Dr. Sheean:        Welcome to the Arthroscopy Association's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Welcome everybody. I'm Dr. Andrew Sheean from the San Antonio Military Medical Center. Today I'm talking to Dr. Jorge Chahla from Rush University and Midwest Orthopaedics at Rush. Dr. Chahla's paper entitled Bony Ingrowth of Coil-Type Open-Architecture Anchors Compared with Screw-Type PEEK Anchors for the Medial Row in Rotator Cuff Repair, a Randomized Controlled Trial was made available online in December, 2019 as an article in press. Dr. Chahla is an incredibly accomplished writer and researcher and so I'm excited to be talking to him today here on the podcast. Dr Chahla, welcome to the podcast and thanks for joining me. 

Dr. Chahla:          Thank you so much, Dr. Sheean. This is a great honor for me. It's been a phenomenal experience to be a part of this growth from the Arthroscopy Journal in regards to the infographics and this podcast that have had an amazing impact in our society. So thank you very much for having me. 

Dr. Sheean:        Yeah, and great plug for the infographics too. I know that just anecdotally a number of my colleagues here down in San Antonio have been really enjoying those. So kudos to you and keep up the good work. 

Dr. Chahla:          I appreciate it. I think everything we do for the Journal to spread out the word on the science, it's a great thing to do because more people can get engaged, not only from a scientific standpoint but also in social media also. Sometimes patients can see those things and get more involved and they can be more informed at the time of making a decision for either surgery or keep going with physical therapy and those things I think are really valuable from a consumer standpoint. 

Dr. Sheean:        Give the readers an overview of what the architecture of this anchors are so they can think about it in their mind's eye. 

Dr. Chahla:          First of all, thank you very much for getting interested in our article. I want to acknowledge all my collaborators and core authors for this article because without them it'd be impossible to have it done. But this is basically the main question, the two types of anchors that we've studied were pretty much solid anchors, which is the conventional anchor that we used to use, and the new newly designed open-architecture anchor, which basically has basically more space in between the threads and it's hollow on the inside. So it makes it easier for the bone to basically ingrow into the anchor and also for the bone marrow elements to come out from the pilot hole that we do to position the anchor. That's the main difference between the regular anchor and the one that has basically a hollow inside with higher threads to be able to have some more ingrowth of bone. 

Dr. Sheean:        I'd like you to describe the two different interventions that you all were interested in investigating and how you went about comparing the different types of anchors. To the great credit of you and your coauthors, there's a number of different comparisons that you guys made with respect to the [inaudible] biology, clinical outcomes, and radiographic outcomes. Can you elaborate on these a little bit more and tell us why you chose the ones you did? 

Dr. Chahla:          Yeah, so we basically looked at three things. One, the synovial and bone marrow content at the time of surgery where we basically extracted the bone marrow at the time of the arthroscopy. We basically drained the fluid of the joint and then with the use of a needle, we extracted the bone marrow and also the synovium to try to assess basically different growth factors and [inaudible] stem cells that were present at the time of the surgery to try to see if having a hollow type of anchor would aid in a better capacity to stimulate the bone marrow from the bone. 

Dr. Chahla:          The second thing that we did was try to measure the bony ingrowth using CT scans at six months, and this was really reconstructing using the Mimics software. This is one of the coolest things from this study was that we used a very complex software that was designed by one of our scientists here at Rush that basically subtracted the anchor from the bone to be able to measure how much bone basically had ingrowth into the anchor. 

Dr. Chahla:          And finally, we did a comprehensive physical examination that was randomized between people that had one or the other anchor in regards to two things, objective measures such as range of motion and strength using a dynamometer, and subjective outcome measures using different questionnaires such as [inaudible] ASES, preoperatively, at six months, and after one year after the surgery was done. 

Dr. Sheean:        And the part about aspirating the effluent from the anchor site, is that a method that you all devised there or is that something that has previously been written about? 

Dr. Chahla:          So this has not been written about before. And this is a great question because it is sometimes hard to know where are the cells coming from and if the growth factors are coming from the debridement of the bursa or where are they coming from? We try not to do any type of bony work before taking the aspiration, because we know that that could have affected the results. But still, it was something that we thought it was probably the best way to assess it, although we don't know if that is the best or the most perfect way to do it. However, we couldn't find a better way ourselves that we can think of. 

Dr. Sheean:        No, I liked it and I thought it was a very practical way of going about it. We've all been there before. We put those medial row anchors in and we see the biologic volcano, as I think I've heard speakers in a podium call it. So again, great work for trying to figure out exactly what- 

Dr. Chahla:          I like the term. 

Dr. Sheean:        Yeah. So what's going on with that stuff coming out? Why don't you summarize the key findings of the study for the listeners? 

Dr. Chahla:          So the main findings of our study were that bone mineral density surrounding the coil-type anchor were significantly greater than in the screw-type anchor. However, the objective and subjective clinical outcomes, including the range of motion, the strength, and the PROs that we measured after the surgery at six months and one year were pretty similar between the two cohorts. Taking a closer look at the data, it demonstrated that there was a trend toward coil-type patients having a larger magnitude of improvement within the first six months. This might have to do with the fact that this patient had a better ingrowth of bone, but this was not significant. Both for SANE, ASES, [inaudible] strength in the objective and external rotation strength. But again, this was not statistically significant. 

Dr. Sheean:        I don't recall if there was an effort to preoperatively assess the greater tuberosity bone in terms of the bone mineral density between the two groups. Do you think that preoperative bone mineral density might affect the amount of bone that gets laid down around these anchors once they've been inserted? 

Dr. Chahla:          I truly think so, and this is a great point, but we did not correlate the BMD preoperatively. I believe this could be a nice follow up study to identify patients that might be at risk and they can further benefit from this anchors, meaning that patients that have a pretty low bone mineral density might benefit a little bit more from a hollow anchor or a coil-type anchor where the bone can actually make a difference. Whereas patients that have pretty good bone might do the same with any type of anchor. So I think that concept might lead us to further study a second followup study where we try to assess that and if there's an at-risk population that we can actually benefit by the use of this newer type of anchors. 

Dr. Sheean:        And I think also too, I think that this just underscores that when we're contemplating a surgical tactic for patients with poor quality bone, there's all sorts of different things we can be doing and planning for, right? We should be facile with managing poor quality bone, whether that be how are we going to deal with cysts, are we going to have to bone graft those defects? Do we have a myriad of anchors available from different sizes? So I like the results of this study that would suggest that besides all the things I mentioned, there's one more arrow in our quiver that we can be using in circumstances, specifically involving perhaps poor quality greater tuberosity bone. 

Dr. Chahla:          I know there has been some surgeons that have been using cement or other type of synthetic type of elements to try to augment or to try to improve the fixation of the [inaudible] of the anchors. However, as you know, it's not the most natural way of doing things and sometimes if that fails, you end up basically with a bigger problem than you started with. So again, trying to get native bone to grow into the anchor might be a more natural solution, but it might take some more time. But at the same time, in the event that it works, it might be a more beneficial approach than trying to use other synthetic type of products. 

Dr. Sheean:        Have the results of this study affected the way you think about or fix rotator cuff tears? 

Dr. Chahla:          So what this study showed us is that if we respect and follow the main principles of rotator cuff repair, that we're taught to as by Dr. Burkhart and others including tear pattern identification, mobilization of the tissue, adequately preparing the footprint and performing a repair without a significant tension, those are the paramounts for achieving good outcomes regardless of the anchor utilized. So again, I think respecting the main principles for repairing cuffs are still the most important thing to address and to assess at the time of surgery. And not only that, but also the indication for surgery to try to achieve the most optimal outcomes. 

Dr. Sheean:        Well, that's going to do it for this edition of the podcast. Jorge, thanks again for joining me today. I really appreciate it. 

Dr. Chahla:          Thank you very much, Andy. It's been a pleasure and thank you again for considering us. 

Dr. Sheean:        Dr. Chahla's article entitled Bony Ingrowth of Coil-Type Open-Architecture Anchors Compared with Screw-Type PEEK Anchors for the Medial Row in Rotator Cuff Repair, a Randomized Controlled Trial was published online December, 2019 as an article in press and can currently be accessed at www.arthroscopyjournal.org. Thank you all for joining us and have a good evening.