probably have, you know, a little more Pain than most, but

Speaker 6Uh, I, I'd love to hear your comments on if you have a patient on a chronic narcotics, does it change your Approach? Because, you know, I'm using the multimodal proto protocol that you use. Um, but I still get a lot of medication refill requests, uh, for, you know, Rotator cuffs and, and actually less for my arthroplasty than, than on, uh, on my Rotator

Speaker 2cuffs.

Speaker 2Yeah, look, I mean, as you know, psychiatric disorders and chronic use before, and it's, that's up to only 3 months. It's gonna make it harder. You're gonna have to give more. And my best strategy, it doesn't work so well is having them identify where are they getting their Pain Medicine before and who is their

Speaker 2Pain management doctor is hopefully, it's not just their internist, cause that's, then you're really in a pickle, cause then, you know, then it's sort of, it's a little of this. But if they have someone who helps them manage chronically, cause you're not gonna get them off, they're gonna need it for longer, uh, and, and you're wedded to a different game.

Speaker 5So Paul, I have a little bit of a different Approach.

Speaker 5And and Tom, if, if I have a patient who is, is on chronic, that has chronic Pain and chronic Pain medication, we have a little contract ahead of time.

Speaker 5And the contract ahead of time is if you've been getting your Pain Medicine elsewhere.

Speaker 5That will continue to be your source. I said, we're gonna have the expert treat that. I'm not gonna pretend to be able to treat that, and I will give them no narcotics afterwards, and any kind of medication they need that's narcotic in nature has gotta come from their Pain clinic doctor, and we give them zero, and that's an agreement we do ahead of time, and I think it's a good agreement, because I said, listen.

Speaker 5I'm not the expert on Pain medication. I try to minimize as well. If you're in that situation, you need to be dealing with the expert, and it's not me. There should only be one person in charge of your medication, and in this case, it should not be me.

Speaker 6Yeah, and thank you for that. I think that's, uh, where, you know, I'm only a couple of months in and the mistake I made early was recognizing on the day of Surgery who, who was on those chronic narcotics because in, in the clinic, I was focusing on who, who am I operating on and, uh, and, and, and Other things. Are they on any blood thinner medicines and, and I go to an ASC and in a hospital, so who can I take to which facility.

Speaker 6And I let that kind of slip through. And, and, and having those discussions in the clinic, I think are, are very important too as far as where they're gonna get their Pain, uh, uh, the multimodal Approach, but also where they're gonna get their Pain medications post-op. I think, I think doing that before Surgery is, uh, a, a quick lesson I learned in my first few months of practice.

Speaker 5Tell them it should, it should not be you.

Speaker 1What was that, Neil?

Speaker 3How old are your patients, um.

Speaker 2So I, I, I take care of a wide swath. Uh, I, I, I operate on a I'm sorry.

Speaker 3How old are your patients?

Speaker 6Uh, in general, you know, I'd say, you know, 40 to 60, they tend to be older, um, you know, they're not, not so many athletes. I would put them in the 40 to 60 year old category for the most

Speaker 6part.

Speaker 1OK.

Speaker 1So Paul, uh, we have like 3 minutes. Um, I just want to make a couple of, uh, comments and then they ask you for a final comment. I, I want to, uh, tell everyone that this is gonna be, this is recorded, we're gonna edit it, we're gonna pass it on to Paul for approval, and it will be posted on a, a YouTube channel and Docs Social channel. Uh, additionally, um,

Speaker 1I wanna uh direct people to Paul's article on the journal. Uh, I think it is.

Speaker 1I don't know, I feel it's a landmark piece. It's written so well, and it's probably gonna go over 1000 views within the next week, uh, which is a testament to a lot of good work by your colleague, Doctor Commodor and yourself. So Paul, maybe some final comments for everybody.

Speaker 2Yeah, well, first of all, thank you and thank you to the journal. I think you, you've started another great thing and I like an open access where, where we're not sort of compelled to pay and, and be in a bad spot to, to get great knowledge. Uh,

Speaker 2I, I do want to acknowledge Parth Kamdar. Parth is currently a medical student who's matched in Orthopedics, uh, and just married, and he's really a superstar. So, so shout out to him. And then look, each of us are gonna handle this slightly differently, but if we can start to accept some sort of framework or protocol and how we're gonna Approach this and stay, stay within that frame.

Speaker 2Framework on how you Approach patients, then I think we can come to, to solutions that are repeatable and, and eventually don't get us into the same hole that we find ourselves in currently where we've got a world of, of imperfect prescription. Uh, and, and as we advance the science of Surgery, I think we have to advance the science of post-operative Pain control in the same way.