ARTHROSCOPIC ROTATOR CUFF REPAIR DOCTORS HOSPITAL CENTER FOR ORTHOPEDICS AND SPORTS MEDICINE CORAL GABLES, FLORIDA June 18, 2008

Transcription

1 ARTHROSCOPIC ROTATOR CUFF REPAIR DOCTORS HOSPITAL CENTER FOR ORTHOPEDICS AND SPORTS MEDICINE CORAL GABLES, FLORIDA June 18, :00:00 JOHN ZVIJAC, M.D.: Good afternoon and welcome to Doctors Hospital in Coral Gables, Florida. I'm Dr. John Zvijac, sports medicine and shoulder surgeon here at Doctors Hospital, and I'll be moderating today's events. In just a moment, we'll be meeting my colleague, internationally-renowned orthopedic surgeon and director of the Musculoskeletal Institute here at Doctors Hospital, Dr. John Uribe. He'll be performing arthroscopic rotator cuff repair and before we get to him I would like you to know that it would be fine for you to ask any questions you wish in either Spanish or English. Feel free to them by hitting the M-Access button on your computer and we'd be happy to answer these throughout our broadcast. Let's get over to Dr. Uribe. You're in OR-3 here at Doctors Hospital. They can't hear anything? 00:00:52 JOHN URIBE, M.D.: Welcome everyone. I'm Dr. John Uribe and I'd like to welcome you. [Speaks in Spanish.] We're in this patient's right shoulder. He's a 67-year old male. He's a professional skier, a ski instructor, who tore his rotator cuff skiing. He's a ski instructor in the east, where there's a fair amount of ice and he actually was sliding and stretched his arm out, sustained this pretty significant rotator cuff tear. So this is a right shoulder. This is a biceps tendon right here. You can see there is some significant fraying of the biceps. That's probably old. He's probably had that for quite a while and not too symptomatic from that. The problem is his rotator cuff, and as we look up, he's actually on his side. We're looking, this big white ball here is the humeral head and down here is the glenoid or the socket. You can see there's good cartilage. The white tissue is the cartilage. So he doesn't have much arthritis. He has a little fraying here. The cartilage is a slightly bit frayed here and that's just from years of wear, but not very significant. As we look up, we see that rotator cuff insertion, the humeral head, and as we come around, you can see where there's a break in the tissue. There's a hole and this tissue belongs attached to the tuberosity, to the humeral head, as that tissue. So he's got a pretty significant tear, looking at it from the under side. You can see the other edge of the tear here. The other problem is that it extends down the front. Here's another part of the rotator cuff musculature. The rotator cuff is essentially four tendons, two that turn the arm to the outside, the external rotators, one on top, the superspinatus, which is the most commonly torn. That's this one. This is his subscapularis right here, this tendon in the front of the shoulder that's torn. I think Dr. Zvijac will show you that anatomy. But this is torn off as well. So, here's the problem. The problem is he has this biceps tear and the biceps is not sitting where it needs to sit and if you let this go postoperatively, he'll have a fair amount of pain. So one of the things we've learned is that the best option here is to actually sacrifice the biceps and incorporate it into the repair. So what I'll do at this time is to cut the biceps tendon and then we'll retrieve it when I come up on the top of the shoulder and incorporate that into the repair. So maybe John you could show them the anatomy while I'm doing that. 00:04:14 JOHN ZVIJAC, M.D.: What I'd like to do is show you the anatomy here of that Dr. Uribe's undertaking arthroscopically from the outer view. This happens to be a right shoulder, which is

2 what we're doing today. There's four tendons that actually make up the rotator cuff. There's one in the front, called the subscapularis, one on top, the superspinatus. Both of these are torn, that Dr. Uribe's already shown you. And then two in the back, the infraspinatus and Teres minor. You can see that the tendons all come together to form this cuff. The biceps actually runs underneath the subscapularis and then attaches inside the shoulder. That's why we have such a beautiful view of it here today in the operating room. But this is the anatomy we're looking at. Right now we're in the joint. A little bit later on, Dr. Uribe's going to go up into this space. It's called the subacromial space, and that is where the rotator cuff repair will then be undertaken. You'll get a nice view of that tear that he's having to deal with this afternoon. 00:05:16 JOHN URIBE, M.D.: So, we'll just finish up cutting this biceps tendon here. There it goes. Let me have the debrider and then and then we'll just kind of clean up the stump. Actually, many people tear the biceps tendon, what we call the long head of the biceps arm, and what this does is this is like a vacuum cleaner. It just kind of cleans up this stump and it happens very frequently in older individuals and even younger individuals. We see it frequently in weightlifters and it causes a little Popeye deformity of the biceps muscle. The good thing is -- stop. The good thing is it doesn't really produce a great deal of disability or pain. Sometimes people have a problem with cramping, but that's not too bad. But here again you can see the tear. We come through the tear and you can appreciate the large hole that it creates. What happens is, it acts like a loose flap of tissue, gets caught in that subacromial space Dr. Zvijac was talking about and that produces the pain, particularly pain at night. So now we're going to take the arthroscope out of the shoulder from inside the shoulder and then come up and we'll look at it on top. You can see here also some of the synovium, or the lining of the joint that's pretty big because it's enflamed and that's what produces the fluid. You see, that's all the synovium. That's the humeral head. You can see how nice and round and smooth it is. Okay, let's go up on top. 00:07:06 JOHN ZVIJAC, M.D.: Dr. Uribe, we're already getting a lot of questions coming in here. One question regarding the biceps there, there are several questions regarding whether you'll lose power and if that's a problem in people, whether you cut it or not, and what's the advantage of cutting it as opposed to tenodesing it or sticking it to the bone? 00:07:28 JOHN URIBE, M.D.: That's a good question. Obviously, the biceps has two heads and the good thing is that studies have shown that losing this head of the biceps only -- you lose perhaps five percent of your power of supenating, that is turning your palm up or curling your elbow. Whereas, if you tear your biceps at the elbow, then you lose much more, over 30 percent. So, what we will do so he doesn't get a deformity in the arm and to be a little more cosmetic, we'll incorporate that tear, the biceps that I took down, we'll incorporate that actually into the repair, so it will help to reinforce the repair as well. 00:08:23 JOHN ZVIJAC, M.D.: There's also a lot of questions already. It seems like a lot of people are either interested in rotator cuff repair or have a rotator cuff tear and several of them sort of come to the same question of, "Is there an age which you wouldn't recommend a repair and are there treatments that you would do prior to repairing?" So, I think if we maybe broke those down a little bit into "Are there certain people that you would recommend the repair in and certain people that you would recommend other treatments?" 00:08:59 JOHN URIBE, M.D.: That's a very good question. It's also somewhat controversial. I think we all feel that an individual -- and then age is relative, as well. So an individual who is young, and again that's hard to equate, but say somebody in their 30s, 40s, 50s, perhaps even 60s, like this gentleman, who sustains a traumatic tear -- let me have a debrider -- who sustains a traumatic tear, then that should be fixed, and the sooner, really, the better. As we published over a decade ago, many people, 30 percent of people over the age of 65 have a torn rotator

3 cuff and they don't even know it, have totally normal shoulders. So, obviously a shoulder can function quite well with a torn cuff. So it really depends on loss of function, the amount of pain, and certainly the quality of the tissues. So there are a lot of factors. It's not just age. I've repaired rotator cuffs in people well into their 80s and also treated people in their 50s conservatively, so it's fairly variable. But again, it's symptoms and activity-related, too. A very sedentary person with a small rotator cuff tear, say in their 50s or 60s, which is not very symptomatic, may respond well to physical therapy. So it truly is patient-dependent. 00:10:47 JOHN ZVIJAC, M.D.: Those are all great points. I think the important thing to point out is that study that we did do a decade ago that it's still a landmark study regarding rotator cuffs and the fact that many people are walking around with rotator cuffs that don't have symptoms, so many variables play in effect into what to do. Just to change the subject a second, just to point out, Dr. Uribe is now in that space we talked about, the subacromial space, and really have an excellent view of a fairly large tear here. This is by no means a small tear. 00:11:20 JOHN URIBE, M.D.: Let me have a grasper. So, -- and what I'll do is I'm going to grasp the rotator cuff tear. Here's the cuff right here and you can see here's our biceps tendon. So we'll incorporate that into the repair. Here's the cuff right here. You can see, this is where it belongs. This is called the tuberosity right here and you can see a portion of the tissue still on the tuberosity. So what we're going to do, and this is a crescent type of tear. They have different patterns. So it really depends on the pattern. That's why it's important, having done a significant number of these, I find that's the real key, to recognize the pattern and reestablish the anatomy. This is the crescent tear, so it's fairly straightforward. This tissue belongs back over here and there's enough play. There are different ways that you can increase the ability of this to mobilize back to its site. The other problem with these, if they stay very long, torn, if they're very chronic, this tendon tends to retract because it's like a rubber band. This is the muscle back here of the rotator cuff. This is a little wad of fat. So the muscle's over here and it's pulling and obviously it's not attached, so over time, the muscle atrophies and this also retracts and scars down. Then it becomes more difficult to repair. So in this case, he's only three or four months from his injury and it's actually relatively easy to restore his anatomy. 00:13:06 JOHN ZVIJAC, M.D.: Several questions. There's a good question here from Jacob Fowler in Louisville, Kentucky, who's asking about, "Are there different ways to fix tears?" and there's also another question regarding, "Are there certain types of anchors that you would use in one tear as opposed to another?" 00:13:28 JOHN URIBE, M.D.: Well, sure. There are many different ways. This is an arthroscopic technique. There are different arthroscopic techniques. There's some controversy about how many anchors you use and we can get into that as I do it. Again, a lot of it depends on the pattern of the rotator cuff tear, as well as the quality of the tissue and also the quality of the bone. Sometimes the bone is extremely osteopenic or osteoporotic and very soft and may not hold an anchor. It may be best to do it open. Also, it depends on the experience of the surgeons. Stop for a second. Some surgeons feel very comfortable with an open technique, some more comfortable arthroscopically, or a combination called the "mini open" that we described years ago. So, as long as it's done well, they do well. So yeah, there are many ways and one way is not necessarily better than another. 00:14:37 JOHN ZVIJAC, M.D.: Maybe you can describe what you're undertaking right now. 00:14:40 JOHN URIBE, M.D.: Yeah. Stop. This is called a radio frequency wand and what this wand does, it uses a vapor layer to ablate soft tissues. So now we have the bone exposed on the under surface of the acromion. What I'm trying to see is if indeed there's a spur or something that may have contributed and that way I would smooth it down. But, in this case, his acromion

4 looks rather normal. It's fairly flat. there's plenty of space. So I'm not going to abrade any bone and that's one of the common complications of arthroscopic surgery or open rotator cuff surgery is you remove this bone and then you immobilize the patient and what happens is that this rotator cuff tissue can then scar against the under surface of the acromion and create somewhat of a frozen shoulder and you have to come back later and take those adhesions down. So, if I don't have to take the bone down, then I won't. So, I'm also going to remove some tissue here in order to put the anchors in and establish a place to insert the rotator cuff back to its normal anatomy. Arm. 00:15:59 JOHN ZVIJAC, M.D.: Just to give you another perspective on what you're looking at. Basically, you're viewing this shoulder from the side. So you're looking at it edge-on here. This is the superspinatus tendon that is torn right here. What Dr. Uribe's doing is looking at this arch right up here. That ligament in the front here and then this arch, which is called the carco-acromial arch, and he's underneath there. That's where he's looking for those bone spurs. That's the space that he's in right now and that's where this rotator cuff repair of this tendon and a little bit of the front tendon and some of this back tendon are all going to come together as one sleeve and come across. 00:16:42 JOHN URIBE, M.D.: Yeah, I'm going to just keep cleaning this and then I'll take a burr, Desmond and Arm. 00:16:50 JOHN ZVIJAC, M.D.: Yeah, one of the questions, because you had mentioned it a few minutes ago, Dr. Uribe, is -- actually there's a question regarding adhesive capsulitis. Someone had rotator cuff surgery and apparently had some complication of adhesive capsulitis. I think that may go along with several questions we have here regarding rehabilitation and what the rehabilitation is like. Would you like to comment a little bit while you're doing this on rehabilitation and the? 00:17:20 JOHN URIBE, M.D.: Obviously that's a very critical part of it and different surgeons obviously have various opinions. Mine is that this tissue here -- I'll take a burr -- has to -- the tissue has to heal to this bone and soft tissue healing to bone takes a minimum of six weeks, but if you keep somebody immobilized for that period of time, then -- Arm -- then, what can happen is that you can create a great deal of scar tissue and [unclear] this frozen shoulder. So I think that's where the delicate balance comes in. my feeling is, it depends on the tear and the quality of the tissue as to how long I hold them. By and large, I like to hold mine about a month with some movement, particularly so they don't get stiff elbows and stiff wrists. Then, I send them to a very qualified therapist, which is also key that they stress the repair enough that it strengthens the repair and strengthens the musculature without damaging itself. 00:18:45 JOHN ZVIJAC, M.D.: And those are great points. When you do these surgeries, the rehabilitation is as important as the surgery itself. A lot of times, the way we do the therapy depends a lot on the type of tear that's being repaired and the type of fixation that's used. So all of those need to play a factor in your rehabilitation. Just a note, I'm appreciating all of your questions, and there's many, many questions coming in. Feel free to continue to send them in, but if I'm unable to get to all of your questions, rest assured that we will give you answers to all the questions that are sent in this afternoon. 00:19:25 JOHN URIBE, M.D.: So now I'm just making a little boney trough for the tissue to basically sit and also there's growth factors in this. The humeral head has a lot of stem cells so we're just creating an environment, a healing environment. 00:19:51 JOHN ZVIJAC, M.D.: I think bringing up stem cells, there's two quick questions. One is, "Will the patient be able to ski again?" I can give you that, a standard yes. People basically return

5 to most of their sports in time. Skiing, actually they end up returning to skiing fairly quickly. The main one seems to be golf. Golf is usually a fairly standard sport that people are back at least chipping and putting within three or four months and then usually playing, depending on the size of the tear, again, fairly quickly, within three, four, five months. The sports that take a little bit more time and there's many questions regarding throwing athletes, baseball players, tennis players. Those tend to take a little bit longer. Again, people can hit ground strokes fairly early, within weeks. However, when it comes to the overhead activities, pitchers, throwers, it takes a fair amount more to rebalance the cuff. That's where the rehabilitation comes into play. But people can return to all those sports within several months. 00:20:52 JOHN URIBE, M.D.: This is called a Smart Stitch device. There are different ways to insert stitches. What this is kind of a very unique device and what it allows me to do is to put a horizontal mattress stitch -- lift up the arm more -- into this rotator cuff, which is a very strong stitch. It's got two needles. You'll see the needles throw the suture, capture the suture, and bring it out. That is what we'll use to pull that cuff back to its site. As you can see, I crossed that trough and there's the insertion. So the edge of that cuff will actually sit in the trough. So that's one set. 00:21:58 JOHN ZVIJAC, M.D.: Just to show you, again, there's many ways we do this. There's several different techniques we use. Dr. Uribe's chosen this particular technique today and I'd like to just show you what exactly he's doing. You've seen this all arthroscopically, so just give you an overview of what we're looking at. This happens to be the instrument that's going into the shoulder. This instrument actually lets you -- he fired both stitches at once and those stitches are about five millimeters apart. What it forms is what's called a horizontal mattress. It's a very strong stitch for this type of a device. One of the beauties of this particular instrument that he's using is that you can actually turn this knob and fire one side at a time. So you can place the stitches in different directions. But what he's done, arthroscopically of course, is to take this tissue, grab it, grab it, and then these needles fire in and grab the stitch at the same time. By doing so, you get this beautiful stitch. You can see on the bottom. It goes all the way through. I hope you can see that. It actually forms a horizontal mattress stitch. So it gives excellent tension on our repair and fixation on our repair. 00:23:18 JOHN URIBE, M.D.: I think we're going to use maybe four on this repair. 00:23:24 JOHN ZVIJAC, M.D.: Yeah, this happens to be a fairly large tear. 00:23:37 JOHN URIBE, M.D.: Yeah. I figured I'd challenge us. 00:23:31 JOHN ZVIJAC, M.D.: Yeah. 00:23:35 JOHN URIBE, M.D.: The quality of the tissue is quite good. I need you to lift up on this. 00:23:50 JOHN ZVIJAC, M.D.: There's questions regarding the length of time of surgery. Just to let people know, the surgery itself is going to be -- you're watching it live. This is exactly how long it takes. It can take anywhere from 30 minutes to an hour or a bit more, depending on the size of the tear and what has to be done in terms of fixation. I would say that somewhere between 45 minutes and an hour is a fairly standard time for this type of surgery. Of course, if you're sitting in the waiting room and you're a family member, there's set up time and anesthesia and wake up time and recovery time, so you have to count those all in. But the actual procedure itself, you're seeing exactly how long it takes. You're watching live. 00:24:41 JOHN URIBE, M.D.: So, what we're going to try and do -- there's a lot of scarring here. So, I'm pulling all these sutures out to give me access to more of the rotator cuff. The other thing you

6 have to do is work rather quickly because what we're using, and I don't know if you can see the instrumentation, we have pumps that are pumping saline into the joint to keep this thing blown up like a balloon, so that we can work. The problem is with that that you swell. So, if you take too long, you're going to be operating on a basketball. So you have to move rather quickly. So I think, no, you know what? I think that's good. This actually brings it quite nice. 00:25:48 JOHN ZVIJAC, M.D.: One of the things you see here also is that there's different colored stitches and that you'll see in a minute when we're trying to differentiate the different stitches, when we put the anchors in, it helps us do that fairly easily. 00:26:01 JOHN URIBE, M.D.: Needle. I think that's good because that's the other stump. So we'll go right there. 00:26:11 JOHN ZVIJAC, M.D.: There's a -- 00:26:13 JOHN URIBE, M.D.: Make another portal. 00:26:15 JOHN ZVIJAC, M.D.: Dr. Uribe as you can see, I don't know if you can see this or not, but he's making another portal on the outside here of the shoulder. This is a secondary portal where he's going to go ahead and grab those stitches so he can start placing the anchors. There's a question. This must be from one of our patients at UHC Sports Medicine Institute, that they're involved in one of our studies and there's a question of, he's involved in a study and he wanted to know if there's any experimental treatments being done and what are they? Go ahead, John. 00:26:52 JOHN URIBE, M.D.: I think you can comment on that because we're working on the one study that we actually should have possibly enrolled this patient is the use of growth factors, where we spin the patient's blood, remove their platelet layer with the growth factor and then put it into the repair to try and stimulate a better junction. One of the problems obviously with the rotator cuff is that it's a watershed area so the blood supply to the edge of the cuff as you grow older decreases and that's one of the reasons that they tear and at this spot. With the use of growth factor, it's felt that that will stimulate the cells to produce a better scar or a better anchor. Okay, so now we're going to put the anchors in, start here. 00:28:00 JOHN ZVIJAC, M.D.: Again, there's a variety of anchors that are utilized. This particular one is made of both metal, as well as synthetic. Like I said, we've discussed in the past, there's a variety of different choices to utilize. There's a question here regarding bone quality, about whether people feel -- they've been told that they have osteoporosis, they've had trouble and there's actually one where it sounds like the gentleman had the anchors pull out. Can you comment about how that would change your surgery? 00:28:46 JOHN URIBE, M.D.: Well, revision, one of the problems obviously with any surgery is that they can fail, and particularly in rotator cuff surgery. The literature is all over the board. What are you doing? 00:29:17 JOHN ZVIJAC, M.D.: As you can see, what we're trying to do here is retrieve these stitches. The more stitches you put in, the more complex this gets in terms of retrieval and appropriate placement and that's where fortunately this patient has Dr. Uribe doing this, so he will get these all done sequentially and in nice form, but it does take just a little bit of skill. 00:29:44 JOHN URIBE, M.D.: Everything has a fiddle factor. 00:29:45 JOHN ZVIJAC, M.D.: Fiddle factor to it, a little skill level. I was going to use the term skill level,

7 as opposed to fiddle factor. But, now what we're going to do is drill the hole. 00:29:58 JOHN URIBE, M.D.: This is just carpentry here now. 00:30:05 JOHN ZVIJAC, M.D.: When you repair -- you had mentioned before putting the biceps into the repair. How does that help? Does it act like a patch? 00:30:14 JOHN URIBE, M.D.: I think it acts a little like a patch, but more importantly, it keeps the biceps muscle from retracting and causing that Popeye deformity. So, it heals in with the rotator cuff. Sometimes the tendon in that area is rather thin, so I think it does help. 00:30:44 JOHN ZVIJAC, M.D.: It looks like a few people have tuned in a couple minutes late and I'd like to bring you up to speed here. It was a question about "How come this isn't a bloody procedure?" One of the things that we do is we put saline into the joint and it's iced saline that helps with keeping the field clear. In addition, anesthesia has done a phenomenal job of keeping the blood pressure down, which is extremely important. At times we put things inside the fluid to help with bleeding. In general, most of the surgeries we do are bloodless. 00:31:31 JOHN URIBE, M.D.: You might maybe introduce the surgical team. 00:31:34 JOHN ZVIJAC, M.D.: Yes, we're going to do that, as a matter of fact. None of this happens without multiple people involved. In addition to Dr. Luis Vargas-Ortiz, who we apologize, he was going to do the translation today, but he's been the able assistant of Dr. Uribe. It usually takes at least three hands, and unfortunately most of us only have two. In addition, in the scrub tech world, who's handing the instruments and making sure everything stays in proper order, are Desmond Sampson and Patrick Dennison, and then we have a circulating nurse who aides on the outside of the team, the people that are unscrubbed, that bring the instruments and keep everything in order, and today we have Amy Roberts. And in the anesthesia world, who is extremely important to these type of cases, as I mentioned before, in terms of keeping the blood pressure low as well as the obvious things that anesthesia does for us is Dr. Nancy Ryerson. 00:32:42 JOHN URIBE, M.D.: So we've -- Where's the other port? No that's this. So we've completed the back part. You can see, that's down and now we're going to come over to the 00:33:01 JOHN ZVIJAC, M.D.: There's a question about "What type of suture do you use? Is it absorbable or not absorbable?" People must know a lot about stitches. People use terms like "chromic", "Dexon", or "do you screw the soft tissue tendon to the bone?" We tend not to use screws through the soft tissue. There may be screws of anchor and then the sutures come off of that anchor. Otherwise, most of these are non-absorbable stitches. However, there are several companies that do make an absorbable stitch also. There are times we use those. It's usually for smaller tears that we tend to use those type of fixation devices. Sounds like a couple people have the unfortunate problem of having a failed rotator cuff or more than one failed rotator cuff and the question is "What should they do?" and obviously that's a very difficult problem that I think Dr. Uribe's alluded to already this afternoon. However, there are times when there are other options depending on what you had done in terms of, instead of them doing them arthroscopically, these can be done through small open incisions called mini-deltoid splitting incisions. In addition, there a variety of techniques that can be utilized. One thing that people keep asking about are the use of patches. You want to comment about that John? The use of patches in these type of cases? 00:34:41 JOHN URIBE, M.D.: There are a variety of patches now on the market, although they really haven't been shown to be effective as standalone, but certainly if you have a very thin rotator

8 cuff and it's difficult to engage the sutures or to hold the sutures, that that can be something you can supplement. Hopefully in the future with stem cells and different substrates, we'll be able to use those substrates to -- we'll probably have to pull. Yeah, let me have the whole 00:35:28 JOHN ZVIJAC, M.D.: One of the things about patches are you really can't fill a hole with a patch. You have to use it as a reinforcer of tissue. There's several issues that deal with using these type of patches. There are instances we use them. For example, this person who's had a couple of failed rotator cuff repairs, that may be an instance where we would go ahead and re-repair it and use some type of other tissue or patch to try to stabilize that rotator cuff and try to relieve there symptoms. There's a lot of questions also about, "What do you do when a cuff is not repairable?" Well, Dr. Uribe's doing that. We'll get his thoughts on that in a moment. There are several other options available. In terms of debridement, just going ahead and cleaning up the joint and trying to take away the flaps that are causing pain. That doesn't help much for strength, but it does help very often for pain, for at least short periods of time. In addition, there's a variety of replacement techniques that are utilized, including reverse total shoulders. There are certain caps that we place on the ball. The whole idea behind this is to try to relieve pain and very often by relieving pain, people get much better function and are able to go through many of their activities. 00:36:56 JOHN URIBE, M.D.: Did you show them how this anchor works and that kind of thing? 00:37:00 JOHN ZVIJAC, M.D.: I didn't get to the anchor yet. I showed them the stitch. We're going to show the anchor next. 00:37:08 JOHN URIBE, M.D.: Okay, yeah. Great. 00:37:11 JOHN ZVIJAC, M.D.: This is called the knotless system. For many years we did this through a -- why can't you open now for me? -- through a tying knots. We used to place anchors past our stitches and then tie the knots. Many of these knotless systems are now available, which becomes a time saver in the operating room. Basically, if I can get maybe you to hold this for me. These stitches that are already in, what's done is that it's filtered through this -- can you get this? Are we getting this well? Good. -- through this. We pull this through. Then 00:38:09 JOHN URIBE, M.D.: Where's the other? Put an anchor there. 00:38:11 JOHN ZVIJAC, M.D.: We just take this. As you can see, we can roll this anchor. Then, what Dr. Uribe's doing is he's placing it down a cannula, and he places it into the hole that he drilled. Then he's able to just fire the anchor. By doing that, you get fixation. Then he's able to tighten the anchor down just by twisting this more and it brings the cuff down in good fixation. The idea behind this is since you have this nice -- I don't think you can see this up here, but since you have this nice area of coverage of the rotator cuff, you get compression over the whole area that Dr. Uribe cleaned up beforehand to allow for healing of the tendon over a big surface area. One of the things to point out from a technical standpoint is that this isn't a point-specific repair. This is a coverage area. So, the greater tuberosity that was cleaned up and burred before has approximately 15 to 20 millimeters of bone that is exposed to allow for a big area for this tendon to heal. 00:39:40 JOHN URIBE, M.D.: So, are we back? 00:39:41 JOHN ZVIJAC, M.D.: Go ahead, John. 00:39:45 JOHN URIBE, M.D.: This will essentially repair the whole cuff and you'll see, there's the trough and the tendon sits in that trough and that's why that exposed bone will scar to the tendon.

9 The tendon will scar down to that exposed bone. Like I said, that's going to take about six weeks, so we'll hold him relatively still. He'll be able to move his elbows, his elbow and wrist, and then at four weeks I usually let them start some motion on their own and send them to therapy to have the therapist help them, but not let them do any resistance for a total of six weeks. Then at six weeks, they start doing the resistance work. So this brings the edge of that cuff back down. You can see now we'll look at the whole cuff. Yeah, yeah. See how that closes down. 00:40:52 JOHN ZVIJAC, M.D.: I want to thank everybody again for all the questions. They keep rolling in and like I pointed out before, if we don't get to all of them, we will certainly you and give you hopefully a useful answer. 00:41:15 JOHN URIBE, M.D.: So, what I'm going to do is cut this last stitch here. I'm having trouble getting in here. No, yeah, it's the angle. 00:41:35 JOHN ZVIJAC, M.D.: Seems to be a lot of questions regarding people having tears that are tennis players and overhead athletes. They want to know if you would do anything different when you repair a tendon in an overhead athlete, as opposed to, I guess, other people. 00:41:56 JOHN URIBE, M.D.: Well, certainly overhead athletes the cuff becomes very critical and so I'm definitely more aggressive. We've had a few professional baseball pitchers with cuff tears and unfortunately, even though the cuff repair works, their ability to throw and generate the same amount of speed is less. So, I think you have to look at things realistically. Now, for tennis players and other overhead athletes that way, it's not a problem as long as you can get an anatomic repair such as we are able to achieve here. Here you can see, you're looking down on the rotator cuff -- let me have a debrider and I'll clean it up a little bit. Then I can go back inside and we can maybe take a look inside, but, arm. 00:43:04 JOHN ZVIJAC, M.D.: Here's a question from someone who has calcifications of the rotator cuff and surgery has been recommended to them. Maybe you can comment a little bit about how calcifications can sometimes be debrided and other times require a repair. 00:43:25 JOHN URIBE, M.D.: Well, that's a good question because calcifications, even though they look hard, it's analogous to toothpaste. That calcium phosphate that can leech out into the soft tissues, it's almost like acid. You can see how white this tissue is. When you see the changes of calcific tendonitis, it's bright red and it's very inflammatory. So, removing that inflamed bursa and removing the calcify deposit usually resolves the symptoms. However, if the deposits are large, it can leave a rather large hole and then you just put some sutures in that and that takes care of it. So, I think if it doesn't dissolve, I like to give them an injection first and see if that helps, and then some therapy. If that doesn't resolve the symptoms, then surgery certainly takes care of it. So here's our final product, as you can see. So the cuff is repaired. Now we'll go back and look at it from the inside. We'll look up and you'll see how that hole is covered. Basically what was happening here, the reason it hurt so much, is you had that large loose flap that was catching on the undersurface of the chromium of this piece of bone here. So it was catching here and that's what causes the pain. This is a ligament, a very taut ligament, that I can release, and in most cases people do release it. I think this person had a rather large tear and I don't wish to release it because it helps support the shoulder in this case because of the large tear. You can see here is the whole repair. There's the edge of the bone here. It's well covered. It's in the trough. He should do extremely well. 00:45:26 JOHN ZVIJAC, M.D.: Yeah, it looks great. How long does it take for that to heal down? 00:45:31 JOHN URIBE, M.D.: As I said, a minimum of six weeks. But if you hold him down for six weeks,

10 I think that's where you start getting into loss of motion and significant capsular contraction. So I like to hold them for four weeks and then let them start moving in a limited range with some assistance. Then after six weeks, they can use their own musculature to move it, and then start strengthening. In terms of him getting back to his professional skiing, before you get into traumatic sports -- I mean, you've seen them and I've seen them multiple times, even in 20-year old football players, we like to keep them from significant trauma for about four months. 00:46:17 JOHN ZVIJAC, M.D.: There's a question regarding, "What do you use to diagnose a rotator cuff tear? What types of tests do you use?" 00:46:23 JOHN URIBE, M.D.: Can we put him back up? 00:46:26 JOHN ZVIJAC, M.D.: Do you have any guidelines that you like to use? 00:46:30 JOHN URIBE, M.D.: I think certainly a physical exam is key. I think symptoms, you can almost diagnose a rotator cuff tear just from the symptoms of the patient. Pain at night, pain with overhead activities, when there are very large errors, there is a definite deficit in terms of strength, but on physical exam, you can palpate the tear. An MRI will certainly show you the tear, show you the pattern of the tear, show you the quality of the muscle, how much it's retracted. Ultrasound is another great option to use. It's less expensive, but it's dynamic. You can move the arm as you're using the ultrasound and it gives you a great picture. So all those methods are very useful. X-rays for the massive tears, where the humeral head has already started to rise up through the tear, you can see that on an x-ray. Although, once it gets to that point, the ability to repair it is very limited. 00:47:37 JOHN ZVIJAC, M.D.: There's some questions regarding stay in the hospital or not. Everyone in general goes home the same day as they've had their surgery. We at UHC like to do our surgeries here in the hospital for a variety of reasons. One of the most important is the staff, which we mentioned before. We have all board-certified anesthesiologists, which is of great importance to us for a whole variety of reasons, as you can imagine. We like also the ability to have a variety of techniques available to us and we are able to do that here in a hospital setting, for all of the different instruments that we may need are readily available and they don't have to be brought in. You showing us the underside here? 00:48:24 JOHN URIBE, M.D.: Yeah, so here's the normal part of the cuff here, the part that wasn't torn. Now you can see there's a continuity of it now. 00:48:34 JOHN ZVIJAC, M.D.: Boy, that looks great. 00:48:35 JOHN URIBE, M.D.: You can see the stitch and there you can see where it's sutured up. So, that's all closed and here's where the biceps was and the subscapularis tendon has also been reattached. So, we're done. 00:48:53 JOHN ZVIJAC, M.D.: One more question, and then we'll wrap it up. There's a question regarding, I think this relates back to, I guess we talked about it early on in the broadcast, about the fact that many people are walking around with rotator cuff tears and don't know it, but the question comes is, "What percentage of tears are traumatic and what are degenerative and when should you have your rotator cuff repaired?" 00:49:19 JOHN URIBE, M.D.: Wow, that's a tough one because that goes back to what we were talking about in terms of "should everybody have their rotator cuff repaired?" Certainly, you can have a traumatic tear at any age. I mean, we've seen rotator cuff tears in children. You can -- so

11 we've seen them at any age and certainly we've seen them as early as, I've seen them in 12-year olds. At any age. The traumatic tears that occur in a young individual, I think the sooner your repair those the better. There is also, as you get older, there is a loss of blood supply to the insertion of the rotator cuff and you can have just and insidious tear that maybe has been tearing all along and you'd never noticed it. Then you reach into the overhead compartment of the airplane and all of a sudden you have this searing pain and you've basically taken the straw that broke the camel's back and then the quandary is your activity level, the quality of the tissue, all those things that we talked about. But, certainly a rotator cuff tear that does not respond to rest and physical therapy, perhaps even an injection, then certainly an attempt can be made either to repair it or to clean it. Fortunately, today with arthroscopy and the different techniques of rotator cuff repair, the results are extremely good. Certainly in the 90 to 95 percent range. 00:51:24 JOHN ZVIJAC, M.D.: This brings us to the conclusion of our webcast. On behalf of Dr. Uribe and myself, our patient, and all of us here at Doctors Hospital, I want to thank you for logging in and watching. Any of your questions that have not yet been answered, we will get to by . If you missed any portion of this, it will be on the website. It will archived on the website later this evening. So with that, good evening from Coral Gables, Florida. 00:51:54 [end of webcast]