109: Dr. Patrick Denard – Treatment of Challenging Rotator Cuff Pathology (Part 1)

Our conversation picks back up with an article published in the December 2020 issue of Current Reviews in Musculoskeletal Medicine titled “Surgical Management of Massive Irreparable Cuff Tears: Superior Capsular Reconstruction.” Authored by our guest today, this review article summarizes the biomechanical properties and functional outcomes of superior capsular reconstruction or “SCR” for treatment of massive irreparable rotator cuff tears. The authors report that SCR decreases superior translation and subacromial contact pressure. Glenoid fixation is maximized with three anchors, while margin convergence to any remaining rotator cuff – particularly posterior – improves stability. Patient selection is key, with the ideal patient being younger than 70 and a healthy nonsmoker with an irreparable posterior cuff tear in the absence of glenohumeral arthritis and a functioning or repairable subscapularis. We finish up our discussion today with the publication titled “Latissimus dorsi transfer or lower trapezius transfer: a treatment algorithm for irreparable posterosuperior rotator cuff tears muscles transfers in posterosuperior rotator cuff tears.” Laurent Lafosse and team compared two tendon transfer options for irreparable posterior-superior rotator cuff tears with rotational deficiency – the latissimus dorsi transfer and the lower trapezius transfer.  They found that active motion, pain scores and function were improved in both groups with a low failure and revision rate.  The authors suggest that lower trapezius transfer better restores external rotation at the side while latissimus dorsi transfer may be a better option for restoration of external rotation and abduction.

On today’s episode we’re focusing on challenging rotator cuff pathology with Dr. Patrick Denard, an orthopedic shoulder surgeon at the Oregon Shoulder Institute. We have some great articles for you that contribute well to our conversation on the treatment options for massive reparable, as well as irreparable, rotator cuff injuries. As always, links to all of the papers that we discuss on this show can be found on our podcast website – www.thesportsdocspod.comWe’ll start off our discussion today with an expert opinion article from the July 2022 issue of Arthroscopy titled “Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates.” Authored by our guest today, this article provides an algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. The authors recommend using a Rotator Cuff Healing Index or “ROHI” cutoff of greater than or equal to 7 to select for the use of tissue augmentation, as the healing rate is 66% at 6 points but decreases substantially to 38% at 7 points.Then, from the May 2019 issue of AJSM, we review an article titled “Rotator Cuff Matrix Augmentation and Interposition: A Systematic Review and Meta-analysis.” The authors concluded that graft augmentation provided significantly lower retear rates and higher ASES scores compared with cuff repair alone. With regards to graft choice for augmentation, the highest rates of healing, as demonstrated by repair integrity on imaging, were shown for allograft at 82% compared to xenograft at 68%. Nonaugmented repairs had a healing rate of only 49%.We finish up our discussion today with the publication titled “Preoperative Nutrition Impacts Retear Rate After Arthroscopic Rotator Cuff Repair.” This level III retrospective study published in the August issue of JBJS this year, sought to determine the relationship between preoperative nutritional status, using the Geriatric Nutritional Risk Index or “GNRI”, and rotator cuff retears after arthroscopic repair in patients 65 years of age and older. The authors found that poor pre-op nutrition, as exhibited by a GNRI less than 103, was an independent risk factor for a cuff retear at 2 years post-op. We are joined today by Dr. Patrick Denard, a board-certified orthopedic shoulder surgeon and Director of the Oregon Shoulder Institute. He is also the Director of the Oregon Shoulder Fellowship and Associate Professor of Orthopedic Surgery at Washington Status University School of Medicine. Dr. Denard is the Chairman and Founder of the Pinnacle Shoulder meeting and a reviewer for the Journal of Shoulder and Elbow surgery. He has published and lectured extensively on the topic of rotator cuff pathology, so we are very excited to have him join our discussion today.

In this episode, we’re going to continue our discussion with Dr. Aaron Krych and focus on surgical advancements to address meniscus extrusion and optimize postoperative outcomes for patients.Our conversation picks back up with an article published last month in Arthroscopy Techniques titled “Arthroscopic Centralization of the Extruded Meniscus With Posterior Root Tear: A Technique Using Meniscotibial Ligament Fixation.”  Most meniscus centralization techniques involved anchoring the meniscus body directly to the tibia, which can limit the normal anatomic motion of the meniscus. Dr. Krych and his team described a novel technique for meniscus centralization that maintains natural meniscal motion by utilizing the meniscotibial ligaments to centralize the meniscus body.Then, from the May 2024 issue of Arthroscopy, we review an article titled “Satisfactory Clinical Outcome, Complications, and Provisional Results of Meniscus Centralization with Medial Meniscus Root Repair for the Extruded Medial Meniscus at Mean 2-Year Follow-Up.” This case series concluded that patients undergoing medial meniscus root repair with meniscus centralization demonstrated significant improvements in pain, function, satisfaction and quality of life.  Additionally, there was no evidence of significant arthritic progression on postoperative imaging.  No patients underwent revision meniscus surgery or total knee arthroplasty. 

On today’s episode we’re focusing on medial meniscus root repairs with Dr. Aaron Krych, Chair of Orthopedic Surgery and Professor of Orthopedic Surgery at The Mayo Clinic in Rochester, Minnesota. We have some great articles for you that contribute well to our conversation on the optimal treatment of medial meniscus root tears, including recent advancements in surgical technique to optimize outcomes. We’ll start off our discussion today with systematic review article from the February issue of Arthroscopy this year titled “Root Repair Has Superior Radiological and Clinical Outcomes Than Partial Meniscectomy and Nonoperative Treatment in the Management of Meniscus Root Tears.”  This review included 56 studies with over 3000 patients.  The authors concluded that root repair demonstrated the least amount of postoperative joint space narrowing and the greatest increase in patient reported outcome scores including IKDC, Lysholm, KOOS pain and activity scales.Then, from the February 2022 issue of OJSM we review the publication titled “Prospective Consecutive Clinical Outcomes After Transtibial Root Repair for Posterior Meniscal Root Tears.” This multicenter case-control study concluded that patients who underwent posterior meniscus root repair utilizing a transtibial pullout technique had significant improvement in clinical outcome scores at 2 years with an overall low complication rate. Increased age, increased BMI, cartilage status, and meniscal extrusion did not have a negative impact on short-term functional outcomes, but age greater than or equal to 50 years and extrusion negatively influenced patient activity level.We finish up our conversation today with the publication titled “Biomechanical Performance of TranstibialPull-Out Posterior Horn Medial MeniscusRoot Repair Is Improved With KnotlessAdjustable Suture Anchor–Based Fixation.” This controlled laboratory study, published in the March issue of OJSM this year, compared four different fixed transtibial pullout repair techniques to a knotless adjustable repair technique. If you are watching this on YouTube you will be able to see the different suture configurations that were compared.  Otherwise, check our social media for images! This study found that the knotless adjustable repair resulted in higher tissue compression and less tissue displacement compared to traditional fixed repair, which is great for healing. Additionally, the rip-stop Mason-Allen suture configuration provided higher resistance to suture cut-through, withstanding repair failure. We are joined today by Dr. Aaron Krych, Chair of Orthopedic Surgery and Professor of Orthopedic Surgery at the Mayo Clinic.  He is also the Chair of the Division of Sports Medicine at Mayo Clinic and team orthopedic surgeon for Minnesota Timberwolves. Dr. Krych received his medical degree and completed his orthopedic surgical residency training at the Mayo Clinic.  He then went on to complete a fellowship in sports medicine at the Hospital for Special Surgery. Dr. Krych has published extensively on the topic of meniscal pathology, and specifically meniscus root repair, so we are very excited to have him join our discussion today. 

Welcome to Overtime with the Sports Docs. On each of these mini episodes, Catherine and I chat about a new topic or surgical technique in the field of sports medicine. We’ll give you our quick take on the most recent data ranging from operative indications, surgical approaches, post-op protocols and most importantly – patient outcomes.Today we’re talking about SLAP tears – tears of the superior labrum from anterior to posterior. We have two great articles for you today that focus on the surgical management of SLAP tears – specifically whether we should be repairing SLAP tears or proceeding directly to biceps tenodesis. We will also discuss the different types of biceps tenodesis procedures – mainly arthroscopic suprapectoral versus open subpectoral.Our first paper looks specifically at this patient population – young overhead athletes – and investigates the functional and athletic outcomes after primary subpectoral biceps tenodesis for type II SLAP tears. Brian Waterman and Tony Romeo published a case series in the January 2023 issue of Arthroscopy titled “High Rate of Return to Sporting Activity Among Overhead Athletes with Subpectoral Biceps Tenodesis for Type II SLAP Tear”. The authors reported that 81% of patients returned to their previous level of play at an average of 4 months post-op. There were also significant improvements in VAS and SANE scores post-op.But how do repairs do in this population? The answer is… not great. Return to preinjury level of play after SLAP repair has been reported in the range of 54% to 63% of elite throwers. In one cohort study by Boileau, 60% of patients reported persistent shoulder pain after SLAP repair and 50% elected to undergo secondary surgery. Provencher published on his outcomes of SLAP repair in an active military population and reported a 37% failure rate and 28% revision rate at short to mid-term follow up.Our second article focuses on this and is titled “No Difference in Clinical Outcomes for Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis at Midterm Follow-up.” Nikhil Verma – who will be joining us at AOSSM – and colleagues at Rush compared arthroscopic suprapectoral tenodesis versus open subpectoral tenodesis for long head of biceps tendon disease, so not SLAP tears. They reported no significant differences in patient reported outcomes or complications at any time point.

Welcome to Overtime with the Sports Docs. On each of these mini episodes, we chat about a new article or new surgical technique in the field of sports medicine. We’ll give you our quick take on the most recent data and how this data will be impacting our practice.Today, we’re talking about hamstring injuries in the NFL. And if your fantasy team is anything like my fantasy team, it currently looks like an infirmary. So, you’ll probably want to listen in to this episode.Now, we’ve covered hamstring injuries in the NFL before.  Last year we did an entire Game Plan episode dedicated to this topic.  That is episode #52 if you want to check it out. Today, we are actually reviewing a new study just published this month in AJSM that focused on how player characteristics, injury severity and imaging findings can impact the amount of time missed as well as risk of recurrent injury. The article is titled “Correlation of Player and Imaging Characteristics with Severity and Missed Time in the National Football League Professional Athletes with Hamstring Strain Injury.” Molly Day, Scott Rodeo and team at HSS published this retrospective cross-sectional study that aimed to identify certain player characteristics, clinical examination findings and MRI  results that were associated with injury severity and missed playing time. As always, links to all of the papers that we discuss on this show can be found on our podcast website – www.thesportsdocspod.com

We get lots of questions from our patients and our listeners each week. And they’re great questions, so rather than responding individually we thought we’d do these mini episodes where highlight some of the best questions and our responses. So, let’s get started! Today’s Ask The Sports Docs is going to focus on one specific question that we get asked a lot from patients, and review a recent article that came out about this topic.We both use cryotherapy and cryo-compression therapy postoperatively after our knee and shoulder surgeries.  Many of these devices are unfortunately not covered by insurance, and therefore require patients to pay out-of-pocket.  A question we get asked all the time from our surgical patients is: “Is this worth it?” Basically, do cryo-compression devices offer a significant benefit compared to a bag of peas? Is the cost worth it?

Welcome to another episode of Game Plan! These Game Plan episodes are specifically designed for patients – to hopefully answer some of the questions you have about the most common sports medicine conditions and surgical treatments. But today’s episode is a little different and we’re excited about it! Today, we’re focusing on common injuries in the NFL and how these injuries impact time missed and player performance once athletes ultimately return to play.This is something that each NFL team looks at carefully when evaluating rookie prospects before draft day. Teams look at the number of previous injuries, the types and severity of the injuries and treatment rendered when trying to decide on the ranking of a draft candidate. Now, this is just one facet of the evaluation – a physical examination is performed at the NFL Combine and performance metrics post-injury are obviously taken into account. But as the literature continues to grow in this area, it is becoming more feasible to project a player’s injury risk, career length and even performance in the NFL. This is useful information for NFL teams but also fantasy football enthusiasts who want to make sure they draft the best players for their team. So, our discussion today is going to focus on common injuries in the NFL and how that injury history may impact player reliability (games played), longevity for the season and performance. 

Welcome to another episode of Game Plan! As you might remember from our episode on ACL graft choices, these Game Plan episodes are specifically designed for patients – to hopefully answer some of the questions you have about the most common sports medicine conditions and surgical treatments. We’re continuing with our favorite topic today – ACL tears – but today’s episode is going to focus on risk factors for ACL tears. Specifically, which of these risk factors can we modify to lessen the chance of sustaining ACL tear and how do we decrease that risk.Please note that this episode is going to focus strictly on ACL reconstruction. For more information on ACL rehab check out our recent two-part episode with Candace Townley Cox back in April of this year. We’ve covered the addition of “LET” or “lateral extra-articular tenodesis” to ACL reconstruction in an Overtime episode in November of 2021 and again with Dr. Brian Waterman live at the AAOS meeting back in March of this year. And, of course, our first Game Plan episode was on how to choose the best ACL graft for reconstruction, so definitely check that out.

Welcome to a very special episode of The Sports Docs Podcast. In celebration of our 101st episode, we are honoring Dr. Mark Price who passed away on August 16, 2024 following his battle with leiomyosarcoma. We wanted to pay tribute to Dr. Price, who mentored us both through our residency at Harvard. His death is an immeasurable loss to his family and the community. Dr. Price was the Head Team Physician and Medical Director of the New England Patriots since 2016 and a team physician for the Boston Red Sox since 2009. He was a Captain in the U.S. Navy Reserves and served in combat operations in Afghanistan, where he was awarded the Bronze Star Medal. Most importantly, he was a bright example of a physician who cared deeply for his friends and family, including his wife Stephanie and their children, Henry, Julia and Sarah. The words shared by family and friends at his memorial service in Wellesley last month demonstrated a life rooted in purpose and accomplishments aligned with his values.Mark was one of our first guests, coming onto the show for Episode #3 and #4 in March of 2021. Consistent with who he was, he was willing to take the time out of his busy schedule to help two of his mentees build something new. So, with that, we thank Mark Price for all that he taught us and the mentorship he provided to not only us, but our community.--On today’s episode we’re continuing our discussion on shoulder instability with Dr. Mark Price, Orthopaedic Surgeon at Massachusetts General Hospital and Head Team Physician for the New England Patriots. We have 5 great articles which we discuss over two episodes that really contribute well this conversation on how to best manage shoulder instability in athletes both in-season and post-season. We’re very honored to have Dr. Mark Price join our discussion today. Dr. Price specializes in sports medicine, knee and shoulder surgery. He is an attending surgeon at Massachusetts General Hospital and Assistant Professor of Orthopaedic Surgery at Harvard Medical School. Dr. Price earned his MD from Harvard Medical School and PhD in Medical Physics from MIT. He completed the Harvard Combined Orthopaedic Residency Program, where Catherine and I both attended as well, and then went on to complete a fellowship in sports medicine and shoulder reconstructive surgery at Mass General. Dr. Price is Head Team Physician and Medical Director for the New England Patriots and a Team Physician for the Boston Red Sox. He is a Captain in the US Navy Reserves and has served in combat operations in Afghanistan, where he was awarded the Bronze Star Medal for meritorious service. We begin with Dr. Hettrich of Brigham and Women’s Hospital who recently investigated the question “Are there racial differences between patients undergoing surgery for shoulder instability?” We’ll dive further into this topic and chat about how this impacts resident and fellow education. We will follow these articles up with a discussion on the surgical management of shoulder instability by reviewing two articles from the March issue of Arthroscopy. The first is a prospective randomized controlled trial titled Arthroscopic Bankart Repair With and Without Curettage of the Glenoid Edge. Desai and his team concluded that curettage of the glenoid edge reduced the incidence of postoperative recurrence of instability likely relating to improved healing of the capsulolabrum repair. Avramidis and colleagues contributed their cases on the management of recurrent anterior shoulder instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System.