welcome to athletico’s webinar wednesday · of rotator cuff tears1 subacromial decompression...

Welcome to Athletico’s

Webinar Wednesday

Webinar Agenda

Today’s Webinar is from 8:30am to 9:30am CST

Agenda

• 8:20 am - 8:30 am: Participants join call

• 8:30 am: Host Introductions

• 8:35 am: Dr Micah Hobbs of St Louis Orthopedics and Sports Medicine,

speaking on Management of Work Related Shoulder Injuries

• 9:20 am: Q & A led by Emily Giesleman, Athletico’s Work Comp Account

Executive in Missouri

• 9:30 am: Closing Remarks

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• A copy of the power point slides

Today’s Speaker:

Micah Hobbs, DO Fellowship Trained Orthopedic Surgeon

Dr. Hobbs was raised in St. Charles, Missouri. He attended the University of Missouri-Columbia where he graduated with a Bachelor of Science in Biology in

2000. He received his medical degree from Kansas City University of Medicine and Biosciences in Kansas City, Missouri in 2005. Dr. Hobbs then completed

a five-year residency in Orthopedic Surgery at Ohio University/Grandview Hospital in Dayton, Ohio. During this time, he participated in the care of the

Cincinnati Reds, Cincinnati Bengals and Wilmington College Quakers.

Following residency, Dr. Hobbs was one of twenty-seven residents nationwide selected to complete a Shoulder and Elbow Surgery fellowship. During his

fellowship at Baylor University Medical Center and the W.B. Carrell Clinic in Dallas, Texas he focused on the conservative and surgical Treatment of

industrial and athletic injuries to the shoulder and elbow with a special emphasis on shoulder replacement, rotator cuff repair, and revision shoulder surgery.

He spent extensive time training with Wayne Z. Burkhead, M.D., one of the premier shoulder surgeons in the world. In addition, Dr. Hobbs will provide all

aspects of general orthopedic care to the community.

Throughout his academic career, Dr. Hobbs has been involved in orthopedic research. He has been published in the Journal of Hand Surgery and written

numerous book chapters regarding the management of shoulder pathology. In addition, Dr. Hobbs has presented his research at the Orthopedic Trauma

Association, American Society for Surgery of the Hand, American Academy of Orthopedic Surgeons, and the American Osteopathic Academy of

Orthopedics annual meetings.

Dr. Hobbs is Board Certified Orthopedic Surgeon.

Education

Undergraduate: University of Missouri, Columbia, MO

Medical: Kansas City University of Medicine and Biosciences, Kansas City, MO

Training

Internship: Grandview Hospital Medical Center, Dayton, OH

Orthopedic Surgery Residency: Grandview Hospital Medical Center, Dayton, OH

Shoulder and Elbow Fellowship: Baylor University Medical Center and WB Carrell Clinic, Dallas, TX

Professional Affiliations

American Osteopathic Academy of Orthopedics

American Academy of Orthopedic Surgeons

American Osteopathic Association

Ohio Osteopathic Association

Hospital Affiliations

Missouri Baptist Medical Center

Des Peres Hospital

Parkland Health Center

Dr. Hobbs has office locations in Sullivan Missouri and Farmington Missouri in addition to his office located in Creve Coeur.

MANAGEMENT OF WORK RELATED SHOULDER INJURIES

ABOUT ME

Francis Howell High School

Missouri State-> Mizzou

Kansas City University- Medical

School

Ohio University- Orthopedic

Surgery Residency

Dayton, OH

Baylor University- Shoulder and

Elbow Fellowship

Dallas, Texas

Private Practice 2011- Current

Designated Doctor exams 2011

AADEP

MY PRACTICE

Shoulder

Rotator cuff repair

Biceps tenodesis

Instability-dislocations

Replacement

Knee

Meniscus

Ligament repair

Replacement

Elbow Lateral epicondylitis

Biceps tendon tears

Fractures Proximal humerus

Distal radius

Ankle

Hip

SAINT LOUIS ORTHOPEDIC AND

SPORTS MEDICINE

675 Old Ballas Creve Coeur, MO 63141

Sullivan every Monday

751 Sappington Bridge Rd

Sullivan, MO 63080

Katie Brickey-Work Comp Coordinator

314-680-6784

katie@stlorthopedic.com

SAINT LOUIS ORTHOPEDIC AND

SPORTS MEDICINE

Understand shoulder anatomy

Learn about shoulder injuries and pathology

Understand treatment options for rotator cuff and labrum

tears

Expectations for return to work following surgery

LEARNING OBJECTIVES

DIAGNOSIS

Rotator cuff tear

• Partial

• Complete

Labrum Tears

• Anterior/Posterior tear

• SLAP

Fracture

• Proximal humerus

• Clavicle

ROTATOR

CUFF

CUFF DISRUPTION Partial vs. full thickness

Acute vs. chronic

Traumatic vs. degenerative

Contributing factors

Trauma

Attrition

Ischemia

Subacromial abrasion

PARTIAL THICKNESS TEARS

Partial thickness tears about twice as common as full thickness lesions

Yamanaka, Fukuda, et al. reported on 249 cadavers with 13% incidence of partial thickness tears

30% of shoulders older than 40 had tears

No tears seen in shoulders younger than 40

3% bursal, 3% articular, 7% intratendinous

BILATERALITY:

Yamaguchi et al. (JBJS 2006)

588 consecutive pts with unilateral shoulder pain

evaluated by U/S

Average age with tear = 62.8

33% unilateral tear

30% bilateral tear

If >66yo: 50% likelihood of bilateral partial tear

If full thickness tear: 35% incidence full thickness on contralateral side

Symptomatic tears were 30% larger than asymptomatic tears

EXTRINSIC CAUSE OF ROTATOR CUFF TEAR

Morrison and Bigliani

Studied acromion in 140 cadaver shoulders

Three types of acromion

Type I – flat (17%)

Type II – curved (43%)

Type III – hooked (39%)

Overall incidence of RC tear was 34%

Type III acromion in 70% of tears, type I in 3%

ROTATOR CUFF TEAR PATHOGENESIS

Multifactorial

Cuff tendons subjected to various adverse factors:

Traction

Compression

Contusion

Subacromial abrasion

Trauma/fall

Age related degeneration

ROTATOR CUFF TEAR

ARTHROPATHY

Chronic tears associated with retraction, loss of excursion, muscle atrophy, and fatty infiltration

These changes, to some extent, are irreversible

PHYSICAL EXAM

Inspection

Palpation

• Excessive passive external rotation (subscapularis)

Range of motion

• Lag signs

• Partial thickness more pain?

• Post-injection

Strength

MRI

Estimate of muscle atrophy can help give an accurate prognosis

Increased atrophy found to correlate with lesser functional results after rotator cuff repair

Help determine chronicity

Goutallier J Shoulder Elbow Surg 2003

NONOPERATIVE TREATMENT

Heat, NSAIDS

PTAvoid offending motions

Eliminate stiffness (especially posterior)

Strengthening (cuff, scapular stabilizers)

Steroid/ lidocaine injection No proven protracted benefit

Look for dramatic improvement over several weeks

NONOPERATIVE TREATMENT

Literature: Rotator cuff tears overall

• Successful in 33% - 92%

Most studies report a satisfactory result in ~ 50% of patients

Positive prognostic factors:

• Tear size <1cm

• Symptom duration <1yr (Bartolozzi 1994)

CUFF REPAIR

Younger

Active/ high demand

Acute

Full thickness tear

Clear trauma history

WHAT ABOUT

PARTIAL

TEARS?

Treatment less clear

Can be due to aging

Can be traumatic

Can progress to full thickness tear

Is there a surgical treatment option for partial tears that

prevents tear progression and allows early arm/shoulder

ROM?

CURRENT STATE RC DISEASE TREATMENT

HIGH RATE OF TEAR PROGRESSION AND RE-TEARS

Severe

Tendinosis/Low-Grade

Partial-Thickness Tears

(PTT) – Failed

Conservative Treatment• Chronic rotator cuff tendinosis has

been identified as a primary cause

of rotator cuff tears1

Subacromial Decompression

(SAD):

Inconsistent results, limited long- term efficacy2

High-Grade Partial-ThicknessTears

• Up to 80% of PTTs increase in size within 2 years3

• ~44% have been reported to

progress to full-thickness tears4

Take down/repair and trans-tendon approach:

Both have challenges and neither

is an ideal treatment option5

Full-Thickness Tears (FTT)

• Small tears progress over time, eventually requiring surgical repair6-8

• Larger tears requiring repair tend to

re-tear over 40% of the time9-11

Repair:

High rate of

revision/retear11

1. Hashimoto T, et al. Clin Orthop Relat Res. 2003;(415):111-20. 2. Kartus J, et al. Arthroscopy. 2006;22(1):44-49. 3. Yamanaka K, Matsumoto T. Clin Orthop Relat Res. 1994;(304):68-73. 4. Keener JD, et al. J Bone Joint

Surg Am. 2015;97(2):89-98.5. Internal knowledge, Smith & Nephew. 6. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. 7. Schlegel TF, et al. J Shoulder Elbow Surg. 2018;27(2):242-251. 8. Washburn R, et al. Arthroscopy

Techniques. 2017:6(2);e297-e301. 9. Bishop J, et al. J Shoulder Elbow Surg. 2006;15(3):290-299. 10. Heuberer PR, et al. Am J Sports Med. 2017;45(6):1283-1288. 11. Henry P, et al. Arthroscopy. 2015;31(12):2472-2480.

• A highly porous, precisely oriented reconstituted

collagen implant made from thoroughly purified, bovine

type I collagen

• Stimulates the body’s natural healing response to support new tendon growth and disrupt diseaseprogression1,2

• Clinically proven to reliably induce new tendon-like tissue and promote tendonhealing1,2

• Gradually absorbs within six months,leaving a layer of new tendon-like tissueto biologically augment the existing tendon3

REGENETEN™ BIOINDUCTIVE IMPLANT

HARNESSING THE BIOLOGY OF THE BODY

1. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. 2. Schlegel TF, et al. J Shoulder Elbow Surg. 2018;27(2):242-251. 3. Van Kampen C, et al. MLTJ. 2013;3(3):229-235.

New tissue integrates and

remodels into the healed

tendon

Strength comes from patient’s own

induced tissue, not the implant,

which completely absorbs within 6

months5

Implant induces new host

tissue onto tendon by 12

weeks

Within 3 months, implant facilitates

the formation of new tendon-like

tissue5

Implant placed over

bursal surface of RCT

Proprietary implant design creates

an environment conducive to

healing2

REGENETEN™ BIOINDUCTIVE IMPLANT

ENABLING THE BODY TO HEAL ITSELF

1. Bokor DJ, et al. MLTJ. 2015;5(3):144-150. 2. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. 3. Schlegel TF, et al. J Shoulder Elbow Surg. 2018;27(2):242-251. 4. Chen Q. Technical Report from the Material and Structural Testing Core. Mayo Clinic: Rochester, Minnesota; 2011. 5. Arnoczky SP, et al. Arthroscopy. 2017;33(2):278-283.

REGENETEN™ BIOINDUCTIVE IMPLANT

ENABLING THE BODY TO HEAL ITSELF

1. Arnoczky SP, et al. Histologic evaluation of biopsy specimens obtained after rotator cuff repair augmented with a highly porous collagen implant. Arthroscopy.

2017;33(2):278-283.

Reconstitutedcollagen

implant

Injured

tendon

Human fibroblasts are

found within the porous

collagen implant.1 Implant

mimics strain signal of

tendon, stimulating

remodeling process.

5 weeks

There is evidence of dissolution of the

implant by host

fibroblasts. 1

3 months

The newly generated

tissue has the histological

appearance of a tendon

with no remnants of the

collagen implant

remaining. 1

6 months

CLINICAL DATA AND EVIDENCE

CONSISTENT EXCELLENCE IN CLINICAL EVIDENCE & PATIENT

OUTCOMES

1. Schlegel TF, et al. J Shoulder Elbow Surg.

2018;27(2):242-251.

Pre-Op

12 Months

Partial-Thickness Tear1 Full-Thickness Tear

Pre-Op:

8 x 12mmtear

Month 3:

Newly induced in homogeneoustissue

Month12:

Better tissue quality;still somewhatamorphous

CLINICAL DATA AND EVIDENCE

MRI EVIDENCE

Images on right courtesy of Jeffrey S. Abrams, MD, Princeton Orthopaedic & Rehabilitation Associates, Princeton, NJ.1. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. (images on left)

Case study data and images courtesy of Theodore F. Schlegel, MD, Steadman Hawkins Clinic – Denver, Greenwood Village, CO1. Schlegel TF, et al. J Shoulder Elbow Surg. 2018;27(2):242-251.

CLINICAL DATA AND EVIDENCE

BURSAL HIGH-GRADE PARTIAL-THICKNESS TEAR (NOREPAIR)1

• 55 y.o. Caucasian Male

• Grade 3 (>50%) bursal

tear

• Treatment

-Bioinductive Implant placed on bursal side of tendon

-No repair

• Recovery data

-Returned to work in 7 days

-Sling removed after 14 days

-Satisfied with procedure

Tendon thickness at tear =

2.0mm

Baseline MRI

• 11 mm x 14 mm, high-

grade bursal tear

• 2.0 mm tendon

thickness at location of

tear

• Mild subacromial,

sub deltoid bursitis

Tendon thickness at tear = 7.5

mm

3 Month MRI

• 7.5 mm tendon thickness

at location of tear;

Thickness ∆= +5.5 mm

• 100% defect fill-in with new, amorphous, immature material

MRI Images and measurements courtesy of Desmond J. Bokor, MD, Macqaurie University, Ryde, Australia. 1. Bokor DJ, et al. MLTJ. 2016;6(1):16-25.

Tendon Thickness = 2.9 mm

Partial-Thickness Tear– Pre-Op

Tendon Thickness = 4.0 mm

Healed Tear– 12 Months Post-Op

CLINICAL DATA AND EVIDENCE

ARTICULAR PARTIAL-THICKNESS TEAR (NOREPAIR)1

Tear Filled

Tear

CLINICAL DATA AND EVIDENCE

PROMOTING TENDON TISSUE GROWTH IN HUMANBIOPSIES1

5 weeks 3 months 6 months

Host cell ingrowth and early collagen production

Increased collagen formation, maturation, andorientation

Dense, regularly-oriented newly- regenerated connective tissue;implant fully absorbed

Images courtesy of Steven P. Arnoczky, DVM, Michigan State University, East Lansing, MI.1. Arnoczky SP, et al. Arthroscopy. 2017;33(2):278-283.

CLINICAL DATA AND EVIDENCE

FIRST TO CLINICALLY DEMONSTRATE REGENERATION OF

TENDON TISSUE1

2 Years2

Years2

Years

1 Year6

Months

3

Months

REGENETEN™Bioinductive Implant

• Induction of new tendon-like tissue

• Thicker tendon2

• Implant completely absorbed

within 6 months.

Dermal Patch

• NO induction of new host tissue by

dermal patch• NO evidence of any functional

remodeling of the dermal patch

@ 2 years. – Dr. Arnoczky

Images courtesy of Steven P. Arnoczky, DVM, Michigan State University, East Lansing, MI.1. Arnoczky SP, et al. Arthroscopy. 2017;33(2):278-283. (image at 6 months) 2. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. (images at 3 months)

• Debridement Only (National Orthopaedic Database) vs. No Repair+Bioinductive Implant (REBUILD REGENETEN™)

• Literature cites up to 44% of these patients tears will progress to full-thickness

• With REGENETEN Implant patients get a healed tendon AND minimal rehab

*Data shown represents REBUILD Registry data cut-off on February 15th, 2018 (Patients Enrolled: N = 367). Enrollment and follow-up are ongoing. **National Orthopaedic Database does not capture patient outcomes at 2 and 6 weeks. ***P-Values Statistically Significant < 0.05.1. REBUILD Registry, data on file.

• Post-op rehab with REGENETEN Implant similar to debridement/

acromioplasty

• Function and pain scores similar to debridement/acromioplasty

• Patients with REGENETENImplant feel better sooner (SANE; 3 mo versus 6 mo)versus standard treatment

REBUILD REGISTRY1*

LOW GRADE < 50% PARTIAL-THICKNESS RESULTS

p<0.05**

*

• Takedown & Repair (National Orthopaedic Database) vs. Bioinductive Implant/No Repair (REBUILD

REGENETEN™)

• With REGENETEN, patients get a healed tendon, faster rehab and feel better sooner

*Data shown represents REBUILD Registry data cut-off on February 15th, 2018 (Patients Enrolled: N = 367). Enrollment and follow-up are ongoing. **National Orthopaedic Database does not capture patient outcomes at 2 and 6 weeks ***P-Values Statistically Significant < 0.05.1. REBUILD Registry, data on file.

Patients with REGENETEN Implant experience faster, superior recovery (ASES, SANE) - 3 months faster than standard treatment

Patients with REGENETENImplant feel better sooner (SANE; 3 mo versus 6 mo)versus standard treatment

REBUILD REGISTRY1*

HIGH GRADE > 50% PARTIAL-THICKNESS

RESULTS

p<0.0 5***p<0.05**

*

42.0

21.0

60.0

60.0

35.0

10.7

13.2

11.1

38.8

19.1

Sling Time

(No Biceps

Surgery)

Return to

Driving

Return to

Work

(Sedentary)

Return to

Work

(Laborer)

Narcotic

Use

0 10 20 30 40

Partial-Thickness Tear; No Repair Cohort,

(REGENETEN)

50 60

Literature: Benchmark for Comparison

*Data shown represents REBUILD Registry data cut-off on February 15th, 2018 (Patients Enrolled: N = 367). Enrollment and follow-up are ongoing.1. REBUILD Registry, data on file.

REBUILD REGISTRY1*

ADDITIONAL PATIENTBENEFITS

Avera

ge

Num

ber

of

Days

15.9 fewer

days

21.2 fewer

days

48.9 fewer

days

7.8 fewer

days

31.3 fewer

days

High Grade Partial Thickness Tear, REGENETEN™ Implant

v Repair

Severe Tendinosis / Low-Grade Partial-Thickness tears(Failed Conservative Treatment)

High-Grade Partial-Thickness

Tears

Full-Thickness Tears

REGENETEN™ Bioinductive Implant:ADDRESSING DISEASE PROGRESSION AT EVERY STAGE

Natural Progression Of Rotator Cuff Disease

1. Bokor DJ, et al. MLTJ. 2015;5(3):144-150. 2. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. 3. Schlegel TF, et al. J Shoulder Elbow Surg. 2018;27(2):242-251. 4. Arnoczky SP, et al. Arthroscopy. 2017;33(2):278-283.5. REBUILD Registry, data on file.

In conjunction with subacromial decompression (SAD) In lieu of standard

repairIn conjunction with standard repair

• Early intervention to reverse tear progression1-

4

• Preserves healthy tissue1,3

• Consistent healing of the tear1,3

• Fast return to normal activity5

• Potentially reduces re-tears1

• Helps to restore the RC footprint1

Severe Tendinosis / Low-Grade Partial-Thickness Tears(Failed Conservative Treatment)

High-Grade Partial-Thickness

Tears

Full-Thickness Tears

• Patients• with suboptimal tissue quality, thin/degenerative tendon tissue• at risk for tear progression• compromised healing potential

• diabetic, smoker, etc.• compliance concerns with current repair rehab protocols• with demanding/high risk lifestyles• overhead athletes

REGENETEN™ Bioinductive Implant:ADDRESSING DISEASE PROGRESSION AT EVERY STAGE

• degenerative/delaminated tendon• revision repairs

Ideal patient candidate for REGENETEN

1. Bokor DJ, et al. MLTJ. 2015;5(3):144-150. 2. Bokor DJ, et al. MLTJ. 2016;6(1):16-25. 3. Schlegel TF, et al. J Shoulder Elbow Surg. 2018;27(2):242-251. 4. Arnoczky SP, et al. Arthroscopy. 2017;33(2):278-283.5. REBUILD Registry, data on file.

In conjunction with subacromial decompression (SAD) In lieu of standard repair In conjunction with standard repair

REGENETEN™ BIOINDUCTIVE IMPLANT:

PHYSICIAN RECOMMENDED REHAB PROTOCOL

REGENETEN™ BIOINDUCTIVE IMPLANT:

PHYSICIAN RECOMMENDED REHAB

PROTOCOL

ROM: Range of Motion; AAROM: Active Assistive Range of Motion; AROM: Active Range of

Motion

REGENETEN™ BIOINDUCTIVE IMPLANT:

PHYSICIAN RECOMMENDED REHAB

PROTOCOL

ROM: Range of

Motion

SLAP TEARS

LABRAL ROLES- FUNCTION

Bearing for joint

Attachment:

Ligaments

Biceps

Joint stability:

External rotation

Internal rotation

SUPERIOR

LABRUM

ANTERIOR

TO

POSTERIOR

(SLAP)

LESIONS

Type I – fraying of superior labrum

•Can be part of aging/degenerative processType

Type II – most common in OHA/ traction injury, detachment of biceps anchorType

Type III – bucket-handle tear of superior labrumType

Type IV – bucket-handle tear with extension into biceps tendonType

TYPE 2IMPORTANCE OF INTRA ARTICULAR DYE

DIAGNOSIS

HISTORY

Pain

•Catching, popping, grinding

•Pain with sleep

•Loss of strength

•Arm “going out”

Mechanical symptoms

•History can be non specific

•What is mechanism of injury?

Similar to other shoulder complaints

•Rotator cuff tears

•Impingment/ bursitis

Associated with other disorders

HISTORY

Acute onset

Fall- outstretched hand, directly onto shoulder

Sudden load, flexed elbow

Pulling, flexed elbow

MVA- hand on wheel, dash

DIAGNOSIS OF

LABRUM TEARS

Loss of labral roles

stability

Change in shoulder function

Pain with overhead activity

History/ clinical exam findings

No great/specific physical exam test

Obrien’s test

Diagnostic imaging

Arthroscopy findings

GADOLINIUM MRI- GOLD STANDARD

DIAGNOSTIC IMAGINGMRI WITH DYE-GOLD STANDARD

SLAP TEAR

WITH BICEPS

TENDONOSIS

CAN MRI PREDICT CHRONICITY

Tear extension

Biceps tendon quality

Look in groove

Biceps tendon split

instability

Degenerative changes

glenohumeral OA

Biceps chondromalacia

Cysts in groove

Biceps instability

TREATMENT

Superior Labrum debridement

Done in conjunction with another procedure

SLAP repair

Young patients

Overhead throwing athletes

Biceps tenotomy

Biceps tenodesis

Above groove

In the groove

Below the groove (sub pectoral)

TREATMENT

SLAP repair

Typically reserved for overhead throwing athletes

Age less than 25

Need for immobilization post operatively

Risk of persistent pain/stiffness in older patients or workers

Does not address instability

Groove pathology

OUTCOMES OF

SLAP REPAIR

AJSM Provencher 2013

37% failure rate

28% revised to open subpectoral tenodesis

Age greater than 36 associated with higher failure/ non-healing

Older age and workers compensation associated with worse outcomes

BICEPS

TENODESIS

BICEPS TENODESIS

Anchor fixation within intertubercular groove

Risk of anterior shoulder pain

Fixation

Screw vs button

Cancellous bone

Groove pathology

More difficult to regain shoulder ROM

SUBPECTORAL BICEPS TENODESIS

SUBPECTORAL

BICEPS

TENODESIS

Postoperative protocol

Sling for 3 weeks

Immediate shoulder ROM

Can progress to active ROM as tolerated

No restrictions on motion of shoulder or elbow

Can begin shoulder girdle strengthening as early

as 4 weeks

Limit elbow flexion against resistance for 6 weeks

Allows fixation to mature

Cosmetic deformity

Typical return to full duties 2 months

CONCLUSIONS SLAP tears can cause significant morbidity

Common injury in heavy laborers and workers

Mechanism of injury key

Characteristic history

Associated with specific shoulder dysfunction

Abnormal physical exam

Subpectoral biceps tenodesis is the best option for return to work/ previous level of function in patients injured at work

QUESTIONS??????THANK YOU!!!!!

QUESTIONS?????????

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