ARTHROSCOPIC ROTATOR CUFF REPAIR BRIGHAM AND WOMEN’S HOSPITAL March 9, 2006 00:00:17 NARRATOR: Today’s webcast from the operating room at Brigham and Women’s Hospital in Boston, Massachusetts will demonstrate a live arthroscopic rotator cuff repair procedure. A tear of the rotator cuff is a common injury that often leads to pain and sometimes weakness in the shoulder and upper arm. Arthroscopic rotator cuff repair uses a small camera to view and guide repair of the rotator cuff. The result for the patient is a faster recovery time with less inflammation, discomfort and scaring. Today’s program is part of our ongoing educational efforts to bring the latest information in healthcare to physicians and patients. During the program, you may send your questions to the OR surgeons at any time. Just click the M-direct access button on the screen. And now your host. 00:01:01 DR. SCOTT MARTIN: Hello, my name is Dr. Scott Martin, and I am attending orthopedic surgeon in the Department of Sports Medicine here at the Brigham and Women’s Hospital. Welcome to our live surgical webcast on arthroscopic rotator cuff repair. This is the latest in a series of surgical webcasts. My colleague, Dr. Laurence Higgins, who is the chief of the Shoulder and Sports Medicine Services, will be performing today’s surgery, an arthroscopic rotator cuff repair. Rotator cuff injury is one of the most common reasons for shoulder pain, and patients often present with pain over the front or outside the shoulder, in addition to variable weakness, especially with overhead activities and reaching. In properly selected patients, surgery is sometimes indicated to reattach the tendon down at the bone. This can be done through one of two procedures: one is the conventional open surgical technique; the alternative is the technique that we’re using today, arthroscopic surgical repair of the rotator cuff. The advantages of arthroscopic repair include smaller incisions, a decreased operative time, less pain, and an accelerated rehabilitation, especially for restoration of motions and decrease in post-operative stiffness. In addition, doing the procedure arthroscopically gives the surgeon the versatility to treat any concomitant pathology of the shoulder at the same time using the same incisions. Throughout this webcast, viewers will be able to submit e-mail questions. If you’d like to submit an e-mail question, please push the button at the bottom of your screen. Throughout the procedure, Dr. Higgins and myself will be answering your questions. And now, let’s go to the operating room with Dr. Higgins. Hello, Dr. Higgins, could you discuss the case that you’re doing today with an overview of the procedure? 00:02:51 LAURENCE HIGGINS, MD: Fantastic, Scott. Thank you. First I’d like to welcome everyone here to Room 37 at the Brigham and Women’s Hospital, and importantly I’d like to introduce the team that makes this all possible. The first person I want to introduce is Dr. Mercedes Conception, who serves as the Director of Regional Anesthesia and Orthopedic Anesthesia here at the Brigham and Women’s Hospital. She’s going to discuss some of the advantages of using the type of anesthesia that we selected today. 00:03:27 MERCEDES CONCEPTION, MD: Hello. Today we have selected brachial plexus block via the interstanen (sp) approach. It is the best anesthetic for shorter surgery, and it is considered now standard fare. Among the many advantages that tracheal anesthesia offers over general

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anesthesia, perhaps the greatest one is the prolonged post-operative alchisea (sp) that it provides without the surface effect of narcotics. 00:03:57 LAURENCE HIGGINS, MD: Thank you, Mercedes. The rest of the team here that’s making this all possible is first, I’d like to introduce our Scrub Assistant, Julio Metrodonia (sp). He’s actually here to help us perform the operation. To my right is John Macropolis (sp), a Physician Assistant, who is going to be helping during surgery. And in the background making most of this possible are two individuals, Michael Quinn and Sheryl Grove, who are going to serve as Circulators to make the flow of case go smoothly. We’d like to go inside arthroscopically for a moment and take a look, and while we’re just doing that, Scott I’m going to hand it back to you so you can talk a little bit about supraspinatus tears. This gentleman is a 72-year-old patient who fell on February 20th. He had a normal shoulder, he had no pain, no dysfunction of his shoulder. He fell on an outstretched arm, and after his fall, he was unable to lift his arm up. He was seen in the emergency department, and then seen by us three days later, and on the basis of his physical exam as well as imaging studies, we determined that he had a supraspinatus tear, one of the four muscles of the rotator cuff. I’m going to turn it back to you, Scott, for a moment to discuss the anatomy of the shoulder. 00:05:11 DR. SCOTT MARTIN: Sure. Thanks, Larry. I think it’s best if I use an anatomical model to explain to you the rotator cuff and the tear that we’re talking about today in this patient. One of the most common tears that we see in the rotator cuff involves the supraspinatus tendon. That’s this tendon right here. And what happens is the tendon actually lifts off its footprint or its attachment to bone. We do have a slide of that also showing the tear repaired using an open technique with the sutures in place. Our plan today is to reattach this tendon down to bone using suture anchors. These are anchors that secure deep into the bone and have sutures attached, which are then secured to the tendon to bring it back down to its footprint, or bony attachment. If we can go to the slide... You can see a picture on our slide, if we can get it up, of a rotator cuff tear. And, the tear that you see is accessed open here through what we call a mini-open split of the deltoid muscle. That’s the muscle that overlies the rotator cuff. The procedure that we’re using today does not request or need for detachment of the deltoid or for splitting it, but this is the tendon that we’re talking about, the supraspinatus tendon. And you can see on the screen it has sutures in it. It’s the most common tendon that we see torn. Other tendons that are commonly torn include the tendon behind the supraspinatus, which is cut out for demonstration in this model, right here where this gap is, and also the tendon in front, the subscapularis tendon. The other tendon that can commonly be torn and is actually torn in this patient, at least partially, is the biceps tendon. The biceps runs in this groove, called the bicipital groove, and attaches deep inside the shoulder to the top of the cup or glenoid. In today’s case, we’re going to be fixing that tendon outside of the shoulder in the bone in this area here, again with suture anchors. Let’s talk a little bit about symptoms of rotator cuff injury. Patients most frequently will present with shoulder pain, as you can see on the slide. It’s the most common complaint that we see, especially night pain. Patients find it very difficult to sleep at night, especially trying to sleep on that side. They may experience pain with overhead activities or with reaching behind them to put on a coat or reaching for shirt or a towel. In addition, the majority of the patients will have difficulty and a variable amount of weakness doing overhead or reaching activities. Most of these patients can be diagnosed with a thorough history and physical examination, along with using radiographs. In addition, using MRI studies, especially with an arthrogram to enhance the visibility of the shoulder and increase its accuracy, have become commonplace and standard for diagnosing some smaller rotator cuff tears. The majority of the patients that have a traumatic shoulder pain can oftentimes be managed without surgery, that is, using things such as steroid injections and physical therapy in altering the shoulder biomechanics by using the shoulder with the elbow more at the side, rather than reaching out, especially with activities that involve pushing, pulling and lifting. We’ll go to our next slide, showing a little bit about the anatomy of the rotator cuff. And it’s a

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series of four muscles and tendons underneath a big muscle called the deltoid that you might be able to see if this slide is up. I’m not sure if it’s up or not. Yep. And the deltoid with an open technique needs to be either split or detached. Just to give you an idea where that is attached, this is the acrom, you know the shoulder velum, and the deltoid overlies like a curtain and drapes over the rotator cuff. To access the rotator cuff tear, the deltoid would either have to be split or detached from the front of this velum. The problem with that is post-operatively that can lead to a catastrophic event called deltoid detachment, which can seriously affect the function of the shoulder, especially long-term, and again is disastrous. 00:09:44 LAURENCE HIGGINS, MD: Scott, we’re just going to want to take a quick look in and then I’m going to hand it back to you so that people can get a look at where we are inside the shoulder. So if we could come to an outside view for just a minute. Here we are. These are the typical approaches that we use. The patient is sitting up, and we’ve got really three little incisions in the shoulder, about 5 mm, and that’s really all we’re going to need to actually repair the rotator cuff, and it was a great discussion you had about doing an open repair. What I want to do is come to an inside view for a second, and just give people a little tour. This is actually the inside of the ball and socket joint. And to my right you see the ball and to my left you see the socket. And you still see some of the blood from the trauma of the injury. And here I’m touching the ball of the ball and socket joint. Interestingly, you can see here this is actually the biceps tendon, and the biceps tendon here has a really substantial tear in it, and that’s something that we’re going to need to address, and we’re really going to cut out that part of the biceps that’s torn and reattach it somewhere else. The other thing that you’re seeing here is this is the rotator cuff up above me, right here. You can see the rotator cuff, that’s the tendon right there. And I’m actually coming right through a hole in the rotator cuff with this device. And you can see here a large hole in the rotator cuff where it’s pulled off of the bone. What we’re going to do is just put a little anchor in here for the biceps tendon, and I’m just going to show people how we do that. Do you have an 11 blade? I have taken a spinal needle, and I put it right at the base of the biceps tendon. We’re going to take that spinal needle out, and we’re going to take an anchor, and there’s the knife there, and we’ll take an anchor, and I use these metal anchors here... 00:11:30 DR. SCOTT MARTIN: Larry, maybe we can get an outside view of that. 00:11:32 LAURENCE HIGGINS, MD: Sure. Why don’t you pop to the outside view and you can cone down and you can kind of see what an anchor looks like. I’m going to actually even come from above here. And if we zoom in here on this anchor, and really it looks like a screw, and on back of the screw there are sutures. And you’ll see that when we put it in. And we’ll actually screw this metal anchor into the joint. 00:11:54 DR. SCOTT MARTIN: And what kind of metal is that? 00:11:55 LAURENCE HIGGINS, MD: This is actually stainless, and we use a special type of suture here that is very, very strong and very hard to tear, and very amenable for this type of repair. So we’re going to put our anchor into the bone, and you can see on the arthroscopic image, there’s the tip of the anchor right there. If we can come back inside, and I’m going to actually just kind of put this into the bone and we’re going to screw this into the bone like it’s a, basically like, almost like a regular screw, and you can see it advancing into the bone. And that’s the screw, and you’ll see as we actually pull off the inserter, you’ll see the sutures still attached to that. And I’m going to leave this inserter inside the joint so you can see the sutures. And those are attached really strong. And so you can come to an outside view here, you can see I’m actually pulling on those sutures, and that’s got a very strong fixation. And we’re going to pass those sutures into the joint here for a minute. I’m going to have you go back to some of the images, Scott, and let you talk a little bit about the anatomy of the rotator cuff.

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00:13:06 DR. SCOTT MARTIN: Yep, thank you, Larry. Well, one of the things that you just saw was Larry is now putting in his anchors, and it’s very important that he puts those in specifically at a 45 degree angle or less. I don’t know if you saw that, we’re going to try to get you a slide of it here. And the importance of that is because a rotator cuff will otherwise with the forces it generates pull out one of those anchors, and so it’s very important to put it in almost like a tent peg to resist the pull of the rotator cuff. In addition, one of the other things that we’re going to do is called a subacromial decompression. And what that is is removing the small hook of bone that oftentimes is present in the majority of our patients. This is the acromion here, and frequently there is a small hook of bone that impedes and impinges the rotator cuff as it comes up with shoulder elevation and rotation. And one of the ways that we prevent that, because we don’t want to disrupt our repair, is by decompressing or burring off of that bone. So instead of being curved, we make it flat. And you’re going to see that in a little bit. And just to give you a better idea with the more complete model here, you can see the tendons coming underneath this acromion right here. There is a small hook in the acromion, and we’ll flatten that hook out, enabling us to have more space for the movement of the rotator cuff underneath the acromion without impinging. 00:14:41 LAURENCE HIGGINS, MD: Okay, Scott, if we could some back to an inside view for a second, you can get a sense of what we’re doing. 00:14:46 DR. SCOTT MARTIN: Excellent. 00:14:47 LAURENCE HIGGINS, MD: So, back inside the joint, what we’ve done is we have taken this device and passed it through the biceps and pulled a suture back through the biceps, and I’ve got a little loop here. And what I’m going to do is I’m going to leave that loop inside the joint, and I’ve come back through the loop and I’m going to actually grab that stitch, so I have created a locking knot on that stitch. And you can kind of see that right there sliding through. And I’ll take an arthroscopic suture grasper... And what we’re going to do is retrieve its partner, and we’re going to actually come back into the joint and get this other green stitch from inside the joint. And you can see we’re working with multiple sutures, and they’re different colors, which is actually very helpful for us at times. If you could just pull on the green stitch there a little bit so we can separate it. Great. That’s perfect. 00:15:42 DR. SCOTT MARTIN: I think Larry is really showing an important part of doing this arthroscopically, and that’s suture management, and that’s one of the things that is critical in this technique, especially in preserving time. And that is why the sutures are color coordinated, so he knows exactly which limb he has, and if entanglement of the sutures does occur, it makes it very easy to untangle them if they’re a different color. 00:16:06 LAURENCE HIGGINS, MD: So if you can look back in, I’ve just taken the other sutures out of the way, and what we’re going to do is those will actually come and grab them (can I have those suture graspers). You can see, just like you said, I’ve got that suture kind of flipped around the back side of that one right there, and I can come over here and I can grab just that limb right over there and pull that out of the way. Can you pull up on the purple sutures for me? Great. Okay. And now we’ve got all the sutures we need where we need them, and now we’re going to grab them, and we’re going to tie that knot down. So I’m going to let John, my assistant here, hold that scope, and if you want to watch from inside, we’re going to tie an arthroscopic knot here. And you can see that’s, that is actually the one, one of the sutures that I’m pulling on. As I pull down it will lock that into the bone. So it’s a little bit of a locking stitch. And Julio here is just going to hand me some instruments here, and we’ll see some instruments coming in and out. Hemostat scissors, please? That right there. Okay, cut right here for me.

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00:17:15 DR. SCOTT MARTIN: How many sutures will you put through the biceps tendon in order to ensure its stability? 00:17:19 LAURENCE HIGGINS, MD: Typically, in younger patients you need more sutures, but as patients age, we tend to use one or two sutures. And what I’m going to do is I’m going to tie a special knot. Can you hold those out of the way for me? Thanks. We’re going to tie just a special knot here. And you’ll see this knot come in. There’s the knot. And we’re able to secure the biceps down. So I’ll probably put one or two of these in, Scott, depending on how much confidence I have in my knot there. I got a little bit of soft tissue that’s come in, and we’ll drag that back out there. There is our third knot. And we’ll get the knot cutter in just a second. Okay. And you see we’re actually tying these down without a cannula, and sometimes you get a little bit of soft tissue in with those. But that knot is pretty secure, and we’ll cut that stitch out of the way. 00:18:25 DR. SCOTT MARTIN: And Larry I just want to remind our viewers that if they would like to submit e-mail questions, that they just need to push the button at the bottom of their screen. And we’re going to start to review some of the questions that have been pouring in. We’re actually going to select out some of the best. 00:18:39 LAURENCE HIGGINS, MD: Well, I’m going to let you go back to some of those slides, and we’ll get ready to do the next one just like that. 00:18:45 DR. SCOTT MARTIN: Let’s go to our first question. Is there specialty training in order to perform an arthroscopic rotator cuff repair? That’s a very good question. The problem with arthroscopic repair, and there are cons to it, is that it does require specialty training. Most patients would want to look for a surgeon who is either fellowship trained or has transitioned from the open technique to the arthroscopic technique. In addition, it requires very specialized equipment, so it is actually more expensive than the open surgical technique, but well worth it in the long run. That’s a very good question. Perhaps we can go through a few more while Larry is continuing. And this is a very good question we have. The pros and cons of arthroscopic over traditional open surgical techniques for cuff repair? The pros for arthroscopic repair we really went over. There’s small incisions, less operative time, decreased pain, an accelerated rehabilitation that can be done postoperatively, especially regaining the motion early, and that leads to decreased stiffness, especially in the post-operative period, that we sometimes can see with the open technique. The cons, again we’ve mentioned them. That it does require specialty training, and it requires a lot of specialized instrumentation. So facilities that are not equipped to do arthroscopic repair should continue to do open surgical repair, which is acceptable. As far as open surgical repair, the advantages would be that you can see the sutures that you’re throwing, but as you can see we have no problem visualizing our knots, but you can throw locking knots where the suture locks on itself, and that now is becoming a possibility using the anchors and cross-locking the anchors and doing a double row technique that Dr. Higgins is going to do today. The other advantages of doing it open would be passing the sutures through a bony tunnel and tying them over a bony bridge. But more recent surgery has shown that the arthroscopic suture anchors actually have a greater pullout strength and are stronger than bony tunnels. The disadvantages of open repair, one of the biggest is that you have to violate the deltoid, and as we discussed, if the deltoid detaches postoperatively, it is a catastrophic event that can lead to severe functional deficiency of the shoulder that may be permanent, especially if not detected early. Larry, how you doing? 00:21:32 LAURENCE HIGGINS, MD: We’re doing great, Scott. We’re just going to tie this last knot in here, and that secured our biceps. We put two sutures in it. If you want to come back to an inside view, get a little bit of focus in there, and you can see both sutures being tied now, so I

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passed both sutures and I tied them, and now what we’re going to do is we’re going to go up to the top of the rotator cuff and look from above and see what the status of our tear is like. 00:21:54 DR. SCOTT MARTIN: Larry, this what you’re doing this, I’ve got a question that’s apropos to what you’re going right now. What is your threshold for biceps tenodesis? And do you ever just cut or tenotomize the tendon? 00:22:04 LAURENCE HIGGINS, MD: I think that’s a great question. And I think tenotomizing the tendon, which means cutting and not sewing it down, for a lot of patients can be very effective. Can I have a pair of arthroscopic scissors? What Scott means by that is not doing that anchor, and sewing it in place. And I think if you’ve got a tendon that’s cut more than say 25%, you probably do need to address it. My feeling about it is that I would rather tenodise them because I think there is some cosmetic advantage to it in thinner patients, and some of the patients get some cramping. What you’re going to see now is what we’re doing in essence is cutting the rest of the tendon, and I’m coming through the tendon here, and we’re just going to cut the tendon out so that we can actually complete the tear of the tendon. And now we’ve kind of cut the edge of the tendon, and now I’ll use a shaver and we’ll get rid of that little stump of the tendon that we have left. 00:22:58 DR. SCOTT MARTIN: Dr. Conception? 00:22:59 MERCEDES CONCEPTION, MD: Yes? 00:23:00 DR. SCOTT MARTIN: I have an excellent question for you. This patient has a block. Is that the only anesthesia that this patient will require? 00:23:08 MERCEDES CONCEPTION, MD: Yes. He has in addition some intravenous sedation, but I can talk to the patient from time to time and ask him how he feels. So that will be all the anesthesia that is required. 00:23:20 DR. SCOTT MARTIN: And is general anesthesia often done for this procedure? 00:23:25 MERCEDES CONCEPTION, MD: Occasionally it’s done, especially if the patient requests a general anesthesia and refuses to be awake. 00:23:33 DR. SCOTT MARTIN: Excellent. 00:23:35 LAURENCE HIGGINS, MD: Okay, so you can see the end of the tendon there, Scott. We’ve left it like that. And now what I’m going to do is I’m going to go above the rotator cuff and we’re going to take a look from up on top, so I’m going to pop up to the top of the shoulder here, and we’re going to space above the rotator cuff. And we’re going to be able to look down. And that’s part of our repair right there. That’s where the biceps tendon was repaired. 00:23:56 DR. SCOTT MARTIN: Larry, since you’re showing me the knots, there’s two good questions. One is, do those sutures ever need to be removed? And will they inhibit the patient’s range of motion postoperatively? 00:24:07 LAURENCE HIGGINS, MD: No, those sutures actually are inside the joint, do not need to be removed, and we’re actually burying those. One thing that happens when you look, arthroscopically is things look so much bigger than they really are. Those ends of those sutures are probably about 3 mm, so it’s really very, very short area. What I’m doing here now is I’m looking down at our tear of the rotator cuff, and I’m going to show you a couple of views of that. But this is the rotator cuff muscle that’s torn off the bone. And we’re going to reattach

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that. But prior to doing that, what we’re going to do is, we’re actually going to take down this little bone spur up here. And a lot of people will talk about bone spurs, and they’re very, very common. We take them down for a couple of reasons. One, we need the room to work, and that really helps us visualize. It’s kind of traditionally been a part of our procedure, and the bone spur in certain cases may actually be pushing down onto the rotator cuff, and can either damage your repair or may even incite a new tear. 00:25:12 DR. SCOTT MARTIN: And do you do a decompression on every rotator cuff repair that you do? 00:25:16 LAURENCE HIGGINS, MD: I do them probably on 80% or so. I know there’s a lot of debate about it. I think in order for us to do these procedures technically in a very, very safe way, I think there is some advantage. You’ll see, I’m really taking away a fair bit of a big bone spur here that this patient had, and that actually is going to really allow us to improve our visualization and it’s going to really make this procedure technically safer for the patient so we’ll be able to see better. 00:25:46 DR. SCOTT MARTIN: And how about the distal clavicle or the end of the collarbone. Do you decompress that at the same time? 00:25:51 LAURENCE HIGGINS, MD: I would say that on occasion I do that. I don’t think it needs to be done all the time. I think it needs to be done a very small percentage of the time, but on occasion, for patients that have symptoms in that area, absolutely. And we can do that all arthroscopically all at the same time. So that is one thing. And you’ll see, sometimes we get a little bit of bleeding from the bone there, and we’ve got these devices here which will allow us to get what we call hemostasis so we don’t see any bleeding inside or we can control the bleeding. And this is basically kind of like a little cautery device, and we’re going to use that to just kind of get control of some of the bleeding that we see. And you can see how quickly that will actually restore our visualization. 00:26:36 DR. SCOTT MARTIN: Larry, we have one question about in younger patients where a rotator cuff repair is done. Is the repair as strong as it was before it tore? And can the athlete resume all of their normal activities, including strength training? 00:26:51 LAURENCE HIGGINS, MD: Absolutely. You know, but there is a healing time, and the sutures are there, the sutures we put in are there to allow the tendon to heal back to the bone. And, you know, once the tendon heals back to the bone, then we don’t have to worry about the strength. The strength improves, though, for up to a year, and as you know, it’s weak in the beginning, and that’s one of the reasons why we immobilize these patients, to protect the repairs. 00:27:16 DR. SCOTT MARTIN: How long do you immobilize them for? 00:27:18 LAURENCE HIGGINS, MD: Well, I keep them in a sling. They start physical therapy within a couple of days of surgery, and I keep them in a sling for up to six weeks, depending on the nature of their tear and exactly how we fix it. But a vast majority of patients are in slings for about five or six weeks. 00:27:35 DR. SCOTT MARTIN: And do you allow them any use of the arm with the elbow at the side to come out of the sling and maybe work a computer or to feed themselves? 00:27:42 LAURENCE HIGGINS, MD: Absolutely. I think you know typing, maybe working on the computer, and kind of some self-care things are things we absolutely let them, we let them do. 00:27:52

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DR. SCOTT MARTIN: Larry, we have one excellent question here. What is the incidence of retearing of the rotator cuff repair? And how can this affect further surgical repair in the future? 00:28:03 LAURENCE HIGGINS, MD: Well, the incidence of re-tears has kind of varied all over the place. I think it depends on the size of the tear. For small tears, most people are quoting numbers of around up to 30% of tears can not completely heal. So it’s not, I’m not so sure it’s a re-tear, but it may be a small area of the tendon that didn’t heal. In large tears, that number can go up. One of the advantages of doing these arthroscopically with the new techniques is we think that our repairs now with these new techniques arthroscopically are every bit as strong as the re-tear rates we have seen with the traditional open repairs. So I’m going to just give you a quick view here of our tear, and I’m going to move the arm around. This is a nice arm holder that we use in the operating room, and that really facilitates the surgery. But I, hopefully you’ll be able to see the tear there. I don’t know, can you get a good view of that there? So, here’s our tear, and that muscle has pulled away from the bone. Can I have a grasper please? And what we’re going to do is just show you exactly where the tear is and what we need to do. In essence, this is a little grasper I have over here. I’m going to actually take this tear and I’m going to kind of cover the bone back. That’s the whole, the tendon pulled off the bone, and that’s what we’re going to accomplish today. We’re going to try to put it back down just like that and make that as water tight as possible. Do you have... And I’m going to start putting some anchors in, Scott. So if you want to kind of edit this or talk about this as we’re doing it... Make comments... 00:29:27 DR. SCOTT MARTIN: Excellent. I would like to ask you one more question. This is from the U.K. If everything goes as planned, how long does it take to do this procedure on the average? 00:29:36 LAURENCE HIGGINS, MD: Um, they take about an hour or so. I think these procedures, you know, we’re probably, we did about probably 15 minutes of prep work before we started, just to make sure that we had an appropriate sized tear, and I think this takes about an hour for us to accomplish. 00:29:53 DR. SCOTT MARTIN: And the second part of that question is will there be restrictions of motion for a long period of time? 00:30:00 LAURENCE HIGGINS, MD: Um, no, actually we’re going to start the patient in physical therapy in three days, and one of the advantages of doing this arthroscopically is it allows us to, I think patients have less pain and they can resume therapy in a much more painless way and have earlier restoration of their function and motion. 00:30:18 DR. SCOTT MARTIN: Excellent. We’re going to go to a slide that kind of shows what you’re doing now... 00:30:21 LAURENCE HIGGINS, MD: Scott, just one quick thing. I just want to point out for the orthopedic doctors or for people that are familiar with the anatomy of the rotator cuff a little bit about where we put this in. If you can, if I can show you this here. This is the inserter for the anchor. And this is right on the articular margin. You can see, it’s right on the, right on the articular margin. Actually, if you can come to the inside view here, and what we’re seeing is, we’re seeing the rotator cuff inserts all the way from here, all the way out to here. And in the past people would put maybe one anchor in. What we’re doing with this technique, is we’re putting one anchor in right adjacent to the cartilage, and you can see that anchor insider the bone right there, and then we’re going to put another anchor kind of over the side. And that’s going to give us a nice what we call footprint type reconstruction of the repair. 00:31:09

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DR. SCOTT MARTIN: And do you do all of your repairs now using a double row technique, Larry, if they’re big enough? 00:31:13 LAURENCE HIGGINS, MD: I do most of them using a double row technique, that is true. 00:31:17 DR. SCOTT MARTIN: Excellent. 00:31:20 LAURENCE HIGGINS, MD: Okay, so we can go back to the slides for a minute, and we’ll get ready to start repairing the rotator cuff there. Can I have some clever hooks please? 00:31:29 DR. SCOTT MARTIN: Yep. We’re going to show you on the model exactly what area he’s putting those anchors in. He said he was at the articular margin. That’s right where the articular cartilage or the coating on the ball joins the footprint or the area where the rotator cuff actually seats down onto the bone. And he’s doing a double row technique, putting one anchor very medial where there’s very good bone with a very high pullout strength, and then one lateral. And he’ll put up to four or five anchors to get a good double row technique and to increase the surface area for that tendon to heal back down. And if we can get our slides to move a little bit here, we’ll show you a nice slide on that. If not, we’ll just go on to something else. Um, let’s go onto the decompression. The decompression part, which he did with that burr, he’s coming in from the side right here and decompressing the hook off the front of the acromion all the way over to this area where the collarbone meets the shoulder bone or the acromion in this region. And he doesn’t decompress all the way back, he comes back to about the back part of this acromion right here. So this whole region here, of course, underneath, he’s burring and opening up the space so there’s more room for the rotator cuff to clear the acromion throughout a full range of motion, including rotation. Larry, how’re you doing? 00:33:03 LAURENCE HIGGINS, MD: We’re doing good. So if you want to come back into an inside view, you can take a look at a little bit what we did. We’ve taken two of the sutures, and I’ve passed them through and through the rotator cuff. And if you look right here, okay just come down on that just a little bit, I want to get on top of the cuff there a little bit, this is underneath the cuff, and these sutures here are actually penetrating the cuff and coming out the back of the shoulder here a little bit, and I’ve got to pull down on the rotator cuff a little bit just to show that. So we’ve got a couple of sutures in through the rotator cuff now, and what we’re going to do is we’re going to keep on passing sutures through and through the rotator cuff. 00:33:35 DR. SCOTT MARTIN: Excellent. 00:33:36 LAURENCE HIGGINS, MD: And I’m just going to get above the cuff here again, and you can see, that’s where, this is the top of the rotator cuff, and we’re going to dive through the rotator cuff and pick up some more sutures. So we’ve kind of got a little bit of bursas still attached to the cuff there. Some people believe that that actually helps with the healing, and probably could have taken a little bit more of it than we did. Again, I’ve passed through the rotator cuff here, and I’m underneath the cuff and I’m going to grab a stitch, and I’m going to back that stitch back out through the rotator cuff, and I’ve got one more stitch to pass, and we’re going to pop in here, and you can kind of see where these sutures are coming through. 00:34:16 DR. SCOTT MARTIN: Excellent. What I’m going to do, Larry, is I’m going to go, our slide is up now showing that double row technique that you’re using. 00:34:22 LAURENCE HIGGINS, MD: Okay. 00:34:23 DR. SCOTT MARTIN: If we can go back to the slide now, and we’ll show you the slide and why use a double row technique. Well you can see on the bottom where there’s a single row

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technique. The footprint is only 46% covered, so there’s only 46% of the area that that rotator cuff has a chance to heal down to, whereas on the bottom right you see what the double row technique, the rotator cuff is 100% covering the footprint. So a much greater chance of it healing down to bone and decreased chance for a re-tear or re-rupture. You can also see in the top left slide that the anchor that is in the area where the articular cartilage joins the footprint is the best bone that there is. It’s a very hard bone, so to secure fixation of the anchor, it allows that rotator cuff to sit down flat onto the footprint, thus increasing the surface area for healing. This is one of the studies here on a cadaver showing the footprint. It averages about 1.5 cm, so it covers a very large area, big enough definitely for at least two of the anchors to fit side-by-side without any difficulty. The MRI on the right shows you the rotator cuff tendon has lifted off that area of the footprint. This double row technique actually reduces the motion of the tendon as the shoulder goes through a full range of motion, including rotation, whereas when you see the single row technique, there is considerable movement at the interface between the tendon and the bone, thus leading to increased failure rates. Larry, we have a question from the U.K. How many different entry portals are you using for your instruments? 00:36:17 LAURENCE HIGGINS, MD: I’m using three, Scott. If you want to come back in, I can show you kind of what we’re using. We’re about to put an anchor in, so what we have is, I’ve got a little posterior portal here from the outside view if you can see that, and I’ve got a view, I’m looking from the side, so I get a nice view of my cuff, and then we have an anterior portal, which we’ll use to kind of retract the sutures and tie our sutures at the very end. 00:36:41 DR. SCOTT MARTIN: We have a good question also that’s right along these lines from Sweden. Are you using epinephrine in your solution, and do you find that that prevents bleeding? 00:36:50 LAURENCE HIGGINS, MD: I do use epinephrine in the solution, and I think what’s really important is to kind of work with the anesthesiologist to make sure that it’s safe for the patient to have it. I do think we use 1:300,000 epinephrine solution, and that tends to I think slow down some of the bleeding, and it makes the environment to do this arthroscopically a little bit easier. Here’s our next anchor coming in, and you can see we’re going to actually, we’re looking right down on the side. And we’re going to put this anchor kind of over the side. And I think we’ll see how a two-anchor repair on this one is going to look. Great. So I’m going to actually insert this anchor now. You want to tap that again for me? A little harder, thanks, good. Okay. So we’re advancing that anchor, and that little laser line shows exactly where that anchor goes to, and we’re going to tape this off here and just leave that inserter still inside the bone. 00:38:00 DR. SCOTT MARTIN: Larry, how do you determine when to repair or just leave a rotator cuff tear alone? That’s one of our questions that just came in. 00:38:06 LAURENCE HIGGINS, MD: I, uh, I think that for acute tears you probably should fix whatever is torn for these acute tears, and someone like this gentleman here. Can I have a clever hook? But I think sometimes there are tears that are not full thickness that we can just debride. Just debriding the tears and not repairing them completely has yielded kind of variable results, and as such it’s not something that we recommend routinely at this point, just debriding the rotator cuff. What I want to do is show how these instruments work here. This is the anchor that we just put into the bone, and John’s going to pull up on that anchor just to show the sutures have a good purchase in there. He’s going to give it a little tug, and you can see that. They’ve got a good purchase. Now what we’re going to do is we’re going to come to the tear and I’m going to actually take this device and I’m going to kind of penetrate the rotator cuff, and I’m going to watch as we penetrate it. And now I’m inside the tear, and I’m going to reach back and I’m going to take one of these sutures back through the rotator cuff, right there. And we’re going

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to back it out through the cuff, and you can see it kind of being pulled out through the rotator cuff. And if I look up above, there is the suture right there. 00:39:18 DR. SCOTT MARTIN: And we have a question from one of the surgeons I think is apropos here. How do you control your suture management before you do your tie-down? Where do you put those limbs? 00:39:27 LAURENCE HIGGINS, MD: They’re all coming out the back of the shoulder. And for me, I try to store the sutures into the back of the shoulder so that I have good access and I have a good place for them to kind of stay out of the way. So I’ve got all my sutures coming out the back except the ones that are still attached to the cannula. What we’re going to do is work from the front now, and try to bring the front of the tear down. So you can see I passed that purple one to the back, and now I’m going to go to my front cannula, and we’re going to try to get the front of this down. And John’s going to hold the cannula in place for me a little bit, and we’re going to try to pop in through the tear here. 00:40:03 DR. SCOTT MARTIN: I’m going to ask you another question that you’re very interested in. I know this using ultrasound versus MRI to detect MRI, uh rotator cuff injuries. Do you think that the ultrasound is just as sensitive as the MRI? And this is a question from Canada. 00:40:18 LAURENCE HIGGINS, MD: Actually, I think that it’s probably not quite as sensitive, but... You’re going to have to pass me those sutures. We’re going to take one of the green sutures through here, so just give me one second, Scott. I don’t think it’s quite as sensitive, but I think that in the right hands you can learn how to be very, very good with it. And you can see I’ve grabbed one of the green sutures and am pulling a green stitch back out. And now we’ve got sutures coming into the front and back of that tear. And what we’re going to do is just kind of leave this here. And I’m going to just take a look and see how this tear is going to look when we start sewing it down, because we’re getting a little bit of, you know, I think we’re getting close to seeing how this is going to appear. So I do think, grasper, that, no regular grasper. I do think that MRI is probably superior, but I think that ultrasound is a really exciting technology, and I think as we get better with it, what’s really nice is it’s kind of, you come and you get evaluated, and you can be determined if you’ve got a tear kind of right at that first visit rather than having to go back and get scheduled for an MRI. 00:41:26 DR. SCOTT MARTIN: Mercedes, Dr. Conception, I have a question for you. How long will the patient be feeling the effects of your scalene block, and what other medications do you use for pain control? 00:41:39 MERCEDES CONCEPTION, MD: The local anesthetic used is Ropivacaine, and this a long-acting local anesthetic. The patient will have analgesia for approximately 12-18 hours postoperatively. The medications used for pain, that’s up to the surgeon, and usually is a mild narcotic and anti-inflammatory, but that is ordered by the surgeon. 00:42:05 LAURENCE HIGGINS, MD: So Scott, what we’re going to do is, we’re going to get ready to tie some of our lateral anchors here. Cut. Can you cut this one there for me? Okay. And if you look right here, I kind of got one of our sutures about to be tied. And that was one limb going through the cuff and this is called a simple suture construct, and I use these for our lateral anchors. 00:42:28 DR. SCOTT MARTIN: Hey, Larry, we have a question from a surgeon. He questions, because a footprint is so important in getting the rotator cuff to heal down to bone and not leading to retear in the future, if you put more anchors in aren’t you disrupting the footprint that could lead to failure of the greater tuberosity?

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00:42:45 LAURENCE HIGGINS, MD: No, I’ve never seen a patient have a tuberosity fracture from something like this. Is that kind of the question that we’re getting here? 00:42:52 DR. SCOTT MARTIN: Well, how about decreased surface area for the tendon to heal down to bone because we’re reaming it out? 00:42:57 LAURENCE HIGGINS, MD: Well, you know there have been several very good studies showing that the contact of the tendon across the footprint is markedly enhanced with a dual row repair. And I think Steve Meyer and Maria Aperlave (sp) in a very nice study have shown that it actually makes a big difference having two anchors, a medial and a lateral row. And I don’t think that has panned out to be a problem. As a matter of fact, if you use a single anchor, as you’ll see in one of the slides that you’re going to show, I know that you only get about a 46% footprint reconstruction versus 100% reconstruction of the footprint when you do a repair with two anchors. So those are our sutures there. 00:43:38 DR. SCOTT MARTIN: And we actually did show that slide, but I think that warrants repeating, so we’ll show that slide again, showing the two anchors in place and the increased surface area contact of the rotator cuff down on the footprint versus the single row that you can see in your lower left hand side of your slide. 00:44:01 LAURENCE HIGGINS, MD: Okay, so we’ve got, we’re about to tie our second anchor. And how about pulling on that, on that one back there. Okay. Good. And this is our first anchor tying down, here’s our second anchor tying down. Okay. Will you hold that there? 00:44:32 DR. SCOTT MARTIN: What’s the proper sequence that you do for tying down your anchors? You have quite a number of sutures there. How do you keep them in order as far as your tiedown and which ones you’re going to tie down first: anterior versus posterior or medial versus lateral? 00:44:48 LAURENCE HIGGINS, MD: I tend to tie the lateral down first. And my philosophy about it is this: I think that if you put your medial anchors in and they’re not exactly right, and you tie your medial anchors first, you may not get the rotator cuff down on the lateral aspect. I know if I pass my lateral anchors first and I tie it down, I’ve a little bit more flexibility on my medial anchors, so I know that I’m going to get real good coverage of the rotator cuff on the footprint. John’s going to just zoom in there and show us that knot one more time. Let’s try to get away from that other knot. 00:45:25 DR. SCOTT MARTIN: And Larry, do you tie down those posterior lateral ones, the ones in the back first, or the ones laterally in the front first? 00:45:31 LAURENCE HIGGINS, MD: Well I tie from front to back, you know, and that’s kind of, I do that because I want to get the sutures out of my way and not have suture tying issues. So we’ll cut this one, and I’ll show you a little bit of what our repair looks like right now. 00:45:46 DR. SCOTT MARTIN: And we have another question from Sweden. Is it important to debride the bone at the footprint to enhance your healing? 00:45:53 LAURENCE HIGGINS, MD: Absolutely. And we did a little bit of that before you guys got to visit with us. Probe for a second? Actually I can use this right here, I think, as our probe. So here is our footprint, and that’s over the edge. And you can see, we really have taken that tendon which was sitting up there, and we’ve really got the tendon kind of back down onto the bone. Can you see that there, Scott?

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00:46:16 DR. SCOTT MARTIN: Looks excellent, yes. 00:46:18 LAURENCE HIGGINS, MD: So we’ve got sutures in each side of it there. Now what we’ll do is we’ll take a look and try to repair some of these medial anchors. And I think we have a few minutes, and what might be interesting is showing people why we like doing these dual anchor repairs. I’m going to give this back to you for a minute and go back into the joint. So I’m going to have you show some more slides if you would for a second, Scott. 00:46:42 DR. SCOTT MARTIN: Sure. And we actually touched upon this previously, but you can see that the double row of anchors really enhances your healing by putting the whole tendon down on the footprint versus a single row in your left lower hand portion of your slide, where there’s only a 46% contact of the rotator cuff tendon with the footprint. We have a question from the U.K. that I think I’ll answer while Larry’s tied up here. How was he trained in arthroscopy, and is it possible to train using simulators? Simulators are always a good idea to begin training, but I think for advanced arthroscopic surgical techniques, such as for rotator cuff repair, the best way to train for it is transitioning from an open to an arthroscopic repair, starting just with maybe decompressions and being able to mobilize the scar tissue around the rotator cuff and getting the cuff back out to where it needs to go, and then starting with the mini-open deltoid split, and then transitioning from that to an all arthroscopic repair. The other way is to do a fellowship in sports medicine, and I think that’s the most accepted way that we see today for advanced arthroscopic techniques such as rotator cuff repair. 00:48:01 LAURENCE HIGGINS, MD: So if you want to, let me just put a probe in through the front... 00:48:05 DR. SCOTT MARTIN: We’ll go back to Larry now. 00:48:08 LAURENCE HIGGINS, MD: Let’s see if we can get... Okay, so, we’re inside here on the scope, and here’s our ball and socket joint again. And what’s interesting here, I mean he’s kind of beaten this tendon up. His is actually a little bit of the remnant of our biceps tendon. But I’ve got the arm up here, and you can see that is where our rotator cuff is torn. And let me get our little probe over here, get it on the other side there. And one of the things that happens with these dual row repairs is that you can see you can get actually a bigger footprint reconstruction. 00:48:44 DR. SCOTT MARTIN: Larry, with the double row technique there’s a question: Do you accelerate their rehab, do you do any different rehab with the double row versus the single row technique? 00:48:52 LAURENCE HIGGINS, MD: Um, I actually am maybe a little, maybe a hair more aggressive than with a single row, but this is I think really the whole reason why we do double row repairs. If you look right here, and I hope you can see this, this is where our first anchor would be. Now, if you did a single row repair, none of these sutures would be pulling down the rotator cuff, and you can see that’s our first row out here, and that whole area of the rotator cuff is not restored. So when I tie these other sutures which are below us, it’s going to pull the rotator cuff down from above us and really demonstrate why some of these double row repairs are really a very nice way of doing it. 00:49:32 DR. SCOTT MARTIN: And Larry, I think I’ll go to the anatomical model to show that a little bit better. And Larry’s looking from the inside out, so it might get a little confusing. But looking from the outside in, he’s tying his outside or lateral sutures first. Those are the two anchors that he placed out here, and then he’ll tie his medial sutures. And the reason he does it in that order is so not to trap the rotator cuff tendon, and being able to make sure it stays out to

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length, and then again, once he ties down that medial row, you’ll see a great increase in the contact of the rotator cuff tendon with the footprint. 00:50:07 LAURENCE HIGGINS, MD: I’m going to go to the outside and tie those down, Scott, and then we’re going to take a look and see how that looks at the end. So, I’m going to leave it with you for just a minute, and we’ll put the scope back in through the side, and we will start tying some of our lateral, or our medial anchors. Grasper, suture manipulator. 00:50:28 DR. SCOTT MARTIN: Larry, do you think there are any indications, this is a question from the U.K., do you think there are any indications to do an open repair? 00:50:36 LAURENCE HIGGINS, MD: Absolutely there are. And I think if you’ve got bad bone quality and you can’t get an anchor to hold in the bone, then we absolutely need to do those through an open approach. Um, and that’s, a really critical, really critical finding. I mean, if you don’t have good bone, then there’s no way you can do these. So I’m going to actually come, and I’m going to grab some of my sutures. We can see these here. These are my medial row. And I’m going to take two of my sutures from my medial row and pull them out, and John is going to hold the scope there. And you can see the lateral row over there and the medial row is medial to that. And now we’re just going to tie these sutures, and then at the end, if we have time, we can go back inside the joint and take a look and why we think there’s an advantage to doing them double-rowed. 00:51:32 DR. SCOTT MARTIN: And Larry, maybe we can get an outside view. There’s a question from Sweden. Are you using any type of traction device on the arm, such as a Spider? 00:51:41 LAURENCE HIGGINS, MD: Yes, I am. And if you want to pan out, I think that this device here is really, really helpful for us. And this is the Spider device. There’s a variety of devices. One’s called the McConnell, one’s called the Spider. This one’s very nice because it’s hydraulic. It allows us to keep the arm in one place and I’ll tell you, it really makes these procedures much, much simpler than if you don’t have these devices. Um, you can see I put the arm in a lot of different positions, and it’s very important for us to be able to hold the arm in one position and really, really get a very good stable position so that we can work without having some fatigue in holding the arm, which is a real problem at times. 00:52:26 DR. SCOTT MARTIN: And Larry, why do you use metal anchors? Why not use an absorbable anchor? 00:52:30 LAURENCE HIGGINS, MD: Um, I think that for me, revising a metal anchor is easier. On occasion, someone may have some reason to go back in, and you can unscrew the metal anchors. The biabsorbable (sp) anchors sometimes are not so easy to remove. So I have elected to use the biabsorbable (sp), the metal anchors over the biabsorbable (sp). I don’t think, I think the jury’s still out. I don’t think there’s a right or wrong answer. Grasper, please. So from my standpoint, I think that you could use either. It’s just been my preference to use the biabsorbable (sp), to use the metal over the biabsorbable (sp) for now. Another stitch there, just tug on it for me? That’s our last stitch here we’re going to tie. And then what we can do is take a look back inside the joint and see why, what kind of a, what our repair looks like. 00:53:24 DR. SCOTT MARTIN: Excellent. 00:53:30 LAURENCE HIGGINS, MD: Cut. Okay, we’ll tie these knots here, and John’s doing a great job helping me out here showing this to me. 00:53:41

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DR. SCOTT MARTIN: And what are some of your tricks for controlling bleeding? We don’t see much bleeding in that shoulder, in fact I don’t see any. What are your tricks besides using the epinephrine in your solution? 00:53:51 LAURENCE HIGGINS, MD: I, you know I wish I could take credit for all of this, but the person who is at the head of the bed is more responsible for what we’re doing than anything else. And that’s the advantage of having someone skilled and who’s an expert like Mercedes doing these, and having the whole team approach that we have here to do these. Because Mercedes makes us look good, and we actually benefit from it. So I want to give kudos to her for managing the blood pressure, and then I think some of the newer devices like these radio frequency devices, we use a device called a vapor device, they really help control the bleeding. What I’m going to do now is just, I’m going to get in here and take a look at the top of the repair. I’m going to bring the arm up here a little bit, and you can see our tendon’s back down on the bone. 00:54:38 DR. SCOTT MARTIN: That’s excellent. 00:54:38 LAURENCE HIGGINS, MD: And, uh, if we get medial here, we’ve kind of restored the whole rotator cuff back to where it should be. I’m going to take the scope and put that back in the joint, and maybe we can see why the double row repairs are an advantage. 00:54:51 DR. SCOTT MARTIN: Excellent. 00:54:54 LAURENCE HIGGINS, MD: So I’m going to turn it back to you for one minute, Scott, and we’ll get back in the joint, and then we can... 00:54:58 DR. SCOTT MARTIN: Sure. And so, I do have a slide up for Steps for a Successful Rotator Cuff Repair. And most importantly it’s to get secure fixation of the tendon back down to the footprint. In some smaller tears, you may not need to have so many anchors, but I think whenever you can fit two anchors in with a double row, getting an increased surface area for healing, that’s definitely the preferred method today, and the newer studies out are showing much decreased incidence of re-tear or re-ruptures. In addition to doing a good and thorough decompression, especially if the patient does have a hook, an anatomic hook on the acromion, and again if there is a spur or a hook off of the distal clavicle, that sometimes will also need to be cleared. The other thing that is interesting, is that questions that we’ve received on the rehabilitation. And it’s extremely variable. 00:55:56 LAURENCE HIGGINS, MD: Scott, if you just take a second and come back in... 00:55:58 DR. SCOTT MARTIN: Sure. 00:55:58 LAURENCE HIGGINS, MD: I think this really demonstrates what we were talking about before. This is the articular margin, and now you can see I can’t demonstrate anything on the articular margin. I’ve got this completely blocked out, and that’s because we’ve taken the rotator cuff and we brought it back down. And you can see as I move the arm, it’s staying attached to the tuberosity there. Do you see that? 00:56:18 DR. SCOTT MARTIN: That looks anatomically, that’s just excellent. 00:56:20 LAURENCE HIGGINS, MD: So, and we’ve got a little bit of degeneration of the tendon up on top. That’s just from some of the conicity (sp) or some of the tendon that was beaten up. You can see even up here, some of the tendon is a little bit damaged just from the trauma. But that will heal very nicely with him. So we’re going to go back up to the top, and we’re going to

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do one more thing that’s going to allow us to really help manage his pain, and we’re going to put in a catheter, a pain catheter. Um, and, um... 00:56:46 DR. SCOTT MARTIN: What kind of medicine do you put through that? 00:56:48 LAURENCE HIGGINS, MD: There are a lot of different types of medicine. There is a medicine called Ropivacaine, which is a medicine that is a long-acting local anesthetic. That tends to work out very, very well, and I kind of like Ropivacaine. But any of the kind of Lidocaine type derivatives. Some of the long-acting ones allow us to do that. So if we could get the cannula for that... 00:57:12 DR. SCOTT MARTIN: I also have a question for both you and Mercedes. What is the patient’s current blood pressure, and what is your pump pressure? This question is from Croatia, and they’re amazed that you have no bleeding. 00:57:24 LAURENCE HIGGINS, MD: The pump pressure is set at 30, and we can show that on the screen if we want. The current blood pressure is... 00:57:33 MERCEDES CONCEPTION, MD: The last blood pressure was 103. 00:57:37 LAURENCE HIGGINS, MD: The systolic was 103. 00:57:38 MERCEDES CONCEPTION, MD: Over 67. 00:57:41 LAURENCE HIGGINS, MD: Over 60. So we’ve got means in the mid-seventies here, and that’s... So now I’ve got a spinal needle in the subacromial space, and we’re going to actually thread a cannula in and that should be kind of the conclusion of what we’re going to accomplish here. This is a little pain cannula. Can we come outside for a second? And through the spinal needle John is threading in this little cannula. And if you come inside for a second now, you’re going to see the cannula come inside the joint. You can see it being fed in through that needle. And John’s going to keep on feeding it in there. And those little marks are on it to just let us know how far it’s in. 00:58:21 DR. SCOTT MARTIN: And how long do you keep that catheter in and how do you get it out? 00:58:24 LAURENCE HIGGINS, MD: There’s a bunch of different dosages that you can use. The one cannula lasts two days, one cannula lasts five days. I tend to use the two-day one. And I think part of that is, part of it’s because I’ve been very successful, very happy with just two days worth of local anesthetic. And then, by then we can get the patients maximized on their oral pain medicine. And the patients tend to just be able to remove this on their own, and they tend to do very well with it. What I’d like to do, if we could, is come to an outside view for a second. Can I have a dry sponge, please? A couple of them? Can I have a couple, please? So, I don’t know if you could see, but what we accomplished was I think a pretty good repair, certainly an anatomic type repair through really three incisions. This is a little stab incision. And we’ll just close those up, and put the patient in a sling, and send him to the recovery room. 00:59:26 DR. SCOTT MARTIN: Excellent. 00:59:35 LAURENCE HIGGINS, MD: Well, a couple of final thoughts. And, first of all this is impossible without the whole team of people working. So, you know, we were able to accomplish in an hour what was a very good-sized tear, and it’s because I’ve got a great team working with us. And I want to thank the people here for doing that. And the care that we give here in the OR

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extends into what we’re able to give in rehab services, also. The therapy is a critical part of this. I’m sure, Scott, you would agree with that... 01:00:04 DR. SCOTT MARTIN: Absolutely. 01:00:05 LAURENCE HIGGINS, MD: And, uh, you know getting in the hands of a skilled therapist is really, really important. So we’re going to sew this up here, and I’ll turn it back to you, Scott. We’re all done here. 01:00:16 DR. SCOTT MARTIN: And one more question, Dr. Higgins. Will those stainless steel anchors set off the detectors at the airport? That’s a question from overseas. 01:00:23 LAURENCE HIGGINS, MD: No, actually they will not. These anchors are very small, very tiny. I’ve gotten that question a lot, as I know you have had, Scott, and no, we have not had that, that’s not been an issue for us. 01:00:37 DR. SCOTT MARTIN: Excellent. In conclusion, the patient, as Larry stated, will now go to the recovery room, will stay in the hospital about another hour or two. But blocks can sometimes last up to 16-18 hours, and that in combination with the pain pump and the catheter, control the pain very nicely. The worst pain is the first 24 hours. The patient can begin immediate active motion of the elbow, the wrist and the hand, so we allow them to eat right away using their arm. We encourage them to use it for the computer, to pump the hand and make sure it doesn’t get swollen. We allow them to drive when they’re off of narcotics, and we allow them passive motion with the physical therapist immediately, and then active and active assisted motion at about six weeks post-op. So for the first six weeks, the main restrictions are not reaching out and not doing anything in front of their body or to the side or to the back. After six weeks, they can do activities below shoulder level, and then six weeks to 12 weeks they can do activities above shoulder level with the supervision of the therapist, and then working on strengthening at about 10-12 weeks post-operatively. Some of the questions asked about activities and when can we get back to regular activities, it really depends on the activities that the patient would like to do. Getting back to normal daily activities of living, usually within the first 10-12 weeks. Strengthening activities like weight lifting, usually around three to four months. Violent activities on the shoulder like throwing usually take longer, sometimes five to six months. Golfing is not that strenuous on the shoulder, so we usually let our patients golf after about three months. They do wear a sling at night for the first six weeks, and that’s mainly in bed so that they don’t inadvertently disrupt their repair, and we tell them to wear it outdoors, so that if they do slip or fall, they don’t reflexively put the arm out to try to break their fall, thus disrupting the repair. The patients are allowed immediate function of the arm at the side, and as long as they’re not reaching out, they’re actually quite comfortable. The only precaution would be when they do not have the brace on they have to be very careful not to fall. I want to thank you for joining us today, and for participating in our live surgical webcast. For future viewing, this surgery will be archived at www.brighamandwomens.org. In addition, we would encourage you to visit this site, because there are other archived live surgeries from previous webcasts. Thanks again for your viewing. 01:03:25 NARRATOR: Thank you for watching the live arthroscopic rotator cuff repair procedure from Brigham and Women’s Hospital in Boston, Massachusetts. For more information, to make an appointment, or make a referral, please click the buttons below. Please contact one of our referral coordinators at 1-800-BWH9999, Monday through Friday, 8:30 am to 5:00 pm. Outside the U.S. at 617-732-9894. Or e-mail us at [email protected].

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