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Dr. Matt Fury and the Nanoscope · The Layback Podcast

0:00
Hey, everyone, welcome back to the Layback Podcast.
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Joining us today now is Layback veteran Doctor Matt Fury.
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He previously came on an interview way back when the
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first kind of run of podcast episodes.
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You might have been a first 10 or so guest.
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So it's nice to have you back on now for I think what's going to
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be episode 116. We we've done, thank you.
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We've done a lap or two around the sun since we last spoke
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officially on this recording. But of course we had you back to
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host some of those Baseball Rehab network kind of group
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discussions, panel discussion. So it's been wonderful to
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continue to work together, grow in the space and really seems
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like the best time to have you back on with some more
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advancements going on in the medical side of baseball.
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So who better to talk to then a surgeon growing in the space and
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thank you for making time in between your busy schedule,
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especially with it being championship season now at LSU
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and then in the LHSAA or whatever the abbreviation is.
1:05
This Isn't this like state championship week for?
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Baseball, they just wrapped up OK.
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They just, they just wrapped up last week.
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So a lot of a lot of action going on, but no, this is great.
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Thanks for having me back on it. Like congratulations on on 160
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plus episodes. I mean, that's I don't know if
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there was a stat a long time ago about how quickly podcasts die.
1:27
Not that I not that I didn't believe in you, but I don't
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think many people get the kind of state power to get up to 160
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and beyond. But I think that's just a credit
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to what you've been doing and and the interest in in this,
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right, You know, appreciate that small.
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Correction though I I want to I want to stress the correct
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syllable is. I do plan on getting to 160 but
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we are at 116. 116. Small difference. 60s in the
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future, you got this. Once you get over, once you get
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over 1, you know, 110, it's, it's all downhill.
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Yeah, that's kind of what it feels like.
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No, no, but seriously, it it is funny, I keep telling myself,
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because I'm pretty sure that line of demarcation is like 10
2:09
episodes, or at least at one point if it was like, if you do
2:13
more than 10 episodes, you're in the top 5% of podcasts ever
2:18
produced. And then if you.
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Yeah, Eclipse 50, you're in the like top 1%.
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So at this point, I don't know, like I if I can call myself A1
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percenter in something, that's pretty cool.
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I'll take it. I think you are.
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But look, the people are, the game's not going away.
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Unfortunately, the injuries are, we're trying to get them to go
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away, but they're still around. And the interest is, is is not
2:41
going away. And so I think there's a, this
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is a critical, critical space that you fill.
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So congratulations. Thank you.
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So that provides a decent segue. If anything, it seems like the
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interest is rising in the space, especially when a player with
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the caliber notoriety of Tarek Skubal goes down with an injury.
3:01
And I use goes down, I guess kind of gingerly because he
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never really went down. He didn't have a true injury.
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He just had something that was bothering him.
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And it sounds like that's Bony spurs or something in the back
3:16
of his elbow that was causing discomfort here and there.
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However, there's been news to come out that he's already back
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to a return to throw program and he was only down with surgery 2
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weeks ago. And it sounds like what was used
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in his operation was something called a nanoscope or Boris is
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calling it now the scubal scope. I don't, I don't want to give
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that too much credit right now as they're trying to make some
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money and maybe marketing rights off of a surgery.
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That's that's something different for me.
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Rebranding surgeries is very odd in my opinion.
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But hey, somebody's got to do it.
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I don't want surgeries become more popular, but next thing you
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know, kids are going to be asking for the scubal scope for
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the holidays, and that's not ideal.
4:00
Yeah. So back, back to the task at
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hand. What is this Nanoscope?
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When was this developed and what can you share with us on it?
4:09
Yeah, no, it's it's a it's a good question.
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It's always interesting for me when these these episodes come
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up. Obviously you never want a
4:16
player, you never want a player to go down with injuries.
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You certainly don't want to see a player of his caliber at this
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time in his, you know, in his career in contract, all the
4:24
other and he's just so. Good, he did sign.
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Yeah, we did sign. I never want to see, I never
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want to see this happen right at any level, but you know,
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especially with Cali Kim. But it is interesting though,
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because it stirs up interest. It stirs up interest within the
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lay community and you get a you get some reporting that
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sometimes I worry about what comes out from managing
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expectations. But situations like this I think
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highlight just pretty cool stuff that's going on in the world of
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orthopedics and with regards to innovation.
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And I think that this is, this is a utilization of technology
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in a way that makes a lot of sense.
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And it truly is incrementally improving care and how we take
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care of folks, right? And I think that that's
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important because sometimes essentially sensationalized
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stories that come out aren't necessarily really something new
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or aren't something that truly moves the needle.
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It's just the way that it's presented.
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And then you have to manage that with patients or amongst the
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community. But for, for this, I think it's,
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this is a meaningful thing and it's interesting and it's cool
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that it generates interest that that people want to talk about
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it to recap or I guess to rewind a little bit.
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So I, you know, I don't, I obviously don't know his his
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case intimately and not can't speak about patient details in
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any sort of way. But posterior compartment issues
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happened in in throwers for a multitude of of reasons.
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And sometimes they're isolated, sometimes it's in the setting of
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prior medial elbow stuff, medial elbow ligament issues starting
5:50
to overload the poster compartment.
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However, there's a lot of just generalized kind of bone spurs
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and arthritic changes that happen in the elbow and and guys
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can develop just isolated posterior compartment concerns.
6:00
You can chip off a bone spur, have a loose body in the back of
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the elbow that can become symptomatic and can cause
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mechanical symptoms. Guys will have locking of the
6:09
elbow to feel like it'll lock or catch on.
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And if that's the case, sometimes what you need to do
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is, is remove that mechanical peace, loose body, whatever it
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is that mechanical insult to the back of the elbow.
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And we've obviously transitioned from open surgeries to
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arthroscopic surgeries over time.
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And, and the arthroscope being a a meaningful way to to cut down
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on the morbidity of some of these operations and to make
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them less invasive. They're minimally invasive, you
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know, opportunities to use poke colon incisions and to access
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areas of the of the elbow that previously had to do much bigger
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significant surgery to get to. Now that being said, there's
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still surgical trauma that occurs any time that you put a
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scope in the elbow or the shoulder or the knee.
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And what was used in this operation is what's called a
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nanoscope. Technically it's the Nanoscope 2
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point O and that's a new development by one of our
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partners in the industry, Arthrax who has seen the the
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opportunity to improve on Arthroscopy because arthroscopic
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equipment when it came to the US was a big deal and changed how
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we took care of people. But then it largely has been
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relatively unchanged since then, right?
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We have not How? Long ago really changed
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interject real quick. Matt, I apologize.
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Oh, I'd have to go back and start over in in Japan.
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I I would have to go back on the actual date range for that.
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But I mean, we're talking about this is this was in the days of
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Jack who Jack Houston and Jimmy Andrews was kind of working with
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Jack Houston at the time. And then it was sort of also one
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of the early adopters and utilizing this in the practice.
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So we're, I mean, we're talking over the last 50 years of sports
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medicine, right? And but the the instrumentations
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have have the instrumentation has largely been unchanged.
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We still use for the most part the same size scopes, the same
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size instruments with some variations.
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But the the nanoscope was a development to essentially
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decrease the diameter of the Arthroscopy equipment so that
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you can access areas of the joint sometimes simultaneously.
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You can use a regular scope in one place, the nanoscope the
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other place see things from from other directions.
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But, but in this case, it was used to, to just have less soft
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tissue disruption and less fluid utilization to make this as
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minimally morbid as possible for his, for his elbow, which, which
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there's a lot of stuff that we do in surgery that has been
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geared towards taking care of the soft tissues, being as kind
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and gentle to the soft tissue as possible.
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Because for somebody like Scubal or some, these timelines really
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matter, you know, and, and, and we're looking at how quickly
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everybody's always asking when can he start throwing?
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When's he going to be back on the bump?
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And these, these little things that we do interoperatively, I
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think matter. And so the nanoscope allows for
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a smaller incision, smaller poke hole.
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There's less fluid that runs through the joint.
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As a result of that, there's going to be less local
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inflammation inside the joint. And that's after the surgery.
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That's what you do, is you're trying to get the joint to
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settle down, get the range of motion back.
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The joint has now become quiet and you're ramping up your
9:16
strengthening. Then you can start from a
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throwing standpoint. And so the goal is trying to
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essentially cut down the timeline for that.
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But I think this unique new Arthroscopy equipment does serve
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an important role. We're trying to minimize some
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morbidity and there's other things that you do with regards
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to managing your fluid pressure and fluid volumes and being very
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surgically efficient. So trying to not switch portal
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sites and because every time you're bringing the instrument
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in and out of the elbow, you're causing some even just low grade
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surgical trauma while doing that.
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And so I think these are the things that we think about when
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we're trying to to really be as efficient, as effective as
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possible for our patients. From what I understand in my
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very minimal research, but of course I can use Google and AI
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like anyone else can, it sounds like this nanoscope technology
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in some cases can help with diagnostics beyond just the
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actual operation. If an MRI doesn't give us the
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perfect view, in this case with Scooble, do you think beyond
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trying to minimize the morbidity?
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I like that phrasing from you a lot by the way, that that makes
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sense. I think the layperson can grasp
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that and that's kind of how I view myself in this situation.
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Do you think they elected to use that technology also because
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they had a good idea of what the case was that they were going
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into? From my understanding, it seems
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like you might hit some limitations with the nanoscope
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on the other side. Like the size is great because
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you're minimizing the trauma and the fluidity and the morbid
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morbidity of the whole situation.
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But also because of the size, you might not be able to perform
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the same tasks that traditional arthroscopic tools may allow
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for. Is that fair to say from?
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Just the basic research I did. No, I think those are good
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points. And I think they even mentioned
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that in the article that was published that, you know, Doctor
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Ella Trash had spoken about this as a tool, but that he'd have,
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look, you'd have all the other stuff available.
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If he couldn't access the compartment they need to or
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effectively execute what he was trying to do, we'd have all the
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stuff, you know, available to him.
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But couple points I mean, you bring up, yes, there's a role
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for utilizing this technology in other situations that we haven't
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done. So diagnostic Arthroscopy can be
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done in a less invasive fashion. There are some now in office
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procedures that can be done outside of the operating room
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that may be, there are ways to address meniscus or other
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pathologies in a treatment setting, you know, not just
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purely diagnostic. The decrease morbidity that
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associated with that's associated with that is helpful.
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So there's other utilizations. I think this type of stuff is
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just going to, it's just going to grow in its application over
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time. To your point, there's there are
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some limitations. However, smaller instrumentation
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I think is likely the future here just from an access
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standpoint. I, I think you have more issues
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surgically sometimes accessing things because of size of
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instrumentation and tightness of compartments.
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I think that's often a bigger problem.
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So I think there's probably going to be an increasing role
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and smaller instrumentation, flexible instrumentation, other
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things. I think that's probably the next
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wave of surgical intervention. But the classic is the classic
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cuz it works though the OG works and so you can have it as a
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backup, but I think there's gonna be kind of an increasing
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role in some of this stuff before.
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Young athletes who have an elbow injury go in asking for the same
12:40
procedure as Scubal. What do you think the general
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population needs to understand? It sounds like you've hit on a
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couple of these points. Like we know we know this was a
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bone spur situation, or at least that's what's being documented
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to us. It was posterior compartment.
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What, what hesitations or I guess what knowledge do you
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encourage the the individual to have the potential patient to
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have before they walk into an office with a hurt elbow and
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say, just give me what you did to school.
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Look, it's a very valid question.
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I think the biggest, the biggest thing is that you got to, you've
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got to be confident in the diagnosis and the treatment plan
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is tailored by somebody who's doing this a lot.
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And it's, it's really thoughtful because just even in this case
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here and again, we don't know any details, but whenever I see
13:32
a posterior compartment issue, it makes me broaden out first.
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It's easy to see a loose body in the back of the elbow and say,
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look, we got to get that loose body out of there.
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But that is really not the appropriate, you know, work up.
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And I'm sure that that's what he went through too as well.
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You know, you're getting in, you're getting a great physical
13:47
exam evaluating the, the, the ligament or prior graft
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immediately on the exam, trying to assess how, what proportion
13:55
of the symptoms are coming from the posterior compartment based
13:57
on off of bounce home testing. What's their overall motion look
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like looking at their imaging again, because you don't want to
14:03
treat a problem in isolation when really it's in the setting
14:07
of something else, right? It's in the setting of a
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ligament that is ailed or prior ligament tear or or an
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osteochondral lesion in the capital and something else.
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My point is you want to be comprehensive, you want to be
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thorough. And so as opposed to patients
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just going and seeking out technology because that's what
14:25
they want, I think they need to seek out expertise because the
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technology is a tool, is a tool, right?
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And I think it's a, it's a nice tool, it's a useful tool, but
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it's not the only way to do something.
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And there's been a lot of great surgery that has been done and
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continue to be done, not necessarily using that.
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And so I think you need to to seek out the expertise and not
14:44
necessarily the tool because I think that's what gets some
14:47
people in trouble. And we've seen that with UCL
14:49
repair and stuff too, right? People come in requesting repair
14:53
for various reasons. And it might not be the best
14:56
move for the patient. And so that's where I think you
14:59
got to, you got to be confident in here talking to you.
15:01
You got to arm yourself and educate yourself too as well.
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So then you're prepared to have the question, a conversation,
15:07
ask the questions that you want to ask, right?
15:09
And that's the best way to get your treatment, not necessarily
15:12
seeking a certain technology. So what it sounds like, if I can
15:17
kind of play translator here, what we need to do is address
15:22
the specific problem at hand. It's not that we're trying to
15:25
treat a symptom. And I'm glad you brought this up
15:28
a couple Times Now. You've mentioned in this case
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being able to address a loose body in based on our assumption.
15:35
Granted, we don't know anything specifically of what Scubal has
15:39
gone through. We don't know his history, we
15:41
don't know what the imaging presented, But we can assume
15:45
based on their course of action that there wasn't additional
15:49
gapping at the medial elbow. The UCL seems to be intact, the
15:53
flexor mask seems to be intact. So they were able to address a
15:57
very acute area as opposed to what what you have said now and
16:02
I'm grateful that you have addressed it is often times
16:05
these posterior issues. However, the pain manifests
16:10
often come from something that was born at the medial elbow.
16:16
So additional gapping at the medial elbow has then led to
16:19
compression on the posterior side.
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It's led to the banging, it's led to compression, bruising,
16:26
swelling, and a lot of time these osseophytes happen because
16:33
the medial elbow is unstable in some capacity, correct?
16:37
Yeah, I think look, you just can't live or work in isolation.
16:41
And that's, that's the medial elbow supports the posterior
16:44
compartment and vice versa. We talk about the flexor
16:47
pronator mass a lot, right? Flexor pronator mass sits on top
16:51
of the the ligament and we think about these injuries, you know,
16:54
not really just like a ligament injury.
16:56
It's really, it's like a flexor injury.
16:58
It's a ligament plus flexor complex.
17:01
Everything is interrelated. I just think it's important to
17:03
have a really holistic view of the thrower, of the the athlete
17:08
of the pathology. And that starts with a good
17:10
history and a good exam, honestly, and then the imaging
17:13
that obviously helps hone that in.
17:15
But I think that's why it's important to seek out expertise
17:18
and not necessarily technology, because like the expertise is
17:20
going to evolve. If they're really at the top of
17:22
the game, if they're really trying to push themselves to be
17:24
better, we're going to look for new technology.
17:26
We're going to look for new ways to do things to try and solve
17:28
clinical problems. I think from the patient's
17:30
standpoint, you just got to find somebody that that trusts and
17:33
has a good track record and really lives and breathes the
17:36
stuff. Speaking of evolutions, another
17:39
seemingly more basic one, rather than the introduction of an
17:43
entirely new technology of the nanoscope is the way that Mr. is
17:49
are now being performed on baseball players elbows or
17:52
really throwers elbows in general.
17:55
And that is commonly being discussed now as the Fever View.
17:59
So can you please take us through what a Fever View MRI
18:03
is? Yeah, so great question.
18:06
I'm a I'm a big fan of the fever view and utilize it routinely in
18:09
in practice Fever stands for flexion elbow valgus external
18:13
rotation. So it's a special MRI sequence
18:18
that was developed by Pam Lund. You go through your standard MRI
18:22
series, their sequences, and then you position them over a
18:25
bolster with a bolster underneath the elbow in a
18:28
sandbag over the wrist. And so it's applying A valgus
18:33
stressed the medial elbow and then the radiology tech when
18:37
they're setting up for the scan orients the planes so that it's
18:41
it's set up, it's a coronal series that goes through the
18:45
plane of the ligament. So it's not just the stress
18:48
view, but also they pause and readjust how they go through the
18:53
elbow. And it's specifically oriented
18:56
along the plane of the UCL. And so I think there's multiple
19:00
benefits to this study. I think the most important
19:03
benefit is that the view of the ligament is it's beautiful.
19:07
I mean, it's it when you reorient it in plane plus with
19:10
the stress applied, you really get a great view of the ligament
19:14
quality, its integrity. And sometimes you get these,
19:17
these tears that have let me back up.
19:21
The tears can happen to multiple multiple different types that
19:24
can tear fully off the bone, you know, distillate, the sublime
19:27
tubercle. They can, you know, tear fully
19:29
off the bone approximately off meet up with condol.
19:31
Sometimes you get these mid substance or delaminating tears
19:34
and there's a couple different variations along the way too.
19:38
The ones that tear off the bone that the ligaments totally blow
19:41
up. You can see that on your
19:42
standard traditional Mris and that's that's not always the
19:46
issue, but sometimes you get some of these delaminated tears
19:49
where it's just kind of split in the intrasubstance and the
19:52
tissue is still sitting on itself, kind of reapproximate
19:55
it. But then you put them in this
19:57
fever view and you put a little bit of stress in the medial
19:59
elbow and just that stress trying to tension the ligament
20:02
will show or expose some of these delaminations.
20:06
I think it just gives a really, really nice view of the ligament
20:09
for for understanding in their study.
20:12
When Pam Lung described the sequence they they showed some
20:15
of the diagnostic data with regards amongst multiple
20:18
radiologists on tear characteristics and and things.
20:21
Now there's another aside from being a pretty picture and a
20:25
great evaluation of the ligament itself, you also get some
20:29
objective data too about the medial joint space, like the
20:32
only human joint gapping. And that's the part for me that
20:37
is potentially very useful, but not all the time.
20:40
And the reason why is because if you don't know where the thrower
20:43
started, then it's it's hard to really make make much of the
20:47
number because we've seen throwers with a millimeter of
20:50
gapping and they're they're having pain.
20:51
They're still having pain on the level and have a hard time
20:53
throwing while they've had others that have had multiple
20:55
millimeters of gapping and still throwing in a very high level.
20:59
And so just like anywhere else, just like everybody's shoulder
21:03
stability feels different. Everybody has some element of
21:06
difference in their ACL exam. I think the medial elbow is
21:10
different, OK. And, and some people are a
21:12
little bit more LAX, while others are wound up a bit tight.
21:16
And we know from prior ultrasound data that the UCL is,
21:19
is not a static structure. It dynamically responds to
21:22
stress, right. And so we've seen from the Peach
21:25
Almers and their ultrasound data about how the ligament thickens
21:29
and becomes more LAX over the course of the season.
21:31
So there may be changes throughout the year with regards
21:34
to the fever review, right, beginning of the season versus
21:37
the end of the season and, and things.
21:38
So I if you have a baseline value of stress with joint
21:43
gapping, I think that's really helpful because then you can
21:44
say, look, it was .8mm and now it's 3 1/2, right.
21:48
That, that is something that you can then correlate and say,
21:51
look, your, your medial elbow is, is, is LAX and no longer
21:55
providing the stability to the medial joint.
21:58
However, if you don't know where they started, I think it's hard
22:00
to necessarily anchor on just a number.
22:02
But that's fine because I mean, again, most of this is history,
22:05
most of this is physical exam and then the imaging just kind
22:08
of takes us home. If you were given the right to,
22:13
I guess, create the rules for MRI diagnostics across the board
22:18
for the entire industry, would you force everyone to just do a
22:22
fever view if they're coming in with medial elbow pain?
22:25
Is there any purpose in not utilizing the fever view at this
22:28
point? Well, so it it is another
22:32
series, it's time in the scanner.
22:34
And so for some institutions, or especially if they're high
22:38
volume or they're trying to fit people in, that's another.
22:40
If you add up, if you're doing a whole bunch of elbow Mrs. the
22:42
day, that can add some time to it.
22:44
But and and you have to do it well, right.
22:47
To get this, to get this value from it, you have to do it well.
22:50
And like there are some poorly done fever views that come in.
22:54
You see them, you're like still out of the plain of the
22:57
ligament. That's not as beneficial as I'd
22:59
love to see it. So it still has to be done well.
23:02
But in general, though, I love it.
23:04
I love the data. Keith Meister really was sort of
23:08
early adopter here and it was one of the ones kind of was
23:11
talking about the utility of this.
23:12
And I think that's just continued to grow.
23:14
And I agree. I mean, I just, I love the view
23:16
of the ligament. I like having some of the
23:18
objective data too as as well. I'd like to see it if I can, but
23:22
not everybody comes in with that.
23:23
And and like we can still read Mris and and diagnose people
23:28
just like we always have, but I like it.
23:31
OK, yeah, I I know you can't, you can't say anything too
23:34
strict. Obviously people have to have
23:37
the the schooling or the teaching to get better at these
23:40
things. But again I.
23:41
I think a world does extrapolate.
23:43
Yeah, well done fee review is very helpful.
23:45
I don't think it's the end all be all, but I like having that
23:48
data. But again, if kids come in and
23:51
they've had an MRI done elsewhere and, and it's a well
23:55
done MRI and you know, it syncs up with the exam and I'm not
23:58
making everybody go redo it, but there are sometimes where they
24:02
come in and the MRI is maybe non diagnostic and their clinical
24:05
history and exam is more concerning.
24:07
And then that's absolutely, that's why I say, hey, look,
24:09
hey, we're going to repeat your MRI and in particular this time
24:11
we're going to do a special stress MRI in conjunction with
24:14
it that can be helpful here. And sometimes that will sort of
24:17
unmask some things that wasn't that weren't appreciated
24:20
previously. I believe we might have talked
24:23
about this way back when, but it's so hard not to discuss it
24:26
when we're Speaking of technology with kind of the
24:31
theme of don't fix it if it ain't broken.
24:34
Arthrogram just seems to be a fantastic way to diagnose
24:39
partial tears. It's been well documented in the
24:42
literature. What's the reason that with
24:45
newly developing MRI technologies, arthrogram, the
24:50
use of dye is able to kind of stay strong as our best
24:55
diagnostic tool for partial UCL injuries?
25:00
Yeah, You know, I think that the, it's a, it's an interesting
25:03
question. I'm I'm smirking because I'll
25:05
give you a little background in a second.
25:06
But to your point though, the literature would support
25:10
especially these partial, these partial sprains that the, the
25:14
dye improves the diagnostic ability of the study.
25:17
And that's because having to dye in the joint will sometimes
25:20
elevate that distal ligament. You'll see that classic T sign
25:23
if you Google image what that looks like.
25:25
And that's just some undercutting of the dye
25:27
underneath the distal ligament where it attaches to sublime
25:29
tubercle. You may not have appreciated
25:32
that on, on a, on a previous MRI.
25:35
I trained at HSS where Hollis Potter and the radiology
25:39
department there is, is very well respected, well
25:43
established. We never did arthrograms on any,
25:47
you know, it was kind of like that was just not the way
25:50
because the, the thought was with the way that, you know,
25:53
there's a couple unique ways that we did our Mris.
25:55
You have your fluid sensitive coronal drive through and then
25:58
you're proton density other series to show the anatomy
26:01
better. They felt like with a well done
26:04
MRI with good equipment and well, well protocol that you can
26:08
see all the stuff that you need to see.
26:10
And because the dye can sort of can kind of blur out some of the
26:13
other things, though sometimes the dye can overpower some peri
26:17
ligamentous edema or understanding kind of how much
26:21
the flexor is ailing. So for instance, if they put dye
26:24
in the joint, they've got a ligament and then extravasates
26:26
into the flexor, you can't really tell how much that's dye
26:28
versus some edema throughout the flexor.
26:30
So it's not perfect, but it does help diagnostic quality on some
26:34
of the partials and in some of the not as well done studies, if
26:39
that makes sense. It probably rate it probably
26:41
raises the floor, right. But I think at the ceiling of
26:44
well protocoled, well performed studies that are that are being
26:48
interpreted by folks that are either look at a bunch of Ucls
26:51
or radiologists that are musculoskeletons specifically
26:53
elbow. I think diagnostically over
26:56
there it's probably about probably about equivalent, if
26:58
that makes sense. No, they that's super helpful
27:01
because we are in a position where, as you know, athletes are
27:05
coming to us all the time, especially those with elbow
27:08
pain. That's why most of the time
27:10
they're seeking out Flex Pro Grip where they're trying to
27:13
figure out what to do diagnostically.
27:15
They don't have an answer for why their elbow hurts, and we
27:19
aren't in a position to provide medical advice.
27:21
But often times all we can do is rely on the literature, give
27:25
people the tools that we have access to or the studies we have
27:30
access to. And of course, we try to lean on
27:32
people like you as much as we possibly can.
27:35
But if they're not going to fly down and see you in Baton Rouge,
27:38
or they're not going to ship an MRA copy of a disk and send it
27:42
off your way, we're often trying to tell them what's going to
27:45
give them the best reads. I mean, that's education for us.
27:48
That's education for me. To your point, you don't know
27:51
where they're getting the study, you don't know what the quality
27:53
of the study you're going to get to.
27:54
And I think that's where the Arthur Grant could sometimes be
27:56
helpful for some of the variabilities in imaging
28:01
technique and quality, but it's not an absolute, but it, it can
28:06
be helpful. I think it's hard for the
28:08
position that you're talking about.
28:09
And obviously we've, we've seen some of these guys not in and I,
28:11
I love trying to help as best we can too.
28:14
But sometimes you see the MRI comes in, this is a, a poorly
28:18
done or non diagnostic MRI. And then you then you got to try
28:21
to help them get in the right direction and get another study
28:24
or get a get an exam. It's hard from the virtual
28:27
consult type of thing. And that's why you got to see
28:29
the player and examine them and and it's another data point
28:32
that's as important as anything. So we we've covered a couple
28:36
different diagnostic measures or new surgical tools.
28:39
We'll re anchor in the surgical space now, and that's kind of
28:45
now to talk about the popularity of hybrid reconstructions that
28:49
gets mentioned all the time here on the Lay Back podcast,
28:52
probably starting with a strange question again, asking you to
28:57
rewrite the way protocols are used across the board here.
29:01
If an individual meets the requirements for a full UCL
29:05
reconstruction, why wouldn't you just do a hybrid at this point?
29:10
So it's a good, it's a good question.
29:12
What I'll tell you is that the, the hybrid reconstructions are
29:16
rising in popularity. There's no doubt about that at
29:19
the at the kind of upper echelons of sport professional
29:22
level. And that's, that's really sort
29:24
of taken over over the last 10 years or so and continues to to
29:28
rise in popular. And a lot of that's done.
29:30
Look, we're, we're standing on the shoulders of giants and the
29:32
people that are continuing to innovate.
29:34
And Keith Meister has done, done a lot of work here with regards
29:37
to trying to address the revision problem.
29:41
That's really how it starts. I think it's probably helpful,
29:43
right? If you rewind and say, OK, well,
29:44
then why were we innovating on a surgery that's been pretty good.
29:49
And because I would say our historical lens of the surgery,
29:54
yes, it's been pretty good because guys previously this was
29:56
career, career ending and then we now had a, a tool that got
30:00
them back to restore careers. But like we've talked about
30:03
before, granularly looking at what does that mean to return?
30:08
We could always be better, right?
30:09
And yes, maybe they're returning to sport, but were they really
30:12
returning to their prior level of performance or their, their
30:16
desired level of performance? And that's a totally different
30:18
conversation. But at the same time, the game
30:21
has falls as well is rising in rate.
30:26
Pitch design era has really changed how how these guys train
30:31
and what pitching looks like. Like turn on the game from 1970
30:34
and look what it looked like and turn on the game from now.
30:36
And it's like, you know, you might think you're watching some
30:40
aliens play ball with just the Velo and the movement and
30:43
everything. But because of that, there's
30:45
been rising concern with regards to the longevity too as well of
30:50
some of the traditional instructions because you guys
30:52
are throwing harder and spin all the other factors.
30:55
And we know that revision surgery does not fare as well,
30:59
right. If you look at the return to
31:00
sport rates, there's a recent study over this past year that
31:03
also kind of re looked at it ends up being around the 70 ish
31:07
percent line. But if you're looking at return
31:10
the same level, you know, it's in the 50s performance stuff
31:15
probably. And Even so, we're not doing as
31:18
well as we as we would like to do in the revision setting.
31:21
And because of that, we've been focused on, OK, well, how do we
31:23
prevent, how are we trying to prevent revisions?
31:25
And that's where the hybrid sort of came to be.
31:28
And a lot of it was again, but you know, Doctor Meister and a
31:30
lot of you know, what he was doing and thinking and trying to
31:33
innovate there. Why shouldn't everybody get a
31:35
hybrid? I think that just goes back to
31:38
where is the data currently sitting and there's
31:41
biomechanical data that shows that the additional suture
31:44
augmentation reconstruction is biomechanically favorable at
31:48
time 0. So strength gapping and and
31:52
things like that, there are advantages to it.
31:54
The clinical data has not necessarily been shown yet
31:58
hasn't been well, I should say has not really been published
32:02
yet per SE. You know, there have been
32:03
clinical series that have been presented and there's certainly
32:06
a track record that we've seen kind of bear out in in the game
32:10
and in front of us. And so I think that over time as
32:13
more data than shows with the hybrid type reconstructions, our
32:17
return to support rates are where we where we think that we
32:20
are and our revision rates are trending in the right direction.
32:24
I think you're going to see more and more adoption.
32:25
Now that being said, there's a there's a push coming from the
32:30
game too as well. You know, guys are asking for it
32:33
too. They want this, it's stronger.
32:35
You know, biomechanically it says it's stronger.
32:36
So I want something stronger. And so guys are requesting it
32:39
too. And so I think that's another
32:41
factor that sort of pushes to to innovate into the evolution of
32:46
this surgery. I do a lot of hybrids because I
32:49
think there's I think there's a lot of benefits from taking this
32:52
multi layered approach. Like if they've got ligament
32:54
tissue there, I'm going to go ahead and repair it back down to
32:56
the bone. Makes sense, right?
32:58
And then if we're going to do a ligament repair, we're going to
33:01
reinforce that with the internal brace to give that a support
33:04
while that native tissue is healing and then putting a graft
33:06
over the top. And I think there's a there's
33:08
benefits to the various timelines of native tissue
33:12
healing while being supported and then a graft reincorporation
33:17
and the ligamatization process of the of the graft occurs over
33:21
over a longer timeline. So I think there there are
33:24
biomechanical advantages, there are likely some biologic
33:27
advantages that inherently makes sense but have not been shown
33:30
and the clinical advantages I think we're seeing but have not
33:32
necessarily been published yet. So long winded answer to say, I
33:35
think we're early on the curve, but you're going to see it more
33:37
and more. But the answer is why not?
33:39
Because look, there's sometimes where too strong is not
33:41
necessarily the answer, right. There's times in history where
33:44
we've done things that are too stiff or too strong and there
33:49
are some downsides to that. I don't think that's the case
33:52
here, but that's the people that are sort of hesitant to embrace
33:56
this technique are probably just waiting to see some more data.
34:00
Potentially strange question here from again, someone not in
34:03
the medical field, but someone that tries to consume a lot of
34:06
information. I have heard in very small camps
34:11
in apprehension surrounding load, not necessarily going
34:15
through the native tissue or the new ligament that you put in, so
34:20
the tendon graft, but the internal brace being so strong
34:25
that the load is then being handled by the internal brace or
34:31
the scaffolding around that tendon graft.
34:34
Are those apprehensions valid? Why might someone be concerned
34:40
in that setting? As you said there, there aren't
34:43
clinical trials at this point with longitudinal data to look
34:47
at what might actually happen to the replaced ligament.
34:51
But before I just continue to talk out of my ass, is there a
34:54
reason for that fear? Well, no, there's, I mean it's
34:57
definitely valid right there. Historically there have been
35:01
artificial ligament type implants in the past that have
35:05
not had good clinical track record for foreign body
35:09
reactions or other things. Now, now this technology has
35:12
been utilized elsewhere. It started in the ankle and it's
35:15
being utilized in other forms of the body and, and, and have not
35:20
seen those same types of foreign body reactions.
35:23
But there is there a couple of a couple of concerns that start
35:27
from joint loading and can you just over compress the joint and
35:32
and point loader or increase the load of the media level if it's
35:34
too tight? That's been tested at least in
35:37
the repair setting. You know, Doctor Dugas and the
35:40
ASMI folks, they tested that in a UCL repair model and shown
35:43
that like you don't, you don't over tighten or overcompress
35:47
the, the medial side. But that's sort of one of the
35:49
concerns, the concern for stress shielding the underlying healing
35:53
structures is also certainly valid too.
35:56
And we see that in, in other areas of the of the body that
35:59
the problem with that is it's very hard to test.
36:01
And we don't really have good load bearing, load sharing, load
36:05
stress shielding type models that you can test like in, you
36:08
know, in an animal setting. That's just something clinically
36:10
you have to, you have to follow over time.
36:13
But there's so many variabilities in how people do
36:14
this. It's hard to really extrapolate
36:16
that. But I think that's a valid
36:18
concern because of that though, like the way I do this, and I
36:21
think the way some others do this too as well, is in the
36:24
order of tensioning. And you're trying to make sure
36:27
that your underlying tissues are still seeing the load and that
36:30
it's not all picked up by the internal brace or by the suture.
36:33
So for example, in a hybrid, I'll repair the ligament and
36:36
then bring the as you bring the brace and the graft up into the
36:39
tunnels will tie the brace down 1st and then tie the graph.
36:45
So the brace essentially sets the joint line and then when you
36:48
tension the graph, that's the last thing being tensioned.
36:51
So you know that the graft is seeing stress because if you
36:54
were to theoretically tension that brace second and a lot
36:58
tighter then the brace, all the stress is seeing the, you know,
37:01
is is being seen by the brace before it's seen by the by the
37:04
graft. If that makes if that makes
37:06
sense as I describe it. But I think those are all very
37:09
valid, you know, valid concerns. And that's also why technically
37:12
we do certain things in a certain manner trying to
37:14
alleviate some of those concerns.
37:16
But look, the, it's the structure of the suture.
37:18
There's some, there's some creep that's going to happen in there
37:21
too as well. And it's not just a, it's not
37:24
just a static structure too. There's at least some lab, you
37:29
know, Gus Mazzaga's lab, they demonstrated that with the fiber
37:33
tape, which is what it is, putting it in a milieu of some
37:36
of the stuff you'd see at the time of surgery, right?
37:38
Some of the, with bone tunnels and other things.
37:40
They put DMAC and PRP and, and some other factors around the
37:44
fiber tape and they show that there was there was increase
37:48
sort of adhesion of some of the osteocytes and ligaments.
37:52
All these, all these cell types that are that are going to play
37:55
a role in the healing. And so clinically though, I
37:58
think we see some of that as well.
38:00
Because if you go back into revision setting and whether
38:03
you're revising a repair to a reconstruction or doing a
38:06
revision of a prior hybrid, when you go down and, and you get to
38:10
the area of the fiber tape, there's often just a lot of
38:13
thick tissue around it. And, and that may be
38:17
demonstrating that there is also a biologic event that happens
38:19
around the tape too as well with regards to adhesion of some of
38:23
the cells. Long winded answer.
38:25
There are so still some concerns, but I think there's
38:28
increasing utilization and there's some good evidence
38:30
that's building for it. It's just not all packaged up,
38:33
but a lot of the athletes aren't, aren't willing to wait
38:36
for the whole package, right, because their career is in the
38:39
now and their concerns are regards to timelines with
38:43
regards to revision rates and all these all these other
38:45
factors. And so I educate them in my
38:48
office like, hey, like this is how we're doing it for your
38:50
tear. I would do a hybrid
38:52
reconstruction. These are, I think the potential
38:54
advantages to it. These are the some of the
38:55
downsides. And you know, we make an
38:57
informed decision with regards to that, but long winded answer,
39:00
but I think you're going to it's not going to win anytime soon.
39:02
Clarifying question here. When you mention those biologic
39:07
events at the site, are you viewing those as a positive
39:13
response? Are we, are we pleased with that
39:15
from the surgical standpoint? Yeah, it's a good question.
39:20
And generally, generally I am because you're, you're asking
39:24
for that tissue to incorporate, you're asking for the tissue to
39:28
mature and you know that you, you need some durable tissue on
39:31
the medial elbow to withstand the stresses that we're asking
39:33
of it now. But to your, to your point,
39:36
though, sometimes you can have an overabundance of healing,
39:39
right? We see in other place you get
39:41
too stiff, right? You do a stability surgery and
39:43
then the knee or the shoulders too stiff and then you have to
39:46
work through that or maybe do something else.
39:48
So there's probably a Goldilocks there.
39:51
However, in general, I think it's likely beneficial.
39:54
And you said to my point, I actually was more at the more
39:59
from the point of view of just a extreme search for knowledge.
40:04
Like when I hear there's a biological event occurring, to
40:07
me, it's like that's exciting. It means there's some sort of
40:11
healing that is happening. Now I I don't know the
40:14
ramifications of that healing, but to me it at least sounds
40:17
like the. The brace is being accepted as
40:22
biological tissue at that point or the body is actually trying
40:25
to utilize it as kind of this butcher scene system as opposed
40:30
to a true foreign body. We think it's helpful, but we
40:33
don't really, we don't, we don't totally know that, but we think
40:35
it is, it is helpful. And that's also, you know, been
40:38
shown now. And then if you take the next
40:40
step with some of these, when you have retails or some of
40:43
these injuries that have occurred in the, in the setting
40:46
of a prior reconstruction or a prior hybrid, often times you
40:49
have good tissue available to then do a graft repair.
40:54
So to go and repair the underlying tissue back down the
40:56
bone and thence and then support that with a suture augmentation
41:00
or internal brace. And so I think having tissue
41:03
there to work with is, is is more helpful than not typically.
41:07
This is fascinating to me. I I feel like I'm getting to
41:11
nerd out. It's really exciting.
41:13
This is the stuff that keeps us, that makes us excited.
41:15
And, and I had the opportunity when I was in in Dallas a couple
41:19
weeks ago, LSU gymnastics when they're competing from national
41:21
gym. I went and spent some time with
41:22
doctor Meister over there on, on a Wednesday and, and just got to
41:28
sit, sit down and, and talk about this stuff that, that he's
41:32
fired up about. And that, and we had to, we sat
41:34
over, you know, in the surgical lounge and just nerd out about
41:38
this, this stuff, nerd out about the flexure, the flexure tendon,
41:42
about the ligament, because I think that's what you, that's
41:45
what you want is like you want people that are going to bed at
41:48
night, putting their hand on the pillow and trying to think about
41:50
how to do this better, right? We got to be better than what we
41:53
are. Sometimes it's you wake up at
41:55
2:00 AM, you're like, you know what, I think we need to look at
41:57
this. I think we got to be a little
41:58
better with how we're handling this part of the tissue.
42:01
And some of the innovation happens there when you're not,
42:03
when you're not, you're not sitting there thinking about it,
42:05
but because you're, you're obsessed by it or it's, it's
42:08
really part of what you care about and part of, you know,
42:11
just you internalize this pursuit that it happens at
42:13
random moments. And so I think that's, that's
42:16
the kind of stuff that you want to see.
42:17
And that's why I love talking to you guys too, because you live
42:19
and breathe this as well. And we have different
42:22
perspectives and different viewpoints of it.
42:25
And I think we can learn a lot from each other.
42:27
The more we talk about this, the more we learn from each other.
42:30
I know that was the theme the first time we had you on was
42:33
talking about the collaboration that actually needs to occur to
42:36
further improve the recovery rate.
42:38
So we we don't need to beat a dead horse on that one.
42:40
But I love that you are passionate about that in
42:43
bringing in rehab professionals. But what I want to ask is if
42:47
there's any dirt that you can share from the the little coffee
42:51
talk that you and Doctor Meister might have had because I that's
42:55
a true meeting of the minds. Is there anything that the
42:57
industry can can accept a little teaser on or a little breadcrumb
43:02
out here in the atmosphere of what might be to come next?
43:05
Like what is keeping you guys up at night?
43:09
No, what I think, I think that you know, he's obviously brought
43:13
a lot of interest to the flexor and and that was a lot of our
43:17
conversation was focused on the relationship between the flexor
43:20
and the ligament. I think that that's just
43:21
becoming a bigger and bigger point of emphasis.
43:24
And these, a lot of these injuries are really flexor
43:28
injuries. You know, we've been talking
43:29
about the ligament, the ligament ligament for years, but it's
43:33
really, it's the ligament flexor complex.
43:35
And there's some, there's some studies in Japan that have shown
43:39
histologically that relationship between the, the common flexor
43:43
tendon and the proximal ligament.
43:45
And, and I just think that that's where that's where the
43:48
future is probably is how do we, how do we address the flexor?
43:52
How do we support the flexor? That's part of what you guys are
43:54
doing too. How do we test the flexor?
43:56
How do we train the flexor? I think that this is, there's
43:58
going to be more and more and more emphasis on recognizing,
44:03
addressing, preventing flexure issues because it's just just as
44:06
important as the ligament to as well.
44:09
So, but like, like I was grateful for the opportunity to
44:11
spend some time and, and, and pick his brain and learn, learn
44:14
a bunch too. But that's where that was a lot
44:16
of the take words like how do we handle the flexure and and I
44:19
think that'll be a point of emphasis that's growing over
44:21
time. This just popped in my head.
44:23
When you kind of bring up what we do in the relationship that
44:27
we share. Do you think that there is a
44:29
place in the examination room, for instance, that you're
44:33
sitting in right now to bring in more objective testing in the
44:39
like the true medical side? Because right now it seems like
44:41
the majority of objective testing, aside from the
44:45
diagnostics, the the actual studies that you talked about
44:48
earlier, nanoscope, MRI, those kind of things, is there a point
44:52
to bring more data actually into the medical examination room?
44:56
I mean, for sure, I'm a huge proponent of that.
44:58
Now, whether it's tested in the room per SE or if it's part of
45:02
the work up as they're presenting for their
45:05
appointment, I think it's a different conversation.
45:07
But absolutely, I'm all for having more data, having
45:11
objective data over some of you know, some of the other aspects
45:15
of clinical exam doesn't replace everything.
45:17
But like, for example, you know, some of the therapists that I
45:20
work with very frequently on my throwers, like they know if I
45:23
got somebody coming in, I will get, I'll get a text message
45:26
like hey, so and so see you later today.
45:28
Here's some of their latest isokinetic testing.
45:30
Here's shoulder motion, we assess their strength.
45:33
Here's their latest flexure pronator numbers as part of
45:35
that's almost, that's the history for me.
45:38
So I go to, I go know they're in the room.
45:40
My staff comes out and says, hey, so and so's back there.
45:43
He feels pretty good. I pull up the text message, I
45:45
start flipping through numbers and I look and realize like,
45:47
hey, he's he's still lacking. He's made some backgrounds on
45:50
his total arc of motion for a shoulder, but he's still lacking
45:53
based off of where we knew his baseline was.
45:55
Test strength is improving. Not quite where we want it to
45:58
be, but then they can come back. And I think the athletes
46:00
appreciate that too, because you can have a conversation that
46:03
evolves from how are you? I'm good, OK, you look good
46:06
versus versus how are you? I'm getting better.
46:09
Yeah, I can see that your strength is up 10%.
46:12
You're still not quite where we were previously, but we're
46:14
making progress. And then they see that as a
46:16
challenge, as a homework. You've got some objective
46:19
numbers where they can grasp and and you're not just necessarily
46:23
the bad guy saying you're not quite ready.
46:25
It's more of a team that just says, hey, look, here's where we
46:28
are. We know what the numbers are.
46:29
We know where you can be or where you've been and let's just
46:32
take a couple more weeks. And I think it's really helpful.
46:35
So I'm all for more data and I think that scenario is great if
46:38
you have it set up. But that's all.
46:39
Not always practical though. Well, I, I appreciate you
46:42
sharing that. Like that stuff excites me that
46:44
that stuff really excites me because that is how we can
46:48
continue to be involved and I think grow as an industry
46:51
together, right. It it's, I hate when we're stuck
46:54
in silos. I never want to be in silos.
46:56
The only way that we're ever going to chip away at this
46:58
problem is if we're arm in arm trying to March towards the same
47:02
goal. But as we near the top of the
47:05
hour here, we're we're kind of coming to a close with what we
47:09
have in our schedules. What have we missed today?
47:12
What else is exciting you or what's on the horizon that you
47:16
can share for us? We could do this all day,
47:20
unfortunately that the the timer's winding down.
47:22
But I think that we're just going to continue to evolve.
47:25
And I think that there are multiple directions in which
47:27
this is going to go. I think we're going to continue
47:30
to understand the implications of the of training the flexor,
47:35
assessing the flexor, training the flexor.
47:37
I think that surgically we're going to see the hybrid data
47:42
over time. I think it'd be interesting to
47:45
then to do what we've done in the past with everything else,
47:47
right? Seeing them return to sports
47:48
stuff and seeing the performance based things, how advanced
47:51
analytics are evolving on the return of what those timelines
47:54
and the times to recovery look like with the hybrid.
47:57
I think there's also a question about can we improve the biology
48:01
that we're working with too? Like there's a lot of
48:04
orthopedics where our implants are strong in our suture
48:06
materials and all this stuff is stronger, stronger, stronger,
48:09
stronger, stronger. But that's not necessarily where
48:12
the delta has to be. That's not where the next change
48:15
has to be. And some of the it's the biology
48:17
aspect and there is some interest in pursuit and other
48:21
area. For instance, in the rotator
48:23
cuff, we're mainly focused on how do we get this thing to
48:25
heal, How do we encourage the healing environment from the
48:28
tendon back down to the bone in the ACL.
48:31
There's also some interest in this or stuff we can do the
48:33
tunnels to make things incorporate faster.
48:35
That's still early. We're not really, we haven't
48:37
seen definitive data, but there's interest in some early
48:40
data there. I think we're going to see some
48:42
of that as well with regards to the UCL.
48:45
Is there a way that we can influence the underlying, you
48:49
know, healing the biology of the ligament in the tunnel, you
48:53
know, attaching to the bone? Is that the types of switching
48:56
materials that you're using, the way that you prepare the bone?
48:59
Is there stuff that we need to be putting in the tunnels?
49:01
And again, that's, that's far ahead of any, any evidence per
49:05
SE. But I think that's where you're
49:07
going to see some, some evolution is trying to address
49:10
the biology. And, and I think you're going to
49:12
continue this to, to see this, this dance between performance
49:17
and, and prevention. And how do we support throwers
49:20
that are going to continue to go and they're going to continue to
49:23
redline and push the boundaries. And we're going to see guys
49:26
throwing harder and harder and, and spin rates just doing what
49:29
they're doing year over year. And we got to figure out how do
49:32
we, how do we recognize intervene without, without
49:38
necessarily getting in the way of guys, you know, how do we
49:41
support them from doing what they want to do?
49:43
Intervening when we know that there's going to or when we
49:45
worry they're at higher risk of an issue, but also not affecting
49:49
them from doing stuff that they love to do.
49:50
And that's that's an art and that's going to continue to
49:52
evolve over time. That's a fantastic exclamation
49:55
point. I went back on some notes that I
49:57
had and like, oh, shoot, I didn't ask that question.
49:59
I didn't ask that one. But as you said, this is
50:02
something that we could do all day.
50:04
So maybe we'll, maybe we'll have you on again sooner than 100
50:08
episode gap and we'll, we'll visit some.
50:11
We can do it by 174. I'm I'll come on anytime.
50:16
I'll talk about this stuff day or night.
50:19
I think it helps everybody. I think it helps for patients to
50:23
be educated, helps for me to hear where some of the questions
50:26
are going. I just think it's good for
50:27
everybody. I'll be on anytime.
50:29
Well, I appreciate that and I'm going to take that as gospel.
50:33
I'm going to hold you to it. I'm probably going to call you
50:36
here at 3:00 AM. I'm going to be at a loss not
50:39
know what to do. Let's do it, Matt.
50:41
Like we we need a solution in episode right now.
50:45
Right now I I can't see, but thank.
50:48
Thank you so much again for your time today.
50:50
Taking it out of the busy schedule.
50:51
Hopefully the Tigers can get something done here in the SEC
50:54
tournament for baseball. Softball is on another great run
50:59
and of course the track and field program is amazing at LSU
51:03
as well. And if I'm not mistaken, it's
51:06
also championship season for them so.
51:09
A. Lot of exciting stuff going on
51:12
in Baton Rouge right now and it's awesome that you get to be
51:14
a part of it. So best of luck to you and the
51:16
Tigers. Thanks again.
51:18
And of course, to everyone out there, thanks for laying back
51:21
with us.