Okay. These are my disclosures. So when we think about rotator cuff repair, we know that cuff tear affects at least 40% of people. Over age 60, a quarter of a million repairs are performed annually. And despite the advances in technique for arthroscopic cuff repair over the last 20 to 30 years, retear still remains a persistent concern now in 2022. And we know that most of them occur within six months after surgery. Failure rates have been described anywhere from 6 to 94%. What we know is as the tear size and pattern complexity increase, the healing rates decrease. And that even though initially results may be similar, deterioration of clinical results does occur over time in patients who have persistent or recurrent tears. Two recent reviews of revision rotator cuff repair revealed that in revisions, 36 to 51% of them did not heal. And nonhealing was associated with worse clinical outcomes in at least one of these series. More concerning, a third of them had positive C acnes cultures at the time of revision. And anywhere from 6 to 12% of them required reoperation revision to reverse within two years. So the real issue is when we have a patient with a rotator cuff tear, we have all kinds of options. Everything from repair all the way through tendon transfer or even shoulder arthroplasty. So how do we choose the right procedure for the right patient at the right time? Well, what we know is that if we are going to proceed with a primary rotator cuff repair, we want that cuff to heal. So that's our goal for primary rotator cuff repair. But when we think about it, there are biologic factors that affect the tendon healing, including we want to optimize the healing environment, maybe provide structural or biologic support. There are mechanical factors, so we know we want to restore the footprint, obtain adequate initial contact pressure, and optimize the strength at time zero. And then we can't forget about cost-effectiveness concerns. If you practice in a surgery center or a big system, there's going to be questions to answer with regard to the cost-effectiveness. These are all biologic factors that have been described affecting healing rates after rotator cuff repair. So you can see there's a big list of patient factors. And there are also tear characteristics, delamination, tear size, poor tissue quality, tendon retraction, muscle atrophy that can affect healing rates. So what makes a cuff tear complex when we think about a complex cuff tear? It's delamination, like you see here. It's also things like tear size, tissue quality, tendon retraction, and muscle atrophy. So when we think about mechanical factors in rotator cuff repair, over the years, we've really progressed from single row to double row to a suture bridge or transosseous equivalent. And although the literature supports that there's not a lot of clinical differences at short- to medium-term follow-up, there is evidence that in large and massive tears that the suture bridge technique works better and that the healing rates are likely better for those patients. In terms of how you do your suture bridge technique, there's still no high-quality studies looking at these different configurations, so no technique shows superiority. So how do we optimize healing? Well, there was a recent meta-analysis, and PRP probably has the most evidence that PRP really does improve healing rates after rotator cuff repair. But patients may ask about stem cells. There's growth factors, amniotic tissue products, scaffolds. And the key thing to know is there's really not a lot of literature yet for us to understand how these might play a role. And in terms of amniotic tissue products, they really don't meet the criteria right now for homologous use, and so they're really limited to studies, or they would carry significant ethical and legal risks. So what's interesting in terms of biologic factors management, at our institution we're actually looking at optimizing our cuff repair patients in the same way that we optimize our total hip, total knee, and total shoulder patients, by making sure that they have good glycemic control, smoking cessation, judicious use of steroid injections. We know that steroid injections, the number and frequency of injections, as well as proximity to surgery, can affect the healing rates and the need for revision. And a C-acne benzoyl peroxide protocol, like you might use for a total shoulder arthroplasty. But what do we do about these other factors, like the patient age, the tear size, retraction, atrophy, and tissue quality? So this was an interesting study in the AGSM in 2019. And in this study, they tried to create a healing index with a score from 0 to 15, and tried to find predictive factors that would help us decide whether the cuff was going to heal or not after surgery. And although there are things like age and osteoporosis, there are a couple factors, like an AP tear size of 25 millimeters or more, increasing retraction affecting healing rates, and then fatty infiltration of the infraspinatus. So Dr. Denard and his colleagues kind of looked at that rotator cuff healing index and tried to create an algorithm. Because what they noticed was that if the healing index was less than 7, two-thirds of patients would heal, whereas if it was 7 or greater, more like a third would heal. So it was a significant drop-off. And that's where there might be a role for augmentation. And in the case of patients who are irreparable, maybe a role for superior capsule reconstruction. So when we think about using allograft or autograft in cuff repair, it does provide a collagen scaffold, and in the case of autograft, can provide viable tenosites. It adds mechanical strength at time zero. It can be used for interposition or augmentation, depending on what you use. And we know that superior capsule reconstruction can restore, or nearly restore, superior translation, subacromial contact pressure, and improve the biomechanics. So allograft augmentation really is demonstrating that in terms of large and massive tears, it can really reduce the re-tear rate. So this was a study looking at a small series, reduced the re-tear rate from 38% to 9%. And then Dr. Wong performed actually a randomized controlled trial. And this was in massive tears, and found that it really substantially improved the healing rates, if you would, allograft at the time of surgery. And also found that it reduced progression of cuff tear arthropathy. A recent meta-analysis also confirmed that if we add augmentation to cuff repairs, it significantly lowers re-tear rates overall, and improved clinical outcomes. So if we take that one step further, I mean, the SCR is kind of a progression of that. Initially, the superior capsule was thought to be just a thin couple layer structure. But now we know, as you see in this picture here, it's actually a really thick structure. It comprises a significant portion of the rotator cuff footprint, and is really important for maintaining glenohumeral kinematics and resisting superior translation. So if we look at SCR, the indications in literature are really becoming more clear, as well as nice studies looking at the minimally clinically important difference. But we want patients to be younger than 65 or 70, no or minimal arthritis for SCR, and have an intact or repairable subscapularis. SCR is also potentially beneficial in revision rotator cuff repair. It has been used in patients with pseudoparalysis, although my preference is to avoid it. And the data also is showing that patients with higher BMI, lower acromiohumeral distance, lower preoperative forward flexion, so things like pseudoparalysis, as well as women in work comp, patients maybe aren't going to do as well. Recent meta-analyses of SCR show that the healing rates are pretty good for superior capsule reconstruction, and that they have acceptable early to midterm clinical results. And the revision to reverse remains reasonably low. The drawbacks, well, it can be spaghetti in there. It's very technically demanding. It's lengthy and adds operative time, which also adds cost. The cost of the allograft, if you use allograft, can be very expensive, multiple anchors. Or if you harvest, then that also adds operative time. And lastly, let's remember, it doesn't restore active external rotation. So in those patients, you need to be thinking about tendon transfer, if that's important. And this is a really large tear, as you see here. So this one, the rotator cuff is repairable. So you can see the tissue comes over to the tuberosity. But just based on the size of that tear, it's at risk for non-healing. So there was a recent study looking at performing the SCR and then repairing the cuff over it. And that showed good clinical outcomes at two years. The healing rates are pretty comparable with SCR. And the cuff would tend to heal over the SCR. What about cost-effectiveness? Well, we have to remember that increasing the rows, anchors, adds to cost. If you add allograft, it adds to cost. Autograft adds operative time and morbidity. So what do we know about whether it's cost-effective and when we should use augmentation or superior capsule reconstruction? Well, if you look at just straight-up cost, SCR is the loser. It's more expensive than a lower trap transfer or reverse. But remember, cost is not necessarily cost-effective. So the double row is more costly but cost-effective. We know that from the literature. The reverse is more costly but can be more cost-effective. And a recent publication by Quigley and his colleagues showed that dermal allograft may be cost-effective because it reduces the re-tear and revision rate. So in the end, only you can choose the right procedure, thinking about all these things, including adding biologic factors, optimizing mechanical factors, and always keeping in mind the cost concerns. What I recommend is that you consider allograft augmentation in tear size 25 by 30 because we know those tears are already at risk for non-healing, fatty infiltration of grade two or more, and consider it in patients who have higher work activity, osteoporosis, or other patient factors like you saw in that big list that might cause those patients to not heal. For SCR, again, my preference is under age 65, intact subscapularis, no or minimal arthritis, but use caution in patients with higher BMI, pseudoparalysis, females. And remember, it doesn't restore active external rotation. Thank you so much for your time.

rotator cuff repairs

retears

cuff tears

failure rates

suture bridge technique