Dr. Chris Tucker:
Welcome to your Arthroscopy Journal podcast. I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and the podcast founding editor. Today we're discussing the repair of massive rotator cuff tears. I'm joined today by Dr. Ivan Wong from Dalhousie University in Halifax, Nova Scotia. Dr. Wong is an orthopedic surgeon specializing in sports medicine and amongst his many professional endeavors, he's an active member of AANA. He commonly speaks from the podium, he participates in committees, and he teaches visiting fellows at his institution. Dr. Wong was the senior author of the recent paper titled, "Bridging Reconstruction with Interpositional Dermal Allograft is Superior Healing than does Maximal Repair for Treatment of Large to Massive Irreparable Rotator Cuff Tears: Secondary Analysis of a Randomized Controlled Trial," which is currently in press for the Arthroscopy Journal. Ivan, congrats on all your work and welcome to our podcast.
Dr. Ivan Wong:
Thanks for having me.
Dr. Chris Tucker:
Ivan, you're probably more known for your recent work with shoulder instability and the arthroscopic glenoid reconstruction. Could you just share with us your interest in this topic of massive rotator cuff tears and what was your origin story for this particular study?
Dr. Ivan Wong:
Absolutely. So it really starts in fellowship and I think most of my experience and feeling comes from there. I got a chance to do my training with Steve Snyder at Southern California Orthopedic Institute. And honestly, my very first operating day with him was with a bridging reconstruction for an irreparable rotator cuff. And it was really that experience that kind of taught me, wow, this is techniques that I never thought was possible. It was an eye-opening experience. And then going through that year, I could see all these patients coming back, not just the patients we operate on, but patients coming back five, 10 years afterwards, and I could see really how well they did.
In my year with him got to see him present his clinical findings all over the world. But what I was kind of disappointed on is not everyone else was doing this type of an operation and helping patients with these massive tears the same way. So really since fellowship, my goal was to get better data on the technique and treatments that he had developed. So this bridging reconstruction is their creation, and I've really just spent my first decade of practice trying to get this randomized trial done.
Dr. Chris Tucker:
Now, I know your practice to this point's been limited to Canada, but I believe you're fairly familiar with the American healthcare system due to your involvement with our specialty societies and your close relationship with many of us who practice here in the US. Could you just tell us if there's any major differences in your approach to caring for patients with cuff tear pathology, given your location in Canada, that sets your practice apart from maybe what myself or anybody else practicing in the US might experience or have to consider?
Dr. Ivan Wong:
Yeah, so it's interesting. Canada and US, obviously we're very close. We have a different way of practice, but we're trained very similarly, which is the nice part. So the communication goes back and forth. The differences, though, is there's a long wait to get healthcare in Canada. It's a one-payer system, so you can think about it like it's Medicare or Medicaid, but that would be all you would have. You would have no other options going through. And so for us, patients wait a long time. And because of having only a one-payer system, there's also a very limited number of jobs. So there's not that many orthopedic surgeons. When you look around, our national meeting is not one-tenth of yours because our population is one-tenth the size. We have much fewer surgeons because, well, the primary payer can choose how many positions are open. And as you probably know, many of my colleagues who train in Canada actually go to the US for jobs because there's not enough jobs in Canada.
That said, our patient, the way we treat patients are the same. We just have different difficulties with taking care of them. So rotator cuff specifically, we have a long wait list before we see them. There's a long wait list for advanced imaging and then there's a long wait list for the surgery. So by the time we actually get to the surgical point of view, most of our patients have large tears and as we know, large tears tend to have higher failure rates and the higher failure rates tend to have more massive tears and tend to be more irreparable. So with that, I get the chance to practice or try different techniques and have more opportunities to do these and to be better able to study these types of populations.
Dr. Chris Tucker:
Yeah, that's interesting because I never really considered the fact that the shift in the paradigm for your rotator cuff practice is really more to the left of say an acute tear that you see that's fairly reparable and you get to do it versus you're managing folks non-operatively for quite a while. Not only is their pathology progressing, which then makes your procedure more difficult, but you also kind of have to, I'm assuming, weigh the cost benefit of failure differently because you kind of want to be one and done before than putting them back in queue for another long wait for potential revision procedure.
Dr. Ivan Wong:
Absolutely. Because all our patients, once we know they're a surgery, there's hundreds of patients in the waiting list. And with the way our healthcare system, we can't get through all of these in one, two, three years. So really, we do have to look if we can get them done once with more work, whatever has less failure rates, that is actually the better system for our healthcare system that we have right now.
Dr. Chris Tucker:
So before we dive into the specifics of this paper, could you just give us a quick overview speaking the pathology of large and massive rotator cuff tears in general, including their impact on patients and some current principles of management that you utilize?
Dr. Ivan Wong:
Absolutely. So large, massive tears, again, we're talking about at least two tendons retracted to the level of the glenoid. These are not our typical rotator cuff. They present with significant weakness. Sometimes pseudoparesis, you can see atrophy already in the supraspinous, infraspinous fossa. And these patients in general complain of pain. Most patients complain of pain. There are some that compensate or that don't, but majority of them do. And it's actually really interesting because they're some of my most happy patients. Every patient coming back for follow-up, these massive tears, even though we have to work so hard, even though their failure rate's higher, they're so happy because we're very good at getting rid of their pain.
And now hopefully when we get into the results here, we are actually getting better at getting them stronger as well. And that's what really is the exciting part, is the paradigm, when I first started doing this, when I first started training, we only talked about outcomes of rotator cuff tears. We're really only, sorry, our only goal is to decrease pain, not really talking about strength or function. Now I think we're going to start having that discussion with patients as we look into this pathology more and more.
Dr. Chris Tucker:
Yeah, I'm excited to hear about that. So let's get underway into the details. So the stated purpose of your study was to compare the radiographic results of bridging rotator cuff reconstruction with human dermal allograft and maximal or what we sometimes call partial repair for larger massive irreparable cuff tears. Can you just share with us how you went about studying this, including reviewing for us your definition of massive irreparable cuff tears and your study design and methods?
Dr. Ivan Wong:
Absolutely. So massive irreparable tears, so we said that was going to be at least two tendons, at least three centimeters, at least to the level of the glenoid. And these are chronic tears. These are not acute tears. So they would also include revision. So failed previous cuff tears, those are definitely in there. And probably just over half of them were that way too. So these are kind of the problematic ones. We do have good data from Burkhart, at least before that said, look, we can do a debridement partial repair, kind of recreate the rotator cable. So all of these we could recreate a rotator cable. So getting two anchors in there, fixing the anterior, the posterior, something back together to get some kind of function of the cuff back. So that's what the definition was.
And we really wanted to focus on this because, again, we're trying to figure out the best way to describe if a bridging reconstruction, which really hasn't been talked about much, not quite like the SCR with Burkhart bringing that up into our armamentarium. We really want to figure out would this, some kind of study to be able to make people or make surgeons think this is a good option and I should spend the time to learn this. So we thought that if we have these massive tears that we can actually get to the right part, should we or should we not put this bridge in between? Should we learn that technique? And so that's why it was designed this way. It was randomized at the time of surgery. So once we know we can get it back to a rotator cable reconstruction, we can then either reconstruct the defect with dermal allograft or not.
Dr. Chris Tucker:
Now you've previously reported on this, and just to be clear, this particular paper is a secondary analysis of that previous randomized controlled trial. So your primary outcome in this study was the MRI healing and re-tear rates, but then also you looked at the secondary outcome of progression of muscle atrophy and fatty infiltration. Am I getting that right?
Dr. Ivan Wong:
Yeah, so that's exactly it. So the trouble with all the papers are, is they limit you to a number of words, and if we try to put too much stuff together, it kind of clouds the results. So in 2021, we published our paper, we presented it to show that the patient reported outcomes, because the whole study was initially powered to be, do patients do better at two years afterwards if they get bridge versus maximal repair? And the answer to that was, absolutely. They got significant benefit. And that's what the story we want to go because that's really the question, do patients get better? That said, there's lots of papers out there that say patients get better depending on how you look at things. So now we want to look at the nitty-gritty, and that's where we said, look, we want to look at the MRI and we want to look at it in much more detail.
So this is not what it's powered for, but this is what we wanted to figure out if these can help delineate why the patients were doing better. So this is the MRI. So minimum of one year follow-up. When we order MRIs in Canada, as we mentioned before, there's a wait, so there's no perfect way. We can't get it exactly when we want. When I order one, I know it's going to come, give or take, two years. So we ordered it all at one year. So these are all one year or greater, some are two, some are three years, some are four years. It took us a few years to do the study. And we wanted to look at the healing. And when you first start looking at this, it's actually quite interesting because there's no good definitions of healing when you're looking at dermal graft reconstructions of rotator cuff.
You can look up any paper and it is not a normal looking cuff. If you get a radiologist that looks at it, they're like, "What is this tiny little three millimeter band that connects the cuff? Is it just a fibrous tissue? Is it a bursa? Is it something?" So it does not look normal, but we actually had to go back and describe this, not we, meaning our radiologist colleague, our MSK radiologist, who actually went in and clearly said, "Look, if you have a tear off the tuberosity side, you're going to see waviness of that graft. That would define a full tear. If you have a small gap, again, that's not the same thing." So they had to go through all these different things to be able to analyze, to say, how is torn, how is not? And then we went one step further because they said, "Look, we are actually noticing the healing rate's very different from the MRIs."
The healing rate was almost 80% in the reconstruction group where we had bridging, whereas it's 80% failure in the maximal repair group. But when you look at the muscle, you could actually see there was a little difference and that's what you want to go measure too. You look at Goutallier, he looked at fatty infiltration as well to see if there's a difference. And again, this study was not powered for this. This is more of an exploratory study, and even though we didn't find significance, you can see the trend to this that patients are getting or the muscle is not getting worse in the bridging reconstruction, whereas in the maximal repair, they definitely are getting worse over time.
Dr. Chris Tucker:
Yeah, you spoke to a lot of your results, which was going to be my next question, and you highlighted the main difference, which was in that re-tear rate between the maximal repair group and the bridging cuff reconstruction group. I guess my question to you is, and I liked how you outlined it in your paper, could you just share with us what's the take home point from this study?
Dr. Ivan Wong:
Yeah, so take home, well, bridging reconstruction with graft has less structural failure rate. Okay, so we're talking about gross failure rate, meaning where cuff is no longer connected to tuberosity. And with that it shows, at least at the two-year mark, it preserves the supraspinatus muscle mass. So in terms of no progressive atrophy, no progressive fatty infiltration, it stays the same at the two-year mark. Whereas maximal repair has a higher failure rate and a well documented continuation of fatty infiltration and atrophy. So they actually can be measurably worse on an MRI. Most papers, the requirement is a minimum two year follow up, and then we don't see anything else about these patients. We don't do these long-term studies in surgery usually, and that's why I think sometimes we're not finding that, whereas this now says I need to start looking at the state at the five year. I need to look at the state at a 10-year mark because I think these patients, if they can maintain their muscle mass, they potentially can have better function for much longer. We're going to detect bigger and bigger differences as time goes on.
Dr. Chris Tucker:
I really enjoyed your discussion section because I think you took a lot of time to explain the why and the philosophy behind what your interpretation of your results were. Could you just talk to that and share with us the inherent biomechanical difference between the maximal repair and the bridging reconstruction and why you think that might be contributing to the observed results that you saw?
Dr. Ivan Wong:
Yeah, so this really comes back with all my mentoring from Steve Snyder. Again, he taught me that anyone can repair a rotator cuff. In fact, there's many mantras out there that say, "There are no rotator cuffs that cannot be repaired." And you're right, if you do enough releases, you do enough mobilizations, there are techniques now that you can get that firmly seated with double, triple rows down to the tuberosity, but that's not the goal in life. The goal in life is to get the cuff to heal for the patient to function and have a good long-term outcome. And not everything's in our control. So mechanically, that's all we have is control, but biologically is what we really need to do and we need to work with biology using our mechanics to make that work.
So how we talk about this in our discussion, we really focus in on where maximal repair is. It's using all our mechanics to get it back to the tuberosity and we have all these things. So we used margin convergence, we used it to pull as much as we could, but try not to pull too much. And our trouble is we don't know what too much is. So I pulled just enough where I thought it's good enough tension, I'm not going to overdo this. I could release more, but this is where I think could have the best chance of healing. And they still failed. We have that in the data. But why would bridging work? We don't know why adding this dead tissue could make it work. So it's the same procedure. I would've just stopped right there. So this is the same on both sides where we would do that cable reconstruction, both anterior and posterior aspects of the cuff. Now the only thing we'd have difference between the two, is I'm going to add a bridge.
So I add a dermal graft that doesn't increase any more tension, but makes the continuity from the remnant cuff to the tuberosity. And because we are adding more tissue, now I add a double row on that tuberosity side to get better mechanical fixation. So how would this work better? Well, we're adding 12 sutures per case to connect all the other aspects of the cuff, not just at what we call the goalpost anchors. That's what we do for the maximal repair, but we're adding these 12 other sutures to attach the remnant cuff to the dermal graft. We're using dermal graft to bridge the defect to the tuberosity, and we're using a double row reconstruction on the tuberosity that we know mechanically is the strongest fixation. So we're getting the benefits of mechanics with the double row, but we're getting the benefits of biology by not over tensioning it all and distributing the force between all these sutures for the cuff in its stable position.
Dr. Chris Tucker:
Yeah, it's a wonderful explanation of the biomechanics and just some of the principles we have to consider. It does sound a little odd to me having support for double row come out of somebody who trained at SCOI, but I know that studies do support what you're saying with regards to the biomechanical stability. Now, there's obviously no free lunch as we like to say. Can you talk to us about some of the controversy in the literature regarding the use of this bridging cuff repair technique? What are some of the issues we need to consider as a profession and what do you think might be some reasonable indications for its use?
Dr. Ivan Wong:
Yeah, so obviously there's controversies for every type of procedure. Bridging specifically, it probably got a bad rap, earlier in the allograft stage there was some porcine graphs that had a lot of rejection, so inflammatory responses. And those definitely hurt bridging reconstruction when that was going on. There were some other things in terms of open reconstruction. So I do think some of them had poor outcomes, but this is following back with Steve Snyder's technique that he's popularized. He's kind of perfected to be able to reconnect. So we've learned many things going through all these patients over the years. We realize that we can't make muscle come back, so we can't hope to have more than a 50% atrophy of a muscle do more than that. So anytime we do a tendon transfer, we expect the tendon transfer strength to go down by one grade. So grade five strength will go down to grade four, whatever that means.
So we don't know if it's a 50% strength decrease, it's some kind of decrease. But if your muscle mass of the supraspinatus that's torn and not connected, it's only 50% muscle bulk compared to the normal side, you can't expect it to be more than 50% strong after it heals, if it heals. So we realize that anything's less than that, you're not really getting that much strength after, so that's probably not worth doing. And we also do know that the less muscle that there is, the more fatty infiltration is, the more re-tear rates there is from the regular rotator cuff repair. And it's the same is true for when you have to bridge because using a bridge with dermal allograft, that's dead dermis, and even though dermis is designed to allow for more capillaries, more healing, it still is allograft, it won't heal the same.
So our indication right now is somebody who has less than 50% atrophy of the supraspinatus and infraspinatus muscle groups and something that's irreparable because obviously repairable is the ideal thing. Patient-owned tissue is always ideal, and if I can repair it and augment it, that'd be great, but if we have to use too much tension, and I think the biggest problem right now is we still don't have that definition of what tension is too much, that's when we'll go to a bridge.
Dr. Chris Tucker:
Great. So speaking now to your own personal evidence-based practice, can you just share with us how the findings of this paper and obviously in conjunction with the previous randomized control trial that this stemmed from, how these findings fit into your current approach to managing patients with massive cuff tears, and what, if anything, has changed now as a result of these findings?
Dr. Ivan Wong:
I think the biggest thing that's changed now is I look at people's muscle a lot more critically. So MRIs are very critical to see how much muscle they have and see if it's worthwhile trying to reconnect it. I want to see if patients are willing to go through this. There's no question, there's a lot of work. It's two years of physiotherapy to try to get those muscles strong. Because we actually see the increase in strength over that whole time. It's rebuilding a muscle that hasn't worked for a long time, and we do know it can work, but not everyone can make it work. So I want to identify those patients that are willing to go through that work.
Those patients that want the quick fix, want the pill, want the quick surgery and then be done, this is not for them, right? They need a different surgery. This is something that they have to be willing to put that in. So what has it changed? It's changed my approach to patients. We use a lot of dynamometer measurements, we use a lot of follow-ups with this to show trends, and if they show a trend and willing to go through this, then we offer this operation to them. Because there's no question, it's an expensive operation, expensive in terms of cost to the system and cost of time for the surgeon. Because this is probably still the hardest, most complex surgery I do with the number of sutures going through a single cannula.
Dr. Chris Tucker:
So now if I ask you to put your research scientist hat on and look a little bit into the future, what do you think is currently a really significant important unanswered question with respect to managing massive cuff tears? I guess in another way of asking it, what are you most excited about seeing us discover or research in future studies in the near future?
Dr. Ivan Wong:
The most exciting thing about coming out, and it's all just on the verge right now. Dermal graft is a structural graft. It doesn't really increase the healing rate and it stretches, right? So we actually have good data now to show that it doesn't heal the same way and you pull on it, its super strong, but it stretches over time and revision surgeries actually can see that it stretches, but it does add collagen. So it works, it adds collagen. The next ones are where we can add structural and biology, because right now our biological graphs have no strength. Our structural graphs have no biology. We want both. I've happened to use both the structural dermal graph and the biologic, and it actually does great, but the costs are just prohibitive.
So I think the next is going to be having some structure and biology together and then having a technique that's going to be able to make it much more feasible to put in. Because there's no question, the learning curve for this operation is steep, and the commitment by the surgeon to do this is a lot because there's a lot of things to manage and not everyone wants to go through that. So once we can get the tools and technology to make this simpler and have the graphs to help both the strength and the healing go, then this is going to be a really good time for rotator cuff surgery, just like instability has been for the past few years.
Dr. Chris Tucker:
I agree with you, Ivan. I think it's exciting to witness in real time our colleagues and yourself included studying topics including biologics, because I think that really is the next frontier for a lot of the things we do, and I think it helps move the needle forward to push into some of these domains that I think as a whole, orthopedics probably hasn't studied as much as other topics that we have looked into. So I'm excited about some of the same things you are as well. I really appreciate you taking all your time to discuss this research with us and share your thoughts on managing massive cuff tears in general. Did you have any other closing remarks or anything you want to share with us before we close out?
Dr. Ivan Wong:
Well, I must say I enjoy listening to your podcast. I really like how AANA and all the publications, the Journal of Arthroscopy, have been doing because this is really what you said, this is how we move the needle. We do need to think outside the box. We do need to innovate for these procedures, but we need to follow our patients and what you're doing, how you're bringing light to this information, because translational research used to take 10 years before people even know about it. Now you're making podcasts about publications that haven't been done yet. So this is huge. I really enjoy being part of it. I really thank you for inviting me here and I look forward to many good things to come.
Dr. Chris Tucker:
Yeah, thanks, Ivan. It's really been a joy talking to you. And as I say many times before, I think I'm just the sounding board for the strength of all the research that Arthroscopy publishes in that all of the fantastic researchers and scientists out there and clinician scientists are doing, the quality just continues to skyrocket. And so I'm just happy to be able to facilitate at least getting the spotlight onto what's important, which is the work that's being put out by hardworking folks like yourself. A paper like this that we can talk about for 20 minutes probably took about six years of your life units to get the results for us to discuss. So kudos to you and your team. Once again, thanks again for joining us. Congrats on all your work, Ivan. Look forward to seeing you at the next meeting.
Dr. Ivan Wong:
Thanks for having me.
Dr. Chris Tucker:
Dr. Wong's paper titled, "Bridging Reconstruction with Interpositional Dermal Allograft is Superior Healing than does Maximal Repair for Treatment of Large to Massive Irreparable Rotator Cuff Tears: Secondary Analysis of a Randomized Controlled Trial," is currently in press for the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org. This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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