Thank you to the program committee. Congratulations on an excellent meeting. So I'm going to talk about rotator cuff repair and the athlete. So here are my disclosures, including I'm the editor of the video journal, Sports Medicine, and this is a video based talk. And so I appreciate the invitation to do so. So as our previous speaker and her coauthors showed us, rotator cuff tears can be subdivided into acute chronic injuries. And while it's not quite as common, we do see true traumatic rotator cuffs, cuff tears in the collision athlete, and more kind of chronic attritional tears in the overhead athletes. And these are very, very common for us to manage and get people back to sports. So the acute cuff tear, this is a different animal, and we need to understand this. The indications are different. These are almost always going to be surgical indications. Timing is more important. These can evolve. The natural history of these is much more precarious. And the surgical repair can be different. Tissue quality can have implications with thickening and intertendinous type tears. Bone quality, some of these younger patients have significant bone quality differences to the patients that we're used to treating with more degenerative tears. Rehab considerations are critical, and then return to sports considerations. So when thinking about how I approach rotator cuff repair surgery, I thought about our basketball coach at the University of Virginia and his five pillars. And so I tried to divide this up into five kind of key buckets or key considerations when you're considering how you approach a rotator cuff repair. So starting with cuff anatomy and function, it's crucial to understand what the cuff really does and what you need to restore if you're trying to repair these. The bursal side contributes a good bit of blood supply. The articular side has a watershed area. And there are key attachments both anteriorly and posteriorly in the supraspinatus, the so-called rotator cuff cable, that deserve careful consideration when you're repairing these in place. In the operating room, when I'm looking at the tissue, we start inside the joint. I typically do these repairs in the beach chair position. You can see here we're debriding a partial tear in this central picture. An arm positioner can be useful to help to put some tension on the rotator cuff and get an idea of what kind of tissue quality you're dealing with. For traumatic tears, you're oftentimes dealing with full thickness tears, and the different types of tear configurations are key to understand. So you get the tissue mobilized, you free it up, and you move it around, and you get a feel for where this needs to go and how you need to repair it. Look for areas of delamination and tissue loss. So how to navigate a rotator cuff repair in a traumatic situation. So number one, you need to pay attention to anatomical repair. You want to restore the footprint attachment of the rotator cuff, again, paying careful consideration to the anterior and posterior cable attachments. I've gone to using knotless techniques most commonly simply because they're effective and avoid any concerns related to knot stacks and other things in the bursal space. It's key to have multiple points of fixation, to have a sturdy repair, and you want to be really, really conscious not to over-lateralize or over-constrain the rotator cuff when you repair it. You also need to be cautious and be conscious of trying to get the rotator cuff to heal, as we know that that's one of the biggest challenges with a rotator cuff repair in general, and in particular in somebody with a high caliber of athletic demand. So here's a case example. This is one of our football players. He was a transfer athlete. He sustained an anterior shoulder dislocation traumatically in practice. There was a background of some, quote, cuff tendonitis in his prior season, but you can see he's got a complete retracted supraspinatus tear. And so here's his case. We got his tissue mobilized, vented, and prepared the tuberosity to try to inspire some healing, and did a knotless-type repair to strongly and securely repair his rotator cuff back into position. What about larger tears? The same principles apply. You need to be conscious of the anterior and posterior cuff, and you want to address the pathology in sequence. So typically, I'll start with the anterior cuff. You do want to maintain, if there is a significant subscap tear, the comma tissue, because this is the anterior attachment of the supraspinatus. I'll then go posteriorly and then superiorly, and really be conscious for an anatomic repair. So here's a video technique of what I currently do with these types of tears. So you can see here, this is a fairly simple crescent-shaped-type repair. We'll try to debride back so we get to the tissue edge, but you can see we leave some of this bursal tissue attached to try to provide a healing environment. We'll put some medial points of fixation, and I do like to have some secure fixation at the medial edge. So this is a knotless repair, but we're taking the medial row sutures, and we're linking them to create a medial bridge, or a medial kind of footprint restoration technique. So we're taking some sutures, we're putting one anteriorly, one centrally, and then some sutures posteriorly, and what we're trying to do is reconstruct the cable attachments here. So you can see we pass these right at the edge of the torn tissue. You can see underneath on that underside, and this tissue did not have much in the way of delamination other than posteriorly, but we're very conscious to get all lamina and pull them back in an anatomic fashion. Now we're going to link these to each other to secure this medial edge, and you can see once we secure this, it pulls the medial tissue back anatomically where it needs to go. Now we're taking our larger tape-type sutures, and we're going just medial to our points of medial fixations to basically create a ripstop-type configuration so you have good purchase on the tissue, and also to serve as almost like a retention stitch to hold and support your repair. Once these sutures have been passed, we then bring them over and have lateral points of fixation you'll see here in a second to secure your tissue back. You'll see with this technique, the tissue comes back to the footprint but not beyond the footprint, and I think that's a key point as I'm doing these repairs. We want this back anatomically, but you again do not want to over-lateralize or over-constrain your rotator cuff, and you can see here a nice secure repair with multiple points of fixation and good anatomic restoration of where this rotator cuff tissue needs to be. Here's the same repair viewed in the inter-articular space where you can see again how this looks back with all laminas restored. What about biological adjuncts? I think this is an area that we'll continue to see increasingly, and it's something that I'm increasingly using in my own practice. My typical indications are either a delayed representation of an acute tear or something like a subacute tear, patients with poor tissue quality or maybe an intertendinous tear, a compromised host or healing concerns, revision cases, and I would submit to you perhaps in the higher demand patients you may want to consider this as well. Either tissue-based or cellular-based, biological adjuncts can certainly help you to get a healing repair and something that may be a little bit more durable. And then finally, you got to be really conscious of the postoperative management of these patients. You want to tailor your treatment to the specific patient, what their demands are, and more importantly the specifics of their tear and the healing environment. So this is kind of a general map of how I progress with postoperative rehab, and maybe I'll add CPD to my regimen as well to help them with pain postoperatively. There are a number of outcomes presented in the literature, both based on age, based on specific athletics and other levels of activity. And the bottom line is this is a fairly devastating injury in the high-demand athlete. And so you got to get it right, and we got to get it to heal for them to get back to their sport of choice. So in summary, management of rotator cuff tears in the athlete is different than the standard population. And you need to realize this. It's a different injury, and there are increased patient demands and increased patient expectations. You need to take these in a stepwise process, understand the indications, the evaluation, and when you're carrying out the repair, tissue management, mobilization, sound anatomic repair, attention to biology, and a tailored rehab progression. These are all critical things to get a good outcome. And even with the best current options, outcomes with regards to full return to sport is still a considerable challenge. So this is an area that we're still working on and still progressing with and deserves for future research and approach. Thank you very much. Thank you.

rotator cuff repair

athletes

surgical techniques

biological adjuncts

research