And first is John Tokish, who's admittedly the smartest guy in the room, and he hates when I say that, but it's true. He's an Air Force Academy grad, a real patriot, and he's had at least two deployments, and I think the world of him. Jimmy Bailey, if you don't like Jimmy, you got personal problems. One of the kindest human beings ever walked the planet, another combat veteran. And the third is Summer Hamoud, who trained my daughter at Jefferson, and my daughter called me and goes, Dad, this woman can operate. And she's a combat veteran, because anyone who can practice in Philadelphia for more than 10 years is a combat veteran. So, how do I advance here? So this is our distinguished panel. I don't know where Craig went, but this is the first case. We're gonna have a lot of fun, and I like to hear these great minds, and we're gonna give you your money's work. So this is a 53 year old who fell three months ago, and look at the high riding head, and this is interesting. So you look at that T1 kernel toe cushion. Doesn't look too bad, does it? And his issue is he can't bench anymore. So I'm trying to inject a little bit of levity today, right? Larry Shaw, right? I used to keep it clean, Kel. So, given that, what are you gonna do, our distinguished panel? You're gonna just say, yeah, you know, that's pretty high riding. That's a mod of three and a half. It's just debris, do a mumpher, do a biceps, do a partial repair. I know Colonel Tokich is a big proponent of low trapezoid transfer. I have zero. We're gonna call my buddy Pat Stamperior. I call Colonel Reverse. He does a fantastic reverse, and he's an honest man. He thinks of reverse as indicated more than primary. So what are you gonna do? Let's start with Jimmy, given that scenario. Yeah, so obviously, he is an active 53 year old aging athlete. He wants to get back to benching, right? So working out. So I think you try and repair that every single day. He had good muscle and So Colonel Tokich, give us some enlightenment on your experience with the low trapezoid transfer. JT and I argue, and he always wins because he's smarter, but his contention, and this is for our audience, if the muscle quality is poor, then you really are better off with a lower trapezoid transfer. I'm a big SCR fan, full disclosure. Colonel, what's your thinking? Well, in this case, the muscle quality is good. So I always say, as you know, where there's muscle, there's hope. So if you've got good muscle, then I don't think there's any way to reconstruct any transfer that's better than what God gave us in the first place. So if you've got a good muscle of the infra, then you're not trying to reconstruct a muscle tendon. You're just trying to reconstruct tendon. My first choice here would be repair, just like Jimmy said, and if he's only three and a half months out, I think that'd be reasonable. And if I couldn't get a repair, then this guy is my indication for SCR. So then it gets interesting, Summer, and I've been faked out, maybe because I don't know how to read the MRIs, but I get in there, and did you ever see Southwest Airlines? I want to get away. His tissue looks like Kleenex. So, Summer, I did not consent him for any other procedures, and you look, you get inside, and you're like, what are you going to do now? Well, so that, you know, I would, you know, you don't show us a video of you pulling on the tissue, but I mean, you could, you know, first attempt some releases, you know, do a posterior interval slide, anterior interval slide, and see kind of the mobility of it. You can get some sense of the tissue quality by using that cuff grasper. And then, you know, Dr. Burns spoke really eloquently in her talk yesterday, there are options even of doing an SCR and then, you know, repairing the cuff on top of it, you know, lead to better outcomes and lower retear rates. I don't know about you, I always consent people for surgery as indicated. That's a good thing. And I think this guy would be upset if you left the OR and didn't fix it. I agree 100%. And Bill Pennington, who's done more SCRs than anyone in the world, taught me a trick. He puts his medial row SCR sutures tapes under the infra in the back, and the first one under the subscap, and it gets kind of like a fold-over effect. And I encourage the audience to try that. So what I did was Steve Savota, I called the priest, number one, and then I got some of this together. And I'm a biologist, not an engineer. I was an English major. I was a double major at J.T. I took up a space and time in college. And I was able to get most of it together, and thanks be to the Lord, he is happy. But I want to just share with the audience, see Burkhardt says massive cuff tears, stage 3 and 4. In his hands, most of them did well, and not in my hands. But I want to just make a comment. I think we've lost the art of tear reduction. I think that many of us are quick to go to double row at the expense of, it's like a fracture to me, reduction. And I think margin convergence somewhere got lost in the shuffle, because the work of Moshe Zuki shows that the lateral footprint is only 1.3 millimeters. So if you see a tear that's more than 1.3 millimeters wide, there has to be some obliquity to the tear. So I just want to put that plug in that I'm a big, big, big margin convergence fan. And I want to know the panel, are they still doing this in their practice or are they going right to double row? Colonel Tokish. I still do some margin convergence. I noticed this patient still had a bicep. So for me, this biceps, I would have used that as augmentation or a biceps SCR in that regard. We're going to get to that, you know, hear your thoughts. Commander Bailey, what do you think about margin convergence? Yeah, I totally agree. And that's what I was going to ask if you would have flipped the biceps up to try and bridge some of that. But I'm trying to determine what kind of tear that is and then bring it together so you can at least bring it down to the medial footprint. So summarizing, I'm sorry, Jim. My daughter tells me you're a biceps killer and I respect that. Are you an ardent biceps killer or are you like, eh? I'm pretty aggressive. What is the word? Remove all pain generators, right? Yeah, I've had a few patients that I didn't do anything and I had to go back in. And, you know, patients hate that, you know, they've got this whole other recovery now. So, yeah. And these older patients who are coming in with cuff tears, it's almost always, but not every single time, but almost. Jimmy. I do just want to say one thing about that because, as you have mentioned, other indicated procedures. And this could be a huge bias from taking care of a military population. But my population is not happy about getting their biceps cut if they had not talked about it beforehand. So I'm super aggressive on consenting them for possible biceps tenodesis, even in instability where I'm worried it might go up the back into the slap. And then if anything, I tell them I didn't have to cut your bicep. This is the first thing I ask. Did you have to cut my biceps? No, I didn't. Yes. And everything else is gravy from that. It's a perception thing, isn't it, Jimmy? That's true. So I want to just ask our panel here. You know, people say subscapularis tears aren't that common. Well, Burkhardt did a study about 46%. When we reviewed our massive cuff tears, guess what we found? 92%. So, audience, what is this? This is a comma sign. So it asks you to look for the comma tissue. And if you don't fix the subscap, you're not doing your patients a service. You have to look for it. The eye sees what the mind knows. And a little gray hair moment. If you don't use a 70-degree scope for fixing these, please try it because it makes your visualization so much better. Colonel Tokish, any comments on subscap in your experience? Yeah, I think it's more common than we used to let on. But I think that, you know, it depends. If you say it's 90%, then you're probably counting those little fraying and those longitudinal ones and everything else. So that might be a little bit of an overshot. I see that you repaired this one. You repaired it intra-articularly, I think, which if you're going to use a 70-degree scope is fine. I worry a little bit about your medializing that footprint a little bit as opposed to when you go outside, you can get it all the way up to that lesser tuberosity. It's duly noted. Touché. Actually, JT, that was 92% that I fixed. I just am a very, very – I hate to use the word aggressive with subscaps. If I pull on it, if I look at the footprint of the 70-degree scope, I see some uncovering, then I'm quick to fix it. So I'd rather, you know, not miss it. That's my own bias. Jimmy, what do you think? I definitely don't have that high of incidence of subscap tears. These are for massive tears, not for every tear. Okay. Well, I'm sure they've seen me more than I've seen them. In my practice, I have begun fixing more and kind of identifying those more subtle upper-world border ones and doing more of that. Summer, do you see it a lot? Yeah. I mean, I would say that it comes into the algorithm, and it's not always identified on MRI. It's definitely not identified by the radiologists. And sometimes, though, when I look at it critically, I identify most of them. But sometimes there are some that I didn't quite identify on the MRI, probably just because of poor, you know, quality of the MRI. But what I would say my only comment was going to be with that comma sign is I think very early in my practice, I found it kind of difficult to work around that comma sign tissue, and I released it a couple of times. And, you know, now I don't, and it's just so useful to leave it intact because once you repair the subscap, the supra is just right there. It's ready to just have you stick it right down. Let me push you on that a little bit, though, John. So in this particular case, you've got a massive cuff tear with a supra and a subscap, so anterior superior tear. And you're leaving your comma tissue intact. Sorry, always. Right. So now you've just fixed your subscap, and you've medialized your footprint, which means you've just short-sheeted your repair for the rest of it. So my take with all of this, having been there and done that a few times, would be to say if you are going to fix your subscap and an anterior superior tear and leave your comma tissue intact, you might want to, one might want to consider fixing that supra first because you can get that out to the footprint, which actually reduces the subscap back up to its normal place. I worry about when we do it here, especially from an interarticular view, you're right against the articular surface, and if you've pulled that down, you've short-sheeted yourself, and you won't get a good repair on the other. As you would say to me, I respectfully disagree, sir. Steve Burkhardt taught me, and Steve Snyder, that if I have trouble with protraction, I medialize it. But Burkhardt calls this an interval sliding continuity, preserving the comma because as Summer mentioned, then I get up top. I have something to sew my infra to. Sometimes the supraspinatus is not seligible, so that's my, but again, JT, his IQ is higher than my malpractice premiums in Philadelphia, so I've got to just back off here. But the thing that I want to share with the panel is Buddy Saville taught me this, and people think I'm crazy. Release the coracolumaral ligament for high-riding humeral head, and the coracolumaral ligament is at the coracoid neck, and Buddy taught me this, too, post your infracaps release to get that head down. Colonel, am I crazy, or, well, we know I'm crazy, but what do you think about this? Yeah, I think capsule releases can help with that inferior. I don't know that there's anything with that Hamada 4 or 5 that you're showing there that's going to bring that head down. I think that's a little bit of wishful thinking, or as Burkhardt would say, would require me to suspend my disbelief here. That being said, if it's an acute setting, sometimes you can get that or a subacute. Summer, are you doing these releases? I mean, I am for when I have a massive cuff tear, I'm always doing these releases, yeah. And Jimmy, you know, you'd be surprised. Buddy has a great video. He actually released the coracoid ligament, actually pulling the arm, the head comes down, because we all know whether it's SCR or whether it's a graft, we have to cover the head and get it down. So our goal was tension-free repair, and we were really lucky you can get something like this. At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Okay, a simple wrong would have done just fine, but then... I just had to inject that because people think I'm wacky. So let's go to the next one, and this is a 51-year-old ex-Marine. And by the way, I get very emotional. We've got so many veterans in here. I see George Mowen, John Bergfeld, all the veterans stand up just for one second, please. Right now, let's do it. Let's give them a round of applause, guys. We don't do enough for these guys. We do not do enough for them. So this is a 51-year-old Marine, and Summer, look at this. This is another one of those want-to-get-away. And he has a hornblower sign, and he's 51, and he's had, God bless him, PTSD with substance abuse, and he doesn't want anything else done that's of a major nature. What are your thoughts here, Summer? What do you want to do? Are you thinking about debris, biceps get out of dodge, partial repair, trapezoid lat transfer, balloon city? I want to hear Jimmy's thoughts on that. Or reverse-a-mania? Summer, what do you think? Can you go back to the imaging? What's the magic word? Please. Sure. Now. So. This is what you get. I'm being very terse on the imaging because this is what we get. We often get HMO, open number eyes. Right, Bernsie? Well, so. I thought the magic word here was non-crappy imaging, John. Thanks, sir. I needed that. So, I mean, in regards to the balloon, I mean, I haven't done any myself, but as we all know, the data is super limited, right? There's only two studies, both this year, you know, showing that it's really not better than, you know, just a breeding in a biceps tenodesis, right? I think Commander Bailey has some words about that. That's okay, you know. But, you know, there's that study showing non-inferior to partial cuff tear, and then the Lancet study showing that it's no better than, you know, just debridement and tenodesis. But this is a guy, so he has positive hornblowers, but not pseudoparalysis, like he can forward flex, although you're just showing us with his elbow flex there. I wouldn't go straight to a reverse in this guy as a first step. He's 51, right? Correct. Yeah, I mean, I'm not a tendon transfer person, so I would defer to JT, but, I mean, I would try either a debride tenodesis, partial repair. You're not going to restore his external rotation actively with an SCR, you know, but I would be thinking all of those things going into it. I certainly, yeah. So, in the interest of time— If I thought he needed a transfer, I would have referred him. I want to just, for disclosure, this is my first SCR I got in there, and I— You are faking. So, I think reverse for younger people, I feel strong on this, I think it's fake news for younger folks. So, I did an SCR, and JT, again, is a lot brighter than I am, but I believe it can be, if it's done properly, can serve as a biologic fulcrum. So, here he is, this is my first SCR, and I saw this JT, and I'm like, oh my God, this works. Now, sadly, my experience has not mirrored this. I've had a couple of, like, you know, miserable failures. But, if you look at the literature, and we hear the panel talk about—Mahata came out with this years ago, 93 percent. Burkhardt says it depends on amata grade, and we have this panoply of other studies. And my experience, about 25, is limited, but Bill Pennington published his first, like, 100 series, 82 SCS score. So, panel, do you believe in SCR, Colonel Tokish, and how do you do it? Do you do what I do? Do you suture the front and the back, as Bill Pennington told me to do? Or do you just, like—I think you were toying with the idea, JT, of using fasciolata. Give us your consensus on this. Yes, I think the reason this worked is that this guy has good muscle. And what you did was restored his muscle tension and got that back, right? So, if the muscle's dead, it won't work, and then the only option for him to restore his hornblower would be a lower trapezius transfer. I don't think he necessarily needs that, and I think you show it really well here because of the muscle quality. But we didn't, you know, see it exactly. So, that's my differentiation. If grade 0, grade 1, then this is an SCR, and this will work. But if it's grade 3, grade 4, then you've got to go right to the transfer. I think one of the keys is to try to incorporate in as much of that cuff onto your patch. I will say this. I worry about the human dermal allograft patch. The reason we all do it is because it's easy, and it's beautiful. If you do a tensor fasciolata or an allograft patch, et cetera, it's harder to work with. It's uglier, and so it's a bigger pain in the tail for all of us. But the truth is is that that capsular tissue is much, much stiffer. So, I'm glad this worked out, but if you take a look at that human dermal allograft and you put it on tension, it doesn't rip, but it will stretch forever. And so, it's a lousy restoration for trying to get real functional return to your construct. Summer, I know you're a tough cookie, and you sell it like it is. Do you think SCRs aren't doing as well? Is it because people aren't doing them correctly? Certainly, it's possible. I mean, I'll tell you when I do them, and I take the measurements between anchors, and, you know, from the glenoid to the greater tuberosity, I always place my holes through it at a shorter distance because it does stretch. But it's possible. But at the same time, when I do this, I'm not promising the world for them. This is not a normal shoulder. This is not like repairing their own cuff. So, Jimmy Bailey, I watched him operate. He's a fantastic surgeon with a lot of experience with balloon. Jimmy, share with the audience your experience on the balloon. I can't get my hospital to pay for it, but what's the bottom line? My experience on the balloon is actually very, very limited. But we have done a couple at Balboa. I saw you pay, Jimmy. Wait, wait, wait. I saw you do one. But everybody should know, you know, JK was like, hey, I'm going to make you look good up there, and then you asked me about the balloon, so you did me dirty. But I think, you know, Tokish, he will say that, you know, when you have a surgery that's quick and easy to do and early good outcomes, it's like crack for us, right? And I think that's where the balloon fits in. And, I mean, you know, there's 10 years of studies overseas on it that all look good, but then that Lancet article could be a killer for it. I will say, so I probably would have done a lower trap on the patient from what I saw here with no external rotation in the hornblower from what we saw of the muscles. So, in full disclosure, I would have done a lower trap on that. I don't have great experience with SCR. I just haven't seen it in my population, and I've had limited on the balloon. But I think if this really didn't have anything for the SCR to tie into posteriorly, and you did not trust him because of some of the substance abuse stuff to rehab and lower trap, I mean, you could maybe try a balloon in this and just have a head depressor, especially for the pseudo-paresis patients that just need a depressor to get past the pain and then allow them to rehab. But, you know, the problem is it's so expensive. So, exactly, in our hospital, I think it's $5,000, and they won't pay for it. But the studies that have been done on balloons have all excluded patients with significant external rotation deficits. Even the most ardent balloon supporter would tell you that they only do it to restore forward flexion. It won't work in external rotation. So this guy would be an absolute contraindication to the balloon. And then they both mentioned the Lancet study, which, if you haven't read, is probably something to take a look at. They actually abandoned the trial because the debridement group did better than the balloon group did. In other words, Johnny Carson, I did not know that. That's great to know. People I really trust in this vocation, including this panel, I asked Ben Kibler. He thinks the balloon works because it helps reduce the scapuloscenesis, and Buddy Savo thinks the balloon should be used in all cup repairs. So just FYI, just to lower the head and decompress the repair. It lowers the head maybe for maybe three months until the vicral goes away, right? Correct. And then the objective of whether or not that works or not is another question. So I think much more data to be done. A couple, I think, take-home points I want to get through to the audience here. Our panel, Summer, are using the biceps as a graph. A lot of papers coming out. Maybe sort of taking it out of the groove, putting an anchor in. What's your take on this? I haven't done it yet, but have been tempted. Yes. Yeah. I have no experience. Jimmy? I did it once in the lab with this guy. Colonel? I've done it a lot. I think it's probably become my first go-to for the smaller massive cuff tear that's irreparable with dead muscle because it's an active transfer, and I think that the results on it have been really good. So for me, the biceps, I cut it. So I go super peck, and I cut the biceps, and then I remove that and transfer it up, and then it becomes an autographed SCR because it's already attached to the glenoid. There are people, however, who are not detaching it at all and just moving it over. Larry Field's got the largest series in literature right now, and I'm shocked because I would have thought that would have caused biceps pain and cramping and all these other things, but nobody's reporting that. There's been three or four series out now. So maybe it's overkill for you to have to cut it. Maybe you just move it over and incorporate it into the cuff tear, and folks have found that to be helpful. It's funny you say that because 20 years ago, Stephen Snyder told me to sew the infraspinatus of the biceps. I've been doing it because I actually tend to posteriorize it. I leave it alone. And Steve Burkhardt, who's a lovely friend but a proponent of the double row, he wrote this paper in 1999 showing how you should sew the infraspinatus of the biceps. So people have been doing this for a long time. It's collagen. It can serve as a depressor, and I think that it is certainly noteworthy, and I'd like to hear more about J.T.'s experience. I do not put an anchor. I just sew it to it, and that's the thing that's always been working well. So just for the panel, who believes in the forced couple theory, and who's a big proponent of partial repair? Do you think, Jimmy, that Steve Burkhardt was right or wrong with this? No, I think the cable is real, and I think if you can get a partial repair, especially trying to restore the cable the best you can is a good way to go. I do partial repairs as a first line. I had a good conversation with Buddy Salvo two days ago, and he said he's pretty much abandoning SCRs, doing more partial repairs. Summer, what do you think? I have not gotten to the point where I'll just leave a partial repair. I will typically go to an SCR, do something to bridge that area. So, yeah, I haven't really jumped on that. Not that I don't believe it. I do believe in the rotator cable. I've just, you know. So the other two arenas I want to touch briefly before we back off here is the graft augmentation. So, JT, I do sometimes freehand. You know, I put some pulleys, as Mark LeBay taught me, like this. But I've also used this Regen Tim, which is, for some reason, $4,000, and our hospital approves this. I want to go down the line, the panel's experience on some of these grafts. Colonel Tokish? Resention I tried early on, and I found actually a really high level of stiffness in my hands. Maybe it was me. But the data has not been the case with that. The data is surprisingly good, for those of you that are believers. I don't ever use this now because we use an autograft biceps tendon. We do biceps. We cut the biceps out, and we've developed a way to smash that biceps into a patch that looks just like that. But it's autograft tenosites. Jimmy, your experience with grafts? Yeah, I've done this graft on our revision rotator cuff repairs and our real high-level, like, seals. And they've done well, just to add a little biology. Summer? I find this particular patch to be the best for partial bursal-sided tears. And patients, although few, because according to that previous presenter, I do use the needle barbitage a lot for calcific tendonitis, but when I do have to operate on them, this is really nice to place on top of that. And then with revision repairs, I'm usually augmenting with dermal allograft. If I can bring the tissue to the medial footprint, then I bridge the rest of the footprint by ‑‑ Serena has a really nice video on Vumedi, but, you know, just incorporating the germ. Serena Nandari, very talented young man. So one study in the literature compares the dermal allograft versus the collagen, bovine collagen here, and actually amnion, and finds that the amnion and the human dermal work much better in a dog model, at least, compared to the bovine collagen. You know, xenografts are troubling, right? We've been down xenograft roads over and over again, and I'm frankly surprised that the literature is reporting the results are being as good as it is with this particular implant. Yeah, so the literature, Alan Barber, another military guy, honest, said if you use a graft, this is an old data, but you roughly halve your recurrence rate if you use grafts. And this won the Herodicus Award three years ago, Buddy's paper, that Buddy did massive repairs, pretty much got him nearly completed, or complete, and he put a regentin patch on, and he had 96% healed by ultrasound. So, JT, this is like the final burning question. You're the man with this. This is your paper. Talk us about your work on the subacromial patch. Is this the real deal, or are you just flirting with this idea? I don't know, honestly. I think that, you know, what we've done is we do SCRs. We did a bunch of SCRs with human dermal, and then we always throw away half of the patch. And one of the challenges, Mihata and others have published, that the thicker your graft, the better. So we're trying to figure out how to be thick. So people say, well, the balloon's thick. Well, actually, it's not very thick. If you do it according to the manufacturer's recommendations, you pull it in, you fill it up, but then you remove some of that fluid because they're worried about the thing overpressurizing, and it's only 5.5 millimeters thick. Human dermal allograft's going to be about 3 to 3.5 millimeters thick. And so we said, well, what's a permanent spacer here? And so what we do is we take the other half of the graft, so you get your human dermal allograft and you cut off half of it and usually throw it in the trash. We said, well, let's just do the SCR like it's done here, and then let's take the other half and put it on the undersurface of the acromion. We call it the SCR plus. Some others have done a portion of that procedure. Rafi Mirazan has done what he calls a biologic tuberoplasty, where he just does human dermal allograft without the SCR on the side. And then Matt Ravenscroft out in the U.K. has done what he calls the bar procedure, which is the other half of it where it's up on the acromion. I do both, but it's an SCR. And I would say that it's allowed me to move to the Hamada 3 for an SCR patient. And so the spacer, it works. It will pull the head down a little bit and is a good pain reliever, but I don't have long-term data. So J.T., brilliant guy. He took this concede by the data showing that if the SCR fails at the glenoid side, those patients had pain relief, sort of inferring or implying that it was really the spacer effect of summer. You were going to say something. No, no, no. Do you have any experience with this, J.T.? No, but I would be open to trying it if the results come out. J.T., for the audience's sake, how hard is this? Well, the SCR is technically demanding. No, yours. Oh, it's not difficult. It's not difficult because you don't really use fixation. Well, I know you're amphibious. You use both hands. So for you, it's maybe easy. No, I don't think so. I think this is one where you just, you know, I now cut a 25 by 25 millimeter graft or 20 by 25 millimeter graft, so I don't even have to measure it. So don't mess with your time. The graft stretches, right, especially human dermal allograft. Oh, you! I'm sorry. That was for Votoni. Sorry, J.T. And then you just have mattress stitches in the corners, which we all are comfortable with. You can do that outside. You don't have to do that arthroscopically, so it's outside on the table. So now you've got this patch that's outside, and then you just do suture passing, AC joint anteriorly and just lateral like you would a spinal needle anterolateral, and you do the same thing. And then the only little trick is that now you've got your four sutures coming out around the acromion, and you make a little incision in the middle, and then you go and you fish the individual sutures, and then you just tie them down over the acromion. So it's not difficult. Preliminary results? Well, I'd say I have one. I'm going to peel your deep Catholic side. Yeah, I have one spectacular failure where I had a poor woman who's detached on me, and that's on me probably. It was probably a technical error. And I have about 15 to 18 of them overall, and it's a little too early in that regard, but we definitely show that it heals with postoperative MRI. Their outcomes are good. The problem is I don't know what the control group is, so I don't have any control, so I don't know what it is. This was for Votoni. You can't handle the truth. I don't think he's a big fan of SCR. Anyway, one last quickie, and this was a very, very prominent surgeon. This is my cousin from Ireland, and he operated on her, and it failed. Look at the double row, and I'm just cautioning you, this is one of the big margin conversions. The footprint looks like a graveyard of anchors. And so this is my cousin, Margaret JT, failed a double row by a prominent surgeon who's not in this room, thank God. Then she drifts into my office and, John D., if you fix my shoulder, I'll give you a case of Guinness. What are you going to do here? I mean, you've got to say yes. So how would you face this one, Colonel? Failed double row. Me? Yes, sir. She's my cousin. 100%. 100%. She gets a reverse. Ow! I don't even care if she has arthritis. And the truth on this is she's 72 years old. That cuff is a cuff at risk anyway, so I want to do a procedure that I don't require them to have. I don't care if the cuff ever heals. And, in fact, as you know, I don't require the subscap on any of my patients. So I tell her that after the surgery she has no limitations. Wow. Okay, Commander Bailey, I know JT is one of your good buddies, but don't worry about insulting him. Tell the truth. No, you're going to insult me. Jimmy's never afraid to insult me. I'll give you a hint, Jimmy. Her tissue quality was not bad. Oh, it's not bad? It's not bad. I was going to say it looks like it tore through the tissue. Whoa, whoa, whoa. What is that about? If I can put a grasper and grab it and my grasper doesn't go through, it's not Kleenex. Well, clearly you just do it better. I like the way you think. Probably reverse. Jimmy, you're not using – okay. I know some are – No, I'm sending this to one of my colleagues to do a reverse. Oh, my gosh. Kurt, what did you get me up here? Holy shiza. All right, so what I did – so, anyway, this is the last point here. Lower trap, and JT's done these, trumps lat transfers. Because as an introvert here, Steve Thomas taught me this. Take a balloon call me in the morning. I'm not doing that. Revise with a graft, kernel, and lower trapezius outperformed lat transfer. And Fasciolata, in this study, back from Korea, showed that it actually outperformed SCR. So, interesting. As always, JT's ahead of the curve. But what I did, I used principles of margin convergence. I got her back together, and I did a pretty much partial repair. She was happy until she fell and broke a humerus, and she went back to New York and got a reverse. And got a reverse. All right, all right. But that's the truth. So, I want to thank our distinguished panel. My wife's picking me up in a few minutes. I want to thank the Society and Kurt Spindler. Wonderful year of presidency. And any other burning questions, please find these folks at the podium. So, thank you all. JT, outstanding job, man. It's always a great pleasure to be on your podium.

shoulder surgery

treatment options

repair

biceps tenodesis

lower trapezius transfer

hornblower sign

PTSD