Incorporating Transosseous into ASCs and Insurance Coverage

Speaker 1With that, I'd like to call on Doctor Capio, uh, uh, to go ahead. He's in, uh, Augusta, Georgia. Um, and so, uh, he was a non-transosseous surgeon that was an anchor surgeon that adopted, uh, Tenssor, and, uh, he's got an interesting tech, um, perspective from Private practice about adoption.

Speaker 2Yeah, so thanks so much, Brett, for having me. Um, I, you know, a couple of things we've already talked about with general tips and tricks and, and whatnot. I mean, we, you know, for, for me, I, I make that lateral acromial portal, uh percutaneous for the medial all placement. I think getting your alls placed well will prevent that suture pullout, um, and then getting low lateral, so that lateral portal is slightly more lateral than.

Speaker 2maybe most of people will do with their, with their anchor placement to really build that bone bridge. Um, yeah, you go ahead and make my, my medial tunnels right away, uh, whether it's 12 or 3, I, you know, I, or, or more, um, I make sure anesthesia has the blood pressure low and you are creating these vents. Um, you know, for, for me, if I'm using more than 2 tunnels, though, I tend to pass, um,

Speaker 2Sutures. I'll make the, the medial tunnels at the same point with you all, but I'll, I'll create two tunnels at a time passing sutures so I don't have too many sutures in, you know, if I'm doing a big, you know, 3 or 4 tunnel repair. That's just my preference to avoid, uh, too much, uh, uh, spaghetti in the some incredible space. Um, and yeah, I typically use 3 sutures per tunnel. Um, the bicep tenodesis,

Speaker 2Actually, um, do prior to cuff repair, I know when I visit you, that seemed to be the last thing that you did, and then you kind of go back in there and release the biceps. I've started just, you know, since I've got that opening, um, that window from the subacromial space, if many of you will join, I'll go ahead and do the tenodesis low.

Speaker 2Um, and then just go through the cuff tear and, and, and resect it and debride any remnant of the biceps, then go to repairing the Rotator Cuff. And, and for me, that's just been a little bit easier as opposed to trying to get back, you know, within the joint at the, at the end of the case when everything's swollen.

Speaker 2Um, yeah, for, for yeah, yes, in this case is you see the tear there, I go directly down to the biceps, get a hold of the biceps, tenodes, and then, then release it within the joint, and then go back and make my tunnels to repair it. Um, for me, you know, when I first started out, I, I did a, you know, just a medium sized tear where there's minimal attraction, um, you know, like type one where it seems like a fairly bread and butter type case for anchors and

Speaker 2And that was, that was a great starting point for me. I was used to tying knots, which um is kind of been a big thing for any of my partners, uh, being slightly reluctant to, to, to start these cases is that a lot of them don't tie knots, but for me it was a fairly easy transition and went in with the two peripheral simples and then the Xbox configuration that, that you so well described, uh.

Speaker 2Um, you know, and then progressed to the larger tears, 34 tunnel type tears with biceps tenodesis. Um, this lady I literally made like just a week before we were doing this presentation. She's 3 months out. I mean, she was at 6 weeks looks phenomenal. This is actually the, I finally got my camera out. It was the 3rd patient of the day that came in, that was right around that time frame and

Speaker 2It's just so, so much more pleasant talking with these people. I mean, the, the Pain threshold is just so much easier. I've yet to refill a Pain, uh, prescription on any of them. Um, you know, so when you asked about, you know, incorporation into our ASC, you know, the hardest adoption problem we had was, honestly, you know,

Speaker 2I'm the new young guy in our practice and everyone's been doing things the same way for a while and so convincing my Surgery center to just buy the device. The savings kind of sounded too good to be true, um, but, you know, I'd be a little persistent on it and, and, um, having the trial, uh, being able to trial the, the device for a while and seeing some post-ops a few months out was, gave me even more kind of credit to say, hey, this is working really well and this is something I wanna, you know, continue using.

Speaker 2Um, you know, cause they were concerned, oh, well this, you know.

Speaker 2You know, sutures pull out or, or whatnot. And, um, you know, are you're trying to, you know, fix a problem that you really don't seem to have with patients recovering well from this. So, um, you know, like I said, for me, the, the Learning curve has felt fairly short just because I'm used to tying knots, um, I think it is very helpful. You know, how, how would I recommend to Other surgeons, you know, debate really is when you talk to me about how there's reduced Pain, the earlier full range of motion, patients were happier.

Speaker 2Um, the hook was then the science and the biology. I mean, you know, the strength, the natural cuff healing on MRI, the less type 2 failures, you know, the, getting the increased number of suture fixation points, all those things that we've already talked about, then really kind of hooked me in, and then, you know, to reel me in the rest of the way.

Speaker 2You know, being in a Private practice, you know, you have to think about your costs, and I mean, if you plan to use more than one anchor, you're saving money. And so for a medium sized tear, if I was going to use 4 anchors previously and then a biceps anchor, I mean, I'm saving at least $1500 a case.

Speaker 2Um, and, and, you know, being the Shoulder specialist in our group, I typically, I don't, I don't really see a lot of just tiny, you know, simple, simple tears. So usually the bigger ones get sent to me or revisions or whatnot. So my, my, uh,

Speaker 2Uh, anchor usage was, was fairly high compared to some Other partners just for that reason. Um, you know, we talked about, you know, pull out with the anchors in the, in the Bone tunnels, but, you know, or the sutures, but, you know, one thing that I ran into was just trying to, you know, get, increase the fixation points, you know, when I was first starting, I, I put two tunnels that were too close together, you know, and, and

Speaker 2So they, they collapsed, but it really was not a big deal at all. And you kind of described that. I mean, the sutures are still there. I could pass in the same way. I had two lateral row, uh, you know, two tunnels from there. It was, it was just the medial tunnel that had kind of was too close together. Um, you know, that's, that's, we, we learn as we go. Um, post-op Pain and rehab, you know, really is.

Speaker 2I have the same post-op protocol to keep things consistent, um, but I do have to hold patients back. They wanna do more. They wanna do more from the start. I had one patient literally accused me of not performing Surgery on his Shoulder cause he had no Pain, and he said he was doing too well compared to everyone else in Physical therapy.

Speaker 2Um, you know, I've, I've had spoken, so, I've spoken to physical therapists about, you know, not releasing patients too early. Um, a lot of times they'll come back, you know, uh, you know, 2.5 months, 3 months, and, and they've been already released well in advance from the therapist. They don't have any more visits. They're not really doing, they're just like back to doing all their normal.

Speaker 2stuff and, and I still, you know, tell them about the biology, how long, you know, it really takes to integrate the tendon in the bone cause, you know, I don't, I don't think that's gonna change necessarily. I think it will integrate better, uh, but I don't think it's gonna, you know, timing is timing in our, in our bodies. So the biggest thing that I've had to do with, with any of my scrub tex is simply just, you know,

Speaker 2You know, teach them how to load that passing suture. It's easy. Uh, I did it today with a new scrub test that just started in the middle of a case, um, and so this is why our scrub that just

Speaker 2You know, showing us on the camera, I mean, that really is like their only Learning curve for this device. I mean, my reps aren't in the room at all. Um, it's just me and one scrub tech doing, doing this case, um, and so that part is super nice. I don't have, you know, I have my Other anchor rep who's, who's always around and open up stuff and whatnot, and this, we don't even need anybody. Um, you know, the Other thing with, uh, with, you know, especially in Private practice or if you have your Surgery centers looking at insurance, um,

Speaker 2And so this is our uh breakdown, you know, the last quarter. Um, you know, with Medicare and non-implant providing insurances, I mean, you are saving money if you use more than one anchor. Um, I've, I've now work comp has covered Tensor as well as uh Blue Cross Blue Shield has recently started to cover Tensor. Um, you know,

Speaker 2For me, it's just, it's been, you know, wording, I think, and, and then also changes that you all have made, you know, it's an all suture anchor system, you know, I, I described how many Suture anchors I've used, you know, if I passed 3 sutures through 2 tunnels, so 6 sutures total, I'll say I use, you know, created 6 suture anchor, um.

Speaker 2Uh, well, you know, fixation points within the Shoulder. Um, because that, I mean, that's what it is. It's a suture that then creates an anchor for the tendon back on to the bone. Um, and it's about time that insurance has started, um, you know, accounting for this. And so I think that's made a difference with, with some of our private insurance companies and work comp that, that typically, that will cover the implants, um,

Speaker 2And that was the biggest pushback I was getting from my Surgery center. Yeah, the, the caveat is, you know, we think that some of these insurance companies may cover 100%, but in reality, they may cover 100% for us, but may, they may only pay 80% that the patient pays the Other 20%. Um, so there's all sorts of stuff like that that they, um, you know, kind of define writing that, you know, we need to be cost-conscious of how we are treating our patients and, and doing stuff. Um, and, and this is, you know,

Speaker 2Um, a huge, huge advantage in that, amongst the Other advantages that I've, I've already gone through. And so, you know, what do I discuss with patients, um, you know, when they, when they come to me and they say, oh, there's so much less Pain, I'm doing so much better than, you know, my, my buddy, you know, who's next to me or whatnot. I mean, I, I do, I, I, I will, I, I give them the credit, you know, I don't want them to feel like, um,

Speaker 2You know, I'll, I'll discuss, you know, some have come to me specifically for this technique. I have to do it on a, you know, one of the, like the head of one of the largest Primary care providers in our area. So a lot have come and said, hey, I want, I want you to do what you did to, you know, so and so. Um, but otherwise, I, I do, I just compliment them on their Pain tolerance, you know, I, I try and give them the credit. I feel like it empowers them to be strong.

Speaker 2With their recovery and whatnot. Um, you know, I, I reinforced physical therapists that, you know, tendon healing the bone is still tendon healing the bone and time span recovery, you know, is the same, even though they are getting, hitting their marker points much, much sooner. I still don't release them out of the gates, you know, until, until they're ready. Um, you know, clinic visit, so much more pleasant.

Speaker 2I hate being a psychiatrist, trying to coax these patients along. It's not why I went in to, to medical school. Um, yeah, therapists, you know, have reached out to me, you know, Pain improved, motion's easier. They, they enjoy these patients so much more as well. And they're not as afraid of, of, of starting out with the, with some of these patients like they are with most Other cuff repairs. Um,

Speaker 2You know, like I said, I, I, I still discuss restricting patients, you know, when they want to do more post-op, I just encourage that they're doing really well, to keep up the good work, that their body's doing what it needs to do, and it just takes time um for, for the tendon to really integrate back into the bone. So, no, my post, post-op protocol hasn't really changed all that much. Um.

Speaker 2So that's, that's it for me, it's.