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