Ultrasound Evaluation of TO Repairs

Speaker 1Next on the list, we have Doctor Cruz, uh, who is an Ultrasound expert and a burgeoning transosseous maven.

Speaker 1Uh, as well in terms of Technology. So, uh, Kevin, you want to go ahead and you should be able to share your screen hopefully.

Speaker 2All right. So, thank you very much, Brett, for having me on. Um, it's pretty cool to be, uh, able to do these types of things. I think this is definitely one of like the, the advantages of COVID that we realized like, hey, we like, we don't need to fly to different places to have meetings like this and, and

Speaker 2It's still fun to go to meetings, but it's really easy to do this, you know, so awesome. Thanks for putting together. Pretty cool. So Brett asked me to talk about a couple of things today. I'm, I'm a, I'm, I'm a huge Ultrasound guy. I love Ultrasound. I think it's amazing. I think it, it, it definitely cuts to a lot of the things that, that Brett's trying to do with his company, his technique, and, and Transosia. So I implore all of you to get involved with Ultrasound if you can, um.

Speaker 2And then also, uh, so looking at the Ultrasound evaluations, which I, what I, which I've done in my career, um, and then also looking at, uh, Pain after, and then Pain after, uh, Rotator or Pain after the repair, which I've looked at some of my SOS data, and then, um, also looking at, uh, what I call the poor man's SCR. So, and by the way, this is my, my contact if anybody wants to look at that. Uh, sorry for that typo there. I don't know I missed that.

Speaker 2But uh yeah, if you, if you, if you wanna email me, you wanna give me a call about anything today, just hit me up.

Speaker 2All right. So main points today is it's gonna be transosseous repair is superior biology and biomechanics compared to Transos equivalent. Uh, and there's been some pretty elegant studies in, uh, the, uh, Japanese data that have shown this, and I actually went to Japan and talked to a lot of the guys there. I went there to actually meet Chiru Mahada, but one of the serendipitous parts of that trip was meeting with a lot of like the really, really high-end orthopedic surgeons looking at Ultrasound, looking at elastography.

Speaker 2And looking at the biology and the biomechanics of cuff repair. So the Japanese are really, they're, they're, uh, they're way ahead of us in terms of that curve. Um, looking at SCR, looking at the cost of SCR and how can you decrease that and some of the things that I've done, um, and then also looking at Pain, um, from a, uh, transosseous technique and what I found with looking at my own data, uh, comparing tunnels versus, uh, anchors. And also I have a, a device that I was gonna show you guys that I didn't know if it was gonna come, but, uh, it's, it's basically like an augment for making transosseous a little bit quicker.

Speaker 2So, looking at the biology and the biomechanics, I think everybody that's spoken today has looked at this. And so this is one of the, you know, looking at the Japanese data, and this is some of the images from some of the papers that I, I pulled that they had. Um, there's a, a guy named Iwe Gawa, who's, who's a really, uh, he's written some really good articles in arthroscopy looking at elastography for Ultrasound and, and being able.

Speaker 2To basically use that as opposed to gutalier for looking at the elastic qualities of the cuff can be repaired or not. Uh, but what they found when they looked at the elastic, um, when they looked at the vascularity of the cuff, when they use Ultrasound to actually measure the vascularity is that they had much more vascularity at the interface of the cuff throughout the repair process with transosseous techniques versus using like a speed bridge construct, which like we've all talked about. So, you know, with the speed bridge, it's, I always tell people it's, it's, it's kind of like.

Speaker 2You know, if you fix the femur, right? You can nail a femur and it's gonna heal, OK? You could also take a femur, you could nail it, then you could open up the leg, strip off the periosteum, and put on 3 locking plates, right? So there's a limit to the biomechanics and, and how far you need to go from a strength standpoint to get what we need to have done.

Speaker 2And there is the law of diminishing returns. And I think, you know, some of the constructs like the speed bridge and Other, and, and some of these Other knotless repair techniques, it's just too tight. And we actually, we did a study when, when I was in Greenville, uh, with Doctor Hawkins looking at the vascularity of the cuff with double rows and, and how you could easily over tension the cuff to cut off the blood supply.

Speaker 2But they also looked at the, the modulus elasticity, some of the Japanese papers, they, they weren't able to get them to me by this talk, but they, they basically show that you create this interface of very stiff construct with something that's very unstiff, which is the mild tender disjunction of the cup, and it's a recipe for, for failures.

Speaker 2And so this is one of my cuffs. It was interesting. I, you know, Brett, I was like, man, you know what, I Ultrasound my cuffs, but I gotta look back and see. I had a guy come in. He was 2.5 months out. This is a transosseous repair, and he fell, hit his arm on the door. I was like, oh, this is beautiful. On Thursday, I'm gonna show this. So this is just a quick video looking at the transosseous repair, and I would call this a suga 1. I mean, that to me looks like a beautiful tendon interface. You can see the tendon very.

Speaker 2Clearly, um, you know, I haven't gone to the level of like med vascularity on my cuffs through the process and looking at the difference. It's, it's very, it's very subjective to try to do that with Ultrasound, but you do know when you do measure it, and the Japanese papers have shown this, that you get more vascularity from time zero up until a healed cuff when you, when you use Bone tunnels versus ankle repairs.

Speaker 2Just another one here. You can see the sutures through it beautifully. So this is, if you guys don't use Ultrasound, it's amazing. Someone falls, they hurt their Shoulder, just put the probe on there. You could show that the tendon's healed. Just be careful because a lot of the patients that are doing OK, you Ultrasound a lot of them, you're gonna, you're gonna realize your failures you're a little bit more than you than you'd like to accept.

Speaker 2Um, so looking at SCR, so, so I actually did this technique. This is like the first Surgery that I did in practice. I know it's insane, but I had a buddy of mine, he, we came in together five years ago in Dallas, and he had just gotten back from Vail with Peter Millett. And so this is like right at the beginning of

Speaker 2When it started taking off and I was, I had my, my partners just sent me all these massive cuffs when I got there cause they wanted to do reverses. And I was like, I don't wanna do a reversal on someone that's got full range of motion, no Arthritis, and just a, a functional cuff tear. So I'm like, I, I, I don't know, I do a reversal on that patient. And so I flew to Vail, learned how to do the technique, and then came back and it was, I it was my second, my 2nd case.

Speaker 2And so we did an SCR on this patient, and it was like a total home run. And I remember afterwards, I was eating dinner with my family and I was pretty proud of myself, like, you know, that I was, I had the audacity to do a case like that and it worked out so well that early in practice. And one of the reps accidentally texted, texted me when they were trying to text with the Other reps that I had spent like $12,000 on the case. It was like Cruz spent $12,000. I used like 8 acres, grab, biceps, subscap.

Speaker 2The whole thing, I mean, I was just like, and I just kind of shrugged it off cause I didn't really, I was like, OK, whatever, who cares? And, and then, and then later on I realized I was a Medicare patient. So like, and that's our surgeon-owned hospital I did that at. So we just totally ate that whole DRG. So that's just a total loss for us. So I've been thinking, you know, I started looking at the numbers more at our center and trying to be more of a value-based guy, and I'm talking to Brett since I was a fellow about using the tunneler more.

Speaker 2And so the, the, and, and when the SR started coming out, I always ask like, you know, why we, we took this very new technique, right? It's like a totally revolutionary thing, a way to treat cuffs, and everybody's all excited about it. And then we just like all of a sudden start using allographs because, you know, Alan Hirahara and, you know, Chris Adams and Arthur said you can use an allograph. I'm like, oh well, you can use an allograph.

Speaker 2Anything, but we're in like a really poor biological environment, right? And we did, we take the guy who's done literally 500 and done 5 years, right? So Turum Mahada had done 500 in 5 years, and we say, you know, we're just gonna use allograph to see how it goes. And, and I was like, why aren't we doing TFL? So I flew to Japan and I watched him for a week do them and um.

Speaker 2And so I came back and I was like, dude, I can do an SER with a tunneler, two corkscrew anchors immediately, which Mahada, believe it or not, this is what he does in the glenoid. He does two old school 45 corkscrew anchors, double-loaded sutures, passes all eight limbs, ties 4 knots.

Speaker 2That's how he fixes it. And then he does a speed bridge laterally cause he's like an arthris guy, but you can easily do a bone tunnel laterally. And so I, I did a couple of these. I did like 10 when I came back, and it was just, it was kind of a beating because I'm a beach chair guy, and he's a lateral guy. And he has, in Japan, it's interesting, like, you don't get to become an orthopedic surgeon until you've been like a junior professor for like 6 years. So he has this guy who scrubs with him every case, who's an.

Speaker 2Orthopedic surgeon, and all he does is get the graft and make the graft, and they're lateral. So he's doing this while, while I'm trying to get the graft with one of my partners, and it was just, it was kind of a cluster and actually two of them get a Piane's infection, right? And Mojada actually had that happen at the beginning of his practice too. He started putting ban on the Shoulder and changing some things which I had never had an infection from a, from a scope before. So that's why I was like, oh, I don't know if I wanna keep doing this.

Speaker 2And so what I've switched to doing now is I use the MTF allograph, which is the cheapest allograph you can get on the market. I double stack it and I weave it with tape, and I just use 25 millimeters because I don't wanna pay for an extra allograph, and I, I double stack it. So, the graph is actually 5 by 5, and so you double stack it and I look at it like an ACL like I'm just trying to create a bridge, and, and then I'd use tunnels and just two anchors. So, you know, I'm spending 1000 bucks, but it's a lot better than 12.

Speaker 2Um, but Mahada is an awesome guy, by the way, like he's, I don't think he's p fudging his data at all. I think he's a really honest dude.

Speaker 2And so these are some of the pictures of these bone tunnel, uh, SERs with TFL, and it's interesting because when I, when I went into the, uh, the Arthrex database, SOS is amazing, by the way, if you don't use it. Uh, I know that we're kind of anti-anchors here and all that stuff, but SOS is, I've used it since I started practice. I love it. But when I type in, uh, Bashalata as the graph and you search the Arthrex database, there's one Other.

Speaker 2Tensor fasciolata graph that has been done in the United States Other than yours truly. There's, it was weird to me. I was like, that's so strange. Like, why isn't anybody doing this? And it's just, it takes a long time and it's really hard. Um, and so I think that's, I'm not, I think it's awesome cause it's biologic, it's free, right, which is amazing, but just from a time standpoint.

Speaker 2In a setup, you know, it depends on how you scope and, and, and you could do it from a beach chair, but it's just hard to get down there low enough. I think if you're a lateral scoper, it's a lot easier, but even then, you know, it's just tough. It's just tough.

Speaker 2So this is another one that I did, and these patients all did really well, by the way, the ones that did not get infected did great. Even the guys that did infected did well. I cleaned them out and just kept the graft.

Speaker 2So yeah, just two double loaded corkscrews, 45s in the glenoid, you can use Puss anchors, something really cheap, and, and so you can, you can take this from something that costs $10,000 when you account for the speed bridge laterally, you know, Arthur always has 3 anchors on all their talks immediately, and they want you to use the knotless fiber attacks, right, because that's the

Speaker 2Newest widget, uh, those are $600 but you can just do 22 anchors immediately double loaded, and Truahada does this on Japanese patients, right? So these are, these are small people, and he's doing 4 or 5 anchors immediately, but it's unbelievably strong, and he's never had a Fracture. He's been doing it from day one.

Speaker 2Uh, and got the chance to do a lot cheaper anchors for, for some of your more value-based products, uh, and then just do both tunnels laterally, and then I use an allograph now just cause it was easier, but I've used a much cheaper allograph. Arthur Re charges $4000 for the allograph, which I think is insane.

Speaker 2And so, Brad, I, I pulled my data. It's interesting because if you look at this, you're like, oh well, you're starting higher. So this is like something that I pulled this week.

Speaker 2But the, the, the one thing, the one I, I, I do a hybrid technique and so when I, if I were to go in and really look closely at my data back when I was using 45 swivel locks on the medial row, the Pain score was actually, it was like 1.5 different. I think one of the reasons why this data, so the blue is transosseous and the, and the red is anchors, right? So you say.

Speaker 2Well, the curve's a little bit steeper and you're lower, but you started higher. Um, I think since I use all Suture anchors on the medial row when I do use anchors, that it, it skews this data because I, I don't think that medial row all Suture anchors hurt as much because it's such a small footprint in the bone, but a 4 or 5 corpsescrew in the subchondral bone on that medial row, I think that's unbelievably, um, I think that causes a lot more Pain in the Shoulder, and I also think having tapes because of how much you over retention the cuff does. So, so when I looked at my data, when I was looking at true.

Speaker 2Like plastic peak anchors on the medial row, it was a significant difference at the Pain, the Pain score. And there was a or uh, the Italians actually showed that one of their studies at their, when they did the randomized trial, they showed, uh, 2-week and 6 weeks BS Pain scores are definitely lower.

Speaker 2And that's all I got for that. So, um, I don't know if you guys have any questions. So, one thing I wanted to show you guys, and I asked Brett if this is OK. I'm not trying to be like a salesman here, but, um, so I love doing Bone tunnels. I also love to be really, really efficient with my Operations, and I will say for me, like taking a, a single row anchor and just passing 4 to 6 limbs from a triple loaded into it like a lateral row anchor, I can do that faster than I can do a trans osseous repair because I'm just not tying knots. And so,

Speaker 2I've been thinking for a while about creating a device where you basically are just linking the sutures from your medial lateral row with a, a clipping device and also would allow you to tension them all at the same time. And so it actually just came in and I'll share you with you guys a little PowerPoint here of the device. So just looking at the device, it's essentially a, a, a clip where there's a male and a female and I actually have one right here.

Speaker 2You can see here

Speaker 2Where's my camera? You see, there's a little clip, there's a male and a female, and it's like a little plug, and this is 3 millimeters tall, which if you measure a knot stack, it's actually 5 to 6 millimeters, and it's, it's like 7 millimeters across, so it's like a little clip that sits on the bone.

Speaker 2Serves two purposes. One, speed, like not having to tie knots if you do a ton of, of suturing, and then also the ability to tension all at the same time. And I also think, you know, I know you guys have said you haven't had any cut out of bone. I, I occasionally do, I will cut a few out. I'm sure it's because of my technique and, but, but I do think that in soft bone, by having that, that edge, a piece of plastic while you're tensioning, it will function similar to the plugs that Mark used in the past.

Speaker 2On every cuff. And so you, the tension that you wanna create with this is, um, you could go way more than what you need, but it's just more controlled, um, and, and just really the whole basis of this idea is speed, right? Like try to make transosseous technique faster and easier so that surgeons will adopt the technique. Um, and so what you have is just this plug, this male and female in, the sutures come through, and then you link it to the tension device, you tench it, you clip it, you lock it, and then you cut it and you're done.

Speaker 2And so I actually just got, I've been working on this for like a year and a half. I just got the, the functional prototype today, so we're hopefully gonna be able to put these in a couple of people this year, get it FDA approved.

Speaker 1Easy, man. Just commercialize it. Come on,

Speaker 2yeah.

Speaker 2We're close, dude. It's not, I mean, we're not that far away like the FDA cause the thing is that the clips, this is like a 510K, right? So like there've been many clips that have been made in the past, but there have been no clips made for like arthroscopic sutures for this, this level of, so we're able to patent the idea and the concept, but in terms of getting it FDA approved, it should be pretty quick. All we have to show is that we're, are not pull out strength is good. So, for me, I'm like Brett. I like to do just simples, right? Like just simple, but I'll do like 4 or 5 pieces of suture tape.

Speaker 2Um, and I've actually got a value company that can get you guys tape cheap if anybody wants to get really cheap tape, cause tapes actually, they're not as cheap as you think. Sometimes they'll charge you $30 to $40 for a piece of tape if you're not careful. Um, but, um, basically, I put, I'll pass 4 or 5, sometimes even 6 pieces of tape through a single tunnel and just do simples. And if I've got a massive cuff, I'll, I'll do 12, and just do 1212 cirlages. I've just gone to just doing simples, but it's just, it just takes time for me to just go up and down the line, tying like 10 or 12 knots on a big.

Speaker 2Cuff, so I figured you take them all at once. You can clip it, and then I've actually got another design for a suture that's specifically designed for tunneling where you basically have one limb of suture that spreads out into 6. So then you're just funneling one limb of suture in through the tunnel and then you pass your 6, so it's like a triple loaded anchor, then you would go 6 to 1, clip the lock, just simple. And this is, it's just a way to basically add to Brett's device to make it a little bit faster, a little bit easier.

Speaker 1Um, cool. Thanks for that, uh, Kevin, and I'd like to just point out a couple of things that he talked about. I mean, there's an order of magnitude Cost reduction possible with SCR. You rarely see that in the device world where you can have literally an order of magnitude reduction. Maybe there's still a few, uh, Pain points there surgically, but that's very interesting to me.

Speaker 1The Pain reduction as well that you noted about. I've heard that as well from, from anchor companies that even the uh soft anchors medially, anything, the hard anchor on the medial side causes uh the most Pain. And even with my hybrid techniques, one anchor laterally, I don't see a big introduction of Pain, but we definitely see reduction of Pain with less hard anchors as the medial row.