And there's quite a few that came in across the app. So there's microphones kind of spread throughout there. Looks like the first couple are for Dr. Tagliero on your distal biceps talk. Two questions. One, what caused the high conversion rate to surgery for the partial thickness tears? So the most common indication to progress to surgery in that group was persistent pain. And that was the indication for almost all of those patients who went on to surgery with the partial thickness tear. Great. Oh, sorry. And I'll just add, I highlighted in the talk, the mean time to surgery is about 110 days, 101 days. And that reflects about three months of non-operative management with persistent pain. Thank you. And then the second question is what was the average percent thickness tear on MRI scan in the operative versus the non-operative group? Yeah, that's a great question. We didn't tease out that specific piece of information because there was a percentage of patients who had, at the time of surgery, the operating surgeon didn't document the amount of tear that they identified. They simply said that it was still attached and they took it down. But we certainly could go back to the pre-surgical MRIs and try to identify if there was a significant difference in between those two numbers at the time of presentation leading to surgery. Great. Dr. McRae, several questions from the group. What were the revision procedures performed in the no acromioplasty group? The revision rate in the no acromioplasty group? What type of procedures were performed? Acromioplasty typically and a revision of the repair itself. So with the results of your study, have they changed doing an acromioplasty or not? Or do you have criteria when you do an acromioplasty? These days, the surgeons typically do not do a routine acromioplasty except with type three acromions and then that is typically their standard of care at this point. And a question asking what's the downside of doing an acromioplasty? Not being a surgeon, I'm not sure I can speak to that, but our surgeons that are also on the paper I'm sure would be happy to report to that at a later time if you like. Thank you. Thank you. Great. And Dr. Bowden, if the traumatic group is weaker with more functional impairment than the non-traumatic group, does that represent a selection bias? Yes. So we did see the traumatic group start weaker, but they did end up about the same strength. They did have more forward flexion motion at the end than the atraumatic group. And so I think there is definitely some potential confounders that we can't account for in our study, but we did see that overall at the end, the strength was equal between the two cohorts. And then a second question for you. Did you examine or count the number of patients who received cortisone injection preoperatively in the non-acute group? We did not, and that is definitely something we would like to look at in the future. Thank you. Dr. Brockmeyer, what is your timeline to define an acute tear? That's a great question. So an acute tear, and I think Dr. Bowden and her colleagues defined an acute tear with a history of a traumatic event. I think a lot of acute tears that we see are really acute and chronic tears. And so sometimes you have to differentiate, is this somebody who had an intact rotator cuff, had a significant event, has a true acute tear, versus somebody with some preexisting disease. And the case example I showed probably had some preexisting disease. I think when there's evidence of a true acute injury that changes somebody's shoulder significantly, that's what I would consider an acute tear. And so timeline as far as acute versus chronic is really based on the injury more than the time. Now as far as when you want to operate on them, for me, typically I try to operate on these patients within six to eight weeks, ideally if you see them soon enough. Because I do think the evolution of that tear is different than what we see in the degenerative tear. Thank you. And Dr. Alea, a few questions for you. First of all, was pre-surgical use of weed or cannabis used as selection exclusion criteria? Yeah, if they were taking cannabis or marijuana beforehand, they were excluded from the study. Great. And are you prescribing CBD now as part of your post-op protocol for these patients? So the answer at this point for me is no. I mean, we are literally just scratching the surface on this. There's no data out there for any of this. So the most data that we had before this study was on a medication called Epidiolex, which is given for very severe tonic-clonic seizures in children. That's all we have that's out there pretty much. So I'm not ready to start prescribing this to everybody. But just to show a hands in the audience, how many patients have asked you about the use of CBD? So it's pretty significant. So I think that we have the ability to now be on the forefront of this. And again, like I said, we're just scratching the surface. I'm not yet prescribing it to patients, but I'm certainly telling them about it. Great. And then just a quick follow-up to that. Someone wondered, how did you figure out what would be a reliable CBD to use for your study? Since CBD is non-regulated, how did you find a reliable substance to use for your study? So I mean, we don't know that it's reliable. So that's why we're doing this study. I mean, this was manufactured by a company called Orkosa. It's a buccal-absorbed medication. And we're still doing lots of studies to see what the bioavailability is, how it's absorbed into the bloodstream, et cetera. So again, this is the first of a series of papers that we plan on doing. Great. Thanks very much. Dr. McCarty, I can't leave you off the hook here. Does your data include any throwing athletes? And can a suprapectral tenodesis be performed for a symptomatic slap lesion? In throwing athletes? So the question is good, and really, you can perform either type of tenodesis, suprapectral or subpectral, in any athletes. As you saw in the literature, and it was not necessarily dedicated to throwing athletes, although there's been a recent paper on that, that really, either technique is going to be fine. And I'm not seeing any differences, whether it was a throwing athlete or another athlete, in terms of which technique. But I prefer suprapectral. And then, Dr. Brockmeyer, could you please speak to the cost of using biological augmentation during primary rotator cuff tear? Yeah, that's a very great question. And that's always been one of the kind of the key, if you're looking at pros and cons, one of the key cons to these. But I recently, in fact, I think at this meeting, saw a study that was listed that kind of tried to justify cost based on re-rupture rate. So I mean, I think the key cost to the patient, as well as kind of societal costs in rotator cuff repair is failure of your repair and revision surgery. And so I think as we continue to quantify the impact of some of the things that we're using and realistically trying in our patients to try to get them to heal, I think one of the key things to consider beyond the cost of the implant or the cellular treatment or the graft is going to be the impact on the outcome and revision rate and cost in that regard. And so certainly we need to continue to study this, but I do think that this is the future of what we're doing in rotator cuff surgery. Thank you. And Dr. Forsythe, do you have a preferred treatment at this time for your biceps? Do you always use the same method for biceps tenodesis? I don't. I will switch between the two depending on what the fellow might want to observe or learn. I found that the key to doing the arthroscopic procedure is to get a complete release of zone two. I think the throwing athlete is probably one that's better treated arthroscopically, as if you place an interference screw lower down on the groove beneath the pec, you may subject the socket to increased torsional stresses. So I think a more proximal approach is probably favored for an overhead throwing athlete, although the risk is low of an untoward event. Patients with severely hypertrophic biceps tendinopathy, those might be technically easier to do via a mini open approach, as it can be difficult to whip stitch or arthroscopically pass suture through an enlarged tendon. You are removing another three centimeters or four centimeters of pathologic tissue with a mini open approach. So those severely tendinotic tissues might do better with the mini open, although the PROs in a randomized trial don't necessarily suggest that there's much difference. It's just technically more challenging arthroscopically. Thank you. Well, with that, it's 10 o'clock, and I think we need to end this session. But it was a great session, and I want to thank all of our speakers for their expert participation. Thanks everyone. Thank you, everyone. Don't forget to go to the exhibit hall. Thank you for attending.

partial thickness tears

persistent pain

acromioplasty

SLAP lesions

biceps tenodesis