Dr. Botker Talks About Virtual Implant Positioning for Shoulder Replacements

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Toree: Hi, I’m Toree McGee, and this is the Rapid Recovery Report, sponsored by ROMTech, the modern technology of rehabilitation.  So, we’ll be doing this series biweekly, every other Thursday at 4:00pm Pacific, 7:00pm Eastern.  And we’re talking to all kinds of surgeons, patients, insiders at ROMTech.  And talking about a whole mess of stuff, so wellness, health, touch a little bit on ROMTech’s PortableConnect.  

So, if you’re new here, this right here that we’re going to show on screen is the PortableConnect.  Isn’t she a beauty?  It’s a high-tech recovery device that’s geared to get patients moving, and on the road to recovery a lot faster.

So, if you want to learn more about us and the PortableConnect, please do check us out at Romtech.com, and you can follow or subscribe to our social channels that are in the description below.  But let’s move right on, because today, we’ve got a really fabulous guest that I’m excited about. 

Arthroscopic Expert Jesse Botker

Dr. Jesse Botker is a fellowship trained, board certified ortho sports medicine surgeon, specializing in arthroscopic minimally invasive joint repair.  And he treats bone, joint, and muscle needs of athletes and active individuals of all ages. 

Dr. Botker attended the University of Minnesota Medical School in Duluth in Minneapolis, where he earned his Doctor of Medicine degree, and completed his internship and residency.  He was then accepted into the Arthroscopy and Sports Medicine Fellowship Program in San Diego, California.  And Dr. Botker now is back in Minnesota at the Orthopedic & Fracture Clinic since 2010.  And he proudly serves as official team physician for Minnesota State University Mankato Athletics, and is a former physician for the San Diego Padres and SDSU.

Welcome Dr. Botker.

Dr. Botker: Thanks.  Thanks for having me on. 

Toree: Yeah, we’re excited about it.  So, we like to start our show usually to try to learn a little bit more about you, kind of an ortho-surgeon ice breaker.  So, it’s always really interesting for us to learn why certain surgeons choose orthopedics above pretty much anything else in medicine.  So, what attracted you to the field?

Dr. Botker: Well, the stock answer that every orthopedics surgeon has to give is that you had a sports injury when you were young, and that’s what really got you on track.  So, I’ll start a little bit with that.  I had an injury when I was younger, one in basketball that kind of started things.  But I’ve always been interested in sports medicine, playing three sports, football, basketball, baseball growing up, football in college.  But what really attracted me to it is really the technical aspect of the surgeries.  And I love to work with my hands.  I think it was a great fit, because I get the balance between meeting patients, seeing them in the office, but also being able to get back on the field of play or back to their lives, and really see improvement.

So, what really attracted me to it, ultimately, was getting to watch the surgeries, and seeing how cool they were from a technical standpoint.  As I refer to it, it’s carpentry in a sterile environment.  But then on the other side of it, it was seeing these patients come back, and they’re so thankful for what you’re able to do for them, at the end of the day.  So, that, for me, was just a great fit that you can really feel like you’re making a difference.

Preparing for Surgery with Prehab

Toree: I love that.  So, let’s talk a little bit about sports prehab.  And I know that that’s important.  One of our sales guys talks about it all the time.  We all know about rehabilitation, but can you explain prehab to us, and why it’s so important?

Dr. Botker: Yeah, so prehab, I’d say, is really getting ready for a surgery.  And whether that’s an elective knee replacement, hip replacement, or let’s say for instance, an athlete goes down with an ACL injury, and that’s really where the prehab is kind of taken flight, because with these patients, we’ve realized over time that if you can get their range of motion back to normal, their swelling in their joint down, in particular case for an ACL, their knee, and you can get their strength back, they will have a much easier time recovering after that particular surgery. 

So, in certain cases where patients go down with an ACL, we actually like to wait three to six weeks, ideally, until we see those parameters met.  And that, we just know, is going to make the recovery that much easier for them.  It’s a delay on the frontend, but on the backend, you’ll make up for it tenfold.

Toree: Okay.  And I mean in the same vein, I guess, of staying moving, and trying to be healthy, patients can get muscle atrophy that can lead to surgical intervention too, right, if they’re injured and don’t really want to move?

Dr. Botker: Absolutely.  We see this all the time.  I mean, patients come in with specific injury, and whatever that is, that injury has led to muscle atrophy, is led to muscle imbalance and flexibility imbalance throughout whatever region of that body that is.  

So, for instance, I work a lot with shoulder patients, and whether it’s a rotator cuff tear or labral tear, dislocating shoulder, those patients, a lot of times, will have something called scapular dyskinesis.  Essentially, their shoulder blade and their shoulder blade muscles aren’t properly working in concert.  And if you go jump straight into the surgery aspect of that without addressing some of those things in the frontend, you can still get the surgery done and get the rehab done.  It just takes a while longer, because you’re retraining those muscles that are going to shut down with that surgery that you’re doing for them.  

So, ideally, yes, prehab is ideal, getting patients going, getting patients active.  I relate it a lot to, if you are someone who is a very sedentary individual, doesn’t work out much, and you decide to start a new workout program.  For the next two or three days, you can barely move.  I mean, that’s what happens when we’re doing surgery on someone.  So, if you’re coming into that, your muscles are already tuned up, you’re strong, you’re in physically good condition, your lungs and heart and everything are, you’re doing regular exercise routine, it just makes everything go so much more smoothly.  We see patients get out of the hospital, and they’re back onto recovery so much quicker. 

Toree: Okay.  Well, that just makes me feel like I need to hop on my rower, and start doing that in case something happens, or I need surgery.

Dr. Botker: Absolutely.  

Dr. Botker’s Patients

Toree: Now, do most of your sports patients have like preexisting conditions prior to needing surgery, or are most of them that you see from an immediate injury that they needed surgery?

Dr. Botker: Well, I’d say it’s probably a good 50-50 mix.  I mean, I certainly have the acute injuries with bad ankle sprain, or fracture, or an ACL tear.  But you also have patients that this has been kind of coming on for some time.  And so, they do repetitive activity, whatever sports, or practice and preparation that leads to the sport prior to it.  So, you see a lot of chronic injuries.  

Sometimes, you see the acute on chronic injuries where they were kind of getting by, and all of a sudden, they injured something a little further, and now things are not going well, and we need to consider a surgical intervention to get them back.  A lot of those things, I see a lot is hip arthroscopy.  So, with the advent of arthroscopic knees and addressing hip pathology and labral tears for hip, a lot of those patients come in, and they may have seen three, four, or five physicians trying to figure out what was going on.  They’ve been trying to rehab.  And finally, ended up in my office, and actually explained what’s going on, and can figure out, and plan a path moving forward.

When to Get Surgery

Toree: So, at what point, I guess, do you decide, or you and your patients together decide to intervene and go the surgical route?

Dr. Botker: I think in those acute on chronic or more chronic issues, I think it really boils down to can you perform and do what is necessary on the field of play, if it’s an athlete.  If it’s a weekend warrior, how much does it bother you and impact your day-to-day activities?  Is it something that you’re getting by with, or is it now causing you to withdraw from those activities, consider not doing those activities?  Because I look at sports medicine as a wide spectrum of athletes.  And you may be beyond your playing years of high school, collegiate, or professional, but we still have those athletes.

I just saw a patient in today in particular that has said, “Well, because of this issue, I gave up golf, I’ve given up things I enjoy doing, pickleball.”  So, they want to get back to those things, and that’s what we’re moving on.  So, I think it’s a mutual decision-making process with yourself, the patients/athletes, and figuring out what is the best route moving forward.  Is this something that we can rehab?  Can we do injections, or is a surgery going to be the best answer in the long run to get them back to 100%?

Postoperative Recovery Timeline

Toree: Sure.  That makes sense.  So now, I know that you do a lot of minimally invasive stuff and new techniques, and everything that you can to stay up to date.  So, have your postoperative goals or expectations change over the years after introducing new techniques or devices to aid in recovery?  Like, where do you expect to see a patient now at two, four, or six weeks versus 5 or 10 years ago for the same injury?

Dr. Botker: Yeah, I think that the advent of our new techniques, new technology, and advanced rehab protocols have completely changed the game.  If I look to when I started 15, 16 years ago, and while I’ve been in practice 11 years, and I had six years of training prior to that, you go back almost two decades, and you look where we were at then, and even a decade prior with how everyone say we used to do it this way, and now we’re doing it this way, it is unbelievable how we have advanced forward.  

I mean, if you take ACL surgery at its advent, they were casted for six weeks after that surgery.  Most patients never got the range of motion back.  Most patients never returned to the field of play after an ACL.  It was just an automatic, we’re just trying to get your knee better, so you can walk for the rest of your life, not back onto the field of play.

Now, with some of the advanced rehab protocols we’re doing, we are cutting that timeframe down substantially.  We’re getting patients better.  With the advent of technology, whether that’s 3D imaging to better understand the patient’s anatomy and to put the implants in better, do the surgery better, to the implants that continue to improve and allow us to repair whatever injury that is, so that we can rehab them, we’re really pushing the envelope with that.  And that, I think, is great for everybody, great for the patients.  And the faster you can get people back, I mean, it helps out everything.  

As a surgeon, you don’t want to be the guy that is holding every ACL out for a year and a half to get back, because no one ever show up back in your office.

Toree: Right.  Yeah, I mean, I’d find the guy that can get me better faster, that’s for sure.

Dr. Botker: Yeah, absolutely.  

Arthrex Virtual Implant Positioning

Toree: So now, most of our guests have predominantly spoken about knee replacements and recovery for that sort of thing, and some ACLs, but you do quite a bit of arm and shoulder surgeries.  

Dr. Botker: Yup.

Toree: We’re curious about that, because that’s not something that we’ve really kind of delved into on the show.  So, you use a procedure using the Arthrex virtual implant positioning for shoulder replacements, and that involves advanced imaging, surgical instrumentation specific to the patient, right?  So, can you explain that a little bit more to us?

Dr. Botker: Yeah.  So, the Arthrex VIP, so virtual implant positioning.  Essentially, what it is we do a CT scan of shoulder.  So, a CT scan subtracts out all the muscles, the tendons, and just shows the bone.  So, we’re able to take a 3D image from that, and on the computer screen, you’re able to rotate that image completely there, and see what is the patient’s normal anatomy, what’s their anatomy compared to normal anatomy.  So, that allows you to then take a computer program, and essentially, plan the placement of the implant, in this case, on the socket side of the shoulder joint to recreate normal anatomy that has gone away over the years because of the wear pattern with their arthritis.  And allows you to better position that implant for longevity and improvement in their function.

So, what we’re seeing with that is that 3D.  And that’s how I’ve always learned is by pictures and 3D of thing.  So, when you’re talking of 3D model, you can just understand it better in your head.  I mean, a lot of the things that you do, you have to have that 3D spatial recognition to really be a surgeon with what we do, to be able to sculp and to put a camera in an instrument together.  So, that just kind of branches off of what I’m used to.  

So, with that, what I’ve noticed is that this allowed me to more precisely place the shoulder in the way that it needs to be, and decreasing the recovery time, and improving patient’s range of motion.

Toree: Wow.  Do you feel like Superman when you can see somebody’s bone 360 like that?

Dr. Botker: A little bit.  I mean, it’s really like when I first started doing it, I was kind of skeptical.  You do a lot of shoulder replacements.  Like really, I know what I’m doing on this.  And then you start planning it, and you see the nuances in patient’s anatomy, and it really opens your eyes to those little things, and it allows you to plan and be more prepared in it.  Rather than just getting in there and figuring it out while you’re doing it, you come in with a game plan.  

I look at it from the sports side of thing.  You got to have a game plan to practice through the week.  Have the game plan.  Execute the game plan on game day to win the game, and that’s what we’re trying to do is give the patient the best outcome, get them back to whatever they want, whatever it is they want to get back to.

Toree: Now, are the tools that are being used, are they customized as well, like as well as the implant?

Dr. Botker: So, there are two different ways that it can be done.  So, there is a customizable jig that, based off that plan, we can adjust essentially their feet that attach onto the socket.  So, your socket shapes a certain way, and the feet will each be at different lengths based off of patient’s anatomy to attach onto the socket.  So, we can put that together on the back table.  

There’s also 3D printers now that allow you to do a customized jig that attaches directly on, and rotates to fit perfect, to then put a pin end exactly where you need it.  So, there’s both ways that this can be done.  And I use the later technology with the 3D printing on my knee replacements with the customizable 3D planning software as well.  So, there’s two different ways, two different implants, but they both accomplish the same goal. 

Reverse Shoulder Replacements

Toree: Okay.  We’re diving back into shoulders again, I know.  So, tell us about reverse shoulder replacement.  Tell us what that is.  It sounds really interesting.  

Dr. Botker: Yeah, and this is a commonly asked question, what’s the difference.  And everybody has this misnomer that if I get a reverse shoulder, that’s a bad thing.  And actually, with the advent of reverse shoulder replacements, we’ve been able to change the game for a lot of patients that won’t be helped as much.  

So, essentially, it’s been around for probably 20 years now.  As I was coming into it, they’re the first ones that are being put in the United States.  It started in Europe.  Essentially, what the problem was is that patients who have arthritis of their shoulder and have a rotator cuff tear, they do not do well with a regular shoulder replacement, and they don’t establish their normal range of motion.  It can cause the socket to loosen prematurely, and so they tried using a larger ball that will extend over the top.  They tried doing a lot of different things.  

When these came out, essentially what it does is it reverses the parts.  We put the ball on the socket side, and the socket on the ball side.  What that does is it harnesses the power of your deltoid muscle, which is the large muscle on the side of your arm that makes up for those rotator cuff muscles that aren’t working any longer.  And that changes the fulcrum or the position of the shoulder, because of the ball being on the socket side, the socket on the ball side, in order to allow you use the fulcrum and the muscle to raise your arm up. 

So, these patients that have essentially call it pseudo-paralysis, they cannot raise their arm up at all.  You put a reverse shoulder in them, and they come back two months later, and they have the most unbelievable motion ever, or some of the happiest patients that you have. 

So, when talking to patients, there’s a little bit of time to explain that to them that, look, your recovery is not going to change at all from a regular shoulder, and you’re going to have great function after this.  

When we first started putting this in, you can only put them in 70-year-old patients or older, and very low-level kind of function.  We didn’t want people doing all these things with it.  Heck, we’re putting it in patients younger and younger, because we’re seeing with the 3D planning software, we can put it in, where we could put these implants in more stable.  They’re going to last longer.  And with the implants continuing to improve, we no longer have some of the restrictions that we have on patients. 

So, I have patients going back to quite a lot of activities, pickleball.  If they want to go hunting with their shotgun, let them do that.  There’s still a few.  I don’t want them to run a jackhammer, and I keep them waiting to split [inaudible 00:18:55], but I let them do quite a bit of other things. 

Toree: I’d be nervous about the shotgun panning.  Some of those things are pretty good [inaudible 00:19:03].

Dr. Botker: Yeah.  It’s a great option for patients.  And in fact, it’s interesting.  As it’s grown with its popularity because we see such good outcomes, we’re much less hasn’t use it for patients, and I’d say probably over half of my shoulder replacements are actually now reverse shoulders. 

Toree: Wow.  And is there a similar technique for knees, or is that just a shoulder thing?

Dr. Botker: So, knees are the same.  You want to put the femur on the femur side, and tibia on the tibia side.  The difference with knees really depends on inherent stability.  So, if patients have collateral ligament injuries or injuries on the sides of their knees, their ligaments aren’t stable, then we had to put in more of a revision cell implant, which confers more stability in the knee, but knees are knees are knees pretty much overall.

Dr. Botker’s Patients on the PortableConnect

Toree: Okay.  Now, back into the knees, since we’ve dove into it here.  Let’s talk a little bit about your experience with the PortableConnect.  I know that you’re using it on a lot of your patients.  So, how are they reacting with the device?

Dr. Botker: When we look at things that have come into my practice and really changed the game, I can’t tell you how much this has changed the game.  I have patients coming in now, routinely getting 125 to 130-plus degrees range of motion on a routine basis.  That used to be kind of the red herring that you’d see it every once in a while.  You say, hey, great, the rehab is really well.  I am now seeing this on a routine basis.

I have patients coming back, and raving about this, saying, “I really think it was that ROMTech bike that helped me along the way with getting my motion back.”  

I still hear a little bit of skepticism from some of the physical therapists, but of course, I get where they’re coming from.  They want to take a lot of the credit too.  I’m not going to discount them at all, because they do great things, but I do think it keeps patients on a regimented rehab protocol at home.  It’s guided.  They can follow along.  And I’m just seeing unbelievable motion early and late, and they’re using less pain pills.  I’ve been really really happy with it.  And I’m trying to tell all my partners that you need to start using this for your patients.

Toree: Good.  Well, I mean, pretty soon, everybody’s going to be doing the thing, where they go to you, because you can get them back out healed faster, and your partners are going to be like, what the heck gives.

Dr. Botker: Yes.  Maybe I don’t want to tell them about it.

Toree: Yeah.  So, last question.  Do you have any thoughts on the device as a whole, and maybe its future, maybe for shoulders?

Dr. Botker: Yeah.  I mean, well, I think there’s a lot of different things.  I’ve started to branch out with a little bit of some of the sports medicine side of the world with some microfractures and things.  

Obviously, you’re always working out kinks.  And I think if you look at where the ROMTech’s bike has been and how it’s continued to improve and evolve, I see a lot of good things for it in the future.  I think you guys are doing a great job with taking patient feedback, and trying to improve on some of those things.  You’re working out the kinks when you got a new technology.

So, I think there’s a lot of roles that I’m excited for the future to see what’s going to come down the pipe.  

Toree: Yeah, us too.  Well, thanks so much, Dr. Botker, for spending some time with us.  I learned a lot actually in this interview, so thank you for that. 

Dr. Botker: No problem.

Toree: Folks, if you want to check out Dr. Botker, and go see him in Mankato, he’s at the Orthopedic & Fracture Clinic.  You can follow them at www.ofc-clinic.com.  And thanks again, Dr. Botker.  

Be sure, folks, to subscribe to our channel, and check us out at Romtech.com.  So, we’ll chat.  And good to see again, Dr. Botker.

Dr. Botker: Yeah, you too.  Take care. 

Toree: Thanks.

Dr. Botker: All right, bye.

Toree: Bye-bye.

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