Dr. Justin Arner:

Welcome, everyone. I'm Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today, I have the pleasure of speaking with Dr. Ivan Wong, Professor of Orthopedic Surgery at Dalhousie University. Dr. Wong was a senior author of the paper titled, “Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results,” which is in press in the Arthroscopy Journal. Welcome, Dr. Wong, and thanks so much for joining me.

Dr. Ivan Wong:

Thanks.

Dr. Justin Arner:

It's great to have you. So first off, congratulations on another great study. You're really always pushing the envelope here for surgical techniques and the thought process. So, we appreciate that. Can you tell us a little bit about the background on interpositional grafts and how you became interested in these?

Dr. Ivan Wong:

Absolutely. Well, again, thank you very much for having me on this podcast. It's wonderful to be here. This is near and dear to me. Everyone talks about their fellowship, and this is all about my fellowship. So I'm a SCOI fellow, 2008 to 2009, with Stephen Snyder. And honestly, the first OR day, first case I ever did with him, was a bridging reconstruction of a cuff. So I never did lateral decubitus shoulder arthroscopy before. And first time I got there, was very humbled to be able to see him rebuild an entire cuff completely arthroscopically. So I spent a wonderful year with him, be able to see lots of these cases. I saw lots of follow-up and realized that this is a potential option that I didn't really know anything about until I did this fellowship. I read one paper really getting there, but it's a whole another experience to see it and then to partake in it.

And the thing that took me back was... Everything I understood about bridging reconstruction was that it's a salvage technique. You might consider it here or there. But watching his patients and what they could do afterwards really intrigued me, where they could barely use their arm, they're back playing tennis, doing sports, really living their life, not being completely normal, but having the ability to do things that I didn't think was possible. And the only thing that was lacking I thought was the research behind it, to be able to teach everyone else around the world what you can possibly do with bridging reconstruction. Though it was talked about, it really wasn't something that many people considered. And it's only when SCR kind of took off, that I realized that we really need to show the outcomes that Stephen Snyder was able to get from this. And I've really been trying to work hard to try to show this data.

Dr. Justin Arner:

Yeah, that's awesome. Talk about a legendary story, first starting in your fellowship. That's pretty great. So, tell us a little bit about your study.

Dr. Ivan Wong:

Absolutely. This is a medium-term outcome. Essentially, it's all of my patients that I've done a bridging reconstruction on since my fellowship. So obviously, everything is exactly how I learned it from Stephen Snyder. I've been following these patients as good as possible. We're obviously up in Canada. So, there's different resource limitations here. We can't seem to get MRIs in time or CTs and follow-ups. Everything we can order, it takes a long time to get this type of information. But the good news is our patients tend to stick with us and really believe in it. So, they keep following up with us. So, we're getting pretty good follow-up with these patients. So over this time, since I've been back from fellowship, we've reached about 91 of these patients that received bridging reconstruction of which I was able to get both pre and postop outcomes. And essentially, what we showed was that we got significantly better patient reported outcomes from before having these graph reconstructions to afterwards. And this improvement really stayed past five years in the majority of patients.

Dr. Justin Arner:

Yeah, that's big time, especially in the longer term follow-up. So, congratulations on that. I mean, it's impressive. Especially, a lot of these younger people, it's tough to get follow-up. So, you've got a great system up there. So, can you tell us a little bit about how you approach these younger patients with your irreparable rotator cuff tears? It's about the most difficult population situation we really deal with.

Dr. Ivan Wong:

Yeah, I completely agree. I didn't see as many when I was doing my fellowship. But coming back to Canada, again, our healthcare system is very different. It's great in that we provide wonderful care to our patients. The problem is they wait a long time. And arthroscopy is not a priority service in Canada. Patients tend to wait a long time. So patients with cuff tears can wait years before they get seen, and then more years before they get surgery. And so, our tears tend not to be small. In fact, they tend to be quite large by the time we get them. And then, if they see someone else who doesn't want to do something like this, then it's even more time to be referred to the appropriate surgeon to do some kind of reconstruction.

Dr. Ivan Wong:

So, my approach to these really is trying to preserve these patients as long as possible. So the younger the patient, the more I want to preserve the anatomy, giving them more options, because obviously, the younger they are, the more likely that we will have to do further surgeries to give them some kind of relief as they get older. So all the different surgical options are really on the table, everywhere from partial repair, to repair with augment, to interpositional grafting, to SCR, to transfers, and then for a reverse shoulder as well. I don't do those, but again, I refer those and work very closely with our upper extremity colleagues.

Dr. Justin Arner:

Yeah. Tell us how those different procedures fit in your practice, how you go through that algorithm when you... Or if you do a partial repair versus an augment versus interpositional in the SCR. It's complicated situation a lot of time.

Dr. Ivan Wong:

Absolutely. So, we can start off. So, partial repair obviously has a great report in literature previously. I really look at it more as a pain relief surgery for older individuals, somebody who doesn't want to go through a reverse total shoulder, has pain and wants something done and really is older. So that's what I would do because it does improve pain, but it doesn't last as long and it can fail, meaning they can progress on with a worse arthritis later on. Everything else is trying to reconstruct the anatomy. So for these so-called irreparable, we know of different releases we can do. And again, I'm a SCOI fellow. So, I really work on trying to minimize the amount of tension going on.

Dr. Ivan Wong:

So, if I can do appropriate releases and get it to the medial aspect of the footprint or even over another five or six millimeters, so medialize the footprint, the tissue tends to be thinner. And if I can just get it there, I'll tend to do a patch augment because the failure rate of something with a large, massive tear, even though we can get it to the tuberosity is quite high. And with an augment, actually that's my best outcome of any patient. They tend to heal the best and they tend to be the strongest. When I can't get it all the way back out, that's where I start making those decisions. And interpositional grafting is usually my treatment of choice. That really is focused on if there is tendon to be able to bridge, to get some kind of graft in between, that's what my preference is going to be.

Dr. Ivan Wong:

So something with atrophy of somewhere around 50% or less, somebody with limited amount of fat atrophy, but something that looks like muscle I could get to use, that's what I'm doing for an interpositional grafting. SCRs really are much smaller type of irreparable tears. So if there's a single tendon, meaning just supraspinatus that's torn, that's irreparable with more than 50% atrophy, that's where I really consider where SCR fits, because we've tried a few of these with the larger ones and they don't seem to work near as well. They have a higher failure rate, at least in my hands. We're actually having a randomized controlled trial going on right now to see where the difference is between SCR and bridging.

Dr. Ivan Wong:

So when they become bigger or more atrophied, something that interpositional won't fit in, that's where I talk about tendon transfer because interpositional, you can actually consider that to be a tendon transfer. We're actually just transferring their torn tendon back to the tuberosity. So if there is tendon that's going to be able to work, I would prefer interpositional grafting because as we know with all tendon transfers, if you have a grade five strength of any tendon and you transfer it, it's going to lose one grade of strength. Well, it's going to be the same thing if you're going to re-tension one of the previously torn cuffs. So, I would always prefer to re-tension that... Sorry. Put another interpositional grafting in there versus doing tendon transfer if it has a chance to work.

Dr. Justin Arner:

Well, those are great pearls and excellent summary and a difficult problem for sure. You mentioned obviously Stephen Snyder such a giant talking about the single row repair and medializing the footprint. He's such a master of those techniques and has really pushed the envelope and taught us a whole lot. Can you tell us a little bit about how you repair those tears that have maybe more tension than you'd like, if you're going to do a double row, and how you really do the interpositional graft or a patch augment? Just some pearls. We all love to hear those for sure.

Dr. Ivan Wong:

Absolutely. So again, SCOI fellow. I drank the Kool-Aid, I've watched the detail. So again, really focusing on outcomes. We spent a lot of time, or I spend a lot of time doing that, trying to make sure my practice is what I want it to be. But my approach to all small tear, large tear, any tear is a medialized single row, triple loaded anchor repair. And so by doing this, I can get every cuff... If it's repairable, I can get every cuff repaired to the least amount of tension. So, I don't do a double row on any repair construct because a double row will always increase the amount of tension on it. Even though there's no question bio-mechanically, it does show that you get stronger initial fixation. I'm not caring about initial fixation. I really just care about healing at the two year time point. It has to heal and it has to function. And so, with Stephen Snyder's Crimson Duvet, with that triple loaded medialized footprint, it definitely heals and regrows that footprint.

Dr. Ivan Wong:

The only time I actually switched to do a double row is when I do a graft. So repair, I'll do the medialized footprint with triple loaded anchors. If I do an augment on top, I'll do the double row using the dermal allograft augment, because now, I can use a larger graft, because that's not on tension, I can make the graft larger, and put that double row on top. So, I get excellent fixation and collagen on top of the entire footprint for healing. And I'd do the same thing with the bridging and with SCR. So all my graph reconstructions have double row fixation because I completely agree double row fixation gives stronger initial time point of fixation. It gives more tissue for more area for healing. But because I'm using a graft, I just put a larger graft than I would've done instead of doing a single row type of repair, mainly because I can, right? We're cutting some other graft to put on top of there, and that's why I would do double row at that stage.

Dr. Justin Arner:

Yeah, that's awesome. The biomechanics in the lab and healing are certainly a different thing. And we care so much about healing labor repairs, preparing the glenoid and everything is so essential, and sometimes you just lose track of that. So, it's great summary. Can you tell us a little bit about how you're fixing the graft to the actual tendon and tell us what you think of the healing in that aspect or how do you optimize that?

Dr. Ivan Wong:

Yeah. So graft to tendon repair, they're all simple stitches, and it's using his original technique described, using stick knots. So, all the work and all the preparation of the graft is done outside the body. The only thing we do is use a suture shuttle to pass inside where we pass through the native cuff. And then, all these sutures we brought out the lateral portal in sequence so that every suture will be taken out posterior to the one behind. So, we won't ever tangle these sutures. So of course, we're not following any of the rules of arthroscopy. We have more than one suture per cannula. In fact, we have about 15 sutures in that single cannula. But if you follow the principle of always going posterior to the previous sutures that you put in, you won't tangle them.

Dr. Ivan Wong:

And by doing this, doing a single suture pass each time, we'll have all the sutures passed into the native cuff, and then you can tie them individually. And it's a simple stitch tie. So, a single SMC knot over top. It is very time consuming that way, because you're tying each of these. But the nice part is when you put it in and sequentially tie them, instead of going to anchors, you can control the amount of tension going to every single suture. And when we put a bridging reconstruction in, there are 15 sutures in that model. And when you tension each of them, you can actually make that graft exact amount of tension and pull the remnant cup to the right amount of tension that you want to do. You control completely by your suture configuration. So, it's very accurate and very precise of how you want to do something like that.

Dr. Justin Arner:

That's awesome. So in your experience, it seems that maybe an SCR wouldn't have to be performed quite as common with all the extensive releases you do in medializing the footprint. Are you having to perform many SCRs? With those techniques you described, are you really able to repair I'm sure most all of them interpositional grafts, many of the others?

Dr. Ivan Wong:

Absolutely. Really, I have not used SCR very much. In fact, before starting this SCR versus bridging reconstruction randomized control trial, we did about six SCRs over probably six years. Probably, one or two a year. Any of the cases that have more than 50% atrophy with no tendon remaining to be able to do a bridging reconstruction, those are the ones I would consider doing SCR. And now, I'm being a little more restrictive, because again, we found that the subscap tears along with them that are not irreparable are having more troubles with SCR since it's a static type of constraint. And so with the limitations, I found that I don't do that many SCRs. Now obviously, I want to make sure that interest in doing SCR is what the differences will be. Again, that's where these randomized control trial will hopefully give us this information in the next year or two.

Dr. Justin Arner:

Okay, randomized control trial is certainly obviously the gold standard. So, we look forward to seeing that. Can you tell us a little bit about why you think that this technique hasn't totally caught on, or basically your experience with it or whether limitations on learning, or those of us that haven't seen or done this very often, how we can get involved in learning this technique and utilizing it like you and obviously Stephen Snyder and the disciples have experienced?

Dr. Ivan Wong:

Yeah. Well, I'll tell you, this is still the hardest surgery that I do. So everything else that I've worked on and done and learned, right? From Stephen and his team at SCOI, this is the ultimate surgery, that is the most complex, that takes the most amount of my intellectual effort to do every single time. They initially designed it as two different surgeries, a stage operation, because it's so complex. And that's where I could see why this technique didn't take off as opposed to SCR where you're really just putting some anchors in, tying them together, compress it down between the anchors. You're not having to tension that many sutures. There is some sutures, but we're more probably tripling the amount of sutures going through.

Dr. Ivan Wong:

And I also think that's probably why this method works more is because you have that many sutures. So distributing that forces all the way around the perimeter, recreating structure, because again, tension, I really do think, has an effect for healing. So to do something like this, or if you want to get into something like this, is really just spend the time. It's not really just watching a video online and being able to try because you'll get your head confused into what you want to do. You really need to be able to see it kind of start to finish. Watching a seven minute podium presentation where you edited out all the complexities, it really takes it away. Actually, COVID is probably one of the best things that's happened for medical education because now, instead of surgeons flying around or myself flying around to learn new techniques, surgeons can really just do a Zoom call.

Dr. Ivan Wong:

We actually just did one with our colleagues in Winnipeg this morning. They wanted to learn about distal tibia allograft, and they sat in their office, I was in the operating room. And with multiple cameras now, we can actually have you immersed in the surgery. You can see the outside view with your hands, you can see an inside view with the scope, you can talk directly with the surgeon real time, you can ask a question, we can highlight it during the case and go really from start to finish. So you can see all the nuances, all the difficulties, all the tricks you have to use to get yourself out of trouble. So, same approach would happen with this bridging. And I really think that would be able to make it more accessible to more surgeons. And now, because of COVID, we've actually extended this even further. We've taken this type of a learning and reversed it.

Dr. Ivan Wong:

So now, we have a reverse type of training where a surgeon would be able to go to their local skill center, we would ship you a suitcase full of cameras and monitors, and you actually place it up. And actually, we can augment your view. You take your surgical scope view, we would feed it back to you, draw on the screen, highlight exactly what you want. It's kind of like connect the dots surgery. So you can go step-by-step, figure out what the problem is, actually physically do it with a surgeon at another site to guide you all the way through. So in fact, I think COVID's really helped us really springboard this technology to be able to help surgical learning to a whole new level, because now, it doesn't need you to take several days off your work, fly to another center, spend time with another surgeon to learn. You're going to do this from the comfort of your own home.

Dr. Justin Arner:

Yeah, that's incredible. Certainly, you've pushed the envelope and taught us all this technology that you're just discussing there. And just a little plug for your... You mentioned distal tibia allograft in your arthroscopic techniques. I think for sure that's going to be the future of what we're doing and who knows how many years until we all get to learn your excellent surgical skill in these techniques? But I think that's going to be what we're all doing in a few years. So, that's awesome. Tell us a little bit about, I know it's a little off-topic, but how you mentioned sending the cameras, and what do you envision that way that there'll be kind of companies or private practice doctors or people medical centers can kind to do that? Or how do you think that evaluation with more master technologists and people that are teaching these techniques? How is that going to work in the future?

Dr. Ivan Wong:

I really think this is the future of surgery, right? So our lives are short, and really if I wanted to learn from Pascal Boileau, I can't fly to France and learn this. I can't fly to you and learn what you're doing. I would love to. So in fact, I try to coordinate that for every conference I go to. But that really isn't feasible for every surgeon to be able to do something like that. That's way too much travel. I really think augmented reality is the future of learning surgery. We talk about virtual reality all the time. And going to the virtual space, it's just not real. You can have an idea what goes on, but you can't physically manipulate tissue, get into problems. Everything is fake. But augmented reality, you're actually doing the surgery, so it's on your own patient or on your own cadaver or watching someone else do it, and you can interact with someone. You can actually draw on the screen, change the way things go.

Dr. Ivan Wong:

Again, during COVID, I spent a long time these past two years, learning about broadcasting and learning about augmented reality and how you interact these two technologies together. And I think the difference is I like spending the time to learn this technology. Most surgeons won't want to do that and I get that. But it's getting to the point where it's easy enough that I can actually ship you a suitcase, have a list of instructions to be able to set this up beforehand, and then for us to spend an hour together or two hours together. And you probably would be able to do it at the end. I haven't done this with a bridging reconstruction yet, but we've done it with distal tibia allograft. We've done it over 30 times in the last two years, and every single surgeon we've done it with is doing it in their practice. I'm getting emails about how great that's coming. So it's really rewarding to see the fact that past two years we haven't been able to travel, yet we can still pass information like technical skills that we really could not do previously in a virtual world.

Dr. Justin Arner:

Yeah, that's awesome. And again, a little off topic, but can you tell us a little bit about, those of us that want to learn this distal tibia allograft arthroscopic technique, how you've done that before in the past? And people just contact your research team, or how has that worked for you?

Dr. Ivan Wong:

Absolutely. So almost anyone who's wanted to learn has either found me at a meeting, emailed me, because if you search, Ivan Wong, you find anything. So if it is specifically for me, you email me, we'll put you in contact usually. We do need equipment unfortunately. So depending on whichever company you have been using to get the equipment, to do the surgery, that's the one who usually helps to get the equipment for you to practice on. And they help coordinate the session. And again, we send you all the equipment that you need, the guide you go through, because obviously you want a lab to set up. So, you need to work with the lab. We work with you to do that because every lab is different, every setup's different. But again, we've figured out now to be able to get all the hardware to the place, we've figured out the teaching scenarios.

Dr. Ivan Wong:

It's really basic. You just need internet connection, you need a second monitor to it, and then you need a Zoom account with a few computers. And we have them all together that get wired together, so we can communicate both ways. And once you get the audio and visual done, just like we're doing for this podcast, it all works. Obviously, there's always technical issues because some kind of a microphone may not pair at whatever time. That's why we try to do this all beforehand, so when we ship the thing, everything already works together. And honestly, the biggest limitations of that kind of technology is understanding how they work together. Once you get it working together, as long as you don't change anything, works great. So, now we just have a suitcase that we kind of ship around.

Dr. Justin Arner:

That's awesome. And another off-topic comment is Dr. Wong certainly helped me figure out my technical difficulties with my microphone for this podcast. So, thanks again for that.

Dr. Ivan Wong:

That's great.

Dr. Justin Arner:

So back on our topic of this awesome interpositional grafting, tell us a little bit about the different graft options that you or Stephen Snyder have tried in the past and what your thoughts are on the future regarding best graft options for the interpositional grafts.

Dr. Ivan Wong:

Yeah. So, I'm good at certain things. The thing I'm good at is miniaturizing something. I'm not a basic scientist. I'm not anything like that. Stephen Snyder really has taught me, just make sure you do what you're good at and make sure you know what you're not good at. Let the best people do whatever they're best at. So, neither of us know very much about dermal matrix. It's all from all the basic scientists. Alan Barber did all his basic science work on rotator cuff strength testing, all mechanical. So I honestly have only used dermal matrix, and I've only just followed what Stephen Snyder's taught me for the technique. The only thing I did was now continue to do his technique and do clinical follow-up with MRI imaging, with patient outcomes, trying to follow the scientific method to be able to show the outcomes of this, because I think that's the key function.

Dr. Ivan Wong:

We don't have long term outcomes of these complicated surgical techniques that have the potential to give fantastic outcomes. And that's what we're trying to do here. So, this is our first medium-term outcome. Obviously, we're going to be continuing this. We're hoping to get the 10-year outcome in three, four years to be able to see what it's like, to know all the nuances. We got lots of information that we're trying to be able to come together. So again, this is the first paper of a medium-term outcome to come out. Again, everything I do is on dermal graft because I'm not a basic scientist. But we now want to be able to tell you all the nuances of the dermal graft.

Dr. Ivan Wong:

Well, because just think about it. We tell you that the failure rate is right around 10%. But what we've learned is when you try to read an MRI of something like this, no one has a classification of how to read a graft in a cuff. Radiologists don't see this. So, it's been a whole another avenue. That's our next paper we're going into is trying to find what is a tear, because is a little gap a tear? Is a graft completely gone a tear? Does it have to be completely gone from one side or the other? From the front or the back? It's very difficult to define these things because we haven't defined them yet. And that's where we're trying to go with this is there's so much more information to go, to be able to understand the nuances of who benefits, how they can fail, and what we need to do to try and minimize those factors.

Dr. Justin Arner:

Right, that's a great point. Another question I have for you is regarding your MRI studies, regarding healing rates and interpositional grafts and with SCRs, tell us a little bit more about that. When I was a fellow at the Steadman clinic with Dr. Millet, he did a study looking at SCRs and do we really care if it's healed on one side or the other? We really don't know.

Dr. Ivan Wong:

Yeah. So again, now we're looking at that, we're still working on collecting all the data, and now we're looking at to analyze it with our MSK radiologists. So, tears can happen from multiple place just like Peter Millett talks about. It can tear from the humoral side, can tear from the tendon side, or the glenoid side if you're doing SCRs. And most of what we find is we have a difficult time determining what a tear is. That way, when we do our MRI findings, we actually list down a partial tear. A partial tear is where the graft is still tensioned. You can see the graft at the tendon side, you can see the graft at the tuberosity side, and you see tension. That graft is taut the entire way. But you see a little gap in between somewhere, whether it's on the tendon side, whether it's in the center, where it's on the tuberosity side, where it's front or back. If you see it gone in any of those places, we say it's a partial tear. If it's completely gone, that's where we say it's a complete tear, right?

Dr. Ivan Wong:

Or it's completely missing, or the graft is recoiled where you actually don't see tension throughout the length between the native tendon and the tuberosity. So, that's what we're finding with MRI. It's very difficult to determine this, to figure out graft tear. And the problem really, just like Peter Millett said, is do we care? At two years, I'll tell you we don't care. But that's not what we want. We want long term, right? Because at two years, we know partial repairs do well and we know they're not healed. But when I follow my partial repairs out, and we've seen this with our randomized control trial study when we look at bridging versus partial repairs, they do worse as you follow them longer and longer, right? We're going to hopefully have our five-year midterm of our randomized control trial where we've been following those patients out, and we should be ready for that in the next year or two. But they are actually doing worse and worse as you follow them out longer and longer.

Dr. Justin Arner:

The five-year follow-up in these rotator cuff tears is huge. So, congratulations on that. We appreciate all these and the answering questions you're helping us with. So, I think we're running out of time and I could talk to you forever. Every time I hear you speak, we learn so much from you. So, any closing thoughts about this topic and what's on the horizon in your mind regarding rotator cuff tears?

Dr. Ivan Wong:

Absolutely. So my really kind of take home point is I look at these algorithms that we've designed for massive cuff tears, and really many times, I actually don't even see bridging as a viable option in them. I see repairs, augments, and I see SCR. And bridging is not really mentioned in there. And I do know it's very complex. Again, I still think it's the most difficult one. I just think that it's really important to say that bridging reconstruction, definitely it's safe, has minimal complications, it recreates anatomy. And hopefully, with our papers coming out now, it's showing that it has good midterm outcomes. It really should be a treatment option. We should to accept that as a treatment option. And we're hopeful that the next few papers coming out that we're going to do, we're trying to analyze all the nuances of this, what the radiographic factors are, how to best analyze these things, how we can correlate the graft status or outcome, and looking at radiographic arthropathy progression of all these types of cases, that this will help define exactly what we should do and when we should do it.

Dr. Justin Arner:

Yeah, thanks so much. I really appreciate that information. And you're right. I think we have to push the envelope for ourselves and continue to get better surgically and with our knowledge. So yeah, we got to learn these technical skills. And again, I appreciate that. Thanks so much for sharing your knowledge with us today. Dr. Wong, I really appreciate your time.

Dr. Ivan Wong:

Thank you.

Dr. Justin Arner:

And Dr. Wong's article titled, “Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results,” is in press in the Arthroscopy Journal and is available online at www.arthroscopyjournal.org. Thanks so much for joining us.

The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.

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