Marketing your practice with Transosseous and Less Patient Postop Pain

Speaker 1Uh, Doctor Brogan's one of the highest volume transosseous arthroscopic transosseous cuff surgeons in the, in the US. He's got a storied history of doing, uh, transosseous cuff repair even before Tenssor was around. So we're very interested in his experience and, um, uh, he's been using tensor, uh, for a while now and, uh,

Speaker 1Uh, he's gonna talk to us about, uh, how he discusses with his patients, um, the benefits of transosseous, um, and, uh, how to market that in the community and to the patient.

Speaker 1All right.

Speaker 1Take it away, bro.

Speaker 2Thank you. Appreciate that, Bro. OK.

Speaker 2So, um, I talked to, uh, the team, Jeff Pollock and Brett about this topic a few times. I, I really feel strongly that, um, in, in my experience, I, I've noticed that, um, my Rotator Cuff patients don't have

Speaker 2Don't have the Pain that, uh, patients who have had anchor-based repairs, um, what they experience.

Speaker 2And, um

Speaker 2It's been a little bit difficult to move the needle with some surgeons who stick to anchors, and I felt that uh focusing on

Speaker 2transosseous as being a significantly uh

Speaker 2less painful method would be uh appropriate at this time and potentially use this as a direct Marketing technique.

Speaker 2To patients. Uh, my personal experience is that, um, at 10 days follow-up, I have a number of patients that have 0 to 1 out of 10 Pain. Uh, my policy is no refills on narcotics. It's discussed with every patient prior to Surgery. They get 15, uh, Norco day of Surgery and they're encouraged, uh, to take them only if they're desperate. Uh.

Speaker 2I really advise them to do everything that they can, otherwise, uh, multimodal with, uh, Tylenol, um, occasional anti-inflammatories, and I'm heavy on ice. Most of my patients, uh, take less than 10 Pain pills, um.

Speaker 2And, uh, our anesthetic technique is an ultrasound-guided scaling block and uh general anesthesia.

Speaker 2So I'm sure a lot of people question that, um.

Speaker 2And I, I guess I don't blame you. Um, if you haven't used this technique, you won't, you won't see this level of consistent, um,

Speaker 2Uh, Pain response, but our PT department has consistently seen the differences in, uh, Pain with regard to transosseous patients, my patients as versus anchor-based Rotator Cuff repairs. Uh, I'll get phone calls from outside PT departments asking why my patients have less Pain after Rotator cuff repair.

Speaker 2And, uh, the bigger problem with that is, uh, you have to slow people down after 10 days.

Speaker 2So this is a, a patient that I did recently. She's 67 years old. Um, I did a transosseous cuff repair and transosseous tenodesis.

Speaker 2And post-op day 10, 0 out of 10 Pain, she took 3 Norco post-op and she's 2 weeks ahead of her protocol.

Speaker 2This is her. Uh, this is her pre-op MRI. Um, this is the, um, Rotator Cuff Tear from, uh, the view from the joint. Uh, I think one of the nicest things about this technique is that you can

Speaker 2Um, work in a small space and you're not taking surface area away from the greater tuberosity, um, for, uh, the repair or for the site of healing. So if I put an anchor in that space that you're looking at, I'm taking up about a third of the surface area just to have an anchor there as opposed to just having biology come in to that particular spot where I've passed the suture.

Speaker 2So I'm getting all of the advantage of, of Bone Marrow coming directly up through that little tunnel into the site that needs it the most instead of plugging that hole with an anchor, taking away surface area and taking away the Bone Marrow elements.

Speaker 2So it's, it's pretty simple. Why do my patients have less Pain? It's not magic. It's, it's not fairy dust. It's that Suture anchors in the humeral head increase intraosseous pressure.

Speaker 2And I don't use them. transosseous suture tunnels allow for a decrease in intraosseous pressure.

Speaker 2So, what about this interosseous pressure?

Speaker 2Intraosseous engorgement, um, it's pressure and Pain that, that, that comes from, uh, Bone Marrow edema. Uh, the engorgement, uh, results in edema and you see that on a post-op MRI there are a number of disease states, uh, of bone that cause increased intraosseous engorgement Pain.

Speaker 2Including Arthritis. Uh, when Arthritis gets really severe and, uh, we get past the point of being able to say scope a Knee. If they have Bone Marrow edema, uh, below their articular cartilage, you know that that's not a patient that you can offer much with an arthroscope. Uh, it's part of the arthritic change and, and significantly part of their Pain. It's described as a deep aching Pain like a toothache.

Speaker 2And the Pain is constant and not relieved with, with rest. In fact, it takes away their ability to rest and get sleep.

Speaker 2Um, and there are no susceptors in the Bone Marrow that sense this increased Pain.

Speaker 2So, this is a recent study, uh, February of 2020. It's in the Journal of uh Knee Surgery, Sports Traumatology and arthroscopy, and it indicates

Speaker 2With um

Speaker 2Uh, a series of 117 patients, uh, after double row arthroscopic Rotator cuff repair that at post-op MRI, uh, at 36, 12, and 24 months, they had

Speaker 263% of the patients show Bone Marrow edema at 3 months and 12% at 6 months.

Speaker 263% at 3 months. That means 63 or 2/3 of the patients are going to have this deep, achy, toothache type Pain because of increased pressure in their humeral head.

Speaker 2So this is a transosseous suture that's just been passed.

Speaker 2Uh, and what you see there is fat and Bone Marrow coming up from that. So, so when I pass the suture, pass the transosseous tunnel, I'm getting Bone Marrow coming up from the tunnel immediately. That means that pressure is being relieved immediately. I don't have to deal with 3 to 6 months of Bone Marrow edema.

Speaker 2That's not gonna happen. This pressure release happens at time 0.

Speaker 2So, the industry recognizes this and they're making the point for us.

Speaker 2You know, we see these vented anchors, the heli coil, for instance, and they do these studies and they like to tout the fact that it doesn't cause increased pressure, it allows for Bone Marrow to come up into the repair site, and they're making the point for us. We get that automatically without having to pay for a $400 anchor.

Speaker 2So a recent meta-analysis of um

Speaker 2Arthroscopic Rotator cuff repair data was published in JBJ JBJS in April of 2019 and they basically came up with three factors that are critical in reducing the retear rate after Rotator cuff repair. And those factors included double row technique, platelet-rich plasma, and early motion, which, as we know, requires a stable repair construct at times zero.

Speaker 2So with Tensor Surgical, the arthroscopic transosseous technique, you're getting all three of those critical elements.

Speaker 2Built into the way that this allows us to do Rotator cuff repair.

Speaker 2So we can do early motion because it's, it's very well fixed. We know that uh transosseous sutures are the gold standard for fixation of a Rotator Cuff.

Speaker 2We get Bone Marrow instead of PRP. We get better than PRP. Uh, we get better growth factors, higher density and growth factors, and we get meal stem, stem cells. So we actually surpass those three critical determinants of fixation, you know, uh, double row, we're better than double row with transosseous and, and, um.

Speaker 2Uh,

Speaker 2You know, it's, it, it doesn't have two points of fixation. It has a circular type of fixation. It's a constant, uh, level of pressure. And if you see there in the picture, you see simple sutures.

Speaker 2Uh, with a circular, uh, pass through the tendon and the bone, what's gonna happen there is that, uh, if there's an area of increased tension or pressure, it's going to offload a little bit to the Other areas. It, it doesn't prevent blood from coming in from medial to lateral through the Rotator Cuff. It is biologically friendly and it's also extremely well fixed.

Speaker 1So Brad, is that your repaired construct, uh, uh, two simples, no strangulation medially, no bridging mattress?

Speaker 2I, yeah, I don't use, uh, pull, if I need extra fixation, I'll do an extra suture or, or two extra sutures through the tunnel. So I might have 2 tunnels and 3 sutures in each tunnel if I need that. Uh, there's the occasional need for more than 2 tunnels, but I think simples, uh, you know, I like the analogy of Gulliver's Travels where you just use a little bit more rope. You, you don't have to tie fancy knots, you just have to use a little bit more rope and just use, um, an extra stitch or two if you have to.

Speaker 2But that's a very solid construct.

Speaker 1Yeah, I, I agree, and I, I, I think those simple sutures are, are one thing that contributes to type one, you know, retear versus type 2. We can talk about that. I, I bring that up because I know you got to get on a plane here. So, uh, uh, Brad, I, I believe uses a, uh, you know, a simple, uh, construct here, and, and as a result, that probably makes your repairs pretty fast,

Speaker 2right? It does,

Speaker 2yeah, I'm, I'm very efficient with these types of cases, um.

Speaker 2I'm not losing any time to anchors, I can tell you that.

Speaker 2Uh, this is, uh, a biceps tenodesis technique and basically we're looking from, um, a lateral viewing portal. We're looking, uh, across toward the biceps groove.

Speaker 2And you can see the biceps tendon within the groove. I've passed, uh, a transosseous suture, um, through the biceps groove out toward the greater tuberosity. Uh, I've already tied, uh, uh, a circlage type of stitch, uh, around the biceps tendon and I simply tie it down and I've got an in-situ repair of the biceps tendon within the groove. It's extraordinarily stable.

Speaker 2And I get again Bone Marrow right to the site and I have far less groove Pain, far less engorgement Pain by avoiding a, a screw or some type of uh suture anchor.

Speaker 2So this also is very cost-efficient. If you're, if you're doing a Rotator cuff repair and a tenodesis with basically the same instruments and um maybe even no additional suture, this is very, very cost-effective, a gold standard for repair, and the best biologically.

Speaker 2So, with all of these factors, uh, again, the concept here is direct Marketing to patients because we're having a hard time with

Speaker 2Pressing this issue with surgeons, quite frankly. Uh, so we're gonna have the patient's message directly that this is the least painful method. We can back that up. We don't have Bone Marrow edema after transosseous repair. We have venting, we have a pressure release. So therefore, patients are going to have less Pain with the transosseous technique.

Speaker 2So, if we explain this simply to patients and show them the images of anchors um in bone with Bone Marrow edema, it's very striking, uh, patients will understand that. They'll be educated enough to go back to their doctor and ask about their doctor's method of repair. Doctors are gonna have to be prepared to answer how they fix a Rotator Cuff.

Speaker 2Uh, surgeons who use anchors are gonna have to defend that position.

Speaker 2And then eventually the educated patients are gonna say, you know, I'm gonna go to a surgeon that does transosseous.

Speaker 2The anchor argument is this, and we hear this all the time, uh, suture anchor Rotator cuff repair is widely accepted. In fact, in that meta-analysis, they used double row anchor type-based repairs for most of that meta-analysis.

Speaker 2Uh, so, we're, we're the minority, for sure. Uh, the Other, uh, argument that you hear is, that's how I was trained, uh, with regard to anchors and that anchors are easier for me or that I'm faster with anchors. Those are the three main arguments that, um, that I've heard and I'm sure Brett's heard.

Speaker 1Right, and what would you say about faster, you know, and easier after, after the Learning curve? I mean, there's, there's there's third-party evidence by Lazarus and Black showing the time equivalence in the OR.

Speaker 2Well, we, we're gonna provide training, you know, um, Amanda Penny and I are, you know, talking about how best to train surgeons. We're coming up with a storyboard, uh, method and then training the reps in order to help train the surgeons and, and help get them over the hump. But once they're over the hump and they, they find that the steps and the suture may

Speaker 2Than anchors.

Speaker 2Then I think uh it'll be embraced. But the tensor response to what, what doctors are clinging to with anchors is that, you know, Suture anchors are driven hard by the industry.

Speaker 2Uh, we see this at meetings, we see this in the, uh, Peer review articles, and the industry is funding both of those. We know that industry makes, they make quite a bit of money selling Suture anchors.

Speaker 2So, to combat that,

Speaker 2We're gonna go directly to patients. We're gonna um market this to patients that this is a less painful method and make the surgeons defend their use of anchors.

Speaker 2Um, we're going to direct market focusing on the fact that this is the least painful method.

Speaker 2Of Rotator cuff repair. That single message alone is uh something that will move the needle with patients. Patients hear all the time how painful Rotator cuff repair is. If they see testimonials from, from patients that have had transosseous.

Speaker 2Then I think that will really drive the patient's heart to our surgeons and uh Tensor will have a list of surgeons who are trained on how to use this device and um we'll make those surgeons available to patients in a given market or a given area.

Speaker 2So the anchor users will have to start explaining these types of things. Why are they using a method that results in more Pain?

Speaker 2Why do they want to pay significantly more for their implants?

Speaker 2And for the case, uh, as a total, why do they accept Bone Marrow edema for up to 6 months? Why are they willing to reduce bone surface area for healing? Why don't they want to have Bone Marrow, uh, elements at, at their repair site? Why wouldn't they use the gold standard for fixation?

Speaker 2And then they'll have to answer why are they're losing patients to transosseous surgeons.

Speaker 2Uh, so it's aggressive, um, but

Speaker 2I think that's where we're at with this because, uh, patients deserve a chance to have a Rotator cuff repair that doesn't result in, in 3 to 6 months of Pain.

Speaker 1Yeah, that's a lot of great points. Um, it kind of made me wanna bring up, um, and I, I just would like to, like to make a, a question to the panel here. Nick Capio, you, you recently adopted, you weren't trained in transosseous. Did your PTs notice that there was something different spontaneously?

Speaker 1In terms of Pain and stiffness, did you notice, you know, tell us your experience on that.

Speaker 3Yeah, no, I mean, I, I was, I was trained by a very good, you know, also trained by very good surgeons and with the great cuff repairs, came into practice first couple of years and did the same thing and I was very happy with my outcomes, but, but I was intrigued by what you had talked about and honestly, it was pretty instantaneous. Um, I, you know,

Speaker 3Uh, the PTs reached out. I was surprised. My clinic staff even asked to what, like what, what is going on with these patients at 2 weeks at 6 weeks coming back. Um, you know, like I said, the therapist reached out as well. It, to me, when I'm doing cuff repairs now, I've, I've now transitioned to a good portion of mine all being

Speaker 3Transos at this point. When I was debating how best to proceed, I would think about that clinic visit post-op and just be like, oh God, I wanna have the talk, be the psychiatrist in the room, trying to discuss with these people, work them through their Pain, trying to be their cheerleader. It's so, it's just so much easier now, um.

Speaker 3To meet with them at their post-op visits cause they just, and they tell their friends too. I mean, they, I have a patch that's right on their sling and they tell them about, you know, how we do stuff and they spread the word. Word of mouth is a huge uh component, especially if, you know, in Augusta, a smaller town, but um

Speaker 3Yeah, it, it really was night and day. I, I, you know, I knew you weren't lying to me when you were first telling me about this technique, but I just didn't realize how profound it was, um, and, and like I said, I, I, I didn't have a problem that I need to change. Um, I really just was intrigued and then, and then that just kind of set things in motion from there.

Speaker 1Yeah, it, you know, it's, we, we know that there's level one evidence, you know, from Randelli, AJSM 2019 that shows this, but that can seem a little abstract and, and when your therapists, you know, are, are coming spontaneously, I mean, that, that's a real effect in my mind, you know, that's not abstract, it's a direct effect when you change that, that you see. And it puts Opioid Free cuff, you know, which is a big deal as well, within striking distance and uh Doctor Brogan was mentioning that.

Speaker 1And I mean, I, I think we are, we are very much within striking distance of, uh, multimodal Opioid Free cuff. Uma, any thoughts on that Opioid Free at Johns Hopkins where you are? Are you broaching that? And, and, uh, what are your thoughts on Pain? Yeah, no,

Speaker 4thanks. Uh, thanks, Brett, for having me and thanks, Brett. That was excellent, uh, talk and going over all the, uh, attractive points. I think an additional one.

Speaker 4I, uh, when you don't have anchors, if you want postoperative imaging, it's so clean. You won't see anything in there, and it looks native. There's no artifact. And the, to, uh, Brett, your point about the Pain, we're working very aggressively to try to get to, um, no opioids, and we're in the same boat. We're trying to, we're pushing the number of opioids we give down. And this, I think it's just one element that adds to your multimodal Approach. With that, I think, uh, as you said, it, uh, a cuff.

Speaker 4Do without opioids is, is totally within striking distance. So I think that's uh tremendous.