Well, I guess we can start. I have a real distinguished faculty here. I'm Ed Bernanke, professor of medicine at Johns Hopkins and an ACOM fellow. The session is entitled Clinical Aspects of Knee Injuries, but we've expanded it, unbeknownst to the folks planning, to shoulder injuries also. So we're going to split it up into a clinical piece that Dr. Nick Sormas is going to handle and he'll get into the clinical details, anatomy, physiology, et cetera. And then we're going to be doing two papers that are epidemiologic, but in essence are focused on knee and shoulder disorders in the workers' comp world. Our first speaker is Nick Sormas. Dr. Sormas received his medical degree from Georgetown University. He began postgraduate training in internal medicine at Penn State, but transferred to George Washington University and completed an orthopedic residency program at GW. He moved to Austin in 1983 and began clinical practice of orthopedics in a multi-specialty group. Three years later, he founded the largest orthopedic specialty group, the Southwest Orthopedic Group, in Austin. In 1983, he was appointed medical consultant and medical director of Texas Mutual Insurance Company. In the mid-'90s, he began teaching, accepting teaching appointments and was appointed to the adjunct faculty at a number of Texas medical schools, and we were lucky enough to get him at Johns Hopkins later on. But University of Texas Medical Branch, UT Tyler, UT Houston, Dell Medical School, as well as now Johns Hopkins University. In 2016, he retired from clinical practice but maintained his position with Texas Mutual Insurance Company. And this role has allowed him to establish centers of excellence for the care of injured workers throughout the state of Texas. For the last seven years, he has been an active member of our divisions at Johns Hopkins Workers' Comp Research Group, and he is the lead author and contributing author on 17 peer-reviewed papers. And at the end, I'd like him to talk about the support of Texas Mutual for the Occupational Medicine residency programs in the state of Texas. And here we are. Next. Thank you, Ed. Well, maybe I'll start out that way. What I actively do now is a medical director of a carrier in the state of Texas, which is probably one of the largest. I think California is the only carrier larger than us in the nation. But we've decided occupational medicine, duh, is really important to workers' compensation. So what we're doing now, we have for the last three years, is University of Texas, we sponsor some residents, meaning we pay for their salary. And that gets me in front of the occupational medicine residents three or four times a year. And then the UT programs at Houston, the UT program at Tyler, Texas, and this, in the next couple of years, the family practice programs all get together for one day, and I get to teach them a little bit about the lost art of medicine, and that's the physical exam diagnosis for musculoskeletal injuries, which we think at Texas Mutual is really important since 90% of all work comp claims have a musculoskeletal basis. So that's what we've been trying to do, and we intend to expand that further. It's worked so well, it's worked so well, that we're going to try and expand that now to probably the family practice and the general practice programs, and maybe even the nurse practitioner programs and the PA programs in the state of Texas. If you're really from the West Coast, we don't care, but if you're really from Texas, then it's really important to us that you get trained right, nor good morning, nor you're late, one of the residents. Well, this morning, let's get started a little bit. We're going to present two papers, but before we get there, since this audience is so disparate in our training, but I wanted to bring everybody up to the same level about what we're going to talk about today, and that's the first paper is going to be our knee paper. Conflicts? I have none. So we're going to talk about the knee today, and our paper is really about meniscectomy and knee replacement. So what is a meniscus? If you remember back way back when, 101, anatomy, meniscus is not something new. Ancient Greeks knew about it, and it's from the Greek word meniscus, it means crescent, and that's just because of what they look like. It is fibrocartilage. You have fibrocartilage, you have meniscus all over your body. You have them in your knee, of course, everybody knows those, but you have them in your wrist, your AC joint, your sternoclavicular joint, and even in your TMJ joint, you have meniscus as well. Your knee, the one we're going to talk about today, your right knee has two meniscus, medial lateral. Why is that important? Anatomically, it's important because only the outer one-third, as you get older, has vascular supply, and without vascular supply, ain't nothing heal in the body. So if you tear a meniscus in the inner two-thirds of the meniscus, it never will heal. It's torn for life. Or if you have a friendly orthopedist, it's in the garbage later in life. So what is the function of a meniscus? To disperse the load, so you don't have a femur on top of a tibia, putting 180 pounds, well, this is America, 220 pounds on your knee joint. It disperses the weight bearing of the joint. It also provides stability to the knee, and very, very important for nutrition to your articular cartilage. This is what you look like on the inside. This is your femur up top, your tibia down below, and those sky blue things are your meniscus, little crescent fibrocartilage. They can tear. They do tear. They tear as you age, and they tear when you play football, baseball, basketball, and cocky. And this is the way they tear. There's only about six or seven different ways they tear. A lot of these are degenerative. You get them from walking around on it for 40, 60, 80 years. They just tear naturally. The only one that really tears is the one on the, I think it's on your left, the middle. That's a radial tear. Those are the ones that are traumatic. Those are the ones where I sit at Texas Mutual as a medical director. Those are the ones I like to see that we accept for a work-related injury. Half of you in this room, not that row with all the residents, but half of you in this room have some kind of tear in those other shape, way, or forms. Probably the most important thing is not your MRI, but the most important thing is your physical exam of the knee. And that's what we have forgotten. That's what we try and teach, and that's what I look at everybody's medical notes to see if this is correlative or not correlative, since it's so common otherwise. Think back hard. You think what the McMurray test was. It's been around since Dr. McMurray invented it back almost 100 years ago, and it's still a very important today, probably one of the most important provocative tests you can do. Joint line tenderness, another physical exam finding. You know where the meniscus is. I just showed you that sky blue thing. You point on it with your, poke on it with your finger. If that hurts, that's a sign of a meniscal tear. A drop test. These are all physical exam findings, inability to straighten the knee, and these are all the physical exam findings that I look for, and hopefully you put in your physical exam notes so I know in Texas, Texas Mutual has to buy this claim, that it's not just an ordinary disease of life being presented while you're on the clock at work. If you want a quick referral site, this website, which we're supposed to be able to click to, has an entire, you can get these slides, is that correct? The slides will be downloaded. This website here will take you to a physical exam quickie. In two minutes, you can go to that website, click on meniscus, the body part there, and in two minutes, seven seconds I think, is the complete meniscal exam for the knee. So going into the room, you can refresh yourself, or coming out of the room, God, did that guy have a meniscus tear or not? This is what you want to put in your notes to reaffirm or refute that this meniscus tear is work-related. That website has been up now for about five years, and it's not just for the knee. From a body part that's important in orthopedics, not zebras, but all the horses that you guys are going to see every day in your clinic, and that has over one million hits on YouTube. That's how many people are using it. The concentra clinics, the Texas medical clinics, Care Now, all over the nation, they're using this to train their physicians in their office. Very popular, and it's a quick two-minute review of what you should remember from 101 school and medical school. So the historical perspective of meniscus. The first meniscus tear was really described in 1731 by an anatomic dissection. The meniscal surgery, first meniscal surgery recorded really was for a big, loose body. Nobody had imaging back then, so he had a loose body the size of a marble or a walnut floating around in the knee, and lo and behold, when they took that out, they saw a meniscus tear. And it was probably for 100 years, no planned meniscus surgery was done anymore. But in the 1920s, with the advent of modern-day orthopedics, it was after the First World War that modern-day orthopedics began, that's when people started paying attention to more surgery and more intervention of all body parts, not just the meniscus. 1950s and 1960s, those 20 years was the era of open arthrotomy, two, two-and-a-half, three-inch incision on the knee, and that was done with the old smiley knife to take the meniscus out. A little bitty tear, a little bitty tear involving five to 10% of the meniscus. Back in the 50s and 60s, the whole thing went in the garbage can. We know that's wrong nowadays, but we did it for 20 years. 1970s, I'll show you, was the advent of the arthroscopy of the knee, the first joint in the body to have that. And from the 1980s to date, that arthroscopy is still being refined today. As opposed to all the other names, like I showed you before, meniscus and Hippocrates, it goes back to, this was not Dr. Smiley with the knife we took the meniscus out with. Smiley is spelled a little bit differently. And interestingly enough, even though these smiley knives have not been used, morning Dahlia, you're late Dahlia, even though these smiley knives have not been used in North America or modern day medicine in 40 years, you can still buy them on Amazon today, which I was really surprised at. I've got my old smiley knife from 40 years ago still, but you can get a new one today. So what's arthroscopy? Well, it was invented by Dr. ... The Japanese really invented it and refined it. The Takagi in Tokyo is credited for the first one, first arthroscopy to be done on the knee, and that was 1990. And all he did was use a cystoscope. That's what he put in the knee joint. 1920s, a fellow named Bircher said, I got a better scope, let's use the thoracolaparoscope. He put that in there. Those were 10 millimeter scopes, huge, quarter inch in diameter. And then a fellow named Watanabe actually is the father of modern day arthroscopy for you name it in a joint, but he started in the knee and that was the 1970s. And how did it come over across the Pacific Ocean? A fellow named Dr. Robert Jackson, a Canadian fellow and orthopedist decided he wanted to go to Japan. He spent a year studying with Watanabe and he brought it back to North America. Canada, it came quickly across the border, just like everybody is nowadays, and it came quickly across the border and America really has refined it. Dr. Jackson, for what he did, was recognized in Sports Illustrated Magazine as the 37th out of 40 most important people in sports today. This is what it looks like in real life. There's your normal meniscus. That's what you look like when you're 16, 18 years old. And there's what you look like when you're 40, 60 years old. And then here's what we, that's what a torn meniscus looks like after we take it out on the left. And this is, I put this to remind me, this is our next talk about, our talk today is going to be on meniscectomy, taking it out. This is called a meniscoraphy. We think we're so good nowadays we can fix them and we stitch them together. So our next paper next year, if come back again, is going to be on what we find after we fix a meniscus. Thank you. And we probably could hold the questions until the end. I'm sure you're burning with a question for Nick, but anyway. Our next speaker is Grant Tao. He's a professor of medicine and the research director of the Division of Occupational and Environmental Medicine at Johns Hopkins University School of Medicine. He has taught occupational and environmental epi for the last 20 years in the Department of Epidemiology at the Bloomberg School of Public Health. His major research interests are long-term and short-term health effects of occupational and environmental exposures, mainly radiation. His recent focus is the measurement of attributes that may be used to construct models that predict time loss from work and ultimate workers' comp costs amongst workers' comp claimants. He has been on the JOEM editorial board since 2020. Dr. Tao? Thank you. Let me hold on, get this load up. Okay. Our second presentation is based on one of our recently published paper at JOEM, trying to answer a question whether prior meniscectomy is associated with a later on total knee replacement among injured workers covered by nationwide works comp insurance carry. We don't have conflict of interest to disclose. And Medicare and Medicaid Part B data indicate there's almost half a million TKA performed in 2019, just one year, and increasing very quickly. So this is numerate data without a denominator, but it's still eye-catching. And meniscectomy in general population linked to increased progression rate to symptomatic osteoarthritis and also the risk of TKA. So this study, excuse me, trying to evaluate the relationship or association between these two procedures using the works comp data. So we used 29 surgical CPT code to have identified 17,247 last time claims with knee injuries. And the data collection ended on the end of 2022, so that all claim had at least five year or four year follow-up. So the average follow-up time is 10.8 years. So we also use CPT code to define the meniscectomy and total knee replacement. So descriptive statistics were used to describe this distribution of the two procedures by time and the demographics. And we also analyzed the day between the two procedures and also the days post-injury. And finally, we used the logistic regression to quantify the risk of TKA associated with prior meniscectomy controlling for available covariate. So this table shows the trend of the meniscectomy and the total knee replacement over time. And you could see the meniscectomy actually slightly decreased from the 39% to 36% slightly. But the TKA percentage is steady around 2.4 on average. You hardly to see an increase or decrease. This table shows the two procedures by gender and age group. So first, you can see that, on average, the TKA receiver are much older. On average, if you can see here, 54.6 years old versus 47 years old for AM. So the TKA is older age procedures. And secondly, you could see the TKA rate increased dramatically with age, but not quite for meniscectomy. And the gender difference also not very much between gender for meniscectomy, but it's two versus three for male and female for TKA. And these slides shows that a clear age effect for TKA and also some gender differences among older age group, but not quite in the younger age group. This is the complicated table and shows the TKA rate with or without meniscectomy by gender and age group. So first, you can see that if you have meniscectomy on average, and that's the TKA rate, the 3.57, which is doubled if you don't have meniscectomy. So the 2.07 is true, the rate ratio. That's first thing you can see. And the second, for TKA rate in both with or without, and it's increasing with age. And also, the female has a little bit higher rate of TKA in both situation, with or without meniscectomy. The final interesting finding of this table is that the differences between with or without minoxidilamine is bigger in younger age group, which means that degeneration had a big impact for taking TKA. So it's become relatively important for older age, so you don't see very much differences in age group, older group. The younger person majorly is because meniscectomy, but for older population, they have degeneration, so they have to have TKA. So this is the final multivariate logistic regression showing that if you have a prior miniscectomy and your risk of total knee replacement will be 2.2, controlled for gender, age, and attorney involvement. And of course, age is the stronger factor, and the female had a 48% higher chance to versus male to have TKA. And attorney involved is significant possibly because the TKA is a big surgery, and it allow or have more chance to be associated with attorney. I think that probably is one of the reasons. So then we look at the time between the two procedures. The older the age, the shorter the days needed to take a TKA between these two procedures. And this is also the same, the older the age, the shorter the time you have a TKA post-injury. So the major finding of this study is that if you claim had an AM before, they will have a 2.2 times more likely to have TKA later on. And that is controlled for age and gender and attorney involvement. And also, the clear association with advancing age and a little bit with the female gender also need to be considered. So the limitations, we have a few limitations. First, our population is highly selective because we used only the surgical code with knee injuries for the study. So the minors and those without surgical treatment are not included. So it's very hard to generalize the result to public population and even the WOCSCOM minor claims. So and also, we may have some loss of follow-up issue as a lot of cohort study, and they may retire or change their work, and we don't have those under control. So I think implication would be with these findings of this risk increase with the prior minisectomy and also the age effect, and the practitioners probably can use this information in advising and plan their treatment. And that's it. Thank you. Okay. Let's load up this. Thank you. Maybe editorial comments by Nick later on on this whole topic, but Nick is going to get up again and talk about shoulder injuries to give us, to set us up for Dan, huh? So that was the knee portion, and Ed, we made it. So let's switch joints now. Let's switch body areas to what I think is becoming a real popular area in workers' comp, and that's shoulder injuries. Again, I have no conflict. Why are we talking about shoulders? It's the new low back pain in workers' compensation. Where I sit at Texas Mutual for the last, I hate to say it, 30 years now, the volume of claims that we see for work events involving shoulder injuries is rising. The cost to both diagnose and treat shoulder injuries is rising. The number of shoulder experts, people being trained specifically in shoulders, is rising. And what happens then? Well, if you're a hammer, the whole world's a nail, right? So that gets at the first two. And our understanding now of shoulder pathology and physiology is really rapidly rising. And our ability to, quote, fix the problem, i.e. surgery, is rising also. So it's a real good reason to study shoulders now. And there are two very, very important surgical cures on the horizon. You read about them in your lay press even, biologics, stem cells, and the reverse total shoulder replacement. Something that's new in orthopedics, new, 15 years ago invented, 10 years ago become very popular. So we'll talk about that a little bit. And of all the things that can go wrong in the shoulder, we wanted to cone down our research on rotator cuff tears. We've decided to focus just on that. Our database is long enough, I think we have maybe 15 years of data on rotator cuff tears. And a large proportion, interestingly enough, of take that 15 years of data and look at it, 53.7% of all shoulder injuries involve rotator cuff tears. So it's worth something to look at. We've come a long way in rotator cuff treatment since we only repaired rotator cuffs in older people. He had to be 65 years and older. And we've come a long way in treatment where you use a rotator cuff repair, oh my gosh, I've got to go in the hospital for three days. I've got to have a three to four inch incision on the front part of my shoulder. I've got to spend six weeks in a sling. And I've got to spend six miserable months of rehab. That ain't the way it is anymore. This is what your shoulder looks like, especially if you're sitting down there today with your arm at your side. And you can see the bursa on top, where's the pointer? The bursa, you see a bony wall, which is your clavicle and your acromion. You see a large bursa in there, kind of a shock absorber, a cushion. And this is where all the money's at, 53.7%. That's the start of a group of tendons known as the rotator cuff in your shoulder, which help move your shoulder. Let's look at that a little bit differently. Your rotator cuff on the left is from the back side, made up of your supraspinatus, your infraspinatus, and your teres minor. Your rotator cuff on the front side, strip away the pectoralis, but is really made up of the subscapularis in front. And why is it called the rotator cuff? Because that's what it really looks like from the side, hence its name. It's a confluence of tendons, which come from the back side of the thorax, the front side of the thorax, and it helps move your shoulder in several important planes, specifically abduction, external, and internal rotation. This is what you don't want your rotator cuff to look like. And that's typically what they look like through the arthroscope or on an MRI. But that's the most common place they tear. That's the supraspinatus. 100%, every time, every place, 100% of tears always begin in the supraspinatus. It's a dead-end vascular supply area, and that's why they have, if you pull on that rope strong enough, long enough, that that's where they tear 100% of the time, and that's a torn supraspinatus tendon. Shoulder thickness, rotator cuff tear. Why is that important, and what do I need to see in your physical exam notes? Just like in the knee, the lost art of the physical examination of the shoulder has to be relearned to corroborate the clinical symptoms, what a patient tells you, where it hurts, how it hurts, where it goes, when it goes, what you put down in your clinical signs. These are the physical exam, when you put your notes, and the imaging, ultrasound, MRI, CAT scan, arthrogram, I don't care what it is, all have to be correlative. Those three cherries, Las Vegas you win, those three cherries, you win in workers' comp, too. Work comp injury. And what are those physical exam signs? Well, real briefly, positive empty Coke can sign, weak external rotators, weak abductors, localized pain to where most of the tears occur on the posterior aspect of the cuff. And your physical exam quickies, here's that website again, same website, there's a body right there. You just click on the shoulder, go to rotator cuff, and there's the physical exam findings that should be in your notes to corroborate or refute the diagnosis, whether this is work-related or not. Hence, our current research, the one we haven't published yet, but it's a paper in progress, is on rotator cuff tears and surgical disease. Historically, these rotator cuff repairs, even done by the best of surgeons in the best of situations, have a poor, poor rate of healing. Literature shows that even in the best of situations, that there's a 20 up to a 50 percent re-tear rate after first surgery in rotator cuff tears. The literature mostly says those tears happen in the first six months, but re-tears can happen and the re-tears occur because it's a lack of fixation, our screws or our sutures don't hold, or you're just too old. Your vascular supply is too poor. It's like building a new barn using new nails, but you have to use the same old rotten wood, and that's why they re-tear. Re-tears require revision surgery. The best of surgeons, again, will often say, okay, it didn't work the first time, let's try one more time. Two times revision surgery, very, very common in rotator cuff tear surgery. And why is that important? Well, our paper, we studied the cost of that, the debility and the impairment for that, for your injured workers, and the lost time, indemnity numbers as well. Where we're headed in the future of rotator cuff surgery is these two areas, again, biologics and the reverse total shoulder replacement. Biologics, as we speak, we are federally constrained. You want stem cells? Go to Puerto Vallarta. You got to cross the border in the other way to get stem cells. They are doing those in Mexico, and in Texas, we know that. But in Texas, if you want biologics, we can do platelets, and we can harvest your fat cells, your adipose tissue. They have good potential as well to being multi-potential. So we can harvest your own cells, and the federal rules are as long as it's a homogeneous material and it has to be given in its native form, you cannot alter it, then we can inject that in the United States. And a lot of orthopedists in the United States are doing that. But I'll tell you right now, the evidence-based medicine is not there to support it. However, we do have something that does work for a failed rotator cuff surgery, one, two, or three times. And we chose to study this as well, and it's called a reverse total shoulder replacement. Shoulder replacements in orthopedics are common. We used an anatomic. We created a piece of metal and a piece of plastic that looks just like what your mama gave you. But you can't use that in torn rotator cuffs. You need an intact, functioning rotator cuff for using, again, what your mama gave you. However, if we reverse the ball in the socket, called a reverse total shoulder replacement, you don't need a rotator cuff. And hence, this is a salvage surgery for failed rotator cuff surgery. And it's been around, so we chose to study this, reverse total shoulders. It has been around for plus-minus 15 years. In the last 10 years, it has shown such good results that everybody is using it now. So the volume of data coming out is very high, and it has very wide acceptance in the orthopedic realm. Good five to, and the first, the last 10 years has shown very, very good outcomes, far superior to putting in an anatomic total shoulder replacement, the kind your mama gave you. Thank you. And now, we're going to give you a hint of our shoulder paper for next year. Thanks, Nick. Our last speaker is Dan Hunt. Dr. Hunt is the Corporate Medical Director of the Accident Fund Group, a nationwide workers' comp insurance carrier. He has been in this role for the last 11 years. Wow, a long time. Thirty years prior to, for the 30 years prior to that, he practiced as a general surgeon in Michigan and was on the faculty of Michigan State University College of Osteopathic Medicine. His current research and clinical interests are in appropriate pain management of injured workers, behavioral health issues in workers' compensation claimants, and the impact of changing medical technology on the surgical care of injured workers. For the last eight years, he has been an active member of our division's workers' comp research group. He has been the lead author and or contributing author on 19 peer-reviewed papers. Dr. Hunt. Thanks. Thanks, Grant. I was hoping you wouldn't make me find my own slides. Well, my co-speakers did great, because I was only supposed to have 10 minutes, but now I've got 25, so I'll expand my talk. Just kidding. So, yeah, thanks for coming out this morning. And to give you some kind of background here, as Ed said, I'm fortunate to be part of this research group, and we take data. AF Group is a nationwide organization, so we have a lot of data. And so we share the data, and then this group kind of works their magic to find what we hope are kind of some clinically significant, clinically pertinent ideas about what's going on in different problems. And with Nick's guidance, we got very interested in shoulder operations, so that's what we started to talk about. I don't have any things to disclose. And so background, so I'm a general surgeon, and so general surgeons, I always feel a little out of place here at the ACON meeting, but I appreciate you all welcoming me anyway. And I had the opportunity, and I didn't know this until Nick told me this, that when I was in practice, every Wednesday, the surgeon next door to me in his room was kind of one of the early adopters of arthroscopic rotator cuff repairs. And I would go in there because I was fascinated by, we did laparoscopic things in general surgery, and they were doing these arthroscopic things in little tiny joint spaces. And I remember thinking at the time, as he was telling me about how quick the recovery was and how good his results were, that rotator cuff repairs through the arthroscope are going to follow the same trajectory as gallbladder surgery. When I started in practice, 85, gallbladder surgery was a big gash and a long recovery time, and you might do one or two of those a week. As laparoscopic cholecystectomy came into vogue, I would do eight to 10 gallbladder surgeries every week. And so I thought that probably we're going to start seeing more and more rotator cuff repairs done through the arthroscope. And that's indeed what's happened, and that's kind of what our data showed. So that's kind of our objectives. We want to look and see, well, what's going on with the frequency of rotator cuff tears, rotator cuff surgeries? And more importantly, how many of these folks are going on to total shoulder replacements? Because the other shift in technology, and I've always been fascinated by surgical technology, is what Nick was talking about, you know, the reverse shoulder arthroplasty. When I first heard that, I thought it was a revision. I thought, well, how many of those can there be? But no, it's the idea of reversing the anatomic relationship of the ball and the socket in your shoulder, giving much quicker recovery times and better overall results. And so part of this was also my nurses coming to me, you know, as the medical director at AF Group, and saying, you know, gosh, we're sure seeing a lot of shoulder injuries, and we're seeing a lot of shoulders that are going on to total shoulder replacements. And, you know, those become expensive claims. They have a long duration, and they have very expensive procedures done, a lot of physical therapy afterwards. So when we were sort of plotting our course of what we were going to research, between Nick and I ganging up on Ed and Grant, we got them to start looking at shoulder problems. And I think this has really been quite interesting, and I hope I can give you a couple of clinical insights that might help you in your practice as you think about this going forward. These are the methods. Those are all the CPT codes related to shoulder injuries. And so you can look at that. All these slides are available to you. And, you know, Grant has all these wonderful statistical analysis that we do, and sort of helps us figure out what is important. Because, you know, what I've learned in this research group is when you're a practicing clinician, you have certain intuitions. You can say, well, I think it's this, or I think it's that. You know, one of the stories used to be if you've done something once, it's in your experience. And if you've done something twice, it's in your series. And if you've done something three times, you can say time and time and time again. When I do this, I get this excellent outcome. But it's really hard sometimes to get real data and real statistics around, well, what really is probably going on in a large cohort? And so this is a bit of a complicated slide, but it just shows that the years of this study, we started pulling data in 2007. We finished in 2022. We could have gone to 2023, but you want to have some time for experiences and development of the claim, so we cut it off at 2022. So 16 years. Our organization is, this is probably data pulled from about 36 different states across the country, pretty widely represented between all the different areas of the country. And I think the things of interest here of shoulder injuries, if you look at the female to male ratio, it's about one female for every two males. So this is really more of a male predominant type of an injury that we see in our workers compensation group. And of all the shoulder injuries, we had 15,000 and some that were in the cohort. The ones that had rotator cuff tears were 8,347. So that's the, I guess, the number of people that went into this study, which I think the importance of that is it's a pretty big study. It's a fairly large cohort of injured workers here. So I think that our findings probably or hopefully reproducible if people with other organizations or other settings looked at their data to see what's happened. And then this is how many have gone on to have, you know, a total shoulder arthroplasty. One of the limits was there is an independent code. If you do an anatomic total shoulder or you do a reverse shoulder arthroplasty, there's not a searchable code. And I told Nick, what kind of a program do your orthopods run? You don't differentiate that. So we just have had to make some assumptions that since 2015, 16, 17, the predominant number of shoulder replacements have probably been reverse shoulder arthroplasties. Although one of the limitations is we don't know that absolutely for sure. But if you can kind of see there, if you start, look at, don't look at the totals, but look at the total shoulder arthroplasty replacements or percentage. You know, 07, 08, 09, 010, it's all single, you know, it's 1.2, 1.6, 1.5. So getting a total shoulder arthroplasty after a rotator cuff tear in the workers' compensation cohort that we studied was fairly uncommon. But as you start to get later in the study, you start to see that the numbers really start to grow. And, you know, I think you can make it sort of a rule of small numbers, but I can say there's been a five-time increase in the number of total shoulder arthroplasties done in this study population, because we went from about 1% in 2007 to almost 5% in 2022. And this is kind of a graphic representation of what's been going on with both the growth in rotator cuff tears. So this shows that this is the percentage of shoulder injuries that had a rotator cuff tear. Less than 50% down in the low 40s early in the study, and then starting to climb up into the 60 and 70% range. And we can't say for sure, based on our analysis, what that reason would be. Likely it's due to improved imaging studies that show better results, you have the better ability to decide whether it's a torn rotator cuff, whether it's partial, whether it's a complete tear or not. And there's some talk about, too, that, well, in the early parts of this study, there really wasn't a good surgery to fix a rotator cuff tear. But as that got better, easier to do, arthroscopic surgeries became more widespread. I think that's also part of it, maybe, why this diagnosis started showing up more in our claims literature. But the point being, the vast majority, if you will, of shoulder injuries now are rotator cuff tears. And then this is the percentage of how many rotator cuff tears go on to have some kind of a surgical intervention. And so I think this is one of the first, what I thought was interesting and presented to our claims department about things, a way to think about it. If you look at that in the last couple of years, your chances of having a surgical operation, which for the most part was an arthroscopic rotator cuff repair, if you have a diagnosis of a rotator cuff tear on some kind of an image study and physical exam findings, it's a 93, 92% chance that you're going to have an operation. And so I think that was important. As we talked to Nick, a clinical practicing orthopedic surgeon, what do you think the statistic is going to be? Maybe around 60%, 70% maybe. But the reality is, as we look at this cohort of injured workers, if you have a diagnosis of rotator cuff tear, you're going to get an operation. I mean, there's a few people there that didn't, and there's always a lot of noise and a little variability in the data. But I think that it's fair to say, if a rotator cuff tear is diagnosed in an injured worker, you're going to get an operation. And I think the importance of that is, is the other thing the nurses told me as they were managing all of these claims, was that they said, boy, shoulders really take a long time to get going. You know, it seems like the physical therapy goes on and on, and then it takes a while to get in to see the surgeon, takes a while for the surgeon to get you scheduled, and then the rehab tends to drag on and on. And I thought that was interesting, too, that, you know, claim duration from a carrier's perspective is really critical, because if you look at the cost of claims, it's not only the injured worker didn't get back to work very fast, but it also becomes a very expensive claim as duration grows. So I think if you start thinking about it, if you're in clinical practice, somebody with a rotator cuff tear, and it's likely they're going to get an operation. And if you have that mindset, I think you might also make some adjustments to physical therapy. And I've got a slide about physical therapy, so we'll talk about that then. Now, this is a slide that looked at differences in sex, as well as age, for who got a rotator cuff repair. And remember we mentioned that the ratio of males to females, if you will, for rotator cuff injury is about two males for every female. So it's much more common in the male population. But once you get diagnosed with a rotator cuff tear, this shows that regardless of gender, you're going to get the same approach to treatment. So age, gender doesn't matter too much. If you have a rotator cuff tear, you're going to get an operation. And then this is kind of a graphical representation of that table. I'm a surgeon, right? Surgeons have simple minds, not like all the internist-based kind of people in the audience. But I think this shows it really well if you look at percentage of rotator cuff tears that ended up with a total shoulder arthroplasty joint replacement grew from 1% up to 4.7%. And I suspect as we look at the data as time goes by, there'll probably be some kind of a limit to it. But I think it will probably continue to increase. This was, again, kind of just looking at age differences and whether there was a difference in sex in terms of who got rotator cuff tears and who got a total shoulder arthroplasty. Within statistical meaning, there probably isn't too much of a difference there. And then this is physical therapy. You know, we didn't really do a deep dive in physical therapy, but we were interested to see, and I don't mean this to be kind of flippant, but does physical therapy work for helping someone with a rotator cuff tear avoid an operation, right? Because that would be part of why you would do it, right? And if you look at the ODG guidelines, it talks about, you know, 10 weeks of physical therapy, 20 sessions before ODG says it's reasonable to think about a surgical intervention. This data would suggest that probably that's a little too long, that probably if you go in with the idea that rotator cuff tear is going to equate to some kind of a surgical intervention, typically an arthroscopic approach to refixing that rotator cuff, that maybe the physical therapy should be maybe four to six weeks. I mean, I think there is some value, perhaps improving strength, perhaps I think helping the injured worker come around to the idea that this injury that they received at work is going to require a surgical intervention. And so physical therapy I think has its role, but I think probably 10 weeks is too much. And again, this is just kind of a corollary of our study here. This certainly isn't dogma, but I think it's reasonable if you realize 93 percent of everyone's going to get an operation. Extended physical therapy probably isn't improving the outcome. Now after surgery, physical therapy, helping with rehab, this has nothing to do with that. But it has to do with does physical therapy help rotator cuff tears avoid an operation? It would appear the answer to that is no. It does not help them avoid an operation. May do some other things for them, but it doesn't help them avoid an operation. And then these are the odds ratios looking at, well, what is your risk? And I always, I like relative risk, it's sort of an easy concept for me to understand. And if you look at that going down, it shows that the area where your relative risk of needing a total shoulder arthroplasty is not a huge surprise if you're older. The older the age of the injured worker, the more likelihood, and you kind of see those relative risk numbers there, not many, but we all have injured workers that are over the age of 70 now, you know, 60 to 69, 15 times relative risk. And so again, as you're thinking about your patient population, you have a 23-year-old that comes in, hurt their shoulder at work, and they have a rotator cuff tear on one of their imaging studies. Well, you know, that's a young individual, and so there may be some opportunity there, depending whether it's partial or complete, for them, you know, to get better. And that percentage of them that are going to go on to a total shoulder arthroplasty is low. But if you've got a 65-year-old male who comes in with a rotator cuff tear, not only are they probably going to get an arthroscopic intervention, but they're probably going to have a higher likelihood of needing a total shoulder arthroplasty. I wouldn't include all the studies. We're putting some other things together in the paper that we're putting together, and hopefully get published later this year. But there's some other variables in there that lead to timing. And if you look at the timing of the older age group between rotator cuff arthroplasty and surgery for replacement, it's relatively short, usually about less than half a year. As the younger people, it tends to be longer, two, three years sometimes. But I've heard a lot of just talking to people, oh, my brother-in-law was 42 years old, got a total shoulder replacement, which is sort of a shock to people. But that's really the way that we're heading. We're heading that a younger and younger age group is going to have these. So age is the predominant driver of who gets a total shoulder arthroplasty. We looked at other things. You know, I guess this is a shout-out to the attorneys, although, as we all know, attorney involvement oftentimes has adverse impact on claims outcomes. That's speaking from the medical director's perspective for an insurance carrier. But here it didn't make any difference whether there was an attorney on the claim or not. It didn't change really the approach or the outcome to those people. So I thought that was interesting. And we looked at PT versus no PT. There really wasn't many that had no physical therapy for a torn rotator cuff. But it gets back to the idea that physical therapy probably is not going to change the ultimate path that these injured workers are going to take. And then finally, we looked at cost. And you know, no surprise here. If you get a total shoulder arthroplasty, it costs more money. If you get, you know, if you have a rotator cuff arthroscopic repair, it costs less money. And the other thing to keep in mind is, although Nick had very dismal statistics around success, at least in this cohort, if 5% ended up with a total shoulder arthroplasty after an arthroscopic repair of the rotator cuff, that must mean 95% of people didn't get a total shoulder arthroplasty. And the assumption being that they ultimately had some recovery and returned to work. And one of the graphs here that's included in the slides that you'll get, you see the claim closure rate. Once claims are three years or older, the claim closure rate is in the 90%, mid-90%. So that, you know, these people do get better ultimately. And they come to some resolution, whether they return to work or they go back to late duty, have some temporary permanent disability, or whether they, you know, get the claim closed in some other fashion. But it's not all dismal in this arena that people do get better. But it's important to understand, I think, that they're going to get an operation. That's just how it's going to be. And so here's kind of a recap of our findings. You know, the number of shoulder injuries, the rotator cuff tear has increased 40% to 60%. That if you have a torn rotator cuff, you're getting an operation, over a 90% chance of that. The number of people getting total shoulder arthroplasty is growing five times in the period of time to 16 years. And but, 88.5% got an arthroscopic repair of their torn rotator cuff and didn't need a shoulder arthroplasty. I think that's pretty good statistics. Nick tells me in the orthopedic world, if you've got more than 2% failure rate, then you're a failure and you're really sad about that. But I think that probably given the fact that in this cohort of individuals, injured workers, I think that's not a bad outcome, actually. I think that if you get 88, almost 90% success rate with an intervention, get people back to work. That's, you know, I think as a carrier, that's fine. Increasing age, increase your risk of total shoulder arthroplasty, male's more likely to have a tear, but there's no gender difference in who gets the surgical interventions. And that PT, similar, whether they had total shoulder arthroplasty or not a total shoulder arthroplasty, physical therapy probably not making a big impact on the trajectory of these claims, other than increasing the duration of the claim, taking it longer to get to some, you know, resolution of what's going on for the injured worker. Limitations. Here's our laundry list. You know, it's like any study, there's limitations to it. We talked about the inability to differentiate between anatomic and reverse. Always a key thing, these findings apply to this cohort of injured workers, right? This is not generalizable to the general population. I mean, it could be, but there's no claim made about that, that, you know, that some of the people over 65 might have ended up having their surgery done under a different insurance, i.e. Medicare. Don't tell the Medicare people they don't like that, Medicare set-asides and all those kind of things. But the point being that we might have under-reported how many people got a total shoulder arthroplasty in this population, which, again, kind of speaks to, oh, if it's 4.7 percent, maybe in reality it was closer to 6 percent, but that's one of the limitations. And we didn't really have the ability to look at different job descriptions, right, to see who's at greater risk of having a torn rotator cuff. I would put in a little blurb here, because Nick taught me this, that really rotator cuff injuries, we think of them as acute injury, and probably in that younger than 40 population it's probably more likely related to that, but it's really a degenerative disease. As time has gone by, Nick tells me a lot of you people out there have partially torn rotator cuffs and maybe don't have too many symptoms from them or symptoms that you just manage, but it's a degenerative disease, and not from the perspective of trying to say, well, we're not going to take that claim because it's a degenerative life disease, but being that, you know, that's probably why the incidence goes up and why it's probably more prevalent in the older population, because they already have some underlying problems. And so the type of injury that gets a rotator cuff tear in the older individual maybe isn't quite as impressive as it might be with somebody younger who got an acute injury for a rotator cuff tear. So thanks for your time, and thanks for your attention, and Ed's going to organize some questions. Thank you. Thank you. Well, we have time, five minutes, some questions. I'm talking about rotator cuffs, is it partial tear or something else? Second thing, improvement, improvement. What are we gauging the improvement with? Pain or function or both? I think Nick, you want to? So you are correct. This data, yeah, this data confuses and conflates partial rotator cuff tears with full thickness rotator cuff tears. Ten years ago, certainly 15 years ago, nobody operated on partial rotator cuff tears. Now, with the number of surgeons out there and with the techniques involved, I would say that probably five out of six, five out of seven rotator cuff repairs are partial rotator cuff repairs. So we are operating on much more less serious disease than we are now. This study, we'd have to look at 8,000 claims to figure out who had partials and who had full thickness tears. We can't do that. So this study does not answer your question, but that's the trend in orthopedics today is, oh, you have a partial rotator cuff tear? Let's fix it. And I think that's why, I think it's a death knell for you in surgery. If you have your ICD-10 code and it says rotator cuff tear, 92% of the time, you're going to get an operation in that claim. And then outcome, your other question, pain, loss of motion, loss of strength. Those are the three criteria. And if you look at what's a failed rotator cuff surgery in the data that I presented, you had to have a documented, objectified re-tear, not just pain and loss of motion or loss of strength. Even in the best of situations, the best of hands, you will have some loss of motion and you will have some loss of strength from a successful rotator cuff repair. Hopefully, your pain goes away. But that's the way we grade those today in orthopedics. Sir? Oftentimes, I see surgeries for rotator cuff. They're doing other surgeries in the joint as well. Is that necessary to do things to the AC joint or to the person? I couldn't hear that. What did you say? Could you speak up a little bit? Yeah. Oftentimes, I see for rotator cuff tears, they're not just repairing the rotator cuff. They're doing something to the AC joint or they're doing something to the person. It seems to be that it's more common to do that than to secure a rotator cuff repair. Is that necessary or is that the trend? So you're confusing two surgeries. There is a garbage diagnosis in orthopedics called impingement syndrome, which really means, I don't know why the hell your shoulder hurts. It hurts. There's nothing on your MRI. You don't have a torn rotator cuff. The labrum's okay. No articular cartilage damage. But you have impingement syndrome. So let's go in and take your bursa. Let's go do a little house cleaning. Let's go take your bursa out, take off the undersurface, or take the distal clavicle out, called a Mumford procedure. One of the most successful operations in orthopedic surgery. And maybe you'll get better then. And that's impingement. So you're conflating impingement syndrome with a torn rotator cuff tear. And that's totally different, though. So if you see impingement syndrome or your doctor says you have impingement syndrome after six months of PT medications and neglect, you're still hurting, he really doesn't know why your shoulder hurts. It just hurts. And Texas Mutual's not going to pay for it. Dahlia. Don't they do bicep stenobesis pretty much all the time? Well, yes. It's an under-recognized diagnosis, bicep tendonitis. And if you're old, all you need to do is cut it and let it fly. If you're young or you want to be pretty and you don't have a bump in your arm, then you need a bicep stenobesis. So it's a procedure that is getting to be much more common. It can be done arthroscopically. So you don't have to have a two-inch hole anymore. You can have two quarter-inch holes. So as you would suspect, it's being done more commonly nowadays. It seems like they're always being done together. Yes. So when you tear your rotator cuff, remember that big picture and it shows it goes all the way from the back and all the way to the front, the confluence of the tendons? You don't just run your car into a brick wall and break the headlight. Then the fender, the bumper, the hood ornament, all scratch the paint. So that happens in a continuum when you injure your shoulder or you're 60 years of age. It just doesn't happen as an isolated event. So they do go in and do a subscapular repair. They do go in a bicep stenobesis and will repair the rotator cuff. There's usually three CPT codes on it, and that's very, very common. Especially as you age. Under 40, acute tears, I buy all the time. I'm glad to pay for those. 40 to 60, over 60, it probably isn't ours. It's probably what your mama gave you. And there was good literature published in clinical orthopedics and related research 10 years ago. And if you have a torn meniscus in your knee, you've got a 62% chance of the same tear being in your other knee, even though it don't hurt. And a 68% chance if you have a torn rotator cuff in your right shoulder, your left shoulder's got a torn rotator cuff too. They just did imaging studies on that non-injured shoulder, and that's what they found. So by and away, this is a disease of life. Yes, Talia. I have a very important question. My question is, like, regarding the knee injuries, it seems like there's a chance maybe it's increasing the chance for a future total knee osteoporosis. So what is the turning point? Like you're saying, okay, I failed conservative management, now I'm going to do it again. Is it, like, time? Or is it MRI findings? When do we make a switch from conservative? So Campbell's operative textbook, the Bible in orthopedic surgery, begins the knee chapter with a sentence, an ACL injury to the knee is the beginning of the end of the knee. And that was Campbell published this back in the 1960s. Our study shows that what you just implied happens a lot sooner in a lot of other injuries in the knee. A simple meniscectomy is now, our study is, I think, showed by 10 years or 12 years. Wasn't the longitude? The first one, 11 years. 11 years. We are already seeing young people having knee replacements at 11 years after a meniscectomy. That's something new in orthopedics, something we're fighting at Texas Mutual all the time. Oh, a simple meniscectomy doesn't give you arthritis. It looks like it does. And when to do that is when you can't control the pain any other way. That still was and still is the indication for joint replacements. Hips, knees, shoulders, I don't care. Can't control the pain any other way. Quality of life is miserable. And that usually implies some kind of night pain. Then it's time for an arthroplasty. Is there an association with an orthopedic injury or just a few meniscus tears? Our study only looked at meniscus. If you look at the CPT codes, our study only used CPT codes for meniscectomy. It only looked at that. Some of those probably had ACLs in there, but we couldn't ferret it out. So you bring up a good point and a shortcoming of our study. Some co-existing injuries. Well, I think we're out of time, and thank you all for coming. I hope you had a good time. Thank you.

rotator cuff tears

surgical intervention

arthroscopic repair

total shoulder arthroplasty

age factor

physical therapy

impingement syndrome

subacromial decompression

bicep tenodesis

joint replacements